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Species distribution models are vital to management decisions that require understanding habitat use patterns, particularly for species of conservation concern. However, the production of distribution maps for individual species is often hampered by data scarcity, and existing species maps are rarely spatially validated due to limited occurrence data. Furthermore, community-level maps based on stacked species distribution models lack important community assemblage information (e.g., competitive exclusion) relevant to conservation. Thus, multispecies, guild, or community models are often used in conservation practice instead. To address these limitations, we aimed to generate fine-scale, spatially continuous, nationwide maps for species represented in the North American Breeding Bird Survey (BBS) between 1992 and 2019. We developed ensemble models for each species at three spatial resolutions-0.5, 2.5, and 5 km-across the conterminous United States. We also compared species richness patterns from stacked single-species models with those of 19 functional guilds developed using the same data to assess the similarity between predictions. We successfully modeled 192 bird species at 5-km resolution, 160 species at 2.5-km resolution, and 80 species at 0.5-km resolution. However, the species we could model represent only 28%-56% of species found in the conterminous US BBSs across resolutions owing to data limitations. We found that stacked maps and guild maps generally had high correlations across resolutions (median = 84%), but spatial agreement varied regionally by resolution and was most pronounced between the East and West at the 5-km resolution. The spatial differences between our stacked maps and guild maps illustrate the importance of spatial validation in conservation planning. Overall, our species maps are useful for single-species conservation and can support fine-scale decision-making across the United States and support community-level conservation when used in tandem with guild maps. However, there remain data scarcity issues for many species of conservation concern when using the BBS for single-species models., (© 2023 The Authors. Ecological Applications published by Wiley Periodicals LLC on behalf of The Ecological Society of America.)

Human activities alter ecosystems everywhere, causing rapid biodiversity loss and biotic homogenization. These losses necessitate coordinated conservation actions guided by biodiversity and species distribution spatial data that cover large areas yet have fine-enough resolution to be management-relevant (i.e., ≤5 km). However, most biodiversity products are too coarse for management or are only available for small areas. Furthermore, many maps generated for biodiversity assessment and conservation do not explicitly quantify the inherent tradeoff between resolution and accuracy when predicting biodiversity patterns. Our goals were to generate predictive models of overall breeding bird species richness and species richness of different guilds based on nine functional or life-history-based traits across the conterminous United States at three resolutions (0.5, 2.5, and 5 km) and quantify the tradeoff between resolution and accuracy and, hence, relevance for management of the resulting biodiversity maps. We summarized 18 years of North American Breeding Bird Survey data (1992-2019) and modeled species richness using random forests, including 66 predictor variables (describing climate, vegetation, geomorphology, and anthropogenic conditions), 20 of which we newly derived. Among the three spatial resolutions, the percentage variance explained ranged from 27% to 60% (median = 54%; mean = 57%) for overall species richness and 12% to 87% (median = 61%; mean = 58%) for our different guilds. Overall species richness and guild-specific species richness were best explained at 5-km resolution using ~24 predictor variables based on percentage variance explained, symmetric mean absolute percentage error, and root mean square error values. However, our 2.5-km-resolution maps were almost as accurate and provided more spatially detailed information, which is why we recommend them for most management applications. Our results represent the first consistent, occurrence-based, and nationwide maps of breeding bird richness with a thorough accuracy assessment that are also spatially detailed enough to inform local management decisions. More broadly, our findings highlight the importance of explicitly considering tradeoffs between resolution and accuracy to create management-relevant biodiversity products for large areas., (© 2022 The Ecological Society of America.)

