Disease activity trajectories in juvenile dermatomyositis from childhood to adulthood.

OBJECTIVES: To assess whether there are identifiable subgroups of disease activity trajectory in a population of juvenile dermatomyositis (JDM) patients-followed throughout childhood and into adulthood-and determine factors that predict those trajectory groupings. METHODS: This is a retrospective, longitudinal inception cohort of patients with idiopathic inflammatory myopathies, largely JDM. We sought to identify baseline factors that predict membership into different groups (latent classes) of disease activity trajectory. RESULTS: A total of 172 patients (64% females), with median age at diagnosis of 7.7 years, were analyzed. We studied 4,725 visits (1,471 patient-years). We identified 3 latent classes of longitudinal disease activity, as measured by the modified disease activity score (DASm), with distinct class trajectories predicted by DASm at baseline, and by the changes of DASm from either baseline to 3 months or baseline to 6 months (early response to therapy). In the analysis in which DASm at baseline and the changes of DASm from baseline to 6 months are included as predictors, Class 1 (10%) has persistently high disease activity, Class 2 (34%) is characterized by moderate disease activity, and Class 3 (56%) is characterized by individuals with a high early disease activity but an apparently good response to treatment and long-term low disease activity. CONCLUSION: High early disease activity, and treatment resistance in the first few months, predict a more chronic longitudinal course of JDM.

Early Abnormal Nailfold Capillary Changes Are Predictive of Calcinosis Development in Juvenile Dermatomyositis.

OBJECTIVE: The long-term outcomes of juvenile dermatomyositis (JDM) are more favorable in recent years. However, calcinosis is still among the complications that can cause serious functional impairment. Little is known about the pathogenesis and risk factors of calcinosis. The aim of this study is to determine risk factors for the development of calcinosis in JDM. METHODS: This was a single-center, retrospective cohort study. All patients were diagnosed and followed at the multidisciplinary JDM clinic of The Hospital for Sick Children, from January 1, 1989, until May 31, 2018. To investigate predictors of incident calcinosis, Cox regression analysis was performed. RESULTS: A total of 172 patients met inclusion criteria, with a median age at diagnosis of 7.7 years (IQR 4.9-12.1), and a median follow-up of 8.5 years (IQR 3.4-12.6, range 0.1-28.3). The only risk factor significantly associated with the development of calcinosis in the univariate analysis was nailfold abnormality at baseline (hazard ratio [HR] 4.86, P = 0.03). In multivariable analysis, including nailfold abnormality, age of diagnosis, sex, and duration from onset to diagnosis, the only statistically significant risk factor for calcinosis was the presence of nailfold abnormalities (HR 4.98, P = 0.03). Further, calcinosis was significantly increased in patients with a chronic course (chi-square 25.8, P < 0.001). CONCLUSION: The presence of abnormal nailfold capillary changes at baseline is predictive for the development of calcinosis in children with idiopathic inflammatory myopathies.

Results From the 2020 Canadian Rheumatology Association's Workforce and Wellness Survey.

OBJECTIVE: The Canadian Rheumatology Association (CRA) launched the Workforce and Wellness Survey to update the Canadian rheumatology workforce characteristics. METHODS: The survey included demographic and practice information, pandemic effects, and the Mini Z survey to assess burnout. French and English survey versions were distributed to CRA members electronically between October 14, 2020, and March 5, 2021. The number of full-time equivalent (FTE) rheumatologists per 75,000 population was estimated from the median proportion of time in clinical practice multiplied by provincial rheumatologist numbers from the Canadian Medical Association. RESULTS: Forty-four percent (183/417) of the estimated practicing rheumatologists (149 adult; 34 pediatric) completed the survey. The median age was 47 years, 62% were female, and 28% planned to retire within the next 5-10 years. Respondents spent a median of 65% of their time in clinical practice. FTE rheumatologists per 75,000 population were 0.62 nationally and ranged between 0.00 and 0.70 in each province/territory. This represents a deficit of 1-78 FTE rheumatologists per province/territory and 194 FTE rheumatologists nationally to meet the CRA's workforce benchmark. Approximately half of survey respondents reported burnout (51%). Women were more likely to report burnout (OR 2.86, 95% CI 1.42-5.93). Older age was protective against burnout (OR 0.95, 95% CI 0.92-0.99). As a result of the pandemic, 97% of rheumatologists reported spending more time engaged in virtual care. CONCLUSION: There is a shortage of rheumatologists in Canada. This shortage may be compounded by the threat of burnout to workforce retention and productivity. Strategies to address these workforce issues are needed urgently.

