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The article examines the transformation of the Cleveland Clinic's organizational structure in 2008 and its impact on the value-based healthcare movement.Topics include the Clinic's evolution, its commitment to continuous improvement, and the crucial role of leadership and organizational design in shaping corporate culture, particularly in the context of the healthcare industry.

Abstract Background The healthcare industry is characterized by intensive, never-ending change occurring on a multitude of fronts. Success in such tumultuous environments requires healthcare providers to be proficient in myriad areas, including the manner in which they organize and deliver services. Less efficient designs drain precious resources and hamper efforts to deliver the best care possible to patients, making it imperative that optimal pathways are identified and pursued. One particular avenue that offers great potential for serving patients efficiently and effectively is known as the hub-and-spoke organization design. Discussion The hub-and-spoke organization design is a model which arranges service delivery assets into a network consisting of an anchor establishment (hub) which offers a full array of services, complemented by secondary establishments (spokes) which offer more limited service arrays, routing patients needing more intensive services to the hub for treatment. Hub-and-spoke networks afford many benefits for healthcare providers, but in order to capitalize fully, proper assembly is required. To advance awareness, knowledge, and use of the hub-and-spoke organization design, this article profiles Willis-Knighton Health System’s service delivery network which has utilized the model for over three decades. Among other things, the hub-and-spoke organization design is defined, benefits are stipulated, and applications are discussed, permitting healthcare providers essential insights for the establishment and operation of these networks. Conclusions The change-rich nature of the healthcare industry places a premium on incorporating advancements that permit health and medical providers to operate as optimally as possible. The hub-and-spoke organization design represents an option that, when deployed correctly, can greatly assist healthcare establishments in their quests to serve patients well.

The article discusses the treatment of Opioid Use Disorder (OUD) in the general hospital, emphasizing the need for healthcare systems and providers to reassess their approach to OUD treatment due to its increasing morbidity, mortality, and cost. It highlights various pharmacologic treatment options, perioperative management considerations, harm reduction strategies, and the importance of addressing stigma and trauma in vulnerable populations.

Healthcare is a unique services environment with increasing demand for services coupled with widely diverse patient needs. In addition, hospitals are under increased pressure to provide quality care yet simultaneously decrease associated costs. This study examines how the use of quality practices and employee empowerment impact hospital unit outcomes. Specifically, the sociotechnical theory is used to explain the relationship of quality practices and employee empowerment in respiratory care services. Utilising data from 101 different hospital units, survey responses from managers and physicians within the same hospital units are used to test the impact on quality and cost of care performance metrics via path modelling. The results show the social side of improvement programs, i.e. employee empowerment, may be a critical component to true quality improvement in hospital units. Furthermore, while respiratory care managers feel that employee empowerment reduces costs of patient care, physicians felt that there was no impact on costs. The implications of these findings and differing perspectives are discussed. [ABSTRACT FROM AUTHOR]

We describe a computer-assisted program for conducting well-body assessments of children with neurodevelopmental disabilities attending a private special education school. Classroom instructors completed daily assessments to detect the presence of bodily injuries and other skin trauma, determine the need for medical treatment, and monitor healing status. Evaluations performed with the classroom instructors revealed that they implemented the program with high integrity and rated several procedural components favorably. Compared to "paper form" data recording, clinicians and supervisors judged the computer-assisted program to track student injuries more thoroughly and record student injuries more accurately. The importance of health monitoring among persons with neurodevelopmental disabilities, advantages of technology-based assessment methods, and practice considerations are discussed. [ABSTRACT FROM AUTHOR]

Background: Alpha-1 antitrypsin deficiency (AATD) is an autosomal co-dominant condition that predisposes to emphysema, cirrhosis, panniculitis, and vasculitis. Underrecognition has prompted efforts to enhance early detection and testing of at-risk individuals. Direct-to-consumer (DTC) genetic testing represents an additional method of detection.Research Question: The study addressed three questions: (1) Does a DTC testing service identify previously undetected individuals with AATD? (2) What was the interval between initial AATD-related symptoms and initial diagnosis of AATD in such individuals? and (3) What was the behavioral impact of learning about a new diagnosis of AATD through a DTC test?Study Design and Methods: In this cross-sectional study, 195,014 individuals responded to a survey within the 23andMe, Inc. research platform.Results: Among 195,014 study participants, the allele frequency for the PI∗S and PI∗Z AATD variants was 21.6% (6.5% for PI∗Z and 15.1% for PI∗S); 0.63% were PI∗ZZ, half of whom reported having a physician confirm the diagnosis. Approximately 27% of those with physician-diagnosed AATD reported first becoming aware of AATD through the DTC test. Among those newly aware participants, the diagnostic delay interval was 22.3 years. Participants frequently shared their DTC test results with health care providers (HCPs) and the reported impact of learning a diagnosis of AATD was high. For example, 51.1% of PI∗ZZ individuals shared their DTC result with an HCP. The OR for PI∗ZZ smokers to report smoking reduction as a result of receiving the DTC result was 1.7 (95% CI = 1.4-2.2) compared with those without a Z allele and for reduced alcohol consumption this was 4.0 (95% CI = 2.6-5.9).Interpretation: In this largest available report on DTC testing for AATD, this test, in combination with clinical follow-up, can help to identify previously undiagnosed AATD patients. Moreover, receipt of the DTC AATD report was associated with positive behavior change, especially among those with risk variants. [ABSTRACT FROM AUTHOR]

Individuals post-stroke experience persisting gait deficits due to altered joint mechanics, known clinically as spasticity, hypertonia, and paresis. In engineering, these concepts are described as stiffness and damping, or collectively as joint mechanical impedance, when considered with limb inertia. Typical clinical assessments of these properties are obtained while the patient is at rest using qualitative measures, and the link between the assessments and functional outcomes and mobility is unclear. In this study we quantify ankle mechanical impedance dynamically during walking in individuals post-stroke and in age-speed matched control subjects, and examine the relationships between mechanical impedance and clinical measures of mobility and impairment. Perturbations were applied to the ankle joint during the stance phase of walking, and least-squares system identification techniques were used to estimate mechanical impedance. Stiffness of the paretic ankle was decreased during mid-stance when compared to the non-paretic side; a change independent of muscle activity. Inter-limb differences in ankle joint damping, but not joint stiffness or passive clinical assessments, strongly predicted walking speed and distance. This work provides the first insights into how stroke alters joint mechanical impedance during walking, as well as how these changes relate to existing outcome measures. Our results inform clinical care, suggesting a focus on correcting stance phase mechanics could potentially improve mobility of chronic stroke survivors. [ABSTRACT FROM AUTHOR]

