Minnesota Community Research Articles

106 Transforming Health Equity with an Innovative Social Determinants of Health Platform: Application of HOUSES Index to Colorectal Cancer Screening

OBJECTIVES/GOALS: To tackle population-level health disparities, quality dashboards can leverage individual socioeconomic status (SES) measures, which are not always readily accessible. This study aimed to assess the feasibility of a population health management strategy for colorectal cancer (CRC) screening rates using the HOUSES index and heatmap analysis. METHODS/STUDY POPULATION: We applied the 2019 Minnesota Community Measurement data for optimal CRC screening to eligible Mayo Clinic Midwest panel patients. SES was defined by HOUSES index, a validated SES measure based on publicly available property data for the U.S. population. We first assessed the association of suboptimal CRC screening rate with HOUSES index adjusting for age, sex, race/ethnicity, comorbidity, and Zip-code level deprivation by using a mixed effects logistic regression model. We then assessed changes in ranking for performance of individual clinics (i.e., % of patients with optimal CRC screening rate) before and after adjusting for HOUSES index. Geographical hotspots of high proportions of low SES AND high proportions of suboptimal CRC screening were superimposed to identify target population for outreach. RESULTS/ANTICIPATED RESULTS: A total of 58,382 adults from 41 clinics were eligible for CRC screening assessment in 2019 (53% Female). Patients with lower SES defined by HOUSES quartile 1-3 have significantly lower CRC screening compared to those with highest SES (HOUSES quartile 4) (adj. OR [95% CI]: 0.52 [0.50-0.56] for Q1, 0.66 [0.62-0.70] for Q2, and 0.81 [0.76-0.85]) for Q3). Ranking of 26 out of 41 (63%) clinics went down after adjusting for HOUSES index suggesting disproportionately higher proportion of underserved patients with suboptimal CRC screening. We were able to successfully identify hotspots of suboptimal CRC (area with greater than 130% of expected value) and overlay with higher proportion of underserved population (HOUSES Q1), which can be used for data-driven targeted interventions such as mobile health clinics. DISCUSSION/SIGNIFICANCE: HOUSES index and associated heatmap analysis can contribute to advancing health equity. This approach can aid health care organizations in meeting the newly established standards by The Joint Commission, which have elevated health equity to a national safety priority.

Don't Say "Beans" When Promoting Plant Protein to Family Meal Planners.

To identify "headlines" that would engage recipients to consider plant protein over red meat. Mail and web survey. Urban Minnesota community. 144 survey respondents from our health plan and community program distribution lists who live with at least 1 other person and eat meat. We asked respondents how likely they would be to click on each of 24 headlines with a motivator (eating plant protein for health vs for environmental reasons) and a barrier (family preferences, knowledge about plant proteins, or cooking skills). 16 headlines contained the word "beans". We created categorical variables for each headline construct: (1) motivator, (2) barrier, and (3) reference to beans. Using a mixed model with random effects, we compared, for each construct, respondents' self-reported likelihood to click on a headline. Health-related headlines performed significantly better than environmental headlines (P = .0019, 95% CI .01, .11). Family-oriented headlines performed slightly better than skills-oriented (P = .0927, 95% CI -.01, .11) and knowledge-oriented (P = .0960, 95% CI -.01, .11) headlines. Headlines containing the word "beans" performed significantly worse than those not containing "beans" (P < .0001, 95% CI -.22, -.12). The population represented by our survey respondents report being most likely to click on headlines that emphasize health and family. They report they are significantly less likely to click on headlines that promote beans.

Determinants of Lung Cancer Screening in a Minnesota Urban Indigenous Community: A Community-Based, Participatory, Action-Oriented Study.

Secondary prevention of lung cancer through screening is potentially lifesaving considering that overall survival of lung cancer is 20% at 5 years but curable if detected at an early stage. This work provides insight into culturally tailored approaches to implementing the service in individuals at high risk of the disease.

