Ambulatory Health Care Research Articles

Impact of COVID-19 on Jobs in Ohio's Health Care Sector

Background: This study seeks to measure the impact of COVID-19 on health care jobs in Ohio. We examine whether health care sector workers were similarly affected compared to workers in other industries in Ohio and if there were any significant differences in job categories within the health care sector. Methods: Using a rich dataset provided by the Ohio Department of Job and Family Services (ODJFS), we study the employment levels for different health care subsectors in Ohio by calculating job creation, destruction, and reallocation rates and analyze the disruption in labor markets caused by COVID-19. Results: Certain health care subsectors such as ambulatory health care services and hospitals recovered almost immediately after the lockdown but are still below their pre-COVID-19 employment levels. The social assistance subsector eventually recovered but also has not reached its pre-COVID-19 employment level. The nursing and residential care subsector has experienced a continuous decline in jobs. Although both job creation and destruction rates reached their relative peaks for all health care subcategories, the gap between pre-COVID-19 and post-COVID-19 levels was higher for job destruction rate. Conclusion: Ohio’s health care sector has not yet fully recovered from the COVID-19 lockdown imposed in 2020.

Telemedicine perceptions and experiences of socially vulnerable households during the early stages of the COVID-19 pandemic: a qualitative study.

Early in the COVID-19 pandemic, efforts to decrease risk of viral transmission triggered an abrupt shift from ambulatory health care delivery toward telemedicine. In this study, we explore the perceptions and experiences of telemedicine among socially vulnerable households and suggest strategies to increase equity in telemedicine access. Conducted between August 2020 and February 2021, this exploratory qualitative study involved in-depth interviews with members of socially vulnerable households needing health care. Participants were recruited from a food bank and primary care practice in Montréal. Digitally recorded telephone interviews focused on experiences and perceptions related to telemedicine access and use. In our thematic analysis, we employed the framework method to facilitate comparison, and the identification of patterns and themes. Twenty-nine participants were interviewed, 48% of whom presented as women. Almost all sought health care in the early stages of the pandemic, 69% of which was received via telemedicine. Four themes emerged from the analysis: delays in seeking health care owing to competing priorities and perceptions that COVID-19-related health care took precedence; challenges with appointment booking and logistics given complex online systems, administrative inefficiencies, long wait times and missed calls; issues around quality and continuity of care; and conditional acceptance of telemedicine for certain health problems, and in exceptional circumstances. Early in the pandemic, participants report telemedicine delivery did not accommodate the diverse needs and capacities of socially vulnerable populations. Patient education, logistical support and care delivery by a trusted provider are suggested solutions, in addition to policies supporting digital equity and quality standards to promote telemedicine access and appropriate use.

A smoking cessation intervention for people with severe mental illness treated in ambulatory mental health care (KISMET): study protocol of a randomised controlled trial

BackgroundSmoking among people with severe mental illness (SMI) is highly prevalent and strongly associated with poor physical health. Currently, evidence-based smoking cessation interventions are scarce and need to be integrated into current mental health care treatment guidelines and clinical practice. Therefore, the present study aims to evaluate the implementation and effectiveness of a smoking cessation intervention in comparison with usual care in people with SMI treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands.MethodsA pragmatic, cluster-randomised controlled trial with embedded process evaluation will be conducted. Randomisation will be performed at the level of FACT teams, which will be assigned to the KISMET intervention or a control group (care as usual). The intervention will include pharmacological treatment combined with behavioural counselling and peer support provided by trained mental health care professionals. The intervention was developed using a Delphi study, through which a consensus was reached on the core elements of the intervention. We aim to include a total of 318 people with SMI (aged 18–65 years) who smoke and desire to quit smoking. The primary outcome is smoking status, as verified by carbon monoxide measurements and self-report. The secondary outcomes are depression and anxiety, psychotic symptoms, physical fitness, cardiovascular risks, substance use, quality of life, and health-related self-efficacy at 12 months. Alongside the trial, a qualitative process evaluation will be conducted to evaluate the barriers to and facilitators of its implementation as well as the satisfaction and experiences of both patients and mental health care professionals.DiscussionThe results of the KISMET trial will contribute to the evidence gap of effective smoking cessation interventions for people treated by FACT teams. Moreover, insights will be obtained regarding the implementation process of the intervention in current mental health care. The outcomes should advance the understanding of the interdependence of physical and mental health and the gradual integration of both within the mental health care system.Trial registrationNetherlands Trial Register, NTR9783. Registered on 18 October 2021.

