Background: Learning health systems (LHSs) iteratively generate evidence that can

Background:The overdose crisis is increasingly characterized by opioid and stimulant co-use. Despite effective pharmacologic treatment for both opioid use disorder (OUD) and contingency management ...

Moral injury is extensively studied among trauma-exposed veterans. Two measurement scales are available to screen for symptoms of moral injury among trauma-exposed veterans; however, no measurement scale exists screening for symptoms of moral injury among trauma-exposed firefighters. The objective of this study aims to address the gap in available instruments by developing a moral injury assessment scale for firefighters. Through this project, a psychometrically accepted moral injury scale will be available to researchers, clinicians, and fire organizations to assess moral injury in trauma-exposed firefighters. Military studies found that moral injury and posttraumatic stress disorder (PTSD) are distinct constructs and can co-exist. PTSD is prevalent in firefighters and despite subject experts expressing the need to expand research efforts to first responders (e.g., firefighters), no moral injury scale is available assessing these symptoms. Exploratory themes are recently emerging in these occupations. The EMIS-F yielded almost perfect interrater reliability across raters (.97). Psychometric properties of the EMIS-F were comparable to the military version, yielding excellent internal consistency (ω = 0.94), in addition to the self-directed (ω = 0.92) and others-directed (ω = 0.89) moral injury subscales. Inter-item and item-total correlations are within acceptable ranges (ρ = 0.30–0.73) to empirically conclude the EMIS-F measures a unidimensional construct. Item-total correlations did not detract from the consistency of the overall scale and independently demonstrated positive correlations with the EMIS-F (ρ = .62–79). The EMIS-F demonstrated strong convergent validity with validated measures of PTSD (ρ = .61), depression (ρ = .50), and suicide ideation (ρ = .38), and evidence of divergent validity with strong support systems (ρ =  − .14).

COVID-19 continues to be a public health concern in the United States. Although safe and effective vaccines have been developed, a significant proportion of the US population has not received a COVID-19 vaccine. This cross-sectional study aimed to describe the demographics and behaviors of Minnesota adults who have not received the primary series of the COVID-19 vaccine, or the booster shot using data from the Minnesota COVID-19 Antibody Study (MCAS) collected through a population-based sample between September and December 2021. Data were collected using a web-based survey sent to individuals that responded to a similar survey in 2020 and their adult household members. The sample was 51% female and 86% White/Non-Hispanic. A total of 9% of vaccine-eligible participants had not received the primary series and 23% of those eligible to receive a booster had not received it. Older age, higher education, better self-reported health, $75,000 to $100,000 annual household income, mask-wearing, and social distancing were associated with lower odds of hesitancy. Gender, race, and previous COVID-19 infection were not associated with hesitancy. The most frequently reported reason for not receiving a COVID-19 vaccination was safety concerns. Mask-wearing and being age 65 or older were the only strong predictors of lower odds of vaccine hesitancy for both the primary series and booster analyses.

Objective:We sought to understand the relative impact of fielding mode on response rate among public health alumni.Methods:As part of the 2021 Career Trends Survey of alumni from the University of ...

Grocery workers were essential to the workforce and exempt from lockdown requirements as per Minnesota Executive Order 20–20. The risk of COVID-19 transmission in grocery settings is not well documented. This study aimed to determine which factors influenced seropositivity among grocery workers. We conducted a cross-sectional study of Minnesota grocery workers aged 18 and older using a convenience sample. Participants were recruited using a flyer disseminated electronically via e-mail, social media, and newspaper advertising. Participants were directed to an electronic survey and were asked to self-collect capillary blood for IgG antibody testing. Data were analyzed using logistic regression and adjusted for urbanicity, which confounded the relationship between number of job responsibilities in a store and seropositivity. Of 861 Minnesota grocery workers surveyed, 706 (82%) were tested as part of this study, of which 56 (7.9%) tested positive for IgG antibodies. Participants aged 65–74 years had the highest percent positivity. Having multiple job responsibilities in a store was significantly associated with seropositivity in our adjusted model (OR: 1.14 95% CI: 1.01–1.27). Workplace factors influenced seropositivity among Minnesota grocery workers. Future research will examine other potential factors (e.g., in-store preventive measures and access to PPE) that may contribute to increased seropositivity.

