Local COVID-19 Epicenter in Detroit Metropolitan Area Causing Profound and Pervasive Reorganization of Clinical, Educational, Research, and Financial Programs of a Large Academic Gastroenterology Division with a GI Fellowship and Primary Medical School Affiliation.

AIM: To report revolutionary reorganization of academic gastroenterology division from COVID-19 pandemic surge at metropolitan Detroit epicenter from 0 infected patients on March 9, 2020, to > 300 infected patients in hospital census in April 2020 and > 200 infected patients in April 2021. SETTING: GI Division, William Beaumont Hospital, Royal Oak, has 36 GI clinical faculty; performs > 23,000 endoscopies annually; fully accredited GI fellowship since 1973; employs > 400 house staff annually since 1995; tertiary academic hospital; predominantly voluntary attendings; and primary teaching hospital, Oakland-University-Medical-School. METHODS: This was a prospective study. Expert opinion. Personal experience includes Hospital GI chief > 14 years until 2020; GI fellowship program director, several hospitals > 20 years; author of > 300 publications in peer-reviewed GI journals; committee-member, Food-and-Drug-Administration-GI-Advisory Committee > 5 years; and key hospital/medical school committee memberships. Computerized PubMed literature review was performed on hospital changes and pandemic. Study was exempted/approved by Hospital IRB, April 14, 2020. RESULTS: Division reorganized patient care to add clinical capacity and minimize risks to staff of contracting COVID-19 infection. Affiliated medical school changes included: changing "live" to virtual lectures; canceling medical student GI electives; exempting medical students from treating COVID-19-infected patients; and graduating medical students on time despite partly missing clinical electives. Division was reorganized by changing "live" GI lectures to virtual lectures; four GI fellows temporarily reassigned as medical attendings supervising COVID-19-infected patients; temporarily mandated intubation of COVID-19-infected patients for esophagogastroduodenoscopy; postponing elective GI endoscopies; and reducing average number of endoscopies from 100 to 4 per weekday during pandemic peak! GI clinic visits reduced by half (postponing non-urgent visits), and physical visits replaced by virtual visits. Economic pandemic impact included temporary, hospital deficit subsequently relieved by federal grants; hospital employee terminations/furloughs; and severe temporary decline in GI practitioner's income during surge. Hospital temporarily enhanced security and gradually ameliorated facemask shortage. GI program director contacted GI fellows twice weekly to ameliorate pandemic-induced stress. Divisional parties held virtually. GI fellowship applicants interviewed virtually. Graduate medical education changes included weekly committee meetings to monitor pandemic-induced changes; program managers working from home; canceling ACGME annual fellowship survey, changing ACGME physical to virtual site visits; and changing national conventions from physical to virtual. CONCLUSION: Reports profound and pervasive GI divisional changes to maximize clinical resources devoted to COVID-19-infected patients and minimize risks of transmitting infection.

La afiliación al sistema de salud de personas migrantes venezolanas en Colombia / The Affiliation to the Health System among Venezuelan Migrants in Colombia

Resumen: Introducción:El acceso de las personas migrantes venezolanas al sistema de salud es fundamental para su supervivencia y bienestar futuro. El objetivo de esta investigación es analizar los niveles de afiliación a dicho sistema de las personas venezolanas en las áreas urbanas de Colombia por periodos de arribo, así como los factores sociodemográficos y laborales asociados. Metodología: Se realiza análisis cuantitativo de tipo estadístico descriptivo e inferencial, a partir de la Gran Encuesta Integrada de Hogares 2018, la cual aporta datos representativos para Colombia y sus 13 ciudades más importantes. Se utilizan los módulos de migración, de variables sociodemográficas del hogar y de ocupación relativos a la población de 14 a 65 años. Resultados:Únicamente 24,5 % de dichos migrantes están inscritos al sistema de salud en contraste a 93 % de las personas colombianas. Los niveles de afiliación se redujeron de 82 % entre las personas venezolanos que arribaron en 2013 o antes a 10 % entre los que llegaron en 2017-2018. Las personas venezolanas afiliadas al sistema de salud son una población selecta en términos sociodemográficos; más joven, más educada, con mayor participación laboral y mayores ingresos que la población nativa en Colombia. La baja inserción de las personas migrantes venezolanas en empleos con contrato escrito restringe dicha afiliación. Conclusiones: Las personas venezolanas en Colombia tienen muy limitada la inscripción al sistema de salud. A pesar de que este es un derecho protegido por los marcos jurídicos internacional y nacional, estas personas enfrentan barreras económicas, políticas y sociales para ejercer ese derecho en Colombia.

