Current Practice Research Articles

Automation of the medication process in Swiss hospitals: results of a survey

ObjectivesMedication management is a core process in hospital administration. The safety, timeliness and efficiency of medication distribution may be improved by automating logistical and administrative aspects of the process. Forming...

Effect of lactate levels on extubation time in coronary artery bypass grafting surgery.

In current practice, fast-track protocols are gaining importance in patients undergoing cardiac surgery. For this purpose, besides different application techniques, biomarkers are frequently examined in the peri-operative period. We aimed to examine whether serum lactate levels at different peri-operative intervals had an effect on the extubation time. The patients were analysed in two groups according to the extubation time (early < 6 hours, and late extubation > 6 hours). Individual characteristics, co-existing diseases, blood transfusion, inotropic support, intra-aortic balloon pump, cardiopulmonary bypass time, aortic cross-clamp time, and the serial measurements of serum lactate levels were recorded. Correlations of serial measurements of lactate levels and the peri-operative variables with extubation times were analysed. No significant differences were observed between the groups in terms of co-existing diseases and individual characteristics. However, cardiopulmonary bypass, aortic cross-clamp times and all lactate levels after aortic cross-clamping were found to be significantly different (p = 0.001). A statistically significant correlation was found between the cut-off value of 1.7 for serum lactate levels after aortic-cross clamping (L2); 1.9 for levels after aortic cross-clamp removal (L3); 2.2 for levels after cardiopumonary bypass (L4); 2.1 for levels after intensive care admission (L5); 1.7 for levels after first postoperative hour in the intensive care unit (L6), and 1.8 for the difference between pre-operative levels (L0) and the peak level of lactate in the peri-operative period (ΔL) in predicting extubation time (p < 0.01). We concluded that cardiopulmonary bypass and aortic cross-clamp times, and intra-operative serum lactate levels were important in predicting early extubation after isolated coronary artery bypass graft surgery.

PLGA Nanoparticles as New Drug Delivery Systems in Leishmaniasis Chemotherapy: A Review of Current Practices.

Although leishmaniasis is one of the most common parasitic diseases, its traditional treatments suffer from some serious problems. To solve such issues, we can take advantage of the effective nanoparticle-based approaches to deliver anti-leishmanial agents into leishmania-infected macrophages either using passive targeting or using macrophagerelated receptors. Despite the high potential of nanotechnology, Liposomal Amphotericin B (AmBisome®) is the only FDA-approved nanoparticle-based anti-leishmanial therapy. In an effort to find more anti-leishmanial nano-drugs, this 2011-2021 review study aimed to investigate the in-vivo and in-vitro effectiveness of poly (lactic-co-glycolic acid) nanoparticles (PLGA-NPs) in the delivery of some traditional anti-leishmanial drugs. Based on the results, PLGA-NPs could improve solubility, controlled release, trapping efficacy, bioavailability, selectivity, and mucosal penetration of the drugs, while they decreased resistance, dose/duration of administration and organotoxicity of the agents. However, none of these nano-formulations have been able to enter clinical trials so far. We summarized the data about the common problems of anti-leishmanial agents and the positive effects of various PLGA nano-formulations on reducing these drawbacks under both in-vitro and in-vivo conditions in three separate tables. Overall, this study proposes two AmB-loaded PLGA with a 99% reduction in parasite load as promising nanoparticles for further studies.

Opinion, uptake and current practice of robot-assisted upper gastrointestinal and oesophagogastric surgery in the UK: AUGIS national survey results.

