Breast Cancer Risk Assessment Tools for Stratifying Women into Risk Groups: A Systematic Review.

BACKGROUND: The benefits and harms of breast screening may be better balanced through a risk-stratified approach. We conducted a systematic review assessing the accuracy of questionnaire-based risk assessment tools for this purpose. METHODS: Population: asymptomatic women aged ≥40 years; Intervention: questionnaire-based risk assessment tool (incorporating breast density and polygenic risk where available); Comparison: different tool applied to the same population; Primary outcome: breast cancer incidence; Scope: external validation studies identified from databases including Medline and Embase (period 1 January 2008-20 July 2021). We assessed calibration (goodness-of-fit) between expected and observed cancers and compared observed cancer rates by risk group. Risk of bias was assessed with PROBAST. RESULTS: Of 5124 records, 13 were included examining 11 tools across 15 cohorts. The Gail tool was most represented (n = 11), followed by Tyrer-Cuzick (n = 5), BRCAPRO and iCARE-Lit (n = 3). No tool was consistently well-calibrated across multiple studies and breast density or polygenic risk scores did not improve calibration. Most tools identified a risk group with higher rates of observed cancers, but few tools identified lower-risk groups across different settings. All tools demonstrated a high risk of bias. CONCLUSION: Some risk tools can identify groups of women at higher or lower breast cancer risk, but this is highly dependent on the setting and population.

Are patients with cancer at higher risk of COVID-19-related death? A systematic review and critical appraisal of the early evidence.

BACKGROUND: Early reports suggested that COVID-19 patients with cancer were at higher risk of COVID-19-related death. We conducted a systematic review with risk of bias assessment and synthesis of the early evidence on the risk of COVID-19-related death for COVID-19 patients with and without cancer. METHODS AND FINDINGS: We searched Medline/Embase/BioRxiv/MedRxiv/SSRN databases to 1 July 2020. We included cohort or case-control studies published in English that reported on the risk of dying after developing COVID-19 for people with a pre-existing diagnosis of any cancer, lung cancer, or haematological cancers. We assessed risk of bias using tools adapted from the Newcastle-Ottawa Scale. We used the generic inverse-variance random-effects method for meta-analysis. Pooled odds ratios (ORs) and hazard ratios (HRs) were calculated separately. Of 96 included studies, 54 had sufficient non-overlapping data to be included in meta-analyses (>500,000 people with COVID-19, >8000 with cancer; 52 studies of any cancer, three of lung and six of haematological cancers). All studies had high risk of bias. Accounting for at least age consistently led to lower estimated ORs and HRs for COVID-19-related death in cancer patients (e.g. any cancer versus no cancer; six studies, unadjusted OR=3.30,95%CI:2.59-4.20, adjusted OR=1.37,95%CI:1.16-1.61). Adjusted effect estimates were not reported for people with lung or haematological cancers. Of 18 studies that adjusted for at least age, 17 reported positive associations between pre-existing cancer diagnosis and COVID-19-related death (e.g. any cancer versus no cancer; nine studies, adjusted OR=1.66,95%CI:1.33-2.08; five studies, adjusted HR=1.19,95%CI:1.02-1.38). CONCLUSIONS: The initial evidence (published to 1 July 2020) on COVID-19-related death in people with cancer is characterised by multiple sources of bias and substantial overlap between data included in different studies. Pooled analyses of non-overlapping early data with adjustment for at least age indicated a significantly increased risk of COVID-19-related death for those with a pre-existing cancer diagnosis.

The risk of contracting SARS-CoV-2 or developing COVID-19 for people with cancer: A systematic review of the early evidence.

