Training Health Professions preceptors in rural practices: A challenge for Interprofessional practice and education.

The ever-increasing mandate for interprofessional practice and education (IPE) faces challenges in rural settings. Oregon Health & Science University (OHSU) launched a preceptor development program as part of its commitment to training interprofessional student groups in rural settings. The objectives of the program were to (1) encourage preceptors to exemplify team behaviors; (2) characterize contemporary learners and learning styles of trainees; (3) encourage interprofessional precepting skills, and (4) apply practical teaching tools in the clinical setting. This was a qualitative observational project performed at OHSU rural faculty primary care clinics. Subjects were a convenience sample of rural interprofessional preceptors who volunteered to participate. Each educational session was based on a prior interview identifying their specific training needs. Data analysis was based on results from an evaluation survey and comments from providers at these sites. Key factors such as dedicated time for preceptor development, good communication between the rural practices and the academic health center, and concerns about billing revenue were discovered to be critical to the success of the program.

Differences in US Regional Healthcare Allocation Guidelines During the COVID-19 Pandemic.

BACKGROUND: Hospitals faced unprecedented scarcity of resources without parallel in modern times during the COVID-19 pandemic. This scarcity led healthcare systems and states to develop or modify scarce resource allocation guidelines that could be implemented during "crisis standards of care" (CSC). CSC describes a significant change in healthcare operations and the level of care provided during a public health emergency. OBJECTIVE: Our study provides a comprehensive examination of the latest CSC guidelines in the western region of the USA, where Alaska and Idaho declared CSC, focusing on ethical issues and health disparities. DESIGN: Mixed-methods survey study of physicians and/or ethicists and review of healthcare system and state allocation guidelines. PARTICIPANTS: Ten physicians and/or ethicists who participated in scarce resource allocation guideline development from seven healthcare systems or three state-appointed committees from the western region of the USA including Alaska, California, Idaho, Oregon, and California. RESULTS: All sites surveyed developed allocation guidelines, but only four (40%) were operationalized either statewide or for specific scarce resources. Most guidelines included comorbidities (70%), and half included adjustments for socioeconomic disadvantage (50%), while only one included specific priority groups (10%). Allocation tiebreakers included the life cycle principle and random number generators. Six guidelines evolved over time, removing restrictions such as age, severity of illness, and comorbidities. Additional palliative care (20%) and ethics (50%) resources were planned by some guidelines. CONCLUSIONS: Allocation guidelines are essential to support clinicians during public health emergencies; however, significant deficits and differences in guidelines were identified that may perpetuate structural inequities and racism. While a universal triage protocol that is equally accepted by all communities is unlikely, the lack of regional agreement on standards with justification and transparency has the potential to erode public trust and perpetuate inequity.

Economic models for sustainable interprofessional education.

Limited information exists on funding models for interprofessional education (IPE) course delivery, even though potential savings from IPE could be gained in healthcare delivery efficiencies and patient safety. Unanticipated economic barriers to implementing an IPE curriculum across programs and schools in University settings can stymie or even end movement toward collaboration and sustainable culture change. Clarity among stakeholders, including institutional leadership, faculty, and students, is necessary to avoid confusion about IPE tuition costs and funds flow, given that IPE involves multiple schools and programs sharing space, time, faculty, and tuition dollars. In this paper, we consider three funding models for IPE: (a) Centralized (b) Blended, and (c) Decentralized. The strengths and challenges associated with each of these models are discussed. Beginning such a discussion will move us toward understanding the return on investment of IPE.

Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system.

