Publications by authors named "Jan Carney"

29 Publications

  • Page 1 of 1

A Peer-Based Strategy to Overcome HPV Vaccination Inequities in Rural Communities: A Physical Distancing-Compliant Approach.

Crit Rev Eukaryot Gene Expr 2021 ;31(1):61-69

KM Consulting, New Jersey, USA.

The human papilloma virus (HPV) vaccine is the world's first proven and effective vaccine to prevent cancers in males and females when administered pre-exposure. Like most of the US, barely half of Vermont teens are up-to-date with the vaccination, with comparable deficits in New Hampshire and Maine. The rates for HPV vaccine initiation and completion are as low as 33% in rural New England. Consequently, there is a compelling responsibility to communicate its importance to unvaccinated teenagers before their risk for infection increases. Messaging in rural areas promoting HPV vaccination is compromised by community-based characteristics that include access to appropriate medical care, poor media coverage, parental and peer influence, and skepticism of science and medicine. Current strategies are predominantly passive access to literature and Internet-based information. Evidence indicates that performance-based messaging can clarify the importance of HPV vaccination to teenagers and their parents in rural areas. Increased HPV vaccination will significantly contribute to the prevention of a broadening spectrum of cancers. Reducing rurality-based inequities is a public health priority. Development of a performance-based peer-communication intervention can capture a window of opportunity to provide increasingly effective and sustained HPV protection. An effective approach can be partnering rural schools and regional health teams with a program that is nimble and scalable to respond to public health policies and practices compliant with COVID-19 pandemic-related modifications on physical distancing and interacting in the foreseeable future.
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http://dx.doi.org/10.1615/CritRevEukaryotGeneExpr.2021036945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128079PMC
March 2021

Jobs, Housing, and Mask Wearing: Cross-Sectional Study of Risk Factors for COVID-19.

JMIR Public Health Surveill 2021 01 11;7(1):e24320. Epub 2021 Jan 11.

Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, United States.

Background: Many studies have focused on the characteristics of symptomatic patients with COVID-19 and clinical risk factors. This study reports the prevalence of COVID-19 in an asymptomatic population of a hospital service area (HSA) and identifies factors that affect exposure to the virus.

Objective: The aim of this study is to measure the prevalence of COVID-19 in an HSA, identify factors that may increase or decrease the risk of infection, and analyze factors that increase the number of daily contacts.

Methods: This study surveyed 1694 patients between April 30 and May 13, 2020, about their work and living situations, income, behavior, sociodemographic characteristics, and prepandemic health characteristics. This data was linked to testing data for 454 of these patients, including polymerase chain reaction test results and two different serologic assays. Positivity rate was used to calculate approximate prevalence, hospitalization rate, and infection fatality rate (IFR). Survey data was used to analyze risk factors, including the number of contacts reported by study participants. The data was also used to identify factors increasing the number of daily contacts, such as mask wearing and living environment.

Results: We found a positivity rate of 2.2%, a hospitalization rate of 1.2%, and an adjusted IFR of 0.55%. A higher number of daily contacts with adults and older adults increases the probability of becoming infected. Occupation, living in an apartment versus a house, and wearing a face mask outside work increased the number of daily contacts.

Conclusions: Studying prevalence in an asymptomatic population revealed estimates of unreported COVID-19 cases. Occupational, living situation, and behavioral data about COVID-19-protective behaviors such as wearing a mask may aid in the identification of nonclinical factors affecting the number of daily contacts, which may increase SARS-CoV-2 exposure.
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http://dx.doi.org/10.2196/24320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7800904PMC
January 2021

Teaching Public and Population Health in Medical Education: An Evaluation Framework.

Acad Med 2020 12;95(12):1853-1863

L. Ortega is program director, Academic Partnerships to Improve Health, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia; ORCID: https://orcid.org/0000-0003-0273-1280.

Curriculum models and training activities in medical education have been markedly enhanced to prepare physicians to address the health needs of diverse populations and to advance health equity. While different teaching and experiential learning activities in the public health and population health sciences have been implemented, there is no existing framework to measure the effectiveness of public and population health (PPH) education in medical education programs. In 2015, the Association of American Medical Colleges established the Expert Panel on Public and Population Health in Medical Education, which convened 20 U.S. medical faculty members whose goal was to develop an evaluation framework adapted from the New World Kirkpatrick Model. Institutional leaders can use this framework to assess the effectiveness of PPH curricula for learners, faculty, and community partners. It may also assist institutions with identifying opportunities to improve the integration of PPH content into medical education programs. In this article, the authors present outcomes metrics and practical curricular or institutional illustrations at each Kirkpatrick training evaluation level to assist institutions with the measurement of (1) reaction to the PPH education content, (2) learning accomplished, (3) application of knowledge and skills to practice, and (4) outcomes achieved as a result of PPH education and practice. A fifth level was added to measure the benefit of PPH curricula on the health system and population health. The framework may assist with developing a locally relevant evaluation to further integrate and support PPH education at U.S. medical schools and teaching hospitals.
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http://dx.doi.org/10.1097/ACM.0000000000003737DOI Listing
December 2020

Consumer Reported Care Deferrals Due to the COVID-19 Pandemic, and the Role and Potential of Telemedicine: Cross-Sectional Analysis.