BACKGROUND: The early COVID-19 literature suggested that people with cancer may be more likely to be infected with SARS-CoV-2 or develop COVID-19 than people without cancer, due to increased health services contact and/or immunocompromise. While some studies were criticised due to small patient numbers and methodological limitations, they created or reinforced concerns of clinicians and people with cancer. These risks are also important in COVID-19 vaccine prioritisation decisions. We performed a systematic review to critically assess and summarise the early literature. METHODS AND FINDINGS: We conducted a systematic search of Medline/Embase/BioRxiv/MedRxiv/SSRN databases including peer-reviewed journal articles, letters/commentaries, and non-peer-reviewed pre-print articles for 1 January-1 July 2020. The primary endpoints were diagnosis of COVID-19 and positive SARS-CoV-2 test. We assessed risk of bias using a tool adapted from the Newcastle-Ottawa Scale. Twelve studies were included in the quantitative synthesis. All four studies of COVID-19 incidence (including 24,181,727 individuals, 125,649 with pre-existing cancer) reported that people with cancer had higher COVID-19 incidence rates. Eight studies reported SARS-CoV-2 test positivity for > 472,000 individuals, 48,370 with pre-existing cancer. Seven of these studies comparing people with any and without cancer, were pooled using random effects [pooled odds ratio 0.91, 95 %CI: 0.57-1.47; unadjusted for age, sex, or comorbidities]. Two studies suggested people with active or haematological cancer had lower risk of a positive test. All 12 studies had high risk of bias; none included universal or random COVID-19/SARS-CoV-2 testing. CONCLUSIONS: The early literature on susceptibility to SARS-CoV-2/COVID-19 for people with cancer is characterised by pervasive biases and limited data. To provide high-quality evidence to inform decision-making, studies of risk of SARS-CoV-2/COVID-19 for people with cancer should control for other potential modifiers of infection risk, including age, sex, comorbidities, exposure to the virus, protective measures taken, and vaccination, in addition to stratifying analyses by cancer type, stage at diagnosis, and treatment received.

What would I do? Perspectives on the factors underlying Lynch syndrome genetic testing and results sharing decisions for high-risk colorectal cancer patients.

OBJECTIVE: Universal tumour testing for Lynch syndrome (LS) in all incident colorectal cancers (CRCs) and sequential diagnostic genetic testing is cost-effective in Australia. Because of this, our study aimed to understand factors underlying possible decisions faced by tumour test-positive CRC patients and their at-risk relatives throughout the LS diagnosis pathway. METHODS: Semi-structured telephone interviews were conducted with 23 participants, using four hypothetical scenarios. Vignette-guided closed- and open-ended questions asked about LS genetic testing uptake, discussing diagnosis with at-risk relatives, and risk-reducing interventions. Personal perspectives on genetic testing were collected pre-post vignette discussion. Inductive thematic analysis was performed on open-ended questions. Decisional pathway diagrams were developed to convey factors influencing complex decision-making processes. RESULTS: Participant responses incorporated unfolding scenario information, resulting in three decision themes: (1) wanting to know one's LS status; (2) informing family about LS; (3) navigating risk-reducing interventions. Across all themes, 'knowledge' emerged as a facilitator, and 'negative emotional experience' as a barrier. Personal supportive views toward genetic testing increased post-interview. CONCLUSIONS: When communicating with tumour test-positive CRC patients or their relatives about LS genetic testing, providing guidance/resources to inform decisions around risk-reducing interventions and informing family members is critical. Scenario-driven interviews provide insight into what individuals might do when facing complex healthcare decisions and could aid informed decision-making. This approach may be applicable in other conditions, particularly with mainstreaming being increasingly introduced into the genetic context.

The predicted impact and cost-effectiveness of systematic testing of people with incident colorectal cancer for Lynch syndrome.

