Cluster Randomized Pragmatic Clinical Trial Testing Behavioral Economic Implementation Strategies to Improve Tobacco Treatment for Patients With Cancer Who Smoke.

PURPOSE: Few cancer centers systematically engage patients with evidence-based tobacco treatment despite its positive effect on quality of life and survival. Implementation strategies directed at patients, clinicians, or both may increase tobacco use treatment (TUT) within oncology. METHODS: We conducted a four-arm cluster-randomized pragmatic trial across 11 clinical sites comparing the effect of strategies informed by behavioral economics on TUT engagement during oncology encounters with cancer patients. We delivered electronic health record (EHR)-based nudges promoting TUT across four nudge conditions: patient only, clinician only, patient and clinician, or usual care. Nudges were designed to counteract cognitive biases that reduce TUT engagement. The primary outcome was TUT penetration, defined as the proportion of patients with documented TUT referral or a medication prescription in the EHR. Generalized estimating equations were used to estimate the parameters of a linear model. RESULTS: From June 2021 to July 2022, we randomly assigned 246 clinicians in 95 clusters, and collected TUT penetration data from their encounters with 2,146 eligible patients who smoke receiving oncologic care. Intent-to-treat (ITT) analysis showed that the clinician nudge led to a significant increase in TUT penetration versus usual care (35.6% v 13.5%; OR = 3.64; 95% CI, 2.52 to 5.24; P < .0001). Completer-only analysis (N = 1,795) showed similar impact (37.7% clinician nudge v 13.5% usual care; OR = 3.77; 95% CI, 2.73 to 5.19; P < .0001). Clinician type affected TUT penetration, with physicians less likely to provide TUT than advanced practice providers (ITT OR = 0.67; 95% CI, 0.51 to 0.88; P = .004). CONCLUSION: EHR nudges, informed by behavioral economics and aimed at oncology clinicians, appear to substantially increase TUT penetration. Adding patient nudges to the implementation strategy did not affect TUT penetration rates.

What matters to psychology trainees when making decisions about internship and postdoctoral training sites: Differences between racial/ethnic minority and White VA trainees.

It is projected that by 2045, racial/ethnic minorities in the U.S. will become the majority. Unfortunately, the numbers of racial/ethnic minority psychologists have not kept up with population trends. This discrepancy poses challenges for many psychology training sites, including the Department of Veterans Affairs (VA). There is a lack of data on what factors are important for psychology applicants, including racial/ethnic minority trainees when they are considering internship and postdoctoral training sites. This quality improvement project surveyed 237 VA psychology trainees (59% psychology interns, 32.5% psychology postdoctoral fellows, 69.6% White, 9.3% multiracial, 6.8% Asian American or Pacific Islander, 5.1% Black/African American, 4.2% Latinx American, 0.8% Native American, 0.8% Middle Eastern) to study what factors are important when considering training sites. Results indicated that overall, racial/ethnic minority and White trainees endorsed similar primary factors when considering training programs. Site related factors (e.g., perceived workload, training opportunities) and future work related factors (e.g., ease of licensure, obtaining a first job) were top considerations regardless of race/ethnicity. The groups diverged in secondary factors with racial/ethnic minorities desiring infusion of diversity in training more than White applicants and White applicants considering quality of life factors such as extracurricular opportunities and convenience of daily living more important than racial/ethnic minority applicants. Qualitative data indicated applicants perceived VA training sites to be more welcoming and offer more opportunities for learning about diversity than non-VA sites. Recommendations for recruiting psychology trainees in general, and then specifically for racial/ethnic minority applicants are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Impact of COVID-19-related care disruptions on blood pressure management and control in community health centers.

