The Emerging Leaders in Public Health Initiative: Individual Leadership Transformation.

The Emerging Leaders in Public Health (ELPH) Initiative, sponsored by The Kresge Foundation, provided leadership development to local governmental public health leaders. An adaptive leadership framework was used to shape the curriculum. The coleads attended multiday convenings and webinars over a 16- to 18-month period. Key components of the initiative included using applied learning to solidify their leadership skills as they worked to develop a new role for their agencies provision of a resource grant from The Kresge Foundation to support agency transformation and technical assistance and consultation provided by a National Program Office. An external evaluator conducted a multicomponent evaluation of individual leadership skill change. Graduates assessed change in their own leadership and change in their colead. Colleagues of ELPH participants were surveyed about their observed changes in the leadership actions of the program graduates. One hundred four leaders from 30 states participated in the initiative in 3 successive cohorts. Leaders demonstrated improvement as shown by self-report and external observation. Improved ability to communicate in a way that inspires others was one of the most significant changes in leadership behaviors. Additional leadership actions were strengthened including the ability to create and maintain high-performing teams, the ability to ask transformational questions, and the ability to actively listen to understand. The pandemic has shown the importance of developing the field, starting with leadership. Leadership development and agency transformation are synergistic; they depend on each other and support each other.

The Emerging Leaders in Public Health Initiative: Leadership Development to Advance Public Health Practice.

CONTEXT: Effective leadership is essential for governmental public health agencies to promote and protect the health of their communities. OBJECTIVE: The Emerging Leaders in Public Health Initiative, a program of The Kresge Foundation, was implemented to strengthen leadership in governmental public health. We seek to examine lessons from the initiative to contribute to the field a better understanding of leadership development practices. DESIGN: An external evaluator conducted a retrospective analysis of participant responses postinitiative to assess the overall impact of the initiative and explore which components were most valuable. SETTING: United States. PARTICIPANTS: Directors and other staff from governmental public health agencies were recruited in 2-person teams to participate in 3 successive cohorts. INTERVENTION: Drawn from adaptive leadership principles, a framework was developed to guide the selection and implementation of educational and experiential activities. Participants were challenged to develop a new role for their public health agency, which provided a learning laboratory to practice individual and team leadership skills. The Kresge Foundation provided participants with a resource grant and a National Program Office offered convenings, webinars, coaching, and technical assistance over the 18 months of the developmental experience. MAIN OUTCOME MEASURES: Satisfaction, perceived value of components, and future intentions were assessed from participants in cohorts II and III (n = 70). The overall response rate was 93%. RESULTS: One hundred four diverse leaders from 52 agencies, representing 30 states participated in the initiative. Participants were extremely satisfied with the program (94%) and indicated a strong likelihood of recommending it to a colleague (96%). Unrestricted grant funding, peer learning, and in-person learning sessions were the program components rated most highly valuable. CONCLUSIONS: This initiative offers insights into principles and processes to be considered for future public health leadership development.

Building diverse leadership in an academic medical center: The ACCLAIM program.

As healthcare systems become more complex, medical education needs to adapt in many ways. There is a growing need for more formal leadership learning for healthcare providers, including greater attention to health disparities. An important challenge in addressing health disparities is ensuring inclusive excellence in the leadership of healthcare systems and medical education. Women and those who are underrepresented in medicine (URMs) have historically had fewer opportunities for leadership development and are less likely to hold leadership roles and receive promotions. One successful initiative for improved learning of medical leadership-presented as a case example here-is the Academic Career Leadership Academy in Medicine (ACCLAIM) at the University of North Carolina at Chapel Hill School of Medicine. ACCLAIM is uniquely designed for faculty identified as having emerging leadership potential, with an emphasis on women and URMs. Using a leadership learning system approach, annual cohorts of participants (Scholars) interactively participate in a multi-faceted nine-month long learning experience, including group (e.g., guest-speaker weekly presentations and exercises) and individual learning components (e.g., an individual leadership project). Since its initiation in 2012 and through 2021, 111 Scholars have participated in ACCLAIM; included were 57% women and 27% URMs. Two important outcomes described are: short-term impact as illustrated by consistent improvements in quantitively measured leadership knowledge and capabilities; and long-term leadership growth, whereby half of the ACCLAIM graduates have received academic rank promotions and almost two-thirds have achieved new leadership opportunities, with even higher percentages observed for women and URMs; for example, 87% of URMs were either promoted or achieved new leadership positions. Also consistently noted, through qualitative assessments, are broader healthcare system knowledge and shared tactics for addressing common challenges among Scholars. This case example shows that the promotion of leadership equity may jointly enhance professional development while creating opportunities for systems change within academic medical centers. Such an approach can be a potential model for academic medical institutions and other healthcare schools seeking to promote leadership equity and inclusion.

