Regional Variation in Laparoscopy Use for Elective Colon Cancer Treatment in Canada: The Importance of Fellowship Training Sites.

BACKGROUND: Over the last decade, use of laparoscopy for the treatment of colon cancer has been variable despite evidence of benefit, possibly reflecting surgeon expertise rather than other factors. OBJECTIVE: The purpose of this study was to examine the spatial variation in the use of laparoscopy for colon cancer surgery and to determine what factors may influence use. DESIGN: This was a population-based retrospective analysis from April 2008 to March 2015. SETTINGS: All Canadian provinces (excluding Quebec) were included. PATIENTS: The study included all patients ≥18 years of age undergoing elective colectomy for colon cancer. MAIN OUTCOME MEASURES: The primary outcome was laparoscopy use rates. Predictors of use included patient and disease characteristics, year of surgery, rurality, hospital and surgeon volumes, and distance from a colorectal fellowship training center. RESULTS: A total of 34,725 patients were identified, and 42% underwent laparoscopic surgery. Significant spatial variations in laparoscopy use were identified, with 95% of high-use clusters located ≤100 km and 98% of low-use clusters located >100 km from a colorectal fellowship center. There were no high-use clusters located around large academic centers without colorectal fellowships. At the individual level, patients living within 25 km and 26 to 100 km of a fellowship center were 2.6 and 1.6 times more likely to undergo laparoscopic surgery compared with those >100 km away (95% CI, 2.47-2.79, p < 0.00; 95% CI, 1.53-1.71, p < 0.001). Surgeon and hospital volumes were associated with increased rates of laparoscopy use (p < 0.001). LIMITATIONS: Data were obtained from an administrative database, and despite 85% to 95% published validity, they remain subject to misclassification, response, and measurement bias. CONCLUSIONS: Significant spatial variations in the use of laparoscopy for colon cancer surgery exist. After adjusting for patient and system factors, proximity to a colorectal fellowship training center remained a strong predictor of laparoscopy use. There remain regional variations in colon cancer treatment, with discrepancies in the surgical care offered to Canadian patients based solely on location. See Video Abstract at http://links.lww.com/DCR/B595. VARIACIN REGIONAL EN EL USO DE LAPAROSCOPIA PARA EL TRATAMIENTO ELECTIVO DEL CNCER DE COLON EN CANAD LA IMPORTANCIA DE LOS SITIOS DE CAPACITACIN PARA RESIDENTES: ANTECEDENTES:Durante la última década, la utilización de la laparoscopia para el tratamiento del cáncer de colon ha sido variable a pesar de la evidencia de beneficio; posiblemente reflejando la experiencia del cirujano, más que otros factores.OBJETIVO:Examinar la variación espacial en el uso de la laparoscopia para la cirugía del cáncer de colon y determinar qué factores pueden influir en la utilización.DISEÑO:Análisis retrospectivo poblacional de abril de 2008 a marzo de 2015.ENTORNO CLÍNICO:Todas las provincias canadienses (excepto Quebec).PACIENTES:Todos los pacientes> 18 años sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fueron las tasas de utilización de laparoscopia. Los predictores de uso incluyeron las características del paciente y la enfermedad, el año de la cirugía, la ruralidad, los volúmenes de hospitales y cirujanos, y la distancia a un centro de formación de residentes colorectales.RESULTADOS:Se identificaron 34.725 pacientes, 42% fueron sometidos a cirugía laparoscópica. Se identificaron variaciones espaciales significativas en el uso de laparoscopia, con el 95% de los conglomerados de alto uso ubicados a <100 km y el 98% de los conglomerados de bajo uso ubicados a> 100 km, desde un centro de residencia colorectal. No había grupos de alto uso ubicados alrededor de grandes centros académicos sin residentes colorrectales. A nivel individual, los pacientes que vivían dentro de los 25 km y 26-100 km de un centro de residentes tenían 2,6 y 1,6 veces más probabilidades de someterse a una cirugía laparoscópica, respectivamente, en comparación con aquellos a> 100 km de distancia (95% CI 2,47-2,79, p <0,00; IC del 95% 1,53-1,71, p <0,001). Los volúmenes de cirujanos y hospitales se asociaron con mayores tasas de utilización de laparoscopia (p <0,001).LIMITACIONES:Los datos se obtuvieron de una base de datos administrativa y, a pesar de una validez publicada del 85-95%, siguen sujetos a errores de clasificación, respuesta y sesgo de medición.CONCLUSIONES:Existen variaciones espaciales significativas en el uso de la laparoscopia para la cirugía del cáncer de colon. Después de ajustar por factores del paciente y del sistema, la proximidad a un centro de formación de residentes colorectales siguió siendo un fuerte predictor del uso de laparoscopia. Sigue habiendo variaciones regionales en el tratamiento del cáncer de colon, con discrepancias en la atención quirúrgica ofrecida a los pacientes canadienses basadas únicamente en la ubicación. Consulte Video Resumen en http://links.lww.com/DCR/B595.

