Training individuals to implement discrete-trial teaching procedures using behavioral skills training: A scoping review with implications for practice and research.

Behavioral skills training (BST) is an evidence-based approach for training individuals to implement discrete-trial teaching procedures. Despite the effectiveness of this approach, implementing BST can be time and resource intensive, which may interfere with a clinical organization's adoption of this training format. We conducted a scoping review of studies using BST components for training discrete-trial teaching procedures in peer-reviewed articles between 1977 and 2021. We identified 51 studies in 46 publications involving 354 participants. We coded descriptive data on (a) participant characteristics, (b) study characteristics, (c) training conditions (including instructions, modeling, rehearsal, and feedback), and (d) training outcomes. The results indicated that studies have primarily attempted to improve the efficacy and efficiency of BST by modifying or omitting common training components. We provide best-practice considerations for using BST to teach discrete-trial teaching procedures and offer a research agenda to guide future investigation in this area.

What is the best way to evaluate social prescribing? A qualitative feasibility assessment for a national impact evaluation study in England.

OBJECTIVES: Despite significant investment in social prescribing in England over the last decade, we still do not know if it works, or how models of social prescribing fit within wider health and care policy and practice. This study explores current service delivery structures and assesses the feasibility of a national evaluation of the link worker model. METHODS: Semi-structured interviews were conducted between May and September 2020, with 25 key informants from across social prescribing services in England. Participants included link workers, voluntary, community and social enterprise staff, and those involved in policy and decision-making for social prescribing services. Interview and workshop transcripts were analysed thematically, adopting a framework approach. RESULTS: We found differences in how services are provided, including by individual link workers, and between organisations and regions. Standards, referral pathways, reporting, and monitoring structures differ or are lacking in voluntary services as compared to clinical services. People can self-refer to a link worker or be referred by a third party, but the lack of standardised processes generated confusion in both public and professional perceptions of the link worker model. We identified challenges in determining the appropriate outcomes and outcome measures needed to assess the impact of the link worker model. CONCLUSIONS: The current varied service delivery structures in England poses major challenges for a national impact evaluation. Any future rigorous evaluation needs to be underpinned with national standardised outcomes and process measures which promote uniform data collection.

Changes in soft drinks purchased by British households associated with the UK soft drinks industry levy: a controlled interrupted time series analysis.

OBJECTIVE: To determine changes in household purchases of drinks 1 year after implementation of the UK soft drinks industry levy (SDIL). DESIGN: Controlled interrupted time series. PARTICIPANTS: Households reporting their purchasing to a market research company (average weekly n=22 091), March 2014 to March 2019. INTERVENTION: A two-tiered tax levied on soft drinks manufacturers, announced in March 2016 and implemented in April 2018. Drinks with ≥8 g sugar/100 mL (high tier) are taxed at £0.24/L, drinks with ≥5 to <8 g sugar/100 mL (low tier) are taxed at £0.18/L. MAIN OUTCOME MEASURES: Absolute and relative differences in the volume of, and amount of sugar in, soft drinks categories, all soft drinks combined, alcohol and confectionery purchased per household per week 1 year after implementation. RESULTS: In March 2019, compared with the counterfactual, purchased volume of high tier drinks decreased by 140.8 mL (95% CI 104.3 to 177.3 mL) per household per week, equivalent to 37.8% (28.0% to 47.6%), and sugar purchased in these drinks decreased by 16.2 g (13.5 to 18.8 g), or 42.6% (35.6% to 49.6%). Purchases of low tier drinks decreased by 170.5 mL (154.5 to 186.5 mL) or 85.8% (77.8% to 93.9%), with an 11.5 g (9.1 to 13.9 g) reduction in sugar in these drinks, equivalent to 87.8% (69.2% to 106.4%). When all soft drinks were combined irrespective of levy tier or eligibility, the volume of drinks purchased increased by 188.8 mL (30.7 to 346.9 mL) per household per week, or 2.6% (0.4% to 4.7%), but sugar decreased by 8.0 g (2.4 to 13.6 g), or 2.7% (0.8% to 4.5%). Purchases of confectionery and alcoholic drinks did not increase. CONCLUSIONS: Compared with trends before the SDIL was announced, 1 year after implementation, volume of all soft drinks purchased combined increased by 189 mL, or 2.6% per household per week. The amount of sugar in those drinks was 8 g, or 2.7%, lower per household per week. Further studies should determine whether and how apparently small effect sizes translate into health outcomes. TRIAL REGISTRATION NUMBER: ISRCTN18042742.

