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Research paper thumbnail of Socioeconomic disadvantage and human papillomavirus (HPV) vaccination uptake

Vaccine, 2022

Importance:Despite availability of safe and effective human papillomavirus (HPV) vaccines, vaccin... more Importance:Despite availability of safe and effective human papillomavirus (HPV) vaccines, vaccination uptake remains low in the U.S. Research examining the impact of neighborhood socioeconomic status on HPV vaccination may help target interventions.Objective:To examine the association between area deprivation and HPV vaccine initiation and completion.Design, Setting, Participants:Retrospective cohort study of individuals aged 11–18 years residing in the upper Midwest region. Receipt of HPV vaccination was examined over a three-year follow-up period (01/01/2016–12/31/2018).Main Outcomes and Measures:Outcomes of interest were initiation and completion of HPV vaccination. Demographic data were collected from the Rochester Epidemiology Project (REP). Area-level socioeconomic disadvantage was measured by calculating an Area Deprivation Index (ADI) score for each person, a measure of socioeconomic disadvantage derived from American Community Survey data. Multivariable mixed effect Cox proportional hazards models were used to examine the association of ADI quartiles (Q1-Q4) with HPV vaccine series initiation and completion given initiation.Results:Individuals residing in census block groups with higher deprivation had significantly lower likelihood of HPV vaccine initiation (Q2: HR=0.91, 0.84–0.99 Q3: HR= 0.83, 0.76–0.90; Q4: HR=0.84, 0.74–0.96) relative to those in the least-deprived block groups (Q1). Similarly, those living in block groups with higher deprivation had significantly lower likelihood of completion (Q2: HR=0.91, 0.86–0.97; Q3: HR= 0.87, 0.81–0.94; Q4: HR=0.82, 0.74–0.92) compared to individuals in the least-deprived block groups (Q1).Conclusions and Relevance:Lower probability of both HPV vaccine-series initiation and completion were observed in areas with greater deprivation. Our results can inform allocation of resources to increase HPV vaccination rates in our primary care practice and provide an example of leveraging public data to inform similar efforts across diverse health systems.

Research paper thumbnail of Clinical decision support with automated text processing for cervical cancer screening

Journal of the American Medical Informatics Association, Sep 1, 2012

Research paper thumbnail of Predictors of patient comfort and adherence with less frequent cervical cancer screening

PubMed, 2011

Background: The Papanicolaou (Pap) test is an effective, well-accepted screening tool that has le... more Background: The Papanicolaou (Pap) test is an effective, well-accepted screening tool that has led to a decrease in cervical cancer incidence and mortality. Updated evidence-based cervical cancer screening guidelines support less frequent testing in low-risk patients but have met resistance from providers and patients. Aims: To assess patient knowledge about cervical cancer screening and attitudes toward recommendations for less frequent testing. Methods: A hard copy of an eight-question survey was distributed to 389 women aged 30-64 years at two primary care clinics in Rochester, Minnesota, over a six-week period. Results: The survey response rate was 86.8%. Of the 280 women who responded to a survey question about the cause of cervical cancer, 212 (75.7%) identified human papillomavirus (HPV) as the cause. Multivariable logistic regression analysis showed that this knowledge was not associated with feeling comfortable with a recommendation for less frequent testing or with support for less frequent testing. The only significant predictor of patient comfort and adherence with a two- to three-year Pap testing interval was the patient's belief about whether a Pap test was needed annually or every two or three years. Conclusions: Patient belief about Pap testing frequency was the strongest predictor of attitude toward less frequent Pap testing and was not based on knowledge of HPV. Future studies should explore why some patients continue to expect annual testing and identify interventions to help providers elicit and change patients' expectations about cervical cancer screening.

