Survey Protocols, Response Rates, and Representation of Underserved Patients: A Randomized Clinical Trial.

Importance: Surveys often underrepresent certain patients, such as underserved patients. Methods that improve their response rates (RRs) would help patient surveys better represent their experiences and assess equity and equity-targeted quality improvement efforts. Objective: To estimate the effect of adding an initial web mode to existing Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey protocols and extending the fielding period on RR and representativeness of underserved patient groups. Design, Setting, and Participants: This randomized clinical trial included 36 001 patients discharged from 46 US hospitals from May through December 2021. Data analysis was performed from May 2022 to September 2023. Exposures: Patients were randomized to 1 of 6 survey protocols: 3 standard HCAHPS protocols (mail only, phone only, mail-phone) plus 3 web-enhanced protocols (web-mail, web-phone, web-mail-phone). Main Outcomes and Measures: RR and number of respondents per 100 survey attempts (yield) were calculated and compared for each of the 6 survey protocols, overall, and by patient age, service line, sex, and race and ethnicity. Results: A total of 34 335 patients (median age range, 55-59 years; 59.3% female individuals and 40.7% male individuals) were eligible and included in the study. Of the respondents, 6.9% were Asian American or Native Hawaiian or Other Pacific Islander, 0.7% were American Indian or Alaska Native, 11.5% were Black, 17.4% were Hispanic, 61.0% were White, and 2.6% were multiracial. Of the 6 protocols, RRs were highest in web-mail-phone (36.5%), intermediate for the 3 two-mode survey protocols (mail-phone, web-mail, web-phone, 30.3%-31.1%), and lowest for the 2 single-mode protocols (mail only, phone only, 22.1%-24.3%). Web-mail-phone resulted in the highest yield for 3 racial and ethnic groups (Black, Hispanic, and White patients) and second highest for another (multiracial patients). Otherwise, the highest or second highest yield was almost always a 2-mode protocol. Mail only was the lowest-yield protocol for Black, Hispanic, and multiracial patients and phone-only was the lowest-yield protocol for White patients; these 2 protocols tied for lowest-yield for Asian American or Native Hawaiian or Other Pacific Islander patients. Gains from multimode approaches were often 2 to 3 times as large for Asian American or Native Hawaiian or Other Pacific Islander, Black, Hispanic, and multiracial patients as for White patients. Web-mail-phone had the highest RR for 6 of 8 age groups and 4 of 5 combinations of service line and sex. Conclusions and Relevance: In this randomized clinical trial, web-first multimode survey protocols significantly improved the RR and representativeness of patient surveys. The best-performing protocol based on RR and representativeness was web-mail-phone. Web-phone performed well for young and diverse patient populations, and web-mail for older and less diverse patient populations. The US Centers for Medicare & Medicaid Services will allow hospitals to use the web-mail, web-phone, and web-mail-phone protocols for HCAHPS administration beginning in 2025.

Associations of Mail Survey Length and Layout With Response Rates.

We assess the association between survey layout and response rates (RRs) in the 2017 Medicare Advantage Consumer Assessment of Healthcare Providers and Systems mail survey. Among 438 Medicare Advantage plans surveyed by six vendors, there was latitude in survey layout, and plans could add up to 12 supplemental items. Regression models predicted survey response from survey characteristics (page count, number of supplemental items, and survey attractiveness), and beneficiary sociodemographics. Beneficiary-age-by-survey-characteristic interactions assessed whether survey characteristics were more strongly related to RRs among older beneficiaries. We found that surveys with more supplemental items and less attractive layouts had lower adjusted odds of response. RRs were more sensitive to format among older beneficiaries. The difference in adjusted RRs for the most favorable versus the least favorable survey design was 14.5%. For a 65-year-old, this difference was 13.6%; for an 80-year-old, it was 21.0%. These findings suggest that even within a relatively standardized survey, formatting can substantially influence RRs.

An Exploration of Virtual Reality Use and Application Among Older Adult Populations.

