The Multilevel Factor Structure of Social Cohesion, Mutual Efficacy, and Informal Social Control: A Case for Practice-Informed Research

Collective efficacy is the process by which social cohesion is activated as informal social control. Mutual efficacy, the perceived capability of the community, mediates the relationship between the two constructs. Interventions based on collective efficacy have a positive impact on individuals but are limited in their ability to affect the broader community. A possible explanation for this finding is that community-level theories operate differently at the individual and neighborhood levels. The present study contributes to the literature by testing the multilevel factor structure of social cohesion, mutual efficacy, and informal social control. Findings suggest that multiple-factor structures demonstrate adequate model fit. However, the three-factor model is most consistent with social work theory and practice. Social workers can foster constructive dialogue to build social cohesion, authentically engage residents to build mutual efficacy, and train residents in skills necessary to institute informal social control.

Salivary Gland Tumors: A 20 Year Review From a Single Community Practice

Objective: Salivary gland tumors are a heterogenous group of lesions with variable pathology and clinical outcomes. Most published data are derived from studies conducted at tertiary care centers. Our study analyzed the experience from a community setting to determine significant differences, if any, in pathological distribution and clinical outcomes compared to the existing literature. Methods: We performed a retrospective analysis of all major salivary gland tumors that presented to a large community practice over a 20 year period. Retrospective chart analysis was performed for demographics, clinical presentation, imaging, cytology, histopathology, and clinical outcome data. Results: Of 806 patients, the parotid gland was the most common site in 683 patients (84.7%), followed by submandibular in 78 (9.7%) and sublingual in 45 (5.6%). A total of 203 patients were managed conservatively with observation without definitive diagnosis or lost to follow-up. A total of 495 patients underwent surgical intervention within the community practice. Twenty-six patients underwent surgical excision at an outside hospital. Eighty-two patients were determined to have a benign diagnosis based on ultrasound-guided fine needle aspiration or excisional biopsy alone. Final histopathology was benign in 505 cases (83.7%), while 98 tumors (16.3%) received a diagnosis of primary or secondary malignancy. For the parotid gland, pleomorphic adenoma (155) and Warthin's tumor (155) were the most common benign diagnoses, while mucoepidermoid carcinoma (13), adenocarcinoma (8), and acinic cell carcinoma (8) were the most common primary malignancies. Conclusions: We found a higher rate of benign tumor pathology compared to the existing literature. While the outcome data on surgical treatment of benign tumors are comparable to the existing literature, the same conclusion cannot be drawn for malignant tumors, given relatively small numbers in our series and likely disparity in the complexity of the surgical cases in tertiary care centers.

Statewide Age-Friendly Virtual Fair as a Tactic for Social Change Across the Aging Ecosystem

Prior research has demonstrated ways in which community events help to establish age-friendly community initiatives and strengthen their impact. We extend these insights by discussing how the design and implementation of a statewide event - the New Jersey Age-Friendly Virtual Fair - exemplifies this practice theory and extends its applicability beyond local community development toward broader state-level age-friendly ecosystems. We describe how events that are deliberately multi-organizational, multi-sectoral, and multi-level can help to further propel the Age-Friendly Movement toward systems change for aging in community.

A Community Social Work Paradigm: Thoughts and Reflections

Community social work (CSW) is often regarded as a practice with a variety of intervention models. The objectives of the present article are to examine CSW's philosophical and theoretical roots and to bridge the gap in the literature regarding the theoretical and philosophical origins of CSW and to conceptualize these theoretical bases as a paradigm with ontological, epistemological, axiological, and methodological aspects. The ontology of the proposed CSW paradigm relies on ecological theory, critical theory, and community psychology. The paradigm's epistemology relies on the basic assumption that community members are autonomous subjective human beings with important and valid knowledge who make decisions concerning their lives. Axiologically, the most prominent value of the paradigm is participation, from which other central values derive. The paradigm's methodology derives from its three abovementioned components. The conceptualization of a CSW paradigm provides a theoretical foundation for community interventions and refining the goals of these interventions. The paradigm can be used as a pedagogical and identity-building tool with students and social workers who focus on CSW.