Background: Non-random non-response bias in surveys requires time-consuming, complicated, post-survey analyses. Our goal was to see if modifying cover letter information would prevent non-random non-response bias altogether. Our secondary goal tested whether larger incentives would reduce non-response bias. Methods: A mailed, survey of 480 male and 480 female, nationally representative, Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND) Veterans applying for Department of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD). Cover letters conveyed different information about the survey’s topics (combat, unwanted sexual attention, or lifetime and military experiences), how Veterans’ names had been selected (list of OEF/OIF/OND Veterans or list of Veterans applying for disability benefits), and what incentive Veterans would receive ($20 or $40). The main outcome, non-response bias, measured differences between survey respondents’ and sampling frame’s characteristics on 8 administrative variables, including Veterans’ receipt of VA disability benefits and exposure to combat or military sexual trauma. Analysis was intention to treat. We used ANOVA for factorial block-design, logistic, mixed-models to assess bias and multiple imputation and expectation-maximization algorithms to assess potential missing mechanisms (missing completely at random, missing at random, or not random) of two self-reported variables: combat and military sexual assault. Results: Regardless of intervention, men with any VA disability benefits, women with PTSD disability benefits, and women with combat exposure were over-represented among respondents. Interventions explained 0.0 to 31.2% of men’s variance and 0.6 to 30.5% of women’s variance in combat non-response bias and 10.2 to 43.0% of men’s variance and 0.4 to 31.9% of women’s variance in military sexual trauma non-response bias. Non-random assumptions showed that men’s self-reported combat exposure was overestimated by 19.0 to 28.8 percentage points and their self-reported military sexual assault exposure was underestimated by 14.2 to 28.4 percentage points compared to random missingness assumptions. Women’s self-reported combat exposure was overestimated by 8.6 to 10.6 percentage points and military sexual assault exposure, by 1.2 to 6.9 percentage points. Conclusions: Our interventions reduced bias in some characteristics, leaving others unaffected or exacerbated. Regardless of topic, researchers are urged to present estimates that include all three assumptions of missingness.

Objective A learning health system (LHS) uses data to generate evidence and answer questions required to continually improve system performance and patient care. Given the complexities of practice transformation, an area where LHS is particularly important is the study of primary care transformation (PCT) as PCT generates several practice-level questions that require study where the findings can be readily implemented. In May 2019, a large integrated health delivery system in Minnesota began implementation of a population management PCT in two of its 40 primary care clinics. In this model of care, patients are grouped into one of five service bundles based on their complexity of care; patient appointment lengths and services provided are then tailored to each service bundle. The objective of this study was to examine the use of a LHS in PCT by utilising the Consolidated Framework for Implementation Research (CFIR) to categorise implementation lessons from the initial two PCT clinics to inform further implementation of the PCT within the health system. Design This was a formative evaluation in which semistructured qualitative interviews were carried out. Observational field notes were also taken. Inductive coding of the data was performed and resultant codes were mapped to the CFIR. Setting Two suburban primary care clinics in the Twin Cities, Minnesota. Participants Twenty-two care team members from the first two clinics to adopt the PCT. Results Seventeen codes emerged to describe care team members’ perceived implementation influences. Codes occurred in each of the five CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals and process), with most codes occurring in the ‘inner setting’ domain. Conclusions Using an LHS approach to determine early-stage implementation influences is key to guiding further PCT implementation, understanding modifications that need to be made and additional research that needs to occur. Data are available upon reasonable request.

