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Background: Quality improvement national registries provide structured, clinically relevant outcome and process-of-care data to practitioners-with regional meetings to disseminate best practices. However, whether a quality improvement collaborative affects processes of care is less clear. We examined the effects of a statewide hospital collaborative on the adherence rates to best practice guidelines in vascular surgery., Methods: A large statewide retrospective quality improvement database was reviewed for 2013 to 2019. Hospitals participating in the quality improvement collaborative were required to submit adherence and outcomes data and meet semiannually. They received an incentive through a pay for participation model. The aggregate adherence rates among all hospitals were calculated and compared., Results: A total of 39 hospitals participated in the collaborative, with attendance of surgeon champions at face-to-face meetings of >85%. Statewide, the hospital systems improved every year of participation in the collaborative across most "best practice" domains, including adherence to preoperative skin preparation recommendations (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.76-1.79; P < .001), intraoperative antibiotic redosing (OR, 1.09; 95% CI, 1.02-1.17; P = .018), statin use at discharge for appropriate patients (OR, 1.18; 95% CI, 1.16-1.2; P < .001), and reducing transfusions for asymptomatic patients with hemoglobin >8 mg/dL (OR, 0.66; 95% CI, 0.66-0.66; P < .001). The use of antiplatelet therapy at discharge remained high and did not change significantly during the study period. Teaching hospital and urban or rural status did not affect adherence. The adherence rates exceeded the professional society mean rates for guideline adherence., Conclusions: The use of a statewide hospital collaborative with incentivized semiannual meetings resulted in significant improvements in adherence to "best practice" guidelines across a large, heterogeneous group of hospitals., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Recent success in the use of immunotherapy for a broad range of cancers has propelled the field of cancer immunology to the forefront of cancer research. As more and more young investigators join the community of cancer immunologists, the Arthur L. Irving Family Foundation Cancer Immunology Symposium provided a platform to bring this expanding and vibrant community together and support the development of the future leaders in the field. This commentary outlines the lessons that emerged from the inaugural symposium highlighting the areas of scientific and career development that are essential for professional growth in the field of cancer immunology and beyond. Leading scientists and clinicians in the field provided their experience on the topics of scientific trajectory, career trajectory, publishing, fundraising, leadership, mentoring, and collaboration. Herein, we provide a conceptual and practical framework for career development to the broader scientific community., (©2021 The Authors; Published by the American Association for Cancer Research.)

What Is Known and Objective: Pharmacist-managed clinics (PMCs) are established to solve drug-related problems and enhance the quality of care of ambulatory patients. Although the benefits of such services have been demonstrated, little is known about PMC operations, especially outside the United States. The aim of this study was to explore how PMCs were established and to discuss implementation issues of PMCs in Taiwan., Methods: A purposive sample of pharmacists, pharmacy administrators and physicians involved with PMCs was recruited from hospitals of varying scales across Taiwan. Semi-structured, individual interviews were conducted to understand the perceptions of the clinical service of PMCs. Interviews were transcribed verbatim and analysed by thematic analysis to find underlying themes., Results: A total of 12 pharmacists, 5 pharmacy administrators and 3 physicians from 8 institutions were interviewed. Pharmacists spent 4 to 20 h per week at PMCs, and the practice experiences of PMC ranged from 1 to 6 years. PMCs have been provided in these institutions for 4 to 11 years with an average volume of 28 h and 25 patient visits weekly. Study participants described influential factors in establishing PMCs, including clinical expertise, attitude towards patient care and trust building with collaborating physicians. Operational concerns in implementing PMCs included role clarifications, manpower shortage, inadequate advanced training or certification, regulatory issues and a lack of service promotion., What Is New and Conclusion: This research broadens the understanding of operating PMC services and reveals key requirements and concerns regarding the care model, which can be useful for other countries. Resolving perceived barriers and collecting other stakeholders' perspectives may reinforce the integration of PMCs into patient care in the future., (© 2021 John Wiley & Sons Ltd.)

Little is known about how the health professions organize in low- and middle-income countries (LMICs). This is particularly troubling as health worker strikes in LMICs appear to be growing more frequent and severe. While some research has been conducted on the impact of strikes, little has explored their social etiology. This article draws on theory from organization and management studies to situate strike behavior in a historical process of sensemaking in Kenya. In this way, doctors seek to expand pragmatic, moral, and cognitive forms of legitimacy in response to sociopolitical change. During the first period (1963-2000), the legacy of colonial biomedicine shaped medical professionalism and tensions with a changing state following independence. The next period (2000-2010) was marked by the rise of corporate medicine as an organized form of resistance to state control. The most recent period (2010-2015) saw a new constitution and devolution of health services cause a fractured medical community to strike as a form of symbolic resistance in its quest for legitimacy. In this way, strike behavior is positioned as a form of legitimation among doctors competing over the identity of medicine in Kenya and is complicating the path to universal health coverage., (Copyright © 2021 by Duke University Press.)

