Statewide Level Research Articles

Improving joy at work and reducing burnout in health care workers in Victoria, Australia using the Institute for Healthcare Improvement joy in work framework: A mixed-methods study.

Burnout in health care workers (HCWs) has serious ramifications for individual well-being, patients, organizations, and health systems. Global evidence demonstrates the COVID-19 pandemic has amplified the risk of burnout. Scalable interventions to address burnout are critical to protect HCW well-being. Underpinned by the Conservation of Resources theory, this study examines the impacts of a statewide improvement initiative (the Initiative), using the Institute for Healthcare Improvement Joy in Work (JiW) Framework, to reduce burnout and increase joy at work across participating health care organizations in Victoria, Australia. An impact evaluation was undertaken utilizing a mixed-methods design. Quantitative outcomes included burnout and joy at work measured using an adapted Mini Z tool. In-depth interviews with implementation teams sought insights into the effectiveness of interventions. Overall, 20 teams from 17 organizations across diverse health care settings and geographical locations participated. At a statewide level, outcomes in burnout and joy at work were inconclusive due to limited data. However, five out of eight teams reporting sufficient data achieved measurable improvements in one or more outcomes. Qualitative data revealed the Initiative increased workplace resources and supports such as providing "permission" for HCWs to prioritize well-being at work, improved communications between management and HCWs, and increased HCWs' teamwork and camaraderie, resulting in safer and more positive workplaces. The JiW Framework, implemented across diverse settings, provided organizations with a structured process to develop multifaceted improvements that resulted in enhanced resources that appeared to improve HCW well-being. Compared to individual well-being support, this approach offers organization-level change and scalability potential.

Assessing Private Equity Involvement in Ophthalmology: Parallels with the Past, Concerns for the Future

PurposeTo discuss the history and current state of private equity in ophthalmology and explore potential implications for ophthalmology practices, physicians, and patients. DesignPerspective. MethodsReview of selected articles in ophthalmology and non-ophthalmology medical literature and commentary based on the authors’ experiences. ResultsInvestment in ophthalmology appeals to private equity firms because of high procedural volumes, fragmented private practices, opportunities for real estate ownership, and an aging population in need of eye care. As a result, acquisition of private practices by large private equity companies has swelled since 2015. Metropolitan areas and practices that possess ambulatory surgical centers or a high proportion of retina surgeons receive the greatest investment. However, little objective data exists regarding the benefits of this trend. Initial research suggests that private equity ownership may negatively impact patient care through greater costs, shorter appointments, and fewer Medicare/Medicaid patients seen. Skeptics of private equity also highlight concerns that include financial risk falling primarily on the acquired practice itself, a short-term business approach that rewards profit maximization, and the erosion of physician autonomy. Furthermore, young ophthalmologists express reservations about working for private equity firms. 78% of trainees indicated they would not consider employment by a private equity owned practice and 81.4% of vitreoretinal fellows voiced concerns about autonomy and job security. Proposed legislation aimed at limiting private equity acquisitions is currently under review at the statewide level, adding additional uncertainty to the future of private equity involvement in ophthalmology. ConclusionAlthough investment by private equity offers potential financial rewards and operational improvements for practices, it also raises significant concerns reminiscent of those experienced by physician practice management companies in the 1990s. Nonanecdotal data is needed to assess the benefits and future of private equity involvement in ophthalmology.

Land use change and ecosystem service tradeoffs on California agricultural land

Abstract Introduction 
The need to transition to sustainable agricultural practices while maintaining high food yield and strengthening resilience to climate change cannot be overstated. California farmers have received incentive funding from federal and state agencies to use land management practices that are less impactful to the land and in line with California’s sustainability goals. However, there are no regional monitoring measures to determine whether farming is becoming more sustainable. 