"Justice Becomes Our Agency." Occupational Therapists in Germany Reflect on Their Practice Processes in and with Communities

Community development and population-oriented approaches are emphasized to advance the occupational therapy profession's scope of practice to meet the increasing demands created by socio-cultural-political and economic changes. This study explored the practice processes of occupational therapists in community settings outside existing health care structures in Germany. Data was gathered through five individual qualitative interviews and one focus group and analyzed using thematic analysis. Three main themes were identified: navigating parallel processes within the larger context or system; building community connections through occupation; growing professional identity. The utilization of occupational science concepts was essential to work successfully on a community level.

Leveraging the Academic Artificial Intelligence Silecosystem to Advance the Community Oncology Enterprise

Over the last 75 years, artificial intelligence has evolved from a theoretical concept and novel paradigm describing the role that computers might play in our society to a tool with which we daily engage. In this review, we describe AI in terms of its constituent elements, the synthesis of which we refer to as the AI Silecosystem. Herein, we provide an historical perspective of the evolution of the AI Silecosystem, conceptualized and summarized as a Kuhnian paradigm. This manuscript focuses on the role that the AI Silecosystem plays in oncology and its emerging importance in the care of the community oncology patient. We observe that this important role arises out of a unique alliance between the academic oncology enterprise and community oncology practices. We provide evidence of this alliance by illustrating the practical establishment of the AI Silecosystem at the City of Hope Comprehensive Cancer Center and its team utilization by community oncology providers.

Impact of COVID-19 on Referral Patterns and Service Delivery for an Integrated Behavioral Health Program

The emergence and rapid spread of COVID-19 led to unprecedented changes for families and systems of care. This study sought to understand the needs of families participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) before and during the pandemic and considers the impact remote service delivery has on access to an integrated behavioral health intervention to support the psychosocial needs of children and caregivers. Needs for referral varied significantly pre- and post-pandemic onset. Analyses revealed that significantly more referrals were made regarding social determinants of health after the onset of COVID-19 (13.8%) compared with prior to the COVID-19 pandemic (4.1%, p < .05). Providers' transition to telehealth services sufficiently served WIC families.

From Private Practice to Academia: The Experience of a General Academic Pediatrician

After pediatric residency, the author worked in a rural community where he was able to immediately practice skills acquired during training such as intubations, bag-mask ventilation, IV placement, ear irrigation, foreign body removal from eyes and ears, abscess incision and drainage, intraosseous placement for rapid hydration of a severely dehydrated infant, EKG, X-ray readings, and ear-irrigations to cite but a few examples. Furthermore, the writer acquired other high-valued procedural skills such as neonatal male circumcision, frenotomy, ligation of supernumerary digits, and manual separation of labial adhesions. The author feels that he could only have acquired and maintained these skills by working in a busy rural pediatric practice. When the writer later became a faculty member, he was able to effectively train medical students and pediatric residents to acquire these same skills. Even though there is a paucity of research information on procedural skills acquisition among general pediatric residents, the writer proposes that the recruitment of full-time general academic pediatricians with real-world experience may be potentially beneficial for the training of medical students and pediatric residents.

Occupational therapists' descriptions of doing observations of people with cognitive impairments in the context of community practice

BACKGROUND

Observation is an important method for occupational therapists (OTs) to gather information on people's occupational performance; yet, not much research has been conducted on OTs' descriptions of doing observations in their practices.

AIMS

This study aimed to explore community OTs descriptions of doing observations during the assessment of persons with cognitive impairments.

MATERIAL AND METHODS

Nineteen OTs participated in focus group interviews. Thematic analysis with an inductive approach was performed.

RESULTS

Three themes were revealed during analysis, the value of doing unstructured observations, the importance of doing observations in familiar contexts, and the importance of experience, structure and competence when doing observation.

