Increasing Rates of Human Pipillomavirus Vaccination in Family Practice: A Quality Improvement Project.

INTRODUCTION: The Centers for Disease Control and Prevention updated recommendations for human papillomavirus (HPV) vaccine in 2016. National and statewide statistics indicate that HPV vaccination in the adolescent population is well below the administration rates for other vaccines. Because cancers associated with HPV infection are vaccine preventable, low administration rates are a cause for concern. METHODS: Through a two-year project funded by the South Dakota Department of Health, Sanford Health implemented a quality improvement project to address the low rate of HPV vaccine administration in their clinics in South Dakota. Evidence-based interventions included: implementation of a client reminder and recall system, vaccine education for providers and staff, a provider assessment and feedback system, and re-education on protocol (standing) orders. RESULTS: Implementation of this quality improvement project resulted in the following: 104,571 client reminders distributed, re-education on standing orders for vaccine administration, as well as feedback on missed opportunities for vaccination, and increased awareness for all providers and staff. In patients ages 11-26, HPV vaccine series completion rates increased by 13 percent in the two-year period. Zero-dose HPV vaccination dropped 22 percent in the seven pilot clinics over the two-year grant period, and by 10 percent overall when the additional clinics (n=32) were added in the second year. DISCUSSION: Implementation of the above practices provided a significant increase in awareness of the need to assess and administer HPV vaccine. The methods used are easily adaptable to any clinic system. These practices can increase HPV vaccination rates and ultimately decrease the number of HPV associated cancers.

Tobacco quitline outcomes for priority populations.

BACKGROUND: Despite declining rates of tobacco use, certain subgroups still experience a disproportionate risk for tobacco-related health issues. The South Dakota QuitLine identifies five priority population subgroups as the following: American Indians, tobacco users receiving Medicaid, youth, pregnant women, and spit tobacco users. The purpose of this study was to describe South Dakota QuitLine use among priority population subgroups and to measure associated cessation rates and service satisfaction. METHODS: Priority population subgroups comprised 22.6 percent (9,558 out of 42,237) of South Dakota QuitLine participants during a six-year period (2008-2013). Of the 34,866 total participants eligible for seven-months follow-up, 15,983 completed a telephone survey that measured tobacco quit status and service satisfaction (45.8 percent overall response). Eligible priority population subgroups had a 41.9 percent response (3,094 out of 7,388). RESULTS: The seven-month tobacco quit rate for the non-priority population group (46.9 percent) was higher than the quit rate for pregnant women (42.3 percent), youth (37.5 percent), American Indians (38.1 percent), Medicaid participants (35.7 percent) and participants with more than one priority subgroup designation (35.1 percent). The quit rate for spit tobacco users was highest overall (57.3 percent). All subgroups were satisfied with South Dakota Quitline services (≥ 3.5/4.0 scale; 4 = very satisfied). CONCLUSIONS: Tobacco users in high risk and underserved population subgroups of the South Dakota QuitLine seek cessation services. Quit rates were overall favorable and varied between population subgroups (35.1-57.3 percent). Health care providers play a vital role in early identification of tobacco use and referral to cessation services for priority populations. Providers should assess tobacco use, advise users to quit, and refer to the South Dakota QuitLine.

Cessation among state quitline participants with a mental health condition.

INTRODUCTION: Telephone quitlines are an effective treatment option for tobacco cessation in the general population. Many participants who use quitline services have mental health conditions (MHC), yet few published studies have examined the use of quitline services in this population. This study examined the prevalence of MHC among state quitline participants and compared cessation outcomes among those with and without MHC. METHODS: Demographic and tobacco use data were collected at enrollment and 7 months post-enrollment using standardized assessments for 10,720 eligible participants who enrolled in a state quitline between September, 2010 and August, 2012. RESULTS: The prevalence of self-reported MHC was 19.8% (2,086/10,720 callers). The intent to treat quit rate for participants with a MHC was 16.4% compared to 21.5% for those without a MHC (p < .001), and the responder quit rate was 36.9% for those with a MHC compared to 44.4% for those without (p < .001). The adjusted odds ratio describing the association of MHC status and tobacco cessation was identical for both the intent-to-treat and responder populations, and indicated that participants with MHC were 23% less likely to quit (p < .05). CONCLUSIONS: This study identified that participants with MHC accessed a state quitline, but were less likely to quit. The finding was independent of other factors influencing tobacco cessation, such as gender, race, and education. These findings indicate that although quitline services are an option for tobacco cessation among persons with MHC, further research is needed to determine why cessation rates are lower.

