Mixed-Methods Evaluation of the Washington State Practice Transformation Support Hub.

PURPOSE: Practice transformation initiatives have the potential to promote collaborations between public health, primary care, and behavioral health, but limited empirical evidence is available on how these programs affect participating clinical practices. OBJECTIVE: To report the findings from a mixed-methods program evaluation of the Washington Practice Transformation Support Hub (Hub), a publicly funded, multicomponent practice transformation initiative in Washington State. DESIGN: We used quantitative and qualitative methods to evaluate the impact of Hub activities on participating primary care and behavioral health practices. Pre- and posttest survey data were combined with administrative program data to understand the effect of program components. Qualitative interviews contextualized findings. SETTING: Urban and rural primary care and behavioral health practices in Washington State. PARTICIPANTS: One hundred seventy-five practices that were recruited to receive Hub coaching and facilitation from 8 coaches; of these, 13 practices and all coaches participated in key informant interviews. INTERVENTION: Practice coaching and facilitation supported by an online resource portal, from January 2017 through January 2019. MAIN OUTCOME MEASURES: Self-reported progress in specific activities in 3 practice-level domains: bidirectional integration of physical and behavioral health care (care integration); alignment with community-based services for whole-person care (clinical-community linkages); and value-based payment. RESULTS: Participation in Hub activities was associated with improvements in care integration and clinical-community linkages but not with progress toward value-based payment. Qualitative results indicated that practice progress was influenced by communication with practices, the culture of the practice, resource constraints (particularly in rural areas), and perceptions about sustainability. CONCLUSIONS: This statewide practice transformation initiative was successful in strengthening primary care and behavioral health integration and clinical-community linkages among participating practices but not value-based payment. Future practice transformation efforts may benefit from addressing barriers posed by communication, limited application of value-based payment, culture change, competing priorities, and resource limitations, particularly for rural communities.

Use cases for genetic epidemiology in malaria elimination.

BACKGROUND: While traditional epidemiological approaches have supported significant reductions in malaria incidence across many countries, higher resolution information about local and regional malaria epidemiology will be needed to efficiently target interventions for elimination. The application of genetic epidemiological methods for the analysis of parasite genetics has, thus far, primarily been confined to research settings. To illustrate how these technical methods can be used to advance programmatic and operational needs of National Malaria Control Programmes (NMCPs), and accelerate global progress to eradication, this manuscript presents seven use cases for which genetic epidemiology approaches to parasite genetic data are informative to the decision-making of NMCPs. METHODS: The use cases were developed through a highly iterative process that included an extensive review of the literature and global guidance documents, including the 2017 World Health Organization's Framework for Malaria Elimination, and collection of stakeholder input. Semi-structured interviews were conducted with programmatic and technical experts about the needs and opportunities for genetic epidemiology methods in malaria elimination. RESULTS: Seven use cases were developed: Detect resistance, Assess drug resistance gene flow, Assess transmission intensity, Identify foci, Determine connectivity of parasite populations, Identify imported cases, and Characterize local transmission chains. The method currently used to provide the information sought, population unit for implementation, the pre-conditions for using these approaches, and post-conditions intended as a product of the use case were identified for each use case. DISCUSSION: This framework of use cases will prioritize research and development of genetic epidemiology methods that best achieve the goals of NMCPs, and ultimately, inform the establishment of normative policy guidance for their uses. With significant engagement of stakeholders from malaria endemic countries and collaboration with local programme experts to ensure strategic implementation, genetic epidemiological approaches have tremendous potential to accelerate global malaria elimination efforts.

Risk factors for infections in international travelers: an analysis of travel-related notifiable communicable diseases.

