Employee Dietary Initiative Improved Chronic Symptoms.

With the awareness that the Standard American Diet is a critical contributor to chronic diseases, this initiative aimed to assess the effects of a 28-day dietary challenge health care improvement project on health system employee energy level, sleep quality, gastrointestinal function, ability to concentrate, and aches/pains, including the impact of adherence level, during a period of restricted intake of gluten, dairy, and sugar offered annually from 2021 to 2023. A total of 754 employees completed the pre-challenge survey; analyses included 354 employees who completed both pre-challenge and post-challenge surveys in at least 1 year of this project. Wilcoxon signed rank tests compared presurvey and postsurvey responses to self-reported energy level, sleep quality, gastrointestinal function, ability to concentrate, and aches/pains. Analysis of variance with Tukey's honestly significant difference tests compared self-reported adherence level with change scores, with η2 representing effect size. In each challenge year, the mean rank levels of energy, sleep quality, gastrointestinal function, concentration, and aches/pains improved significantly between pre-surveys and post-surveys (all P<.001). Although an association between significant positive change and diet adherence level was found for all items in at least 1 challenge year, those who mostly or completely adhered to the challenge diet restrictions reported significantly greater positive change in energy levels and gastrointestinal symptoms than those who did not or minimally adhered in all challenge years, with small to medium effect sizes. In conclusion, Essentia Health's employee challenge appeared to improve self-reported outcomes in 5 symptom domains, with energy levels and gastrointestinal symptoms correlating most favorably to adherence to the challenge. These findings have health and cost implications, which could be confirmed by formal research in employee and other populations.

Physician and Advanced Practice Clinician Burnout in Rural and Urban Settings.

INTRODUCTION: Recruiting rural-practicing clinicians is a high priority. In this study, we explored burnout and contributing work conditions among rural, urban, and family practice physicians and advanced practice clinicians (APCs) in an Upper Midwestern health care system. METHODS: The Mini Z burnout reduction measure was administered by anonymous electronic survey in March 2022. We conducted bivariate analyses of study variables, then assessed relationships of study variables to burnout with multivariate binary logistic regression. RESULTS: Of 1118 clinicians (63% response rate), 589 physicians and 496 APCs were included in this study (n = 1085). Most were female (56%), physicians (54%), and White (86%), while 21% were in family practice, 46% reported burnout, and 349 practiced rurally. Rural and urban clinician burnout rates were comparable (45% vs 47%). Part-time work protected against burnout for family practice and rural clinicians, but not urban clinicians. In multivariate models for rural clinicians, stress (OR: 8.53, 95% CI: 4.09 to 17.78, P < .001), lack of workload control (OR: 3.06, 95% CI: 1.47-6.36, P = .003), busy/chaotic environments (OR: 2.53, 95% CI: 1.29-4.99, P = .007), and intent to leave (OR: 2.18, 95% CI: 1.06-4.45, P = .033) increased burnout odds. In family practice clinicians, stress (OR: 13.43 95% CI: 4.90-36.79, P < .001) also significantly increased burnout odds. CONCLUSIONS: Burnout was comparable between rural and urban physicians and APCs. Part-time work was associated with decreased burnout in rural and family practice clinicians. Addressing burnout drivers (stress, workload control, chaos) may improve rural work environments, reduce turnover, and aid rural clinician recruitment. Addressing stress may be particularly impactful in family practice.

Racial Differences in Psychiatric Symptoms, Maladaptive Eating, and Lifestyle Behaviors After Bariatric Surgery.

There are several psychological and behavioral factors associated with poorer outcomes following bariatric surgery, yet it is unknown whether and how these factors may differ by race. In this cross-sectional study, individuals who underwent bariatric surgery from 2018 to 2021 and up to 4 years post-surgery were invited to complete an online survey. Psychiatric symptoms, maladaptive eating patterns, self-monitoring behaviors, and exercise frequency were examined. Participants (N = 733) were 87% women, 63% White, with a mean age of 44 years. Analyses of covariance demonstrated that White individuals endorsed greater anxiety symptoms (p =.01) and emotional eating due to depression (p = .01), whereas Black individuals endorsed greater depression severity (p = .02). Logistic regression analyses demonstrated that White individuals were more likely to experience loss of control eating (OR= 1.7, p = .002), grazing (OR= 2.53, p <.001), and regular self-weighing (OR= 1.41, p <.001) than Black individuals, and were less likely to skip meals (OR= .61, p = .04), or partake in nighttime eating (OR= .40, p <.001). There were no racial differences in binge eating, emotional eating due to anxiety or frustration, use of a food diary, or exercise. Thus, depressive symptoms, skipping meals, and nighttime eating may be important, modifiable intervention targets to optimize the benefits of bariatric surgery and promote equitable outcomes.

