Barriers Associated with Access to Prescription Medications in Patients Diagnosed with Type 2 Diabetes Mellitus Treated at Federally Qualified Health Centers.

This study describes access to prescription medications and examines personal, financial, and structural barriers associated with access to prescription medications in patients with type 2 diabetes treated at Federally Qualified Health Centers. We used a cross-sectional design to analyze data retrieved from the 2014 Health Center Patient Survey. Adult participants who self-reported having type 2 diabetes were included in this study. Predictor variables were categorized into personal, financial, and structural barriers. Outcomes include being unable to get and delayed in getting prescription medications. Chi-square and multivariable regression models were conducted to examine associations between predictor and outcome variables. A total of 1097 participants with type 2 diabetes were included in analyses. Approximately 29% of participants were delayed, and 24% were unable to get medications. Multivariable regression results showed that personal barriers, such as federal poverty level, health status, and psychological distress were associated with being unable to get medications. Financial barriers including out-of-pocket medication cost and employment were associated with access to prescription medications. Type of health center funding program as a structural barrier was associated with access to medications. In conclusion, multi-level tailored strategies and policy changes are needed to address these barriers to improve access to prescription medications and health outcomes in underserved patient populations.

Access and Utilization of Asthma Medications Among Patients Who Receive Care in Federally Qualified Health Centers.

OBJECTIVES: To describe access to and use of prescription asthma medications, and to assess factors associated with asthma exacerbation, healthcare utilization, and health status among asthma patients treated at Federally Qualified Health Centers. METHODS: This is a retrospective cross-sectional study. We analyzed data from the 2014 National Health Center Patient Survey. This data is publicly available from the Health Resources and Services Administration. Data was collected from patients receiving face-to-face care from health centers funded under Section 330 of the Public Health Service Act. Data from patients was collected between October 8, 2014, and April 17, 2015. We included adult participants who reported having a diagnosis of asthma and confirmed that they still have asthma. Association between explanatory variables (access to prescription medications and use of asthma controller medications) and outcome variables (asthma exacerbations, asthma hospitalizations or emergency department visits, and self-rated health) was assessed using multivariable regression analyses while adjusting for demographics. RESULTS: A total of 919 participants with asthma were included. Approximately 32% of the participants experienced delays in getting prescription medications, 26% were unable to get them, 60% experienced an asthma exacerbation last year, 48% rated their health as fair/poor, and 19% visited a hospital or an emergency department last year. Multivariable results showed that participants who were currently taking controller medications were more likely to have experienced an asthma exacerbation (OR = 4.02; 95% CI 1.91 to 8.45; P < .01), or visited a hospital or an emergency department (OR = 3.07; 95% CI 1.39 to 6.73; P < .01) in the last year compared with those who had never taken controller medications. Experiencing difficulties in accessing asthma medications was associated with lower self-rated health (ß = -.51; 95% CI -0.94 to -0.08; P = .02). CONCLUSIONS: Future interventions should seek to improve asthma patient care and health outcomes using innovative strategies that act at multiple levels of the healthcare system (eg, individual, interpersonal, community levels).

A Multi-Site Evaluation of A National Employee Wellness Initiative at the Department of Veterans Affairs.

Background: The Department of Veterans Affairs (VA) seeks to transform its health care delivery from disease-centered, episodic care to a holistic and patient-centered model known as the Whole Health System (WHS) of care. Employee engagement and buy-in are crucial to this cultural transformation. The VA aspires to provide employees with opportunities to experience whole health in their personal and professional lives through a national Employee Whole Health (EWH) program. Although there are national recommendations, different local facilities may have unique strategies and challenges as they implement this program. Objective: This study aimed to conduct a program evaluation of EWH at three different VA facilities across the United States in order to identify facilitators and barriers to the implementation of EWH. Methods: The team used the RE-AIM framework to develop an interview guide to assess various domains of implementation. Quantitative data on whole health offerings at each site were gauged using a national employee education platform. Standardized employee-related metrics at each site were assessed using the annual, national VA employee survey. Results: EWH has had variable implementation at the three sites. Sites noted main facilitators as employee interest as well as available skills and expertise for delivering complementary and integrative care to employees. Limited staffing for EWH and a lack of dedicated employee time were cited as barriers. The infrastructure to perform local program evaluations to demonstrate effectiveness and impact were missing. Conclusion: Employee engagement in whole health activities has the potential to support the VA's mission to transform its health care delivery model. Currently, the use of EWH and its potential impact are difficult to discern based on available information. Local sites need guidance to conduct program evaluations and find creative solutions to enhance employee participation. A robust measurement system to demonstrate effectiveness is paramount to ensure the success of this initiative.