Background: Approximately 50 % of the population in Uganda seeks health care from private facilities but there is limited data on the quality of care for malaria in these facilities. This study aimed to document the knowledge, practices and resources during the delivery of malaria care services, among private health practitioners in the Mid-Western region of Uganda, an area of moderate malaria transmission.Methods: This was a cross sectional study in which purposive sampling was used to select fifteen private-for-profit facilities from each district. An interviewer-administered questionnaire that contained both quantitative and open-ended questions was used. Information was collected on availability of treatment aides, knowledge on malaria, malaria case management, laboratory practices, malaria drugs stock and data management. We determined the proportion of health workers that adequately provided malaria case management according to national standards.Results: Of the 135 health facilities staff interviewed, 61.48 % (52.91-69.40) had access to malaria treatment protocols while 48.89 % (40.19-57.63) received malaria training. The majority of facilities, 98.52 % (94.75-99.82) had malaria diagnostic services and the most commonly available anti-malarial drug was artemether-lumefantrine, 85.19 % (78-91), followed by Quinine, 74.81 % (67-82) and intravenous artesunate, 72.59 % (64-80). Only 14.07 % (8.69-21.10) responded adequately to the acceptable cascade of malaria case management practice. Specifically, 33.33 % (25.46-41.96) responded correctly to management of a patient with a fever, 40.00 % (31.67-48.79) responded correctly to the first line treatment for uncomplicated malaria, whereas 85.19 % (78.05-90.71) responded correctly to severe malaria treatment. Only 28.83 % submitted monthly reports, where malaria data was recorded, to the national database.Conclusions: This study revealed sub-optimal malaria case management knowledge and practices at private health facilities with approximately 14 % of health care workers demonstrating correct malaria case management cascade practices. To strengthen the quality of malaria case management, it is recommended that the NMCD distributes current guidelines and tools, coupled with training; continuous mentorship and supportive supervision; provision of adequate stock of essential anti-malarials and RDTs; reinforcing communication and behavior change; and increasing support for data management at private health facilities. [ABSTRACT FROM AUTHOR]

Emotional intelligence (EI) has become widely appreciated as an important leadership attribute, in business, education and, increasingly, in health care. Defined as "the capacity to understand your own and others' emotions and to motivate and develop yourself and others in service of improved work performance and enhanced organizational effectiveness," EI is correlated with a number of success attributes in several sectors; for example, in business, with enhanced business performance and enhanced personal career success, and in health care, with enhanced patient satisfaction, lower burnout, lower litigation risk, and enhanced leadership success. While multiple models of EI have evolved, perhaps the most popular model is framed around four general rubrics with component competencies. The general rubrics are: self-awareness, self-management, social awareness, and relationship management. EI can be measured by using available instruments, and it can be learned and taught. Indeed, teaching EI has become increasingly common in health-care organizations in service of improving health care and health-care leadership. Although more research is needed, ample evidence supports the notion that EI is a critical success element for success as a health-care leader, especially because EI competencies differ markedly from the clinical and scientific skills that are core to being a clinician and/or investigator. This review of EI presents evidence in support of the relevance of EI to health care and health-care leadership, discusses how and when EI can be developed among health-care providers, and considers remaining questions. [ABSTRACT FROM AUTHOR]

Change is a fact of life; the absence of change creates stagnation. This is perhaps especially true in health care, where progress in treating disease depends on innovation and progress. At the same time, change is often uncomfortable. Thus, it is helpful to model the change process to optimize the chances of successfully effecting change. Furthermore, how to lead change is a critical leadership competency. Three models for leading change are reviewed: the first-the eight stages of change-which was not designed for health care; the second called "switch"; and the third called Amicus, which was uniquely designed for health care. The models share many common features, with the explicit reminder in the third model that physicians should be involved in the change effort early. Although sparse, the evidence does suggest the applicability of these models to health care. Beyond having a roadmap for leading change, it is helpful to assess the worthiness of undertaking a change effort and of predicting the phasic response to change efforts, given that humans are often change-averse. In this regard, both the "payoff matrix" and the change curve, derived from the work of Kübler-Ross on grieving, are offered as tools. Finally, physicians' avidity for change is framed by two opposing vectors. On the one hand, physicians share in the general human aversion to change. On the other hand, physicians are data-reverent and also wish to do their best for patients, which encourages their embrace of ever-increasing evidence and change. [ABSTRACT FROM AUTHOR]

Objectives: Academic emergency physicians must find ways to teach residents, medical students, and advanced practice providers amidst the myriad demands on their time during clinical shifts. In this study, we sought to characterize in detail what types of teaching occurred, how often they occurred, and how attending teaching styles differed at one academic emergency department (ED). Methods: We conducted this observational study in a large, urban, quaternary care, academic Level I trauma center with an emergency medicine (EM) residency. The on-shift activities of EM attending physicians (attendings) were observed and recorded over 42 hours by a fourth-year EM resident with co-observations by an EM education fellow. Teaching categories were identified, developed iteratively, and validated by the study team. We then characterized the distribution of teaching activities during shifts through the coding of attending activities every 30 seconds during observations. Teaching archetypes were then developed through the synthesis of notes taken during observations. Results: Attendings spent a mean of 25% (standard deviation 7%) of their time engaging in teaching activities during shifts. Of this teaching time 36% consisted of explicit instruction, while the remaining 64% of teaching occurred implicitly through the discussion of cases with learners. The time distribution of on-shift activities varied greatly between attendings, but three archetypes emerged for how attendings coupled patient care and teaching: "in-series"; "in-parallel modeling"; and "in-parallel supervision." Conclusions: Teaching in this academic ED took many forms, most of which arose organically from patient care. The majority of on-shift teaching occurred through implicit means, rather than explicit instruction. Attendings also spent their time in markedly different ways and embodied distinct teaching archetypes. The impact of this variability on both educational and patient care outcomes warrants further study. [ABSTRACT FROM AUTHOR]

India has an unenviable reputation as one of the world's most gender disparate countries. Previous studies of sex bias in childhood have shown large differences between Indian boys and girls in immunization and curative healthcare, but little difference in health status as indicated by anaemia and stunting. India has changed rapidly in past decades, hence we reappraise the situation with the National Family Health Survey-4 (2015–16). We found no evidence of sex differentials in immunization coverage but a small degree of discrimination in favour of boys in medical treatment for common symptoms of infection. This discrimination was no greater in the North and Central regions of India, where severe excess mortality among female children persists. Sex differences in anaemia and stunting were small, with no regional pattern. We found no evidence that healthcare or health status of girls was influenced by the presence of other daughters in the family. [ABSTRACT FROM AUTHOR]

