Storylines of family medicine VI: ways of being-in the office with patients

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VI: ways of being-in the office with patients', authors address the following themes: 'Patient-centred care-cultivating deep listening skills', 'Doctor as witness', 'Words matter', 'Understanding others-metaphor and its use in medicine', 'Communicating with patients-making good use of time', 'The patient-centred medical home-aspirations for the future', 'Routine, ceremony or drama?' and 'The life course'. May readers better appreciate the nuances of patient care through these essays.

Storylines of family medicine XII: family medicine and the healthcare system

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XII: Family medicine and the future of the healthcare system', authors address the following themes: 'Leadership in family medicine', 'Becoming an academic family physician', 'Advocare-our call to act', 'The paradox of primary care and three simple rules', 'The quadruple aim-melding the patient and the health system', 'Fit-for-purpose medical workforce', 'Universal healthcare-coverage for all', 'The futures of family medicine' and 'The 100th essay.' May readers of these essays feel empowered to be part of family medicine's exciting future.

A longitudinal multi-site evaluation of community-based partnerships: implications for researchers, funders, and communities

BACKGROUND

Innovative Models Promoting Access to Care Transformation (IMPACT) was a five-year (2013-2018), Canadian-Australian research program that aimed to use a community-based partnership approach to transform primary health care (PHC) organizational structures to improve access to appropriate care for vulnerable populations. Local Innovation Partnerships (LIPs) were developed to support the IMPACT research program, and to be ongoing structures that would continue to drive local improvements to PHC.

METHODS

A longitudinal development-focused evaluation explored the overall approach to governance, relationships and processes of the LIPs in the IMPACT program. Semi-structured interviews were conducted with purposively selected participants including researchers with implementation roles and non-researchers who were members of LIPs at four time points: early in the development of the LIPs in 2014; during intervention development in 2015/2016; at the intervention implementation phase in 2017; and nearing completion of the research program in 2018.  A hybrid deductive-inductive thematic analysis approach was used. A Guide developed to support the program was used as the framework for designing questions and analysing data using a qualitative descriptive method initially. A visual representation was developed and refined after each round of data collection to illustrate emerging themes around governance, processes and relationship building that were demonstrated by IMPACT LIPs. After all rounds of data collection, an overarching cross-case analysis of narrative summaries of each site was conducted.

RESULTS

Common components of the LIPs identified across all rounds of data collection related to governance structures, stakeholder relationships, collaborative processes, and contextual barriers.  LIPs were seen primarily as a structure to support implementation of a research project rather than an ongoing multisectoral community-based partnership.  LIPs had relationships with many and varied stakeholders although not necessarily in ways that reflected the intended purpose. Collaboration was valued, but multiple barriers impeded the ability of LIPs to enact real collaboration in daily operations over time. We learned that experience, history, and time matter, especially with respect to community-oriented collaborative skills, structures, and relationships.

CONCLUSIONS

This longitudinal multiple case study offers lessons and implications for researchers, funders, and potential stakeholders in community-based participatory research.

At the edge of chaos: a prospective multiple case study in Australian general practices adapting to COVID-19

OBJECTIVES

The rapid onset and progressive course of the COVID-19 pandemic challenged primary care practices to generate rapid solutions to unique circumstances, creating a natural experiment of effectiveness, resilience, financial stability and governance across primary care models. We aimed to characterise how practices in Melbourne, Australia modified clinical and organisational routines in response to the pandemic in 2020-2021 and identify factors that influenced these changes.

DESIGN

Prospective, qualitative, participatory case study design using constant comparative data analysis, conducted between April 2020 and February 2021. Participant general practitioner (GP) investigators were involved in study design, recruitment of other participants, data collection and analysis. Data analysis included investigator diaries, structured practice observation, documents and interviews.

SETTING

The cases were six Melbourne practices of varying size and organisational model.

PARTICIPANTS

GP investigators approached potential participants. Practice healthcare workers were interviewed by social scientists on three occasions, and provided feedback on presentations of preliminary findings.

RESULTS

We conducted 58 interviews with 26 practice healthcare workers including practice owners, practice managers, GPs, receptionists and nurses; and six interviews with GP investigators. Data saturation was achieved within each practice and across the sample. The pandemic generated changes to triage, clinical care, infection control and organisational routines, particularly around telehealth. While collaboration and trust increased within several practices, others fragmented, leaving staff isolated and demoralised. Financial and organisational stability, collaborative problem solving, creative leadership and communication (internally and within the broader healthcare sector) were major influences on practice ability to negotiate the pandemic.

CONCLUSIONS

This study demonstrates the complex influences on primary care practices, and reinforces the strengths of clinician participation in research design, conduct and analysis. Two implications are: telehealth, triage and infection management innovations are likely to continue; the existing payment system provides inadequate support to primary care in a global pandemic.

The Craft of Generalism clinical skills and attitudes for whole person care

RATIONALE, AIMS AND OBJECTIVES

Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism.

METHODS

The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research.

RESULTS

The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent.

CONCLUSIONS

Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

INTRODUCTION

To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care.

METHODS

Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach.

RESULTS

Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes.

DISCUSSION

Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

Multimodal single-cell analysis of human TILs across multiple tumor types reveals heterogeneity and potential opportunities for personalized immunotherapy

Immune checkpoint blockade (ICB) efficacy varies among tumor types likely due to differences in tumor infiltrating lymphocyte (TIL) composition and function within the tumor microenvironment (TME). To help understand these differences, we conducted multimodal single-cell analysis of TILs including single-cell RNA sequencing (scRNA-seq), CITE-seq (oligo-tagged antibodies), and scTCR-seq (10× Genomics) in (non-small cell lung cancer: NSCLC; head and neck squamous cell carcinoma: HNSCC; renal cell carcinoma: RCC; and breast cancer: BrCa; n=48). We found that regulatory T cell (Treg) frequency was higher in HNSCC, whereas exhausted T cells (Tex) were higher in NSCLC and RCC. In contrast to other tumor types, Tex in RCC lacked the expression of CD103, a hallmark of tissue-resident T cells. On the other hand, expression of PD-1, TIM-3, and LAG-3 were more prominent in Tex in RCC. Interestingly, Tex in HNSCC showed higher expression of TIGIT than other tumor types. Previous work has demonstrated an increased presence of CD4+CD8+ double-positive T cells (DPT) in RCC, which was associated with better overall survival. Therefore, we used CITE-seq to identify DPT and then compared the composition of DPT among different tumor types. DPT were CD39+, a marker for tumor-reactive T cells, and the vast majority were transcriptionally categorized as CD8+ T cells in RCC, whereas DPT in other tumor types are mixture of CD4+ or CD8+ T cell subsets. We also found overlap of TCR profiles between DPT and CD8+ T cell subsets (Tex, ZNF683-CD8, and GZMK-CD8) in RCC. Together, multimodal single-cell analysis of TILs highlighted heterogeneity among tumor types that may provide insight into novel strategies to treat cancer.

