4R Model Research Articles

Does the innovative 4R Care Delivery Model improve timing and sequencing of guideline recommended breast cancer care in safety net and non-safety net centers?

36 Background: Under the NCI ASCO Teams Project, we proposed a 4R Model which enables patient (pt) and care team to manage timing and sequencing of interdependent care with a novel multimodality 4R Care Project Plan (Trosman JOP ’16). 4R (Right Info/Care/Patient/Time) was previously piloted at 3 Chicago centers (Weldon ASCO ‘18). Methods: A new study tested impact of 4R on timing and sequencing of guideline recommended care at 4 safety net and 3 non safety net US centers. 4R Plans were provided to stage 0-III breast cancer pts Jan - Nov’18, 4R cohort. Clinical and pt reported data analyses compared 4R cohort (N = 105) to a historical control cohort of pts who received care pre-4R, Jan - Dec ’17 (N = 190). Results: We significantly improved 3 referral metrics and 4 referral completion metrics - receipt of care by pts who were referred (Table). After referrals, safety net pts had a significant increase in 4R vs control cohort in receiving genetic consult (72%, 21/29 vs. 42%, 18/43, p = .02) and dental visit (100%, 6/6 vs. 20%, 1/5, p = .02). They had lower increases in flu shot referrals (41%, 24/58, vs 36%, 37/104, NS) and dental referrals (10%, 6/58, vs 5%, 5/104, NS) than non safety net pts who had significant increases. Other metrics improved at a similar rate for safety net and non safety net pts. Conclusions: 4R markedly improved referral and receipt of interdependent guideline recommended breast cancer care. For most metrics safety net pts benefited from 4R at a similar or higher rate than non safety net pts, indicating that 4R may reduce care disparities. Low increases in referrals for safety net pts and in trial referral/enrollment for all pts must be addressed. An expansion of 4R across the US continues this work. [Table: see text]

Does the innovative 4R Cancer Care Delivery Model improve patient self-management in safety net and non-safety net centers?

172 Background: Under the NCI ASCO Teams Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R (Right Info/Care/Patient/Time) enables patient (pt) and care team to manage complex care continuum with an innovative multimodality 4R Care Project Plan. 4R includes a novel “project” feature – a graphical description of care interdependencies. 4R was previously piloted at 3 Chicago centers (Trosman ASCO ‘18). Methods: In this new study, we improved and tested 4R for impact on pSM at 4 safety net and 3 non safety net centers across the US. 4R Plans were provided to stage 0-III breast cancer pts Jan - Nov’18 (4R cohort). We surveyed the 4R cohort and a historical control cohort of pts who received care at same centers pre-4R, Jan - Dec ’17. Results: Survey response rates: 65%, 105/162 (4R cohort); 44%, 190/432 (control). 4R markedly improved 4 of 5 pSM metrics vs control (Table). Additional analyses showed that safety net pts had a significant increase in 4R vs control cohort in “seldom overwhelmed” (84%, 49/58 vs 64%, 67/104 respectively, p = .007), while non safety net pts had nonsignificant increase. Other metrics improved to a similar extent for safety net vs non safety net pts. Within the 4R cohort, 85% found 4R useful in organizing their care and 73% found 4R’s novel “project” feature useful in understanding care interdependencies. Safety net pts reported similar usefulness of 4R in organizing their care as non safety net pts (88%, 51/58 vs 81%, 38/47, NS) and similar usefulness of the “project’ feature in understanding care interdependencies as non safety net pts (74% vs. 72%, NS). Conclusions: 4R significantly improved patient self-management, but further efforts are needed to expand the benefit to as close to a 100% of pts as feasible. Safety net pts benefited from 4R at similar or higher rates than non safety net pts, indicating that 4R may reduce care disparities. An expansion of 4R across the US continues this work. [Table: see text]

Does the innovative 4R Cancer Care Delivery Model improve patient self-management in safety net and non-safety net centers?