Introduction: Adverse effects of administrative burden on emergency physicians have been described previously, but the impact of electronic health record documentation by academic emergency attendings on resident education is not known. In this observational study of a quaternary care, academic emergency department, we sought to assess whether the amount of time attending physicians spent on documentation affected the amount of time they spent teaching. Methods: A fourth-year emergency medicine (EM) resident observed 10 attending physicians over 42 hours during 11 shifts, recording their activities every 30 seconds. Activity categories were developed iteratively by the study team and validated through co-observation by an EM education fellow with a kappa of 0.89. We used regression analysis to assess the relationship between time spent documenting and time spent teaching, as well as the relationship between these two activities and all other attending activity categories. Results: Results demonstrate that time spent documenting was significantly and specifically associated with less time spent teaching, controlling for patient arrivals per hour; every minute spent on documentation was associated with 0.48 fewer minutes spent teaching (p<0.05). Further, documentation time was not strongly associated with time spent on any other activity including patient care, nor did any other activity significantly predict teaching time. Conclusion: Findings suggest that academic attendings may face a trade-off between their documentation and teaching duties. Further study is needed to explore how administrative expectations placed on academic emergency physicians might interfere with trainee education. [ABSTRACT FROM AUTHOR]

Care providers within human services organizations have many job responsibilities and performance expectations. In the present study, we conducted social validity assessment with 78 care providers concerning their attitudes and opinions about behavior data recording with adults who had intellectual disability and lived in community group homes. Specifically, the care providers responded to a written questionnaire that inquired about the practicality, training/supervision, and value of behavior data recording in the context of service delivery. Results indicated generally high approval of behavior data recording practices, purposes, and approaches to training. We discuss implications of these findings for implementing data recording by care providers and the contribution of social validity assessment to training and performance management within human services organizations. [ABSTRACT FROM AUTHOR]

This article comments on the article "Entrepreneurship: A Weak Link in the Welfare State?" by Magnus Henrekson. The author agrees with Henrekson's finding of a strong welfare state and a weak entrepreneurial culture in Sweden and his assumption that a different organizational mode could have provided a basis for the emergence of new high-growth industries in the health sector in that country. The author goes on to say that the main differences between public and private providers of health care services lie in wage and labor standards and maybe the use of immigrants but not in technology.

Background: Attention to research and planning are increasingly being devoted to newcomer health, but the needs of newcomers with disabilities remain largely unknown. This information is difficult to determine since population-level data are rarely available on newcomers or on people with intellectual and developmental disabilities (IDD), although in Ontario, Canada these databases are accessible. This study compared the prevalence of IDD among first generation adult newcomers to adult non-newcomers in Ontario, and assessed how having IDD affected the health profile and health service use of newcomers. Methods: This population-based retrospective cohort study of adults aged 19–65 in 2010 used linked health and social services administrative data. Prevalence of IDD among newcomers (n = 1,649,633) and non-newcomers (n = 6,880,196) was compared. Among newcomers, those with IDD (n = 2,830) and without IDD (n = 1,646,803) were compared in terms of health conditions, and community and hospital service use. Results: Prevalence of IDD was lower in newcomers than non-newcomers (171.6 versus 898.3 per 100,000 adults, p<0.0001). Among newcomers, those with IDD were more likely than those without IDD to have comorbid physical health disorders, non-psychotic, psychotic and substance use disorders. Newcomers with IDD were also more likely to have psychiatry visits, and frequent emergency department visits and hospitalizations. Conclusion: First generation adult newcomers have lower rates of IDD than non-newcomers. How much of this difference is attributable to admission policies that exclude people expected to be high health service users versus how much is attributable to our methodological approach is unknown. Finding more medical and psychiatric comorbidity, and more health service use among newcomers with IDD compared to newcomers without IDD is consistent with patterns observed in adults with IDD more generally. To inform polices that support newcomers with IDD future research should investigate reasons for the prevalence finding, barriers and facilitators to timely health care access, and pathways to care. [ABSTRACT FROM AUTHOR]

Background: Marketing arguably is the most critical administrative responsibility associated with the pursuit and realization of growth and prosperity, making prowess in the discipline essential for any healthcare institution, especially given the competitive intensity that characterizes the industry. But in order to truly gain an advantage, healthcare establishments must tap into innovative pathways that their competitors have yet to discover. Here, thinking like an outsider can pay tremendous dividends, as health and medical organizations tend to focus inwardly, limiting their exposure to externally-derived innovations and advancements which often can supply differentiation opportunities.Discussion: Some years ago, during a formative period in preparation for expanding its footprint, Willis-Knighton Health System opted to think like an outsider, peering beyond the walls of healthcare institutions in search of tools and techniques that would allow its growth ambitions to be realized. Associated pursuits and subsequent successes created a culture of challenging status quo perspectives, affording innovations and resulting competitive advantages. Marketing advancements, in particular, have been fueled by this outsider mentality, benefiting the institution and its patient populations. This article profiles several of these advancements, discusses the dangers of insular mindsets, and suggests avenues for encouraging broad perspectives.Conclusions: Due to extreme competitive intensity and ever-increasing patient needs, health and medical establishments must perform at optimal levels, with marketing efforts playing a critical role in the achievement of such. By shedding status quo perspectives and peering beyond the walls of healthcare institutions, health and medical providers have opportunities to discover new and different marketing approaches for potential use in their own organizations, affording mutual benefits, including all-important competitive advantages. [ABSTRACT FROM AUTHOR]

Background: Healthcare establishments serve as key community resources, bringing into locales a wealth of resources aimed at enhancing and improving health and wellness. Without effective communications, current and prospective patients will remain unaware of available offerings, foiling opportunities for mutually beneficial exchange. Today, healthcare organizations engage audiences by selecting from among the components of the marketing communications mix, but this wasn't always the case. There was a time not long ago when communications options were limited due to industry traditions, creating associated challenges.Discussion: Willis-Knighton Health System faced a communications dilemma in the 1970s when, as a small healthcare provider desirous of growth, it could not achieve a satisfactory media presence via the usual and customary route of the day: submitting press releases to news media organizations, requesting conveyance of associated stories to their audiences. This forced the institution to explore other possibilities, ultimately leading it to experiment with and embrace advertising at a time period when its use was generally shunned in the industry. Willis-Knighton Health System's pioneering deployment of advertising helped the institution achieve its intended promotions goals, supplying mutual benefits and affording insights which influence its communications approach to this day.Conclusions: Deploying advertising years in advance of its widespread acceptance and use in the healthcare industry, Willis-Knighton Health System forged new pathways and acquired experience which fostered provider-patient engagement initiatives, affording an enduring marketing communications approach. Challenging situations are quite common in the healthcare industry and the one faced by Willis-Knighton Health System was no exception, but it supplied an immense opportunity to innovate, leading to communications prowess, resulting growth, informed audiences, and lasting mutual benefits. [ABSTRACT FROM AUTHOR]

