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Context: Several studies suggest improved survival among patients in whom a higher number of nodes are examined after colectomy for colon cancer. The National Quality Forum and other organizations recently endorsed a 12-node minimum as a measure of hospital quality.Objective: To assess whether hospitals that examine more lymph nodes after resection for colon cancer have superior late survival rates.Design, Setting, and Patients: Retrospective cohort study, using the national Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1995-2005), of US patients undergoing colectomy for nonmetastatic colon cancer (n = 30 625). Hospitals were ranked according to the proportion of their patients in whom 12 or more lymph nodes were examined and then were sorted into 4 evenly sized groups. Late survival rates were assessed for each hospital group, adjusting for potentially confounding patient and clinician characteristics.Main Outcome Measures: Hospitals' lymph node examination rates in association with cancer staging, use of adjuvant chemotherapy (indicated for patients with node-positive disease), and 5-year survival rate.Results: Hospitals with the highest proportions of patients with examination of 12 or more lymph nodes tended to treat lower-risk patients and had substantially higher procedure volumes. After adjusting for these and other factors, there remained no statistically significant relationship between hospital lymph node examination rates and survival after surgery (adjusted hazard ratio, highest vs lowest hospital quartile, 0.95; 95% confidence interval, 0.88-1.03). Although the 4 hospital groups varied widely in the number of lymph nodes examined, they were equally likely to find node-positive tumors and had very similar overall unadjusted rates of adjuvant chemotherapy (26% vs 25%, highest vs lowest hospital quartile).Conclusions: The number of lymph nodes hospitals examine following colectomy for colon cancer is not associated with staging, use of adjuvant chemotherapy, or patient survival. Efforts by payers and professional organizations to increase node examination rates may have limited value as a public health intervention. [ABSTRACT FROM AUTHOR]

Objective: Elevated tumour necrosis factor-alpha (TNF-alpha) production in adipose tissue has been associated with obesity. We investigated whether mononuclear cell production of TNF-alpha decreased with weight loss in an obese population.Research Methods and Procedures: Seventeen obese patients with type 2 diabetes (BMI 32.5+/-0.9 kg/m(2)) and 33 obese, non-diabetic controls (BMI 31.2+/-0.5 kg/m(2)) underwent 12 weeks of 30% total energy restriction (6622+/-84 KJ per day). Every 4 weeks, weight and blood pressure were measured and fasting venous blood was analysed for lipid, glucose and insulin concentrations. At the beginning and end of energy restriction, mononuclear cells were isolated from whole blood and TNF-alpha production measured by ELSIA.Results: TNF-alpha production was not associated with the degree of adiposity but was higher in diabetic subjects (P<0.04). There was a reduction after energy restriction (281+/-43 to 182+/-30 pg/ml, P<0.05) however the presence of type 2 diabetes did not influence the magnitude of this change. Plasma glucose and insulin levels decreased after weight loss in all subjects and weak correlations were found with TNF-alpha concentrations (r=0.3, P<0.05).Conclusions: We conclude that maximal production of TNF-alpha from mononuclear cells decreases with energy restriction and is weakly associated with plasma glucose and insulin concentrations in obese patients. [ABSTRACT FROM AUTHOR]

Background: Physical examination, mammography, ultrasonography, and fine needle aspiration are traditionally used to guide further management of palpable breast masses, often leading to open biopsy of benign masses. The triple test score (TTS) integrates physical examination, mammography, and fine needle aspiration in the initial evaluation, limiting open biopsy.Objective: To compare cost-effectiveness of TTS and traditional methods.Methods: The primary measure of clinical effectiveness, frequency of missed malignancy, was determined for each strategy using probabilities and outcomes from a systematic literature review. Costs were calculated using the Medicare resource-based relative-value scale. A decision-analytic model compared costs of initial work-up, costs per mass evaluated, and costs per malignancy diagnosed. Sensitivity analyses assessed the influence of variations in model assumptions.Results: In the base case, neither strategy led to undiagnosed breast cancer. However, open biopsy was required in 13% of benign masses using TTS versus 88% using the traditional strategy. The cost of the initial work-up using traditional management was less than TTS (377 US dollars vs. 627 US dollars), but cost per mass evaluated and cost per malignancy diagnosed (1793 US dollars vs. 925 US dollars and 5670 US dollars vs. 2925 US dollars) favored TTS, due to substantially reduced open biopsy.In sensitivity analyses, TTS cost varied most with changes in cost of initial evaluation, whereas the traditional strategy cost varied most with changes in open biopsy cost.Conclusions: The TTS provides equivalent diagnostic effectiveness but substantially lower cost than traditional management. Cost savings are based on decreased open biopsy, a major contributor to the cost of traditional evaluation in this model. [ABSTRACT FROM AUTHOR]

