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The screening of healthcare workers for COVID-19 (coronavirus disease 2019) symptoms and exposures prior to every clinical shift is important for preventing nosocomial spread of infection but creates a major logistical challenge. To make the screening process simple and efficient, University of California, San Francisco Health designed and implemented a digital chatbot-based workflow. Within 1 week of forming a team, we conducted a product development sprint and deployed the digital screening process. In the first 2 months of use, over 270 000 digital screens have been conducted. This process has reduced wait times for employees entering our hospitals during shift changes, allowed for physical distancing at hospital entrances, prevented higher-risk individuals from coming to work, and provided our healthcare leaders with robust, real-time data for make staffing decisions.

The screening of healthcare workers for COVID-19 (coronavirus disease 2019) symptoms and exposures prior to every clinical shift is important for preventing nosocomial spread of infection but creates a major logistical challenge. To make the screening process simple and efficient, University of California, San Francisco Health designed and implemented a digital chatbot-based workflow. Within 1 week of forming a team, we conducted a product development sprint and deployed the digital screening process. In the first 2 months of use, over 270 000 digital screens have been conducted. This process has reduced wait times for employees entering our hospitals during shift changes, allowed for physical distancing at hospital entrances, prevented higher-risk individuals from coming to work, and provided our healthcare leaders with robust, real-time data for make staffing decisions.

As entertainment education (EE) becomes an increasingly popular medium for delivering health information, evaluation of EE is key to better understanding how it not only influences audiences but also how it can be better implemented. We suggest that EE evaluation has largely focused on impact while its implementation, specifically through narrative, characters, and genre, has remained unexplored. We propose drawing from theories and methods used in media studies to complement current approaches to understanding and evaluation of EE that can help improve EE for health education. East Los High serves as a case study, through which we examine the characters and the narrative demands of the telenovela genre to reveal a disproportional depiction of Latino men and women that ultimately replays familiar Latino stereotypes of criminality and exaggerated sexuality. We discuss the implications this has on the show's ability to do public health work.

Quantitative metrics are used to develop profiles of health care institutions, including hospitals, nursing homes, and dialysis clinics. These profiles serve as measures of quality of care, which are used to compare institutions and determine reimbursement, as a part of a national effort led by the Center for Medicare and Medicaid Services in the United States. However, there is some concern about how misclassification in case-mix factors, which are typically accounted for in profiling, impacts results. We evaluated the potential effect of misclassification on profiling results, using 20 744 patients from 2740 dialysis facilities in the US Renal Data System. In this case study, we compared 30-day readmission as the profiling outcome measure, using comorbidity data from either the Center for Medicare and Medicaid Services Medical Evidence Report (error-prone) or Medicare claims (more accurate). Although the regression coefficient of the error-prone covariate demonstrated notable bias in simulation, the outcome measure-standardized readmission ratio-and profiling results were quite robust; for example, correlation coefficient of 0.99 in standardized readmission ratio estimates. Thus, we conclude that misclassification on case-mix did not meaningfully impact overall profiling results. We also identified both extreme degree of case-mix factor misclassification and magnitude of between-provider variability as 2 factors that can potentially exert enough influence on profile status to move a clinic from one performance category to another (eg, normal to worse performer).

International initiatives to strengthen national health laboratory systems in resource-poor countries are often hampered by unfamiliarity with the country's health laboratory environment and turnover of international partners during the initiative. This study provides an overview of, and lessons learned from, the use of a laboratory long-term partnership approach (ie, "twinning") to strengthen the national public health laboratory system in an international setting. We focused on the partnering of the Uganda Ministry of Health Central Public Health Laboratory (CPHL) with the New Mexico State Public Health Laboratory to help the CPHL become Uganda's national public health reference laboratory (Uganda National Health Laboratory Services [UNHLS] Institute) and leader of its nascent Uganda National Health Laboratory Network (UNHLN). Via twinning, CPHL leadership received training on laboratory leadership and management, quality systems, facility management, and the One Health environmental strategy (ie, that the health of persons is connected to the health of animals and the environment), and drafted a National Health Laboratory Policy, UNHLS Institute business plan, and strategic and operating plans for the UNHLS Institute and UNHLN. The CPHL is now responsible for the UNHLS Institute and coordinates the UNHLN. Lessons learned include (1) twinning establishes stable long-term collaborations and (2) success requires commitment to a formal statement of activities and objectives, as well as clear and regular communication among partners.

This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation.