The uptake of upper gastrointestinal (GI) robotic surgery in the United Kingdom (UK), and Europe more widely, is expanding rapidly. This study aims to present a current snapshot of the practice and opinions of the upper GI community with reference to robotic surgery, with an emphasis on tertiary cancer (oesophagogastric) resection centres. An electronic survey was circulated to the UK upper GI surgical community via national mailing lists, social media and at an open-invitation conference on robotic upper GI surgery in January 2023. The survey included questions on surgeons' current practice or planned adoption (if any) of robotics at individual and unit level, and their opinions on robotic upper GI surgery in general. Priority ranking and Likert-scale response options were used. In total, 81 respondents from 43 hospitals were included. Thirty-four resectional centres responded, including 30 of 31 (97%) recognised upper GI cancer centres in England. Respondents reported performing robotic surgery in 21 of 34 (61.8%) resectional centres, with a median of 65 procedures per centre performed at the time of the survey (range 0-500, interquartile range 93.75). Every centre without a robotic programme expressed a desire or had active plans to implement one. Respondents ranked surgeon ergonomics as the most important reason for pursuing robotics, followed by improvements in patient outcomes and oncological efficacy. Robotic upper GI practice is nascent but rapidly growing in the UK with plans for uptake in almost all tertiary centres. There is growing opinion that this is likely to become the predominant surgical approach in future with benefits to both patients and surgeons. This snapshot offers a point of reference to all stakeholders in upper GI surgery.

Managing opioids and mitigating opioid risks in patients with cancer: An environmental scan of the attitudes, confidence, and practices of ambulatory, community and hospital pharmacists practicing in Canada.

Canada is in the midst of an overdose crisis. The use of prescription opioids in Canada has increased steadily over the past two decades, with stark increases in opioid-induced respiratory depression and related deaths. Opioids are the mainstay of treatment for cancer-related pain. Patients with cancer are not immune to the risks associated with opioid use but are underrepresented in available literature outlining risk mitigation strategies. Pharmacists are ideally placed to employ opioid risk mitigation practices to support safe and effective opioid use for patients with cancer-related pain. However, the current attitudes, confidence, and safety practices of pharmacists around how to best support these patients are not known. This study was a descriptive environmental scan of pharmacists who provide direct patient care in Canada. An electronic questionnaire was built using the web based Opinio software. It was distributed via email by several provincial and national pharmacy organizations and online platforms. The questionnaire consisted of Likert-scale and open-ended questions and was open to participants for a 6-week period from February 12th to March 23rd, 2020. Analysis was conducted using descriptive statistics and qualitative content analysis. Eighty-one responses from pharmacists in nine provinces were included in the analysis. Respondents endorsed limited and varied practices when caring for patients receiving opioids for cancer-related pain. Further, they demonstrated wide ranging confidence and attitudes regarding opioid risk mitigation practices and beliefs. Less than 50% of pharmacists were aware of resources available for their patients with non-medical opioid use, and/or patients at high risk of opioid-induced respiratory depression. Education, resources, and communication were the most commonly reported perceived facilitators and barriers to resource use. Pharmacists in Canada report employing opioid risk mitigation practices with low and varied frequency when caring for patients receiving opioids for cancer-related pain. They endorsed varied confidence and limited awareness of available provider and patient resources. These findings may help inform the development of new education models and evidence-based guidelines. New education models and evidence-based guidelines will support pharmacists in their pharmaceutical care of this vulnerable patient population, ultimately aiming to improve patient outcomes.

First investigation of RH gene polymorphism in patients with sickle cell disease and associated blood donors in Cameroon, Central Africa.

