Mixed Mode Substantially Increases Hospital Consumer Assessment of Healthcare Providers and Systems Response Rates Relative to Single-Mode Protocols.

BACKGROUND: Low response rates (RRs) can affect hospitals' data collection costs for patient experience surveys and value-based purchasing eligibility. Most hospitals use single-mode approaches, even though sequential mixed mode (MM) yields higher RRs and perhaps better patient representativeness. Some hospitals may be reluctant to incur MM's potential additional cost and complexity without knowing how much RRs would increase. OBJECTIVE: The aim of this study was to estimate the differences in RR and patient representation between MM and single-mode approaches and to identify hospital characteristics associated with the largest RR differences from MM of single-mode protocols (mail-only, phone-only). RESEARCH DESIGN: Patients were randomized within hospitals to one of 3 modes (mail-only, phone-only, MM). SUBJECTS: A total of 17,415 patients from the 51 nationally representative US hospitals participating in a randomized HCAHPS mode experiment. RESULTS: Mail-only RRs were lowest for ages 18-24 (7%) and highest for ages 65+ (31%-35%). Phone-only RRs were 24% for ages 18-24, increasing to 37%-40% by ages 55+. MM RRs were 28% for ages 18-24, increasing to 50%-60% by ages 65-84. Lower hospital-level mail-only RRs strongly predicted greater gains from MM. For example, a hospital with a 15% mail-only RR has a predicted MM RR >40% (with >25% occurring in telephone follow-up). CONCLUSION: MM increased representation of hard-to-reach (especially young adult) patients and hospital RRs in all mode experiment hospitals, especially in hospitals with low mail-only RRs.

Primary care and abortion provider perspectives on mail-order medication abortion: a qualitative study.

BACKGROUND: This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion. METHODS: Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation. RESULTS: We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care. CONCLUSION: Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined. TRIAL REGISTRATION: Registry: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER: NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.

Support for Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion.

According to this study.

Email recruitment for chronic pain clinical trials: results from the LAMP trial.

BACKGROUND: Recruitment for clinical trials and large-scale studies is challenging, especially for patients with complex conditions like chronic pain. Email recruitment has the potential to increase efficiency, to reduce costs, and to improve access for underrepresented patient populations. The objective of this study was to examine the effectiveness, efficiency, and equitability of email versus postal mail recruitment for the Learning to Apply Mindfulness to Pain (LAMP) study, a three-site clinical trial of mindfulness-based interventions for chronic pain. METHODS: Patients with chronic pain diagnoses were recruited from three United States Department of Veterans Affairs (VA) facilities using the VA electronic health record (EHR). Recruitment materials were sent using either postal mail (n = 7986) or email (n = 19,333). Patients in the email recruitment group were also mailed introductory postcards before any emails. Mailing addresses and email addresses were obtained from the EHR. Effectiveness was measured by the response rate of patients who logged into the secure LAMP study website. Efficiency was measured by the number of days from when the recruitment materials were sent to when patients logged into the LAMP portal as well as the estimated costs of each recruitment approach. To assess equitability, we examined whether email recruitment was less effective for underrepresented populations, based on demographic information from the EHR. RESULTS: Effectiveness-unadjusted response rates were greater for email versus postal-mail recruitment (18.9% versus 6.3%), and adjusted response rates were over three times greater for email recruitment (RR = 3.5, 95% CI 3.1-3.8) based on a multivariable analysis controlling for age, gender, race, ethnicity, rurality, and site. Efficiency-email recruitment had a significantly lower mean response time (1 day versus 8 days) and a lower cost. Equity-email recruitment led to higher response rates for all subpopulations, including older, non-White, Hispanic, rural, and female Veterans. CONCLUSIONS: Email recruitment is an effective, efficient, and equitable way to recruit VA patients to large-scale, chronic pain clinical trials. TRIAL REGISTRATION: Clinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial.

OBJECTIVES: To evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix adjusted feedback reports and messages emphasising antibiotic associated harms. DESIGN: Pragmatic, factorial randomised controlled trial. SETTING: Primary care physicians in Ontario, Canada PARTICIPANTS: All primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial. INTERVENTION: A letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics. MAIN OUTCOME MEASURES: Antibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression. RESULTS: 5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03)). CONCLUSIONS: Peer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04594200.

