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Background: Despite consensus guideline recommendations, the use of warfarin patient self‐management (PSM) in the United States (US) healthcare system remains underutilized. Objectives: To gain an understanding of the barriers and facilitators to warfarin PSM in US healthcare systems through qualitative exploration of the opinions of select US patients receiving warfarin therapy. Methods: Individual patient interviews were conducted at five geographically diverse sites. Grounded theory analysis was performed on interview transcriptions using the consolidated framework for implementation research (CFIR) to identify facilitators and barriers to PSM implementation within the US healthcare system. Results: A total of 40 patients were interviewed. Four major themes emerged from the interviews: (1) "Patients are resourceful problem solvers who know themselves better than clinicians" (CFIR domain "Characteristics of Individuals"); (2) The provider‐patient relationship is key to successful PSM (CFIR domains "Inner Setting" and "Intervention Characteristics"); (3) Patients are willing and interested in trying PSM if not already doing so (CFIR domains "Process," "Intervention Characteristics," "Inner Setting, and "Characteristics of Individuals"); and (4) Point‐of‐care international normalized ratio (INR) monitoring is an important PSM facilitator (CFIR "Intervention Characteristics," "Outer Setting," "Inner Setting," and "Process" domains). Conclusions: Interview participants were willing and interested in trying PSM. Core elements of warfarin PSM include timely access to INR results, and a framework to support PSM decision making. Home INR monitoring is likely ideal for facilitating PSM implementation as is maintaining strong provider‐patient relationships where providers, including clinical pharmacists, trust their patients and act as a safety net for PSM decision making. [ABSTRACT FROM AUTHOR]

Background: Despite consensus guideline recommendations, the use of warfarin patient self‐management (PSM) in the US healthcare system remains small in comparison to European countries. Objectives: To gain understanding of the barriers and facilitators to warfarin PSM in US healthcare systems through exploration of the opinions of select US anticoagulation management service providers. Methods: Focus group discussions were conducted at five geographically diverse sites. Grounded theory analysis was performed on focus group transcriptions using the consolidated framework for implementation research (CFIR) to identify facilitators and barriers to PSM implementation within the US healthcare system. Results: A total of 29 providers participated in eight focus group sessions. Five major themes emerged from the interviews: (1) "Ideal" PSM candidates possess identifiable characteristics (CFIR domain "Characteristics of Individuals"); (2) Providers harbor fears and lack familiarity with PSM facts and principles (CFIR domains "Characteristics of Individuals"; "Inner Setting"; and "Outer Setting"); (3) Providers mistrust patients' capability to engage in PSM (CFIR domains "Characteristics of Individuals"; "Inner Setting"; "Outer Setting"; and "Process"); (4) Despite acknowledging PSM advantages many providers cite workflow issues as barriers to implementation (CFIR domains "Intervention Characteristics"; "Inner Setting"; "Outer Setting"; and "Process"); and (5) Providers differed on how to best train patients to do PSM (CFIR domains "Intervention Characteristics"; and "Inner Setting"). Conclusions: Provider concern for patient safety contributes to hesitancy to relinquish control and mistrust of patients' ability to participate in PSM. Education and implementation strategies will be key to overcoming barriers to PSM in the United States. [ABSTRACT FROM AUTHOR]

In this paper, we explain changes made in an introductory Real Analysis classroom that address common challenges and that may allow for all levels of students to meet a high standard of learning and written work. We aim for this goal by fusing elements of a hybrid course with scaffolded collaborative work to improve student learning. The hybrid structure allows students to engage new material at their pace, while the scaffolding allows for more challenging coursework and models for students some typical arguments in analysis. As a result, students that initially submitted proofs needing significant improvement in coherence and organization show positive gains in self-confidence and are enabled to progress quickly to submitting mathematical writing of a high calibre. Our case study occurred at a large institution serving many underrepresented and non-traditional student populations. The approach may be effective at schools with similar goals and challenges. [ABSTRACT FROM AUTHOR]

Direct oral anticoagulants (DOAC) are the most widely prescribed oral anticoagulants in the United States. Despite advantages over warfarin, system-level improvements are needed to optimize outcomes. While Veterans Health Administration and others have described successful DOAC management dashboard implementation, the extent of use nationally is unknown. A survey of Anticoagulation Forum's members was conducted to assess access to digital tools available within a dashboard and to describe implementation models. An Expert Forum was subsequently convened to identify barriers to dashboard development and adoption. Responses were received from 340 targeted recipients (8.5% of invitees). Only a minority of inpatient (25/52, 48.1%) and outpatient (47/133, 35.3%) respondents outside of Veterans Health Administration were able to generate rosters of DOAC users on-demand, and fewer had the ability to digitally display key clinical data elements, identify drug-related problems, document interventions, or generate reports. The lack of regulatory requirements regarding Anticoagulation Stewardship was identified by the Expert Forum as the major barrier to widespread development of digital tools for improved anticoagulation management. While some health systems have demonstrated the feasibility of DOAC dashboards and described their impact on quality and efficiency, these tools do not appear to be widely available in the United States apart from Veterans Health Administration. The lack of regulatory requirements for Anticoagulation Stewardship may be the primary barrier to the development of digital resources to better manage anticoagulants. Efforts to secure regulatory requirements for Anticoagulation Stewardship are needed, and evidence of improvements in clinical and financial outcomes through DOAC dashboard use will likely bolster such efforts., (© 2023. The Author(s).)

Forest disturbances alter land biophysics. Their impacts on local climate and land surface temperature (LST) cannot be directly measured by comparing pre- and post-disturbance observations of the same site over time (e.g., due to confounding such as background climate fluctuations); a common remedy is to compare spatially-adjacent undisturbed sites instead. This space-for-time substitution ignores the inherent biases in vegetation between two paired sites, interannual variations, and temporal dynamics of forest recovery. Besides, there is a lack of observation-based analyses at fine spatial resolutions capable of capturing spatial heterogeneity of small-scale forest disturbances. To address these limitations, here we report new satellite analyses on local climate impacts of forest loss at 30 m resolution. Our analyses combined multiple long-term satellite products (e.g., albedo and evapotranspiration [ET]) at 700 sites across major climate zones in the conterminous United States, using time-series trend and changepoint detection methods. Our method helped isolate the biophysical changes attributed to disturbances from those attributed to climate backgrounds and natural growth. On average, forest loss increased surface albedo, decreased ET, and reduced leaf area index (LAI). Net annual warming-an increase in LST-was observed after forest loss in the arid/semiarid, northern, tropical, and temperate regions, dominated by the warming from decreased ET and attenuated by the cooling from increased albedo. The magnitude of post-disturbance warming was related to precipitation; climate zones with greater precipitation showed stronger and longer warming. Reduction in leaf or LAI was larger in evergreen than deciduous forests, but the recovery in LAI did not always synchronize with those of albedo and ET. Overall, this study presents new evidence of biophysical effects of forest loss on LST at finer spatial resolutions; our time-series method can be further leveraged to derive local policy-relevant ecosystem climate regulation metrics or support model-based climate-biosphere studies., 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 © 2021 Elsevier B.V. All rights reserved.)