Research paper thumbnail of How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation

Human Vaccines & Immunotherapeutics, Apr 3, 2020

Research paper thumbnail of EPA-0017 – Remission decreased outpatient visit counts in depressed primary care patients treated with collaborative care management or usual care

European Psychiatry, 2014

Introduction: Depression symptoms contribute to significant morbidity and health care utilization... more Introduction: Depression symptoms contribute to significant morbidity and health care utilization. Healthcare reform should consider improvements in clinical outcomes as well as decreased overall utilization as mechanisms to control health care costs. Objectives/Aims: The aim of this study was to determine the impact of remission on outpatient clinical visits by depressed primary care patients in collaborative care management (CCM) or usual care (UC). The hypothesis was that depressed patients with worse outcomes at six months would have increased outpatient visit counts, regardless of treatment type. Methods: The study was a retrospective, chart review analysis of 1,733 patients with six month follow-up data. The data set included baseline data (demographic information, diagnosis, medical comorbidity, prior outpatient visit counts and depression severity) and six month follow up data (PHQ-9 scores and number of outpatient visits utilized). Results: Multiple logistic regression demonstrated that remission at six months was an independent predictor of outpatient visit outlier status (>8 visits) (OR 0.609 CI 0.460-0.805, p<0.01), when controlling for all other independent variables. The odds ratio of being an outpatient visit outlier status for those patients NOT in remission at six months was the inverse of this at 1.643 (CI 1.243-2.173). Conclusions: In primary care patients treated for depression, successful treatment to remission at six months decreased the likelihood of the patient having more than 8 visits during the six months after diagnosis. This holds true even when controlling for the individual patient's prior outpatient visit counts, health care comorbidities and enrollment into CCM vs. UC.

Research paper thumbnail of Extensive scarring alopecia and widespread rash

The Journal of Family Practice, Mar 1, 2022

Research paper thumbnail of Association of both consistency and strength of self-reported clinician recommendation for HPV vaccination and HPV vaccine uptake among 11- to 12-year-old children

Research paper thumbnail of Trends Over Time in Pap and Pap-HPV Cotesting for Cervical Cancer Screening

Journal of Womens Health, Feb 1, 2019

Research paper thumbnail of Formative evaluation of the accuracy of a clinical decision support system for cervical cancer screening

Journal of the American Medical Informatics Association, Jul 1, 2013

Research paper thumbnail of Granular Quality Reporting for Cervical Cytology Testing

PubMed, 2015

Quality reporting for cervical cancer prevention is focused on patients with normal cervical cyto... more Quality reporting for cervical cancer prevention is focused on patients with normal cervical cytology, and excludes patients with cytological abnormalities that may be at higher risk. The major obstacles for granular reporting are the complexity of surveillance guidelines and free-text data. We performed automated chart review to compare the cytology testing rates for patients with 'atypical squamous cells of undetermined significance' (ASCUS) cytology, with the rates for patients with normal cytology. We modeled the surveillance guidelines, and extracted information from free-text cytology reports, to perform this study on 28101 female patients. Our results show that patients with ASCUS cytology had significantly higher adherence rates (94.9%) than those for patients with normal cytology (90.4%). Overall our study indicates that the quality of care varies significantly between the high and average risk patients. Our study demonstrates the use of health information technology for higher granularity of reporting for cervical cytology testing.

Research paper thumbnail of Clinical Decision Support with Natural Language Processing for Cervical Cancer Screening

Research paper thumbnail of Impact of Symptom Remission on Outpatient Visits in Depressed Primary Care Patients Treated with Collaborative Care Management and Usual Care

Population Health Management, Jun 1, 2014

Research paper thumbnail of Awareness of HPV Testing and Acceptability of Self-sampling for Cervical Cancer Screening Among Women in Minnesota

Journal of General Internal Medicine, May 13, 2021

Research paper thumbnail of Increased Adherence to Prenatal Group B Streptococcal Screening Guidelines Through a Paired Electronic Reminder and Education Intervention