Methods 
In this study, we used land cover change analysis and ecosystem services modeling to understand how farming practices influence environmental benefits on California farmland from 2010 to 2020. We analyzed the tradeoffs between soil erosion control, soil carbon storage, and production of California’s top agricultural commodities, and we compared these changes to changes in land cover in five agricultural regions statewide. 

Results and Conclusion 
We found that the trade-offs in ecosystem services and food production differ depending on the regional context, and that major expansion in almond production and land use changes have had different impacts throughout California. Statewide, soil organic carbon storage increased, soil erosion control increased slightly, and food production boomed for most commodities. Incentive programs that influence farming practices may need to operate at a regional level rather than a statewide level to achieve sustainable outcomes specific to each region.

Low vs. high income: The impact of high-rise buildings on prevalence of obesity

The relationship between health, proxied by the prevalence of obesity, and the level of income is well documented. Based on the CDC report at a US statewide level between 2011 and 2020, the current study extends this discussion by exploring the impact of urban environments, proxied by the number of skyscrapers, on this relationship. In this context, the question that still remains open is what is the extent of urban development that can reduce the dimensions of the obesity pandemic to a minimum and whether this effect is different across poor versus rich populations. Consequently, the contribution of this study is the use of the quadratic model, which permit non-monotonic relationships between obesity prevalence and the number of skyscrapers. We also examine the incremental change in the number of skyscrapers. The global aspect of our study may be described as follows. For countries with per-capita GDP higher than $75,000 (lower than $25,000) – urban development of skyscrapers is expected to be beneficial on obesity prevalence up to 142 (126) skyscrapers. Compared to poor countries, the incremental impact of high-rise construction on obesity prevalence at the downward domain of the U-shaped curve is expected to be much more beneficial among rich countries.

Young vs. Old Population: Does Urban Environment of Skyscrapers Create Different Obesity Prevalence?

This study investigates the impact of more densely populated urban environments proxied by the number of skyscrapers on the obesity prevalence among young vs. old populations at a US statewide level. Obesity is a global pandemic, as well as a major risk factor for a long series of health problems and increased mortality rates. We employ a quadratic model, which relaxes the a priori assumption of the monotonic rise or drop in obesity prevalence with the number of skyscrapers. The outcomes demonstrated a U-shaped curve and a sharper decrease (increase) in the projected obesity prevalence with the number of skyscrapers in the range of 0–147 (147–270) skyscrapers for the old population age cohorts above 65 years old. One possible explanation is the different motivation for physical activity among dissimilar age cohorts. While younger people are focused on maintaining a slim body shape, older people identify with the importance of sports. The public policy outcome of our study is the need to implement different recommendations in dissimilar urban environments based on age cohort stratification. Given that skyscrapers are the manifestation of wealth economics and present the typical characteristics of modern cities, which, in turn, are the future of economic development and productivity, these recommendations might prove to be important.

Population vulnerability to heat: A case-crossover analysis of heat health alerts and hospital morbidity data in Victoria, Australia

ObjectiveFrom 2010 to 2022, the Victorian Department of Health operated a heat health alert system. We explored whether changes to morbidity occurred during or directly after these alerts, and how this differed for certain population groups. MethodsWe used a space-time-stratified case-crossover design and conditional logistic regression to examine the associations between heat health alerts and heat-related and all-cause emergency department (ED) presentations and hospital admissions at the state-wide level, with models created for the whole population and subgroups. Data were included for the warm season (November-March) from 2014 to 2021. ResultsIncreases occurred in heat-related ED presentations (OR 1.73, 95% CI: 1.53-1.96) and heat-related hospital admissions (OR 1.23, 95% CI: 1.16-1.30) on days on or after heat health alerts. Effect sizes were largest for those 65 years and older, Aboriginal and Torres Strait Islander people, and those living in the most disadvantaged areas. ConclusionsWe confirm that increases in morbidity occurred in Victoria during heat health alerts and describe which population groups are more likely to require healthcare in a hospital. Implications for Public HealthThese findings can inform responses before and during periods of extreme heat, data-driven adaptation strategies, and the development of heat health surveillance systems.

