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BACKGROUND: Workplace burnout among healthcare professionals is a critical public health concern. Few studies have examined organizational and individual factors associated with burnout across healthcare professional groups. OBJECTIVE: The purpose of this study was to examine the association between practice adaptive reserve (PAR) and individual behavioural response to change and burnout among healthcare professionals in primary care. DESIGN: This cross-sectional study used survey data from 154 primary care practices participating in the EvidenceNOW Heart of Virginia Healthcare initiative. PARTICIPANTS: We analysed data from 1279 healthcare professionals in Virginia. Our sample included physicians, advanced practice clinicians, clinical support staff and administrative staff. MAIN MEASURES: We used the PAR instrument to measure organizational capacity for change and the Change Diagnostic Index© (CDI) to measure individual behavioural response, which achieved a 76% response rate. Logistic regression analysis was used to estimate the effects of PAR and CDI on burnout. KEY RESULTS: As organizational capacity for change increased, burnout in healthcare professionals decreased by 51% (OR: 0.49; 95% CI, 0.33, 0.73). As healthcare professionals showed improved response toward change, burnout decreased by 84% (OR: 0.16; 95% CI, 0.11, 0.23). Analysis by healthcare professional type revealed a significant association between high organizational capacity for change, positive response to change and low burnout among administrative staff (OR: 2.92; 95% CI, 1.37, 6.24). Increased hours of work per week was associated with higher odds of burnout (OR: 1.07; 95% CI, 1.05, 1.10) across healthcare professional groups. CONCLUSION: As transformation efforts in primary care continue, it is critical to understand the influence of these initiatives on healthcare professionals’ well-being. Efforts to reduce burnout among healthcare professionals are needed at both a system and organizational level. Building organizational capacity for change, supporting providers and staff during major change and consideration of individual workload may reduce levels of burnout. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06367-z.

Evidence-based practice (EBP) is crucial in keeping nurses aware of the current knowledge and improving clinical decision-making. The integration of nurses’ EBP competencies and organizational support has been suggested to create an effective arena in implementing EBP. The purpose of the study was to examine organizational factors influencing nurses’ EBP knowledge, attitudes, and implementation and identify staff nurses’ perceptions of EBP nursing leadership and hospital supports in Saudi Arabia. Data were collected from a convenience sample of staff nurses (N = 227) working in four hospitals using a cross-sectional, correlational descriptive design. Level of education (p < 0.05), EBP training (p < 0.05), unit type (ICU (p < 0.001) and ER (p < 0.01)), perceived nursing leadership (p < 0.001), and work environment (p < 0.05) supports were found significantly associated with nurses’ knowledge. Magnet recognition (p < 0.01) and knowledge (p < 0.001) had significant influence on nurses’ attitudes. Unit type (ER) (p < 0.05), knowledge (p < 0.001), and attitudes (p < 0.001) were associated with implementation. Encouragement to attend EBP trainings from nursing leadership was perceived by most nurses (51.1%). Nurses reported their hospitals support EBP through training (68.2%). Findings support the need for healthcare systems to create a culture that facilitates EBP implementation to enhance nurses’ EBP competencies and improve patients’ outcomes. Nursing managers may consider preparing nurses through education.

Objective: The main objective of this work was to characterize the prevalence of acute medical needs by examining emergency department (ED) and outpatient wound care clinic (WCC) visits before, during, and after the 2017 Hurricanes Irma and Maria, in St. Thomas, United States (U.S.) Virgin Islands. Methods: Descriptive statistics and logistic regression were used to assess associations between the occurrence of the storms and visits due to injuries and chronic conditions presented to the ED and WCC from September 1, 2016 to May 31, 2018. Results: ED visits increased and the rate of injury care was higher during the storms (12 patient visits per day) than before or after the storms (9 patient visits per day). WCC visits increased during (12%) and after the storms (45%), and were associated with patients 60 years and older. The odds of ED and WCC visits due to injury during the storms were significantly higher (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.17, 1.40) than prior to the storms. The odds for visits due to injuries were 1.19 (95% CI: 1.12, 1.28) times higher after the storms. Conclusions: Increases occurred in ED and WCC visits for injury care during the storms and in WCC visits after the storms. Public health preparedness mandates understanding how major hurricanes impact the prevalence of acute medical needs, and the factors that influence decisions to seek medical care, in their wake.