Background: Despite rapid technological advances and growth, quality in imaging has not received the focus seen elsewhere in cardiovascular medicine, resulting in significant gaps between guidelines and practice. Contemporary echocardiography practice requires comprehensive real-time data collection to allow dynamic auditing and benchmarking of key performance indices. The American College of Cardiology (ACC) proposed additional data standardisation, structured reporting identifying key data elements and imaging registries. In the absence of an Australian echocardiography registry, we developed a national clinical quality registry (GenesisCare Cardiovascular Outcomes Echo Registry). We hypothesised that measurement and local reporting of data would improve compliance of echo studies with quality guidelines and hence their clinical value., Methods and Results: We prospectively collected data on 4 099 281 echocardiographic studies entered directly into a central electronic database from 63 laboratories across four Australian states between 2010 and 2021. Real-time auditing of key data elements and introduction of quality improvement pathways were performed to maximise completeness and uniformity of data acquisition and reporting. We compared completeness of key data element acquisition (AV peak velocity, left ventricular ejection fraction, E/e', LA area, rhythm, RVSP) by time and state using de-identified data. Key performance outcomes benchmarked against the aggregated study cohort and international standards were reported to individual sites to drive quality improvement. Between 2010 and 2014 there were significant improvements in data completeness (72.0%+/-26.8% vs 86.8%+/-13.5%, p=0.02), which were maintained to 2020. In addition, interstate variability fell for both EF and E/e' (p<0.002)., Conclusions: This large-scale collaboration provides a platform for the development of major quality improvement initiatives in echocardiography. Introduction of local quality assurance programmes via a unified national data set significantly improved the completeness of reporting of key echo quality measures. This in turn significantly improved the quality of, and reduced the interstate variability of, echo data. Developing a centralised database allowed rapid adoption nationally of local quality improvements., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Increasing recognition of the adverse events older adults experience in post-acute care in skilled nursing facilities (SNFs) has led to multiple efforts to improve care integration between hospitals and SNFs. We sought to measure current care integration activities between hospitals and SNFs., Design: Cross-sectional survey., Setting and Participants: A total of 500 randomly selected Medicare-certified SNFs in the United States in 2019. The survey inquired about 12 care integration activities with the 2 highest volume referring hospitals for each SNF., Methods: We collapsed survey responses into 5 categories of integration based on high correlations between the individual measures. These were: (1) formal integration (co-location or co-ownership); (2) informal integration (eg, formal affiliation, participation in SNF collaborative, shared pay for performance, or clinical leadership meetings between hospital and SNF); (3) shared quality/safety activities (eg, initiatives to improve medication safety or reduce hospital admission); (4) shared care coordinators; and/or (5) shared supervising clinicians. We then conducted multivariate regressions to examine associations between different care integration activities and hospital/SNF characteristics., Results: Our overall response rate was 53.0%, including 265 SNFs that represented 487 SNF-hospital pairs. Informal integration was most common (in 53.3% of pairs), whereas shared clinicians (43.0%), care coordinators (36.5%), shared quality/safety activities (35.1%), and formal integration (7.4%) were present in a minority. Hospital-SNF pairs had lower odds of being formally integrated if the SNF was for-profit compared with not-for-profit [odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03-0.42, adjusted P = .04)] and higher odds of sharing quality improvement activities in metropolitan rather than rural areas (OR 4.06, 95% CI 1.80-9.17, adjusted P = .02) and in the Midwest compared with West (OR 2.95, 95% CI 1.44-6.06, adjusted P = .049)., Conclusions and Implications: These findings raise important questions about what is driving variability in hospital-SNF integration activities, and which activities may be most effective for improving transitional care outcomes., (Published by Elsevier Inc.)

Introduction: The extremely low accident rate for U.S air carriers relative to that of general aviation (∼1 and ∼60/million flight hours respectively) partly reflects advanced airman certification, more demanding recurrency training and stringent operational regulations. However, whether such skillset/training/regulations translate into improved safety for airline pilots operating in the general aviation environment is unknown and the aim of this study., Methods: Accidents (1998-2017) involving airline pilots and instrument-rated private pilots (PPL-IFR) operating non-revenue light aircraft were identified from the NTSB accident database. An online survey informed general aviation flight exposure for both pilot cohorts. Statistics used proportion testing and Mann-Whitney U tests., Results: In degraded visibility, 0 and 40% (χ 2 p = 0.043) of fatal accidents involving airline and PPL-IFR airmen were due to in-flight loss-of-control, respectively. For landing accidents, airline pilots were under-represented for mishaps related to airspeed mismanagement (p = 0.036) relative to PPL-IFR but showed a dis-proportionate count (2X) of ground loss-of-directional control accidents (p = 0.009) the latter likely reflecting a preference for tail-wheel aircraft. The proportion of FAA rule violation-related mishaps by airline pilots was >2X (7 vs. 3%) that for PPL-IFR airmen. Moreover, airline pilots showed a disproportionate (χ 2 p = 0.021) count of flights below legal minimum altitudes. Not performing an official preflight weather briefing or intentionally operating in instrument conditions without an IFR flight plan represented 43% of airline pilot accidents involving FAA rule infractions., Conclusions: These findings inform safety deficiencies for: (a) airline pilots, landing/ground operations in tail-wheel aircraft and lack of 14CFR 91 familiarization regulations regarding minimum operating altitudes and (b) PPL-IFR airmen in-flight loss-of-control and poor landing speed management. Practical Applications: For PPL-IFR airmen, training/recurrency should focus on unusual attitude recovery and managing approach speeds. Airline pilots should seek additional instructional time regarding landing tail-wheel aircraft and become familiar with 14CFR 91 rules covering minimum altitudes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 National Safety Council and Elsevier Ltd. All rights reserved.)