Background: Branding-the assignment of names, logos, slogans, and related elements of identity to institutions and their product offerings for the purpose of conveying desired images to target audiences-is of paramount importance in the health services industry. Associated initiatives traditionally have centered on developing verbal and visual brand expressions, but opportunities abound to drive brand equity by supplementing traditional pursuits with new, different, and unexpected expressions that afford highly memorable experiences.Discussion: Willis-Knighton Health System has possessed an expanded view of branding for decades. While the system has directed thorough attention toward traditional brand expressions, additional identity opportunities outside the bounds of traditional branding thought have been pursued vigorously. There perhaps is no better illustration of Willis-Knighton Health System's expanded approach to branding than that of Willis the Bear, the institution's iconic teddy bear mascot developed to promote labor and delivery services. This article presents the origins and development of this brand expression, particularly emphasizing the need to address nontraditional elements of identity for purposes of driving brand equity.Conclusions: Given the importance of brand management and extraction of associated value, health services organizations must diligently direct attention toward branding initiatives. Traditional approaches, when executed well, deliver excellent results, but enhanced value can be derived by addressing nontraditional brand elements which afford unique opportunities to differentiate given establishments from their competitors, facilitating institutional viability and vitality. [ABSTRACT FROM AUTHOR]

Background: Target marketing, a practice used to more effectively address the wants and needs of customers, involves three interrelated activities: market segmentation, targeting, and product positioning. The practice follows a perfectly logical process. For a given offering, healthcare institutions select a desired group to pursue and arrange service characteristics and related attributes in a manner to entice that particular group to forward patronage and become customers. Pursuits often focus on heavily-traveled routes teeming with competitors, but occasionally an off the beaten path can be identified to amplify target marketing efforts.Discussion: In an earlier chapter of its history, Willis-Knighton Health System identified and pursued an off the beaten path in its bid to capture market share in pediatric healthcare services. The direct route-targeting current and prospective parents-was heavily pursued by competitors, prompting the institution to seek a unique approach; a road less traveled which would reach the same audiences but do so via a different route. Children, as direct care recipients, supplied one such route, and while their ability to influence associated parental decisions was unclear, the institution viewed developing a bond with them to have great potential. Painstaking efforts yielded Willis-Knighton Health System's Pediatric Orientation Program, fostering an affinity between the institution and children, which in turn influenced parents, affording opportunities for enhanced patronage in pediatric medicine and beyond.Conclusions: Willis-Knighton Health System's decision to look off the beaten path for an avenue capable of amplifying its target marketing initiatives resulted in a novel pursuit which distinguished the institution from its competitors and set the stage for achieving its goal of providing healthcare services for a greater percentage of children in the marketplace. Additional spillover effects bolstering share in other areas also were afforded. This unique initiative addressed desires to pursue an increasingly important road less traveled to reach prime audiences. When roads less traveled can be identified, opportunities abound for better connecting with customer groups, warranting investigation and pursuit. [ABSTRACT FROM AUTHOR]

Background: Modern marketing thought heavily emphasizes the need for healthcare providers to possess a customer orientation, placing patients at the focal point of attention within health and medical establishments. This has motivated significant investments in tools and techniques that foster outstanding service, attention, and support. Such investments in isolation, however, offer no guarantees that a true customer orientation will emerge. Proper implementation also is required-and that falls on the shoulders of health and medical personnel.Discussion: The most innovative and expensive of customer-oriented tools and techniques mean very little unless they are placed in the hands of capable individuals possessing the ability and desire to serve patients well. But the rigors of industry life complicate matters, resulting occasionally in lost focus, compromising the patient experience. One of the simplest and most effective methods for encouraging patient attentiveness rests with a reflective exercise that encourages staff members to see themselves and their actions from the perspective of patients. Asking the operative question, "Am I seeing things through the eyes of patients?" serves as an effective reminder of priorities, building empathy and motivating personnel to continually deliver their very best.Conclusions: Viewing one's actions from the perspective of patients can be very revealing, opening eyes wide and permitting opportunities for any necessary improvements, making for a simple but powerful learning experience. The "Am I seeing things through the eyes of patients?" reflective exercise helps well-intentioned staff members avoid tendencies which can lull them into states of complacency, ensuring that they remain focused on those in their care. [ABSTRACT FROM AUTHOR]

Background: Given the importance of communicating effectively with current and prospective patients, healthcare institutions must direct considerable energies toward achieving associated excellence. Pursuits usually center on addressing the marketing communications mix properly, but in order to maximize communications prowess, attention also should be directed toward incorporating emerging communications innovations, when and where possible, to bolster opportunities to connect with patients.Discussion: In pursuit of communications excellence, Willis-Knighton Health System's executives reflected on campus dynamics in the context of modern outdoor advertising technologies, namely, digital billboards, which present electronic advertisements on-demand, around-the-clock. They surmised that, with Willis-Knighton Health System's campuses being positioned in highly-visible fashion along highly-transited roadways, the institution could deploy this relatively new roadside advertising innovation to better engage audiences. This particular train of thought ultimately led to the installation of digital billboards at several of its locations. This article profiles the development of Willis-Knighton Health System's new marketing communications asset and offers advice for healthcare establishments desirous of placing digital billboards onsite to better connect with patients.Conclusions: Opportunities affording enriched communications with patients should continually be sought by health and medical entities. Digital billboards, institutionally-owned and operated, supply one such opportunity, pairing a state-of-the-art, uniquely-capable advertising medium with the excellent locational characteristics possessed by many healthcare establishments. As Willis-Knighton Health System has observed, digital billboards offer an exceptional mechanism for engaging audiences, affording mutual benefits which ultimately foster patronage and prosperity. [ABSTRACT FROM AUTHOR]