Relationships between Key Functions of Patient-Provider Communication, Trust, and Motivation across White, African American, and Hispanic/Latino Patients with Asthma.

Patient-provider communication is essential for providing effective care for asthma patients. However, little is known about key functions of communication and their relationships with outcomes in asthma patients across racial/ethnic groups. This study assessed asthma patients' perceptions of key functions of patient-provider communication, and examined associations between key functions, trust, and motivation across racial/ethnic groups. In this study, a sample of 470 US adults responded to an assessment of patient-provider communication, trust, and motivation through an electronically administered survey. Key functions of patient-provider communication included: exchanging information, responding to emotions, making decisions, enabling self-management, managing uncertainty, and fostering relationships. Results showed no differences in the mean scores of key functions of communication across racial/ethnic groups. The key function fostering relationships was positively associated with trust and motivation in both Whites and African Americans. However, the key function making decisions was associated with trust, and the key function managing uncertainty was associated with motivation only for Hispanic/Latinos. Results suggest different cultures may place different values on key functions of communication which may engender trust and motivation. Practical implications and suggestions for future research are discussed.

Comparing the use of Arabic decision aid to usual care. A multicenter randomized controlled trial for Arabic speaking metastatic colorectal cancer patients in Saudi Arabia.

OBJECTIVES: To evaluate the effect of decision aids (DAs) for metastatic colorectal cancer (mCRC) patients in the Arabic language. METHODS: A multi-centered randomized control trial was used to evaluate the effect of Arabic DA use with usual care for mCRC patients compared to usual care alone. Patients were recruited from 4 main oncology centers in Saudi Arabia: King Fahad Medical City, Riyadh; King Khalid University Hospital, Riyadh; King Saud Medical City, Riyadh; and King Fahd Specialist Hospital, Dammam, Saudi Arabia, between March 2016 and  October 2018. The final follow up was in April 2019. The study measured patient understanding of prognosis, treatment options, and the level of the patient's anxiety. RESULTS: Ninety-two patients were included in the analysis; 51 in the intervention group. A small proportion of both (DA with usual care and usual care) understood that mCRC was incurable (8% and 5%) of the 2 groups, respectively. There was no significant difference between groups in anxiety level; however, a time effect both initially and after one month was significantly higher than at 6 month. CONCLUSION: The study shows that a higher level of patient's baseline understanding lowered anxiety levels over time.  Decision aids group presented low levels of anxiety over time than those provided the usual care. We recommend  using Arabic DA in the oncology centers dealing with mCRC patients, aiming to empower patients in decision making.

Teaching Genomic Pathology: Translating Team-Based Learning to a Virtual Environment Using Computer-Based Simulation.

CONTEXT.­: Developing skills related to use of computer-based tools is critical for practicing genomic pathology. However, given the relative novelty of genomics education, residency programs may lack faculty members with adequate expertise and/or time to implement training. A virtual team-based learning (TBL) environment would make genomic pathology education available to more trainees. OBJECTIVE.­: To translate an extensively implemented in-person TBL genomic pathology workshop into a virtual environment and to evaluate both knowledge and skill acquisition. DESIGN.­: Using a novel interactive simulation approach, online modules were developed translating aspects of the TBL experience into the virtual environment with a goal of acquisition of necessary computer-related skills. The modules were evaluated at 10 postgraduate pathology training programs using a pre-post test design with participants deidentified. A postmodule anonymous survey obtained participant feedback on module quality and efficacy. RESULTS.­: There were 147 trainees who received an email request to voluntarily participate in the study. Of these, 43 trainees completed the pretest and 15 (35%) subsequently completed the posttest. Mean overall scores were 45% on the pretest compared with 70% on the posttest ( P < .001; effect size = 1.4). Posttest improvement of results was similar for questions testing acquisition of knowledge versus skills. Regarding the 19 participants who took the survey, 18 (95%) would recommend the modules to others and believed they met the stated objectives. CONCLUSIONS.­: A simulation-based approach allows motivated pathology trainees to acquire computer-related skills for practicing genomic pathology. Future work can explore efficacy in a nonvoluntary setting and adaptation to different specialties, learners, and computer tools.

