Increasing nursing student interest in rural healthcare: lessons from a rural rotation program in Democratic Republic of the Congo.

BACKGROUND: Many challenges exist in providing equitable access to rural healthcare in the Democratic Republic of the Congo (DRC). WHO recommends student exposure to rural clinical rotations to promote interest in rural healthcare. Challenges to rural engagement include lack of adequate infrastructure and staff to lead rural education. This case report highlights key steps in developing a rural rotation program for DRC nursing students. Case presentation To implement a rural rotation (RR) program, ICAP at Columbia University (ICAP) consulted with students, the Ministries of Health (MoH) and Education (MoE), and nursing schools to pilot and expand a rural rotation program. Nursing schools agreed to place students in rural clinics and communities. Key stakeholders collaborated to assess and select rural sites based on availability of nursing mentors, educational resources, security, accessibility, and patient volume. To support this, 85 preceptors from 55 target schools and 30 rural health facilities were trained of which 30 were selected to be "master trainers". These master trainers led the remaining 55 preceptors implementing the rural rotation program. We worked with rural facilities to engage community leaders and secure accommodation for students. A total of 583 students from five Lubumbashi schools and two rural schools outside Kinshasa participated across 16 rural sites (298 students in 2018-2019 school year and 285 in 2019-2020). Feedback from 274 students and 25 preceptors and nursing school leaders was positive with many students actively seeking rural assignments upon graduation. For example, 97% agreed or strongly agreed that their RR programs had strengthened their educational experience. Key challenges, however, were long-term financial support (35%) for rural rotations, adequate student housing (30%) and advocacy for expanding the rural workforce. CONCLUSIONS: With nearly 600 participants, this project showed that a RR program is feasible and acceptable in resource-limited settings yet availability of ample student accommodation and increasing availability of rural jobs remain health system challenges. Using a multipronged approach to rural health investment as outlined by WHO over two decades ago remains essential. Attracting future nurses to rural health is necessary but not sufficient to achieve equitable health workforce distribution.

Disclosing a diagnosis of cancer: where and how does it occur?

PURPOSE: While disclosing a cancer diagnosis to a patient is common practice, how it is disclosed and the impact it has on the patient are poorly understood. We examined how cancer diagnoses were first given to patients and the impact of different aspects of disclosure on patient satisfaction. PATIENTS AND METHODS: We provided a self-administered questionnaire to a total of 460 oncology patients of the National Cancer Institute (NCI) being treated at the National Institutes of Health (NIH) Clinical Center in Bethesda, MD. RESULTS: Of the 437 patients who completed the survey, 54% were told their diagnosis in-person in the physician's office, 18% by phone, and 28% in the hospital. Forty-four percent of patients reported discussions of 10 minutes or fewer, 53% reported discussions lasting longer than 10 minutes, and 5% could not remember. Treatment options were not discussed for 31% of those who could clearly remember. Higher mean satisfaction scores were associated with diagnoses revealed in person rather than over the phone (68.2 +/- 1.6 v 47.2 +/- 3.7), diagnoses revealed in a personal setting rather than an impersonal setting (68.9 +/- 1.6 v 55.7 +/- 2.8), discussions lasting longer than 10 minutes rather than fewer than 10 minutes (73.5 +/- 1.9 v 54.1 +/- 2.4), and inclusion of treatment options rather than exclusion (72.0 +/- 1.9 v 50.7 +/- 3.2; P < .001 for each aspect). CONCLUSION: Physicians should disclose a cancer diagnosis in a personal setting, discussing the diagnosis and treatment options for a substantial period of time whenever possible.

Private Practice Administrative Costs Influenced by Insurance Payer Mix.

