Protocol of a patient randomized clinical trial to improve medication adherence in primary care.

BACKGROUND: Enhanced awareness of poor medication adherence could improve patient care. This article describes the original and adapted protocols of a randomized trial to improve medication adherence for cardiometabolic conditions. METHODS: The original protocol entailed a cluster randomized trial of 28 primary care clinics allocated to either (i) medication adherence enhanced chronic disease care clinical decision support (eCDC-CDS) integrated within the electronic health record (EHR) or (ii) usual care (non-enhanced CDC-CDS). Enhancements comprised (a) electronic interfaces printed for patients and clinicians at primary care encounters that encouraged discussion about specific medication adherence issues that were identified, and (b) pharmacist phone outreach. Study subjects were individuals who at an index visit were aged 18-74 years and not at evidence-based care goals for hypertension (HTN), diabetes mellitus (DM), or lipid management, along with low medication adherence (proportion of days covered [PDC] <80%) for a corresponding medication. The primary study outcomes were improved medication adherence and clinical outcomes (BP and A1C) at 12 months. Protocol adaptation became imperative in response to major implementation challenges: (a) the availability of EHR system-wide PDC calculations that superseded our ability to limit PDC adherence information solely to intervention clinics; (b) the unforeseen closure of pharmacies committed to conducting the pharmacist outreach; and (c) disruptions and clinic closures due to the Covid-19 pandemic. CONCLUSION: This manuscript details the protocol of a study to assess whether enhanced awareness of medication adherence issues in primary care settings could improve patient outcomes. The need for protocol adaptation arose in response to multiple implementation challenges.

Clinical Decision Support to Reduce Opioid Prescriptions for Dental Extractions using SMART on FHIR: Implementation Report.

BACKGROUND: Clinical decision support (CDS) has the potential to improve clinical decision-making consistent with evidence-based care. CDS can be designed to save health care providers time and help them provide safe and personalized analgesic prescribing. OBJECTIVE: The aim of this report is to describe the development of a CDS system designed to provide dentists with personalized pain management recommendations to reduce opioid prescribing following extractions. The use of CDS is also examined. METHODS: This study was conducted in HealthPartners, which uses an electronic health record (EHR) system that integrates both medical and dental information upon which the CDS application was developed based on SMART (Substitutable Medical Applications and Reusable Technologies) on FHIR (Fast Healthcare Interoperability Resources). The various tools used to bring relevant medical conditions, medications, patient history, and other relevant data into the CDS interface are described. The CDS application runs a drug interaction algorithm developed by our organization and provides patient-specific recommendations. The CDS included access to the state Prescription Monitoring Program database. IMPLEMENTATION (RESULTS): The pain management CDS was implemented as part of a study examining opioid prescribing among patients undergoing dental extraction procedures from February 17, 2020, to May 14, 2021. Provider-level use of CDS at extraction encounters ranged from 0% to 87.4% with 12.1% of providers opening the CDS for no encounters, 39.4% opening the CDS for 1%-20% of encounters, 36.4% opening it for 21%-50% of encounters, and 12.1% opening it for 51%-87% of encounters. CONCLUSIONS: The pain management CDS is an EHR-embedded, provider-facing tool to help dentists make personalized pain management recommendations following dental extractions. The SMART on FHIR-based pain management CDS adapted well to the point-of-care dental setting and led to the design of a scalable CDS tool that is EHR vendor agnostic. TRIAL REGISTRATION: ClinicalTrials.gov NCT03584789; https://clinicaltrials.gov/study/NCT03584789.

Factor Analysis in Distinguishing Coronavirus Disease 2019 From Other Influenza-like Illness Using a Validated Patient-Reported Outcome Instrument FLU-PRO Plus: A Prospective Real-world Cohort Study.

