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PURPOSE: This longitudinal study explores causal attributions in newly diagnosed head/neck cancer (HNC) patients and their caregivers. METHODS: Perceptions of causal attributions and associated level of responsibility regarding each patient’s HNC diagnosis at baseline (n=72 dyads) were described and then tested as predictors of depressive symptoms, cancer worry, and perceived support six months later. RESULTS: When causes were reported, tobacco and alcohol use topped the list of both patients and caregivers. Three-quarters of dyads agreed about perceptions of the patients’ responsibility in causing their HNC. Some dyad-level patterns of causal attribution were associated with patients’ and caregivers’ cancer worry (p

Rationale: Evidence-based practices promote quality care for intensive care unit patients but chronic evidence-to-practice gaps limit their reach. Objectives: To characterize key determinants of evidence-based practice uptake in the rural intensive care setting. Methods: A parallel convergent mixed methods design was used with six hospitals receiving a quality improvement intervention. Guided by implementation science principles, we identified barriers and facilitators to uptake using clinician surveys (N = 90), key informant interviews (N = 14), and an implementation tracking log. Uptake was defined as completion of eight practice change steps within 12 months. After completing qualitative and quantitative data analyses for each hospital, site, staff, and program delivery factors were summarized within and across hospitals to identify patterns by uptake status. Results: At the site level, although structural characteristics (hospital size, intensivist staffing) did not vary by uptake status, interviews highlighted variability in staffing patterns and culture that differed by uptake status. At the clinician team level, readiness and self-efficacy were consistently high across sites at baseline with time and financial resources endorsed as primary barriers. However, interviews highlighted that as initiatives progressed, differences across sites in attitudes and ownership of change were key uptake influences. At the program delivery level, mixed methods data highlighted program engagement and leadership variability by uptake status. Higher uptake sites had better training attendance; more program activities completed; and a stable, engaged, collaborative nurse and physician champion team. Conclusions: Results provide an understanding of the multiple dynamic influences on different patterns of evidence-based practice uptake and the importance of implementation support strategies to accelerate uptake in the intensive care setting.

BACKGROUND: The number of colorectal cancer (CRC) survivors in the US is increasing and factors associated with CRC surveillance require attention. PURPOSE: This study examined the role of personal, provider, and practice-level factors on CRC survivor care surveillance experiences and outcomes. METHODS: A telephone survey, informed by the Chronic Care Model, was conducted over a one-year period with 150 CRC survivors identified via the South Carolina Central Cancer Registry. Participants were ages ≥21 years and diagnosed with stages I-III CRC within 1.5 years of study enrollment. Data were analyzed using descriptive statistics and logistic regression. Adherence was defined as receipt of surveillance colonoscopy at 13 months post-CRC surgery, as recommended by evidence-based guidelines. RESULTS: The majority of participants were male (55%) and white (86%), with a median age of 65 years (range 25–89). Almost half (43%) had attained a high school degree or less. Cancer stage was fairly evenly distributed, and 58% had received treatment by surgery alone (provider-level factor). Few participants (56%) received a survivorship care plan (practice-level factor), and adherence to surveillance colonoscopy was lowest (36%) among participants with more than one comorbidity (personal-level factor). Logistic regression models showed that the only significant effect of personal, provider, or practice-level factors on CRC surveillance adherence was related to type of health insurance coverage (Private/HMO vs. Other; p=0.04). DISCUSSION: This is one of the first studies to evaluate CRC surveillance in a socioeconomically diverse sample. The only associations found among the examined factors and adherence were related to type of health insurance coverage. Participants with private/HMO health insurance were significantly more likely than participants with “other” health insurance coverage types (i.e., none, Medicare without supplement, Medicare with supplement) to be adherent to the 13-month colonoscopy. Therefore, future education strategies and patient navigation interventions could focus on identifying and overcoming multi-level barriers to CRC surveillance services.

PURPOSE: The objectives of this study were to test the acceptability and feasibility of a survivorship needs assessment planning (SNAP) tool for head and neck cancer (HNC) survivors and caregivers, evaluate short-term changes in psychosocial outcomes after completing the SNAP session and develop strategies for system refinement. METHODS: We used a prospective one-group design and mixed methods with HNC survivors and caregivers (N=25 dyads). Participants completed baseline and 6-week surveys before and after completing a SNAP clinic visit to assess psychosocial outcomes and acceptability. Intervention sessions included tablet-based needs assessments driving tailored care plans. Dyads’ open-ended feedback and clinician interviews (N=12) evaluated acceptability and feasibility. RESULTS: SNAP data collection time burden and technology challenges were minimal and care plans included messages (M=19), educational materials (M=13) and referrals (M=4.5; 86% Behavioral Medicine, 77% Nutrition, 65% Physical Therapy). Participants reported high satisfaction with the session and care plan, highlighting the key strengths of pulling complex medical information together and the focus on caregiver well-being, with multiple suggestions to facilitate clinic workflow. Depression and unmet needs decreased and survivorship knowledge increased significantly in survivors and caregivers (p

The Institute of Medicine recommended in their landmark report "From Cancer Patient to Cancer Survivor: Lost in Transition" that services to meet the needs of cancer patients should extend beyond physical health issues to include functional and psychosocial consequences of cancer. However, no systems exist in the US to support state-level data collection on availability of support services for cancer patients. Developing a mechanism to systematically collect these data and document service availability is essential for guiding comprehensive cancer control planning efforts. This study was carried out to develop a protocol for implementing a statewide survey of all Commission on Cancer (CoC) accredited cancer centers in South Carolina and to implement the survey to examine availability of patient support services within the state. We conducted a cross-sectional survey of CoC-certified cancer centers in South Carolina. An administrator at each center completed a survey on availability of five services: 1) patient navigation; 2) distress screening; 3) genetic risk assessment and counseling, 4) survivorship care planning; and 5) palliative care. Completed surveys were received from 16 of 17 eligible centers (94%). Of the 16 centers, 44% reported providing patient navigation; 31% reported conducting distress screening; and 44% reported providing genetic risk assessment and counseling. Over 85% of centers reported having an active palliative care program, palliative care providers and a hospice program, but fewer had palliative outpatient services (27%), palliative inpatient beds (50%) or inpatient consultation teams (31%). This was a small, yet systematic survey in one state. This study demonstrated a practical method for successfully monitoring statewide availability of cancer patient support services, including identifying service gaps.