AIMS:To determine the power of a conceptual clinical nurse leader practice model to explain the care model's enactment and trajectory in real world settings. BACKGROUND:How nursing, organised into specific models of care, functions as an organisational strategy for quality is not well specified. Clinical nurse leader integrated care delivery is one emerging model with growing adoption. A recently validated clinical nurse leader practice model conceptualizes the care model's characteristics and hypothesizes their mechanisms of action. METHODS:Pattern matching case study design and mixed methods were used to determine how the care model's constructs were operationalized in one regional United States health system that integrated clinical nurse leaders into their care delivery system in 2010. RESULTS:The findings confirmed the empirical presence of all clinical nurse leader practice model constructs and provided a rich description of how the health system operationalized the constructs in practice. The findings support the hypothesized model pathway from Clinical Nurse Leader structuring to Clinical Nurse Leader practice and outcomes. CONCLUSION:The findings indicate analytic generalizability of the clinical nurse leader practice model. IMPLICATIONS FOR NURSING MANAGEMENT:Nursing practice organised to focus on microsystem care processes can catalyse multidisciplinary engagement with, and consistent enactment of, quality practices. The model has great potential for transferability across diverse health systems.

AIMS:To determine the power of a conceptual clinical nurse leader practice model to explain the care model's enactment and trajectory in real world settings. BACKGROUND:How nursing, organised into specific models of care, functions as an organisational strategy for quality is not well specified. Clinical nurse leader integrated care delivery is one emerging model with growing adoption. A recently validated clinical nurse leader practice model conceptualizes the care model's characteristics and hypothesizes their mechanisms of action. METHODS:Pattern matching case study design and mixed methods were used to determine how the care model's constructs were operationalized in one regional United States health system that integrated clinical nurse leaders into their care delivery system in 2010. RESULTS:The findings confirmed the empirical presence of all clinical nurse leader practice model constructs and provided a rich description of how the health system operationalized the constructs in practice. The findings support the hypothesized model pathway from Clinical Nurse Leader structuring to Clinical Nurse Leader practice and outcomes. CONCLUSION:The findings indicate analytic generalizability of the clinical nurse leader practice model. IMPLICATIONS FOR NURSING MANAGEMENT:Nursing practice organised to focus on microsystem care processes can catalyse multidisciplinary engagement with, and consistent enactment of, quality practices. The model has great potential for transferability across diverse health systems.

OBJECTIVES:To estimate potential impacts of California Assembly Bill (AB) 1316: a requirement for universal screening and insurance coverage for child blood lead testing. METHODS:In April 2017 the California Health Benefits Review Program (Oakland, CA) analyzed AB 1316 for the California legislature, including a systematic review of lead screening effectiveness, commercial insurer surveys regarding screening coverage, and actuarial utilization and cost implication assessments. RESULTS:Universal screening requirements would increase child lead testing by 273%, raise affected populations' premiums by 0.0043%, and detect an additional 4777 exposed children 1 year after implementation. CONCLUSIONS:The evidence for a net societal benefit of universal screening approach is limited and is not supported by prominent medical professional groups. Public Health Implications. California expanded targeted screening to identify additional children at higher risk for lead poisoning on the basis of California-specific risk factors, while mitigating the potential harms of universal screening such as an increase in false positive tests and health care costs.

OBJECTIVES:To estimate potential impacts of California Assembly Bill (AB) 1316: a requirement for universal screening and insurance coverage for child blood lead testing. METHODS:In April 2017 the California Health Benefits Review Program (Oakland, CA) analyzed AB 1316 for the California legislature, including a systematic review of lead screening effectiveness, commercial insurer surveys regarding screening coverage, and actuarial utilization and cost implication assessments. RESULTS:Universal screening requirements would increase child lead testing by 273%, raise affected populations' premiums by 0.0043%, and detect an additional 4777 exposed children 1 year after implementation. CONCLUSIONS:The evidence for a net societal benefit of universal screening approach is limited and is not supported by prominent medical professional groups. Public Health Implications. California expanded targeted screening to identify additional children at higher risk for lead poisoning on the basis of California-specific risk factors, while mitigating the potential harms of universal screening such as an increase in false positive tests and health care costs.

Large for-profit nursing home chains in the United States have generally reported low nurse staffing levels. This historical case study examined a class action litigation case regarding staffing levels, resident rights, and quality outcomes in 12 Arkansas nursing homes owned by a large for-profit chain. The questions were as follows: (1) How did the residents' care needs compare with actual nurse staffing levels? (2) How did the staffing levels compare with federal and state nurse staffing requirements and professional staffing standards? (3) Did the facilities comply with state and federal residents' rights and quality of care requirements? The findings showed staffing levels marginally above state minimum standards, staffing shortages that violated state standards, staffing levels not adjusted for resident acuity, and shortages that resulted in omitted care. Staffing levels were lower than needed according to nursing directors, lower than average facilities in the state, and lower than professional standards. The findings showed many resident grievances regarding basic care and residents' rights, clinical measures of poor quality, and state deficiencies. A large settlement was agreed on to compensate the residents. The case shows that chain's management, as well as the regulatory system, failed to ensure adequate staffing levels that took into account regulatory requirements and professional standards and resulted in violations of residents' rights, health, safety, and well-being.