Antibiotic Prescription Patterns for Acute Respiratory Infections in Rural Primary Healthcare Settings in Guangdong, China: Analysis of 162,742 Outpatient Prescriptions

Overuse and inappropriate use of antibiotics are important contributors to bacterial antimicrobial resistance (AMR), especially in ambulatory primary healthcare (PHC) settings in low- and middle-income countries. This study aimed to investigate antibiotic prescription patterns among patients with acute respiratory infections (ARIs) in rural PHC facilities in the Guangdong Province, China. A total of 444,979 outpatient prescriptions were extracted from the electronic medical record system of 35 township health centers (THCs) and 2 community health centers (CHCs) between November 2017 and October 2018. We used the chi-square test to analyze the antibiotic prescription patterns and binary logistic regression to explore patient-related factors associated with antibiotic prescriptions. Of the 162,742 ARI prescriptions, 85.57% (n = 139,259) included at least one antibiotic. Among the 139,259 prescriptions with antibiotics, 37.82% (n = 52,666) included two or more antibiotics, 55.29% (n = 76,993) included parenteral antibiotics, and 56.62% (n = 78,852) included Watch group antibiotics. The binary logistic regression indicated that (1) female patients were slightly less likely to be prescribed antibiotics than males (adjusted odds ratio (OR) = 0.954, 95% confidence interval [CI] [0.928-0.981]; p = 0.001); and (2) compared to patients aged ≤5 years, those who were 6-15 years old (adjusted OR = 1.907, 95% CI [1.840-1.978]; p < 0.001), 16-60 years old (adjusted OR = 1.849, 95% CI [1.785-1.916]; p < 0.001), and >60 years old (adjusted OR = 1.915, 95% CI [1.810-2.026]; p < 0.001) were more likely to be prescribed antibiotics. The overuse and irrational use of antibiotics in PHC settings remain major healthcare challenges in rural Guangdong. Thus, it is imperative to implement targeted antimicrobial stewardship (AMS) policies to address this problem.

Prevalence of non-alcoholic fatty liver disease in overweight and obese children seeking ambulatory healthcare in Nairobi, Kenya

BackgroundWhile linked to obesity and associated with an increased cardiovascular morbidity, non-alcoholic fatty liver disease (NAFLD) is an often-asymptomatic cause of chronic liver disease in children. Early detection provides opportunity...

A Stepped Health Services Intervention to Improve Care for Mental and Neurological Diseases: Protocol for a Prospective Cohort Trial

Mental and neurological disorders cause a large proportion of morbidity burden and require adequate health care structures. However, deficits in the German health care system like long waiting times for access to specialized care and a lack of coordination between health care providers lead to suboptimal quality of care and elevated health care costs. To overcome these deficits, we implement and evaluate a unique stepped and coordinated model of care (the Neurologisch-psychiatrische und psychotherapeutische Versorgung [NPPV] program) for patients with mental and neurological diseases. Patients included in the program receive an appropriate treatment according to medical needs in a multiprofessional network of ambulatory health care providers. The therapy is coordinated by a managing physician and complemented by additional therapy modules, such as group therapy, internet-based cognitive behavioral therapy, and a case management. Statutory health insurance (SHI) routine data and data from a longitudinal patient survey will be used to compare the program with regular care and evaluate SHI expenditures and patient-related outcomes. A health care provider survey will evaluate the quality of structure and processes and provider satisfaction. Finally, an analysis of ambulatory claims data and drug prescription data will be used to evaluate if health care providers follow a needs-led approach in therapy. Ethics approval for this trial was obtained from the ethics committee of the chamber of physicians in North Rhine (September 13, 2017, reference No. 2017287). Patient enrollment of NPPV ended in September 2021. Data analysis has been completed in 2022. The results of this study will be disseminated through scientific publications, academic conferences, and a publicly available report to the German Federal Joint Committee, which is expected to be available in the first half of 2023. The NPPV program is the first intervention to implement a stepped model of care for both mental and neurological diseases in Germany. The analysis of several data sources and a large sample size (more than 14,000 patients) enable a comprehensive evaluation of the NPPV program. German Clinical Trials Register DRKS00022754; https://tinyurl.com/3mx9pz5z. DERR1-10.2196/37569.