CONCLUSIONS AND SIGNIFICANCE

This study showed that the participants regarded observation as one of OTs' core competencies, and they described doing observations in different ways. The results emphasised the importance of doing unstructured observations in persons' familiar contexts when assessing persons with cognitive impairments. However, the participants highlighted the need for increasing OTs structure and competence through implementing more occupation-based standardised assessment tools for OTs in community services to facilitate evidence-based practice.

Pharmacists' Perceptions About the Effect of Work Environment Factors on Patient Safety in Large-Chain Retail Pharmacies

This commentary evaluates large-chain retail pharmacists' perceptions on their work environment factors' effects on patient safety from the July 2020 survey conducted by the Ohio Board of Pharmacy. Respondents rated 7 questions using a 5-point Likert scale to rate how they perceive work environment factors in large-chain retail pharmacies influence patient safety. Weighted average, weighted sums, and weighted total scores were calculated to determine if pharmacists' perceptions were positive or negative. Low scores indicated pharmacists' negative perceptions. Work factors in large-chain retail pharmacies need to change to improve pharmacists' perception about work environment factors on patient safety.

Community-oriented primary care for National Health Insurance in South Africa

This is a report on Chiawelo Community Practice (CCP) in Ward 11, Soweto, South Africa, a community-oriented primary care (COPC) model for National Health Insurance (NHI) in South Africa, developed by a family physician. A shift to capitation contracting for primary health care (PHC) under NHI will carry risk for providers – both public and private, especially higher number of patient visits. Health promotion and disease prevention, especially using a COPC model, will be important. Leading the implementation of COPC is an important role for family physicians in Africa, but global implementation of COPC is challenged. Cuba and Brazil have implemented COPC with panels of 600 and 3500, respectively. The family physician in this report has developed community practice as a model with four drivers using a complex adaptive system lens: population engagement with community health workers (CHWs), a clinic re-oriented to its community, stakeholder engagement and targeted health promotion. A team of three medical interns: 1 clinical associate, 3 nurses and 20 CHWs, supervised by the family physician, effectively manage a panel of approximately 30 000 people. This has resulted in low utilisation rates (less than one visit per person per year), high population access and satisfaction and high clinical quality. This has been despite the challenge of a reductionist PHC system, poor management support and poor public service culture. The results could be more impressive if panels are limited to 10 000, if there was a better team structure with a single doctor leading a team of 3–4 nurse/clinical associates and 10–12 CHWs and PHC provider units that are truly empowered to manage resources locally.

Giving, Receiving, and Doing Together: Interorganizational Interactions in Age-Friendly Community Initiatives

Multi-sectoral collaboration is widely considered essential for age-friendly community change; however, there has been little empirical research to describe the ways in which organizations interact as part of age-friendly community initiatives (AFCIs). We conducted a qualitative descriptive study using data from multiple waves of semi-structured interviews with core teams of eight grant-funded AFCIs in the north-eastern U.S. We employed iterative, inductive coding to systematically describe ways in which AFCI core teams described working with other organizational entities. Findings indicated two overarching themes: (a) helping each other (giving and receiving linking, informational, and instrumental assistance), and (b) doing something together (organizing community events, planning collaborative projects, participating in meetings). We discuss the implications of this characterization for guiding research, evaluation, and policy to optimize AFCI implementation and impact across diverse settings.

Patients' Perceptions of Residents Involved in Their Care in a Community General Surgery Practice

BACKGROUND

Resident involvement in patient care in the general surgery setting is most often encountered in an academic setting. Many community hospitals have residents involved in patient care as well. There are no studies that gauge patients' perceptions in the involvement of residents in their general surgery care in the community setting.

METHODS

Patients were given a Northeast Georgia Health System Graduate Medical Education Department Institutional review Board approved 26-question questionnaire during their office visit gauging their wiliness to allow a resident be involved in their care, and their understanding of what a resident is.