Changing Practice Patterns for Cytotechnologists: A Comparative Analysis of Data from the 2009 and 2015 ASCP BOC Practice Analysis Surveys.

BACKGROUND: The American Society for Clinical Pathology (ASCP) Board of Certification (BOC) surveys US certified cytotechnologists (CTs) at approximately 5-year intervals to gain information about current practice patterns. Although the purpose of this survey is to inform valid content development for the BOC CT examination, comparative longitudinal analysis of the survey data provides information about changes in cytotechnology practice. MATERIALS AND METHODS: BOC Practice Analysis Survey data for 2009 and 2015 were examined, comparing survey demographics and performance of laboratory tasks. The 2015 survey added tasks not previously surveyed and considered them emerging when performed by a majority of respondents. RESULTS: Two hundred thirty-five participants completed the survey in 2015 and 151 in 2009. Respondents reported an overall decrease in performing conventional Papanicolaou tests (-25.3%). Respondents reported increases in morphologic tasks such cytologyehistology correlation (17.5%), cell-block interpretation (17.5%), and preliminary interpretation of histochemical stains (e.g., mucin and Grocott's methenamine silver stain) (16.7%), as well as quality assurance tasks. Majority-performed, newly surveyed tasks included touch prep preparation (57.8%) and interpretation (59.2%) and ancillary test triage (59.6%). Molecular tasks such as tumor identification (6.8%) and preparation of cytology specimens for oncology molecular testing (9.4%) did not meet majority reporting thresholds. CONCLUSIONS: Although performance of the Papanicolaou test is declining, CTs report increases in additional morphologic as well as other laboratory tasks. Emerging tasks (2015) focus on FNA specimens. Knowledge of cytology practice patterns will help guide development of education and training resources toward maintaining an appropriately trained workforce.

Changing practice patterns for cytotechnologists: a comparative analysis of data from the 2009 and 2015 ASCP BOC Practice Analysis Surveys.

BACKGROUND: The American Society for Clinical Pathology (ASCP) Board of Certification (BOC) surveys US certified cytotechnologists (CTs) at approximately 5-year intervals to gain information about current practice patterns. Although the purpose of this survey is to inform valid content development for the BOC CT examination, comparative longitudinal analysis of the survey data provides information about changes in cytotechnology practice. MATERIALS AND METHODS: BOC Practice Analysis Survey data for 2009 and 2015 were examined, comparing survey demographics and performance of laboratory tasks. The 2015 survey added tasks not previously surveyed and considered them emerging when performed by a majority of respondents. RESULTS: Two hundred thirty-five participants completed the survey in 2015 and 151 in 2009. Respondents reported an overall decrease in performing conventional Papanicolaou tests (-25.3%). Respondents reported increases in morphologic tasks such cytology-histology correlation (17.5%), cell-block interpretation (17.5%), and preliminary interpretation of histochemical stains (e.g., mucin and Grocott's methenamine silver stain) (16.7%), as well as quality assurance tasks. Majority-performed, newly surveyed tasks included touch prep preparation (57.8%) and interpretation (59.2%) and ancillary test triage (59.6%). Molecular tasks such as tumor identification (6.8%) and preparation of cytology specimens for oncology molecular testing (9.4%) did not meet majority-reporting thresholds. CONCLUSIONS: Although performance of the Papanicolaou test is declining, CTs report increases in additional morphologic as well as other laboratory tasks. Emerging tasks (2015) focus on FNA specimens. Knowledge of cytology practice patterns will help guide development of education and training resources toward maintaining an appropriately trained workforce.

Does Taking the Fellowship In-Service Hematopathology Examination and Performance Relate to Success on the American Board of Pathology Hematology Examination?

OBJECTIVES: The biannual Fellow In-Service Hematopathology Examination (FISHE) assesses knowledge in five content areas. We examined the relationship between taking the FISHE and performance on it with outcomes on the first attempted American Board of Pathology Hematology subspecialty certifying examination (ABP-HE). METHODS: The pass rate between the ABP-HE candidates who took the spring FISHE and those who did not were compared. The likelihood of fellows passing the ABP-HE based on their percentiles on the FISHE was also assessed. RESULTS: ABP-HE candidates who took the spring FISHE had a higher pass rate (96.4%) than those who did not (76.1%, P < .001). Spring FISHE performance, including total percentile and percentiles in four of five FISHE content areas, was only a weak predictor of passing the ABP-HE. CONCLUSIONS: Candidates who take the spring FISHE do better on the ABP-HE than those who do not. Most fellows passed the first attempted ABP-HE regardless of FISHE performance. Whether this is due to fellows making use of the FISHE as a self-evaluation tool to help identify and then correct their knowledge deficiencies remains to be determined.