Importance Identification of SARS-CoV-2 infection via antibody assays is important for monitoring natural infection rates. Most antibody assays cannot distinguish natural infection from vaccination. Objective To assess the accuracy of a nucleocapsid-containing assay in identifying natural infection among vaccinated individuals. Design A longitudinal cohort comprised of healthcare workers (HCW) in the Minneapolis/St. Paul metropolitan area was enrolled. Two rounds of seroprevalence studies separated by one month were conducted from 11/2020-1/2021. Capillary blood from round 1 and 2 was tested for IgG antibodies against SARS-CoV-2 spike proteins with a qualitative chemiluminescent ELISA (spike-only assay). In a subsample of participants (n=82) at round 2, a second assay was performed that measured IgGs reactive to SARS-CoV-2 nucleocapsid protein (nucleocapsid-containing assay). Round 1 biospecimen collections occurred prior to vaccination in all participants. Vaccination status at round 2 was determined via self-report. Setting The Minneapolis/St. Paul, Minnesota metropolitan area. Participants HCW age 18-80 years. Exposures Round 1 recent SARS-CoV-2 infection assessed via a spike-only assay and participant self-report. Outcomes Round 2 SARS-CoV-2 infection assessed via the nucleocapsid-containing assay. Area under the curve (AUC) was computed to determine the discriminatory ability of round 2 IgG reactivity to nucleocapsid for identification of recent infection determined during round 1. Results Participants had a mean age of 40 (range=23-66) years, 83% were female, 46% reported vaccination prior to the round 2 testing. Round 1 seroprevalence was 9.5%. Among those not recently infected, when comparing vaccinated vs. unvaccinated individuals, elevated levels of spike 1 (p<0.001) and spike 2 (p=0.01) were observed while nucleocapsid levels were not statistically significantly different (p=0.90). Among all participants, nucleocapsid response predicted recent infection with an AUC(95%CI) of 0.93(0.88,0.99). Among individuals vaccinated >10 days prior to antibody testing, the specificity of the nucleocapsid-containing assay was 92% and while the specificity of the spike-only assay was 0%. Conclusions and Relevance An IgG assay identifying reactivity to nucleocapsid protein is an accurate predictor of natural infection among vaccinated individuals while a spike-only assay performed poorly. In the era of SARS-CoV-2 vaccination, seroprevalence studies monitoring natural infection will require assays that do not rely on spike-protein response alone.

BACKGROUND: Due to the US opioid epidem

Background The Centers for Disease Control and Prevention (CDC) issued guidelines and certain healthcare payers have made pharmacy coverage changes (PCC) focusing on regulating prescription opioids. Aim We evaluated differences in the rate of first-time opioid fills at doses ≥ 50 morphine milligram equivalents (MME)/day and first-time opioid fills with benzodiazepine fill overlap following the CDC guidelines and following a PCC between provider types, geographic locations, and insurance types. Method We used OptumLabs® Data Warehouse claims data between 2014 and 2018. Subjects were opioid naïve non-cancer care patients, 18 years and older who had an identified chronic pain condition ICD diagnosis within 2 weeks prior to their first-time opioid fill. We used multiple treatment period segmented regression analysis with interaction terms to test the differences between primary care providers (PCPs) and specialist providers (SPs), urban and rural primary care service areas (PCSAs), and Medicare Advantage (MA) and commercially insured patients (CIPs) in their first-time opioid fill patterns. Results Prescribing first-time opioid fills at doses ≥ 50MME/day declined following the CDC guidelines and PCC, the decline was greater among SPs than PCPs and in rural PCSAs than urban PCSAs. Also, following the CDC guidelines, the decline was greater among MA patients however following the PCC the decline was greater among CIPs. There were no differences in rate of first-time opioid fill with benzodiazepine overlap between groups. Conclusion Responses to the CDC opioid guidelines and a PCC differed between PCPs and SPs, urban and rural PCSAs, and when prescribing to MA and CIPs. Understanding these differences is important to help inform future guidelines.