Large for-profit nursing home chains in the United States have generally reported low nurse staffing levels. This historical case study examined a class action litigation case regarding staffing levels, resident rights, and quality outcomes in 12 Arkansas nursing homes owned by a large for-profit chain. The questions were as follows: (1) How did the residents' care needs compare with actual nurse staffing levels? (2) How did the staffing levels compare with federal and state nurse staffing requirements and professional staffing standards? (3) Did the facilities comply with state and federal residents' rights and quality of care requirements? The findings showed staffing levels marginally above state minimum standards, staffing shortages that violated state standards, staffing levels not adjusted for resident acuity, and shortages that resulted in omitted care. Staffing levels were lower than needed according to nursing directors, lower than average facilities in the state, and lower than professional standards. The findings showed many resident grievances regarding basic care and residents' rights, clinical measures of poor quality, and state deficiencies. A large settlement was agreed on to compensate the residents. The case shows that chain's management, as well as the regulatory system, failed to ensure adequate staffing levels that took into account regulatory requirements and professional standards and resulted in violations of residents' rights, health, safety, and well-being.

BackgroundPatients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems.MethodsWe undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization's Health Systems Framework.ResultsWe followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district's per capita income. We identified and mapped challenges according to the World Health Organization's Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity.ConclusionThe results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.

BackgroundPatients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems.MethodsWe undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization's Health Systems Framework.ResultsWe followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district's per capita income. We identified and mapped challenges according to the World Health Organization's Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity.ConclusionThe results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.

Few opportunities exist for physician trainees to gain exposure to, and training in, the field of clinical informatics, an Accreditation Council for Graduate Medical Education-accredited, recently board-certified specialty. Currently, 21 approved programs exist nationwide for the formal training of fellows interested in pursuing careers in this discipline. Residents and fellows training in medical and surgical fields, however, have few avenues available to gain experience in clinical informatics. An early introduction to clinical informatics brings an opportunity to generate interest for future career trajectories. At University of California Los Angeles (UCLA) Health, we have developed a novel, successful, and sustainable program, the Resident Informaticist Program, with the goals of exposing physician trainees to the field of clinical informatics and its academic nature and providing opportunities to expand the clinical informatics workforce. Herein, we provide an overview of the development, implementation, and current state of the UCLA Health Resident Informaticist Program, with a blueprint for development of similar programs.

We analyzed what happens to a nursing home chain when private equity takes over, with regard to strategy, financial performance, and resident well-being. We conducted a longitudinal (2000-2012) case study of a large nursing home chain that triangulated qualitative and quantitative data from 5 different data sources. Results show that private equity owners continued and reinforced several strategies that were already put in place before the takeover, including a focus on keeping staffing levels low; the new owners added restructuring, rebranding, and investment strategies such as establishing new companies, where the nursing home chain served as an essential "launch customer."

We analyzed what happens to a nursing home chain when private equity takes over, with regard to strategy, financial performance, and resident well-being. We conducted a longitudinal (2000-2012) case study of a large nursing home chain that triangulated qualitative and quantitative data from 5 different data sources. Results show that private equity owners continued and reinforced several strategies that were already put in place before the takeover, including a focus on keeping staffing levels low; the new owners added restructuring, rebranding, and investment strategies such as establishing new companies, where the nursing home chain served as an essential "launch customer."

Sustainment of evidence-based interventions (EBIs) in human services depends on the inner context of community-based organizations (CBOs) that provide services and the outer context of their broader environment. Increasingly, public officials are experimenting with contracting models from for-profit industries to procure human services. In this case study, we conducted qualitative interviews with key government and CBO stakeholders to examine implementation of the Best Value-Performance Information Procurement System to contract for EBIs in a child welfare system. Findings suggest that stakeholder relationships may be compromised when procurement disregards local knowledge, communication, collaboration, and other factors supporting EBIs and public health initiatives.

