Diverse Practice Settings Research Articles

Intimate Partner Violence Prevention and Intervention Group-Format Programs for Immigrant Latinas: a Systematic Review.

Immigrant Latinas (IL) experiencing intimate partner violence (IPV) often experience barriers to accessing formal support systems due to immigration-related issues (e.g., fear of deportation, language proficiency, lack of family support in the U.S.). This paper contains a systematic review of peer-reviewed published articles within the past 25 years addressing IPV prevention and intervention programming designed for this vulnerable population. We examined specific group-format programs and curricula conducted at community-based agencies with social services across the country. Qualitative analysis of the 10 articles that met search criteria (i.e., programs must be culturally specific, designed to serve IL, conducted in group-format, focused on IPV intervention or prevention) generated information regarding the nature of group interventions addressing this issue and population. Several themes emerged upon completion of the qualitative review describing key characteristics of each intervention. All reviewed articles reported generally positive outcomes using a variety of methods. Studies using quantitative methods found statistically significant outcomes for constructs including depression, self-esteem, and knowledge of wellness. Professionals from diverse practice settings working with IL would likely benefit by developing intervention and prevention group-format programming to address this problem.

Implementation of the Institute of Medicine treatment plan in oncology practice.

e19233 Background: Participation in the Center for Medicare and Medicaid Services (CMS) value-based payment reform, The Oncology Care Model, requires that every beneficiary has a documented 13-point Institute of Medicine (IOM) treatment plan (TP) when commencing antineoplastic therapy. The intent of this document is to enhance shared decision making between the patient and care team by providing transparent treatment recommendations and engaging patients and caregivers in meaningful discussion. There is limited discussion in the literature on how to adapt the CMS recommendations to diverse practice settings while maintaining fidelity to the intent of the TP. Methods: We compare how three clinically and geographically unique OCM participating institutions implemented the TP in their respective institutions within the domains of the Consolidated Framework for Implementation Research (CFIR). Settings include a community cancer institute in the northeast, an academic hospital setting in the southeast, and a large community cancer network in the southern United States. Results: We identified similar themes in implementation including engaging stakeholders, leveraging information technology, structuring the TP, development of clinic processes and considering scalability. We also describe adaptations unique to the culture and setting of each site. Conclusions: Although studies have shown patients do not feel informed of their diagnosis, there are currently many approaches to improving shared decision making including utilizing the 13 points of the IOM TP as mandated by the OCM. We provide practical strategies for incorporation of the TP into clinical care with lessons from diverse settings. As shown by the wide variability in implementing shared decision making, further research is needed to optimize illness understanding. Additionally, optimal implementation of CMS’s IOM TP would ideally include concrete metrics measuring impact on shared decision making, illness understanding, or patient satisfaction.

Population Health, Prevention, Health Promotion, and Wellness Competencies in Physical Therapist Professional Education: Results of a Modified Delphi Study.

Physical therapists are well positioned to meet societal needs and reduce the global burden of noncommunicable diseases through the integration of evidence-based population health, prevention, health promotion, and wellness (PHPW) activities into practice. Little guidance exists regarding the specific PHPW competencies that entry-level clinicians ought to possess. The objective of this study was to establish consensus-based entry-level PHPW competencies for graduates of US-based physical therapist education programs. In a 3-round modified Delphi study, a panel of experts (N=37) informed the development of PHPW competencies for physical therapist professional education. The experts, including physical therapists representing diverse practice settings and geographical regions, assessed the relevance and clarity of 34 original competencies. Two criteria were used to establish consensus: a median score of 4 (very relevant) on a 5-point Likert scale, and 80% of participants perceiving the competency as very or extremely relevant. Twenty-five competencies achieved final consensus in 3 broad domains: preventive services and health promotion (n=18), foundations of population health (n=4), and health systems and policy (n=3). Adoption of the 25 accepted competencies would promote consistency across physical therapist education programs and help guide physical therapist educators as they seek to integrate PHPW content into professional curricula. This is the first study to establish consensus-based competencies in the areas of PHPW for physical therapist professional education in the United States. These competencies ought to guide educators who are considering including or expanding PHPW content in their curricula. Development of such competencies is critical as we seek to contribute to the amelioration of chronic disease and transform society to improve the human experience.