6601 Background: Under the NCI ASCO Teams Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R (Right Info / Care / Patient / Time) enables patient (pt) and care team to manage complex care continuum with an innovative multimodality 4R Care Project Plan. 4R includes a novel “project” feature – a graphical description of care interdependencies. 4R was previously piloted at 3 Chicago centers (Trosman ASCO ‘18). Methods: In this new study, we improved and tested 4R for impact on pSM at 4 safety net and 3 non safety net centers across the US. 4R Plans were provided to stage 0-III breast cancer pts Jan - Nov’18 (4R cohort). We surveyed the 4R cohort and a historical control cohort of pts who received care at same centers pre-4R, Jan - Dec ’17. Results: Survey response rates: 65%, 105/162 (4R cohort); 44%, 190/432 (control). 4R markedly improved 4 of 5 pSM metrics vs control (Table). Additional analyses showed that safety net pts had a significant increase in 4R vs control cohort in “seldom overwhelmed” (84%, 49/58 vs 64%, 67/104 respectively, p = .007), while non safety net pts had nonsignificant increase. Other metrics improved to a similar extent for safety net vs non safety net pts. Within the 4R cohort, 85% found 4R useful in organizing their care and 73% found 4R’s novel “project” feature useful in understanding care interdependencies. Safety net pts reported similar usefulness of 4R in organizing their care as non safety net pts (88%, 51/58 vs 81%, 38/47, NS) and similar usefulness of the “project’ feature in understanding care interdependencies as non safety net pts (74% vs. 72%, NS). Conclusions: 4R significantly improved patient self-management, but further efforts are needed to expand the benefit to as close to a 100% of pts as feasible. Safety net pts benefited from 4R at similar or higher rates than non safety net pts, indicating that 4R may reduce care disparities. An expansion of 4R across the US continues this work. [Table: see text]

Does the innovative 4R Care Delivery Model improve timing and sequencing of guideline recommended breast cancer care in safety net and non-safety net centers?

562 Background: Under the NCI ASCO Teams Project, we proposed a 4R Model which enables patient (pt) and care team to manage timing and sequencing of interdependent care with a novel multimodality 4R Care Project Plan (Trosman JOP ’16). 4R (Right Info/Care/Patient/Time) was previously piloted at 3 Chicago centers (Weldon ASCO ‘18). Methods: A new study tested impact of 4R on timing and sequencing of guideline recommended care at 4 safety net and 3 non safety net US centers. 4R Plans were provided to stage 0-III breast cancer pts Jan-Nov’18, 4R cohort. Clinical and pt reported data analyses compared 4R cohort (N=105) to a historical control cohort of pts who received care pre-4R, Jan - Dec ’17 (N=190). Results: We significantly improved 3 referral metrics and 4 referral completion metrics - receipt of care by pts who were referred (Table). After referrals, safety net pts had a significant increase in 4R vs control cohort in receiving genetic consult (72%, 21/29 vs. 42%, 18/43, p=.02) and dental visit (100%, 6/6 vs. 20%, 1/5, p=.02). They had lower increases in flu shot referrals (41%, 24/58, vs 36%, 37/104, NS) and dental referrals (10%, 6/58, vs 5%, 5/104, NS) than non safety net pts who had significant increases. Other metrics improved at a similar rate for safety net and non safety net pts. Conclusions: 4R markedly improved referral and receipt of interdependent guideline recommended breast cancer care. For most metrics safety net pts benefited from 4R at a similar or higher rate than non safety net pts, indicating that 4R may reduce care disparities. Low increases in referrals for safety net pts and in trial referral/enrollment for all pts must be addressed. An expansion of 4R across the US continues this work. [Table: see text]

Results from a pilot of an innovative 4R Cancer Care Delivery Model: Impact on patient self-management.

224 Background: Under the “NCI ASCO Teams” Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R is Right Info / Care / Patient / Time. It enables patient (pt) and care team to manage interdependent care along the care continuum with an innovative multimodality personalized 4R Care Project Plan. We piloted 4R at 3 centers (academic, community, safety net) and assessed its impact on pSM. Methods: 4R Plans were administered to breast cancer pts stage 0-III Sep ’16 – Aug ’17 (4R cohort). We surveyed the 4R cohort and a comparable historical cohort of pts who received care pre-4R, Jun ’15 – May ’16 (control). We used simple frequencies and Fisher’s exact test in analyses. Results: Survey response rates: 68%, 185/271 (4R cohort); 47%, 241/410 (control). 75% of 4R respondents reported 4R Plans very useful / useful in overall understanding and organizing their care; 68% found 4R’s novel “project” component, very useful / useful in managing timing & sequencing of interdependent care. Care complexity impacted 4R usefulness: 67% of pts who received > 6 care services found 4R very useful / useful vs. 47% of pts who received < = 6 services, p = .01. Pts with lower care complexity suggested how to make 4R more useful to them, eg focus on endocrine therapy. Table compares pSM metrics in the 4R and control cohort. Care complexity was a significant factor of feeling overwhelmed for pts in the control cohort (51% of pts receiving > 6 care services felt overwhelmed vs. 31% of pts receiving < = 6 services, p = .02), but not a significant factor for pts in the 4R cohort (30% vs. 28%, p = .9). Conclusions: The 4R model significantly improved pt self-management in early breast cancer and reduced the impact of care complexity on pts, but provider factors of pSM need improvement. A 4R pilot at additional 12 cancer centers across the U.S. is in progress.[Table: see text]

Results from a pilot of an innovative 4R Cancer Care Delivery Model in early breast cancer: Impact on timing and sequencing of guideline recommended care.