BACKGROUND: Uncontrolled hypertension is a leading risk factor for cardiovascular disease. To ensure continuity of care, community health centers (CHCs) nationwide implemented virtual care (telehealth) during the pandemic. CHCs use the Centers for Medicare & Medicaid Services (CMS) 165v8 Controlling High Blood Pressure measure to report blood pressure (BP) control performance. CMS 165v8 specifications state that if no BP is documented during the measurement period, the patient's BP is assumed uncontrolled. METHODS: To examine trends in BP documentation and control rates in CHCs as telehealth use increased during the pandemic compared with pre-pandemic period, we assessed documentation of BP measurement and BP control rates from December 2019 - October 2021 among persons ages 18-85 with a diagnosis of hypertension who had an in-person or telehealth encounter in 11 CHCs. Rates were compared between CHCs that did and did not implement self-measured BP monitoring (SMBP). RESULTS: The percent of patients with hypertension with no documented BP measurement was 0.5% in December 2019 and increased to 15.2% (overall), 25.6% (non-SMBP CHCs), and 11.2% (SMBP CHCs) by October 2021. BP control using CMS 165v8 was 63.5% in December 2019 and decreased to 54.9% (overall), 49.1% (non-SMBP), and 57.2% (SMBP) by October 2021. When assessing BP control only in patients with documented BP measurements, CHCs largely maintained BP control rates (63.8% in December 2019; 64.8% (overall), 66.0% (non-SMBP), and 64.4% (SMBP) by October 2021). CONCLUSIONS: The transition away from in-person to telehealth visits during the pandemic likely increased the number of patients with hypertension lacking a documented BP measurement, subsequently negatively impacting BP control using CMS 165v8. There is an urgent need to enhance the flexibility of virtual care, improve EHR data capture capabilities for patient-generated data, and implement expanded policy and systems-level changes for SMBP, an evidence-based strategy that can build patient trust, increase healthcare engagement, and improve hypertension outcomes.

Prevalence of social and economic stressors among transgender veterans with alcohol and other drug use disorders.

Transgender persons have high rates of alcohol and other drug use disorders (AUD and DUD, respectively) and commonly experience social and economic stressors that may compound risk for adverse substance-related outcomes. National VA electronic health record data were extracted for all outpatients in each facility with documented alcohol screening 10/1/09-7/31/17. We describe the prevalence of eight individual-level social and economic stressors (barriers to accessing care, economic hardship, housing instability, homelessness, social and family problems, legal problems, military sexual trauma, and other victimization) among transgender patients with and without AUD and DUD (alone and in combination), overall and compared to cisgender patients in a national sample of VA outpatients. Among 8,872,793 patients, 8619 (0.1%) were transgender; the prevalence of AUD, DUD, and both was 8.6%, 7.2%, and 3.1% among transgender patients and 6.1%, 3.9%, and 1.7% among cisgender patients, respectively. Among all patients, prevalence of stressors was higher among those with AUD, DUD, or both, relative to those with neither. Within each of these groups, prevalence was 2-3 times higher among transgender compared to cisgender patients. For instance, prevalence of housing instability for transgender vs. cisgender patients with AUD, DUD, and both was: 40.8% vs 24.1%, 45.8% vs. 36.6%, and 57.4% vs. 47.0%, respectively. (all p-values <0.001). Social and economic stressors were prevalent among patients with AUD, DUD, or both, and the experience of these disorders and social and economic stressors was more common among transgender than cisgender patients in all groups. Further research regarding experiences of transgender persons and influences of stressors on risk of AUD and DUD, substance-related outcomes, and treatment uptake are needed. Routine screening for social and economic stressors among patients with substance use disorders (SUDs) could improve equitable substance-related care and outcomes. Treatment of SUDs among all persons should consider social and economic risk factors.

Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke.

BACKGROUND: Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. METHODS: A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or "nudges") promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. DISCUSSION: This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021.

COVID-19 Among American Indian and Alaska Native Persons - 23 States, January 31-July 3, 2020.