BackgroundThe US Preventive Services Taskforce (USPSTF) recommends routine lipid screening beginning age 35 for men [1]. For women age 20 and older, as well as men age 20-34, screening is recommended if cardiovascular risk factors are present. Prior research has focused on underutilization but not overuse of lipid testing. The objective is to document over- and under-use of lipid testing in an insured population of persons at low, moderate and high cardiovascular disease (CVD) risk for persons not already on statins.MethodsThe study is a retrospective cohort study that included all adults without prior CVD who were continuously enrolled in a large integrated healthcare system from 2005 to 2010. Measures included lipid test frequency extracted from administrative data and Framingham cardiovascular risk equations applied using electronic medical record data. Five year lipid testing patterns were examined by age, sex and CVD risk. Generalized linear models were used to estimate the relative risk for over testing associated with patient characteristics.ResultsAmong males and females for whom testing is not recommended, 35.8 % and 61.5 % received at least one lipid test in the prior 5 years and 8.4 % and 24.4 % had two or more. Over-testing was associated with age, race, comorbidity, primary care use and neighborhood income. Among individuals at moderate and high-risk (not already treated with statins) and for whom screening is recommended, between 21.4 % and 25.1 % of individuals received no screening in the prior 5 years.ConclusionsBased on USPSTF lipid screening recommendations, this study documents substantial over-testing among individuals with low CVD risk and under-testing among individuals with moderate to high-risk not already on statins. Opportunity exists to better focus lipid screening efforts appropriate to CVD risk.

BackgroundThe US Preventive Services Taskforce (USPSTF) recommends routine lipid screening beginning age 35 for men [1]. For women age 20 and older, as well as men age 20-34, screening is recommended if cardiovascular risk factors are present. Prior research has focused on underutilization but not overuse of lipid testing. The objective is to document over- and under-use of lipid testing in an insured population of persons at low, moderate and high cardiovascular disease (CVD) risk for persons not already on statins.MethodsThe study is a retrospective cohort study that included all adults without prior CVD who were continuously enrolled in a large integrated healthcare system from 2005 to 2010. Measures included lipid test frequency extracted from administrative data and Framingham cardiovascular risk equations applied using electronic medical record data. Five year lipid testing patterns were examined by age, sex and CVD risk. Generalized linear models were used to estimate the relative risk for over testing associated with patient characteristics.ResultsAmong males and females for whom testing is not recommended, 35.8 % and 61.5 % received at least one lipid test in the prior 5 years and 8.4 % and 24.4 % had two or more. Over-testing was associated with age, race, comorbidity, primary care use and neighborhood income. Among individuals at moderate and high-risk (not already treated with statins) and for whom screening is recommended, between 21.4 % and 25.1 % of individuals received no screening in the prior 5 years.ConclusionsBased on USPSTF lipid screening recommendations, this study documents substantial over-testing among individuals with low CVD risk and under-testing among individuals with moderate to high-risk not already on statins. Opportunity exists to better focus lipid screening efforts appropriate to CVD risk.

BackgroundThe California Right Care Initiative (RCI) accelerates the adoption of evidence-based guidelines and improved care management practices for conditions for which the gap between science and practice is significant, resulting in preventable disability and death.MethodsMedical directors and quality improvement leaders from 11 of the 12 physician organizations that met the 2010 national 90th percentile performance benchmarks for control of hyperlipidemia and glycated hemoglobin in 2011 were interviewed in 2012. Interviews, as well as surveys, assessed performance reporting and feedback to individual physicians; medication management protocols; team-based care management; primary care team huddles; coordination of care between primary care clinicians and specialists; implementation of shared medical appointments; and telephone visits for high-risk patients.ResultsAll but 1 of 11 organizations implemented electronic health records. Electronic information exchange between primary care physicians and specialists, however, was uncommon. Few organizations routinely used interdisciplinary team approaches, shared medical appointments, or telephonic strategies for managing cardiovascular risks among patients. Implementation barriers included physicians' resistance to change, limited resources and reimbursement for team approaches, and limited organizational capacity for change. Implementation facilitators included routine use of reliable data to guide improvement, leadership facilitation of change, physician buy-in, health information technology use, and financial incentives.ConclusionTo accelerate improvements in managing cardiovascular risks, physician organizations may need to implement strategies involving extensive practice reorganization and work flow redesign.

BackgroundThe California Right Care Initiative (RCI) accelerates the adoption of evidence-based guidelines and improved care management practices for conditions for which the gap between science and practice is significant, resulting in preventable disability and death.MethodsMedical directors and quality improvement leaders from 11 of the 12 physician organizations that met the 2010 national 90th percentile performance benchmarks for control of hyperlipidemia and glycated hemoglobin in 2011 were interviewed in 2012. Interviews, as well as surveys, assessed performance reporting and feedback to individual physicians; medication management protocols; team-based care management; primary care team huddles; coordination of care between primary care clinicians and specialists; implementation of shared medical appointments; and telephone visits for high-risk patients.ResultsAll but 1 of 11 organizations implemented electronic health records. Electronic information exchange between primary care physicians and specialists, however, was uncommon. Few organizations routinely used interdisciplinary team approaches, shared medical appointments, or telephonic strategies for managing cardiovascular risks among patients. Implementation barriers included physicians' resistance to change, limited resources and reimbursement for team approaches, and limited organizational capacity for change. Implementation facilitators included routine use of reliable data to guide improvement, leadership facilitation of change, physician buy-in, health information technology use, and financial incentives.ConclusionTo accelerate improvements in managing cardiovascular risks, physician organizations may need to implement strategies involving extensive practice reorganization and work flow redesign.

