Complex Oncological Decision-Making Utilizing Fast-and-Frugal Trees in a Community Setting-Role of Academic and Hybrid Modeling

Non-small cell lung cancer is a devastating disease and with the advent of targeted therapies and molecular testing, the decision-making process has become complex. While established guidelines and pathways offer some guidance, they are difficult to utilize in a busy community practice and are not always implemented in the community. The rationale of the study was to identify a cohort of patients with lung adenocarcinoma at a City of Hope community site (n = 11) and utilize their case studies to develop a decision-making framework utilizing fast-and-frugal tree (FFT) heuristics. Most patients had stage IV (N = 9, 81.8%) disease at the time of the first consultation. The most common symptoms at initial presentation were cough (N = 5, 45.5%), shortness of breath (N = 3, 27.2%), and weight loss (N = 3, 27.2%). The Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0-1 in all patients in this study. Distribution of molecular drivers among the patients were as follows: EGFR (N = 5, 45.5%), KRAS (N = 2, 18.2%), ALK (N = 2, 18.2%), MET (N = 2, 18.2%), and RET (N = 1, 9.1%). Seven initial FFTs were developed for the various case scenarios, but ultimately the decisions were condensed into one FFT, a molecular stage IV FFT, that arrived at accurate decisions without sacrificing initial information. While these FFT decision trees may seem arbitrary to an experienced oncologist at an academic site, the simplicity of their utility is essential for community practice where patients often do not get molecular testing and are not assigned proper therapy.

Advancing the Science and Management of Renal Cell Carcinoma: Bridging the Divide between Academic and Community Practices

The treatment of metastatic renal cell carcinoma (mRCC) has rapidly evolved; however, the progress made in the field is heavily contingent upon timely and efficient accrual to clinical trials. While a substantial proportion of accrual occurs at tertiary care centers, community sites are playing an increasing role in patient recruitment. In this article, we discuss strategies to optimize collaborations between academic and community sites to facilitate clinical research. Further, as the role of biomarker discovery has become increasingly important in tailoring therapy, we will discuss opportunities to bridge diverse accrual sites for the purpose of translational research.

Team Communication on Tasks Performed in Blood Pressure Clinics in Community Pharmacies

Background: To successfully deliver pharmacy services, pharmacists and technicians need to work as a team and have effective communication. Objectives: To measure the amount of communication between community pharmacists and their technicians during monthly blood pressure (BP) clinics. Methods: Cross-sectional survey method was used to assess the amount of communication pharmacists and technicians had on each task. Study participants were pharmacist-technician pairs (teams) from 10 intervention community pharmacies in the Team Education and Adherence Monitoring (TEAM) trial. Each team provided services designed to improve BP among hypertensive African American patients. Thirteen specific tasks were identified as essential in providing monthly BP clinics, and they were being performed by either the pharmacist or technician. At the end of the trial, each pharmacist and technician were asked to report his/her perception of discussion levels that occurred for each task. The level of team communication was summarized for each task (task-specific) and for each team (team-specific). Results: For task-specific communication, 3 teams had communication regarding pharmacist tasks and 5 teams engaged in communication for technician tasks. More communication was reported for newly developed technician tasks in the BP clinic. For team-specific communication, 2 teams reported no communication on any task, and another 2 teams reported having communication on all the tasks. Overall, pharmacy teams showed different levels of communication in this study. Conclusion: The amounts of communication between pharmacists and technicians were found to vary for different tasks and teams. This suggests that the nature of tasks and the unique dynamics existing in each pharmacy team could influence pharmacist-technician communication.

Hazards of Our Helping Profession: A Practical Self-Care Model for Community Practice

The social work profession is a helping profession; social workers provide services with the intent to improve life opportunities in pursuit of social justice for individuals, groups, communities, and society as a whole. Social workers are called to work on behalf of the most vulnerable people in our society, and as such, the hazards of our helping profession are abundant. Though the literature offers numerous frameworks that can be used by social workers in a variety of settings, many issues that are unique to community practice settings can lead to professional burnout and compassion fatigue for social workers. At present there are no comprehensive models for self-care that attend specifically to the unique needs of the community practitioner. This article presents the iM-PAACT model, a four-part conceptual framework that helps to fill this gap in the literature. This practical self-care model has been designed specifically for social workers engaged primarily in community practice settings, including the community activist, community organizer, and community-engaged scholar.