Potential best practices for assessment of interprofessional team-ready behaviors on APPEs.

INTRODUCTION: To determine potential best practices for assessment of team-ready behaviors of pharmacy students participating in interprofessional advanced pharmacy practice experiences (APPEs). METHODS: Preceptors received training on two interprofessional behavioral assessment tools, the modified interprofessional collaborator assessment rubric (mICAR) and individual teamwork observation and feedback tool (iTOFT). Preceptors evaluated students at midpoint and end of APPE using each tool. Preceptors completed a utility survey on each tool to determine a preference. Focus groups were conducted with a subset of preceptors to elicit further perspectives. Experts in interprofessional education (IPE) and accrediting board members were interviewed to determine a national perspective of best practices. RESULTS: Nineteen preceptors participated in the study. Of these, 12 completed all components of the study. No significant difference was found comparing utility of mICAR to iTOFT, although mICAR trended toward being easier to use/understand (p = 0.29). Focus group participants (n = 8) felt using a tool led to enhanced feedback and interprofessional experiences and all preferred mICAR. IPE experts and accrediting board members perceived best practices to include using a tool that aligns with IPE collaborative competencies, embedding the tool into existing APPE evaluation processes, and that is applicable to all health professional learners/evaluators. CONCLUSIONS: Preceptors preferred mICAR to iTOFT, though no significant difference was observed. Additional research is needed to confirm these results and for best practices to emerge. Future steps include evaluating interprofessional teamwork using a tool in a 360-evaluation of the individual learner by preceptors outside of the learner's own profession.

Design and Content Validation of Three Setting-Specific Assessment Tools for Advanced Pharmacy Practice Experiences.

Objective. To develop and validate three assessment tools to measure student performance in clinical settings during required advanced pharmacy practice experiences (APPEs). Methods. Each assessment tool was developed by subject-matter experts and validated using three sources of evidence. Proposed content underwent a job-task analysis by external APPE preceptors, evaluating each outcome in terms of importance and frequency of opportunity for student demonstration. After implementation, tool performance was evaluated using a measure of item applicability and student achievement. Finally, a two-step grade verification process was developed and grade acceptance by preceptor was determined. A priori benchmarks for acceptable tool performance were established for each strategy. Results. The job-task analysis was completed by 131 preceptors (52% response), with items achieving a composite score from 1.08 to11.83 (possible range: 1=most valuable, 25=least valuable). The mean item applicability ranged from 91.3% to 94.1% (n=849 student assessments) during the first year. Preceptors accepted the tool-generated grade in 798 (94%) assessments. Conclusion. Data from three evaluation strategies provide evidence of effective design and use of three unique APPE setting-specific student assessment tools. Pharmacy programs can adopt similar methodologies to develop and validate their assessment tools.

Establishing nurse practitioner clinical practicums: Addressing fiscal realities.

As demand expands for nurse practitioner clinical practicum sites, the supply of preceptors is decreasing. The traditional model of in-kind clinical training is losing its foothold for a variety of reasons. A looming question is how quickly a "pay to precept" norm will grow and what will be the costs. The pay for precepting movement is discussed including current trends, costs, and emerging compensation models. To adapt to this trend, alternative ways of drawing the precepting value proposition are suggested, particularly decreasing preceptor and site demands while increasing students' readiness to enter clinical practicum and tapping into faculty expertise to add value to the partnership. The authors provide suggestions on building a strategy for rethinking the structure of student precepting arrangements and compensation models.