A statewide assessment of smoke-free policy in multiunit housing settings.

INTRODUCTION: The prevalence of smoke-free policies in multiunit housing (MUH) in South Dakota was examined. Owner beliefs about smoke-free policies were identified. METHODS: Stratified random sampling included 27 South Dakota counties classified as frontier, large rural, or urban. Data collection with MUH owners in selected counties employed a telephone survey with mailed backup. RESULTS: The owner response rate was 41.5% (324/780). A written smoke-free policy was reported by 175 (54.0%) owners, and 31 (10%) reported a verbal smoke-free policy. Owners in large rural counties (57.4%) had more written smoke-free policies than owners in urban (52.2%) and frontier (53.5%) counties. Only 8.5% of properties had policies covering both buildings and grounds. Owners without policies were more than twice as likely to manage U.S. Department of Housing and Urban Development subsidized units and were three times as likely to be current smokers. Owners without a smoke-free policy anticipated that a policy would decrease maintenance costs but increase turnover and vacancy rates. Nearly one-half (47.9%) of owners with no smoke-free policy had previously considered implementing a policy. Owners self-reported beliefs about smoke-free policies identified perceived benefits such as decreased maintenance and costs, improved tenant safety and health, and conscientious tenants. Perceived drawbacks included increased outdoor maintenance, enforcement problems, concerns about long-term tenants who smoke, and freedom/rights of smokers. CONCLUSIONS: This study provides a baseline assessment of smoke-free polices in MUH settings. Perceptions of owners without smoke-free policies focused on economic concerns that were inconsistent with reports from those owners with smoke-free policies.

Palliative and end-of-life care in South Dakota.

BACKGROUND: Geographical disparities play a significant role in palliative and end-of-life care access. This study assessed availability of palliative and end of life (hospice) care in South Dakota. METHODS: Grounded in a conceptual model of advance care planning, this assessment explored whether South Dakota health care facilities had contact persons for palliative care, hospice services, and advance directives; health care providers with specialized training in palliative and hospice care; and a process for advance directives and advance care planning. Trained research assistants conducted a brief telephone survey. RESULTS: Of 668 health care eligible facilities, 455 completed the survey for a response rate of 68 percent (455 out of 668). Over one-half of facilities had no specific contact person for palliative care, hospice services and advance directives. Nursing homes reported the highest percentage of contacts for palliative care, hospice services and advance directives. Despite a lack of a specific contact person, nearly 75 percent of facilities reported having a process in place for addressing advance directives with patients; slightly over one-half (53 percent) reported having a process in place for advance care planning. Of participating facilities, 80 percent had no staff members with palliative care training, and 73 percent identified lack of staff members with end-of-life care training. Palliative care training was most commonly reported among hospice/home health facilities (45 percent). CONCLUSIONS: The results of this study demonstrate a clear need for a health care and allied health care workforce with specialized training in palliative and end-of-life care.

Tobacco quitline outcomes by service type.