In China, pharmacists have started to manage cancer pain at outpatient clinics. This retrospective study performed at a tertiary teaching hospital was aimed to evaluate the effects of a physician-pharmacist joint clinic for cancer pain management. The study was performed between December 2016 and August 2019 and included 113 outpatients with moderate to severe cancer-related pain. Patients were divided into two groups according to the clinic each patient visited: the physician-pharmacist joint clinic (joint group, n = 59) or physician-only clinic (usual group, n = 54). Brief Pain Inventory (BPI) and Morisky Medication Adherence Measure (MMAM) were used to collect data on pain intensity, interference and medication adherence. Pain Management Index (PMI) was also calculated. BPI, MMAM and PMI were assessed at baseline (patients' first visit, week 0) and week 4 follow-up. The Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) was used to assess patients' health-related quality of life (HRQoL) at week 4. The primary outcomes were the improvement in pain intensity, adequacy of pain management and medication adherence. The secondary outcome was the improvement in HRQoL. At week 4, compared to the usual group, the BPI pain intensity categories except the pain right now were significantly lower in the joint group: worst pain, 4 (3-7) vs 6 (4-8), P = .020; least pain, 1 (0-2) vs 2 (1-3), P = .010; average pain, 3 (2-4) vs 4 (2-5), P = .023; pain right now, 2 (1-3) vs 2 (0-4), P = .796. For the seven pain interference categories, there were no significant improvements in the joint group (P > .05). Significantly more patients achieved adequate pain control in the joint group than the usual group ((P = .002). There was also a significant difference in medication adherence between the two groups (P = .001). There were no significant differences in HRQoL between the two groups. The study suggests that pharmacist participation in outpatient cancer pain management is associated with improvement of patients' pain control and medication adherence., (© 2021 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).)

Machine learning (ML) algorithms are powerful prediction tools with immense potential in the clinical setting. There are a number of existing clinical tools that use ML, and many more are in development. Physicians are important stakeholders in the health care system, but most are not equipped to make informed decisions regarding deployment and application of ML technologies in patient care. It is of paramount importance that ML concepts are integrated into medical curricula to position physicians to become informed consumers of the emerging tools employing ML. This paradigm shift is similar to the evidence-based medicine (EBM) movement of the 1990s. At that time, EBM was a novel concept; now, EBM is considered an essential component of medical curricula and critical to the provision of high-quality patient care. ML has the potential to have a similar, if not greater, impact on the practice of medicine. As this technology continues its inexorable march forward, educators must continue to evaluate medical curricula to ensure that physicians are trained to be informed stakeholders in the health care of tomorrow., (Copyright © 2021 by the Association of American Medical Colleges.)

Organizational Culture Matters: Culture is a key driver of organizational performance and underpins strategy. As previously discussed, if the strategy is the plants and the garden plan for a garden, the culture is the soil. Without a healthy culture, nothing will grow, irrespective of how well planned the garden or how beautiful the individual flowers. Using the case of establishing the culture in an institute at the Cleveland Clinic, the article examines an approach to establishing and maintaining an organizational culture. Anchors for this process are a situational assessment of the current culture as a new leader steps in and mindfulness by the leader of how members of the institute should experience the organization. Critical success factors include open communication and establishing psychological safety as well as modeling integrity. Fundamentally, when cultures are grounded in the seven classical virtues-trust, compassion, courage, justice, wisdom, temperance, and hope-they are best positioned to unleash the discretionary effort of its members. When people expend discretionary effort, they do the right thing when nobody is watching and the performance drivers are internal motivation and alignment with mission rather than external drivers to seek reward (carrots) or to avoid punishment (sticks)., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

While advances in science and technology continue to be at the forefront of the evolution of medical practice, the 21st century is also undergoing a unique and profound cultural shift that is changing the very nature of what it means to be a medical professional, namely humankind's transition to an information-based internet society. Medical care will increasingly depend on computer-generated probabilities guided and supported by a growing variety of individuals in health care-related professions, including statisticians, technologists, and information managers. Perhaps the biggest challenge to the profession will come from the erosion of professional autonomy, driven by smart machines, social networks, and internet search engines. As a result of these and other changes, physicians are facing a systematic loss of control, often without the direct input and leadership of the profession itself. In this commentary, the author urges the profession to adopt several strategies, including shifting its focus from reimbursement to the care patients value most, meaningfully addressing critical issues in health policy, becoming the definitive source for publicly available medical information, reimagining medical education, and overhauling the existing accreditation and licensing systems. Medical education must go beyond a focus on physicians whose professional identity revolves around being the exclusive source of medical knowledge. In the digitized 21st century, medical education should emphasize the centrality of the humanistic interface with patients such that the doctor-patient relationship is paramount in the complex medical world of machines and social media. Removing the roadblocks to successful professional reform is no small task, but the process can begin with a grassroots movement that empowers physicians and facilitates organizational and behavioral change. Failure to take action may well hasten the diminishment of patient care and the profession's trusted role in society., (Copyright © 2021 by the Association of American Medical Colleges.)