A clinician's guide to obesity prevention in the UK.

Across the UK, people's lives are being cut short because of obesity, and the lives of the most deprived members of our communities are being cut the most. The role of the medical professional in managing overweight and obesity is extensive, but, for many patients, maintaining a healthy weight needs to be supported by creating environments that help people to stay healthy in the first place. The building blocks of health are the environmental, commercial, economic and social factors that largely determine our health and wellbeing and impact our capability, opportunity and motivation to maintain healthy-weight behaviours. Although the role of the healthcare professional generally is to focus on the individual patient, clinicians can still influence these building blocks. Clinicians have the skills to create change, they often hold power in organisations with local to international impact and there are actions, big or small, that every clinician can take to improve obesity prevention. Here, we outline an environmental-behavioural framework for the primary prevention of obesity and consider the role of clinicians in catalysing change.

Correction: Anticipatory changes in British household purchases of soft drinks associated with the announcement of the Soft Drinks Industry Levy: A controlled interrupted time series analysis.

[This corrects the article DOI: 10.1371/journal.pmed.1003269.].

The role of health protection teams in reducing health inequities: findings from a qualitative study.

INTRODUCTION: The UK Health Security Agency's (UKHSA) Health Protection Teams (HPTs) provide specialist public health advice and operational support to NHS, local authorities and other agencies in England. The development of a three-year UKHSA Health Equity strategy creates a unique opportunity for HPTs to reduce health inequities within their work. AIMS: This study aimed to understand current health equity activities and structures within HPTs, and to propose future HPT-led health equity activities. METHODS: Between November 2021 - March 2022, HPT staff from the nine UKHSA regions were invited to participate in a semi-structured interview or focus group. RESULTS: Twenty-seven participants covering all nine UKHSA regions took part in a total of 18 interviews and two focus groups. There was enthusiasm to address health inequity, and many reported this as their motivation for working in public health. All HPTs routinely engaged in health equity work including, variously: liaising with other organisations; advocacy in case and outbreak management meetings; developing regional HPT health equity action plans; and targeting under-served populations in day-to-day work. HPT staff discussed the challenge of splitting their time between reacting to health protection incidents (e.g., COVID as the main priority at the time) and pro-active work (e.g., programmes to reduce risk from external hazards for vulnerable populations). Although COVID had raised awareness of health inequities, knowledge of health equity among the professionally diverse workforce appeared variable. Limited evidence about effective interventions, and lack of clarity about future ways of working with other organisations were also shared as barriers to tackling health inequities. CONCLUSION: HPTs welcomed the development of UKHSA's health equity strategy, and through this study identified opportunities where HPTs can influence, support and lead on tackling health inequities. This includes embedding health equity into HPTs' acute response activities, stakeholder working, and staff management. This study also identified a need for health equity training for HPTs to improve knowledge and skills, utilising evidence-based approaches to health equity. Finally, we have identified areas where HPTs can lead, for example using brief advice interventions and through developing resources, such as standard operating procedures that focus on vulnerable populations. These findings will support a more integrated approach to addressing health equity through health protection work.

Evaluation of deep learning based implanted fiducial markers tracking in pancreatic cancer patients.