Suicide attempts after bariatric surgery: comparison to a nonsurgical cohort of individuals with severe obesity.

BACKGROUND: The rate of suicide is higher among individuals following bariatric surgery compared with the general population; however, it is not clear whether risk is associated with bariatric surgery beyond having severe obesity. OBJECTIVE: To compare the risk of a suicide attempt among those who had bariatric surgery versus a nonsurgical cohort with severe obesity. SETTING: Aggregate count data were collected from 5 healthcare systems. METHODS: Individuals were identified in the surgical cohort if they underwent bariatric surgery between 2009 and 2017 (n = 35,522) and then were compared with a cohort of individuals with severe obesity who never had bariatric surgery (n = 691,752). Suicide attempts were identified after study enrollment date using International Classification of Diseases, Ninth and Tenth Editions (ICD-9 and ICD-10) diagnosis codes from 2009 to 2021. RESULTS: The relative risk of a suicide attempt was 64% higher in the cohort with bariatric surgery than that of the nonsurgical cohort (2.2% versus 1.3%; relative risk = 1.64; 95% CI, 1.53-1.76). Within the cohort with bariatric surgery, suicide attempts were more common among the 18- to 39-year age group (P < .001), women (P = .002), Hawaiian-Pacific Islanders (P < .001), those with Medicaid insurance (P < .001), and those with a documented mental health condition at baseline (in the previous 2 years; P < .001). CONCLUSIONS: The relative risk of suicide attempts was higher among those who underwent bariatric surgery compared with a nonsurgical cohort, though absolute risk remained low. Providers should be aware of this increased risk. Screening for suicide risk after bariatric surgery may be useful to identify high-risk individuals.

Assessing the differential item functioning of PHQ-9 items for diverse racial and ethnic adults with mental health and/or substance use disorder diagnoses: A retrospective cohort study.

BACKGROUND: Improving health equity in depression care and suicide screening requires that measures like the Patient Health Questionnaire 9 (PHQ-9) function similarly for diverse racial and ethnic groups. We evaluated PHQ-9 differential item functioning (DIF) between racial/ethnic groups in a retrospective cohort study of secondary electronic health record (EHR) data from eight healthcare systems. METHODS: The population (n = 755,156) included patients aged 18-64 with mental health and/or substance use disorder (SUD) diagnoses who had a PHQ-9 with no missing item data in the EHR for primary care or mental health visits between 1/1/2009-9/30/2017. We drew two random samples of 1000 from the following racial/ethnic groups originally recorded in EHRs (n = 14,000): Hispanic, and non-Hispanic White, Black, Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, multiracial. We assessed DIF using iterative hybrid ordinal logistic regression and item response theory with p < 0.01 and 1000 Monte Carlo simulations, where change in model R2 > 0.01 represented non-negligible (e.g., clinically meaningful) DIF. RESULTS: All PHQ-9 items displayed statistically significant, but negligible (e.g., clinically unmeaningful) DIF between compared groups. The negligible DIF varied between random samples, although six items showed negligible DIF between the same comparison groups in both random samples. LIMITATIONS: Our findings may not generalize to disaggregated racial/ethnic groups or persons without mental health and/or SUD diagnoses. CONCLUSIONS: We found the PHQ-9 had clinically unmeaningful cross-cultural DIF for adult patients with mental health and/or SUD diagnoses. Future research could disaggregate race/ethnicity to discern if within-group identification impacts PHQ-9 DIF.

Diagnosed Posttraumatic Stress Disorder and Other Trauma-Associated Stress Disorders and Risk for Suicide Mortality.