Physician engagement is an important factor in improving care quality and patient safety, but engaging physicians is not easy. Winston Churchill's famous assertion about never wasting a crisis has defined the approach taken by many leaders during the COVID-19 pandemic. This paper describes three case studies of successful physician engagement across the continuum of acute care, chronic care and primary care settings during the pandemic. These examples offer insights on physician engagement within unique settings by leveraging intrinsic motivators and Spurgeon's model of medical engagement., (Copyright © 2021 Longwoods Publishing.)

Background: This study aimed to determine the rate of scalpel cricothyroidotomy conducted by a physician-paramedic prehospital trauma service over 20 years and to identify indications for, and factors associated with the intervention., Methods: A retrospective observational study was conducted from 1 January 2000 to 31 December 2019 using clinical database records. This study was conducted in a physician-paramedic prehospital trauma service, serving a predominantly urban population of approximately 10 million in an area of approximately 2500 km 2 ., Results: Over 20 years, 37 725 patients were attended by the service, and 72 patients received a scalpel cricothyroidotomy. An immediate 'primary' cricothyroidotomy was performed in 17 patients (23.6%), and 'rescue' cricothyroidotomies were performed in 55 patients (76.4%). Forty-one patients (56.9%) were already in traumatic cardiac arrest during cricothyroidotomy. Thirty-two patients (44.4%) died on scene, and 32 (44.4%) subsequently died in hospital. Five patients (6.9%) survived to hospital discharge, and three patients (4.2%) were lost to follow-up. The most common indication for primary cricothyroidotomy was mechanical entrapment of patients (n=5, 29.4%). Difficult laryngoscopy, predominantly due to airway soiling with blood (n=15, 27.3%) was the most common indication for rescue cricothyroidotomy. The procedure was successful in 97% of cases. During the study period, 6570 prehospital emergency anaesthetics were conducted, of which 30 underwent rescue cricothyroidotomy after failed tracheal intubation (0.46%, 95% CI 0.31% to 0.65%)., Conclusions: This study identifies a number of indications leading to scalpel cricothyroidotomy both as a primary procedure or after failed intubation. The main indication for scalpel cricothyroidotomy in our service was as a rescue airway for failed laryngoscopy due to a large volume of blood in the airway. Despite high levels of procedural success, 56.9% of patients were already in traumatic cardiac arrest during cricothyroidotomy, and overall mortality in patients with trauma receiving this procedure was 88.9% in our service., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

In sub-Saharan Africa, there is a significant unmet need for emergency care, with a shortage of trained providers. One model to increase the number of providers is to task-share: roles traditionally filled by clinicians are shared with lay workers who have received task-specific training. Separately, there has been much recent interest in the possible implications of artificial intelligence (AI) on healthcare. This paper proposes that, by combining the task-sharing model with AI, it is possible to design an Emergency Unit (EU) that shares the tasks currently undertaken by physicians and nurses with lay providers, with the activities of lay providers guided and supervised by AI. The proposed model would free emergency care clinicians to focus on higher-acuity and complex cases while AI-supervised routine care is provided by lay providers. The paper outlines the model for such an implementation and considers the potential benefits to patient care, as well as considering the risks, costs, effect on providers, and ethical questions. The paper concludes that AI and healthcare workers can operate as a team, with significant potential to augment human resources for health in sub-Saharan Africa., Competing Interests: The author declares no competing interests., (Copyright: Camillo Lamanna et al.)

Under the direction of U.S. Northern Command for COVID-19 pandemic response efforts, approximately 500 Navy Reserve medical professionals were deployed to the New York City area from April to June 2020. Some of these providers were asked to serve in 11 overburdened local hospitals to augment clinic staffs that were exhausted from the battle against coronavirus. Two maternal/fetal medicine physicians were granted emergency clinical providers to assist in these efforts. KEY POINTS: · Maternal-fetal medicine physicians contributed significantly to the COVID-19 pandemic by managing ICU patients.. · Disparate, diverse medical professionals can pull together to form cohesive and functional teams.. · The Department of Defense can mobilize a large group of providers in a short amount of time.., Competing Interests: None declared., (Thieme. All rights reserved.)