Evaluating the impact of community health worker certification in Massachusetts: Design, methods, and anticipated results of the Massachusetts community health worker workforce survey.

Professional certification of community health workers (CHWs) is a debated topic. Although intended to promote CHWs, certification may have unintended impacts given the grassroots nature of the workforce. As such, both intended effects and unintended adverse effects should be carefully evaluated. However, there is a lack of published literature describing such effective evaluations with a robust methodology. In this methods paper, we describe a key component of evaluating CHW certification in Massachusetts-the Massachusetts CHW Workforce Survey. Design of the surveys was informed by a program theory framework that delineated both positive and negative potential impacts of Massachusetts CHW certification on CHWs and CHW employers. Using this framework, we developed measures of interest and preliminary CHW and CHW employer surveys. To validate and refine the surveys, we conducted cognitive interviews with CHWs and CHW employers. We then finalized survey tools with input from state and national stakeholders, CHWs, and CHW employers. Our sample consisted of three frames based on where CHWs are most likely to be employed in Massachusetts: acute care hospitals, community-based organizations, and ambulatory care health centers, primarily community health centers and federally qualified health centers. We then undertook extensive outreach efforts to determine whether each organization employed CHWs and to obtain CHW and CHW employer contact information. Our statistical analysis of the data utilized inverse probability score weighting accounting for organizational, site, and individual response. Wave one of the survey was administered in 2016 prior to launch of Massachusetts CHW certification and wave two in 2021. We report descriptive statistics of the three sample frames and response rates of each survey for each wave. Further, we describe select anticipated results related to certification, including outcomes of the program theory framework. The Massachusetts CHW Workforce Survey is the culmination of 5 years of effort to evaluate the impact of CHW certification in Massachusetts. Our comprehensive description of our methodology addresses an important gap in CHW research literature. The rigorous design, administration, and analysis of our surveys ensure our findings are robust, valid, and replicable, which can be leveraged by others evaluating the CHW workforce.

Charting a new path forward for pharmacy residency expansion

AbstractA core component of the vision of the American College of Clinical Pharmacy (ACCP) for the profession is that most pharmacists will provide direct patient care. Residency training programs are considered a prerequisite to meet the standards and competencies required for pharmacists providing direct patient care. Barriers to residency training expansion are numerous and include, but are not limited to, lack of funding, challenges in meeting accreditation standards for residency programs, limited practice sites, and lack of qualified preceptors. The demand for postgraduate year one (PGY1) and postgraduate year two (PGY2) pharmacy residency training has exceeded position availability over the past 10 years. The American Society of Health‐System Pharmacists (ASHP) Foundation Pharmacy Forecast 2021 predicts pharmacy expansion within ambulatory care, population health, specialty pharmacy, and home care. To promote pharmacy residency expansion and maintenance of pharmacy residency quality, this commentary makes four recommendations with specific actions for consideration: develop preceptors and promote board certification, promote and foster innovation in residency training, expand residency training to address health equity with a focus on rural/underserved areas, and expand nontraditional residency training programs.

Posúdenie rizikových faktorov pádu u pacientov v ambulantnej starostlivosti

Objective: To identify risk factors for falls in ambulatory health care. Methodology: We carried out the research in a general practitioner’s clinic in the period from January 2021 to June 2021. The file consisted of 937 respondents who completed a preventive examination. We used the fall risk screening test and the Morse Fall Scale. Data were processed using multiple regression analysis (p &lt; 0.05). Results: The average increasing age of patients is the most significant fall risk factor. We found a statistical dependence between age (≥ 75 years) and the risk of falling. Gender is not statistically significant. We identified an average risk of falling in the our sample. Comorbidity and medication were the most frequently occurring risk factors for falls in the research sample. Conclusion: Fall risk assessment in ambulatory care will become an essential part of comprehensive care. We consider the implementation of this nurse competence to be an activity of a preventive nature with a focus on the creation of programs for the prevention of falls in all forms of health care, including patient education.