BACKGROUND/OBJECTIVE: InFLUenza Patient-reported Outcome (FLU-PRO Plus) is a 34-item patient-reported outcome instrument designed to capture the intensity and frequency of viral respiratory symptoms. This study evaluates whether FLU-PRO Plus responses could discriminate between symptoms of coronavirus disease 2019 (COVID-19) and influenza-like illness (ILI) with no COVID diagnosis, as well as forecast disease progression. METHODS: FLU-PRO Plus was administered daily for 14 days. Exploratory factor analysis was used to reduce the FLU-PRO Plus responses on the first day to 3 factors interpreted as "symptom clusters." The 3 clusters were used to predict COVID-19 versus ILI diagnosis in logistic regression. Correlation between the clusters and quality of life (QoL) measures was used to assess concurrent validity. The timing of self-reported return to usual health in the 14-day period was estimated as a function of the clusters within COVID-19 and ILI groups. RESULTS: Three hundred fourteen patients completed day 1 FLU-PRO Plus, of which 65% had a COVID-19 diagnosis. Exploratory factor analysis identified 3 symptom clusters: (1)general Body, (2) tracheal/bronchial, and (3) nasopharyngeal. Higher nasopharyngeal scores were associated with higher odds of COVID-19 compared with ILI diagnosis [adjusted odds ratio = 1.61 (1.21, 2.12)]. Higher tracheal/bronchial scores were associated with lower odds of COVID-19 [0.58 (0.44, 0.77)]. The 3 symptom clusters were correlated with multiple QoL measures ( r = 0.14-0.56). Higher scores on the general body and tracheal/bronchial symptom clusters were associated with prolonged time to return to usual health [adjusted hazard ratios: 0.76 (0.64, 0.91), 0.80 (0.67, 0.96)]. CONCLUSION: Three symptom clusters identified from FLU-PRO Plus responses successfully discriminated patients with COVID-19 from non-COVID ILI and were associated with QoL and predicted symptom duration.

De-Implementing Opioids for Dental Extractions (DIODE): a multi-clinic, cluster-randomized trial of clinical decision support strategies in dentistry.

BACKGROUND: Opioid pain relievers are commonly prescribed following dental extractions, but evidence shows that non-opioid analgesics often provide adequate pain relief with fewer risks. The current study examined clinical decision support (CDS) as a tool for de-implementing opioid prescribing in dentistry. METHODS: This prospective, cluster-randomized trial examined CDS for dental pain management at 22 HealthPartners Dental Group clinics in Minnesota. Dental providers (n = 49) were randomized to deliver care using CDS, CDS with patient education materials (CDS-E), or standard practice (SP). Randomization was stratified by provider type (dentist vs. oral surgeon) and baseline opioid prescribing volume. Patient records of dental extractions were examined for January 2019 through May 2021, representing a 12-month baseline and 15-month intervention period (N = 12,924). Opioid prescription at the visit (no vs. yes) was the primary outcome. Data were analyzed using generalized linear mixed models, adjusting for patient sex and age, extraction complexity, and baseline prescribing strata (volume and provider type). RESULTS: Patients were 56.2% female, with a mean age of 46.7 (SD = 20.0) years. Providers were 8% oral surgeons, 57% female, and with a mean age of 43.7 (SD = 11.2) years. There were significant decreases in opioid prescribing during the study (P < 0.001), representing a continuation of pre-existing trends to reduce opioid prescribing in these dental practices. There were no significant differences in opioid prescribing between CDS and SP (OR = 1.29; 97.5% CI = 0.93, 1.79; P = 0.08), or CDS-E and SP arms (OR = 1.27; 97.5% CI = 0.86, 1.79; P = 0.18). The direction of the association favored greater reductions in opioid prescribing in the SP arm. Despite training and implementation support, utilization of the CDS was low, particularly among oral surgeons, who were significantly more likely than other dentists to prescribe opioids. Among non-oral surgeon providers with the opportunity to access it, CDS utilization was not significantly associated with opioid prescribing. CONCLUSIONS: Equipping dentists with CDS resources, whether alone or accompanied by patient education materials, did not accelerate reductions in opioid prescribing beyond those observed in standard practice. Strategies are needed to enhance CDS utilization for patient care and safety surrounding analgesia following dental extractions. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03584789.

De-implementing opioid prescribing in a dental group practice: Lessons learned.