Frequency of Animal Leptospirosis in the Southern United States and the Implications for Human Health.

Leptospirosis is a zoonotic disease with symptoms in humans and animals, ranging from subclinical to serious and fatal. The disease occurs worldwide, but there is limited recognition of the public and animal health risks it poses in the southern United States. A systematic review of the frequency of animal leptospirosis in 17 states and jurisdictions covering the southern continental United States was performed to advance our understanding of the pathogen's distribution and identify transmission patterns that could be targeted for prevention efforts. Fifty-two articles, spanning >100 years, met the analysis criteria. A wide range of techniques were used to measure seroprevalence and isolate the bacteria. The assessment identified exposure to Leptospira spp and Leptospira spp infection among a diverse range of species, spanning 22 animal families within 14 states, suggesting that the pathogen is distributed throughout the southern region. Disease frequency trends were assessed among animals in various habitats (all habitats, nonwild habitats, and wild habitats). The frequency of Leptospira spp detection in animals in wild habitats increased slightly over time (<0.2%/year). We identified reports of 11 human leptospirosis illness clusters and outbreaks in the southern United States. Exposure to potentially contaminated surface waters were documented for at least seven of the events, and interactions with infected or likely infected animals were documented for at least six of the events. This analysis highlights the need for stronger partnerships across the public and animal health fields to enhance diagnostics, surveillance, and reporting. The early identification of leptospirosis in animals may serve as an indicator of environmental contamination and trigger prevention measures, such as vaccinating companion animals and livestock, use of potable water, and the wearing of waterproof protective clothing near water that may be contaminated.

Building capacity for Public Health 3.0: introducing implementation science into an MPH curriculum.

BACKGROUND: Many public health programs fail because of an inability to implement tested interventions in diverse, complex settings. The field of implementation science is engaged in developing strategies for successful implementation, but current training is primarily researcher-focused. To tackle the challenges of the twenty-first century, public health leaders are promoting a new model titled Public Health 3.0 where public health practitioners become "chief health strategists" and develop interdisciplinary skills for multisector engagement to achieve impact. This requires broad training for public health practitioners in implementation science that includes the allied fields of systems and design thinking, quality improvement, and innovative evaluation methods. At UNC Chapel Hill's Gillings School of Global Public Health, we created an interdisciplinary set of courses in applied implementation science for Master of Public Health (MPH) students and public health practitioners. We describe our rationale, conceptual approach, pedagogy, courses, and initial results to assist other schools contemplating similar programs. METHODS: Our conceptual approach recognized the vital relationship between implementation research and practice. We conducted a literature review of thought leaders in public health to identify skill areas related to implementation science that are priorities for the future workforce. We also reviewed currently available training programs in implementation science to understand their scope and objectives and to assess whether any of these would be a fit for these priorities. We used a design focused implementation framework to create four linked courses drawing from multiple fields such as engineering, management, and the social sciences and emphasizing application through case studies. We validated the course content by mapping them to implementation science competencies in the literature. RESULTS: To date, there is no other program that provides comprehensive interdisciplinary skills in applied implementation science for MPH students. As of April 2018, we have offered a total of eleven sections of the four courses, with a total enrollment of 142, of whom 127 have been master's-level students in the school of public health. Using Kirkpatrick's Model, we found positive student reaction, learning, and behavior. Many students have completed applied implementation science focused practicums, master's papers, and special studies. CONCLUSIONS: A systematically designed interdisciplinary curriculum in applied implementation science for MPH students has been found by students to be a useful set of skills. Students have demonstrated the capability to master this material and incorporate it into their practicums and master's papers.

Senior PharmAssist: Less Hospital Use with Enrollment in an Innovative Community-Based Program.