An Advanced Clinician Practitioner in Arthritis Care (ACPAC) Maintains a Positive Patient Experience While Increasing Capacity in Rheumatology Community Care.

PURPOSE: This study describes patient care experiences of solo-rheumatologist and co-managed care models utilizing an Advanced Clinician Practitioner in Arthritis Care-trained Extended Role Practitioner (ACPAC-ERP) in three community rheumatology practices. MATERIALS AND METHODS: Patients with inflammatory arthritis (IA) were assigned to care provided by one of three (2 senior, 1 early-career) community-based rheumatologists (usual care), or an ACPAC-ERP (co-managed care) for the 6-months following diagnosis. Patient experiences were surveyed using validated measures of patient satisfaction (Patient Doctor Interaction Scale-PDIS), global ratings of confidence and satisfaction, referral patterns, disease activity (RADAI) and self-perceived disability (HAQ-Disability) as well as demographic information. Practice capacity was evaluated 18-months prior to, and across, the study period. RESULTS: Of 55 participants (mean age 56.6 years, 61.8% female), 33 received co-managed care. Most participants were diagnosed with rheumatoid arthritis (65.5%) with a median symptom duration of 1.1 years. At 6-months, patients from both models of care were equally satisfied in terms of the information provided (usual care 4.6 vs co-managed care 4.7/5=greater satisfaction), rapport with health-care provider (4.6 vs 4.6/5) and having needs met (4.7 vs 4.5/5). Overall satisfaction was high (87.2 vs 85.3/100=completely satisfied) as was confidence in the system by which care was received (85.0 vs 82.1/100=completely confident). Usual care patients reported higher perceived disability than co-managed patients (HAQ-Disability 0.5 vs 0.2/3=unable to do). Significant differences in overall RADAI score (p=0.014) were found between the two models. The senior rheumatologist, with a previously saturated practice, attained a 37% capacity increase for new patients utilizing the co-managed care model. CONCLUSION: The ACPAC-ERP model was equivalent to the solo-rheumatologist model with regard to patient experience and satisfaction. A co-management model utilizing a highly trained ACPAC-ERP can increase capacity in community rheumatology clinics for patients newly diagnosed with IA while maintaining confidence and satisfaction with their care.

Measuring Advanced/Extended Practice Roles in Arthritis and Musculoskeletal Care in Canada.

OBJECTIVE: Our objective was to characterize Canadian workforce attributes of extended role practitioners (ERPs) in arthritis care. METHODS: We used an exploratory, mixed-methods study that was based on the Canadian Rheumatology Association's Stand Up and Be Counted Rheumatologist Workforce Survey (2015). An anonymous online survey was deployed to groups of non-physician health care professionals across Canada who potentially had post-licensure training in arthritis care. Demographic and practice information were elicited. Qualitative responses were analyzed using grounded theory techniques. RESULTS: Of 141 respondents, 91 identified as practicing in extended role capacities. The mean age of ERP respondents was 48.7; 87% were female, and 41% of ERPs planned to retire within 5 to 10 years. Respondents were largely physical or occupational therapists by profession and practiced in urban/academic (46%), community (39%), and rural settings (13%). Differences in practice patterns were noted between ERPs (64.5%) and non-ERPs (34.5%), with more ERPs working in extended role capacities while retaining activities reflective of their professional backgrounds. Most respondents (95%) agreed that formal training is necessary to work as an ERP, but only half perceived they had sufficient training opportunities. Barriers to pursuing training were varied, including personal barriers, geographic barriers, patient-care needs, and financial/remuneration concerns. CONCLUSION: To our knowledge, no previous studies have assessed the workforce capacity or the perceived need for the training of ERPs working in arthritis and musculoskeletal care. Measurement is important because in these health disciplines, practitioners' scopes of practice evolve, and ERPs integrate into the Canadian health care system. ERPs have emerged to augment provision of arthritis care, but funding for continuing professional development opportunities and for role implementation remains tenuous.