OBJECTIVE: Strong evidence exists for posttraumatic stress disorder (PTSD) as a risk factor for suicidal thoughts and behaviors across diverse populations. However, few empirical studies have examined PTSD and other trauma-associated stress disorders as risk factors for suicide mortality among health system populations. This study aimed to assess trauma-associated stress diagnoses as risk factors for suicide mortality in a U.S. health system population. METHODS: This case-control, matched-design study examined individuals who died by suicide between 2000 and 2015 and had received care from nine U.S. health systems affiliated with the Mental Health Research Network (N=3,330). Individuals who died by suicide were matched with individuals from the general health system population (N=333,000): 120 individuals with PTSD who died by suicide were matched with 1,592 control group members, 84 with acute reaction to stress were matched with 2,218 control individuals, and 331 with other stress reactions were matched with 8,174 control individuals. RESULTS: After analyses were adjusted for age and sex, individuals with any trauma-associated stress condition were more likely to have died by suicide. Risk was highest among individuals with PTSD (adjusted OR [AOR]=10.10, 95% CI=8.31-12.27), followed by those with other stress reactions (AOR=5.38, 95% CI=4.78-6.06) and those with acute reaction to stress (AOR=4.49, 95% CI=3.58-5.62). Patterns of risk remained the same when the analyses were adjusted for any comorbid psychiatric condition. CONCLUSIONS: All trauma-associated stress disorders are risk factors for suicide mortality, highlighting the importance of health system suicide prevention protocols that consider the full spectrum of traumatic stress diagnoses.

Alcohol use disorder in the intensive care unit a highly morbid condition, but chemical dependency discussion improves outcomes.

BACKGROUND: Alcohol use disorders (AUD) are common in patients admitted to intensive care units (ICU) and increase the risk for worse outcomes. In this study, we describe factors associated with patient mortality after ICU admission and the effect of chemical dependency (CD) counseling on outcomes in the year following ICU admission. METHODS: We retrospectively reviewed patient demographics, hospital data, and documentation of CD counseling by medical providers for all ICU patients with AUD admitted to our institution between January 2017 and March 2019. Primary outcomes were in-hospital and 1-year mortality. RESULTS: Of the 527 patients with AUD requiring ICU care, median age was 56 years (range, 18-86). Both in-hospital (12%) and 1-year mortality rates (27%) were high. Rural patients, comorbidities, older age, need for mechanical ventilation, and complications were associated with increased risk of in-hospital and 1-year mortality. CD counseling was documented for 73% of patients, and 50% of these patients accepted alcohol treatment or resources prior to discharge. CD evaluation and acceptance was associated with a significantly decreased rate of readmission for liver or alcohol-related issues (36% vs. 58%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.27-0.61) and 1-year mortality (7% vs. 19.5%; OR, 0.32; 95% CI, 0.16-0.64). CD evaluation alone, regardless of patient acceptance, was associated with a significantly decreased 1-year post-discharge mortality rate (12% vs. 23%; OR, 0.44; 95% CI, 0.25-0.77). CONCLUSIONS: ICU patients with AUD had high in-hospital and 1-year mortality. CD evaluation, regardless of patient acceptance, was associated with a significant decrease in 1-year mortality.

Clinician perceptions of a clinical decision support system to reduce cardiovascular risk among prediabetes patients in a predominantly rural healthcare system.

