Anemia In Pregnancy: Examining Missed Diagnoses and Racial Disparities in the Upper Midwest.

Anemia in pregnancy (AIP) is associated with poor maternal/fetal outcomes. The prevalence of AIP globally ranges from 44-53% and varies drastically depending on maternal race/ethnicity and other factors. Screening and treatment of AIP is disputed. This study is a retrospective review of electronic medical records (EMR) of pregnant adults over three years (2018-2020, inclusive) of Sanford Health, a large healthcare system in the upper Midwest. AIP was determined by either diagnosis or lab values (hemoglobin, hematocrit, and ferritin) overlapping with pregnancy. A missed diagnosis was characterized by confirmed anemia through lab values but lacking a diagnosis of anemia within EMR. A total of 35,498 patients were included in this study, 42.9% were determined to have AIP. Of AI/AN (American Indian/Alaska Native) patients, 58.3% were anemic and 55.1% of Black/African American patients were anemic compared to 40.0% of anemic white patients. Of anemic patients, 81.1% did not have an anemia diagnosis listed in EMR. This study identifies racial and ethnic disparities of AIP among patients in the upper Midwest. In addition, this study highlights the need for improved data integrity within EMR.

Description and Evaluation of a Multilevel Intervention for Improving HPV Vaccination Rates in a Rural South Dakota Clinic.

BACKGROUND: This study describes an education-based, multilevel intervention and its impact on human papilloma virus (HPV) vaccination rates in a rural South Dakota clinic. METHODS: At a clinic-level, nurses and clinicians were provided education on HPV vaccination guidelines and opt-out communication techniques. At a community-level, parents/guardians attended an educational session at the local middle school orientation. Surveys assessed subjective and objective knowledge pre- and post-intervention. Electronic medical records were used to examine HPV immunization rates for adolescents (aged 9-13 years), 2016-2020. These figures were compared to the number of vaccinations given across the healthcare system footprint. RESULTS: 72.7 percent of nurses and providers in the clinic utilize opt-out communication when discussing vaccinations. Increases in self-reported and objective knowledge among participants were noted. EMR review revealed the percent of adolescents vaccinated for HPV increased post-intervention. CONCLUSION: Implementation of multiple community interventions correlated with increases in community knowledge and HPV immunization in adolescents in the service area.

Predicting unplanned medical visits among patients with diabetes: translation from machine learning to clinical implementation.

BACKGROUND: Diabetes is a medical and economic burden in the United States. In this study, a machine learning predictive model was developed to predict unplanned medical visits among patients with diabetes, and findings were used to design a clinical intervention in the sponsoring healthcare organization. This study presents a case study of how predictive analytics can inform clinical actions, and describes practical factors that must be incorporated in order to translate research into clinical practice. METHODS: Data were drawn from electronic medical records (EMRs) from a large healthcare organization in the Northern Plains region of the US, from adult (≥ 18 years old) patients with type 1 or type 2 diabetes who received care at least once during the 3-year period. A variety of machine-learning classification models were run using standard EMR variables as predictors (age, body mass index (BMI), systolic blood pressure (BP), diastolic BP, low-density lipoprotein, high-density lipoprotein (HDL), glycohemoglobin (A1C), smoking status, number of diagnoses and number of prescriptions). The best-performing model after cross-validation testing was analyzed to identify strongest predictors. RESULTS: The best-performing model was a linear-basis support vector machine, which achieved a balanced accuracy (average of sensitivity and specificity) of 65.7%. This model outperformed a conventional logistic regression by 0.4 percentage points. A sensitivity analysis identified BP and HDL as the strongest predictors, such that disrupting these variables with random noise decreased the model's overall balanced accuracy by 1.3 and 1.4 percentage points, respectively. These recommendations, along with stakeholder engagement, behavioral economics strategies, and implementation science principles helped to inform the design of a clinical intervention targeting behavioral changes. CONCLUSION: Our machine-learning predictive model more accurately predicted unplanned medical visits among patients with diabetes, relative to conventional models. Post-hoc analysis of the model was used for hypothesis generation, namely that HDL and BP are the strongest contributors to unplanned medical visits among patients with diabetes. These findings were translated into a clinical intervention now being piloted at the sponsoring healthcare organization. In this way, this predictive model can be used in moving from prediction to implementation and improved diabetes care management in clinical settings.