RESULTS

A total of 196 patients completed the survey with answers that could be analyzed. Overall, 67.3% would allow residents be involved in their care. The main reasons for this were to educate future surgeons, they enjoy a teaching environment, and that they have had residents involved in their care and it was a good experience. Of the 27 % that did not want a resident involved in their care, the main reason was they only wanted their doctor involved in their care. Of the respondents, 58 % were comfortable having a resident involved in their surgery or procedure. Only 14% noted that they would prefer not to have a resident involved in their procedure or surgery.

CONCLUSIONS

Patents appear receptive to general surgery residents' involvement in their care in the community setting. This is reassuring as community practices may be more receptive to including residents in their practices, based upon these findings.

Patient Engagement With Urologists on Social Media in a Community Practice

Background

Based on the Boston Area Community Health Survey, 52 million adults in the United States will have lower urinary tract symptoms, urine leakage, painful bladder syndrome, and prostatitis, which may parallel the prevalence of cardiovascular disease. In the year 2000, benign prostatic hyperplasia (BPH) accounted for 117,000 emergency department visits and 105,000 hospitalizations. These numbers underscore the burden of urological conditions and highlight the importance of patient education in preventing unnecessary hospitalizations and emergency department visits. Certain factors that may alter the progression and severity of disease include physical activity and other lifestyle changes. Based on current trends, patient education via social media may be an invaluable tool in limiting the burden on urologists and the healthcare system in the future.

Aims

This study aims to determine whether patients in a community urology practice would engage with their urologists over social media and if the likelihood to engage was associated with various demographic factors. Furthermore, the likelihood to engage actively (defined as commenting/sharing) versus passively (defined as liking a post) on two different topics within the scope of urology was determined. The two topics used were erectile dysfunction (ED)/urinary incontinence and kidney stone prevention.

Methods

Participants were recruited from a community urologic clinic in Alabama. During the month of April 2021, 293 participants completed a survey that included basic demographic questions as well as questions with a visual analog 5-point Likert scale. Responses on the Likert scale were given a value of one (very unlikely) to five (very likely), and a two-tailed Mann-Whitney U test with an α of 0.05 was used to determine significance in differences of responses. In the case of ties, the mid-rank method was used to assign ranks. For analysis of the Likert scale responses, only those respondents who had social media accounts were included.

Results

Overall, respondents were more likely to interact with a post by their urologist passively engage rather than actively. They were also less likely to passively and actively engage on a topic concerning ED/urinary incontinence versus kidney stone prevention. On the topic of kidney stone prevention, respondents were less likely to engage actively than passively. There was no difference in the likelihood of actively or passively engaging on the topic of ED/urinary incontinence. Compared to men, women were more likely to actively and passively engage on social media. On the topic of ED/urinary incontinence, women were more likely than men to actively engage; however, there was no difference in passive engagement. On the topic of kidney stone prevention, women were more likely to actively and passively engage. When looking at the likelihood of engagement based on age, there was no difference in active or passive engagement between those 55 and under or older than 55. This held true when data were stratified by topic.

Conclusion

Based on these results, the maximum impact of a social media page from a urological practice would be gained by focusing on preventative practices for less sensitive urological conditions. Furthermore, the data suggests that as the population of social media users continues to age, physicians should not expect a change in engagement patterns anytime soon.

EMDIA Case Series-Effective Medication Therapy Management (MTM) for Diabetes Type 2 Patients-A Proof of Concept Study

Background: A 2016 meta-analysis of pharmaceutical care for patients with diabetes mellitus showed that the following four components were most effective: (a) individual goal setting, (b) sending feedback to the physician, (c) reviewing the medication, and (d) reviewing blood glucose measurements. Methods: To formulate a hypothesis regarding the effect of these four pharmaceutical care components on glycemic control in patients with diabetes mellitus and the feasibility of these components in practice. Ten patients with type 2 diabetes were included in the case series and received medication therapy management over four months. Results: The four care components were feasible in everyday practice and could be implemented within one patient visit. The average visits were 49 and 28 min at the beginning and end of the study, respectively. The glycated hemoglobin values did not change over the study period, though the fasting blood glucose decreased from 142 to 120 mg/dl, and the number of unsolved drug-related problems decreased from 6.9 to 1.9 per patient by the study end. Conclusions: This case series supports the hypothesis that community pharmacists can implement structured pharmaceutical care in everyday pharmacy practice for patients with type 2 diabetes mellitus.