African-American, Puerto-Rican, and Other Hispanic Fathers' Differential Responses to a Parenting Intervention

Despite the recognized importance of fathers to children's well-being, there is a lack of research exploring the impact of parenting interventions on young fathers. Further, little work has been done to identify whether fatherhood interventions differentially benefit specific subgroups of fathers, including Hispanic subgroups.This research examines a 15-week fatherhood intervention for African American, Puerto Rican, and non-Puerto Rican Hispanic young fathers. Data were collected from 312 fathers ages 15-24 at baseline, post-intervention (15 weeks), and at 8 months, 12 months, and 16 months post-baseline follow-up. Latent growth models were used to examine differential shapes of change for the three groups. Results suggest different intervention responses across the three groups on risky parenting attitudes, African American fathers in the study indicated more risky parenting attitudes than Hispanic and Puerto Rican fathers. The practice and research implications of disaggregating data for minority fathers, particularly for Latino subgroups, are discussed.

Translation and Evaluation of a Lung Cancer, Palliative Care Intervention for Community Practice

CONTEXT

A notable gap in the evidence base for palliative care (PC) for cancer is that most trials were conducted in specialized centers with limited translation and further evaluation in "real-world" settings. Health systems are desperate for guidance on effective, scalable models.

OBJECTIVES

The objective of this study was to determine the effects of a nurse-led PC intervention for patients with non-small-cell lung cancer and their family caregivers (FCGs) in a community-based setting.

METHODS

Two-group, sequential, quasi-experimental design with Phase 1 (usual care [UC]) followed by Phase 2 (intervention) was conducted at three Kaiser Permanente Southern California sites. Participants included patients with Stage 2-4 non-small-cell lung cancer and their FCG. Standard measures of quality of life (QOL) included Functional Assessment of Cancer Therapy-Lung, Functional Assessment of Chronic Illness Therapy-Spirituality Subscale, City of Hope Family QOL; other outcomes were distress, health care utilization, caregiver preparedness, and burden.

RESULTS

Patients in the intervention cohort had significant improvements in three (physical, emotional, and functional well-being) of the five QOL domains at one month that were sustained through three month compared to UC (P < 0.01). Caregivers in the intervention cohort had improvements in physical (P = 0.04) and spiritual well-being (P = 0.03) and preparedness (P = 0.04) compared to UC. There were no differences in distress or health care utilization between cohorts.

CONCLUSION

Our findings suggest that a research-based PC intervention can be successfully adapted to community settings to achieve similar, if not better, QOL outcomes for patients and FCGs compared to UC. Nonetheless, additional modifications to ensure consistent referrals to PC and streamlining routine assessments and patient/FCG education are needed to sustain and disseminate the PC intervention.

Getting Started: An Empirically Derived Logic Model for Age-Friendly Community Initiatives in the Early Planning Phase

Age-friendly community initiatives (AFCIs) foster efforts across stakeholders to make localities more supportive and inclusive of older adults, and potentially better for residents of all ages. This study drew on in-depth interviews with leaders of nine newly forming AFCIs in northern New Jersey to develop an empirically based logic model for the initiatives in the early planning phase. The results obtained from a conventional content analysis indicated three main activities in the early planning phase: assessing the community; meeting; and communicating with stakeholders; and facilitating communitywide communications. These activities worked toward two outputs: increased understanding of aging in the community and more engaged stakeholders in aging. Participants described leveraging the contributions of lead staff, consultants, elected officials, organizational partners, volunteers, interns, funders, and other AFCIs to engage in their focal activities. Based on these findings, a logic model for AFCIs in the early planning phase is presented. AFCI leaders can draw on this model to evaluate AFCI processes and outcomes in their formative stages, as well as to strategically plan for the start of an AFCI within a given locality. Findings also suggest important directions for future research on the development of AFCIs and the community changes that they seek to influence.

