Understanding Falls Risk Screening Practices and Potential for Electronic Health Record Data-Driven Falls Risk Identification in Select West Virginia Primary Care Centers

Unintentional falls among older adults are a complex public health problem both nationally and in West Virginia. Nationally, nearly 40% of community-dwelling adults age 65 and older fall at least once a year, making unintentional falls the leading cause of both fatal and non-fatal injuries among this age group. This problem is especially relevant to West Virginia, which has a population ageing faster on average than the rest of the nation. Identifying falls risk in the primary care setting poses a serious challenge. Currently, the Timed Get-Up-and-Go test is the only recommended screening tool for determining risk. However, nationally this test is completed only 30-37% of the time. Use of electronic health record data as clinical decision support in identifying at-risk patients may help alleviate this problem. However, to date there have been no published studies on using electronic health record data as clinical decision support in the identification of this particular population. This presents opportunity to contribute to the fields of falls prevention and health informatics through novel use of electronic health record data. That stated, this research is designed to: 1) develop an understanding of current falls risk screening practices, facilitators, and barriers to screening in select West Virginia primary care centers; 2) assess the capture of falls risk data and the quality of those data to help facilitate identification of at-risk patients; and 3) build an internally validated model for using electronic health record data for identification of at-risk patients. Through focus group discussions with primary care partners, we find a significant lack of readiness to innovatively use routinely collected data for population health management for falls prevention. The topic of falls risk identification is a rarely discussed topic across these sites, with accompanying low rates of screening and ad-hoc documentation. The need for enhanced team-based care, policy, and procedure surrounding falls is evident. Using de-identified electronic health record data from a sample of West Virginia primary care centers, we find that it is both feasible and worthwhile to repurpose routinely collected data to identify older adult patients at-risk for falls. Among 3,933 patients 65 and older, only 133 patients (3.4%) have an indication in their medical records of falling. Searching the free text data was vital to finding even this low number of patients, as 33.8% were identified using free text searches. Given the focus group findings, underreporting of falls on the part of the patients and missed opportunities to learn of falls due to lack of information sharing across health care service sites are also contributing factors. Similarly, documentation of falls risk assessments were sparse with only 23 patients (0.6%) having documentation of a falls risk assessment in their medical records at some point in the past. As with falls, locating documentation of falls risk assessments was largely dependent on semi-structured and free text data. Current Procedural Terminology coding alone missed 26.1% of all falls risk assessments. Repurposing electronic health record data in a population health framework allows for concurrent examination of primary and secondary falls risk factors in a way which is sensitive to time constraints of the routine office visit, complementary to the movement toward Meaningful Use, while providing opportunity to bolster low screening rates

Physician burnout among West Virginia primary care providers

TITLE: Physician burnout among West Virginia primary care providers INTRODUCTION: Work related burnout is highly prevalent in US physicians and linked to adverse effects on patients, providers and organizations. This study measures burnout in West Virginia (WV) primary care providers, allowing for comparison of results to a similar, recent study of US physicians. METHODS: Anonymous survey through email that included Maslach Burnout Inventory, demographic, workload, and practice characteristics. Responses were analyzed using JMP Pro 13. Analysis used JMP Pro 13 for descriptive statistics, chi-square and regression modeling. RESULTS: Subjects = 110, female/male ratio 1.4, all primary care physicians (PCP), or advanced practice registered nurses or physician assistants (APRN/PA). PCP and APRN/PA differed on sex ratio (p /= 65 vs under 0.178 (p 0.032). Severe burnout in WV PCP was 57.6% and in all US physicians 43.9% (p 0.015). The OR for severe burnout in PCP versus APRN/PA was 2.89 (p 0.039). Burnout in PCP \u3e APRN in rural (p 0.046) but not urban. Private practice 17.6% in our population, 48% US physicians (p 0.0003). Burnout increased linearly with work hours (p 0.003). Self-estimate of burnout correlated with MBI results (p \u3c0.0001). DISCUSSION/CONCLUSION: Severe burnout was highly prevalent in this high risk specialty serving a patient population at risk in regards to poverty, age and medical complexity. This community had a low rate of private practice, fewer providers over age 65, a higher rate of burnout in physicians compared to APRN/PA, and a linear association of burnout to work hours. There was also validation of a single question burnout screening tool. High risk community systems could be a reservoir for burnout research and improvement there could reduce costs and improve outcomes