Decentralized HIV testing: comparing peer and mail-based distribution strategies to improve the reach of HIV self-testing among people who use drugs in Florida.

INTRODUCTION: People who use drugs (PWUD) are at increased risk for HIV infection. HIV self-testing (HIVST) is a promising method for identifying new infections, but optimal distribution strategies remain understudied. METHODS: To characterize PWUD by HIVST distribution strategy (peers vs. mail), we examined data from July 2022 to June 2023 collected from a real-world HIVST program led by the non-profit, Florida Harm Reduction Collective. We used descriptive statistics and Poisson regressions with robust error variance to compare those who received HIVST through peers or via mail by socio-demographics, Ending the HIV Epidemic (EHE) county designation, and HIV testing experience. RESULTS: Among 728 participants, 78% received HIVST from peers, 47% identified as cisgender female, 48% as heterosexual, and 45% as non-White; 66% resided in an EHE county, and 55% had no HIV testing experience. Compared to those who received an HIV self-test from peers, those who received tests via mail were less likely to be cisgender male (vs. cisgender female; prevalence ratio [PR] = 0.59, 95% confidence interval [CI]: 0.43, 0.81), non-Hispanic Black (vs. non-Hispanic White; PR = 0.57, 95% CI: 0.36, 0.89) or from EHE counties (vs. non-EHE counties; PR = 0.33, 95% CI: 0.25, 0.44). Those who received tests via mail were also more likely to identify their sexual orientation as "Other/Undisclosed" (vs. straight/heterosexual; PR = 2.00, 95% CI: 1.51, 2.66). CONCLUSION: Our findings support the role of community-based HIVST distribution strategies in increasing HIV testing coverage among PWUD. Additional research could help inform the equitable reach of HIVST.

Analysis of unknown (unlabeled/mislabeled) drug products for active pharmaceutical ingredients and related substances by an international mail facility satellite laboratory equipped with rapid screening devices.

Two chemists employed a three-device rapid screening "toolkit" consisting of a handheld Raman spectrometer, transportable mass spectrometer, and portable Fourier transform infrared (FT-IR) spectrometer at an international mail facility (IMF) satellite laboratory to examine unknown (unlabeled/mislabeled) products for the presence of active pharmaceutical ingredients (APIs). Phase I of this project previously demonstrated that this toolkit was the most effective collection of instruments for identifying APIs in product types collected at IMFs during a nationwide mail blitz and Phase II of this project previously demonstrated that results generated using the toolkit during a satellite laboratory pilot program were as reliable as those generated by a full-service library when two or more of these instruments identify an API. This study (Phase III) described the results of the satellite laboratory toolkit during production mode and encompassed the period ranging from June 2021 through December 2022. During this study, a total of 858 products were examined on-site at the IMF. The satellite laboratory yielded conclusive results for 726 (84.6%) products, which were used to support regulatory action, and identified 132 (15.4%) products that required additional full-service laboratory analyses due to inconclusive results. The satellite and full-service laboratory verified/confirmed at least one API/related substance in 617 (71.9%) products. A total of 709 APIs/related substances were found in the 617 products, and 202 of these 709 compounds were unique/different. Overall, during Phases I through III of this program, 350 different substances have been identified in products collected at IMFs.

Costs and Projected Effect of a Federally Qualified Health Center-Based Mailed Colorectal Cancer Screening Program in Texas.