OBJECTIVES: To evaluate the health impact and cost-effectiveness of systematic testing for Lynch syndrome (LS) in people with incident colorectal cancer (CRC) in Australia. DESIGN, SETTING, PARTICIPANTS: We investigated the impact of LS testing strategies in a micro-simulation model (Policy1-Lynch), explicitly modelling the cost of testing all patients diagnosed with incident CRC during 2017, with detailed modelling of outcomes for patients identified as LS carriers (probands) and their at-risk relatives throughout their lifetimes. For people with confirmed LS, we modelled ongoing colonoscopic surveillance. MAIN OUTCOME MEASURES: Cost-effectiveness of six universal tumour testing strategies (testing for DNA mismatch repair deficiencies) and of universal germline gene panel testing of patients with incident CRC; impact on cost-effectiveness of restricting testing by age at CRC diagnosis (all ages, under 50/60/70 years) and of colonoscopic surveillance interval (one, two years). RESULTS: The cost-effectiveness ratio of universal tumour testing strategies (annual colonoscopic surveillance, no testing age limit) compared with no testing ranged from $28 915 to $31 904/life-year saved (LYS) (indicative willingness-to-pay threshold: $30 000-$50 000/LYS). These strategies could avert 184-189 CRC deaths with an additional 30 597-31 084 colonoscopies over the lifetimes of 1000 patients with incident CRC with LS and 1420 confirmed LS carrier relatives (164-166 additional colonoscopies/death averted). The most cost-effective strategy was immunohistochemistry and BRAF V600E testing (incremental cost-effectiveness ratio [ICER], $28 915/LYS). Universal germline gene panel testing was not cost-effective compared with universal tumour testing strategies (ICER, $2.4 million/LYS). Immunohistochemistry and BRAF V600E testing was cost-effective at all age limits when paired with 2-yearly colonoscopic surveillance (ICER, $11 525-$32 153/LYS), and required 4778-15 860 additional colonoscopies to avert 46-181 CRC deaths (88-103 additional colonoscopies/death averted). CONCLUSIONS: Universal tumour testing strategies for guiding germline genetic testing of people with incident CRC for LS in Australia are likely to be cost-effective compared with no testing. Universal germline gene panel testing would not currently be cost-effective.

A feasibility study comparing a web-based intervention to a workshop intervention for caregivers of adults with eating disorders.

OBJECTIVE: To assess for the validity of a future trial, the current feasibility study aimed to compare the feasibility and efficacy of a web- and workshop-based education intervention for caregivers of adults with eating disorders. METHODS: Psychoeducation was provided to caregivers, who were randomly assigned to a web or workshop condition. Independent samples t tests were conducted to analyse the between-group effect sizes for intervention condition with regard to change over time. A random selection of participants from each intervention provided qualitative feedback about their experiences. RESULTS: Overall, participants reported positive experiences in both education interventions. From baseline to the end of intervention, small between-group effect sizes were observed for changes in caregiver accommodation, problem-solving abilities, the quality of psychological health, and the quality of social relationships, favouring the web-based intervention, and changes in expressed emotion in the family context, caregiver burden, perceived stress, and the quality of the environment, supporting the workshop intervention. CONCLUSIONS: There was a difference in initial feasibility of the web intervention. A future large-scale trial of these interventions is supported by the results of this feasibility study.

Family-based treatment for transition age youth: the role of expressed emotion and general family functioning.

The aim of this study was to investigate changes in family functioning and parental expressed emotion (EE) in parents and transition age youth (18 to 25 years old) with Anorexia Nervosa participating in Family-Based Treatment for Transition Age Youth (FBT-TAY). Further, we examined whether perceived family functioning and EE were associated with changes in eating disorder behaviour and weight in participants at end-of-treatment and three months post-treatment. Generalized estimating equations revealed that changes in family functioning significantly improved from baseline to end-of-treatment (p = .0001), and baseline to three months post-treatment (p = .0001) in parents; and from baseline to end-of-treatment (p = .011), and baseline to three months post-treatment (p = .0001) in transition age youth. The level of parental EE did not differ significantly from baseline to end-of-treatment (p = .379), or baseline to three months post-treatment (p = .185). A series of Ordinary Least Square regression models demonstrated that changes in perceived family functioning and EE were not significantly associated with changes in eating disorder behaviour and weight restoration of transition age youth at end-of-treatment and three months post-treatment. Overall, perceptions of family functioning improved during the course of FBT-TAY, but EE did not.

Family-based treatment for transition age youth: parental self-efficacy and caregiver accommodation.

