Team-Based Approach to Successful Annual Wellness Visits.

OBJECTIVE: The purpose of this study was to implement a 2-phase approach to rapidly increase the number of annual wellness visits (AWVs) and build a sustainable model at 3 study units (Mayo Clinic in Rochester, Minnesota, and clinics in 2 regions of Mayo Clinic Health System), which collectively serve approximately 80 000 patients who qualify for an AWV annually. METHODS: In the rapid improvement phase, beginning in July 2022, goals at the facilities were reoriented to prioritize AWVs, educate staff on existing AWV resources, and create low-effort workflows so that AWVs could be incorporated into existing patient appointments. Staff at all 3 study units worked independently and iterated quickly. In the second phase, all study units collaborated to design and implement a best-practice solution while they leveraged the engagement and lessons learned from the first phase and invested in additional system elements and change management to codify long-term success. RESULTS: The number of AWVs completed monthly increased in each study unit. In the rapid improvement phase, the number of AWVs increased but then plateaued (or decreased at some study units). In April 2023, the final scheduled outreach automation and visit tools were implemented, and the number of AWVs was sustained or increased, while outreach and scheduling times were decreased. The number of completed AWVs increased from 1148 across all study units in the first 6 months of 2022 to 14 061 during the first 6 months of 2023. CONCLUSIONS: The lessons learned from this project can be applied to other health systems that want to provide more patients with AWVs while improving operational efficiency. The keys are to have a clear vision of a successful outcome, engage all stakeholders, and iterate quickly to find what works best for the organization.

For the rural curious: mixed methods evaluation of a rural pharmacy practice elective.

BACKGROUND: As of 2020, 20% of people residing in the United States of America (U.S.) lived in rural communities. Despite rural residents tending to be older, poorer, and having greater disease burden than their urban counterparts, the number of rural primary care providers continues to decline. Nearly 66% of U.S. Primary Care Health Professional Shortage Areas are designated as rural. Pharmacists can help address this shortage of rural primary care providers, often serving as providers of first-contact care; however, only 12% of U.S. pharmacists practice in rural communities. To help address this gap, in 2022 an elective Rural Pharmacy course was created at the University of Minnesota College of Pharmacy by a faculty member who has rural practice experience. METHODS: The course combines formal lectures, guest presentations by rural pharmacists and student interviews with additional rural pharmacists. For the 42 students enrolled in the course in 2022 and 2023, non-parametric statistics were used to compare the percentage of students who were raised in rural communities or who otherwise had extensive exposure to rural, and compare student interest ratings (1 to 7) about practicing/living rural at the beginning and end of the course. Students also wrote end-of-course reflection papers, commenting on the course and their interviews with rural pharmacists. RESULTS: Across both years, 45% of the enrolled students had previous experience in rural communities. The net change in Rural Interest scores among students completing both questionnaires was + 5 in 2022 and + 2 in 2023, both non-significant differences. The largest shifts in student interest were from "Not Sure" at the start of the course to "Interested" or "Not Interested" at the end of the course, and from "Interested" to "Very Interested." In their reflection papers nearly 60% of students reported being most impressed by their interviews with rural pharmacists. CONCLUSIONS: A course addressing the benefits and challenges of practicing pharmacy in rural communities was well-received by pharmacy students. Even students who have little interest in living in a rural community can benefit from being introduced to rural culture, enabling them to provide more culturally-responsive care for patients from rural communities.

Outbreak of Human Trichinellosis - Arizona, Minnesota, and South Dakota, 2022.

Trichinellosis is a parasitic zoonotic disease transmitted through the consumption of meat from animals infected with Trichinella spp. nematodes. In North America, human trichinellosis is rare and is most commonly acquired through consumption of wild game meat. In July 2022, a hospitalized patient with suspected trichinellosis was reported to the Minnesota Department of Health. One week before symptom onset, the patient and eight other persons shared a meal that included bear meat that had been frozen for 45 days before being grilled and served rare with vegetables that had been cooked with the meat. Investigation identified six trichinellosis cases, including two in persons who consumed only the vegetables. Motile Trichinella larvae were found in remaining bear meat that had been frozen for >15 weeks. Molecular testing identified larvae from the bear meat as Trichinella nativa, a freeze-resistant species. Persons who consume meat from wild game animals should be aware that that adequate cooking is the only reliable way to kill Trichinella parasites and that infected meat can cross-contaminate other foods.

Human papillomavirus and occupational exposure: The need for vaccine provision for healthcare providers.

