Pima County COVID-19 vaccine solutions dashboard project: lessons learned

Recent improvements in the accessibility of mapping tools and an increased recognition of the importance of leveraging data to inform public health operations has led to enthusiasm among public health departments to rapidly evolve their ability to analyze and apply data to programs. As the COVID-19 pandemic made evident, many health department data systems have been neglected for decades and data literacy among staff low. Significant federal dollars have been allocated to local health departments to modernize health systems. This case study recounts the effort to equip the Pima County Health Department with a highly sophisticated "COVID-19 Vaccines Solutions Dashboard" in 2021-2022, quantifying community vulnerability in the midst of the COVID-19 pandemic and shares key successes and challenges in process and outcomes that can guide other such dashboard initiatives. The experience informed the development of Pima' County Health Department's Data & Informatics Team as well as efforts to cultivate a more robust data culture throughout the department. Many health departments around the United States are in a similar position, and these lessons learned are widely applicable.

Predictors of Willingness to Participate in COVID-19 Screening Testing from a Pilot School Survey in the United States

BACKGROUND

COVID-19 screening testing (ST) can detect asymptomatic or pre-symptomatic cases, allowing for prompt identification of cases and close contacts. This study examined parents' and school staffs' knowledge and attitudes toward to a pilot school-based ST program in a school district in southern Arizona.

METHODS

In May 2021, online surveys to parents and school staff were administered to examine attitudes toward ST and impacts of the COVID-19 pandemic. Unweighted percent estimates were calculated, and bivariate differences were examined by demographics. Associations were assessed using chi-square tests and logistic regression.

RESULTS

The survey had response rates of 10% (606/6085) and 22% (187/849) among parents and staff, respectively. Approximately one-third of responding parents (35%) would or already allow their child to participate in school-based ST, 37% would not participate; 28% were unsure. Among responding staff, 46% would or already participate in ST, 33% would not; 21% were unsure. The top concern (38%) among responding staff was taking job-related leave if testing positive.

CONCLUSION

Schools work to balance the needs of students, families, and staff by implementing supportive and flexible policies and practices founded on buy-in and acceptance from their communities.

Enhancing the nation's public health information infrastructure: a report from the ACMI symposium

The COVID-19 pandemic exposed multiple weaknesses in the nation's public health system. Therefore, the American College of Medical Informatics selected "Rebuilding the Nation's Public Health Informatics Infrastructure" as the theme for its annual symposium. Experts in biomedical informatics and public health discussed strategies to strengthen the US public health information infrastructure through policy, education, research, and development. This article summarizes policy recommendations for the biomedical informatics community postpandemic. First, the nation must perceive the health data infrastructure to be a matter of national security. The nation must further invest significantly more in its health data infrastructure. Investments should include the education and training of the public health workforce as informaticians in this domain are currently limited. Finally, investments should strengthen and expand health data utilities that increasingly play a critical role in exchanging information across public health and healthcare organizations.

Making Vaccines Equitably Available to All Persons in Pima County, Arizona, 2020-2021

We review the Pima County (Arizona) Health Department's efforts to achieve equitable COVID-19 vaccine distribution in a county with a social vulnerability index of 0.88. We expedited vaccine distribution, focusing on equitable distribution, implementing a multi-point of dispensing approach, and using a periurban and rural strategy. Pima County has one of the highest vaccine distribution percentages among the highest social vulnerability index quartiles and is more than 10 percentage points ahead of other large counties in Arizona in vaccine uptake. (Am J Public Health. 2022;112(11):1560-1563. https://doi.org/10.2105/AJPH.2022.307040).

A Multiresource Event Model Developed to Increase Access to COVID-19 Vaccines in Pima County, Arizona, Summer 2021

In summer 2021, the Pima County Health Department (PCHD) developed and implemented a multiresource event model for vaccine clinics to increase access to COVID-19 vaccines and other resources, such as food, rental assistance, and public health services, in Pima County, Arizona, communities. The PCHD aimed to improve vaccine access in areas with vaccination rates <40% by involving community partners to plan a multiresource event with resources (eg, food, connection to economic resources, information on childcare, and heat relief)and incentives specific to community needs that could drive attendance. Resources would be made available to community members regardless of whether they received a COVID-19 vaccine at the event. The PCHD selected census tract 41.15 as the pilot group to apply the multiresouce COVID-19 vaccine event model. Census tract 41.15 is a heat-stressed area of Pima County comprising mostly Latino people and people with lower incomes and is an area with low vaccination rates for COVID-19. The vaccination rate increased in census tract 41.15 by 12.8 percentage points (absolute increase), starting at 33.9% on June 1, 2021, and increasing to 46.7% as of September 1, 2021. In addition, attendance at the pilot event versus attendance at previous events that did not use this model increased by >100%. The multiresource COVID-19 vaccine event, when held within a hyperlocal area and when the needs of residents in the community are considered, can improve vaccine uptake. This model provides a roadmap for COVID-19 vaccine delivery in areas of low uptake.