The conflicted practice: Municipal occupational therapists' experiences with assessment of clients with cognitive impairments

BACKGROUND

The practice of Norwegian occupational therapists (OTs) in municipal practice is a little explored area and with the Coordination Reform Act from 2012, Norwegian OTs in municipal practice have received responsibilities concerning clients with cognitive impairments. The aim of this study was to explore municipal OTs experiences with assessment of clients with cognitive impairments.

METHOD

Fourteen individual interviews with OTs who worked with clients with cognitive impairments, were conducted. An inductive thematic analysis, using text condensation and coding, was performed.

RESULTS

The results revealed three themes; power of occupation, advantages and disadvantages of assessments used and the need for competencies within municipal services. The participants emphasized using observation in the assessment process and reflected on pros and cons of the standardized assessment tools they used. They expressed a need for competence development, although it was difficult to prioritize to do so.

CONCLUSION

This study illustrated a conflicted practice related to choices OTs make in their practices. They valued the importance of working occupation based, however, they chose to use impairment based standardized assessments. They expressed a need to engage in professional development, but due to heavy workloads, the limited power they experienced and lack of knowledge, this was difficult.

SPOTS: A Model for the Creation of Sustainable, Population-Based, Occupational Therapy Fieldwork Sites

This paper describes a model for the creation of sustainable, population-based, occupational therapy fieldwork sites (SPOTS). An example of a population-based fieldwork site was created with Appalachian Mountain People in Kentucky and its outcomes are presented. Outcomes were gathered using a wide variety of evaluation feedback forms. The results indicate that all staff, student, and college feedback were extremely favorable as detailed and suggest that others may use the SPOTS Model to develop population-based occupational therapy services that address public health issues for people with disabilities identified in Healthy People 2020 and create scholarly opportunities for students and faculty.

Effective Interventions for Diabetes Patients by Community Pharmacists: A Meta-analysis of Pharmaceutical Care Components

OBJECTIVE

To evaluate randomized controlled trials (RCTs) that included interventions provided by community pharmacists for patients with type 1 and 2 diabetes, the analysis of each component of the intervention(s), and the description of the training that the pharmacists received.

DATA SOURCES

The literature research was conducted in PubMed and in the Cochrane Central Register of Controlled Trials (January 2000 to April 2016) for RCTs with interventions provided by community pharmacists for patients with diabetes. Corresponding authors were contacted about missing data and intervention and training design.

STUDY SELECTION AND DATA EXTRACTION

RCTs published in English or German were included if pharmaceutical care or medication therapy management was conducted by community pharmacists with diabetes patients. Basic information, intervention and training design data were extracted.

DATA SYNTHESIS

The literature research resulted in 11 eligible studies for further analysis. The corresponding authors of 6 studies responded to our request and sent their raw data. The calculated meta-analytical effect of 640 analyzed patients was a hemoglobin A_1C (A1C) difference of -0.66%, with a 95% CI of -0.86% to -0.45%. The analysis revealed that most intervention elements had a significant positive meta-analytical effect on the A1C values.

CONCLUSIONS

Our meta-analysis suggests that community pharmacist-led interventions can improve glycemic control in patients with type 1 and 2 diabetes. The most effective intervention components were patient centered and interdisciplinary. Pharmaceutical care interventions should, therefore, include the following components: sending feedback to the physician, setting individual goals, reviewing medication, and assessing patients' health beliefs and medication knowledge.