Becoming a Community-Based Physician Researcher

Years ago, as a contented community family physician practicing with 4 physician colleagues, I focused on applying medical knowledge to help patients. After a young patient’s death from smoking I became interested in improving our strategy for helping smokers quit. A researcher offered us the opportunity to test a cessation intervention that had been successful in an academic setting. I was concerned that this study would interfere with my patient care duties until I visited a practitioner researcher in Wales. I was inspired and worked with a research professional to build colleague support and carry out this project. After this gratifying experience I had similar experiences working with other research teams. As an ordinary practitioner I had expanded my role to become significantly involved in research. In this role I was working with a team to improve patient care. It was a fundamental change that brought me great satisfaction.

U.S. student pharmacist perceptions of the pharmacist's role in methadone for opioid use disorder: A qualitative study

BACKGROUND

Of the over 20 million Americans reporting an opioid use disorder, only around 3 million report receiving treatment of any kind. The gold standard for opioid use disorder treatment is medication in combination with psychosocial support, but despite robust evidence supporting treatment, barriers are substantial and include limited insurance coverage, patient beliefs, ease of access, regulatory hurdles, and stigma. Although trained as medication experts, U.S. pharmacists are not routinely involved in opioid use disorder treatment and may represent an underutilized care team member.

OBJECTIVE

To explore U.S. pharmacy students' perspectives on pharmacists as providers of methadone-based medications for opioid use disorder treatment.

METHODS

A qualitative design with focus groups of student pharmacists in a U.S. college of pharmacy in the Southeastern United States.

RESULTS

Over 2 months in 2020, three focus groups were conducted with 15 students in each group participating, and including second-, third-, and fourth-year student pharmacists. Three overarching themes emerged from the data: (1) student pharmacists desire exposure to therapeutic knowledge and lived experiences related to opioid use disorder and methadone treatment, (2) students perceive stigmatizing views held by practicing pharmacists toward opioid use disorder and methadone treatment, (3) pharmacists should play a role in methadone treatment.

CONCLUSION

Student pharmacists desire an active and larger role in the care of patients managing opioid use disorder. Findings indicate these students perceive less stigma toward opioid use disorder than currently practicing pharmacists. Pharmacy curricula should emphasize stories of lived experiences of patients with opioid use disorder, therapeutic knowledge and guidelines related to medications for opioid use disorder, and the regulatory environment surrounding opioid use disorder treatment.

An Exploratory Study of Pharmacist Perceptions of Opioid Interventions for Acute Pain

Background: As the last health care provider encountered before an opioid is dispensed, pharmacists have a vital role in reducing unnecessary opioid exposure while facilitating access to non-opioid alternatives. Objective: To characterize pharmacist perceptions in providing interventions for patients with an opioid prescription for acute pain. Methods: This cross-sectional survey was administered over 3 months to pharmacy preceptors affiliated with the University of Tennessee Health Science Center College of Pharmacy. The electronic survey utilized 7 demographical and baseline questions, 1 open-ended question, and 5 Likert-type scales to assess the following domains: responsibility in making decisions, willingness to provide information, comfort in speaking to patients, willingness to use a standing order, and importance of following up with patients. Results: Of the 380 participants invited to participate, 126 responded to at least one question and 90 completed all survey questions. Most participants were PharmD graduates practicing in hospital and community settings. Participants felt that opioids are frequently overprescribed and pharmacist interventions are often necessary. Most participants reported that pharmacists and physicians share similar responsibilities in making opioid-related decisions. Participants were willing to provide information about opioid alternatives but were only somewhat comfortable speaking to patients. Responses to the open-ended question revealed the following themes: Significance of educating the patient; Importance of alternatives to opioid medications; Impacts of pharmacist interventions; and Need for enhanced collaboration with physicians. Conclusions: Pharmacists face complex issues with limited clinical guidance when providing opioid-related interventions. Future research is needed to develop evidence-based clinical support tools and collaborative practice models.