Maternal and Child Health Journal, 2014

The 2010 Centers for Disease Control and Prevention (CDC) update on perinatal group B streptococc... more The 2010 Centers for Disease Control and Prevention (CDC) update on perinatal group B streptococcal (GBS) prevention advises universal vaginal-rectal GBS screening of pregnant women in the 35th through 37th week of gestation. Because GBS colonization is transient, a test performed more than 5 weeks before delivery may not have sufficient negative predictive value to be clinically useful. Our objective was to increase rates of quality-improved, CDC-adherent GBS screening and decrease repeat screening. A reminder for maternal vaginal-rectal GBS testing was added to the physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; electronic ordering screen, and family medicine physicians and residents were educated about screening guidelines through standardized, in-person presentations. Retrospective chart review was performed before and after these interventions. Univariate or bivariate analysis was performed for demographic factors, timing of first screen, rates of CDC-adherent screening (the newly defined quality-improved screen and the usual screen), and rates of repeat and unnecessary screens. Multivariate analysis was performed with quality-improved and usual screening as dependent variables. Bivariate analysis showed that post-intervention rates of quality-improved screening increased from 30 to 62 % (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), usual screening increased from 69 to 84 % (P = .005), and repeat GBS screening decreased from 20 to 8 % (P = .007). Multivariate analysis showed increased post-intervention odds of quality-improved screening [odds ratio (OR) 3.59; 95 % CI 2.07-6.34] and usual screening (OR 2.67; 95 % CI 1.40-5.25). Low-cost, reproducible quality improvement interventions (electronic order reminder, educational sessions) have the potential to increase guideline adherence for GBS screening in pregnant women and decrease repeat screening.

Research paper thumbnail of Outcomes in women age 40 years and older with cytologically benign endometrial cells

American Journal of Obstetrics and Gynecology, Nov 1, 2012

Research paper thumbnail of Routine pelvic examinations: A descriptive cross-sectional survey of women's attitudes and beliefs after new guidelines

Preventive Medicine, 2017

Research paper thumbnail of Repeat Retail Clinic Visits: Impact of Insurance Coverage and Age of Patient

Population Health Management, Dec 1, 2012

Research paper thumbnail of A Comparison of Perceived Lifetime Breast Cancer Risk to Calculated Lifetime Risk Using the Gail Risk Assessment Tool

Journal of Womens Health, Mar 1, 2022

Background: Understanding the accuracy of a woman's perceived breast cancer risk can enhance ... more Background: Understanding the accuracy of a woman's perceived breast cancer risk can enhance shared decision-making about breast cancer screening through provider and patient discussion. We aim to report and compare women's perceived lifetime breast cancer risk to calculated lifetime breast cancer risk. Methods: Women presenting to Mayo Clinic in Arizona and Minnesota in July 2016 completed a survey assessing their perceived breast cancer risk. Lifetime Gail risk scores were calculated from questions pertaining to health history and were then compared with perceived breast cancer risk. Results: A total of 550 predominantly white, married, and well-educated (≥college) women completed surveys. Using lifetime Gail risk scores, 5.6% were classified as high risk (>20% lifetime risk), 7.7% were classified as intermediate risk (15%-20%), and 86.6% were classified as average risk (<15%). Of the 27 women who were classified as high risk, 18 (66.7%) underestimated their risk and of the 37 women who were intermediate risk, 12 (32.4%) underestimated risk. Women more likely to underestimate their risk had a reported history of an abnormal mammogram and at least one or more relative with a history of breast cancer. Surveyed women tended to overestimate risk 4.3 (130/30) times as often as they underestimated risk. Conclusion: In a group of predominantly white, educated, and married cohort of women, there was a large portion of women in the elevated risk groups who underestimated risk. Specific aspects of medical history were associated with underestimation including a history of abnormal mammogram and family history of breast cancer. Overall, in our sample, more women overestimated than underestimated risk.

Research paper thumbnail of To Screen or Not to Screen: Is the Pelvic Examination the Answer?