Provider and patient perspectives to improve lung cancer screening with low-dose computed tomography 5 years after Medicare coverage: a qualitative study

Lung cancer remains the leading cause of cancer-related deaths for both men and women in the U.S., yet uptake of preventive cancer screening for people with a heavy smoking history remains low. This qualitative interview study of patients and providers from a large ambulatory healthcare system in northern and central California reevaluated perceptions of lung cancer screening with low-dose computed tomography (LCS-LDCT) 5 years after Medicare coverage. We hypothesized that initial attitudes and barriers within the LCS-LDCT discussion and process have likely persisted with little change since Medicare coverage and we sought to understand how these attitudes continue to impact effective implementation and uptake of screening with the goal of identifying opportunities for improvement. Between 2019 and 2020, interviews were conducted with 10 primary care physicians and 30 patients using semi-structured interview guides. Providers and patients expressed that they were both aware and supportive of LCS-LDCT, a change from earlier studies, but continued to report little to no shared decision making nor use of a decision aid despite being Medicare requirements. Creation and incorporation of a single-page, graphic heavy decision aid may help address many of the persistent barriers around implementation for both providers and patients. Given recently expanded guidelines from the U.S. Preventive Services Task Force for LCS-LDCT screening and their coverage by Medicare, it is important for healthcare systems to understand provider and patient perceptions to further improve the implementation of LCS-LDCT to ultimately reduce lung cancer mortality.

The prevalence and correlates of depression among patients with chronic diseases in the United Arab Emirates.

Chronic diseases constitute a major public health problem in the United Arab Emirates (UAE) and are the leading cause of mortality and morbidity. Chronic diseases have been found to be associated with an increased prevalence of depression and depressive symptoms. Depression can have detrimental effect on the prognosis of the disease and quality of life in patients. This study aimed to estimate the prevalence and correlates of depression in a sample of patients suffering from chronic disease in Al-Ain city, UAE. A cross-sectional survey based study was conducted with 417 participants recruited from seven primary health care centers of Al-Ain city. Men and women aged 18 years and above suffering from chronic disease filled the Patient Health Questionnaire (PHQ-9). Univariate and multivariable logistic regressions were performed on the collected data to investigate correlates of different factors with depression. Data was analyzed using SPSS (version 26). The study was approved by Ambulatory Healthcare Services (AHS) Human Ethics Research Committee. The majority 62.41% (n = 254) of the sample were females, 57.97% (n = 240) aged above 55 years and with a median (Q25, Q75) duration of chronic disease of 8 (4, 15) years. The prevalence of depression was 21.1% (95% CI: 17.5%-25.3%). With severe depression was in 1.7% and mild-moderate in 34.7% of the participants. Depression severity was statistically significantly associated with increasing age (p = 0.006), low level of education (p<0.001), presence of asthma (p = 0.007) and heart disease (p = 0.013). Unadjusted logistic regression reported that presence of depression was significantly associated with female gender (cOR = 1.8, [95% CI; 1.1-3.1], p = 0.025), and presence of chronic kidney disease (cOR = 4.9, [95% CI; 1.3-20.2], p = 0.020) and heart disease (cOR = 2.9, [95% CI; 1.6-5.4], p = 0.001) longer duration of disease in years (cOR = 1.04, [95% CI; 1.01-1.07], p = 0.003). However, in the adjusted logistic regression analysis, participants with heart disease (aOR = 2.8, [95% CI; 1.4-5.5], p = 0.004), and with longer duration of disease (aOR = 1.04, [1.01-1.07], p = 0.014) remained significantly associated statistically with higher chance of having depression. The prevalence of depression was quite high and the study highlights for health care professionals and policy makers, the importance of mental health support as part of a comprehensive management plan for patients with chronic diseases. A multidisciplinary comprehensive program will improve the long-term outcomes of these patients. Patients with chronic diseases may need more support and counseling at primary health care levels.

Australian older persons mental health inpatient and ambulatory services in 2015-2020 - A descriptive analysis and commentary.