BACKGROUND: Hospice, a patient-centered care system for those with limited life expectancy, is important for enhancing quality of life and is understudied in integrated health care systems. METHODS: This was a retrospective cohort study of 21,860 decedents with advanced-stage lung cancer diagnosed from January 2007 to June 2013 in the national US Veterans Affairs Health Care System. Trends over time, geographic regional variability, and patient and tumor characteristics associated with hospice use and the timing of enrollment were examined. Multivariable logistic regression and Cox proportional hazards modeling were used. RESULTS: From 2007 to 2013, 70.3% of decedents with advanced-stage lung cancer were enrolled in hospice. Among patients in hospice, 52.9% were enrolled in the last month of life, and 14.7% were enrolled in the last 3 days of life. Hospice enrollment increased (adjusted odds ratio [AOR], 1.07; P < .001), whereas the mean time from the cancer diagnosis to hospice enrollment decreased by 65 days (relative decrease, 32%; adjusted hazard ratio, 1.04; P < .001). Relative decreases in late hospice enrollment were observed in the last month (7%; AOR, 0.98; P = .04) and last 3 days of life (26%; AOR, 0.95; P < .001). The Southeast region of the United States had both the highest rate of hospice enrollment and the lowest rate of late enrollment. Patient sociodemographic and lung cancer characteristics were associated with hospice enrollment. CONCLUSIONS: Among patients with advanced-stage lung cancer in the Veterans Affairs Health Care System, overall and earlier hospice enrollment increased over time. Considerable regional variability in hospice enrollment and the persistence of late enrollment suggests opportunities for improvement in end-of-life care. Cancer 2018;124:426-33. © 2017 American Cancer Society.

Mechanisms of wound closure following acute arm injury in Octopus vulgaris.

BACKGROUND: Octopoda utilise their arms for a diverse range of functions, including locomotion, hunting, defence, exploration, reproduction, and grooming. However the natural environment contains numerous threats to the integrity of arms, including predators and prey during capture. Impressively, octopoda are able to close open wounds in an aquatic environment and can fully regenerate arms. The regrowth phase of cephalopod arm regeneration has been grossly described; however, there is little information about the acute local response that occurs following an amputation injury comparable to that which frequently occurs in the wild. METHODS: Adult Octopus vulgaris caught in the Bay of Naples were anaesthetised, the distal 10 % of an arm was surgically amputated, and wounded tissue was harvested from animals sacrificed at 2, 6, and 24 h post-amputation. The extent of wound closure was quantified, and the cell and tissue dynamics were observed histologically, by electron microscopy, as well as using ultrasound. RESULTS: Macroscopic, ultrasonic and ultrastructural analyses showed extensive and significant contraction of the wound margins from the earliest time-point, evidenced by tissue puckering. By 6 h post amputation, the wound was 64.0 ± 17.2 % closed compared to 0 h wound area. Wound edge epithelial cells were also seen to be migrating over the wound bed, thus contributing to tissue repair. Temporary protection of the exposed tip in the form of a cellular, non-mucus plug was observed, and cell death was apparent within two hours of injury. At earlier time-points this was apparent in the skin and deeper muscle layers, but ultimately extended to the nerve cord by 24 h. CONCLUSIONS: This work has revealed that O. vulgaris ecologically relevant amputation wounds are rapidly repaired via numerous mechanisms that are evolutionarily conserved. The findings provide insights into the early processes of repair preparatory to regeneration. The presence of epithelial, chromatophore, vascular, muscle and neural tissue in the arms makes this a particularly interesting system in which to study acute responses to injury and subsequent regeneration.

An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units.

BACKGROUND: There is controversy about how to manage requests by patients or surrogates for treatments that clinicians believe should not be administered. PURPOSE: This multisociety statement provides recommendations to prevent and manage intractable disagreements about the use of such treatments in intensive care units. METHODS: The recommendations were developed using an iterative consensus process, including expert committee development and peer review by designated committees of each of the participating professional societies (American Thoracic Society, American Association for Critical Care Nurses, American College of Chest Physicians, European Society for Intensive Care Medicine, and Society of Critical Care). MAIN RESULTS: The committee recommends: (1) Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultants. (2) The term "potentially inappropriate" should be used, rather than futile, to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Clinicians should explain and advocate for the treatment plan they believe is appropriate. Conflicts regarding potentially inappropriate treatments that remain intractable despite intensive communication and negotiation should be managed by a fair process of conflict resolution; this process should include hospital review, attempts to find a willing provider at another institution, and opportunity for external review of decisions. When time pressures make it infeasible to complete all steps of the conflict-resolution process and clinicians have a high degree of certainty that the requested treatment is outside accepted practice, they should seek procedural oversight to the extent allowed by the clinical situation and need not provide the requested treatment. (3) Use of the term "futile" should be restricted to the rare situations in which surrogates request interventions that simply cannot accomplish their intended physiologic goal. Clinicians should not provide futile interventions. (4) The medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used. CONCLUSIONS: The multisociety statement on responding to requests for potentially inappropriate treatments in intensive care units provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.