Despite increased research on virtual reality (VR) platforms in recent years, there are very few studies that specifically examine its application within a gerontological context. This study examines the usability, preferences, and application considerations of a mobile VR platform by individually interviewing community-dwelling older adults both before and after trying the Samsung Gear VR. Participants were asked to self-select and view short VR videos (30 s-3 min) that were filmed within the local community (e.g., walking path and art museum). Semi-structured interview questions explored participant perceptions of using the device and was followed with two focus group sessions. Thematic analysis was employed when reviewing observational notes and transcribed audio recordings. Ten adults (aged 63-89) participated and themes identified include (a) usability, (b) video subject matter preferences, and (c) application. These themes highlighted both the challenges and opportunities of VR use among a wide range of older populations and provided greater insight with its exploration and application in future studies. This included potential use among those older adults who have notable functional limitations, such as those who are immobile, or reside within a care facility.

Novel Delivery Systems for Checkpoint Inhibitors.

Checkpoint inhibition (CPI) therapies have been proven to be powerful clinical tools in treating cancers. FDA approvals and ongoing clinical development of checkpoint inhibitors for treatment of various cancers highlight the immense potential of checkpoint inhibitors as anti-cancer therapeutics. The occurrence of immune-related adverse events, however, is a major hindrance to the efficacy and use of checkpoint inhibitors as systemic therapies in a wide range of patients. Hence, methods of sustained and tumor-targeted delivery of checkpoint inhibitors are likely to improve efficacy while also decreasing toxic side effects. In this review, we summarize the findings of the studies that evaluated methods of tumor-targeted delivery of checkpoint inhibitors, review their strengths and weaknesses, and discuss the outlook for therapeutic use of these delivery methods.

The effects of survey version on patient experience scores and plan rankings.

OBJECTIVE: To assess the effect of changing survey questions on plan-level patient experience measures and ratings. DATA SOURCE: 2015 Medicare Advantage CAHPS Survey respondents. STUDY DESIGN: Ninety three randomly selected beneficiaries in each of 40 MA plans received a revised (5.0) CAHPS survey; 38 832 beneficiaries received version 4.0. Linear mixed-effect regression predicted CAHPS measures from fixed effects for survey version and beneficiary characteristics and random effects for plan and plan-by-version random slope. PRINCIPAL FINDINGS: Response rates were 42 percent for both versions. Removal of "try to" from screeners increased the percentage of respondents eligible for follow-up questions. Version 5.0 caused a small increase (1-3 points on a 0-100 scale, P < 0.05) in the mean of three altered measures and a moderate increase (>3 points) in one. There was a small statistically significant increase in two unaltered measures. These changes were uniform across plans, so there would be no expected change compared to results using the legacy survey in the score distributions other than uniform mean shifts, and no expected effect on summary measures. CONCLUSIONS: These analyses illustrate how to assess the impact of seemingly minor survey modifications for other national surveys considering changes and highlight the importance of screeners in instrument design.

Using predicted Spanish preference to target bilingual mailings in a mail survey with telephone follow-up.

OBJECTIVE: Spanish-preferring Medicare beneficiaries are underrepresented in national patient experience surveys. We test a method for improving their representation via higher response rates. DATA SOURCES/STUDY SETTING: 2009-2010 Medicare CAHPS surveys; Medicare population. STUDY DESIGN: We used surname and address to predict Spanish-language preference for a national sample of 177 139 beneficiaries. We randomized half of the 10 000 non-Puerto Rico beneficiaries with the highest predicted probabilities of Spanish preference (>10 percent) to bilingual mailings (intervention) and half to standard English-only mailings (control). DATA COLLECTION: Medicare CAHPS Survey data were collected through mail surveys with telephone follow-up of nonrespondents. PRINCIPAL FINDINGS: Mail response rate was higher for intervention (28.7 percent) than control (23.9 percent) (P < 0.0001); phone response rates among mail nonrespondents were similar in intervention and control arms (15.8 percent vs 15.7 percent, P = 0.90). Targeted bilingual mailings induced 6.5 percent of those who would not have responded to respond by mail and 54.0 percent of those who would have responded in English to respond in Spanish. Beneficiaries with greater Spanish probabilities showed greater increases in response rates, a higher proportion of responses in Spanish, and lower control response rates among. CONCLUSIONS: Targeted bilingual mailing of mixed-mode surveys using commonly available surname and address information can efficiently increase representation of this underrepresented group.

Investigating antenatal corticosteroid clinical guideline practice at an organisational level.