281 Background: Under the “NCI ASCO Teams” Project, we proposed a 4R Model of teamwork and patient self-management (Trosman JOP ’16). 4R = Right Info / Care / Patient / Time. It enables patient and care team to manage timing / sequencing of interdependent care with an innovative multimodality personalized 4R Care Project Plan. We piloted 4R at 3 centers (academic, community, safety net) and assessed impact on timing / sequencing of guideline based care. Methods: 4R Plans were administered to breast cancer patients stage 0-III Sept ’17 – Aug ’17. Clinical data for 185 patients who received 4R (4R cohort) were compared with a historical control cohort of comparable patients who received care pre-4R, Jun ’16 – May ’17. We used simple frequencies and Fisher’s exact test in analyses. Results: We improved timing / sequencing of 7 guideline recommended metrics (Table). Significant improvements were shown for care lacking in the control cohort. 4R improved rate of patients receiving genetic test results and fertility in a timely manner. Neoadjuvant therapy rate doubled, but low sample size precluded statistical conclusions. However, timing / sequencing of care needed prior to neoadjuvant therapy (eg fertility, flu shot) were significantly improved. Conclusions: The 4R model significantly improved timing / sequencing of guideline recommended care in early breast cancer. An ongoing 4R pilot at 12 additional cancer centers across the U.S. is continuing to accrue patients and focusing on other guideline-recommended metrics. [Table: see text]

Community- Based Education: Tikrit University College of Medicine Experience. PART ONE: Concept and Rationale of Community –Based Education.

Tikrit University College of Medicine [TUCOM] is a community based college incorporating PBL and it is the first and only medical school in Iraq to introduce an innovative curriculum [1]. TUCOM/CBE programme constitutes a community based curriculum including an acceptable balance of community based activities through out of the educational settings [6 years of study] [2]. CBE is one of the most powerful and important teaching and learning strategy that allows students to study the sources, nature and magnitude of health and related problems [3]. In CBE, the community plays an important role in determining its own health needs, health problems and to overcome such problems. Furthermore, the students encouraged to learn from the community and assist them to attain their educational objectives [4]. Furthermore, well planning and well implementation of CBE are the important factors that driven the outcome of such innovative education method [5]. Recently, Worley [5] perform analysis of CBE and proposed a model for the key relationship in which student must be an active participant to facilitate high quality learning. He provided evidence for “the role of clinical, institutional, social and interpersonal relationships in providing a framework for describing quality in CBME curricula- the 4R model”

Results from a pilot of an innovative 4R Cancer Care Delivery Model in early breast cancer: Impact on timing and sequencing of guideline recommended care.

281Background: Under the “NCI ASCO Teams” Project, we proposed a 4R Model of teamwork and patient self-management (Trosman JOP ’16). 4R = Right Info / Care / Patient / Time. It enables patient and ...

How well is interdependent care managed across specialties in breast cancer? Metrics and pre-implementation data from the 4R in Oncology Project.

e12067 Background: The “NCI ASCO Teams” Project emphasized management of interdependent cancer care across specialties as crucial to teamwork, yet a considerable challenge (Taplin JOP 2015). Interdependent care requires well-managed timing and sequencing of events across specialties. We developed the 4R model (Right Information / Care / Patient / Time) to manage interdependent care and facilitate teamwork (Trosman JOP 2016). 4R is being implemented at 3 centers: academic, community and safety net. Pre-implementation, we identified guideline recommended interdependent care whose timing / sequencing is challenging, developed relevant adherence metrics and gathered current state data. Methods: Interviews with 42 clinicians across breast cancer (BC) specialties at the 3 sites, using theme analysis to identify challenging interdependent care. Guidelines and literature were used to define adherence metrics. Clinical data were reviewed for 216 Stage I-III patients at 3 sites to measure adherence. Results: We identified 7 BC interdependent care events for which timing / sequencing is a challenge - Table. Adherence ranged from 0% to 100%, and was < 50% for 5 of the 7 care events. Preoperative BRCA 1/2 results and neoadjuvant consult showed highest adherence, yet were most frequently noted as a challenge: interviewees reported substantial ad-hoc efforts applied to managing timeliness of these events. Conclusions: Identified challenges and adherence gaps support the need for the 4R implementation for systematic, consistent and timely delivery of interdependent care. Established metrics will allow pre / post 4R implementation comparison and may inform broader adoption of the 4R model. [Table: see text]

