SARS-CoV-2 (COVID-19) Vaccine Intentions in Kentucky.

Background: At the time of our writing, the COVID-19 pandemic continues to cause significant disruption to daily lives. In Kentucky, the burdens from this disease are higher, and vaccination rates for COVID-19 are lower, in comparison to the U.S. as a whole. Understanding vaccine intentions across key subpopulations is critical to increasing vaccination rates. Purpose: This study explores COVID-19 vaccine intentions in Kentucky across demographic subpopulations and also investigates the influences on vaccine intention of attitudes and beliefs about COVID-19. Methods: A population-based survey of 1,459 Kentucky adults was conducted between January 26 and March 20, 2021, with over-sampling of black/African American and Latino/a residents, using online and telephonic modalities. Descriptive statistics characterize the sample and overall vaccine intentions and beliefs. Multivariable linear regression models probed relationships between demographics and vaccination intentions, as well as relationships between vaccination beliefs and vaccination intention. Results: Of the 1,299 unvaccinated respondents, 53% reported intent to get vaccinated, 16% had not decided, and 31% felt they would not get vaccinated. Lower vaccination intention was independently associated with age, lower educational attainment, black/African American race, lower income, Republican political affiliation, rural residence, and several beliefs: low vaccine safety, low vaccine efficacy, the rapidity of vaccine development, and mistrust of vaccine producers. Implications: Increasing COVID-19 vaccination rates will help end this pandemic. Findings from this study can be used to tailor information campaigns aimed at helping individuals make informed decisions about COVID-19 vaccination.

Research Partnerships with Healthcare Providers in Rural Community Health Centers: Needs and Challenges in Diabetes Research.

Kentucky has among the highest rates of diabetes and obesity in the United States. The Kentucky Diabetes and Obesity Collaborative (KDOC) was designed to develop a novel research infrastructure that can be used by researchers focusing on obesity and diabetes among patients cared for by Federally Qualified Health Centers (FQHC) serving rural Kentucky. Focus groups were carried out to develop an understanding of the needs and interests of FQHC practitioners and staff regarding participation in KDOC. Focus groups were conducted with 6 FQHCs and included a total of 41 individuals including health care providers, administrative staff and clinical staff. The discussions ranged in time from 30 to 70 minutes and averaged 45 minutes. Analysis of the transcripts of the focus groups revealed 4 themes: 1) contextual factors, 2) infrastructure, 3) interpersonal relationships, and 4) clinical features. The participants also noted four requirements that should be met for a research project to be successful in rural primary care settings: 1) there must be a shared understanding of health priorities of rural communities between the researcher and the practices/providers; 2) the proposed research must be relevant to clinics and their communities; 3) research and recommendations for evidence-based interventions need to reflect the day-to-day challenges of rural primary care providers; and 4) there needs to be an understanding of community norms and resources. Although research-clinic partnerships were viewed favourably overall, challenges in data integration to support both research and clinical outcomes were identified.

Achieving meaningful use of electronic health records (EHRs) in primary care: Proposed critical processes from the Kentucky Ambulatory Network (KAN).

OBJECTIVE: The Kentucky Ambulatory Network, a practice-based research network, conducted this study to propose critical processes for electronic health record (EHR) implementation. METHODS: Periodic observation of the implementation process and assessment of meaningful use (MU) metrics within 10 small primary care practices working with a regional extension center. RESULTS: Through focus groups and structured interviews, the strategies, processes, and procedures used by these practices to achieve MU of EHRs were determined. Implementation themes related to and critical processes associated with EHR adoption were proposed. CONCLUSIONS: Five proposed critical processes for EHR adoption and achievement of MU were identified; these processes were supported by 70% (7 of 10) of the study practices meeting MU criteria.

Factors relating to patient visit time with a physician.

This study sought to identify factors that increase or decrease patient time with a physician, determine which combinations of factors are associated with the shortest and longest visits to physicians, quantify how much physicians contribute to variation in the time they spend with patients, and assess how well patient time with a physician can be predicted. Data were acquired from a modified replication of the 1997-1998 National Ambulatory Medical Care Survey, administered by the Kentucky Ambulatory Network to 56 primary care clinicians at 24 practice sites in 2001 and 2002. A regression tree and a linear mixed model (LMM) were used to discover multivariate associations between patient time with a physician and 22 potentially predictive factors. Patient time with a physician was related to the number of diagnoses, whether non-illness care was received, and whether the patient had been seen before by the physician or someone at the practice. Approximately 38% of the variation in patient time with a physician was accounted for by predictive factors in the tree; roughly 33% was explained by predictive factors in the LMM, with another 12% linked to physicians. Knowledge of patient characteristics and needs could be used to schedule office visits, potentially improving patient flow through a clinic and reducing waiting times.