Clinical Outcomes of Monoclonal Antibody Therapy During a COVID-19 Outbreak in a Skilled Nursing Facility-Arizona, 2021

Background

Adult residents of skilled nursing facilities (SNF) have experienced high morbidity and mortality from SARS‐CoV‐2 infection and are at increased risk for severe COVID‐19 disease. Use of monoclonal antibody (mAb) treatment improves clinical outcomes among high‐risk outpatients with mild‐to‐moderate COVID‐19, but information on mAb effectiveness in SNF residents with COVID‐19 is limited. We assessed outcomes in SNF residents with mild‐to‐moderate COVID‐19 associated with an outbreak in Arizona during January–February 2021 that did and did not receive a mAb.

Methods

Medical records were reviewed to describe the effect of bamlanivimab therapy on COVID‐19 mortality. Secondary outcomes included referral to an acute care setting and escalation of medical therapies at the SNF (e.g., new oxygen requirements). Residents treated with bamlanivimab were compared to residents who were eligible for treatment under the FDA's Emergency Use Authorization (EUA) but were not treated. Multivariable logistic regression was used to determine association between outcomes and treatment status.

Results

Seventy‐five residents identified with COVID‐19 during this outbreak met eligibility for mAb treatment, of whom 56 received bamlanivimab. Treated and untreated groups were similar in age and comorbidities associated with increased risk of severe COVID‐19 disease. Treatment with bamlanivimab was associated with reduced 21‐day mortality (adjusted OR = 0.06; 95% CI: 0.01, 0.39) and lower odds of initiating oxygen therapy (adjusted OR = 0.07; 95% CI: 0.02, 0.34). Referrals to acute care were not significantly different between treated and untreated residents.

Conclusions

mAb therapy was successfully administered to SNF residents with COVID‐19 in a large outbreak setting. Treatment with bamlanivimab reduced 21‐day mortality and reduced initiation of oxygen therapy. As the COVID‐19 pandemic evolves and newer immunotherapies gain FDA authorization, more studies of the effectiveness of mAb therapies for treating emerging SARS‐CoV‐2 variants of concern in high‐risk congregate settings are needed.

Association Between K-12 School Mask Policies and School-Associated COVID-19 Outbreaks - Maricopa and Pima Counties, Arizona, July-August 2021

CDC recommends universal indoor masking by students, staff members, faculty, and visitors in kindergarten through grade 12 (K-12) schools, regardless of vaccination status, to reduce transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Schools in Maricopa and Pima Counties, which account for >75% of Arizona's population (2), resumed in-person learning for the 2021-22 academic year during late July through early August 2021. In mid-July, county-wide 7-day case rates were 161 and 105 per 100,000 persons in Maricopa and Pima Counties, respectively, and 47.6% of Maricopa County residents and 59.2% of Pima County residents had received at least 1 dose of a COVID-19 vaccine. School districts in both counties implemented variable mask policies at the start of the 2021-22 academic year (Table). The association between school mask policies and school-associated COVID-19 outbreaks in K-12 public noncharter schools open for in-person learning in Maricopa and Pima Counties during July 15-August 31, 2021, was evaluated.

Consumer Perspectives on Maternal and Infant Health Apps: Qualitative Content Analysis

BACKGROUND

Despite the popularity of maternal and infant health mobile apps, ongoing consumer engagement and sustained app use remain barriers. Few studies have examined user experiences or perceived benefits of maternal and infant health app use from consumer perspectives.

OBJECTIVE

This study aims to assess users' self-reported experiences with maternal and infant health apps, perceived benefits, and general feedback by analyzing publicly available user reviews on two popular app stores-Apple App Store and Google Play Store.

METHODS

We conducted a qualitative assessment of publicly available user reviews (N=2422) sampled from 75 maternal and infant health apps designed to provide health education or decision-making support to pregnant women or parents and caregivers of infants. The reviews were coded and analyzed using a general inductive qualitative content analysis approach.

RESULTS

The three major themes included the following: app functionality, where users discussed app features and functions; technical aspects, where users talked about technology-based aspects of an app; and app content, where users specifically focused on the app content and the information it provides. The six minor themes included the following: patterns of use, where users highlighted the frequency and type of use; social support, where users talked about receiving social support from friends, family and community of other users; app cost, where users talked about the cost of an app within the context of being cost-effective or a potential waste of money; app comparisons, where users compared one app with others available in app stores; assistance in health care, where users specifically highlighted the role of an app in offering clinical assistance; and customer care support, where users specifically talked about their interaction with the app customer care support team.

CONCLUSIONS

Users generally tend to value apps that are of low cost and preferably free, with high-quality content, superior features, enhanced technical aspects, and user-friendly interfaces. Users also find app developer responsiveness to be integral, as it offers them an opportunity to engage in the app development and delivery process. These findings may be beneficial for app developers in designing better apps, as no best practice guidelines currently exist for the app environment.

Content analysis of behavior change techniques in maternal and infant health apps

Maternal and infant health (MIH) mobile applications (apps) are increasingly popular and frequently used for health education and decision making. Interventions grounded in theory-based behavior change techniques (BCTs) are shown to be effective in promoting healthy behavior changes. MIH apps have the potential to be useful tools, yet the extent to which they incorporate BCTs is still unknown. The objective of this study was to assess the presence of BCTs in popular MIH apps available in the Apple App and Google Play stores. Twenty-nine popular MIH apps were coded for the presence of 16 BCTs using the mHealth app taxonomy. Popular MIH apps whose purpose was to provide health education or decision-making support to pregnant women or parents/caregivers of infants were included in the final sample. On an average, the reviewed apps included seven BCTs (range 2-16). Techniques such as personalization, review of general or specific goals, macro tailoring, self-monitoring of goals, and health behavior linkages were most frequently present. No differences in the presence of BCTs between paid and free apps were observed. Popular MIH apps typically included only a minority of BCTs found to be useful for health promotion. However, apps developed by healthcare developers incorporated a higher number of BCTs within the app content. Therefore, app developers and policymakers may consider strategies to increase health expert involvement in app design and content delivery.