Use of statewide financial incentives to improve documentation of hernia and mesh characteristics in ventral hernia repair.

Documentation of intraoperative details is critical for understanding and advancing hernia care, but is inconsistent in practice. Therefore, to improve data capture on a statewide level, we implemented a financial incentive targeting documentation of hernia defect size and mesh use. The Abdominal Hernia Care Pathway (AHCP), a voluntary pay for performance (P4P) initiative, was introduced in 2021 within the statewide Michigan Surgical Quality Collaborative (MSQC). This consisted of an organizational-level financial incentive for achieving 80% performance on eight specific process measures for ventral hernia surgery, including complete documentation of hernia defect size and location, as well as mesh characteristics and fixation technique. Comparisons were made between AHCP and non-AHCP sites in 2021. Of 69 eligible sites, 47 participated in the AHCP in 2021. There were N = 5362 operations (4169 at AHCP sites; 1193 at non-AHCP sites). At AHCP sites, 69.8% of operations had complete hernia documentation, compared to 50.5% at non-AHCP sites (p < 0.0001). At AHCP sites, 91.4% of operations had complete mesh documentation, compared to 86.5% at non-AHCP sites (p < 0.0001). The site-level hernia documentation goal of 80% was reached by 14 of 47 sites (range 14-100%). The mesh documentation goal was reached by 41 of 47 sites (range 4-100%). Addition of an organizational-level financial incentive produced marked gains in documentation of intra-operative details across a statewide surgical collaborative. The relatively large effect size-19.3% for hernia-is remarkable among P4P initiatives. This result may have been facilitated by surgeons' direct role in documenting hernia size and mesh use. These improvements in data capture will foster understanding of current hernia practices on a large scale and may serve as a model for improvement in collaboratives nationally.

Exploring factors associated with parent-reported early childhood caries with Alaska's childhood understanding behaviors survey data.

Early Childhood Caries (ECC) can negatively impact the lives of young children, despite being preventable. The purpose of this study was to utilize available data in Alaska to describe changes in parent reports of ECC, and identify factors related to ECC. The Childhood Understanding Behaviors Survey (CUBS) is a population-based survey of parents of 3-year-old children and was utilized to describe changes in: parent-reported ECC among children with a dental visit, access to and or utilization of dental care, and consumption of three or more cups of sweetened beverages between 2009-2011 and 2016-2019. Logistic regression modeling was used to explore factors associated with parent-reported ECC among children with a dental visit. Over time, a significantly smaller proportions of parents whose 3-year-old child had seen a dental professional reported ECC. Additionally, a smaller proportion of parents reported three or more cups of sweetened beverage consumption by their child, while larger proportions had seen a dental professional by age 3. Factors associated with parent-reported ECC included consumption of three or more cups of sweetened beverages, and enrollment in Medicaid or Tribal health care insurance, while protective factors included a parent earning a college degree, and military insurance. Although at the statewide level, improvements were observed in parent-reported measures over time, regional disparities were apparent. Social and economic factors as well as excessive consumption of sweetened beverages appear to play important roles in ECC. CUBS data can help identify trends in ECC within Alaska.

Using Crowdsourced Data to Reduce Traffic Congestion by Improving Detection of and Response to Disabled or Abandoned Vehicles on Florida Limited-Access Facilities

