The Evolution of Employee Assistance Programs to Best Support Healthcare Organizations.

GOAL: Employee assistance programs (EAPs) have been evolving since they first became prevalent in the 1970s. The important counseling component of EAPs is sometimes lost in discussions about what they do, with many EAPs marketing a broad portfolio of services such as childcare, elder care, legal referral, and other concierge services rather than counseling. The objective of this study was to examine outcomes for the EAP of one organization (Mayo Clinic), compare them to outcomes reported in the literature, and gain insights to help all healthcare organizations best support their employees. METHODS: Consistent with customary EAP practice, data for this study was collected through an anonymous survey link distributed by e-mail to users of individual counseling as well as users of organizational consulting services such as advising leaders and supervisors and leading educational sessions. PRINCIPAL FINDINGS: All (n = 82) individual counseling respondents indicated they would recommend the EAP, none reported worse symptoms, 90% decreased their stress levels, 92% reduced their feelings of anxiety, 88% enjoyed an overall improvement in mood, and 95% developed new skills. If their concern was work-related, 96% agreed the counselor understood the work culture and was able to provide helpful guidance; of the clients who were feeling burned out, 86% agreed they gained strategies to reduce its symptoms. Thematic analysis of individual counseling services indicated that participants highly valued their counselors. Regarding organizational consulting services, respondents (n = 50) indicated EAP services increased their confidence as leaders, supported their work, and provided tangible guidance. They appreciated having an internal EAP counselor. Thematic analysis of organizational consulting services indicated that EAP supported leaders by listening, coaching, and empowering them to normalize issues. PRACTICAL APPLICATIONS: EAPs have evolved into distinct internal, external, and hybrid internal-external models. Internal model counselors are company employees with inside knowledge of company culture, external EAP model counselors are contracted outside of the company, and hybrid models combine a small cadre of internal counselors with the support of outside contractors. Regardless of the model, EAP counselors must collaborate with internal stakeholders, notably the human resources department, to efficiently identify and troubleshoot employee relational issues and allow for customized initiatives to improve mental health. Based upon these findings and the authors' direct experiences with EAP providers, components of an ideal EAP are outlined to show how EAPs can best support employees. Healthcare leaders seeking to add EAP services are advised to focus on offerings that are custom fit to the organization.

Vitamin D, melanoma risk, and tumor thickness in PLCO cancer screening trial patients.

OBJECTIVE: The incidence of melanoma is increasing. Other than limiting UV exposure, few factors prevent or reduce the risk of melanoma. The aim of this study is to evaluate the relationship between vitamin D intake and melanoma risk in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial. METHODS: A secondary data analysis was performed on PLCO data. More than 1,300 participants developed melanoma. RESULTS: Melanoma risk may be increased among men within the highest quartile of vitamin D intake (HR 1.27, 95% CI 0.99, 1.61). Women in the highest quartile of vitamin D intake had a decreased risk of invasive melanoma (HR 0.63, 95% CI 0.41, 0.96). Higher education and being white corresponded with deeper tumors (P < .001). CONCLUSION: High reported vitamin D intake resulted in an increased risk of melanoma among men. Vitamin D intake yielded a protective effect against invasive melanoma in women.

Rate of Recurrence of Lentigo Maligna Treated With Off-Label Neoadjuvant Topical Imiquimod, 5%, Cream Prior to Conservatively Staged Excision.

