Out Of State Research Articles

Abortion provision and characteristics of abortion patients in an academic medical center in Washington state before and after Dobbs.

To examine abortion care in the largest academic medical center in Washington, a state protective of abortion rights, before and after the Supreme Court Dobbs decision. This retrospective cohort study evaluated abortion provision at the University of Washington between January 1, 2022 and October 31, 2023. Data on patient sociodemographic and clinical characteristics were extracted from electronic medical records. We assessed differences in patient sociodemographics, clinical characteristics, and type of care (medication vs. procedural) comparing the pre-Dobbs (January 1, 2022- June 23, 2022) and post-Dobbs (June 24, 2022 - October 31, 2023) periods using chi-squared tests for categorical variables and t-tests for continuous variables. Among the 494 abortions performed during the study period, most were procedural (63%) and performed in the hospital setting (68%), over one-third (37%) had a fetal anomaly, and 4% were among individuals from out of state. The distribution of gestational duration was bimodal: over one-third of abortions occurred at less than 8weeks gestation (34%) and 38% were 18weeks or greater. The weekly number of abortions remained stable and there were minimal significant differences in patient characteristics or type of care comparing the pre-and-post Dobbs periods. Academic medical centers provide comprehensive abortion services that span primary to complex specialty care. The minimal changes in abortion care following Dobbs suggests academic medical centers have important patient care and training opportunities to expand abortion access in Washington state.

Catastrophic Health Expenditures for In-State and Out-of-State Abortion Care

Most US individuals who access abortion care pay out of pocket due to insurance coverage restrictions on abortion. More research is needed on the financial and psychological burdens of abortion seeking, particularly for those traveling across state lines for care. To estimate the proportion of patients seeking abortion who incur abortion-related catastrophic health expenditures (CHEs), assess whether CHE differs between those seeking care in state vs out of state, and examine the association of CHE with mental health symptoms. In this cross-sectional study conducted before the Dobbs v Jackson Women's Health Organization decision, surveys were administered between January and June 2019 among individuals aged 15 to 45 years seeking abortion in 4 clinics located in abortion-supportive states (California, Illinois, and New Mexico). Participants completed self-administered questionnaires while awaiting their abortion appointment. Analyses were conducted from November 2023 to April 2024. Travel for abortion care, categorized as either out of state or in state based on participants' state of residence and the clinic location. Self-reported abortion care costs and additional non-health care costs (eg, transportation, accommodation, and missed work), which were considered catastrophic if they were 40% or greater of participants' ability to pay (defined as monthly income remaining after meeting subsistence needs). Multivariable regression analyses were conducted to examine associations between CHE, out-of-state travel for abortion care, and mental health symptoms including stress, anxiety, and depression. Among the 675 participants included in the analytic sample, mean (SD) age was 27.33 (6.27) years; most were in their 20s (374 [55%]), and all but 196 (29%) sought abortion before or at 12 weeks' gestation. A total of 285 participants (42%) were estimated to incur abortion-related CHEs, which was associated with anxiety (APR, 1.13; 95% CI, 1.07-1.19) and depression (APR, 1.25; 95% CI, 1.12-1.39). Of people traveling from out of state (212 [31%]), more were likely to incur CHEs (138 [65%]) compared with those seeking care in state (147 of 463 [32%]) (APR, 2.24; 95% CI, 1.67-3.00). In this cross-sectional study of US patients seeking abortion, many individuals and their households were estimated to incur CHEs, particularly those traveling from out of state. The financial and psychological burdens of abortion seeking have likely worsened after the Dobbs decision, as more people need to cross state lines to reach abortion care. The findings suggest expansion of insurance coverage to ensure equitable access to abortion care, irrespective of people's state of residence, is needed.