BACKGROUND: Drug overdose has become a leading cause of accidental death in the United States. Between 2000 and 2015, the rate of deaths from drug overdoses increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (including opioid pain relievers and heroin). Unnecessary opioid prescribing is one of the factors driving this epidemic. OBJECTIVES: The primary objective of this paper is to share lessons learned while conducting a randomized trial to de-implement opioids for post-extraction pain management utilizing clinical decision support (CDS) with and without patient education. The lessons learned from conducting this trial in a real-world setting can be applied to future dissemination and implementation oral health research. METHODS: The sources informing lessons learned were generated from qualitative interviews conducted with 20 of the forty-nine dental providers involved in the study following the implementation phase of the trial. Ongoing policy, social and environmental factors were tracked throughout the study. RESULTS: Dental providers in the trial identified the impact of training that involved health professionals sharing information about the personal impact of pain and opioid use. Additionally, they found utility in being presented with a dashboard detailing their prescribing patterns related to other dentists. For the 30 general dentists with access to the CDS, use of its portal varied widely, with most using it 10%-49% of the time related to extractions. CONCLUSIONS: In the context of a downward trend in opioid prescribing and considering the influence of the COVID pandemic during the trial, dental providers indicated benefit in training about negative personal impacts of prescribing opioids, and personally relevant feedback about their prescribing patterns. Only modest use of the CDS was realized. Implementation of this trial was impacted by governmental and health system policies and the COVID pandemic, prompt the consideration of implications regarding continuing ways to limit opioid prescribing among dental providers.

Systematic surveillance of patient-reported symptoms of viral respiratory tract infectious Syndromes in diverse populations.

BACKGROUND: Patient reported outcome measures (PROM) can improve patient care and be crucial for symptom tracking especially during disease outbreaks. FLU-PRO Plus is a validated PROM used to track viral respiratory symptoms. Our study aimed to evaluate the feasibility of using FLU-PRO© Plus, to track symptoms across three healthcare systems. METHODS: The prospective, longitudinal study recruited adults between February-May 2021 from HealthPartners Institute (HP), Kaiser Permanente Georgia (KPGA), and Kaiser Permanente Mid-Atlantic States (KPMAS). Adult members were eligible if they had a positive lab or diagnosis for either COVID-19 or influenza-like illness (ILI) or exhibited 2 + viral respiratory symptoms. Descriptive statistics were calculated to describe the patient characteristics for participants that were eligible for FLU-PRO Plus, successfully contacted, attempted to log in to the FLU-PRO Plus website, and participants who completed FLU-PRO Plus Day 1. Bivariable and multivariable logistic regression using PROC GLIMMIXX investigated the patient characteristics associated with (1) successful contact and (2) FLU-PRO Plus Day 1 completion. RESULTS: We identified a total of 15,650 eligible participants during the enrollment period: 9,582 from HP, 1,740 from KPGA, and 4,328 from KPMAS. Among the total of 409 eligible adults who attempted to participate in FLU-PRO Plus, 317 completed FLU-PRO Plus Day 1. Among the 317 individuals that completed FLU-PRO Plus Day 1, 205 (67.5%) were diagnosed with COVID-19; 112 adults diagnosed with COVID-19 completed FLU-PRO Plus Day 14. Among adults successfully contacted, adults aged 35-64 (OR = 1.40, 95% CI 1.05, 1.87), females (OR = 1.77, 95% CI 1.38, 2.27), and adults diagnosed with COVID-19 (OR = 1.66, 95% CI 1.27, 2.17) had higher odds of completing FLU-PRO Plus Day 1; Asian adults (OR = 0.38, 95% CI 0.19, 0.76) and Black and African American adults (OR = 0.33, 95% CI 0.19, 0.76) had lower odds compared to White adults. CONCLUSION: Our study reports on the feasibility of patients across three integrated healthcare systems utilizing FLU-PRO Plus to monitor their respiratory symptoms. Patient reported outcome measures (PROM) can improve patient care, quality of life, and reduce the strain of limited resources on healthcare systems. Future FLU-PRO Plus studies should develop an implementation strategy to fully integrate FLU-PRO Plus within clinical care and patient management.

FINDINGS AND FUTURE DIRECTIONS FROM A SMOKING CESSATION TRIAL UTILIZING A CLINICAL DECISION SUPPORT TOOL.

