Nursing turnover in a large, rural health system.

PURPOSE: Nursing turnover is a leading cause of inefficiency in health care delivery. Few studies have examined turnover among nurses who work in rural areas. METHODS: We accessed human resources data that tracked hiring and terminations from a large health system operating in South Dakota, North Dakota, and Minnesota between January 2016 and December 2017. Our study sample included 7,634 registered nurses, 1,765 of whom worked in a rural community. Within the health system, there were 27 affiliated hospitals, 17 of which were designated critical access hospitals. We estimated nursing turnover rates overall and stratified turnover rates by available demographic and occupational characteristics, including whether the nurse worked in a community with an affiliated acute care hospital or critical access hospital. FINDINGS: Overall, 19% of nurses left their position between January 2016 and December 2017. Turnover rates were associated with state, nurse gender and age, and occupational tenure, but were similar in urban and rural areas. Of note, turnover rates were significantly higher in communities without an affiliated acute care hospital or critical access hospital. CONCLUSION: Between 2016 and 2017, nearly 1 in 5 nurses working in this health system left their position. Turnover rates differed based on nurse demographics and selected occupational characteristics, including tenure. We also found higher turnover rates among nurses who worked in communities without an affiliated hospital, which points to a potential but unexplored benefit of hospitals in rural areas.

The IDeaS initiative: pilot study to assess the impact of rare diseases on patients and healthcare systems.

BACKGROUND: Rare diseases (RD) are a diverse collection of more than 7-10,000 different disorders, most of which affect a small number of people per disease. Because of their rarity and fragmentation of patients across thousands of different disorders, the medical needs of RD patients are not well recognized or quantified in healthcare systems (HCS). METHODOLOGY: We performed a pilot IDeaS study, where we attempted to quantify the number of RD patients and the direct medical costs of 14 representative RD within 4 different HCS databases and performed a preliminary analysis of the diagnostic journey for selected RD patients. RESULTS: The overall findings were notable for: (1) RD patients are difficult to quantify in HCS using ICD coding search criteria, which likely results in under-counting and under-estimation of their true impact to HCS; (2) per patient direct medical costs of RD are high, estimated to be around three-fivefold higher than age-matched controls; and (3) preliminary evidence shows that diagnostic journeys are likely prolonged in many patients, and may result in progressive, irreversible, and costly complications of their disease CONCLUSIONS: The results of this small pilot suggest that RD have high medical burdens to patients and HCS, and collectively represent a major impact to the public health. Machine-learning strategies applied to HCS databases and medical records using sentinel disease and patient characteristics may hold promise for faster and more accurate diagnosis for many RD patients and should be explored to help address the high unmet medical needs of RD patients.

Using Electronic Medical Records and Health Claim Data to Develop a Patient Engagement Score for Patients With Multiple Chronic Conditions: An Exploratory Study.

The study objective was to (1) develop a statistical model that creates a novel patient engagement score (PES) from electronic medical records (EMR) and health claim data, and (2) validate this developed score using health-related outcomes and charges of patients with multiple chronic conditions (MCCs). This study used 2014-16 EMR and health claim data of patients with MCCs from Sanford Health. Patient engagement score was created based on selected patients' engagement behaviors using Gaussian finite mixture model. The PES was validated using multiple logistic and linear regression analyses to examine the associations between the PES and health-related outcomes, and hospital charges, respectively. Patient engagement score was generated from 5095 patient records and included low, medium, and high levels of patient engagement. The PES was a significant predictor for low-density lipoprotein, emergency department visit, hemoglobin A1c, estimated glomerular filtration rate, hospitalization, and hospital charge. The PES derived from patient behaviors recorded in EMR and health claim data can potentially serve as a patient engagement measure. Further study is needed to refine and validate the newly developed score.

Recommendations for strengthening the role of embedded researchers to accelerate implementation in health systems: Findings from a state-of-the-art (SOTA) conference workgroup.