Real-time target position verification during pancreas stereotactic body radiation therapy (SBRT) is important for the detection of unplanned tumour motions. Fast and accurate fiducial marker segmentation is a Requirement of real-time marker-based verification. Deep learning (DL) segmentation techniques are ideal because they don't require additional learning imaging or prior marker information (e.g., shape, orientation). In this study, we evaluated three DL frameworks for marker tracking applied to pancreatic cancer patient data. The DL frameworks evaluated were (1) a convolutional neural network (CNN) classifier with sliding window, (2) a pretrained you-only-look-once (YOLO) version-4 architecture, and (3) a hybrid CNN-YOLO. Intrafraction kV images collected during pancreas SBRT treatments were used as training data (44 fractions, 2017 frames). All patients had 1-4 implanted fiducial markers. Each model was evaluated on unseen kV images (42 fractions, 2517 frames). The ground truth was calculated from manual segmentation and triangulation of markers in orthogonal paired kV/MV images. The sensitivity, specificity, and area under the precision-recall curve (AUC) were calculated. In addition, the mean-absolute-error (MAE), root-mean-square-error (RMSE) and standard-error-of-mean (SEM) were calculated for the centroid of the markers predicted by the models, relative to the ground truth. The sensitivity and specificity of the CNN model were 99.41% and 99.69%, respectively. The AUC was 0.9998. The average precision of the YOLO model for different values of recall was 96.49%. The MAE of the three models in the left-right, superior-inferior, and anterior-posterior directions were under 0.88 ± 0.11 mm, and the RMSE were under 1.09 ± 0.12 mm. The detection times per frame on a GPU were 48.3, 22.9, and 17.1 milliseconds for the CNN, YOLO, and CNN-YOLO, respectively. The results demonstrate submillimeter accuracy of marker position predicted by DL models compared to the ground truth. The marker detection time was fast enough to meet the requirements for real-time application.

Reliability and validity of using structured visual-inspection criteria to interpret latency-based functional analysis outcomes.

Prior research has evaluated the reliability and validity of structured visual inspection (SVI) criteria for interpreting functional analysis (FA) outcomes (Hagopian et al., 1997; Roane et al., 2013). We adapted these criteria to meet the unique needs of interpreting latency-based FA outcomes and examined the reliability and validity of applying SVI criteria to 43 previously published latency-based FA datasets. Overall, raters agreed on SVI-determined FA outcomes (98% of functions and 95% of cases) and these outcomes corresponded well to the interpretations provided by the authors of these 43 datasets (94% of functions and 88% of cases), indicating a high degree of reliability and concurrent validity. Our findings suggest that the use of SVI criteria may (a) serve as an objective aid in the identification of behavioral function(s), (b) produce high levels of agreement among expert raters, and (c) serve as a useful resource when teaching students how to interpret latency-based FA outcomes.

MArkerless image Guidance using Intrafraction Kilovoltage x-ray imaging (MAGIK): study protocol for a phase I interventional study for lung cancer radiotherapy.

INTRODUCTION: In radiotherapy, tumour tracking leads the radiation beam to accurately target the tumour while it moves in a complex and unpredictable way due to respiration. Several tumour tracking techniques require the implantation of fiducial markers around the tumour, a procedure that involves unnecessary risks and costs. Markerless tumour tracking (MTT) negates the need for implanted markers, potentially enabling accurate and optimal radiotherapy in a non-invasive way. METHODS AND ANALYSIS: We will perform a phase I interventional trial called MArkerless image Guidance using Intrafraction Kilovoltage x-ray imaging (MAGIK) to investigate the technical feasibility of the MTT technology developed at the University of Sydney (sponsor). 30 participants will undergo the current standard of care lung stereotactic ablative radiation therapy, with the exception that kilovoltage X-ray images will be acquired continuously during treatment delivery to enable MTT. If MTT indicates that the mean lung tumour position has shifted >3 mm, a warning message will be displayed to indicate the need for a treatment intervention. The radiation therapist will then pause the treatment, shift the treatment couch to account for the shift in tumour position and resume the treatment. Participants will be implanted with fiducial markers, which act as the ground truth for evaluating the accuracy of MTT. MTT is considered feasible if the tracking accuracy is <3 mm in each dimension for >80% of the treatment time. ETHICS AND DISSEMINATION: The MAGIK trial has received ethical approval from The Alfred Human Research Ethics Committee and has been registered with ClinicalTrials.gov with the Identifier: NCT04086082. Estimated time of first recruitment is early 2022. The study recruitment and data analysis phases will be performed concurrently. Treatment for all 30 participants is expected to be completed within 2 years and participant follow-up within a total duration of 7 years. Findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT04086082; Pre-result.