Clinical spectrum and therapeutics in Canadian patients with anti-melanoma differentiation-associated gene 5 (MDA5)-positive dermatomyositis: a case-based review.

The objective of the study was to determine the clinical features and treatment course in Canadian patients with dermatomyositis (DM) associated with the anti-melanoma differentiation-associated gene 5 antibody (MDA5). A retrospective chart review of consecutive patients with anti-MDA5 antibody DM from two Canadian tertiary care centre between 2014 and 2018 was done. Twenty-one consecutive cases of anti-MDA5-positive DM were identified. Median age at diagnosis was 52 years, 71% Asians, predominantly Chinese, and 29% Caucasians. In this case series, all patients had either typical DM rash, or vasculopathy and ulceration unique to anti-MDA5-positive DM. 38% of the patients had rapid progressive (RP)-interstitial lung disease (RP-ILD), 33% had chronic ILD and 29% had asymptomatic ILD. Anti-Ro52 positivity was more prevalent in RP-ILD. Mortality was high in the RP-ILD group, with five deaths in eight patients. Lung transplant was life-saving intervention for three of the RP-ILD patients who survived. A review of the literature in treating RP-ILD associated with anti-MDA5 is presented. Although evidence is limited to small case series, cyclophosphamide (CYC) for refractory skin lesions, and CYC or mycophenolate mofetil plus a calcineurin inhibitor or rituximab (RTX) for RP-ILD appear efficacious. This is the largest North American case series of anti-MDA5-positive DM patients to date. There is a wide spectrum of clinical presentation of this entity. Survival is poor in those with RP-ILD; early aggressive immunosuppression and timely lung transplant were life-saving in our patients with RP-ILD.

Telemedicine delivery of patient education in remote Ontario communities: feasibility of an Advanced Clinician Practitioner in Arthritis Care (ACPAC)-led inflammatory arthritis education program.

OBJECTIVE: Telemedicine-based approaches to health care service delivery improve access to care. It was recognized that adults with inflammatory arthritis (IA) living in remote areas had limited access to patient education and could benefit from the 1-day Prescription for Education (RxEd) program. The program was delivered by extended role practitioners with advanced training in arthritis care. Normally offered at one urban center, RxEd was adapted for videoconference delivery through two educator development workshops that addressed telemedicine and adult education best practices. This study explores the feasibility of and participant satisfaction with telemedicine delivery of the RxEd program in remote communities. MATERIALS AND METHODS: Participants included adults with IA attending the RxEd program at one of six rural sites. They completed post-course program evaluations and follow-up interviews. Educators provided post-course feedback to identify program improvements that were later implemented. RESULTS: In total, 123 people (36 in-person and 87 remote, across 6 sites) participated, attending one of three RxEd sessions. Remote participants were satisfied with the quality of the video-conference (% agree/strongly agree): could hear the presenter (92.9%) and discussion between sites (82.4%); could see who was speaking at other remote sites (85.7%); could see the slides (95.3%); and interaction between sites adequately facilitated (94.0%). Educator and participant feedback were consistent. Suggested improvements included: use of two screens (speaker and slides); frontal camera angles; equal interaction with remote sites; and slide modifications to improve the readability on screen. Interview data included similar constructive feedback but highlighted the educational and social benefits of the program, which participants noted would have been inaccessible if not offered via telemedicine. CONCLUSION: Study findings confirm the feasibility of delivering the RxEd program to remote communities by using telemedicine. Future research with a focus on the sustainability of this and other models of technology-supported patient education for adults with IA across Ontario is warranted.

A prospective comparison of telemedicine versus in-person delivery of an interprofessional education program for adults with inflammatory arthritis.