Modernizing health information technology: lessons from healthcare delivery systems

Objective

To identify recurrent themes, insights, and process recommendations from stakeholders in US organizations during the health information technology (HIT) modernization of an existing electronic health record (EHR) to a commercial-off-the-shelf product in both resource-plentiful settings and in a resource-constrained environment, the US Indian Health Service.

Materials and Methods

Thirteen qualitative interviews with stakeholders in various organizations were conducted about HIT modernization efforts. Using a Theory of Change framework, recurring themes were identified and analyzed.

Results

The interviewees emphasized the importance of organizational and process revision during modernization, converting historical data, and clinical and leadership involvement. HIT implementation required technological and infrastructure redesign, additional training, and workflow reconfiguration. Motivations for modernization included EHR usability dissatisfaction, revenue enhancements, and improved clinical operations. Decision-making strategies, primarily during HIT selection, included meetings with stakeholders. Successful modernization resulted in improvements in clinical operations, patient experience, and financial outlay.

Discussion

Existing implementation frameworks fail to provide experiential feedback, such as implementation challenges, like data conversion, regulatory, functionality, and interoperability requirements. Regardless of the healthcare environment, HIT modernization requires the engagement of leadership and end-users during HIT selection and through all stages of the implementation to prepare people, processes, and technology. Organizations must iteratively define the technological, infrastructure, organizational, and workflow changes required for a successful HIT modernization effort.

Conclusions

HIT modernization is an opportunity for organizational and technological change. Successful modernization requires a comprehensive, intentional, well-communicated, and multidisciplinary approach. Resource-constrained environments have the additional challenges of financial burdens, limited staffing, and unstable infrastructure.

COVID-19 TestNorm: A tool to normalize COVID-19 testing names to LOINC codes

Large observational data networks that leverage routine clinical practice data in electronic health records (EHRs) are critical resources for research on coronavirus disease 2019 (COVID-19). Data normalization is a key challenge for the secondary use of EHRs for COVID-19 research across institutions. In this study, we addressed the challenge of automating the normalization of COVID-19 diagnostic tests, which are critical data elements, but for which controlled terminology terms were published after clinical implementation. We developed a simple but effective rule-based tool called COVID-19 TestNorm to automatically normalize local COVID-19 testing names to standard LOINC (Logical Observation Identifiers Names and Codes) codes. COVID-19 TestNorm was developed and evaluated using 568 test names collected from 8 healthcare systems. Our results show that it could achieve an accuracy of 97.4% on an independent test set. COVID-19 TestNorm is available as an open-source package for developers and as an online Web application for end users (https://clamp.uth.edu/covid/loinc.php). We believe that it will be a useful tool to support secondary use of EHRs for research on COVID-19.

Design of microresonators to minimize thermal noise below the standard quantum limit

Microfabricated resonators play a crucial role in the development of quantum measurement, including future gravitational wave detectors. We use a micro-genetic algorithm and a finite element method to design a microresonator whose geometry is optimized to maximize the sub-Standard Quantum Limit (SQL) performance including lower thermal noise (TN) below the SQL, a broader sub-SQL region, and a sub-SQL region at lower frequencies. For the proposed design, we study the effects of different geometries of the mirror pad and cantilever microresonator on sub-SQL performance. We find that the maximum ratio of SQL to TN is increased, its frequency is decreased, and the sub-SQL range is increased by increasing the length of the microresonator cantilever, increasing the radius of the mirror pad, decreasing the width of the microresonator cantilever, and shifting the laser beam location from the mirror center. We also find that there exists a trade-off between the maximum ratio of SQL to TN and the sub-SQL bandwidth. The performance of this designed microresonator will allow it to serve as a test-bed for quantum non-demolition measurements and to open new regimes of precision measurement that are relevant for many practical sensing applications, including advanced gravitational wave detectors.

Factors Related to User Ratings and User Downloads of Mobile Apps for Maternal and Infant Health: Cross-Sectional Study

BACKGROUND

Mobile health apps related to maternal and infant health (MIH) are prevalent and frequently used. Some of these apps are extremely popular and have been downloaded over 5 million times. However, the understanding of user behavior and user adoption of these apps based on consumer preferences for different app features and categories is limited.

OBJECTIVE

This study aimed to examine the relationship between MIH app characteristics and users' perceived satisfaction and intent to use.

METHODS

The associations between app characteristics, ratings, and downloads were assessed in a sample of MIH apps designed to provide health education or decision-making support to pregnant women or parents and caregivers of infants. Multivariable linear regression was used to assess the relationship between app characteristics and user ratings, and ordinal logistic regression was used to assess the relationship between app characteristics and user downloads.