Prevalence of colorectal cancer screening among a multimorbid rural Appalachian population.

OBJECTIVES: The purpose of this study was to determine the relation among multiple morbidities and the prevalence of colorectal cancer (CRC) screening among older adult Appalachian residents of Kentucky. This is the first known study to address multiple morbidities exclusively with a health-disparities population. METHODS: This was a cross-sectional study of 1153 subjects, aged 50 to 76 years, from Appalachian Kentucky. RESULTS: White race, post-high school education, and perception of having more than enough income on which to survive were associated with higher rates of any guideline concordant CRC screening. Statistically significant trends in the outcome of adjusted odds ratios for colonoscopy with greater number of morbidities (P < 0.05) were noted; the higher number of morbidities, the higher rates of screening. CONCLUSIONS: Contrary to much existing research, within a health-disparities population, we found a dose-response relation between comorbidities and greater likelihood of CRC screening. Future research in this area should focus on explanations for this seldom-described finding. In addition, this finding has meaningful clinical and behavioral implications, including ensuring provider screening recommendation during routine office visits and outreach, perhaps through community clinics and public health departments, to extremely vulnerable populations lacking access to preventive care.

Communication efforts among local health departments and health care professionals during the 2009 H1N1 outbreak.

OBJECTIVES: The purpose of this study was to examine the public health response to the emergence of influenza H1N1 by evaluating the effectiveness of communication between health departments, community physicians, and pharmacists in Kentucky during the initial H1N1 outbreak. METHODS: This study used a cross-sectional survey design to gather information from health departments, physicians, and pharmacists regarding information dissemination and receipt during the early H1N1 outbreak (April to July2009). Study participants included members of practice-based research networks in public health, primary care, pharmacy, and their partners. RESULTS: Ninety-five percent of participating local health departments (LHDs) reported that health care professional notification was a risk mitigation strategy initiated in their local jurisdiction, and 81% of responding LHDs rated their capacity to disseminate information to health care providers as very good or excellent. However, only 52% of surveyed physicians and 16% of surveyed pharmacists reported receiving any information about H1N1 from an LHD. Seventy-four percent of pharmacists were not aware of their LHD's emergency plan in the event of an influenza outbreak. CONCLUSION: These findings suggest that deficiencies exist in the outreach and effectiveness of information dissemination efforts from LHDs to health care professionals during an influenza outbreak. Research that identifies improved methods for members of public health and health care systems to communicate and share information with one another is needed. An intervention focused on improving communication about infectious disease outbreaks and examining the impact of such an intervention would be useful and productive.

Cancer risk assessment by rural and Appalachian family medicine physicians.

CONTEXT: Challenges to the identification of hereditary cancer in primary care may be more pronounced in rural Appalachia, a medically underserved region. PURPOSE: To examine primary care physicians' identification of hereditary cancers. METHODS: A cross-sectional survey was mailed to family physicians in the midwestern and southeastern United States, stratified by rural/non-rural and Appalachian/non-Appalachian practice location (n = 176). Identification of hereditary breast-ovarian cancer (BRCA1/2), hereditary non-polyposis colon cancer (HNPCC), and other hereditary cancers was assessed. FINDINGS: Less than half of physicians (45%) reported having patients with cancer genetic testing. Most (70%) correctly identified the BRCA1/2-relevant scenario; 49% correctly identified the HNPCC-relevant scenario. Factor analysis of psychosocial variables revealed 2 factors: Confidence (knowledge, comfort, confidence) and importance (responsible, important, effective, need) of identifying hereditary cancer. Greater confidence was associated with use of 3 generation pedigree in taking family history. Greater knowledge and access to genetic services were associated with use of genetic testing. More recent graduation year, greater knowledge, and greater confidence were associated with identifying the BRCA1/2-relevant scenario. Greater knowledge and confidence were associated with identifying the HNPCC-relevant scenario. CONCLUSIONS: Though rural Appalachian physicians do not differ in ability to identify high risk individuals, access barriers may exist for genetic testing. Interventions are needed to boost physician confidence in identifying hereditary cancer and to improve availability and awareness of availability of genetic services.

Cardiovascular risk education and social support (CaRESS): report of a randomized controlled trial from the Kentucky Ambulatory Network (KAN).

