Engage, resist, transform: the essential role of community practice

Training the Future: Protecting the Scope and Diversity of Oral and Maxillofacial Surgery

The management of chronic hepatitis B patients is not well characterized in real-world practice. We compared baseline characteristics of CHB patients on entecavir, the frequency of on-treatment monitoring, and the effectiveness of ETV treatment between academic and community practices. Treatment-naïve CHB patients ≥18years old, treated with ETV for ≥12months from 2005 to 2013, in 26 community and academic practices throughout the USA were retrospectively evaluated. Of 841 patients enrolled, 658 (65% male, 83% Asian, median age 47, 9% with cirrhosis) met inclusion criteria. Half of the patients (52%) were from community practices. A lower percentage of patients in community practices had cirrhosis or liver cancer (5 vs. 14%). Community practices more often treated patients with baseline ALT < 2 × ULN. Over a median follow-up of 4years, community practices were more likely to discontinue ETV with less frequent laboratory monitoring compared to academic practices. The 5-year cumulative probability of ALT normalization was greater among patients treated in community practices (70 vs. 50%, p < 0.001), but the 5-year cumulative probability of undetectable HBV DNA was lower (45 vs. 70%, p < 0.001) than those treated in academic practices. Academic practices saw CHB patients with more advanced liver disease, more often followed AASLD guidelines, and monitored patients on ETV treatment more frequently than community practices. While patients in community practices were less likely to achieve undetectable HBV DNA and more likely to achieve ALT normalization, the rates of HBeAg loss and seroconversion as well as HBsAg loss were similar.

Here is the only book that gives you a comparison of model frameworks and a critique of multiple perspectives. Community Practice: Conceptual Models (along with its companion volume, Community Practice: Models in Action) illustrates the diverse ways that community practice is conceived and delineates both the central and subtle differences among models to guide community assessment, action planning, and practice. By knitting together the complex ideas from the social sciences and community practice, this book shows how to combine these ideas to improve teaching, practice, analysis, and research for social work faculty; social work students; practitioners in community work, administration, and social planning; and faculty of related disciplines.The scope of Community Practice: Conceptual Models is broad, providing the first historical report on model development and implementation since 1965. Its chapters present diverse views on community practice approaches and provide the compilation, critique, and analysis of current models --while illustrating how these approaches developed over time. Included is Rothman’s long-awaited revision and elaboration of his 1970s classic, three models conceptual framework. Other vital topics you learn about include: collaborative community development social planning, reform movements, and social action ecological theory in community practice a feminist response and critique to Rothman’s approaches to community intervention a comparison of community practice in the U.S. and U.K., with an emphasis on nonracist practice and community-based service developmentCommunity Practice: Conceptual Models offers challenges and indicates directions for practice, theory elaboration, testing, and research and shows community practice in relation to characteristics such as goals and desired outcomes, change strategies, targets of change, primary constituencies, and focus or scope of concern. This book provides the strongest perspectives on community practice to help you improve your practice, assessments, action plans, and research.

In his article, Thomas Weil notes correctly that attracting physicians to certain historically underserved inner-city and rural communities appears to be an intractable social and public policy dilemma. He suggests that this problem may be amenable to solution if health networks interested in capitalizing on those markets provide leadership in building systems of care in those communities. He posits that the existence of such systems might attract physicians to establish practices in underserved communities, provided that the networks also provide financial incentives. Implicit in Weil's thinking is that physicians will be unlikely to establish practices in the target communities, unless viable systems of care are in place. On this point, we believe he is correct. At issue, however, is whether establishing systems of care in historically underserved urban and rural communities, while necessary, will prove sufficient to attract physicians to those communities. Weil suggests that over the years policymakers have implemented three specific strategies to address this problem: (1) increase the number of U.S. medical school graduates; (2) allow graduates of non-U.S. medical schools to enter the country for residency training and practice; and (3) establish the NHSC. He concludes that individually and collectively, those policies failed to accomplish the stated goal. Weil's analysis is only partially true. While there is no question that the policies he describes did not solve the problem of geographic maldistribution of physicians, it is important to recognize that only the last one of the three was intended to do so. With the limited space available for this commentary, we cannot review in detail the history of the policies referenced, but we would assert that increasing the number of U.S. medical school graduates and allowing graduates of non-U.S. medical schools to enter residency programs in this country were not policy initiatives intended primarily to provide physicians for inner-city and rural communities. It is therefore not surprising that the programs established to implement these policies did not resolve the problem of medically underserved communities. By contrast, the NHSC was established specifically to fill this need. However, this program has never been funded by the federal government at the level required to place physicians in all of the communities of need. Moreover, the NHSC has been plagued over the years by congressionally mandated changes in the program's goals and objectives. Regardless of how one interprets the relevant policymaking events of the past quarter century, the fact remains that certain urban and rural communities in which residents lack ready access to physician services continue to exist. If one hopes to create systems of care to remedy this situation, one must first identify and understand the reasons that more physicians have not chosen to establish permanent practices in those communities. Decisive Factors We believe that three major factors determine whether an individual physician is likely to establish a practice in an urban innercity or rural community that has historically been without a physician: 1. the physician's specialty; 2. the economics of medical practice in the community; and 3. the living conditions in most medically underserved communities in relation to the legitimate lifestyle aspirations of most physicians. Let us consider each factor in turn. First, the greatest need in medically underserved communities is for physicians who practice primary care medicine. Accordingly, physicians trained as family physicians, general internists, or general pediatricians (the kinds of physicians who generally practice primary care medicine) are virtually the only physicians likely to consider practicing in these communities. Furthermore, given the broad range of primary care services (e.g., routine obstetrical care) that physicians must be prepared to provide in underserved areas, family medicine physicians are much more likely than general internists or general pediatricians to succeed in relatively isolated practice (particularly in rural communities). …