Nursing home (NH) staff do not receive adequate training for providing feeding assistance to residents with dementia who exhibit aversive feeding behaviors (e.g., clamping mouth shut). The result is often low meal intake for these residents. This feasibility study tested a web-based dementia feeding skills program for staff in two United States NHs. Randomly assigned, the intervention staff received web-based dementia feeding skills training with coaching. Both groups participated in web-based pre-/post-tests assessing staff knowledge and self-efficacy; and meal observations measured NH staff and resident feeding behaviors, time for meal assistance, and meal intake. Aversive feeding behaviors increased in both groups of residents; however, the intervention NH staff increased the amount of time spent providing assistance and meal intake doubled. In the control group, less time was spent providing assistance and meal intake decreased. This study suggests that training staff to use current clinical practice guidelines improves meal intake.

The purpose of this formative qualitatively driven mixed-methods study was to refine a measurement tool for use in interventions to improve colorectal cancer (CRC) surveillance care. We employed key informant interviews to explore the attitudes, practices, and preferences of four physician specialties. A national survey, literature review, and expert consultation also informed survey development. Cognitive pretesting obtained participant feedback to improve the survey’s face and content validity and reliability. Results showed that additional domains were needed to reflect contemporary interdisciplinary trends in survivorship care, evolving practice changes and current health policy. Observed dissonance in specialists’ perspectives poses challenges for the development of interventions and psychometrically sound measurement. Implications for future research include need for a flexible care model with enhanced communication and role definitions among clinical specialists, improvements in surveillance at multilevels (patients, providers, and systems), and measurement tools that focus on multispecialty involvement and the changing practice and policy environment.

Colon cancer is one of the most commonly diagnosed cancers in the United States, and an increasing number of survivors has underscored the need for improved colon cancer surveillance care quality. Post-treatment surveillance includes follow-up care visits and tests as well as psychosocial support and lifestyle counseling. This formative study explored the individual, interpersonal, and organizational-level factors related to adherence to surveillance care guidelines to identify modifiable factors for potential educational intervention strategies. A convenience sample of 22 survivors (12 women and 10 men) from two cancer centers were recruited to participate in focus groups or key informant telephone interviews to explore their experiences with care after completing treatment and complete a brief survey. Content analysis was used to identify themes. Results confirmed that survivors navigated a complex surveillance care schedule and described a strong trust in their health care providers that guided their follow-up care experiences. Participants defined the terms "survivorship" and "follow-up" in a variety of different ways. Individual-level themes critical to survivors' experiences included having a positive attitude, relying on one's faith, and coping with fears. Interpersonal-level themes centered around interactions and communication with family and health care providers in follow-up care. While organizational-level factors were highlighted infrequently, participants rated office reminder systems and communication among their multiple providers as valuable. Educational interventions capitalizing on survivors' connections with their physicians and focusing on preparing survivors for what to expect in the next phase of their cancer experience, could be beneficial at the end of treatment to activate survivors for the transition to the post-treatment period.

The purpose of this study was to examine the physical and emotional well-being and social support in newly diagnosed head and neck cancer (HNC) patients and caregivers and identify sociodemographic, clinical, and behavioral risk factors associated with compromised well-being in patients and caregivers. Newly diagnosed HNC patients and their primary caregivers (N = 72 dyads) completed questionnaires before treatment assessing physical and mental well-being, depression, cancer worry, and open-ended support questions. Patients reported worse physical well-being than caregivers (p < 0.05) but similar levels of mental well-being. Caregivers reported providing emotional and instrumental support most frequently with an emphasis on nutrition and assistance with speech, appearance, and addictions. Both patients and their caregivers reported suboptimal mental well-being and depression. Smoking was associated with compromised well-being in patients, caregivers, and dyads. Compromised well-being in patients and their caregivers was more likely when patients were younger, had worse symptoms, and smoked/consumed alcohol (p < 0.05). While patients face more physical strain than caregivers, both equally confront emotional challenges. Results highlight risk factors for compromised well-being in both patients and their caregivers that should be assessed at diagnosis to guide identification of needed dyadic-focused supportive care resources.

The purpose of this study was to characterize primary end-of-treatment challenges in head and neck cancer (HNC) to drive the development of a survivorship needs assessment planning (SNAP) tool and evaluate its acceptability and feasibility.Using qualitative methods (focus groups, interviews), we identified physical, emotional, and social post-treatment challenges from the perspectives of survivors (N = 17), caregivers (N = 14), and healthcare providers (N = 14) and pretested the SNAP tool. After Advisory Board ratings and consensus, the tool was finalized.Survivors, caregivers and clinicians consistently highlighted the importance of assessing symptoms and functional abilities (e.g., dry mouth, speech/swallowing difficulties, weight loss), health behaviors (e.g., smoking, alcohol), emotional concerns (e.g., depression, isolation, nutritional distress), and social challenges (e.g., support, finances). Caregivers were overwhelmed and intensely focused on survivors' nutrition and trach/feeding tube care while clinicians emphasized financial and access concerns. Most participants were enthusiastic about the tool and directed a flexible care plan design due to variability in dyad needs. Over 75% reported high comfort using and navigating questions on a tablet and were in strong agreement that the care plan would help families practically and emotionally. Coordination of survivorship visits with follow-up care was critical to address travel and time barriers. While survivors and clinicians recommended waiting 1-6 months after treatment, caregivers preferred earlier survivorship visits.Results pinpointed optimal end-of-treatment domains for routine assessment and support the feasibility of implementing a SNAP tool in the clinic.Capitalizing on technology to direct HNC survivorship care is promising.