BACKGROUND: Tobacco smoking is the leading cause of disease, death, and disability in the United States. Dental practitioners are advised to provide evidence-based smoking cessation interventions to their patients, yet dental practitioners frequently fail to deliver brief smoking cessation advice. OBJECTIVES: To test whether giving dental practitioners a clinical decisions support (CDS) system embedded in their electronic dental record would increase the rate at which patients who smoke (1) report receiving a brief intervention or referral to treatment during a recent dental visit, (2) taking action related to smoking cessation within 7 days of visit, and (3) stop smoking for 1 day or more or reduce the amount smoked by 50% within 6 months. METHODS: Two-group, parallel arm, cluster-randomized trial. From March through December 2019, 15 nonacademic primary care dental clinics were randomized via covariate adaptive randomization to either a usual care arm or the CDS arm. Adult smokers completed an initial telephone survey within 7 days of their visit and another survey after 6 months. RESULTS: Forty-three patients from 5 CDS and 13 patients from 2 usual care clinics completed the 7-day survey. While the proportion of patients who reported receipt of a brief intervention or referral to treatment was significantly greater in the CDS arm than the usual care arm (84.3% vs 58.6%; P = .005), the differences in percentage of patients who took any action related to smoking cessation within 7 days (44.4% vs 22.3%; P = .077), or stopped smoking for one day or more and/or reduced amount smoked by 50% within 6 months (63.1% vs 46.2%; P = .405) were large but not statistically significant. CONCLUSIONS: Despite interruption by COVID-19, these results demonstrate a promising approach to assist dental practitioners in providing their patients with smoking cessation screening, brief intervention and referral to treatment.

Pain management after third molar extractions in adolescents: a qualitative study.

BACKGROUND: Understanding how adolescent patients make decisions about pain management after complex dental procedures could help reduce the use of opioid medications and the potential for future opioid misuse in this population. This qualitative study explores how adolescents manage pain, including how decision making with parents and providers affect their experience with opioid and non-opioid analgesics after third molar dental extractions. METHODS: We used a qualitative approach for the analysis of 30 telephone-based semi-structured interviews completed by 15 dyads between May and August 2019, which included 15 adolescents (15-17 years) who underwent a dental extraction, and a parent or guardian for each adolescent. The total sample included 30 participants. Interviews were conducted separately for patients and parents. De-identified interview transcripts were analyzed using qualitative analysis software using a directed content analysis approach. RESULTS: A total of 15 patient/parent dyads were interviewed. Key themes associated with pain management included sources of information, pain management behaviors engaged in by the adolescents and their caregivers, and the use of medication. In addition to conversations with their dental provider, most patients and their parents discussed pain management plans that included non-medication options, over-the-counter medications, and opioid medications to be taken as needed, which guided their post-extraction behaviors. All participants reported that the adolescent received an opioid prescription for post-extraction pain management, to be taken on an "as needed" basis, but most only took it the day of the extraction and up to 2 days following, usually based on the patient's reported pain levels and perceptions of over-the-counter medication adequacy. Participants said they did not receive guidance from their provider concerning disposal of unused opioid medications. CONCLUSIONS: Involving adolescents in the pain management decision making process and allowing them to carry out the plan with some caregiver support was acceptable and well executed following third molar extractions. Providers may have an opportunity to reduce the number of opioids prescribed, since respondents reported little to no use of opioids that they were prescribed. Providers should educate patients and their parents about safe disposal of opioids to mitigate the potential for diversion.

Human Papillomavirus vaccination clinical decision support for young adults in an upper midwestern healthcare system: a clinic cluster-randomized control trial.

INTRODUCTION: Human papillomavirus (HPV) vaccination rates are low in young adults. Clinical decision support (CDS) in primary care may increase HPV vaccination. We tested the treatment effect of algorithm-driven, web-based, and electronic health record-linked CDS with or without shared decision-making tools (SDMT) on HPV vaccination rates compared to usual care (UC). METHODS: In a clinic cluster-randomized control trial conducted in a healthcare system serving a largely rural population, we randomized 34 primary care clinic clusters (with three clinics sharing clinicians randomized together) to: CDS; CDS+SDMT; UC. The sample included young adults aged 18-26 due for HPV vaccination with a study index visit from 08/01/2018-03/15/2019 in a study clinic. Generalized linear mixed models tested differences in HPV vaccination status 12 months after index visits by study arm. RESULTS: Among 10,253 patients, 6,876 (65.2%) were due for HPV vaccination, and 5,054 met study eligibility criteria. In adjusted analyses, the HPV vaccination series was completed by 12 months in 2.3% (95% CI: 1.6%-3.2%) of CDS, 1.6% (95% CI: 1.1%-2.3%) of CDS+SDMT, and 2.2% (95% CI: 1.6%-3.0%) of UC patients, and at least one HPV vaccine was received by 12 months in 13.1% (95% CI: 10.6%-16.1%) of CDS, 9.2% (95% CI: 7.3%-11.6%) of CDS+SDMT, and 11.2% (95% CI: 9.1%-13.7%) of UC patients. Differences were not significant between arms. Females, those with prior HPV vaccinations, and those seen at urban clinics had significantly higher odds of HPV vaccination in adjusted models. DISCUSSION: CDS may require optimization for young adults to significantly impact HPV vaccination. TRIAL REGISTRATION: clinicaltrials.gov NCT02986230, 12/6/2016.

