Identifying the Roles of Medical Providers when Addressing Barriers to HPV Vaccination Rates in Rural NE Clinics

Background: Although many interventions to address vaccine hesitancy until now have operated on the presumption that misperceptions are due to a lack of knowledge about HPV and the vaccine, this may not always be the reason behind vaccine hesitancy. Nyhan et. al found [1] that correcting myths about vaccines- such as autism links or vaccine side effects- do not increase vaccine rates among adolescents. Medical providers play a crucial role on influencing parents’ decision to vaccinate. In a study exploring how vaccination coverage among children 19-35 months old is associated with health care providers' influence on the parents' decision to vaccinate, parents who report their providers as being influential in the study are twice as likely to respond that vaccines are safe for children [2]. In the 2016 Clinical Report on Countering Vaccine Hesitancy by the American Academy of Pediatrics, motivational interviewing is listed as a potential communication technique that may be useful as pediatricians discuss vaccines with vaccine-hesitant parents. Research Question: The research attempting to find the best approaches to reverse the increasing rates of unvaccinated minors is limited and inconclusive. This project addressed the impact of medical providers’ attitudes of HPV vaccination on their early adolescent patient populations. Methods: Our cohort prospective study first examined medical providers’ baseline attitudes and approaches of HPV vaccination in privately insured clinics in rural areas of Nebraska. A survey was sent to eleven Phase III patient centered medical home (PCMH) NE clinics. The survey assessed medical staffs’ attitudes and approaches to HPV vaccination, particularly among specific patient age groups. In addition to each clinic’s collective survey responses, baseline HPV vaccination data was collected at eleven Phase 3 PCMH rural clinics in Nebraska for pediatric patients 11-15-years-old. The follow-up intervention implemented educational interventions in the clinics to increase HPV vaccination rates for pediatric patients 9-15-years-old. Our educational outreach program at the selected 10-13 clinics will serve as these rural clinics’ first efforts to selectively work toward improving HPV vaccination rates. Results: America’s Health Rankings (2017) found 42.4% of adolescents living in rural areas compared to 52.4% in urban areas are up-to-date on their HPV immunizations. The eleven rural clinics selected for the study show only a 0.9% completion of the vaccine series for 9-11-year-old patients (n=855), and 25.0% completion of the series for 12-15-year-old patients (n=1268) as of 2019. This implies a pressing health disparity that needs addressing in rural Nebraskan communities. 92.6% of all respondents chose the 12-15 age range as the patient population the clinics would typically ask about the vaccine versus 59.6% who chose the 9-11 age range. The most chosen reason for not mentioning the HPV vaccine is “parents previously voiced vaccine hesitancy” (33.3%) followed by “not enough clinic time” (22.2%). The most popular reason contributing to parental hesitancy is “they have concerns the vaccine is not safe for their child” (70.4%). The greatest benefit of the HPV vaccine was listed as “prevention from multiple forms of cancer” (33.3%) and the greatest drawbacks were both “multiple dose series completion” (40.7%) and “difficulty in convincing parents to vaccinate minors” (40.7%). The 9-11 age range was chosen as the most difficult age group to vaccinate (33.3%). The most difficult scenarios when addressing HPV vaccination concerns were “lack of vaccine education” (55.6%), “religious reasons against the vaccine (44.4%), and “language/cultural barriers” (37%). Qualitative results were also analyzed separately and focused on each individual clinic’s strengths and weaknesses regarding vaccination encouragement. Discussion: The baseline patient data show that clinics selected for the study exhibit a large disparity of HPV vaccination rates among a vulnerable age group. Survey responses show both a clinical observation regarding parents’ low-level education levels about the HPV vaccine as well as a lack of comfort engaging in open dialogue between patients and healthcare personnel. Focusing on these two variables alone could help increase rates of vaccination significantly. Survey results ultimately illustrate the urgent need for empirically-supported educational resources that will enhance communication- both within individual clinics among staff as well as between medical staff and patients’ families- to sustainably increase HPV vaccination rates across rural clinics.

Predictors of At-Home Death for Cancer Patients in Rural Clinics in Japan

Background: The prediction of at-home deaths has become an important topic in rural areas of Japan with an advanced aging society. However, there are no well-established predictors to explain how these factors influence intention. This study aims to investigate the possible predictors of at-home death for cancer patients in rural clinics in Japan. Methods: This is a nationwide cross-sectional survey. A self-administered questionnaire was sent to 493 rural clinics in Japan. The main outcome was the realization of at-home deaths for cancer patients. Results: Among the 264 clinics (54%) that responded to the survey, there were 194 clinics with the realization of at-home death. The use of a clinical pathway (adjusted odds ratio 4.19; 95% confidence interval 1.57–11.19) and the provision of organized palliative care (adjusted odds ratio 19.16; 95% confidence interval 7.56–48.52) were associated with the prediction of at-home death, irrespective of island geography or the number of doctors and nurses. Conclusions: Having a clinical pathway and systematizing palliative care could be important to determine the possibility of at-home deaths for cancer patients in rural clinics in Japan.

Enhancement of digitized X-ray films using Contrast-Limited Adaptive Histogram Equalization (CLAHE)

Background: Rural clinics still have X-ray facilities that produce physical films, which are sent to the nearest hospital for evaluation. Purchasing digitalization facilities is costly, thus, sending digitized films to the radiologist may be a solution. This can be achieved via digital photo capture. However, there can be different output resolutions that may not be optimized for online diagnosis. This paper investigates if digitized X-ray films can be enhanced using image processing techniques of Contrast-Limited Adaptive Histogram Equalization (CLAHE), Normalized-CLAHE (N-CLAHE) and Min-Max Normalized-CLAHE (MMCLAHE). Methods: We collected and digitized 21 X-ray films with low, medium, and high resolutions and implemented the CLAHE, N-CLAHE and MMCLAHE image enhancement. These methods introduced a limit to clip the histogram of image intensities so as to reduce any noise amplification before file compression with the Fast Fourier Transform (FFT) and Discrete Cosine Transform (DCT). Quantitative metrics of the Peak Signal-to-Noise Ratio (PSNR) and Mean-Squared Error (MSE) were used to compare the accuracies between digitized and processed X-ray films. A qualitative evaluation was performed by a medical practitioner to validate the accuracy of enhanced digitized X-ray. Results: It had been found that both CLAHE and MMCLAHE provided good average PSNR values of 31dB - 32dB and produced low MSE values compared to N-CLAHE. The results of qualitative evaluation attained 89.9% correct diagnosis on nine randomly selected images. Generally, the evaluation indicated that the results fulfill the acceptable criteria for further evaluation and there seemed to be no pathological differences observed. Conclusion: This paper presented a proof of concept on an implementation of the CLAHE technique and its variations on digitized X-ray films. This paper had shown potential improvements with the proposed enhancement methods that may contribute to an increase efficiency in healthcare processes at rural clinics.

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

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