Purpose: Clostridium difficile infection has been associated with several types of antibiotics, including fluoroquinolones. The incidence of C difficile infection related to the nonabsorbed antibiotic rifaximin is unknown. Rifaximin is approved for the treatment of travelers' diarrhea caused by noninvasive strains of Escherichia coli and is being investigated for the treatment of hepatic encephalopathy (HE). This retrospective study evaluated the incidence of C difficile infection in patients with cirrhosis who received rifaximin for treatment of HE in community and university gastroenterology practices. Methods: Medical charts for all patients diagnosed with cirrhosis who received oral rifaximin for the treatment of HE between January 2004 and May 2008 were reviewed; patients had been treated at 1 university practice and 3 community practices. Patients who developed diarrhea (>6 bowel movements/d) during treatment with rifaximin were included in the analyses. Stool samples had been analyzed by cytotoxin assay testing to determine if diarrheal symptoms (ie, markedly increased stool frequency and decreased stool viscosity) were due to C difficile infection. Results: Analyses included 212 patients with cirrhosis who received rifaximin for the treatment of HE. The mean dose of rifaximin was 1055 mg/d (range, 600–1600 mg/d) for a mean duration of 250 days (range, 180–385 d). Of the 212 patients who received rifaximin, 155 were treated in a university practice and 57 were treated in community practices; 97% of patients had been diagnosed with grade 2 or 3 HE. Eighteen patients (8%) developed diarrhea during rifaximin treatment; 13 were male and 5 were female (mean age, 52 y). Twelve of the 18 patients (67%) who developed diarrhea had received treatment in the university setting and the remaining 6 (33%) had received treatment in community practices. Stool cytotoxin test results were negative for C difficile in all 18 of these patients. Diarrheal symptoms resolved in all cases with standard therapy administered after stool analyses had excluded infection. Conclusion: These findings suggest that long-term treatment with rifaximin was not associated with the development of C difficile infection in patients with cirrhosis who received rifaximin for treatment of HE. Therefore, rifaximin does not appear to increase risk of C difficile infection. Further investigations of the incidence of C difficile infection in patients who receive rifaximin are warranted.

e15594 Background: The age of life expectancy in the United States is 78.9 years of age and continues to increase with the help of public health initiatives along with scientific and technological breakthroughs in medicine. However, colorectal cancer screening guidelines for those over age 75 are individualized and not recommended in those over 85. We aimed to investigate the demographic differences of colorectal cancer by sex and race in patients aged 75 vs those aged 50-75, in the community and academic practice. Methods: Data were analyzed from the National Cancer Database between 2010-2014. Results were divided into two categories (50-75 year old, &gt;75 year old) and included number of patients, sex and race. Patient characteristics were compared with Mann-Whitney U, Pearson’s Chi-square, and the Kaplan-Meier method. Data was further analyzed comparing sex and race using chi-square analysis. Results: 167, 059 patients were included in the analysis. 49,551 cases identified in the academic practice and 117, 508 in the community practice. In the academic practice, group A (age 50-75), 57.3% (20,810) were male vs. 42.7% (15,488) female. In community practice, group A, 56.5% (43, 915) were male vs 43.5% (33, 742) female (p-value &lt;0.05). Conversely, in the academic practice-group B (age &gt;75), 46.2% (6127) were male vs 53.8% (7126) female. In the community practice-group B, 55.3% (22,027) were female vs 44.7% (17,824) male; (p-value &lt;0.05).For Black patients, decline in cases is seen by age. In academic practice, 16.5% of cases were aged 50-75 vs. 11.9% over age 75. In community practice; 11.5% were aged 50-75 vs. 6.5%, p&lt;0.05). Comparatively there was an increase in cases in White patients by age diagnosed in academic and community practice; 77.5% vs 84.2 in 50-75 and 84.8 vs. 90.9% in &gt;75, respectively (p&lt;0.05). Conclusions: Women age &gt;75 comprised a statistically significant greater proportion of colorectal cancer cases compared to men age &gt;75 in both the community and academic setting. Contrary to established reports detailing higher incidence rates in males aged 50-75. Furthermore, there is an increase in cases with age in White patients in comparison with a decrease in cases in Black patients. These findings may suggest the need for a more universal and less individualized approach for individuals over age 75.