To provide a commentary on Australian state/territory older persons mental health service (OPMHS) expenditure, inpatient and outpatient services and key performance indicators (KPIs). Descriptive analysis of data from the Australian Institute of Health and Welfare (AIHW), the Australian Bureau of Statistics and the World Health Organisation. Between 2015-16 and 2019-20, annual expenditure on OPMHS in Australia increased by an average of only 2.3%, compared to 2.9% for all population groups, despite an increase in the number of over 65 year olds. Per capita recurrent expenditure on OPMHS decreased by an average of 1% annually. Australia's total mental health beds increased, whereas OPMHS beds decreased, mainly due to a reduction in non-acute beds. Outcomes for OPMHS admissions were similar to other age groups, except for a longer length of stay and reduced readmission rate. Older Australians accessed ambulatory mental health care at a lower rate and had a lower rate of improvement after a completed episode. OPMHS expenditure has not increased at commensurate levels compared to other populations. The mental health of people aged over 65 appears to be a neglected policy priority in Australia. The Royal Commission into Aged Care Quality and Safety may herald service and expenditure changes.

Characteristics of desirable ambulatory health and oral healthcare from the perspective of community-dwelling people aged 80 and over-a qualitative examination.

people aged 80 and over frequently have diverse and complex health trajectories, which has been well studied. But their oral health is seldom included in care models. To realise comprehensive healthcare, both general and oral ambulatory (i.e. outpatient) healthcare need to be explored and conceptualised equally. to elicit what matters to very old people regarding ambulatory health and oral healthcare. interviews were conducted with non-institutionalised people aged 80 and over living in the area of Cologne, Germany. They were interviewed regarding their experiences of and views on ambulatory healthcare and oral healthcare care, respectively. Thematic analysis was performed to understand their motives and elicit relevant characteristics of desirable health services. from the interviews with 22 participants, 16 characteristics of good healthcare were described. These were generally similar for both general and oral healthcare and had a particular focus on patient-provider interaction and the organisation of care. However, regarding oral healthcare, the participants focused more strongly on the technical-medical skills of professionals and the perceptible treatment results and were more concerned about costs. It was noticeable that older people had the urge to differentiate themselves from 'others unnecessarily using health services'. They were unaware of possible future oral health deterioration and the resulting future needs. characteristics of good health and oral healthcare from the perspective of older people should be incorporated to ensure patient-centredness in care models. Older patients, as well as healthcare providers, need to be sensitised to their oral health needs to realise comprehensive healthcare.

Exploring determinants and regional variation of diagnostic imaging utilization rates in German inpatient care

IntroductionGermany ranks high concerning the per capita supply of computer tomographs (CT) and positron emission tomographs (PET) which may incentivize supply-induced use. Beyond that, international comparison shows high per capita examinations. However, misuse of diagnostic imaging may cause harm to patients and the health care system. The use of diagnostic imaging in Germany has been insufficiently studied so far. Therefore, the study aimed to determine the extent of regional differences as well as supply and demand side factors of per capita CT and PET examinations in German inpatient care. MethodsCartographic visualizations and a random intercept model controlling for the regional disease burden, ambulatory provided supply and demand, and population deprivation between 2010 and 2017 for CT and between 2016 and 2017 for PET were applied. For this purpose, the Nationwide hospital discharge data (DRG statistics), hospital structured quality reports, the National Association of Statutory Health Insurance Physicians, the Central Research Institute of Ambulatory Health Care in Germany, and the German Index of Socioeconomic Deprivation were used. ResultsWe found a substantial regional variation of examination rates (–63 to +108% for CT and from –94 up to +847% for PET). Regarding PET, the supply structures have a significant impact on examinations per 1,000 inhabitants (28.46, p < .000). Both devices were used in correlation with the regional disease burden. Ambulatory and inpatient CT examination rates were positively associated. DiscussionThe regional differences identified are to some extent attributable to the regional burden of disease and thus warranted. Although the inpatient PET supply influences utilization rates, the direction of the effect should be investigated more closely for valid statements. The findings in terms of CT should be treated with caution. The cartographic distribution and examination rates indicate global overuse. The clear separation of inpatient and ambulatory sectors leads to misallocation of scarce resources, medically unnecessary multiple examinations, and capacity utilization problems. ConclusionThe results obtained have great potential for assessing and analyzing the adoption and rapid expansion of imaging technologies. Capacity utilization figures should be the focus of further research to assess utilization rates both economically and medically. Policy makers should address ongoing issues of operational and organizational separation of inpatient and ambulatory sectors in the German health care system.