Although genetic polymorphism of the RH blood group system is well known in sub-Saharan Africa, national/regional specificities still remain to be described precisely. For the first time in Cameroon, Central Africa, and in order to better characterize the molecular basis driving RH phenotype variability, as well as to identify the main antigens that may be potentially responsible for alloimmunization, we sought 1) to study the RH genes in a cohort of 109 patients with sickle cell disease; 2) to study the same genes in the corresponding donors whose red blood cells (RBCs) were transfused to the patients (108 donors in 98 patients); 3) to predict RH phenotype on the basis of the molecular data and compare the results with serologic testing; and 4) to identify retrospectively patients at risk for alloimmunization. In order to generate an exhaustive dataset, the RH genes of all patient and donor samples were systematically investigated 1) by quantitative multiplex PCR of short fluorescent fragments (QMPSF) for characterization of RHD gene zygosity and potential structural variants (SVs), and 2) by Sanger sequencing for identification of single nucleotide variants (SNVs). Subsequent to molecular analysis, the genotypes and RH phenotype were deduced and predicted, respectively, from reference databases. In a total of 217 Cameroonian individuals, as many as 24 and up to 22 variant alleles were identified in the RHD and RHCE genes, respectively, in addition to the reference alleles. Interestingly, 65 patients with SCD (66.3%) were assumed to be exposed to one or more undesirable RH antigen(s) with varying degrees of clinical relevance. Beyond the comprehensive report of the nature and distribution of RH variant alleles in a subset of Cameroonian patients treated by transfusion therapy, this work highlights the need for an extensive review of current practice, including routine serologic typing procedures, preferably in the near future.

Should Obtaining Informed Consent Be Considered an Entrustable Professional Activity? Insights From Whether and How Attendings Entrust Surgical Trainees.

Because residents are frequently delegated the task of obtaining consent early in their training, the American Association of Medical Colleges describes "obtaining informed consent" as a core entrustable professional activity (EPA) for medical school graduates. However, prior studies demonstrated that residents frequently perform this task without receiving formal instruction or assessment of competency. This study sought to understand how attending physicians decide to delegate obtaining informed consent for surgical procedures to trainees. The authors conducted a survey of attending surgeons at a university-based health care system of 6 affiliated teaching hospitals (October-December 2020) to collect data about current entrustment practices and attendings' knowledge, experience, and attitudes surrounding the informed consent process. Summary statistics and bivariate analyses were applied. Eighty-five attending surgeons participated (response rate, 49.4%) from diverse specialties, practice types, and years in practice. Fifty-eight of 85 (68.2%) stated they "never" granted responsibility for the consent conversation to a trainee, and 74/81 (91.4%) reported they typically repeated their own consent conversation whenever a trainee already obtained consent. The most common reasons they retained responsibility for consent were ethical duty (69/82, 84.1%) and the patient relationship (65/82, 79.3%), while less than half (40/82, 48.8%) described concerns about trainee competency. Reflecting on hypothetical clinical scenarios, increased resident competency did not correspond with increased entrustment ( P = .27-.62). Nearly all respondents (83/85, 97.7%) believed residents should receive formal training; however, only 41/85 (48.2%) felt additional training and assessment of residents might change their current entrustment practices. Attendings view informed consent as an ethical and professional obligation that typically cannot be entrusted to trainees. This practice is discordant with previous literature studying residents' perspectives. Furthermore, resident competency does not play a predominant role in this decision, calling into question whether informed consent can be considered an EPA.

La Linterna: Clinical model for trauma-exposed, migrant children.

Exposure to childhood adversity is increasingly recognized as an important topic in pediatric medicine and a powerful driver of adult disease burden. While significant evidence exists that early intervention is critical for children exposed to adversities, few models have been established for addressing the complex medical, psychological, and social needs of these patients in a holistic manner. La Linterna is an interdisciplinary clinical initiative providing trauma-informed primary care, mental health treatment, immigration legal counsel, and comprehensive case management to children (and their families) exposed to adversities throughout the migration process. Started in 2019, the clinic serves immigrant families throughout the city of Los Angeles. Described as the process of implementing an interdisciplinary, trauma-informed practice to meet the medical, mental health, social care needs of this uniquely vulnerable patient population. Strong evidence exists in the medical literature arguing for the implementation of a holistic, trauma-informed model of patient care. We describe "principles" and "lessons learned" during implementation, as well as detail an approach to improving services to immigrant families who have experienced adversities via an interactive, patient-centered process. Trauma-informed care is critical for meeting the needs of vulnerable children and their families. La Linterna represents an innovative and effective way to enhance care for one of the most vulnerable United States populations, immigrant and refugee families. Implementation of all or some of the program's components is possible throughout the United States and would mark an improvement over current practice. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

SpectrumVA: Visual Analysis of Astronomical Spectra for Facilitating Classification Inspection.