OBJECTIVE: To report and examine associations with infant vitamin D intake and meeting recommendations among a national sample participating in WIC. DESIGN: Secondary analysis from the 2013–2015 WIC Infant Toddler Feeding Practices Study-2. PARTICIPANTS: US Infants. VARIABLES MEASURED: Total reported vitamin D intake from diet and supplementation at the time of data collection. ANALYSIS: Descriptive statistics and generalized estimating equations. RESULTS: The median total vitamin D intake ranged from 5.43 (95% CI: 5.40, 5.46) mcg/day at month 1 to 8.18 (95% CI: 8.11, 8.20) mcg /day at month 13, with 16–36% of infants meeting the infant vitamin D recommendation over that time. Overall 6 to 12% of all participants reported supplementation, across all time points. Although most (between 78–98%) of supplemented breastfed infants met the recommendation, very few were supplemented as a group. Hence, breastfed infants were less likely to meet the recommendation as compared to those who were formula fed across at time points except month 1 (P < 0.001 for all). Whereas infant age, feeding type, and/or their interaction were significant predictors of both receiving supplementation and meeting the recommendation, maternal nativity (P = 0.006) and parity (P = 0.01 and P < 0.001) predicted receiving supplementation, and child sex (P < 0.001) and maternal race/ethnicity (P < 0.001) predicted meeting the recommendation. CONCLUSIONS AND IMPLICATIONS: Among a national sample of infants participating in WIC between 2013–2015, a high proportion were not meeting the current vitamin D recommendation. The WIC program is one resource for promoting strategies for increasing the number of American infants meeting D recommendations yet, a coordinated approach involving other health care providers is likely needed. Future research exploring the reason for lack of supplementation, from both the perspective of parents and providers, as well as the clinical impact of low vitamin D intake is warranted.

OBJECTIVES: To explore vitamin D intake and adherence with current recommendations among a national sample of infants participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). METHODS: Data were analyzed from the WIC Infant Toddler Feeding Practices Study-2, the most recent longitudinal assessment of mother-child dyads participating in WIC around the time of childbirth. Only data collected from 1, 3, 5, 7, 9, 11- and 13-months post-partum interviews were included in the current analysis. Total vitamin D intake was measured from a 24-hour dietary recall, which included supplementation. Infant feeding was categorized at each time point as only breastmilk, only formula, both breastmilk and formula (mixed feeding) and neither. A generalized estimating equation was constructed to assess predictors of meeting the infant vitamin D recommendation of ≥400 IU/day. RESULTS: A total of 3398 infants were included in this study at 1 month. The median total vitamin D intake ranged from 217 (95% CI: 210, 226) IU/day at 1 month to 324 (314, 333) IU/day at 13 months, with 16–36% of infants meeting the infant vitamin D recommendation. There were significant differences (P

Purposes Describe implementation of Institute of Medicine (IOM) early infant feeding recommendations for child obesity prevention by immigrant mothers from Central America; examine potential relationships with food insecurity and postpartum depressive symptoms. Design and Methods Using a cross-sectional, descriptive design, face-to-face interviews were conducted with 318 mothers of 2 month old infants at a large pediatric setting for low income families. Logistic regression models assessed feeding practices, food insecurity and postpartum depressive symptoms. Results Exclusive breastfeeding rates were low (9.4%); most mothers (62.7%) both breastfed and bottle fed their infants. Mothers who bottle fed at moderate and high intensity were twice as likely to affirm that if you give a baby a bottle, you should always make sure s/he finishes it (OR = 2.30, 95% CI = 1.13, 4.69; OR = 2.29, 95% CI = 1.26, 4.14). Food insecurity was experienced by 57% of mothers but postpartum depressive symptoms were low (Possible range = 0–30; M = 2.96, SD =3.6). However, for each increase in the postpartum depressive symptoms score, the likelihood of affirming a controlling feeding style increased by 11–13%. Conclusions Immigrant mothers from Central America were more likely to both breastfeed and bottle feed (las dos cosas) than implement exclusive breastfeeding. Bottle feeding intensity was associated with a controlling feeding style. Practice Implications Infant well visits provide the ideal context for promoting IOM recommendations for the prevention of obesity among children of immigrant mothers from Central America.