Current Burden of and Geographic Disparities in Liver Mortality and Access to Liver Transplant

Liver disease is a leading cause of mortality in the US. Liver transplant can be a lifesaving procedure for patients with severe liver disease. To assess temporal trends and geographic variance in liver-related mortality (LRM) and liver transplant in the US. In this cohort study, the frequencies and geographic variance of LRM in 2018 and 2021 were obtained in a cross-sectional analysis of the Underlying Cause of Death data available on the Centers for Disease Control and Prevention's Epidemiologic Research database. The number of livers donated and transplanted according to the state of residence of each donor and recipient were obtained from the United Network for Organ Sharing. Liver-related mortality in 2018 and 2021, overall and by state, as well as the liver transplant rate according to state of residence of recipient and donor. Overall LRM in the US was 93 418 in 2021, with a crude rate of 28.1 per 100 000 individuals, an increase of 19.1% compared with rates seen immediately prior to the COVID-19 pandemic in 2018 (77 282 [23.6 per 100 000 individuals]). Liver-related mortality in 2021 varied several-fold between states, from 18.4 per 100 000 individuals per year in Utah to 65.9 per 100 000 individuals per year in New Mexico. The mean number of liver-related deaths per transplant from all donor sources (in state and out of state) was 7.2 in the lowest LRM quintile compared with 21.5 in the highest (95% CI, 12.1-16.6; SE, 1.1; P < .001). Ten states had no liver transplant center. Paradoxically, residents of states with the highest LRM had a much lower rate of liver transplant (at any location) from organs procured from in-state residents than states with the lowest LRM quintile (13.0% vs 35.2% in-state donors; 95% CI, 14.1%-30.3%; SE, 3.9%; P < .001). This study suggests that rates of LRM have increased dramatically since the COVID-19 pandemic and vary several-fold between states. Rates of liver transplant are paradoxically lowest among residents living in states with the highest LRM. These findings highlight apparent geographic disparities in access to liver transplant that allocation policy cannot address.

Telemedicine and Patient Experience Ratings at an Academic Integrative Medicine Practice: Retrospective Examination.

The use of telemedicine (TELE) increased exponentially during the COVID-19 pandemic. While patient experience with TELE has been studied in other medical disciplines, its impact and applicability to integrative medicine practices remain unknown. The aim of this study is to assess the impact of visit modality, TELE versus face-to-face (F2F) encounters, on patient experience at an integrative medicine practice at a single academic medical center. Given the significant role of the patient-physician relationship, therapeutic presence, and touch in integrative medicine, we hypothesized that TELE would result in reduced patient experience compared to traditional F2F encounters. A retrospective examination of Press Ganey surveys at an academic, consultative, and integrative medicine practice was conducted. Anonymous surveys completed by patients, older than 18 years of age, who had TELE or F2F appointments from April 1, 2020, to March 31, 2023, were included. At our medical center, patients commonly travel in from out of state for complex care. We examined percentage "top box" scores (ie, the percentage of respondents who selected the most positive response category on the survey, "very good"), across a variety of experience metrics. ANOVA and chi-square analyses were completed, with a significance threshold of P<.05. Over the 36 months, a total of 1066 surveys were completed and returned (TELE: n=333; F2F: n=733). Overall, 73% (n=778) of respondents were female with an average age of 57.6 (SD 13.84) years. Most patients were English-speaking (n=728, 99.3%), White (n=1059, 92.7%), and not Hispanic or Latino (n=985, 92.4%). There was significantly higher satisfaction with access to care for TELE visits compared to F2F visits. There were no differences in satisfaction with the care provider or in overall experience. When examining the specific aspects of using technology during TELE visits, there were no differences in audio quality, visual quality, or ease of talking to the care provider based on sex. There was, however, a difference in video quality based on age, where those 80 years and older rated significantly lower video quality compared to all other age groups. Top-level patient experience can be attained with TELE integrative medicine visits. Additional studies, particularly those correlating positive experience findings with specific behaviors used during TELE visits, would further our understanding of the integrative medicine patient experience. In the meantime, efforts should be made to ensure a policy that promotes the ongoing provision of TELE in integrative medicine.