BACKGROUND: Family-Based Treatment (FBT) is the first line of care in paediatric treatment while adult programs focus on individualized models of care. Transition age youth (TAY) with Anorexia Nervosa (AN) are in a unique life stage and between systems of care. As such, they and their caregivers may benefit from specialized, developmentally tailored models of treatment. METHODS: The primary purpose of this study was to assess if parental self-efficacy and caregiver accommodation changed in caregivers during the course of FBT-TAY for AN. The secondary aim was to determine if changes in parental self-efficacy and caregiver accommodation contributed to improvements in eating disorder behaviour and weight restoration in the transition age youth with AN. Twenty-six participants (ages 16-22) and 39 caregivers were recruited. Caregivers completed the Parents versus Anorexia Scale and Accommodation and Enabling Scale for Eating Disorders at baseline, end-of-treatment (EOT), and 3 months follow-up. RESULTS: Unbalanced repeated measures designs for parental self-efficacy and caregiver accommodation towards illness behaviours were conducted using generalized estimation equations. Parental self-efficacy increased from baseline to EOT, although not significantly (p = .398). Parental self-efficacy significantly increased from baseline to 3 months post-treatment (p = .002). Caregiver accommodation towards the illness significantly decreased from baseline to EOT (p = 0.0001), but not from baseline to 3 months post-treatment (p = 1.000). Stepwise ordinary least squares regression estimates of eating disorder behaviour and weight restoration did not show that changes in parental-self efficacy and caregiver accommodation predict eating disorder behaviour or weight restoration at EOT or 3 months post-treatment. CONCLUSIONS: Our findings demonstrate, albeit preliminary at this stage, that FBT-TAY promotes positive increases in parental self-efficacy and assists caregivers in decreasing their accommodation to illness behaviours for transition age youth with AN. However, changes in the parental factors did not influence changes in eating and weight in the transition age youth.

"I would love to have online support but I don't trust it": Positive and negative views of technology from the perspective of those with eating disorders in Canada.

This qualitative study aims to explore how individuals who are seeking help and support for eating disorders use various forms of technology. Fifteen participants, recruited from an Eating Disorder Program in a hospital setting and an eating disorder community support centre, voluntarily participated in focus groups and individual interviews in 2015. The authors used thematic analysis to code and analyse the qualitative data, and three themes were identified: safety, connection and technology development. This study identifies the need for technology use to be addressed and integrated into clinical services for eating disorders, as well as for safe and helpful technology tools to be developed for this population.

Open Trial of Family-Based Treatment of Anorexia Nervosa for Transition Age Youth.

OBJECTIVE: This pilot study conducted an open trial of a manualized adaptation to Family-Based Treatment for Transition Age Youth (FBT-TAY) for Anorexia Nervosa (AN). The aims were: (1) determine the acceptability of FBT for TAY; and, (2) establish preliminary effect sizes for the impact of FBT-TAY on eating disorder behaviour and weight restoration. METHOD: Twenty-six participants across two paediatric and one adult hospital site were recruited to participate. Participants completed the Eating Disorder Examination Questionnaire (EDE-Q) at the start of treatment, the end-of-treatment, and three-month follow-up. RESULTS: FBT-TAY is an acceptable and feasible treatment to all study therapists as evidenced by their fidelity to the model. FBT-TAY is a feasible and acceptable intervention to transition age youth, given only 27.27% chose treatment as usual over FBT-TAY. Participants presented significant improvement at end-of-treatment and three-months post-treatment (p < .001; ES = 0.34) from baseline on the EDE-Q Global Score. Participants also achieved and maintained weight restoration at the end-of-treatment and three-months post-treatment when compared to baseline (p < .0001, ES = 0.54). CONCLUSIONS: FBT-TAY, the first manualized AN treatment for TAY, demonstrated feasibility and acceptability with therapists and participants as well as improvement for participants in EDE-Q global score and weight. Given the current dearth of effective treatments for TAY with AN, FBT-TAY is a promising adaptation of FBT. A larger clinical trial with a 12-month follow-up is recommended.