Online Journal Clubs to Enhance Fieldwork Educator Competency in Support of Student Experiential Learning.

Fieldwork educators receive little or no formal training for student supervision and have sought inexpensive, flexible, online options for role-specific continuing education. To investigate the use of online journal clubs to enhance fieldwork educator role competency. Mixed-methods study with a prospective cohort design; 5-wk intervention with 6-mo follow-up. Online asynchronous message board system distributed to fieldwork educators affiliated with two occupational therapy programs. Academic fieldwork coordinators from two universities facilitated online journal clubs for fieldwork educators. Fourteen fieldwork educators participated in the 5-wk journal club, which included reading an article, engaging in online discussion, and creating a personal application plan. Participants demonstrated strong engagement in the online journal club. Postsurvey results revealed strong and positive feedback related to ease of use, relevance of learning, and satisfaction with the experience. At the 6-mo follow-up, 11 of the 14 participants reported implementing a new strategy to support the fieldwork education process, and all reported that the strategy had been helpful. The use of an online journal club was effective as a method for sharing evidence about the fieldwork educator role and supporting knowledge translation. Online journal clubs can be an effective tool for providing role-specific training in diverse practice settings and parts of the country.

Perinatal health care providers' approaches to recommending and providing pertussis vaccination in pregnancy: a qualitative study.

In 2018, the Canadian National Advisory Committee on Immunization and the Society of Obstetricians and Gynaecologists of Canada recommended a single dose of tetanus toxoid, reduced diphtheria toxoid and reduced acellular pertussis (Tdap) vaccine in every pregnancy. To understand how perinatal health care providers in Canada are translating recent recommendations for universal antenatal Tdap vaccine into routine clinical practice, we examined health care providers' perceptions of what influences their ability to recommend and provide Tdap vaccine consistently to pregnant women. Between June 2018 and July 2019, we conducted semistructured telephone interviews with perinatal health care providers (nurses, midwives, family physicians and obstetricians) from 5 provinces (British Columbia, Manitoba, Ontario, Quebec and Nova Scotia) representing diverse educational experiences, practice settings and models of care. We analyzed the data using interpretive description. We interviewed 44 perinatal health care providers (13 family physicians, 12 midwives, 10 obstetricians and 9 nurses) practising in a variety of settings. Health care providers' ability to recommend and provide antenatal Tdap vaccine was strongly influenced by structural constraints in the Canadian perinatal health care system. The participants' clinical training varied, which resulted in different knowledge and practices. Participants felt hindered by a lack of lay information resources. Consistent and convenient vaccine access was perceived to be key to promoting confidence and encouraging uptake, yet antenatal Tdap vaccine was not easily accessible for all women. Our findings suggest that Canada's fragmented health care model has a detrimental effect on health care providers' ability to recommend and ensure access to antenatal Tdap vaccine. Lessons from this study are pertinent to the implementation of successful pertussis vaccine programs and future pregnancy vaccination initiatives.

PD57-01 MR/US FUSION-GUIDED PROSTATE BIOPSY IMPROVES CLINICALLY SIGNIFICANT PROSTATE CANCER DETECTION FOR BIOPSY-NAIVE PATIENTS ACROSS DIVERSE PRACTICE SETTINGS