Supported by a research grant from GlaxoSmithKline and the Providence Portland Medical Foundation.

Supported by a research grant from GlaxoSmithKline and the Providence Portland Medical Foundation.

Immunological profiling of tumor-infiltrating CD8+ T lymphocytes in non-small cell lung cancer, head and neck squamous cell carcinoma, breast cancer, and renal cell cancer

To explore whether the variation in clinical response to immune checkpoint blockade (ICB) reflects intrinsic characteristics of tumor-infiltrating lymphocytes (TIL), TILs from multiple tumor types were analyzed by multiparameter flow cytometry. Recent work identified CD39+CD103+ double positive (DP) CD8 TIL as tumor-reactive, therefore we assessed this phenotype in primary NSCLC (n=28), BCa (n=23), HNSCC (n=23), and RCC (n=23) specimens. TILs from NSCLC and HNSCC had significantly higher frequencies of DP T cells than BCa and RCC (NSCLC: median=34.2, IQR=15.0–53.8%; HNSCC: median=28.6%, IQR=13.5–44.5%), while TILs from BCa and RCC had low frequencies of DP T cells (BCa: median=2.4%, IQR=1.1–3.9%; RCC: median=4.2%, IQR=1.5–16.6%). Additionally, DP cells in NSCLC and HNSCC were co-expressed immune checkpoint markers PD-1, TIM-3, and LAG-3 at a higher frequency than RCC or BCa (P&lt;0.05). DP CD8 T cells in NSCLC and HNSCC also exhibited increased effector potential (granzyme B+) as compared to BCa and RCC, suggesting functional differences. Expression of the transcription factor Eomesodermin, associated with T cell exhaustion, was higher in effector CD8 T cells from RCC (median=84.5%, IQR=44.9–97.4%) as compared to NSCLC (median=28.7%, IQR=20.7–61.4%), BCa (median=30.1%, IQR=0–50%), and HNSCC (median=40.3%, IQR=20.1–61.2%). Additionally, 4-1BB, an indicator of TCR engagement, trended higher in RCC (mean=8.6%, IQR=1.4–46.7%) as compared to BCa (median=1.9%, IQR=0.4–8.6%). These data highlight the heterogeneity of human TILs isolated from distinct tumor types and provide insight into the basal expression of actionable therapeutic targets.

Supported by GlaxoSmithKline and the Providence Portland Medical Foundation

A Novel Mixed Methods Approach Combining Geospatial Mapping and Qualitative Inquiry to Identify Multilevel Policy Targets: The Focused Rapid Assessment Process (fRAP) Applied to Cancer Survivorship

Multi-level perspectives across communities, medical systems and policy environments are needed, but few methods are available for health services researchers with limited resources. We developed a mixed method health policy approach, the focused Rapid Assessment Process (fRAP), that is designed to uncover multi-level modifiable barriers and facilitators contributing to public health issues. We illustrate with a study applying fRAP to the issue of cancer survivorship care. Through this multi-level investigation we identified two major modifiable areas impacting high-quality cancer survivorship care: 1) the importance of cancer survivorship guidelines/data, 2) the need for improved oncology-primary care relationships. This article contributes to the mixed methods literature by coupling geospatial mapping to qualitative rapid assessment to efficiently identify policy change targets.

The Time Is Now: A Plan to Redesign Family Medicine Residency Education

A new graduate medical education program in family medicine is urgently needed now. We propose an innovative plan to develop community-based, community-owned family medicine residency programs. The plan is founded on five guiding principles in which residencies will (1) transition to independent, community-owned organizations; (2) sustain comprehensiveness and generalism; (3) emphasize collaborative learning and interprofessional education; (4) develop local educators with national guidance; and (5) share resources, responsibilities, and learning. We describe actionable steps to begin the process of transforming residencies and strengthening primary care. As community-based and locally-run organizations, residencies will gain self-determination in how time is allocated, budgets are spent, and teams function. Building on the momentum of the National Academy of Medicine's 2021 primary care implementation plan and recommendations by family medicine organization leaders, we propose a Decade of Family Medicine Residency Transformation. We encourage individuals and organizations spanning disciplines, health care systems, and communities, to join forces to reimagine and recreate the preparation of outstanding personal physicians dedicated to individual and community health and well-being.

Indicator species characterization and removal in a detention pond in the Plaster Creek watershed

Microbial pathogen contamination is a leading cause of impairment for urban rivers and streams in Michigan. Reports on the ability of green infrastructure best management practices to remove microbial pathogens have been highly variable. This study evaluated the influence of a detention basin (Kreiser Pond) on microbial dynamics in the Plaster Creek watershed in West Michigan. High levels of fecal indicator bacteria and coliphage were documented in influent and effluent water, with significant increases in indicator microbe concentrations during storm events. In dry conditions, Kreiser Pond efficiently reduced the number of indicator microbes flowing through the basin. Rainfall volume had a greater influence on the diversity of bacteria than sampling location. Antibiotic resistance was prevalent in culturable E. coli from Kreiser Pond, demonstrating a potential public health risk and highlighting the need for identifying the ultimate sources of microbial pollution.

How do general practices respond to a pandemic? Protocol for a prospective qualitative study of six Australian practices

INTRODUCTION

The COVID-19 pandemic has transformed healthcare systems worldwide. Primary care providers have been at the forefront of the pandemic response and have needed to rapidly adjust processes and routines around service delivery. The pandemic provides a unique opportunity to understand how general practices prepare for and respond to public health emergencies. We will follow a range of general practices to characterise the changes to, and factors influencing, modifications to clinical and organisational routines within Australian general practices amidst the COVID-19 pandemic.