Healthcare-Associated COVID-19 across Five Pandemic Waves: Prediction Models and Genomic Analyses.

Background: Healthcare-associated SARS-CoV-2 infections need to be explored further. Our study is an analysis of hospital-acquired infections (HAIs) and ambulatory healthcare workers (aHCWs) with SARS-CoV-2 across the pandemic in a Belgian university hospital. Methods: We compared HAIs with community-associated infections (CAIs) to identify the factors associated with having an HAI. We then performed a genomic cluster analysis of HAIs and aHCWs. We used this alongside the European Centre for Disease Control (ECDC) case source classifications of an HAI. Results: Between March 2020 and March 2022, 269 patients had an HAI. A lower BMI, a worse frailty index, lower C-reactive protein (CRP), and a higher thrombocyte count as well as death and length of stay were significantly associated with having an HAI. Using those variables to predict HAIs versus CAIs, we obtained a positive predictive value (PPV) of 83.6% and a negative predictive value (NPV) of 82.2%; the area under the ROC was 0.89. Genomic cluster analyses and representations on epicurves and minimal spanning trees delivered further insights into HAI dynamics across different pandemic waves. The genomic data were also compared with the clinical ECDC definitions for HAIs; we found that 90.0% of the ‘definite’, 87.8% of the ‘probable’, and 70.3% of the ‘indeterminate’ HAIs belonged to one of the twenty-two COVID-19 genomic clusters we identified. Conclusions: We propose a novel prediction model for HAIs. In addition, we show that the management of nosocomial outbreaks will benefit from genome sequencing analyses.

Use of Electronic Health Records and Quality of Ambulatory Healthcare.

Background This study aimed to measure the association between electronic health record (EHR) use and quality measures in ambulatory healthcare. Methodology A quantitative, retrospective, cross-sectional design was used by examining secondary data from the 2015-2016 National Ambulatory Medical Care Survey. The relationship between EHR use and seven quality measures was examined using the Donabedian model as a framework. Quality measures included (a) diabetes measures, (b) obesity measures, (c) blood pressure screening, (d) depression screening, and (e) breast cancer screening. A total of 37,290 office visits were included, representing 817 million national office visits. For each of the quality measures, we determined the (a) associations using unadjusted and adjusted regression models based on subsets of the sample that met the inclusion criteria for quality measures; and (b) the changes in the area under the curve (AUC). Results Approximately 75% of office visits fulfilled all EHR use. Positive associations were found between EHR use and better quality for the following three out of seven measures: higher odds of screening for obesity (odds ratio (OR) = 2.2; p = <0.0001), blood pressure (OR = 2.5; p = <0.0001), and breast cancer (OR = 1.8; p = 0.0166). Receiver operating curve results showed the highest gain in the AUC for process-grouped measures. Hence, it was considered to be a strong predictor for all quality measures. Conclusions Evidence showed improvement in some quality measures (screening for obesity, blood pressure, and breast cancer). Common and standardized health processes were more likely to be completed and recorded than others. Future policies concerning health information technology can shift the focus from improving EHR use to enhancing patient and quality outcomes. Further research is needed to identify circumstances where quality is improved.

Promoting rational antibiotic therapy among high antibiotic prescribers in German primary care—study protocol of the ElektRA 4-arm cluster-randomized controlled trial