OBJECTIF: Cette étude pilote a mené un essai ouvert de l'adaptation dans un manuel du traitement familial pour jeunes en âge de transition (TF-JAT) pour l'anorexie mentale (AM). Les objectifs étaient: (1) déterminer l'acceptabilité du TF pour les JAT; et (2) établir des tailles de l'effet (TE) préliminaires pour l'effet du TF-JAT sur le comportement du trouble alimentaire et la reprise de poids. MÉTHODE: Vingt-six participants dans deux centres pédiatriques et un hôpital pour adultes ont été recrutés pour participer. Les participants ont répondu au questionnaire d'examen sur les troubles alimentaires (EDE-Q) au début du traitement, à la fin du traitement, et au suivi de 3 mois. RÉSULTATS: Le TF-JAT est un traitement acceptable et faisable pour tous les thérapeutes de l'étude comme en atteste leur fidélité au modèle. Le TF-JAT est une intervention faisable et acceptable pour les jeunes en âge de transition, étant donné que seulement 27,27% ont choisi le traitement habituel plutôt que le TF-JAT. Les participants ont présenté une amélioration significative au score global du EDE-Q à la fin du traitement et au suivi de trois mois (p < 0,001; TE = 0,34) comparé au début. Les participants ont également réussi à reprendre du poids et à le maintenir à la fin du traitement et au suivi de 3 mois comparé au début (p < 0,0001, TE = 0,54). CONCLUSIONS: Le TF-JAT, le premier traitement de l'AM dans un manuel pour les JAT, a démontré faisabilité et acceptabilité chez les thérapeutes et les participants ainsi qu'une amélioration pour les participants au score global de l'EDE-Q et de leur poids. Étant donné la rareté actuelle de traitements efficaces pour les JAT souffrant d'AM, le TF-JAT est une adaptation prometteuse du TF. Un essai clinique plus vaste avec suivi de 12 mois est recommandé.

The Effects of Stigma on Recovery Attitudes in People With Anorexia Nervosa in Intensive Treatment.

Self-stigma in individuals with anorexia nervosa (AN) may affect engagement in intensive treatment. The objective of this study was to test a Model of Self-Stigma to identify the influence of public stigma, internalized stigma, self-esteem, and self-efficacy on recovery attitudes in individuals in inpatient treatment for AN. Using a cross-sectional design, 36 female participants with AN completed questionnaires during the first week of intensive inpatient treatment. Better attitude towards recovery was positively correlated with higher self-esteem and self-efficacy and negatively correlated with greater internalized stigma and perceptions of others devaluing families of individuals with AN. Together, these factors accounted for 63% of the variance in recovery attitudes. Findings demonstrate the adverse effects perceived stigma towards families, self-stigma, and self-esteem have on recovery attitudes in individuals with AN. Clinical interventions are needed to challenge internalized stigma and bolster self-esteem to enhance individuals' recovery efforts.

The perceptions of individuals with anorexia nervosa regarding their family's understanding of their illness, treatment, and recovery.

The current study explores how affected individuals understand their family's perceptions of anorexia nervosa (AN). Perceptions of individuals with AN regarding their family's understanding of the illness may influence their ability to accept family support. Thematic analysis was used on qualitative data of 19 individuals with AN undergoing inpatient treatment. Participants perceived that families: (a) considered AN a problem with food rather than a mental illness; and (b) viewed treatment as time limited, and complete recovery as achievable. Family-based interventions are needed to facilitate understanding about AN, as well as the behavioral and psychological adjustments required during treatment and recovery.

"You don't have anorexia, you just want to look like a celebrity": perceived stigma in individuals with anorexia nervosa.