METHODS AND ANALYSIS

This is a prospective case study of multiple general practices using a participatory approach for design, data collection and analysis. The study is informed by the sociological concept of routines and will be set in six general practices in Melbourne, Australia during the 2020-2021 COVID-19 pandemic. General practitioners associated with the Monash University Department of General Practice will act as investigators who will shape the project and contribute to the data collection and analysis. The data will include investigator diaries, an observation template and interviews with practice staff and investigators. Data will first be analysed by two external researchers using a constant comparative approach and then later refined at regular investigator meetings. Cross-case analysis will explain the implementation, uptake and sustainability of routine changes that followed the commencement of the pandemic.

ETHICS AND DISSEMINATION

Ethics approval was granted by Monash University (23950) Human Research Ethics Committees. Practice reports will be made available to all participating practices both during the data analysis process and at the end of the study. Further dissemination will occur via publications and presentations to practice staff and medical practitioners.

Simple Rules That Guide Generalist and Specialist Care

The sometimes-paradoxical emergent behavior of complex systems may be explained by the interaction of simple rules. The paradox of primary care-that systems based on primary care have healthier populations, fewer health inequities, lower health care expenditures, and better system-level evidence-based disease care, despite less evidence-based care for individual diseases-may be explained by the iterative interaction among three simple rules that describe the generalist approach: (1) Recognize a broad range of problems/opportunities; (2) Prioritize attention and action with the intent of promoting health, healing, and connection; and (3) Personalize care based on the particulars of the individual or family in their local context. These are complemented by three simple rules for specialist care that represent current approaches to quality and health care system improvement: (1) Identify and classify disease for management; (2) Interpret through specialized knowledge; (3) Generate and carry out a management plan. Health care systems that support the enactment of the simple rules of the generalist approach are likely to have more effective primary and specialty care, and greater population health, equity, quality, and sustainable cost.

Comparison of sample types from white-tailed deer (Odocoileus virginianus) for DNA extraction and analyses

Collection of biological samples for DNA is necessary in a variety of disciplines including disease epidemiology, landscape genetics, and forensics. Quantity and quality of DNA varies depending on the method of collection or media available for collection (e.g., blood, tissue, fecal). Blood is the most common sample collected in vials or on Whatman Flinders Technology Associates (FTA) cards with short- and long-term storage providing adequate DNA for study objectives. The focus of this study was to determine if biological samples stored on Whatman FTA Elute cards were a reasonable alternative to traditional DNA sample collection, storage, and extraction. Tissue, nasal swabs, and ocular fluid were collected from white-tailed deer (Odocoileus virginianus). Tissue samples and nasal swabs acted as a control to compare extraction and DNA suitability for microsatellite analysis for nasal swabs and ocular fluid extracted from FTA Elute cards. We determined that FTA Elute cards improved the extraction time and storage of samples and that nasal swabs and ocular fluid containing pigmented fluid were reasonable alternatives to traditional tissue DNA extractions.

Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context

PURPOSE

We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care.

METHODS

We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes.

RESULTS

In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes.

CONCLUSIONS

There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.

Simple Method to Determine the Apparent Quantum Yield Matrix of CDOM Photobleaching in Natural Waters

The photobleaching of chromophoric dissolved organic matter (CDOM) is considered an important loss process for CDOM absorption in sunlit natural waters, where it can regulate the biota's exposure to sunlight, surface solar heating, and dissolved organic matter dynamics. Despite its importance, this sink remains poorly quantified, primarily because of the difficulty of determining photobleaching apparent quantum yields (AQYs) that capture the dual spectral dependency of this process and are applicable to polychromatic sunlight. Here, we present a simple method to determine a CDOM photobleaching AQY matrix (AQY-M) for natural water samples that does not require any a priori assumptions about the spectral dependency of photobleaching. It combines controlled irradiation experiments, a partial least-square regression, and an optimization procedure to produce AQY-Ms that are spectrally coherent and optimized for modeling accurate photobleaching rates in natural waters. Water temperature and the solar exposure history of CDOM had a major influence on the magnitude and spectral characteristics of the AQY-M. These factors should be considered when determining the AQY-M of samples and provide constraints when modeling photobleaching rates in natural waters. We expect that this effective method will provide future studies with a robust means to characterize and understand the variability of AQY-M in natural waters.

Leading Innovative Practice: Leadership Attributes in LEAP Practices

Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes.

CONTEXT

Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes.

METHODS

A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices.

FINDINGS

We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others.

CONCLUSIONS

Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

Assessment of spatial genetic structure to identify populations at risk for infection of an emerging epizootic disease

Understanding the geographic extent and connectivity of wildlife populations can provide important insights into the management of disease outbreaks but defining patterns of population structure is difficult for widely distributed species. Landscape genetic analyses are powerful methods for identifying cryptic structure and movement patterns that may be associated with spatial epizootic patterns in such cases.We characterized patterns of population substructure and connectivity using microsatellite genotypes from 2,222 white-tailed deer (Odocoileus virginianus) in the Mid-Atlantic region of the United States, a region where chronic wasting disease was first detected in 2009. The goal of this study was to evaluate the juxtaposition between population structure, landscape features that influence gene flow, and current disease management units.Clustering analyses identified four to five subpopulations in this region, the edges of which corresponded to ecophysiographic provinces. Subpopulations were further partitioned into 11 clusters with subtle (F ST ≤ 0.041), but significant genetic differentiation. Genetic differentiation was lower and migration rates were higher among neighboring genetic clusters, indicating an underlying genetic cline. Genetic discontinuities were associated with topographic barriers, however.Resistance surface modeling indicated that gene flow was diffuse in homogenous landscapes, but the direction and extent of gene flow were influenced by forest cover, traffic volume, and elevational relief in subregions heterogeneous for these landscape features. Chronic wasting disease primarily occurred among genetic clusters within a single subpopulation and along corridors of high landscape connectivity.These results may suggest a possible correlation between population substructure, landscape connectivity, and the occurrence of diseases for widespread species. Considering these factors may be useful in delineating effective management units, although only the largest features produced appreciable differences in subpopulation structure. Disease mitigation strategies implemented at the scale of ecophysiographic provinces are likely to be more effective than those implemented at finer scales.

Cancer Survivorship Care Roles for Primary Care Physicians

PURPOSE

Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors.

METHODS

We conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians' perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process.

RESULTS

Divergent views exist regarding primary care's role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology's responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge.

CONCLUSIONS

This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.

Can genetic assignment tests provide insight on the influence of captive egression on the epizootiology of chronic wasting disease?