Using a Team-Based Learning Approach at National Meetings to Teach Residents Genomic Pathology.

BACKGROUND: Accumulating data suggest that team-based learning (TBL) is more effective than lecture-based teaching strategies. Educational sessions at national meetings, however, tend to be lecture-based, and unlike most examples of TBL, involve participants who do not know each other or the instructor. OBJECTIVE: We evaluated a 1-day TBL genomic pathology workshop for residents held at 3 national meetings. METHODS: A committee of experts developed the workshop. Prior to attending, participants were provided access to readings and asked to answer preparation questions. Each of the 4 modules within the workshop consisted of a 60-minute TBL activity flanked by 15- to 30-minute preactivity and postactivity lectures. We used surveys to acquire participant evaluation of the workshop. RESULTS: From 2013-2014, 86 pathology residents from 61 programs participated in 3 workshops at national meetings. All workshops were well received, with over 90% of attendees indicating that they would recommend them to other residents and that the material would help them as practicing pathologists. An incremental approach facilitated decreasing faculty presence at the workshops: the first 2 workshops had 7 faculty each (1 facilitator for each team and 1 circulating faculty member), while the final workshop involved only 2 faculty for 6 teams. For this final session, participants agreed that circulating faculty provided adequate support. Participant "buy-in" (requiring completion of a preworkshop survey) was critical in enabling a TBL approach. CONCLUSIONS: These results demonstrate that TBL is a feasible and effective strategy for teaching genomic medicine that is acceptable to pathology residents at national meetings.

The American Society for Clinical Pathology's 2014 vacancy survey of medical laboratories in the United States.

OBJECTIVES: To determine the extent and distribution of workforce shortages within the nation's medical laboratories. Historically, the results of this biennial survey have served as a basis for additional research on laboratory recruitment, retention, education, marketing, certification, and advocacy. METHODS: The 2014 Vacancy Survey was conducted through collaboration between American Society for Clinical Pathology's Institute of Science, Technology, and Policy in Washington, DC, and the Evaluation, Measurement, and Assessment Department and Board of Certification in Chicago, Illinois. Data were collected via an Internet survey that was distributed to individuals who were able to report on staffing and certifications for their laboratories. RESULTS: Data reveal increased overall vacancy rates since 2012 for all departments surveyed except cytology and cytogenetics. Also, results show higher anticipated retirement rates for both staff and supervisors. Overall certification rates are highest among laboratory personnel in cytogenetics, hematology/coagulation, and flow cytometry departments and lowest among phlebotomy, specimen processing, and anatomic pathology. CONCLUSIONS: Factors such as retirement and the improving economy are driving the need for more laboratory professionals. Recruitment of qualified laboratory professionals in the workforce and students in laboratory programs will be the key in fulfilling the higher vacancies revealed from the survey results in 2014.

The current state of resident training in genomic pathology: a comprehensive analysis using the resident in-service examination.

OBJECTIVES: To determine the current state of pathology resident training in genomic and molecular pathology. METHODS: The Training Residents in Genomics (TRIG) Working Group developed survey and knowledge questions for the 2013 pathology Resident In-Service Examination (RISE). Sixteen demographic questions related to amount of training, current and predicted future use, and perceived ability in molecular pathology vs genomic medicine were included, along with five genomic pathology and 19 molecular pathology knowledge questions. RESULTS: A total of 2,506 pathology residents took the 2013 RISE, with approximately 600 individuals per postgraduate year (PGY). For genomic medicine, 42% of PGY-4 respondents stated they had no training, compared with 7% for molecular pathology (P < .001). PGY-4 residents' perceived ability, comfort in discussing results, and predicted future use as a practicing pathologist were reported to be less in genomic medicine than in molecular pathology (P < .001). Based on PGY, knowledge question scores showed a greater increase in molecular pathology than in genomic pathology. CONCLUSIONS: The RISE is a powerful tool for assessing the state of resident training in genomic pathology and current results suggest a significant deficit. The results also provide a baseline to assess future initiatives to improve genomics education for pathology residents such as those developed by the TRIG Working Group.