JMIR Public Health Surveill 2020 09 14;6(3):e21607. Epub 2020 Sep 14.

Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, United States.

Background: The COVID-19 pandemic forced many health systems to proactively reduce care delivery to prepare for an expected surge in hospitalizations. There have been concerns that care deferral may have negative health effects, but it is hoped that telemedicine can provide a viable alternative.

Objective: This study aimed to understand what type of health care services were being deferred during the COVID-19 pandemic lockdown, the role played by telemedicine to fill in care gaps, and changes in attitudes toward telemedicine.

Methods: We conducted a cross-sectional analysis of survey responses from 1694 primary care patients in a mid-sized northeastern city. Our main outcomes were use of telemedicine and reports of care deferral during the shutdown.

Results: Deferred care was widespread-48% (n=812) of respondents deferred care-but it was largely for preventive services, particularly dental and primary care, and did not cause concerns about negative health effects. In total, 30.2% (n=242) of those who delayed care were concerned about health effects, with needs centered around orthopedics and surgery. Telemedicine was viewed more positively than prior to the pandemic; it was seen as a viable option to deliver deferred care, particularly by respondents who were over 65 years of age, female, and college educated. Mental health services stood out for having high levels of deferred care.

Conclusions: Temporary health system shutdowns will give rise to deferred care. However, much of the deferrals will be for preventive services. The effect of this on patient health can be moderated by prioritizing surgical and orthopedic services and delivering other services through telemedicine. Having telemedicine as an option is particularly crucial for mental health services.
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http://dx.doi.org/10.2196/21607DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498465PMC
September 2020

Public Health Is Essential: COVID-19's Learnable Moment for Medical Education.

Acad Med 2020 12;95(12):1799-1801

J.K. Carney is professor of medicine and associate dean for public health and health policy, Larner College of Medicine at the University of Vermont, Burlington, Vermont.

The COVID-19 pandemic, an unprecedented challenge for this generation of physicians and for the health care system, has reawakened calls to strengthen the United States' public health systems. This global event is also a "learnable moment" for medical education-an opportunity to decisively incorporate public health, including public health systems, through the continuum of medical education. Although medical educators have made progress in integrating public health content into medical curricula, "public health" is not a phrase that is consistently used in curricular standards, and public health colleagues are not identified as unique and critical partners to improve and protect health. The COVID-19 crisis has demonstrated how a strong public health system is necessary to support the health of patients and populations, as well as the practice of medicine. Partnerships between medical and public health communities, through individual- and population-based interventions, can also more effectively combat more common threats to health, such as chronic diseases, health inequities, and substance abuse.To achieve a more effective medicine-public health relationship in practice, curricula across the continuum of medical education must include explanations of public health systems, the responsibilities of physicians to their local and state governmental public health agencies, and opportunities for collaboration. Medical education should also prepare physicians to advocate for public health policies, programs, and funding in order to improve and protect the health of their patients and communities. Pandemic COVID-19 demonstrates with laser focus that all physicians are part of public health systems and that public health content has a distinct and essential place across the continuum of medical education to prepare physicians to participate in, collaborate with, and advocate for public health systems.
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http://dx.doi.org/10.1097/ACM.0000000000003517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7255400PMC
December 2020

Patients' Perspectives of Diagnostic Error: A Qualitative Study.

J Patient Saf 2020 Mar 11. Epub 2020 Mar 11.

Department of Medicine, The Larner College of Medicine at The University of Vermont, Burlington, Vermont.

Objectives: The Institute of Medicine (IOM) defines diagnostic error as the failure to establish an accurate or timely explanation for the patient's health problem(s) or effectively communicate the explanation to the patient. Using this definition, we sought to characterize diagnostic errors experienced by patients and describe patient perspectives on causes, impacts, and prevention strategies.

Methods: We conducted interviews of adults hospitalized at an academic medical center. We used the framework of the IOM definition of diagnostic error to perform thematic analysis of qualitative data. Descriptive statistics were used to summarize quantitative data.

Results: Based on the IOM's definition of diagnostic error, 27 of the 69 included patients reported at least one diagnostic error in the past 5 years. The errors were distributed evenly across the following three dimensions of the IOM definition: accuracy, communication, and timeliness. Limited time with doctors, communication, clinical assessment, and clinical management emerged as major themes for causes of diagnostic error and for strategies to reduce diagnostic error. Impacts of errors included emotional distress, adverse health outcomes, and impaired activities of daily living.