The Patient Protection and Affordable Care Act (ACA) has increased insurance coverage among underserved individuals, but the effect of ACA on cancer diagnosis is currently debated, particularly in Medicaid non-expansion states. Therefore, we aimed to assess the effect of ACA implementation on stage at diagnosis among underserved cancer patients in Texas, a Medicaid non-expansion state. We used data from the institutional registry of the JPS Center for Cancer Care, which serves an urban population of underserved cancer patients. Eligible individuals were aged 18 to 64 years and diagnosed with a first primary invasive solid tumor between 2008 and 2015. We used a natural experiment framework and interrupted time-series analysis to assess level (i.e. immediate) and slope (over time) changes in insurance coverage and cancer stage at diagnosis between pre- and post-ACA periods. Our study population comprised 4808 underserved cancer patients, of whom 51% were racial/ethnic minorities. The prevalence of uninsured cancer patients did not immediately change after ACA implementation but modestly decreased over time (PR = 0.94; 95% CL: 0.90, 0.98). The prevalence of early- and advanced-stage diagnosis did not appreciably change overall or when stratified by screen-detectable cancers. Our results suggest that ACA implementation decreased the prevalence of uninsured cancer patients but had little effect on cancer stage at diagnosis in an underserved population. Given that Texas is a Medicaid non-expansion state, Medicaid expansion and alternative approaches may need to be further explored to improve earlier cancer diagnosis among underserved individuals., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Being prepared for a natural disaster, infectious disease outbreak or other emergency where many injured or ill people need medical care while maintaining ongoing operations is a significant challenge for local health systems. Emergency preparedness requires coordination of diverse entities at the local, regional and national levels. Given the diversity of stakeholders, fragmentation of local health care systems and limited resources, developing and sustaining broad community coalitions focused on emergency preparedness is difficult. While some stakeholders, such as hospitals and local emergency medical services, consistently work together, other important groups--for example, primary care clinicians and nursing homes--typically do not participate in emergency-preparedness coalitions, according to a new qualitative study of 10 U.S. communities by the Center for Studying Health System Change (HSC). Challenges to developing and sustaining community coalitions may reflect the structure of preparedness activities, which are typically administered by designated staff in hospitals or large medical practices. There are two general approaches policy makers could consider to broaden participation in emergency-preparedness coalitions: providing incentives for more stakeholders to join existing coalitions or building preparedness into activities providers already are pursuing. Moreover, rather than defining and measuring processes associated with collaboration--such as coalition membership or development of certain planning documents--policy makers might consider defining the outcomes expected of a successful collaboration in the event of a disaster, without regard to the specific form that collaboration takes.

Objective: Recent national surveys have documented that the majority of adults in the United States do not meet the recommended levels of healthy lifestyle-related behaviors. The Nutrition and Physical Activity (NuPA) study was designed to promote fruit and vegetable consumption, physical activity, and weight management for a working population., Method: Data were collected nationwide, USA, from 2005 to 2007 and analyzed in 2008. A total of 2470 employed participants were randomized into the self-help (SH: n=1191) or self-help plus telephone counseling (SH+C: n=1279) group. The SH+C group received nine structured telephone counseling sessions in addition to the print materials., Results: A series of hierarchical regression analyses for each of the health behavior outcomes in the present-at-follow-up subsample (n=1098-1148) revealed that the SH+C was effective in increasing fruit and vegetable consumption. Among the overweight and obese participants, weight loss was significant in both the SH and SH+C groups., Conclusion: Using a theory-based behavioral change counseling technique and targeting multiple health behaviors among employed individuals, our findings demonstrate that the addition of telephone counseling to mailed self-help materials is effective in promoting healthy diet and weight management., (2009 Elsevier Inc. All rights reserved.)

As we look at the literature from the 1970s and the present, it seems we have come full circle with regard to our understanding of objectives, competencies and outcomes. Our guidelines for writing them have become very complex. During the past few decades, health professions educators often have lost sight of the original intent and focused on the process of developing and writing objectives and competency statements. The process is now so complex that it is almost impossible to write a simple, understandable objective or competency statement. Perhaps that is why the "outcome" term was born. Outcome statements are really fairly broad competency statements. If we focus on the real purpose of objectives and make them simple, they become easier to evaluate. In the next article, we will explore methods for evaluating competence in the clinical setting.

