Arizona Experience Research Articles

Making of home: Transportation mobility and well-being among Tucson refugees

The article is based on a multidisciplinary research project that aimed to study mobility challenges that refugees in Tucson, Arizona experience after their resettlement. Using qualitative and quantitative data collected from interviews and survey data, we argue that mobility shapes the ways refugees foster social connections, attain employment and access educational opportunities. Accordingly, barriers to mobility negatively impact refugees' perception of well-being in post resettlement. However, these challenges are not experienced unevenly. Nor are refugees passive subjects who lack agency in overcoming various barriers they experience. The study also reveals the resilience of the refugee community in navigating the intersectional challenges they confront related to their mobility. We hope that the implications of this study can inform various stakeholders to better support refugees in navigating existing mobility and transportation challenges and to promote policy change that can increase better spatial mobility for all Tucson community members.

Prevalence of marijuana use among trauma patients before and after legalization of medical marijuana: The Arizona experience

Background In recent years, marijuana has become legal for use in many states, for either medicinal or recreational purposes. Objective: The primary objective is to determine if legalization of medical marijuana is associated with an increased use among trauma patients. Methods: Prospective observational study included three periods; (pre-legalization; period 1); legal to grow for medicinal purposes but no dispensaries open (period 2); and legal to purchase medicinal marijuana in a dispensary (period 3). The study included all adult trauma patients presenting to an urban level I trauma center in Phoenix, AZ. The prevalence of use (as defined by positive urine drug screen or self-reporting) in each time period was determined and compared using two sample tests of proportion. Confidence intervals for prevalence (self-reporting only) were compared with published age matched data from the same geographical region of the general population. Results: The prevalence of marijuana use increased significantly from pre-legalization (period 1) to post legalization (periods 2 and 3), but there was no significant change between the two post legalization periods. After controlling for age and sex, the odds of being marijuana positive post-legalization vs. pre-legalization was 1.36, p = 0.006 95%CI [1.09–1.7]. Overall, the prevalence of marijuana among trauma patients was nearly four-fold higher than the population as a whole in the same geographic region. Patients who use marijuana are more likely to use cocaine or amphetamine (OR 2.31; 95% CI 1.86–2.89) or had an ethanol level above 80 mg/dL (OR 1.57; 95% CI 1.32–1.87). Conclusion: The legalization of medicinal marijuana is associated with significantly increased prevalence among trauma patients. It appears that legalization, rather than the convenience of dispensaries, is associated with an increase in use.

Linear Accelerator-based Single and Multifractional Stereotactic Radiosurgery (SRS) for Resected Brain Metastases: The Mayo Clinic Arizona Experience

Linear Accelerator-based Single and Multifractional Stereotactic Radiosurgery (SRS) for Resected Brain Metastases: The Mayo Clinic Arizona Experience

Establishing voluntary certification of community health workers in Arizona: a policy case study of building a unified workforce

BackgroundCommunity health workers (CHWs) are widely recognized as essential to addressing disparities in health care delivery and outcomes in US vulnerable populations. In the state of Arizona, the sustainability of the workforce is threatened by low wages, poor job security, and limited opportunities for training and advancement within the profession. CHW voluntary certification offers an avenue to increase the recognition, compensation, training, and standardization of the workforce. However, passing voluntary certification legislation in an anti-regulatory state such as Arizona posed a major challenge that required a robust advocacy effort.Case presentationIn this article, we describe the process of unifying the two major CHW workforces in Arizona, promotoras de salud in US-Mexico border communities and community health representatives (CHRs) serving American Indian communities. Differences in the origins, financing, and even language of the population-served contributed to historically divergent interests between CHRs and promotoras. In order to move forward as a collective workforce, it was imperative to integrate the perspectives of CHRs, who have a regular funding stream and work closely through the Indian Health Services, with those of promotoras, who are more likely to be grant-funded in community-based efforts. As a unified workforce, CHWs were better positioned to gain advocacy support from key health care providers and health insurance companies with policy influence. We seek to elucidate the lessons learned in our process that may be relevant to CHWs representing diverse communities across the US and internationally.ConclusionsLegislated voluntary certification provides a pathway for further professionalization of the CHW workforce by establishing a standard definition and set of core competencies. Voluntary certification also provides guidance to organizations in developing appropriate training and job activities, as well as ongoing professional development opportunities. In developing certification with CHWs representing different populations, and in particular Tribal Nations, it is essential to assure that the CHW definition is in alignment with all groups and that the scope of practice reflects CHW roles in both clinic and community-based settings. The Arizona experience underscores the benefits of a flexible approach that leverages existing strengths in organizations and the population served.

Optimal surgical intervention for achalasia: laparoscopic or robotic approach.