Importance: Although there have been signs of increasing interest in entrepreneurship among physicians as well as claims of a paucity of entrepreneurial activity in health care in general, there is little systematic evidence of the extent, type, and characteristics of entrepreneurship by physicians. Physician involvement in entrepreneurship may result in more innovative and financially successful health care companies., Objective: To evaluate the proportion and characteristics of physicians who founded new businesses and the types of businesses that they started., Design, Setting, and Participants: This cross-sectional study was conducted by matching all 33 770 physicians holding a Massachusetts medical license in 2017 with the Massachusetts new business registration records from 1960 to 2017 to identify companies founded by physicians. Data were analyzed from September 2017 to December 2019., Main Outcomes and Measures: The number of physician-founded companies in Massachusetts and the types of businesses as characterized by the stated purpose at the time of founding., Results: Among the 33 770 physicians holding a Massachusetts license in 2017, 13 839 (41.0%) were women and 8029 (23.8%) were international medical graduates; the median year of graduation from medical school was 1994 (interquartile range, 1983-2004). A total of 6494 (19.2%) physicians had founded at least 1 new business, and 831 of the 2448 physicians (33.9%) who graduated from medical school between 1974 and 1978 had founded a business. A total of 9501 companies were founded, of which 6267 (66.0%) were clinical practice, real estate, or practice management companies; 703 companies (7.4%) were in the public interest, including advocacy, public health, and philanthropy; 533 (5.6%) were biotechnology, health care information technology, or medical device companies; and 1759 (18.5%) were other business pursuits. For physician entrepreneurs, the mean (SD) time from medical school graduation to company founding was 20.2 (9.8) years. Regression analysis suggested that female physicians founded companies at lower rates than male physicians (odds ratio [OR], 0.529; 95% CI, 0.494-0.567) and that there was an association between attending a top-10 medical school by National Institutes of Health research funding and starting a clinical practice (OR, 0.687; 95% CI, 0.616-0.766) or biotechnology company (OR, 4.326; 95% CI, 2.951-6.344)., Conclusions and Relevance: The findings of this cross-sectional study suggest that physicians may be substantially involved in entrepreneurship, although there may be disparities by sex. Facilitation of physician entrepreneurship by policy makers, educators, and institutions may enhance medical innovation and public health.

Background: An estimated 10% of Americans experience a diagnostic error annually, yet little is known about pediatric diagnostic errors. Physician reporting is a promising method for identifying diagnostic errors. However, our pediatric hospital medicine (PHM) division had only 1 diagnostic-related safety report in the preceding 4 years. We aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months., Methods: Our improvement team used the Model for Improvement, targeting the PHM service. To promote a safe reporting culture, we used the term diagnostic learning opportunity (DLO) rather than diagnostic error, defined as a "potential opportunity to make a better or more timely diagnosis." We developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. The outcome measure, the number of DLO reports per 100 patient admissions, was tracked on an annotated control chart to assess the effect of our interventions over time. We evaluated DLOs using a formal 2-reviewer process., Results: Over the course of 13 weeks, there was an increase in the number of reports filed from 0 to 1.6 per 100 patient admissions, which met special cause variation, and was subsequently sustained. Most events (66%) were true diagnostic errors and were found to be multifactorial after formal review., Conclusions: We used quality improvement methodology, focusing on psychological safety, to increase physician reporting of DLOs. This growing data set has generated nuanced learnings that will guide future improvement work., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Unlike developed countries which have purely intensivists also called critical care physicians or intensive care physicians to manage critically ill patients like those with severe forms of COVID-19, the practice of critical care medicine in Africa is coined to anaesthesiology. Hence, anaesthesiologist-intensivist physicians are the medical specialists taking care of critically ill COVID-19 patients in Africa. Likewise, unlike intensive care units (ICUs) in high income countries, those in most African countries face the challenge of a lack of emergency drugs and resuscitation equipment, limited health infrastructure and understaffed and underfunded health care systems. The COVID-19 pandemic is an unprecedented one faced by intensivists in high-income countries and anaesthesiologist-intensivist phycisians in Africa. Infected patients with severe forms of the disease like those having grave COVID-19 complications like massive pulmonary embolism, severe cardiac arrhythmias, cardiogenic shock, septic shock, acute kidney injury or acute respiratory distress syndrome require ICU admission for better management. Both intensivists or anaesthesiologist-intensivist physicians have the peculiarity of securing the airways of critically COVID-19 patients and providing respiratory support with mechanical ventilation after laryngoscopy and endotracheal intubation when needed. In so doing, they can easily be infected from respiratory droplets or aerosols expired by the COVID-19 patients. Hence, in Africa, anaesthesiologist-intensivist phycisians have a higher risk of contracting COVID-19 compared to other health professionals. It's worth to mention that the COVID-19 pandemic struck African anaesthesiologist-intensivist phycisians and ICUs when there were neither prepared skillfully or lacked the required ICU capacity to meet the demands of thousands of severe COVID-19 African patients. These further weakened the already strained health systems in Africa. It required a lot of creativity, engineering skills and courage for these ill prepared African anaesthesiologist-intensivist physicians to provide care to these critically ill patients and improve their outcomes as the pandemic progressed. However, despites the numerous efforts made in African anaesthesiologist-Intensivist phycisians to care for critically ill COVID-19 patients, the pandemic is spreading at a rapid rate across Africa. There is an urgent need for African health authorities to anticipate on how to scale up the future high ICU capacity needs and limited ICU workforce, infrastructure and equipment to manage severe forms of COVID-19 in future. It cannot be overemphasized that these severe forms of COVID-19 are potentially fatal and are a major contributor to the death toll of the COVID-19 pandemic., Competing Interests: The authors declare no competing interests., (Copyright: Junnette Arlette Mbengono Metogo et al.)