Aims To explore factors at the family caregiver and nursing home administrative levels that may affect participation in a clinical trial to determine the efficacy of hand feeding vs. percutaneous gastrostomy tube feeding in persons with late-stage dementia. Background Decision-making regarding use of tube feeding vs. hand feeding for persons with late-stage dementia is fraught with practical, emotional and ethical issues and is not informed by high levels of evidence. Design Qualitative case study. Methods Transcripts of focus groups with family caregivers were reviewed for themes guided by behavioural theory. Analyses of notes from contacts with nursing home administrators and staff were reviewed for themes guided by an organizational readiness model. Data were collected between the years 2009–2012. Results Factors related to caregiver willingness to participate included understanding of the prognosis of dementia, perceptions of feeding needs and clarity about research protocols. Nursing home willingness to participate was influenced by corporate approval, concerns about legal and regulatory issues, and prior relationships with investigators. Conclusion Participation in rigorous trials requires lengthy navigation of complex corporate requirements and training competent study staff. Objective deliberation by caregivers will depend on appropriate recruitment timing, design of recruitment materials and understanding of study requirements. The clinical standards and policy environment and the secular trends there-in have relevance to the responses of people at all levels.

Study Objective Human papillomavirus (HPV) vaccines provide an opportunity to greatly reduce the burden of cervical cancer. Although there has been improvement in uptake, there are notable ethnic/racial disparities. This qualitative study was conducted to better understand factors related to vaccine uptake among female adolescents from 3 racial/ethnic groups: African American (AA), Hispanic, and Caucasian. Findings can inform the development of optimal messages and strategies for clinical and population-based interventions. Design and Setting This mixed-methods descriptive study included completion of a brief structured survey and focus group discussion. Six focus groups were conducted with female adolescents, 2 each in the AA, Hispanic, and Caucasian groups. Brief structured survey questions and the focus group protocol addressed knowledge, perceptions, and behaviors related to HPV, HPV vaccination, and cervical cancer. Participants, Interventions, and Main Outcome Measures Participants were 60 female adolescents (ages 13-19, mean age = 16.6 years) recruited from high schools, public health clinics, and churches. Results Themes across questions were remarkably similar among AA, Hispanic, and Caucasian participants. Each group had high awareness of the terms HPV, HPV vaccination, and cervical cancer, but with little in-depth knowledge about these topics. There was a high acceptance of HPV vaccination. Misperceptions about optimal cervical cancer prevention strategies such as simply knowing one's partner and good hygiene were most common among Hispanic adolescents. Awareness about Pap testing was most common among Caucasian adolescents. Conclusion Predominantly uniform perceptions of HPV vaccines across racial/ethnic groups suggest a “one size fits all” approach will likely have greater reach with cervical cancer prevention messaging than culturally tailored interventions.

In 1999, researchers and policy makers recognized the challenge of creating an integrated patient-centered cancer care process across the many types of care from risk assessment through end of life. More than a decade later, there has been limited progress toward that goal even though the standard reductionist approach to health services and medical research has resulted in major advances in tests, procedures, and individualized patient approaches to care. In this commentary, we propose that considering an entire care process within its multilevel context may increase progress toward an integrated experience and improvements in the quality of care. As an illustrative case, we describe the multilevel context of care delivery for the process of follow-up to an abnormal screening mammogram. By taking a multilevel perspective on this process, we identify a rich set of options for intervening and improving follow-up to abnormalities and, therefore, outcomes of screening. We propose that taking this multilevel perspective when designing interventions may improve the quality of cancer care in an effective and sustainable way. Cancer Epidemiol Biomarkers Prev; 21(10); 1709–15. ©2012 AACR.

The complex environmental context must be considered as we move forward to improve cancer care and, ultimately, patient and population outcomes. The cancer care continuum represents several care types, each of which includes multiple technical and communication steps and interfaces among patients, providers, and organizations. We use two case scenarios to 1) illustrate the variability, diversity, and interaction of factors from multiple levels that affect care quality and 2) discuss research implications and provide hypothetical examples of multilevel interventions. Each scenario includes a targeted literature review to illustrate contextual influences upon care and sets the stage for theory-informed interventions. The screening case highlights access issues in older women, and the survivorship case illustrates the multiple transition challenges faced by patients, families, and organizations. Example interventions show the potential gains of implementing intervention strategies that work synergistically at multiple levels. While research examining multilevel intervention is a priority, it presents numerous study design, measurement, and analytic challenges.

Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicine's six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.

A growing number of older adults coupled with a limited number of physicians trained in geriatrics presents a major challenge to ensuring quality medical care for this population. Innovations to incorporate geriatrics education into internal medicine residency programs are needed. To meet this need, in 2009, faculty at the Medical University of South Carolina developed Aging Q(3)-Quality Education, Quality Care, and Quality of Life. This multicomponent initiative recognizes the need for improved geriatrics educational tools and faculty development as well as systems changes to improve the knowledge and clinical performance of residents. To achieve these goals, faculty employ multiple intervention strategies, including lectures, rounds, academic detailing, visual cues, and electronic medical record prompts and decision support. The authors present examples from specific projects, based on care areas including vision screening, fall prevention, and caring for patients with dementia, all of which are based on the Assessing Care of Vulnerable Elders quality indicators. The authors describe the principles driving the design, implementation, and evaluation of the Aging Q(3) program. They present data from multiple sources that illustrate the effectiveness of the interventions to meet the knowledge, skill level, and behavior goals. The authors also address major challenges, including the maintenance of the teaching and modeling interventions over time within the context of demanding primary care and inpatient settings. This organized, evidence-based approach to quality improvement in resident education, as well as faculty leadership development, holds promise for successfully incorporating geriatrics education into internal medicine residencies.