Abortion Provision and Delays to Care in a Clinic Network in Washington State After Dobbs

The Supreme Court decision Dobbs v Jackson Women's Health Organization (Dobbs) overturned federal protections to abortion care and altered the reproductive health care landscape. Thus far, aggregated state-level data reveal increases in the number of abortions in states where abortion is still legal, but there is limited information on delays to care and changes in the characteristics of people accessing abortion in these states after Dobbs. To examine changes in abortion provision and delays to care after Dobbs. Retrospective cohort study of all abortions performed at an independent, high-volume reproductive health care clinic network in Washington state from January 1, 2017, to July 31, 2023. Using an interrupted time series, the study assessed changes in abortion care after Dobbs. Abortion care obtained after (June 24, 2022, to July 31, 2023) vs before (January 1, 2017, to June 23, 2022) Dobbs. Primary outcomes included weekly number of abortions and out-of-state patients and weekly average of gestational duration (days) and time to appointment (days). Among the 18 379 abortions during the study period, most were procedural (13 192 abortions [72%]) and funded by public insurance (11 412 abortions [62%]). The mean (SD) age of individuals receiving abortion care was 28.5 (6.44) years. Following Dobbs, the number of procedural abortions per week increased by 6.35 (95% CI, 2.83-9.86), but then trended back toward pre-Dobbs levels. The number of out-of-state patients per week increased by 2 (95% CI, 1.1-3.6) and trends remained stable. The average gestational duration per week increased by 6.9 (95% CI, 3.6-10.2) days following Dobbs, primarily due to increased gestations of procedural abortions. The average gestational duration among out-of-state patients did not change following Dobbs, but it did increase by 6 days for in-state patients (5.9; 95% CI, 3.2-8.6 days). There were no significant changes in time to appointment. These findings provide a detailed picture of changes in abortion provision and delays to care after Dobbs in a state bordering a total ban state. In this study, more people traveled from out of state to receive care and in-state patients sought care a week later in gestation. These findings can inform interventions and policies to improve access for all seeking abortion care.

Increased Proportion of Black Transfusion Dependent Thalassemia Patients in a Single Southeast U.S. Center

Thalassemia is a common disorder worldwide but remains relatively rare in the United States (U.S). Over the past decade, there has been a significant demographic shift as more patients are entering care as either international adoptees or refugees from under-resourced countries. We analyzed our own center's demographic evolution from 2014 to 2023. Only transfusion dependent thalassemia (TDT) patients fully managed within our pediatric center are represented in Table 1. We did not include non-transfusion dependent thalassemia (NTDT) patients nor TDT patients who have graduated to adult care, relocated, or those who travel to our center only for comprehensive visits from out of state. When compared to the national data collected by the Cooley's Anemia Foundation (CAF), we saw a similar increase in patients from China and Southeast Asia (SEA), reflecting the increased number of adoptees in the period from 2014-2019 (Tables 1 &amp; 2). Since that time, we have seen an increase in patients from South Asia (SA) and the Middle East (ME). These patients are mostly refugees from regional conflicts (Syria, Afghanistan, Myanmar, etc.). This trend is similar to other centers, according to the CAF (unpublished communication). Interestingly, however, our center has a significantly larger proportion of Black TDT patients compared to the national data (Table 2 ). As can be seen in the tables below, we have nearly 20x more Black patients (20-22.9% vs. 0.9-1.2%) when compared to the national data. This may be in part due to our center's location in Atlanta, Georgia. However, according to the latest U.S. Census data, Georgia's population is 33.1% Black, compared to 13.6% in the U.S population as a whole. Based on this, we would expect a 2.4x increase, as opposed to a 20x increase. Vichinsky et al published a study in Pediatr Blood Cancer in 2017 using data collected from 4 Comprehensive Thalassemia Treatment Centers (CTTC) in the Northeast, Midwest and West coast of the U.S. looking at the racial distribution and changes of NTDT patients. They also found a higher-than-expected proportion of Black patients, about 17%. Of our 65 NTDT patients, 26% are Black and an additional 5% are mixed race, Black and Asian. The majority (60%) have Hemoglobin H disease. We looked to see if our TDT patients were relatives of sickle cell disease (SCD) patients, since our center has the largest pediatric SCD population in the U.S. However, only 20% (2/10) report family members with any form of SCD. The majority (8/10) of the patients identify as African American, whereas the remaining 2 are 1st generation Somalian and Ghanaian. Genotype data is available for 9/10 patients, with three ß0/ß0 and six ß+/ß0. The most common mutations seen were IVS II-849 A&amp;gt;G (ß0), -29nt A&amp;gt;G (ß+), Promoter -88nt G&amp;gt;T (ß+) and Codon 5 (-CT) frameshift (ß0). All are mutations predominantly found in Blacks. Clinically, as a group, they had a high rate of splenomegaly (8/10) and skull changes (6/10) before transfusions began. Transfusions began ages 6mos-9 yrs. with 50% occurring after age 3 yrs. Black TDT patients may face unique challenges in the U.S. where there are &amp;gt;50 SCD patients for every thalassemia patient. Indications for transfusion and overall clinical management are vastly different for these two diseases, but providers with little experience in the treatment of Thalassemia may inappropriately treat them like SCD patients.