Objective: To assess public understanding of medicine safety, approach to risks and preferences in accessing safety information., Methods: Qualitative data were obtained from an online survey (n = 1079) covering four major themes around side effects and risks of medicines: willingness to accept side effects of medications, information seeking, sufficiency of information and understanding pharmacovigilance process. Comparisons were made for age, gender and social/financial status., Key Findings: Most respondents acknowledged medications were associated with side effects. If side effects were experienced, most (73%) would seek advice from their doctor or pharmacist. Four in 10 respondents felt doctors and pharmacists do not provide sufficient information about medications, even though many (47%) relied on their doctor to provide this. Although 51% felt that pharmaceutical companies were already providing enough information to patients, 95% responded that extra effort could still be made. Two-thirds of the respondents felt it was the companies' responsibility to educate doctors and pharmacists so they could pass the information on, even though younger respondents preferred direct communication to patients compared to older respondents (<24 years, 36% versus >65 years, 10%; P < 0.001). Men were more willing to accept risks, while women were more likely to seek information about their medicines. Understanding of the role of pharmaceutical companies and government in maintaining the safety of medicines was generally poor., Conclusions: There is an ongoing need for consumer education regarding medicine safety. Doctors and pharmacists remain the more trusted source of information. Pharmaceutical companies play an important role in ensuring such information is both accessible and accurate., (© 2020 The Authors. International Journal of Pharmacy Practice published by John Wiley & Sons Ltd on behalf of Royal Pharmaceutical Society.)

Objective: To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes., Data Sources: Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data., Study Design: Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse., Data Collection/extraction Methods: 1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions)., Principal Findings: Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76])., Conclusions: Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients., (© Health Research and Educational Trust.)

This article describes the tension that the coronavirus disease 2019 (COVID-19) pandemic brought up between administrators and physicians and offers a potential set of solutions to deal with it.

Even though COVID-19 vaccines are closer than ever to use by the general public, many questions remain about how they will be distributed to Texas physicians - and how they'll be received by Texans. That's why TMA in October weighed in on the state's distribution plan with recommendations to help ensure COVID-19 vaccines are not only distributed effectively and efficiently, but also seen as trusted tools in the fight against the illness.

BACKGROUND: Clinical services provided by pharmacists embedded in practices can improve patient outcomes within the primary care setting. Little is known about whether physician organizations (POs) will retain the services of clinical pharmacists after outside funding for a statewide implementation program is ended. OBJECTIVE: To evaluate a statewide program, Michigan Pharmacists Transforming Care and Quality (MPTCQ), that incorporated pharmacists within 17 POs. METHODS: A descriptive study was conducted using data collected from June 2016 to September 2018 from primary care clinical pharmacist encounters in POs participating in MPTCQ. Process outcomes included the number of participating POs, patient encounters, and average visits per patient. Analyses at the encounter level were stratified by 2 encounter types: disease state management (DSM) or comprehensive medication review (CMR). Separately by encounter type, pharmacist effect was described by the number, type, and reasons for medication changes, as well as medication adherence and cost barriers found and addressed. Clinical outcomes included hemoglobin A1c and blood pressure change. Sustainability and patient satisfaction of pharmacists providing clinical services are reported. RESULTS: Across 17 POs, 27 pharmacists participated in the MPTCQ program. Pharmacists completed 24,523 patient encounters for DSM with 5,942 patients, with an average of 5 visits per patient with diabetes and 2 visits for hypertension. Pharmacists made 15,153 therapeutic medication changes during visits for diabetes and hypertension, with approximately 70% related to efficacy. Pharmacists completed 4,203 CMR visits for 3,092 patients. During CMR visits, 1,296 therapeutic medication changes were recommended. Problems with medication cost were identified in 13% of CMR visits. Blood pressure and A1c levels decreased in patients managed by pharmacists. In 157 patients surveyed, 87% rated their pharmacists' care as excellent. Sixteen POs retained their pharmacists at the end of funding. CONCLUSIONS: A statewide provider-payer partnership successfully integrated and retained primary care pharmacists within POs. Pharmacists in the MPTCQ program contributed to improvements in disease control by changing medications to improve patient clinical outcomes. DISCLOSURES: Support for MPTCQ was provided by Blue Cross and Blue Shield of Michigan (BCBSM) as part of the BCBSM Value Partnerships program. Coe was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR002241. Although BCBSM and MPTCQ work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have no conflicts of interest to report.