Updated Strategies for Making Regular Contact With the Scholarly Literature.

The Ethics Code for Behavior Analysts (Behavior Analyst Certification Board, 2020a) states that behavior analysts must provide services based on the published scientific evidence (Code 2.01, "Providing Effective Treatment") and maintain competence by reading relevant scholarly literature (Code 1.06, "Maintaining Competence"). Carr and Briggs (2010) acknowledged several potential barriers that might prevent behavior analysts from pursuing this obligation and offered helpful recommendations for circumventing these barriers. Although the nature of these barriers has primarily stayed the same since the publication of Carr and Briggs, the profession and field have grown more complex over the past decade, and several additional barriers have emerged. Luckily, technological advances and resources recently made available offer additional solutions for behavior analysts to consider adopting. Therefore, the purpose of this article is to provide an update to the strategies described by Carr and Briggs for overcoming barriers related to searching the literature, accessing journal content, and contacting the contemporary literature. In addition, we conclude with how leaders might incorporate the proposed strategies into their organization at a systems-wide level.

The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews.

BACKGROUND: Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity. METHODS: We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data. RESULTS: The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse. CONCLUSIONS: In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.

Changes in soft drinks purchased by British households associated with the UK soft drinks industry levy: controlled interrupted time series analysis.

OBJECTIVE: To determine changes in household purchases of drinks and confectionery one year after implementation of the UK soft drinks industry levy (SDIL). DESIGN: Controlled interrupted time series analysis. PARTICIPANTS: Members of a panel of households reporting their purchasing on a weekly basis to a market research company (average weekly number of participants n=22 183), March 2014 to March 2019. INTERVENTION: A two tiered tax levied on manufacturers of soft drinks, announced in March 2016 and implemented in April 2018. Drinks with ≥8 g sugar/100 mL (high tier) are taxed at £0.24/L and drinks with ≥5 to <8 g sugar/100 mL (low tier) are taxed at £0.18/L. Drinks with <5 g sugar/100 mL (no levy) are not taxed. MAIN OUTCOME MEASURES: Absolute and relative differences in the volume of, and amount of sugar in, soft drinks categories, all soft drinks combined, alcohol, and confectionery purchased per household per week one year after implementation of the SDIL compared with trends before the announcement of the SDIL. RESULTS: In March 2019, compared with the counterfactual estimated from pre-announcement trends, purchased volume of drinks in the high levy tier decreased by 155 mL (95% confidence interval 240.5 to 69.5 mL) per household per week, equivalent to 44.3% (95% confidence interval 59.9% to 28.7%), and sugar purchased in these drinks decreased by 18.0 g (95% confidence interval 32.3 to 3.6 g), or 45.9% (68.8% to 22.9%). Purchases of low tier drinks decreased by 177.3 mL (225.3 to 129.3 mL) per household per week, or 85.9% (95.1% to 76.7%), with a 12.5 g (15.4 to 9.5 g) reduction in sugar in these drinks, equivalent to 86.2% (94.2% to 78.1%). Despite no overall change in volume of no levy drinks purchased, there was an increase in sugar purchased of 15.3 g (12.6 to 17.9 g) per household per week, equivalent to 166.4% (94.2% to 238.5%). When all soft drinks were combined, the volume of drinks purchased did not change, but sugar decreased by 29.5 g (55.8 to 3.1 g), or 9.8% (17.9% to 1.8%). Purchases of confectionery and alcoholic drinks did not change. CONCLUSIONS: Compared with trends before the SDIL was announced, one year after implementation, the volume of soft drinks purchased did not change. The amount of sugar in those drinks was 30 g, or 10%, lower per household per week-equivalent to one 250 mL serving of a low tier drink per person per week. The SDIL might benefit public health without harming industry. TRIAL REGISTRATION: ISRCTN18042742.