Summary: Background: Irritable bowel syndrome (IBS) is common and is characterised by recurrent abdominal pain, which is a major contributor to healthcare seeking. The neurobiological basis of this pain is incompletely understood. Conditioned pain modulation is a neuromodulatory mechanism through which the brain inhibits the nociceptive afferent barrage through the descending pathways. Reduced conditioned pain modulation has been implicated in the pathophysiology of IBS, although to date only in studies with relatively small sample sizes. Aim: To clarify the relationship between conditioned pain modulation and IBS by undertaking a systemic review and meta‐analysis Methods: A systematic review of MEDLINE and Web of Science databases was searched (up to 10 May 2018). We included studies examining conditioned pain modulation in adults with IBS and healthy subjects. Data were pooled for meta‐analysis to calculate the odds ratio and effect size of abnormal conditioned pain modulation in IBS, with 95% confidence intervals (CI). Results: The search strategy identified 645 studies, of which 13 were relevant and 12 met the inclusion criteria. Conditioned pain modulation in IBS patients vs healthy subjects was significantly reduced, odds ratio 4.84 (95% CI: 2.19‐10.71, P < 0.0001), Hedges’ g effect size of 0.85 (95% CI: 0.42‐1.28, P < 0.001). There was significant heterogeneity in effect sizes (Q‐test χ2 = 52, P < 0.001, I2 = 78.8%) in the absence of publication bias. Conclusion: Conditioned pain modulation is significantly diminished in patients with IBS vs healthy controls. These data suggest that abnormal descending pathways may play an important pathophysiological role in IBS, which could represent an investigation and a therapeutic target in IBS. [ABSTRACT FROM AUTHOR]

Purpose Since 1990, the Cleveland Clinic has trained physicians in team skills through various iterations of a program called Leading in Healthcare (LHC). In the present study, the authors utilize a case study approach to gain insight into the LHC curriculum, and more specifically, the team project. The purpose of this paper is to better understand the Cleveland Clinic’s position on the issue and its approach to education – specifically among physicians.Design/methodology/approach The authors utilized a case study approach with four key program architects.Findings The results of this exploratory research yielded three themes: There is a lack of formal physician education in teamwork, there is a growing trend of inter-disciplinary teams and the team project was an important component of teambuilding in LHC.Research limitations/implications A breakdown in team function adversely impacts patient care. While formal and informal participation in teams is imbedded in the role, physicians are rarely trained in leadership or teambuilding in their formal medical education – much of it is learned on the job in hidden curricula. In addition to the adverse effects of dysfunctional teams on patient care, the authors have explored another area that will be affected by a lack of education – the team experience at the administrative level. As more and more physicians take on leadership roles in healthcare, there is an additional need to build competencies around teams (e.g. team theory, cross-functional team participation and leading teams) from an administrative perspective.Originality/value This is one of only a few studies which have specifically examined the impact of a teamwork education for physicians. [ABSTRACT FROM AUTHOR]

Background: While quick and easy access to healthcare services is a reality for some, others experience significant hardships, even for receipt of the most basic health and medical care and attention. To those who effectively have been shut out of the healthcare marketplace due largely to economic deficiencies, healthcare providers engaged in the delivery of charitable services are a critical lifeline. Myriad attempts by governmental entities to remedy disparate access and shore up the delivery of healthcare services directed toward the disadvantaged have failed to close gaps, warranting pursuit of novel methods that offer potential and the hope that sufficient access might one day become a reality.Discussion: One innovative approach for enhancing and improving charitable healthcare endeavors in communities was developed by Willis-Knighton Health System. The initiative, known as the Tithing the Bottom Line program, essentially takes a portion of the health system's earnings and directs these resources to fund pursuits that improve quality of life in the community, with the enhancement of health and wellness services for the underprivileged being a top priority. These resources magnify the efforts of establishments already endeavoring to serve those in need and create powerful synergies which positively impact the health status of disadvantaged populations. To shed light on Willis-Knighton Health System's unique charitable initiative, this article describes its tithing program in detail, supplying operational guidance that will permit healthcare institutions to establish like programs in their communities.Conclusions: With healthcare access gaps remaining pronounced despite numerous attempts by governmental entities to realize full access, grassroots efforts remain critical to bolster health and wellness broadly in communities. Deficiencies carry dramatic consequences for both the disadvantaged and the greater communities in which they reside. The synergistic, cooperative effort realized by Willis-Knighton Health System's tithing program offers great potential for reducing healthcare disparities, yielding healthier populations, enhanced opportunities, and better communities. [ABSTRACT FROM AUTHOR]

Background: The healthcare industry is characterized by intensive, never-ending change occurring on a multitude of fronts. Success in such tumultuous environments requires healthcare providers to be proficient in myriad areas, including the manner in which they organize and deliver services. Less efficient designs drain precious resources and hamper efforts to deliver the best care possible to patients, making it imperative that optimal pathways are identified and pursued. One particular avenue that offers great potential for serving patients efficiently and effectively is known as the hub-and-spoke organization design.Discussion: The hub-and-spoke organization design is a model which arranges service delivery assets into a network consisting of an anchor establishment (hub) which offers a full array of services, complemented by secondary establishments (spokes) which offer more limited service arrays, routing patients needing more intensive services to the hub for treatment. Hub-and-spoke networks afford many benefits for healthcare providers, but in order to capitalize fully, proper assembly is required. To advance awareness, knowledge, and use of the hub-and-spoke organization design, this article profiles Willis-Knighton Health System's service delivery network which has utilized the model for over three decades. Among other things, the hub-and-spoke organization design is defined, benefits are stipulated, and applications are discussed, permitting healthcare providers essential insights for the establishment and operation of these networks.Conclusions: The change-rich nature of the healthcare industry places a premium on incorporating advancements that permit health and medical providers to operate as optimally as possible. The hub-and-spoke organization design represents an option that, when deployed correctly, can greatly assist healthcare establishments in their quests to serve patients well. [ABSTRACT FROM AUTHOR]

Background: Healthcare providers operate in a unique industry characterized by pursuit of perhaps the most noble of missions: the delivery of vital health and medical services to those in need. Distinguishing features abound, differentiating the healthcare industry from others, with such facets having the potential to compel those serving in health and medical establishments to focus exclusively on their selected industry. But directing attention solely within can result in missed opportunities, especially regarding innovation. Many innovations which are well suited for healthcare establishments emerge externally, making at least some exposure beyond the healthcare industry essential for institutions desirous of operating on the innovation frontier.Discussion: True innovation emerges from broad worldviews, allowing healthcare providers to comprehensively understand the current state of the art. With such an understanding, novel tools, techniques, and approaches, regardless of industry of origin, can be examined for their potential to elevate the status and stature of efforts within health and medical establishments. It is this very open, inquisitive mindset that permitted Willis-Knighton Health System to identify and incorporate a range of innovations which originated outside of the healthcare industry. Its embracement of and associated successes with the repurposing approach known as adaptive reuse, the delivery of complex medical services via centers of excellence, and the structuring of operations using the hub-and-spoke organization design, for example, would never have occurred had executives not directed attention externally in search of innovations that could be used within.Conclusions: Innovations offer key pathways for healthcare providers to enhance the depth and breadth of health and medical services offered in their establishments and communities. By peering beyond the walls of healthcare institutions, providers amplify opportunities to discover novel methods and approaches that potentially can be transferred into their own organizations, benefiting themselves and their patient populations. [ABSTRACT FROM AUTHOR]