Introduction: Mailed stool testing for colorectal cancer (CRC) may improve screening uptake and reduce the incidence and mortality of CRC, especially among patients at federally qualified health centers (FQHCs). To expand screening programs it is important to identify cost-effective approaches. Methods: We developed a decision-analytic model to estimate the cost, effects on screening and patient outcomes (CRCs detected, CRCs prevented, CRC deaths prevented), and cost-effectiveness of implementing a state-wide mailed stool testing program over 5 years among unscreened, age-eligible (aged 50-75 y) patients at FQHCs in Texas. We compared various outreach strategies and organizational structures (centralized, regional, or a hybrid). We used data from our existing regional mailed stool testing program and recent systematic reviews to set parameters for the model. Costs included start-up and ongoing activities and were estimated in 2022 US dollars from the perspective of a hypothetical third-party payer. Cost-effectiveness was assessed by using both incremental and average cost-effectiveness ratios. Results: Using either a statewide centralized or hybrid organizational configuration to mail stool tests to newly eligible FQHC patients and patients who have responded at least once since program inception is likely to result in the best use of resources over 5 years, enabling more than 110,000 additional screens, detecting an incremental 181 to 194 CRCs, preventing 91 to 98 CRCs, and averting 46 to 50 CRC deaths, at a cost of $10 million to $11 million compared with no program. Conclusions: A statewide mailed stool testing program for FQHC patients can be implemented at reasonable cost with considerable effects on CRC screening outcomes, especially when its structure maximizes program efficiency while maintaining effectiveness.

Primary Care's Role in Prescribing Mail-Order Mifepristone.

This Viewpoint discusses the controversy over mail-order mifepristone prescribed by primary care clinicians for first-trimester abortion as it relates to the history of initial approval, the Supreme Court case Alliance for Hippocratic Medicine v US Food and Drug Administration, and available clinical research.

Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening.

Importance: Before 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion. Objective: To estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy. Design, Setting, and Participants: This prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023. Intervention: Mifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person. Main Outcomes and Measures: Proportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications. Results: Clinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing. Conclusions and Relevance: The findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.

Characterizing participants who respond to text, email, phone calls, or postcards in a SARS-CoV-2 prevalence study.

INTRODUCTION: Multiple modalities and frequencies of contact are needed to maximize recruitment in many public health surveys. The purpose of this analysis is to characterize respondents to a statewide SARS-CoV-2 testing study whose participation followed either postcard, phone outreach or electronic means of invitation. In addition, we examine how participant characteristics differ based upon the number of contacts needed to elicit participation. METHODS: This is a cross-sectional analysis of survey data collected from participants who were randomly selected to represent Indiana residents and were invited to be tested for Covid-19 in April 2020. Participants received invitations via postcard, text/emails, and/or robocalls/texts based upon available contact information. The modality, and frequency of contacts, that prompted participation was determined by when the notification was sent and when the participant responded and subsequently registered to participate in the study. Chi square analyses were used to determine differences between groups and significant findings were analyzed using multinomial logistic regression. RESULTS: Respondents included 3,658 individuals and were stratified by postcards (7.9%), text/emails (26.5%), and robocalls/text (65.7%) with 19.7% registering after 1 contact, 47.9% after 2 contacts, and 32.4% after 3 contacts encouraging participation. Females made up 54.6% of the sample and responded at a higher rate for postcards (8.2% vs. 7.5%) and text/emails (28.1 vs. 24.6%) as compared to males (χ2 = 7.43, p = 0.025). Compared to males, females responded at a higher percentage after 1 contact (21.4 vs. 17.9%, χ2 = 7.6, p = 0.023). Those over 60 years responded most often after 2 contacts (χ2 = 27.5, p < 0.001) when compared to others at younger age groups. In regression analysis, participant sex (p = 0.036) age (p = 0.005), educational attainment (p = < 0.0001), and being motivated by "free testing" (p = 0.036) were correlated with participation in the prevalence study. DISCUSSION: Researchers should be aware that the modality of contact as well as the number of prompts used could influence differential participation in public health studies. Our findings can inform researchers developing studies that rely on selective participation by study subjects. We explore how to increase participation within targeted demographic groups using specific modalities and examining frequency of contact.

Where are you hiding the pangolins? screening tools to detect illicit contraband at international borders and their adaptability for illegal wildlife trafficking.