Clinical Decision Support with or without Shared Decision Making to Improve Preventive Cancer Care: A Cluster-Randomized Trial.

BACKGROUND: Innovative interventions are needed to address gaps in preventive cancer care, especially in rural areas. This study evaluated the impact of clinical decision support (CDS) with and without shared decision making (SDM) on cancer-screening completion. METHODS: In this 3-arm, parallel-group, cluster-randomized trial conducted at a predominantly rural medical group, 34 primary care clinics were randomized to clinical decision support (CDS), CDS plus shared decision making (CDS+SDM), or usual care (UC). The CDS applied web-based clinical algorithms identifying patients overdue for United States Preventive Services Task Force-recommended preventive cancer care and presented evidence-based recommendations to patients and providers on printouts and on the electronic health record interface. Patients in the CDS+SDM clinic also received shared decision-making tools (SDMTs). The primary outcome was a composite indicator of the proportion of patients overdue for breast, cervical, or colorectal cancer screening at index who were up to date on these 1 y later. RESULTS: From August 1, 2018, to March 15, 2019, 69,405 patients aged 21 to 74 y had visits at study clinics and 25,198 were overdue for 1 or more cancer screening tests at an index visit. At 12-mo follow-up, 9,543 of these (37.9%) were up to date on the composite endpoint. The adjusted, model-derived percentage of patients up to date was 36.5% (95% confidence interval [CI]: 34.0-39.1) in the UC group, 38.1% (95% CI: 35.5-40.9) in the CDS group, and 34.4% (95% CI: 31.8-37.2) in the CDS+SDM group. For all comparisons, the screening rates were higher than UC in the CDS group and lower than UC in the CDS+SDM group, although these differences did not reach statistical significance. CONCLUSION: The CDS did not significantly increase cancer-screening rates. Exploratory analyses suggest a deeper understanding of how SDM and CDS interact to affect cancer prevention decisions is needed. Trial registration: ClinicalTrials.gov ID: NCT02986230, December 6, 2016.

Primary care clinicians' opinions before and after implementation of cancer screening and prevention clinical decision support in a clinic cluster-randomized control trial: a survey research study.

BACKGROUND: Electronic health record (EHR)-linked clinical decision support (CDS) may impact primary care clinicians' (PCCs') clinical care opinions. As part of a clinic cluster-randomized control trial (RCT) testing a cancer prevention and screening CDS system with patient and PCC printouts (with or without shared decision-making tools [SDMT]) for patients due for breast, cervical, colorectal, and lung cancer screening and/or human papillomavirus (HPV) vaccination compared to usual care (UC), we surveyed PCCs at study clinics pre- and post-CDS implementation. Our primary aim was to learn if PCCs' opinions changed over time within study arms. Secondary aims including examining whether PCCs' opinions in study arms differed both pre- and post-implementation, and gauging PCCs' opinions on the CDS in the two intervention arms. METHODS: This study was conducted within a healthcare system serving an upper Midwestern population. We administered pre-implementation (11/2/2017-1/24/2018) and post-implementation (2/2/2020-4/9/2020) cross-sectional electronic surveys to PCCs practicing within a RCT arm: UC; CDS; or CDS + SDMT. Bivariate analyses compared responses between study arms at both time periods and longitudinally within study arms. RESULTS: Pre-implementation (53%, n = 166) and post-implementation (57%, n = 172) response rates were similar. No significant differences in PCC responses were seen between study arms on cancer prevention and screening questions pre-implementation, with few significant differences found between study arms post-implementation. However, significantly fewer intervention arm clinic PCCs reported being very comfortable with discussing breast cancer screening options with patients compared to UC post-implementation, as well as compared to the same intervention arms pre-implementation. Other significant differences were noted within arms longitudinally. For intervention arms, these differences related to CDS areas like EHR alerts, risk calculators, and ordering screening. Most intervention arm PCCs noted the CDS provided overdue screening alerts to which they were unaware. Few PCCs reported using the CDS, but most would recommend it to colleagues, expressed high CDS satisfaction rates, and thought patients liked the CDS's information and utility. CONCLUSIONS: While appreciated by PCCs with high satisfaction rates, the CDS may lower PCCs' confidence regarding discussing patients' breast cancer screening options and may be used irregularly. Future research will evaluate the impact of the CDS on cancer prevention and screening rates. TRIAL REGISTRATION: clinicaltrials.gov , NCT02986230, December 6, 2016.