Physician Burnout, Resilience, and Patient Experience in a Community Practice: Correlations and the Central Role of Activation

Clinician burnout and patient experience are important issues that are often considered separately. New measures of resilience may influence both. We explored relationships among clinician resilience, burnout, and patient experience. Analysis included 490 physicians who completed surveys measuring burnout and resilience (decompression and activation) and had at least 30 patient experience surveys available for analysis. Burnout was measured with 2 items from the Maslach Burnout Inventory (MBI) which were part of the organization’s ongoing measurement of clinician experience. Resilience was measured with 8 items from 2 Press Ganey validated subscales related to clinicians’ ability to decompress from work and their experience of feeling of activation and connection to purpose while at work. Clinicians reporting more frequent symptoms of burnout based on the MBI items reported less ability to decompress (r for individual measures ranged from −.183 to −.475, P < .01) and less feeling of activation (r for individual measures ranged from −.116 to −.401, P < .01). Individual elements of decompression and activation were significantly associated with patient experience. In terms of activation, feeling that one’s work makes a difference (r ranged from .121 to .159, P < .05) and believing one’s work to be meaningful (r ranged from .102 to .135, P < .05) were positively associated with patient experience with their care provider. However, elements of decompression such as being able to free one’s mind from work (r ranged from −.092 to −.119, P < .05) and being able to disconnect from work communications such as e-mails (r ranged from −.094 to −.130, P < .05) were negatively associated with patient experience with their care providers. Patient and provider experience are intertwined in that clinician resilience is associated with both burnout and patient experience, but individual mechanisms of resilience may be beneficial for the clinician but not for the patient.

Beautiful stranger: Voices from the front lines of community practice in Israel

Over the past few decades, economic, political and cultural forces have altered the development of social policies and affected the life circumstances of oppressed communities in many countries. In response, calls for greater understanding and awareness of macro practice skills and interventions have been increasing within many of the social care professions. These calls have been particularly strong within the social work profession. A major field in macro social work is community practice, which aims to help people organise, plan and act for change. To date, there has been a dearth of studies examining social workers' involvement in community practice at the ground level. Drawing on in-depth interviews with 26 community social workers in public social services in Israel, this qualitative study examines community social workers' everyday experiences of community practice and the meanings they attribute to it. Findings highlight three main themes: (a) the elusive and unbounded nature of community practice; (b) the tense relations that community social workers maintain with various actors within the profession; and (c) the complex relations they maintain with the communities in which they work. We discuss these findings in light of Georg Simmel's concept of 'the stranger'. Implications to community practice are outlined.

Total Thyroidectomy as an Ambulatory Procedure in Community Practice

Objective

Increasingly, total thyroidectomy is offered as an ambulatory procedure. Most of the relevant outcomes research derives from academic centers, but most thyroid surgeries are performed in the community. The goal of this study is to evaluate the safety of total thyroidectomy performed as an ambulatory procedure in a community otolaryngology practice.

Study Design

Retrospective review and national database analysis.

Setting

A single community otolaryngology practice.

Methods

Adult patients undergoing total thyroidectomy by a single otolaryngologist between 2013 and 2019 were divided into 2 cohorts: planned ambulatory and planned admission. Charts were reviewed for demographics and surgical outcomes in the 2 groups. The Healthcare Cost and Utilization Project databases for New York and Florida between 2015 and 2016 were also analyzed to compare outcomes of thyroidectomy as an ambulatory surgery between different practice settings.