Journal of Womens Health, Jul 1, 2015

Research paper thumbnail of Impact of Contraception on Female Sexual Function

Journal of Womens Health, Mar 1, 2017

Research paper thumbnail of Socioeconomic disadvantage and human papillomavirus (HPV) vaccination uptake

Vaccine, 2022

Importance:Despite availability of safe and effective human papillomavirus (HPV) vaccines, vaccin... more Importance:Despite availability of safe and effective human papillomavirus (HPV) vaccines, vaccination uptake remains low in the U.S. Research examining the impact of neighborhood socioeconomic status on HPV vaccination may help target interventions.Objective:To examine the association between area deprivation and HPV vaccine initiation and completion.Design, Setting, Participants:Retrospective cohort study of individuals aged 11–18 years residing in the upper Midwest region. Receipt of HPV vaccination was examined over a three-year follow-up period (01/01/2016–12/31/2018).Main Outcomes and Measures:Outcomes of interest were initiation and completion of HPV vaccination. Demographic data were collected from the Rochester Epidemiology Project (REP). Area-level socioeconomic disadvantage was measured by calculating an Area Deprivation Index (ADI) score for each person, a measure of socioeconomic disadvantage derived from American Community Survey data. Multivariable mixed effect Cox proportional hazards models were used to examine the association of ADI quartiles (Q1-Q4) with HPV vaccine series initiation and completion given initiation.Results:Individuals residing in census block groups with higher deprivation had significantly lower likelihood of HPV vaccine initiation (Q2: HR=0.91, 0.84–0.99 Q3: HR= 0.83, 0.76–0.90; Q4: HR=0.84, 0.74–0.96) relative to those in the least-deprived block groups (Q1). Similarly, those living in block groups with higher deprivation had significantly lower likelihood of completion (Q2: HR=0.91, 0.86–0.97; Q3: HR= 0.87, 0.81–0.94; Q4: HR=0.82, 0.74–0.92) compared to individuals in the least-deprived block groups (Q1).Conclusions and Relevance:Lower probability of both HPV vaccine-series initiation and completion were observed in areas with greater deprivation. Our results can inform allocation of resources to increase HPV vaccination rates in our primary care practice and provide an example of leveraging public data to inform similar efforts across diverse health systems.

Research paper thumbnail of Clinical decision support with automated text processing for cervical cancer screening

Journal of the American Medical Informatics Association, Sep 1, 2012

Research paper thumbnail of Predictors of patient comfort and adherence with less frequent cervical cancer screening

PubMed, 2011

Background: The Papanicolaou (Pap) test is an effective, well-accepted screening tool that has le... more Background: The Papanicolaou (Pap) test is an effective, well-accepted screening tool that has led to a decrease in cervical cancer incidence and mortality. Updated evidence-based cervical cancer screening guidelines support less frequent testing in low-risk patients but have met resistance from providers and patients. Aims: To assess patient knowledge about cervical cancer screening and attitudes toward recommendations for less frequent testing. Methods: A hard copy of an eight-question survey was distributed to 389 women aged 30-64 years at two primary care clinics in Rochester, Minnesota, over a six-week period. Results: The survey response rate was 86.8%. Of the 280 women who responded to a survey question about the cause of cervical cancer, 212 (75.7%) identified human papillomavirus (HPV) as the cause. Multivariable logistic regression analysis showed that this knowledge was not associated with feeling comfortable with a recommendation for less frequent testing or with support for less frequent testing. The only significant predictor of patient comfort and adherence with a two- to three-year Pap testing interval was the patient's belief about whether a Pap test was needed annually or every two or three years. Conclusions: Patient belief about Pap testing frequency was the strongest predictor of attitude toward less frequent Pap testing and was not based on knowledge of HPV. Future studies should explore why some patients continue to expect annual testing and identify interventions to help providers elicit and change patients' expectations about cervical cancer screening.