Quantification of the geometric uncertainty when using implanted markers as a surrogate for lung tumor motion.

BACKGROUND: Fiducial markers are used as surrogates for tumor location during radiation therapy treatment. Developments in lung fiducial marker and implantation technology have provided a means to insert markers endobronchially for tracking of lung tumors. This study quantifies the surrogacy uncertainty (SU) when using endobronchially implanted markers as a surrogate for lung tumor position. METHODS: We evaluated SU for 17 patients treated in a prospective electromagnetic-guided MLC tracking trial. Tumor and markers were segmented on all phases of treatment planning 4DCTs and all frames of pretreatment kilovoltage fluoroscopy acquired from lateral and frontal views. The difference in tumor and marker position relative to end-exhale position was calculated as the SU for both imaging methods and the distributions of uncertainties analyzed. RESULTS: The mean (range) tumor motion amplitude in the 4DCT scan was 5.9 mm (1.7-11.7 mm) in the superior-inferior (SI) direction, 2.2 mm (0.9-5.5 mm) in the left-right (LR) direction, and 3.9 mm (1.2-12.9 mm) in the anterior-posterior (AP) direction. Population-based analysis indicated symmetric SU centered close to 0 mm, with maximum 5th/95th percentile values over all axes of -2.0 mm/2.1 mm with 4DCT, and -2.3/1.3 mm for fluoroscopy. There was poor correlation between the SU measured with 4DCT and that measured with fluoroscopy on a per-patient basis. We observed increasing SU with increasing surrogate motion. Based on fluoroscopy analysis, the mean (95% CI) SU was 5% (2%-8%) of the motion magnitude in the SI direction, 16% (6%-26%) of the motion magnitude in the LR direction, and 33% (23%-42%) of the motion magnitude in the AP direction. There was no dependence of SU on marker distance from the tumor. CONCLUSION: We have quantified SU due to use of implanted markers as surrogates for lung tumor motion. Population 95th percentile range are up to 2.3 mm, indicating the approximate contribution of SU to total geometric uncertainty. SU was relatively small compared with the SI motion, but substantial compared with LR and AP motion. Due to uncertainty in estimations of patient-specific SU, it is recommended that population-based margins are used to account for this component of the total geometric uncertainty.

Preference for and reinforcing efficacy of different types of attention in preschool children.

It is unknown whether and to what extent common types of attention delivered in early childhood environments are preferred by and function as reinforcers for young children. We assessed children's preference for commonly delivered types of attention across 31 preschool-aged participants (Experiment 1). Next, we conducted a reinforcer assessment (Experiment 2) and a progressive-ratio assessment (Experiment 3) to (a) validate the results of the preference assessment and (b) determine the relative reinforcing efficacy of each type of attention. Results of Experiment 1 showed that most participants preferred conversation or physical interaction. Results of Experiment 2 validated the results of Experiment 1 showing preferred types of attention were more likely to function as reinforcers. Finally, although some types of attention functioned as reinforcers, results of Experiment 3 indicated these reinforcers only maintained responding under relatively dense schedules of reinforcement. Clinical implications and directions for future research are discussed.

Toward real-time verification for MLC tracking treatments using time-resolved EPID imaging.