BACKGROUND AND OBJECTIVE: Providing patients access to their medical records offers many potential benefits including identification and correction of errors. The process by which patients ask for changes to be made to their records is called an amendment request. Little is known about the nature of such amendment requests and whether they result in modifications to the chart. METHODS: We conducted a qualitative content analysis of all patient-initiated amendment requests that our institution received over a 7-year period. Recurring themes were identified along three analytic dimensions: (1) clinical/documentation area, (2) patient motivation for making the request, and (3) outcome of the request. RESULTS: The dataset consisted of 818 distinct requests submitted by 181 patients. The majority of these requests (n=636, 77.8%) were made to rectify incorrect information and 49.7% of all requests were ultimately approved. In 6.6% of the requests, patients wanted valid information removed from their record, 27.8% of which were approved. Among all of the patients requesting a copy of their chart, only a very small percentage (approximately 0.2%) submitted an amendment request. CONCLUSIONS: The low number of amendment requests may be due to inadequate awareness by patients about how to make changes to their records. To make this approach effective, it will be important to inform patients of their right to view and amend records and about the process for doing so. Increasing patient access to medical records could encourage patient participation in improving the accuracy of medical records; however, caution should be used.

The apolitical legitimacy of "evidence-based medicine" offers a practical means for ethnography and critical social-science-and-humanities-of-health theory to transfer survival resources to structurally vulnerable populations and to engage policy and services audiences with urgent political problems imposed on the urban poor in the United States that harm health: most notably, homelessness, hyperincarceration, social service cut-backs and the War on Drugs. We present four examples of collaborations between ethnography and clinical research projects that demonstrate the potentials and limits of promoting institutional reform, political debate and action through distinct strategies of cross-methodological dialog with epidemiological and clinical services research. Ethnographic methods alone, however, are simply a technocratic add-on. They must be informed by critical theory to contribute effectively and transformatively to applied health initiatives. Ironically, technocratic, neoliberal logics of cost-effectiveness can sometimes render radical service and policy reform initiatives institutionally credible, fundable and capable of generating wider political support, even though the rhetoric of economic efficacy is a double-edged sword. To extend the impact of ethnography and interdisciplinary theories of political-economic, cultural and disciplinary power relations into applied clinical and public health research, anthropologists - and their fellow travelers - have to be able to strategically, but respectfully learn to see through the positivist logics of clinical services research as well as epidemiological epistemology in order to help clinicians achieve - and extend - their applied priorities. In retrospect, these four very differently-structured collaborations suggest the potential for "good-enough" humble scientific and political strategies to work for, and with, structurally vulnerable populations in a punitive neoliberal era of rising social inequality, cutbacks of survival services, and hyperincarceration of the poor.

Bilingual staff is used to provide interpreter services in community health centers. Little is known about the language proficiency of dual-role staff interpreters. Golden Valley Health Centers implemented a formal language assessment program to improve the number of qualified dual-role staff interpreters and ultimately improve the quality of patient care.

BackgroundHealth-policy decision making is a complex and dynamic process, for which strong evidentiary support is required. This includes scientifically produced research, as well as information that relates to the context in which the decision takes place. Unlike scientific evidence, this "contextual evidence" is highly variable and often includes information that is not scientifically produced, drawn from sources such as political judgement, program management experience and knowledge, or public values. As the policy decision-making process is variable and difficult to evaluate, it is often unclear how this heterogeneous evidence is identified and incorporated into "evidence-based policy" decisions. Population-based colorectal cancer screening poses an ideal context in which to examine these issues. In Canada, colorectal cancer screening programs have been established in several provinces over the past five years, based on the fecal occult blood test (FOBT) or the fecal immunochemical test. However, as these programs develop, new scientific evidence for screening continues to emerge. Recently published randomized controlled trials suggest that the use of flexible sigmoidoscopy for population-based screening may pose a greater reduction in mortality than the FOBT. This raises the important question of how policy makers will address this evidence, given that screening programs are being established or are already in place. This study will examine these issues prospectively and will focus on how policy makers monitor emerging scientific evidence and how both scientific and contextual evidence are identified and applied for decisions about health system improvement.MethodsThis study will employ a prospective multiple case study design, involving participants from Ontario, Alberta, Manitoba, Nova Scotia, and Quebec. In each province, data will be collected via document analysis and key informant interviews. Documents will include policy briefs, reports, meeting minutes, media releases, and correspondence. Interviews will be conducted in person with senior administrative leaders, government officials, screening experts, and high-level cancer system stakeholders.DiscussionThe proposed study comprises the third and final phase of an Emerging Team grant to address the challenges of health-policy decision making and colorectal cancer screening decisions in Canada. This study will contribute a unique prospective look at how policy makers address new, emerging scientific evidence in several different policy environments and at different stages of program planning and implementation. Findings will provide important insight into the various approaches that are or should be used to monitor emerging evidence, the relative importance of scientific versus contextual evidence for decision making, and the tools and processes that may be important to support challenging health-policy decisions.