Introduction We evaluated two modes of delivery of an inflammatory arthritis education program ("Prescription for Education" (RxEd)) in improving arthritis self-efficacy and other secondary outcomes. Methods We used a non-randomized, pre-post design to compare videoconferencing (R, remote using telemedicine) versus local (I, in-person) delivery of the program. Data were collected at baseline (T1), immediately following RxEd (T2), and at six months (T3). Self-report questionnaires served as the data collection tool. Measures included demographics, disorder-related, Arthritis Self-Efficacy Scale (SE), previous knowledge (Arthritis Community Research and Evaluation Unit (ACREU) rheumatoid arthritis knowledge questionnaire), coping efficacy, Illness Intrusiveness, and Effective Consumer Scale. Analysis included: baseline comparisons and longitudinal trends (R vs I groups); direct between-group comparisons; and Generalized Estimating Equations (GEE) analysis. Results A total of 123 persons attended the program (I: n = 36; R: n = 87) and 111 completed the baseline questionnaire (T1), with follow-up completed by 95% ( n = 117) at T2 and 62% ( n = 76) at T3. No significant baseline differences were found across patient characteristics and outcome measures. Both groups (R and I) showed immediate effect (improved arthritis SE, mean change (95% confidence interval (CI)): R 1.07 (0.67, 1.48); I 1.48 (0.74, 2.23)) after the program that diminished over six months (mean change (95% CI): R 0.45 (-0.1, 0.1); I 0.73 (-0.25, 1.7)). For each of the secondary outcomes, both groups showed similar trends for improvement (mean change scores (95% CI)) over time. GEE analysis did not show any meaningful differences between groups (R vs I) over time. Discussion Improvements in arthritis self-efficacy and secondary outcomes displayed similar trends for I and R participant groups.

Genetic Myopathies Initially Diagnosed and Treated as Inflammatory Myopathy.

OBJECTIVES: Differentiating genetic myopathies from inflammatory myopathies can be challenging because of multiple overlapping clinical features. Examples are presented to highlight important clinical features that assist in the differentiation between the two. METHODS: Clinical features including age at onset, history, pattern of weakness, serum creatine kinase activity, electromyography findings, and muscle biopsies are reported in six patients initially thought to have an inflammatory myopathy in whom the final diagnosis was a genetic myopathy. RESULTS: All six patients met Bohan and Peter criteria for at least probable idiopathic polymyositis and were subsequently found to have a genetic myopathy (4 DYSF, RYR1, and GNE). The key distinguishing clinical were minimal to no response to immunosuppression and atypical involvement of distal muscles in the majority of cases. CONCLUSIONS: Patients diagnosed with inflammatory myopathies should be reevaluated for the possibility of a genetic myopathy if they fail to respond to a course of disease-modifying agents and/or there is atypical distal muscle involvement.

Don't let up: implementing and sustaining change in a new post-licensure education model for developing extended role practitioners involved in arthritis care.

KEY MESSAGE: Across a 9-year period, the Advanced Clinician Practitioner in Arthritis Care program has achieved a set of short-term "wins" giving direction and momentum to the development of new roles for health care practitioners providing arthritis care. IMPLICATION: This is a viable model for post-licensure training offered to multiple allied health professionals to support the development of competent extended role practitioners (extended scope practice). Challenges at this critical juncture include: retain focus, drive, and commitment; develop academic and financial partnerships transferring short-term success to long-term sustainability; advanced, context-driven, system-level evaluation including fiscal outcome; health care policy adaptation to new human health resource development. SUPPORTING EVIDENCE: Success includes: completed 2-year health services research evaluating 37 graduates; leadership, innovation, educational excellence, and human health resource benefit awards; influential publications/presentations addressing post-licensure education/outcome, interprofessional collaboration, and improved patient care.

The patient perspective: arthritis care provided by Advanced Clinician Practitioner in Arthritis Care program-trained clinicians.

OBJECTIVE: To assess patient satisfaction with the arthritis care services provided by graduates of the Advanced Clinician Practitioner in Arthritis Care (ACPAC) program. MATERIALS AND METHODS: This was a cross-sectional evaluation using a self-report questionnaire for data collection. Participants completed the Patient-Doctor Interaction Scale, modified to capture patient-practitioner interactions. Participants completed selected items from the Group Health Association of America's Consumer Satisfaction Survey, and items capturing quality of care, appropriateness of wait times, and a comparison of extended-role practitioner (ERP) services with previously received arthritis care. RESULTS: A total of 325 patients seen by 27 ERPs from 15 institutions completed the questionnaire. Respondents were primarily adults (85%), female (72%), and living in urban areas (79%). The mean age of participants was 54 years (range 3-92 years), and 51% were not working. Patients with inflammatory (51%) and noninflammatory conditions (31%) were represented. Mean (standard deviation) Patient-Practitioner Interaction Scale subscale scores ranged from 4.50 (0.60) to 4.63 (0.48) (1 to 5 [greater satisfaction]). Overall satisfaction with the quality of care was high (4.39 [0.77]), as was satisfaction with wait times (referral to appointment, 4.27 [0.86]; in clinic, 4.24 [0.91]). Ninety-eight percent of respondents felt the arthritis care they received was comparable to or better than that previously received from other health care professionals. CONCLUSION: Patients were very satisfied with and amenable to arthritis care provided by graduates of the ACPAC program. Our findings provide early support for the deployment and integration of ACPAC ERPs into the Ontario health care system and should inform future evaluation at the patient level.