Molecular surveillance detects the zoonotic nematode parasite Toxocara in soils from public spaces in a Minnesota community

Toxocara canis and Toxocara cati are common nematode parasites of dogs and cats, and are capable of causing a variety of pathologies in humans. Human toxocariasis is a ubiquitous and likely under-diagnosed public health concern across the globe. Examination of soils in numerous public spaces worldwide readily detect Toxocara eggs and serological studies indicate a substantial exposure to this parasitic roundworm in human populations. This study sought to determine whether genetic evidence of pathogenic Toxocara species could be found in soils from local public spaces in a Minnesota community. Total genomic DNA was purified from soil samples obtained from public parks and PCR was performed using primers specific to either T. canis or T. cati. Genetic evidence for both species of Toxocara was found in soils surveyed. T. canis was identified in five of 12 public spaces surveyed and T. cati was present in two of the same 12 public spaces. Although the infectious potential of the Toxocara identified was not determined, the presence of this parasite in locations amenable to transmission to humans indicates the need for proper veterinary care of domestic dogs and cats as well as a greater emphasis on public health education and actions to prevent human infection.

Saturday pap smear clinic: Addressing barriers to women’s health.

105 Background: Screening for cervical cancer with pap smears and HPV testing can improve patient outcomes by allowing for early identification of cervical cancer. The Minnesota Community Measure and Mayo Clinic's goal is to have a cervical cancer screening rate of 82% (Detailed Report-Cervical Cancer Screening, 2020). Healthy People 2030 aims to have a cervical cancer screening rate of 83.4% (Increase the proportion of females who get screened for cervical cancer -C-09, 2021). Community Internal Medicine cervical cancer screening rates are below this level at 63.09% compliance, with 5,239 patients non-compliant, who are eligible for cervical cancer screenings. Olmsted County only offers acute services on the weekends with no primary care services, which leaves women who work during the week or have childcare/caregiver issues with no options on the weekend or evenings when they have availability to attend appointments. Methods: Based on guidelines for pap smear screening (women ages 21-65), 14,195 women were identified within CIM to be eligible for screening. Of those, 5,239 were due for screening. The Saturday Pap Smear Clinic had 88 available spots. We aimed to improve cervical cancer screening rates among non-compliant women within Community Internal Medicine by 1% (52 women, total noncompliant women = 5,239) by January 2021 without adversely impacting coverage of existing clinic hours. Results: The electronic medical record (EMR), EPIC, was utilized to identify all patients who were eligible for a pap smear based on current guidelines (Total eligible = 14,195; Sample size/non-compliant: 5,239 patients) within Community Internal Medicine (CIM) of the Baldwin Building in Rochester, MN. Interventions included: surveys that were sent to patients via the Patient Portal. Advertising for the Saturday Clinic included Primary Care News, E-boards, Posters, Social Media, SCOPE, Mayo News, and Providers. The Saturday clinic allowed time outside the traditional hours. One unique feature of the clinic is that all females staffed it during clinic hours in an attempt to alleviate some of the fear/anxiety. After completion of the pilot Saturday Pap Clinic, pap smear compliance from the Saturday Pap Clinic alone arose 1.2% (62 patients) within CIM. Conclusions: Post-intervention, cervical screening rates among non-compliant women within Baldwin CIM improved by 1.2% (62 women total).

Association of Cardiovascular Disease Risk Factors With Sociodemographic Characteristics and Health Beliefs Among a Community-Based Sample of African American Adults in Minnesota