BACKGROUND: Increased staffing and oncology drug costs per physician, combined with decreased drug revenue, have made private hematology-oncology practices susceptible to increased financial risk. We hypothesized that practices with a higher combined commercial insurance (CCI) mix would experience greater inefficiencies in insurance billing (IB) processes and higher IB administrative costs. METHODS: A cross-sectional survey was administered to a national pool of private hematology-oncology practices. Practices were identified through the ASCO online registry. Participants self-reported insurance information. T and Wilcoxon rank sum tests were used to compare high (50% or more) Medicare payer mix groups and high (50% or more) CCI payer mix groups for practice operation indicators. These tests were also used to compare denial processing cost per Medicare patient and CCI patient. RESULTS: Among the 33 practices that responded to the survey, the mean total IB administrative cost for high Medicare payer mix groups was $191,646.25 (standard deviation [SD], $173,031.63), significantly lower (P = .0454) than the mean for high CCI groups at $476,280.00 (SD, $475,408.57). The mean annual cost per IB support staff member was significantly higher (P = .0453) in the high CCI group at $49,778.67 (SD = $14,896.32) compared with the mean cost in the high Medicare group, which was $39,413.08 (SD, $12,068.17). Medicare patient denial processing cost was significantly lower (P = .0237) than that for CCI patients. CONCLUSION: Practices with a high Medicare payer mix experience both lower mean cost per FTE IB support staff member and total overall IB administrative cost. Processing denials for reimbursement for Medicare patients requires fewer practice resources than does processing for CCI patients.

NCI designated cancer center funding not influenced by organizational structure.

BACKGROUND: National Cancer Institutes (NCI) designated cancer centers use one of three organizational structures. The hypothesis of this study is that there are differences in the amount of annual NCI funding per faculty member based on a cancer center's organizational structure. The study also considers the impact of secondary factors (i.e., the existence of a clinical program, the region and the size of the city in which the cancer center is located) on funding and the number of Howard Hughes Medical Institute (HHMI) investigators at each cancer center. RESULTS: Of the 63 cancer centers, 44 use a matrix structure, 16 have a freestanding structure, and three have a Department of Oncology structure. Kruskal-Wallis tests reveal no statistically significant differences in the amount of funding per faculty member or the number of HHMI investigators between centers with a matrix, freestanding or Department of Oncology structure. METHODS: Online research and telephone interviews with each cancer center were used to gather information, including: organizational structure, the presence of a clinical program, the number of faculty members, and the number of Howard Hughes Medical Institute investigators. Statistical tests were used to assess the impact which organizational structure has on the amount of funding per faculty member and number of HHMI investigators. CONCLUSION: While the results seem to suggest that the organizational structure of a given cancer center does not impact the amount of NCI funding or number of HHMI investigators which it attracts, the existence of this relationship is likely masked by the small sample size in this study. Further studies may be appropriate to examine the effect organizational structure has on other measurements which are relevant to cancer centers, such as quality and quantity of research produced.

Scientific collaboration results in higher citation rates of published articles.

STUDY OBJECTIVE: The primary objective was to analyze the relationship between the citation rate of an article and the extent of collaboration. The secondary objective was to analyze the relationship between the number of authors/article and the number of institutions/article for the period of study. METHODS: We counted the number of original research articles published in six leading journals--Cell, Science, Nature, New England Journal of Medicine, The Lancet, and Journal of the American Medical Association--for the years 1975, 1985, and 1995. For each article, we determined the number of authors and the number of separate institutions. We also determined the number of times each article that was published in 1995 was cited in future scientific articles from the Science Citation Index database. RESULTS: Science, Cell, Nature, New England Journal of Medicine, The Lancet, and Journal of the American Medical Association had 2014, 868, 3856, 643, 785, and 465 total articles published/3-year study period, respectively. There was a median of 2, 2, 2, 3, 3, and 3 institutions/article, respectively. All of the final models had a significant linear author component for which all of the parameter estimates were positive, yet variable. Thus, the number of times an article was cited correlated significantly with the number of authors and the number of institutions. CONCLUSION: A correlation exists between the number of authors and the number of times an article is cited in other articles. Investigators who are open to collaborations and those who seem to adequately manage those collaborations produce a superior product that results in a higher impact.