Identifying the sources of ongoing and novel disease outbreaks is critical for understanding the diffusion of epizootic diseases. Identifying infection sources is difficult when few physical differences separate individuals with different origins. Genetic assignment procedures show great promise for assessing transmission dynamics in such situations. Here, we use genetic assignment tests to determine the source of chronic wasting disease infections in free-ranging white-tailed deer (Odocoileus virginianus) populations. Natural dispersal is thought to facilitate the geographic diffusion of chronic wasting disease, but egression from captive cervid populations represents an alternative source of infection that is difficult to detect due to physical similarities with wild deer. Simulated reference populations were created based on allele frequencies from 1,912 empirical microsatellite genotypes collected in four sampling subregions and five captive facilities. These reference populations were used to assess the likelihood of ancestry and assignment of 1,861 free-ranging deer (1,834 noninfected and 27 infected) and 51 captive individuals to captive or wild populations. The ancestry (Q) and assignment scores (A) for free-ranging deer to wild populations were high (average Q wild = 0.913 and average A wild = 0.951, respectively), but varied among subregions (Q wild = 0.800-0.947, A wild = 0.857-0.976). These findings suggest that captive egression and admixture are rare, but risk may not be spatially uniform. Ancestry and assignment scores for two free-ranging deer with chronic wasting disease sampled in an area where chronic wasting disease was previously unobserved in free-ranging herds indicated a higher likelihood of assignment and proportion of ancestry attributable to captive populations. While we cannot directly assign these individuals to infected facilities, these findings suggest that rare egression events may influence the epizootiology of chronic wasting disease in free-ranging populations. Continued disease surveillance and genetic analyses may further elucidate the relative disease risk attributable to captive and wild sources.

Understanding primary care-oncology relationships within a changing healthcare environment

Background

Management of care transitions from primary care into and out of oncology is critical for optimal care of cancer patients and cancer survivors. There is limited understanding of existing primary care-oncology relationships within the context of the changing health care environment.

Methods

Through a comparative case study of 14 innovative primary care practices throughout the United States (U.S.), we examined relationships between primary care and oncology settings to identify attributes contributing to strengthened relationships in diverse settings. Field researchers observed practices for 10–12 days, recording fieldnotes and conducting interviews. We created a reduced dataset of all text related to primary care-oncology relationships, and collaboratively identified patterns to characterize these relationships through an inductive “immersion/crystallization” analysis process.

Results

Nine of the 14 practices discussed having either formal or informal primary care-oncology relationships. Nearly all formal primary care-oncology relationships were embedded within healthcare systems. The majority of private, independent practices had more informal relationships between individual primary care physicians and specific oncologists. Practices with formal relationships noted health system infrastructure that facilitates transfer of patient information and timely referrals. Practices with informal relationships described shared commitment, trust, and rapport with specific oncologists. Regardless of relationship type, challenges reported by primary care settings included lack of clarity about roles and responsibilities during cancer treatment and beyond.

Conclusions

With the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate strengths of informal primary care-oncology relationships in addition to formal system driven relationships.

Spatial heterogeneity of prion gene polymorphisms in an area recently infected by chronic wasting disease

Genetic variability in the prion protein (Prnp) gene influences host susceptibility to many pathogenic prion diseases. Understanding the distribution of susceptible Prnp variants and determining factors influencing spatial genetic patterns are important components of many chronic wasting disease mitigation strategies. Here, we describe Prnp variability in white-tailed deer (Odocoileus virginianus) from the Mid-Atlantic region of the United States of America, an area with a recent history of infection and low disease incidence. This population is characterized by lower rates of polymorphism and significantly higher frequencies of the more susceptible 96GG genotype compared to previously surveyed populations. The prevalence of the most susceptible genotypes at disease-associated loci did vary among subregions, indicating that populations have innate differences in genotype-dictated susceptibility.

Identification and evaluation of a core microsatellite panel for use in white-tailed deer (Odocoileus virginianus)

Background

Microsatellite loci have been used extensively over the past two decades to study the genetic characteristics of non-model species. The ease of microsatellite development and ability to adapt markers from related species has led to the proliferation of available markers for many commonly studied species. Because it is often infeasible to genotype individuals across all available loci, researchers generally rely on subsets of markers. Marker choice can bias inferences made using disparate suites of loci. This has been a primary motivation for efforts to identify uniform marker panels. Here, we use the geographic distribution of previous studies to identify microsatellite loci for white-tailed deer (Odocoileus virginianus) with the potential for widespread use, and we evaluate the effectiveness of this panel in a portion of the range where few previous studies have been conducted. The purpose was to consolidate the numerous genetic resources for this species into a manageable panel and to provide a uniform methodology that improves comparisons between past and future studies.

Results

We reviewed microsatellite panels from 58 previous or ongoing projects and identified 106 candidate loci. We developed a multiplex protocol and evaluated the efficacy of 17 of the most commonly used loci using 720 DNA samples collected from the Mid-Atlantic region of the United States of America. Amplification errors were detected in six of these loci. The 11 remaining loci were highly polymorphic, exhibited low frequencies of null alleles, and were easy to interpret with the aid of allele binning software.

Conclusions

The development of broadly-applicable, core microsatellite panels has the potential to improve repeatability and comparative ability for commonly studied species. The properties of the consolidated 11 microsatellite panel suggest that they are applicable for many common research objectives for white-tailed deer. The geographic distribution of previous studies using these markers provides a greater degree of confidence regarding the robustness to common sources of error related to amplification anomalies, such as null alleles, relative to loci with more limited use. While this does not replace further evaluation of genotyping errors, it does provide a common platform that benefits future research studies.

Electronic supplementary material

The online version of this article (10.1186/s12863-019-0750-z) contains supplementary material, which is available to authorized users.

Shifting Implementation Science Theory to Empower Primary Care Practices

Observers of the past 10 to 15 years have witnessed the simultaneous growth of dramatic changes in the practice of primary care and the emergence of a new field of dissemination and implementation science (D&I). Most current implementation science research in primary care assumes practices are not meeting externally derived standards and need external support to meet these demands. After a decade of initiatives, many stakeholders now question the return on their investments. Overall improvements in quality metrics, utilization cost savings, and patient experience have been less than anticipated. While recently conducting a research project in primary care practices, we unexpectedly discovered 3 practices that profoundly shifted our thinking about the sources and directionality of practice change and the underlying assumptions of D&I. Inspired by these practices-along with systems thinking, complexity theory, action research, and the collaborative approaches of community-based participatory research-we propose a reimagining of D&I theory to empower practices. We shift the emphasis regarding the source and direction of change from outside-in to inside-out Such a shift has the potential to open a new frontier in the science of dissemination and implementation and inform better health policy.

Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension

Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension-technological and quality improvement support, practice capacity building, and linking with community resources-to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services.

Opportunities for improving cancer care management through primary care-oncology relationships

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Background: Improvements in the management of care transitions between primary care and oncology are critical for achieving optimal care quality and outcomes for cancer patients and survivors. We examine relationships between innovative PC practices and oncologists to inform and strengthen PC-oncology interfaces in diverse healthcare settings. Methods: Comparative case studies of 14 innovative PC practices throughout the United States examined strategies for providing cancer survivorship care. Field researchers observed each practice for 10-12 days, recording fieldnotes and conducting key informant and formal, semi-structured interviews with clinicians and staff. We extracted all data related to PC-oncology relationships and then collaboratively identified patterns to characterize these relationships through an inductive “immersion/crystallization” analysis process. Results: Nine of the 14 practices discussed either formal or informal PC-oncology relationships. Nearly all practices with existing formal PC-oncology relationships were embedded within healthcare systems. Private, independent practices had more informal relationships between individual PC physicians and specific oncologists. Practices with formal relationships noted ease of communication and transfer of patient information, timeliness in patient referrals, and direct access to oncologists; while practices with informal relationships noted the benefits of having close engagement with specific oncologists. Regardless of relationship type, remaining challenges include lack of clarity about roles during cancer treatment and beyond. Conclusions: With the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate the strengths of both formal and informal PC-oncology relationships to improve care for cancer patients and survivors.

Limited hatchery introgression into wild brook trout (Salvelinus fontinalis) populations despite reoccurring stocking

Due to increased anthropogenic pressures on many fish populations, supplementing wild populations with captive-raised individuals has become an increasingly common management practice. Stocking programs can be controversial due to uncertainty about the long-term fitness effects of genetic introgression on wild populations. In particular, introgression between hatchery and wild individuals can cause declines in wild population fitness, resiliency, and adaptive potential and contribute to local population extirpation. However, low survival and fitness of captive-raised individuals can minimize the long-term genetic consequences of stocking in wild populations, and to date the prevalence of introgression in actively stocked ecosystems has not been rigorously evaluated. We quantified the extent of introgression in 30 populations of wild brook trout (Salvelinus fontinalis) in a Pennsylvania watershed and examined the correlation between introgression and 11 environmental covariates. Genetic assignment tests were used to determine the origin (wild vs. captive-raised) for 1,742 wild-caught and 300 hatchery brook trout. To avoid assignment biases, individuals were assigned to two simulated populations that represented the average allele frequencies in wild and hatchery groups. Fish with intermediate probabilities of wild ancestry were classified as introgressed, with threshold values determined through simulation. Even with reoccurring stocking at most sites, over 93% of wild-caught individuals probabilistically assigned to wild origin, and only 5.6% of wild-caught fish assigned to introgressed. Models examining environmental drivers of introgression explained <3% of the among-population variability, and all estimated effects were highly uncertain. This was not surprising given overall low introgression observed in this study. Our results suggest that introgression of hatchery-derived genotypes can occur at low rates, even in actively stocked ecosystems and across a range of habitats. However, a cautious approach to stocking may still be warranted, as the potential effects of stocking on wild population fitness and the mechanisms limiting introgression are not known.

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries

BACKGROUND

Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm.

OBJECTIVE

To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices.

METHODS

An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies.

RESULTS

Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect.

CONCLUSION

The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach

BACKGROUND

Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies.

OBJECTIVE

To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials.

METHODS

We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights.

RESULTS

CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions.

CONCLUSIONS

The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.

Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices

PURPOSE

Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations.

METHODS

In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from -28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score.

RESULTS

The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system-owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores.

CONCLUSION

There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models.

Cancer Survivorship Care in Advanced Primary Care Practices: A Qualitative Study of Challenges and Opportunities

IMPORTANCE

Despite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors.

OBJECTIVE

To explain why primary care has not begun to integrate comprehensive cancer survivorship services.

DESIGN, SETTING, AND PARTICIPANTS

Comparative case study of 12 advanced primary care practices in the United States recruited from March 2015 to February 2017. Practices were selected from a national registry of 151 workforce innovators compiled for the Robert Wood Johnson Foundation. Practices were recruited to include diversity in policy context and organizational structure. Researchers conducted 10 to 12 days of ethnographic data collection in each practice, including interviews with practice personnel and patient pathways with cancer survivors. Fieldnotes, transcripts, and practice documents were analyzed within and across cases to identify salient themes.

MAIN OUTCOMES AND MEASURES

Description of cancer survivorship care delivery in advanced patient-centered medical homes, including identification of barriers and promotional factors related to that care.

RESULTS

The 12 practices came from multiple states and policy contexts and had a mix of clinicians trained in family or internal medicine. All but 3 were recognized as National Committee on Quality Assurance level 3 patient-centered medical homes. None of the practices provided any type of comprehensive cancer survivorship services. Three interdependent explanatory factors emerged: the absence of a recognized, distinct clinical category of survivorship in primary care; a lack of actionable information to treat this patient population; and current information systems unable to support survivorship care.

CONCLUSIONS AND RELEVANCE

To increase the potential for primary care transformation efforts to integrate survivorship services into routine care, survivorship must become a recognized clinical category with actionable care plans supported by a functional information system infrastructure.

CWDPRNP: a tool for cervid prion sequence analysis in program R

Summary

Chronic wasting disease is a fatal, neurological disease caused by an infectious prion protein, which affects economically and ecologically important members of the family Cervidae. Single nucleotide polymorphisms within the prion protein gene have been linked to differential susceptibility to the disease in many species. Wildlife managers are seeking to determine the frequencies of disease-associated alleles and genotypes and delineate spatial genetic patterns. The CWDPRNP package, implemented in program R, provides a unified framework for analyzing prion protein gene variability and spatial structure.

Availability and implementation

The CWDPRNP package, manual and example data files are available at http://ecosystems.psu.edu/research/labs/walter-lab/additional-labs/population-genetics-lab. This package is available for all commonly used platforms.