BACKGROUND: The early detection and management of uncontrolled cardiovascular risk factors among prediabetes patients can prevent cardiovascular disease (CVD). Prediabetes increases the risk of CVD, which is a leading cause of death in the United States. CVD clinical decision support (CDS) in primary care settings has the potential to reduce cardiovascular risk in patients with prediabetes while potentially saving clinicians time. The objective of this study is to understand primary care clinician (PCC) perceptions of a CDS system designed to reduce CVD risk in adults with prediabetes. METHODS: We administered pre-CDS implementation (6/30/2016 to 8/25/2016) (n = 183, 61% response rate) and post-CDS implementation (6/12/2019 to 8/7/2019) (n = 131, 44.5% response rate) independent cross-sectional electronic surveys to PCCs at 36 randomized primary care clinics participating in a federally funded study of a CVD risk reduction CDS tool. Surveys assessed PCC demographics, experiences in delivering prediabetes care, perceptions of CDS impact on shared decision making, perception of CDS impact on control of major CVD risk factors, and overall perceptions of the CDS tool when managing cardiovascular risk. RESULTS: We found few significant differences when comparing pre- and post-implementation responses across CDS intervention and usual care (UC) clinics. A majority of PCCs felt well-prepared to discuss CVD risk factor control with patients both pre- and post-implementation. About 73% of PCCs at CDS intervention clinics agreed that the CDS helped improve risk control, 68% reported the CDS added value to patient clinic visits, and 72% reported they would recommend use of this CDS system to colleagues. However, most PCCs disagreed that the CDS saves time talking about preventing diabetes or CVD, and most PCCs also did not find the clinical domains useful, nor did PCCs believe that the clinical domains were useful in getting patients to take action. Finally, only about 38% reported they were satisfied with the CDS. CONCLUSIONS: These results improve our understanding of CDS user experience and can be used to guide iterative improvement of the CDS. While most PCCs agreed the CDS improves CVD and diabetes risk factor control, they were generally not satisfied with the CDS. Moreover, only 40-50% agreed that specific suggestions on clinical domains helped patients to take action. In spite of this, an overwhelming majority reported they would recommend the CDS to colleagues, pointing for the need to improve upon the current CDS. TRIAL REGISTRATION: NCT02759055 03/05/2016.

Human Papillomavirus vaccination clinical decision support for young adults in an upper midwestern healthcare system: a clinic cluster-randomized control trial.

INTRODUCTION: Human papillomavirus (HPV) vaccination rates are low in young adults. Clinical decision support (CDS) in primary care may increase HPV vaccination. We tested the treatment effect of algorithm-driven, web-based, and electronic health record-linked CDS with or without shared decision-making tools (SDMT) on HPV vaccination rates compared to usual care (UC). METHODS: In a clinic cluster-randomized control trial conducted in a healthcare system serving a largely rural population, we randomized 34 primary care clinic clusters (with three clinics sharing clinicians randomized together) to: CDS; CDS+SDMT; UC. The sample included young adults aged 18-26 due for HPV vaccination with a study index visit from 08/01/2018-03/15/2019 in a study clinic. Generalized linear mixed models tested differences in HPV vaccination status 12 months after index visits by study arm. RESULTS: Among 10,253 patients, 6,876 (65.2%) were due for HPV vaccination, and 5,054 met study eligibility criteria. In adjusted analyses, the HPV vaccination series was completed by 12 months in 2.3% (95% CI: 1.6%-3.2%) of CDS, 1.6% (95% CI: 1.1%-2.3%) of CDS+SDMT, and 2.2% (95% CI: 1.6%-3.0%) of UC patients, and at least one HPV vaccine was received by 12 months in 13.1% (95% CI: 10.6%-16.1%) of CDS, 9.2% (95% CI: 7.3%-11.6%) of CDS+SDMT, and 11.2% (95% CI: 9.1%-13.7%) of UC patients. Differences were not significant between arms. Females, those with prior HPV vaccinations, and those seen at urban clinics had significantly higher odds of HPV vaccination in adjusted models. DISCUSSION: CDS may require optimization for young adults to significantly impact HPV vaccination. TRIAL REGISTRATION: clinicaltrials.gov NCT02986230, 12/6/2016.

Clinical Decision Support with or without Shared Decision Making to Improve Preventive Cancer Care: A Cluster-Randomized Trial.

BACKGROUND: Innovative interventions are needed to address gaps in preventive cancer care, especially in rural areas. This study evaluated the impact of clinical decision support (CDS) with and without shared decision making (SDM) on cancer-screening completion. METHODS: In this 3-arm, parallel-group, cluster-randomized trial conducted at a predominantly rural medical group, 34 primary care clinics were randomized to clinical decision support (CDS), CDS plus shared decision making (CDS+SDM), or usual care (UC). The CDS applied web-based clinical algorithms identifying patients overdue for United States Preventive Services Task Force-recommended preventive cancer care and presented evidence-based recommendations to patients and providers on printouts and on the electronic health record interface. Patients in the CDS+SDM clinic also received shared decision-making tools (SDMTs). The primary outcome was a composite indicator of the proportion of patients overdue for breast, cervical, or colorectal cancer screening at index who were up to date on these 1 y later. RESULTS: From August 1, 2018, to March 15, 2019, 69,405 patients aged 21 to 74 y had visits at study clinics and 25,198 were overdue for 1 or more cancer screening tests at an index visit. At 12-mo follow-up, 9,543 of these (37.9%) were up to date on the composite endpoint. The adjusted, model-derived percentage of patients up to date was 36.5% (95% confidence interval [CI]: 34.0-39.1) in the UC group, 38.1% (95% CI: 35.5-40.9) in the CDS group, and 34.4% (95% CI: 31.8-37.2) in the CDS+SDM group. For all comparisons, the screening rates were higher than UC in the CDS group and lower than UC in the CDS+SDM group, although these differences did not reach statistical significance. CONCLUSION: The CDS did not significantly increase cancer-screening rates. Exploratory analyses suggest a deeper understanding of how SDM and CDS interact to affect cancer prevention decisions is needed. Trial registration: ClinicalTrials.gov ID: NCT02986230, December 6, 2016.