Conclusions: This study uses the recent IOM definition of diagnostic error to provide insights into diagnostic error from the patient perspective. We found that diagnostic errors were commonly reported by hospitalized adults and have a profound impact on patients' well-being. Patients' insights regarding potential causes and prevention strategies may help identify opportunities to reduce diagnostic errors.
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http://dx.doi.org/10.1097/PTS.0000000000000642DOI Listing
March 2020

The Role of the Dental Community in Oropharyngeal Cancer Prevention Through HPV Vaccine Advocacy.

J Cancer Educ 2021 Apr;36(2):299-304

Robert Larner, MD College of Medicine, University of Vermont, 89 Beaumont Ave, Burlington, VT, 05405, USA.

As rates of human papillomavirus (HPV)-related oropharyngeal cancer (OPC) continue to rise, the dental community's role in primary prevention efforts related to HPV vaccination will become increasingly important. The aim of this study was to assess knowledge, beliefs, practices, and perceived barriers regarding HPV and HPV vaccine advocacy within the dental community. A sample of 266 dentists and dental hygienists completed an online survey, and responses were then analyzed using frequencies of responses, t tests, chi-square tests, and Spearman's correlations. Ninety percent of providers believe it is important to play an "active role" in their patients' general medical care, yet only 50% believe it is their responsibility to recommend the HPV vaccine. Only 50% feel knowledgeable enough to recommend the vaccine. 78.6% of providers rarely discuss HPV vaccination with their age-appropriate patients, and 82% rarely recommend the vaccine. The two most strongly agreed-upon barriers were "parent concerns about the safety or efficacy of the vaccine" (71.6%) and "parent opposition to HPV vaccination for philosophical or religious reasons" (72.6%). Dentists were more knowledgeable about HPV vaccination and more likely to recommend the vaccine than hygienists. Higher levels of HPV-related knowledge correlated positively with beliefs and practices that support HPV vaccine advocacy. We have identified multiple opportunities for intervention aimed at increasing vaccine advocacy among oral health providers. These include clarification of role from dental professional organizations, alleviation of concerns related to perceived parental objection to the vaccine, and educational interventions targeting knowledge deficits among oral health providers.
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http://dx.doi.org/10.1007/s13187-019-01628-wDOI Listing
April 2021

Brief Commentary: Advocating for Blunt Policy.

Authors:
Jan K Carney

Ann Intern Med 2019 01 8;170(2):121. Epub 2019 Jan 8.

Larner College of Medicine at the University of Vermont, Burlington, Vermont (J.K.C.).

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http://dx.doi.org/10.7326/M18-3167DOI Listing
January 2019

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper.

Ann Intern Med 2018 12 27;169(11):796-799. Epub 2018 Nov 27.

David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California (P.G.).

In this position paper, the American College of Physicians (ACP) examines the rationale for patient and family partnership in care and reviews outcomes associated with this concept, including greater adherence to care plans, improved satisfaction, and lower costs. The paper also explores and acknowledges challenges associated with implementing patient- and family-centered models of care. On the basis of a comprehensive literature review and a multistakeholder vetting process, the ACP's Patient Partnership in Healthcare Committee developed a set of principles that form the foundation for authentic patient and family partnership in care. The principles position patients in their rightful place at the center of care while acknowledging the importance of partnership between the care team and patient in improving health care and reducing harm. The principles state that patients and families should be treated with dignity and respect, be active partners in all aspects of their care, contribute to the development and improvement of health care systems, and be partners in the education of health care professionals. This paper also recommends ways to implement these principles in daily practice.
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http://dx.doi.org/10.7326/M18-0018DOI Listing
December 2018

Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians.

Ann Intern Med 2018 11 30;169(10):704-707. Epub 2018 Oct 30.

Texas Medical Home Initiative, Dallas, Texas (S.S.B.).

For more than 20 years, the American College of Physicians (ACP) has advocated for the need to address firearm-related injuries and deaths in the United States. Yet, firearm violence continues to be a public health crisis that requires the nation's immediate attention. The policy recommendations in this paper build on, strengthen, and expand current ACP policies approved by the Board of Regents in April 2014, based on analysis of approaches that the evidence suggests will be effective in reducing deaths and injuries from firearm-related violence.
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http://dx.doi.org/10.7326/M18-1530DOI Listing
November 2018

Achieving Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of Physicians.

Ann Intern Med 2018 05 17;168(10):721-723. Epub 2018 Apr 17.

Southern Illinois University School of Medicine, Springfield, Illinois (S.T.H.).