BACKGROUND: We sought to describe travel-related illness among our residents and gain insight into targeting pre-travel health advice to prevent travel-related illness. METHODS: A supplemental travel questionnaire was developed and administered for cases with a legally notifiable communicable disease reported in 2011-2012, who spent at least part of their exposure period outside the United States. RESULTS: Among 451 cases meeting the eligibility criteria, 259 were interviewed. Forty four percent reported receiving pre-travel advice. Two-thirds adhered fully with risk behavior recommendations; 94% followed immunization recommendations partially or fully; and 84% adhered fully with malaria prophylaxis recommendations. The primary reasons for not obtaining pre-travel advice were being unaware of the need (47.5%), or believing they already knew what to do (34.5%). Adults (OR = 2.8, 95% CI = 1.4-5.5), males (OR = 1.8, 95% CI = 1.1-3.0), those born outside the United States (OR = 2.0, 95% CI = 1.1-3.7), and those with planning time under two weeks (OR = 4.8, 95% CI = 1.5-15.9) or travel duration less than 7 days (OR = 7.9, 95% CI = 3.0-20.9) were more likely to travel without seeking pre-travel advice. CONCLUSIONS: The majority of cases reported not receiving pre-travel advice. Understanding the predictors of failure to receive pre-travel advice may help target public health prevention efforts.

2009 pandemic influenza a vaccination of pregnant women--King County, Washington State, 2009-2010.

OBJECTIVES: Our objectives were to estimate 2009 pandemic influenza A (pH1N1) vaccination coverage among pregnant women and identify associated factors. METHODS: We distributed a multimodal survey to 5341 women who gave birth between November 1, 2009, and January 31, 2010, identified by hospitals in King County, Washington State, with maternity services (n = 11). RESULTS: Of 4205 respondents, 3233 (76.9%) reported that they had received pH1N1 vaccine during pregnancy or within 2 weeks after delivery. Women whose prenatal care provider recommended vaccine had a higher vaccination prevalence than women whose provider did not (81.5% vs 29.6%; adjusted prevalence ratio = 2.1; 95% confidence interval = 1.72, 2.58). Vaccination prevalence was lower among women who had received prenatal care from a midwife only compared with women who had received care from other providers (62.9% vs 78.8%; adjusted prevalence ratio = 0.89; 95% confidence interval = 0.83, 0.96). CONCLUSIONS: Among pregnant women in King County, pH1N1 vaccination coverage was high. To improve coverage during nonpandemic seasons, influenza vaccine should be recommended routinely by prenatal care providers and vaccination provided where prenatal care is received. Barriers to midwives providing vaccination recommendations to patients should be explored.

2009 pandemic influenza A vaccination of pregnant women: King County, Washington State, 2009-2010.

PURPOSE: The objectives were to estimate 2009 pandemic influenza A (pH1N1) vaccination coverage among pregnant women and identify associated factors. METHODS: A multimodal survey was distributed to 5341 women who gave birth between November 1, 2009, and January 31, 2010, identified by hospitals in King County, Washington State, with maternity services (n=11). RESULTS: Of 4205 respondents, 3233 (76.9%) reported that they had received pH1N1 vaccine during pregnancy or within 2 weeks after delivery. Women whose prenatal care provider recommended vaccine had a higher vaccination prevalence than women whose provider did not (81.5% vs 29.6%; adjusted prevalence ratio=2.1; 95% CI=1.72, 2.58). Vaccination prevalence was lower among women who had received prenatal care from a midwife only compared with women who had received care from other providers (62.9% vs 78.8%; adjusted prevalence ratio=0.89; 95% CI=0.83, 0.96). CONCLUSIONS: Among pregnant women in King County, pH1N1 vaccination coverage was high. To improve coverage during nonpandemic seasons, influenza vaccine should be recommended routinely by prenatal care providers and vaccination provided where prenatal care is received. Barriers to midwives providing vaccination recommendations to patients should be explored.

Shedding of pandemic (H1N1) 2009 virus among health care personnel, Seattle, Washington, USA.