OBJECTIVES: To evaluate changes in acute health services use of Senior PharmAssist participants. DESIGN: Retrospective analysis. SETTING: Community-based, nonprofit program in Durham County, North Carolina. PARTICIPANTS: Adults aged 60 and older with income of 200% of the federal poverty level or less who enrolled in the Senior PharmAssist program (N = 191) between August 1, 2011, and March 15, 2017. INTERVENTION: Medication therapy management (MTM), customized community referrals, Medicare insurance counseling, and medication copayment assistance provided by Senior PharmAssist. MEASUREMENTS: Primary outcomes were self-reported emergency department (ED) visits and hospital admissions in the previous year, assessed at baseline and every 6 months for up to 2 years. RESULTS: Mean number of ED visits declined over time (0.83 visits per year at baseline to 0.53 visits per year at 24 months, P = .002), as did the percentage of participants reporting an ED visit in the past year (49% at baseline to 31% at 24 months, P = .003). Mean hospital admissions also decreased (0.56 admissions per year at baseline to 0.4 admissions per year at 24 months, P = .02). There was no significant change in percentage of participants reporting a hospital admission in the past year (33% at baseline to 25% at 24 months, P = .23). CONCLUSION: Older adults who enrolled in a community-based program that helps them manage medications, connect with community resources, and overcome barriers to medication access experienced reductions in acute health services use. J Am Geriatr Soc 66:2394-2400, 2018.

National Institutes of Health Pathways to Prevention Workshop: Advancing Research to Prevent Youth Suicide.

The National Institutes of Health (NIH) Pathways to Prevention Workshop "Advancing Research to Prevent Youth Suicide" was cosponsored by the NIH Office of Disease Prevention, National Institute of Mental Health, National Institute on Drug Abuse, and National Center for Complementary and Integrative Health. A multidisciplinary working group developed the agenda, and an evidence-based practice center prepared an evidence report that addressed data systems relevant to suicide prevention efforts through a contract with the Agency for Healthcare Research and Quality. During the workshop, experts discussed the evidence and participants commented during open forums. After considering the data from the evidence report, expert presentations, and public comments, an independent panel prepared a draft report that was posted on the NIH Office of Disease Prevention Web site for 5 weeks for public comment. This abridged version of the final report provides a road map for optimizing youth suicide prevention efforts by highlighting strategies for guiding the next decade of research in this area. These strategies include recommendations for improving data systems, enhancing data collection and analysis methods, and strengthening the research and practice community.

Building the evidence for decision-making: the relationship between local public health capacity and community mortality.

OBJECTIVES: We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina. METHODS: We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality. RESULTS: Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and children's services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05). CONCLUSIONS: Our findings, in the context of other studies, provide support for investment in local public health services to improve community health.

Effects of performance improvement programs on preparedness capacities.

OBJECTIVE: In response to public health systems and services research priorities, we examined the extent to which participation in accreditation and performance improvement programs can be expected to enhance preparedness capacities. METHODS: Using data collected by the Local Health Department Preparedness Capacities Assessment Survey, we applied a series of weighted least-squares models to examine the effect of program participation on each of the eight preparedness domain scores. Participation was differentiated across four groups: North Carolina (NC) accredited local health departments (LHDs), NC non-accredited LHDs, national comparison LHDs that participated in performance or preparedness programs, and national comparison LHDs that did not participate in any program. RESULTS: Domain scores varied among the four groups. Statistically significant positive participation effects were observed on six of eight preparedness domains for NC accreditation programs, on seven domains for national comparison group LHDs that participated in performance programs, and on four domains for NC non-accredited LHDs. CONCLUSIONS: Overall, accreditation and other performance improvement programs have a significant and positive effect on preparedness capacities. While we found no differences among accredited and non-accredited NC LHDs, this lack of significant difference in preparedness scores among NC LHDs is attributed to NC's robust statewide preparedness program, as well as a likely exposure effect among non-accredited NC LHDs to the accreditation program.

Comparative effectiveness of follow-up imaging approaches in pancreatic cancer.

AIM: Although PET imaging is sometimes used in follow-up of pancreatic cancer, evidence regarding comparative effectiveness of PET and older imaging modalities is limited. PATIENTS & METHODS: Linked cancer registry and Medicare claims data were analyzed to examine patterns of imaging and effects on treatment patterns and survival among newly diagnosed pancreatic cancer patients from 2003 to 2007. RESULTS: 12% of patients received PET during follow-up. In a time-varying exposure model, computed tomography/MRI was associated with lower mortality risk relative to PET in surgical patients (HR: 0.66; 95% CI: 0.52-0.83). In a subset analysis, type of follow-up imaging before 180 days was not associated with mortality after 180 days (computed tomography/MRI vs PET; hazard ratio: 0.98; 95% CI: 0.84-1.16). CONCLUSION: Follow-up PET is uncommon among Medicare beneficiaries with pancreatic cancer, and is generally used late in the disease course. This pattern of PET use was not associated with decreased mortality risk compared with conventional imaging.