Survey of surgical training and experience of associate clinicians compared with medical officers to understand task-shifting in a low-income country.

Background: A workforce crisis exists in global surgery. One solution is task-shifting, the delegation of surgical tasks to non-physician clinicians or associate clinicians (ACs). Although several studies have shown that ACs have similar postoperative outcomes compared with physicians, little is known about their surgical training. This study aimed to characterize the surgical training and experience of ACs compared with medical officers (MOs) in Tanzania. Methods: All surgical care providers in Pwani Region, Tanzania, were surveyed. Participants reported demographic data, years of training, and procedures assisted and performed during training. They answered open-ended questions about training and post-training surgical experience. The median number of training cases for commonly performed procedures was compared by cadre using Wilcoxon rank sum and Student's t tests. The researchers performed modified content analysis of participants' answers to open-ended questions on training needs and experiences. Results: A total of 21 ACs and 12 MOs participated. ACs reported higher exposure than MOs to similar procedures before their first independent operation (median 40 versus 17 cases respectively; P = 0·031). There was no difference between ACs and MOs in total training surgical volume across common procedures (median 150 versus 171 cases; P = 0·995). Both groups reflected similarly upon their training. Each cadre relied on the other for support and teaching, but noted insufficient specialist supervision during training and independent practice. Conclusions: ACs report similar training and operative experience compared with their physician colleagues in Tanzania.

Antecedentes: La falta de cirujanos en determinadas áreas geográficas es flagrante. Una posible solución es el intercambio de tareas, es decir, la delegación de tareas quirúrgicas en personal sanitario no médico o en clínicos asociados (associate clinicians, AC). Si bien varios estudios han demostrado que los AC obtienen resultados postoperatorios similares a los de los médicos, hay poco información acerca de su entrenamiento quirúrgico. Este estudio tuvo como objetivo caracterizar la capacitación quirúrgica y la experiencia de los AC en comparación con los médicos titulados (medical officer, MO) en Tanzania. Métodos: En este estudio, se encuestaron todos los proveedores de atención quirúrgica de la Región de Pwani, Tanzania. Los participantes proporcionaron datos demográficos, años de entrenamiento y número y tipo de procedimientos realizados y a los que se había asistido durante el periodo de capacitación. Además, respondieron a preguntas abiertas sobre el entrenamiento y su experiencia quirúrgica posterior al entrenamiento. Se comparó la mediana del número de procedimientos más realizados por cada grupo mediante la suma de rangos de Wilcoxon y la prueba de la t de Student. Los investigadores realizaron un análisis del contenido de las respuestas a las preguntas abiertas sobre las necesidades y la experiencia durante la etapa de entrenamiento. Resultados: En el estudio participaron 21 ACs y 12 MOs. Los CA estuvieron expuestos a un mayor número procedimientos del mismo tipo antes de efectuar su primera operación de forma independiente en comparación con los OM (40 versus 17 casos, P = 0,031). No hubo diferencias en el volumen operatorio total de los procedimientos comunes entre los AC y los MO (150 versus 171 casos, P = 0,995). Las opiniones de los dos grupos sobre el entrenamiento fueron similares. Los dos grupos se dieron soporte entre ellos, pero quedó patente que la supervisión por parte de un especialista durante el entrenamiento y la práctica independiente era insuficiente. Conclusiones: En Tanzania, los asociados clínicos tienen entrenamientos y experiencias quirúrgicas similares a las de sus colegas médicos.

Providers' Perceptions and Training Needs for Counseling Adolescents Undergoing Voluntary Medical Male Circumcision.