We examined how prenatal exposure to breastfeeding information from various media sources, maternal knowledge of benefits, family and clinician support, and peer practices influence breastfeeding outcomes in early infancy. Initiation of breastfeeding, any breastfeeding at two months, and exclusivity of breastfeeding at two months were examined in a cohort of US women using data from the Infant Feeding Practices Study II. Descriptive statistics, chi-square analyses and logistic regression were conducted. Approximately 85 percent of the women initiated breastfeeding. At two months, 63.8 percent continued breastfeeding, while only 38.1 percent breastfed exclusively. Mothers with greater knowledge about breastfeeding benefits were 11.2 (95% CI: 6.87–18.45) times more likely to initiate breastfeeding and 5.62 (95% CI: 4.19–7.54) times more likely to breastfeed at two months than those with lower levels of knowledge. Women whose families prenatally supported exclusive breastfeeding were 8.21(5.12–13.2) times more likely to initiate and continue breastfeeding (OR 3.21, 95% CI: 2.51–4.11). Clinicians who supported breastfeeding only also increased the odds of a woman initiating breastfeeding (OR 1.95, 95% CI: 1.31–2.88). Interventions to increase maternal knowledge of breastfeeding benefits and family and clinician support of breastfeeding in the prenatal period may help increase breastfeeding rates. The encouragement of breastfeeding needs to be a priority among health care providers to improve the health of mothers and infants.

The purpose of this study was to examine ethnic differences among non-Hispanic black and white births in the distribution of maternal risk factors of infant mortality across specific causes of death. The data were obtained from the North Carolina linked birth/infant death files (1989 to 1997). Logistic regression models were built to assess the risk distribution of demographic, behavioral and health related variables in relation to causes of infant death, which included congenital anomalies, short gestation/low birth weight (LBW), sudden infant death syndrome, infections and obstetric conditions. Infants born to black women had the highest rates for all causes of mortality compared to those born to white women. Having at least one prior live birth now dead was associated with congenital anomalies, obstetric conditions and short gestation/LBW related deaths in both ethnic groups. Deaths caused by infections were more likely to occur among white young (

INTRODUCTION: Although progress has been made to reduce adolescent pregnancies in the United States rates of unplanned pregnancy among young adults aged (aged 18-29 years) remain high. In this study we assessed factors associated with perceived likelihood of pregnancy (likelihood of getting pregnant/getting partner pregnant in the next year) among sexually experienced young adults who were not trying to get pregnant and had previously used contraceptives. METHODS: We conducted a secondary analysis of 660 young adults aged 18 to 29 years in the United States from the cross-sectional National Survey of Reproductive and Contraceptive Knowledge. Logistic regression and classification tree analyses were conducted to generate profiles of young adults most likely to report anticipating a pregnancy in the next year. RESULTS: Nearly one-third (32%) of young adults indicated that they believed they had at least some likelihood of becoming pregnant in the next year. Young adults who believed that avoiding pregnancy was not very important were most likely to report pregnancy likelihood (odds ratio [OR] 5.21; 95% confidence interval [CI] 2.80-9.69) as were young adults who considered avoiding a pregnancy to be important but who were not satisfied with their current contraceptive method (OR 3.93; 95% CI 1.67-9.24) and who attended religious services frequently (OR 3.0; 95% CI 1.52-5.94) were uninsured (OR 2.63; 95% CI 1.31-5.26) and were likely to have unprotected sex in the next 3 months (OR 1.77; 95% CI 1.04-3.01). DISCUSSION: These results may help guide future research and the development of pregnancy-prevention interventions targeting sexually experienced young adults. (c) 2015 by the American College of Nurse-Midwives.