BACKGROUND: Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery. OBJECTIVE: Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns. DESIGN: Cross-sectional analysis of data from a nationally representative survey conducted in 2006-2007. PARTICIPANTS: 1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists. MAIN MEASURES: Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics. RESULTS: The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering. CONCLUSIONS: PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.

Current public health priorities emphasize the elimination of health disparities, translational research, and transdisciplinary and community alliances. The Center for Community Health Partnerships is a proactive initiative to address new paradigms and priorities in health care through institutionalization of community-university partnerships. This report highlights innovative strategies and lessons learned.

Background: Although systems strategies are effective in improving health care delivery, little is known about their use for cancer screening in U.S. primary care practice. Methods: We assessed primary care physicians' (N = 2,475) use of systems strategies for breast, cervical, and colorectal cancer (CRC) screening in a national survey conducted in 2007. Systems strategies included patient and physician screening reminders, performance reports of screening rates, electronic medical records, implementation of in-practice guidelines, and use of nurse practitioners/physician assistants. We evaluated use of both patient and physician screening reminders with other strategies in separate models by screening type, adjusted for the effects of physician and practice characteristics with multivariate logistic regression. Results: Fewer than 10% of physicians used a comprehensive set of systems strategies to support cancer screening; use was greater for mammography and Pap testing than for CRC screening. In adjusted analyses, performance reports of cancer screening rates, medical record type, and in-practice guidelines were associated with use of both patient and physician screening reminders for mammography, Pap testing, and CRC screening (P < 0.05). Conclusion: Despite evidence supporting use of systems strategies in primary care, few physicians report using a comprehensive set of strategies to support cancer screening. Impact: Current health policy initiatives underscore the importance of increased implementation of systems strategies in primary care to improve the use and quality of cancer screening in the United States. Cancer Epidemiol Biomarkers Prev; 20(12); 2471–9. ©2011 AACR.

Falls are a major problem in older adults, and physicians receive inadequate training in falls evaluation. A multicomponent program (lecture, academic detailing, and case studies) was implemented to enhance medical residents' knowledge, skills, decisions, and interventions made about falls as part of a larger project to improve assessment and care of older adults. Electronic medical record (EMR) template modifications provided cues and reminders, decision support, and documentation into the visit note. Nursing staff and the EMR prompted residents to evaluate patients with a history of falls. Knowledge and confidence were assessed using a pre- and postintervention questionnaire, and an attending physician assessed skills by direct observation of the Timed Up and Go Test (TUG). Effect on clinical actions was assessed using the EMR database. Participation in training of faculty and staff was high. Over the 3-month intervention period, an attending physician reviewed the detailing sheet outlining important points of the training with 86% of residents, and 64% demonstrated a TUG to an attending physician. Of 895 older adults seen, 15% (134) had a positive screen for falls, of whom 92% (123) had an EMR falls template completed, and 42% (56) had a TUG performed. Of the patients evaluated with the TUG, 53% (29) failed. A review of charts for patients who failed the screen or TUG revealed that the majority had special circumstances limiting their participation, even after a physical therapy evaluation. Education and system changes facilitated improvements in resident knowledge, skill, self-efficacy, and clinical action in screening, evaluating, and managing falls in older adults.

Aim This randomized clinical trial was conducted 2008 – 2009 to investigate a cryotherapy (cooling) gel wrap applied to lower leg skin affected by chronic venous disorders to determine whether therapeutic cooling improves skin microcirculation. Impaired skin microcirculation contributes to venous leg ulcer development, thus new prevention therapies should address the microcirculation to prevent venous leg ulcers.

This case study was conducted between 2000 and 2003 to examine the implementation of community based tobacco treatment programs funded by the Massachusetts Department of Public Health Tobacco Control Program (MTCP). Four dimensions of implementation, drawn from several models of program evaluation are explored: (a) quantity of services, (b) quality of services, (c) implementation/use of systems, and (d) sustainability. The quantity of services delivered was high, reflecting MTCP’s focus on increasing availability of services, particularly in underserved populations. The quality of physician-delivered tobacco intervention did not meet national benchmarks for delivery of all 5As (Ask, Advise, Assess, Assist, Arrange follow-up) and only about half of organizations reported routine systems for auditing tobacco use documentation. Implementation of systems to identify tobacco users and deliver tobacco treatment varied widely by community health settings, with low rates of tobacco use documentation found. Finally, in an era of greater competition for scarce prevention dollars, sustainability of services over time must be planned for from the outset, as indicated by the success of programs that sustained services by proactively and creatively incorporating tobacco treatment into their organizations. This case study can inform states’ policies in their design of tobacco treatment services in community health settings.

Step Ahead was a randomized controlled trial testing ecologically based weight gain prevention interventions in the hospital workplace. The RE-AIM framework is used to assess the intervention’s Reach, Effectiveness, Adoption, Implementation, and Maintenance. Some intervention components reached a large percentage of the workforce. Although the intervention was not effective in changing BMI on a population level, a dose response was observed, in which persons who used more of the intervention components and materials were more likely to prevent weight gain. Adoption of the intervention by sites invited was 100%. Implementation of healthy eating interventions in the hospital setting was especially challenging because close collaboration was necessary with hospital employees and contractors, and their mission and priorities often were at odds with the intervention goals. There are some notable instances of intervention maintenance at the institutional level: Farmers markets have been expanded at both sites since the end of the intervention period, and new wellness programs are being adopted and implemented. Implications for practice include the translation of this research into other workplace settings.