BACKGROUND: Tobacco use is a burden in terms of mortality, chronic disease, and economic impact. Effective treatments exist to aid tobacco users who are motivated to quit. The South Dakota QuitLine provides coaching to all participants and the option of a cessation product (nicotine replacement therapy [NRT], or the prescription medications, varenicline or bupropion) at no cost. This study describes the types of services requested by South Dakota QuitLine participants and the associated cessation outcomes across service types. METHODS: Data from South Dakota QuitLine enrollees during a four year period (2008 to 2011) were included. Enrollment data (demographics and tobacco use) and outcome evaluation data (30 day point prevalence - abstinence) collected seven months later were accessed (N = 11,603/26,876 enrollees, 43.2 percent response). The frequency of requests for each type of cessation service and associated cessation outcomes are reported. Abstinence at seven months was compared for the different services. RESULTS: Frequencies of cessation services requested were coaching/varenicline (64.6 percent), coaching/bupropion (5 percent), coaching/NRT (22.6 percent), and coaching only (5.4 percent). Overall abstinence at seven months was 47.2 percent. Abstinence rates for service types were the following: coaching/varenicline (49.8 percent), coaching/bupropion (47.3 percent), coaching/NRT (42.9 percent), and coaching only (40.3 percent). Chi-square analysis and confidence interval comparisons identified significantly higher abstinence (p < .05) for varenicline/coaching in comparison to coaching only or coaching/NRT. CONCLUSIONS: All service options available from the South Dakota QuitLine result in cessation rates of 40 percent or greater. Providers should assess tobacco use, advise users to quit, and refer to the South Dakota QuitLine.

Evaluation of school tobacco-free policies in a rural Northern Plains state.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) has called for tobacco-free school (TFS) policies. In South Dakota (SD), a rural state with a large American Indian population, collaboration between state agencies focused on development and dissemination of a model TFS policy in 2008. This study explored the current status of TFS policies in statewide SD school districts. METHODS: Tobacco policies were requested from all SD school district administrators. A 26-point checklist based on CDC TFS policy guidelines was used to evaluate policies. Follow-up interviews were conducted with selected superintendents. RESULTS: Policies were received from 144 of 217 districts (66% response). Participation was higher for public districts than tribal/Bureau of Indian Education (BIE) districts and nonpublic districts. The overall mean policy score was 11.6 (SD 5.1). Public school districts had the highest mean (12.3) followed by nonpublic (8.9) and tribal/BIE (7.5). In a subset of districts with a large American Indian population (>30%), policy scores were lower for those located on reservation or tribal lands compared with other locations. Barriers to policy development were identified as time and staff expertise. CONCLUSIONS: There is a need to improve statewide TFS policies. A district report card with recommendations for improvement and a resource guide were developed and disseminated.

Reduction in medication costs for patients with chronic nonmalignant pain completing a pain rehabilitation program: a prospective analysis of admission, discharge, and 6-month follow-up medication costs.

OBJECTIVE: Chronic nonmalignant pain (CNMP) is both a prevalent and a costly health problem in our society. Pain rehabilitation programs have been shown to provide cost-effective treatment. A treatment goal for some rehabilitation programs is reduction in the use of pain-related medication. Medication costs savings from pain rehabilitation programs have not been analyzed in previous studies. DESIGN: This prospective cohort study of 186 patients with CNMP addresses the costs of medications at admission to a 3-week outpatient pain rehabilitation program, at discharge, and at 6-month follow-up. Medication use was determined through a detailed pharmacist interview with patients at admission and discharge. Patients were sent questionnaires 6 months after program completion, which obtained current medication information. RESULTS: Statistically significant medication cost savings were seen for program completers at discharge and at 6-month follow-up (P < 0.05). The mean (standard deviation) daily prescription medication cost reduction from admission to discharge was $9.31 ($12.70) using the average wholesale price of medications. From the original study cohort, 121 patients completed the 6-month follow-up survey. The mean daily prescription medication cost savings from admission to 6-month follow-up was $6.68 ($14.40). CONCLUSION: Patients benefited from significant medication cost savings at the completion of the 3-week outpatient pain rehabilitation program and maintained significant savings after 6 months. This study adds to the current literature on the economic value of comprehensive pain rehabilitation programs.