PURPOSE: In multileaf collimator (MLC) tracking, the MLC positions from the original treatment plan are continuously modified to account for intrafraction tumor motion. As the treatment is adapted in real time, there is additional risk of delivery errors which cannot be detected using traditional pretreatment dose verification. The purpose of this work is to develop a system for real-time geometric verification of MLC tracking treatments using an electronic portal imaging device (EPID). METHODS: MLC tracking was utilized during volumetric modulated arc therapy (VMAT). During these deliveries, treatment beam images were taken at 9.57 frames per second using an EPID and frame grabber computer. MLC positions were extracted from each image frame and used to assess delivery accuracy using three geometric measures: the location, size, and shape of the radiation field. The EPID-measured field location was compared to the tumor motion measured by implanted electromagnetic markers. The size and shape of the beam were compared to the size and shape from the original treatment plan, respectively. This technique was validated by simulating errors in phantom test deliveries and by comparison between EPID measurements and treatment log files. The method was applied offline to images acquired during the LIGHT Stereotactic Ablative Body Radiotherapy (SABR) clinical trial, where MLC tracking was performed for 17 lung cancer patients. The EPID-based verification results were subsequently compared to post-treatment dose reconstruction. RESULTS: Simulated field location errors were detected during phantom validation tests with an uncertainty of 0.28 mm (parallel to MLC motion) and 0.38 mm (perpendicular), expressed as a root-mean-square error (RMSError ). For simulated field size errors, the RMSError was 0.47 cm2 and field shape changes were detected for random errors with standard deviation ≥ 2.5 mm. For clinical lung SABR deliveries, field location errors of 1.6 mm (parallel MLC motion) and 4.9 mm (perpendicular) were measured (expressed as a full-width-half-maximum). The mean and standard deviation of the errors in field size and shape were 0.0 ± 0.3 cm2 and 0.3 ± 0.1 (expressed as a translation-invariant normalized RMS). No correlation was observed between geometric errors during each treatment fraction and dosimetric errors in the reconstructed dose to the target volume for this cohort of patients. CONCLUSION: A system for real-time delivery verification has been developed for MLC tracking using time-resolved EPID imaging. The technique has been tested offline in phantom-based deliveries and clinical patient deliveries and was used to independently verify the geometric accuracy of the MLC during MLC tracking radiotherapy.

MLC tracking for lung SABR is feasible, efficient and delivers high-precision target dose and lower normal tissue dose.

BACKGROUND AND PURPOSE: The purpose of this work is to present the clinical experience from the first-in-human trial of real-time tumor targeting via MLC tracking for stereotactic ablative body radiotherapy (SABR) of lung lesions. METHODS AND MATERIALS: Seventeen patients with stage 1 non-small cell lung cancer (NSCLC) or lung metastases were included in a study of electromagnetic transponder-guided MLC tracking for SABR (NCT02514512). Patients had electromagnetic transponders inserted near the tumor. An MLC tracking SABR plan was generated with planning target volume (PTV) expanded 5 mm from the end-exhale gross tumor volume (GTV). A clinically approved comparator plan was generated with PTV expanded 5 mm from a 4DCT-derived internal target volume (ITV). Treatment was delivered using a standard linear accelerator to continuously adapt the MLC based on transponder motion. Treated volumes and reconstructed delivered dose were compared between MLC tracking and comparator ITV-based treatment. RESULTS: All seventeen patients were successfully treated with MLC tracking (70 successful fractions). MLC tracking treatment delivery time averaged 8 minutes. The time from the start of CBCT to the end of treatment averaged 22 minutes. The MLC tracking PTV for 16/17 patients was smaller than the ITV-based PTV (range -1.6% to 44% reduction, or -0.6 to 18 cc). Reductions in mean lung dose (27 cGy) and V20Gy (50 cc) were statistically significant (p < 0.02). Reconstruction of treatment doses confirmed a statistically significant improvement in delivered GTV D98% (p < 0.05) from planned dose compared with the ITV-based plans. CONCLUSION: The first treatments with lung MLC tracking have been successfully performed in seventeen SABR patients. MLC tracking for lung SABR is feasible, efficient and delivers high-precision target dose and lower normal tissue dose.