ObjectiveTo assess cardiovascular disease (CVD) and CVD risk factors and their association with sociodemographic characteristics and health beliefs among African American (AA) adults in Minnesota. MethodsA cross-sectional analysis was conducted of a community-based sample of AA adults enrolled in the Minnesota Heart Health Program Ask About Aspirin study from May 2019 to September 2019. Sociodemographic characteristics, health beliefs, and self-reported CVD and CVD risk factors were collected. Prevalence ratio (PR) estimates were calculated using Poisson regression modeling to assess the association between participants’ characteristics and age- and sex-adjusted CVD risk factors. ResultsThe sample included 644 individuals (64% [412] women) with a mean age of 61 years. Risk factors for CVD were common: hypertension (67% [434]), hyperlipidemia (47% [301]), diabetes (34% [219]), and current cigarette smoking (25% [163]); 19% (119) had CVD. Those with greater perceived CVD risk had a higher likelihood of prevalent hyperlipidemia (PR, 1.34; 95% CI, 1.14 to 1.57), diabetes (PR, 1.61; 95% CI, 1.30 to 1.98), and CVD (PR 1.61; 95% CI, 1.16 to 2.23) compared with those with lower perceived risk. Trust in health care provider was high (83% [535]) but was not associated with CVD or CVD risk factors. ConclusionIn this community sample of AAs in Minnesota, CVD risk factors were high, as was trust in health care providers. Those with greater CVD risk perceptions had higher CVD prevalence. Consideration of sociodemographic and psychosocial influences on CVD and CVD risk factors could inform development of effective cardiovascular health promotion interventions in the AA Minnesota community.

Advancing Health Equity for Medicaid Beneficiaries by Adding Colorectal Cancer Screening to the Centers for Medicare and Medicaid Services Adult Core Set

Advancing Health Equity for Medicaid Beneficiaries by Adding Colorectal Cancer Screening to the Centers for Medicare and Medicaid Services Adult Core Set

Using social network analysis to evaluate relationships among community nutrition education partners

Abstract Background The Supplemental Nutrition Assistance Program - Education (SNAP-Ed) program is an evidence-based program funded by the United States Department of Agriculture (USDA) that provides direct education and multi-level interventions for low-income families about nutrition, physical activity, and making healthy choices on a limited budget. Each U.S. state is funded to administer the program. SNAP-Ed works by building partnerships with community organizations. The purpose of this study was to identify characteristics of Minnesota's community partnership network involved in the SNAP-Ed program from the federal fiscal years 2016 (FY16) to 2020 (FY20). Analysis aims include 1) mapping the growth of SNAP-Ed community partners each year, 2) identifying essential network patterns and thereby highlight potential network gaps, 3) gauging the current level of partner involvement, and 4) enabling a data-driven approach for future collaborative network improvements. Methods Social network theory and analysis (SNA) was used to examine changes in partnerships over time. The data was retrieved from Minnesota's SNAP Education Evaluation and Database System (SEEDS) where maintained program and evaluation data; SNA metrics such as size, breadth, density, degree centralization, clusters, and modularity were calculated for each network. Results Partners of SNAP-Ed programs expanded from 869 in FY16 to 1032 in FY19. Due to COVID-19, in FY20, the number of partners decreased to 804. The network density decreased over time due to expansion of the number of partners between FY16(.0263) and FY19(.021). In FY20, the network density significantly decreased to .001 since partners were not able to be connected to each other. Network centrality will also be reported. Conclusions Our study presents a novel use of social network analysis methods to evaluate the community partnerships involved in the SNAP-Ed program. Key messages Using social network analysis to analyze the quantity and quality of the relationship among community nutrition education program partners gives practical policy recommendations. A novel use of social network analysis methods to evaluate the community partnerships involved in the SNAP-Ed program.

Barriers to using clinical decision support in ambulatory care: Do clinics in health systems fare better?

We quantify the use of clinical decision support (CDS) and the specific barriers reported by ambulatory clinics and examine whether CDS utilization and barriers differed based on clinics' affiliation with health systems, providing a benchmark for future empirical research and policies related to this topic. Despite much discussion at the theoretic level, the existing literature provides little empirical understanding of barriers to using CDS in ambulatory care. We analyze data from 821 clinics in 117 medical groups, based on in Minnesota Community Measurement's annual Health Information Technology Survey (2014-2016). We examine clinics' use of 7 CDS tools, along with 7 barriers in 3 areas (resource, user acceptance, and technology). Employing linear probability models, we examine factors associated with CDS barriers. Clinics in health systems used more CDS tools than did clinics not in systems (24 percentage points higher in automated reminders), but they also reported more barriers related to resources and user acceptance (26 percentage points higher in barriers to implementation and 33 points higher in disruptive alarms). Barriers related to workflow redesign increased in clinics affiliated with health systems (33 points higher). Rural clinics were more likely to report barriers to training. CDS barriers related to resources and user acceptance remained substantial. Health systems, while being effective in promoting CDS tools, may need to provide further assistance to their affiliated ambulatory clinics to overcome barriers, especially the requirement to redesign workflow. Rural clinics may need more resources for training.