Contact

wlm159psu@gmail.com.

ePrescribing: Reducing Costs through In-Class Therapeutic Interchange

INTRODUCTION

Spending on pharmaceuticals in the US reached $373.9 billion in 2014. Therapeutic interchange offers potential medication cost savings by replacing a prescribed drug for an equally efficacious therapeutic alternative.

METHODS

Hard-stop therapeutic interchange recommendation alerts were developed for four medication classes (HMG-CoA reductase inhibitors, serotonin receptor agonists, intranasal steroid sprays, and proton-pump inhibitors) in an electronic prescription-writing tool for outpatient prescriptions. Using prescription data from January 2012 to June 2015, the Compliance Ratio (CR) was calculated by dividing the number of prescriptions with recommended therapeutic interchange medications by the number of prescriptions with non-recommended medications to measure effectiveness. To explore potential cost savings, prescription data and medication costs were analyzed for the 45,000 Vanderbilt Employee Health Plan members.

RESULTS

For all medication classes, significant improvements were demonstrated - the CR improved (proton-pump inhibitors 2.8 to 5.32, nasal steroids 2.44 to 8.16, statins 2.06 to 5.51, and serotonin receptor agonists 0.8 to 1.52). Quarterly savings through the four therapeutic interchange interventions combined exceeded $200,000 with an estimated annual savings for the health plan of $800,000, or more than $17 per member.

CONCLUSION

A therapeutic interchange clinical decision support tool at the point of prescribing resulted in increased compliance with recommendations for outpatient prescriptions while producing substantial cost savings to the Vanderbilt Employee Health Plan - $17.77 per member per year. Therapeutic interchange rules require rational targeting, appropriate governance, and vigilant content updates.

A national evaluation of a dissemination and implementation initiative to enhance primary care practice capacity and improve cardiovascular disease care: the ESCALATES study protocol

Background

The Agency for Healthcare Research and Quality (AHRQ) launched the EvidenceNOW Initiative to rapidly disseminate and implement evidence-based cardiovascular disease (CVD) preventive care in smaller primary care practices. AHRQ funded eight grantees (seven regional Cooperatives and one independent national evaluation) to participate in EvidenceNOW. The national evaluation examines quality improvement efforts and outcomes for more than 1500 small primary care practices (restricted to those with fewer than ten physicians per clinic). Examples of external support include practice facilitation, expert consultation, performance feedback, and educational materials and activities. This paper describes the study protocol for the EvidenceNOW national evaluation, which is called Evaluating System Change to Advance Learning and Take Evidence to Scale (ESCALATES).

Methods

This prospective observational study will examine the portfolio of EvidenceNOW Cooperatives using both qualitative and quantitative data. Qualitative data include: online implementation diaries, observation and interviews at Cooperatives and practices, and systematic assessment of context from the perspective of Cooperative team members. Quantitative data include: practice-level performance on clinical quality measures (aspirin prescribing, blood pressure and cholesterol control, and smoking cessation; ABCS) collected by Cooperatives from electronic health records (EHRs); practice and practice member surveys to assess practice capacity and other organizational and structural characteristics; and systematic tracking of intervention delivery. Quantitative, qualitative, and mixed methods analyses will be conducted to examine how Cooperatives organize to provide external support to practices, to compare effectiveness of the dissemination and implementation approaches they implement, and to examine how regional variations and other organization and contextual factors influence implementation and effectiveness.

Discussion

ESCALATES is a national evaluation of an ambitious large-scale dissemination and implementation effort focused on transforming smaller primary care practices. Insights will help to inform the design of national health care practice extension systems aimed at supporting practice transformation efforts in the USA.

Clinical Trial Registration

NCT02560428 (09/21/15)

Increased CD4+ T cell proliferation upon treatment correlates with improved overall survival of patients with metastatic melanoma upon anti-CTLA-4 therapy

Blockade of cytotoxic T-lymphocyte antigen 4 (CTLA-4) augments anti-tumor immunity and has shown success in treating patients with metastatic melanoma. Mechanisms of anti-CTLA-4 efficacy have been proposed in animal models, yet the mechanisms in humans remain to be elucidated. Increased frequency of ICOS+ CD4+ T cells has been shown to be a marker of drug bioactivity, but discovery of prognostic indicators and baseline indicators of which patients are most likely to benefit from CTLA-4 blockade remains a priority.

PBMCs from 29 metastatic melanoma patients in a multicenter compassionate use trial of anti-CTLA-4 antibody were evaluated using flow cytometry. At baseline and 12 weeks following initiation of treatment, CTLA-4, HLA-DR, ICOS, PD-L1, PD-1, and Ki-67 frequencies were assessed on CD4+ and CD8+ T cells, as well as CD3+CD4+ regulatory T cells.

Independent of survival, anti-CTLA-4 treatment significantly increased the frequency of ICOS+ CD4+ T cells, corroborating previous findings. Interestingly, this increase was also observed in ICOS+ Tregs, but not in CD8+ T cells. Increased proliferative Ki67+ CD4+ T cells and Ki67+ Tregs upon CTLA-4 blockade were both associated with prolonged overall survival. Additionally, when the frequency of Ki67+ CD4+ T cells post-treatment was compared to the baseline frequency, patients with a ratio greater than 1.5 had greater overall survival. Increased post-treatment absolute lymphocyte count—a known prognostic biomarker—also correlated with clinical outcome. Our results suggest that anti-CTLA-4 therapy may be mediated by proliferation of CD4+ T cells, and we identify this proliferation as a novel prognostic biomarker in metastatic melanoma patients treated with anti-CTLA-4 antibody.

Maximizing the Patient-Centered Medical Home (PCMH) by Choosing Words Wisely

BACKGROUND

Culture is transmitted through language and reflects a group's values, yet much of the current language used to describe the new patient-centered medical home (PCMH) is a carryover from the traditional, physician-centric model of care. This language creates a subtle yet powerful force that can perpetuate the status quo, despite transformation efforts. This article describes new terminology that some innovative primary care practices are using to support the transformational culture of the PCMH.

METHODS

Data come from the Agency for Healthcare Research and Quality-funded Working Conference for PCMH Innovation 2013, which convened 10 innovative practices and interdisciplinary content experts to discuss innovative practice redesign. Session and interview transcripts were analyzed using a grounded theory approach to identify patterns and explore their significance.