In astronomical spectral analysis, class recognition is essential and fundamental for subsequent scientific research. The experts often perform the visual inspection after automatic classification to deal with low-quality spectra to improve accuracy. However, given the enormous spectral volume and inadequacy of the current inspection practice, such inspection is tedious and time-consuming. This article presents a visual analytics system named SpectrumVA to promote the efficiency of visual inspection while guaranteeing accuracy. We abstract inspection as a visual parameter space analysis process, using redshifts and spectral lines as parameters. Different navigation strategies are employed in the "selection-inspection-promotion" workflow. At the selection stage, we help the experts identify a spectrum of interest through spectral representations and auxiliary information. Several possible redshifts and corresponding important spectral lines are also recommended through a global-to-local strategy to provide an appropriate entry point for the inspection. The inspection stage adopts a variety of instant visual feedback to help the experts adjust the redshift and select spectral lines in an informed trial-and-error manner. Similar spectra to the inspected one rather than different ones are visualized at the promotion stage, making the inspection process more fluent. We demonstrate the effectiveness of SpectrumVA through a quantitative algorithmic assessment, a case study, interviews with domain experts, and a user study.

Toward More Comprehensive Evaluations of 3D Immersive Sketching, Drawing, and Painting.

To understand current practice and explore the potential for more comprehensive evaluations of 3D immersive sketching, drawing, and painting, we present a survey of evaluation methodologies used in existing 3D sketching research, a breakdown and discussion of important phases (sub-tasks) in the 3D sketching process, and a framework that suggests how these factors can inform evaluation strategies in future 3D sketching research. Existing evaluations identified in the survey are organized and discussed within three high-level categories: 1) evaluating the 3D sketching activity, 2) evaluating 3D sketching tools, and 3) evaluating 3D sketching artifacts. The new framework suggests targeting evaluations to one or more of these categories and identifying relevant user populations. In addition, building upon the discussion of the different phases of the 3D sketching process, the framework suggests to evaluate relevant sketching tasks, which may range from low-level perception and hand movements to high-level conceptual design. Finally, we discuss limitations and challenges that arise when evaluating 3D sketching, including a lack of standardization of evaluation methods and multiple, potentially conflicting, ways to evaluate the same task and user interface usability; we also identify opportunities for more holistic evaluations. We hope the results can contribute to accelerating research in this domain and, ultimately, broad adoption of immersive sketching systems.

Ripples in the Water: Physical Education Teacher Education Program Influence on Graduates’ Perceptions of Expanded Physical Activity Programming

Physical educators are often asked to promote whole-school physical activity programming beyond their scheduled class times. Previous research has supported that training in expanded roles would be beneficial during university-based physical education teacher education (PETE) training. In this qualitative study, 13 graduates from a single PETE program that has integrated expanded physical activity into programming shared information about their current programming as physical education teachers in K–12 schools. Campus visits and one-on-one interviews were included. Some practices and values learned during participants’ PETE training were evident in graduates’ current practices. Aligning with previous studies of professional socialization of physical educators, the resulting themes concluded that (a) strategies and resources gained during PETE training were valued and still used and (b) other ripples of influence, such as administrators and other teachers at their current placement, influenced programming. PETE programming with whole-school physical activity can lead to expanded teaching practices in schools.

Description of Specialty Practice-10 Years Onward: The Changes in Geriatric Physical Therapy.