BACKGROUND: High-quality, evidence-based guidelines can improve the quality of health care and facilitate standardisation of practice within and across healthcare organisations. Limited information is known regarding existing antenatal corticosteroid (ACS) guideline practices within organisations across Australia and New Zealand. AIMS: To assess existing ACS clinical practice guidelines (CPG). To describe current organisational practice related to the production, implementation and renewal of CPG. DESIGN: A cross-sectional survey of hospital practice using an online questionnaire. METHODS: Clinical Managers at 27 secondary and 25 tertiary maternity hospitals, that contribute data to the Australia and New Zealand Neonatal Network, were approached from May to September 2015 and completed the questionnaire on behalf of their organisation. RESULTS: Of the hospitals surveyed, 93% reported having a CPG or protocol. Of these, 89% of CPG included recommendations on a single course of ACS, 37% on the use of repeat course/s and 41% on use prior to elective caesarean section at term. Variation in the recommendations provided existed between countries and depending on the level of neonatal care provided. A guideline development group existed in 85% of hospitals. The preferred tools to facilitate implementation of a CPG include: email with a link to the hospital intranet, education sessions and an opinion leader. Only 28% of respondents reported auditing the use of ACS administration. CONCLUSIONS: There is significant variation in the recommendations provided by current ACS CPGs. Utilisation of a single ACS CPG reflective of the current available evidence base may limit this variation.

Possibilities for Shortening the CAHPS Clinician and Group Survey.

BACKGROUND: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group adult survey (CG-CAHPS) includes 34 items used to monitor the quality of ambulatory care from the patient's perspective. CG-CAHPS includes items assessing access to care, provider communication, and courtesy and respect of office staff. Stakeholders have expressed concerns about the length of the CG-CAHPS survey. OBJECTIVES: This paper explores the impact on reliability and validity of the CAHPS domain scores of reducing the numbers of items used to assess the 3 core CG-CAHPS domains (Provider Communication, Access to Care, and Courteous and Helpful Office Staff). RESEARCH DESIGN: CG-CAHPS data reported here consist of 136,725 patients across 4 datasets including ambulatory clinics, patient-centered medical homes, and Accountable Care Organizations. Analyses are conducted in parallel across the 4 settings to allow evaluations across data source. ANALYSES: Multiple regression and ANOVA techniques were used to evaluate reliability for shorter sets of items. Site-level correlations with the overall rating of the provider were compared to evaluate the impact on validity. The change in practices' rank-ordering as a function of domain revision is also reported. RESULTS: Findings suggest that the Provider Communication (6 items) and Access (5 items) domains can be reduced to as few as 2 items each and Office Staff (2 items) can be reduced to a single item without a substantial loss in reliability or content. CONCLUSIONS: The performance of several of the reduced-length options for CG-CAHPS domains closely matches the full versions and may be useful in health care settings where the full-length survey is impractical due to time or cost constraints.

Evaluation of a Care Coordination Measure for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare survey.

There is widespread interest in assessing care coordination to improve overall care quality. We evaluated a five-item measure of care coordination included in the 2012 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare survey (n = 326,194 respondents, 46% response rate). This measure includes patient reports of whether their personal doctor discusses their medicines, has medical records and other relevant information, and is informed about care from specialists, and whether the patient gets help in managing care and timely follow-up on test results. A one-factor categorical confirmatory factor analytic model indicated that five items constituted a coherent scale. Estimated health-plan-level reliability was 0.70 at about 102 responses per plan. The composite had a strong unique association with the CAHPS global rating of health care, controlling for the CAHPS core composite scores. This measure can be used to evaluate relative plan performance and characteristics associated with better care coordination.

Evaluating the content of the communication items in the CAHPS(®) clinician and group survey and supplemental items with what high-performing physicians say they do.