The Effect of Maternal Smoking on Offspring Smoking Is Unrelated to Heritable Personality Traits or Initial Subjective Experiences.

INTRODUCTION: Maternal smoking is a risk factor for offspring smoking. Lifetime maternal smoking vs. prenatal tobacco exposure (PTE) appears to act through different mechanisms. This study tested the hypothesis that maternal smoking measures' effects on offspring smoking could be attributable to hereditary mechanisms: personality traits (novelty-seeking, impulsivity, neuroticism, and self-esteem) and initial subjective smoking experiences (pleasurable, unpleasurable, and dizziness). METHODS: Data were drawn from the Social and Emotional Contexts of Adolescent Smoking Patterns study, an 8-year longitudinal study of 9th or 10th graders at baseline (≈age 15) who experiment with smoking (<100 lifetime cigarettes; N = 594) at baseline. The young adult smoking frequency at the 8-year follow-up (≈age 23) was examined as a function of baseline characteristics (heritable trait, maternal smoking, PTE, and sex) and baseline smoking frequency and nicotine dependence. Structural equation models determined whether the inclusion of each heritable trait among offspring confounded the effects of maternal smoking (PTE or maternal smoking) on offspring smoking and nicotine dependence. RESULTS: Impulsiveness was associated with intermediate adolescent smoking frequency (B = 0.135, SD = 0.043, p = .002) and nicotine dependence (B = 0.012, SD = 0.003, p < .001). Unpleasurable first experience (B = 0.886, SD = 0.374, p = .018) and dizziness (B = 0.629, SD = 0.293, p = .032) showed a trend with intermediate smoking frequency that was nonsignificant after correcting for multiple comparisons. These traits did not confound maternal smoking's effects. CONCLUSIONS: None of the heritable traits examined in this model explained the effect of maternal smoking measures on adolescence or young adulthood offspring smoking. Further research is needed to elucidate the mechanism by which PTE and maternal smoking are linked to offspring smoking. IMPLICATIONS: Prenatal tobacco exposure (PTE) and mother's lifetime smoking present separate and independent risks for offspring smoking; however, their mechanisms seem unrelated to heritable personality traits and initial subjective smoking experiences. These findings have implications for separate screening strategies tailored to different age groups, especially related to PTE's risk of smoking in young adulthood. Additionally, these findings add to the known risks of maternal smoking. Further research is needed to understand the mechanism underlying the risk posed by maternal lifetime smoking and PTE on offspring smoking behavior.

Smoking is associated with a higher risk of unplanned medical visits among adult patients with diabetes, using retrospective electronic medical record data from 2014 to 2016.

BACKGROUND: Smoking exacerbates the complications of diabetes, but little is known about whether patients with diabetes who smoke have more unplanned medical visits than those who do not smoke. This study examines the association between smoking status and unplanned medical visits among patients with diabetes. METHODS: Data were drawn from electronic medical records (EMR's) from a large healthcare provider in the Northern Plains region of the US, from adult (≥18 years old) patients with type 1 or type 2 diabetes who received care at least once during 2014-16 (N = 62,149). The association between smoking status (current, former, or never smoker) and having ≥1 unplanned visit (comprised of emergency department visits, hospitalizations, hospital observations, and urgent care) was examined after adjusting for age, race/ethnicity, and body mass index (BMI). The top ten most common diagnoses for unplanned visits were examined by smoking status. RESULTS: Both current and former smoking were associated with an approximately 1.2-fold increase in the odds of having at least one unplanned medical visit in the 3-year period (OR = 1.22, 95% CI = 1.16-129; OR = 1.23, 95% CI = 1.19-1.28, respectively), relative to never-smokers. Most common diagnoses for all patients were pain-related. However, diagnoses related to musculoskeletal system and connective tissue disorders were more common among smokers. Smoking is associated with a higher rate of unplanned medical visits among patients with diabetes in this regional healthcare system. CONCLUSIONS: Results from this study reveal higher rates of unplanned visits among smokers and former smokers, as well as increased frequencies of unplanned medical visits among current smokers.