An analysis of practice is conducted by the American Board of Physical Therapy Specialties (ABPTS) every 10 years to revalidate, update, and revise the description of specialty practice (DSP) for each specialty. The Geriatric Specialty Council recently conducted an analysis of practice and revised its content consistent with established procedures by the ABPTS. The purpose of this article is threefold: first, to describe the process of the most recent practice analysis; second, to report revisions to the description of specialty practice based on the analysis of practice; and third, to identify elements of practice that define current specialist practice in geriatric physical therapy. A 10-member committee of subject matter experts (SMEs) and a psychometric consultant developed a survey instrument addressing geriatric physical therapy specialty practice areas. The survey was initially pilot-tested and subsequently administered online to a sample of 801 board-certified geriatric clinical specialists. The consultant facilitated the consensus process to determine decision rules in selecting the final competencies describing current geriatric physical therapy specialty practice. A total of 372 respondents fully or partially completed the survey, resulting in a response rate of 46.4%. Based on a priori decision rules regarding survey data, consensus of the group of SMEs, and input from the ABPTS, the DSP for geriatric physical therapy specialty practice was revised. Revisions (elimination [-] of prior items and addition [+] of new items) were made in Section 1: Knowledge Areas (-8 and +6), in Section 2: Professional Roles, Responsibilities, and Values (-14 and +4), and Section 3: Practice Expectations (-53 and +28). The revised DSP will be used as the basis for the development of the examination blueprint for the specialist examination in geriatric physical therapy and the curricula for residency programs in geriatric physical therapy.

Efficacy and Safety of Bempedoic Acid in Patients with High Cardiovascular Risk: An Update.

Statins play a significant role in the prevention of cardiovascular (CV) diseases (CVDs); however, non-adherence with statin treatment or statin intolerance (mainly attributed to muscleassociated side effects) is not uncommon. New agents such as bempedoic acid (BA) can provide more treatment options. BA is administered orally, once daily, at a dose of 180 mg in current clinical practice. It can decrease circulating low-density lipoprotein cholesterol (LDL-C) levels by nearly 30% as monotherapy or by 20% as an add-on to statins. CV outcome studies have shown that BA decreases major adverse CV event risk in patients with established CVD or high CV risk by 13%. When patients with high CV risk were analyzed alone, the risk reduction was 30%. Its side effects include a rise in serum uric acid levels and liver enzyme activity, whereas it does not increase diabetes risk as statins do. BA can be used as adjunctive therapy to statins in patients at high CV risk in whom lipid targets cannot be achieved or as an alternative to statins in patients with statin intolerance.

Older Adults With Alzheimer's Disease Have Lower Bone Mineral Density Compared to Older Adults Without Dementia: A Systematic Review With Meta-analysis of Observational Studies.

The literature has associated bone mineral density (BMD) and Alzheimer's disease (AD). The aim of the present systematic review was to investigate BMD in older adults with AD compared with older adults with no dementia. Searches were performed in the MEDLINE, EMBASE, CINAHL, and Web of Science databases from inception to May 2022. Observational studies that compared BMD in the populations of interest were included. Methodical quality (risk of bias) was appraised using the Newcastle-Ottawa Scale. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Standardized mean differences (SMD) were calculated for meta-analyses. Five studies were included, involving a total of 1772 older adults (373 with AD and 1399 with no dementia). A first meta-analysis compared 207 older adults with AD and 1243 with no dementia for BMD in the femoral neck. The results showed lower BMD in the AD groups (SMD =-1.52; 95% CI, -2.61 to -0.42; P = .007, low quality of evidence). A second meta-analysis considering different sites of the body (whole body, trunk, femur, and lumbar spine) also showed lower BMD in older adults with AD compared with the group with no dementia (SMD =-0.98; 95% CI, -1.91 to -0.05; P = .04, low quality of evidence). Newcastle-Ottawa Scale scores ranged from 7 to 9, indicating low risk of bias. Bone mineral density is lower in older adults with AD than in older adults with no dementia, especially in the femoral neck. These results suggest that older adults with AD may be at greater risk of developing osteopenia and osteoporosis. Current clinical practice guidelines should be amended for screening frequency and methodology for this particular cohort. Further studies are needed to confirm whether older people with AD have lower BMD in other sites of the body.