Editorial Policy

Editorial Policy

Background: The World Health Organization’s recommendation for infant feeding is exclusive breastfeeding for the first six months followed by semi-solid food. The purpose of the study is to analyse determinant factors related to low exclusive breastfeeding’s practice in the urban slum community of Surabaya. Methods: This is a qualitative study with a case study in one of the urban slum areas of Surabaya. Data were collected by in-depth interviews and focus group discussion (FGD) with mothers, interviews with key-informants; posyandu cadre and the community leader for validation. Ishikawa diagram tool was used to identify and categorize determinant factors. The Urgency, Seriousness, Growth (USG) method was used to prioritize factors.Results: There are 9 determinant factors categorized into 5 categories; two ‘main’ factors, three ‘method’ factors, two ‘material’ factors, one ‘money’ factor and one ‘environment’ factor. The one factor that was considered the priority to be resolved is from the environment factor that is local beliefs of breastfeeding and expressed breast milk.Discussions and Conclusions: Education of mothers about expressed breast milk is an initial step to overcome low exclusive breastfeeding’s practice in this community due to mothers having to work outside the house. There is also a need for strengthening support groups so working mothers continuously exclusive breastfeed and provide optimal nutrition for infants.

ABSTRACTPrescribing in acute healthcare settings is a complex interprofessional process with a high incidence of medication errors. Opportunities exist to improve prescribing learning through collaborative practice. This qualitative interview-based study aimed to investigate the development of junior doctors’ prescribing capacity and how pharmacists contribute interprofessionally to this development and the prescribing practices of a medical community. The setting for this study was a large teaching hospital in Australia where ethical approval was gained before commencing the study. A constructionist approach was adopted and the interviews were held with a purposive sample of 34 participants including junior doctors (n = 11), clinical supervisors (medical; n = 10), and pharmacists (n = 13). Informed by workplace learning theory, interview data were thematically analysed. Three key themes related to pharmacists’ contributions to prescribing practices emerged: building prescribing capacities of junior doctors through guidance and instruction; sustaining safe prescribing practices of the community in response to junior doctor rotations; and transforming prescribing practices of the community through workplace learning facilitation and team integration. These findings emphasize the important contributions made by pharmacists to building junior doctors’ prescribing capacities that also assist in transforming the practices of that community. These findings suggest that rather than developing more conventional education programs for prescribing, further consideration should be given to interprofessional collaboration in everyday activities and interactions as a means to promote both effective learning for individuals and advancing the enactment of effective prescribing practice.

Interpersonal Social Work Skills for Community Practice

Commentary: Observations on the University of California at Irvine Experience: Common Ground With Community Practices

Treatment Outcomes with Hypomethylating Agents and Venetoclax for AML in the Community Compared to an Academic Setting

Community knowledge, attitudes and practices towards environmental conservation: Assessing influencing factors in Jor Bay Lombok Indonesia

1538 Background: Although many tertiary cancer centers offer access to myriad research protocols, the majority of patients nevertheless receive treatment at community practices. We sought to examine the barriers that hamper clinical collaboration between tertiary and community practice environments in Southern California. Methods: A 31-item survey was distributed to community and tertiary oncologists using REDCap, a browser-based electronic data capture system. Survey questions assessed the following attributes: demographics and features of clinical practice, referral patterns, availability and knowledge pertaining to clinical trials, strategies for knowledge acquisition, and integration of community and tertiary practices. Results: The survey was distributed to 98 oncologists, 85 (87%) of whom completed it in full. The most common institutional affiliations were City of Hope Comprehensive Cancer Center (58%), University of California, Los Angeles (10%), and Cedars Sinai Medical Center (8%). In total, 52 (61%) respondents were community practitioners and 33 (38%) were tertiary oncologists. A majority (56%) of community oncologists defined themselves as general oncologists whereas almost all (97%) tertiary oncologists reported a subspecialty. Clinical trial availability was the most common reason for pt referrals to tertiary centers (73%). The most frequent barrier to tertiary referral was financial considerations (59%). Clinical trials were offered by 97% of tertiary practitioners as compared to 67% of community oncologists (p = 0.001). Of note, while a majority of tertiary center providers (52%) described the primary value of community practices to be a source of referrals for clinical trials, most community oncologists (82%) reported only a minimal-to-moderate understanding of clinical trials available at regional tertiary centers. Conclusions: Community oncologists refer patients to tertiary centers primarily with the intent of clinical trial enrollment; however, significant gaps exist in their knowledge of trial availability. Our results identify the need for enhanced communication and collaboration between community and tertiary providers to expand patients’ access to clinical trials.