Primary care clinicians' opinions before and after implementation of cancer screening and prevention clinical decision support in a clinic cluster-randomized control trial: a survey research study.

BACKGROUND: Electronic health record (EHR)-linked clinical decision support (CDS) may impact primary care clinicians' (PCCs') clinical care opinions. As part of a clinic cluster-randomized control trial (RCT) testing a cancer prevention and screening CDS system with patient and PCC printouts (with or without shared decision-making tools [SDMT]) for patients due for breast, cervical, colorectal, and lung cancer screening and/or human papillomavirus (HPV) vaccination compared to usual care (UC), we surveyed PCCs at study clinics pre- and post-CDS implementation. Our primary aim was to learn if PCCs' opinions changed over time within study arms. Secondary aims including examining whether PCCs' opinions in study arms differed both pre- and post-implementation, and gauging PCCs' opinions on the CDS in the two intervention arms. METHODS: This study was conducted within a healthcare system serving an upper Midwestern population. We administered pre-implementation (11/2/2017-1/24/2018) and post-implementation (2/2/2020-4/9/2020) cross-sectional electronic surveys to PCCs practicing within a RCT arm: UC; CDS; or CDS + SDMT. Bivariate analyses compared responses between study arms at both time periods and longitudinally within study arms. RESULTS: Pre-implementation (53%, n = 166) and post-implementation (57%, n = 172) response rates were similar. No significant differences in PCC responses were seen between study arms on cancer prevention and screening questions pre-implementation, with few significant differences found between study arms post-implementation. However, significantly fewer intervention arm clinic PCCs reported being very comfortable with discussing breast cancer screening options with patients compared to UC post-implementation, as well as compared to the same intervention arms pre-implementation. Other significant differences were noted within arms longitudinally. For intervention arms, these differences related to CDS areas like EHR alerts, risk calculators, and ordering screening. Most intervention arm PCCs noted the CDS provided overdue screening alerts to which they were unaware. Few PCCs reported using the CDS, but most would recommend it to colleagues, expressed high CDS satisfaction rates, and thought patients liked the CDS's information and utility. CONCLUSIONS: While appreciated by PCCs with high satisfaction rates, the CDS may lower PCCs' confidence regarding discussing patients' breast cancer screening options and may be used irregularly. Future research will evaluate the impact of the CDS on cancer prevention and screening rates. TRIAL REGISTRATION: clinicaltrials.gov , NCT02986230, December 6, 2016.

Implementing a Screening and Brief Intervention Protocol for Excessive Alcohol Use in a Trauma Center: A Healthcare Improvement Project.