Background: Centers of excellence-specialized programs within healthcare institutions which supply exceptionally high concentrations of expertise and related resources centered on particular medical areas and delivered in a comprehensive, interdisciplinary fashion-afford many advantages for healthcare providers and the populations they serve. To achieve full value from centers of excellence, proper assembly is an absolute necessity, but guidance is somewhat limited. This effectively forces healthcare providers to pursue establishment largely via trial-and-error, diminishing opportunities for success.Discussion: Successful development of a center of excellence first requires the acquisition of a detailed understanding of the delivery model and its benefits. Then, concerted actions must be taken on a particular series of administrative and clinical fronts, treating them in prescribed manners to afford synergies which yield an exceptionally high level of care. To reduce hardships associated with acquiring this rather elusive knowledge, remedy shortcomings in the literature, and potentially bolster community health broadly, this article presents information and insights gleaned from Willis-Knighton Health System's extensive experience assembling and operating centers of excellence. This work is intended to educate and enlighten, but most importantly, supply guidance which will permit healthcare establishments to replicate noted processes to realize their own centers of excellence.Conclusions: Centers of excellence have the ability to dramatically enhance the depth and breadth of healthcare services available in communities. Given the numerous mutual benefits afforded by this delivery model, it is hoped that the light shed by this article will help healthcare providers better understand centers of excellence and be more capable and confident in associated development initiatives, affording greater opportunities for themselves and their patient populations. [ABSTRACT FROM AUTHOR]

Background: Adaptive reuse-the practice of identifying, acquiring, renovating, and placing back into service a building or similar structure for a purpose different than that for which it was originally designed-offers great potential for addressing the spatial expansion needs of healthcare establishments in a unique and mutually beneficial manner. This repurposing approach, however, has received very little attention in the health sciences literature, diminishing the opportunities of those serving in hospitals, medical clinics, and related care providing institutions to acquire an understanding of the practice.Discussion: The delivery of healthcare services primarily is site based, requiring physical space for physicians, nurses, administrators, and others to carry out the many duties associated with the provision of medical care and attention. But this space often represents a significant expenditure, consuming financial resources which otherwise could be directed toward patient care. Economies on this front are possible through adaptive reuse, permitting more resources to be directed toward mission fulfillment activities. This article directs attention toward adaptive reuse by profiling Willis-Knighton Health System's associated experiences and implementation strategies. Among other things, opportunities and obstacles are discussed, detailed cases are presented, and an operational framework is provided, permitting healthcare providers to understand and make use of this novel practice for addressing spatial expansion needs more affordably.Conclusions: Since space considerations exist throughout the lives of healthcare establishments, providers must ensure an awareness of methods for productively attending to these requirements. Evidenced by Willis-Knighton Health System's associated experiences and outcomes, adaptive reuse presents an option for more economically addressing spatial requirements, fostering opportunities to expand the delivery of health and medical services. [ABSTRACT FROM AUTHOR]

Objectives: Challenges in healthcare demand great leadership. In response, leadership training programs have been developed within academic medical centers, business schools, and healthcare organizations; however, we are unaware of any well-developed programs for physicians-in-training.Methods: To address this gap, we developed a two-day leadership development course for chief residents (CRs) at the Cleveland Clinic, framed around the concept of emotional intelligence. This paper describes our five-year experience with the CRs leadership program.Results: Since inception, 105 CRs took the course; 81 (77%) completed before-and-after evaluations. Participants indicated that they had relatively little prior knowledge of the concepts that were presented and that the workshop greatly enhanced their familiarity with leadership competencies. Qualitative analysis of open-ended responses indicated that attendees valued the training, especially in conflict resolution and teamwork, and indicated specific action plans for applying these skills. Furthermore, the workshop spurred some participants to express plans to learn more about leadership competencies.Conclusions: This study extends prior experience in offering an emotional intelligence-based leadership workshop for CRs. Though the program is novel, further research is needed to more fully understand the impact of leadership training for CRs and for the institutions and patients they serve. [ABSTRACT FROM AUTHOR]

Background: Stroke is a major complication of sickle cell anaemia (SCA). It occurs commonly in childhood with about 10 % of children with sickle cell anaemia getting affected by this complication. In Uganda, there is paucity of data on the prevalence of stroke in children admitted in a tertiary institution. We determined the prevalence of stroke amongst children with SCA admitted to Mulago National Referral Hospital in Uganda and described the ir co-morbidities.Methods: We conducted a retrospective record review of children with SCA admitted from August 2012 to August 2014 to the Paediatric Haematology Ward of Mulago Hospital in Kampala, Uganda. The target population was SCA children age 6 months-17 years of age. A descriptive analysis was used to summarize the demographic characteristics and clinical diagnosis.Results: There were 2,176 children with SCA admitted who were included in this study. There were 147 children with stroke. Their mean age 6.1, (SD 3), with a male to female ratio was 1:1 (71 males and 76 females). The M: F ratio of non-stroke children was 1.1:1 (1084 males and 945 females) with a mean age of 5.2, (SD 3). The prevalence of stroke was 6.8 % (147 of 2176). Amongst the children with stroke, 72.1 % (106 of 147) had co-morbidities which included severe anaemia 21.7 % (23 of 106), bacteraemia and vaso-occlusive crisis 17 % (18 of 106), pneumonia 8.4 % (9 of 106) and malaria 6.6 % (7 of 106).Conclusion: The prevalence of stroke in hospitalized Ugandan children with SCA was 6.8 %. Children with stroke were often admitted with other medical conditions such as severe anaemia, bacteraemia and vaso-occlusion. [ABSTRACT FROM AUTHOR]

Objective: We aim to describe the rationale for and spectrum of leadership development programs, highlighting experience at a large healthcare institution (Cleveland Clinic, Cleveland, Ohio, USA).Conclusions: Developing leaders is a universal priority to sustain organizational success. In health care, significant challenges of ensuring quality and access and making care affordable are widely shared internationally and demand effective physician leadership. Yet, leadership competencies differ from clinical and scientific competencies and features of selecting and training physicians-who have been called "heroic lone healers" -often conspire against physicians being effective leaders or followers. Thus, developing leadership competencies in physicians is critical.Leadership development programs have been signature features of successful organizations and various Australian organizations offer such training (e.g. The Australian Leadership Foundation and the University of South Australia), but relatively few health care organizations have adopted the practice of offering such training, both in Australia and elsewhere. As a United States example of one such integrated program, the Cleveland Clinic, a large, closed-staff physician-led group practice in Cleveland, Ohio has offered physician leadership training for over 15 years. This paper describes the rationale, structure, and some of the observed impacts associated with this program. [ABSTRACT FROM AUTHOR]

In a Perspective, James Boyce and Michael Ash discuss Lara Cushing and colleagues' research study on the implications of California's policy on carbon trading. [ABSTRACT FROM AUTHOR]

The article describes the partnership between Karolinska Institute in Sweden and Makerere University in Uganda and the benefits of partnerships between universities in developing national health research capacity in low-and middle-income countries. It discusses the history of the research collaboration between the two institutions, which includes a joint doctor of philosophy degree program. It also describes the benefits of the collaborative research environment for the Ugandan health system.