BACKGROUND: Minimal research has been conducted on how individuals with Anorexia nervosa (AN) undergoing treatment perceive public stigma. AIM: Explore how affected individuals with AN believe the general public perceives AN. METHOD: Using thematic analysis, 19 participants with AN were interviewed at the beginning of treatment. RESULTS: Three interrelated themes were ascertained: (1) AN is not an illness; (2) eating disorder behaviours are volitional and the public endorses a socio-cultural explanation for the disorder; 3) affected individuals delay disclosing their illness and experience shame engaging in intensive treatment for AN as a result of their perception of stigma. CONCLUSIONS: Individuals with AN viewed the public as trivializing AN by viewing behaviours as within their control and by attributing eating disorder behaviours solely to socio-cultural factors. Participants believed that the public minimizes the challenges associated with treatment. Findings suggest that clinical interventions targeting stigma are required to counteract perceptions held by service users regarding how others view their illness. "Mental health literacy" interventions are needed for health professionals working with high risk groups likely to avoid seeking help due to fears of stigmatization.

Pilot study comparing multi-family therapy to single family therapy for adults with anorexia nervosa in an intensive eating disorder program.

Multi-family therapy (MFT) has yet to be evaluated in families of adults with anorexia nervosa (AN). The study aims were: (i) assess the feasibility of MFT for AN; and, (ii) assess whether MFT is associated with improved outcomes for families compared with single-family therapy (SFT). Adult patients with AN consecutively referred to an eating disorder treatment program were assigned (non-randomly) to receive eight sessions of SFT or MFT. Assessment occurred pre-therapy, immediately post-therapy, and at 3-month follow-up. A total of 37 female patients (13 SFT, 24 MFT) and 45 family members (16 SFT, 29 MFT) completed treatment. There were significant time effects for patients' BMI, eating disorder-related psychopathology and multiple family outcome measures. There were no differences between MFT and SFT on family outcome measures at end of treatment and 3 months post treatment. MFT is a feasible intervention that can be used in adult intensive treatment for those with AN.

Family-based treatment with transition age youth with anorexia nervosa: a qualitative summary of application in clinical practice.

BACKGROUND: Family based treatment (FBT) has been empirically investigated in adolescents between the ages of 12 and 19 years of age. Although parental control over eating symptoms and the weight gain process are temporary and necessary due to serious medical complications, FBT may be developmentally inappropriate when working with older adolescents. To date, there are no studies identifying how the principles of this model are used differentially across different stages of adolescence. This study aimed to identify how clinicians informed by FBT employ this model with transition age youth (TAY) (16-21) with an eating disorder. METHODS: Using content analysis, seven individual interviews and six focus groups were conducted with 34 clinicians from specialized Eating Disorder Treatment programs across Ontario, Canada. RESULTS: Participants consistently reported modifying FBT to increase its developmental appropriateness with TAY in the following ways: working more collaboratively with the patient, increasing individual time spent with the patient prior to the family meeting, providing greater opportunities for the individual to practice eating without parental support and introducing relapse prevention in the latter phase of the treatment. CONCLUSIONS: In all adaptations of the model, participants in focus groups and individual interviews cited the age of the individual with the eating disorder, their level of autonomy and independence in all areas of their lives, and their pending transfer of care from paediatric to adult eating disorder programs as main factors that influenced the modification of FBT with TAY. While adaptations were made across all three phases of FBT, adherence to the model progressively declined over the course of treatment with adaptations increasing significantly in the later phases. Future research is needed to evaluate the effectiveness of an adapted version of FBT with TAY.

Inpatients with severe anorexia nervosa and their siblings: non-shared experiences and family functioning.

OBJECTIVES: The aims of this study were the following: to identify perceptions of patients with anorexia nervosa (AN) and their siblings regarding differential experiences within and external to the family including sibling interactions, parental treatment, relationships with peers and events that are unique to each sibling; (2) to compare how patients and their siblings perceive eating disorder symptoms, parental affection/control, social support and stigma; and (3) to test associations with family functioning for patients with AN and their siblings. METHOD: A total of 26 patients paired with their siblings were recruited from an Eating Disorder Program and administered standardized instruments measuring different experiences within and external to the family, the impact of eating disorder behaviours, stigma, social support and family functioning. RESULTS: Patients rated high on the differential experience of jealousy in contrast to their siblings. Patients scored higher than their siblings on eating symptoms, whereas siblings scored higher on social support. The impact of AN on the family, stigma towards the individual and family, and social support accounted for 37% of the variance in family functioning from the sibling perspective after controlling for age and gender. Of these variables, impact of AN on the family made the largest contribution. DISCUSSION: Family-based and sibling-based interventions that aim to reduce the effects of the illness on the sibling relationship and the family are recommended.

