Health care workers promote COVID-19 vaccination for adolescent patients, and as parents, may influence their own children to get vaccinated. We conducted virtual, semi-structured qualitative interviews with vaccinated health care workers and their adolescent children to explore their decision-making process for COVID-19 vaccination. In total, 21 health care workers (physicians, nurses, and medical staff) and their adolescent children (N = 17) participated in interviews. The following three themes described parent-adolescent decision-making for COVID-19 vaccination: (1) family anticipation and hesitation about COVID-19 vaccine approval; (2) parents' or adolescents' choice: the decision maker for adolescent COVID-19 vaccination; and (3) leveraging one's vaccination status to encourage others to get vaccinated. Nurses encouraged adolescent autonomy in decisions for COVID-19 vaccination while physicians viewed vaccination as the parent's decision. Health care workers and their adolescent children used role-modeling to motivate unvaccinated peers and may model their decision-making process for adolescent COVID-19 vaccination with their own children to support their patients' and parents' vaccine decisions.

BACKGROUND:Uterine leiomyomas and adenomyosis are both common and often associated with abnormal uterine bleeding (AUB), including the symptom of heavy menstrual bleeding (HMB). Understanding the prevalence of adenomyosis in women with uterine leiomyomas could inform clinicians and patients in a way that may improve therapeutic approaches. OBJECTIVE:To explore the prevalence of adenomyosis in a group of women who underwent hysterectomy for AUB-L, to determine the prevalence of submucous leiomyomas, and to examine the utility of preoperative ultrasound to detect the presence of adenomyosis. METHODS:The Kaiser Permanente Hysterectomy Database (KPHD) was searched for women aged 18-52 undergoing hysterectomy for leiomyoma-associated chronic AUB (AUB-L) in 2018 and 2019. A target sample of 400 comprised those with at least 3 years in the Health System. Radiologists evaluated preoperative pelvic ultrasound images to determine leiomyoma size and level 2 FIGO type (submucous or other), and the linked electronic medical record abstracted for clinical features, including histopathological evidence of adenomyosis. RESULTS:Of the 370 subjects that met the study criteria, adenomyosis was identified via histopathology in 170 (45.9%). There was no difference in the adenomyosis prevalence with (47.1%) and without (43.0%) at least one submucous leiomyoma. Subgroup analysis of ultrasound images by an expert radiologist for the presence of adenomyosis demonstrated a positive predictive value of 54.0% and a negative predictive value of 43.4%. CONCLUSIONS:Adenomyosis was present in almost half of this AUB-L cohort undergoing hysterectomy and was equally prevalent in those with and without submucous leiomyomas as determined by sonographic evaluation. The imaging findings are in accord with prior investigators and demonstrate that 2-D ultrasound is insensitive to the presence of adenomyosis when the uterus is affected by leiomyomas. Further research is necessary to determine the impact of various adenomyosis phenotypes on the presence and severity of the symptom of HMB.

Purpose: Transgender individuals who pursue gender affirmation medical procedures often need to navigate a complex health system and interact with multiple health care providers in primary and specialty care. We sought to better understand patient, provider, and system level barriers to transgender care in a large integrated health care system in California.Methods: Three 90-min focus groups were conducted with 13 transgender individuals who received specialty care between April and August 2018 in Kaiser Permanente Southern California.Results: Participants cited common adversities such as misgendering and system-wide insensitivity during health care encounters and low levels of understanding of their transgender experience among primary care providers. Provider-patient relationship improvements were recommended for pre- and postsurgical care and service-provider sensitivity training. Suggestions include better care coordination, reducing redundancy in clearance for specialty care services, and enhancing patient support for navigation of gender affirmation services. Participants requested careful consideration when implementing systemwide routine processes such as using pronouns and names when calling patients in for visits or describing procedures on service invoices.Conclusions: Education and training programs for improving transgender care competency and enhancing care coordination between primary care and specialty care for transgender patients are warranted. Including transgender voices with lived-experience as active stakeholders in ongoing efforts such as community advisory boards to identify care gaps may facilitate patient-centered and culturally sensitive transgender care and increased patient satisfaction.Policy Implications: There is a need for systematic training for transgender care competent providers and enhancement of care coordination between primary care and specialty care.