Community Home-Based Care (CHBC) has evolved in resource-limited settings to fill the unmet needs of people living with HIV/AIDS (PLHA). We compare HIV and tuberculosis (TB) outcomes from the Nsambya CHBC with national averages in Kampala, Uganda. This retrospective observational study compared HIV and TB outcomes from adults and children in the Nsambya CHBC to national averages from 2007 to 2011. Outcomes included numbers of HIV and TB patients enrolled into care, retention, loss to follow-up (LTFU), and mortality among patients on antiretroviral therapy (ART) at 12 months from initiation; new smear-positive TB cure and defaulter rates; and proportion of TB patients tested for HIV. Chi-square test and trends analyses were used to compare outcomes from Nsambya CHBC with national averages. By 2011, approximately 14,000 PLHA had been enrolled in the Nsambya CHBC, and about 4,000 new cases of TB were detected and managed over the study period. Overall, retention and LTFU of ART patients 12 months after initiation, proportion of TB patients tested for HIV, and cure rates for new smear-positive TB scored higher in the Nsambya CHBC compared to national averages. The findings show that Nsambya CHBC complements national HIV and TB management and results in more positive outcomes. [ABSTRACT FROM AUTHOR]

To ensure that psychological issues are on policymakers' agenda, psychologists often focus professional advocacy efforts in the political and social realm. Psychologists working in organizations, however, also have a role in ensuring that professional issues rise into the consciousness of organizational decision makers. In an era of health care reform, the advent of program-based management, limited resources, and managed care, psychologists are under increasing pressure to show their worth inside organizations and often have limited ability to communicate with organizational leaders. Psychologists typically report to nonpsychologists who may have only a general understanding of what psychology offers and can often misunderstand requests from psychologists about patient care alternatives, time for research, ability to present at conferences, and so forth. Advocacy is one avenue for increasing effective communication of psychologists' perspectives and interests that can serve to educate leaders about the value of psychology and how to best use psychological expertise. A major benefit of organizational advocacy is learning advocacy skills in a known environment, which can then be transferred to broader social advocacy. The article discusses the development of advocacy skills in organizations and suggests possible advocacy activities that are consistent with the professional role. It is argued that clarity of the message and partnering with decision makers are important as psychologists advocate for the role of psychology in service delivery. [ABSTRACT FROM AUTHOR]

Alpha-1 antitrypsin deficiency (AATD) is relatively common but under-recognized. Indeed, fewer than 10% of the estimated 100,000 Americans with AATD have been diagnosed currently, with common reports of long delays between initial symptoms and first detection and the need to see multiple physicians before diagnosis. Because detection can confer benefits (e.g., identification of at-risk family members, lower smoking likelihood, consideration of augmentation therapy), targeted detection of AATD in at-risk groups such as all symptomatic adults with COPD has been endorsed. Two general approaches to detection have been studied: population-based screening (in which testing is performed in a group for whom no increased risk of having AATD exists) and targeted detection or case-finding (in which testing is confined to those with an attributable condition such as COPD or chronic liver disease). Studies to date have suggested that population-based screening is not cost-effective, whereas targeted detection of AATD has been advocated by official society guidelines. Efforts to enhance detection of AATD individuals have included various approaches, including educational campaigns, provision of free test kits, issuance of reminders with medical reports or within an electronic medical record, and empowering respiratory therapists to conduct testing for AATD in pulmonary function laboratories. Such programs have identified individuals with severe deficiency of alpha-1 antitrypsin in up to 12% of subjects, with considerable variation across series by testing criteria. Overall, the persistence of under-recognition of AATD underscores the need for continued efforts to optimize detection of this potentially debilitating genetic disease. [ABSTRACT FROM AUTHOR]

The article evaluated a clinical test of recognition reaction time (RT) in healthy adults. It states that although the RT has the potential as an evaluative tool, it is not commonly used by most clinicians because its measurement usually requires a computer and a dedicated software. It found that the test for evaluating recognition RT is feasible in a healthy population across a broad adult age range.

Abstract: Background: Wait times and patient satisfaction are important administrative metrics in emergency departments (EDs), as they are critical to return patronage, liability, and remuneration. Although several factors have been shown to impact patient satisfaction, little attention has been paid to understanding the psychology of waiting and patient satisfaction. Objective: We utilize concepts that have been applied in other service industries to conceptualize factors that impact patient satisfaction. We focus on wait times, a key factor in patient satisfaction, and describe how these concepts can be applied in research and daily practice. Discussion: Patient satisfaction can be conceptualized as the difference between a patient’s perceptions and their expectations. Perception is the psychological process by which an individual understands and interprets sensory information. Changes in the wait experience can decrease the perceived wait times without a change in actual wait times. Other changes such as improved staff interpersonal and communication skills that provide patients with an increased sense of the staff’s dedication as well as a greater understanding of their care, can also affect patient perceptions of their care quality. These changes in patient perception can synergize with more expensive investments such as state-of-the-art facilities and increased ED beds to magnify their impact on patient satisfaction. Expectation is the level of service a patient believes they will receive during their ED visit. Patients arrive with expectations around the component of their care such as wait times, needed diagnostic tests, and overall time in the ED. These expectations are affected by individual-specific, pre-encounter, and intra-encounter factors. When these factors are identified and understood, they can be managed during the care process to improve patient satisfaction. Conclusion: Interventions to decrease perception of wait times and increase the perception of service being provided, when combined with management of patient expectations, can improve patient satisfaction. [Copyright &y& Elsevier]