Although non-Hispanic American Indian and Alaska Native (AI/AN) persons account for 0.7% of the U.S. population,* a recent analysis reported that 1.3% of coronavirus disease 2019 (COVID-19) cases reported to CDC with known race and ethnicity were among AI/AN persons (1). To assess the impact of COVID-19 among the AI/AN population, reports of laboratory-confirmed COVID-19 cases during January 22†-July 3, 2020 were analyzed. The analysis was limited to 23 states§ with >70% complete race/ethnicity information and five or more laboratory-confirmed COVID-19 cases among both AI/AN persons (alone or in combination with other races and ethnicities) and non-Hispanic white (white) persons. Among 424,899 COVID-19 cases reported by these states, 340,059 (80%) had complete race/ethnicity information; among these 340,059 cases, 9,072 (2.7%) occurred among AI/AN persons, and 138,960 (40.9%) among white persons. Among 340,059 cases with complete patient race/ethnicity data, the cumulative incidence among AI/AN persons in these 23 states was 594 per 100,000 AI/AN population (95% confidence interval [CI] = 203-1,740), compared with 169 per 100,000 white population (95% CI = 137-209) (rate ratio [RR] = 3.5; 95% CI = 1.2-10.1). AI/AN persons with COVID-19 were younger (median age = 40 years; interquartile range [IQR] = 26-56 years) than were white persons (median age = 51 years; IQR = 32-67 years). More complete case report data and timely, culturally responsive, and evidence-based public health efforts that leverage the strengths of AI/AN communities are needed to decrease COVID-19 transmission and improve patient outcomes.

Military Service and Military Health Care Coverage are Associated with Reduced Racial Disparities in Time to Mental Health Treatment Initiation.

We aimed to evaluate whether military service and access to veteran heath care coverage attenuates racial/ethnic disparities in time to mental health treatment initiation for posttraumatic stress disorder (PTSD), major depressive disorder, and/or alcohol-use disorder. Results are based on 13,528 civilians and 1392 veterans from NESARC-III. Among civilians, racial/ethnic minorities reported longer time to PTSD and depression treatment initiation than non-Hispanic whites. Among veterans, racial/ethnic minorities did not differ from whites in time to PTSD and depression treatment initiation, and showed shorter time to treatment initiation for alcohol-use disorder treatment. Racial/ethnic minorities with past year veteran health care coverage showed the strongest evidence for attenuated disparities.

Race/Ethnicity and Sexual Orientation Disparities in Mental Health, Sexism, and Social Support among Women Veterans.

OBJECTIVE: To identify patterns of risk and resilience by the intersections of race/ethnicity and sexual orientation in mental health symptom severity, sexism, and social support among U.S. women veterans. METHODS: A national sample of women veterans (n = 648, 38% sexual minority, 15% racial/ethnic minority) was recruited online in 2013 using social networking websites and listservs. Using cross-sectional survey data, we evaluated main and interactive associations between race/ethnicity and sexual orientation on depression, anxiety, posttraumatic stress, unhealthy alcohol use, sexism, and social support. Models were adjusted for other demographic characteristics. RESULTS: Across depression, anxiety, and sexism, White heterosexual women reported the least distress and racial/ethnic minority heterosexual women the most distress (race/ethnicity x sexual orientation interactions p < .05). Among White women, sexual minority women reported greater levels of depression, anxiety, and sexism than heterosexual women. The effects were the opposite among racial/ethnic minority women, where heterosexual women reported similar or worse depression, anxiety, and sexism than sexual minority women. There were no race/ethnicity or sexual orientation interaction effects on posttraumatic stress symptoms or unhealthy alcohol use and marginally significant effects on social support. CONCLUSIONS: Among women veterans, race/ethnicity and sexual orientation were associated with mental health and sexism, alone and in combination. Findings suggest that those who were both racial/ethnic and sexual minorities may develop resilience from their lived experience. On the other hand, women veterans with a minority race/ethnicity or a minority sexual orientation appeared more vulnerable to adverse outcomes and may need targeted care.

Reimbursement Incentives to Improve Adherence to Follow-Up of Cervical Cancer Cytology Screening Results in Peru.

