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Background: There is wide variation in rates of both “high-value” noninvasive cardiovascular testing that is recommended by guidelines and “low-value” testing that provides minimal patient benefit. Little is known about what makes hospitals successful in maximizing high-value and minimizing low-value testing. Methods: We used the Colorado all-payer claims database from 2016-2019 to identify hospital use of 1) high-value tests including assessment of left ventricular ejection fraction in patients hospitalized with acute myocardial infarction or incident heart failure, and 2) low-value tests including preoperative stress testing prior to low-risk surgery and routine stress testing within 2 years of coronary revascularization. We identified two “top-performing” hospitals with optimal testing rates (i.e., high-value testing rates in the highest quintile and low-value testing rates in the lowest quintile of hospitals in the state). We performed a qualitative study using in-depth, semi-structured interviews (n=19) with clinical and administrative staff (quality officers, lab directors, and ordering clinicians) at these two “top-performing” hospitals. We examined interview transcripts using directed content analysis to develop our codebook, and analyzed data using a matrix analysis to identify themes that may lead to optimal use of testing. Results: Four main themes were identified: 1) cardiologist involvement (either through screening programs or through direct contact with primary care clinicians); 2) open and direct communication between noninvasive cardiologists and ordering clinicians; 3) a strong sense of mission to deliver high quality and individualized patient care by clinical and administrative staff; and 4) an organizational and leadership culture of approachability and responsiveness to quality improvement initiatives. Conclusions: We identified four themes that characterized the experiences of two hospitals that have optimized use of noninvasive testing. Given the complexity of organizational change to improve care quality, these themes may help hospitals focus future efforts to improve value in testing.

Background As an evidence-based intervention to prevent maternal and neonatal morbidity and mortality, cesarean birth at rates of under 2%, which is the case in rural Southwest Ethiopia, is an unacceptable public health problem and represents an important disparity in use of this life-saving treatment compared to more developed regions. The objective of this study is to explore an innovative clinical solution (a mobile cesarean birth center) to low cesarean birth rates resulting from the Three Delays to emergency obstetric care in isolated and underserved regions of Ethiopia, and the world. Methods We will used mixed but primarily qualitative methods to explore and prepare the mobile cesarean birth center for subsequent implementation in communities in Bench Sheko and West Omo Zones. This will involve interviews and focus groups with key stakeholders and retreat settings for user-centered design activities. We will present stakeholders with a prototype surgical truck that will help them conceive of the cesarean birth center concept and discuss implementation issues related to staffing, supplies, referral patterns, pre- and post-operative care, and relationship to locations for vaginal birth. Discussion Completion of our study aims will allow us to describe participants’ perceptions about barriers and facilitators to cesarean birth and their attitudes regarding the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as a solution. It will also result in a specific, measurable, attainable, relevant, and timely (SMART) implementation blueprint(s), with implementation strategies defined, as well as recruitment plans identified. This will include the development of a logic model and process map, a timeline for implementation with strategies selected that will guide implementation, and additional adaptation/adjustment of the mobile center to ensure fit for the communities of interest.

Background As an evidence-based intervention to prevent maternal and neonatal morbidity and mortality, cesarean birth at rates of under 2%, which is the case in rural Southwest Ethiopia, is an unacceptable public health problem and represents an important disparity in the use of this life-saving treatment compared to more developed regions. The objective of this study is to explore an innovative clinical solution (a mobile cesarean birth center) to low cesarean birth rates resulting from the Three Delays to emergency obstetric care in isolated and underserved regions of Ethiopia, and the world. Methods We will use mixed but primarily qualitative methods to explore and prepare the mobile cesarean birth center for subsequent implementation in communities in Bench Sheko and West Omo Zones. This will involve interviews and focus groups with key stakeholders and retreat settings for user-centered design activities. We will present stakeholders with a prototype surgical truck that will help them conceive of the cesarean birth center concept and discuss implementation issues related to staffing, supplies, referral patterns, pre- and post-operative care, and relationship to locations for vaginal birth. Discussion Completion of our study aims will allow us to describe participants’ perceptions about barriers and facilitators to cesarean birth and their attitudes regarding the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as a solution. It will also result in a specific, measurable, attainable, relevant, and timely (SMART) implementation blueprint(s), with implementation strategies defined, as well as recruitment plans identified. This will include the development of a logic model and process map, a timeline for implementation with strategies selected that will guide implementation, and additional adaptation/adjustment of the mobile center to ensure fit for the communities of interest. Trial registration There is no healthcare intervention on human participants occurring as part of this research, so the study has not been registered.

Background: Attendance policies for common pediatric illnesses vary widely across childcare centers despite nationally published guidelines from the American Academy of Pediatrics. The COVID-19 pandemic has exacerbated this problem, leading to economic loss from parental work absenteeism and excess medicalization of children with common illnesses. We sought to understand barriers to and recommendations for adopting best practices on attendance policies at Early Head Start and Head Start (EHS/HS) childcare centers. Methods: We conducted 19 semistructured qualitative interviews: 9 with childcare leadership and 10 with parents from EHS/HS childcare centers across Colorado. Interviews took place between April and December 2021. Interviews were audio-recorded, transcribed, and coded in ATLAS.ti using a priori and emergent coding strategies. Descriptive content analysis was used to identify central themes, which were iteratively revised by 2 authors. Results: We derived 7 convergent and 4 divergent themes from leadership and parents addressing attendance decisions. Overlapping themes on barriers to adopting best practices included difficulty assessing symptom severity, limited medical provider understanding of childcare requirements, parent employment pressures, and the impact of the COVID-19 pandemic on exclusion durations. Leadership and parent perspectives differed on resources utilized, understanding of exclusionary symptoms, and role of medical providers in making attendance decisions. Overlapping themes on recommendations for best practices included access to registered nursing, concrete guidance on symptoms, and partnering with health departments. Leadership and parents agree that the COVID-19 pandemic led to increased guideline use in making attendance decisions and increased rates of excluding children from class for minor illness compared to prepandemic times. Both leadership and parents recommended consistency in exclusion practices, but leadership and parents identified medical providers and childcare leadership, respectively, as current sources of inconsistency. Salient findings showed variability in defining a fever by age from both leadership and parents. Conclusions: Coordination is needed between childcare centers, medical facilities, and health departments to improve attendance decisions for common pediatric illnesses. Future work should (1) develop concrete symptom guidance for parents with specific exclusion criteria (eg, via a decision aid), (2) assess the utility and feasibility of regular classroom access to registered nursing, and (3) advocate for employee protections to care for sick children at home.Funding: NoneDisclosures: None