Objective: Major depression is the most common psychiatric disorder among breast cancer patients and is associated with substantial impairment. Although some research has explored the utility of psychotherapy with breast cancer patients, only 2 small trials have investigated the potential benefits of behavior therapy among patients with well-diagnosed depression. Method: In a primarily Caucasian, well-educated sample of women (age = 55.4 years, SD = 11.9) diagnosed with breast cancer and major depression (n = 80), this study was a randomized clinical trial testing the efficacy of 8 sessions of behavioral activation treatment for depression (BATD) compared to problem-solving therapy. Primary outcome measures assessed depression, environmental reward, anxiety, quality of life, social support, and medical outcomes. Results: Across both treatments, results revealed strong treatment integrity, excellent patient satisfaction with treatment protocols, and low patient attrition (19%). Intent-to-treat analyses suggested both treatments were efficacious, with both evidencing significant pre-post treatment gains across all outcome measures. Across both treatments, gains were associated with strong effect sizes, and based on response and remission criteria, a reliable change index, and numbers-needed-to-treat analyses, approximately ¾ of patients exhibited clinically significant improvement. No significant group differences were found at posttreatment. Treatment gains were maintained at 12-month follow-up, with some support for stronger maintenance of gains in the BATD group. Conclusions: BATD and problem-solving interventions represent practical interventions that may improve psychological outcomes and quality of life among depressed breast cancer patients. Study limitations and future research directions are discussed. [ABSTRACT FROM AUTHOR]

Summary: Diabetes is a highly prevalent, chronic disease that requires ongoing, multi-specialty medical care combined with patient self-management, family support, and education to prevent or delay end-organ morbidity and mortality. There is clearly an increased prevalence of major depressive disorder, a relatively common and costly central nervous system syndrome, in diabetic patients. During the past two decades, multiple studies reveal that not only are depressive symptoms a risk factor for the development of type 2 diabetes, but they have also been shown to contribute to hyperglycemia, diabetic complications, functional disability and all-cause mortality among diabetic patients. This article reviews studies examining the relationship between depression and diabetes, neurochemical underpinnings of the two disorders, and the diagnosis and treatment of depression associated with diabetes. We examine the validity of rating scales used to diagnose depression in diabetic patients and review the literature on psychotherapeutic and psychopharmacologic management for these patients. The challenges of optimal depression screening and treatment in primary care settings of diabetic patients are currently under close scrutiny, especially regarding their potential impact related to improvements in diabetes-related outcomes and decreased health care costs, be it “depression” or “diabetes” relevant. Much of the current literature regarding the intertwined nature of diabetes and depression is cross-sectional in nature. Future research should focus on longitudinal, prospective studies to determine causal factors. What is clear from the research reviewed in this article is that depression and diabetes should be treated together rather than as isolated diseases. The mind/body dualism is a false dichotomy and a truly team-based approach is necessary to address both issues of depression and diabetes. Collaborative care and the “patient-centered medical home” have emerged as potentially effective interventions to improve quality of care and patient outcomes in patients with depression and medical illnesses such as diabetes. [Copyright &y& Elsevier]

The third annual report of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) provides documentation of the current landscape of durable mechanical circulatory support in the United States. With nearly 3,000 patients entered into the database, the transition to continuous-flow pump technology is evident and dramatic. This report focuses on the rapidly expanding experience with mechanical circulatory support as destination therapy. The current 1-year survival of 75% with continuous-flow destination therapy provides a benchmark for the evolving application of this therapy. [ABSTRACT FROM AUTHOR]

Abstracted from: Reichle, J., Johnson, L., Monn, E., & Harris, M. (2010). Task engagement and escape maintained challenging behavior: Differential effects of general and explicit cues when implementing a signaled delay in the delivery of reinforcement. Journal of Autism and Developmental Disorders, 40, 709–720. Source of funding and disclosure of interest: No source of funding reported, and the original authors of this research report no conflicts of interest and alone are responsible for the content and writing of the paper. [ABSTRACT FROM AUTHOR]

The article discusses different models for implementing change in respiratory care. An 8-stage model of change is based on the observation that people and organizations generally resist change. Another model, known as the Amicus model, is based on leadership, shared vision, and culture, and addresses resistance and builds consistency among physicians. The Respiratory Therapy Consult Service (RTCS), which was implemented at the Cleveland Clinic, is also discussed in detail.

The healthcare industry is increasingly turning to billboard advertising to promote various medical services, yet little attention has been directed toward understanding the performance and policy implications of billboard advertising from the perspective of the patients targeted. To shed light on this, we initiated a field experiment investigating the impact of an urgent care center's billboard advertising campaign, collecting primary data over a 32-day period at the center's two clinics. Over the course of the billboard campaign, perspectives from 1,640 patients were collected via questionnaire. Institutionally supplied business metrics were also monitored. Our principal findings indicate that billboard advertisements are noticed by patients, favorably viewed by patients, and effective across the sequence of steps leading to patient patronage. Enhancement of awareness exerts the most powerful influence on patronage, but the capacity to inform consumers is also highly significant. These effects are not limited to new patients, as many returning clients were made more aware of the clinics and were influenced by the campaign. The study offers insights for creative billboard treatments and campaign planning. Although effects remained strong throughout the campaign, some degree of "wearout" was evident after three weeks, which suggests the need to rotate billboards frequently and to consider digital billboards. Corner tabs-small announcements sometimes placed in the corners of billboard advertisements-proved largely ineffective as a promotional device and may clutter the central messages. Given these findings, we believe healthcare institutions are justified in using billboards, as they perform effectively and appear relatively free of controversy. Careful planning of creative billboard treatments and appropriate scheduling patterns are essential to maximize their communications potential. [ABSTRACT FROM AUTHOR]

Cardiovascular (CV) imaging plays a critical role in therapeutic decision making and is performed in more than 10 million patients each year; a large share of the nearly 40 million patients living with CV disease. CV imaging may serve as a valuable component of a patient''s evaluation, provided that its enhanced diagnostic findings invoke appropriate and targeted therapies that improve symptom burden and long-term outcomes and are not offset by the upfront procedural and induced costs of care. As well, the overall clinical benefit that imaging imparts to the patient must significantly outweigh any untoward risk, including radiation or procedural complications. Explosive growth in imaging has resulted in a rapid escalation of costs for testing encumbering an estimated $80 billion dollars annually and represents a sizeable portion of cardiologists'' income. Concern remains that continued expansion of CV imaging services may further add to the complexity of health care services and magnify the societal burden of health care. The field of CV imaging is beset by high procedural use, high growth rates, and often, a lack of demonstrable quality. The end result of our current health care system and reimbursement models is an over emphasis on volume and throughput, extensive efforts necessary for justification of procedural use, and a broad referral population exceeding guideline-accepted best practices. An inextricable link between imaging markers and outcomes forms a critical nexus that can be used to establish the value of a test, and is now the standard upon which technology will be evaluated by private payers and governmental agencies alike. This new benchmark necessitates high-quality research to compare the effectiveness of CV imaging modalities to elicit improvements in health outcomes; representing a dramatic paradigm shift for the field of CV imaging research. In this review, we will discuss current health policy of CV imaging as well as the future of CV imaging-based comparative effectiveness research. [Copyright &y& Elsevier]