OBJECTIVE: The aim of this healthcare improvement project was to evaluate healthcare provider use of screening and brief interventions (SBIs) for patients screening positive for alcohol at an upper Midwestern adult trauma center transitioning from Level II to Level I. METHOD: Trauma registry data for 2,112 adult patients with trauma who screened positive for alcohol were compared between three periods: pre-formal-SBI protocol (January 1, 2010, to November 29, 2011); first post-SBI protocol (February 6, 2012, to April 17, 2016) after protocol implementation, healthcare provider training, and documentation changes; and second post-SBI protocol (June 1, 2016, to June, 30, 2019) after additional training and process improvements. Data analysis included descriptive statistics and logistic regression for comparisons over time and between admitting services. RESULTS: For the trauma admitting service, SBI rates increased from 32% to 90% over time, compared with 18%-51% for other admitting services combined. Trauma-service-admitted patients screening positive for alcohol had higher odds of receiving a brief intervention than other admitting services in each period in adjusted models: pre-SBI (OR = 1.99, 95% CI [1.15, 3.43], p = .014), first post-SBI (OR = 2.89, 95% CI [2.04, 4.11], p < .001), and second post-SBI (OR = 11.40, 95% CI [6.27, 20.75], p < .001) protocol periods. Within trauma service admissions, first post-SBI protocol (OR = 2.15, 95% CI [1.64, 2.82], p < .001) and second post-SBI protocol (OR = 21.56, 95% CI [14.61, 31.81], p < .001) periods had higher rates and odds of receiving an SBI than the pre-SBI protocol period. CONCLUSION: The number of SBIs completed with alcohol-positive adult patients with trauma significantly increased over time through SBI protocol implementation, healthcare provider training, and process improvements, suggesting other admitting services with lower SBI rates could adopt similar approaches.

Patient Perceptions of Using Clinical Decision Support for Cancer Screening and Prevention: "I wouldn't have thought about getting screened without it."

PURPOSE: We sought to gain an understanding of cancer prevention and screening perspectives among patients exposed to a clinical decision support (CDS) tool because they were due or overdue for certain cancer screenings or prevention. METHODS: Semi-structured qualitative interviews were conducted with 37 adult patients due or overdue for cancer prevention services in 10 primary care clinics within the same health system. Data were thematically segmented and coded using qualitative content analysis. RESULTS: We identified three themes: 1) The CDS tool had more strengths than weaknesses, with areas for improvement; 2) Many facilitators and barriers to cancer prevention and screening exist; and 3) Discussions and decision-making varied by type of cancer prevention and screening. Almost all participants made positive comments regarding the CDS. Some participants learned new information, reporting the CDS helped them make a decision they otherwise would not have made. Participants who used the tool with their provider had higher self-reported rates of deciding to be screened than those who did not. CONCLUSIONS: Learning about patients' perceptions of a CDS tool may increase understanding of how patient-tailored CDS impacts cancer screening and prevention rates. Participants found a personalized CDS tool for cancer screening and prevention in primary care useful and a welcome addition to their visit. However, many providers were not using the tool with eligible patients.

Is it a matter of time? The effect of transfer time on femur fracture outcomes.

BACKGROUND: Trauma systems in rural areas often require longdistance transfers for definitive care. Delays in care, such as delayed femurfracture repair have been reported to be associated with poorer outcomes, butlittle is known about how transfer time affects time to repair or outcomesafter femur fractures. METHODS: We conducted a retrospective review of all trauma patients transferred to our level 1 rural trauma center between May 1, 2016-April 30, 2019. Patient demographics and outcomes were abstracted from chart and trauma registry review. All patients with femur fractures were identified. Transfer time was defined as the time from admission at the initial hospital to admission at the trauma center, and time to repair was defined as time from admission to the trauma center until operative start time. Our outcome variables were mortality, in-hospital complications, and hospital length of stay (LOS). RESULTS: Over the study period1,887 patients were transferred to our level 1 trauma center and 398 had afemur fracture. Compared to the entire transfer cohort, femur fracture patientswere older (71 versus 57 years), and more likely to be female (62% versus 43%). The majority (74%) of patients underwent fracture repair within 24hours. Delay in fracture fixation >24 hours wasassociated with increased length of stay (5 days versus 4 days; p<0.001), higher complication rates (23% versus 12%; p=0.01), and decreased dischargehome (19% vs. 32%, pp=0.02), but was not associated with mortality (6% versus5%; p=0.75). Transfer time and time at the initial hospital were not associatedwith mortality, complication rate, or time to femur fixation. DISCUSSION: Fixation delay greater than 24 hours associated with increased likelihood of in-hospital complications, longer length of stay, and decreased likelihood of dischargehome. Transfer time not related to patient outcomes or time to femur fixation. LEVEL OF EVIDENCE: Level III; therapeutic/care management.

Evaluating the Cross-Cultural Measurement Invariance of the PHQ-9 between American Indian/Alaska Native Adults and Diverse Racial and Ethnic Groups.