REhabilitation Approaches in CHildren with cerebellar mutism syndrome (REACH): An international cross-disciplinary survey study.

Pediatric cerebellar mutism syndrome (pCMS) can occur following resection of a posterior fossa tumor and, although some symptoms are transient, many result in long-lasting neurological deficits. A multi-disciplinary rehabilitation approach is often used in cases of pCMS; however, there have been no clinical trials to determine gold standards in rehabilitation practice in this population, which remains a research priority. The purpose of this study was to identify and compare intervention practices used in pCMS throughout the disciplines of occupational and physical therapy, speech-language pathology, and neuropsychology across geographic regions. A 55-question e-survey was created by an international multidisciplinary research group made up of members of the Posterior Fossa Society and sent to rehabilitation professionals in pediatric neuro-oncology centers in the US, Canada, and Europe. Although some differences in the type of intervention used in pCMS were identified within each discipline, many of the targeted interventions including dose, frequency, and intensity were similar within disciplines across geographic regions. In addition, there were common themes identified across disciplines regarding challenges in the rehabilitation of this population. These results provide a foundation of current practices on which to build future intervention-based clinical trials.

Communicating Study Design Trade-offs in Software Engineering

Reflecting on the limitations of a study is a crucial part of the research process. In software engineering studies, this reflection is typically conveyed through discussions of study limitations or threats to validity. In current practice, such discussions seldom provide sufficient insight to understand the rationale for decisions taken before and during the study, and their implications. We revisit the practice of discussing study limitations and threats to validity and identify its weaknesses. We propose to refocus this practice of self-reflection to a discussion centered on the notion of trade-offs . We argue that documenting trade-offs allows researchers to clarify how the benefits of their study design decisions outweigh the costs of possible alternatives. We present guidelines for reporting trade-offs in a way that promotes a fair and dispassionate assessment of researchers’ work.

Misdiagnosis and missed diagnosis of twice-exceptional students: Examining current psychoeducational assessment practices.

Misdiagnosis and missed diagnosis of twice-exceptional students: Examining current psychoeducational assessment practices.

Successful Implementation of the AIUM Standardized 4-Year Residency Ultrasound Curriculum in Obstetrics and Gynecology: Lessons Learned and Way Forward.

Significant disparities in sonographic education exist in Obstetrics and Gynecology programs in the United States. To address the lack of standardization in ultrasound teaching, the American Institute of Ultrasound in Medicine (AIUM) assembled a multi-society task force in 2018 that resulted in the publication of a Consensus Report outlining a standardized ultrasound curriculum and competency assessment. The primary objective of the study was to implement the AUIM standardized curriculum within an Obstetrics and Gynecology residency program at a tertiary medical center, and report on the early implementation experience. The secondary objective was to assess current national practices in ultrasound training in Obstetrics and Gynecology residency programs. Study design was an effectiveness-implementation hybrid study of a structured ultrasound educational program based on the 2018 AIUM Consensus Report. The theoretical portion of the curriculum consisted of 26 hours of didactic lectures distributed over 4 years. For the practical component, residents received instruction from faculty and sonographers and independently acquired the required images as part of their regular clinical work. Simulator app access was also provided for additional opportunities to practice and acquire images. Deidentified images for the required competencies were uploaded to a WhatsApp group for review. Theoretical knowledge was assessed with a series of multiple-choice exams. Practical skills were assessed through grading of images submitted through WhatsApp as well as direct observations of resident scans. At the completion of 4 years, the assessment of both theoretical knowledge and practical skills was carried out using the ISUOG Basic Training Examination. National patterns in the area of ultrasound education were assessed with a four-question electronic survey of Obstetrics and Gynecology program directors in the United States. Analysis of both portions of the study was primarily descriptive. Four Obstetrics and Gynecology residents completed the curriculum spanning postgraduate years 1 through 4. The number of competencies completed ranged from 7 to 19 out of 41. All of the residents passed the theoretical and practical components of the ISUOG Basic Training Examination. For the residency program director survey portion of the study, response rate was 20% (59 of 290). Among the respondents, 55.9% reported having a structured curriculum and 34.4% reported implementing the AIUM curriculum. The two most commonly cited obstacles to implementation of structured ultrasound teaching were uncertainty with how to start the process (49.2%) and lack of faculty engagement (49.2%). Implementation of the AIUM Curriculum within the framework of an Obstetrics and Gynecology residency program at a tertiary medical center is feasible. In our experimental group, completion of the curriculum resulted in passing of an internationally recognized validated assessment. Obstacles to implementation in our program included a wide range of engagement and participation among residents, and limited opportunities to obtain some of the required competencies. Identification of obstacles to implementation from the perspective of residency program directors is critical for developing targeted approaches to ensure widespread implementation. Successful standardized validated sonographic training of graduating Obstetrics and Gynecology residents is crucial for this operator-dependent modality that has tremendous implications on patient safety and clinical care.