Abstract: Introduction: Venezuelan migrants' access to the health system is fundamental to their survival and future well-being. This article aims to analyze the level of affiliation to the health care system of these migrants in the urban areas in Colombia by arrival periods and the associated sociodemographic and labor factors. Methodology: To this end, quantitative analysis is done based on descriptive and inferential statistical analyses of the 2018 Gran Encuesta Integrada de Hogares, which is a representative survey for Colombia and its 13 more important urban areas. We use the modules on migration, sociodemographic variables of the household and occupation relative to the population aged 14 to 65. Results: Only 24,5% of Venezuelan migrants are affiliated with any health care provider in contrast to 93% of Colombians. The levels of affiliation diminished from 82% among Venezuelans who arrived in 2013 or before to 10% among Venezuelans who arrived in 2017-2018. Venezuelans registered in the health system are a select population in sociodemographic terms; younger, more educated, with more labor participation and higher income than the native population in Colombia. The low insertion of Venezuelan immigrants in jobs with a written contract restricts this enrollment. Conclusions:The Venezuelans in Colombia have a very limited affiliation with the health system. Even though this is a right protected by international and national legal frameworks, Venezuelans encounter economic, political, and social barriers to exercise it in Colombia.

The Impact of Hospital/University Affiliation on Research Productivity Among US-Based Authors in the Fields of Trauma, Surgical Critical Care, Acute Care, and Emergency General Surgery.

BACKGROUND: Research productivity is critical to academic surgery and essential for advancing surgical knowledge and evidence-based practice. We aim to determine if surgeon affiliation with top US universities/hospitals (TOPS) is associated with increased research productivity measured by numbers of peer-reviewed publications in PubMed (PMIDs). METHODS: A bibliometric analysis was performed for PMIDs. Affiliated authors who published in trauma surgery (TS), surgical critical care (SCC), acute care surgery (ACS), and emergency general surgery (EGS) were evaluated for publications between 2015 and 2019, and lifetime productivity. Our analysis included 3443 authors from 443 different institutions. Our main outcome was PMIDs of first author (FA) and senior author (SA) in each field (2015-2019) and total lifetime publications. RESULTS: Significant differences exist between PMIDs from TOPS vs non-TOPS in FA-TS (1.34 vs 1.23, P = .001), SA-TS (1.71 vs 1.46, P < .001), total SA-PMIDs (44.10 vs 26.61, P < .001), and SA-lifetime PMIDs (90.55 vs 59.03, P < .001). There were no significant differences in PMIDs for FA or SA-SCC, FA or SA-ACS, FA or SA-EGS, FA-total PMIDs 2015-2019, or FA-lifetime PMIDs (P > .05 for all). CONCLUSION: There were significantly higher TS PMIDs among FAs and SAs affiliated with top US institutions in 2015-2019, along with higher total PMIDs (2015-2019) and lifetime PMIDs. These findings are of significance to future graduate medical applicants and academic surgeons who need to make decisions about training and future career opportunities.

Single- Versus Multicenter Surgeons' Risk-Adjusted Coronary Artery Bypass Graft Procedural Outcomes.