OBJECTIVE: The purpose of this study was to determine Peruvian women's attitudes toward novel reimbursement incentives used to improve adherence to obtaining cervical cytology test results. MATERIALS AND METHODS: Women presenting for cervical cancer screening in Peru completed a 34-item Investigational Review Board-approved questionnaire. The questionnaire determined their attitudes toward various reimbursement incentives to improve adherence to obtaining cervical cytology results. Descriptive statistics, generalized linear models, and Kruskal-Wallis tests were used in the analyses. RESULTS: Completed questionnaires were available for 997 women. Most women (51%) would be more likely to return for their Pap result if an incentive was provided, 79% (759/956) agreed that they would pay for the Pap test, and 51% (402/859) would be willing to pay 10 Soles or less. Quechua-speaking women considered follow-up more difficult (p < .0001) but were less likely to return for their Pap results (p < .0001), pay for the Pap test (p < .0001), and afford paying more than 5 Soles (p < .0001) than women who spoke Spanish or both languages. More women who earn 1000 Soles/year or less would likely return if incentivized (p < .0001), felt the incentive would help them remember to return (p = .0047), and would be willing to pay whether there was a rebate (p = .010) as compared with women earning more money. CONCLUSIONS: A reimbursement incentive program designed to improve follow-up of cervical cytology test results was acceptable to most Peruvian women. Such a behavioral-modifying program may improve patient follow-up after cervical cytology testing. Implementation may reduce the morbidity and mortality of cervical cancer in remote regions of the country.

Using Voice-Activated Conversational Interfaces for Reporting Patient Safety Incidents: A Technical Feasibility and Pilot Usability Study.

Conversational interfaces and speech recognition capabilities are being increasingly used to create more natural and intuitive user interaction with digital technology. While voice-activated technologies have been used to support clinical documentation, their use for reporting patient safety incidents has not been previously investigated. The purpose of this paper is to assess the technical feasibility of an application for reporting incidents that combines a conversational interface with speech recognition software, and to undertake a pilot study of its usability. We built a prototype finite state-based application where incidents involving digital health technologies could be reported by answering five questions about the task being performed, the response of the software and the outcome of the clinical situation. Pilot tests showed that the conversational interface was usable. However, participants expressed concerns with speaking out loud about sensitive patient safety and quality improvement issues, including human error and system failures, in busy clinical environments. Further work is required to identify the clinical contexts in which conversational interfaces can be used to support incident reporting.

The combined utility of extended focused assessment with sonography for trauma and chest x-ray in blunt thoracic trauma.

BACKGROUND: Portable chest x-ray (CXR) and extended focused assessment with sonography for trauma (EFAST) screen patients for thoracic injury in the trauma bay. It is unclear if one test alone is sufficient, if both are required, or if the two investigations are complementary. Study objectives were to define the combined diagnostic yield of EFAST and CXR among stable blunt thoracic trauma patients and to determine if a normal EFAST and CXR might obviate the need for computed tomography (CT) scan of the chest. METHODS: All blunt trauma patients 15 years or older presenting to LAC+USC Medical Center in 2016 were screened. Only patients who underwent CT thorax were included. Patients were excluded if they presented more than 24 hours after injury, were transferred, or if they did not undergo EFAST and CXR. Demographics, physical examination (PEx) of the thorax, injury data, investigations, procedures, and outcomes were collected. The EFAST, CXR, and PEx findings were compared to the gold standard CT thorax to calculate the diagnostic yield of each investigation and combinations thereof in the assessment for clinically significant thoracic injury. RESULTS: One thousand three hundred eleven patients met inclusion/exclusion criteria. Most common mechanisms of injury were motor vehicle collision (n = 385, 29%) and auto versus pedestrian trauma (n = 379, 29%). Mean Injury Severity Score was 11 (1-75), with mean Abbreviated Injury Scale chest score of 1.6 (1-6). The sensitivities of EFAST, CXR, and PEx, either individually or in combination, were less than 0.73 in the detection of clinically significant thoracic injury. The most common missed clinically significant injuries were sternal fractures, scapular fractures, clavicular fractures, and pneumothoraces. Motorcycle collisions and auto versus pedestrian traumas resulted in the highest rates of missed injury. CONCLUSION: Even in conjunction with the physical examination, the sensitivity of EFAST+CXR in the detection of clinically significant thoracic injury is low. Therefore, if clinical suspicion for injury exists after blunt thoracic trauma, a normal EFAST+CXR is insufficient to exclude injury and CT scan of the chest should be performed. LEVEL OF EVIDENCE: Diagnostic tests/criteria, level III.