Despite overall declines in cancer mortality in the USA over the past three decades, many patients in community settings fail to receive evidence-based cancer care. Networks that link academic medical centers (AMCs) and community providers may reduce disparities by creating access to specialized expertise and care, but research on network effectiveness is mixed. The objective of this study was to identify factors related to whether and how an exemplar AMC network served to provide advice and referral access in community settings. An embedded in–depth single case study design was employed to study a network in the Midwest USA that connects a leading cancer specialty AMC with community practices. The embedded case units were a subset of 20 patients with young-onset colorectal cancer or risk-related conditions and the providers involved in their care. The electronic health record (EHR) was reviewed from January 1, 1990, to February 28, 2018. Social network analysis identified care, advice, and referral relationships. Within-case process tracing provided detailed accounts of whether and how the network provided access to expert, evidence-based care or advice in order to identify factors related to network effectiveness. The network created access to evidence-based advice or care in some but not all case units, and there was variability in whether and how community providers engaged the network, including the path for referrals to the AMC and the way in which advice about an evidence-based approach to care was communicated from AMC specialists to community providers. Factors related to instances when the network functioned as intended included opportunities for both rich and lean communication between community providers and specialists, coordinated referrals, and efficient and adequately utilized documentation systems. Network existence alone is insufficient to open up access to evidence-based expertise or care for patients in community settings. In-depth understanding of how this network operated provides insight into factors that support or inhibit the potential of networks to minimize disparities in access to evidence-based community cancer care, including both personal and organizational factors.

The study tests the effects of data collection modes on patient responses associated with the multi-item measures such as Patient-Reported Outcomes Measurement System (PROMIS®), and single-item measures such as Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE), and Numerical Rating Scale (NRS) measures. Adult cancer patients were recruited from five cancer centers and administered measures of anxiety, depression, fatigue, sleep disturbance, pain intensity, pain interference, ability to participate in social roles and activities, global mental and physical health, and physical function. Patients were randomized to complete the measures on paper (595), interactive voice response (IVR, 596) system, or tablet computer (589). We evaluated differential item functioning (DIF) by method of data collection using the R software package, lordif. For constructs that showed no DIF, we concluded equivalence across modes if the equivalence margin, defined as ± 0.20 × pooled SD, completely surrounds 95% confidence intervals (CI's) for difference in mean score. If the 95% CI fell totally outside the equivalence margin, we concluded systematic score difference by modes. If the 95% CI partly overlaps the equivalence margin, we concluded neither equivalence nor difference. For all constructs, no DIF of any kind was found for the three modes. The scores on paper and tablet were more comparable than between IVR and other modes but none of the 95% CI’s were completely outside the equivalence margins, in which we established neither equivalence nor difference. Percentages of missing values were comparable for paper and tablet modes. Percentages of missing values were higher for IVR (2.3% to 6.5% depending on measures) compared to paper and tablet modes (0.7% to 3.3% depending on measures and modes), which was attributed to random technical difficulties experienced in some centers. Across all mode comparisons, there were some measures with CI’s not completely contained within the margin of small effect. Two visual modes agreed more than visual-auditory pairs. IVR may induce differences in scores unrelated to constructs being measured in comparison with paper and tablet. The users of the surveys should consider using IVR only when paper and computer administration is not feasible.