Background and aims: In patients with phenylketonuria (PKU), overnight fasting is associated with rises in serum phenylalanine (PHE) concentration. This is thought to result from catabolism of endogenous protein, which can be reduced by a bedtime snack accompanied by a dose of PHE-free protein substitute (P/S). This study assessed the effectiveness of this strategy and whether any additional benefit was conferred by omitting PHE from the bedtime snack. Methods: Data are presented for 18 PKU children (aged 9-16 years), studied over a 48-h period whilst following diets of known composition. All the subjects had a bedtime snack accompanied by 25% of their P/S daily requirement. Half the subjects (Group X) had 25% of their daily PHE allowance in the bedtime snack, whilst the others (Group Z) ate only 'PHE-free' foods at this time. Results: Overnight changes in serum PHE levels were generally small for both groups; the mean serum PHE level changed very little overnight (Group X: 405 nucrimol L-1 post snack, 389 micromol L-1 prebreakfast; Group Z: 430 micromol L-1 post snack, 426 micromol L-1 pre breakfast). Conclusion: Overnight changes in serum PHE levels can be minimized by a bedtime snack accompanied by a proportion of the daily protein substitute. Omission of PHE from the snack confers no extra advantage. [ABSTRACT FROM AUTHOR]

Abstract Background The strategies that parents use to guide and discipline their children may influence their emotional health. Relatively little research has been conducted examining the association of parenting practices to depressive symptoms among Caribbean adolescents. This project examines the association of parenting styles to levels of depressive symptoms among adolescents in Jamaica, the Bahamas, St. Kitts and Nevis, and St. Vincent. Methods Adolescents attending grade ten of academic year 2006/2007 in Jamaica, the Bahamas, St. Vincent, and St. Kitts and Nevis were administered the Parenting Practices Scale along with the BDI-II. Authoritative, Authoritarian, Permissive and Neglectful parenting styles were created using a median split procedure of the monitoring and nurturance subscales of the Parenting Practices Scale. Multiple regression analyses were used to examine the relationships of parenting styles to depressive symptoms. Results A wide cross-section of tenth grade students in each nation was sampled (n = 1955; 278 from Jamaica, 217 from the Bahamas, 737 St. Kitts and Nevis, 716 from St. Vincent; 52.1% females, 45.6% males and 2.3% no gender reported; age 12 to 19 years, mean = 15.3 yrs, sd = .95 yrs). Nearly half (52.1%) of all adolescents reported mild to severe symptoms of depression with 29.1% reporting moderate to severe symptoms of depression. In general, authoritative and permissive parenting styles were both associated with lower levels of depressive symptoms in adolescents. However, the relationship of parenting styles to depression scores was not consistent across countries (p Conclusions There appears to be an association between parenting styles and depressive symptoms that is differentially manifested across the islands of Jamaica, the Bahamas, St. Kitts and Nevis and St. Vincent.

Abstract Background The number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States. Methods This is a secondary data analysis of the 1996–1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week. Results Compared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs. Conclusion There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.

Background: The use of a watch and wait management strategy following a complete clinical response to neoadjuvant therapy for rectal cancer is increasing. However, insights into implementation, treatments, and outcomes, on a United States national level, are limited., Objective: To investigate and report on watch & wait management practices and outcomes in the US., Design: Retrospective study., Setting: Multicenter., Patients: Stage II or III rectal cancer patients who underwent intentional watch & wait management between January 2015 and August 2022., Main Outcome Measures: Patient and tumor characteristics, neoadjuvant treatment and response, local cancer regrowth and metastasis, salvage surgery, overall and disease-specific survival., Results: Among 545 patients from 33 centers, follow-up was 21 months (range, 9-37). Total neoadjuvant therapy or other types of neoadjuvant were used in 395 (72%) and 150 (28%) of patients, respectively. Estimated 3-year local regrowth rate was 23.8% (95% CI: 19.1-29.4%). Patients with local regrowth had higher distant metastases incidence (14.2% vs. 3.5%, p < 0.001). Salvage surgery was performed in 74/84 (88%) patients with local regrowth and included rectal resection in 66 (89%), and local excision in 8 (11%). Of 64 salvage resections with known pathology results, 58 (91%) were margin-negative. Overall, 3-year overall survival was 94.8% (95% CI: 90.5 - 97.2%) and 3-year disease specific survival 96.2% (95% Cl 91.8 - 98.2%). Patients with and without local regrowth exhibited 3-year overall survival of 83.6% (95% Cl 68.4 - 91.9%), and 97.7% (95% CI: 93.3 - 99.2%), respectively., Limitations: Retrospective study., Conclusion: This multicenter study indicates that the watch & wait approach for locally advanced rectal cancer is feasible with acceptable outcomes across a variety of geographical regions and practice settings in the US. Local regrowth and distant metastasis rates were within published norms and salvage surgery proved effective. See Video Abstract., (Copyright © The ASCRS 2024.)