Laparoscopic esophageal myotomy is the standard surgical intervention for achalasia. Compared to standard laparoscopic techniques, use of the robot has theoretical advantages of improved visualization and dexterity. We evaluated the University of Arizona's experience with the two alternatives to compare outcomes. Patients who underwent either laparoscopic or robot-assisted myotomy were identified from a retrospective database from 1/1/2006 to 12/31/2015. Patient demographics, prior treatment, intra-operative complications, operative time, post-operative length of stay and complications, and long-term results were compared between the two groups. We identified 35 laparoscopic and 37 robot-assisted Heller myotomies performed by multiple surgeons. Patient demographics were similar between the two groups with no statistical difference in age, gender, previous operations, pre-operative Botox or dilation treatment, or pre-op Eckardt score. In univariate analysis, the patients with the robotic procedure received a longer myotomy (5.85cm vs. 5.56cm for esophageal and 2.92cm vs. 2.68cm for gastric) and had a lower post-operative Eckardt score (0.51 vs. 1.09). A trend toward lower incidence of recurrent achalasia symptoms was found in the robotic group (0 patient vs. 4 patients) compared with those who had laparoscopic surgery (p < 0.05). Multivariate analysis showed that a longer gastric myotomy was associated with a lower recurrence rate (p = 0.0002). Both laparoscopic and robot-assisted Heller myotomy can provide definitive treatment of achalasia with good results and few complications. The mechanical advantage provided by the robotic approach may improve outcomes by providing a more complete myotomy and durable long-term result.

Mixing Electronic and Non-Electronic Health Records Limits Physician Productivity - The Arizona Experience

Objective: Estimate the effects of electronic health records (EHRs) on physician productivity in day-to-day practice by including the combinations of EHRs with nonelectronic records that typify current practice. Study Design: Cross section of 7,725 physicians representing 70% of physicians who provided patient care in 2012-2014 in Arizona. The sample was divided into office based (OFB) and non-office based (NOFB) physicians. Methods: Information from licensing applications was combined with a survey of the uses of electronic and nonelectronic health records. Productivity was measured as patient visits per hour in a typical work week. The effects of EHRs on productivity were estimated from a regression model that compared users to non-users and an model that included combinations of electronic, paper and scanned records. The results are compared to the physicians’ rankings of the effect of each combination of records on staff and physician productivity. Results: The productivity of OFB physicians is increased by the use of e-prescribing (+17.4%, p<0.001) and intervention reminders (+5.7%, p=0.03). There are no significant effects of the different mixes of health records. Among NOFB physicians, e-prescribing is the only contributor to productivity (+7.7%, p=0.069). Physicians rank EHR-only as more productive than any combinations of EHRs with non-electronic records. Conclusion: The potential productivity of EHRs is severly limited by the typical practice of combining EHRs with non-electronic records. Reducing the number of different types of records used in a practice will increase the positive effects of EHRs on productivity. One requirement for such reductions is an increased availability of health information exchanges.

Usefulness of cardiac arrest centers - extending lifesaving post-resuscitation therapies: the Arizona experience - .

The post-cardiac arrest syndrome is a complex, multisystems response to the global ischemia and reperfusion injury that occurs with the onset of cardiac arrest, its treatment (cardiopulmonary resuscitation) and the re-establishment of spontaneous circulation. Regionalization of post-cardiac arrest care, utilizing specified cardiac arrest centers (CACs), has been proposed as the best solution to providing optimal care for those successfully resuscitated after out-of-hospital cardiac arrest. A multidisciplinary team of intensive care specialists, including critical care/pulmonologists, cardiologists (general, interventional, and electrophysiology), neurologists, and physical medicine/rehabilitation experts, is crucial for such centers. Particular attention to the timely initiation of targeted temperature management and early coronary angiography/percutaneous coronary intervention is best provided by such CACs. A State-wide program of CACs was started in Arizona in 2007. This is a voluntary program, whereby medical centers agree to provide all resuscitated cardiac arrest patients brought to their facility with state-of-the-art post-resuscitation care, including targeted temperature management for comatose patients and strong consideration for emergent coronary angiography for all patients with a likely cardiac etiology for their cardiac arrest. Survival improved by more than 50% at facilities that became CACs with a commitment to provide aggressive post-resuscitation care to all such patients. Providing aggressive, post-resuscitation care is the next real opportunity to increase long-term survival for cardiac arrest patients.