BACKGROUND: Since 2010, 460+ hospital mergers have occurred in the United States, rerouting historical coronary artery bypass graft (CABG) referral patterns. The goals of this study were: (1) to compare risk-adjusted CABG outcomes between single-center versus multicenter surgeons; and (2) for multicenter surgeons, to evaluate the risk-adjusted outcomes between their home (primary) versus satellite (secondary) hospitals. METHODS: Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, nonemergent, first-time CABG procedures (n = 543,403) performed in the US between 2011 and 2014 were extracted across 1,120 centers and for 2,676 surgeons. Surgeons were classified as multicenter if they performed operations at two separate hospitals for ≥ 2 consecutive quarters; their home hospital was identified as their highest volume center. Observed-to-expected outcome ratios were reported using approved multivariable risk models for 30-day operative mortality and major morbidity. RESULTS: Of 2,676 cardiac surgeons, 668 (25.0%) operated at multiple centers. The observed-to-expected mortality ratios were 1.06 (95% confidence interval [CI], 1.01 to 1.12) and 0.97 (95% CI, 0.94 to 1.00) for multi- and single-center surgeons (p < 0.001). For multicenter surgeons, the observed-to-expected mortality ratios were 1.17 (95% CI, 1.09 to 1.27) versus 1.01 (95% CI, 0.96 to 1.07), p < 0.001, for their satellite versus home facilities, respectively. CONCLUSIONS: Single-center surgeons performing CABG had lower risk-adjusted outcome rates compared with multicenter surgeons, who performed better at their home versus satellite hospitals. To improve future quality of care, surgeons, health care networks, and health policy makers should now more closely scrutinize their single versus multicenter performance.

How is the sustainability of chronic disease health programmes empirically measured in hospital and related healthcare services?-a scoping review.

OBJECTIVES: Programmes to address chronic disease are a focus of governments worldwide. Despite growth in 'implementation science', there is a paucity of knowledge regarding the best means to measure sustainability. The aim of this review was to summarise current practice for measuring sustainability outcomes of chronic disease health programmes, providing guidance for programme planners and future directions for the academic field. SETTINGS: A scoping review of the literature spanning 1985-2015 was conducted using MEDLINE, CINAHL, PsychINFO and The Cochrane Library limited to English language and adults. Main search terms included chronic disease, acute care, sustainability, institutionalisation and health planning. A descriptive synthesis was required. Settings included primary care, hospitals, mental health centres and community health. PARTICIPANTS: Programmes included preventing or managing chronic conditions including diabetes, heart disease, depression, respiratory disease, cancer, obesity, dental hygiene and multiple chronic diseases. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome measures included clarifying a sustainability definition, types of methodologies used, timelines for assessment, criteria levels to determine outcomes and how methodology varies between intervention types. RESULTS: Among 153 abstracts retrieved, 87 were retained for full article review and 42 included in the qualitative synthesis. Five definitions for sustainability outcome were identified with 'maintenance of programme activities' most frequent. Achieving sustainability was dependent on inter-relationships between various organisational and social contexts supporting a broad scale approach to evaluation. An increasing trend in use of mixed methods designs over multiple time points to determine sustainability outcomes was found. CONCLUSIONS: Despite the importance and investment in chronic disease programmes, few studies are undertaken to measure sustainability. Methods to evaluate sustainability are diverse with some emerging patterns in measurement found. Use of mixed methods approaches over multiple time points may serve to better guide measurement of sustainability. Consensus on aspects of standardised measurement would promote the future possibility of meta-analytic syntheses.

Integrating team resource management program into staff training improves staff's perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan.

BACKGROUND: The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. METHODS: We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. RESULTS: During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. CONCLUSION: Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation.

Level of evidence and geographic origin of articles published in Chilean dental journals / Nivel de evidencia y origen geográfico de los artículos publicados en revistas odontológicas chilenas

The aim of this study is to determine the geographic origin and level of evidence (LE) of articles published in Chilean dental journals during 2012. The target population for the bibliometric study was articles published in exclusively-scientific Chilean dental journals. These variables were analyzed: journal, area, language, country, region, design, scenario, and LE. A total of 120 articles were published in four journals: International Journal of Odontostomatology (IJOS=59), Revista Clínica de Periodoncia, Implantología y Rehabilitación Oral (PIRO=28), Journal of Oral Research (JOR=18), and Revista Dental de Chile (RDC=15). From the total, 80.83 percent were published in Spanish and 70 percent had a Chilean affiliation. Most publications corresponded to areas of pathology (21) others (20) and prosthodontics (20). None of the articles was Level 1 Evidence, 6.49 percent was 2b, 14.29 percent was 2c, 63.64 percent was 4, and 15.58 percent was 5. Chilean dental journals mainly publish articles of domestic origin and low LE.