Written care plan and patient enablement: Pre-implementation data from the 4R in Oncology Project.

e18032 Background: The IOM ’11 and ’13 reports recommend a written care plan (WCP) at cancer diagnosisto enable teamwork and patient (pt) engagement. Standardized multimodality WCP is a key part of the 4R model of care planning and pt engagement proposed under “NCI ASCO Teams” Project (Trosman JOP 2016). 4R (Right Information / Care / Patient / Time) is under implementation at 3 centers: academic, community and safety net. As current state assessment prior to implementing 4R and standard multimodality WCP, we surveyed pts not impacted by 4R on care planning, enablement and whether they received any WCP. Methods: Survey of breast cancer stage I-III pts who received care at the three sites Jan ’15 - Mar ’16, prior to 4R. We used simple frequencies and Fisher’s exact test in analysis. Results: Survey response rate: 47%, 241/515. Gaps of > 30% were reported in 7 of 8 aspects of care planning and pt enablement - Table. A non standard WCP was received by 46% of pts. Receiving a WCP impacted whether pts were clear about care (85% with WCP vs 52% without, p < .0001), able to manage own care (79% with WCP vs 58% without, p = .0005) and overwhelmed (35% with WCP vs 49% without, p = .04). Care complexity was a significant factor for feeling overwhelmed by pts without WCP (49% of pts receiving > 6 care services felt overwhelmed vs. 30% of pts receiving < = 6 services, p = .04), but not a significant factor in pts with WCP (45% vs 41%, p = .7). More pts with WCP reported well managed care by providers than pts without WCP (77%, 62%, P = .02). Conclusions: Serious gaps found in care planning and pt enablement at our sites support the need for 4R implementation. Even pre-4R, non standard WCPs improve pt understanding of care and ability to manage it, and reduce the impact of care complexity on pts. Providers using WCP appear to also coordinate care, but WCP itself may be an important factor of patient enablement. [Table: see text]

How well is interdependent care managed across specialties in breast cancer? Metrics and pre-implementation data from the 4R in Oncology Project.

171 Background: The “NCI ASCO Teams” Project emphasized management of interdependent cancer care across specialties as crucial to teamwork, yet a considerable challenge (Taplin JOP 2015). Interdependent care requires well-managed timing and sequencing of events across specialties. We developed the 4R model (Right Information / Care / Patient / Time) to manage interdependent care and facilitate teamwork (Trosman JOP 2016). 4R is being implemented at 3 centers: academic, community and safety net. Pre-implementation, we identified guideline recommended interdependent care whose timing / sequencing is challenging, developed relevant adherence metrics and gathered current state data. Methods: Interviews with 42 clinicians across breast cancer (BC) specialties at the 3 sites, using theme analysis to identify challenging interdependent care. Guidelines and literature were used to define adherence metrics. Clinical data were reviewed for 162 Stage I-III patients at 3 sites to measure adherence. Results: We identified 7 interdependent BC care events for which timing / sequencing is a challenge - Table. Adherence ranged from 0% to 100%, and was < = 50% for 6 of the 7 care events. Preoperative BRCA 1/2 results and neoadjuvant consult showed highest adherence, yet were most frequently noted as a challenge: interviewees reported substantial ad-hoc efforts applied to managing timeliness of these events. Conclusions: Identified challenges and adherence gaps support the need for the 4R implementation for systematic, consistent and timely delivery of interdependent care. Established metrics will allow pre / post 4R implementation comparison and may inform broader adoption of the 4R model. [Table: see text]

Written care plan and patient enablement: Pre-implementation data from the 4R in Oncology Project.

