Improving Colorectal Cancer Screening Decision Making Processes

Introduction: Although shared decision making is recommended for cancer screening, it is not routinely completed in practice because of time constraints. We evaluated a process for improving decision making about colorectal cancer (CRC) screening using mailed decision aids (DA) with follow-up telephone support in primary care practices. Methods: We identified patients aged 50-75 who were not up to date with CRC screening in three primary care practices. DA were distributed via mail with telephone follow-up to eligible patients, and charts were reviewed six months later for CRC screening completion. Results: Among 1,064 eligible patients who received the mailed DA, 513 (48.2%) were reached by phone. During the six months after the intervention, 148/1064 (13.9%) patients were screened for CRC (4.8% underwent FIT, 9.1% underwent colonoscopy). Younger patients (aged 50-54) had higher rates of any screening (32.4%) compared with all other age groups (range 12.8%-19.6%), p=0.026, while Medicaid patients had the lowest rates of screening (4.0%), and insured patients had the highest rates (45.3%), p=0.003. Overall, 113/513 (22.0%) who were reached by phone went on to complete screening within 6 months, compared with 35/551 (6.4%) of patients who were not reached by phone (p Conclusion: A standard process for identifying patients unscreened for CRC and DA distribution via mail with telephone decision support modestly increased CRC screening and is consistent with the goal of providing preference-sensitive care and informed decision making. Improving care processes to include decision support outside of office visits is possible in primary care practices

Development of a Certificate in Healthcare Improvement for Inter-Professional Teams

Introduction To address gaps in care team improvement-science education and connect geographically dispersed learners, we created a healthcare improvement certificate program, now completing the third program year, for inter-professional (IP) healthcare teams, including third year medical students. Methods This hybrid learning program consists of five modules: Learning Healthcare Systems, Improvement Science, Patient Safety and Diagnostic Error, Population Health and Health Equity and Leading Change. The curricular materials are comprised of focused readings, concise videos, faculty-moderated discussion boards, weekly synchronous calls of participants with faculty, and a longitudinal improvement project. The faculty are content experts, and worked with a curricular designer to define learning objectives and develop content. Results We have completed three years of this six-month program, training 61 participants (17 of whom were medical students) at 14 sites. In the third year, several medical students participated without an IP team. Development of the materials has been iterative, with feedback from learners and faculty used to shape the materials. Discussion We demonstrate the development and rollout of a hybrid-learning program for diverse and geographically dispersed IP teams, including medical students. Time restrictions limited the depth of topics, and scheduling overlap caused some participants to miss the interactive calls. We plan to evaluate the utility of the program for participants over time, using qualitative methods. Conclusion This educational model is feasible for IP teams studying improvement science and implementing change projects, and can be adopted to dispersed geographic settings

The Vehicle, Fall 1987

Table of Contents Sketches in the SunRodger L. Patiencepage 3 Reflecting PoolRob Montgomerypage 5 Grandpa\u27s Porcelain DollRichard E. Hallpage 6 Tintype 1837Catherine Friemannpage 6 PhotographSteven M. Beamerpage 7 Washerwoman\u27s SongBob Zordanipage 8 Scrambled Eggs for D.O.Lynne A. Rafoolpage 8 my mother would sayMonica Grothpage 9 Retired by His ChildrenDan Von Holtenpage 10 I am the oldestMonica Grothpage 11 Ice on WheatRob Montgomerypage 12 The Nature of the RoseTroy Mayfieldpage 12 Past NebraskaDan Hornbostelpage 13 Five Minute Jamaican VacationChristy Dunphypage 14 PhotographSteven M. Beamerpage 14 The Angry PoemChristy Dunphypage 15 Road UnfamiliarChristy Dunphypage 15 raised voicesMonica Grothpage 16 Old Ladies & MiniskirtsKara Shannonpage 17 FreakspeakBob Zordanipage 18 PortraitDan Von Holtenpage 18 Mobile VacuumKathleen L. Fairfieldpage 19 Rev. Fermus DickSteve Hagemannpage 20 PhotographSteven M. Beamerpage 21 What\u27s the Name of That Flower?Richard Jesse Davispage 22 RequestChristy Dunphypage 23 SketchPaul Seabaughpage 24 ExperiencedMarilyn Wilsonpage 26 Leaving: Two ViewsTina Phillipspage 27 AntaeusDan Von Holtenpage 28 Misogyny at 19J. D. Finfrockpage 29 A Mental CrippleSteve Hagemannpage 32 AssociationsRhonda Ealypage 33 Banana BreadGail Bowerpage 34 Bill and JackBradford B. Autenpage 35 After Image No. 2Rob Montgomerypage 35 VrrooomBeth Goodmanpage 36 Mr. Modern LoverMolly Maddenpage 36 TravelogueRodger L. Patiencepage 37 Down the HighwayJoan Sebastianpage 38 A Retread HeavenRob Montgomerypage 41 StuporDan Von Holtenpage 42 Love Poem After a Seizure in Your BedBob Zordanipage 43 PalsyChristy Dunphypage 44 Interview with Mr. MatthewsBob Zordanipage 45 Chasing Down Hot Air Balloons on a Sunday MorningRob Montgomerypage 48https://thekeep.eiu.edu/vehicle/1049/thumbnail.jp

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Understanding the Role of Misinformation in COVID-19 Vaccine Hesitancy in a Rural State