Background The worksite represents a promising venue in which to address the issue of obesity. Design Pair-matched, cluster-RCT. Data were collected from 2005 to 2008 and analyzed in 2008. Setting/participants A random sample of 806 employees was selected to represent the workforce of six hospitals in central Massachusetts. Intervention The 2-year ecologic intervention sought to prevent weight gain through changes in worksite weight-related norms using strategies targeted at the organization, interpersonal environment, and employees. Main outcome measures The primary outcome was change in BMI at the 12- and 24-month follow-ups. Change in perceptions of organizational commitment to employee health and normative coworker behaviors were secondary outcomes. Results There was no impact of the intervention on change in BMI from baseline to 12 (β=0.272; 95% CI=−0.271, 0.782) or 24 months (β=0.276; 95% CI=−0.338, 0.890) in intention-to-treat analysis. When intervention exposure (scale=0 to 100) was used as the independent variable, there was a decrease of 0.012 BMI units (95% CI=−0.025, 0.001) for each unit increase in intervention participation at the 24-month follow-up. Employees in intervention sites reported significantly greater improvements in perceptions of organizational commitment to employee health at 12 and 24 months compared to control sites, but there was no impact on perceptions of normative coworker behaviors. Conclusions The intervention had a dose–response relationship with BMI, with positive effects proportional to extent of participation. Although the intervention was able to change organizational perceptions, successfully improving changes in actual and perceived social norms may be needed to achieve population-level impact in complex worksite organizations.

The reliability and validity of two diabetes-specific quality-of-life instruments were examined with aging African Americans with limited literacy. Cognitive interviews with 15 persons and content analysis were conducted. Participants’ mean age was 72 years, and 40% had less than a high school education. Most observed problems with the surveys related to comprehension and response categories. Respondents had difficulty distinguishing between certain functional limitations and/or level of satisfaction as being associated with chronic illness or aging. This study underscores the need for research with special populations on the appropriateness of instruments previously validated and shown reliable for more general populations. While cognitive interviewing is resource intensive, ignoring this investment may result in inappropriate interpretations about the effectiveness of interventions to improve care and outcomes, understand differences, and eliminate disparities.

Previous studies have consistently observed that women are more likely to perceive themselves as overweight compared to men. Similarly, women are more likely than men to report trying to lose weight. Less is known about the impact that self-perceived weight has on weight loss behaviors of adults and whether this association differs by gender. We conducted a cross-sectional analysis among an employee sample (n=899) to determine the association of self-perceived weight on evidence-based weight loss behaviors across genders, accounting for body mass index (BMI) and demographic characteristics. Women were more likely than men to consider themselves to be overweight across each BMI category, and were more likely to report attempting to lose weight. However, perceiving oneself to be overweight was a strong correlate for weight loss attempts across both genders. The effect of targeting accuracy of self-perceived weight status in weight loss interventions deserves research attention.

Objective:Most patients diagnosed with lung cancer present with advanced stage disease and have a poor chance of long-term survival. Despite the advantages of hospice care for lung cancer patients, many are enrolled late in the course of their illness or not at all. We sought to identify reasons for this pattern.Method:A list of perceived barriers to hospice enrollment was generated and used to create two self-administered surveys, one for physicians and one for caregivers. After focus group testing, the finalized instruments were mailed to physicians in South Carolina and to caregivers of lung cancer patients who died under hospice care with a local hospice between 2000 and 2004.Results:Fifty-three caregivers and 273 physicians responded to the survey. From the caregivers' perspectives, leading reasons for deferred hospice enrollment included patients' unanticipated rapid transition from well to sick and a belief that hospice means giving up hope. From the physicians' perspectives, impediments to earlier hospice enrollment included patients and caregivers overestimating survival from lung cancer and an (incorrect) assumption that patients need to be “DNR/DNI” prior to hospice enrollment.Significance of results:Lung cancer patients may benefit from earlier introduction to the concepts of hospice care and more education regarding prognosis so that an easier transition in goals of care could be achieved. A smaller proportion of lung cancer patients may benefit from earlier hospice enrollment.

This commentary considers the important roles that primary care providers, practices, and health systems play in promoting effective colorectal cancer (CRC) screening according to guidelines, and how interventions can improve performance.1,2 The 4 articles in this section provide examples of efforts

Purpose This article reviews the literature on definitions and issues related to measurement of quality of life in people with diabetes and summarizes reviews of evidence of intervention studies, with a particular focus on interven- tions targeted for underserved and minority populations. Methods An integrative literature review of reviews was conducted on adult diabetes interventions and outcomes. Five electronic databases were searched. Eligible publications were those published between 1999 and 2006 that described outcome measures. Twelve review articles are included. Results Review studies were heterogeneous in terms of intervention type, content, participants, setting, and outcome measures. Interventions used variable operational definitions and frequently lacked adequate description; therefore, comparisons of findings proved difficult. A clinical outcome, A1C, was the most frequently assessed, with little inclusion of quality-of-life measures. Several reviews and independent studies did not explicitly con- sider interventions aimed at the underserved. When quality of life was considered, measures and operational definition of domains were limited. Conclusions Understanding the relationship between interventions and resulting outcomes, particularly quality of life, will require attention to operational definitions and better conceptual models. There is an evidence base emerging about important characteristics of effective intervention programs. This evidence base can guide public health and clinical program planners to better understand and make prudent decisions about assessment, planning, implementation, and evaluation of interventions for people with complex chronic illnesses such as diabetes.

Percutaneous endoscopic gastrostomy tubes are being placed with increasing frequency in the United States among elderly patients with dementia. Health care providers believe there may be long-term benefits for enteral feeding in this population, yet previous study of this topic has failed to yield any convincing evidence to support this hypothesis. In this study, we review the evidence regarding outcomes for artificial enteral feeding in older individuals with dementia. We found that there is a lack of evidence supporting artificial feeding in the specific outcomes of survival, pressure ulcers, nutrition, and aspiration pneumonia. A brief discussion regarding hand feeding is included. The data suggest that hand feeding may be a viable alternative to tube feeding in elderly patients with dementia, although a direct comparison trial of the 2 interventions is lacking.