BackgroundHealth-policy decision making is a complex and dynamic process, for which strong evidentiary support is required. This includes scientifically produced research, as well as information that relates to the context in which the decision takes place. Unlike scientific evidence, this "contextual evidence" is highly variable and often includes information that is not scientifically produced, drawn from sources such as political judgement, program management experience and knowledge, or public values. As the policy decision-making process is variable and difficult to evaluate, it is often unclear how this heterogeneous evidence is identified and incorporated into "evidence-based policy" decisions. Population-based colorectal cancer screening poses an ideal context in which to examine these issues. In Canada, colorectal cancer screening programs have been established in several provinces over the past five years, based on the fecal occult blood test (FOBT) or the fecal immunochemical test. However, as these programs develop, new scientific evidence for screening continues to emerge. Recently published randomized controlled trials suggest that the use of flexible sigmoidoscopy for population-based screening may pose a greater reduction in mortality than the FOBT. This raises the important question of how policy makers will address this evidence, given that screening programs are being established or are already in place. This study will examine these issues prospectively and will focus on how policy makers monitor emerging scientific evidence and how both scientific and contextual evidence are identified and applied for decisions about health system improvement.MethodsThis study will employ a prospective multiple case study design, involving participants from Ontario, Alberta, Manitoba, Nova Scotia, and Quebec. In each province, data will be collected via document analysis and key informant interviews. Documents will include policy briefs, reports, meeting minutes, media releases, and correspondence. Interviews will be conducted in person with senior administrative leaders, government officials, screening experts, and high-level cancer system stakeholders.DiscussionThe proposed study comprises the third and final phase of an Emerging Team grant to address the challenges of health-policy decision making and colorectal cancer screening decisions in Canada. This study will contribute a unique prospective look at how policy makers address new, emerging scientific evidence in several different policy environments and at different stages of program planning and implementation. Findings will provide important insight into the various approaches that are or should be used to monitor emerging evidence, the relative importance of scientific versus contextual evidence for decision making, and the tools and processes that may be important to support challenging health-policy decisions.

BackgroundThe Robert Wood Johnson Foundation funded Hablamos Juntos (HJ), a $10-million multiyear demonstration to improve access to health care for Latinos with limited English proficiency and to explore cost-effective ways for health care organizations to provide language access services.Hablamos juntosIn this manuscript, the authors draw on their experiences in evaluating HJ, provide brief descriptions of innovative interventions, estimate operating costs, and synthesize lessons learned about implementation. A number of barriers and facilitators are documented.ConclusionThe experience of HJ grantees provides guidance for organizations contemplating similar efforts. In particular, it highlights the need for health care organizations to involve physicians in the design and adoption of language services.

BackgroundThe Robert Wood Johnson Foundation funded Hablamos Juntos (HJ), a $10-million multiyear demonstration to improve access to health care for Latinos with limited English proficiency and to explore cost-effective ways for health care organizations to provide language access services.Hablamos juntosIn this manuscript, the authors draw on their experiences in evaluating HJ, provide brief descriptions of innovative interventions, estimate operating costs, and synthesize lessons learned about implementation. A number of barriers and facilitators are documented.ConclusionThe experience of HJ grantees provides guidance for organizations contemplating similar efforts. In particular, it highlights the need for health care organizations to involve physicians in the design and adoption of language services.

We investigated how industries use front groups to combat public health measures by analyzing tobacco industry documents, contemporaneous media reports, journal articles, and press releases regarding "Get Government Off Our Back," a coalition created by the tobacco industry. RJ Reynolds created Get Government Off Our Back in 1994 to fight federal regulation of tobacco. By keeping its involvement secret, RJ Reynolds was able to draw public and legislative support and to avoid the tobacco industry reputation for misrepresenting evidence. The tobacco industry is not unique in its creation of such groups. Research on organizational background and funding could identify other industry front groups. Those who seek to establish measures to protect public health should be prepared to counter the argument that government should not regulate private behavior.