RESULTS

The analyses of user ratings and downloads included 421 and 213 apps, respectively. The average user rating was 3.79 out of 5. Compared with the Apple App Store, the Google Play Store was associated with high user ratings (beta=.33; P=.005). Apps with higher standardized user ratings (beta=.80; P<.001), in-app purchases (beta=1.12; P=.002), and in-app advertisements (beta=.64; P=.02) were more frequently downloaded. Having a health care organization developer as part of the development team was neither associated with user ratings (beta=-.20; P=.06) nor downloads (beta=-.14; P=.63).

CONCLUSIONS

A majority of MIH apps are developed by non-health care organizations, which could raise concern about the accuracy and trustworthiness of in-app information. These findings could benefit app developers in designing better apps and could help inform marketing and development strategies. Further work is needed to evaluate the clinical accuracy of information provided within the apps.

Envisioning health equity for American Indian/Alaska Natives: a unique HIT opportunity

The Indian Health Service provides care to remote and under-resourced communities in the United States. American Indian/Alaska Native patients have some of the highest morbidity and mortality among any ethnic group in the United States. Starting in the 1980s, the IHS implemented the Resource and Patient Management System health information technology (HIT) platform to improve efficiency and quality to address these disparities. The IHS is currently assessing the Resource and Patient Management System to ensure that changing health information needs are met. HIT assessments have traditionally focused on cost, reimbursement opportunities, infrastructure, required or desired functionality, and the ability to meet provider needs. Little information exists on frameworks that assess HIT legacy systems to determine solutions for an integrated rural healthcare system whose end goal is health equity. This search for a next-generation HIT solution for a historically underserved population presents a unique opportunity to envision and redefine HIT that supports health equity as its core mission.

Independent or simultaneous lowering of core and skin temperature has no impact on self-paced intermittent running performance in hot conditions

Purpose

To investigate the effects of lowering core (T_gi) and mean skin temperature (T_sk) concomitantly and independently on self-paced intermittent running in the heat.

Methods

10 males (30.5 ± 5.8 years, 73.2 ± 14.5 kg, 176.9 ± 8.0 cm, 56.2 ± 6.6 ml/kg/min) completed four randomised 46-min self-paced intermittent protocols on a non-motorised treadmill in 34.4 ± 1.4 °C, 36.3 ± 4.6% relative humidity. 30-min prior to exercise, participants were cooled via either ice slurry ingestion (INT); a cooling garment (EXT); mixed-cooling (ice slurry and cooling garment concurrently) (MIX); or no-cooling (CON).

Results

At the end of pre-cooling and the start of exercise T_gi were lower during MIX (36.11 ± 1.3 °C) compared to CON (37.6 ± 0.5 °C) and EXT (36.9 ± 0.5 °C, p < 0.05). Throughout pre-cooling T_sk and thermal sensation were lower in MIX compared to CON and INT, but not EXT (p < 0.05). The reductions in thermophysiological responses diminished within 10–20 min of exercise. Despite lowering T_gi, T_sk, body temperature (T_b), and thermal sensation prior to exercise, the distances covered were similar (CON: 6.69 ± 1.08 km, INT: 6.96 ± 0.81 km, EXT: 6.76 ± 0.65 km, MIX 6.87 ± 0.70 km) (p > 0.05). Peak sprint speeds were also similar between conditions (CON: 25.6 ± 4.48 km/h, INT: 25.4 ± 3.6 km/h, EXT: 26.0 ± 4.94 km/h, MIX: 25.6 ± 3.58 km/h) (p > 0.05). Blood lactate, heart rate and RPE were similar between conditions (p > 0.05).

Conclusion

Lowering T_gi and T_sk prior to self-paced intermittent exercise did not improve sprint, or submaximal running performance.

Electronic supplementary material

The online version of this article (10.1007/s00421-019-04173-y) contains supplementary material, which is available to authorized users.

Overcoming the Maternal Care Crisis: How Can Lessons Learnt in Global Health Informatics Address US Maternal Health Outcomes?

Despite unprecedented spending, US maternal outcomes have worsened drastically over the past decade. In comparison, maternal outcomes of many Low and Middle-Income Countries (LMIC) have improved. Lessons learnt by their success may be applicable to the US. We performed a literature review to identify innovations that had met with success across LMIC, and should be considered for adoption in the US. mHealth and patient facing alerts, Telehealth, patient controlled health records, inclusion of patient relationship data in health information systems and positioning empowered community health workers as catalysts of maternal care delivery were identified as innovations worthy of further evaluation. These innovations were categorized into several themes; knowledge, technology, patient/community empowerment, coordination and process change. Tools that place informed and empowered patients and community members at the center of maternal care has greatly improved maternal outcomes, and are suitable to be considered for the US healthcare system.

Leveraging the Value of Human Relationships to Improve Health Outcomes. Lessons learned from the OpenMRS Electronic Health Record System

OBJECTIVES

Despite significant awareness on the value of leveraging patient relationships across the healthcare continuum, there is no research on the potential of using Electronic Health Record (EHR) systems to store structured patient relationship data, or its impact on enabling better healthcare. We sought to identify which EHR systems supported effective patient relationship data collection, and for systems that do, what types of relationship data is collected, how this data is used, and the perceived value of doing so.

MATERIALS AND METHODS

We performed a literature search to identify EHR systems that supported patient relationship data collection. Based on our results, we defined attributes of an effective patient relationship model. The Open Medical Record System (OpenMRS), an open source medical record platform for underserved settings met our eligibility criteria for effective patient relationship collection. We performed a survey to understand how the OpenMRS patient relationship model was used, and how it brought value to implementers.