Purpose We tested the hypothesis that clinician knowledge, clinician barriers, and perceived parental barriers relevant to the human papillomavirus (HPV) vaccination account for the variation in vaccine delivery at the practice-site level. Methods We conducted a survey from October 2015 through January 2016 among primary care clinicians (n = 280) in a 27-county geographic region to assess clinician knowledge, clinician barriers, and perceived parental barriers regarding HPV vaccination. Primary care clinicians included family medicine physicians, general pediatricians, and family and pediatric nurse-practitioners. We also used the Rochester Epidemiology Project to measure HPV vaccination delivery. Specifically we used administrative data to measure receipt of at least one valid HPV vaccine dose (initiation) and receipt of three valid HPV vaccine doses (completion) among 9–18 year old patients residing in the same 27-county geographic region. We assessed associations of clinician survey data with variation in vaccine delivery at the clinical site using administrative data on patients aged 9–18 years (n = 68,272). Results Consistent with our hypothesis, we found that greater knowledge of HPV and the HPV vaccination was associated with higher rates of HPV vaccination initiation (Incidence rate ratio [IRR] = 1.05) and completion of three doses (IRR = 1.28). We also found support for the hypothesis that greater perceived parental barriers to the HPV vaccination were associated with lower rates of initiation (IRR = 0.94) and completion (IRR = 0.90). These IRRs were statistically significant even after adjustment for site-level characteristics including percent white, percent female, percent ages 9–13, and percent with government insurance or self-pay at each site. Conclusions Clinician knowledge and their report of the frequency of experiencing parental barriers are associated with HPV vaccine delivery rates—initiation and completion. Higher measures of knowledge correlated with higher rates. Fewer perceived occurrences of parental barriers correlated with lower rates. These data can guide efforts to improve HPV vaccine delivery in clinical settings.

BACKGROUND Although the Affordable Care Act has been successful in expanding Medicaid to >17 million people, insurance alone may not translate into access to health care. Even among the insured, substantial barriers to accessing services inhibit health care utilization. OBJECTIVES We examined the effect of selected barriers to health care access and the magnitude of those barriers on health care utilization. RESEARCH DESIGN Data come from a 2008 survey of adult enrollees in Minnesota's public health care programs. We used multivariate logistic regression to estimate the effects of perceived patient, provider, and system-level barriers on past year delayed, foregone, and lack of preventive care. SUBJECTS A total of 2194 adults enrolled in Minnesota Health Care Programs who were mostly female (66%), high school graduates (76%), unemployed (62%), and living in metro areas (67%) were included in the analysis. RESULTS Reporting problems across all barriers increased the odds of delayed care from 2 times for provider-related barriers (OR=2.0; 95% CI, 1.2-3.3) to >6 times for access barriers (OR=6.2; 95% CI, 3.8-10.2) and foregone care from 2.6 times for family/work barriers (OR=2.6; 95% CI, 1.3-5.1) to >7 times for access barriers (OR=7.1; 95% CI, 3.9-13.1). Perceived discrimination was the only barrier consistently associated with all 3 utilization outcomes. CONCLUSIONS Multiple types of barriers are associated with delayed and foregone care. System-level barriers and discrimination have the greatest effect on health care seeking behavior.

OBJECTIVE: To examine the effect of survey mode (mail vs. telephone) on the likelihood of reporting health care-related discrimination based on race, ethnicity, or nationality. METHODS: We use data from a mixed-mode, mail and telephone survey of public health care program enrollees (N=2807), including Somali, Hmong, African American, American Indian, and Latino populations. Self-reported discrimination was measured as the experience of unfair treatment by health care providers due to race, ethnicity, or nationality. We use propensity score matching to create exchangeable groups of phone and mail respondents based on the probability of completing the survey by phone. RESULTS: Overall, 33.1% of respondents reported having experienced discrimination in health care, but only 23.6% of telephone respondents reported discrimination compared with 36.8% of mail respondents. After matching phone and mail respondents based on probability of responding by telephone, all observable significant differences between respondents that were brought about by differential self-selection into mode were erased, allowing us to estimate the effect of survey mode on report of discrimination. Even after matching, the mode effect remains, where report of health care discrimination for telephone respondents would have been 12.6 percentage points higher had they responded by mail (22.6% vs. 35.2%). CONCLUSIONS: Survey mode has a significant effect on report of discrimination. Respondents may be more willing to disclose experiences of discrimination in a mail survey than to a telephone interviewer. Findings have substantial policy and clinical significance as variation in report of discrimination based on mode may lead to underestimation of the extent of the problem.