Synthesis and Structural Characterization of Iron(II) Complexes with Tris(imidazolyl)phosphane Ligands: A Platform for Modeling the 3-Histidine Facial Triad of Nonheme Iron Dioxygenases

Several monoiron(II) complexes containing tris(imidazolyl)phosphane (TIP) ligands have been prepared and structurally characterized by using X-ray crystallography and NMR spectroscopy. Two TIP ligands were employed: tris(2-phenylimidazol-4-yl)phosphane (4-TIPPh) and tris(4,5-diphenyl-1-methylimidazol-2-yl)phosphane (2-TIPPh2). These tridentate ligands resemble the 3-histidine (3His) facial triad found recently in the active sites of certain nonheme iron dioxygenases. Three of the reported complexes are designed to serve as convenient precursors to species that model the enzyme–substrate intermediates of 3His dioxygenases; thus, each contains an [Fe(κ3-TIP)]2+ unit in which the remaining coordination sites are occupied by easily displaced ligands, such as solvent molecules and/or carboxylate groups. The viability of these complexes as precursors was demonstrated through the synthesis of TIP-based complexes with β-diketonate and salicylate ligands that represent faithful models of β-diketone dioxygenase and salicylate 1,2-dioxygenase, respectively

Fe(II) Complexes That Mimic the Active Site Structure of Acetylacetone Dioxygenase: O\u3csub\u3e2\u3c/sub\u3e and NO Reactivity

Acetylacetone dioxygenase (Dke1) is a bacterial enzyme that catalyzes the dioxygen-dependent degradation of β-dicarbonyl compounds. The Dke1 active site contains a nonheme monoiron(II) center facially ligated by three histidine residues (the 3His triad); coordination of the substrate in a bidentate manner provides a five-coordinate site for O2 binding. Recently, we published the synthesis and characterization of a series of ferrous β-diketonato complexes that faithfully mimic the enzyme–substrate intermediate of Dke1 (Park, H.; Baus, J.S.; Lindeman, S.V.; Fiedler, A.T. Inorg. Chem.2011, 50, 11978–11989). The 3His triad was modeled with three different facially coordinating N3 supporting ligands, and substituted β-diketonates (acacX) with varying steric and electronic properties were employed. Here, we describe the reactivity of our Dke1 models toward O2 and its surrogate nitric oxide (NO), and report the synthesis of three new Fe(II) complexes featuring the anions of dialkyl malonates. Exposure of [Fe(Me2Tp)(acacX)] complexes (where R2Tp = hydrotris(pyrazol-1-yl)borate with R-groups at the 3- and 5-positions of the pyrazole rings) to O2 at −70 °C in toluene results in irreversible formation of green chromophores (λmax ∼750 nm) that decay at temperatures above −60 °C. Spectroscopic and computational analyses suggest that these intermediates contain a diiron(III) unit bridged by a trans μ-1,2-peroxo ligand. The green chromophore is not observed with analogous complexes featuring Ph2Tp and PhTIP ligands (where PhTIP = tris(2-phenylimidazoly-4-yl)phosphine), since the steric bulk of the phenyl substituents prevents formation of dinuclear species. While these complexes are largely inert toward O2, Ph2Tp-based complexes with dialkyl malonate anions exhibit dioxygenase activity and thus serve as functional Dke1 models. The Fe/acacX complexes all react readily with NO to yield high-spin (S = 3/2) {FeNO}7 adducts that were characterized with crystallographic, spectroscopic, and computational methods. Collectively, the results presented here enhance our understanding of the chemical factors involved in the oxidation of aliphatic substrates by nonheme iron dioxygenases