RESULTS

The OpenMRS patient relationship model has won widespread adoption across many implementations and is perceived to be valuable in enabling better health care delivery. Patient relationship information is widely used for community health programs and enabling chronic care. Additionally, many OpenMRS implementers were using this feature to collect custom relationship types for implementation specific needs.

CONCLUSIONS

We believe that flexible patient relationship data collection is critical for better healthcare, and can inform community care and chronic care initiatives across the world. Additionally, patient relationship data could also be leveraged for many other initiatives such as patient centric care and in the field of precision medicine.

Data Quality and Interoperability Challenges for eHealth Exchange Participants: Observations from the Department of Veterans Affairs' Virtual Lifetime Electronic Record Health Pilot Phase

Authors studied the United States (U.S.) Department of Veterans Affairs' (VA) Virtual Lifetime Electronic Record (VLER) Health pilot phase relative to two attributes of data quality - the adoption of eHealth Exchange data standards, and clinical content exchanged. The VLER Health pilot was an early effort in testing implementation of eHealth Exchange standards and technology. Testing included evaluation of exchange data from the VLER Health pilot sites partners: VA, U.S. Department of Defense (DoD), and private sector health care organizations. Domains assessed data quality and interoperability as it relates to: 1) conformance with data standards related to the underlying structure of C32 Summary Documents (C32) produced by eHealth Exchange partners; and 2) the types of C32 clinical content exchanged. This analysis identified several standards non-conformance issues in sample C32 files and informed further discourse on the methods needed to effectively monitor Health Information Exchange (HIE) data content and standards conformance.

Challenging behaviour and sleep cycle disorder following brain injury: a preliminary response to agomelatine treatment

BACKGROUND

Sleep disturbances are common after acquired brain injury. Sedatives can exacerbate behavioural disorders.

OBJECTIVES

This study reports the case of a severely brain damaged man (TM) who developed a non-24 hour sleep cycle disorder that was effectively managed by the administration of a melatonin receptor agonist, agomelatine.

METHOD

TM suffered significant brain damage as a result of a large subarachnoid haemorrhage of his right anterior cerebral artery complicated by midline shift and subsequent infarction of his left middle cerebral artery. In addition to challenging behaviour and cognitive impairment, TM presented with a recurrent disturbed sleep-wake pattern that significantly worsened his quality-of-life. He was diagnosed as suffering of non-24 hour sleep-wake disorder. Challenge was recorded using the Overt Aggression Scale Modified for Neuro-Rehabilitation (OASMNR).

RESULTS

Typical hypnotics had no or ill effects. Agomelatine prescription (25 mg) led to significant OASMNR and sleep efficiency change with effects apparent at 1.5 years later.

CONCLUSIONS

Administration of the melatonin receptor (MT₁ and MT₂) agonist agomelatine each night resulted in an immediate and sustained improvement on sleep and on indices of challenging behaviour.

Influenza surveillance using electronic health records in the American Indian and Alaska Native population

OBJECTIVE

Increasing use of electronic health records (EHRs) provides new opportunities for public health surveillance. During the 2009 influenza A (H1N1) virus pandemic, we developed a new EHR-based influenza-like illness (ILI) surveillance system designed to be resource sparing, rapidly scalable, and flexible. 4 weeks after the first pandemic case, ILI data from Indian Health Service (IHS) facilities were being analyzed.

MATERIALS AND METHODS

The system defines ILI as a patient visit containing either an influenza-specific International Classification of Disease, V.9 (ICD-9) code or one or more of 24 ILI-related ICD-9 codes plus a documented temperature ≥100°F. EHR-based data are uploaded nightly. To validate results, ILI visits identified by the new system were compared to ILI visits found by medical record review, and the new system's results were compared with those of the traditional US ILI Surveillance Network.

RESULTS

The system monitored ILI activity at an average of 60% of the 269 IHS electronic health databases. EHR-based surveillance detected ILI visits with a sensitivity of 96.4% and a specificity of 97.8% based on chart review (N=2375) of visits at two facilities in September 2009. At the peak of the pandemic (week 41, October 17, 2009), the median time from an ILI visit to data transmission was 6 days, with a mode of 1 day.

DISCUSSION

EHR-based ILI surveillance was accurate, timely, occurred at the majority of IHS facilities nationwide, and provided useful information for decision makers. EHRs thus offer the opportunity to transform public health surveillance.

Validation of algorithm to identify American Indian/Alaska Native pregnant women at risk from pandemic H1N1 influenza

Pregnant women and American Indian and Alaska Native people are at elevated risk of severe disease and mortality from 2009 pandemic influenza A/H1N1. We validated an electronic health record-based algorithm used by Indian Health Service to identify pregnant women in near real-time surveillance of pandemic influenza A/H1N1. We randomly selected a stratified sample of 515 patients at 3 Indian Health Service-funded hospitals with varied characteristics. With comprehensive review of patients' electronic health records as the gold standard, we calculated the positive predictive value and sensitivity of the pregnancy algorithm. The sensitivity of the algorithm at individual hospitals ranged from 94.1-96.0%. Positive predictive value ranged from 94.4-98.3%. Despite differences among hospitals on key characteristics, the pregnancy algorithm performed nearly equivalently with high positive predictive value and sensitivity at all facilities. It may prove helpful for surveillance during future epidemics and for targeting interventions for pregnant women and infants.