Women comprise more than one third of the active physician workforce, an estimated 46% of all physicians-in-training, and more than half of all medical students in the United States. Although progress has been made toward gender diversity in the physician workforce, disparities in compensation exist and inequities have contributed to a disproportionately low number of female physicians achieving academic advancement and serving in leadership positions. Women in medicine face other challenges, including a lack of mentors, discrimination, gender bias, cultural environment of the workplace, imposter syndrome, and the need for better work-life integration. In this position paper, the American College of Physicians summarizes the unique challenges female physicians face over the course of their careers and provides recommendations to improve gender equity and ensure that the full potential of female physicians is realized.
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http://dx.doi.org/10.7326/M17-3438DOI Listing
May 2018

Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper.

Ann Intern Med 2018 04;168(8):577-578

Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania (G.C.K.).

Social determinants of health are nonmedical factors that can affect a person's overall health and health outcomes. Where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy. In this position paper, the American College of Physicians acknowledges the role of social determinants in health, examines the complexities associated with them, and offers recommendations on better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.
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http://dx.doi.org/10.7326/M17-2441DOI Listing
April 2018

Population representation among anatomical donors and the implication for medical student education.

Clin Anat 2018 Mar 6;31(2):250-258. Epub 2017 Dec 6.

Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts.

Dissection provides a unique opportunity to integrate anatomical and clinical education. Commonly, cadavers are randomly assigned to courses, which may result in skewed representation of patient populations. The primary aim of this study was to determine if the anatomical donors studied by students at the University of Massachusetts Medical School (UMMS) accurately represent the disease burden of the local patient population. This cross-sectional study compared the University of Massachusetts Memorial Medical Center patient claims data and body donation data from the UMMS Anatomical Gift Program (AGP). This study examined age, race, sex, and morbidities within a 10-year timeframe in 401,258 patients and 859 anatomical donors who met inclusion criteria. An independent t test was conducted to compare the mean ages of the two populations. Chi square analysis was conducted on race, sex, and 10 morbidity categories. A Fischer's exact test was conducted for two morbidity categories with n < 10. Demographic analysis showed a significant difference in age, and racial representation between the populations. No statistical difference was found regarding sex. Morbidities were separated into 22 ICD-10 categories. Twelve categories were excluded and 10 were analyzed for population comparison. Two categories were over represented and seven were under-represented in the AGP population. One category showed no significant difference between populations. Targeted selection of cadavers in anatomy courses would improve morbidity variability in the anatomy lab. In addition, AGP acceptance guidelines should be evaluated to increase disease variation among the donor population. Clin. Anat. 31:250-258, 2018. © 2017 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23013DOI Listing
March 2018

Death Certification Errors and the Effect on Mortality Statistics.

Public Health Rep 2017 Nov/Dec;132(6):669-675. Epub 2017 Nov 1.

1 Office of the Chief Medical Examiner, Vermont Department of Health, Burlington, VT, USA.

Objective: Errors in cause and manner of death on death certificates are common and affect families, mortality statistics, and public health research. The primary objective of this study was to characterize errors in the cause and manner of death on death certificates completed by non-Medical Examiners. A secondary objective was to determine the effects of errors on national mortality statistics.

Methods: We retrospectively compared 601 death certificates completed between July 1, 2015, and January 31, 2016, from the Vermont Electronic Death Registration System with clinical summaries from medical records. Medical Examiners, blinded to original certificates, reviewed summaries, generated mock certificates, and compared mock certificates with original certificates. They then graded errors using a scale from 1 to 4 (higher numbers indicated increased impact on interpretation of the cause) to determine the prevalence of minor and major errors. They also compared International Classification of Diseases, 10th Revision (ICD-10) codes on original certificates with those on mock certificates.

Results: Of 601 original death certificates, 319 (53%) had errors; 305 (51%) had major errors; and 59 (10%) had minor errors. We found no significant differences by certifier type (physician vs nonphysician). We did find significant differences in major errors in place of death ( P < .001). Certificates for deaths occurring in hospitals were more likely to have major errors than certificates for deaths occurring at a private residence (59% vs 39%, P < .001). A total of 580 (93%) death certificates had a change in ICD-10 codes between the original and mock certificates, of which 348 (60%) had a change in the underlying cause-of-death code.

Conclusions: Error rates on death certificates in Vermont are high and extend to ICD-10 coding, thereby affecting national mortality statistics. Surveillance and certifier education must expand beyond local and state efforts. Simplifying and standardizing underlying literal text for cause of death may improve accuracy, decrease coding errors, and improve national mortality statistics.
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http://dx.doi.org/10.1177/0033354917736514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5692167PMC
December 2017

Access to transportation for Chittenden County Vermont older adults.

Aging Clin Exp Res 2016 Aug 5;28(4):769-74. Epub 2015 Nov 5.