We investigated how industries use front groups to combat public health measures by analyzing tobacco industry documents, contemporaneous media reports, journal articles, and press releases regarding "Get Government Off Our Back," a coalition created by the tobacco industry. RJ Reynolds created Get Government Off Our Back in 1994 to fight federal regulation of tobacco. By keeping its involvement secret, RJ Reynolds was able to draw public and legislative support and to avoid the tobacco industry reputation for misrepresenting evidence. The tobacco industry is not unique in its creation of such groups. Research on organizational background and funding could identify other industry front groups. Those who seek to establish measures to protect public health should be prepared to counter the argument that government should not regulate private behavior.

Community-based participatory research (CBPR) has been identified as a useful strategy to overcome disparities in minority elders. However, little consensus exists with respect to appropriate CBPR training and mentoring mechanisms. In this paper, we summarize the mentoring activities in each of the six currently funded Resource Centers on Minority Aging Research (RCMAR). In addition to mentoring trainees and/or junior faculty, we also explore the bi-directional mentoring that occurs when faculty at academic health centers develop partnerships with members of their target communities.

Community-based participatory research (CBPR) has been identified as a useful strategy to overcome disparities in minority elders. However, little consensus exists with respect to appropriate CBPR training and mentoring mechanisms. In this paper, we summarize the mentoring activities in each of the six currently funded Resource Centers on Minority Aging Research (RCMAR). In addition to mentoring trainees and/or junior faculty, we also explore the bi-directional mentoring that occurs when faculty at academic health centers develop partnerships with members of their target communities.

An important question in the alcoholism treatment field is how research findings can be translated into real-world clinical practice. Researchers have developed a new research-practice integration (RPI) model that can both drive the formulation of studies and new research questions and promote improvements in treatment quality. The hallmark of this model is a collaborative relationship between the key stakeholders in both alcohol and other drug (AOD) treatment and research, including health plan administrators and clinicians, treatment program administrators, psychiatry and primary care departments, patients and their families, purchasers, and researchers. The issue of technology transfer is especially relevant in the realm of adolescent AOD treatment. The implementation and feasibility of the RPI model are illustrated by a case study of a managed health care plan's treatment services for adolescents with AOD dependence. In this setting, key research findings are being used to shape the plan's adolescent health services.

ObjectiveCommunity-based participatory research is recommended for research on health disparities and to improve uptake of clinical research findings. We describe the development of a multicenter consortium designed to support a community agency-academic partner infrastructure to support community-based, health-services research on multiple sources of health and healthcare disparities in local communities.DesignWe describe the development of the Los Angeles Community Health Improvement Collaborative (CHIC).ResultsThe CHIC partners examined the research capacity and health priorities of its partners and developed a research agenda focused on four tracer conditions (depression, violence, diabetes, and obesity) and four areas for development of research capacity: public participation in all phases of research; understanding community and organizational context for clinical services interventions; practical clinical services trial methods; and advancing health information technology for clinical services research. The partners pooled resources to develop these areas for the tracer conditions.ConclusionsThe challenges of a participatory approach to community-based clinical services research go beyond the significant methodologic and operational issues for specific projects and include building a sustainable capacity for research, community programs, and partnership across diverse communities and stakeholder organizations even when funding sources are not fully aligned with these goals.

An important question in the alcoholism treatment field is how research findings can be translated into real-world clinical practice. Researchers have developed a new research-practice integration (RPI) model that can both drive the formulation of studies and new research questions and promote improvements in treatment quality. The hallmark of this model is a collaborative relationship between the key stakeholders in both alcohol and other drug (AOD) treatment and research, including health plan administrators and clinicians, treatment program administrators, psychiatry and primary care departments, patients and their families, purchasers, and researchers. The issue of technology transfer is especially relevant in the realm of adolescent AOD treatment. The implementation and feasibility of the RPI model are illustrated by a case study of a managed health care plan's treatment services for adolescents with AOD dependence. In this setting, key research findings are being used to shape the plan's adolescent health services.