You have accessJournal of UrologyProstate Cancer: Staging II (PD57)1 Apr 2020PD57-01 MR/US FUSION-GUIDED PROSTATE BIOPSY IMPROVES CLINICALLY SIGNIFICANT PROSTATE CANCER DETECTION FOR BIOPSY-NAIVE PATIENTS ACROSS DIVERSE PRACTICE SETTINGS Brett Watson*, MD Ji Qi, Anna Johnson, and for the Michigan Urological Surgery Improvement Collaborative Brett Watson*Brett Watson* More articles by this author , Ji QiJi Qi More articles by this author , Anna JohnsonAnna Johnson More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000967.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Multicenter trials have compared fusion to systematic prostate biopsy in the biopsy-naive population. These reports are predominantly from large academic centers with significant expertise. However, the added value of MR targeted biopsy for biopsy-naive patients in the community setting is largely unknown. METHODS: The Michigan Urological Surgery Improvement Collaborative (MUSIC) registry maintains a prospective MR and fusion biopsy database with technical, patient, provider, and lesion level data. All patients undergoing targeted and systematic biopsy in the same setting with no prior biopsy from August 2017 - May 2019 were included. Software-based MR/US fusion was used in all cases. Primary outcomes were the proportion of patients upgraded to ≥GG2 prostate cancer (PCa) by target and the proportion upgraded to ≥GG2 PCa based on systematic biopsy. RESULTS: Of 2375 fusion biopsies in the registry, 437 patients from 22 practices met inclusion criteria. Median age and pre-diagnosis PSA for the cohort was 66 years and 6.3 ng/ml, respectively. Overall cancer detection rate was 76.4% and the rate of clinically significant prostate cancer (csPCa) detection was 51.9%. Of the 227 cases of csPCa, 16% were detected by standard biopsy only, 17% by targeted biopsy only, and 67% by both techniques. Of all patients, 39 (8.9%) were upgraded to csPCa by targeted biopsy while 36 (8.2%) were upgraded to csPCa by standard biopsy. On bivariate analysis, we did not identify significant factors predictive of upgrading to csPCa by either technique. CONCLUSIONS: In biopsy-naïve patients, targeted biopsy upgrades approximately 1 in 10 patients to ≥GG2 prostate cancer. A similar proportion of patients with negative targeted biopsies were upgraded by systematic biopsy alone. There were no clinical variables associated with upgrading to ≥GG2 PCa by either biopsy method. Our findings suggest there is value in the community setting to adding mpMRI with targeted biopsy to the initial evaluation of biopsy-naive patients. Source of Funding: MUSIC is funded by Blue Cross Blue Shield of Michigan © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1193-e1193 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brett Watson* More articles by this author Ji Qi More articles by this author Anna Johnson More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

Center and Donor Factors Associated with Discrepant Responses to Donor Lung Offers

Practice standardization may decrease donor lung shortages, however, the cause of organ acceptance pattern variation is not known. Our objective was to compare donor call practices in diverse settings. This was a prospective, multi-center study of 10 centers from 6 distinct regions. Characteristics of consecutive, first-recipient eligible, donor offers (aged ≥13) received by participating centers with definitive decisions from May 1, 2016 to October 31, 2016 were abstracted along with reasons for organ offer turn downs (as applicable) and final organ disposition. A discrepant decision was defined as a donor lung offer declined by one center that was then accepted for transplant by an alternate center. We evaluated 2,000 consecutive offers; the majority (89.9%) were brain dead donors (BDD). Mean transplant volume was 33 transplants/year (range 11-98). Most centers had ex vivo lung perfusion and all had extra-corporeal membrane oxygenation bridging programs. Surgeons made final acceptance determinations at all centers. Declined organs had a mean donor age of 39 years, with a mean PaO2 to FiO2 (P/f) ratio of 352. The most common primary reason for offer decline was abnormal imaging followed by a low or decreasing P/f ratio. There were 412 (20.7%) discrepant offer decisions (8.1 to 41.2% of offers depending on center). Discrepant decisions significantly differed from non-discrepant decisions by transplant center mean annual volume, donor age, absolute and decreasing P/f ratio, and donor type (BDD versus circulatory death) (p<0.001 in all cases). Age was associated with an increased odds of discrepant offer (OR 3.5, 95% CI 2.2-5.7, p<0.001). For every 10-year increase in donor age, the odds of a discrepant decision increased 1.23 fold. Conversely, for every 50-unit increase in P/f ratio, the odds of a discrepant decision decreased (OR 0.79, 95% CI 0.75-0.84; p<0.001.) Although donor smoking status was not different between discrepant and non-discrepant decisions, for every 5-pack-year increase in donor smoking history the odds of a discrepant decision increased by 1.22 fold. (95% CI 1.1-1.36; p<0.001). One in five donor offers that were initially declined by one transplant center were accepted for transplantation by another, highlighting significant variability in donor practices . Key donor and center factors were associated with discrepant decisions.