Purpose: To evaluate neuro-oncology clinician time utilization for medication management and identify a cost beneficial role for integration of a dedicated pharmacy specialists., Methods: A pharmacist was temporarily integrated into a neuro-oncology clinic for a 30-day period to evaluate the clinical practice and perform a 14-day clinical chart evaluation and patient interactions as part of a single institutional exploratory analysis. The pharmacist completed screenings for drug-drug interactions, new therapies, medication reconciliation, and advanced interventions as part of a collaborative practice agreement for pharmacist autonomy. Pharmacist time spent was calculated and documented within the patient encounters to support physician decision-making. A comparative estimate of pharmacist versus physician time utilization and cost for each was completed to derive a savings analysis for integration of a dedicated clinic pharmacist., Result: During the 14-day clinical assessment, the pharmacist completed 147 encounters with 338 interventions. Of the encounters, 90% (n = 132) were higher complexity requiring plan modification, and approximately 48% (n = 162) of all interventions required ≥10 minutes of the pharmacist's time. Physician non-patient-facing time devoted to medication tasks was 5-hours weekly (0.125 FTE, full time equivalents), an estimated direct salary cost of $937/week ($45,000 yearly). Hire of a part-time pharmacist at 0.50 FTE would cover the clinical need with supported documentation and medication monitoring at a cost of $45,000/year., Conclusion: Defining the roles for dedicated neuro-oncology clinic pharmacists allows for cost-savings through re-allocation of physician time and improves subspecialty clinic operations as well as patient care.

Symptom management and end-of-life care are core skills for all physicians, although in ordinary times many anesthesiologists have fewer occasions to use these skills. The current coronavirus disease (COVID-19) pandemic has caused significant mortality over a short time and has necessitated an increase in provision of both critical care and palliative care. For anesthesiologists deployed to units caring for patients with COVID-19, this narrative review provides guidance on conducting goals of care discussions, withdrawing life-sustaining measures, and managing distressing symptoms.

Introduction: asthma is a chronic inflammatory and a heterogeneous condition of respiratory system whose pathogenesis is linked with variable structural changes. The clinical manifestation of asthma includes attacks of breathlessness, cough, chest tightness and wheezing. Provision of basic equipment and test for asthma diagnosis and access to essential medicines by asthmatic patients reduces morbidity and mortality rates. Significant progress has been made in the diagnosis and management of asthma in other countries but not in the health care delivery system in Zimbabwe. Therefore, the aim of this study was to develop algorithm for asthma diagnosis and management for Zimbabwe., Methods: a two stage Delphi model was used to collect data in order to develop an algorithm of asthma diagnosis and management. A baseline interview with 44 doctors was done to understand their experiences and knowledge regarding asthma diagnosis and management. We collected data using the KoBo Collect Toolbox installed on Android mobile phone and transferred the data to an Excel 2016 spreadsheet for cleaning. The data was qualitatively analysed and themes were constructed. These themes were further explored in stage two at an algorithm development workshop which was led by 4 medical expert panellists in order to develop consensus on the information to be included in the algorithms for asthma diagnosis and management. A total of 15 doctors and 30 nurses participated at the workshop., Results: doctors who attended the workshop described the challenges in asthma diagnosis and management that they experienced. These challenges were attributed to lack of basic equipment such as spirometers and Peak Expiratory Flow Meters and tests which included IgE tests, Skin Allergen Tests and RAST. Asthma diagnosis clinical history and management was based on the doctors' knowledge. The doctors indicated the need for refresher courses to update their knowledge on asthma diagnosis and enhance their diagnostic skills. A draft algorithm framework for asthma diagnosis was developed at the workshop and later refined by the core-research team. The final algorithm described in this paper was circulated for further contributions and endorsement by the asthma experts., Conclusion: we established the need for doctors to receive constant refresher courses on asthma diagnosis for upskilling. We recommend adoption by the Zimbabwe's Ministry of Health and Child Care of the asthma diagnostic algorithm we developed., Competing Interests: The authors declare no competing interests., (Copyright: Pisirai Ndarukwa et al.)

Purpose: UNC Medical Center converted to an electronic health record (EHR) in 2014. This conversion allowed for the transition of paper chemotherapy orders to be managed electronically. This article describes the process for converting inpatient paper chemotherapy orders into the new EHR in a safe and effective manner., Summary: A collaborative interdisciplinary approach to the EHR transition enabled our organization to move from using paper chemotherapy orders to fully electronic chemotherapy treatment plans in both ambulatory and acute care areas. Active chemotherapy orders for acute care inpatients were reviewed and transcribed by two oncology pharmacists in the cancer hospital prior to being signed by an attending physician. The newly input orders were independently verified by two pharmacists in the cancer hospital inpatient pharmacy. Nurse review of the signed and verified treatment plans, along with reconciliation of the medication administration record ensured a safe transition to the new EHR workflow. Providers benefit from the ability to review treatment plans remotely, track changes, and include supportive medications in one consolidated location. The coordinated team effort allowed for a smooth transition with minimal interruptions to patient care., Conclusion: The pharmacist-led, multidisciplinary conversion to electronic chemotherapy orders was safe, accurate, and occurred ahead of schedule for the EHR go-live. Advance communication and planning around scheduled inpatient admissions helped to minimize the impact of the transition from paper to electronic treatment plans. Both pharmacist and physician engagement were necessary to ensure a smooth transition for active inpatient treatment plans., (© American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: as South Africa's maternal mortality ratio increased between 1990 and 2015, the country failed to reach the United Nations millennium development goal 5a. The maternal mortality ratio of Limpopo province is higher than the national average and previous studies report shortages of manpower and medical equipment in Limpopo province. The overall study aim was to elucidate views and experiences of medical doctors regarding maternal healthcare by identifying the challenges they experience and solutions they suggest., Methods: a qualitative interview-based study was performed with ten medical doctors as participants. Manifest content analysis was used to analyze the data., Results: the main findings were categorized as lack of material and human resources, feelings of experienced isolation and solution-focused expressions. The challenges identified included logistical issues, staffing issues, demographic characteristics of the patient population, poor interinstitutional communication and lack of support from the administration. The solutions included revision of resource allocation and improvement of the interinstitutional cooperation. For example, participants suggested that exchange programs between hospitals could be arranged, that the emergency medical service personnel could triage patients and that private practitioners could be contracted to work at public institutions., Conclusion: most identified challenges were related to a lack of resources. Based on their inside experience, the participants suggested several solutions. These firsthand accounts of the local medical doctors highlight the need for intervention and should be taken into account when it comes to improving the provincial healthcare and working toward achieving the healthcare-related sustainable development goals by 2030., Competing Interests: The authors declare no competing interests., (Copyright: Carl-Johan Valentin Olseén et al.)