Effective Decentralization of a Pharmacy Technician to Facilitate Delivery of Medications Prior to Discharge in a Community Hospital

Background: There are many benefits to a well-designed prescription process and delivery service at the time of discharge from the hospital. However, the discharge prescription delivery service in our hospital has historically been infrequently utilized. Objective: To assess the number of patients with prescriptions in hand prior to discharge, the number of prescriptions filled, the duration of time to get discharge prescriptions to the floor, and the motivation patients had for declining the service. Methods: This single-center, quality improvement project was initiated as a pilot program from March through December 2015, utilizing a certified pharmacy technician (CPhT) on a 56-bed cardiovascular floor from Monday through Friday, 9:00 am to 5:30 pm. All patients discharged during the pilot time period were included in the analysis. The CPhT was responsible for collecting, inputting, processing, delivering, and charging for discharge prescriptions. Results: The number of patients utilizing the service increased from an average of 68 to 132 per month, pre- and postintervention, respectively. Total prescriptions increased from 296 preintervention to 456 postintervention per month. Prescription delivery time to the patient was decreased by 28 minutes. Conclusions: The utilization of a decentralized CPhT in a 56-bed cardiology unit at a large community hospital increased both the number of patients and total number of prescriptions filled prior to discharge. Future studies are warranted to evaluate medication interventions at discharge and readmission rates in patients who have prescriptions in hand prior to discharge versus those that do not.

Integration of a Palliative Care Intervention into Community Practice for Lung Cancer: A Study Protocol and Lessons Learned with Implementation

BACKGROUND

A notable gap in the evidence base for outpatient palliative care (PC) for cancer is that most trials were conducted in specialized oncology or academic centers with limited translation and further evaluation in "real-world" settings. Health systems are desperate for guidance regarding the most effective and sustainable PC service models.

OBJECTIVE

Describe the study protocol to evaluate the dissemination of a previously tested nurse-led PC intervention (PCI) for patients with lung cancer and their family caregiver in community-based settings, lessons learned in adapting and implementing the PCI, and implications for future dissemination-translational efforts Design: Two-group, prospective sequential, quasi-experimental design with Phase 1 (Usual care) followed by Phase 2 (Intervention) setting/subjects. Three Kaiser Permanente Southern California sites. Patients with stage 2-4 nonsmall cell lung cancer and their caregiver.

MEASUREMENTS

Standard measures of quality of life (QOL; FACT-L, FACIT- SP12, City of Hope Family QOL), symptom burden, distress, and caregiver preparedness and perceived burden.

RESULTS

Adaptations were made to the PCI (comprehensive patient/caregiver assessment, interdisciplinary care planning, and patient/caregiver education) to harmonize with existing workflows, minimize burden to patients, caregivers, and the PC team, and maximize chances of sustainability. Implementation facilitators include external competitive pressures, internal readiness, and adaptability of the PCI. Barriers include the changing lung cancer therapeutic landscape and perceived need for PC support by patients and providers, insufficient staffing, and people-dependent processes.

CONCLUSIONS

Efforts to disseminate and implement previously tested PC models into real-world community practices need to be more realistic and consider the local context.

Quality Improvement in Concussion Care: Influence of Guideline-Based Education

OBJECTIVE

To evaluate the potential impact of a concussion management education program on community-practicing pediatricians.

STUDY DESIGN

We prospectively surveyed 210 pediatricians before and 18 months after participation in an evidence-based, concussion education program. Pediatricians were part of a network of 38 clinically integrated practices in metro-Atlanta. Participation was mandatory for at least 1 pediatrician in each practice. We assessed pediatricians' self-reported concussion knowledge, use of guidelines, and comfort level, as well as self-reported referral patterns for computed tomography (CT) and/or emergency department (ED) evaluation of children who sustained concussion.

RESULTS

Based on responses from 120 pediatricians participating in the 2 surveys and intervention (response rate, 57.1%), the program had significant positive effects from pre- to postintervention on knowledge of concussions (-0.26 to 0.56 on -3 to +1 scale; P < .001), guideline use (0.73-.06 on 0-6 scale; P < .01), and comfort level in managing concussions (3.76-4.16 on 1-5 scale; P < .01). Posteducation, pediatricians were significantly less likely to self-report referral for CT (1.64-1.07; P < .001) and CT/ED (4.73-3.97; P < .01), but not ED referral alone (3.07-3.09; P = ns).