An exploration of genetic counseling information needs and information-seeking behaviors.

Genetic counseling is a rapidly growing field with increasingly diverse practice settings. The growth of genomics and precision medicine across all medical specialties has been accompanied by corresponding growth in the amount of information available to genetic counselors. However, few published studies on genetic counseling information needs and seeking behaviors exist, and none look at information use across the profession. Meanwhile, a substantial body of research exists on this topic for other healthcare professionals, providing an evidence base supporting profession-tailored information-related services and resources. The purpose of this cross-sectional study was to explore genetic counseling information needs and seeking behaviors and to compare these needs and seeking behaviors across genetic counseling students and genetic counselors broadly, as well as to explore differences across various professional subgroups of genetic counselors. Genetic counselors and genetic counseling students were recruited via the National Society of Genetic Counselors and accredited genetic counseling programs to complete an online survey assessing information needs and seeking behaviors. Respondents were asked how often they used 70 different resources; whether 16 specific situations required additional information and how long it would take to get it and about specific barriers to obtaining that information. The results included a range of observations, including that GeneReviews and PubMed are frequently used resources across all respondents, that genetic counselors working 0-5years are significantly more likely to need additional information when counseling patients from different cultural backgrounds than those working 6+years, and that not having enough time is a common barrier to getting information across various situations. These results provide initial evidence to guide additional study on the efficient use and provision of information within the genetic counseling field.

Knowledge and practice regarding prostate cancer germline testing among urologists: Gaps to address for optimal implementation✰,✰✰

BackgroundGermline testing is recommended for all men with metastatic prostate cancer (PCa), and for some with localized PCa meeting specific histologic or family history criteria. Germline genetic evaluation has important implications for PCa prognosis and management, as well as implications for family members and cancer screening. Despite the importance of germline evaluation, its utilization in urologic practice is unknown. Materials and MethodsWe conducted a 32-item survey of U.S. urologists to examine knowledge of germline testing guidelines and practice patterns. It was shared through email to 6 American Urological Association sections, the Veterans Affairs Urology Mailgroup, and social media. ResultsAmong 132 total respondents from diverse practice settings across the U.S., 12% perform germline testing, 44% refer to a genetic counselor, 11% do both, and 33% do not test/refer. Only 4% had formal education in genetics. While 98% ask about PCa family history, only 76% and 52% ask about breast and ovarian cancer. When presented with hypothetical case scenarios where germline testing is indicated, many respondents indicated they would not offer genetic counseling or testing. Younger age (p = 0,03), academic practice (p = 0.04), and specializing in PCa/oncology (p = 0.007) were significantly associated with performing or referring for germline testing. Specializing in PCa/oncology was significantly associated with recommending germline testing for all case scenarios involving metastatic PCa (p = 0.0009) ConclusionOur results suggest significant gaps in knowledge of germline testing and alignment of practice with national guidelines among urologists. Germline testing education and facilitation of genetic evaluation in urologic practice is warranted.

Deprescribing psychotropic medications in children: results of a national qualitative study

Background and ObjectivePrescriptions for psychotropic medications to children have risen dramatically in recent years despite few regulatory approvals and growing concerns about side effects. Government policy and numerous programmes are...

Virtual Reality-Based Resilience Programs: Feasibility and Implementation for Inpatient Oncology Nurses.