RESULTS

Language innovations are used by 5 practices. Carefully selected terms facilitate creative reimagining of traditional roles and spaces through connotations that highlight practice goals. Participants felt that the language used was important for reinforcing substantive changes.

CONCLUSIONS

Reworking well-established vernacular requires openness to change. True transformation does not, however, occur through a simple relabeling of old concepts. New terminology must represent values to which practices genuinely aspire, although caution is advised when using language to support cultural and clinical change.

A Semi-automated Approach to Preparing Antibody Cocktails for Immunophenotypic Analysis of Human Peripheral Blood

Immunophenotyping of peripheral blood by flow cytometry determines changes in the frequency and activation status of peripheral leukocytes during disease and treatment. It has the potential to predict therapeutic efficacy and identify novel therapeutic targets. Whole blood staining utilizes unmanipulated blood, which minimizes artifacts that can occur during sample preparation. However, whole blood staining must also be done on freshly collected blood to ensure the integrity of the sample. Additionally, it is best to prepare antibody cocktails on the same day to avoid potential instability of tandem-dyes and prevent reagent interaction between brilliant violet dyes. Therefore, whole blood staining requires careful standardization to control for intra and inter-experimental variability.

Here, we report deployment of an automated liquid handler equipped with a two-dimensional (2D) barcode reader into a standard process of making antibody cocktails for flow cytometry. Antibodies were transferred into 2D barcoded tubes arranged in a 96 well format and their contents compiled in a database. The liquid handler could then locate the source antibody vials by referencing antibody names within the database. Our method eliminated tedious coordination for positioning of source antibody tubes. It provided versatility allowing the user to easily change any number of details in the antibody dispensing process such as specific antibody to use, volume, and destination by modifying the database without rewriting the scripting in the software method for each assay.

A proof of concept experiment achieved outstanding inter and intra- assay precision, demonstrated by replicate preparation of an 11-color, 17-antibody flow cytometry assay. These methodologies increased overall throughput for flow cytometry assays and facilitated daily preparation of the complex antibody cocktails required for the detailed phenotypic characterization of freshly collected anticoagulated peripheral blood.

Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries

Context

A key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. However, the impact of these changes on practitioners has not been well understood.

Objective

To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices.

Design

Collaborative synthesis of 12 mixed methods studies.

Setting

Primary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec).

Methods

We conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context.

Results

There was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups.

Conclusion

The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level.

Fshb-iCre mice are efficient and specific Cre deleters for the gonadotrope lineage

Genetic analysis of development and function of the gonadotrope cell lineage within mouse anterior pituitary has been greatly facilitated by at least three currently available Cre strains in which Cre was either knocked into the Gnrhr locus or expressed as a transgene from Cga and Lhb promoters. However, in each case there are some limitations including CRE expression in thyrotropes within pituitary or ectopic expression outside of pituitary, for example in some populations of neurons or gonads. Hence, these Cre strains often pose problems with regard to undesirable deletion of alleles in non-gonadotrope cells, fertility and germline transmission of mutant alleles. Here, we describe generation and characterization of a new Fshb-iCre deleter strain using 4.7 kb of ovine Fshb promoter regulatory sequences driving iCre expression exclusively in the gonadotrope lineage within anterior pituitary. Fshb-iCre mice develop normally, display no ectopic CRE expression in gonads and are fertile. When crossed onto a loxP recombination-mediated red to green color switch reporter mouse genetic background, in vivo CRE recombinase activity is detectable in gonadotropes at more than 95% efficiency and the GFP-tagged gonadotropes readily purified by fluorescence activated cell sorting. We demonstrate the applicability of this Fshb-iCre deleter strain in a mouse model in which Dicer is efficiently and selectively deleted in gonadotropes. We further show that loss of DICER-dependent miRNAs in gonadotropes leads to profound suppression of gonadotropins resulting in male and female infertility. Thus, Fshb-iCre mice serve as a new genetic tool to efficiently manipulate gonadotrope-specific gene expression in vivo.

Trust and Reflection in Primary Care Practice Redesign

OBJECTIVE

To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH).

DATA SOURCES/STUDY SETTING

Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH.

STUDY DESIGN

We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices.

DATA COLLECTION/EXTRACTION METHODS

We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method.

PRINCIPAL FINDINGS

Trust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection.

CONCLUSIONS

Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign.

Contact lens care solution killing efficacy against Acanthamoeba castellanii by in vitro testing and live-imaging

In the past decade there has been an increased incidence of Acanthamoeba keratitis, particularly in contact lens wearers. The aim of this study was to utilize in vitro killing assays and to establish a novel, time-lapse, live-cell imaging methodology to demonstrate the efficacy of contact lens care solutions in eradicating Acanthamoeba castellanii (A. castellanii) trophozoites and cysts. Standard qualitative and quantitative in vitro assays were performed along with novel time-lapse imaging coupled with fluorescent dye staining that signals cell death. Quantitative data obtained demonstrated that 3% non-ophthalmic hydrogen peroxide demonstrated the highest percent killing at 87.4% corresponding to a 4.4 log kill. The other contact lens care solutions which showed a 72.9 to 29.2% killing which was consistent with 4.3-2.8 log reduction in trophozoite viability. Both analytical approaches revealed that polyquaternium/PHMB-based was the least efficacious in terms of trophicidal activity. The cysticidal activity of the solutions was much less than activity against trophozoites and frequently was not detected. Live-imaging provided a novel visual endpoint for characterizing the trophocidal activity of the care solutions. All solutions caused rapid rounding or pseudocyst formation of the trophozoites, reduced motility and the appearance of different morphotypes. Polyquaternium/alexidine-based and peroxide-based lens care system induced the most visible damage indicated by significant accumulation of debris from ruptured cells. Polyquaternium/PHMB-based was the least effective showing rounding of the cells but minimal death. These observations are in keeping with care solution biocides having prominent activity at the plasma membrane of Acanthamoeba.

Learning Evaluation: blending quality improvement and implementation research methods to study healthcare innovations

Background

In healthcare change interventions, on-the-ground learning about the implementation process is often lost because of a primary focus on outcome improvements. This paper describes the Learning Evaluation, a methodological approach that blends quality improvement and implementation research methods to study healthcare innovations.