Declining trends in local health department preparedness capacities.

OBJECTIVES: We examined local health department (LHD) preparedness capacities in the context of participation in accreditation and other performance improvement efforts. MetHODS: We analyzed preparedness in 8 domains among LHDs responding to a preparedness capacity instrument from 2010 through 2012. Study groups included LHDs that (1) were exposed to a North Carolina state-based accreditation program, (2) participated in 1 or more performance improvement programs, and (3) had not participated in any performance improvement programs. We analyzed mean domain preparedness scores and applied a series of nonparametric Mann-Whitney Wilcoxon tests to determine whether preparedness domain scores differed significantly between study groups from 2010 to 2012. RESULTS: Preparedness capacity scores fluctuated and decreased significantly for all study groups for 2 domains: surveillance and investigation and legal preparedness. Significant decreases also occurred among participants for plans and protocols, communication, and incident command. Declines in capacity scores were not as great and less likely to be significant among North Carolina LHDs. CONCLUSIONS: Decreases in preparedness capacities over the 3 survey years may reflect multiple years of funding cuts and job losses, specifically for preparedness. An accreditation program may have a protective effect against such contextual factors.

Quality measures for hospice and palliative care: piloting the PEACE measures.

BACKGROUND: The Carolinas Center for Medical Excellence launched the PEACE project in 2006, under contract with the Centers for Medicare & Medicaid Services (CMS), to identify, develop, and pilot test quality measures for hospice and palliative care programs. OBJECTIVES: The project collected pilot data to test the usability and feasibility of potential quality measures and data collection processes for hospice and palliative care programs. Settings/subjects: Twenty-two hospices participating in a national Quality Improvement Collaborative (QIC) submitted data from 367 chart reviews for pain care and 45 chart reviews for nausea care. Fourteen additional hospices completed a one-time data submission of 126 chart reviews on 60 potential patient-level quality measures across eight domains of care and an organizational assessment evaluating structure and processes of care. DESIGN: Usability was assessed by examining the range, variability and size of the populations targeted by each quality measure. Feasibility was assessed during the second pilot study by surveying data abstractors about the abstraction process and examining the rates of missing data. The impact of data collection processes was assessed by comparing results obtained using different processes. RESULTS: Measures shown to be both usable and feasible included: screening for physical symptoms on admission and documentation of treatment preferences. Methods of data collection and measure construction appear to influence observed rates of quality of care. CONCLUSIONS: We successfully identified quality measures with potential for use in hospices and palliative care programs. Future research is needed to understand whether these measures are sensitive to quality improvement interventions.

Use of electronic documentation for quality improvement in hospice.

Little evidence exists about the use of electronic documentation (ED) in hospice and its relationship to quality improvement (QI) practices. The purposes of this study were to (1) estimate the prevalence of ED use in hospice, (2) identify organizational characteristics associated with use of ED, and (3) determine whether quality measurement practices differed based on documentation format (electronic vs nonelectronic). Surveys concerning the use of ED for QI practices and the monitoring of quality-related care and outcomes were collected from 653 hospices. Users of ED were able to monitor a wider range of quality-related data than users of non-ED. Quality components such as advanced care planning, cultural needs, experience during care of the actively dying, and the number/types of care being delivered were more likely to be documented by users of ED. Use of ED may help hospices monitor quality and compliance.

Impact of distance to a urologist on early diagnosis of prostate cancer among black and white patients.