Background: Opioid substitution therapy (also known as 'opioid agonist therapy' or 'medication treatment of opioid use disorder') is associated with improved health and social outcomes for people who use heroin and other illicit opioids. It is typically managed in the community and is not always continued when people are admitted to hospital. This causes opioid withdrawal, patient-directed discharge, and increased costs. We are establishing a project called iHOST (improving hospital opioid substitution therapy) to address these problems. This is an applied health research project in which we will develop and evaluate an intervention that aims to improve opioid substitution therapy in three acute hospitals in England. The intervention was developed in collaboration with stakeholders including people who use opioids, hospital staff, and other professionals who work with this group. It includes five components: (1) a card that patients can use to help hospital clinicians confirm their opioid substitution therapy, (2) a helpline for patients and staff, (3) an online training module for staff, (4) a clinical guideline for managing opioid withdrawal in hospital, and (5) 'champion' roles at each hospital., Methods: We will do a mixed-methods study including a quasi-experimental quantitative study and a qualitative process evaluation. The primary outcomes for the quantitative study are patient-directed discharge and emergency readmission within 28 days. We will do a difference-in-difference analysis comparing changes in these outcomes for patients at iHOST sites with changes for patients at control hospitals. The process evaluation will use in-depth interviews, focus groups, and site observations with people who use opioids and staff. We will assess acceptability of the intervention, barriers and facilitators to implementation, and contextual factors impacting outcomes., Impact: We anticipate that iHOST will improve care for hospital patients who use illicit opioids and/or are receiving community-based opioid substitution therapy. Depending on the results, we will promote the intervention at hospitals across the UK. Dissemination, including through publication, will inform hospital-based services for people who use drugs both in the UK and other countries., Competing Interests: Competing interests: AH is conducting a PhD funded by the Medical Research Council, grants MR/W006308/1 and MR/X018636/1; he is Co-Chair of the Faculty of Public Health Drugs Special Interest Group; volunteers for the Loop (a drug checking organisation); is a member of the Drug Science Enhanced Harm Reduction Working Group (EHRWG); and in the last three years was Associate Director of International Doctors for Healthier Drug Policies., (Copyright: © 2024 Lewer D et al.)

Background: Between 2006 and 2016 the prevalence of overweight and obesity among children and adolescents aged 5-19 years in Peru increased from 22.7 to 27.0%. This investment case quantifies the economic impacts of childhood and adolescent overweight and obesity in Peru. It identifies and quantifies the potential impact of a set of new or expanded interventions that can strengthen current national efforts to prevent and reduce child and adolescent overweight and obesity., Methods: A deterministic Markov cohort model with a societal cost perspective estimated reductions in mortality and morbidity from implementing interventions to prevent and reduce child and adolescent overweight and obesity and the impact in savings in healthcare costs and gains in wages and productivity. Interventions identified through a review of published literature includes a school-based social marketing campaign, exclusive breastfeeding promotion and support, a healthy food and drink policy for school premises, and a 20% subsidy on fruits and vegetables for people living below the national poverty line. The return on investment (ROI) was calculated along with the estimated cost savings associated with the interventions. Analysis was conducted to test ROI sensitivity to changes in the key parameters and assumptions., Results: Between 2025 and 2092, the expected combined direct and indirect healthcare costs attributable to child and adolescent overweight and obesity in Peru are 210.6 billion USD. The direct healthcare costs are 1.8 billion USD, and the indirect costs are 208.8 billion USD. Expected savings for all interventions combined is 13.9 billion USD with a per-person savings of 12,089.8 USD. The expected ROI of the four interventions combined is 39.3 USD (30-years), 64.6 USD (50-years), and 164.1 USD (66-years) per one USD invested., Conclusions: The overweight and obesity epidemic among children and adolescents in Peru requires wide-ranging and expanded implementation of policies to achieve long-term reductions in prevalence. This study's findings show that the four priority interventions have high ROIs and can be used to guide policy to address the complex interplay of factors that contribute to the obesogenic environment., (© 2024. The Author(s).)