BackgroundThe rational use of antibiotics is of great importance in health care. In primary care, acute respiratory infections are the most common cause of inappropriate antibiotic prescribing. Since existing studies aiming to optimize antibiotic use are usually based on the voluntary participation of physicians, general practitioners (GPs) with inappropriate prescribing behavior are underrepresented. For the first time in Germany, the ElektRA study will assess and compare the effects of three interventions on antibiotic prescribing rates for respiratory and urinary tract infections among high prescribers in primary care.MethodElektRA is a 4-arm cluster-randomized controlled trial among German GPs in nine regional Associations of Statutory Health Insurance Physicians. On their behalf, the Central Research Institute of Ambulatory Health Care in Germany (Zi) analyses all outpatient claims and prescription data. Based on this database, high antibiotic prescribing GPs are identified and randomized into four groups: a control group (N=2000) and three intervention arms. We test social norm feedback on antibiotic prescribing (N=2000), social norm feedback plus online training on rational prescribing practice and communication strategies (N=2000), and social norm feedback plus online peer-moderated training on rational antibiotic prescribing, communication strategies, and sustainable behavior change (N=1250). The primary outcome is the overall rate of antibiotic prescriptions. Outcomes are measured before intervention (T0, October 2020–September 2022) and over a period of 15 months (T1, October 2022 to December 2023) after randomization.DiscussionThe aim of the study is to implement individualized, low-threshold interventions to reduce antibiotic prescribing among high prescribers in primary care. If successful, a change in behavior among otherwise difficult-to-reach high prescribers will directly improve patient care. The increase in quality of care will ideally be achieved both in terms of the quantity of antibiotics used as well as the kind of substances prescribed. Also, if effective strategies for high prescribers are identified through this study, they can be applied not only to the antibiotics addressed in this study, but also to other areas of prescription management.Trial registrationCurrent Controlled Trials ISRCTN95468513.

Lean Practices for Resource Use, Timeliness, and Coordination of Care in Breast Cancer Navigation.

Cancer care is described as insufficiently patient-centered, requiring improved accessibility and coordination. Breast oncology nurse navigators may help provide timely patient care by improving care coordination. This study evaluated a breast cancer navigation (BCN) program in a large ambulatory healthcare system. It examined measures related to quality and value, including timely service delivery, appropriate use of resources, and care coordination. Using Lean methods, a BCN program focused on women receiving a breast biopsy was developed at a pilot site and later implemented throughout the healthcare system. Study data evaluated timely disclosure of biopsy results, prompt scheduling of initial consultations, outpatient use of cancer specialists, and coordination between primary care and oncology practices. After implementing the BCN program, more timely biopsy results were delivered to patients. Patients were more likely to complete an initial consultation within two weeks of biopsy and made fewer outpatient visits. Referrals to cancer specialists within a month of biopsy increased, and primary care encounters with patients decreased.

Indigenizing Medicine.

The drive to the reservation took me through busy highways and shopping centers, then slowed down on winding roads through rising hills and rocky scenes. Just an hour-long drive from the University of California San Diego campus took me to a drastically different landscape, both geographically and culturally. The Tribal Ambulatory Healthcare Experience, an elective created by our Association of Native American Medical Students, provided a formative experience for me as a Chickasaw medical student. Everyone was so kind and welcoming as I found my way to my preceptor’s office at the Indian Health Center. This is not always the experience of a medical student navigating a new clinic. My preceptor, who grew up on a nearby reservation, went out of his way to introduce me and even emailed my picture with a short biography to the staff. It seemed like everyone was family and they made me feel right at home. It was clear that the staff had great relationships with each other and their patients. When discussing the day ahead, they knew the patients’ stories and families. When patients called or came into the office, they were greeted as relatives. I began to notice a stark difference in the treatment of patients as family, rather than strangers or customers. We first saw an adolescent girl with an inflamed inguinal lymph node and ordered tests to check for sexually transmitted infections. When we disclosed that she was positive for chlamydia and that we would prescribe antibiotics, I noticed how comfortable she seemed discussing a sensitive issue—evidently due to the long-standing relationship she had with my preceptor. After taking time to answer her questions, she inquired about my medical training and mentioned her own interest in becoming a lab technician. My preceptor suggested she consider a local medical assistant program, which she was visibly excited to hear about. Throughout the day, I observed how youths and adults alike were comfortable opening up to my preceptor. Whether discussing career advice or recommending nearby hiking trails for exercise, each patient was met with care attentive to their Native identity and where they lived. I even learned there was a sweat lodge in the back of the clinic to foster holistic and communal healing. Receiving care within this relational context fostered trust in the clinic staff, many of whom were community members. Trust in a government structure like the Indian Health Service (IHS) is rightfully hard to build, but placing relationships at the center of care allowed my preceptor to do so. This is not the typical approach that has been modeled to me in medical school. I am often taught to empathize with patients, but to stay removed; to acknowledge culture, but keep it disintegrated from Western medicine. Yet, it was easy to see how relationship-centric care was making an impact on this community. This approach to care is an ideal way to promote health equity on a broad scale. Within a space of trust, we might be better able to promote open communication to guide care, health literacy for patients, adherence to treatment regiments, and continuity of care. On my drive back through those same serpentine roads, I thought of our patients that day. I thought of their comparison to reductive statistics in literature: sexually transmitted diseases, diet and exercise counseling, painful peripheral neuropathy from chronic alcohol consumption. Each visit personified how structural determinants of health drive inequity in Native communities. These are not problems unique to Indigenous peoples but a fault of our systems. They are the result of inadequate federal resources allocated to Indigenous health; food deserts and abused ecosystems; and the trauma of genocide, dispossession, and assimilation still carried in Indigenous bodies and minds. In the face of all these issues, how can I advocate for a healthier future for tribal nations? My preceptor showed me how relationship-centric care fosters medical trust and builds community. Within this space, I saw the potential to impactfully care for individuals and families. This requires longitudinal commitment to a place and people. It specifically requires training a workforce made up of community members. IHS facilities nationwide are understaffed and experience significant turnover. We must encourage Native youth to consider careers in health care, just as my preceptor and I did in conversation at clinic. And then, I think about how I will bring Indigenous values into Western medicine; how I can relate to the whole person in front of me, rather than tending toward efficiency and detachment; how I will see where our systems may have positioned them and take time to build trust; how I will see my patient’s health as tied to their culture, land, and community. Indigenizing medicine certainly has the potential to promote health equity, but also enables us to see and partake in the interconnected human experience.