ObjectiveCommunity-based participatory research is recommended for research on health disparities and to improve uptake of clinical research findings. We describe the development of a multicenter consortium designed to support a community agency-academic partner infrastructure to support community-based, health-services research on multiple sources of health and healthcare disparities in local communities.DesignWe describe the development of the Los Angeles Community Health Improvement Collaborative (CHIC).ResultsThe CHIC partners examined the research capacity and health priorities of its partners and developed a research agenda focused on four tracer conditions (depression, violence, diabetes, and obesity) and four areas for development of research capacity: public participation in all phases of research; understanding community and organizational context for clinical services interventions; practical clinical services trial methods; and advancing health information technology for clinical services research. The partners pooled resources to develop these areas for the tracer conditions.ConclusionsThe challenges of a participatory approach to community-based clinical services research go beyond the significant methodologic and operational issues for specific projects and include building a sustainable capacity for research, community programs, and partnership across diverse communities and stakeholder organizations even when funding sources are not fully aligned with these goals.

We obtained detailed quantitative and interview data from Aetna U.S. Healthcare and six physician organizations to examine changes between 1998 and 2000 in the scope of capitation contracting and delegation of responsibility for claims payment and medical management in New York and California. The physician organizations in New York included Benchmark (Continuum), Montefiore IPA, and Lenox Hill Healthcare Network. In California they included Brown and Toland Medical Group, Monarch Healthcare, and Santa Clara County IPA. In both California, where global and shared risk capitation have been common, and New York, where they have not, we find movement to reduce the scope of prepayment and a rethinking of the delegated contractual relationship by physician organizations and health plans. This represents a departure from the 1990s, when many industry participants and analysts expected capitated and delegated relationships to spread across the nation.

Outreach, training, technology transfer, and research are often treated as programmatically distinct activities. The interdisciplinary and applied aspects of the Superfund Basic Research Program offer an opportunity to explore different models. A case study is presented that describes a collaborative outreach effort that combines all of the above. It involves the University of California's Davis and Berkeley program projects, the University of California Systemwide Toxic Substances Research and Teaching Program, the U.S. Navy's civilian workforce at the former Mare Island Naval Shipyard, Vallejo, California (MINSY), a Department of Defense (DoD) Environmental Education Demonstration Grant program, and the Private Industry Council of Napa and Sonoma counties in California. The effort applied a Superfund-developed technology to a combined waste, radium and polychlorinated biphenyl contamination, stemming from a problematic removal action at an installation/restoration site at MINSY. The effort demonstrates that opportunities for similar collaborations are possible at DoD installations.

Outreach, training, technology transfer, and research are often treated as programmatically distinct activities. The interdisciplinary and applied aspects of the Superfund Basic Research Program offer an opportunity to explore different models. A case study is presented that describes a collaborative outreach effort that combines all of the above. It involves the University of California's Davis and Berkeley program projects, the University of California Systemwide Toxic Substances Research and Teaching Program, the U.S. Navy's civilian workforce at the former Mare Island Naval Shipyard, Vallejo, California (MINSY), a Department of Defense (DoD) Environmental Education Demonstration Grant program, and the Private Industry Council of Napa and Sonoma counties in California. The effort applied a Superfund-developed technology to a combined waste, radium and polychlorinated biphenyl contamination, stemming from a problematic removal action at an installation/restoration site at MINSY. The effort demonstrates that opportunities for similar collaborations are possible at DoD installations.

Medical groups are growing and merging to improve efficiency and bargaining leverage in the competitive managed care environment. An increasing number are affiliating with physician practice management (PPM) firms that offer capital financing, expertise in utilization management, and global capitation contracts with health insurance entities. These physician organizations provide an alternative to affiliation with a hospital system and to individual physician contracting with health plans.To describe the growth, structure, and strategy of PPM organizations that coordinate medical groups in multiple markets and contract with health maintenance organizations (HMOs).Case studies, including interviews with administrative and clinical leaders, review of company documents, and analysis of documents from investment bankers, the Securities and Exchange Commission, and industry observers.Medical groups and independent practice associations (IPAs) in California and New Jersey affiliated with MedPartners, FPA Medical Management, and UniMed.Growth in number of primary care and specialty care physicians employed by and contracting with affiliated medical groups; growth in patient enrollment from commercial, Medicare, and Medicaid HMOs; growth in capitation and noncapitation revenues; structure and governance of affiliated management service organizations and professional corporations; and contracting strategies with HMOs.Between 1994 and 1996, medical groups and IPAs affiliated with 3 PPMs grew from 3787 to 25763 physicians; 65% of employed physicians provide primary care, while the majority of contracting physicians provide specialty care. Patient enrollment in HMOs grew from 285503 to 3028881. Annual capitation revenues grew from $190 million to $2.1 billion. Medical groups affiliated with PPMs are capitated for most professional, hospital, and ancillary clinical services and are increasingly delegated responsibility by HMOs for utilization management and quality assurance.Physician practice management organizations and their affiliated medical groups face the challenge of continuing rapid growth, sustaining stock values, and improving practice efficiencies while maintaining the loyalty of physicians and patients.