The illegal movement of wildlife poses a public health, conservation and biosecurity threat, however there are currently minimal screening tools available at international ports of entry to intercept wildlife trafficking efforts. This review first aimed to explore the screening tools available or under development for the detection of concealed wildlife contraband at international ports, including postal services, airlines, road border crossings and maritime routes. Where evidence was deficient, publications detailing the use of methods to uncover other illicit substances, such as narcotics, weapons, human trafficking, explosives, radioactive materials, or special nuclear material, were compiled and assessed for their applicability to the detection of wildlife. The first search identified only four citations related to the detection of wildlife, however the secondary search revealed 145 publications, including 59 journal articles and 86 conference proceedings, describing screening tools for non-wildlife illicit contraband detection. The screening tools uncovered were analysed for potential fitness for purpose for wildlife contraband detection, to evaluate the feasibility of their implementation and their ease of use. The deficiencies evident in terms of resource availability and research efforts targeting wildlife trafficking highlights a potentially substantial national and international security threat which must be addressed.

Strategies to increase survey participation: A randomized controlled study in a population of breast cancer survivors.

BACKGROUND: Data collection by mailing questionnaires to the study population is one of the main research methods in epidemiologic studies. As participation rates are decreasing, easy-to-implement and cost-effective strategies to increase survey participation are needed. In this study, we tested the effect of a pragmatic combination of evidence-based interventions. METHODS: We conducted a two-armed randomized controlled trial, nested in a cohort of breast cancer survivors (n = 1000) in the setting of a health outcomes survey. The intervention arm received a postal pre-notification, a non-monetary incentive (ballpoint with the study logo) and an alternative invitation letter in which several lay-out and textual adjustments were implemented according to behavioural science techniques. The alternative invitation letter also contained a QR-code through which an information video about the study could be accessed. The control arm was invited according to standard practice. Participants had the option to fill-out a questionnaire either on paper or online. A questionnaire with more than 50% of the questions answered classified as participation. RESULTS: Overall participation rate was 62.9%. No significant difference in participation rate was observed between intervention and control arm (64.5% vs 61.3%, Risk Ratio (RR) 1.05, 95% CI [0.96 - 1.16]). Older age at study (>65 vs <51 years), and high socio-economic status (highest vs lowest quartile) were associated with higher participation rates (RR 1.30, 95% CI [1.07 - 1.57] and 1.24, 95% CI [1.09 - 1.42] respectively). In-situ carcinoma compared to invasive cancer and longer interval since treatment were associated with lower participation (RR 0.86, 95% CI [0.74 - 0.99] and RR 0.92, 95% CI [0.87 - 0.99] per 5 year increase, respectively). CONCLUSION: Overall, the combination of four interventions tested in this study did not improve survey participation among breast cancer survivors. The overall participation rate was relatively high, possibly due to the study population of cancer survivors.

Effects of Academic Detailing, Panel Management and Mailed Multi-Target Stool-DNA Testing on Colorectal Cancer Screening.

INTRODUCTION: Academic detailing, patient-panel management, and mailed, stool-based testing have each been utilized to increase colorectal cancer (CRC) screening in rural clinics. The effectiveness of combining these interventions to increase CRC screening during COVID-19 restrictions was unclear. METHODS: We explored the effects of a multi-component intervention including academic detailing, active patient panel management, and mailed MT-sDNA testing on colorectal cancer screening in our rural family medicine clinic. Baseline interventions included EMR-based provider alerts and mailed patient reminders. Our intervention (March-May 2020) and follow-up periods (June-August 2020) coincided with the initial COVID-19 surge, giving us the opportunity to observe the effects of our intervention during COVID-19 restrictions. RESULTS: A total of 407 patients were eligible and overdue for colorectal cancer screening. Our clinic's CRC screening rate increased significantly after intervention (69.7%) as compared with before (64.3%) (P = <0.01; 95%CI = 5.39-5.4). Our clinic's CRC screening rates increased significantly during the initial 3 months of the COVID-19 surge (67.8%) compared with the same period the prior year. (62.3%) (P = .003; 95%CI = 3.4-7.6). Our CRC screening rates increased after intervention (69.7%) compared with our regional health system (67%) (P = <0.01; 95%CI = 2.6-2.77). Our weekly stool-based CRC screening increased (94% increase) compared with other health systems nationally (61 to 83% decrease). DISCUSSION: A multi-component intervention, including academic detailing, panel management, and mailed MT-sDNA testing, can lead to significant increases in CRC screening in a rural family medicine clinic, empowering providers to maintain an effective CRC screening outreach during COVID-19 related restrictions.