Operationalization of decentralized clinical trials: The BrUOG354 experience.

100 Background: Decentralized clinical trials (DCT) aim to bring a trial’s activities to the patient. However, to date there is little practical experience about conducting them in the therapeutic arena. Due to the COVID-19 pandemic, and in partnership with Bristol Myers Squibb (BMS), we modified our Investigator-Initiated study, BrUOG354 (ClinicalTrials.gov ID: NCT03355976), a phase II trial on the role of Nivolumab and Ipilimumab in extra-renal clear cell carcinoma. This allowed for the shipment of investigational product (IP) to the patient for local administration without trial site activation. Here we report the experience and lessons learned. Methods: The administrative process to facilitate decentralization on BrUOG-354 required FDA guidance, BMS agreement, and Lifespan IRB approval. Brown University Oncology Group (BrUOG) databases were mined for all communications with local sites and providers. We report on enrollment figures per quarter pre- and during/post-pandemic, the number of off-study sites approached, and agreements reached. The reasons for not moving forward at the local site were characterized by two authors (DD, RW). Results: This study was initiated at two Providence health systems initially and activated a third site at the University of Illinois at Chicago in 2021. In total, 46 volunteers were consented to this trial between April 2018 and April 2023, with 16 (34.8%) registered prior to the lockdown in March 2020 and 30 (65.2%) after. Among 34 patients treated at the PI’s institution, seven travelled from out of state for treatment. Two who started treatment pre-lockdown were successfully transitioned so that protocol therapy was administer locally, and both remain on study. Five people were registered during the pandemic and six institutions were approached; three accommodated the request. Reasons provided for not allowing local administration of IP including: unavailability of a research pharmacy (1), blanket institutional prohibition (1) and lack of indemnification language (1). Conclusions: The experience with BrUOG354 exemplifies the potential of DCTs in an oncological setting while simultaneously highlighting barriers to implementation. Therapeutic DCTs are feasible and heightened capacity for future patient-centric trial designs is an exciting prospect. For these to succeed, the ability to conduct study visits by telehealth, especially for out of state residents, is critical. While not originally designed to be decentralized, adopting this approach enabled us to complete enrollment in a rare tumor during the pandemic. By shifting to a patient-centric model, DCTs may improve patient access and options for clinical trials in particular for less common malignancies, while preserving quality of life, addressing financial toxicity, and foster a more diverse trial population. Clinical trial information: NCT03355976 .

FRI627 Lost In The Striato-sphere: Diabetic Striatopathy In An Elderly Patient Who Was Lost To Follow-up