El objetivo de esta investigación es determinar el origen y nivel de evidencia (NE) de los artículos publicados en las revistas odontológicas chilenas durante el año 2012. Estudio bibliométrico, la población objetivo fueron todos los artículos publicados en revistas dentales chilenas de orientación exclusivamente científica. Se analizaron variables: Revista, Área, Idioma, País, Región, Diseño, Escenario y NE. Se hallaron 120 artículos publicados en cuatro revistas: International Journal of Odontostomatology (IJOS = 59), Revista Clínica de Periodoncia, Implantología y Rehabilitación Oral (PIRO = 28), Journal of Oral Research (JOR = 18) y Revista Dental de Chile (RDC = 15). El 80.83 por ciento de los artículos fue publicado en español y el 70 por ciento corresponden a autores chilenos. La mayor cantidad de publicaciones correspondieron a las áreas de Patología (21), Otra (20) y Prostodoncia (20). No se hallaron artículos de NE 1, 6.49 por ciento fue 2b, 14.29 por ciento fue 2c, 63,64 por ciento fue 4 y 15.58 por ciento fue 5. Las revistas odontológicas chilenas publican principalmente artículos de origen nacional y con un bajo NE.

Small community hospitals programs affiliation with university programs; "lessons learned" in 28-year successful affiliation.

OBJECTIVE: Community hospitals affiliation with university hospitals in post graduate surgical education is essential for the 2 types of training programs. Many factors affect the success of the affiliation process. Additionally, various pitfalls and challenges are encountered. The goal of this work is to study the lessons learned in 28 years successful affiliation. DESIGN/SETTING: small community hospital affiliation with university program for 28 years. PARTICIPANTS: surgery residency programs in small community hospital and university hospital. RESULTS: successful affiliation for 28 years between community hospital and university program.

Correlation between financial relationships with commercial interests and research prominence at an oncology meeting.

PURPOSE: Little is known about the effects of financial relationships between biomedical researchers and industry (financial conflicts of interest [FCOIs]) on research prominence. We examined the prevalence of FCOIs in oncology and associations between FCOIs and research prominence among abstracts presented at American Society of Clinical Oncology (ASCO) annual meetings. METHODS: We analyzed 20,718 abstracts presented at ASCO meetings in 2006 and 2008 to 2011. Measures included the following: financial relationships, peer review score (PRS), and meeting placement prominence (descending order of prominence: plenary session, clinical science symposium, oral presentation, poster discussion, general posters, and publish only). RESULTS: Of 20,718 abstracts, 36% reported at least one author with an FCOI. The proportion of abstracts with any FCOI increased from 33% in 2006 to 38% in 2011 (P < .001). Abstracts with FCOIs had significantly higher meeting prominence compared with publish only and general poster abstracts. The odds ratios compared with general posters were 7.3 for plenary session, 2.2 for clinical science symposium, 1.9 for oral presentation, and 1.7 for poster discussion (P < .001). Abstracts with FCOIs had significantly better PRSs compared with those without FCOIs. For all abstracts, PRS was 2.76 (95% CI, 2.75 to 2.77) with FCOIs compared with 3.01 (95% CI, 3.001 to 3.02) without FCOIs (P < .001). Omitting publish-only abstracts, PRS was 2.62 (95% CI, 2.61 to 2.63) with FCOIs compared with 2.73 without FCOIs (95% CI, 2.71 to 2.73). CONCLUSION: Abstracts with FCOIs had more prominent meeting placement and better PRSs. FCOIs were reported more frequently by year, suggesting an increasing influence of industry on cancer research, greater disclosure, or both.

Food, fizzy, and football: promoting unhealthy food and beverages through sport - a New Zealand case study.