Heart failure is a serious clinical management challenge for both patients and primary care physicians. The authors studied the perceptions and practices of internal medicine residents and faculty at an academic medical center in the Southeast to guide design of strategies to improve heart failure care. Data were collected via a self-administered survey. Eighty-nine faculty and resident physicians in general internal medicine and geriatrics participated (74% response rate). Items measured perceived skills and barriers, adherence to guidelines, and physician understanding of patient prognosis. Case studies explored practice approaches. Clinical knowledge and related scales were generally good and comparable between physician groups. Palliative care and prognostic skills were self-rated with wide variance. Physicians rated patient noncompliance and low lifestyle change motivation as major barriers. Given the complexities of caring for elderly persons with heart failure and comorbid conditions, there are significant opportunities for improving physician skills in decision making, patient-centered counseling, and palliative care.

BACKGROUND As we learn about patient experiences with head and neck cancer, it is also important to consider caregivers so that family-centered care can be improved. OBJECTIVES The purpose of this systematic review was to (a) identify the research questions, methods, and measures that have been examined in quality-of-life studies with head and neck cancer patients and their caregivers (dyads) and (b) identify gaps and future directions for research and practice. METHODS We conducted a systematic search of electronic databases using keywords (head and neck cancer, caregiver, quality of life) and included studies that assessed quality of life-related constructs in both patients and caregivers. A dyadic quality-of-life conceptual model guided the summary of observations. RESULTS Thirteen studies met eligibility criteria. The most common research questions included comparing patient and caregiver quality of life, examining relationships between personal and clinical factors in 1 dyad member and a quality-of-life outcome in the other, and exploring relationships between interpersonal processes and quality of life. Psychological quality-of-life constructs were most commonly studied. There was substantial variability in study findings, in part due to differences in study questions and samples. CONCLUSIONS Future research is needed to examine longitudinal interpersonal processes in head and neck cancer. Unique caregiving tasks should be inventoried, and dyadic data analysis techniques should be used. IMPLICATIONS FOR PRACTICE Head and neck cancer dramatically affects quality of life in patients and caregivers, and quality clinical care requires a dyadic focus. Oncology nurses have a unique opportunity to develop and implement dyadic illness management models for head and neck cancer.

Background Interventions addressing cancer survivors' posttreatment concerns can be time-intensive and require specialized staff. Research is needed to identify feasible minimal intervention strategies to improve survivors' quality of life after treatment. Objectives The objective of this study was to evaluate the feasibility and short-term impact of a minimal clinic intervention on breast cancer survivors' quality of life, unmet needs, distress, and cancer worry. Interventions/methods In this randomized controlled pilot trial, we enrolled breast cancer survivors at the end of treatment and administered baseline surveys. Participants were randomized to study arm (4-week video plus educational booklet intervention group and usual care group) and completed follow-up surveys at 10 weeks. Linear regression was used to examine intervention effects on quality of life outcomes controlling for clinical and demographic factors. Open-ended questions were used to examine program satisfaction and obtain feedback to improve the intervention. Results We enrolled 92 survivors in the trial. Participants rated the intervention highly and reported feeling less isolated and having more realistic expectations about their recovery after completing the program. Despite positive qualitative findings, no significant intervention effects were observed for quality of life, unmet needs, distress, or cancer worry in unadjusted or adjusted analyses. Conclusions Future research is needed to define optimal intervention elements to prepare breast cancer survivors for the posttreatment period. Implications for practice Effective survivorship interventions may require more intensive components such as clinical input and longer follow-up periods.

To examine age group differences in predictors of mammography screening in women with a first-degree female relative (FDFR) with recent diagnosis of breast cancer. A cohort study of 577 women ages 18 and over with a FDFR diagnosed with incident stage 0-III breast cancer was conducted. Telephone interviews were conducted at baseline, 6 months and 12 months. Logistic regression was used to model factors associated with mammography screening since diagnosis. Mammography rates were 32%, 71% and 75% for women aged 18–39, 40–49 and 50 and above, respectively. Among the youngest group, belief in cancer screening effectiveness, mammography history and MD recommendation predicted mammography. For those 40–49, excellent self-rated health, perceived similarity of personality to the patient and higher intrusive thoughts predicted mammography. Perceived similarity of health care utilization to the patient and higher risk perceptions were associated with mammography among women aged 50 and above. Mammography rates were high among women aged 40–49 and 50 and above, and considerable among women aged 18–30, even in view of the lack of evidence-based guidelines. Continued attention should be paid to the 25–30% of older women who do not report screening.

Heart failure is a high prevalence, high burden disease with an unpredictable trajectory. Given that approximately 50% of persons with the diagnosis die within 5 years, the implications for communication about advance planning and end of life, although simultaneously providing hope and treatment, are extremely challenging. This article reports on a feasibility trial of a modest continuing education seminar to increase awareness and communication skills of inpatient nurses. Curriculum design details, including objectives and methods, are described. Needs assessment and evaluation data are reported. At the 2-month posttest, a summary communications skill score showed significant improvement. Data also illustrated that the challenge of facing issues about dying are complicated by a work force of relatively young staff and low exposure to few actual deaths during relatively short lengths of stay.

Objective: Effective communication is recognized as an essential process to providing quality care, including palliative and end-of-life care. Discussion of prognosis and support needs of patients with heart failure is particularly challenging given the nature of the condition and care across several settings. The objective was to design, implement, and evaluate an interdisciplinary workshop aimed at improving attitudes and skills related to communication with patients and family, health team communication and documentation, and assessment of physical and emotional symptoms.Methods: A pretest, delayed posttest evaluation design was used to evaluate two 4-h workshops offered to nurses, social workers, and other nonphysician clinicians.Results: Although baseline reports of skills were high for the participants, significant improvement was noted for objectives emphasized in the workshop.Significance of results: This project demonstrated the feasibility of designing, marketing a brief workshop, and positively impacting communication and documentation skills.