Abstract Disclosure: C.L. Loughner: None. E. Mahmood: None. A. Sheharyar: None. Introduction: Diabetic striatopathy (DS) represents a spectrum of central nervous system derangements associated with uncontrolled hyperglycemia.1 The most common site of brain involvement is the putamen but can involve any region of the striatal nuclei. The exact mechanism behind DS remains unclear, but current theories postulate hyperosmolarity-related ischemic events that lead to breakdown in the blood-brain barrier and mineral deposition2. We present a case of DS demonstrating a rare neurologic complication resulting from uncontrolled diabetes mellitus. Clinical Case: An 82-year-old female was admitted for workup following new-onset left-sided involuntary jerking movements. On exam, there were choreiform movements in the left upper and lower extremities. Initially, Levetiracetam was started for possible focal motor seizures but with no improvement. MRI brain showed T1 hyperintensity of the right lentiform nucleus, consistent with DS. She had moved recently from out of state and had inconsistent follow-up for type 2 diabetes mellitus for years. Her HbA1c was 13.8%. She was non-compliant with glucose monitoring and insulin therapy. With a comprehensive treatment plan including Haloperidol, physical therapy, improved CGM compliance, and four-times-daily insulin regimen, her chorea improved and resolved completely over a few weeks. Clinical Lesson: DS can present with a variety of neurologic manifestations, including chorea. While choreiform movements can severely impact a patient’s life, they are rarely permanent if treated with either glycemic control or anti-chorea medications. This case highlights the importance to recognize rarer complications of diabetes and the impact of good glycemic control for successful treatment of diabetic striatopathy.

Midwives Safeguarding Abortion Access: Establishing Medication Abortion Services.

The abortion access landscape for patients has changed dramatically in the wake of the US Supreme Court Dobbs v. Jackson Women's Health Organization decision in June of 2022. In response, the Division of Midwifery at Baystate Medical Center in Springfield, Massachusetts, began a medication abortion service for both established patients and those who may seek care from out of state. This service increases access to abortion care now while also providing the clinical experience needed for student nurse-midwives to become future abortion providers. This article outlines the steps taken to implement a medication abortion service and ways it can be adopted by other midwifery practices. Strategies to address possible clinical, administrative, and logistical challenges are addressed. Finally, this article is a call to action because midwives are well qualified to provide high quality, safe, and comprehensive medication abortion within the midwifery model of care.

182 North Carolina Small Ruminant Improvement Program Workshops Build Producer Knowledge of Important Management Techniques

Abstract Growing interest in small ruminant production, strong market demand, and producers’ minimal use of data-driven management practices led to the development of the North Carolina Small Ruminant Improvement Program (NCSRIP) in 2021. This program seeks to improve the number and quality of small ruminants produced in North Carolina as well as improve producer profitability. Three workshops were held to increase producer awareness of new small ruminant production practices and opportunities. All workshops included classroom and breakout sessions featuring hands-on activities. In February 2022, the Lambing and Kidding Workshop was held in cooperation with NC Sheep Producers Association at the North Carolina State Small Ruminant Educational Unit (Raleigh, NC). Topics included pre-lambing/kidding management, lambing and kidding diseases, the birthing process, dystocia management and lamb/kid processing. The Flock Management Workshop was held in May on a working sheep farm near Dobson, NC. Attendees learned about hay sampling and analysis, ration balancing, flock health management and cost share resources for small ruminant operations. In June, the NCSRIP joined with the Eastern Alliance for Production Katahdins to host a grazing school in Roxboro, NC. The agenda featured predator regulatory considerations, herding dog use, parasite management, genetic selection, soil health and pasture management. Workshop pre-registrations were 162 with 65 attending the events with 63 evaluations completed. Fifty-six percent of participants owned 1-50 breeding females. Twenty-seven percent of participants had no livestock but were gathering information for future endeavors. Fifty-seven percent of operations owned sheep, 13.0% raised goats, 7.4% produced cattle and 22.4% grazed combinations of all species. Fifty-seven percent of producers lived in the North Carolina Piedmont region while 14.3% resided in the Coastal region, 2.9% from the Mountain region and 25.7% from out of state. Post-workshop evaluations asked attendees to rank their increased understanding of each major agenda topic. On a scale of 1 to 5 (1 = no improvement to 5 = significant improvement), participants indicated they had improvement in all topics (mean = 4.18). When asked about participating in future NCSRIP events, producers suggested they would attend (mean = 4.62; 1 = will not participate to 5 = will attend if possible). When asked about what they like most about these workshops, attendees mentioned the hands-on approach and practical knowledge gained. Producer feedback indicates a growing interest in small ruminant production and a need for continued practical education programs.