Background: The majority of individuals who seek voluntary medical male circumcision (VMMC) services in sub-Saharan Africa are adolescents (ages 10-19 years). However, adolescents who obtain VMMC services report receiving little information on human immunodeficiency virus (HIV) prevention and care. In this study, we assessed the perceptions of VMMC facility managers and providers about current training content and their perspectives on age-appropriate adolescent counseling. Methods: Semistructured in-depth interviews were conducted with 33 VMMC providers in Tanzania (n = 12), South Africa (n = 9), and Zimbabwe (n = 12) and with 4 key informant facility managers in each country (total 12). Two coders independently coded the data thematically using a 2-step process and Atlas.ti qualitative coding software. Results: Providers and facility managers discussed limitations with current VMMC training, noting the need for adolescent-specific guidelines and counseling skills. Providers expressed hesitation in communicating complete sexual health information-including HIV testing, HIV prevention, proper condom usage, the importance of knowing a partner's HIV status, and abstinence from sex or masturbation during wound healing-with younger males (aged <15 years) and/or those assumed to be sexually inexperienced. Many providers revealed that they did not assess adolescent clients' sexual experience and deemed sexual topics to be irrelevant or inappropriate. Providers preferred counseling younger adolescents with their parents or guardians present, typically focusing primarily on wound care and procedural information. Conclusions: Lack of training for working with adolescents influences the type of information communicated. Preconceptions hinder counseling that supports comprehensive HIV preventive behaviors and complete wound care information, particularly for younger adolescents.

Excess Costs Associated with Possible Misdiagnosis of Alzheimer's Disease Among Patients with Vascular Dementia in a UK CPRD Population.

BACKGROUND: Prior diagnosis of Alzheimer's disease (AD) among patients later diagnosed with vascular dementia (VaD) has been associated with excess costs, suggesting potential benefits of earlier rule-out of AD diagnosis. OBJECTIVE: To investigate whether prior diagnosis with AD among patients with VaD is associated with excess costs in the UK. METHODS: Patients with a final VaD diagnosis, continuous data visibility for≥6 months prior to index date, and linkage to Hospital Episode Statistics data were retrospectively selected from de-identified Clinical Practice Research Datalink data. Patients with AD diagnosis before a final VaD diagnosis were matched to similar patients with no prior AD diagnosis using propensity score methods. Annual excess healthcare costs were calculated for 5 years post-index, stratified by time to final diagnosis. RESULTS: Of 9,311 patients with VaD, 508 (6%) had prior AD diagnosis with a median time to VaD diagnosis exceeding 2 years from index date. Over the entire follow-up period, patients with prior AD diagnosis had accumulated healthcare costs that were approximately GBP2,000 higher than those for matched counterparts (mostly due to higher hospitalization costs). Cost differentials peaked particularly in the period including the final VaD diagnosis, with excess costs quickly declining thereafter. CONCLUSION: Potential misdiagnosis of AD among UK patients with VaD resulted in substantial excess costs. The decline in excess costs following a final VaD diagnosis suggests potential benefits from earlier rule-out of AD.

Creating a Community Capacity Assessment to Identify Agency Outcomes Related to Occupational Therapy Student Community Partnerships.

Service-learning experiences immerse students in authentic situations and build partnerships with community agencies to support the health of those we serve in practice. Most occupational therapy curriculum evaluations do not systematically capture community agency benefits. Through the use of qualitative interviews and Q Methodology, the Community Agency Capacity Questionnaire (CACQ) was developed to capture the agency experience in these partnerships. This paper describes the iterative analytic process that resulted in the CACQ with 29 statements covering 6 domains: programming, evaluation, partnership, staff, funding, and marketing. The CACQ offers a means to identify outcomes from the service-learning partners' perspective.

Is there a relationship between the diversity characteristics of nursing students and their clinical placement experiences? A literature review.