Designated medical directors for emergency medical services: recruitment and roles.

CONTEXT: Emergency medical services (EMS) agencies rely on medical oversight to support Emergency Medical Technicians (EMTs) in the provision of prehospital care. Most states require EMS agencies to have a designated medical director (DMD), who typically is responsible for the many activities of medical oversight. PURPOSE: To assess rural-urban differences in obtaining a DMD and in their responsibilities. METHODS: A national survey of 1,425 local EMS directors, conducted in 2007. FINDINGS: Rural EMS directors were more likely than urban ones to report DMD recruitment problems, but recruitment barriers were similar, with the most commonly reported barrier being an unwillingness of local physicians to serve. Rural EMS directors reported that their DMDs were less likely to be trained in Emergency Medicine, and were less likely to provide educational support functions such as continuing education. Rural agencies were more likely to get on-line medical direction from their DMD, but were less likely to always get the on-line support they needed. Common barriers to on-line support were typical of rural communication barriers. CONCLUSIONS: Existing recommendations for DMD qualifications may be difficult to attain in rural communities. To develop programs that will support medical direction for rural EMS agencies, it is important to learn what physicians identify as the barriers to serving as DMDs, and whether there are alternative and innovative ways to provide an optimal level of medical oversight. Solutions will likely be multi-faceted, as EMS activities and organizational structures are diverse and the responsibilities of the DMD are broad.

Recruitment and retention in rural and urban EMS: results from a national survey of local EMS directors.

Maintaining an adequate staff is a challenge for rural emergency medical services (EMS) providers. This national survey of local EMS directors finds that rural EMS are more likely to be freestanding, that is, not affiliated with other public services, to employ only emergency medical technician-basics (EMT-Bs), and to be all volunteer. Rural EMS directors are more likely than urban ones to report that they are not currently fully staffed. The most common barriers to recruitment of EMTs in both urban and rural areas include unwillingness of community members to volunteer and lack of certified EMTs in the area. In rural areas, barriers to EMT training were noted more often than in urban areas as was the lack of employer support for employee volunteers. Similar rural training barriers affected retention of staff. Rural respondents reported that they lose staff to burnout and to difficulty in meeting continuing education requirements. Among rural respondents, those who direct all-volunteer EMS were the most likely to report recruitment and retention problems. The results suggest areas for further study including how volunteer EMS agencies can transition to paid agencies, how to bring EMS education to rural areas, and how EMS can work with other agencies to ensure EMS viability.

Intensive care in critical access hospitals.

CONTEXT: Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. PURPOSE: To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community. METHODS: A semistructured interview of directors of nursing at CAHs that provide intensive care services. RESULTS: Two thirds of CAHs that provide intensive care do so in a distinct unit. Most have continuous or computerized electrocardiography and ventilators. Other ICU equipment common in larger hospitals was reported less frequently. Nurse:patient ratio ranged from 1:1 to 1:3, and some or all nursing staff have advanced cardiac life support certification. Most CAHs admit patients to the ICU daily or weekly, primarily treating cardiac, respiratory, gastrointestinal, endocrine, and drug- or alcohol-related conditions. ICUs are also used for postsurgical recovery. Respondents felt that closure of the ICU would be burdensome to patients and families, result in lost revenue, negatively impact staff, and affect the community's perception of the hospital. CONCLUSIONS: Intensive care services provided by CAHs fall along a continuum, ranging from care in a unit that resembles a scaled-down version of ICUs in larger hospitals to care in closely monitored medical-surgical beds. Nurse to patient ratio, not technology, is arguably the defining characteristic of intensive care in CAHs. Respondents believe these services to be important to the well-being of the hospital and of the community.