Applying a research ethics review processes in rural practice-based research

Introduction: Partnering with rural primary care in practice-based research allows researchers access to a vital segment of the health care sector and a window into some of the most vulnerable, high-risk, high-need patient populations. The readiness for rural primary care to fully embrace research partnerships, however, is often tempered by ethical questions in conducting research in close-knit settings. This research provides practices with a refined decision support tool for evaluating the fit of research opportunities for their unique practices. Materials and Methods: A two-phase effort was conducted to glean insight from currently available literature on ethical considerations in practice-based research and augment this information by consulting with state-based subject matter experts. Qualitative data were gathered through semi-structured interviews with key stakeholders at each of the West Virginia medical schools. Results: The literature clearly acknowledges the need to ensure ethical standards in practice-based research – from the standpoints of the clinician and the researcher. The need to ensure comprehensive, culturally appropriate institutional review board approval is essential in developing and safeguarding participants. From discussions with subject matter experts, we find complementary guidance. However, tempering this sentiment is an overall caution of the unique role of rural primary care in representing and protecting the needs of the community. Five fundamental cautions regarding the conduct of practice-based research in rural settings are here identified, spanning the protection of individual patients, their communities, and clinicians. Discussion: Findings from this study can support and empower primary care clinicians and practices, especially those in rural and close-knit communities, to address essential considerations in practice-based research. Results allow for framing of a refined decision support tool for primary care practices and clinicians to use in evaluating the fit of research opportunities for their unique practices, instilling a sense of shared power in the research process by better equipping primary care to proactively engage in substantive dialogue with research partners

Applying a research ethics review processes in rural practice-based research

Introduction: Partnering with rural primary care in practice-based research allows researchers access to a vital segment of the health care sector and a window into some of the most vulnerable, high-risk, high-need patient populations. The readiness for rural primary care to fully embrace research partnerships, however, is often tempered by ethical questions in conducting research in close-knit settings. This research provides practices with a refined decision support tool for evaluating the fit of research opportunities for their unique practices. Materials and Methods: A two-phase effort was conducted to glean insight from currently available literature on ethical considerations in practice-based research and augment this information by consulting with state-based subject matter experts. Qualitative data were gathered through semi-structured interviews with key stakeholders at each of the West Virginia medical schools. Results: The literature clearly acknowledges the need to ensure ethical standards in practice-based research – from the standpoints of the clinician and the researcher. The need to ensure comprehensive, culturally appropriate institutional review board approval is essential in developing and safeguarding participants. From discussions with subject matter experts, we find complementary guidance. However, tempering this sentiment is an overall caution of the unique role of rural primary care in representing and protecting the needs of the community. Five fundamental cautions regarding the conduct of practice-based research in rural settings are here identified, spanning the protection of individual patients, their communities, and clinicians. Discussion: Findings from this study can support and empower primary care clinicians and practices, especially those in rural and close-knit communities, to address essential considerations in practice-based research. Results allow for framing of a refined decision support tool for primary care practices and clinicians to use in evaluating the fit of research opportunities for their unique practices, instilling a sense of shared power in the research process by better equipping primary care to proactively engage in substantive dialogue with research partners

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange

Background Using a new needle for every injection can reduce the spread of infectious disease among people who inject drugs (PWID). No previous study has examined new needle use barriers among PWIDs residing in the rural Appalachian part of the United States, an area currently in the midst of a heroin epidemic. Objective Therefore, our primary aim was to explore self-reported barriers to using a new needle by PWID attending a needle exchange program (NEP). Methods We conducted a cross-sectional survey of PWID attending two NEPs in rural West Virginia located in the heart of Central Appalachia. A convenience sample of PWID (n = 100) completed the Barriers to Using New Needles Questionnaire. Results The median number of barriers reported was 5 (range 0–19). Fear of arrest by police (72% of PWID “agreed” or “strongly agreed”) and difficulty with purchasing needles from a pharmacy (64% “agreed” or “strongly agreed”) were the most frequently cited barriers. Conclusions/Importance Congruent with previous findings from urban locations, in rural West Virginia, the ability of PWID to use a new needle obtained from a needle exchange for every injection may be compromised by fear of arrest. In addition, pharmacy sales of new needles to PWID may be blunted by an absence of explicit laws mandating nonprescription sales. Future studies should explore interventions that align the public health goals of NEPs with the occupational safety of law enforcement and health outreach goals of pharmacists