When using patient self-report of processes of care as part of measuring quality performance, validity and reliability are important considerations. In this study, the congruence of patient report of recommendations of screening follow-up care was compared with record audit data. Survey data were collected from a random sample of patients with abnormal breast (n = 230) or cervical (n = 219) cancer screening tests from four health centers. With patient consent, record audits were conducted to validate self-report. Measures of congruence for recommendations for follow-up were calculated along with sensitivity and specificity for procedure-specific recommendations. Overall congruence was higher in the mammography sample (81%) as compared to the Pap sample (61%). Predictors of overall congruence for the abnormal Pap test sample included health plan, self-reported health status, and test result. There were no significant predictors of congruence for the abnormal mammogram test sample from the potential variables collected. Raw agreement rates support using patient self-report in assessing abnormal test follow-up recommendations.

Background The U.S. Public Health Service clinical practice guideline calls for clinicians and healthcare organizations to identify and treat every tobacco user seen in a healthcare setting. There is little information on the extent of compliance with the guideline's treatment model described by the "5A's" (Ask, Advise, Assess, Assist, Arrange). Methods In 1999–2000 a survey was mailed to 64,764 members aged 25 to 75 years, of nine nonprofit HMOs participating in the National Cancer Institute-funded Cancer Research Network. These plans provide medical care to more than 8 million Americans including a minority enrollment of 30%. Smokers were asked about tobacco-cessation treatments received during primary care visits in the past year. Results A 70% response rate identified a smoking prevalence of 10% ( n =4207). Results indicated that 90% of smokers were asked about smoking, 71% were advised to quit, 56% were assessed for their willingness to quit, 49% received assistance interventions, and 9% had follow-up arranged. Treatment was provided more often to smokers who asked for help and/or intended to quit. Few and only modest associations were found between other patient characteristics and receipt of 5A's cessation services. In contrast to widely reported concerns about smokers' resistance to tobacco interventions, smokers who received treatment were more satisfied with health plan services. Conclusions Results demonstrate substantial clinician compliance with the first two steps—Ask and Advise. Greater efforts are needed in providing the more effective tobacco treatments—Assist and Arrange. Compliance with the guideline is associated with greater patient satisfaction.

In 1997, the Institute of Medicine called for reform, improved quality and expanded research in end-of-life care. Yet little empirical information about preferences of African Americans has been documented. A community-campus partnership was formed to guide a needs assessment related to end-of-life care in a Southern, urban, African American community. This paper presents focus group findings related to end-of-life and palliative care.A qualitative design of multiple-meeting focus groups was used to explore experiences, preferences, needs, and feelings expressed by family members with at least one relative who had died in a hospital (group 1) or at home (group 2). Sessions were taped and transcribed; themes were identified using systematic analytic procedures.Thematic analysis revealed key concerns related to health care provider communications about end-of-life care and dying. Positive communications empowered and showed respect for patients and family members and recognized the importance of their spiritual beliefs; informed them about resources available to assist dying at home; and, for patients dying in the hospital, treated them with nurturing, compassion, and diligent monitoring of the patient's medical status and needs. Other themes related to end-of-life care issues include preparation, planning, and access. A table of quotes from participants is available from the corresponding author.Findings suggest important clinical implications for clinicians and other health professionals. These voices from the community remind us of the heterogeneity in needs and preferences and challenge us to listen and tailor communication to each patient and their families.

Background Professional societies and government organizations have promoted guidelines and best practices that encourage clinicians to routinely integrate cessation counseling into patient encounters. While research in health maintenance organizations has demonstrated that the development and maintenance of office systems do enable clinicians’ smoking-cessation services, little is known about the adoption of system strategies in diverse organizations serving disadvantaged populations. Methods Data were collected via face-to-face interviews from November 2001 to October 2002 using a standardized systems assessment checklist at service delivery sites of 83 funded community health service agencies, which included hospitals, community health centers, and other organizations (e.g., substance abuse, mental health, and multiservice). The content of the structured assessment reflected system elements with proven effectiveness that have been included in guidelines and best practices recommendations. Detailed information was collected on the implementation strategies. Results This study found considerable attention to systems that support cessation services in diverse healthcare organizations, but much remains to be done. There is a wide diversity of implementation strategies employed, with varied degrees of sophistication. Conclusions A major challenge is to develop systems capable of providing population-based feedback to, and between, providers, which will enable further quality improvement efforts.

Background Although primary care physicians understand the importance of preventive services for patients with multiple risk factors (MRF) for coronary heart disease, physician intervention is limited. This study investigated (1) physicians' views of challenges faced in managing patients with MRF; (2) the counseling and management methods they utilize; and (3) possible strategies to enhance MRF intervention in the primary care setting. Methods Two focus groups were conducted with primary care physicians from varying settings to gain insight into these issues noted above. Each group was co-facilitated by a physician and a behavioral scientist using a previously developed semistructured interview guide. The group discussions were tape recorded and subsequently transcribed. Transcripts were analyzed using the constant comparative method for analysis. Results Physicians are challenged by knowledge limitations (contribution of individual risk factors to overall risk); limited support (guidelines, materials, and staff); and logistic difficulties (organizational issues, time limitations). Their approach to MRF management tends to be highly individualized with an initial preference for lifestyle change interventions rather than prescription of medications with some qualifying circumstances. Physicians favored a serial rather than a parallel approach to MRF intervention, starting with behaviors that the patient perceives as a priority. Proposed solutions to current challenges emphasize physician education and the development of innovative approaches that include physician assistance and a team approach. Conclusions Physicians are aware of and sensitive to the complexity of MRF management for their patients and themselves. However, future MRF interventions will require nonphysician staff involvement and increased systems support.

Objectives. We compared complication rates after surgical abortions performed by physician assistants with rates after abortions performed by physicians. Methods. A 2-year prospective cohort study of women undergoing surgically induced abortion was conducted. Ninety-one percent of eligible women (1363) were enrolled. Results. Total complication rates were 22.0 per 1000 procedures (95% confidence interval [CI] = 11.9, 39.2) performed by physician assistants and 23.3 per 1000 procedures (95% CI = 14.5, 36.8) performed by physicians (P = .88). The most common complication that occurred during physician assistant–performed procedures was incomplete abortion; during physician-performed procedures the most common complication was infection not requiring hospitalization. A history of pelvic inflammatory disease was associated with an increased risk of total complications (odds ratio = 2.1; 95% CI = 1.1, 4.1). Conclusions. Surgical abortion services provided by experienced physician assistants were comparable in safety and efficacy to those provided by physicians.