BACKGROUND: Traditional research approaches do not promote timely implementation of evidence-based innovations (EBIs) to benefit patients. Embedding research within health systems can accelerate EBI implementation by blending rigorous methods with practical considerations in real-world settings. A state-of-the-art (SOTA) conference was convened in February 2019 with five workgroups that addressed five facets of embedded research and its potential to impact healthcare. This article reports on results from the workgroup focused on how embedded research programs can be implemented into heath systems for greatest impact. METHODS: Based on a pre-conference survey, participants indicating interest in accelerating implementation were invited to participate in the SOTA workgroup. Workgroup participants (N = 26) developed recommendations using consensus-building methods. Ideas were grouped by thematic clusters and voted on to identify top recommendations. A summary was presented to the full SOTA membership. Following the conference, the workgroup facilitators (LJD, CDH, NR) summarized workgroup findings, member-checked with workgroup members, and were used to develop recommendations. RESULTS: The workgroup developed 12 recommendations to optimize impact of embedded researchers within health systems. The group highlighted the tension between "ROI vs. R01" goals-where health systems focus on achieving return on their investments (ROI) while embedded researchers focus on obtaining research funding (R01). Recommendations are targeted to three key stakeholder groups: researchers, funders, and health systems. Consensus for an ideal foundation to support optimal embedded research is one that (1) maximizes learning; (2) aligns goals across all 3 stakeholders; and (3) implements EBIs in a consistent and timely fashion. CONCLUSIONS: Four cases illustrate a variety of ways that embedded research can be structured and conducted within systems, by demonstrating key embedded research values to enable collaborations with academic affiliates to generate actionable knowledge and meaningfully accelerate implementation of EBIs to benefit patients. IMPLICATIONS: Embedded research approaches have potential for transforming health systems and impacting patient health. Accelerating embedded research should be a focused priority for funding agencies to maximize a collective return on investment.

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.

Rasch calibration of the 25-item Connor-Davidson Resilience Scale.

Rasch modeling was used to examine the 25-item Connor-Davidson Resilience Scale within adults (n = 410) in a weight management program. Rasch analysis assessed model-data fit, item difficulty and person's resilience level, an item-person map to evaluate relative distribution items and persons, and rating scale function. Four misfit items were identified and removed. Item difficulty ranged from 1.25 to 1.19 logits (higher logit values indicate more difficult items). Persons' resilience level had wide distribution (resilience = 2.27 ± 1.56 logits). Item difficulty levels did not adequately assess higher resilience levels. An improved inventory that measures a wider range of resilient behaviors would improve measurement quality.

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.

Cultivating Native American scientists: an application of an Indigenous model to an undergraduate research experience.

With growing evidence demonstrating the impact of undergraduate research experiences on educational persistence, efforts are currently being made to expand these opportunities within universities and research institutions throughout the United States. Recruiting underrepresented students into these programs has become an increasingly popular method of promoting diversity in science. Given the low matriculation into postsecondary education and completion rates among Native Americans, there is a great need for Native American undergraduate research internships. Although research has shown that Western education models tend to be less effective with Native populations, the implementation of indigenous epistemologies and pedagogies within higher education, including research experiences, is rare. This study explores the applicability of a cognitive apprenticeship merged with an indigenous approach, the Circle of Courage, to build a scientific learning environment and enhance the academic and professional development of Native students engaged in an undergraduate research experience in the health sciences. Data were drawn from focus groups with 20 students who participated in this program in 2012-2014. Questions explored the extent to which relational bonds between students and mentors were cultivated as well as the impact of this experience on the development of research skills, intellectual growth, academic and professional self-determination, and the attachment of meaning to their research experiences. Data were analyzed via deductive content analysis, allowing for an assessment of how the theoretical constructs inherent to this model (belonging, mastery, independence, and generosity) impacted students. Findings suggest that engaging Native students in research experiences that prioritize the needs of belonging, mastery, independence, and generosity can be a successful means of fostering a positive learning environment, in which students felt like significant members of a research team, developed a greater understanding and appreciation for the role of science in education and its various applications to socially relevant health issues, made more informed decisions about a career in research and the health sciences, and worked toward improving the health and well-being of others while also inspiring hope among their people back home. This study represents an extension of the application of the Circle of Courage to an undergraduate research experience and provides evidence of its ability to be used as a framework for cultivating Native scientists.

Genetic Counseling in Middle School Science Club: A Pilot Study.

Compared to demographic data from other healthcare professions, genetic counselors (GCs) are more likely to be Caucasian females. Many current underrepresented in genetic counseling (URGC) professionals in the field found genetic counseling later in their careers due in part to their lack of awareness. A pilot study consisting of equal numbers of male and female sixth grade science club students was conducted to explore the impact that direct teaching might have on students' awareness of and interest in genetic counseling. The analysis used the non-parametric Wilcoxon signed rank test due to the ordinal, Likert-scale data. Results derived from a pre- and post-survey of lesson participants indicated a statistically significant increase in students' perceptions of having a role model in a science career. Efforts to reach local middle school students to highlight genetic counseling as a potential career choice, especially by role models, may add to the continued work being done to increase the diversity of future genetic counseling applicant pools.