Geographic, Occupational, and Sociodemographic Variations in Uptake of COVID-19 Booster Doses Among Fully Vaccinated US Adults, December 1, 2021, to January 10, 2022

COVID-19 booster vaccine can strengthen waning immunity and widen the range of immunity against new variants. To describe geographic, occupational, and sociodemographic variations in uptake of COVID-19 booster doses among fully vaccinated US adults. This cross-sectional survey study used data from the Household Pulse Survey conducted from December 1, 2021, to January 10, 2022. Household Pulse Survey is an online, probability-based survey conducted by the US Census Bureau and is designed to yield estimates nationally, by state, and across selected metropolitan areas. Receipt of a booster dose was defined as taking 2 or more doses of COVID-19 vaccines with the first one being the Johnson and Johnson (Janssen) vaccine, or taking 3 or more doses of any of the other COVID-19 vaccines. Weighted prevalence estimates (percentages) were computed overall and among subgroups. Adjusted prevalence ratios (APRs) were calculated in a multivariable Poisson regression model to explore correlates of receiving a booster dose among those fully vaccinated. A total of 135 821 adults completed the survey. Overall, 51.0% were female and 41.5% were aged 18 to 44 years (mean [SD] age, 48.07 [17.18] years). Of fully vaccinated adults, the percentage who reported being boosted was 48.5% (state-specific range, from 39.1% in Mississippi to 66.5% in Vermont). Nationally, the proportion of boosted adults was highest among non-Hispanic Asian individuals (54.1%); those aged 65 years or older (71.4%); those with a doctoral, professional, or master's degree (68.1%); those who were married with no children in the household (61.2%); those with annual household income of $200 000 or higher (69.3%); those enrolled in Medicare (70.9%); and those working in hospitals (60.5%) or in deathcare facilities (eg, funeral homes; 60.5%). Conversely, only one-third of those who ever received a diagnosis of COVID-19, were enrolled in Medicaid, working in pharmacies, with less than a high school education, and aged 18 to 24 years old were boosted. Multivariable analysis of pooled national data revealed that compared with those who did not work outside their home, the likelihood of being boosted was higher among adults working in hospitals (APR, 1.23; 95% CI, 1.17-1.30), ambulatory health care centers (APR, 1.16; 95% CI, 1.09-1.24), and social service settings (APR, 1.08; 95% CI, 1.01-1.15), whereas lower likelihood was seen among those working in food or beverage stores (APR, 0.85; 95% CI, 0.74-0.96) and the agriculture, forestry, fishing, or hunting industries (APR, 0.83; 95% CI, 0.72-0.97). These findings suggest continuing disparities in receipt of booster vaccine doses among US adults. Targeted efforts at populations with low uptake may be needed to improve booster vaccine coverage in the US.