Results

A total of 99 total thyroidectomies were performed during the study time period; 66 of 99 (67%) were planned as ambulatory procedures and 33 of 99 (33%) were planned admissions. Five of the 66 (8%) planned outpatient surgeries required admission. Complications of vocal fold dysfunction, symptomatic hypocalcemia, and seroma formation were more commonly seen in the inpatient cohort. Only 2 ambulatory patients required admission after discharge. Nationally, odds of complication were higher for ambulatory total thyroidectomy at nonteaching practice sites, which is not duplicated in our study.

Conclusions

Ambulatory total thyroidectomy can be undertaken safely in the community in carefully selected cases.

Identifying Barriers That Prevent the Usage of Health Information Exchange in Ohio

Background: As clinical services expand in community pharmacies, access to patient information through a health information exchange (HIE) may be of increased benefit to patient care. Objectives: To identify perceptions and barriers to the use of HIE by high-performing clinical pharmacists within a grocery store chain and collect other health care provider perceptions of using HIE. Methods: Two web-based surveys consisting of multiple choice, select all that apply, and 5-point Likert-type scale questions were administered via email to Ohio pharmacists working in high clinical performing pharmacies and Ohio health care providers utilizing CliniSync, an Ohio-based HIE program. Outcomes measured included pharmacist perceptions of preparedness to participate in HIE, their relationship with patients and health care providers, and barriers to utilizing HIE. Provider outcomes included perceptions of relationships with patients, awareness of community pharmacy services, referral habits, and perceived benefit of a HIE. Results: Pharmacists tend to believe they have the skill (median 5, interquartile range [IQR] 1) and desire (median 5, IQR 1) to be a part of the HIE network. Pharmacists appear confident in their abilities to provide patient care as a part of HIE networks (median 4, IQR 1). While 66% of providers surveyed are aware of services provided by community pharmacists, 75% state that they do not refer patients to a pharmacy for those services. Conclusion: Implementing HIE into clinical pharmacy workflow and encouraging providers to use it to make patient health information available to pharmacists would provide additional information for pharmacists to review when providing clinical services in the community pharmacy setting, ultimately benefiting patient care.

Small Cell Lung Cancer from Traditional to Innovative Therapeutics: Building a Comprehensive Network to Optimize Clinical and Translational Research

Small cell lung cancer (SCLC) is an aggressive, complex disease with a distinct biology that contributes to its poor prognosis. Management of SCLC is still widely limited to chemotherapy and radiation therapy, and research recruitment still poses a considerable challenge. Here, we review the current standard of care for SCLC and advances made in utilizing immunotherapy. We also highlight research in the development of targeted therapies and emphasize the importance of a team-based approach to make clinical advances. Building an integrative network between an academic site and community practice sites optimizes biomarker and drug target discovery for managing and treating a difficult disease like SCLC.

NCI-Clinical Trial Accrual in a Community Network Affiliated with a Designated Cancer Center

Most cancer care is delivered in the community, while most clinical trials exist in academic centers. We analyzed clinical trial accrual of a tertiary care cancer center and its affiliated community sites to better understand what types of trials accrued at the community sites and whether community accrual increased ethnic diversity. The institutional clinical trial database was searched for solid tumor accruals during 2018–2019. Patient’s race was abstracted, and trial’s funding source, phase, and disease type/stage were tabulated. Of 3689 accruals, 133 were at community sites, representing 26 unique trials while the main campus accrued to 93 unique trials. Community site accruals were highest for breast and colorectal cancer, but patients with less common cancers such as renal, nasopharyngeal, and gastric cancer were also accrued at community sites. Accruals occurred to randomized trials, as well as phase Ib and translational biomarker studies. Minority patients constituted 20.0% and 32.5% of community site accruals for therapeutic and non-therapeutic trials respectively, compared to 20.6% and 29.8% of main campus accruals for therapeutic and non-therapeutic trials, respectively. We conclude that community sites affiliated with an academic cancer center can accrue to a broad spectrum of clinical trials while enhancing racial diversity in participation of clinical trials. Further expansion of access to clinical trials in community sites is necessary to broaden patient access to state-of-the-art and next-generation treatment options.

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.