Evaluation of mailed results versus telephone disclosure of normal cancer genetic test results in a low-risk underserved population.

Scalable models for result disclosure are needed to ensure large-scale access to genomics services. Research evaluating alternatives to genetic counseling suggests effectiveness; however, it is unknown whether these findings are generalizable across populations. We assessed whether a letter is non-inferior to telephone genetic counseling to inform participants with no personal or family history of cancer of their normal results. Data were collected via self-report surveys before and after result disclosure (at 1 and 6 months) in a study sample enriched for individuals from underserved populations. Primary outcomes were subjective understanding of results (global and aggregated) and test-related feelings, ascertained via three subscales (uncertainty, negative emotions, and positive feelings) of the Feelings About genomiC Testing Results (FACToR) measure. Secondary outcomes related to satisfaction with communication. Non-inferiority tests compared outcomes among disclosure methods. Communication by letter was inferior in terms of global subjective understanding of results (at 1 month) and non-inferior to telephoned results (at 6 months). Letter was non-inferior to telephone for aggregated understanding (at 6 months). Letter was superior (at 1 month) to telephone on the uncertainty FACToR subscale. Letter was non-inferior to telephone on the positive-feelings FACToR subscale (at 6 months). Letter was non-inferior to telephone for satisfaction with mode of result delivery and genetic test results. Communication via letter was inferior to telephone in communicating the "right amount of information." The use of written communication to relay normal results to low-risk individuals is a promising strategy that may improve the efficiency of care delivery.

Genetic counseling services delivered in the usual way­during clinic visits­can take up a lot of time for patients and genetic counselors. Alternatives to this practice have been studied among genetic counseling patients to spare genetic counselors' time and expand access and flexibility for patients. Yet, in these studies, the participants have lacked diversity. So, it is not known how these research findings pertain to all populations. In this study, we looked at the use of an alternative care model, a mailed letter, for sharing normal genetic test results with study participants from underserved populations. We tested whether patients viewed the mailed letter as no worse than a telephone conversation with a genetic counselor, which has been shown to be well received by patients. We learned that study participants felt they understood their results, were not distressed to receive the results, and were satisfied with how their results were delivered. Lastly, we found that participants were more satisfied with the amount of information provided about their test results during the telephone conversation compared with the mailed letter. This study provides new information about different ways to deliver test results to individuals receiving genetic services.

Comprehensive quality assurance for intracranial radiosurgery treatments using a postal system / Garantía de calidad para tratamientos de radiocirugía intracranial usando un sistema postal

Radiosurgery is a high-precision technique for delivering, in most cases, a single highly conformal dose to a stereotactically localized target. It can be indicated for small intracranial injury treatment, using either multiple sources of 60Co (γ rays) or high energy photon beams produced by linear accelerators. In order to minimize the impact of inaccurate localization of the target or dose delivery, a rigorous Quality Assurance (QA) program must be enforced, which should include an independent auditing system. This work proposes a simple and reliable postal QA phantom to be used as an independent evaluation. In it two important parameters were verified such as, the dosimetric precision of the planning system, by comparing the absorbed doses measured in the target volume using different dosimeters (ionization chamber, films, thermoluminescent dosimeters and L-alanine dosimeters) all calibrated against a small volume ion chamber. The exact positioning of the target volume was localized using air spaces and small steel spheres to find the appropriate target coordinates. The head phantom and the instruction sheets were extensively tested and sent by mail to selected institutions. The overall results were very encouraging and suggest that the proposed phantom may be used as a postal system as part of an independent QA tool in radiosurgery.