University of Vermont College of Medicine, 89 Beaumont Ave., Burlington, VT, 05405, USA.

Background: Aging often leads to decreased independence and mobility, which can be detrimental to health and well-being. The growing population of older adults will create a greater need for reliable transportation.

Aims: Explore whether and how lack of transportation has compromised areas of daily lives in older adults.

Methods: 1221 surveys with 36 questions assessing transportation access, usage, and impact on activities were distributed to Chittenden County, Vermont older adults; 252 met criteria for analysis.

Results: Older adults reported overwhelming difficulty getting to activities considered important, with 69 % of participants delaying medical appointments due to transportation barriers. Although family and friends represent a primary method of transportation, older adults reported difficulty asking them for help.

Discussion: Lack of accessible transportation leads to missed healthcare appointments and social isolation, which may have detrimental effects on older adults' quality of life.

Conclusion: Many older adults face significant transportation challenges that negatively affect their health and well-being.
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http://dx.doi.org/10.1007/s40520-015-0476-3DOI Listing
August 2016

An Exploratory Analysis of Public Awareness and Perception of Ionizing Radiation and Guide to Public Health Practice in Vermont.

J Environ Public Health 2015 28;2015:476495. Epub 2015 Apr 28.

University of Vermont College of Medicine, 89 Beaumont Avenue, Burlington, VT 05405, USA.

Exposure to ionizing radiation has potential for acute and chronic health effects. Within the general public of the United States, there may be a discrepancy between perceived and actual health risks. In conjunction with the Vermont Department of Health, a survey designed to assess public perception and knowledge of ionizing radiation was administered at 6 Vermont locations (n = 169). Descriptive and inferential statistical analyses were conducted. Eighty percent of respondents underestimated the contribution of medical imaging tests to total ionizing radiation exposure. Although only thirty-nine percent of participants were confident in their healthcare professional's knowledge of ionizing radiation, most would prefer to receive information from their healthcare professional. Only one-third of individuals who received a medical imaging test in the past year were educated by their healthcare professional about the risks of these tests. Those who tested their home for radon were twice as likely to choose radon as the greatest ionizing radiation risk to self. Although respondents had an above-average education level, there were many misperceptions of actual risks of exposure to ionizing radiation, particularly of medical imaging tests. Educating healthcare professionals would therefore have a profound and positive impact on public understanding of ionizing radiation.
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http://dx.doi.org/10.1155/2015/476495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4427848PMC
May 2016

Factors contributing to suboptimal rates of childhood vaccinations in Vermont.

J Child Health Care 2015 Dec 12;19(4):558-68. Epub 2014 May 12.

University of Vermont College of Medicine, USA

Childhood immunizations are invaluable in preventing contagious diseases. Nonetheless, vaccines have become increasingly controversial with growing numbers of caregivers refusing to vaccinate their children. The percentage of fully vaccinated children in Vermont is one of the lowest nationally. This study set out to determine Vermont caregivers' attitudes toward immunizations to better explain why the percentage of fully vaccinated children has fallen in Vermont. A survey regarding caregivers' health care knowledge about children, their vaccination concerns, and their children's vaccination status was sent to participants in the Vermont Women, Infants and Children's Program from two districts. In total, 83% (n = 379) of respondents reported their children received all recommended vaccinations for their age. Respondents who considered themselves highly knowledgeable regarding their children's health care and confident about the safety of vaccinations were significantly associated with reporting their children as being current on vaccinations and with their intent to continue vaccinations. Respondents indicated highest concern regarding the safety and number of vaccinations administered during one visit. Primary care providers were indicated as important resources for addressing concerns about vaccinations and health care knowledge of children. The results help to understand low vaccination rates in Vermont and can be used for targeting health campaigns to improve vaccination rates.
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http://dx.doi.org/10.1177/1367493514530955DOI Listing
December 2015

Community-academic partnerships: how can communities benefit?

Am J Prev Med 2011 Oct;41(4 Suppl 3):S206-13

Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont 05405, USA.

In answer to the question of how academic institutions will meet medical education needs and public health challenges of the 21st century, a strong, vibrant, and sustained community partnership has been developed to teach public health, address community public health needs, and develop health policy to sustain these improvements, all with a practical approach. In this paper, the partnership between the University of Vermont College of Medicine and various community agencies is described from the perspective of how the community can benefit from educational efforts in public health. Particular focus is given to the community-academic partnership model in public health, a strong and sustained partnership between the University of Vermont College of Medicine and the United Way of Chittenden County Volunteer Center that began in 2004. Public health projects are designed, through partnerships with community nonprofit agencies, to be effective in addressing community issues while helping prepare students to become problem-solvers in population health. Examples of benefits seen by the community are used to illustrate the success of this approach. Project examples and a brief case study illustrate how community-academic partnerships in medical education can serve as a "catalyst" to improving community health.
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http://dx.doi.org/10.1016/j.amepre.2011.05.020DOI Listing
October 2011

Planning and incorporating public health preparedness into the medical curriculum.

