Love over gold and mind over matter? Identifying capabilities that preserve medical assistants' sustainable employability.

BACKGROUND: Medical assistants (MAs) are crucial for affordable, high-quality primary care, but what motivates this low-wage occupational group to stay in their job remains underexplored. This paper identifies the work aspects that MAs value ("capabilities"), and how they affect sustainable employability, which refers to employees' long-term ability to function and remain in their job. METHODS: We used structural equation modelling to assess how capabilities relate to four outcomes among MAs: burnout, job satisfaction, intention to quit, and experiencing work as meaningful. RESULTS: We find that earning a good income, developing knowledge and skills, and having meaningful relationships at work relate to the outcomes. Meaningful relationships represent a stronger predictor than salary for one's intention to quit. CONCLUSIONS: Competitive salaries are necessary but not sufficient to motivate low-wage health care workers like MAs to stay in their job. Health care leaders and managers should also structure work so that MAs can foster meaningful relationships with others as well as develop competencies.

Being "low on the totem pole": What makes work worthwhile for medical assistants in an era of primary care transformation.

BACKGROUND: Primary care is undergoing a transformation to become increasingly team-based and multidisciplinary. The medical assistant (MA) is considered a core occupation in the primary care workforce, yet existing studies suggest problematic rates and costs of MA turnover. PURPOSE: We investigated what MAs perceive their occupation to be like and what they value in it to understand how to promote sustainable employability, a concept that is concerned with an employee's ability to function and remain in their job in the long term. APPROACH: We used a case of a large, integrated health system in the United States that practices team-based care and has an MA career development program. We conducted semistructured interviews with 16 MAs in this system and performed an inductive analysis of themes. RESULTS: Our analysis revealed four themes on what MAs value at work: (a) using clinical competence, (b) being a multiskilled resource for clinic operations, (c) building meaningful relationships with patients and coworkers, and (d) being recognized for occupational contributions. MAs perceived scope-of-practice regulations as limiting their use of clinical competence. They also perceived task similarity with nurses in the primary care setting and expressed a relative lack of performance recognition. CONCLUSION: Some of the practice changes that enable primary care transformation may hinder MAs' ability to attain their work values. Extant views on sustainable employability assume a high bar for intrinsic values but are limited when applied to low-wage health care workers in team-based environments. PRACTICE IMPLICATIONS: Efforts to effectively employ and retain MAs should consider proactive communications on scope-of-practice regulations, work redesign to emphasize clinical competence, and the establishment of greater recognition and respect among MAs and nurses.

Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease.

BACKGROUND/AIMS: We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD). METHODS: We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool. RESULTS: Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%. CONCLUSION: Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.

Hydrolysis of wheat flour arabinoxylan, acid-debranched wheat flour arabinoxylan and arabino-xylo-oligosaccharides by ß-xylanase, α-L-arabinofuranosidase and ß-xylosidase.

A range of α-L-arabinofuranosyl-(1-4)-ß-D-xylo-oligosaccharides (AXOS) were produced by hydrolysis of wheat flour arabinoxylan (WAX) and acid debranched arabinoxylan (ADWAX), in the presence and absence of an AXH-d3 α-L-arabinofuranosidase, by several GH10 and GH11 ß-xylanases. The structures of the oligosaccharides were characterised by GC-MS and NMR and by hydrolysis by a range of α-L-arabinofuranosidases and ß-xylosidase. The AXOS were purified and used to characterise the action patterns of the specific α-L-arabinofuranosidases. These enzymes, in combination with either Cellvibrio mixtus or Neocallimastix patriciarum ß-xylanase, were used to produce elevated levels of specific AXOS on hydrolysis of WAX, such as 3(2)-α-L-Araf-(1-4)-ß-D-xylobiose (A(3)X), 2(3)-α-L-Araf-(1-4)-ß-D-xylotriose (A(2)XX), 3(3)-α-L-Araf-(1-4)-ß-D-xylotriose (A(3)XX), 2(2)-α-L-Araf-(1-4)-ß-D-xylotriose (XA(2)X), 3(2)-α-L-Araf (1-4)-ß-D-xylotriose (XA(3)X), 2(3)-α-L-Araf-(1-4)-ß-D-xylotetraose (XA(2)XX), 3(3)-α-L-Araf-(1-4)-ß-D-xylotetraose (XA(3)XX), 2(3),3(3)-di-α-L-Araf-(1-4)-ß-D-xylotriose (A(2+3)XX), 2(3),3(3)-di-α-L-Araf-(1-4)-ß-D-xylotetraose (XA(2+3)XX), 2(4),3(4)-di-α-L-Araf-(1-4)-ß-D-xylopentaose (XA(2+3)XXX) and 3(3),3(4)-di-α-L-Araf-(1-4)-ß-D-xylopentaose (XA(3)A(3)XX), many of which have not previously been produced in sufficient quantities to allow their use as substrates in further enzymic studies. For A(2,3)XX, yields of approximately 16% of the starting material (wheat arabinoxylan) have been achieved. Mixtures of the α-L-arabinofuranosidases, with specific action on AXOS, have been combined with ß-xylosidase and ß-xylanase to obtain an optimal mixture for hydrolysis of arabinoxylan to L-arabinose and D-xylose.