The high prevalence of compassion fatigue contributes to burnout among oncology nurses. Interventions are needed to support individuals across diverse roles and practice settings in oncology. Virtual reality (VR) is an emerging technology that has been applied in healthcare education and training and is being explored as an intervention to reduce stress and support wellness for healthcare providers. This article reviews recommendations from an implementation project about a VR intervention for oncology nurses.

A Process for Assessing Products for Infection Prevention in Health Care Settings: A Framework From the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention.

Infection control is a complex task that spans people, products, and practices in diverse settings. For years, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has provided advice and guidance to the Centers for Disease Control and Prevention (CDC) on how best to prevent infections. These recommendations have focused largely on health care delivery practices and occasionally on general categories of products. With an influx of novel infection control products and growing use of these products by frontline clinicians, an efficient process for developing transparent, rigorous product recommendations that includes myriad data sources was necessary. To address this gap, the CDC asked HICPAC to develop a process that would help inform committees considering product-related recommendations. This article describes the process to develop this approach and provides an outline of how the tool may be used when products with infection control claims are recommended in guidelines or recommendations for infection prevention.

Prospective study to define the clinical utility and benefit of Decipher testing in men following prostatectomy

BackgroundGenomic classifiers (GC) have been shown to improve risk stratification post prostatectomy. However, their clinical benefit has not been prospectively demonstrated. We sought to determine the impact of GC testing on postoperative management in men with prostate cancer post prostatectomy.MethodsTwo prospective registries of prostate cancer patients treated between 2014 and 2019 were included. All men underwent Decipher tumor testing for adverse features post prostatectomy (Decipher Biosciences, San Diego, CA). The clinical utility cohort, which measured the change in treatment decision-making, captured pre- and postgenomic treatment recommendations from urologists across diverse practice settings (n = 3455). The clinical benefit cohort, which examined the difference in outcome, was from a single academic institution whose tumor board predefined “best practices” based on GC results (n = 135).ResultsIn the clinical utility cohort, providers’ recommendations pregenomic testing were primarily observation (69%). GC testing changed recommendations for 39% of patients, translating to a number needed to test of 3 to change one treatment decision. In the clinical benefit cohort, 61% of patients had genomic high-risk tumors; those who received the recommended adjuvant radiation therapy (ART) had 2-year PSA recurrence of 3 vs. 25% for those who did not (HR 0.1 [95% CI 0.0–0.6], p = 0.013). For the genomic low/intermediate-risk patients, 93% followed recommendations for observation, with similar 2-year PSA recurrence rates compared with those who received ART (p = 0.93).ConclusionsThe use of GC substantially altered treatment decision-making, with a number needed to test of only 3. Implementing best practices to routinely recommend ART for genomic-high patients led to larger than expected improvements in early biochemical endpoints, without jeopardizing outcomes for genomic-low/intermediate-risk patients.

Dabigatran Persistence and Outcomes Following Discontinuation in Atrial Fibrillation Patients from the GLORIA-AF Registry

Prospective studies evaluating persistence to nonvitamin K antagonist oral anticoagulants in patients with atrial fibrillation are needed to improve our understanding of drug discontinuation. The study objective was to evaluate if and when patients with newly diagnosed atrial fibrillation stop dabigatran treatment and to report outcomes following discontinuation. Patients prescribed dabigatran in diverse clinical practice settings were consecutively enrolled and followed for 2 years. Dabigatran persistence over time, reasons for discontinuation, and outcomes post discontinuation were assessed. Of 4,859 patients, aged 70.2 ± 10.4 years, 55.7% were male. Overall 2-year dabigatran persistence was 70.9% (95% confidence interval [CI] 69.6 to 72.2). Persistence probability was lower in the first 6-month period (83.7% [82.7 to 84.8]) than in subsequent periods for patients on dabigatran at the start of each period (6 to 12 months, 92.5% [91.6 to 93.3]; 12 to 18 months, 95.1% [94.3 to 95.8]; 18 to 24 months, 96.3% [95.6 to 96.9]). Of 1,305 patients (26.9%) who discontinued dabigatran, adverse events were reported as the reason for discontinuation in 457 (35.0%). Standardized stroke incidence rate post discontinuation (per 100 patient-years) in patients discontinuing without switching to another oral anticoagulant was 1.76 (95% CI 0.89 to 2.76) and 1.02 (95% CI 0.43 to 1.76) in those who switched, consistent with the expected benefit of remaining on treatment. Patients persistent with treatment at 1 year had >90% probability of remaining persistent at 2 years suggesting clinical interventions to improve persistence should be focused on the early period following treatment initiation.