BACKGROUND: High participation rates in sport and increasing recognition of how diet benefits athletic performance suggest sports settings may be ideal locations for promoting healthy eating. While research has demonstrated the effect of tobacco and alcohol sponsorship on consumption, particularly among youth, few studies have examined the extent or impact of food and beverage company sponsorship in sport. Studies using brand logos as a measure suggest unhealthy foods and beverages dominate sports sponsorship. However, as marketing goes beyond the use of brand livery, research examining how marketers support sponsorships that create brand associations encouraging consumer purchase is also required. This study aimed to identify the characteristics and extent of sponsorships and associated marketing by food and non-alcoholic beverage brands and companies through a case study of New Zealand sport. METHODS: We conducted a systematic review of 308 websites of national and regional New Zealand sporting organisations to identify food and beverage sponsors, which were then classified as healthy or unhealthy using nutrient criteria for energy, fat, sodium and fibre levels. We interviewed 18 key informants from national and regional sporting organisations about sponsorships. RESULTS: Food and beverage sponsorship of sport is not extensive in New Zealand. However, both healthy and unhealthy brands and companies do sponsor sport. Relatively few support their sponsorships with additional marketing. Interviews revealed that although many sports organisations felt concerned about associating themselves with unhealthy foods or beverages, others considered sponsorship income more important. CONCLUSIONS: While there is limited food and beverage sponsorship of New Zealand sport, unhealthy food and beverage brands and companies do sponsor sport. The few that use additional marketing activities create repeat exposure for their brands, many of which target children. The findings suggest policies that restrict sponsorship of sports by unhealthy food and beverage manufacturers may help limit children's exposure to unhealthy food marketing within New Zealand sports settings. Given the global nature of the food industry, the findings of this New Zealand case study may be relevant elsewhere.

Grumblers in the time of Diagnosis-Related Groups: sand in the gear or lubricating oil?

OBJECTIVE: After the change from cost allowance to a German system of Diagnosis-Related Groups there has been much public discussion about how the new terms of employment within the health sector are increasingly in conflict with individuals'original motivations for their career choice. If such criticism remains unheard a further loss of employees might occur. METHODS: Two decades of professional experiences have been reviewed. The results were personally assessed and summarized in a field report. PARTICIPANTS: One senior physician, Department of Anesthesiology, University Hospital. RESULTS: In total, a deliberate contact approach by management to address employees' criticisms and grumbling about the terms of employment is essential for enterprise's success. CONCLUSIONS: While employees can introduce criticisms more constructively to contribute ideas that protect the enterprise'ssuccess, executives will have to position themselves in such a way as to be open to these perspectives. Constructive contact with "hospital troublemakers" should be implemented into the enterprise culture. Guidance is necessary to institute such changes.

Sustainability and performance of the National Cancer Institute's Community Clinical Oncology Program.

INTRODUCTION: The National Cancer Institute's (NCI) Community Clinical Oncology Program (CCOP) contributes one third of NCI treatment trial enrollment ("accrual") and most cancer prevention and control (CP/C) trial enrollment. Prior research indicated that the local clinical environment influenced CCOP accrual performance during the 1990s. As the NCI seeks to improve the operations of the clinical trials system following critical reports by the Institute of Medicine and the NCI Operational Efficiency Working Group, the current relevance of the local environmental context on accrual performance is unknown. MATERIALS AND METHODS: This longitudinal quasi-experimental study used panel data on 45 CCOPs nationally for years 2000-2007. Multivariable models examine organizational, research network, and environmental factors associated with accrual to treatment trials, CP/C trials, and trials overall. RESULTS: For total trial accrual and treatment trial accrual, the number of active CCOP physicians and the number of trials were associated with CCOP performance. Factors differ for CP/C trials. CCOPs in areas with fewer medical school-affiliated hospitals had greater treatment trial accrual. CONCLUSIONS: Findings suggest a shift in the relevance of the clinical environment since the 1990s, as well as changes in CCOP structure associated with accrual performance. Rather than a limited number of physicians being responsible for the preponderance of trial accrual, there is a trend toward accrual among a larger number of physicians each accruing relatively fewer patients to trial. Understanding this dynamic in the context of CCOP efficiency may inform and strengthen CCOP organization and physician practice.

Turnkey offering a claimed sector 'first'.