Vocational Outcomes of Service Members and Veterans After Traumatic Brain Injury: A Scoping Review.

OBJECTIVE: The purpose of this scoping review was to evaluate the current literature related to vocational outcomes among US service members and veterans with traumatic brain injury (TBI). METHODS: Seven research databases (Ovid MEDLINE, PsycINFO, EMBASE, CINAHL Plus, Cochrane Library, Scopus, and SPORTDiscus) were queried for human studies between the database inception and February, 2020. We included studies that focused on US service members and veterans who sustained a TBI and their vocational outcomes. Conference abstracts, systematic reviews, literature reviews, editorials, consensus reports, commentaries, dissertations, and qualitative studies were excluded. Two rounds of independent reviews were performed. Details of study design, intervention, and vocational outcomes were recorded. RESULTS: The search yielded 5667 articles; 48 articles met inclusion criteria. Forty-three studies were observational (90%), and 5 were randomized controlled trials. A majority of interventions were in the outpatient setting (71%). Interventions related to return to work and duty utilized physical therapy and occupational therapy to address cognitive skills and functional deficits and provide supportive employment. CONCLUSION: Community reintegration research among service members and veterans with brain injuries is underdeveloped. Because of heterogeneity of severity and smaller sample sizes, no consensus was reached on interventions that improve vocational outcomes. Evidence thus far suggests that future studies should incorporate an interdisciplinary team approach beyond physical therapy and occupational therapy, longer-term outcomes, and sample subgroups.

Patient Perceptions of Using Clinical Decision Support for Cancer Screening and Prevention: "I wouldn't have thought about getting screened without it."

PURPOSE: We sought to gain an understanding of cancer prevention and screening perspectives among patients exposed to a clinical decision support (CDS) tool because they were due or overdue for certain cancer screenings or prevention. METHODS: Semi-structured qualitative interviews were conducted with 37 adult patients due or overdue for cancer prevention services in 10 primary care clinics within the same health system. Data were thematically segmented and coded using qualitative content analysis. RESULTS: We identified three themes: 1) The CDS tool had more strengths than weaknesses, with areas for improvement; 2) Many facilitators and barriers to cancer prevention and screening exist; and 3) Discussions and decision-making varied by type of cancer prevention and screening. Almost all participants made positive comments regarding the CDS. Some participants learned new information, reporting the CDS helped them make a decision they otherwise would not have made. Participants who used the tool with their provider had higher self-reported rates of deciding to be screened than those who did not. CONCLUSIONS: Learning about patients' perceptions of a CDS tool may increase understanding of how patient-tailored CDS impacts cancer screening and prevention rates. Participants found a personalized CDS tool for cancer screening and prevention in primary care useful and a welcome addition to their visit. However, many providers were not using the tool with eligible patients.

Patient, Provider Type, and Procedure Type Factors Associated with Opioid Prescribing by Dentists in a Health Care System.