Disabled or abandoned vehicles (DAVs) cause a significant proportion of non-recurring traffic congestion. Waze data has the potential to help traffic management center (TMC) operators detect and respond to DAVs more quickly, reducing congestion. Previous studies have examined Waze data on a small scale, but not at a statewide level. This paper analyzes over 2 years of DAV Waze data on Florida Department of Transportation (FDOT) limited-access roadways (with more than 10 million alerts) and compares them with reported DAV events (crashes and non-crash TMC reports). Over 46% of the DAV events had an associated Waze alert before the DAV event occurred, indicating significant potential for earlier detection. These Waze alerts typically happened about 16 min before the DAV event and were most common during daytime hours and in urban areas. Two roadway segments, I-4 in FDOT District 5 and State Road 91 (SR-91) in FDOT District 4, were examined in more detail. A methodology was developed to estimate the delay reduction and congestion savings achieved by the earlier detection provided by the Waze alerts for lane-blocking and shoulder-blocking disabled vehicle events. The estimated congestion savings for the second half of 2019 were $4.3 million (I-4) and $2.5 million (SR-91), with benefit-cost ratios of 61 and 27, respectively. An additional $4.3 million could potentially have been saved as a result of Waze alerts allowing responders to reach DAVs before a crash occurred. These results can help agencies understand how crowdsourced data can be effectively utilized to best improve freeway operations.

The Scottish Parliamentary Elections and the Transformation of Electoral Behaviour

The rise of the decentralisation or devolution reforms in Europe in the past decades brought scholars' attention to the voting behaviour in multi-level electoral systems. Some types of elections, such as local or regional, might be considered less important for voters than national ones. However, in some regions, the importance of the sub-state level of governance is rising, which might lead voters to change their perception of the regional elections. Since the beginning of the devolution in the UK, the Scottish parliament has become one of the most powerful regional parliaments in Europe. The study reviewed the main differences in electoral behaviour between general and regional elections in Scotland. The analysis used four aspects of the theoretical model of the second-order election. It focused on the turnout in both elections, the success of small and regional parties, the change of support for government and opposition parties and the main campaign topics. The results showed that the Scottish electoral behaviour went through a significant transformation at regional and state-wide level in the past two decades. The different electoral behaviour in regional elections was significantly influenced by the voting system that helped regional nationalist parties increase their support and become the main political force in the region that determines electoral competition. The transformation of electoral behaviour in the Scottish parliamentary election continued to the state-wide level. It determined that the regional elections, in the case of Scotland, cannot be perceived as less important and subordinated to the general elections.

Is obesity a risk factor for melanoma?

ObjectivesAre twofold: 1) to estimate the relationship between obesity (BMI ≥30) and the prevalence of melanoma in different US states and 2) to examine the possibility of defining a new risk group. This might enhance the possibility of detection, which in turn, might increase the survival rates of patients.Study designA cohort Study, based on data at the US statewide level in 2011–2017, where the dependent variable (the annual new melanoma cases per 100,000 persons) is adjusted for age.MethodQuadratic regression analysis. This model permits a non-monotonic variation of obesity with new melanoma cases adjusted for age, where the control variable is the level of UV radiation.ResultsDemonstrate a negative correlation between obesity and incidence of melanoma. This outcome is further corroborated for Caucasians.ConclusionsWe should continue to establish primary prevention of melanoma by raising photo protection awareness and secondary prevention by promoting skin screening (by physician or self) among the entire population group in all BMI ranges. Advanced secondary melanoma prevention including noninvasive diagnosis strategies including total body photography, confocal microscopy, AI strategies should focus the high-risk sub group of Caucasians with BMI < 30.

Lessons Learned from the Colorado Project to Comprehensively Combat Human Trafficking

Countering human trafficking at a statewide level requires a combination of knowledge from lived experience, inter-sector collaborations, and evidence-based tools to measure progress. Since 2010, the nonprofit Laboratory to Combat Human Trafficking (LCHT) has collected and analyzed the data on how partners and organizations across the state work toward ending human trafficking. LCHT uses Community-Based Participatory Research (CBPR) to measure and illuminate promising paths toward ending human trafficking. Through CBPR, many collaborative working documents and activities have been created: Colorado Action Plans, Policy Recommendations, a Partnership Toolkit, and Partnership Convenings. This paper provides a single case study analysis of the Colorado Project, from 2013 through 2023, and offers a glimpse into the goals for the Colorado Project 2028. The ideas, strengths, and challenges presented here can guide other local efforts to support data-informed responses to trafficking. The CBPR methodology sheds light on the changes in Colorado’s anti-trafficking movement and the actions taken on behalf of partnerships (task forces and coalitions) across the state of Colorado. This paper offers a roadmap for collaborative design and decision-making among academic, nonprofit, and public sector partners seeking to conduct research on social movements utilizing a community-engaged process.