BACKGROUND: There has been an increase in ethno-cultural, linguistic, and socio-demographical diversity in students enrolling in undergraduate nursing programs. Diversity also involves other characteristics, but little is known about how diversity impacts on the clinical experiences of nursing students. AIM: The aim of this review is to identify studies which describe the clinical placement experiences of nursing students who have a broad range of diversity characteristics. METHODS: Major databases were searched and original studies published from 2003 to 30 June 2013 were eligible for inclusion. An expanded definition of diversity was used to include characteristics such as ethnicity, language, age, religion, gender, socioeconomic status, carer responsibilities, sexual orientation and special needs/disability. FINDINGS: Male gender and speaking English as a second language are diversity characteristics associated with a less positive clinical experience. These students are also more likely to leave their nursing program. Mature-aged students and those from ethnic minority groups were also noted to have a less positive clinical experience and in some cases, this also increased attrition. However, it was difficult to determine the impact of these characteristics alone as they appeared to be linked with other characteristics such as financial difficulties and carer responsibilities in the case of mature-aged students, and language and international student status in the case of ethnicity. CONCLUSIONS: Given the significant benefits associated with preparing a diverse nursing workforce, it is an imperative to better understand the impact of diversity on nursing students to ensure that every placement becomes a positive and valuable learning experience.

Increasing quality and quantity of student placements in smaller rural health services: It can be done.

PROBLEM: Future rural nursing and midwifery workforce shortage and current shortage of placements for undergraduate nursing and midwifery students. DESIGN: Developmental evaluation. SETTING: Five small hospitals and a regional community health service. KEY MEASURES OF IMPROVEMENT: Increased number of placements available for students; sustainable, quality clinical placement system in place for the future. STRATEGIES FOR CHANGE: Clinical facilitators developed a clinical facilitation model and resources that increased quality and quantity of student placements, assisted clinicians to provide higher quality teaching to students, enabled students to develop skills in rural health care service provision and enhanced knowledge around future career options. EFFECTS OF CHANGE: Placement targets were met and all health services involved chose to continue the model of clinical facilitation developed after project funding ceased. The clinical education skills developed by staff under the project remain in the region to support future students. LESSONS LEARNT: It is possible to create a sustainable, high-quality, rural placement experience for larger numbers of nursing and midwifery students. Funding sources are available to continue the clinical facilitation model in to the future, but for it to work optimally, a steady supply of students across the year is required.

Pharmacy practice in Virginia in 2011.

BACKGROUND: Opportunities for pharmacy practice reform exist at state and national levels. The Virginia Commonwealth University (VCU) School of Pharmacy created a working group to assess these opportunities with a mission to advance pharmacy practice in Virginia. OBJECTIVES: To assess the perceptions of chronic and acute care pharmacy practice and confidence in providing patient care and medication therapy management (MTM) activities and characterize current work activities of pharmacists in Virginia. METHODS: A cross-sectional, online survey was used. VCU School of Pharmacy pharmacist preceptors, students, and faculty members were eligible. The questionnaire contained items that assessed perceptions of chronic and acute care pharmacy practice and confidence in patient care and MTM activities. Demographic and practice site characteristics were also collected. RESULTS: A total of 974 preceptors, 515 students, and 78 faculty members were invited to participate, and 335 preceptors, 155 students, and 41 faculty members had usable responses, yielding response rates of 34%, 30%, and 53%, respectively. Preceptors, students, and faculty members favorably viewed direct patient care roles in the chronic and acute care settings. Pharmacists were very confident or confident in performing many patient care and MTM activities. They were least confident in considering genetic characteristics when adjusting medications and creating business plans for new services. Many pharmacists in chronic and acute care settings provided some type of patient care service, but few were regularly providing services. Inadequate time, staffing, and reimbursement, and lack of perceived value from patients and providers were most frequently cited as barriers to service provision. CONCLUSIONS: VCU preceptors, students, and faculty members overwhelmingly believe that pharmacists should provide direct patient care and MTM activities. To transform pharmacy practice, it will be important to define the pharmacist's role, responsibilities, and expected outcomes and to consider time, staffing, and compensation as well as to engage patients and providers.

Comparison of extramural clinical rotation days: did the Pipeline program make a difference?