Objective: Low birth weight (LBW) is a major public health problem. Compared to normal weight infants, LBW is positively associated with infant mortality and negatively associated with normative childhood cognitive and physical development. In the past two decades, research has identified important risk factors of LBW. In this study, we used classification trees to study the interactive nature of these factors. In particular we: (1) identify subgroups of women who are at a high risk of a LBW outcome in seven geographical regions of Florida, and (2) study the predictive performance of classification trees by comparing the tree-based results to those obtained using logistic regression. Methods: The data, 181,690 singleton births, were derived from Florida birth certificates recorded in 1998. Classification trees and logistic regression models were built based on seven geographical regions. The outcome variable consisted of two classes, namely LBW ( =2500g) cases, while a large number of known risk factors was examined. Tree and logistic regression models were compared using Receiving Operating Curves, and sensitivity and specificity analyses. Results: The use of classification trees has revealed a number of high-risk subgroups. For instance, White, Hispanic or Other non-white mothers who were healthy and smoked with a weight gain less than 20lbs had a higher risk of a LBW birth compared to those with the same characteristics but with a weight gain of more than 20lbs. Factors such as parity and marital status were important predictors for pregnancy outcomes among nonsmoker White, Hispanic or Other non-white mothers. Furthermore, we found that Black mothers were directly classified as a high-risk subgroup in the regions of Panhandle, Northeast, North Central, while in the Southern regions a series of other characteristics further defined the high-risk subgroup of Black mothers. Overall, the differences in predictive performance between tree models and logistic regression were minimal. Conclusion: The present study demonstrated that classification trees can be used to identify high-risk subgroups of mothers who are at risk of LBW outcomes. Although these exploratory tree analyses revealed a number of distinctive variable interactions for each geographical area, the variable selection was similar across all seven regions. This study also demonstrated that classification trees did not outperform logistic regression models or vice versa; both approaches provided useful analyses of the data.

It is estimated that 20% of children in the USA are affected by at least one chronic disease. Although the burden of chronic conditions is greater for minority populations of children, research that has explored the prevalence and risk factors of chronic disease across different racial/ethnic groups is scarce. The aim of this study was to examine racial/ethnic disparities in the prevalence rates of common physical, chronic diseases in White, Black and Hispanic children; and assess the effect of several factors on the risk of having a chronic disease.Using the 2007 National Survey of Childrens Health, prevalence estimates were calculated for asthma, hearing impairment, visual impairment, joint/bone/muscle problems, brain injury and other illnesses for each racial/ethnic group. Multivariate logistic regression analyses were conducted to examine the effects of several risk factors on the risk of each of these health conditions.The findings show that the prevalence for all health conditions was significantly higher (25.3%) among Black children than White (19.8%) and Hispanic (18.6%) children. Furthermore, 19.5% of Black children have had or currently have asthma compared with 12.2% of White and Hispanic children. More Black and Hispanic children were covered by public health insurance, while 19% of Hispanic children were currently uninsured. White children whose mothers had a health problem were associated with asthma, hearing impairment, visual impairment and joint/bone/muscle problems, while Black children were more likely to report asthma and Hispanics reported visual impairment and joint/bone muscle problems. Hispanic children who were living in poverty or were uninsured were at lower risk for any chronic disease. Regardless of race/ethnicity, children living in a single-parent household were more likely to be associated with any health condition.This study provides evidence that racial/ethnic disparities in chronic physical conditions and health care among US children are extensive. It underscores that uninsured children who do not have access to the healthcare system are not being screened for chronic diseases, or are not obtaining medical care for such health problems. Healthcare providers should educate families about prevention measures and community services that might be able to assist them in improving the health of their children.

Objective: Quality improvement in the healthcare industry has evolved over the past few decades. In recent years, an increased focus on coordination of care efforts and the introduction of health information technology has been of high importance in improving the quality of patient care.Methods: In this review, we present a history of quality improvement efforts, discuss quality improvement in the healthcare industry, and examine quality improvement strategies with a focus on patient-centered care and information technology applications via patient registries.Results: Evidence shows that the key to quality improvement efforts in the healthcare industry is the coordination of patient care efforts through better data evaluation processes. By utilizing patient registries that can be linked to electronic health records (EHRs) and the Patient-Centered Medical Home (PCMH) framework, the quality of care provided to patients can be improved.Conclusions: While many healthcare organizations have quality improvement departments or teams in place that may be able to handle these types of efforts, it is important for organizations to be familiar with processes and frameworks that employees at different levels of the organization can be involved in. In order to ensure successful outcomes from quality improvement initiatives, managers and clinicians should work together in identifying problems and developing solutions.