Effects of smoking status on immediate treatment outcomes of multidisciplinary pain rehabilitation.

OBJECTIVE: The primary aim of this study was to determine the effects of smoking on treatment outcomes following multidisciplinary pain rehabilitation. A secondary aim was to assess the tobacco use characteristics of smokers with chronic pain. DESIGN: A prospective, nonrandomized, repeated measures design. SETTING: Multidisciplinary pain rehabilitation center at a tertiary referral medical center. PATIENTS: All patients (N = 193) consecutively admitted from August 2005 through February 2006. INTERVENTIONS: A 3-week outpatient multidisciplinary pain rehabilitation program. OUTCOME MEASURES: The Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Center for Epidemiologic Studies-Depression scale (CES-D), Pain Anxiety Symptom Scale (PASS-20) and Pain Catastrophizing Scale (PCS) were administered at admission and dismissal. RESULTS: The study involved 49 (83% women) smokers and 144 (83% women) nonsmokers. The mean number of cigarettes smoked daily was 17.5 (SD 11.1) and the mean duration of smoking was 21.5 years (SD 12.1). After adjusting for demographic differences, repeated measures of analysis of covariance showed a main effect of smoking status for MPI affective distress (P = 0.008), CES-D (P = 0.001) and PCS (P = 0.011). An interaction of smoking status and time was found for the PASS-20 (P = 0.028), MPI affective distress (P = 0.033), MPI life control (P = 0.003) and SF-36 role-emotional (P = 0.004) subscale. While the majority of smokers were ready to consider smoking abstinence, 43% declined a brief smoking cessation intervention. CONCLUSIONS: In this series of patients undergoing multidisciplinary treatment for chronic pain, immediate treatment effects for a variety of outcome measures were similar or significantly better in smokers compared with nonsmokers.

Intervention for erythromelalgia, a chronic pain syndrome: comprehensive pain rehabilitation center, Mayo Clinic.

OBJECTIVE: To describe the response in patients with erythromelalgia to the pain rehabilitation program at Mayo Clinic, Rochester, Minnesota. DESIGN: Retrospective case series. SETTING: Comprehensive Pain Rehabilitation Center at a tertiary referral medical center. Patients Eight patients with erythromelalgia admitted to the pain rehabilitation program from January 1, 2002, through June 30, 2007. MAIN OUTCOME MEASURES: The Multidimensional Pain Inventory, the 36-Item Short Form Health Survey, the Pain Catastrophizing Scale, and the Center for Epidemiologic Studies Depression Scale were administered at admission and dismissal from the program. Mean differences in scores were compared using 2-sided paired t tests. RESULTS: Scores for the life interference, life control, and general activity subscales of the Multidimensional Pain Inventory showed significant improvement from admission to dismissal (all P < .05). Similarly, the scores of the Pain Catastrophizing Scale, the Center for Epidemiologic Studies Depression Scale, and the physical functioning and emotional role limitation subscales of the 36-Item Short Form Health Survey were significantly improved after intervention (all P < .01). Conclusion The results of our study indicate that pain rehabilitation is a useful method for managing pain-related impairment in physical and emotional functioning in patients with erythromelalgia.

A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission.