Potential for Manganese-Induced Neurologic Harm to Formula-Fed Infants: A Risk Assessment of Total Oral Exposure.

Background:High oral exposure and biological vulnerabilities may put formula-fed infants at risk for manganese-induced neurotoxicity.Objectives:We sought to characterize manganese concentrations in public drinking water and prepared infant formulas commonly purchased in the United States, integrate information from these sources into a health risk assessment specific to formula-fed infants, and examine whether households that receive water with elevated manganese concentrations avoid or treat the water, which has implications for formula preparation.Methods:Manganese was measured in 27 infant formulas and nearly all Minnesota community public water systems (CPWS). The risk assessment produced central tendency and upper-end exposure estimates that were compared to a neonatal animal-based health reference dose (RfD) and considered possible differences in bioavailability. A survey study assessed esthetic concerns, treatment, and use of water in a Twin Cities community with various levels of manganese in drinking water.Results:Ten percent of CPWSs were estimated to exceed the EPA health advisory level of . Manganese concentrations in formula ranged from 69.8 to , with amino formula concentrations. Central tendency estimates of soy and amino acid formula reconstituted with water at the CPWS 95th percentile manganese concentration exceeded the neonatal-based RfD. Upper-end estimates of manganese intake from formula alone, independent of any water contribution, equaled or exceeded the neonatal-based RfD. In the survey study, we observed increased awareness of esthetic issues and water avoidance at higher manganese concentrations, but these concentrations were not a reliable consumption deterrent, as the majority of households with inside tap drinking water results above reported drinking the water.Discussion:Excessive exposure to manganese early in life can have long-lasting neurological impacts. This assessment underscores the potential for manganese overexposure in formula-fed infants. U.S. agencies that regulate formula and drinking water must work collaboratively to assess and mitigate potential risks. https://doi.org/10.1289/EHP7901

Mothers’ Milk: How Gender and Immigration Obscure Agricultural Expertise and Care Work in Dairyland

AbstractGender is a key lens through which to understand industrial agricultural production in rural twenty‐first century communities. Here, I examine the gendered imaginaries of dairy production that perpetuate the meaning of “farmer” as masculine and white. The expertise of Mexican immigrant workers, and particularly that of women on spousal visas, challenges such assumptions and highlights the role of unremunerated labor in sustaining the industrial food chain. Everyday experiences of gender and race are shaped not only by local‐level assumptions but also by federal‐level immigration policies and employer recruitment practices that result in a mostly male immigrant agricultural workforce. In this article, I draw on interviews with rural Minnesota community members, as well as local and regional news coverage, to examine how gender and race intersect to marginalize the work and expertise of Mexican immigrants in the rural Midwest. In this case, Mexican immigrant mothers frame their labor as part of a complex calculus of immigration benefits and sacrifices.

Growing North Minneapolis: Connecting Youth and Community through Garden-based Experiential Learning

Growing North Minneapolis (GNM) is an urban agriculture and youth development summer program sited in the North Minneapolis, MN, neighborhood. The program is a university–community partnership between faculty at the University of Minnesota (UMN) and North Minneapolis community partners. We leverage resources from the city of Minneapolis Step-Up program to recruit, train, and employ youth (14–15 years old) who face barriers to employment—particularly youth from low-income families, youth of color, youth from immigrant families, and youth with disabilities. Youth interns are placed in a 10-week-long summer program and are matched with undergraduate student mentors from the UMN and North Minneapolis gardener mentors. The undergraduate students and garden mentors work together to lead teams of youth and work in multiple urban garden sites located in North Minneapolis, a designated low-resource community in the metro area. One of our goals is to develop leadership experience for UMN undergraduate students and improve food and horticultural skills among urban youth through garden-based education. Learning is experiential and contextualized in the various community garden sites through activities focused on food justice and accessibility, food production systems, and horticultural science. Youth learning and development outcomes are reported based on written postprogram qualitative survey questions prompting youth to identify what they learned throughout the program, what they enjoyed the most, and what challenged them after the summer program in 2018. Our results show that youth participants learned across multiple domains of knowledge and valued the social interaction offered by the intergenerational mentorship structure. The GNM program can serve as a model for garden-based experiential learning with early high school youth.