Trends in quality of care and barriers to improvement in the Indian Health Service

BACKGROUND

Although Native Americans experience substantial disparities in health outcomes, little information is available regarding healthcare delivery for this population.

OBJECTIVE

To analyze trends in ambulatory quality of care and physician reports of barriers to quality improvement within the Indian Health Service (IHS).

DESIGN

Longitudinal analysis of clinical performance from 2002 to 2006 within the IHS, and a physician survey in 2007.

PARTICIPANTS

Adult patients cared for within the IHS and 740 federally employed physicians within the IHS.

MAIN MEASURES

Clinical performance for 12 measures of ambulatory care within the IHS; as well as physician reports of ability to access needed health services and use of quality improvement strategies. We examined the correlation between physician reports of access to mammography and clinical performance of breast cancer screening. A similar correlation was analyzed for diabetic retinopathy screening.

KEY RESULTS

Clinical performance significantly improved for 10 of the 12 measures from 2002 to 2006, including adult immunizations, cholesterol testing, and measures of blood pressure and cholesterol control for diabetes and cardiovascular disease. Breast cancer screening rates decreased (44% to 40%, p = 0.002), while screening rates for diabetic retinopathy remained constant (51%). Fewer than half of responding primary care physicians reported adequate access to high-quality specialists (29%), non-emergency hospital admission (37%), high-quality imaging services (32%), and high-quality outpatient mental health services (16%). Breast cancer screening rates were higher at sites with higher rates of physicians reporting routine access to mammography compared to sites with lower rates of physicians reporting such access (46% vs. 35%, ρ = 0.27, p = 0.04). Most physicians reported using patient registries and decision support tools to improve patient care.

CONCLUSIONS

Quality of care has improved within the IHS for many services, however performance in specific areas may be limited by access to essential resources.

Completing the circle: follow-up screening of STD patients in three clinics of the United States Indian Health Service

We reviewed charts of newly diagnosed STD patients in three health facilities to determine the proportion who received follow-up STD screening. In a 12-month period, the three facilities had 140 STD cases. STD screening was not indicated for 50 (36%) patients. Among the 90 remaining STD patients, 29 (32%) were screened and 61 (68%) not screened. Among non-screened patients, 36% (22/61) were tested, but outside the time parameters allowed by the audit. The remaining 64% (39/61) received no screening at all, and represented clinical missed opportunities; in this group, nearly all (95%) had chlamydia but were not screened for HIV or syphilis. Linking chlamydia patients with a screen for HIV and syphilis using a clinical reminder in the facilities' electronic health record (EHR) or other tool, would eliminate 95% of the missed opportunities in this sample.

Innovation in Indian healthcare: using health information technology to achieve health equity for American Indian and Alaska Native populations

The US Indian health system utilizes a diverse range of health information technology and innovative tools to enhance health service delivery for American Indians and Alaska Natives. This article provides an overview of efforts and experience using such tools to achieve health equity for American Indian and Alaska Native communities. Specific attention is given to the Indian Health Service Electronic Health Record and to two examples of telehealth innovation.

Design and assessment of a common, multi-national public health informatics infrastructure to enable H1N1 influenza surveillance

Public health organizations in different nations face similar needs for gathering and analyzing population health data to detect and manage infectious disease outbreaks, including outbreaks of the 2009 Novel H1N1 Influenza A virus or "swine flu." This paper presents our progress to date on the design and assessment of a multi-national public health informatics infrastructure for data collection and disease surveillance. This initial work, under the aegis of an open health tools collaborative, lays the foundation for best practices in patient care and public health preparedness in the national health IT sector. This multinational collaboration is the first to identify essential electronic health record (EHR) data sets as well as standard public health informatics indicators to electronically monitor a notifiable public health condition internationally.

Implementation and use of an electronic health record within the Indian Health Service

OBJECTIVES

There are limited data regarding implementing electronic health records (EHR) in underserved settings. We evaluated the implementation of an EHR within the Indian Health Service (IHS), a federally funded health system for Native Americans.

DESIGN

We surveyed 223 primary care clinicians practicing at 26 IHS health centers that implemented an EHR between 2003 and 2005.

METHODS

The survey instrument assessed clinician attitudes regarding EHR implementation, current utilization of individual EHR functions, and attitudes regarding the use of information technology to improve quality of care in underserved settings. We fit a multivariable logistic regression model to identify correlates of increased utilization of the EHR.

RESULTS

The overall response rate was 56%. Of responding clinicians, 66% felt that the EHR implementation process was positive. One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased the quality of the patient-doctor interaction. One-third of clinicians (34%) reported consistent use of electronic reminders, and self-report that EHRs improve quality was strongly associated with increased utilization of the EHR (odds ratio 3.03, 95% confidence interval 1.05-8.8). The majority (87%) of clinicians felt that information technology could potentially improve quality of care in rural and underserved settings through the use of tools such as online information sources, telemedicine programs, and electronic health records.

CONCLUSIONS

Clinicians support the use of information technology to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the IHS, potentially due to limited use of key functions within the EHR.