Research paper thumbnail of How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation

Human Vaccines & Immunotherapeutics, Apr 3, 2020

Research paper thumbnail of EPA-0017 – Remission decreased outpatient visit counts in depressed primary care patients treated with collaborative care management or usual care

European Psychiatry, 2014

Introduction: Depression symptoms contribute to significant morbidity and health care utilization... more Introduction: Depression symptoms contribute to significant morbidity and health care utilization. Healthcare reform should consider improvements in clinical outcomes as well as decreased overall utilization as mechanisms to control health care costs. Objectives/Aims: The aim of this study was to determine the impact of remission on outpatient clinical visits by depressed primary care patients in collaborative care management (CCM) or usual care (UC). The hypothesis was that depressed patients with worse outcomes at six months would have increased outpatient visit counts, regardless of treatment type. Methods: The study was a retrospective, chart review analysis of 1,733 patients with six month follow-up data. The data set included baseline data (demographic information, diagnosis, medical comorbidity, prior outpatient visit counts and depression severity) and six month follow up data (PHQ-9 scores and number of outpatient visits utilized). Results: Multiple logistic regression demonstrated that remission at six months was an independent predictor of outpatient visit outlier status (>8 visits) (OR 0.609 CI 0.460-0.805, p<0.01), when controlling for all other independent variables. The odds ratio of being an outpatient visit outlier status for those patients NOT in remission at six months was the inverse of this at 1.643 (CI 1.243-2.173). Conclusions: In primary care patients treated for depression, successful treatment to remission at six months decreased the likelihood of the patient having more than 8 visits during the six months after diagnosis. This holds true even when controlling for the individual patient's prior outpatient visit counts, health care comorbidities and enrollment into CCM vs. UC.

Research paper thumbnail of Extensive scarring alopecia and widespread rash

The Journal of Family Practice, Mar 1, 2022

Research paper thumbnail of Association of both consistency and strength of self-reported clinician recommendation for HPV vaccination and HPV vaccine uptake among 11- to 12-year-old children

Research paper thumbnail of Trends Over Time in Pap and Pap-HPV Cotesting for Cervical Cancer Screening

Journal of Womens Health, Feb 1, 2019

Research paper thumbnail of Formative evaluation of the accuracy of a clinical decision support system for cervical cancer screening

Journal of the American Medical Informatics Association, Jul 1, 2013

Research paper thumbnail of Granular Quality Reporting for Cervical Cytology Testing

PubMed, 2015

Quality reporting for cervical cancer prevention is focused on patients with normal cervical cyto... more Quality reporting for cervical cancer prevention is focused on patients with normal cervical cytology, and excludes patients with cytological abnormalities that may be at higher risk. The major obstacles for granular reporting are the complexity of surveillance guidelines and free-text data. We performed automated chart review to compare the cytology testing rates for patients with 'atypical squamous cells of undetermined significance' (ASCUS) cytology, with the rates for patients with normal cytology. We modeled the surveillance guidelines, and extracted information from free-text cytology reports, to perform this study on 28101 female patients. Our results show that patients with ASCUS cytology had significantly higher adherence rates (94.9%) than those for patients with normal cytology (90.4%). Overall our study indicates that the quality of care varies significantly between the high and average risk patients. Our study demonstrates the use of health information technology for higher granularity of reporting for cervical cytology testing.

Research paper thumbnail of Clinical Decision Support with Natural Language Processing for Cervical Cancer Screening

Research paper thumbnail of Impact of Symptom Remission on Outpatient Visits in Depressed Primary Care Patients Treated with Collaborative Care Management and Usual Care

Population Health Management, Jun 1, 2014

Research paper thumbnail of Awareness of HPV Testing and Acceptability of Self-sampling for Cervical Cancer Screening Among Women in Minnesota

Journal of General Internal Medicine, May 13, 2021

Research paper thumbnail of Increased Adherence to Prenatal Group B Streptococcal Screening Guidelines Through a Paired Electronic Reminder and Education Intervention