Introduction: While patient throughput and emergency department (ED) length of stay (LOS) are recognized as important metrics in the delivery of efficient care, they must be balanced with the educational mission of academic centers. Prior studies examining the impact of learners on throughput and LOS when staffing directly with attending physicians have yielded mixed results. Herein we sought to examine the impact of a staffing model involving a supervisory resident "pre-attending" (PAT) on ED throughput and LOS, as this model offers a valuable educational experience for residents, but may do so at the expense of operational efficiency., Methods: We retrospectively analyzed 26,702 unique patient encounters at a university-affiliated community ED between July 1, 2017-January 1,2019. The experimental group was comprised of patients seen primarily by midlevel providers, who staffed with a PAT, who subsequently staffed with an attending physician. The control group was comprised of patients seen by midlevel providers and staffed directly with attendings without a PAT. We used a parametric hazard model to analyze the effect of the presence of a PAT on service time, controlling for potential confounders including timing of presentation and patient demographics., Results: The presence of a PAT is associated with a statistically significant increase in service time of five minutes (p = 0.006). Holding other variables equal, predicted service time in the experimental group was 173 minutes (95% confidence interval (CI), 171-176), while that for controls was 168 minutes (95% CI, 165-171)., Conclusion: The presence of a PAT is associated with a statistically significant increase in service time, but the magnitude (five minutes) is likely operationally insignificant. The negligible increase in service time is offset by the benefit to residents' training. The results of this study may be helpful for residency programs considering the addition of a PAT shift structure.

A variety of operational and administrative factors have the potential to decrease wellness and negatively impact emergency physicians, in terms of both their on-the-job performance and their long-term career satisfaction. Among these are the issues of workload balance, physiologic and circadian stresses, and larger issues of malpractice risk and institutional support. This overview covers both emerging research on how these problems affect emergency physicians and strategies to help mitigate these challenges., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.

Background Pulmonary hypertension is a rare, chronic and life-threatening group of diseases. Recent advances in pulmonary hypertension management prolong survival and improve quality-of-life. However, highly complex drug therapy enhances the risk of drug-related problems. Objective To assess the impact of involving clinical pharmacists in the collaborative care of pulmonary hypertension patients. Setting Ten French University Hospital Pneumology departments, all members of the French Network for Pulmonary Hypertension. Methods This prospective multicenter randomized controlled trial included incident pulmonary hypertension patients who were followed-up for 18 months. Randomization using an adapted Zelen method allocated patients to collaborative care (n = 41) or usual care groups (n = 51). A collaborative care program involving clinical pharmacists was developed through a close partnership between with physicians, nurses and pharmacists. Besides usual care, the program includes regular one-to-one interviews between the pharmacist and the patient. These interviews had following objectives: to perform an exhaustive medication history review; to identify the patient' needs, knowledge and skills; to define educational objectives and to provide patients with relevant information when needed. Following each interview, a standardized report form containing the pharmacist's recommendations was provided to physicians and nurses and discussed collaboratively. An ancillary economic analysis was performed. Main outcome measure Number of drug-related problems and their outcomes. Results The number of drug-related problems was not significantly different between groups (1.6 ± 1.5 vs. 1.9 ± 2.4; p = 0.41). More problems were resolved in the collaborative care group than in the usual care group (86.5% vs. 66.7%, p = 0.01). Time to clinical worsening, therapeutic adherence, satisfaction or quality-of-life were not statistically different between groups. Collaborative care decreased costs of drug-related hospitalizations. Conclusion Including clinical pharmacists in the multidisciplinary care of hospitalized patients with pulmonary hypertension improved the outcome of drug-related problems and reduced the costs of related hospitalization. However, we observed no efficacy on medication errors, clinical outcomes or medication adherence. Clinical Trial Registration ClinicalTrials.gov Identifier NCT01038284.