Cultural and Social Predictors of Substance Abuse Recovery among American Indian and Non-American Indian Pregnant and Parenting Women.

Substance abuse is especially undesirable among pregnant or parenting women (PPW). As such, there is a need to examine the factors impacting positive treatment outcomes, particularly among American Indian/Alaska Native (AI/AN) PPW, as they are seeking substance abuse treatment at rates considerably higher than the national average. This study aimed to identify the social and cultural mechanisms that support their recovery. Qualitative analyses were used to identify mechanisms used by AI and non-AI PPW in their recovery. Several differences between AI and non-AI PPW emerged. AI participants mentioned their families more often as the reason why they wanted to become or stay sober. In addition to familial support, AI participants relied on a variety of other sources for assistance in their recovery. Many of the women had difficulty defining specific aspects of their culture, especially in relation to their recovery. However, for AI PPW, many aspects of AI culture were identified as they described their recovery, suggesting the often subtle ways culture can impact everyday life. Our findings indicated that women utilized cultural supports in different ways; therefore, it is necessary to help them define their culture in ways that are meaningful in their recovery.

Examining the Prevalence and Impact of Peer Victimization and Social Support for Rural Youth.

INTRODUCTION: Peer victimization is a common experience in early adolescence often associated with psychosocial issues, following some youth into adulthood. Preliminary findings from a longitudinal study on peer victimization and protective factors were measured in rural elementary youth. Bullying is often seen as a schoolonly issue but research findings suggest the importance of systems outside the school setting as important protective factors for intervention. METHODS: Preliminary data were collected through online questionnaires focused on direct, relational, and electronic victimization. Protective factors, including parent and community support, were also measured. Participants include 307 children (52.8 percent female; 80.4 percent White; mean age = 10) attending the fourth and fifth grade at four rural, South Dakota public school districts. RESULTS: Overall, 91.2 percent of the sample reported at least one peer victimization experience during the first wave of data collection. Traditional victimization results include 57.7 percent citing direct and 89.5 percent relational. Electronic victimization was 25.3 percent. Participants reported high levels of community (94.8 percent) and parent (68.3 percent) support. Community support was significantly, negatively correlated with all types of victimization but parent support was only significant in relation to direct victimization. CONCLUSIONS: Findings provide an important baseline of the prevalence of direct, relational, and electronic victimization among rural young adolescents and the importance of community and parent support. Results demonstrate the need for a community wide approach including, health care providers, to take an active role to prevent and assist affected youth.

Peer Victimization in Rural Youth and Why it Matters.

Peer victimization is a major public health concern due to its psychological, emotional, and physical short and potentially long-term effects on children. Research conducted with rural youth have shown heightened peer victimization rates compared to urban and suburban locales. Protective factors, such as social support, are underresearched and less emphasized compared to risk factors, particularly in the context of rural youth. This article will review the literature surrounding the constructs of peer victimization in relation to risk and resiliency factors, with a specific focus on rural children.

A research experience for American Indian undergraduates: Utilizing an actor-partner interdependence model to examine the student-mentor dyad.

The majority of research examining Undergraduate Research Experiences focuses singularly on student-reported outcomes, often overlooking assessment of the mentor role in student learning and outcomes following these experiences. The goal of the current study was to examine the student-mentor dyad at the beginning and end of a 10-week summer research experience for American Indian undergraduates utilizing a series of actor-partner interdependence models within SEM. Participants included 26 undergraduate interns (50% American Indian; 50% American Indian and White; M age = 24) and 27 mentors (89% White; M age = 47). Findings indicated that in accounting for all potential paths between students and mentors, the partner path between mentor beliefs at the beginning of the program and students' skills related to autonomy (ß =.59, p = .01) and academic resilience (ß =.44, p = .03) at the end of the program were significant. These findings suggest the important impact of mentor beliefs on student outcomes, a relationship that should be adequately assessed and continue to be important focus of undergraduate research experiences. Findings further indicate the important role of mentors for American Indian undergraduates.

Applying the Theory of Reasoned Action to Understanding Teen Pregnancy with American Indian Communities.