Maternal and Child Health Journal, 2014

The 2010 Centers for Disease Control and Prevention (CDC) update on perinatal group B streptococc... more The 2010 Centers for Disease Control and Prevention (CDC) update on perinatal group B streptococcal (GBS) prevention advises universal vaginal-rectal GBS screening of pregnant women in the 35th through 37th week of gestation. Because GBS colonization is transient, a test performed more than 5 weeks before delivery may not have sufficient negative predictive value to be clinically useful. Our objective was to increase rates of quality-improved, CDC-adherent GBS screening and decrease repeat screening. A reminder for maternal vaginal-rectal GBS testing was added to the physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; electronic ordering screen, and family medicine physicians and residents were educated about screening guidelines through standardized, in-person presentations. Retrospective chart review was performed before and after these interventions. Univariate or bivariate analysis was performed for demographic factors, timing of first screen, rates of CDC-adherent screening (the newly defined quality-improved screen and the usual screen), and rates of repeat and unnecessary screens. Multivariate analysis was performed with quality-improved and usual screening as dependent variables. Bivariate analysis showed that post-intervention rates of quality-improved screening increased from 30 to 62 % (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), usual screening increased from 69 to 84 % (P = .005), and repeat GBS screening decreased from 20 to 8 % (P = .007). Multivariate analysis showed increased post-intervention odds of quality-improved screening [odds ratio (OR) 3.59; 95 % CI 2.07-6.34] and usual screening (OR 2.67; 95 % CI 1.40-5.25). Low-cost, reproducible quality improvement interventions (electronic order reminder, educational sessions) have the potential to increase guideline adherence for GBS screening in pregnant women and decrease repeat screening.

Research paper thumbnail of Outcomes in women age 40 years and older with cytologically benign endometrial cells

American Journal of Obstetrics and Gynecology, Nov 1, 2012

Research paper thumbnail of Routine pelvic examinations: A descriptive cross-sectional survey of women's attitudes and beliefs after new guidelines

Preventive Medicine, 2017

Research paper thumbnail of Repeat Retail Clinic Visits: Impact of Insurance Coverage and Age of Patient

Population Health Management, Dec 1, 2012

Research paper thumbnail of A Comparison of Perceived Lifetime Breast Cancer Risk to Calculated Lifetime Risk Using the Gail Risk Assessment Tool

Journal of Womens Health, Mar 1, 2022

Background: Understanding the accuracy of a woman's perceived breast cancer risk can enhance ... more Background: Understanding the accuracy of a woman's perceived breast cancer risk can enhance shared decision-making about breast cancer screening through provider and patient discussion. We aim to report and compare women's perceived lifetime breast cancer risk to calculated lifetime breast cancer risk. Methods: Women presenting to Mayo Clinic in Arizona and Minnesota in July 2016 completed a survey assessing their perceived breast cancer risk. Lifetime Gail risk scores were calculated from questions pertaining to health history and were then compared with perceived breast cancer risk. Results: A total of 550 predominantly white, married, and well-educated (≥college) women completed surveys. Using lifetime Gail risk scores, 5.6% were classified as high risk (>20% lifetime risk), 7.7% were classified as intermediate risk (15%-20%), and 86.6% were classified as average risk (<15%). Of the 27 women who were classified as high risk, 18 (66.7%) underestimated their risk and of the 37 women who were intermediate risk, 12 (32.4%) underestimated risk. Women more likely to underestimate their risk had a reported history of an abnormal mammogram and at least one or more relative with a history of breast cancer. Surveyed women tended to overestimate risk 4.3 (130/30) times as often as they underestimated risk. Conclusion: In a group of predominantly white, educated, and married cohort of women, there was a large portion of women in the elevated risk groups who underestimated risk. Specific aspects of medical history were associated with underestimation including a history of abnormal mammogram and family history of breast cancer. Overall, in our sample, more women overestimated than underestimated risk.

Research paper thumbnail of To Screen or Not to Screen: Is the Pelvic Examination the Answer?

Journal of Womens Health, Jul 1, 2015

Research paper thumbnail of Impact of Contraception on Female Sexual Function

Journal of Womens Health, Mar 1, 2017