INTRODUCTION: Reports examining opioid prescribing for dental conditions are limited and do not examine patient-level factors. This study examines the association of patient age, sex, race, ethnicity, Medicaid coverage, and the need for an interpreter in addition to procedure type and dental provider type with receipt of an opioid prescription in dental care settings within a large health system. MATERIALS AND METHODS: This study was conducted utilizing data from the electronic health record of HealthPartners, a large dental practice embedded within a health care system. The analytic sample consisted of all 169,173 encounters from 90,487 patients undergoing a dental procedure in the baseline period (9/1/2018 to 8/30/2019), prior to implementing a clinical trial to de-implement opioids in dentistry. RESULTS: Opioids were prescribed at 1.9% of all 169,173 encounters and rates varied by patient factors, procedure category, and provider type. Opioid prescriptions were most likely for extraction encounters (25.9%). In a multivariable analysis of 8760 extraction encounters, all patient age groups were more likely than those age 66+ to receive an opioid prescription, particularly those age 18-25 (OR=6.94). Patients having a complex rather than simple extraction were more likely to receive an opioid prescription (OR=6.31) and those seen by an oral surgeon rather than a general dentist (OR=9.11) were more likely to receive an opioid prescription. Among 108,748 encounters with a diagnostic procedure, opioid prescribing was more likely among male than female patients (OR=1.20), Black patients relative to White (OR=1.69), patients with Medicaid coverage (OR=1.86), and patients seeing an oral surgeon rather than a general dentist (OR=27.81). CONCLUSION: Opioid prescribing rates vary considerably depending on procedure type. Patterns of associations between patient factors and opioid prescribing also vary considerably across procedure type. To understand which patient groups are more at risk of being prescribed opioids, it is essential to consider the procedures they are receiving.

The impact of personalized clinical decision support on primary care patients' views of cancer prevention and screening: a cross-sectional survey.

BACKGROUND: Few studies have assessed the impact of clinical decision support (CDS), with or without shared decision-making tools (SDMTs), on patients' perceptions of cancer screening or prevention in primary care settings. This cross-sectional survey was conducted to understand primary care patient's perceptions on cancer screening or prevention. METHODS: We mailed surveys (10/2018-1/2019) to 749 patients aged 18 to 75 years within 15 days after an index clinical encounter at 36 primary care clinics participating in a clinic-randomized control trial of a CDS system for cancer prevention. All patients were overdue for cancer screening or human papillomavirus vaccination. The survey compared respondents' answers by study arm: usual care; CDS; or CDS + SDMT. RESULTS: Of 387 respondents (52% response rate), 73% reported having enough time to discuss cancer prevention options with their primary care provider (PCP), 64% reported their PCP explained the benefits of the cancer screening choice very well, and 32% of obese patients reported discussing weight management, with two-thirds reporting selecting a weight management intervention. Usual care respondents were significantly more likely to decide on colorectal cancer screening than CDS respondents (p < 0.01), and on tobacco cessation than CDS + SDMT respondents (p = 0.02) and both CDS and CDS + SDMT respondents (p < 0.001). CONCLUSIONS: Most patients reported discussing cancer prevention needs with PCPs, with few significant differences between the three study arms in patient-reported cancer prevention care. Upcoming research will assess differences in screening and vaccination rates between study arms during the post-intervention follow-up period. TRIAL REGISTRATION: clinicaltrials.gov , NCT02986230 , December 6, 2016.

De-Implementing Opioid Use and Implementing Optimal Pain Management Following Dental Extractions (DIODE): Protocol for a Cluster Randomized Trial.