PURPOSE: We examined whether an increased distance to a urologist is associated with a delayed diagnosis of prostate cancer among black and white patients, as manifested by higher risk disease at diagnosis. MATERIALS AND METHODS: North Carolina Central Cancer Registry data were linked to Medicare claims for patients with incident prostate cancer diagnosed in 2004 to 2005. Straight-line distances were calculated from the patient home to the nearest urologist. Race stratified multivariate ordinal logistic regression was used to examine the association between distance to a urologist and prostate cancer risk group (low, intermediate, high or very high/metastasis) at diagnosis for black and white patients while accounting for age, comorbidity, marital status and diagnosis year. An overall model was then used to examine the distance × race interaction effect. RESULTS: Included in analysis were 1,720 white and 531 black men. In the overall cohort the high risk cancer rate increased monotonically with distance to a urologist, including 40% for 0 to 10, 45% for 11 to 20 and 57% for greater than 20 miles. Correspondingly the low risk cancer rate decreased with longer distance. On race stratified multivariate analysis longer distance was associated with higher risk prostate cancer for white and black patients (p = 0.04 and <0.01, respectively) but the effect was larger in the latter group. The distance × race interaction term was significant in the overall model (p = 0.03). CONCLUSIONS: Longer distance to a urologist may disproportionally impact black patients. Decreasing modifiable barriers to health care access, such as distance to care, may decrease racial disparities in prostate cancer.

Structural/organizational characteristics of health services partly explain racial variation in timeliness of radiation therapy among elderly breast cancer patients.

Observed racial/ethnic disparities in the process and outcomes of breast cancer care may be explained, in part, by structural/organizational characteristics of health care systems. We examined the role of surgical facility characteristics and distance to care in explaining racial/ethnic variation in timing of initiation of guideline-recommended radiation therapy (RT) after breast conserving surgery (BCS). We used Surveillance Epidemiology and End Results-Medicare data to identify women ages 65 and older diagnosed with stages I-III breast cancer and treated with BCS in 1994-2002. We used stepwise multivariate logistic regression to examine the interactive effects of race/ethnicity and facility profit status, teaching status, size, and institutional affiliations, and distance to nearest RT on timing of RT initiation, controlling for known covariates. Among 38,574 eligible women who received BCS, 39% received RT within 2 months, 52% received RT within 6 months, and 57% received RT within 12 months post-diagnosis, with significant variation by race/ethnicity. In multivariate models, women attending smaller surgical facilities and those with on-site radiation had higher odds of RT at each time interval, and women attending governmental facilities had lower odds of RT at each time interval (P < 0.05). Increasing distance between patients' residence and nearest RT provider was associated with lower overall odds of RT, particularly among Hispanic women (P < 0.05). In fully adjusted models including race-by-distance interaction terms, racial/ethnic disparities disappeared in RT initiation within 6 and 12 months. Racial/ethnic disparities in timing of RT for breast cancer can be partially explained by structural/organizational health system characteristics. Identifying modifiable system-level factors associated with quality cancer care may help us target policy interventions that can reduce disparities in outcomes.

Predictors of timing of adjuvant chemotherapy in older women with hormone receptor-negative, stages II-III breast cancer.

Adherence to consensus guidelines for cancer care may vary widely across health care settings and contribute to differences in cancer outcomes. For some women with breast cancer, omission of adjuvant chemotherapy or delays in its initiation may contribute to differences in cancer recurrence and mortality. We studied adjuvant chemotherapy use among women with stage II or stage III, hormone receptor-negative breast cancer to understand health system and socio-demographic correlates of underuse and delayed adjuvant chemotherapy. We used Surveillance Epidemiology and End Results (SEER)-Medicare linked data to examine the patterns of care for 6,678 women aged 65 and older diagnosed with stage II or stage III hormone receptor-negative breast cancer in 1994-2002, with claims data through 2007. Age-stratified logistic regression was employed to examine the potential role of socio-demographic and structural/organizational health services characteristics in explaining differences in adjuvant chemotherapy initiation. Overall utilization of guideline-recommended adjuvant chemotherapy peaked at 43% in this population. Increasing age, higher co-morbidity burden, and low-income status were associated with lower odds of chemotherapy initiation within 4 months, whereas having positive lymph nodes, more advanced disease, and being married were associated with higher odds (P < 0.05). Health system-related structural/organizational characteristics and race/ethnicity offered little explanatory insight. Timely initiation of guideline-recommended adjuvant chemotherapy was low, with significant variation by age, income, and co-morbidity status. Based on these findings, future studies should seek to explore the more nuanced reasons why older women do not receive chemotherapy and why delays in care occur.

Implementing person-centered care in nursing homes.