Purpose: This study explored the perceptions of healthcare worker parents (physicians, nurses, and staff) and their adolescents (aged 12-17 years) on adolescent self-consent to COVID-19 vaccination by applying the concept of positive deviance of those already vaccinated against COVID-19. Methods: We used a qualitative descriptive design to conduct individual, semi-structured in-terviews with COVID-19-vaccinated healthcare workers in Southern California and their vacci-nated adolescent children. Separate interviews were conducted with parents and adolescents from November to December 2021 using digital phone conferencing software. All interviews were recorded and transcribed. Thematic and constant comparative analysis techniques were used to identify relevant themes and subthemes. Results: Twenty one healthcare workers (9 nurses, one nurse practitioner, one technologist, and 10 physicians) and their adolescents (N 1/4 17) participated. Three overarching themes were identified to describe participants' perspectives about adolescent self-consent for COVID-19 vaccination: (1) Family values and practices around adolescent vaccination; (2) Differences in parent and adoles-cent support for vaccine self-consent laws; and (3) Parent and adolescent uncertainty on readiness for vaccine self-consent laws. Adolescents largely supported self-consent while parents supported the policy if they would be able to have a discussion with their adolescent prior to the decision. Discussion: Parents and adolescents supported adolescent self-consent for COVID-19 vaccination, with the reservation that adolescents should discuss the decision alongside their parents to ex-ercise their medical autonomy with supportive guidance. Greater adolescent involvement in making decisions and providing self-consent for healthcare, including vaccines, could prepare adolescents to have a greater sense of autonomy over their health and contribute to population health measures. (c) 2023 Society for Adolescent Health and Medicine. All rights reserved.

Background: There is evidence of disparities in COVID-19 vaccine acceptance among health care providers. The purpose of this study was to examine confidence receiving and recommending COVID-19 vaccines by health care provider type and race/ethnicity. Methods: This mixed methods study involved a cross-sectional survey and qualitative, semi-structured interviews from March to May 2021 among a sample of physicians, advanced practice providers, nurses, and pharmacists. These workers were recruited through voluntary response sampling from an integrated health system in Southern California. The primary dependent variables were (a) confidence in vaccine safety, (b) confidence in vaccine effectiveness, and (c) intent to recommend the vaccine to others. The primary independent variables were health care provider type and race/ethnicity. Findings: A total of 2,948 providers completed the survey. Nurses relative to physicians were 15% less likely to perceive the COVID-19 vaccine to be safe (risk ratio [RR] = 0.85; 95% confidence interval [CI] = 0.83–0.87); 27% less likely to perceive the vaccine to prevent COVID-19 (RR = 0.73; 95% CI = 0.69–0.76); and 11% less likely to recommend the vaccine to others (RR = 0.89; 95% CI = 0.87–0.91). Hispanic/Latinx providers were 10% less likely to perceive the vaccine to prevent COVID-19 (RR = 0.90; 95% CI = 0.83–0.98) relative to White providers. Qualitative themes included: No need for vaccine; distrusting vaccine research and roll-out; caretaking barriers; uncertainty and potential to change one’s mind; framing vaccine decisions around personal beliefs. Conclusions & Application to Practice: Health care workplaces should consider interventions to increase COVID-19 vaccination among their workers, including education and mandatory vaccination policies.

The Anticoagulation Length of Therapy and Risk of New Adverse Events In Venous Thromboembolism (ALTERNATIVE) study was designed to compare the benefits and harms of different treatment options for extended treatment of venous thromboembolism (VTE). In this paper, we describe the study cohort, survey data collection, and preliminary results. We identified 39,605 adult patients (age ≥ 18 years) from two large integrated health care delivery systems who were diagnosed with incident VTE and received initial anticoagulation therapy of 3 months or longer. A subset of the cohort (12,737) was invited to participate in a survey. Surveys were completed in English, Spanish or Mandarin via a mailed questionnaire, an online secure web link, or telephone. The survey domains included demographics, personal medical history, anticoagulant treatment history, anticoagulant treatment satisfaction, health-related quality of life and health literacy. A total of 5,017 patients participated in the survey for an overall response rate of 39.4%. The mean (SD) age of the survey respondents was 63.0 (14.5) years and self-reported race was 76.0% White/European, 11.1% Black/African American, and 3.8% Asian/Pacific Islander and 14.0% reported Hispanic ethnicity. Sixty percent of respondents completed the web survey, while 29.0% completed the mail-in paper survey, and 11.0% completed the survey via telephone. The ALTERNATIVE Study will address knowledge gaps by comparing several treatment alternatives for the extended management of VTE so that this information could be used by patients and clinicians to make more informed, patient-centered treatment choices.