BACKGROUND: The Patient Health Questionnaire-9 (PHQ-9), a self-reported depression screening instrument for measurement-based care (MBC), may have cross-cultural measurement invariance (MI) with a regional group of American Indian/Alaska Native (AI/AN) and non-Hispanic White adults. However, to ensure health equity, research was needed on the cross-cultural MI of the PHQ-9 between other groups of AI/AN peoples and diverse populations. METHODS: We assessed the MI of the one-factor PHQ-9 model and five previously identified two-factor models between non-Hispanic AI/AN adults (ages 18-64) from healthcare systems A (n=1,759) and B (n=2,701) using secondary data and robust maximum likelihood estimation. We then tested either fully or partially invariant models for MI between either combined or separate AI/AN groups, respectively, and Hispanic (n=7,974), White (n=7,974), Asian (n=6,988), Black (n=6,213), and Native Hawaiian/Pacific Islander (n=1,370) adults from healthcare system B. All had mental health or substance use disorder diagnoses and were seen in behavioral health or primary care from 1/1/2009-9/30/2017. RESULTS: The one-factor PHQ-9 model was partially invariant, with two-factor models partially, or in one case fully, invariant between AI/AN groups. The one-factor model and three two-factor models were partially invariant between all seven groups, while a two-factor model was fully invariant and another partially invariant between a combined AI/AN group and other racial and ethnic groups. CONCLUSIONS: Achieving health equity in MBC requires ensuring the cross-cultural validity of measurement tools. Before comparing mean scores, PHQ-9 models should be assessed for individual racial and ethnic group fit for adults with mental health or substance use disorders.

The impact of personalized clinical decision support on primary care patients' views of cancer prevention and screening: a cross-sectional survey.

BACKGROUND: Few studies have assessed the impact of clinical decision support (CDS), with or without shared decision-making tools (SDMTs), on patients' perceptions of cancer screening or prevention in primary care settings. This cross-sectional survey was conducted to understand primary care patient's perceptions on cancer screening or prevention. METHODS: We mailed surveys (10/2018-1/2019) to 749 patients aged 18 to 75 years within 15 days after an index clinical encounter at 36 primary care clinics participating in a clinic-randomized control trial of a CDS system for cancer prevention. All patients were overdue for cancer screening or human papillomavirus vaccination. The survey compared respondents' answers by study arm: usual care; CDS; or CDS + SDMT. RESULTS: Of 387 respondents (52% response rate), 73% reported having enough time to discuss cancer prevention options with their primary care provider (PCP), 64% reported their PCP explained the benefits of the cancer screening choice very well, and 32% of obese patients reported discussing weight management, with two-thirds reporting selecting a weight management intervention. Usual care respondents were significantly more likely to decide on colorectal cancer screening than CDS respondents (p < 0.01), and on tobacco cessation than CDS + SDMT respondents (p = 0.02) and both CDS and CDS + SDMT respondents (p < 0.001). CONCLUSIONS: Most patients reported discussing cancer prevention needs with PCPs, with few significant differences between the three study arms in patient-reported cancer prevention care. Upcoming research will assess differences in screening and vaccination rates between study arms during the post-intervention follow-up period. TRIAL REGISTRATION: clinicaltrials.gov , NCT02986230 , December 6, 2016.

Evaluating our progress with trauma transfer imaging: repeat CT scans, incomplete imaging, and delayed definitive care.

PURPOSE: Many trauma patients present at non-trauma centers and require transfer. CT imaging obtained at the initial hospital (IH) may lead to delays in definitive trauma care, and previous studies have shown imaging is often repeated at the trauma center (TC). METHODS: A retrospective review was performed of all tier 1 trauma patients transferred to our TC between May 2018 and April 2019. Patients that did and did not undergo CT imaging at the IH were compared (n = 147). Of those with IH CT imaging (n = 68), we identified 4 imaging "inadequacies": (1) repeat CT scans: CT scan of the same body region performed at IH and at TC; (2) C-spine inadequacies: severely injured patients who underwent head CT without a C-spine CT; (3) incomplete chest-abdomen-pelvis (CAP): patients with partial CAP CT imaging at IH that underwent an additional portion of CAP imaging at TC; (4) CAP CT without IV contrast. RESULTS: IH time was significantly prolonged when CT imaging was obtained. Of those that had IH imaging, 13 patients (19%) required repeat CT, ten (15%) had a C-spine inadequacy, 11 (16%) had incomplete CAP, and 28 (41%) had one or more inadequacy. Patients with any inadequacy underwent more CT imaging. Most patients (76%) with imaging at the IH returned to the CT scan at the TC. CONCLUSION: In severely injured trauma patients transferred to our TC, we identified many continuing issues with IH CT imaging. The imaging inadequacies detailed above lead to delays in definitive care and subject patients to increased radiation.