To probe the understanding of healthcare providers regarding occupational exposure to human papillomavirus and their knowledge about human papillomavirus vaccination in relation to the American Society for Colposcopy and Cervical Pathology (ASCCP) recommendations. In this cross-sectional study, the healthcare providers at Mayo Clinic Arizona, Florida, and Minnesota were delivered an electronic survey. The survey was completed by 349 healthcare providers, with one respondent excluded for inconsistent entry. The mean age of respondents was 42.7 ± 10.9, and of those, 68% were female and 32% were male. Of the unvaccinated respondents, 43.3% were ≤ 45 y of age (eligible for vaccination), while those vaccinated formed 41% of the respondents. Healthcare providers are highly concerned about their cancer safety, as shown by their awareness of occupational human papillomavirus hazards and broad knowledge about vaccine efficacy. The use of personal protective equipment varied widely, including eyewear, double gloving, procedural face mask, N95 face mask, and/or nothing. Human papillomavirus and cancer risk was clearly perceived by healthcare providers. For professions, pairwise comparisons revealed that nurse practitioners, physician assistants, certified registered nurse anesthetists, and allied healthcare providers had lower scores than medical doctors. Despite the high level of understanding among healthcare providers of occupational human papillomavirus exposure, only a few of them knew of the recommendations of the ASCPP for vaccination of healthcare providers treating human papillomavirus-related diseases. In such cases, most of those surveyed embraced vaccination, which was considered 100% safe by medical doctors and allied health professionals.

Corticosteroid Injections and Risk of Fracture.

Importance: Corticosteroid injections (CSIs) are an important tool for pain relief in many musculoskeletal conditions, but the longitudinal effects of these treatments on bone health and fracture risk are unknown. Objective: To determine whether cumulative doses of corticosteroid injections are associated with higher risk of subsequent osteoporotic and nonosteoporotic fractures. Design, Setting, and Participants: This cohort study included adult patients receiving any CSI from May 1, 2018, through July 1, 2022. Eligible patients resided in Olmsted County, Minnesota, and were empaneled to receive primary care within the Mayo Clinic. Cox proportional hazards regression models were used to evaluate risk of fracture based on cumulative injected corticosteroid dose. Exposure: Receipt of any CSI during the study period. Main Outcomes and Measures: The primary outcome was risk of fracture by total triamcinolone equivalents received. Secondary outcomes consisted of risks of fracture based on triamcinolone equivalents received in subgroups of patients not at high risk for fracture and patients with osteoporosis. Results: A total of 7197 patients were included in the study (mean [SD] age, 64.4 [14.6] years; 4435 [61.6%] women; 183 [2.5%] Black and 6667 [92.6%] White), and 346 (4.8%) had a new fracture during the study period. Of these fractures, 149 (43.1%) were considered osteoporotic. In the adjusted Cox proportional hazards regression model, there was no association of higher fracture risk based on cumulative CSI dose (adjusted hazard ratio [HR], 1.04 [95% CI, 0.96-1.11]). There was also no associated higher risk of fracture in the non-high-risk (adjusted HR, 1.11 [95% CI, 0.98-1.26]) or osteoporosis (adjusted HR, 1.01 [95% CI, 0.90-1.11]) subgroups. Age, Charleson Comorbidity Index, and previous fracture were the only factors that were associated with higher fracture risk. Conclusions and Relevance: In this cohort study of cumulative injected corticosteroid dose and risk of subsequent fracture, no association was observed, including in patients with a preexisting diagnosis of osteoporosis. Treatment of painful conditions with CSI should not be withheld or delayed owing to concern about fracture risk.

"We Feel Alone and Not Listened To": Parents' Perspectives on Pediatric Serious Illness Care in Somali, Hmong, and Latin American Communities.

PURPOSE: The experience of ethnically diverse parents of children with serious illness in the US health care system has not been well studied. Listening to families from these communities about their experiences could identify modifiable barriers to quality pediatric serious illness care and facilitate the development of potential improvements. Our aim was to explore parents' perspectives of their children's health care for serious illness from Somali, Hmong, and Latin-American communities in Minnesota. METHODS: We conducted a qualitative study with focus groups and individual interviews using immersion-crystallization data analysis with a community-based participatory research approach. RESULTS: Twenty-six parents of children with serious illness participated (8 Somali, 10 Hmong, and 8 Latin-American). Parents desired 2-way trusting and respectful relationships with medical staff. Three themes supported this trust, based on parents' experiences with challenging and supportive health care: (1) Informed understanding allows parents to understand and be prepared for their child's medical care; (2) Compassionate interactions with staff allow parents to feel their children are cared for; (3) Respected parental advocacy allows parents to feel their wisdom is heard. Effective communication is 1 key to improving understanding, expressing compassion, and partnering with parents, including quality medical interpretation for low-English proficient parents. CONCLUSIONS: Parents of children with serious illness from Somali, Hmong, and Latin-American communities shared a desire for improved relationships with staff and improved health care processes. Processes that enhance communication, support, and connection, including individual and system-level interventions driven by community voices, hold the potential for reducing health disparities in pediatric serious illness.