PURPOSE: Test a practice-based intervention to foster involvement of a relative or friend for the reduction of cardiovascular risk in patients with type 2 diabetes. METHODS: We enrolled in a randomized controlled trial 199 patients and 108 support persons (SPs) from 18 practices within a practice-based research network. All patient participants had type 2 diabetes with suboptimal blood pressure control and were prepared to designate a SP. A subset of the patients also had dyslipidemia. All study visits were conducted at the practice sites where staff took standardized blood pressure measurements and collected blood samples. All patients completed one education session and received newsletters aimed at improving key health behaviors. Intervention group patients included their chosen SP in the education session and the SPs received newsletters. RESULTS: After 9 to 12 months, the intervention had no significant effect on systolic blood pressure, HbA1C, health-related quality of life, patient satisfaction, medication adherence, or perceived health competence. Power was insufficient to detect an effect on low-density lipoprotein cholesterol. Baseline cardiovascular risk values were not very high, with mean systolic blood pressure at 140 mm Hg; mean HbA1C at 7.6%; and mean low-density lipoprotein at 137 mg/dL. Patient health care satisfaction was high. CONCLUSION: This practice-based intervention to foster social support for chronic care management among diabetics had no significant impact on the targeted outcomes.

Patients, practices, and relationships: challenges and lessons learned from the Kentucky Ambulatory Network (KAN) CaRESS clinical trial.

The Cardiovascular Risk Education and Social Support (CaRESS) study is a randomized controlled trial that evaluates a social support intervention toward reducing cardiovascular risk in type 2 diabetic patients. It involves multiple community-based practice sites from the Kentucky Ambulatory Network (KAN), which is a regional primary care practice-based research network (PBRN). CaRESS also implements multiple modes of data collection. The purpose of this methods article is to share lessons learned that might be useful to others developing or implementing complex studies that consent patients in PBRNs. Key points include building long-term relationships with the clinicians, adaptability when integrating into practice sites, adequate funding to support consistent data management and statistical support during all phases of the study, and creativity and perseverance for recruiting patients and practices while maintaining the integrity of the protocol.

Communication about complementary and alternative medicine: perspectives of primary care clinicians.

BACKGROUND: People in the United States are using complementary and alternative medicine (CAM) increasingly while they are also receiving conventional care. National population-based surveys and studies in primary care settings have documented inadequate communication about CAM between patients and their conventional healthcare providers. Most studies about CAM communication have surveyed urban practices and focused on physicians. Information about how physicians and non-physician in rural areas clinicians communicate with their patients about CAM is needed to develop strategies for improving the quality of care for patients in rural areas. OBJECTIVE: To investigate how primary care clinicians in the Kentucky Ambulatory Network (KAN) communicate with patients about CAM and to determine interest in additional education about CAM. METHODS: A self-administered survey was mailed to 112 community clinicians in a research network of largely rural practices. KAN members include primary care physicians, nurse practitioners, certified nurse midwives, and physician assistants practicing in 32 counties in central and eastern Kentucky. RESULTS: Of 102 deliverable surveys, 65 (64%) were returned. Sixty-one (94%) clinicians reported patient CAM use. Few clinicians consistently asked patients about CAM. A positive attitude toward patient CAM use was associated with clinician comfort in advising patients. Most clinicians recommended CAM to patients. Seventy percent of KAN clinicians expressed interest in continuing education about CAM. CONCLUSIONS: Kentucky primary care clinicians are aware of their patients' CAM use and are motivated to learn more about CAM so that they can appropriately advise their patients. They need evidence-based, clinically relevant education about CAM to provide better patient care.

Information-seeking behaviors of practitioners in a primary care practice-based research network (PBRN).

OBJECTIVE: The aim of this study was to examine the information-seeking behaviors (e.g., information resource usage patterns, access to types of sources and to medical libraries, and use of particular information technologies) of members in a primary care practice-based research network (PBRN) to inform future efforts supporting primary care practitioners in their daily care of patients. METHODS: Every primary care practitioner who was a member of the Kentucky Ambulatory Network-including family practitioners, general practitioners, nurse practitioners, and physician assistants-was surveyed. The cross-sectional survey included twenty-six questions to investigate the information-seeking behavior of primary care practitioners. RESULTS: The response rate was 51% (59 of 116). Most practitioners (58%) stated they sought information to support patient care several times per week, and most (68%) noted they do this while the patient waited. Many practitioners (40%) never or almost never perform literature searches from online sources such as MEDLINE, although 44% said they did so a few times per month. A significant correlation between use of online sources and use of print sources suggests that those who seek online information more frequently than those who do not also seek information from print sources frequently, and vice versa. Access to medical libraries was also reported as high. CONCLUSIONS: Consistent with previous studies, the primary care practitioners in this rural PBRN reported more frequent use of print and interpersonal sources compared to online sources. There appeared to be, however, a clear difference between those practitioners who are more likely to seek information, regardless of format, and those who are less inclined. Future interventions will need to address such barriers as time, cost, and information-seeking skills.

How and why to study the practice content of a practice-based research network.