CONCLUSIONS

Adoption of a multifaceted, evidence-based, education program translated into a positive modification of self-reported practice behavior for youth concussion case management. Given the surging demand for community-based youth concussion care, this program can serve as a model for improving the quality of pediatric concussion management.

Major Depressive Disorder Among Preadolescent Canadian Children: Rare Disorder or Rarely Detected?

OBJECTIVE

Despite agreement that preadult onset of depression is associated with greater illness severity, and that children can meet the diagnostic criteria for major depressive disorder (MDD), few studies have examined the presentation of MDD among young children. This is the first nationwide study of MDD among preadolescent children in Canada.

METHODS

Pediatrician members (2500) of a Canadian pediatric surveillance network were surveyed monthly over 3 years to report new cases of MDD among 5- to 12-year-olds. Survey response and questionnaire completion rates were 80% and 85%, respectively. Symptom presentation and duration, impairment, medical and psychiatric history, and management were reported.

RESULTS

Twenty-nine new cases of MDD were identified by pediatricians. Of these, 23 (79%) experienced symptoms for >6 months before presentation with global functional impairment. Parental depression or anxiety, commonly maternal, was present in 21 cases (72%). Twenty-two children (76%) reported suicidal ideation; 6 (21%) had attempted suicide. Twenty-three children (79%) were treated with medication. Thirteen children (45%) were treated with 2 or more medications.

CONCLUSIONS

Children with MDD frequently had a parental history of mood disorders, experienced long-standing symptom presence, high symptom burden and functional impairment prior to presentation; and commonly treatment with polypharmacy.

Evaluation of Medication Errors in Community Pharmacy Settings: A Retrospective Report

Background. Drug-related errors can compromise patient care, increase health care costs, and, in worst case scenarios, result in patient deaths. Objective. To evaluate the incidence and contributing factors of medication dispensing errors in community pharmacy settings reported to the New Hampshire Board of Pharmacy (NHBOP). Methods. Medication errors reported to the NHBOP from February 1, 2007, to July 31, 2012, in a community pharmacy setting were reviewed. Quality Related Event Report (QRER), a standardized form developed by the NHBOP, was used to record the errors. The QRER allows collection of information related to the error, including time, date, type of error, and contributing environmental factors. Results. There were a total of 68 reported errors. The majority of errors (40%) involved dispensing an incorrect medication; 31% involved incorrect doses, and 12% involved incorrect directions. A majority of the errors involved new prescriptions (78%); 51% occurred during the pharmacist final check stage and 26% occurred during the data entry phase of the initial processing of the prescription. A greater percentage of errors (68%) occurred when only 1 pharmacist was on duty versus 29% with 2 pharmacists on duty. Conclusions. Contributing factors for errors included high prescription volumes and lack of adequate pharmacist coverage. Increasing pharmacist overlap hours in stores with high prescription volumes and implementing a formal technician certification program to ensure the consistency in training quality could assist in decreasing medication errors and improving patient safety.

Conventional transbronchial needle aspiration in community practice

Conventional transbronchial needle aspiration (C-TBNA) provides an opportunity to diagnose mediastinal lesions and stage bronchogenic carcinoma in a minimally invasive fashion. The procedure is easy to learn and requires zero upfront cost. Any community pulmonologist can acquire and maintain the skills of C-TBNA without undergoing formal interventional pulmonary fellowship training. Besides being used for the diagnosis and staging of lung cancer, C-TBNA can be used in patients suspected to have benign conditions such as sarcoidosis and tuberculosis. It also contributes in improving the diagnostic yield of flexible bronchoscopy while dealing with endobronchial, submucosal, peribronchial, or peripheral lesions. C-TBNA may be the only diagnostic modality that can be performed in patients in whom mediastinoscopy is contraindicated due to a bleeding diathesis. The procedure is safe and has great potential to augment the welfare of patients with pulmonary ailments. The learning curve of the procedure is short and steep. Every community pulmonologist should be able to perform C-TBNA.