Background: Sub-Saharan Africa (SSA) faces the highest burden of disease amenable to surgery while having the lowest surgeon to population ratio in the world. Some 25 SSA countries use surgical task-shifting from physicians to non-physician clinicians (NPCs) as a strategy to increase access to surgery. While many studies have investigated barriers to access to surgical services, there is a dearth of studies that examine the barriers to shifting of surgical tasks to, and the delivery of safe essential surgical care by NPCs, especially in rural areas of SSA. This study aims to identify those barriers and how they vary between surgical disciplines as well as between countries., Methods: We performed a scoping review of articles published between 2000 and 2018, listed in PubMed or Embase. Full-text articles were read by two reviewers to identify barriers to surgical task-shifting. Cited barriers were counted and categorized, partly based on the World Health Organization (WHO) health systems building blocks., Results: Sixty-two articles met the inclusion criteria, and 14 clusters of barriers were identified, which were assigned to four main categories: primary outcomes, NPC workforce, regulation, and environment and resources. Malawi, Tanzania, Uganda, and Mozambique had the largest number of articles reporting barriers, with Uganda reporting the largest variety of barriers from empirical studies only. Obstetric and gynaecologic surgery had more articles and cited barriers than other specialties., Conclusion: A multitude of factors hampers the provision of surgery by NPCs across SSA. The two main issues are surgical pre-requisites and the need for regulatory and professional frameworks to legitimate and control the surgical practice of NPCs.

Dutch medical disciplinary boards consider physicians' gut feelings an element of the professional standards. Some indications can be found in the international literature suggesting intuitive feelings of unease of patients or their relatives can also contribute to adequate diagnostics. What is the view of disciplinary boards on this? A search in the disciplinary boards' database (2010-2017) found 55 rulings where the search term 'ongerust' (worried) was related to a patient, family member or partner and 51 rulings where the term 'bezorgd' (concerned) was related to a patient, family member or partner. The disciplinary boards expect that doctors are prepared to discuss worry and concern with their patients. Additionally, they consider patients' worry and concern to be a useful part of the doctors' diagnostics, which may possibly result in reviewing the diagnosis. This is consistent with the international literature.

Background: This study aims to explore the effect of public hospital managers' risk and gain perception on their attitude towards physician dual practice (PDP)., Methods: A cross-sectional study enrolling 1513 managers from public hospitals in the East, Middle and West of China was conducted. Generalized linear mixed models (GLMM) were used to identify the determinants of managers' support for PDP., Results: The rate of managers' support for allowing PDP or implementing PDP with restriction, was 94.3% (95% CI: 0.93, 0.95). The mean score of managers' risk perception was 67.7 ± 14.46, and the mean score of managers' gain perception was 24.0 ± 5.56. After controlling for individual and institutional characteristics, the GLMM presented the score for risk perception increased 1 score and the rate of managers' support for PDP decreased by 5% (OR = 0.95, 95% CI: 0.93, 0.97); while the score for gain perception increased 1 score and the rate of managers' support increased by 18% (OR = 1.18, 95% CI: 1.12, 1.24)., Conclusions: Our data demonstrate that the majority of Chinese public hospital managers are in favor of allowing or implementing PDP with restrictions. Although gain perception is comparatively weaker than risk perception, a stronger influence in determining public hospital managers' support for PDP is demonstrated.

We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife-provided abortion care in Sweden. Identified facilitating factors were: (1) the historical role and high status of Swedish midwives; (2) Swedish research and development of medical abortion that enabled an enlarged clinical role for midwives; (3) collaborations between individual clinicians and researchers within the professional associations, and the autonomy of clinical units to implement changes in clinical practice; (4) a historic precedent of changes in abortion policy occurring without prior official or legal sanction; (5) a context of liberal abortion laws, secularity, gender equality, public support for abortion, trust in public institutions; and (6) an increasing global interest in task-shifting to increase access and reduce costs. Identified barriers/risks were: (1) the lack of systems for monitoring and evaluation; and (2) a loss of physician competence in abortion care., (© 2020 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

First-trimester abortion became legal in Mexico City in April 2007. Since then, 216 755 abortions have been provided, initially in hospitals, by specialized physicians using surgical techniques. With time and experience, services were provided increasingly in health centers, by general physicians using medical therapies. Meanwhile, abortion remains legally restricted in the remaining 31/32 Mexican states. Demand and need for abortion care have increased throughout the country, while overall abortion-specific mortality rates have declined. In an effort to ensure universal access to and improved quality of reproductive and maternal health services, including abortion, Mexico recently expanded its cadres of health professionals. While initial advances are evident in pregnancy and delivery care, many obstacles and barriers impair the task-sharing/shifting process in abortion care. Efforts to expand the provider base for legal abortion and postabortion care to include midlevel professionals should be pursued by authorities in the new Mexican administration to further reduce abortion mortality and complications., (© 2020 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)