Importance: Staged excision of lentigo maligna (LM) often requires multiple stages and can result in significant cosmetic morbidity. Imiquimod cream has been used off-label as monotherapy in the treatment of LM and may be used in the neoadjuvant setting prior to staged excision as a strategy to reduce the size of the surgical margins required to confirm negative histologic margins. Objective: To examine the rate of recurrence of LM in patients treated with neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions. Design, Setting, and Participants: This was a retrospective medical record review of 334 patients with 345 biopsy-confirmed LM tumors from June 2004 to January 2012 who were treated with imiquimod prior to undergoing staged excisions at the University of Utah Medical Center and Huntsman Cancer Institute, large academic hospitals in Salt Lake City. Interventions: Patients were treated with off-label imiquimod, 5%, cream 5 nights per week for 2 to 3 months. Those deemed to have an inadequate inflammatory response were also treated with tazarotene, 0.1%, gel twice weekly. Conservatively staged excisions, beginning with 2-mm margins, were then performed. Main Outcomes and Measures: The rate of recurrence of LM after long-term follow-up. Results: Patients included 235 men (70%) and 99 women (30%) with a mean (SD) age of 67 (13) years. Patients were treated with imiquimod cream for a mean of 2.5 months prior to undergoing conservatively staged excisions. There were 12 local recurrences (a rate of 3.9%) with a mean time to recurrence of 4.3 years and a mean length of follow-up of 5.5 years. Conclusions and Relevance: Neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions for LM allowed for negative histologic margins with a median final margin of 2 mm and a rate of recurrence similar to reported recurrence rates with standard staged excisions by either Mohs surgery or en face permanent sections.

A randomized trial of the off-label use of imiquimod, 5%, cream with vs without tazarotene, 0.1%, gel for the treatment of lentigo maligna, followed by conservative staged excisions.

OBJECTIVE: To determine if the complete response rates of lentigo maligna (LM) to imiquimod, 5%, cream can be improved by the addition of a topical retinoid. DESIGN: Prospective randomized study of patients treated with imiquimod alone vs imiquimod plus a topical retinoid, followed by conservative staged excisions. SETTING: Mohs surgical clinic in an academic institution. PATIENTS: Ninety patients with biopsy-confirmed LM. INTERVENTIONS: Ninety patients with 91 LMs were randomized into 2 groups. One group received imiquimod, 5%, cream 5 d/wk for 3 months, while the other group also received tazarotene, 0.1%, gel 2 d/wk for 3 months. Following topical therapy, all patients underwent staged excisions and frozen section analysis with Melan-A immunostaining to confirm negative margins. MAIN OUTCOME MEASURE: The presence or absence of residual LM at the time of staged excision. RESULTS: Forty-six patients with 47 LMs were randomized to receive monotherapy: 42 of 47 LMs reached the intended treatment duration, with 27 complete responses (64%). Forty-four patients with 44 LMs were randomized to receive combined therapy: 37 of 44 LMs reached the intended treatment duration, with 29 complete responses (78%). This difference did not reach statistical significance (P=.17). There have been no recurrences to date, with a mean follow-up period of 42 months. CONCLUSIONS: Among patients who received topical imiquimod with vs without tazarotene, 22% (8 of 37) of lesions vs 36% (15 of 42) of lesions showed residual LM on staged excisions. Pretreating LM with imiquimod, 5%, cream may decrease surgical defect sizes; however, total reliance on topical imiquimod as an alternative to surgery may put the patient at increased risk of a local recurrence.

Use of physician assistants in Mohs micrographic surgery: a survey of fellowship-trained Mohs micrographic surgeons.

BACKGROUND: An increasing number of dermatologists are using physician assistants (PAs) in their practices. A lack of information regarding the use of PAs in Mohs micrographic surgery (MMS) served as the driving force for this research. OBJECTIVES: To quantify the extent to which Mohs surgeons are using PAs in MMS. METHODS: Five hundred seventy-six fellows of the American College of Mohs Surgery were sent surveys in the mail in January 2009. The survey was focused on what percentage of Mohs surgeons are using PAs and how those PAs are being used. RESULTS: One hundred forty-three of the 576 surgeons surveyed (24.8%) responded; 43 of those (30.1%) currently employed one or more PAs; and of those 43, 15 (34.9%) reported that PAs in their practice perform preoperative consults, 25 (58.1%) reported that PAs perform postoperative follow-up, 18 (41.9%) reported that PAs were participating in some aspect of repairs, and 35 (81.4%) reported that PAs were seeing general dermatology patients. CONCLUSION: Mohs surgeons are using PAs for perioperative care, as well as seeing general dermatology patients. A smaller percentage of Mohs surgeons are using PAs to perform portions of MMS or the consequent repairs.