UNLABELLED: Use of opioids for chronic non-cancer pain is controversial and the efficacy of comprehensive pain rehabilitation programs (CPRPs) that incorporate opioid withdrawal requires further investigation. We test the hypothesis that patients with chronic pain and longstanding opioid use who undergo opioid withdrawal in the course of rehabilitative treatment will experience significant and sustained improvement in pain and functioning similar to patients who were not taking opioids. A longitudinal design study compared 373 consecutive patients admitted to the Mayo Clinic Pain Rehabilitation Center at admission, discharge and six-month posttreatment by opioid status at admission. Measures of pain severity, depression, psychosocial functioning, health status, and pain catastrophizing were used to assess between- and within-group differences. Treatment involved a 3-week interdisciplinary pain rehabilitation program focused on functional restoration. Over one-half of patients (57.1%) were taking opioids daily at admission. The majority of patients (91%) completed rehabilitation and 70% of patients who completed the program returned questionnaires six months posttreatment. On admission, patients taking low- and high-dose opioids reported significantly greater pain severity (P=.001) and depression (P=.001) than the non-opioid group. Significant improvement was found on all outcome variables following treatment (P<.001) and six-month posttreatment (P<.001) regardless of opioid status at admission. There were no differences between the opioid and non-opioid groups upon discharge from the program or at six months following treatment. CONCLUSION: Patients with longstanding CPRP on chronic opioid therapy, who choose to participate in interdisciplinary rehabilitation that incorporates opioid withdrawal, can experience significant and sustained improvement in pain severity and functioning.

Withdrawal of analgesic medication for chronic low-back pain patients: improvement in outcomes of multidisciplinary rehabilitation regardless of surgical history.

OBJECTIVE: To determine the posttreatment outcomes of multidisciplinary pain rehabilitation that incorporates analgesic medication withdrawal for chronic low-back pain patients on the basis of lumbar spine surgical history. DESIGN: This is a retrospective analysis of 383 consecutive chronic low-back pain patients participating in a 3-wk, outpatient, intensive, multidisciplinary pain rehabilitation program. The study sample was divided into three groups based on history of spine surgery: 196 patients without previous lumbar spine surgery, 125 with history of lumbar fusion, and 62 with history of nonfusion lumbar spine surgery. Patients were assessed at admission and dismissal for medication use, pain severity and affective characteristics, physical functioning, depression, and pain catastrophizing. RESULTS: At admission, patients in both the fusion and nonfusion surgery groups were using more opioids compared with the no-surgery group. Reported pain severity and duration was highest in the fusion group compared with the other groups. Admission to dismissal comparisons showed significant and nearly equal improvements for all groups in health and medication measures. CONCLUSIONS: Study results demonstrate that multidisciplinary pain rehabilitation treatment incorporating analgesic medication withdrawal is associated with significant clinical improvements in physical and emotional functioning, regardless of lumbar spine surgical history.

Prevalence and clinical correlates of vitamin D inadequacy among patients with chronic pain.

OBJECTIVE: Vitamin D inadequacy is associated with medication refractory musculoskeletal pain and neuromuscular dysfunction. This vitamin deficiency could subsist as an unrecognized comorbid condition among patients with chronic pain. The primary objective of this study was to determine the prevalence and clinical correlates of vitamin D inadequacy in patients seeking treatment for chronic pain. DESIGN: Retrospective case series. SETTING: Multidisciplinary pain rehabilitation center at a tertiary referral medical center. PATIENTS: The study involved 267 chronic pain patients admitted from February to December 2006. INTERVENTION: Serum 25-hydroxyvitamin D (25[OH]D) was drawn at admission. OUTCOME MEASURES: Patients with serum 25[OH]D levels < or=20 ng/mL were considered to have inadequate levels and those with levels >20 ng/mL were considered to have adequate levels. Upon admission, opioid intake was documented and patients completed the Short Form-36 Health Status Questionnaire. RESULTS: The prevalence of vitamin D inadequacy was 26% (95% confidence interval, 20.6-31.1%). Among patients using opioids, the mean morphine equivalent dose for the inadequate vitamin D group was 133.5 mg/day compared with 70.0 mg/day for the adequate group (P = 0.001). The mean duration of opioid use for the inadequate and adequate groups were 71.1 months and 43.8 months, respectively (P = 0.023). Opioid users with inadequate levels reported worse physical functioning (P = 0.041) and health perception (P = 0.003) than opioid users with adequate levels. CONCLUSION: The prevalence and clinical correlates identified in this pilot study provide the basis for the assertion that vitamin D inadequacy may represent an under-recognized source of nociception and impaired neuromuscular functioning among patients with chronic pain.