rofacial clefts-cleft lip with or without cleft palate and cleft palate only-are among the most common congenital anomalies in the United States and the world. 1,2 Children born with orofacial clefts may experience significant long-term health sequelae, including dental and speech pathologies and stigmatizing appearance differences, even after reconstructive surgery. 3,4 Ample research has explored the multifactorial etiology of orofacial clefts, including disparities in incidence across populations. [5][6][7] Genome-wide association studies have identified multiple populationspecific genetic loci that may predispose individuals to nonsyndromic orofacial clefts. [8][9][10][11][12] The risks of cleft lip with or without cleft palate and cleft palate only also vary across different racial/ethnic groups, with lowest frequencies in African-derived populations and highest in Asians, in general. 6 Maternal factors (such as exposure to tobacco smoke, alcohol, and anticonvulsants) and nutritional deficiencies
Objectives
We developed and piloted a process for sharing guideline-based clinical decision support (CDS) across institutions, using health screening of newly arrived refugees as a case example.
Materials and Methods
We developed CDS to support care of newly arrived refugees through a systematic process including a needs assessment, a 2-phase cognitive task analysis, structured preimplementation testing, local implementation, and staged dissemination. We sought consensus from prospective users on CDS scope, applicable content, basic supported workflows, and final structure. We documented processes and developed sharable artifacts from each phase of development. We publically shared CDS artifacts through online dissemination platforms. We collected feedback and implementation data from implementation sites.
Results
Responses from 19 organizations demonstrated a need for improved CDS for newly arrived refugee patients. A guided multicenter workflow analysis identified 2 main workflows used by organizations that would need to be supported by shared CDS. We developed CDS through an iterative design process, which was successfully disseminated to other sites using online dissemination repositories. Implementation sites had a small-to-modest analyst time commitment but reported a good match between CDS and workflow.
Conclusion
Sharing of CDS requires overcoming technical and workflow barriers. We used a guided multicenter workflow analysis and online dissemination repositories to create flexible CDS that has been adapted at 3 sites. Organizations looking to develop sharable CDS should consider evaluating the workflows of multiple institutions and collecting feedback on scope, design, and content in order to make a more generalizable product.
Children in immigrant families are less likely to screen positive with the Children with Special Health Care Needs Screener (CSHCN-S). This may indicate that children in immigrant families are healthier or require fewer health services than non-immigrant peers. Alternatively, the screener may under-identify special healthcare needs in this population. Using the 2011-2012 National Survey of Children's Health, we examined the prevalence of a positive CSHCN-S among children from first, second, and third generation households with an equivalent number of currently diagnosed chronic conditions (0, 1, 2+). Multivariate analyses controlled for sociodemographic factors. Among children with an equivalent number of chronic conditions, fewer children from first and second generation households screened positive with the CSHCN-S relative to children from third generation households. This association remained after adjusting for covariates. The CSHCN Screener may under-identify children from immigrant households, allowing for missed opportunities to allocate health resources.
Background Access to surgical care is a pressing challenge, particularly for vulnerable populations. Informal and formal community health workers (CHWs), including lay people, increasingly function in pivotal roles in primary care, however, remain disconnected from surgical care in most environments. This study examined the degree to which CHW understanding of surgical conditions could be improved through the use of a pictorially based manual. Methods A manual and associated situational problem-solving questionnaire instrument were developed and contextualized through focus groups in Central America. A baseline assessment was obtained. In the program implementation, cohorts of formal and informal CHWs were introduced and trained to use the manual through a short curriculum. Assessment was repeated in program implementation, first with access to relevant manual content only, and then after the teaching session. Participants were also surveyed about manual scheme, usability, and utility. Results A total of 100 subjects (67% female) participated in baseline assessment, and 403 subjects (68% female) were assessed through the program implementation. Baseline problem-solving averaged 11.8 (SD 2.46) out of a possible 20 points. Mean score increased to 15.4 (SD 3.10) when participants had access to relevant surgical manual content and again to 15.9 (SD 3.09, p \ 0.0001) following participation with an instructive curriculum. Participant score while utilizing the manual correlated with amount of education completed (r = 0.26), but baseline score did not. High readability 389 (96%) and high self-reported willingness for use 398 (96%) were noted. Conclusion Baseline familiarity with surgically treatable conditions appears modest among rural Central American populations, and improves with access to a contextualized, pictorial manual focused on recognizing and appropriately referring surgical conditions.Please note that this study has eight authors. The international, multisite nature of this study, with core involvement of surgeons, statisticians, and global health researchers from several sites were included in all key phases of the study. Each meets WJS criteria as an author.
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