Am J Prev Med 2011 Oct;41(4 Suppl 3):S193-9

Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont 05405, USA.

As part of a 2010 conference entitled "Patients and Populations: Public Health in Medical Education," faculty from four U.S. medical schools (Case Western Reserve University, Harvard Medical School, the University of Colorado School of Medicine, and the University of Vermont College of Medicine), collaborated on a workshop to help other medical educators develop scenario-based learning experiences as practical, engaging, and effective mechanisms for teaching public health principles to medical school students. This paper describes and compares four different medical schools' experiences using a similar pandemic exercise scenario, discusses lessons learned, and suggests a curricular framework for medical schools adding such exercises to their population health curriculum. Different strategies to create realistic scenarios and engage students, including use of professionals and stakeholders from the community, are described.
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http://dx.doi.org/10.1016/j.amepre.2011.05.026DOI Listing
October 2011

Evaluation of a modified prescription form to address prescribing errors.

Am J Health Syst Pharm 2011 Jan;68(2):151-7

Center for Clinical and Translational Science, University of Vermont, Burlington, 05405, USA.

Purpose: The impact of a modified paper prescription form on the occurrence of prescribing errors was evaluated.

Methods: Rural primary care providers practicing in the United States who wrote paper prescriptions in English were eligible for study participation. The prescribers agreed to use only the prescription pads provided to them during the study. The study prescription pads contained 50 prescription forms, each with a duplicate. Each prescription and duplicate contained a unique serial number for data identification purposes. When a prescriber wrote a prescription, the original was provided to the patient per usual practice, and the duplicate was retained as the study data. Two prescription pads contained modified forms and two prescription pads were similar to the prescription pads the prescriber had been using. Providers completed 100 standard and 100 modified prescriptions. Pharmacist consultants reviewed each prescription for the presence or absence of errors. The primary outcome measure was the number of errors. Secondary outcomes were risk differences between standard and modified prescription forms for various error types.

Results: Of the 327 prescribers who were eligible and expressed interest in the study, 111 started the study and 84 completed the study. A total of 16,061 prescriptions were eligible for analysis. Pharmacists identified at least one prescribing problem in 987 prescriptions (6.1%). Modified prescription forms were associated with significantly more prescribing problems than standard prescription forms (odds ratio, 1.85; 95% confidence interval, 1.5-2.2; p < 0.001).

Conclusion: Modified prescription forms were associated with more errors than were standard prescription forms in a sample of rural prescribers.
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http://dx.doi.org/10.2146/ajhp100063DOI Listing
January 2011

Prevalence of food insecurity and utilization of food assistance program: an exploratory survey of a Vermont middle school.

J Sch Health 2011 Jan;81(1):15-20

Department of Pharmacy Administration and Allied Health Sciences, College of Pharmacy and Allied Health Professions, St. John's University, 8000 Utopia PKWY, Jamaica, NY 11439, USA.

Background: Access to sufficient food--in terms of both quality and quantity--is especially critical for children. Undernourishment during childhood and adolescence can have health implications, both short and long term. The prevalence of food insecurity was assessed in a sample of Vermont school children, as well as the relationship between food insecurity, participation in school breakfast or lunch, exercise and body mass index (BMI), all with a goal to identify needs to improve effectiveness of current programs.

Methods: A cross-sectional, 23-item self-administered survey of students attending a public middle school in Vermont.

Results: Twenty percent of the children were residing in a food insecure household. No statistically significant differences were observed in terms of age, sex or BMI percentile and food security status. Food insecure (with or without hunger) participants were less likely to eat breakfast at home compared to food secure participants (67.1% vs 81.4%, p = .007). However, such differences were not observed between eating school breakfast or lunch. Sixty-two percent of food insecure (with or without hunger) participants engaged in daily exercise compared to 75.9% food secure participants (p = .014).

Conclusion: Children in food insecure households were less likely to be physically active and to eat breakfast at home. However, the school breakfast program is negating any difference between the 2 groups in terms of eating breakfast at all. We consider this a success given the short- and long-term implications of food insecurity in children. We believe these findings have important implications for schools, policy makers, and programs to reduce food insecurity.
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http://dx.doi.org/10.1111/j.1746-1561.2010.00552.xDOI Listing
January 2011

Barriers to pediatric lead screening: implications from a web-based survey of Vermont pediatricians.

Clin Pediatr (Phila) 2010 Jul 11;49(7):656-63. Epub 2010 Feb 11.

University of Vermont, Burlington, VT, USA.