OBJECTIVE While socioeconomic status (SES) and race/ethnicity are known predictors of breastfeeding practices, the added disparity caused by the rising rates of obesity among women of childbearing age remains untested. The purpose of this study was to examine differences in breastfeeding initiation and duration among black, white and Hispanic women of low and middle SES within the context of prepregnancy body mass index (BMI). METHODS Data from the Early Childhood Longitudinal Study-Birth Cohort were analyzed. Adjusted logistic regression models were built to examine differences in breastfeeding initiation and duration for the three racial/ethnic groups of low and middle SES. RESULTS Normal BMI Hispanic women of low SES demonstrated higher rates of breastfeeding initiation (74%) compared to other groups. Overweight/obese black women of low SES had lower rates of breastfeeding initiation. Overweight/obese Hispanic women of middle SES were significantly less likely to continue breastfeeding up to 4 months (OR: 0.65, 95% CI: 0.41, 0.98) compared to their white counterparts. Among women who initiated breastfeeding, overweight/obese white women of low SES had the highest rate of stopping within two months of giving birth (66.7%). CONCLUSIONS Examination of SES and racial/ethnic differences within the context of prepregnancy weight revealed specific groups with low rates of breastfeeding initiation and duration. Interventions tailored for these at-risk groups are needed to increase the overall proportion of mothers and infants who benefit from the positive health outcomes associated with breastfeeding.

INTRODUCTION Several studies suggest that obstructive sleep apnea (OSA) is a novel risk factor for cerebrovascular and cardiovascular disease. The Berlin Questionnaire (BQ) which is an inexpensive screen for OSA was used in the current study to examine potential associations between OSA (as measured by BQ), stroke and transient ischemic attack (TIA). METHODS During the 2008 calendar year 1,434 stroke and/or TIA patients were evaluated by the stroke response nurses at Inova Fairfax Hospital. Although the original sample size provided by the Inova staff was 1,433, not all of the patients responded to the BQ. Of the 1,433 cases, 113 were eliminated because they had non-unique responses. Of the remaining cases, 60 cases were left that provided complete responses to the BQ and had no missing values. STATISTICAL ANALYSIS We focused only on two outcomes, ischemic stroke and TIA. Demographic variables: Gender, race (white and non-white), and age. Descriptive statistics were performed for all variables. Univariate analyses were performed and associations between the dependent variables and the predictors were analyzed using exact tests. Logistic regression models were built to identify any potential risk factors for TIA and ischemic stroke. RESULTS In this sample, approximately 28.3% were females and 71.6% were male. The sample was composed of 65% white and 35% non-white patients. The average age of the entire sample was 65.6 years (SD= 13.2 years). Further, 23.3% were identified as having TIA, 55.5% had suffered ischemic stroke while 21.6% had other type of stroke or no diagnosis. Exact tests of significance failed to detect any significant associations between stroke type and OSA as measured by BQ. Furthermore, we did not find any significant associations or differences between age, race, gender, OSA and the outcome variables. Findings from the binary logistic regression models did not identify any significant predictors of TIA and ischemic stroke. CONCLUSIONS Although in this study we did not find a significant association between OSA, TIA and ischemic stroke, we recommend that this study be replicated with larger samples. An analysis of the cause of such low number of complete responses will follow as well.

Aims: This study examines predictors of neonatal and postneonatal mortality among infants born to black, white, and Hispanic women. Methods: Linked birth/infant death records from North Carolina for the period 1999–2007 were the source of data. Logistic regression models were constructed to estimate the effect of maternal and infant characteristics on neonatal (

In order to create an empirically derived parsimonious typology of physician financial incentives that will be useful for future research, we used data from the nationally representative 2004-2005 Community Tracking Study Physician Survey (N = 6,628). Linear regression analyses informed by economic theory were used to identify the combinations of incentives associated with an overall financial incentive to expand services to individual patients. The approach was validated using two nonparametric methods (CART analysis and data mining techniques) and by examining the relationship between the resulting typology and other measures of physician behavior including hours worked, visit volume, and specialty-adjusted income. Of the 6,628 physicians surveyed, approximately 25% (1,605) reported an overall incentive to increase services and 75% (5,023) reported either neutral incentives or incentives to decrease services. Men, who were approximately 75% of respondents, were slightly more likely to report incentives to increase services (P < 0.05). There were no differences in reported incentives according to specialty. We created two typologies (one with eleven categories and the other with a collapsed set of six categories) based on combinations of variables measuring ownership, base compensation methods, and financial incentives. The percentage with an overall incentive to increase services ranges from 6% for employed physicians compensated via fixed salary to 36.7% for owners in low capitation environments with either individual or practice level productivity incentives. The criterion validity of the typology was established by examining the relationship with adjusted physician income, hours worked, and visit volume, which showed generally consistent relationships in the expected direction. A parsimonious typology consisting of six mutually exclusive groups reasonably captures the continuum of incentives to increase service delivery experienced by physicians.