BACKGROUND: A doctor's ability to communicate effectively is key to establishing and maintaining positive doctor-patient relationships. The Consumer Assessment of Healthcare Providers and System (CAHPS(®)) Clinician and Group Survey is the standard for collecting and reporting information about patients' experiences of care in the USA. OBJECTIVE: To evaluate how well CAHPS(®) Clinician and Group 2.0 core and supplemental survey items (CG-CAHPS) with a 12-month reference capture doctor-patient communication. DATA SOURCES/STUDY SETTING: Eleven of the 40 highest-rated physicians on the CG-CAHPS survey treating patients in a Midwest commercial health plan. STUDY DESIGN: Data were obtained via semi-structured interviews. Specific behaviors, practices, and opinions about doctor communication were coded and compared to the CG-CAHPS items. PRINCIPAL FINDINGS: CG-CAHPS fully captures six of the nine behaviors most commonly mentioned by high-performing physicians: employing office staff with good people skills; involving office staff in communication with patients; spending enough time with patients; listening carefully; providing clear, simple explanations; and devising an action plan with each patient. Three physician behaviors identified as key were not captured in CG-CAHPS items: use of nonverbal communication; greeting patients and introducing oneself; and tracking personal information about patients. CONCLUSIONS: CG-CAHPS survey items capture many of the most commonly mentioned doctor-patient communication behaviors and practices identified by high-performing physicians. Nonverbal communication, greeting patients, and tracking personal information about patients were identified as key aspects of doctor-patient communication, but are not captured by the current CG-CAHPS. We recommend further research to assess patients' perceptions of specific verbal and nonverbal behaviors (such as leaning forward in a chair, casually asking about other family members), followed by the development of new items (if needed) that aim to capture what these specific behaviors represent to patients (e.g., listens attentively, seems to care about me as a person, empathy). We also recommend including items about greeting and tracking personal information about patients in future CAHPS item sets addressing doctor-patient communication. Enriching the content of the CAHPS communication measure can help health-care organizations improve doctor-patient communication and interactions.

Preventive intervention in diabetes: a new model for continuing medical education.

Competence and skills in overcoming clinical inertia for diabetes treatment, and actually supporting and assisting the patient through adherence and compliance (as opposed to just reiterating what they "should" be doing and then assigning them the blame if they fail) is a key component to success in addressing diabetes, and to date it is a component that has received little formal attention. To improve and systematize diabetes care, it is critical to move beyond the "traditional" continuing medical education (CME) model of imparting knowledge as the entirety of the educational effort, and move toward a focus on Performance Improvement CME. This new approach does not just teach new information but also provides support for improvements where needed most within practice systems based on targeted data-based on self-assessments for the entire system of care. Joslin data conclude that this new approach will benefit support, clinical, and office teams as well as the specialist. In short, the Performance Improvement CME structure reflects the needed components of the successful practice today, particularly for chronic conditions such as diabetes, including the focus on interdisciplinary team care and on quality improvement, which is becoming more and more aligned with reimbursement schemes, public and private, in the U.S.

Reporting CAHPS and HEDIS data by race/ethnicity for Medicare beneficiaries.

OBJECTIVE: To produce reliable and informative health plan performance data by race/ethnicity for the Medicare beneficiary population and to consider appropriate presentation strategies. DATA SOURCES: Patient experience data from the 2008-2009 Medicare Advantage (MA) and fee-for-service (FFS) CAHPS surveys and 2008-2009 HEDIS data (MA beneficiaries only). STUDY DESIGN: Mixed effects linear (and binomial) regression models estimated the reliability and statistical informativeness of CAHPS (HEDIS) measures. PRINCIPAL FINDINGS: Seven CAHPS and seven HEDIS measures were reliable and informative for four racial/ethnic subgroups-Whites, Blacks, Hispanics, and Asian/Pacific Islanders-at sample sizes of 100 beneficiaries (200 for prescription drug plans). Although many plans lacked adequate sample size for reporting group-specific data, reportable plans contained a large majority of beneficiaries from each of the four racial/ethnic groups. CONCLUSIONS: Statistically reliable and valid information on health plan performance can be reported by race/ethnicity. Many beneficiaries may have difficulty understanding such reports, however, even with careful guidance. Thus, it is recommended that health plan performance data by subgroups be reported as supplemental data and only for plans meeting sample size requirements.

A randomized experiment investigating the suitability of speech-enabled IVR and Web modes for publicly reported surveys of patients' experience of hospital care.