Enhancing Stress Management Coping Skills Using Induced Affect and Collaborative Daily Assessment.

The purpose of this paper is to highlight the use of induced affect (IA) and collaborative (therapeutic) assessment (CA) as components of Cognitive-Affective Stress Management Training (CASMT). IA is a technique for rehearsing cognitive and physical relaxationcoping skills under conditions of high affective arousal, which has been shown to result in high levels of coping self-efficacy. CA provides diary-based feedback to clients about the processes underlying theirstress experiences and helps identify affect-arousing experiences to be targeted by IA. We include descriptions of the IA technique and anonline stress and coping daily diary, as well as sample transcripts illustrating how CA is integrated into CASMT and how IA evokes high affective arousal and skills rehearsal. To illustrate idiographic assessment, we also describe threetreatment cases involving female clients between the ages of 20 and 35 with anxiety symptoms who participated in six weeks of CASMT and reported their daily stress and coping experiences (before, during, and following the intervention)for a total of ten weeks. The resulting time series data, analyzed using Simulation Modeling Analysis (SMA), revealed that all clients reported improved negative affect regulation over the course of treatment, yet they exhibited idiographic patterns of change on other outcome and coping skills variables. These results illustrate how IA and CA may be used to enhance emotional self-regulation and how time-series analyses can identify idiographic aspects of treatment response that would not be evident in group data.

Impact of a physician-led point of care medication delivery system on medication adherence.

OBJECTIVES: To evaluate the impact of a physician-led point of care medication delivery system (POCMDS) on adherence to glucose, blood pressure, and cholesterol-lowering medications. STUDY DESIGN: Prepost intervention observational study. METHODS: From December 15, 2010, to December 14, 2012, we conducted a prepost analyses of 800 Medicare Advantage members receiving care in a network of capitated clinics in south Florida serving a predominantly minority population. Eligibility criteria included a diagnosis of diabetes for at least 1 year, taking at least 1 of the 3 classes of medications, and having received care in the clinic network for at least for 12 months before and after the POCMDS implementation. Our primary outcome is the medication possession ratio (proportion of days covered [PDC]) for each class of medication. RESULTS: We found an absolute increase of 17 percentage points (95% CI, 13-20) in the PDC for oral antidiabetic agents, 29 (95% CI, 26-32) for cholesterol medications, and 21 (95% CI, 19-23) for blood pressure medications. Most of the subjects (80%) reported POCMDS was more convenient than using retail pharmacies. By having the POCMDS prioritize generic medications, the increases in adherence were not associated with increased pharmacy costs. At baseline, over half the patients were at goal for low-density lipoprotein cholesterol, glycated hemoglobin, and systolic blood pressure; thus, we did not detect any additional improvements in these intermediate clinical outcomes. CONCLUSIONS: Among elderly minority patients with diabetes, a POCMDS improved adherence to various medications classes without increasing pharmacy costs. Thus, POCMDS may be of interest to policy makers, particularly in our current era of healthcare reform.

Understanding sexual activity and Chlamydia testing rate based on linked national survey and Medicaid claims data.