Manufacturer and supplier of LED theatre lights, HD camera systems, video integration technologies, and ceiling support units, Trumpf Medical Systems UK, and "logistical services" company Canute International Medical Services (CIMS), one of whose specialities is providing mobile medical units for diagnostic imaging, have entered into a partnership that will see the two companies offer fully fitted out modular operating theatres and other medical/clinical buildings incorporating the latest technology and equipment, on a fully project-managed, "turnkey" basis. Oliver Law, Trumpf Medical Systems UK managing director, explains the background, and the new service's anticipated customer benefits.

Consumer evaluation of complaint handling in the Dutch health insurance market.

BACKGROUND: How companies deal with complaints is a particularly challenging aspect in managing the quality of their service. In this study we test the direct and relative effects of service quality dimensions on consumer complaint satisfaction evaluations and trust in a company in the Dutch health insurance market. METHODS: A cross-sectional survey design was used. Survey data of 150 members of a Dutch insurance panel who lodged a complaint at their healthcare insurer within the past 12 months were surveyed. The data were collected using a questionnaire containing validated multi-item measures. These measures assess the service quality dimensions consisting of functional quality and technical quality and consumer complaint satisfaction evaluations consisting of complaint satisfaction and overall satisfaction with the company after complaint handling. Respondents' trust in a company after complaint handling was also measured. Using factor analysis, reliability and validity of the measures were assessed. Regression analysis was used to examine the relationships between these variables. RESULTS: Overall, results confirm the hypothesized direct and relative effects between the service quality dimensions and consumer complaint satisfaction evaluations and trust in the company. No support was found for the effect of technical quality on overall satisfaction with the company. This outcome might be driven by the context of our study; namely, consumers get in touch with a company to resolve a specific problem and therefore might focus more on complaint satisfaction and less on overall satisfaction with the company. CONCLUSIONS: Overall, the model we present is valid in the context of the Dutch health insurance market. Management is able to increase consumers' complaint satisfaction, overall satisfaction with the company, and trust in the company by improving elements of functional and technical quality. Furthermore, we show that functional and technical quality do not influence consumer satisfaction evaluations and trust in the company to the same extent. Therefore, it is important for managers to be aware of the type of consumer satisfaction they are measuring when evaluating the handling of complaints within their company.

Successful affiliations: principles and practices.

An affiliation can help a healthcare provider prepare for the challenges of healthcare reform, the rapidly changing landscapes of the commercial insurance industry, and the public's expectations about service and quality. UC Davis Medical Center, a 645-bed tertiary hospital in Sacramento, California, with many hospital-based clinics and a community-based group of primary care clinics, has developed a number of principles for affiliation. These principles are based on its experience in legal and financial affiliations with an academic practice group, with individual and small groups of primary care physicians, and with community hospitals around oncology services linked with U.C. Davis' National Cancer Institute-designated cancer center. This article offers a process for evaluating the appropriateness of an affiliation. The chances for a successful affiliation improve if each party has indicated the value it hopes to derive and how to measure that value, has communicated with all affected constituents, and has an agreed-upon method for resolving disputes.

Perils, pitfalls, and benefits of a surgeon as a health system employee: the contracting process.

One would be hard pressed today to find a general surgeon or subspecialty-trained general surgeon who has not been approached by a health system to discuss employment. The majority of physicians find these initial discussions with a hospital administrator daunting at best regardless of whether they are just finishing residency or fellowship training or have had many successful years of private practice under their belt. Just as real estate has the mantra of "location, location, location," I would suggest that physician employment by a health system should have the mantra of "relationship, relationship, relationship." The following tips provide guidance on how to better understand the potential perils, pitfalls, and benefits of specific content sections of a standard template employment agreement between a health system and a physician. Physicians should review, understand, and be ready to engage in dialogue with the hospital administrator before involving attorneys. My experience is that if the dialogue begins with the attorneys representing each party, the opportunity to fully develop a partnership relationship between the parties is either lost or at minimum severely delayed in its development.

The role of organizational affiliations and research networks in the diffusion of breast cancer treatment innovation.