The HCAHPS Survey obtains hospital patients' experiences using four modes: Mail Only, Phone Only, Mixed (mail/phone follow-up), and Touch-Tone (push-button) Interactive Voice Response with option to transfer to live interviewer (TT-IVR/Phone). A new randomized experiment examines two less expensive modes: Web/Mail (mail invitation to participate by Web or request a mail survey) and Speech-Enabled IVR (SE-IVR/Phone; speaking to a voice recognition system; optional transfer to an interviewer). Web/Mail had a 12% response rate (vs. 32% for Mail Only and 33% for SE-IVR/Phone); Web/Mail respondents were more educated and less often Black than Mail Only respondents. SE-IVR/Phone respondents (who usually switched to an interviewer) were less often older than 75 years, more often English-preferring, and reported better care than Mail Only respondents. Concerns regarding inconsistencies across implementations, low adherence to primary modes, or low response rate may limit the applicability of the SE-IVR/Phone and Web/Mail modes in HCAHPS and similar standardized environments.

Development of and field test results for the CAHPS PCMH Survey.

OBJECTIVE: To develop and evaluate survey questions that assess processes of care relevant to Patient-Centered Medical Homes (PCMHs). RESEARCH DESIGN: We convened expert panels, reviewed evidence on effective care practices and existing surveys, elicited broad public input, and conducted cognitive interviews and a field test to develop items relevant to PCMHs that could be added to the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician & Group (CG-CAHPS) 1.0 Survey. Surveys were tested using a 2-contact mail protocol in 10 adults and 33 pediatric practices (both private and community health centers) in Massachusetts. A total of 4875 completed surveys were received (overall response rate of 25%). ANALYSES: We calculated the rate of valid responses for each item. We conducted exploratory factor analyses and estimated item-to-total correlations, individual and site-level reliability, and correlations among proposed multi-item composites. RESULTS: Ten items in 4 new domains (Comprehensiveness, Information, Self-Management Support, and Shared Decision-Making) and 4 items in 2 existing domains (Access and Coordination of Care) were selected to be supplemental items to be used in conjunction with the adult CG-CAHPS 1.0 Survey. For the child version, 4 items in each of 2 new domains (Information and Self-Management Support) and 5 items in existing domains (Access, Comprehensiveness-Prevention, Coordination of Care) were selected. CONCLUSIONS: This study provides support for the reliability and validity of new items to supplement the CG-CAHPS 1.0 Survey to assess aspects of primary care that are important attributes of PCMHs.

Giving voice to the vulnerable: the development of a CAHPS nursing home survey measuring family members' experiences.

BACKGROUND: To complement a nursing home resident survey, the team developed a survey asking family members about their experiences with nursing homes. Although a family member does not receive care directly from a nursing home, their experiences at the nursing home and with staff can contribute to understanding nursing home quality. OBJECTIVES: To describe how the nursing home family member instrument was developed, refined, tested, and finalized. RESEARCH DESIGN: The team developed a draft survey using information from a literature review, 12 focus groups with family members involved in choosing a nursing home for someone, review of nursing home surveys, and expert/stakeholder input. The survey went through 2 rounds of cognitive interviews (n=54) and revisions and was fielded in 15 nursing homes. Data from the pilot survey (n=885) were subjected to psychometric analyses to evaluate the measurement properties of items as well as the reliability and validity of the resulting composites. On the basis of these analyses and input from experts, the survey was finalized. RESULTS: Focus groups and experts provided input into discerning important indicators of quality, although in some cases family members were not the best sources of information. Cognitive testing refined the survey and eliminated some of the proxy items. The field test analysis and input from experts eliminated 10 items. The final survey included 21 items organized into 4 composites. CONCLUSIONS: This survey measures family members' experiences of nursing home care, and the results contribute to the understanding of quality of care in nursing homes.

Development and evaluation of CAHPS questions to assess the impact of health information technology on patient experiences with ambulatory care.