Information technology as a tool to improve the quality of American Indian health care

The American Indian/Alaska Native population experiences a disproportionate burden of disease across a spectrum of conditions. While the recent National Healthcare Disparities Report highlighted differences in quality of care among racial and ethnic groups, there was only very limited information available for American Indians. The Indian Health Service (IHS) is currently enhancing its information systems to improve the measurement of health care quality as well as to support quality improvement initiatives. We summarize current knowledge regarding health care quality for American Indians, highlighting the variation in reported measures in the existing literature. We then discuss how the IHS is using information systems to produce standardized performance measures and present future directions for improving American Indian health care quality.

Testing models of thalamic dysfunction in schizophrenia using neuroimaging

Neural models of schizophrenia have implicated the thalamus in deficits of early sensory processing and multimodal integration. We have reviewed the existing neuroimaging literature for evidence in support of models that propose abnormalities of thalamic relay nuclei, the mediodorsal thalamic nucleus, and large-scale cortico-thalamic networks. Thalamic volume reduction was found in some but not all studies. Studies of the early stages of schizophrenia suggest that thalamic volume reduction is present early in the course of the illness. Functional imaging studies have revealed task related abnormalities in several cortical and subcortical areas including the thalamus, suggesting a disruption of distributed thalamocortical networks. Chemical imaging studies have provided evidence for a loss of thalamic neuronal integrity in schizophrenia. There is, at present, inadequate data to support the hypothesis that schizophrenia is associated with abnormalities of sensory relay or association nuclei. There is evidence for a perturbation of cortico-thalamic networks, but further research is needed to elucidate the underlying mechanisms at the cellular and systems levels. The challenges ahead include better delineation of thalamic structure and function in vivo, the combination of genetic and imaging techniques to elucidate the genetic contributions to a thalamic phenotype of schizophrenia, and longitudinal studies of thalamic structure and function.

Diabetes outcomes in the Indian health system during the era of the Special Diabetes Program for Indians and the Government Performance and Results Act

OBJECTIVES

We reviewed changes in blood glucose, blood pressure, and cholesterol levels among American Indians and Alaska Natives between 1995 and 2001 to estimate the quality of diabetes care in the Indian Health Service (IHS) health care delivery system.

METHODS

We conducted a cross-sectional analysis of data from the Indian Health Service Diabetes Care and Outcomes Audit.

RESULTS

Adjusted mean Hemoglobin A1c (HbA1c) levels (7.9% vs 8.9%) and mean diastolic blood pressure levels (76 vs 79 mm Hg) were lower in 2001 than in 1995, respectively. A similar pattern was observed for mean total cholesterol (193 vs 208 mg/dL) and triglyceride (235 vs 257 mg/dL) levels in 2001 and 1995, respectively.

CONCLUSIONS

We identified changes in intermediate clinical outcomes over the period from 1995 to 2001 that may reflect the global impact of increased resource allocation and improvements in processes on the quality of diabetes care, and we describe the results that may be achieved when community, health program, and congressional initiatives focus on common goals.

Intranigral or intrastriatal injections of GDNF: effects on monoamine levels and behavior in rats

The present studies were designed to determine whether administration of recombinant human glial cell line-derived neurotrophic factor (rhGDNF) into either the substantia nigra or striatum is capable of augmenting dopamine function of the nigrostriatal pathway in normal rats. Single bolus intracranial injections of rhGDNF at either site increased locomotor activity and decreased food and water consumption and body weight in a dose-dependent manner when compared to vehicle-treated animals. These behavioral responses returned to pre-control levels within 3 weeks post rhGDNF administration. Administration of rhGDNF intranigrally increased dopamine, dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) levels of the ipsilateral substantia nigra at 2 and 6 weeks post injection but had no augmenting effects on dopamine or its metabolites in the striatum. Administration of rhGDNF intrastriatally increased DOPAC and HVA levels of the ipsilateral striatum, although striatal dopamine levels were unchanged. Ipsilateral nigral dopamine levels were increased after intrastriatal injection of rhGDNF. The effects of intracranial rhGDNF were not specific to the nigrostriatal dopamine system, since nigrostriatal serotonin, 5-hydroxyindoleacetic acid (5-HIAA), epinephrine and norepinephrine transmitter levels were altered depending on administration route for rhGDNF and dose. Taken together, these data demonstrate long-lasting neurochemical and behavioral changes which suggest that rhGDNF can augment function in adult rat dopamine neurons. Therefore, rhGDNF may have therapeutic potential for Parkinson's disease.

Glial cell line-derived neurotrophic factor: the lateral cerebral ventricle as a site of administration for stimulation of the substantia nigra dopamine system in rats

The direct application of recombinant human glial cell line-derived neurotrophic factor (rhGDNF) to the deep structures of the nigrostriatum has been shown previously to augment dopamine function and inhibit loss of substantia nigra neurons in rodent models of Parkinson's disease. The present studies were designed to determine whether administration of rhGDNF into the lateral ventricle, a more clinically accessible intracranial target, is capable of augmenting dopamine function of the nigrostriatal pathway in normal rats. Single bolus intracerebroventricular (i.c.v) injections of rhGDNF increased locomotor activity and decreased food and water consumption and body weight gain in a dose-dependent manner. rhGDNF increased concentrations of dopamine and dopamine metabolites in the substantia nigra, ventral tegmental area and hypothalamus, but had no significant effects in the striatum. rhGDNF had no effect on striatal or substantia nigral serotonin (5-HT) and 5-hydroxyindoleacetic acid levels, but these levels were significantly increased in the ventral tegmental area and hypothalamus respectively. The augmentation of the dopamine and 5-HT systems was detected 2 weeks but not 3 days or 6 weeks after rhGDNF administration. After a repeat injection of i.c.v rhGDNF (6 weeks after the initial injection), substantia nigral dopamine, 5-HIAA and noradrenalin levels were increased. These results indicate that i.c. v administration of rhGDNF has an influence on adult rat dopamine neurons. This route of administration may be useful for stimulating dopamine neurons in Parkinson's disease.