Translating Evidence into Practice: ACOs' Use of Care Plans for Patients with Complex Health Needs.

BACKGROUND: Care plans are an evidence-based strategy, encouraged by the Centers for Medicare and Medicaid Services, and are used to manage the care of patients with complex health needs that have been shown to lead to lower hospital costs and improved patient outcomes. Providers participating in payment reform, such as accountable care organizations, may be more likely to adopt care plans to manage complex patients. OBJECTIVE: To understand how Medicare accountable care organizations (ACOs) use care plans to manage patients with complex clinical needs. DESIGN: A qualitative study using semi-structured interviews with Medicare ACOs. PARTICIPANTS: Thirty-nine interviews were conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff. APPROACH: Development, structure, use, and management of care plans for complex patients at Medicare ACOs. KEY RESULTS: Most (11) of the interviewed ACOs reported using care plans to manage care of complex patients. All care plans include information about patient history, current medical needs, and future care plans. Beyond the core elements, care plans included elements based on the ACO's planned use and level of staff and patient engagement with care planning. Most care plans were developed and maintained by care management (not clinical) staff. CONCLUSIONS: ACOs are using care plans for patients with complex needs, but their use of care plans does not always meet the best practices. In many cases, ACO usage of care plans does not align with prescribed best practices: ACOs are adapting use of care plans to better fit the needs of patients and providers.

Geometric uncertainty analysis of MLC tracking for lung SABR.

PURPOSE: The purpose of this work was to report on the geometric uncertainty for patients treated with multi-leaf collimator (MLC) tracking for lung SABR to verify the accuracy of the system. METHODS: Seventeen patients were treated as part of the MLC tracking for lung SABR clinical trial using electromagnetic beacons implanted around the tumor acting as a surrogate for target motion. Sources of uncertainties evaluated in the study included the surrogate-target positional uncertainty, the beam-surrogate tracking uncertainty, the surrogate localization uncertainty, and the target delineation uncertainty. Probability density functions (PDFs) for each source of uncertainty were constructed for the cohort and each patient. The total PDFs was computed using a convolution approach. The 95% confidence interval (CI) was used to quantify these uncertainties. RESULTS: For the cohort, the surrogate-target positional uncertainty 95% CIs were ±2.5 mm (-2.0/3.0 mm) in left-right (LR), ±3.0 mm (-1.6/4.5 mm) in superior-inferior (SI) and ±2.0 mm (-1.8/2.1 mm) in anterior-posterior (AP). The beam-surrogate tracking uncertainty 95% CIs were ±2.1 mm (-2.1/2.1 mm) in LR, ±2.8 mm (-2.8/2.7 mm) in SI and ±2.1 mm (-2.1/2.0 mm) in AP directions. The surrogate localization uncertainty minimally impacted the total PDF with a width of ±0.6 mm. The target delineation uncertainty distribution 95% CIs were ±5.4 mm. For the total PDF, the 95% CIs were ±5.9 mm (-5.8/6.0 mm) in LR, ±6.7 mm (-5.8/7.5 mm) in SI and ±6.0 mm (-5.5/6.5 mm) in AP. CONCLUSION: This work reports the geometric uncertainty of MLC tracking for lung SABR by accounting for the main sources of uncertainties that occurred during treatment. The overall geometric uncertainty is within ±6.0 mm in LR and AP directions and ±6.7 mm in SI. The dominant uncertainty was the target delineation uncertainty. This geometric analysis helps put into context the range of uncertainties that may be expected during MLC tracking for lung SABR (ClinicalTrials.gov registration number: NCT02514512).