U. of South Carolina's Scott Verzyl: Long‐term programs helped boost applications, spur enrollment, and raise the university's graduation rate

When Scott Verzyl joined the University of South Carolina in 2004, the school's goals were clear but wide‐ranging. The public university wanted to grow its enrollment, increase applicants from both in‐state and out of state, and improve the profile of the student body.

Long‐term programs helped spur enrollment

When Scott Verzyl joined the University of South Carolina in 2004, the school's goals were clear but wide‐ranging. The public university wanted to grow its enrollment, increase applicants from both in‐state and out of state, and improve the profile of the student body.

Long‐term programs helped boost applications, spur enrollment

When Scott Verzyl joined the University of South Carolina in 2004, the school's goals were clear but wide‐ranging. The public university wanted to grow its enrollment, increase applicants from both in‐state and out of state, and improve the profile of the student body.

U. of South Carolina's Scott Verzyl: Long‐term programs helped boost applications, spur enrollment

U. of South Carolina's Scott Verzyl: Long‐term programs helped boost applications, spur enrollment

Association of Texas’ 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States

Texas' 2021 ban on abortion in early pregnancy may demonstrate how patterns of abortion might change following the US Supreme Court's June 2022 decision overturning Roe v Wade. To assess changes in the number of abortions and changes in the percentage of out-of-state abortions among Texas residents performed at 12 or more weeks of gestation in the first 6 months following implementation of Texas Senate Bill 8 (SB 8), which prohibited abortions after detection of embryonic cardiac activity. Retrospective study of a sample of 50 Texas and out-of-state abortion facilities using an interrupted time series analysis to assess changes in the number of abortions, and Poisson regression to assess changes in abortions at 12 or more weeks of gestation. Data included 68 820 Texas facility-based abortions and 11 287 out-of-state abortions among Texas residents during the study period from September 1, 2020, to February 28, 2022. Abortion care obtained after (September 2021-February 2022) vs before (September 2020-August 2021) implementation of SB 8. Primary outcomes were changes in the number of facility-based abortions for Texas residents, in Texas and out of state, in the month after implementation of SB 8 compared with the month before. The secondary outcome was the change in the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation during the 6-month period after the law's implementation. Between September 2020 and August 2021, there were 55 018 abortions in Texas and 2547 out-of-state abortions among Texas residents. During the 6 months after SB 8, there were 13 802 abortions in Texas and 8740 out-of-state abortions among Texas residents. Compared with the month before implementation of SB 8, the number of Texas facility-based abortions significantly decreased from 5451 to 2169 (difference, -3282 [95% CI, -3171 to -3396]; incidence rate ratio [IRR], 0.43 [95% CI, 0.36-0.51]) in the month after SB 8 was implemented. The number of out-of-state abortions among Texas residents significantly increased from 222 to 1332 (difference, 1110 [95% CI, 1047-1177]; IRR, 5.38 [95% CI, 4.19-6.91]). Overall, the total documented number of Texas facility-based and out-of-state abortions among Texas residents significantly decreased from 5673 to 3501 (absolute change, -2172 [95% CI, -2083 to -2265]; IRR, 0.67 [95% CI, 0.56-0.79]) in the first month after SB 8 was implemented compared with the previous month. Out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation increased from 17.1% (221/1291) to 31.0% (399/1289) (difference, 178 [95% CI, 153-206]) during the period between September 2021 and February 2022 (P < .001 for trend). Among a sample of abortion facilities, the 2021 Texas law banning abortion in early pregnancy (SB 8) was significantly associated with a decrease in the documented total of facility-based abortions in Texas and obtained by Texas residents in surrounding states in the first month after implementation compared with the previous month. Over the 6 months following SB 8 implementation, the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation significantly increased.

Covid, colleges, and classes

ABSTRACT At the start of the 2020 school year, some colleges chose to reopen in person while others offered primarily online classes. We find that colleges responded to financial and other incentives largely as one might expect. Larger shares of revenue attributed to in-person activities, such as dorms and dining halls, led schools to reopen in person. In general, the share of revenue due to tuition and fees had little association with reopening in-person, which is consistent with the idea that the effect of the mode of reopening on enrolment was ambiguous. However, private schools experiencing financial distress due to tuition and fees were more likely to reopen in-person while public schools were less likely. Public colleges were influenced by political pressures and the fraction of students from out of state, while private schools responded to the severity of COVID in their local community.