La radiocirugía es una técnica de alta precisión para administrar, en la mayoría de los casos, una sola dosis altamente conformada en un objetivo localizado estereotípicamente. Puede estar indicado para el tratamiento de pequeñas lesiones intracraneales, utilizando múltiples fuentes de 60Co (rayos γ) o haces de fotones de alta energía producidos por aceleradores lineales. Con el fin de minimizar el impacto de la ubicación inexacta de la administración de la meta o de la dosis, se debe aplicar un riguroso programa de control de calidad (QA), que debe incluir un sistema de auditoría independiente. Este documento propone un fantoma postal de control de calidad simple y fiable que se utilizará como evaluación independiente. Se verificó dos parámetros importantes, como la precisión dosimétrica del sistema de planificación, comparando las dosis absorbidas medidas en el volumen objetivo mediante diferentes dosis (cámara de ionización, películas, dosímetros Termoluminiscentes y dosímetros de L-alanina) todos calibrados con una pequeña cámara de iones de volumen. El posicionamiento exacto del volumen objetivo se localizó utilizando espacios aéreos y pequeñas esferas de acero para encontrar las coordenadas de destino adecuadas. El fantoma principal y las hojas de instrucciones fueron ampliamente probados y enviados por correo a instituciones seleccionadas. Los resultados generales fueron muy alentadores y sugieren que el fantoma propuesto puede utilizarse como sistema postal como parte de una herramienta independiente de control de calidad en radiocirugía.

Cuidados profesionales en Tu Sello, fuente para la Historia de la Enfermería / Cuidado profissional em Tu Sello, fonte da História da Enfermagem / Professional care in Tu Sello, source for the History of Nursing

Esta investigación ofrece la trayectoria del servicio postal Tu Sello (2007-2019),de Correos y Telégrafos en España, en emisión de sellos con fenomenología enfermera eidentifica imagen, denominación, tirada, lugar de emisión, diseñador/a, patrocinadores,año, número de sellos y emisiones. Es un estudio observacional, descriptivo yretrospectivo. Los resultados, 17 emisiones y 23 modelos de Tu Sello en torno aEnfermería con tirada media de 200-500 ejemplares. Destaca la Dra. Dª Mª TeresaMiralles Sangro, pionera del estudio Enfermería vs Filatelia. Estas emisiones surgenfundamentalmente en CCAA de Madrid y Andalucía, sus patrocinadores, compañeras/os,Colegios, Universidades, Asociaciones Profesionales, Sociedades Filatélicas y Órdenesreligiosas. Ilustran galardón profesional, retrato compañera, situación clínica, logotiposeventos profesionales, ámbitos profesionales etc. Sus motivos de emisión, Imposición galardón, Aniversarios Colegios, Facultad, Asociación de Enfermería, Congregaciónreligiosa, creación Título Enfermera, Premio Investigación, Celebración eventoprofesional, Pioneras Enfermería, Reconocimiento Colegio, Día Internacional,Fundadoras y Patrona Enfermería. Se constata relevancia profesional de la Filateliacomo fuente de investigación válida. La apuesta firme por el Tu Sello para conmemorarefemérides profesionales. Un número de emisiones, aceptable, tiradas, ajustadas,tendencia al alza y motivos del Tu Sello variados y pertinentes. Las autoras confían queel Tu Sello, continúe en auge para el conocimiento de nuestra Enfermería.(AU)

his research offers the trajectory of the Tu Sello postal service (2007-2019), ofPost and Telegraph in Spain, in issue of stamps with nurse phenomenology and identifiesimage, denomination, circulation, place of emission, designer, sponsors, year, number ofstamps and emissions. It is an observational, descriptive and retrospective study. Theresults, 17 issues and 23 models of Tu Sello around Nursing with average circulation of200-500 copies. Dr. Mª Teresa Miralles Sangro, pioneer of the Nursing vs Philately studystands out. These emissions arise mainly in CCAA of Madrid and Andalusia, its sponsors,partners, colleges, universities, professional associations, philatelic societies andreligious orders. They illustrate professional award, companion portrait, clinical situation,logos, professional events, professional fields, etc. Its motives of issuance, Impositionaward, Anniversaries Colleges, Faculty, Association of Nursing, Religious Congregation,creation Nurse Title, Research Prize, Celebration professional event, Nursing Pioneers,Recognition College, International Day, Founders and Patron Nursing. The professionalrelevance of philately is verified as a valid research source. The firm commitment to theTu Sello to commemorate professional ephemeris. A number of issues, acceptable, pulled,adjusted, upward trend and Tu Sello motives varied and relevant. The authors trust thatthe Tu Sello, continue to rise for the knowledge of our Nursing.(AU)