Venous thromboembolism (VTE) treatment requires complex management, and patients with limited health literacy (HL) may perceive higher burden and lower benefits associated with their treatment. To examine the association of HL with treatment satisfaction among patients with VTE. Retrospective cohort study Kaiser Permanente Southern and Northern California members who were taking oral anticoagulants (OAC) for incident VTE between 2015 and 2018 were surveyed. Main Measures HL was assessed using a 3-item HL assessment and dichotomized as having adequate or limited HL. High treatment burden and low treatment benefit were defined as Anti-Clot Treatment Scale (ACTS) scores below the 25th percentile of the distributions for ACTS Burdens and Benefits survey components, respectively. Using Poisson regression, multivariable adjusted risk ratios (RR) and 95% confidence intervals (CI) were calculated for the association of HL with high treatment burden and low treatment benefits. Among 2154 respondents, 397 (18.4%) had limited HL. Patients with limited vs adequate HL were older (47.9% vs 27.5% aged ≥ 75 years, p<0.001), more likely to use a non-English language when discussing their health (10.8% vs 1.7%, p<0.001), to have less than high school education (10.1% vs 1.7%, p<0.001), and to self-rate their health as fair or poor (47.6% vs 25.5%, p<0.001). After multivariable adjustment, patients with limited HL were more likely to have higher perceived treatment burden (RR 1.24, 95% CI 1.07, 1.45) and lower perceived treatment benefits (RR 1.21, 95% CI 1.08, 1.37). Limited HL was associated with lower OAC treatment satisfaction, though absolute differences in satisfaction scores were small. Further examination of the intersection of HL with VTE treatment satisfaction and compliance among older and non-English speaking patients is warranted.

Although pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV infection, only around 25% of at-risk individuals in the United States have accessed a prescription. One way to increase PrEP uptake is through the sexual health screening of patients and linkage to PrEP in primary care settings. The objective of this analysis was to assess the barriers and implementation strategies during a screening and linkage to PrEP pilot intervention. Primary care patients were screened for PrEP indication during routine primary care visits. Of the 1,225 individuals screened, 1.8% (n=22) were eligible for PrEP and from those, 77.3% (n=17) attended the specialist appointment and were prescribed PrEP. Primary care patients (n=30) and providers (n=8) then participated in semi-structured interviews assessing their experience with the pilot intervention. Using an applied thematic analytic approach, patients and providers identified barriers and related improvement strategies that could be classified into four main categories: 1) Financial Barriers: Individual- vs. Clinic-level Considerations 2) The Role of Stigma, Discomfort, and Cultural Factors 3) Logistical Hurdles and Streamlining the Intervention, and 4) The Lack of PrEP Knowledge and the Need for Education. Findings support the accepatability and feasibility of screening for PrEP in primary care along with appropriate implementation strategies. This study suggests that because of the high volume of patients seen in primary care, sexual health screenings and linkage to PrEP interventions have the potential to reduce new incident HIV infections among diverse sexual minority men.

Medication errors during transitions of care are common, dangerous and costly. Medication reconciliation can help mitigate this risk, but it is a complex and time-consuming process when performed properly. Increasingly, pharmacy staff have been engaged to help improve medication reconciliation. However, many organizations lack the resources and staff required to perform accurate medication histories and other reconciliation tasks on all patients. We describe how three academic medical centers implemented risk scoring systems to allocate limited pharmacy resources to patients with the highest likelihood of medication reconciliation related errors. We found that (1) development of a tailored medication risk scoring system and integration into the electronic health record is feasible, (2) workflow around the risk calculator is critical to the success of the implementation, and (3) the complex coordination of professional disciplines during the medication reconciliation process remains an ongoing challenge at all three institutions.

PURPOSE:The purpose of this study was to develop a natural language processing algorithm to identify suicidal ideation/attempt from free-text clinical notes.METHODS:Clinical notes containing prespecified keywords related to suicidal ideation/attempts from 2010 to 2018 were extracted from our organization's electronic health record system. A random sample of 864 clinical notes was selected and equally divided into 4 subsets. These subsets were reviewed and classified as 1 of the following 3 suicidal ideation/attempt categories (current, historical, and no) by experienced research chart abstractors. The first 3 data sets were used to develop the rule-based computerized algorithm sequentially and the fourth data set was used to evaluate the algorithm's performance. The validated algorithm was then applied to the entire study sample of clinical notes.RESULTS:The computerized algorithm correctly identified 23 of the 26 confirmed current suicidal ideation/attempts and all 10 confirmed historical suicidal ideation/attempts in the validation data set. It produced an 88.5% sensitivity and a 100.0% positive predictive value for current suicidal ideation/attempts, and a 100.0% sensitivity and positive predictive value for historical suicidal ideation/attempts. After applying the computerized algorithm to the entire set of study notes, we identified a total of 1,050,287 current ideation/attempt events and 293,037 historical ideation/attempt events documented in clinical notes. Those for which current ideation/attempt events were documented were more likely to be female (59.5%), 25-44 years old (28.3%), and White (43.4%).CONCLUSION:Our study demonstrated that a computerized algorithm can effectively identify suicidal ideation/attempts from clinical notes. This algorithm can be utilized in support of suicide prevention research programs and patient care quality improvement initiatives.