Containing a measles outbreak in Minnesota, 2017: methods and challenges.

We report on a measles outbreak largely occurring in Minnesota's under-vaccinated Somali community in the spring of 2017. The outbreak was already into its third generation when the first two cases were confirmed, and rapid public health actions were needed. The aim of our response was to quickly end transmission and contain the outbreak. The state public health department performed laboratory testing on suspect cases and activated an Incident Command staffed by subject matter experts that was operational within 2 h of case confirmation. Epidemiologic interviews identified exposures in settings where risk of transmission was high, that is, healthcare, childcare, and school settings. Vaccination status of exposed persons was assessed, and postexposure prophylaxis (PEP) was offered, if applicable. Exposed persons who did not receive PEP were excluded from childcare centers or schools for 21 days. An accelerated statewide measles, mumps, and rubella (MMR) recommendation was made for Somali Minnesota children and children in affected outbreak counties. Partnerships with the Somali Minnesota community were deepened, building off outreach work done with the community since 2008. Public health identified 75 measles cases from 30 March to 25 August 2017: 43% were female, 81% Somali Minnesotan, 91% unvaccinated, and 28% hospitalized. The median age of cases was 2 years (range: 3 months-57 years). Most transmission (78%) occurred in childcare centers and households. A secondary attack rate of 91% was calculated for unvaccinated household contacts. Over 51,000 doses of MMR were administered during the outbreak above expected baseline. At least 8490 individuals were exposed to measles; 155 individuals received PEP; and over 500 persons were excluded from childcare and school. State and key public health partners spent an estimated $2.3 million on response. This outbreak demonstrates the necessity of immediate, targeted disease control actions and strong public health, healthcare, and community partnerships to end a measles outbreak.

Historical vignette: Leonard T. Kurland, FACE (1921–2001), the rise of neuroepidemiology, and the Rochester Epidemiology Project

The creation of the field of neuroepidemiology was one of the two principal professional achievements of the American College of Epidemiology Fellow Leonard T. Kurland (1921–2001), the other being the establishment of the Rochester Project. In the former, Kurland established the role of the neuroepidemiologists in the development of the corpus of knowledge needed to control and prevent the occurrence of neurological conditions. Two examples of his endeavors in this regard were his work on the Guamanian focus of neurodegenerative diseases and his seminal investigations into the epidemiology of multiple sclerosis. He was also instrumental in the development of the Rochester, Minnesota community as a population laboratory within which epidemiologic investigations could be mounted. This pioneering achievement created a resource used by many generations of epidemiologists and clinicians to examine health and disease in the population.

How are medical groups identified as high-performing? The effect of different approaches to classification of performance

BackgroundPayers and policy makers across the international healthcare market are increasingly using publicly available summary measures to designate providers as “high-performing”, but no consistently-applied approach exists to identifying high performers. This paper uses publicly available data to examine how different classification approaches influence which providers are designated as “high-performers”.MethodsWe conducted a quantitative analysis of cross-sectional publicly-available performance data in the U.S. We used 2014 Minnesota Community Measurement data from 58 medical groups to classify performance across 4 domains: quality (two process measures of cancer screening and 2 composite measures of chronic disease management), total cost of care, access (a composite CAHPS measure), and patient experience (3 CAHPS measures). We classified medical groups based on performance using either relative thresholds or absolute values of performance on all included measures.ResultsUsing relative thresholds, none of the 58 medical groups achieved performance in the top 25% or 35% in all 4 performance domains. A relative threshold of 40% was needed before one group was classified as high-performing in all 4 domains. Using absolute threshold values, two medical groups were classified as high-performing across all 4 domains. In both approaches, designating “high performance” using fewer domains led to more groups designated as high-performers, though there was little to moderate concordance across identified “high-performing” groups.ConclusionsClassification of medical groups as high performing is sensitive to the domains of performance included, the classification approach, and choice of threshold. With increasing focus on achieving high performance in healthcare delivery, the absence of a consistently-applied approach to identify high performers impedes efforts to reliably compare, select and reward high-performing providers.