Researchers and their community partners have been challenged by funders and political entities to translate what is learned in research into practice. Such translation is more challenging than it appears, and it is important to systematically make use of opportunities available to learn about facilitators and barriers to the implementation of effectiveness research in real-world settings. This article presents a case study of the process evaluation undertaken as part of Quit Together, a randomized trial of the effectiveness of an intervention to improve smoking cessation and relapse prevention among low-income pregnant and postpartum women who receive care at community health centers (CHCs). The analysis considers areas of program implementation failure that may need critical rethinking. The article demonstrates the importance of process-monitoring methods to examine context factors of collaborative research, outlines lessons learned and the challenges of research carried out in CHCs, and summarizes implications for researchers and for practitioners.

Background. Overlapping responsibilities of health care delivery professionals in the United States has propelled medical, graduate nursing, and public health schools to rethink their curricula. The University of Massachusetts Medical School implemented the Cancer Prevention and Control Education (CPACE) initiative, an interdisciplinary curriculum focusing on behavioral and psychosocial aspects of cancer prevention, control, and research. Methods. An interdisciplinary Operations Committee developed courses, clerkships, and programs. Continuing education programs stressed the team approach. Results and Discussion. CPACE teaching objectives were congruent in the three schools, but logistical issues were challenging. Positive preevaluations and postevaluations indicated potential for shaping a collaborative attitude among health care providers. J Cancer Educ. 2004; 19:37-44.

Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors-public policy, organizational systems and practice settings, clinicians, and patients-influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues.

Objective The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians regarding colorectal cancer screening. Methods We surveyed 77 primary care providers in six clinics in central Massachusetts to evaluate several factors related to colorectal cancer screening. Results Most agreed with guidelines for fecal occult blood test (97%) and sigmoidoscopy (87%), which were reported commonly as usual practice. Although the majority (86%) recommended colonoscopy as a colorectal cancer screening test, it was infrequently reported as usual practice. Also, 36% considered barium enema a colorectal cancer screening option, and it was rarely reported as usual practice. Despite lack of evidence supporting effectiveness, digital rectal examinations and in-office fecal occult blood test were commonly reported as usual practice. However, these were usually reported in combination with a guideline-endorsed testing option. Although only 10% reported that fecal occult blood test/home was frequently refused, 60% reported sigmoidoscopy was. Frequently cited patient barriers to sigmoidoscopy compliance included fear the procedure would hurt and that patients assume symptoms occur if there is a problem. Perceptions of health systems barriers to sigmoidoscopy were less strong. Conclusions Most providers recommended guideline-endorsed colorectal cancer screening. However, patient refusal for sigmoidoscopy was common. Results indicate that multiple levels of intervention, including patient and provider education and systems strategies, may help increase prevalence.

Background: Despite the strong evidence of harmful effects, tobacco and alcohol use during pregnancy continue to be major public health challenges. Some women, however, do stop spontaneously when they learn of their pregnancy. No study has investigated spontaneous cessation of both behaviors in a low-income predominantly unmarried U.S. population. Objective: To describe the prevalence of spontaneous cessation of cigarette and alcohol use alone and in combination and associated factors among low-income pregnant women. Methods: Subjects (N=601) were currently smoking or smoking when they became pregnant and participating in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs in the greater Boston, Massachusetts, area. Baseline interviews assessed the factors being studied and the spontaneous cessation of cigarette and alcohol use with pregnancy. Saliva cotinine verified self-reported smoking status. Results: Spontaneous cessation of smoking and alcohol use was reported by 28% and 80% of the women, respectively; 25% spontaneously quit both, and 15% stopped neither. Multivariable analyses indicated that smoking cessation was less likely in women who had previous births, had a husband or partner who smoked, were born in the United States, were black (non-Hispanic, non-Portuguese), had less than a high school education, were highly addicted, reported lower perceived risk to the fetus, and reported “too many other problems in life to stop.” Hispanic ethnicity, younger age, and more social support to quit smoking were related to spontaneous alcohol abstinence. Conclusions: Targeted multiple strategies, including those aimed at increasing participation of partners, are needed for low-income pregnant smokers.

Background: Developing effective programs to promote colorectal cancer (CRC) screening requires understanding of the effect of healthcare system factors on access to screening and adherence to guidelines. Methods: This study assessed the role of insurance status, type of plan, the frequency of preventive health visits, and provider recommendation on utilization of CRC screening tests using a cross-sectional, random-digit-dial survey of 1002 Massachusetts residents aged ≥50. Results: A broad definition of CRC screening status included colonoscopy or barium enema (screening or diagnostic) within 10 years, flexible sigmoidoscopy (FSIG) within 5 years, and fecal occult blood testing (FOBT) in the past year as options; 51.7% of subjects aged 50 to 64 and 61.5% of older subjects were current. The uninsured had the lowest current testing rate. Among insured participants, type of insurance had little impact on CRC testing; older subjects enrolled in HMOs had marginally higher rates, although not statistically significant. Increased frequency of preventive health visits and ever receiving a physician’s recommendation for FSIG or ever receiving FOBT cards were associated with higher rates of CRC screening among both age groups. Conclusions: Even when broad criteria are used to define current CRC screening status, a substantial proportion of the age-eligible population remains underscreened. Obtaining regular preventive care and receiving a physician’s recommendation for screening appear to be potent facilitators of screening that should be considered in designing promotional efforts.

Objective. Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia. Methods. A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons aged ≥30 years presenting with chest pain or discomfort to ...