Risk factors for Cryptosporidium contamination in Minnesota public supply wells.

In a recent monitoring study of Minnesota's public supply wells, Cryptosporidium was commonly detected with 40% of the wells having at least one detection. Risk factors for Cryptosporidium occurrence in drinking water supply wells, beyond surface water influence, remain poorly understood. To address this gap, physical and chemical factors were assessed as potential predictors of Cryptosporidium occurrence in 135 public supply wells in Minnesota. Univariable analysis, regression techniques, and classification trees were used to analyze the data. Many variables were identified as significant risk factors in univariable analysis and several remained significant throughout the succeeding analysis techniques. These factors fell into general categories of well use and construction, aquifer characteristics, and connectedness to the land surface, well capture zones, and land use therein, existence of potential contaminant sources within 200-feet of the well, and variability in the chemical and isotopic parameters measured during the study. These risk categories, and the specific variables and threshold values we have identified, can help guide future research on factors influencing Cryptosporidium contamination of wells and can be used by environmental health programs to develop risk-based sampling plans and design interventions that reduce associated health risks.

Influence of temporary emigration on wood turtle (Glyptemys insculpta) detectability, with implications for abundance estimation.

Reliable population estimates are important for making informed management decisions about wildlife species. Standardized survey protocols have been developed for monitoring population trends of the wood turtle (Glyptemys insculpta), a semi-aquatic freshwater turtle species of conservation concern throughout its distribution in east-central North America. The protocols use repeated active search surveys of defined areas, allowing for estimation of survey-specific detection probability (p) and site-specific abundance. These protocols assume population closure within the survey area during the survey period, which is unlikely to be met as wood turtles are a highly mobile species. Additionally, current protocols use a single-pass design that does not allow for separation of availability (pa) and detectability (pd). If there are systematic influences on pa or pd that are not accounted for in the survey design or data analysis, then resulting abundance estimates could be biased. The objectives of this study were to determine if pa is a random process and if pa and pd are influenced by demographic characteristics. We modified the wood turtle survey protocol used in the upper Midwest to include a double-pass design, allowing us to estimate pa and pd using a robust design capture-recapture model. The modified protocol was implemented at 14 wood turtle monitoring sites in Minnesota and Wisconsin between 2017 and 2022. Our results indicated that pa was non-random and that pd increased with turtle carapace length. Our study suggests that model assumptions for current wood turtle population models may be violated, likely resulting in an overestimation of abundance. We discuss possible protocol and modeling modifications that could result in more accurate wood turtle abundance estimates.

COVID-19 vaccine uptake among non-US-born populations in the United States, 2020-2022.

BACKGROUND: In the United States (US), COVID-19 vaccination rates among non-US-born individuals (i.e., refugees, immigrants, and migrants [RIM]) are variable. Understanding baseline COVID-19 vaccine coverage among these populations and determining if disparities exist is essential for quality improvement initiatives and public health interventions. METHODS: Baseline COVID-19 vaccination rates for both primary series and booster doses were calculated at four health systems located in Minnesota, Colorado, and Pennsylvania participating in the Minnesota Department of Health's Center of Excellence in Newcomer Health. Patients aged ≥5 years as of 1/1/22, seen for ≥1 primary care visit during 7/1/2019-6/30/22 were included. Descriptive statistics were calculated for three measures of COVID-19 vaccine coverage during 12/14/2020-6/30/2022: 1) initiation of primary series; 2) completion of primary series; 3) completion of first booster. We calculated vaccine coverage rates for the entire population and stratified by subgroup including country of origin, refugee status, and primary language preference. RESULTS: We included 1,624,573 patients eligible for COVID-19 primary series vaccine and 907,749 eligible for COVID-19 booster vaccination. The percent of eligible patients who completed a COVID-19 primary series (63.4 %) and booster dose (66.2 %) were similar. Completion of the primary series was higher for non-US-born persons (72.7 %) compared with US born persons (65.4 %), similar among refugees (63.5 %) and non-refugees (63.4 %), and lower in patients with language preference other than English (62.7 %) compared with English preferring patients (63.6 %). Booster completion was lower for non-US-born persons (61.8 %), refugees (46.7 %), and patients with language preference other than English (55.3 %) compared with US-born (70 %), non-refugees (66.3 %), and English preferring patients (67.3 %) respectively. CONCLUSIONS: This evaluation identified disparities in COVID-19 vaccination rates among non-US-born persons and persons with a language preference other than English living in the US. Targeted outreach efforts may be beneficial in reaching these populations.