Are health promotion and prevention interventions integrated into occupational therapy practice with older adults having disabilities? Insights from six community health settings in Québec, Canada

BACKGROUND/AIM

Increasingly, health-care systems should promote seniors' health and prevent disability. As they enable engagement in meaningful activities within the individuals' living environment, community occupational therapists have great potential to contribute to health promotion and prevention. Despite this potential, little is known about current health promotion and prevention activities in occupational therapy community practice. This study thus aimed to: (1) identify health promotion and prevention interventions used with seniors having disabilities, and (2) explore barriers to integrating such interventions into practice.

METHODS

Secondary data analysis of a qualitative study was carried out using thematic saliency analysis. Eleven community occupational therapists working with seniors having disabilities were recruited in six community health settings in Québec, Canada. Observations of 12 home visits, followed by 12 semi-structured interviews, were conducted with occupational therapists.

RESULTS

Most interventions involved optimising independence in personal care and mobility. Explicit health promotion interventions were limited and included enabling healthy lifestyles by increasing health literacy and empowerment. Meaningful activities (leisure, community participation) were not targeted. Barriers to integrating health promotion into practice were clients' complex health conditions and limited openness to change combined with organisational and professional obstacles, such as a misunderstanding of occupational therapists' role in health promotion.

CONCLUSIONS

Health promotion and prevention interventions are not intentionally integrated into community occupational therapy practice with seniors having disabilities. As a result, seniors' needs to engage in meaningful activities might remain unmet. Overcoming barriers to integrating health promotion and prevention in practice could help improve population health and wellbeing.

Perceived Challenges to the Sustainability of Community-Based Aging Initiatives: Findings from a National Study of Villages

Concerns have been raised regarding the sustainability of Villages, a rapidly-expanding set of organizations that typically use a participant-directed approach to improve older adults' quality of life and ability to age in place. Using online survey and telephone-interview data from a 2013 follow-up study of Villages across the United States, this study examined organizational leaders' perceptions of the major challenges to sustainability. Major challenges identified included: (a) funding, (b) membership recruitment, (c) leadership development, (d) meeting members' service needs, and (e) limitations of the Village model itself. Findings point to a number of important considerations for the development, implementation, and sustainability of the Village model, including the role of social workers in addressing these challenges.

Impact of a Transitions of Care Training Module on Community Pharmacists' Knowledge and Attitudes

Background: Community pharmacists' accessibility to patient histories and personal patient relationships situates them to have a potentially significant impact on transitions of care. Recent literature has demonstrated that improved patient outcomes and an overall reduction in health care costs occur when pharmacists are involved in medication reconciliation during transitions of care. Objective: To develop a transitions of care training module for community pharmacists. To assess the training module's impact on pharmacists' transition of care knowledge and their attitude toward actively participating in the transitions of care for their patients. Methods: Community pharmacists practicing in a supermarket pharmacy chain participated in this study. A pretest and posttest were administered around a 30-minute transitions of care training module. The attitude assessment consisted of a 5-point Likert-type scale, while the knowledge-based assessment consisted of true/false and multiple-choice questions. SPSS version 21.0 was used to generate descriptive and nonparametric statistical analyses. The study was approved by the University of Toledo Social, Behavioral, and Educational Institutional Review Board. Results: Thirty-six pharmacists (72%) successfully completed the pre-post survey. The average pharmacist posttest knowledge survey score improved from the pretest score, 73% to 99%. A paired Student's t test demonstrated the posttest percentage of correct questions on the knowledge-based survey improved from the baseline knowledge. Pharmacists' average posttest attitudes regarding participation in patients' transitions of care statistically improved compared to their pretest attitudes. Conclusion: Community pharmacists' transitions of care knowledge and attitudes can be improved through a training module.