INTRODUCTION: The National Institutes of Health (NIH) sees provider-based research networks and other organizational linkages between academic researchers and community practitioners as promising vehicles for accelerating the translation of research into practice. This study examines whether organizational research affiliations and teaching affiliations are associated with accelerated diffusion of sentinel lymph node biopsy (SLNB), an innovation in the treatment of early-stage breast cancer. METHODS: Surveillance Epidemiology and End Results-Medicare data were used to examine the diffusion of SLNB for treatment of early-stage breast cancer among women aged 65 years and older diagnosed between 2000 and 2002, shortly after Medicare approved and began reimbursing for the procedure. RESULTS: In this population, patients treated at an organization affiliated with a research network--the American College of Surgeons Oncology Group (ACOSOG) or other National Cancer Institute (NCI) cooperative groups--were more likely to receive the innovative treatment (SLNB) than patients treated at unaffiliated organizations (odds ratio: 2.70, 95% confidence interval: 1.77-4.12; odds ratio: 1.84, 95% confidence interval: 1.26-2.69, respectively). Neither hospital teaching status nor surgical volume was significantly associated with differences in SLNB use. DISCUSSION: Patients who receive cancer treatment at organizations affiliated with cancer research networks have an enhanced probability of receiving SLNB, an innovative procedure that offers the promise of improved patient outcomes. Study findings support the NIH Roadmap and programs such as the NCI's Community Clinical Oncology Program, as they seek to accelerate the translation of research into practice by simultaneously accelerating and broadening cancer research in the community.

Challenges of multisite surgical teaching programs: a review of surgery clerkship.

OBJECTIVE: As the enrollment in medical schools increases, the need for affiliated sites to participate in clerkship teaching will continue. The aim of this literature review was to provide a summary of measures that have been used to compare the training in affiliated community hospital sites with the tertiary teaching hospitals. METHODS: An extensive literature search was conducted using PubMed, MEDLINE, and EMBASE. A total of 386 articles were identified, of which 20 were found to be relevant to this topic. The references of those articles were also consulted and were included in the preparation of this manuscript when deemed appropriate. RESULTS: A significant difference does not seem to exist in either written examination or clinical performance evaluations among medical students who receive training at either tertiary care teaching hospitals or affiliated community hospital sites. Positive role models are important in influencing the choice of a surgical career, regardless of where clerkship training takes place. CONCLUSIONS: Although more research is merited in this area, the current evidence suggests that affiliated sites are comparable in their ability to train medical students during their surgical clerkship.

Reexploring differences among for-profit and nonprofit dialysis providers.

OBJECTIVE: To determine whether profit status is associated with differences in hospital days per patient, an outcome that may also be influenced by provider financial goals. DATA SOURCES: United States Renal Data System Standard Analysis Files and Centers for Medicare and Medicaid Services cost reports. DESIGN: We compared the number of hospital days per patient per year across for-profit and nonprofit dialysis facilities during 2003. To address possible referral bias in the assignment of patients to dialysis facilities, we used an instrumental variable regression method and adjusted for selected patient-specific factors, facility characteristics such as size and chain affiliation, as well as metrics of market competition. DATA EXTRACTION METHODS: All patients who received in-center hemodialysis at any time in 2003 and for whom Medicare was the primary payer were included (N=170,130; roughly two-thirds of the U.S. hemodialysis population). Patients dialyzed at hospital-based facilities and patients with no dialysis facilities within 30 miles of their residence were excluded. RESULTS: Overall, adjusted hospital days per patient were 17+/-5 percent lower in nonprofit facilities. The difference between nonprofit and for-profit facilities persisted with the correction for referral bias. There was no association between hospital days per patient per year and chain affiliation, but larger facilities had inferior outcomes (facilities with 73 or more patients had a 14+/-1.7 percent increase in hospital days relative to facilities with 35 or fewer patients). Differences in outcomes among for-profit and nonprofit facilities translated to 1,600 patient-years in hospital that could be averted each year if the hospital utilization rates in for-profit facilities were to decrease to the level of their nonprofit counterparts. CONCLUSIONS: Hospital days per patient-year were statistically and clinically significantly lower among nonprofit dialysis providers. These findings suggest that the indirect incentives in Medicare's current payment system may provide insufficient incentive for for-profit providers to achieve optimal patient outcomes.