Background: Unnecessary antibiotic prescriptions in primary care are common and contribute to antimicrobial resistance in the population. Audit and feedback (A&F) on antibiotic prescribing to primary care can improve the appropriateness of antibiotic prescribing, but the optimal approach is uncertain. We performed two pragmatic randomized controlled trials of different approaches to audit and feedback. The trial results showed that A&F was associated with significantly reducing antibiotic prescribing. Still, the effect size was small, and the modifications to the A&F interventions tested in the trials were not associated with any change. Herein, we report a theory-informed qualitative process evaluation to explore potential mechanisms underlying the observed effects., Methods: Ontario family physicians in the intervention arms of both trials who were sent A&F letters were invited for one-on-one interviews. Purposive sampling was used to seek variation across interested participants in personal and practice characteristics. Qualitative analysis utilized inductive and deductive techniques informed by the Clinical Performance Feedback Intervention Theory., Results: Modifications to the intervention design tested in the trial did not alter prescribing patterns beyond the changes made in response to the A&F overall for various reasons. Change in antibiotic prescribing in response to A&F depended on whether it led to the formation of specific intentions and whether those intentions translated to particular behaviours. Those without intentions to change tended to feel that their unique clinical context was not represented in the A&F. Those with intentions but without specific actions taken tended to express a lack of self-efficacy for avoiding a prescription in contexts with time constraints and/or without an ongoing patient relationship. Many participants noted that compared to overall prescribing, A&F on antibiotic prescription duration was perceived as new information and easily actionable., Conclusion: Our findings indicate that contextual factors, including the types of patients and the setting where they are seen, affect how clinicians react to audit and feedback. These results suggest a need to test tailored feedback reports that reflect the context of how, where, and why physicians prescribe antibiotics so that they might be perceived as more personal and more actionable., Trial Registration: Clinical Trial registration IDs: NCT04594200, NCT05044052., (© 2024. The Author(s).)

Background: Lack of health insurance is a public health crisis, leading to foregone care and financial strain. Hospital Presumptive Eligibility (HPE) is a hospital-based emergency Medicaid program that provides temporary (up to 60 d) coverage, with the goal that hospitals will assist patients in applying for ongoing Medicaid coverage. It is unclear whether HPE is associated with successful longer-term Medicaid enrollment., Objective: To characterize Medicaid enrollment 6 months after initiation of HPE and determine sociodemographic, clinical, and geographic factors associated with Medicaid enrollment., Design: This was a cohort study of all HPE approved inpatients in California, using claims data from the California Department of Healthcare Services., Setting: The study was conducted across all HPE-participating hospitals within California between January 1, 2016 and December 31, 2017., Participants: We studied California adult hospitalized inpatients, who were uninsured at the time of hospitalization and approved for HPE emergency Medicaid. Using multivariable logistic regression models, we compared HPE-approved patients who enrolled in Medicaid by 6 months versus those who did not., Exposures: HPE emergency Medicaid approval at the time of hospitalization., Main Outcomes and Measures: The primary outcome was full-scope Medicaid enrollment by 6 months after the hospital's presumptive eligibility approval., Results: Among 71,335 inpatient HPE recipients, a total of 45,817 (64.2%) enrolled in Medicaid by 6 months. There was variability in Medicaid enrollment across counties in California (33%-100%). In adjusted analyses, Spanish-preferred-language patients were less likely to enroll in Medicaid (aOR 0.77, P <0.001). Surgical intervention (aOR 1.10, P <0.001) and discharge to another inpatient facility or a long-term care facility increased the odds of Medicaid enrollment (vs. routine discharge home: aOR 2.24 and aOR 1.96, P <0.001)., Conclusion: California patients who enroll in HPE often enroll in Medicaid coverage by 6 months, particularly among patients requiring surgical intervention, repeated health care visits, and ongoing access to care. Future opportunities include prospective evaluation of HPE recipients to understand the impact that Medicaid enrollment has on health care utilization and financial solvency., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Coaching interventions in graduate medical education have proven successful in increasing technical and communication skills, reducing errors, and improving patient care. Effective stakeholder engagement enhances the relevance, value, and long-term sustainability of interventions, yet specific strategies for stakeholder engagement remain uncertain. The purpose of this article is to identify strategies to foster engagement of diverse stakeholder groups in coaching interventions., Material and Methods: We conducted 35 semi-structured interviews between November 2021 and April 2022 with purposively sampled key stakeholders that captured participants' perspectives on physicians' communication training needs, roles, and involvement in, as well as contextual factors, facilitators, barriers, and improvement strategies of the multi-departmental Communication Coaching Program at our institution. We utilized the Consolidated Framework of Implementation Research to guide data collection and analysis. An analytic approach relied on team-based thematic analysis with high inter-coder agreement between three raters (Cohen's kappa coefficient 0.83). Several validation techniques were used to enhance the credibility and trustworthiness of the study., Results: Analysis of transcribed interviews with stakeholders directly involved in the Communication Coaching Program, including 10 residents, 10 faculty coaches, 9 medical education leaders, and 8 programmatic sponsors, revealed five key engagement strategies: (1) embrace collaborative design, (2) enable flexible adjustments and modifications, (3) secure funding, (4) identify champions, and (5) demonstrate outcomes. Additionally, a patient-centered approach to delivering the best possible patient care emerged as a primary objective that linked all stakeholder groups., Discussion: Evaluating the experiences of key stakeholders in the Communication Coaching Program helped identify targetable strategies to facilitate participant engagement across all organizational levels. The analysis also revealed universal alignment around the importance of providing high-quality patient care. Insights from this work provide guidance for clinical training programs moving toward the implementation of coaching interventions.