Characterizing Older Adults' Involvement in Naturally Occurring Retirement Community (NORC) Supportive Service Programs

Naturally Occurring Retirement Community (NORC) Supportive Service Programs constitute one of the longest-standing models for age-friendly community initiatives. As a support-focused model, NORC programs typically offer a range of benefits--including direct services, group activities, and broader community development activities--that are intended to engage older adults with diverse needs, preferences, and interests. Moreover, NORC programs are designed to be used according to the needs of the particular participant engaging with them at a particular point in time. This range and flexibility of benefits indicate the importance of more systematically characterizing the ways in which older adults are involved with NORC programs. For this purpose, we used data from in-depth interviews with 35 residents across 6 NORC programs in New York City. Qualitative analysis revealed 6 ordered categories of involvement: (a) consciously no involvement; (b) involved, but not consciously; (c) relationship with staff only; (d) selectively involved with a strong sense of security; (e) NORC program leaders; and (f) dependence on the NORC program. Overall, results indicate how older adults' involvement in NORC programs can be characterized beyond their utilization of specific types of services and by their relationship with the program as a whole. Findings suggest the importance for outcomes research on NORC programs and related models to consider subgroup differences by involvement. Results also provide directions for theory development on engagement in voluntary programs, as well as for practice to enhance older adults' involvement in supportive service programs.

Efficacy of electronic cigarettes for smoking cessation

OBJECTIVE

To review data demonstrating effective smoking cessation with electronic cigarettes (e-cigarettes).

DATA SOURCES

A literature search of MEDLINE/PubMed (1946-March 2014) was performed using the search terms e-cigarettes, electronic cigarettes, and smoking cessation. Additional references were identified from a review of literature citations.

STUDY SELECTION AND DATA EXTRACTION

All English-language clinical studies assessing efficacy of e-cigarettes compared with baseline, placebo, or other pharmacological methods to aid in withdrawal symptoms, smoking reduction, or cessation were evaluated.

DATA SYNTHESIS

A total of 6 clinical studies were included in the review. In small studies, e-cigarettes significantly decreased desire to smoke, number of cigarettes smoked per day, and exhaled carbon monoxide levels. Symptoms of nicotine withdrawal and adverse effects were variable. The most common adverse effects were nausea, headache, cough, and mouth/throat irritation. Compared with nicotine patches, e-cigarettes were associated with fewer adverse effects and higher adherence. Most studies showed a significant decrease in cigarette use acutely; however, long-term cessation was not sustained at 6 months.

CONCLUSIONS

There is limited evidence for the effectiveness of e-cigarettes in smoking cessation; however, there may be a place in therapy to help modify smoking habits or reduce the number of cigarettes smoked. Studies available provided different administration patterns such as use while smoking, instead of smoking, or as needed. Short-term studies reviewed were small and did not necessarily evaluate cessation with a focus on parameters associated with cessation withdrawal symptoms. Though long-term safety is unknown, concerns regarding increased poisoning exposures among adults in comparison with cigarettes are alarming.

Patterns of antibacterial use and impact of age, race/ethnicity, and geographic region on antibacterial use in an outpatient medicaid cohort

STUDY OBJECTIVES

To describe patterns of outpatient antibacterial use among California Medicaid (Medi-Cal) fee-for-service system beneficiaries, and to investigate the influence of demographic factors-age, race/ethnicity, state county, and population density-on those patterns.

DESIGN

Retrospective analysis of administrative claims data.

DATA SOURCE

Medi-Cal fee-for-service system claims database.

PATIENTS

All outpatient Medi-Cal fee-for-service system beneficiaries enrolled between 2006 and 2011 who had at least one systemic antibacterial claim.