Perioperative Outcomes and Trends in the Use of Robotic Colectomy for Medicare Beneficiaries From 2010 Through 2016

The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice. To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings. This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019. Receipt of robotic colectomy. Incidence of postoperative medical and surgical complications and length of stay. A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]). While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.

A protocol analysis of use of forward and backward reasoning during valuation problem solving

PurposeBehavioural studies of valuers have suggested that valuers rely on a number of cognitive strategies involving reasoning and intuition when undertaking a valuation task. However, there are few studies of the actual reasoning mechanisms in valuation. In other fields, much attention has been paid to forward and backward reasoning, as this shows the choices and decisions that are made in undertaking a complex task. This paper studied this during a valuation task. The purpose of this paper is twofold: first, to develop a methodological approach for empirical research on valuers’ reasoning, and, second, to report expert-novice differences on valuers’ use of forward and backward reasoning during a valuation problem solving.Design/methodology/approachThe study utilised a verbal protocol analysis (VPA) to elicit think-aloud data from a purposive sample of a group of valuers of different levels of expertise undertaking a commercial-valuation task. Through a content analysis interpretive strategy, the transcripts were analysed into different cognitive segments identifying the forward and backward reasoning strategies.FindingsThe findings showed that valuers accomplished the valuation task by dividing the overall problem into sub-problems. These sub-problems are thereafter solved by integrating available data with existing knowledge by relying more on forward reasoning than backward reasoning. However, there were effects associated with the level of expertise in the way the processes of forward and backward reasoning are used, with the expert and intermediate valuers being more thorough and comprehensive in their reasoning process than the novices.Research limitations/implicationsThis study explores the possibility that forward and backward reasoning play an important role in commercial valuation problem solving using a limited sample of valuers. Given this, data cannot be generalised to all valuation practice settings but may motivate future research that examines the effectiveness of forward and backward reasoning in diverse valuation practice settings and develops a holistic model of valuation reasoning.Practical implicationsThe findings of this study are applicable to valuation practice. Future training efforts need to evaluate the usefulness of teaching problem solving and explicitly recognise forward and backward reasoning, along with other problem-solving strategies uncovered in this study, as standard training strategies for influencing the quality of valuation decisions.Originality/valueBy adopting VPA, this study employs an insightful and rich dataset which allows an interpretation of thoughts of valuers into cognitive reasoning strategies that provide a deeper level of understanding of how valuers solve valuation problem; this has not been possible in previous related valuation studies.

The effectiveness of a proven chronic disease prevention and screening intervention in diverse and remote primary care settings: an implementation study on the BETTER 2 Program.