BACKGROUND: We describe the rationale, methods, and important lessons learned from doing a practice content study in a new practice-based research network (PBRN). METHODS: We performed a modified replication of the National Ambulatory Medical Care Survey (NAMCS) in the Kentucky Ambulatory Network (KAN). Network clinicians had input into focused modifications of the NAMCS protocol, including addition of data fields of special interest to them. Cross-sectional sampling of patient visits was done for a 1-year period, with each practice collecting data during 2 separate weeks. We used selected results to illustrate lessons learned and the value of this endeavor. RESULTS: Twenty-three KAN clinicians helped recruit 33 of their colleagues, and these 56 community-based primary care clinicians collected data on 2,228 office visits. Patient demographics (except race) and the top 10 diagnoses were similar to US NAMCS data. One third of visits addressed 3 or more diagnoses, and one fourth of the visits involved 4 or more medications. The top 10 primary diagnoses represented only one third of all primary diagnoses. Seventy percent of adult patients were either overweight (30%) or obese (40%). Rates of counseling on diet or exercise rose with increases in body mass index. CONCLUSION: This study helped us establish and activate our new PBRN, increasing its membership in the process. The descriptive data gained will stimulate, guide, and support our future research activities.

Current state of information technology use in a US primary care practice-based research network.

OBJECTIVES: To examine the current levels of information technology (IT) use in a primary care practice-based research network (PBRN) in order to inform future development of its infrastructure. PARTICIPANTS: Every primary care practitioner who is a member of the Kentucky Ambulatory Network (KAN),as well as the office managers of each practice. Practitioners included family practitioners, general practitioners, nurse practitioners and physician assistants. METHODS: A cross-sectional study using two survey instruments: one for office managers and one for practitioners. The office manager survey included questions related to the current state of IT within the practice, plans for enhancement and general IT issues from the perspective of managing a practice. The practitioner survey was designed to measure current IT use and attitudes of primary care practitioners. RESULTS: Response rates for the surveys were 46% (n = 68) for the office managers and 51% (n = 116) for practitioners. All but one practice had internet access; however, 43% had only dial-up service. Only 21% of practitioners use an electronic medical record (EMR), with dollar cost being the barrier reported most frequently (58%). More than half of the office managers were either 'somewhat interested' (45%) or 'very interested' (17%) in a low-cost, standardised EMR that was, at the time, to be sponsored by the American Academy of Family Physicians. For practitioners, 71% were either 'somewhat' or 'very' interested in such a system. Responses to other IT issues are reported. CONCLUSION: While interest in enabling information technologies was high in KAN, adoption was variable, with use of several key technologies reported as low.The results suggest that research in this network that would be dependent on or enhanced by IT might be impeded and, generally, greater attention should be given to enhancing the IT infrastructure in primary care.

The development and validation of a comorbidity index for prostate cancer among Black men.

BACKGROUND AND OBJECTIVES: The purpose of this study was to develop a comorbidity index specific to Black Men with prostate cancer, because certain comorbidities and prostate cancer are particularly prevalent among this racial group. METHODS: This research used the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database to develop an index of comorbidity burden based on survival, and the presence/absence of comorbid illness in 2,931 Black males diagnosed with prostate cancer. Comorbidity burden was recognized using inpatient, outpatient, and physician claims for a 2-year period prior to the diagnosis of prostate cancer. We compared five different statistical models, each with two-way, three-way, and/or four-way interactions among the comorbidities, and selected the model with only two-way interactions as the optimal choice. We demonstrated the utility of refining the simplest model, with 27 comorbidity categories only, by adjusting for the number of different diagnoses within statistically significant categories.

Can we identify medical students at admission who will enter primary care residencies?

We sought to estimate the predictive value of admissions interviewers' impressions about student interest in primary care at the University of Kentucky College of Medicine (UKCOM). We counted the number of UKCOM students considered by the admissions interviewers to be interested in primary care careers prior to matriculation. We then compared the interviewers' impressions with the same students' choices of residency programs at graduation. Analyses were restricted to students who entered UKCOM in 1995, 1996, and 1997, and graduated on time in 1999, 2000, and 2001. Each student completed two admissions interviews. Over the three-year study period, both admissions interviewers agreed that 107 (45%) of 237 graduating students demonstrated a clear preference at matriculation for entering a primary care career. Of these 107 graduates, 69 (64%) entered a primary care field. Of the 69 students labeled as not inclined toward primary care, 26 (39%) did enter a primary care field. Of the 61 students about whom the interviewers had split opinions, 30 (49%) entered a primary care field. All total, 125 (53%) of the 237 graduates entered a primary care field. Agreement by both interviewers on students' predilections toward (or away) from primary care were correct 64% of the time. A major limitation in our analysis was lack of information on how many primary carebound students would ultimately pursue subspecialty fellowships. We conclude that interviewers can help select medical students interested in primary care, that their performance might be improved by more meticulous application of known predictive factors, and that their performance could be more accurately measured if data on ultimate practice type at the end of all training were available.