55 Background: The IOM ’11 and ’13 reports recommend a written care plan (WCP) at cancer diagnosisto enable teamwork and patient (pt) engagement. Standardized multimodality WCP is a key part of the 4R model of care planning and pt engagement proposed under “NCI ASCO Teams” Project (Trosman JOP 2016). 4R (Right Information / Care / Patient / Time) is under implementation at three centers: academic, community and safety net. As current state assessment prior to implementing 4R and standard multimodality WCP, we surveyed pts not impacted by 4R on care planning, enablement and whether they received any WCP. Methods: Survey of breast cancer stage I-III pts who received care at the three sites Jan ’15 - Mar ’16, prior to 4R. We used simple frequencies and Fisher’s exact test in analysis. Results: Survey response rate: 48%, 197/410. Gaps of > 30% were reported in 6 of 8 aspects of care planning and pt enablement - Table. A non standard WCP was received by 45% of pts. Receiving a WCP impacted whether pts were clear about care (90% with WCP vs 50% without, p < .0001), able to manage own care (81% with WCP vs 59% without, p = .001) and overwhelmed (49% with WCP vs 68% without, p = .006). Care complexity was a significant factor for feeling overwhelmed by pts without WCP (60% of pts receiving > 6 care services felt overwhelmed vs. 39% of pts receiving < = 6 services, p = .04), but not a significant factor in pts with WCP (38% vs 44%, p = .7). More pts with WCP reported well managed care by providers than pts without WCP (78%, 64%, P = .04). Conclusions: Serious gaps found in care planning and pt enablement at our sites support the need for 4R implementation. Even pre-4R, non standard WCPs improve pt understanding of care and ability to manage it, and reduce the impact of care complexity on pts. Providers using WCP appear to also coordinate care, but WCP itself may be an important factor of patient enablement. [Table: see text]

Content Fusion in Traditional and New Media: A Conceptual Study

The Elaboration Likelihood Model is the motivation for this study, which puts forward various peripheral routes that are used by an advertiser for not only making the advertisement attractive but also creating an impulse among the audience. The article details various possible dimensions of content that are applicable in an advertisement. Through rigorous literature review, the article identifies various theories and models that have led to the successful adaptation and implementation of each variant of content. The discussion at the end of the article presents a 4R model of content generation that will enable advertisers to make corrective decisions for advertisement in traditional and new media channels.

An Accidental Tourist Finds Her Way In The Dangerous Land Of Serious Illness

A survivor of four cancer diagnoses calls for policies that support the increased responsibilities patients and families now must fulfill to achieve the best outcomes from their health care.

Docking Flexible Peptide to Flexible Protein by Molecular Dynamics Using Two Implicit-Solvent Models: An Evaluation in Protein Kinase and Phosphatase Systems

Reliable prediction of protein-ligand docking pose requires proper account of induced fit effects. Treating both the ligand and the protein as flexible molecules is still challenging because many degrees of freedom are involved. Peptides are one type of ligand that are particularly difficult to study because of their extreme flexibility. In this study, we tested a molecular dynamics-based simulated-annealing cycling protocol in docking peptides to four protein kinases and two phosphatases using two implicit-solvent models: a distance-dependent dielectric model (epsilon(r) = 4r) and a version of the Generalized Born model termed GBMV. We found that the simpler epsilon(r) = 4r model identified docking pose better than the more expensive GBMV model. In addition, rescoring structures obtained from one implicit-solvent model with the other identified good docking poses for all six systems studied. Including protein energy in scoring also improved results.

A study of vibrational dynamics of poly (a-n-butyl-b-l-aspartate) (panbla)

Poly(-N-butyl--L-aspartate) (PANBLA) is nylon-3 derivative in which an alcoxycarbonyl group has been stereoregularly attached to -carbon of the repeating unit. Like poly(-isobutyl--L-aspartate) (PAIBLA) exists in two helical forms, namely hexagonal form (13/4 helix) and tetragonal form (4/1 helix), were characterized by X-ray diffraction. The hexagonal form appears to be poorly crystalline and it could not be obtained well oriented. On the other hand tetragonal form turns to be highly crystalline. Both molecular mechanics calculations and the linked-atom least square (LALS) methodology using X-ray diffraction data have revealed that an antiparallel packing of 13/4 helices with a right handed (2R) scheme of hydrogen bonds is most favourable for hexagonal form of PANBLA. Regarding tetragonal form the above techniques favour a parallel arrangement of 4/1 helices according to right handed 4R model. IR dichroism studies also support the above results. Although the vibrational dynamics of both forms of PAIBLA has been studied, no such study has been performed for PANBLA. In the present communication the vibrational dynamics of PANBLA in tetragonal form (4/1 helix) has been studied through the dispersion of normal modes. The effect of side chain nature on the dynamical behaviour has also been analyzed. Apart from detailed assignments of modes, various characteristic features of dispersion curves have been explained as arising due to internal symmetry in energy momentum space. Finally, the density of states has been used to calculate heat capacity of this polymer.