INTRODUCTION:There is evidence for relatively lower COVID-19 vaccine uptake among people of color in the United States. The purpose of this study was to investigate associations between race/ethnicity and COVID-19 vaccine uptake among nurses.METHODS:Nurses in Southern California (N = 1183) completed a one-time, web-based survey to assess COVID-19 vaccine perceptions and uptake.RESULTS:In all, 82.8% of respondents (N = 979) received at least one COVID-19 vaccine dose. Identifying as East Asian was associated with 14% higher odds of COVID-19 vaccine uptake relative to identifying as White (odds ratio [OR] = 1.14/95% confidence interval [CI] = [1.06, 1.24]); identifying as Filipino was associated with 14% higher odds of uptake (OR = 1.14/95% CI = [1.08, 1.20]); and identifying as Hispanic/Latinx was associated with 6% higher odds of uptake (OR = 1.06/95% CI = [1.00, 1.12]).DISCUSSION:Although nurses and people of color have been identified as groups with low levels of COVID-19 vaccine uptake, this study found that nurses of color received the vaccine at higher levels than their White counterparts.

A web-based survey was widely distributed between November 1 st –December 27 th , 2021, to health care providers and ancillary staff to assess reported COVID-19 vaccination of their children as well as their vaccine concerns. Fewer nurses and laboratory / radiology technicians reported COVID-19 vaccination of their adolescent children and intent to vaccinate their younger children compared to physicians and pharmacists, along with more frequently reported concern about anaphylaxis and infertility. Focused efforts to update ancillary staff as well as all health care providers on emerging COVID-19 vaccine safety information for children is crucial to promote strong COVID-19 vaccine recommendations. Impact Nurses, laboratory technicians and radiology technicians frequently reported concern about anaphylaxis and infertility after COVID-19 vaccination despite reassuring safety data. Education of ancillary staff with emerging safety data is important to strengthen health care provider vaccine recommendations.

BACKGROUND:Information and opinions shared by health care providers can affect patient vaccination decisions, but little is known about who health care providers themselves trust for information in the context of new COVID-19 vaccines.OBJECTIVE:The purpose of this study is to investigate which sources of information about COVID-19 vaccines are trusted by health care providers and how they communicate this information to patients.METHODS:This mixed methods study involved a one-time, web-based survey of health care providers and qualitative interviews with a subset of survey respondents. Health care providers (physicians, advanced practice providers, pharmacists, nurses) were recruited from an integrated health system in Southern California using voluntary response sampling, with follow-up interviews with providers who either accepted or declined a COVID-19 vaccine. The outcome was the type of information sources that respondents reported trusting for information about COVID-19 vaccines. Bivariate tests were used to compare trusted information sources by provider type; thematic analysis was used to explore perspectives about vaccine information and communicating with patients about vaccines.RESULTS:The survey was completed by 2948 providers, of whom 91% (n=2683) responded that they had received ≥1 dose of a COVID-19 vaccine. The most frequently trusted source of COVID-19 vaccine information was government agencies (n=2513, 84.2%); the least frequently trusted source was social media (n=691, 9.5%). More physicians trusted government agencies (n=1226, 93%) than nurses (n=927, 78%) or pharmacists (n=203, 78%; P<.001), and more physicians trusted their employer (n=1115, 84%) than advanced practice providers (n=95, 67%) and nurses (n=759, 64%; P=.002). Qualitative themes (n=32 participants) about trusted sources of COVID-19 vaccine information were identified: processing new COVID-19 information in a health care work context likened to a "war zone" during the pandemic and communicating information to patients. Some providers were hesitant to recommend vaccines to pregnant people and groups they perceived to be at low risk for COVID-19.CONCLUSIONS:Physicians have stronger trust in government sources and their employers for information about COVID-19 vaccines compared with nurses, pharmacists, and advanced practice providers. Strategies such as role modeling, tailored messaging, or talking points with standard language may help providers to communicate accurate COVID-19 vaccine information to patients, and these strategies may also be used with providers with lower levels of trust in reputable information sources.