The Centers for Disease Control and Prevention (CDC) recommends that health care personnel (HCP) infected with pandemic influenza (H1N1) 2009 virus not work until 24 hours after fever subsides without the use of antipyretics. During an influenza outbreak, we examined the association between viral shedding and fever among infected HCP. Participants recorded temperatures daily and provided nasal wash specimens for 2 weeks after symptom onset. Specimens were tested by using PCR and culture. When they met CDC criteria for returning to work, 12 of 16 HCP (75%) (95% confidence interval 48%-93%) had virus detected by PCR, and 9 (56%) (95% confidence interval 30%-80%) had virus detected by culture. Fever was not associated with shedding duration (p = 0.65). HCP might shed virus even when meeting CDC exclusion guidelines. Further research is needed to clarify the association between viral shedding, symptoms, and infectiousness.

Spring 2009 H1N1 influenza outbreak in King County, Washington.

BACKGROUND: In April 2009, King County, Washington, experienced a sustained outbreak of 2009 H1N1 influenza A. This report describes the epidemiology of that outbreak in King County, home to a diverse population of 1.9 million people. METHODS: The 2 primary sources of data are case investigations of reported laboratory-confirmed 2009 H1N1 influenza A and a population-based syndromic surveillance system that captures data from emergency departments (EDs). A syndromic category for influenza-like illness was defined based on chief complaint and diagnosis. RESULTS: ED visits for influenza-like illness peaked quickly in the first week of the outbreak and remained high for approximately 6 weeks, with school-age children accounting for the greater number of ED visits, followed by young adults. Children ages 0 to 4 years had the highest rate of hospitalization. Among reported cases, blacks, Asians, and Hispanics were more likely to be hospitalized. Predisposing factors associated with admission were immune compromise, chronic lung disease, chronic heart disease, pregnancy, diabetes, and asthma. Of people receiving antiviral treatment, 34% started their medication more than 2 calendar days after the onset of illness. Mean days between illness onset and antiviral treatment were greater for blacks, Hispanics, and foreign language speakers. CONCLUSIONS: The spring 2009 influenza A H1N1 outbreak disproportionately affected children, young adults, and racial and ethnic minorities. Opportunities exist to improve the timeliness of antiviral treatment. Potential barriers to care for racial and ethnic minorities should be proactively addressed to ensure prompt evaluation and treatment.

Health services utilization by low-income limited English proficient adults.

OBJECTIVES: We evaluated the health care utilization of limited English proficiency (LEP) compared to English proficient (EP) adults with the same health insurance (Medicaid managed care) and full access to professional medical interpreters. METHODS: Health care utilization over two years was compared for 567 LEP and 1162 EP adults. Multivariate analysis controlled for age, gender, months enrolled in Medicaid and morbidity. RESULTS: LEP compared to EP subjects were enrolled longer and more continuously in Medicaid, were 94% more likely to use primary care and 78% less likely to use the emergency department. Specialty visits and hospitalization did not differ. CONCLUSIONS: When language barriers are reduced and health insurance coverage is the same, LEP patients show ambulatory health care utilization associated with lower cost and more access to preventive care through establishing a primary care home.

Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion.

OBJECTIVE: To better understand the risk of fatal toxic shock caused by Clostridium sordellii in women who had a recent medical abortion with mifepristone and misoprostol. METHODS: We performed active and passive surveillance for cases of toxic shock associated with medical or spontaneous abortion. To identify the cause of toxic shock, immunohistochemical assays for multiple bacteria were performed on formalin-fixed surgical and autopsy tissues. We extracted DNA from tissues, performed Clostridium species-specific polymerase chain reaction assays, and sequenced amplified products for confirmation of Clostridium species. RESULTS: We report four patients with toxic shock associated with Clostridium species infection after medical or spontaneous abortion. Two women had fatal Clostridium perfringens infections after medically induced abortions: one with laminaria and misoprostol and one with the regimen of mifepristone and misoprostol. One woman had a nonfatal Clostridium sordellii infection after spontaneous abortion. Another woman had a fatal C sordellii infection after abortion with mifepristone and misoprostol. All four patients had a rapidly progressive illness with necrotizing endomyometritis. CONCLUSION: Toxic shock after abortion can be caused by C perfringens as well as C sordellii, can be nonfatal, and can occur after spontaneous abortion and abortion induced by medical regimens other than mifepristone and misoprostol. LEVEL OF EVIDENCE: III.