Assessing the Impact of the 340B Drug Pricing Program: A Scoping Review of the Empirical, Peer-Reviewed Literature.

Despite remarkable growth and relevance of the 340B Drug Pricing Program to current health care practice and policy debate, academic literature examining 340B has lagged. The objectives of this scoping review were to summarize i) common research questions published about 340B, ii) what is empirically known about 340B and its implications, and iii) remaining knowledge gaps, all organized in a way that is informative to practitioners, researchers, and decision makers. We conducted a scoping review of the peer-reviewed, empirical 340B literature (database inception to March 2023). We categorized studies by suitability of their design for internal validity, type of covered entity studied, and motivation-by-scope category. The final yield included 44 peer-reviewed, empirical studies published between 2003 and 2023. We identified 15 frequently asked research questions in the literature, across 6 categories of inquiry-motivation (margin or mission) and scope (external, covered entity, and care delivery interface). Literature with greatest internal validity leaned toward evidence of margin-motivated behavior at the external environment and covered entity levels, with inconsistent findings supporting mission-motivated behavior at these levels; this was particularly the case among participating disproportionate share hospitals (DSHs). However, included case studies were unanimous in demonstrating positive effects of the 340B program for carrying out a provider's safety net mission. In our scoping review of the 340B program, the highest-quality evidence indicates nonprofit, DSHs may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements. Future studies should examine heterogeneity by covered entity types (i.e., hospitals vs. public health clinics), characteristics, and time period of 340B enrollment. Our findings provide additional context to current health policy discussion regarding the 340B program.

We need to change how we compute RMSEA for nested model comparisons in structural equation modeling.

Comparison of nested models is common in applications of structural equation modeling (SEM). When two models are nested, model comparison can be done via a chi-square difference test or by comparing indices of approximate fit. The advantage of fit indices is that they permit some amount of misspecification in the additional constraints imposed on the model, which is a more realistic scenario. The most popular index of approximate fit is the root mean square error of approximation (RMSEA). In this article, we argue that the dominant way of comparing RMSEA values for two nested models, which is simply taking their difference, is problematic and will often mask misfit, particularly in model comparisons with large initial degrees of freedom. We instead advocate computing the RMSEA associated with the chi-square difference test, which we call RMSEAD. We are not the first to propose this index, and we review numerous methodological articles that have suggested it. Nonetheless, these articles appear to have had little impact on actual practice. The modification of current practice that we call for may be particularly needed in the context of measurement invariance assessment. We illustrate the difference between the current approach and our advocated approach on three examples, where two involve multiple-group and longitudinal measurement invariance assessment and the third involves comparisons of models with different numbers of factors. We conclude with a discussion of recommendations and future research directions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).