Qualitative case study of needle exchange programs in the Central Appalachian region of the United States

Background The Central Appalachian region of the United States is in the midst of a hepatitis C virus epi- demic driven by injection of opioids, particularly heroin, with contaminated syringes. In response to this epidemic, several needle exchange programs (NEP) have opened to pro- vide clean needles and other supplies and services to people who inject drugs (PWID). How- ever, no studies have investigated the barriers and facilitators to implementing, operating, and expanding NEPs in less populous areas of the United States. Methods This qualitative case study consisted of interviews with program directors, police chiefs, law enforcement members, and PWID affiliated with two NEPs in the rural state of West Virginia. Interview transcripts were coded inductively and analyzed using qualitative data analysis software. Final common themes related to barriers and facilitators of past program open- ings, current program operations, and future program plans, were derived through a consen- sus of two data coders. Results Both NEPs struggled to find existing model programs, but benefited from broad community support that facilitated implementation. The largest operational barrier was the legal conun- drum created by paraphernalia laws that criminalize syringe possession. However, both PWID and law enforcement appreciated the comprehensive services provided by these pro- grams. Program location and transportation difficulties were additional noted barriers. Future program operations are threatened by funding shortages and bans, but necessitated by unexpected program demand. Conclusion Despite broad community support, program operations are threatened by growing partici- pant volumes, funding shortages, and the federal government’s prohibition on the use of funds to purchase needles. Paraphernalia laws create a legal conundrum in the form of criminal sanctions for the possession of needles, which may inadvertently promote needle sharing and disease transmission. Future studies should examine additional barriers to using clean needles provided by rural NEPs that may blunt the effectiveness of NEPs in pre- venting disease transmission

A Better Life: Factors that Help and Hinder Entry and Retention in MAT from the Perspective of People in Recovery

Introduction: Opioid addiction and opioid-related overdoses and deaths are serious public health problems nationally and in West Virginia, in particular. Medication-assisted treatment (MAT) is an effective yet underutilized treatment for opioid use disorder (OUD). Purpose: Research examining factors that help individuals succeed in MAT has been conducted from provider and program perspectives, but little research has been conducted from the perspective of those in recovery. Methods: This study, co-developed with individuals in recovery, took place in West Virginia-based MAT programs using an exploratory sequential mixed methods approach. The survey was open February through August 2021. Data were analyzed late 2021 through mid 2022. Results: Respondents experienced many barriers to MAT entry and retention, including community bias / stigma, lack of affordable programming, and lack of transportation. Respondents sought MAT primarily for personal reasons, such as being tired of being sick, and tired of having to look for drugs every day. As one respondent shared, “I wanted to better my life, to get it under control.” Implications: Programs and policies should make it easy for individuals to enter treatment when ready, through affordable and accessible treatment options, reduced barriers to medications, focused outreach and education, individualized care, and reduced stigmatization

Case Study of a Comprehensive Team-Based Approach to Increase Colorectal Cancer Screening

Introduction: Colorectal cancer is the second leading cause of cancer deaths among men and women in West Virginia. In addition, 51% of all colorectal cancers diagnosed in West Virginia from 2012 to 2016 were detected at either regional (31%) or distant (20%) stages indicating a need for improved early detection. Methods: West Virginia University Cheat Lake Physicians participated in the West Virginia Program to Increase Colorectal Cancer Screening, a program of Cancer Prevention and Control at the WVU Cancer Institute. As a result, Cheat Lake Physicians assembled a team of health care professionals to implement evidence-based interventions and system changes including provider assessment and feedback, patient reminders, accurate data capture, and tracking of CRC screening tests. Results: These efforts resulted in a 15.8% increase in colorectal cancer screening rates within one year of implementation. Additionally, the clinic achieved a 66% return rate for Fecal Immunochemical Test kits, an inexpensive, stool-based colorectal cancer screening test. Implications: The utilization of a team-based approach to patient care yields positive results that can be carried over to other cancer and disease prevention efforts in primary care clinics