Objective: To evaluate the effectiveness of the Centers for Disease Control and Prevention's CD4+ T-cell laboratory testing improvement program and the influence of other laboratory improvement programs on CD4+ T-cell testing practices., Design: Surveys asking for practice changes and factors that influenced the changes, a survey of clinicians' perceptions of laboratory quality in CD4 testing, and analysis of data from the Model Performance Evaluation Program., Interventions: Centers for Disease Control and Prevention interventions included a series of 3-day workshops on flow cytometry, CD4+ T-cell testing guidelines published in the Morbidity and Mortality Weekly Report, the Clinical Laboratory Improvement Amendments of 1988, and the Model Performance Evaluation Program., Participants: All known laboratories in the United States that perform clinical CD4+ T-cell testing, workshop participants, and a sample of clinicians that treat patients infected with the human immunodeficiency virus., Main Outcome Measures: Changes in practices, factors most influential in effecting change, and performance on samples mailed to laboratories by the Model Performance Evaluation Program; knowledge before and after presentation of material in workshops; and practicing clinicians' observations of any effects of changes in laboratory practices., Results: Many existing laboratories changed practices as a result of both governmental and nongovernmental CD4+ T-cell testing improvement programs. Sources of influence varied with each testing practice. Perceptions that test results were more reproducible seemed to offset presumed increases in the time and cost of testing. Clinicians who had ordered CD4+ T-cell testing for more than 10 years noted some improvements in results reported., Conclusions: As new complex testing methodologies are introduced into clinical and public health laboratories, the users seem to seek guidance in appropriate application of preanalytic, analytic, and postanalytic phases of the testing process. Testing improvement programs from a variety of sources were credited with changing practices and should continue to provide this guidance.

Much has been written about quality assurance in medical practice over the past 15 years. Medicine suddenly found itself trying to design systems that ensured that medicine was being practiced according to standards of quality when it had neither a definition of its product nor defined standards of practice. Consequently, early quality assurance programs focused primarily on documentation of patient care. As the process matured, it evolved to generic screens, with tolerances and outliers. The theory was that the quality of medical care was enhanced by physicians who practiced within often artificially established norms and was diminished by physicians who practiced outside those same norms. It was much like saying that the quality of manufacturing a new car could be improved by reducing all systems down to one of closely standardizing, observing, and documenting how each individual assembly worker put on a lock nut and then holding each worker independently accountable for the final quality of the care. Physicians felt they were being held responsible for conforming to a rigid set of poorly designed and retrospectively applied standards. Moreover, they were held accountable for applying those standards to all practice situations. Understandably, physicians felt at the mercy of nonphysician quality assurance "detectives" in hospitals and became increasingly suspicious of nurses and administrators, who were perceived as abusing the system at the expense of the physicians. Because of these inadequacies of the earlier quality assurance programs, paranoia among physicians about the quality assurance process remains rampant today. The use of blind outcome scores and practice patterns in credentialing and the reporting of these data to databanks have reinforced the paranoia.(ABSTRACT TRUNCATED AT 250 WORDS)

The past two decades witnessed dramatic growth in support for comprehensive school health promotion. Yet, many questions about its effectiveness and feasibility remain unanswered. This article poses several research and policy questions, the answers to which may help to shape the future of school health programs in this country.

Today's health care climate creates increased potential for conflict between hospital administrators and hospital-based physicians. Voluminous regulations, increasing operating costs, professional liability exposure, changing methods of reimbursement, constraints on capital expenditures, and similar constraints on bed expansion have caused hospitals to explore new and innovative sources of revenue. Hospitals have become more eager to provide "bundled" services and health care "packages" in order to compete for discounted reimbursement contracts demanded by large-volume purchasers. While the impact of these changes is clearly felt in the private sector, similar fiscal constraints also may require university hospitals to modify their traditional role as leaders in education, research, and community service. In short, all hospitals are under intense pressure to increase revenues, reduce operating costs, and maintain the scope and quality of services provided.

Health care services in the late 1980's are undergoing drastic changes. Similarly the laws, insurance regulations, etc. are changing so rapidly that the health care system appears to be having a difficult time keeping up with the ever changing needs of the consumers (that is, the patients). Diagnosis Related Groups (DRGs) have resulted in decreased hospital stays for patients with subacute and chronic conditions, and therefore patients are being care for in outpatient rehabilitation agencies, and/or outpatient clinics associated with hospitals. In short, a patient cannot stay in the hospital unless he or she is acutely ill or in need of surgery. Outpatient care is gradually becoming more important since patients who would have still been in the hospital several years ago, are now released to go home, with an order to receive outpatient therapy at the local rehabilitation agency. Currently there is no model available for starting an outpatient rehabilitation agency, and as a result health care professionals interested in starting such a facility have no guidelines or methodology for establishing a private rehabilitation practice.

The relatively few number of articles available concerning the utility of physical exercise or physical sports activities within rehabilitation, according to a recent literature search, may reflect a general scarcity of such articles and/or programs. According to the 115 references located however, exercise appears potentially useful as a rehabilitation tool, in spite of various programmatic and methodological complications. It is apparent that all forms of exercise training are not suitable for all rehabilitation clients. However, based on the rehabilitation-related characteristics of the 15 different activities represented herein, there are certain forms of physical exercise which (1) are more congruent with normalization principles, (2) are more easily adapted to all disabilities, including the elderly, and (3) employ brief, high-intensity training principles, and therefore seem to be well suited for rehabilitation programming, in general. The anecdotal and empirical reports represented in this literature analysis should provide a base for continued investigation of the rehabilitative impact and relative efficiency of physical fitness/sports activities upon impaired individuals.