A 15 Year Ecological Comparison for the Market Dynamics of Minnesota Community Pharmacies from 2002 to 2017.

Background: Understanding the factors that influence the market entry, exit, and stability of community pharmacies (i.e., market dynamics) is important for stakeholders ranging from patients to health policymakers and small business owners to large corporate institutions. Objective: The study’s first objective was to describe the market dynamics of community pharmacies for Minnesota counties in 2002, 2007, 2012, and 2017 by associating county (a) population density and (b) metropolitan designation with the change in the number of ‘All community pharmacies,’ ‘Chain community pharmacies’, and ‘Independent community pharmacies’. The study’s second objective was to describe the number and proportion of community pharmacies for Minnesota counties in 2002, 2007, 2012, and 2017 by (1) ‘Business Organization Structure’ and (2) ‘Pharmacy Type.’ Methods: County-level data were obtained from the Minnesota Board of Pharmacy, US Census Bureau, and Minnesota State Demographic Center for 2002, 2007, 2012, and 2017. Findings were summarized and the associations between study variables described using descriptive statistics. Results: The ratio of ‘Independent community pharmacies’ to ‘Chain community pharmacies’ was about 1:1 (466:530) in 2002, 1:2 (352:718) in 2007, 1:2 (387:707) in 2012, and 1:3 (256:807) in 2017. There was not a consistent relationship that carried through the 15 year analysis between county population density and metropolitan designation and the market dynamic patterns of community pharmacies. The types of pharmacy in Minnesota changed significantly over the study with increases in state, regional, and national chains and declines in single entity and small chain independents. There were also notable declines in mass merchandiser community pharmacies and increases in clinic and medical center community pharmacies. Discussion: The findings suggest that different or additional factors beyond traditional market dynamic predictors of population density and metropolitan designation were at play in each five year interval of this study. We propose that the traditional dichotomy of independent and chain community pharmacy groupings no longer provide an optimal characterization for the market dynamics of pharmacies today. Instead, community pharmacies may be better organized by their capacity to operate as healthcare access points that provide and are reimbursed for patient care and public health services like medication therapy management, immunizations, and more. Conclusions: The findings showed that community pharmacy distribution in Minnesota’s 87 counties has shifted between 2002 and 2017 from traditional retail models to emerging healthcare models based on population health needs. This signals the need for not only a new approach for tracking community pharmacy market dynamics but also adjustments by community pharmacies to remain relevant in a new environment of patient care services.

Results of a 2-year randomized, controlled obesity prevention trial: Effects on diet, activity and sleep behaviors in an at-risk young adult population

Excess weight gain tends to occur in young adulthood. However, research examining effective weight-related interventions for this age group has been limited. As one of seven trials in the EARLY Trials consortium (Early Adult Reduction of weight through LifestYle intervention), the CHOICES Study (Choosing Healthy Options in College Environments and Settings) tested effects of a technology-integrated, young adult weight gain prevention intervention. It was a randomized controlled trial with assessments at baseline (2011) and 4-, 12- and 24-months post-intervention initiation and included 441 participants (ages 18–35) who were students at three Minnesota community colleges. The 24-month intervention included a 1-credit academic course and social networking and support online intervention. This analysis examined effects on 12 secondary behavioral outcomes across three domains: diet (fast food, sugary beverages, breakfast, at-home meal preparation), physical activity/screen time (minutes and energy expenditure in leisure time physical activity, television viewing, leisure time computer use) and sleep (hours of sleep, time required to fall asleep, days not getting enough rest, difficulty staying awake). The intervention resulted in significant reductions in fast food (p=0.007) but increases in difficulty staying awake (p=0.015). There was limited evidence of other behavior changes at 4months (0.05<p<0.1) in the expected direction but differences by treatment condition dissipated over time. Analyses examining summary treatment effects (i.e., modeling effects on all behavioral outcomes simultaneously) indicated significant overall effects (p=0.014), largely driven by 4-month results (p=0.005). Additional research is needed to understand effective obesity prevention among young adults, particularly when addressing multiple weight-related outcomes.