Objectives American Indian girls have higher teen pregnancy rates than the national rate. Intervention studies that utilize the Theory of Reasoned Action have found that changing attitudes and subjective norms often leads to subsequent change in a variety of health behaviors in young adults. The current study goal is to better understand sexual decision-making among American Indian youth using the Theory of Reasoned Action model and to introduce ways to utilize attitudes and subjective norms to modify risky behaviors. Methods The project collected qualitative data at a reservation site and an urban site through 16 focus groups with American Indian young people aged 16-24. Results Attitudes towards, perceived impact of, and perception of how others felt about teen pregnancy vary between American Indian parents and non-parents. Particularly, young American Indian parents felt more negatively about teen pregnancy. Participants also perceived a larger impact on female than male teen parents. Conclusions There are differences between American Indian parents and non-parents regarding attitudes towards, the perceived impact of, and how they perceived others felt about teen pregnancy. Teen pregnancy prevention programs for American Indian youth should include youth parents in curriculum creation and curriculum that addresses normative beliefs about teen pregnancy and provides education on the ramifications of teen pregnancy to change attitudes.

Identifying sexual health protective factors among Northern Plains American Indian youth: An ecological approach utilizing multiple perspectives.

This study examined aspects of the sociocultural context in which American Indian (AI) teen pregnancy occurs, focusing specifically on protective factors for Northern Plains AI youth. Principles of community-based participatory research guided the qualitative data collection from 185 community members (focus groups with AI youth, youth parents, and elders; interviews with health care providers and school personnel) from a reservation and an urban community. Results indicated three protective systems impacted the sexual health and behaviors of AI youth: school, family, and enculturation. These findings provide a better understanding of how specific protective factors within these systems may buffer AI youth from involvement in risky sexual behaviors and work to inform culturally relevant prevention and intervention efforts.

Midwest Science Festival: Exploring Students' and Parents' Participation in and Attitudes Toward Science.

INTRODUCTION: Compared to national numbers, South Dakota has a higher proportion of students interested in science, technology, engineering, and mathematics (STEM) fields. Interest in science can be influenced by exposure to science through formal and informal learning. Informal science activities (including exposures and participation) have been found to elicit higher levels of interest in science, likely impacting one's attitude towards science overall. The current study goal is to better understand the levels and relationships of attitude, exposure, and participation in science that were present among students and parents attending a free science festival. METHODS: The project collected survey data from 65 students and 79 parents attending a science festival ranging from age 6 to 65. RESULTS: Informal science participation is significantly related to science attitudes in students and informal science exposure is not. No relationship was found for parents between science attitudes and participation. CONCLUSIONS: Students who indicated high levels of informal science participation (i.e., reading science-themed books) were positively related to their attitudes regarding science. However, informal science exposures, such as attending the zoo or independently visiting a science lab, was not significantly associated with positive attitudes towards science.

Teen Pregnancy Prevention Program Recommendations from Urban and Reservation Northern Plains American Indian Community Members.

Despite declines over the past few decades, the United States has one of the highest rates of teen pregnancy compared to other industrialized nations. American Indian youth have experienced higher rates of teen pregnancy compared to the overall population for decades. Although it's known that community and cultural adaptation enhance program effectiveness, few teen pregnancy prevention programs have published on recommendations for adapting these programs to address the specific needs of Northern Plains American Indian youth. We employed a mixed-methods analysis of 24 focus groups and 20 interviews with a combined total of 185 urban and reservation-based American Indian youth and elders, local health care providers, and local school personnel to detail recommendations for the cultural adaptation, content, and implementation of a teen pregnancy prevention program specific to this population. Gender differences and urban /reservation site differences in the types of recommendations offered and the potential reasons for these differences are discussed.

Understanding gender roles in teen pregnancy prevention among American Indian youth.

OBJECTIVES: To examine the impact of gender norms on American Indian (AI) adolescents' sexual health behavior. METHODS: The project collected qualitative data at a reservation site and an urban site through 24 focus groups and 20 key informant interviews. RESULTS: The reasons that AI youth choose to abstain or engage in sexual intercourse and utilize contraception vary based on gender ideologies defined by the adolescent's environment. These include social expectations from family and peers, defined roles within relationships, and gender empowerment gaps. CONCLUSIONS: Gender ideology plays a large role in decisions about contraception and sexual activity for AI adolescents, and it is vital to include redefinitions of gender norms within AI teen pregnancy prevention program.