Objective: To characterize the quality of statistical methods for studies of racial and ethnic disparities in the surgical-relevant literature during 2021-2022., Background: Hundreds of scientific papers are published each year describing racial and ethnic disparities in surgical access, quality, and outcomes. The content and design quality of this literature have never been systematically reviewed., Methods: We searched for 2021 to 2022 studies focused on describing racial and/or ethnic disparities in surgical or perioperative access, process quality, or outcomes. Identified studies were characterized in terms of 3 methodological criteria: (1) adjustment for variables related to both race/ethnicity and outcomes, including social determinants of health (SDOH), (2) accounting for clustering of patients within hospitals or other subunits ("providers"), and (3) distinguishing within-provider and between-provider effects., Results: We identified 224 papers describing racial and/or ethnic differences. Of the 38 single-institution studies, 24 (63.2%) adjusted for at least one SDOH variable. Of the 186 multisite studies, 113 (60.8%) adjusted for at least one SDOH variable, and 43 (23.1%) accounted for the clustering of patients within providers using appropriate statistical methods. Only 10 (5.4%) of multi-institution studies made efforts to examine how much of the overall disparities were driven by within versus between-provider effects., Conclusions: Most recently published papers on racial and ethnic disparities in the surgical literature do not meet these important statistical design criteria and, therefore, may risk inaccuracy in the estimation of group differences in surgical access, quality, and outcomes. The most potent leverage points for these improvements are changes to journal publication guidelines and policies., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background & Aims: Biliary complications are a major cause of morbidity and mortality in liver transplantation. Up to 25% of patients that develop biliary complications require additional surgical procedures, re-transplantation or die in the absence of a suitable regraft. Here, we investigate the role of the primary cilium, a highly specialised sensory organelle, in biliary injury leading to post-transplant biliary complications., Methods: Human biopsies were used to study the structure and function of primary cilia in liver transplant recipients that develop biliary complications (n = 7) in comparison with recipients without biliary complications (n = 12). To study the biological effects of the primary cilia during transplantation, we generated murine models that recapitulate liver procurement and cold storage, and assessed the elimination of the primary cilia in biliary epithelial cells in the K19CreER T Kif3a fl /fl mouse model. To explore the molecular mechanisms responsible for the observed phenotypes we used in vitro models of ischemia, cellular senescence and primary cilia ablation. Finally, we used pharmacological and genetic approaches to target cellular senescence and the primary cilia, both in mouse models and discarded human donor livers., Results: Prolonged ischemic periods before transplantation result in ciliary shortening and cellular senescence, an irreversible cell cycle arrest that blocks regeneration. Our results indicate that primary cilia damage results in biliary injury and a loss of regenerative potential. Senescence negatively impacts primary cilia structure and triggers a negative feedback loop that further impairs regeneration. Finally, we explore how targeted interventions for cellular senescence and/or the stabilisation of the primary cilia improve biliary regeneration following ischemic injury., Conclusions: Primary cilia play an essential role in biliary regeneration and we demonstrate that senolytics and cilia-stabilising treatments provide a potential therapeutic opportunity to reduce the rate of biliary complications and improve clinical outcomes in liver transplantation., Impact and Implications: Up to 25% of liver transplants result in biliary complications, leading to additional surgery, retransplants, or death. We found that the incidence of biliary complications is increased by damage to the primary cilium, an antenna that protrudes from the cell and is key to regeneration. Here, we show that treatments that preserve the primary cilia during the transplant process provide a potential solution to reduce the rates of biliary