Design and rationale of an intervention to improve cancer prevention using clinical decision support and shared decision making: A clinic-randomized trial.

BACKGROUND: Despite decades of research the gap in primary and secondary cancer prevention services in the U. S. remains unacceptably wide. Innovative interventions are needed to address this persistent challenge. Electronic health records linked with Web-based clinical decision support may close this gap, especially if delivered to both patients and their providers. OBJECTIVES: The Cancer Prevention Wizard (CPW) study is an implementation, clinic-randomized trial designed to achieve these aims: 1) assess impact of the Cancer Prevention Wizard-Clinical Decision Support (CPW-CDS) alone and CPW-CDS plus Shared Decision Making Tools (CPW + SDMTs) compared to usual care (UC) on tobacco cessation counseling and drugs, HPV vaccinations, and screening tests for breast, cervical, colorectal, or lung cancer; 2) assess cost of the CPW-CDS intervention; and 3) describe critical facilitators and barriers for CPW-CDS implementation, use, and clinical impact using a mixed-methods approach supported by the CFIR and RE-AIM frameworks. METHODS: 34 predominantly rural, primary care clinics were randomized to CPW-CDS, CPW + SMDTs, or UC. Between August 2018 and October 2020, primary care providers and their patients who met inclusion criteria in intervention clinics were exposed to the CPW-CDS with or without SDMTs. Study outcomes at 12 months post index visit include patients up to date on screening tests and HPV vaccinations, overall healthcare costs, and diagnostic codes and billing levels for cancer prevention services. CONCLUSIONS: We will test in rural primary care settings whether CPW-CDS with or without SDMTs can improve delivery of primary and secondary cancer prevention services. The trial and analyses are ongoing with results expected in 2021.

Pre-implementation adaptation of primary care cancer prevention clinical decision support in a predominantly rural healthcare system.

BACKGROUND: Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients' cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system's goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes. METHODS: In a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR. RESULTS: Based on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements. CONCLUSIONS: Pre-implementation changes to CDS may help meet healthcare systems' evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems. TRIAL REGISTRATION: NCT02986230.

Understanding Respiratory Rate Assessment by Emergency Nurses: A Health Care Improvement Project.

INTRODUCTION: Respiratory rate is the first sign of patient decline. Monitoring and recording respiratory rate are essential nursing competencies. However, health care system emergency nurses' ability to differentiate normal from abnormal respiratory rates was unknown. We conducted a health care improvement project to assess emergency nurses' accuracy in "spot" and "formal" assessments, understand assessment practices, and determine competency and training needs. METHODS: In an anonymous cross-sectional survey, 78 emergency nurses from 1 health care system viewed 3 "spot" and 3 "formal" mock patient videos and answered questions in REDCap (Vanderbilt University, Nashville, TN). Accuracy (abnormal/normal), systematic error (bias), and random error (imprecision) were assessed. Descriptive statistics, bivariate analyses, and qualitative content analysis of open-ended questions were reported. RESULTS: Most emergency nurses identified respiration as abnormal in spot and formal assessment videos. Accuracy was lowest for the video displaying 6 breaths per minute. Emergency nurses were more likely to identify abnormal breathing in all formal assessment videos (n = 59, 75.7%) than in all spot assessment videos (n = 41, 52.6%) (McNemar χ2 = 10.32, P = 0.001). Most emergency nurses reported a willingness to use formal assessments and thought that respiratory rate was a good indicator of a patient's condition. The barriers to accurate assessment included time limitations, prior training focusing on assessments lasting less than 30 seconds, and monitor and staff errors. DISCUSSION: Respiratory rate assessment may be best assessed formally, particularly for bradypnea, where formal checks may outperform spot checks. The results present areas for improving respiratory rate assessment training and clinical practice.