Guideline funding and conflicts of interest: article 4 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report.

INTRODUCTION: Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that healthcare recommendations are informed by the best available research evidence. This is the fourth of a series of 14 articles prepared to advise guideline developers in respiratory and other disease. It focuses on commercial funding of guidelines and managing conflict of interest effectively in the context of guidelines. METHODS: In this review, we addressed the following topics and questions. (1) How are clinical practice guidelines funded? (2) What are the risks associated with commercial sponsorship of guidelines? (3) What relationships should guideline committee members be required to disclose? (4) What is the most efficient way to obtain complete and accurate disclosures? (5) How should disclosures be publicly shared? (6) When do relationships require management? (7) How should individual conflicts of interest be managed? (8) How could conflict of interest policies be enforced? The literature review included a search of PubMed and other databases for existing systematic reviews and relevant methodological research. Our conclusions are based on available evidence, consideration of what guideline developers are doing, and workshop discussions. RESULTS AND DISCUSSION: Professional societies often depend on industry funding to support clinical practice guideline development. In addition, members of guideline committees frequently have financial relationships with commercial entities, are invested in their intellectual work, or have conflicts related to clinical revenue streams. No systematic reviews or other rigorous evidence regarding best practices for funding models, disclosure mechanisms, management strategies, or enforcement presently exist, but the panel drew several conclusions that could improve transparency and process.

Communication by nurses in the intensive care unit: qualitative analysis of domains of patient-centered care.

BACKGROUND: High-quality communication is a key determinant and facilitator of patient-centered care. Nurses engage in most of the communication with patients and patients' families in the intensive care unit. OBJECTIVE: To perform a qualitative analysis of nurses' communications. METHODS: Ethnographic observations of 315 hours of interactions and 53 semistructured interviews with 33 nurses were conducted in a 26-bed cardiac-medical intensive care unit in an academic hospital and a 26-bed general intensive care unit in a Veterans Affairs hospital in Portland, Oregon. Communication interactions were categorized into 5 domains of patient-centered care. Interviews were analyzed to identify major themes in nurses' roles and preferences for communicating with patients and patients' families within the domains. RESULTS: Most communication occurred in the domains of biopsychosocial information exchange, patient as person, and clinician as person. Nurses endorsed the importance of the domains of shared power and responsibility and therapeutic alliance but had relatively few communication interactions in these areas. Communication behaviors were strongly influenced by the nurses' roles as translators of information between physicians and patients and the patients' families and what the nurses were and were not willing to communicate to patients and patients' families. CONCLUSIONS: Critical care, including communication, is a collaborative effort. Understanding how nurses engage in patient-centered communication in the intensive care unit can guide future interventions to improve patient-centered care.

Medical student views on interactions with pharmaceutical representatives.

OBJECTIVE: In 2006, the Housestaff Association presented the Dean at Oregon Health and Science University (OHSU) with a proposal to effectively end the influence of the pharmaceutical industry on campus. The Dean convened a workgroup to examine the issue, and faculty, residents, and medical students were surveyed on their views and interactions. Authors present here the responses from medical students. METHODS: A web-based, anonymous survey was sent to all OHSU medical students in 2007; 59% completed it. The survey included items measuring attitudes about the pharmaceutical industry and interactions with pharmaceutical representatives (PRs). RESULTS: Only 5% of clinical and 7% of preclinical students agreed that PRs have an important teaching role, and fewer than 1 in 6 believed that PRs provided useful and accurate information on either new or established drugs; 54% of clinical students indicated that PRs should be restricted from making presentations on campus, versus 32% of preclinical students, and only 30% of clinical students agreed that accepting gifts had no impact on their own prescribing, versus 50% of preclinical students. Students who acknowledged the influence of PRs and perceived less educational benefit were less likely to accept gifts such as textbooks; however, 84% of clinical students had attended an on-campus event sponsored by a pharmaceutical company in the previous year. CONCLUSIONS: Only a small proportion of OHSU medical students value interactions with PRs, but many still attend events sponsored by pharmaceutical companies.