Nearly a decade after becoming formally available in the U.S., HIV pre-exposure prophylaxis (PrEP) remains underutilized by populations at risk for HIV acquisition. The next generation of PrEP research is pivoting toward implementation research in order to identify the most impactful avenues for scaling up PrEP uptake. Rapid identification of patients who may be at risk for HIV in primary care settings and the ability to provide brief consultation and prescription or referral for PrEP could help to increase PrEP uptake. The current study aimed to develop and pilot-test a PrEP screening instrument that could be integrated into the workflow of busy primary care clinics to help facilitate PrEP uptake among at-risk men. During the study, PrEP screening occurred for 12 months in two primary care clinics nested within a large integrated healthcare delivery system in Southern California. An interrupted time series analysis found a significant increase in PrEP referrals overall during the screening intervention period as compared to the preceding 12 months. Findings suggest that brief HIV risk screening in primary care is acceptable, feasible, and shows preliminary effects in increasing PrEP referral rates for Black and Hispanic/Latinx men.

Purpose: Identifying risk factors for suicide using progress notes and administrative data is time consuming and usually requires manual case review. In this study, a natural language processing computerized algorithm was developed and implemented to automatically ascertain suicide ideation/attempt from clinical notes in a large integrated healthcare system, Kaiser Permanente Southern California. Methods: Clinical notes containing prespecified relevant keywords and phrases related to suicidal ideation/attempt between 2010 and 2018 were extracted from our organization’s electronic health record system. A random sample of 864 clinical notes was selected and equally divided into four subsets. These subsets were reviewed and classified as one of the following three suicide ideation/attempt categories: “Current”, “Historical” and “No” for each note by experienced research chart abstractors. The first three training datasets were used to develop the rule-based computerized algorithm sequentially and the fourth validation dataset was used to evaluate the algorithm performance. The validated algorithm was then applied to the entire study sample of clinical notes. Results: The computerized algorithm ascertained 23 of the 26 confirmed “Current” suicide ideation/attempt events and all 10 confirmed “Historical” suicide ideation/attempt events in the validation dataset. This algorithm produced a 88.5% sensitivity and 100.0% positive predictive value (PPV) for “Current” suicide ideation/attempt, and a 100.0% sensitivity and 100.0% PPV for “Historical” suicide ideation/attempt. After applying the computerized process to the entire study population sample, we identified a total of 1,050,289 “Current” ideation/attempt events and 293,038 “Historical” ideation/attempt events during the study period. Among the 400,436 individuals who were identified as having a “Current” suicide ideation/attempt event, 115,197 (28.8%) were 15-24 years old at the first event, 234,924 (58.7%) were female, 165,084 (41.7%) were Hispanic, and 150,645 (37.6%) had two or more events in the study period. Conclusions: Our study demonstrated that a natural language processing computerized algorithm can effectively ascertain suicide ideation/attempt from the free-text clinical notes in the electronic health record of a diverse patient population. This algorithm can be utilized in support of suicide prevention programs and patient care management.

Pseudo-atrial flutter is an EKG artifact that mimics a true atrial flutter. We report a case of pseudo-atrial flutter in a 67-year-old male with quadriplegia and ventilator dependence due to amyotrophic lateral sclerosis (ALS) who was hospitalized for respite care. Ihe pseudo-atrial flutterwas found to be due to percussions from a built-in chest wall percussion device in a hospital mattress used for chest physiotherapy.

BACKGROUND:Despite the availability of effective therapies, most gout patients achieve suboptimal treatment outcomes. Current best practices suggest gradual dose-escalation of urate lowering therapy and serial serum urate (sUA) measurement to achieve sUA<6.0mg/dl. However, this strategy is not routinely used. Here we present the study design rationale and development for a pharmacist-led intervention to promote sUA goal attainment. METHODS:To overcome barriers in achieving optimal outcomes, we planned and implemented the Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) study. This is a large pragmatic cluster-randomized trial designed to assess a highly automated, pharmacist-led intervention to optimize allopurinol treatment in gout. Ambulatory clinics (n=101) from a large health system were randomized to deliver either the pharmacist-led intervention or usual care to gout patients over the age of 18years newly initiating allopurinol. All participants received educational materials and could opt-out of the study. For intervention sites, pharmacists conducted outreach primarily via an automated telephone interactive voice recognition system. The outreach, guided by a gout care algorithm developed for this study, systematically promoted adherence assessment, facilitated sUA testing, provided education, and adjusted allopurinol dosing. The primary study outcomes are achievement of sUA<6.0mg/dl and treatment adherence determined after one year. With follow-up ongoing, study results will be reported subsequently. CONCLUSION:Ambulatory care pharmacists and automated calling technology represent potentially important, underutilized resources for improving health outcomes for gout patients.