Economic geography aspects of the Panama Canal

AbstractThis paper studies how the opening of the Panama Canal in 1914 changed counties’ market potential and influenced the economic geography of the USA. We compute shipment effective distances with and without the canal from each US county to each other US county and to international ports and compute the resulting change in market potential. The main elasticity would imply that a 1% increase in market potential led to a total increase of population by around 2.3% in 1940. We compute similar elasticities for wages, land values, and immigration from out of state. Tradable (manufacturing) industries react stronger than non-tradable (services) industries.

Rural community pharmacist willingness to dispense Suboxone® - A secret shopper investigation in South-Central Appalachia

BackgroundBuprenorphine access is limited for patients with opioid use disorder, especially in rural areas. Telephone audits have identified pharmacist limitations to the dispensing of buprenorphine particularly in independent pharmacies in comparison to chain pharmacies and in rural areas. The objective of this study was to assess rural community pharmacists' stated willingness to dispense buprenorphine-naloxone, and document potential bias and or stigma that the shopper experiences when asking about buprenorphine- naloxone. MethodsTo assess pharmacist willingness, a telephone audit of 15 rural Appalachian North Carolina pharmacies was conducted. Three secret shopper scenarios were utilized including one shopper posing as a new patient, one shopper posing as an out of state patient, and one shopper first asking about buying syringes. Encounters were noted by willingness to dispense buprenorphine, and shoppers were to note any potential stigma and or bias that they experienced while asking for Suboxone®. ResultsOverall, 60% of pharmacies audited indicated willingness to dispense buprenorphine without reservation, and 31% indicated willingness to dispense only under certain circumstances. Pharmacies tended to add more conditions to dispensing to the out of state patient (46%), such as only dispensing if the practitioner was from in state in comparison to the other shopper scenarios. Potential stigma and bias were encountered in 40% of the 45 encounters. ConclusionAlthough pharmacies overall seemed willing to dispense, nuances regarding who pharmacies are most likely to dispense are felt in rural areas. Buprenorphine access limitations were more common in independent pharmacies and more often placed on patients from out of state. Pharmacy- directed education is necessary to reduce stigma and bias and increase patient access to buprenorphine.

An Exploration of Nonresident Student Enrollment and Institutional Finances at Public Universities

Many public universities have sought to increase the number of students they enroll from other states, with the assumption that a larger share of nonresident students increases institutional revenues and prestige. In this paper, I examine the extent to which out-of-state undergraduate student enrollment shares are associated with changes in per-student revenue and expenditure patterns at four-year public universities both as a whole and by selectivity and Carnegie classification. I find that an increase in the percentage of students from out of state is associated with decreases in per-student tuition revenue and is often associated with a decline in per-student expenditures.

Beginning Teacher Support Model: Elementary Teachers’ Resilience and Retention in Arizona

In the United States, beginning teacher retention rates are extraordinarily low; only 50% of teachers remain in the classroom after five years. In particular, the State of Arizona has been recruiting significant numbers of teachers from out of state and attempting to retain them with minimal success. This persistent problem has led the neediest of students to have teachers with lower levels of professional experience, leaving those students with continually lower achievement gains. Drawing on integrated action research and grounded theory methodology, this study’s took place in a large kindergarten to eighth grade elementary school district located in a high-poverty neighborhood in Arizona. The study invited six new teachers in their first year of teaching to explore innovative strategies to increase these teachers’ retention in the profession. The ultimate goal was to understand how such support might alter a beginning teacher’s perceptions of their own persistence and resilience in dealing with the challenges of first-year teaching, thereby reducing beginning teacher attrition. The study finds that teachers must be nurtured and cared for in order for them to fully devote their time and energy to effectively care for the students in their classroom. Increasing self-awareness and resiliency has the potential to create a ripple effect to retain more beginning teachers, as they become more likely to persevere, ask for help, connect with others, and achieve a healthy life/work balance while positively impacting students and their community.