Frustrating patient visits

OBJECTIVES

This study, part of a national mail survey of dentist malpractice liability claims, reports the reliability and validity of a new 22-item instrument measuring frustrating patient visits.

METHODS

The items were subjected to factor analysis and subscales constructed. Reliability was assessed using Cronbach's alpha. Validity was assessed by comparing subscale scores to self-reports of satisfaction and liability claims.

RESULTS

Factor analysis revealed four subscales representing unpleasant feelings, lack of communication, compliance, and practice organization (alpha = 0.60-0.86). Compliance was the most important factor. Subscale scores were related to satisfaction with practice and the proportion of patient visits in the practice that were frustrating to the dentist. Dentists who reported frustrating patient visits as quite typical of their practices were more likely to have had a malpractice liability claim within the last five years.

CONCLUSION

This instrument may be of value in detecting patient-dentist communication difficulties that are the precursor to liability claims.

A recombinant tail-less integrin beta 4 subunit disrupts hemidesmosomes, but does not suppress alpha 6 beta 4-mediated cell adhesion to laminins

To examine the function of the alpha 6 beta 4 integrin we have determined its ligand-binding ability and overexpressed two potentially dominant negative mutant beta 4 subunits, lacking either the cytoplasmic or extracellular domain, in bladder epithelial 804G cells. The results of cell adhesion and radioligand-binding assays showed that alpha 6 beta 4 is a receptor for several laminin isoforms, including laminin 1, 2, 4, and 5. Overexpression of the tail-less or head-less mutant beta 4 subunit did not suppress alpha 6 beta 4-mediated adhesion to laminins, as both types of transfectants adhered to these ligands in the presence of blocking anti-beta 1 antibodies as well as the controls. However, immunofluorescence experiments indicated that the endogenous alpha 6 beta 4 integrin and other hemidesmosomal markers were not concentrated in hemidesmosomes in cells overexpressing tail-less beta 4, while the distribution of these molecules was not altered in cells overexpressing the head-less subunit. Electron microscopic studies confirmed that cells overexpressing tail-less beta 4 had a drastically reduced number of hemidesmosomes, while cells expressing the head-less subunit had a normal number of these structures. Thus, expression of a tail-less, but not a head-less mutant beta 4 subunit leads to a dominant negative effect on hemidesmosome assembly without suppressing initial adhesion to laminins. We conclude that the alpha 6 beta 4 integrin binds to several laminins and plays an essential role in the assembly and/or stability of hemidesmosomes, that alpha 6 beta 4-mediated adhesion and hemidesmosome assembly have distinct requirements, and that it is possible to use a dominant negative approach to selectively interfere with a specific function of an integrin.

Malpractice claims during 1988-1992: a national survey of dentists

Between 1988 and 1992, almost a quarter of surveyed dentists reported at least one patient complaint to malpractice insurance carriers. The incidence of claims more than doubled in that time and payment size increased nearly five times between 1988 and 1991. These and other trends in professional liability are examined in this national survey of general dentists.

Evaluation of fetal arrhythmias

Fetal arrhythmias occur in approximately 1 to 3 percent of all pregnancies. Successful management depends on early identification and evaluation. Arrhythmias are classified as irregular, bradycardiac or tachycardiac. With proper monitoring, fetuses with irregular arrhythmias can usually be delivered by family physicians. For fetuses with bradyarrhythmias or tachyarrhythmias, referral to a high-risk specialists for ongoing fetal surveillance and delivery is necessary.

The faculty and continuing medical education: an attitude study

Meager or nonexistent faculty reward systems hamper continuing medical education (CME) programs conducted by U.S. medial schools. In light of a growing number of mandatory CME regulations and a consequent increase in physician attendance of CME programs, the need for a competent faculty is apparent. A survey of faculty members designed to ascertain the importance of a faculty reward system was conducted by the University of Washington Division of Continuing Medical Education. Results reveal that faculty members are twice as likely to teach in CME programs outside of the university system as within the system. Survey respondents of nonprofessor rand considered faculty advancement the single greatest source of encouragement to participate in CME programs, yet this participation is seldom considered by the university in evaluations for promotion or tenure. If medical schools are to accept a responsibility for the continuing education of medical professionals, a commitment to provide adequate faculty incentive is imperative.

Lack of agreement between subjective ratings of instructors and objective testing of knowledge acquisition in a urological continuing medical education course

Objective scores from multiple-choice questions before and after a postgraduate course were compared to subjective ratings of the instructors at a 3-day seminar. The objective mean scores after the course were significantly higher than the scores before the course (p less than 0.0001). There was no correlation between test results and subjective ratings of instructors.