Transoral laser microsurgery followed by radiation therapy for oropharyngeal tumors: The mayo clinic arizona experience

The purpose of this study was to report the treatment outcomes of patients with advanced oropharyngeal cancer treated with transoral laser microsurgery (TLM) followed by radiation therapy (RT) at Mayo Clinic in Arizona. A retrospective study of 80 patients treated from January 1, 2000 to November 7, 2011 was performed. All patients had stage III/IV oropharyngeal tumors and underwent TLM with neck dissection. Adjuvant RT was then given. Thirty-seven patients received concurrent adjuvant chemotherapy. The primary outcome was locoregional control. Median follow-up was 47.3 months (range, 9.7-139.2 months). The 3-year locoregional control, recurrence-free survival, and overall survival rates were 98.6% (95% confidence interval [CI], 91% to 100%), 91.1% (95% CI, 81% to 96%), and 93.7% (95% CI, 84% to 98%), respectively. There were a total of 5 treatment failures, 1 regional and 4 distant. Twenty-six patients underwent neck only RT with exclusion of the primary site. TLM followed by RT for advanced oropharyngeal cancer results in excellent locoregional control rates.

Protecting Adolescents' Right to Seek Treatment for Sexually Transmitted Diseases without Parental Consent: The Arizona Experience with Senate Bill 1309

In 2010, Senate Bill 1309 included language to repeal an existing Arizona law that enables minors younger than 18 years of age to seek diagnosis and treatment of sexually transmitted diseases (STDs) without parental consent. Numerous implications were identified that would have stemmed from parental consent provisions originally proffered in Senate Bill 1309. These implications included diminished access to essential health services among minors, exacerbated existing health disparities, increased health-care spending costs, and thwarted efforts to curb the spread of STDs. Lastly, minors would have been deprived of existing privacy protections concerning their STD-related medical information. This case study describes how collaborative advocacy efforts resulted in the successful amendment of Senate Bill 1309 to avert the negative sexual and reproductive health outcomes among adolescents stemming from the potential repeal of their existing legal right to seek STD treatment without parental consent.

Presymptomatic Parkinson's disease: The Arizona experience

There is a growing interest in presymptomatic diagnosis of Parkinson's disease (PD), but the best and most practical method to screen and confirm asymptomatic individuals for PD needs further study. The Banner-Sun Health Brain and Body Donation program in Sun City, Arizona has studied primarily PD and Alzheimer's disease. Enrollees receive annual prospective standardized evaluation that includes clinical, biomarker testing, and at autopsy, neuropathological examination is performed followed by a consensus conference that determines final diagnosis. Since numerous Controls receive these assessments, these subjects become an excellent cohort to study presymptomatic PD. We found that Controls with partial diagnostic criteria for PD (1 of either rest tremor or bradykinesia) had a 6.6 relative risk for eventually developing full diagnostic criteria for PD. Neuropathologic examination has uncovered cases of "incidental Lewy body disease" (ILBD). We have shown that ILBD cases during life demonstrated no significant differences in clinical assessment versus similarly assessed controls. However, electrophysiological assessment showed subclinical low frequency rest discharges in some ILBD cases. Electroencephalography spectral frequency of ILBD cases was lower than for controls but not as low as for PD cases. The longitudinal assessments of this brain bank offer significant opportunities for the study of presymptomatic PD.

Registered Nurse CEOs: The Arizona Experience

Have you ever been wowed? Let us tell you the story of 12 amazing nurses in Arizona. Currently, Arizona hospitals boast 15 chief executive officers (CEOs) who are registered nurses (RNs), three of whom are corporate CEOs—the CEOs of CEOs. This article is about their stories, their visions, and their insights. They are sharp learning machines, visionaries, relationship builders, and they have it. They have a presence that shows they are comfortable in their own shoes and with others. You feel their energy the moment you sit down with them. They all look back and see their nursing experience as a cornerstone of the job, although, historically, nurses who became hospital administrators were characterized as having sold out. 1 Finkler S Kovner C Jones C Financial Management for Nurse Managers. Saunders Elsevier, Philadelphia, PA2007: 35 Google Scholar Who in the C-suite is more appropriate to align clinician input from the bedside with financial demands? Have you ever been wowed? Let us tell you the story of 12 amazing nurses in Arizona. Currently, Arizona hospitals boast 15 chief executive officers (CEOs) who are registered nurses (RNs), three of whom are corporate CEOs—the CEOs of CEOs. This article is about their stories, their visions, and their insights. They are sharp learning machines, visionaries, relationship builders, and they have it. They have a presence that shows they are comfortable in their own shoes and with others. You feel their energy the moment you sit down with them. They all look back and see their nursing experience as a cornerstone of the job, although, historically, nurses who became hospital administrators were characterized as having sold out. 1 Finkler S Kovner C Jones C Financial Management for Nurse Managers. Saunders Elsevier, Philadelphia, PA2007: 35 Google Scholar Who in the C-suite is more appropriate to align clinician input from the bedside with financial demands?

The total artificial heart in refractory cardiogenic shock: saving the patient versus saving the heart

Marvin J Slepian and Jack G Copeland present their Viewpoint on the University of Arizona's experience with the CardioWest™total artificial heart (TAH-t) in patients with protracted refractory cardiogenic shock accompanying acute myocardial infarction. The authors assert that the TAH-t could provide a lifeline to patients whose prognosis would otherwise be bleak.