The pernicious effects of lead on child health are well documented. The Vermont Department of Health (VDH) recommends screening all 12- and 24-month-old children for elevated blood lead levels (BLL). In 2006, only 41.4% of 24-month-old Vermont children were screened. To identify barriers preventing pediatricians from performing blood lead screening, a survey was distributed to Vermont primary care pediatricians-divided in higher and lower screening groups. Vermont pediatricians were more likely to be lower screeners if they reported negative health outcomes began at BLL >" xbd="641" xhg="618" ybd="1456" yhg="1421"/> 10 microg/dL (odds ratio [OR] = 3.64, 95% confidence interval [CI] = 1.12-11.99), practiced in Chittenden County (OR = 3.34, 95% CI = 1.14-9.78), or disagreed with the VDH's recommendation (OR = 4.90, 95% CI = 1.66-15.50). Adjusted analysis indicated the most significant determinants of lower screening rates were male gender, a perceived dangerous BLL as >10 microg/dL and low self-reported Medicaid population. The VDH may have an opportunity to increase BLL screening emphasizing the significant health risks associated with BLL < or = 10 microg/dL.
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http://dx.doi.org/10.1177/0009922809360926DOI Listing
July 2010

Medical education for a healthier population: reflections on the Flexner Report from a public health perspective.

Acad Med 2010 Feb;85(2):211-9

Association of American Medical Colleges, Washington, DC 20037, USA.

Abraham Flexner's 1910 report is credited with promoting critical reforms in medical education. Because Flexner advocated scientific rigor and standardization in medical education, his report has been perceived to place little emphasis on the importance of public health in clinical education and training. However, a review of the report reveals that Flexner presciently identified at least three public-health-oriented principles that contributed to his arguments for medical education reform: (1) The training, quality, and quantity of physicians should meet the health needs of the public, (2) physicians have societal obligations to prevent disease and promote health, and medical training should include the breadth of knowledge necessary to meet these obligations, and (3) collaborations between the academic medicine and public health communities result in benefits to both parties. In this article, commemorating the Flexner Centenary, the authors review the progress of U.S. and Canadian medical schools in addressing these principles in the context of contemporary societal health needs, provide an update on recent efforts to address what has long been perceived as a deficit in medical education (inadequate grounding of medical students in public health), and provide new recommendations on how to create important linkages between medical education and public health. Contemporary health challenges that require a public health approach in addition to one-on-one clinical skills include containing epidemics of preventable chronic diseases, reforming the health care system to provide equitable high-quality care to populations, and responding to potential disasters in an increasingly interconnected world. The quantitative skills and contextual knowledge that will prepare physicians to address these and other population health problems constitute the basics of public health and should be included throughout the continuum of medical education.
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http://dx.doi.org/10.1097/ACM.0b013e3181c885d8DOI Listing
February 2010

Public awareness of mercury in fish: analysis of public awareness and assessment of fish consumption in vermont.

Mcgill J Med 2009 Nov 16;12(2):39. Epub 2009 Nov 16.

Exposure to mercury from environmental sources, such as fish consumption, poses potential health risks to the public. The state of Vermont has developed educational brochures and posters displaying safe fish consumption guidelines in order to educate the public regarding mercury exposure through fish. In this study, a group of medical students from the University of Vermont College of Medicine, in partnership with the Vermont Department of Health, conducted a study in Chittenden County, Vermont in order to assess both fish consumption practices and overall awareness of such safe eating guidelines and mercury advisories. A total of 166 Vermont residents were surveyed during a six week period. The results of this survey suggest that in Chittenden county of Vermont, these educational efforts are markedly successful, with 48% of respondents being specifically aware of the safe eating guidelines. Further, these results suggest that 61% of those respondents that reported low monthly canned tuna consumption had a decreased their consumption in response to the safe eating guidelines. last, a series of specific, yet widely applicable recommendations are presented for future public educational efforts regarding mercury exposure through fish consumption.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997264PMC
November 2009

Community-academic partnerships: a "community-first" model to teach public health.

Educ Health (Abingdon) 2008 Mar 9;21(1):166. Epub 2008 Apr 9.

University of Vermont College of Medicine, Burlington, Vermont, USA.

Context: Physicians face complex public health issues in clinical practice today. We describe an innovative "community-first" model that teaches public health to medical students.

Methods: The United Way of Chittenden County Volunteer Center (UWCCVC) in the State of Vermont, U.S.A., was chosen as the focal point for projects because of its documented history, success, and credibility. A simple form, sent to local community agencies, facilitated participation and identified Healthy People 2010 focus areas as the public health framework. Community agencies identified the health needs of populations that were served through this process. Projects were subsequently jointly developed and following student completion, assessed jointly by university faculty and community agency mentors.