Development and Evaluation of Surveillance System for Identifying Jail-Associated COVID-19 Cases in Minnesota, USA, 2022.

Confinement facilities are high-risk settings for the spread of infectious disease, necessitating timely surveillance to inform public health action. To identify jail-associated COVID-19 cases from electronic laboratory reports maintained in the Minnesota Electronic Disease Surveillance System (MEDSS), Minnesota, USA, the Minnesota Department of Health developed a surveillance system that used keyword and address matching (KAM). The KAM system used a SAS program (SAS Institute Inc., https://www.sas.com) and an automated program within MEDSS to identify confinement keywords and addresses. To evaluate KAM, we matched jail booking data from the Minnesota Statewide Supervision System by full name and birthdate to the MEDSS records of adults with COVID-19 for 2022. The KAM system identified 2,212 cases in persons detained in jail; sensitivity was 92.40% and specificity was 99.95%. The success of KAM demonstrates its potential to be applied to other diseases and congregate-living settings for real-time surveillance without added reporting burden.

Surveillance for highly pathogenic avian influenza A (H5N1) in a raptor rehabilitation center-2022.

An ongoing, severe outbreak of highly pathogenic avian influenza virus (HPAI) A H5N1 clade 2.3.4.4b has been circulating in wild and domestic bird populations throughout the world, reaching North America in 2021. This HPAI outbreak has exhibited unique characteristics when compared to previous outbreaks. The global distribution of disease, prolonged duration, extensive number of species and individual wild birds affected, and the large impact on the global poultry industry have all exceeded historical impacts of previous outbreaks in North America. In this study, we describe the results of HPAI surveillance conducted at The Raptor Center, a wildlife rehabilitation hospital at University of Minnesota (Saint Paul, MN, U.S.A.), from March 28th-December 31, 2022. All wild raptors admitted to the facility were tested for avian influenza viruses using polymerase chain reaction (PCR) testing. All non-negative samples were submitted to the United States Department of Agriculture (USDA) Animal and Plant Health Inspection Service (APHIS) National Veterinary Services Laboratories for confirmatory HPAI testing and genetic sequencing. During the study period, 996 individual birds representing 20 different species were tested for avian influenza, and 213 birds were confirmed HPAI positive. Highly pathogenic avian influenza surveillance conducted at The Raptor Center contributed 75% of the HPAI positive raptor detections within the state of Minnesota, located within the Mississippi flyway, significantly augmenting state wildlife surveillance efforts. The viral genotypes observed in birds sampled at The Raptor Center were representative of what was seen in wild bird surveillance within the Mississippi flyway during the same time frame. Wildlife rehabilitation centers provide an opportune situation to augment disease surveillance at the human, wildlife and domestic animal interface during ongoing infectious disease outbreaks.

Predictors of willingness to receive updated 2023-2024 COVID-19 booster vaccines among a convenience sample in Minnesota.

OBJECTIVES: To determine factors associated with intention to receive recommended COVID-19 booster vaccines in 2023-2024. METHODS: A cross-sectional study of 1,256 individuals at Minnesota State and County fairs was conducted to assess their intention to receive a COVID-19 booster vaccine in the coming year if recommended. The association between booster intention and multiple factors believed to influence willingness to receive the vaccine, including perceived vaccine safety, perceived risk of COVID-19, public health knowledge, fear of future pandemics, and political affiliation, were analyzed using ordinal logistic regression and adjusted odds ratios (aOR). RESULTS: Intention to receive a COVID-19 booster vaccine was high among our participants with 56% reporting they were extremely likely to receive the vaccine this year and another 15% reporting that they were likely to do the same. A strong association with getting a booster vaccine was found between perceived vaccine safety (aOR: 15.3, 95% CI: 10.6-22.2), perceived COVID-19 risk (aOR: 3.5, 95% CI: 2.4-5.1), pandemic fear (aOR: 3.4, 95% CI: 2.4-4.8), public health knowledge (aOR: 1.3, 95% CI: 0.9-1.8), and democrat political affiliation (aOR: 2.8, 95%CI: 1.8-4.4). CONCLUSIONS: Our study emphasizes the importance of perceived vaccine safety as a predictor of intention to accept COVID-19 vaccines and highlights the continued need to effectively communicate with the public about the safety of vaccines.