Extramural clinical rotations are implemented by dental schools for a combination of clinical and didactic or behavioral goals. In the United States, the Pipeline, Profession, and Practice: Community-Based Dental Education program was launched to increase the number of underrepresented minority students who are recruited and retained in dental education, to expand the dental curriculum in cultural competence, and to incorporate community-based extramural rotations into the dental schools' clinical curriculum. The objective of this study was to conduct an impact analysis regarding the change in number of extramural clinical rotation weeks for Pipeline and non-Pipeline program students over the time period of 2003 to 2007. National data from the American Dental Education Association's senior survey and other secondary sources were used to determine what student, school, and community characteristics are associated with a difference in the student report of the number of required weeks they expect to spend during their last year in dental school providing care at extramural clinic settings. Students reported a mean of 7.2 weeks for Pipeline students and 6.4 weeks for non-Pipeline students in 2003, increasing to 8.2 weeks for Pipeline students and 6.6 weeks for non-Pipeline students (p<0.05) in 2007. The multivariable model showed the Pipeline program increased significantly the number of rotational weeks reported by students. Three other variables significantly increased rotation weeks: 1) a lower baseline number of reported weeks in community rotations; 2) a lower level of debt student reported upon graduation; and 3) student reports of a higher orientation toward service to others as a reason to enter dentistry.

The use and compensation of community preceptors in U.S. medical schools.

PURPOSE: To better understand how U.S. medical schools are using and compensating community preceptors. METHOD: In 1995, the authors sent questionnaires to associate deans for education at all 125 U.S. medical schools. Each questionnaire asked whether that school used community preceptors to teach students and, if so, from what disciplines community preceptors came, at what sites community preceptors taught students, how community preceptors were compensated, and how these factors varied for each year of medical school. RESULTS: One hundred schools (80%) completed the questionnaire. Ninety-six reported using community preceptors. Primary care physicians were used most often, and private practices were the dominant teaching location. A clinical academic appointment was the most common compensation. Few schools compensated community preceptors monetarily. Community preceptors' involvement was substantial in all four years, but greatest in year three. CONCLUSION: Community preceptors are widely used in educating medical students, especially in year three. More recognition and better compensation of these important educators is necessary.

The effects of precepting on and the support desired by community-based preceptors in Iowa.

PURPOSE: To survey community-based family physician-preceptors about teaching costs, issues, and support desired. METHOD: In late 1994 a questionnaire was mailed to all 139 community family physicians who served as preceptors for the University of Iowa College of Medicine's third-year family practice preceptorship. The questionnaire contained items regarding teaching costs and the kinds of assistance desired from the university, the difficult and enjoyable aspects of precepting, and demographic data. Analyses were done to explore the associations between the preceptors' demographic variables and the effects of precepting on number of patients seen, practice income, and time spent at work. Also tested were the associations between the demographic variables and the kinds of support desired. RESULTS: In all, 130 surveys were returned, for a response rate of 94%. Nearly all of the respondents were Caucasian, male, and residency trained; 61% were in group practices. While precepting, 87% spent more time at work, 31% saw fewer patients, and 25% lost practice income; mean daily cost estimates of precepting were 51 more minutes at work, 1.4 fewer patients seen, and $34 in lost income. The support the preceptors were most interested in receiving was training in and access to computer-based information. Financial compensation was desired more often by the physicians whose first year of practice was after 1977 (p = .009). Motivations for precepting included positive interactions with students and enjoyment of teaching. Time concerns were overwhelmingly the most difficult aspect of precepting. CONCLUSION: The physicians-many of whom noted their enjoyment of teaching for its intrinsic rewards-spent a significant amount of extra time teaching while precepting, and thus both lost income and saw fewer patients. Medical schools need to recognize the valuable contributions of preceptors and find ways to support them.

Assessment of clinical service contracts between hospital pharmacies and colleges of pharmacy.

The purpose of this study is to assess the advantages and disadvantages of various annual financial clinical contract options between the Atlanta metropolitan area hospital and the Mercer University Southern School of Pharmacy (Atlanta, GA). Forty-five surveys with 17 statements in a Likert scale format were mailed to all directors, clinical staff of each hospital (adjunct faculty), and full-time clinical faculty to validate the perceived advantages and disadvantages of financial contracts between their hospital and the School of Pharmacy. The survey questionnaire was returned by 84% of the participants. Survey results indicate that the School of Pharmacy and area hospital pharmacies appear to have benefited from this marriage of common interests in clinical program development with 79% agreeing that the overall benefits of the educational affiliation and contract out-weighed the disadvantages.