complications., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: Diabetes care remains unavailable and unaffordable for many people. Adapting models of care to low-income and middle-income country contexts is a priority. Digital technology offers substantial potential yet must surmount health system, technological and acceptability issues. This formative research aimed to identify the potential for a digital technology solution (Diabetes Compass) to address diabetes care gaps in primary healthcare., Design: Qualitative research was conducted in selected districts of Sri Lanka and Tanzania with practitioners, patients and family members. In-depth interviews assessed how digital solutions may improve diabetes care, acceptability and usability; contextual and clinical observations identified practitioner clinical competencies, strengths and weaknesses, and the influence of the care environment on service delivery; and workshop discussions explored strategies to encourage digital solution uptake and sustain use., Setting: The research was undertaken in 2022 at nine health facilities in Sri Lanka's Southern Province (Galle), and 16 health facilities in Tanzania's Lindi and Pwani Regions., Participants: Participants included primary and secondary care practitioners, facility managers, patients and family members., Results: There was striking concordance in the diabetes care gaps and potential for digital solutions in the two countries, and between practitioners, patients and family members. Five main gaps were practitioner training; health information systems and data; service delivery; infrastructure, equipment and medication; and community awareness and knowledge. Practitioners, patients and family members saw strong potential for digital solutions to improve early detection, diagnosis, secondary prevention of complications and improve patients' and families' experience of living with diabetes. They identified specific design and implementation considerations to enable the Diabetes Compass to realistically meet these needs and overcome challenges., Conclusion: There was a strong appetite among practitioners, patients and family members for a digital solution to strengthen diabetes care. Their experience of challenges and practical recommendations informed the Diabetes Compass design., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: While communication is an essential skill for providing effective medical care, it is infrequently taught or directly assessed, limiting targeted feedback and behavior change. We sought to evaluate the impact of a multi-departmental longitudinal residency communication coaching program. We hypothesized that program implementation would result in improved confidence in residents' communication skills and higher-quality faculty feedback., Methods: The program was implemented over a 3-year period (2019-2022) for surgery and neurology residents at a single institution. Trained faculty coaches met with assigned residents for coaching sessions. Each session included an observed clinical encounter, self-reflection, feedback, and goal setting. Eligible residents completed baseline and follow-up surveys regarding their perceptions of feedback and communication. Quantitative responses were analyzed using paired t-tests; qualitative responses were analyzed using content analysis., Results: The baseline and follow-up survey response rates were 90.0% (126/140) and 50.5% (46/91), respectively. In a paired analysis of 40 respondents, residents reported greater confidence in their ability to communicate with patients (inpatient: 3.7 vs. 4.3, p < 0.001; outpatient: 3.5 vs. 4.2, p < 0.001), self-reflect (3.3 vs. 4.3, p < 0.001), and set goals (3.6 vs. 4.3, p < 0.001), as measured on a 5-point scale. Residents also reported greater usefulness of faculty feedback (3.3 vs. 4.2, p = 0.001). The content analysis revealed helpful elements of the program, challenges, and opportunities for improvement. Receiving mentorship, among others, was indicated as a core program strength, whereas solving session coordination and scheduling issues, as well as lowering the coach-resident ratio, were suggested as some of the improvement areas., Conclusions: These findings suggest that direct observation of communication in clinical encounters by trained faculty coaches can facilitate long-term trainee growth across multiple core competencies. Future studies should evaluate the impact on patient outcomes and workplace-based assessments., (© 2024. The Author(s).)