Flipping the Classroom in Residency Didactics Leads to Higher American Board of Surgery in-Training Examination Scores.

OBJECTIVE: Didactic education in General Surgery (GS) residency typically follows a nationally standardized curriculum; however, instructional format varies by institution. In recent years, GS residents at our institution expressed discontentment with weekly didactics and were not meeting their goals on the American Board of Surgery In-Training Examination (ABSITE). We sought to develop improvements in our didactic curriculum to increase resident satisfaction and ABSITE scores of GS junior residents (Jrs). DESIGN: In a quality improvement project, we changed the weekly didactic curriculum format from hour-long lectures in the 2018 to 2019 academic year (AY) to a partially-flipped classroom in the 2019 to 2020 AY, involving a 30-minute faculty-led presentation followed by 30 minutes of resident-led practice questions. The outcomes measured were ABSITE scores taken in 2019 and 2020 and resident opinions via an anonymous survey. SETTING: This study was conducted at the University of Minnesota (Minneapolis, MN). PARTICIPANTS: The cohort for this study included all GS Jrs in our GS residency program, including postgraduate year (PGY) 1 nondesignated preliminary, PGY1 to 3 categorical GS residents, and residents in their lab time. Senior residents attended a separate didactics session. RESULTS: After curriculum changes, the ABSITE percentile scores for GS Jrs rose from 52% ± 5% to 66% ± 4% (p = 0.03). No categorical GS Jr scored <30% in 2020, compared to 20% (6/30) of categorical General Surgery residents in 2019. All residents preferred the new format overall and reported greater engagement in and preparation for didactics. CONCLUSIONS: After changing didactic education from hour-long lectures in the 2018 to 2019 AY to a flipped classroom model in the 2019 to 2020 AY including 30 minutes of faculty-led lecture followed by 30 minutes of resident-led practice questions, ABSITE scores and resident satisfaction at the University of Minnesota General Surgery Program improved.

Effect of a Multicomponent Food Pantry Intervention in Client Subgroups.

Nutrition promotion programs may have varying effects and influence health disparities. SuperShelf promotes healthy choices in food pantries through inventory changes and nudge implementation (e.g., choice architecture). This secondary analysis of the SuperShelf cluster-randomized trial assessed whether the effect of SuperShelf on client diet quality differed by equity characteristics. English-, Spanish-, or Somali-speaking adult clients from 11 food pantries in Minnesota were included (N = 193). We measured change in diet quality by the Healthy Eating Index 2015 (HEI-2015; maximum score 100) using up to two 24 h dietary recalls from pre-intervention and post-intervention periods. We used linear mixed-effects models to determine whether the effect of SuperShelf on diet quality varied by self-reported gender, race/ethnicity, education, and employment status. In separate adjusted models, the interactions of SuperShelf and gender, education, or employment status were not significant. The interaction of SuperShelf and race/ethnicity was significant (p-interaction = 0.008), but pairwise comparisons in diet quality were non-significant in all racial/ethnic subgroups. SuperShelf did not have differential effects on diet quality by gender, race/ethnicity, education, or employment status, suggesting it does not worsen dietary disparities among food pantry clients, though more subgroup analyses are needed to explore potential racial/ethnic disparities in this context.

Long-term outcomes with abandoning versus extracting sterile leads: A 10-year population-based study.

BACKGROUND: Long-term outcomes of sterile lead management strategies of lead abandonment (LA) or transvenous lead extraction (TLE) remain unclear. METHODS: We performed a retrospective study of a population residing in southeastern Minnesota with follow-up at the Mayo Clinic and its health systems. Patients who underwent LA or TLE of sterile leads from January 1, 2000, to January 1, 2011, and had follow-up for at least 10 years or until their death were included. RESULTS: A total of 172 patients were included in the study with 153 patients who underwent LA and 19 who underwent TLE for sterile leads. Indications for subsequent lead extraction arose in 9.1% (n = 14) of patients with initial LA and 5.3% (n = 1) in patients with initial TLE, after an average of 7 years. Moreover, 28.6% of patients in the LA cohort who required subsequent extraction did not proceed with the extraction, and among those who proceeded, 60% had clinical success and 40% had a clinical failure. Subsequent device upgrades or revisions were performed in 18.3% of patients in the LA group and 31.6% in the TLE group, with no significant differences in procedural challenges (5.2% vs. 5.3%). There was no difference in 10-year survival probability among the LA group and the TLE group (p = .64). CONCLUSION: An initial lead abandonment strategy was associated with more complicated subsequent extraction procedures compared to patients with an initial transvenous lead extraction strategy. However, there was no difference in 10-year survival probability between both lead management approaches.