Arizona Surge Line: An emergent statewide COVID-19 transfer service with equity as an outcome.

The Arizona Surge Line was an emergent initiative during the COVID-19 pandemic to facilitate COVID-19 patient transfers and load-level hospitals on a statewide level. It was designed and implemented by the Arizona Department of Health Services in preparation for the first hospital surge due to COVID-19, recognizing the disproportionate impact that hospital surge would have on rural and tribal populations. We analyzed the Arizona Surge Line transfer data for the state's first two COVID-19 surges (4/16/2020-3/6/2021). Transfer data included transfer request characteristics, patient demographics and participating hospital characteristics. When applicable, we compared this data with Arizona census data, COVID-19 case data, and the CDC/ATSDR Social Vulnerability Index. The primary outcomes studied were the proportion of COVID-19 patient requests being successfully transferred, the median transfer time, and the proportion of vulnerable populations impacted. During the period of study, 160 hospitals in Arizona made 6,732 requests for transfer of COVID-19 patients. The majority of these patients (84%, 95% CI: 83-85%) were placed successfully with a median transfer time of 59 min (inter-quartile range 33-116). Of all transfer requests, 58% originated from rural hospitals, 53% were for patients of American Indian/Alaska Native ethnicity, and 73% of patients originated from highly vulnerable areas. The majority (98%) of receiving facilities were in urban areas. The Arizona Surge Line matched the number of transfers with licensed market shares during the period of study. The Arizona Surge Line is an equity-enhancing initiative that disproportionately benefited vulnerable populations. This statewide transfer infrastructure could become a standard public health mechanism to manage hospital surges and enhance access to care during a health emergency.

Association Between Neighborhood Socioeconomic Deprivation and Likelihood Of Lower Extremity Arterial Revascularization Versus Amputation

Previous studies suggest that median household income is a major determinant of the likelihood of amputation versus revascularization on a national level. It has recently been postulated that it is not primarily income but overall socioeconomic deprivation that influences this disparity. We undertook this study to determine the effect of socioeconomic deprivation on the likelihood of revascularization versus amputation on a statewide level.

The Statewide Patient Load Balancing Work of Washington State's Medical Operations Coordination Center.

Load balancing of constrained healthcare resources has become a critical aspect of assuring access to care during periods of pandemic related surge. These impacts include patient surges, staffing shortages, and limited access to specialty resources. This research focuses on the creation and work of a novel statewide coordination center, the Washington Medical Coordination Center (WMCC), whose primary goal is the load balancing of patients across the healthcare continuum of Washington State. This article discusses the origins, development, and operations of the WMCC including key partners, cooperative agreements, and structure necessary to create a patient load balancing system on a statewide level. As of April 21, 2022, the WMCC received 3821 requests from Washington State hospitals. Nearly 90% were received during the pandemic surge. Nearly 75% originated from rural hospitals that are most often limited in their ability to transfer patients when referral centers are also overwhelmed. The WMCC served as an effective tool to carry out patient load balancing activities during the COVID-19 pandemic surge in Washington State. It (the WMCC) has been shown to be an equity enhancing, cost effective means of managing healthcare surge events across a broad geographic region.