System integration and clinical utilization of the Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program-Trained Extended Role Practitioners in Ontario: a two-year, system-level evaluation.

BACKGROUND: The Advanced Clinician Practitioner in Arthritis Care (ACPAC) program was developed in 2005 to prepare experienced physical and occupational therapists to function as extended role practitioners (ERPs) within models of arthritis care across Ontario, Canada. PURPOSE: To examine the system-level integration and clinical utilization of the ACPAC program-trained ERP. METHOD: A longitudinal survey was administered to all ACPAC graduates over a two-year period (n=30). RESULTS: The majority of ERPs were physical therapists working in urban settings. Family physicians or physician specialists referred the majority of patients. The longest median wait time to access ERPs' services was 22 days. Half of the ERPs triaged patients, and most of those who did triage (75%) worked under medical directives. Approximately half (51.6%) of the patients seen had a diagnosis of osteoarthritis, followed by rheumatoid arthritis (14.7%). CONCLUSION: Understanding the system-level impact of this unique human resource can help to shape healthcare planning and delivery of care.

Evaluation of perceived collaborative behaviour amongst stakeholders and clinicians of a continuing education programme in arthritis care.

Successful implementation of new extended practice roles which transcend conventional boundaries of practice entails strong collaboration with other healthcare providers. This study describes interprofessional collaborative behaviour perceived by advanced clinician practitioner in arthritis care (ACPAC) graduates at 1 year beyond training, and relevant stakeholders, across urban, community and remote clinical settings in Canada. A mixed-method approach involved a quantitative (survey) and qualitative (focus group/interview) evaluation issued across a 4-month period. ACPAC graduates work across heterogeneous settings and are on teams of diverse size and composition. Seventy per cent perceived their team as actively working in an interprofessional care model. Mean scores on the Bruyère Clinical Team Self-Assessment on Interprofessional Practice subjective subscales were high (range: 3.66-4.26, scale: 1-5 = better perception of team's interprofessional practice), whereas the objective scale was lower (mean: 4.6, scale: 0-9 = more interprofessional team practices). Data from focus groups (ACPAC graduates) and interviews (stakeholders) provided further illumination of these results at individual, group and system levels. Issues relating to ACPAC graduate role recognition, as well as their deployment, integration and institutional support, including access to medical directives, limitation of scope of practice, remuneration conflicts and tenuous funding arrangements were barriers perceived to affect role implementation and interprofessional working. This study offers the opportunity to reflect on newly introduced roles for health professionals with expectations of collaboration that will challenge traditional healthcare delivery.

Prescription for education: development, evaluation, and implementation of a successful interprofessional education program for adults with inflammatory arthritis.

OBJECTIVE: To assess the feasibility of recruitment and standardize care delivery for an interprofessional program for inflammatory arthritis education (Prescription for Education, or RxEd), and to explore outcomes relevant to arthritis patient education. METHODS: A patient-based needs assessment and ongoing patient feedback guided program development. An interprofessional team was involved in developing program content and delivering and adapting the program to patient needs. A quasiexperimental, waitlisted control with crossover design was used to evaluate the program. Data were collected at baseline, immediately following intervention, at 6 months (when the crossover control group received intervention), and at 1 year. Self-report measures included demographics, disorder-related data, Arthritis Self-efficacy Scale, arthritis knowledge, coping efficacy, and illness intrusiveness. Analysis included baseline comparisons and longitudinal trends; direct between-group comparison at 6 months; and generalized estimating equations (GEE) analysis to evaluate the main effect of the intervention on the primary outcome (arthritis self-efficacy) and secondary outcomes. RESULTS: Program modifications based on patient input made recruitment possible. Forty-two persons participated (including 19 controls), with 93% followup at 1 year. Comparison of change shows moderate effect sizes (standardized effect size 0.5 to 0.7). GEE analysis showed significant main effect, before to after the program, in both groups for primary outcome (arthritis self-efficacy) and most secondary outcomes. CONCLUSION: Program feasibility was dependent on patient feedback. Our pilot study provides evidence that the RxEd program is feasible and improves arthritis self-efficacy and other outcomes.