Esta pesquisa oferece a trajetória do serviço postal Tu Sello (2007-2019), deCorreios e Telégrafos na Espanha, em emissão de selos com fenomenologia de enfermeirae identifica imagem, denominação, circulação, local de emissão, projetista,patrocinadores, ano, número de selos e emissões. Trata-se de um estudo observacional,descritivo e retrospectivo. Os resultados, 17 questões e 23 modelos de Tu Sello em tornode Enfermagem com circulação média de 200-500 exemplares. Mª Teresa MirallesSangro, pioneira do estudo Enfermagem vs Filatelia, destaca-se. Estas emissões surgemprincipalmente no CCAA de Madrid e Andaluzia, seus patrocinadores, parceiros,faculdades, universidades, associações profissionais, sociedades filatélicas e ordensreligiosas. Eles ilustram prêmio profissional, retrato de companheiro, situação clínica, Cultura de los Cuidados. 2º Cuatrimestre 2021. Año XXV. nº 60171logotipos, eventos profissionais, campos profissionais, etc. Seus motivos de emissão, deatribuição Imposição, Aniversários Escolas, Professores, Associação de Enfermagem,congregação religiosa, criação Research Award enfermeira Título, Comemoraçãoprofissional, o reconhecimento Escola Pioneras Enfermagem, Dia Internacional,fundador e patrono de enfermagem. A relevância profissional da filatelia é verificadacomo uma fonte de pesquisa válida. O firme compromisso com o Tu Sello de comemoraras efemérides profissionais. Um número de questões, aceitável, puxado, ajustado,tendência ascendente e motivos Tu Sello variados e relevantes. Os autores confiam que oTu Sello, continua a subir para o conhecimento da nossa Enfermagem.(AU)

Recordatorio a través de múltiples cartas para vacunación contra influenza / Multiple mail reminders to increase adherence to influenza vaccination

INTRODUCCIÓN: Distintas intervenciones han sido propuestas para reforzar el uso de la vacuna contra la influenza. El uso de recordatorios, ya sea a través de cartas, llamadas telefónicas, panfletos o aplicaciones tecnológicas, entre otras, ha destacado dentro de aquellas orientadas a incrementar la adherencia al tratamiento. Sin embargo, su efectividad no está clara. En este resumen, que forma parte de una serie de evaluaciones de recordatorios, se abordará el envío de múltiples recordatorios enviados por correo. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un meta-análisis y prepara-mos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos ocho revisiones sistemáticas que en conjunto incluyeron 35 estudios primarios, de los cuales cuatro corresponden a ensayos aleatorizados que analizan el uso de múltiples recordatorios enviados por correo. Concluimos que más de un recordatorio enviado por correo probablemente aumenta la adherencia a vacunación contra influenza en pacientes mayores de 60 años, mien-tras que podría resultar en poca o nula diferencia en menores de 6 años, pero la certeza de la evidencia es baja.

INTRODUCTION: Different interventions have been proposed to reinforce the use of the influenza vaccine. The use of reminders, whether through letters, phone calls, pamphlets or technological applications, among others, has stood out among those aimed at increasing ad-herence to treatment. However, its effectiveness is not clear. In this summary, which is part of a series of reminder evaluations, we assess the use of multiple mail reminders. METHODS: We conducted a search in Epistemonikos, the largest database of systematic health reviews, which is maintained by screening multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews, analyzed the data from the primary studies, performed a meta-analysis and prepared a summary table of the results using the GRADE method. RESULTS AND CONCLUSIONS: We identified eight systematic reviews including 35 primary studies, of which four analyze the use of more than one letter as a reminder. We conclude that the use of multiple mail reminders probably increase adherence to influenza vaccination in patients over 60; while it may make little or no difference in children under 6 years, but the certainty of the evidence is low.