Rhetoric, Policy, and Medicine: An Analysis of the Effects of COVID-19 on Florida Policymaking

As with most institutions in the United States, healthcare is subject to its own unique set of issues, the largest of which pertain to the quality of and access to medical care. These issues were initially spawned at the federal level and currently still exist on a national scale; however, due to the political structure of the U.S., statewide governments have a large hand in the control and dispersal of medical care. With the onset of the COVID-19 pandemic, greater emphasis has been placed on the installment of public health measures like Coronavirus testing, mask-wearing, and vaccination, as a response to the shortcomings of clinical care; a result of this public health emphasis is a heightened need for governmental regulation of healthcare at a statewide level. This meta-analytical study aims to assess the role of political rhetoric in regulating healthcare amid COVID-19, specifically within the state of Florida. Applying a rhetorical lens to the politico-medical intersection has yielded four overarching means of general healthcare regulation: legislation, executive order, speech, and action. These four political extensions of rhetoric have each played a role in managing the health and livelihood of Florida residents throughout the COVID-19 public health crisis, and the assessment of these extensions has immediate implications with regard to understanding the issues of the U.S. healthcare system in other states, and on a federal level. Beyond this, analyzing the role of rhetoric in the politico-medical relationship may also help improve and understand the conditions of both institutions in many contexts.

Not Policies. People

Not Policies. People

Student learning and teacher retention for graduates of Texas Noyce programs

The shortage of secondary STEM teachers has led to periodic calls over the past four decades for federal intervention. For more than 15 years, the National Science Foundation Robert Noyce Teacher Scholarship Program has constituted the most important response at the national level to these calls. The main activity is direct support to undergraduate students and degree holders to become K-12 STEM teachers. Here we examine the Noyce program by looking beyond the qualities of particular university programs and measuring long-term outcomes on a statewide level. We accomplished this through a collaboration of eight Texas universities that pooled data on Noyce scholars supported as far back as 2003. Making use of a state longitudinal dataset, we examined whether recipients of Noyce Scholarships are more likely than other math and science teachers to remain in teaching, determined where Noyce scholars taught, and estimated student learning in classes taught by Noyce Scholars. Noyce Scholars are more likely than other STEM teachers from the same universities to teach marginalized students, and students of Noyce Scholars obtained higher value-added scores in mathematics than students of other teachers at the same schools. These are some of the most important intended outcomes. However, Noyce Scholars did not stay in teaching as long as other STEM teachers from their universities, and they were more likely to switch away from schools with low-income students. The Noyce program currently operates far below the scale needed to start reducing national STEM teacher shortages. We conclude with prospects for expansion and modification of the Noyce program.

Addressing Shortcomings in Contingency Standards of Care

Addressing Shortcomings in Contingency Standards of Care

O49 - Stillbirth Investigations and Shared Decision Making - Healthcare Professional learning needs

As part of the South Australian Stillbirth Autopsy and Investigations Project (SAIP), a staff survey was conducted across medical, midwifery and Aboriginal maternal infant care workers. The survey asked staff 12 questions focusing on capability, capacity and confidence regarding stillbirth investigations, shared-decision making with parents in regards to autopsy and investigations processes and consent and provision of bereavement care (including awareness of ‘protective parenting’) that underpins these crucial conversations. The staff survey formed a key element in the development of the online education for health care professionals aiming to improve capability, capacity and confidence of staff discussing, consenting, communicating stillbirth investigations process and autopsy for women experiencing a stillbirth. 157 respondents completed the survey. Few staff indicated that they had formal education in counselling bereaved parents. Key learning areas identified included location and use of the Stillbirth Investigations Algorithm, benefits and limitations of autopsy, what is involved in the different types of autopsy and how a baby would look afterwards. Additionally gaps were identified in process knowledge, including transport of babies, time required for autopsy, time before results are ready and funeral home arrangements. The other major learning need that emerged was cultural and/or religious considerations that may impact decision-making, including potential for involvement of cultural or religious leaders and how to approach this with parents. The identification of key learning areas has enabled the creation of a robust education program directly created to meet staff learning needs. Building the capacity, capability and confidence of the staff with stillbirth investigations and shared-decision making will in turn improve the care for parents, facilitate crucial conversations and improve the uptake of stillbirth investigations on a state wide level.