OBJECTIVE: to identify factors associated with COVID19 vaccine hesitancy, including sources of information among residents of Maine. METHODS: 148 study participants, recruited through community partners and primary care offices in Maine, completed an anonymous 15 item online survey. Recruitment and data collection occurred from May to September, 2021. Hesitancy was determined through a single question, Will you get one of the COVID vaccines when it is offered to you? RESULTS: vaccine hesitant respondents were younger than not hesitant respondents ( = 0.01). Hesitant individuals were significantly more likely to report concerns regarding the speed of COVID-19 vaccine production, vaccine efficacy, and potential vaccine side effects ( \u3c 0.05 for each). Hesitant individuals were also significantly more likely to have discussed vaccination with their primary physician ( = 0.04). CONCLUSIONS: overall, hesitant individuals are more likely to be younger and had less trust in information from government sources, but they sought input from primary care. They were also more concerned about efficacy, side effects, and the rapid development of COVID-19 vaccines. Primary care physicians are in key positions to address these concerns due to contact with individuals who need accurate information

Variation in additional testing and patient outcomes after stress echocardiography or myocardial perfusion imaging, according to accreditation status of testing site.

BACKGROUND: The purpose of the present study was to determine whether patients receiving a stress echocardiogram or myocardial perfusion imaging (MPI) test have differences in subsequent testing and outcomes according to accreditation status of the original testing facility. METHODS AND RESULTS: An all-payer claims dataset from Maine Health Data Organization from 2012 to 2014 was utilized to define two cohorts defined by an initial stress echocardiogram or MPI test. The accreditation status (Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) or none) of the facility performing the index test was known. Descriptive statistics and multivariate regression were used to examine differences in subsequent diagnostic testing and cardiac outcomes. We observed 4603 index stress echocardiograms and 8449 MPI tests. Multivariate models showed higher odds of subsequent MPI testing and hospitalization for angina if the index test was performed at a non-accredited facility in both the stress echocardiogram cohort and the MPI cohort. We also observed higher odds of percutaneous coronary interventions (PCI) performed (OR 1.68, 95% CI 1.13-2.50), if the initial MPI test was done in a non-accredited facility. CONCLUSION: Cardiac testing completed in non-accredited facilities were associated with higher odds of subsequent MPI testing, hospitalization for angina, and PCI

Intraperitoneal chemotherapy among women in the Medicare population with epithelial ovarian cancer.

BACKGROUND: Intraperitoneal combined with intravenous chemotherapy (IV/IP) for primary treatment of epithelial ovarian cancer results in a substantial survival advantage for women who are optimally debulked surgically, compared with standard IV only therapy (IV). Little is known about the use of this therapy in the Medicare population. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 4665 women aged 66 and older with epithelial ovarian cancer diagnosed between 2005-2009, with their Medicare claims. We defined receipt of any IV/IP chemotherapy when there was claims evidence of any receipt of such treatment within 12 months of the date of diagnosis. We used descriptive statistics to examine factors associated with treatment and health services use. RESULTS: Among 3561 women with Stage III or IV epithelial ovarian cancer who received any chemotherapy, only 124 (3.5%) received IV/IP chemotherapy. The use of IV/IP chemotherapy did not increase over the period of the study. In this cohort, younger women, those with fewer comorbidities, whites, and those living in Census tracts with higher income were more likely to receive IV/IP chemotherapy. Among women who received any IV/IP chemotherapy, we did not find an increase in acute care services (hospitalizations, emergency department visits, or ICU stays). CONCLUSION: During the period between 2005 and 2009, few women in the Medicare population living within observed SEER areas received IV/IP chemotherapy, and the use of this therapy did not increase. We observed marked racial and sociodemographic differences in access to this therapy

Completion of adjuvant chemotherapy and use of health services for older women with epithelial ovarian cancer.

PURPOSE: This analysis identifies factors associated with completion of adjuvant chemotherapy for patients with ovarian cancer and subsequent use of health services. PATIENTS AND METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare database to identify 4,617 women age 65 years or older with ovarian cancer diagnosed from 2001 to 2005. By using multivariable analyses with completion of chemotherapy as the outcome of interest, we describe factors associated with completion of treatment, including age, race, marital status, comorbidities, and sociodemographic factors. Use of health services was captured from Medicare claims. RESULTS: Among 4,617 patients with untreated ovarian cancer, 1,329 (28.8%) received no chemotherapy, 1,139 (24.7%) received a partial course of chemotherapy, and 2,149 (46.5%) completed chemotherapy. Women age 75 years or older were at greater risk of incomplete chemotherapy versus women age 65 to 74 years (odds ratio [OR], 1.64; 95% CI, 1.33 to 2.04). Having two or more comorbidities was also significantly associated with incomplete chemotherapy (OR, 1.83; 95% CI, 1.34 to 2.50). Among women who received either a partial or complete course of chemotherapy, we did not find an increase in use of health services (hospitalizations, emergency department visits, or physician visits) for the oldest women (age 80 years or older) compared with younger women. CONCLUSION: There is considerable room for improvement in helping older patients with ovarian cancer initiate and complete chemotherapy. The oldest women who completed chemotherapy in this study did not use health services more than younger women did. Treatment teams for older patients with ovarian cancer should include expertise in geriatric assessment, should carefully identify medical and psychosocial barriers to completing treatment, and should support patients throughout treatment