Methods

Learning Evaluation is an approach to multi-organization assessment. Qualitative and quantitative data are collected to conduct real-time assessment of implementation processes while also assessing changes in context, facilitating quality improvement using run charts and audit and feedback, and generating transportable lessons. Five principles are the foundation of this approach: (1) gather data to describe changes made by healthcare organizations and how changes are implemented; (2) collect process and outcome data relevant to healthcare organizations and to the research team; (3) assess multi-level contextual factors that affect implementation, process, outcome, and transportability; (4) assist healthcare organizations in using data for continuous quality improvement; and (5) operationalize common measurement strategies to generate transportable results.

Results

Learning Evaluation principles are applied across organizations by the following: (1) establishing a detailed understanding of the baseline implementation plan; (2) identifying target populations and tracking relevant process measures; (3) collecting and analyzing real-time quantitative and qualitative data on important contextual factors; (4) synthesizing data and emerging findings and sharing with stakeholders on an ongoing basis; and (5) harmonizing and fostering learning from process and outcome data. Application to a multi-site program focused on primary care and behavioral health integration shows the feasibility and utility of Learning Evaluation for generating real-time insights into evolving implementation processes.

Conclusions

Learning Evaluation generates systematic and rigorous cross-organizational findings about implementing healthcare innovations while also enhancing organizational capacity and accelerating translation of findings by facilitating continuous learning within individual sites. Researchers evaluating change initiatives and healthcare organizations implementing improvement initiatives may benefit from a Learning Evaluation approach.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0219-z) contains supplementary material, which is available to authorized users.

Coaching strategies for enhancing practice transformation

BACKGROUND

Current research on primary care practice redesign suggests that outside facilitation can be an important source of support for achieving substantial change.

OBJECTIVES

To analyse the specific sequence of strategies used by a successful practice facilitator during the American Academy of Family Physicians' (AAFP) National Demonstration Project (NDP).

METHODS

This secondary analysis describes a sequence of strategies used to produce change in family medicine practices attempting to adopt a new model of care. The authors analysed qualitative data generated by one facilitator and six practices by coding facilitator field notes, site visit reports, qualitative summaries, depth interviews and email strings.

RESULTS

The facilitator utilized practice member coaching in addition to consulting, negotiating and connecting approaches. Coaching strategies encouraged: (i) expansive, multi-directional, attentive styles of communication; (ii) solving practical problems together; (iii) modelling facilitative leadership and (iv) encouraging an expanded vision of care. Practice members who received consistent coaching reported internal shifts and new ways of conceptualizing work, not just success at implementing model components. They indicated that their facilitator had helped them think and behave in new ways while helping them achieve benchmarks.

CONCLUSIONS

It was once believed that the transition from traditional models of family medicine practice to new models of care meant implementing new technological components, suggesting that outside facilitators should act as technological and care delivery consultants. However, coaches may be especially useful in helpful in practices undertake substantial changes.

Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science

Background

The application of complexity science to understanding healthcare system improvement highlights the need to consider interdependencies within the system. One important aspect of the interdependencies in healthcare delivery systems is how individuals relate to each other. However, results from our observational and interventional studies focusing on relationships to understand and improve outcomes in a variety of healthcare settings have been inconsistent. We sought to better understand and explain these inconsistencies by analyzing our findings across studies and building new theory.

Methods

We analyzed eight observational and interventional studies in which our author team was involved as the basis of our analysis, using a set theoretical qualitative comparative analytic approach. Over 16 investigative meetings spanning 11 months, we iteratively analyzed our studies, identifying patterns of characteristics that could explain our set of results.

Our initial focus on differences in setting did not explain our mixed results. We then turned to differences in patient care activities and tasks being studied and the attributes of the disease being treated. Finally, we examined the interdependence between task and disease.

Results

We identified system-level uncertainty as a defining characteristic of complex systems through which we interpreted our results. We identified several characteristics of healthcare tasks and diseases that impact the ways uncertainty is manifest across diverse care delivery activities. These include disease-related uncertainty (pace of evolution of disease and patient control over outcomes) and task-related uncertainty (standardized versus customized, routine versus non-routine, and interdependencies required for task completion).

Conclusions

Uncertainty is an important aspect of clinical systems that must be considered in designing approaches to improve healthcare system function. The uncertainty inherent in tasks and diseases, and how they come together in specific clinical settings, will influence the type of improvement strategies that are most likely to be successful. Process-based efforts appear best-suited for low-uncertainty contexts, while relationship-based approaches may be most effective for high-uncertainty situations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0165-1) contains supplementary material, which is available to authorized users.

Blending remote sensing data products to estimate photochemical production of hydrogen peroxide and superoxide in the surface ocean

Hydrogen peroxide (H₂O₂) and its precursor, superoxide (O₂(-)), are well-studied photochemical products that are pivotal in regulating redox transformations of trace metals and organic matter in the surface ocean. In attempts to understand the magnitude of both H₂O₂ and O₂(-) photoproduction on a global scale, we implemented a model to calculate photochemical fluxes of these products from remotely sensed ocean color and modeled solar irradiances. We generated monthly climatologies for open ocean H₂O₂ photoproduction rates using an average apparent quantum yield (AQY) spectrum determined from laboratory irradiations of oligotrophic water collected in the Gulf of Alaska. Because the formation of H₂O₂ depends on secondary thermal reactions involving O₂(-), we also implemented a temperature correction for the H₂O₂ AQY using remotely sensed sea surface temperature and an Arrhenius relationship for H₂O₂ photoproduction. Daily photoproduction rates of H₂O₂ ranged from <1 to over 100 nM per day, amounting to ∼30 μM per year in highly productive regions. When production rates were calculated without the temperature correction, maximum daily rates were underestimated by 15-25%, highlighting the importance of including the temperature modification for H₂O₂ in these models. By making assumptions about the relationship between H₂O₂ and O₂(-) photoproduction rates and O₂(-) decay kinetics, we present a method for calculating midday O₂(-) steady-state concentrations ([O₂(-)]ss) in the open ocean. Estimated [O₂(-)]ss ranged from 0.1-5 nM assuming biomolecular dismutation was the only sink for O₂(-), but were reduced to 0.1-290 pM when catalytic pathways were included. While the approach presented here provides the first global scale estimates of marine [O₂(-)]ss from remote sensing, the potential of this model to quantify O₂(-) photoproduction rates and [O₂(-)]ss will not be fully realized until the mechanisms controlling O₂(-) photoproduction and decay are better understood.