Effectiveness of a parental educational intervention in reducing antibiotic use in children: a randomized controlled trial.

OBJECTIVE: To determine whether an educational intervention aimed at parents leads to fewer antibiotic prescriptions for their children. DESIGN: Placebo-controlled, randomized controlled trial. SETTING: Offices of primary care pediatricians who are members of a regional practice-based research network. PARTICIPANTS: Healthy children younger than 24 months old enrolled at the time of an office visit. INTERVENTIONS: Parents of study children were randomized to receive either a pamphlet and videotape (featuring one of their child's pediatricians) promoting the judicious use of antibiotics (intervention group) or brochures about injury prevention (control group). A total of 499 eligible children were enrolled, and data on outpatient visits during a 12-month observation period were collected. MAIN OUTCOME MEASURES: We compared the number of visits for upper respiratory tract infections (URIs), number of diagnoses and antibiotic prescriptions for otitis media and/or sinusitis and total number of antibiotics per patient among children in the intervention and control groups using Poisson regression analysis, adjusted for clustering into different practices. RESULTS: : Data on 4924 visits were reviewed; 28.8% of these visits were because of URI symptoms. The mean number of visits per study patient for URI symptoms was 2.8. Including all visits, the mean number of diagnoses of otitis media in study children was 2.1, mean number of diagnoses of otitis media and/or sinusitis was 2.3 and mean number of antibiotic prescriptions was 2.4; there were no significant differences between children in the intervention and control groups for any of these outcomes. Overall physicians prescribed 1 or more antibiotics during 45.9% of visits for a chief complaint of URI symptoms; 92% of antibiotic usage in children presenting with URI symptoms was for a diagnosis of otitis media and/or sinusitis. CONCLUSIONS: An educational intervention aimed at parents did not result in a decrease in the number of antibiotic prescriptions in their children. The use of antibiotics among children with URI symptoms was common; other interventions promoting the judicious use of these medications are needed.

Effectiveness of an educational intervention in modifying parental attitudes about antibiotic usage in children.

OBJECTIVE: To determine the effectiveness of educational materials in improving the attitudes of parents of young children about the judicious use of antibiotics. METHODS: We conducted a randomized controlled trial by recruiting parents of children who were younger than 24 months and being seen for any reason in primary care pediatric offices. At the time of enrollment, study parents indicated their level of agreement with 16 statements, including 9 statements about antibiotic usage and 7 about injury prevention. After being randomized, parents received either a pamphlet and a videotape promoting the judicious use of antibiotics (intervention group) or brochures about effective injury prevention (control group). Six weeks after enrollment, each group received another copy of the pamphlet or brochures and a follow-up questionnaire with the identical 16 statements. Responses on both questionnaires were transformed to an ordinal scale for analysis. Scores on the follow-up questionnaire for each statement about antibiotic use and injury prevention in the 2 groups were compared using linear regression, after controlling for the score obtained for the statement at enrollment. RESULTS: We enrolled a total of 499 eligible parents in the study; 358 (72%) completed the follow-up questionnaires. At study entry, there were no significant differences between parents in the intervention and control groups regarding attitudes for 15 of the 16 statements assessed. However, 6 weeks after receiving the antibiotic educational materials, parents in the intervention group had significantly different attitude scores for 5 of the 9 statements about the antibiotic use. In each case, the scores reflected attitudes that would promote the judicious use of antibiotics. We found significant attitudinal change for statements about the use of antibiotics for specific conditions in children; there were no differences between the 2 groups for more general or theoretical statements about antibiotic use. CONCLUSIONS: A simple educational effort was successful in modifying parental attitudes about the judicious use of antibiotics. Information about specific childhood conditions may be more effective in changing attitudes than more general information about antibiotic usage.