Results: A total of 41 projects have been completed, spanning 11 different areas of Healthy People 2010. Many different local community agencies have participated. An annual poster session is held at project completion. Assessment includes both faculty mentor and community agency assessment of student groups' progress and project quality. Community agencies are surveyed following project completion. Nearly all community agencies agreed that projects benefited the populations served and anticipated continuing the partnership.

Conclusions: Putting community public health needs first, in developing projects, was critical to success. This "community-first" model provides opportunities to teach public health and benefit health in local communities.
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March 2008

Relationship of uric acid with progression of kidney disease.

Am J Kidney Dis 2007 Aug;50(2):239-47

Division of Renal Diseases and Hypertension, University of Colorado Health Sciences Center, Denver, CO 80262, USA.

Background: Uric acid levels are increased in patients with kidney dysfunction. We tested the hypothesis that uric acid may be associated with kidney disease progression.

Study Design: Cohort study.

Setting & Participants: 5,808 participants of the Cardiovascular Health Study.

Predictor: Uric acid levels.

Outcomes & Measurements: Kidney disease progression was defined as a decrease in estimated glomerular filtration rate (GFR) of 3 mL/min/1.73 m(2) per year or greater (>or=0.05 mL/s) and as incident chronic kidney disease (CKD). Measures of kidney function were estimated GFR using the Modification of Diet in Renal Disease Study equation.

Results: Higher quintiles of uric acid levels were associated with greater prevalences of estimated GFR less than 60 mL/min/1.73 m(2) (<1.00 mL/s) of 7%, 14%, 12%, 25%, and 42% for quintiles 1 (6.90 mg/dL [>410 micromol/L]), respectively. In comparison, there was only a modest, but significant, association between quintiles of uric acid levels and progression of kidney function decrease, with adjusted odds ratios of 1.0, 0.88 (95% confidence interval [CI], 0.64 to 1.21), 1.23 (95% CI, 0.87 to 1.75), 1.47 (95% CI, 1.04 to 2.07), and 1.49 (95% CI, 1.00 to 2.22) for quintiles 1 through 5, respectively. No significant association was found between uric acid level and incident CKD (adjusted odds ratio, 1.00; 95% CI, 0.89 to 1.14).

Limitations: Measurements of albuminuria were not available.

Conclusions: Uric acid levels are associated strongly with prevalent CKD. In comparison, greater uric acid levels had a significant, but much weaker, association with progression of kidney disease.
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http://dx.doi.org/10.1053/j.ajkd.2007.05.013DOI Listing
August 2007

Enhancing nuclear emergency preparedness: Vermont's distribution program for potassium iodide.

J Public Health Manag Pract 2003 Sep-Oct;9(5):361-7

Department of Health, Burlington, USA.

On January 31, 2002, Vermont's health commissioner requested potassium iodide (KI) for individuals in the 10-mile Emergency Planning Zone of the nuclear power facility. Vermont's KI distribution program emphasized public information about the role, risks, and benefits of KI. Predistribution ensured that individuals could receive KI in a 0- to 4-hour time period, to provide maximum protection. Five months after the program began, more than 1,000 individuals had received KI, and 3,000-4,000 KI doses have been distributed in schools. Efforts are ongoing to identify barriers to participation, provide public education, and evaluate KI distribution efforts.
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http://dx.doi.org/10.1097/00124784-200309000-00006DOI Listing
November 2004

Relationships of a brief measure of youth assets to health-promoting and risk behaviors.

J Adolesc Health 2004 Mar;34(3):184-91

Vermont Agency of Human Services, Waterbury, Vermont 05671, USA.

Purpose: To test the utility of a brief measure of developmental assets for predicting risk and health-promoting behaviors.

Methods: Six "assets" questions were added to an existing school-based survey of health-related behaviors. "Asset" questions dealt with students' grades in school, their communication with parents about school, students' perceptions of their role in school decision-making, students' participation in after-school activities and volunteering, and students' perceptions that they "matter" in their community. Participants were 30,916 Vermont students in grades 8-12. The sample included approximately equal numbers of girls and boys. It was 92% white. Fifty-nine percent of students' mothers had completed at least some postsecondary education (according to student report). Data were analyzed by Chi-square techniques and logistic regression.

Results: Number of assets (0-6) was negatively related to students' engagement in each of seven risk behaviors, and positively related to three health-promoting behaviors. The effects of number of assets were in most cases independent of demographic variables. Among the six assets, academic success (grades in school) contributed the greatest effect for most of the outcome measures; however, each of the assets contributed significant independent effects to multiple risk- and health-behaviors.

Conclusions: Students' assets, even if relatively few, may make important contributions to wellness, independent of other well-established demographic factors.
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http://dx.doi.org/10.1016/j.jadohealth.2003.05.004DOI Listing
March 2004
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