Deaths of Mexican and Central American Children along the US Border: The Pima County Arizona Experience

Using data obtained through the Arizona Child Fatality Review Program, we reviewed deaths of all children (birth-17 years) who were Mexican or Central American residents and who died in Pima County, Arizona during the years 1995-2004. They accounted for 5% of all pediatric deaths in the county. Causes of death were motor vehicle collision (32%), environmental exposure (17%), prematurity (11%), other trauma (11%) and other medical conditions (28%). Fifty-three percent of these children were in the US seeking medical care; 36% were undocumented migrants. Significant trends over the 10 years were toward fewer children seeking medical care and more children dying while border crossing. Border health and economic disparities affected overall child mortality in this US county, but current prevention efforts are unlikely to affect this population group.

Stroke complications following implantation of the CardioWest total artificial heart: University of Arizona experience

Stroke complications following implantation of the CardioWest total artificial heart: University of Arizona experience

Assessment of Distress in Conventional Hot-Mix Asphalt and Asphalt–Rubber Overlays on Portland Cement Concrete Pavements

The purpose of this study is to assess the way distresses are predicted by using the new Mechanistic–Empirical Design of New and Rehabilitated Pavement Structures (design guide), developed under NCHRP Project 1–37A. Two pavement sections were used: a conventional hot-mix asphalt reconstruction and an asphalt–rubber overlay on a portland cement concrete (PCC) pavement. The design guide does not include rehabilitation design for asphalt–rubber overlays. However, many large-scale asphalt–rubber overlays on interstate highways in Arizona have been built and monitored for performance, providing an opportunity to determine to what degree the design guide can predict their performance. The input data for both types of pavements were derived from two different projects on the same highway, Interstate 40. The actual data measurements that summarize the pavement performance were compared with calculated values obtained by using the design guide. Three pavement performance parameters were evaluated on the basis of the available data: rutting, cracking, and international roughness index (IRI). Rutting was one of the distresses that the design guide predicted more accurately. The fatigue cracking prediction, evaluated with Level-3 data input, was not accurate; future analysis should consider calibrated fatigue models for the different mixtures. The predicted IRI results differed from the actual measured field performance because of inaccurate distress prediction. The Arizona experience using asphalt–rubber overlays to rehabilitate aged PCC pavements has been successful. For that reason, a calibration process that allows the use of the asphalt–rubber mixtures in the design guide should be considered in the future.

Barriers to Enrollment and Successful Outreach Strategies in CHIP: Reflections on the Arizona Experience

This paper presents a case study of the efforts by one state (Arizona) to increase Children's Health Insurance Program enrollment through outreach projects funded by private foundations. Barriers to enrollment include the organization of the Children's health Insurance Program and perceptions of parents. The most successful outreach either involves intensive personal contact or is connected with a health care provider agency. The paper concludes by discussing how the barriers and successful outreach strategies in Arizona can be generalized to other states and can inform Children's Health Insurance Program outreach broadly.

Long-Term Care Approaches to Aphasia Treatment and Management

Long-Term Care Approaches to Aphasia Treatment and Management

Arizona experience with CardioWest total artificial heart bridge to transplantation

Background. We hypothesized that bridge to transplantation with the CardioWest Total Artificial Heart would succeed in a large percentage of patients. Further, we hypothesized that this success rate would not be significantly decreased by infection or thromboembolism. Methods. From 1993 to March 1999, 24 patients received implants with the intention of bridge to transplantation. Data were collected prospectively. Heparin, coumadin, aspirin, ticlopidine, dipyridamole, and pentoxifylline were used for anticoagulation. Results. Four patients died while on device support. Nineteen of 23 patients (83%) were transplanted. All 19 survived long term. One patient remains on CardioWest Total Artificial Heart support 6 weeks after implant. There was one stroke on the day of transplantation. There was a second stroke on the day of implantation. Neither stroke caused significant residual deficits. Both were in close relationship to an operative procedure. There were no serious device-related infections. Conclusions. The CardioWest Total Artificial Heart salvaged 20 of 24 critically ill patients. Neither infections nor neurologic problems were significant. We believe it is the device of choice for decompensating patients with biventricular failure who have adequate body and heart size.

The Arizona Experience: empowering patients and families

The Arizona Experience: empowering patients and families

Criteria for selecting type of bridge to heart transplantation: The univertity of arizona experience: FA Arabia, RG Smith, DA Arzouman, V Paramesh, B Toporoff, GK Sethi, JG Copeland University of Arizona, Tucson, AZ

Criteria for selecting type of bridge to heart transplantation: The univertity of arizona experience: FA Arabia, RG Smith, DA Arzouman, V Paramesh, B Toporoff, GK Sethi, JG Copeland University of Arizona, Tucson, AZ