An official American Thoracic Society Policy statement: managing conflict of interest in professional societies.

BACKGROUND: Competing interests occur frequently in health care. This results in the potential for conflict of interest (COI). COI can lead to biased generation or assessment of evidence and misinform healthcare decision makers. Declaration of COI is insufficient to neutralize potentially harmful effects. Medical professional societies are obliged to develop robust mechanisms to "manage" COI, particularly in the development of official guidance documents that affect health care. PURPOSE: This document describes the background, methods, and content of the new "American Thoracic Society (ATS) Policy on Management of COI in Official ATS Documents, Projects, and Conferences." METHODS: We used existing reviews on COI policies that were prepared for the World Health Organization and for an ATS guideline methodology workshop as the evidence base for this work. We reviewed existing policies of selected organizations and other relevant literature. Members of the ATS Documents Development and Implementation Committee and the ATS Ethics and COI Committee collaborated to draft a COI policy. We used face-to-face meetings, electronic correspondence, and teleconferences to finalize the draft. The policy then underwent review and ultimate approval by the ATS Board of Directors. RESULTS: The ATS developed a new policy and procedures for declaration and management of COI. These procedures include: (1) self declaration of COI, (2) review of potential participants' COI, (3) disclosure of COI to project participants, (4) refusal or excusal from certain decisions or recommendations when appropriate, (5) disclosure of COI to users of documents or attendees of conferences, (6) handling disputes in COI resolution. This policy includes a tool that may be useful for supporting decision makers in management of COIs as they assess the value and relevance of conflicts. CONCLUSIONS: The ATS Policy on Management of COI in Official ATS Documents, Projects, and Conferences, in effect since March 2008, promises greater organizational transparency. Application and ongoing evaluation of the policy will give the ATS the opportunity to determine its usefulness in specific settings.

Assessing future need for acute care in adult asthmatics: the Profile of Asthma Risk Study: a prospective health maintenance organization-based study.

STUDY OBJECTIVES: To develop simple clinical tools predictive of acute asthma care and to identify modifiable risk factors. DESIGN: Prospective cohort study. SETTING: A large health maintenance organization (430,000 members). PATIENTS/PARTICIPANTS: Adult members (18 to 55 years old) with asthma. INTERVENTIONS: Data from a questionnaire, skin-prick testing for inhalant allergens, and spirometry were collected at the baseline visit. Acute care utilization data were obtained from administrative databases for a subsequent 30-month period. METHODS: This two-phase study first identified and performed a split-sample validation on three clinical tools to determine their predictive ability by employing data from a questionnaire, questionnaire plus spirometry, and questionnaire plus spirometry and skin-prick testing. Second, it identified modifiable independent risk factors. MEASUREMENTS AND RESULTS: The 554 study participants generated 173 episodes of acute care over 1,258 person-years of follow-up (0.14 episodes per person per year). Of these, 101 participants had at least one episode, and one third of this group had two or more episodes. Clinical scoring into risk groups was done by reverse stepwise regression analyses. Using relative risks (RRs) as a guide, high-risk, moderate-risk, and low-risk groups were identified. The high-risk groups, 13 to 21% of the validation sample, had a 7- to 11-fold increased risk for hospital care compared to the low-risk groups. The moderate-risk groups, 46 to 50% of the validation sample, had a twofold- to fourfold-increased risk. FEV(1) was the most significant predictor (RR, 4.33). Of the four potentially modifiable risk factors identified, current cigarette smoke exposure (RR, 1.6) and ownership and skin-prick test positivity to cat or dog (RR, 1.5) were the most significant. CONCLUSIONS: These models stratify asthma patients at risk for acute care. Patients with lower FEV(1) values are at significantly higher risk, underscoring the importance of spirometry in asthma care.