Health System Consolidation and Diabetes Care Performance at Ambulatory Clinics

We addressed two questions regarding health system consolidation through the acquisition of ambulatory clinics: (1) Was increasing health system size associated with improved diabetes care performance and (2) Did the diabetes care performance of acquired clinics improve postacquisition? Six hundred sixty-one ambulatory clinics in Minnesota and bordering states that reported performance data from 2007 to 2013. We employed fixed effects regression to determine if increased health system size and being acquired improved clinics' performance. Using our regression results, we estimated the average effect of consolidation on the performance of clinics that were acquired during our study. Publicly reported performance data obtained from Minnesota Community Measurement. Acquired clinics experienced performance improvements starting in their third year postacquisition. By their fifth year postacquisition, acquired clinics had 3.6 percentage points (95 percent confidence interval: 2.0, 5.1) higher performance than if they had never been acquired. Increasing health system size was associated with slight performance improvements at the end of the study. Health systems modestly improved the diabetes care performance of their acquired clinics; however, we found little evidence that systems experienced large, system-wide performance gains by increasing their size.

Association of Safety Culture with Surgical Site Infection Outcomes

Hospital workplace culture may have an impact on surgical outcomes; however, this association has not been established. We designed a study to evaluate the association between safety culture and surgical site infection (SSI). Using the Hospital Survey on Patient Safety Culture and National Healthcare Safety Network definitions, we measured 12 dimensions of safety culture and colon SSI rates, respectively, in the surgical units of Minnesota community hospitals. A Pearson's r correlation was calculated for each of 12 dimensions of surgical unit safety culture and SSI rate and then adjusted for surgical volume and American Society of Anesthesiologists (ASA) classification. Seven hospitals participated in the study, with a mean survey response rate of 43%. The SSI rates ranged from 0% to 30%, and surgical unit safety culture scores ranged from 16 to 92 on a scale of 0 to 100. Ten dimensions of surgical unit safety culture were associated with colon SSI rates: teamwork across units (r=-0.96; 95% CI [-0.76,-0.99]), organizational learning (r=-0.95; 95% CI [-0.71,-0.99]), feedback and communication about error (r=-0.92; 95% CI [-0.56,-0.99]), overall perceptions of safety (r=-0.90; 95% CI [-0.45,-0.99]), management support for patient safety (r=-0.90; 95% CI [-0.44,-0.98]), teamwork within units (r=-0.88; 95% CI [-0.38,-0.98]), communication openness (r=-0.85; 95% CI [-0.26,-0.98]), supervisor/manager expectations and actions promoting safety (r=-0.85; 95% CI [-0.25,-0.98]), non-punitive response to error (r=-0.78; 95% CI [-0.07,-0.97]), and frequency of events reported (r=-0.76; 95% CI [-0.01,-0.96]). After adjusting for surgical volume and ASA classification, 9 of 12 dimensions of surgical unit safety culture were significantly associated with lower colon SSI rates. These data suggest an important role for positive safety and teamwork culture and engaged hospital management in producing high-quality surgical outcomes.

Celebrating the life and career (to date) of George Somero.

If you had to predict the best start in life for a budding marine biologist, growing up in a remote Minnesota community founded on timber and mining near the Canadian border probably wouldn't rank high. But for George Somero, the isolation and winters spent fishing in ice holes with cousins, friends