BACKGROUND: Overdose deaths from prescription opioid analgesics are a continuing crisis in the United States. Opioid analgesics are among the most frequently prescribed drugs by dentists. An estimated 5 million people undergo third-molar extractions in the United States each year, resulting in postoperative pain. Studies show that, in most cases, the combination of ibuprofen and acetaminophen is an effective alternative to commonly prescribed opioid analgesics for the management of postextraction pain. Nevertheless, many dentists routinely prescribe opioids after dental extractions. OBJECTIVE: We describe the rationale, design, and methods for a randomized trial of interventions designed to de-implement opioid prescribing by dentists while implementing effective nonopioid analgesics following dental extractions. METHODS: Using a prospective, 3-arm, cluster randomized trial design with dentists as the unit randomized and patient-level prescribing data as the primary outcome, we will compare different strategies to reduce the reliance on opioids and increase the use of alternative pain management approaches utilizing information support tools aimed at both providers and their patients. The study will test the efficacy of 2 interventions to decrease opioid prescribing following dental extractions: clinical decision support with (CDS-E) and without patient education (CDS). Providers will be randomized to CDS, CDS-E, or standard practice. Patient-level outcomes will be determined via review of comprehensive electronic health records. We will compare study arms on differential change in prescribing patterns from pre- to postimplementation of the intervention. The primary outcome of interest is a binary indicator of whether or not the patient received an opioid prescription on the day of the extraction encounter. We will also examine recommendations or prescriptions for nonopioid analgesics, patients' perceptions of shared decision making, and patients' pain experiences following the extraction. RESULTS: The HealthPartners Institutional Review Board approved the study. All study materials including the CDS and patient education materials have been developed and pilot tested, and the protocol has been approved by the National Institute of Dental and Craniofacial Research. The intervention was implemented in February 2020, with 51 dentists who were randomized to 1 of the 3 arms. CONCLUSIONS: If the intervention strategies are shown to be effective, they could be implemented more broadly in dental settings with high levels of opioid prescribing. TRIAL REGISTRATION: ClinicalTrials.gov NCT03584789, https://clinicaltrials.gov/ct2/show/NCT03584789. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24342.

Design and rationale of an intervention to improve cancer prevention using clinical decision support and shared decision making: A clinic-randomized trial.

BACKGROUND: Despite decades of research the gap in primary and secondary cancer prevention services in the U. S. remains unacceptably wide. Innovative interventions are needed to address this persistent challenge. Electronic health records linked with Web-based clinical decision support may close this gap, especially if delivered to both patients and their providers. OBJECTIVES: The Cancer Prevention Wizard (CPW) study is an implementation, clinic-randomized trial designed to achieve these aims: 1) assess impact of the Cancer Prevention Wizard-Clinical Decision Support (CPW-CDS) alone and CPW-CDS plus Shared Decision Making Tools (CPW + SDMTs) compared to usual care (UC) on tobacco cessation counseling and drugs, HPV vaccinations, and screening tests for breast, cervical, colorectal, or lung cancer; 2) assess cost of the CPW-CDS intervention; and 3) describe critical facilitators and barriers for CPW-CDS implementation, use, and clinical impact using a mixed-methods approach supported by the CFIR and RE-AIM frameworks. METHODS: 34 predominantly rural, primary care clinics were randomized to CPW-CDS, CPW + SMDTs, or UC. Between August 2018 and October 2020, primary care providers and their patients who met inclusion criteria in intervention clinics were exposed to the CPW-CDS with or without SDMTs. Study outcomes at 12 months post index visit include patients up to date on screening tests and HPV vaccinations, overall healthcare costs, and diagnostic codes and billing levels for cancer prevention services. CONCLUSIONS: We will test in rural primary care settings whether CPW-CDS with or without SDMTs can improve delivery of primary and secondary cancer prevention services. The trial and analyses are ongoing with results expected in 2021.

Exploring the Provider Preferences of Multiracial Patients.

BACKGROUND: Patient-provider race concordance has been argued as one way to improve patient-provider communication, patient satisfaction, and even patient outcomes. However, much of this literature focuses on or assumes that both patients and providers identify with only one race. OBJECTIVE: The purpose of this study was to understand multiracial patients' preferences in choosing a health-care provider. METHODS: We conducted 15 interviews and 3 focus groups. We performed a directed content analysis to understand participants' expressed preferences. RESULTS: Thirty-one participants shared their health-care preferences. Participants described proximity to their homes or work, convenience in terms of availability, and health insurance coverage as reasons for selecting a provider. The majority articulated preferences related to provider gender and race. However, participants noted key barriers to receiving care from their preferred providers. CONCLUSION: This study highlights the preferences for health-care providers and the factors influencing those preferences and decisions among multiracial individuals. Findings illustrate the need to increase health workforce diversity, especially among primary care providers. Findings also show the need for increased empathy and cultural sensitivity among health-care professionals.

Pre-implementation adaptation of primary care cancer prevention clinical decision support in a predominantly rural healthcare system.

BACKGROUND: Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients' cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system's goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes. METHODS: In a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR. RESULTS: Based on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements. CONCLUSIONS: Pre-implementation changes to CDS may help meet healthcare systems' evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems. TRIAL REGISTRATION: NCT02986230.