BACKGROUND: Charged with caring for frail and disabled elders, nursing homes are complex organizations that operate under high regulatory scrutiny and low public opinion. Despite efforts to improve, many nursing home residents receive poor care. By focusing on residents' relationships, life experiences, abilities, and preferences, person-centered care represents an innovation in nursing home care. Because person-centered care requires organization-wide change, implementation can be challenging. PURPOSE: The purpose of this research is to apply innovation implementation theory to understand factors and conditions that help or hinder the implementation of person-centered care in nursing homes. METHODOLOGY: Data come from the Person-Centered Care Program conducted by the Carolinas Center for Medical Excellence. Eight nursing homes participated in the Person-Centered Care Program for 1 year. A multiple-case-study design and pattern-matching logic were employed to examine organizational factors associated with implementation effectiveness. Data sources included semistructured key informant interviews, archival documents, surveys, and expert rankings of nursing homes' implementation effectiveness. FINDINGS: On the basis of this research, we suggest that effective implementation of organization-wide change in nursing homes is associated with high-quality management communications about the change, organizational readiness for change, and favorable perceptions from direct care providers about the priority of the innovation to the organization. Notably, neither the amount of training nor the financial resources dedicated to person-centered care were associated with implementation effectiveness. PRACTICE IMPLICATIONS: Effective implementation of person-centered care in nursing homes is most likely when management follows through with plans as advertised, when leadership teams have confidence in their ability to meet goals for change, and when change fosters smooth operations in the daily routines of direct care providers.

Physician visits and colorectal cancer testing among Medicare enrollees in North Carolina and South Carolina, 2005.

INTRODUCTION: Many Medicare enrollees do not receive colorectal cancer tests at recommended intervals despite having Medicare screening coverage. Little is known about the physician visits of Medicare enrollees who are untested. Our study objective was to evaluate physician visits of enrollees who lack appropriate testing to identify opportunities to increase colorectal cancer testing. METHODS: We used North Carolina and South Carolina Medicare data to compare type and frequency of physician visits for Medicare enrollees with and without a colorectal cancer test in 2005. Type of physician visit was defined by the physician specialty as primary care, mixed specialty (more than 1 specialty, 1 of which was primary care), and nonprimary care. We used multivariate modeling to assess the influence of type and frequency of physician visits on colorectal cancer testing. RESULTS: Approximately half (46.5%) of enrollees lacked appropriate colorectal cancer testing. Among the untested group, 19.8% had no physician visits in 2005. Enrollees with primary care visits were more likely to be tested than those without a primary care visit. Many enrollees who had primary care visits remained untested. Enrollees with visits to all physician types had a greater likelihood of having colorectal cancer testing. CONCLUSION: We identified 3 categories of Medicare enrollees without appropriate colorectal cancer testing: those with no visits, those who see primary care physicians only, and those with multiple visits to physicians with primary and nonprimary care specialties. Different strategies are needed for each category to increase colorectal cancer testing in the Medicare population.

Predictors of screening mammography among a North and South Carolina Medicare population.

Despite guidelines recommending that women aged 40 years and older undergo screening mammography at least biennially, reports find that many women do not adhere to these recommendations. The authors' objective was to investigate the factors associated with undergoing a screening mammography. Eligible women were enrolled in Medicare during 2004 and 2005 and resided in North or South Carolina. Information on morbidities, demographics, and physician visits were assessed as predictors for whether a woman underwent a screening mammography. Approximately 50% of the women included in the study had undergone a screening mammography during the study period. An increasing number of physician visits was positively associated with having a screening mammography. Women making at least 1 visit to a gynecologist were more likely to be screened compared with women who saw only a primary care physician and/or a medical specialist. Older age, having certain morbidities, and Medicaid eligibility were inversely related to being screened.

Quality improvement in hospice: adding a big job to an already big job?

Hospice organizations are adopting quality measurement and quality improvement (QI) practices to comply with the Medicare Conditions of Participation effective January 31, 2009. However, little is known about organizational best practices or specific needs during implementation. This study identified and described the barriers and facilitators to QI implementation in hospice. Using semistructured interviews with a national sample of key informants (n = 52) concerning facilitators and barriers to QI in hospice, 4 major themes emerged from the data regarding participants' experiences and perceptions: (1) external factors constrain QI implementation; (2) internal factors limit capacity for QI; (3) research on best practices is limited; and (4) traditional QI may not be a good fit for hospice. Though challenging, participants provided recommendations that they believed would facilitate QI in hospice. Categorizing barriers and facilitators as within or outside an organization's control may help organizations assess their capabilities and locate resources to address areas for improvement.