BACKGROUND: Monitoring adherence to national recommendations for annual chlamydia screening of female adolescents and young adult women is important for targeting quality improvement interventions to improve low screening rates. However, accurate measurement of rates may vary depending on the data source used to determine eligible sexually-active women. METHODS: The 2001-2004 NHANES data linked with Medicaid administrative data by respondent's unique identifier, the 2011-2012 NHANES data, and the 2004 and 2010 Medicaid data were used in this cross-sectional analysis. We defined self-reported sexual activity by self-reported sexual behaviors, claim-identified sexual activity by reproductive-related claims among women who had ≥ one healthcare claim, HEDIS-defined sexual activity by reproductive-related claims among women who were enrolled in Medicaid for ≥330 days and had ≥ one healthcare claim, and chlamydia tests by claims submitted in the 12 months prior to the survey interview. RESULTS: Of Medicaid women aged 18-25 years, 91.5% self-reported to be sexually-active. Of self-reported sexually-active women aged 18-25 years, 92.0% had ≥ one healthcare claim in the 12 months prior to the survey interview; of this subpopulation, only 58.8% were enrolled in Medicaid for ≥ 330 days in the 12 months prior to the survey interview; of this further subpopulation, 74.1% had healthcare claims identifying them as sexually-active in the 12 months prior to the survey interview. Of HEDIS-defined sexually-active women, 42.4% had chlamydia testing. CONCLUSION: Our study suggests that the number of sexually-active women aged 18-25 years used as the denominator in the chlamydia testing measure could be significantly different, depending upon the definition applied and the data used. Our data highlight the limited representativeness of Medicaid population in the current HEDIS measure on chlamydia testing when a high proportion of women who were enrolled in Medicaid for <330 days had been excluded from the measure. The interventions that can improve the proportion of women who were enrolled in Medicaid for ≥ 330 days among all young Medicaid women are needed not only for improving health care services, but also for measuring quality of healthcare.

Cognitive-affective processing system analysis of intra-individual dynamics in collaborative therapeutic assessment: translating basic theory and research into clinical applications.

According to the cognitive-affective processing system (CAPS) model, behavior is a function of how the distinctive cognitive-affective system of the individual responds to one's subjective experience of the situation encountered. Thus an individual's maladaptive coping processes may be understood by identifying the nature of the situations that a client experiences as highly stressful and the psychological reactions they trigger. An initial study established the feasibility and utility of an Internet-based CAPS daily diary program; it was then used to facilitate a clinical stress-management intervention. The daily diary enabled researchers and clinicians to gather Highly-Repeated Within-Persons (HRWP) data on the situational features, cognitions, affect, and coping behaviors associated with daily life stress, which were then analyzed separately for each participant to identify each individual's unique and distinctive pattern of intra-individual dynamics. Results suggested that individuals differed reliably in the features of psychological situations that triggered stress and maladaptive coping behaviors. HRWP analysis of daily diary data enhanced the efficacy of clinical intervention, and clients' self-regulatory capabilities and life satisfaction were shown to increase over the course of the intervention. We discuss how our program of research fits into the larger goals of translational science and current NIMH clinical research priorities.

Internet-Based Approaches to Collaborative Therapeutic Assessment: New Opportunities for Professional Psychologists.

Collaborative (or therapeutic) assessment is an empirically supported procedure that involves the client as an active participant in the assessment process. Clients discuss data they provide with the assessor in a collaborative manner designed to provide insights and assist in setting mutually agreeable treatment goals. Internet-based procedures allow for ongoing (including daily) tracking of psychological variables and provision of immediate graphic feedback to therapists, clients, and clinical supervisors. As an example, we describe one such system: Evidence-Based Assessment System for Clinicians (EAS-C) that contains more than 30 brief and empirically validated assessment instruments that can be completed via the internet or smartphone. We also provide examples from a stress management intervention demonstrating how single-client data from a web-based daily stress and coping diary tied to the EAS-C were utilized to provide clients with individualized feedback, assess progress, identify idiographic patterns of cognitions, affect, and coping strategies, and test clinical hypotheses. Internet- and computer-based technological advances can improve service delivery and help bridge the gap that currently exists between science and practice.