BackgroundThe Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) randomised control trial (RCT) showed that the BETTER Program improved chronic disease prevention and screening (CDPS) by 32.5% in urban team-based primary care clinics.AimTo evaluate outcomes from implementation of BETTER in diverse clinical settings.Design & settingAn implementation study was undertaken to apply the CDPS intervention from the BETTER trial to diverse settings in BETTER 2. Patients aged 40–65 years were invited to enrol in the study from three clinics in Newfoundland and Labrador, Canada.MethodAt baseline, eligibility for 27 CDPS actions (for example, cancer, diabetes and hypertension screening, lifestyle) was determined. Patients then met with a trained provider and prioritised goals to address their eligible CDPS actions. Providers received training in behaviour change theory and practice. Descriptive analysis of clinical outcomes and success factors were reported.ResultsA total of 154 patients (119 female and 35 male) had a baseline visit; 106 had complete outcome assessments, and the remainder had partial outcome assessments. At baseline, patients were eligible for a mean of 12.3 CDPS actions and achieved a mean of 6.0 (49%, 95% confidence intervals [CI] = 24% to 74%) at 6-month follow-up, including reduced hypertension (86% of eligible patients, 95% CI = 67% to 96%), weight control (51% of eligible patients, 95% CI = 42% to 60%), and smoking cessation (36% of eligible patients, 95% CI = 17% to 59%). Male, highly educated, and lower income individuals achieved a higher proportion of CDPS manoeuvers than their counterparts.ConclusionClinical outcomes from this implementation study were comparable with those of the prior BETTER RCT, providing support for the BETTER Program as an effective approach to CDPS in more diverse general practice settings.

Development of Phase-Specific Breast Cancer Survivorship Care Plans

IntroductionPhase-specific survivorship care plans (SCPs) have the potential to be powerful tools in providing individualized, comprehensive survivorship care, particularly in terms of care coordination and transition, if used as dynamic documents. Materials and MethodsWe designed an initial follow-up care plan (FCP) to be used at the conclusion of curative therapy, as well as distinct, phase-specific FCPs for periodic use at 5-year and 10-year time points in the survivorship course. These FCPs incorporate the 4 essential components of survivorship care outlined by the Institute of Medicine: prevention, surveillance, intervention for consequences of cancer treatment, and coordination among health care providers. ResultsPhase-specific SCPs were designed by a multidisciplinary team with expertise in breast health, survivorship, and cancer care delivery across diverse practice settings. The FCPs were formulated to align with national guidelines and emergent, peer-reviewed literature, and reflect evolving recommendations regarding the duration of adjuvant hormone therapy. The SCPs were pilot-tested and successfully integrated into the existing work flow of the electronic medical records at each practice site. ConclusionPhase-specific SCPs were developed to incorporate new knowledge about evolving treatment recommendations, screening guidelines, and updated genetic information to encourage timely discussions relevant to the specific stage of survivorship.

Aseptic technique: how do we achieve best practice in diverse settings?

In the absence of evidence, the RCN has been gathering its members’ views on a core skill

Aligning Inpatient Pediatric Research With Settings of Care: A Call to Action.

* Abbreviations: KID — : Kids’ Inpatient Database QI — : quality improvement Hospital-based pediatric care occurs in structurally diverse settings, ranging from large freestanding children’s hospitals to small rural community hospitals. Although there has been a recent trend toward increasingly regionalized pediatric care,1 the majority of pediatric patients are still cared for in nonchildren’s hospitals.2 A recent study revealed that less than one-third of all pediatric hospitalizations in the United States occur at freestanding children’s hospitals.2 In contrast, more than half of hospitalizations for children are estimated to occur in community hospitals,2 which we define as general hospitals that are neither freestanding nor nested children’s hospitals that admit children to licensed pediatric beds. Currently the majority of pediatric research funded by the National Institutes of Health originates at a relatively small number of children’s hospitals,3 and the creators of a national initiative to establish pediatric inpatient research priorities used data that exclusively represented patients cared for at freestanding children’s hospitals.4 The absence of community-hospital representation in the research arena leaves questions that may be the most pertinent to clinical care in these hospitals both unasked and unanswered. Because of heterogeneity of patient volumes, diverse practice settings, and often limited access to pediatric-specific resources in community hospitals, clinical guidelines and quality improvement (QI) recommendations derived from research conducted at children’s hospitals may not be directly applicable in … Address correspondence to Corrie E. McDaniel, DO, Department of Pediatrics, Seattle Children’s Hospital, 4800 Sandpoint Way NE, Mailstop FA.2.115, PO Box 5371, Seattle, WA 98105. E-mail: corrie.mcdaniel{at}seattlechildrens.org