MEASUREMENTS AND MAIN RESULTS

Rates of antibacterial prescribing and the proportion of broad-spectrum antibacterial use were measured over the study period and among age, racial/ethnic, and geographic (county) groups. Of the 10,018,066 systemic antibacterial claims selected for analysis, antibacterial prescribing rates decreased from 542 claims/1000 beneficiaries in 2006 to 461 claims/1000 beneficiaries in 2011 (r = -0.971, p=0.0012; τ-b = -1.00, p=0.009). Among age groups, children had the highest rate of use (605 claims/1000 beneficiaries, χ(2) (2) = 320,000, p<0.001); among racial/ethnic groups, Alaskan Natives and Native Americans had the highest rate of use (1086/1000 beneficiaries, χ(2) (5) = 197,000, p<0.001). Broad-spectrum antibacterial prescribing increased from 28.1% (95% confidence interval [CI] 28.1-28.2%) to 32.7% (95% CI 32.6-32.8%) over the study period. Senior age groups and whites received the highest proportions of broad-spectrum agents (53.4% [95% CI 52.5-54.3%] and 36.6% [95% CI 36.6-36.7%], respectively). Population density was inversely related to both overall antibacterial use (ρ = -0.432, p=0.0018) and broad-spectrum antibacterial prescribing (ρ = -0.359, p<0.001). The rate of prescribing decreased over the study period for all antibacterial classes with the exception of macrolides and sulfonamides. Amoxicillin was the most frequently prescribed agent.

CONCLUSION

Overall and broad-spectrum antibacterial use in the Medi-Cal fee-for-service program are less than that observed nationally. Significant variations in prescribing exist between age and racial/ethnic groups, and heavily populated areas are associated with both less antibacterial use and less broad-spectrum antibacterial prescribing. Studies are needed to determine the reasons for the observed differences in antibacterial use among demographic groups.

Evaluation of a primary-care setting at a veterinary teaching hospital by a student business group: implementing business training within the curriculum

This article provides an introduction to the use of students' business skills in optimizing teaching opportunities, student learning, and client satisfaction in a primary health care setting at a veterinary teaching hospital. Seven veterinary-student members of the local chapter of the Veterinary Business Management Association (VBMA) evaluated the primary-care service at the University of Georgia (UGA) veterinary teaching hospital and assessed six areas of focus: (1) branding and marketing, (2) client experience, (3) staff and staffing, (4) student experience, (5) time management, and (6) standard operating procedures and protocols. For each area of focus, strengths, weaknesses, opportunities, and threats were identified. Of the six areas, two were identified as areas in need of immediate improvement, the first being the updating of standard operating protocols and the second being time management and the flow of appointments. Recommendations made for these two areas were implemented. Overall, the staff and students provided positive feedback on the recommended changes. Through such a student-centered approach to improving the quality of their education, students are empowered and are held accountable for their learning environment. The fact that the VBMA functions without a parent organization and that the primary-care service at UGA functions primarily as a separate entity from the specialty services at the College of Veterinary Medicine allowed students to have a direct impact on their learning environment. We hope that this model for advancing business education will be studied and promoted to benefit both veterinary education and business practice within academia.

Examination of factors that influence students' average client transactions in a small-animal primary care clinical environment

The purpose of this study was to describe the average client transaction (ACT) of fourth-year veterinary students in a university community practice setting at the University of Georgia (UGA) and to investigate variables that may affect the students' ACT. The revenue generated by each student was assessed to determine whether gender, ethnicity, academic class rank, area of emphasis, and UGA versus non-UGA student could affect the ACT of the students. Two hundred one students were evaluated over 19 continuous 3-week-long clinical rotations. For all students, the M±SD gross revenue was $2,836±$1,051, the total number of client transactions was 18±6, and the ACT was $154±$35 per student. During the study, hospital fees (price class) increased four times. No student-related factors were significantly associated with the ACT in the univariate analyses. No factors except price class were found to be significant in the two-factor analyses. Generating an ACT equivalent to the national average demonstrates that the typical student at the community practice clinic should provide a level of productivity to the practice owners who hire these students. The factors measured demonstrated little influence on the student's revenue-generating ability at the community practice clinic. Mentorship provided to students for each appointment might have affected the study outcome. Other variables, such as communication style, may affect the ACT more than those investigated in this study and warrant further study.