Arthritis extended-role practitioners: impact on community practice (an exploratory study).

PURPOSE: We compared practice of extended role practitioners and experienced therapists without extended practice training to determine differences in assessment and management of clients with inflammatory arthritis, in preparation for a randomized controlled trial. METHODS: Retrospective review of randomly selected charts of extended-role trained occupational therapists or physiotherapists and from experienced therapists matched on therapist discipline, geographical location, and time of referral. Three trained reviewers used standardized forms to extract data independently. RESULTS: We reviewed 58 charts of adult clients with inflammatory arthritis. Compared with experienced therapists, extended-role practitioners were more likely to receive referrals specifically for assessments (52% vs. 14%); to treat clients with undifferentiated arthritis (48% vs. 10%); to document comorbidities (90% vs. 66%); to advocate on behalf of the client with the client's family, physician, or specialist (52% vs. 21%); to recommend or provide exercise or physical activity (86% vs. 62%); to educate clients about pain management (41% vs. 28%), energy conservation (24% vs. 14%), and posture (21% vs. 7%); to recommend splints (41% vs. 31%); and to refer for or recommend radiologic or laboratory assessments (14% vs. 3%). Experienced therapists were more likely to provide education about joint protection (41% vs. 31%), community resources (31% vs. 7%), and assistive devices (45% vs. 21%). CONCLUSIONS: We identified possible differences in practice between extended-role practitioners and experienced therapists without training for extended practice. Capturing these details in future studies evaluating the efficacy of extended role practitioner interventions will be important.

Development and Early Evaluation of an Inter-professional Post-licensure Education Programme for Extended Practice Roles in Arthritis Care.

PURPOSE: The Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program was developed to train experienced physical and occupational therapists within extended practice roles with the aim of facilitating optimal, timely, and appropriate delivery of health care to patients with arthritis. This paper presents (1) the development of the ACPAC Program and (2) performance across the programme, as well as early quantitative and qualitative changes in clinical practice roles for the 2006 through 2008 cohorts of ACPAC Program graduates (n=19). METHODS: Measurement of change in skills and knowledge involved standardized baseline and end-of-programme examinations as well as self-evaluation of a number of areas of clinical competence. Practice-focused surveys issued at baseline, mid-programme, and end of programme, as well as at 6 and 12 months after graduation, evaluated the practitioners' integration of advanced knowledge and skills acquired during the ACPAC Program into their extended practice roles. RESULTS: Participants significantly increased their scores on examinations of clinical knowledge (p<0.001) and skills (p<0.001) from baseline through programme completion. There was an increase in frequency of performance of clinical tasks and assumption of responsibilities related to their extended practice roles from the beginning to the end of the programme. The five areas that changed in relation to these new roles were increased clinical responsibilities, efficiencies in practice settings, roles as educational leaders and mentors in the field of arthritis care, inter-professional collaboration, and improved access to care for patients with arthritis, particularly in remote areas. CONCLUSION: Graduates of the ACPAC Program have demonstrated knowledge and skills for practising in extended roles that enhance the available human health resource pool for patients with arthritis.

Leading change in the transformation of arthritis care: development of an inter-professional academic-clinical education training model.

The Advanced Clinician Practitioner in Arthritis Care (ACPAC) program is a novel, competency-based, rigorously evaluated advanced clinical and academic educational program created in 2005 and hosted by St. Michael's Hospital and The Hospital for Sick Children, Toronto, Ontario. The program is offered to experienced physical and occupational therapists selected to engage in expanded scope of practice roles with the aim to provide optimal, timely and appropriate delivery of healthcare to patients with arthritis in academic, non-academic and remote community healthcare settings. The ACPAC program is offered at a critical time in the context of rapidly changing healthcare delivery, producing highly skilled advanced practitioners across Ontario central to the development of innovative models of chronic disease management in arthritis care. The processes driving change and the risks assumed thereof, as well as a description of the successes, challenges and shortcomings of the ACPAC program, are intended to be instructive to other healthcare facilities considering similar initiatives.