Acceptability of an eHealth Intervention to Prevent Alcohol-Exposed Pregnancy Among American Indian/Alaska Native Teens.

BACKGROUND: A tribally led Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) Program has successfully decreased the risk of alcohol-exposed pregnancies (AEPs) among adult American Indian/Alaska Native (AI/AN) women by either reducing risky drinking or increasing contraception use. However, a community needs assessment revealed a need to implement a similar intervention with AI/AN teens. The goal of the project was to develop and establish the acceptability of CHOICES for AI/AN teens. METHODS: Key informant interviews were conducted to review the existing OST CHOICES intervention. After modifications to the existing program, focus groups with AI/AN teens were conducted to ensure validity and to finalize the OST CHAT (CHOICES for American Indian Teens) intervention. RESULTS: Key informant (N = 15) participants suggested that a Web-based intervention may increase teen engagement by making the intervention more interactive and visually stimulating. Based on this formative research, CHAT was developed via Research Electronic Data Capture (REDCap). Feedback on the online CHAT curriculum was given by focus groups comprised of AI/AN adolescents, and participants felt that this type of intervention would be both acceptable and able to implement with a community of reservation-based teens. CONCLUSIONS: This study outlines the development of a Web-based intervention for an AEP intervention for AI/AN teens and will inform future prevention efforts. Implications include an expansion of the evidence-based CHOICES intervention for AI/AN teens and also development of a Web-based intervention for rural, reservation-based AI/AN communities.

Using Tribal Data Linkages to Improve the Quality of American Indian Cancer Data in Michigan.

This study examines the extent to which data linkages between Indian Health Service, tribal data, and cancer registries affect cancer incidence rates among American Indians/Alaska Natives (AI/ANs) in Michigan. The incidence of tobacco- and alcohol-associated cancers for 1995-2012 was analyzed to compare rates of the Upper Peninsula (UP) and Lower Peninsula (LP) in Michigan and among AI/ANs and non-Hispanic Whites (NHWs). Complete linkage resulted in 1,352 additional AI/AN cases; 141 cases were linked via IHS records alone, while 373 were linked via tribal records alone; 838 were linked through both IHS and tribal records. Age-adjusted incidence rates for AI/ANs increased from 214.39 per 100,000 to 405.41 per 100,000, similar to that of NHWs after complete linkage (421.46 per 100,000). In the UP, AI/ANs had age-adjusted incidence rates 1.67 times higher than NHWs (596.69 per 100,000 vs. 356.32 per 100,000 respectively). This study indicates a substantial number of AI/AN cancer cases remain misclassified in Michigan.

"But Problems Dwell so the Urge Is Constant " Qualitative Data Analysis of the OST CHOICES Program.

BACKGROUND: Fetal alcohol spectrum disorders are a major public health concern including among American Indian (AI)/Alaska Native (AN) communities. Various studies have demonstrated higher alcohol consumption among AI/AN women during pregnancy compared with other groups. This study intends to understand the milieu within which such consumption patterns flourish. The study utilizes qualitative and quantitative data from the Oglala Sioux Tribe (OST) CHOICES Program, a tribally run public health program that aims to reduce alcohol-exposed pregnancy preconceptually in AI women. METHODS: Alcohol consumption pattern (n = 264) is analyzed using descriptive statistics. Consumption patterns included average drinks consumed daily, their choice of drinks (beer, whiskey, wine, etc.), how much money participants were spending on alcohol and amount of calories consumed from alcohol. Qualitative data analysis included open coding of data from decisional balance exercise of the CHOICES program that looked at good things and not so good things about participants' drinking. RESULTS: Women reported drinking an average of 12 drinks daily, ranging between 1 and 86. Women drinking at home spent a median of $4,320 and $12,960 if drinking at a bar. A median of 1,200 calories per day from alcohol was reported. More women reported drinking beer compared with other types of alcohol within a domestic setting. Qualitative data analysis identified positive and negative aspects of drinking among the participants of OST CHOICES Program. Positive aspects included escaping from problems, socializing, and relaxation. Negative aspects included impact on families and domestic violence. CONCLUSIONS: While understanding their milieu, our study also unraveled different struggles (such as violence, peer pressure, financial burden, and depression) encountered by Native women in their daily lives. According to the participants, positive aspects of drinking outweigh the negative aspects and they viewed their drinking as a solution and not a problem.