BACKGROUND: Little is known about whether health information technology (HIT) affects patient experiences with health care. OBJECTIVE: To develop HIT questions that assess patients care experiences not evaluated by existing ambulatory Consumer Assessment of Health Plans and Systems (CAHPS) measures. RESEARCH DESIGN: We reviewed published articles and conducted focus groups and cognitive testing to develop survey questions. We collected data, using mail and the internet, from patients of 69 physicians receiving care at an academic medical center and 2 regional integrated delivery systems in late 2009 and 2010. We evaluated questions and scales about HIT using factor analysis, item-scale correlations, and reliability (internal consistency and physician-level) estimates. RESULTS: We found support for 3 HIT composites: doctor use of computer (2 items), e-mail (2 items), and helpfulness of provider's website (4 items). Corrected item-scale correlations were 0.37 for the 2 doctor use of computer items and 0.71 for the 2 e-mail items, and ranged from 0.50 to 0.60 for the provider's website items. Cronbach α was high for e-mail (0.83) and provider's website (0.75), but only 0.54 for doctor use of computer. As few as 50 responses per physician would yield reliability of 0.70 for e-mail and provider's website. Two HIT composites, doctor use of computer (P<0.001) and provider's website (P=0.02), were independent predictors of overall ratings of doctors. CONCLUSIONS: New CAHPS HIT items were identified that measure aspects of patient experiences not assessed by the CAHPS C&G 1.0 survey.

Differences in CAHPS reports and ratings of health care provided to adults and children.

BACKGROUND: Consumer assessment of health care is an important metric for evaluating quality of care. These assessments can help purchasers, health plans, and providers deliver care that fits patients' needs. OBJECTIVE: To examine differences in reports and ratings of care delivered to adults and children and whether they vary by site. RESEARCH DESIGN: This observational study compares adult and child experiences with care at a large west coast medical center and affiliated clinics and a large mid-western health plan using Consumer Assessment of Healthcare Providers and Systems Clinician & Group 1.0 Survey data. RESULTS: Office staff helpfulness and courtesy was perceived more positively for adult than pediatric care in the west coast site. In contrast, more positive perceptions of pediatric care were observed in both sites for coordination of care, shared decision making, overall rating of the doctor, and willingness to recommend the doctor to family and friends. In addition, pediatric care was perceived more positively in the mid-west site for access to care, provider communication, and office staff helpfulness and courtesy. The differences between pediatric care and adult care were larger in the mid-western site than the west coast site. CONCLUSIONS: There are significant differences in the perception of care for children and adults with care provided to children tending to be perceived more positively. Further research is needed to identify the reasons for these differences and provide more definitive information at sites throughout the United States.

Association of the von Hippel-Lindau protein with AUF1 and posttranscriptional regulation of VEGFA mRNA.

The von Hippel-Lindau (VHL) tumor suppressor gene product is the recognition component of an E3 ubiquitin ligase and is inactivated in patients with VHL disease and in most sporadic clear-cell renal cell carcinomas (RCC). pVHL controls oxygen-responsive gene expression at the transcriptional and posttranscriptional levels. The VEGFA mRNA contains AU-rich elements (ARE) in the 3'-untranslated region, and mRNA stability or decay is determined through ARE-associated RNA-binding factors. We show here that levels of the ARE-binding factor, AUF1, are regulated by pVHL and by hypoxia. pVHL and AUF1 stably associate with each other in cells and AUF1 is a ubiquitylation target of pVHL. AUF1 and another RNA-binding protein, HuR, bind to VEGFA ARE RNA. Ribonucleoprotein (RNP) immunoprecipitations showed that pVHL associates indirectly with VEGFA mRNA through AUF1 and/or HuR, and this complex is associated with VEGFA mRNA decay under normoxic conditions. Under hypoxic conditions pVHL is downregulated, whereas AUF1 and HuR binding to VEGF mRNA is maintained, and this complex is associated with stabilized mRNA. These studies suggest that AUF1 and HuR bind to VEGFA ARE RNA under both normoxic and hypoxic conditions, and that a pVHL-RNP complex determines VEGFA mRNA decay. These studies further implicate the ubiquitin-proteasome system in ARE-mediated RNA degradation.

The integrated Joslin performance improvement/CME program: a new paradigm for better diabetes care.

Ongoing continuing medical education is an essential component of life-long learning and can have a positive influence on patient outcomes. However, some evidence suggests that continuing medical education has not fulfilled its potential as a performance improvement (PI) tool, in part due to a paradigm of CME that has focused on the quantity of continuing medical education credits attained rather than the quality of outcomes. The Joslin Diabetes Center has undertaken a new performance-based CME program model that offers performance improvement and continuing medical education as a unified entity that is convenient and accessible for the overburdened primary care physician. This paper describes the origins of the Joslin Professional Educational Continuum as well as its infrastructure and intended outcomes.