Leaving the emergency department without complete care: disparities in American Indian children.

BACKGROUND: Children who leave the emergency department (ED) without complete evaluation or care (LWCET) have poorer outcomes in general. Previous studies have found that American Indian (AI) children have higher rates of LWCET than other racial or ethnic groups. Therefore, this study aims to examine LWCET in AI children by exploring differences by ED location and utilization patterns. METHODS: This is a retrospective cohort study of five EDs in the upper Midwest between June 2011 and May 2012. We included all visits by children aged 0-17 who identified as African American (AA), AI or White. Logistic regression was used to determine differences in LWCET by race and ED location controlling for other possible confounding factors including sex, age, insurance type, triage level, distance from ED, timing of visit, and ED activity level. RESULTS: LWCET occurred in 1.73% of 68,461 visits made by 47,228 children. The multivariate model revealed that AIs were more likely to LWCET compared to White children (Odds Ratio (OR) = 1.62, 95% Confidence Interval (CI) = 1.30-2.03). There was no significant difference in LWCET between AA and White children. Other factors significantly associated with LWCET included triage level, distance from the ED, timing of visit, and ED activity level. CONCLUSION: Our results show that AI children have higher rates of LWCET compared to White children; this association is different from other racial minority groups. There are likely complex factors affecting LWCET in AI children throughout the upper Midwest, which necessitates further exploration.

Community Perspectives on Emergency Department Use and Care for American Indian Children.

Emergency department (ED) utilization by American Indian (AI) children is among the highest in the nation. Numerous health disparities have been well documented in AI children, but limited information is available on parental experiences of care for AI children in the ED. Our objective was to understand parental attitudes towards ED care for AI children. Focus groups were held with AI parents/caregivers at five sites in the Upper Midwest. Traditional content analysis was used to identify themes. A total of 70 parents participated in ten focus groups. Three main themes were identified: healthcare environment, access to care, and interaction with providers. Healthcare environment issues included availability of specialists, wait times, and child-friendly areas. Transportation and financial considerations were major topics in access to care. Issues in interaction with providers included discrimination, stereotyping, and trust. This is one of the first studies to assess parent perspectives on ED use for AI children. Obtaining parental perspectives on ED experiences is critical to improve patient care and provide important information for ED providers.

Exploring the Uptake of Long-Acting Reversible Contraception in South Dakota Women and the Importance of Provider Education.

BACKGROUND: Long-acting reversible contraception (LARC) methods, including the intrauterine device (IUD) and the birth control implant, are the most effective form of prescribed birth control for pregnancy prevention. However, uptake of this highly effective form of birth control is slow. The purpose of this study was to explore use of the LARC methods in South Dakota women prescribed contraception and the importance of the provider in promoting this type of contraception. METHODS: This was a cross-sectional study of female patients who had been prescribed contraception at one of five locations in a South Dakota hospital system. Records were obtained through electronic health records for a six-month period. Descriptive analysis was performed using chi-square with counts and percentages. Logistic regression was used to determine differences in LARC prescriptions by patient age and provider title. RESULTS: A total of 2,174 individual patients were included in analysis. Of the 378 (17.4 percent) who were prescribed LARC methods, most (78.6 percent) were prescribed an IUD. Younger women (aged 11-19) were less likely to be prescribed LARCs compared to women aged 30-34. There were also significant differences in LARC prescriptions by provider type. Futhermore, we noted differences in LARC prescriptions for a provider who received a specific education and training on LARC from the American College of Obstetrics and Gynecology. CONCLUSIONS: There are many important factors to consider by the patient when choosing the most appropriate contraceptive method, including safety, effectiveness, accessibility, and affordability. Provider education may play an important role in promoting LARC methods.