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Rationale, aims and objectives Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism. Methods The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research. Results The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent. Conclusions Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.

To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care.Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720).Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours,Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

Solar radiation initiates photochemical oxidation of dissolved organic carbon (DOC) to dissolved inorganic carbon (DIC) in inland waters, contributing to their carbon dioxide emissions to the atmosphere. Models can determine photochemical DIC production over large spatiotemporal scales and assess its role in aquatic C cycling. The apparent quantum yield (AQY) spectrum for photochemical DIC production, defined as mol DIC produced per mol chromophoric dissolved organic matter-absorbed photons, is a critical model parameter. In previous studies, the principle for the determination of AQY spectra is the same but methodological specifics differ, and the extent to which these differences influence AQY spectra and simulated aquatic DIC photoproduction is unclear. Here, four laboratories determined AQY spectra from water samples of eight inland waters that are situated in Alaska, Finland, and Sweden and span a nearly 10-fold range in DOM absorption coefficients. All AQY values fell within the range previously reported for inland waters. The inter-laboratory coefficient of variation (CV) for wavelength-integrated AQY spectra (300–450 nm) averaged 38% ± 3% SE, and the inter-water CV averaged 63% ± 1%. The inter-laboratory CV for simulated photochemical DIC production (conducted for the five Swedish lakes) averaged 49% ± 12%, and the inter-water CV averaged 77% ± 10%. This uncertainty is not surprising given the complexities and methodological choices involved in determining DIC AQY spectra and needs to be considered when applying photochemical rate modeling. Thus, we also highlight current methodological limitations and suggest future improvements for DIC AQY determination to reduce inter-laboratory uncertainty. peerReviewed

ObjectivesThe rapid onset and progressive course of the COVID-19 pandemic challenged primary care practices to generate rapid solutions to unique circumstances, creating a natural experiment of effectiveness, resilience, financial stability and governance across primary care models. We aimed to characterise how practices in Melbourne, Australia modified clinical and organisational routines in response to the pandemic in 2020–2021 and identify factors that influenced these changes.DesignProspective, qualitative, participatory case study design using constant comparative data analysis, conducted between April 2020 and February 2021. Participant general practitioner (GP) investigators were involved in study design, recruitment of other participants, data collection and analysis. Data analysis included investigator diaries, structured practice observation, documents and interviews.SettingThe cases were six Melbourne practices of varying size and organisational model.ParticipantsGP investigators approached potential participants. Practice healthcare workers were interviewed by social scientists on three occasions, and provided feedback on presentations of preliminary findings.ResultsWe conducted 58 interviews with 26 practice healthcare workers including practice owners, practice managers, GPs, receptionists and nurses; and six interviews with GP investigators. Data saturation was achieved within each practice and across the sample. The pandemic generated changes to triage, clinical care, infection control and organisational routines, particularly around telehealth. While collaboration and trust increased within several practices, others fragmented, leaving staff isolated and demoralised. Financial and organisational stability, collaborative problem solving, creative leadership and communication (internally and within the broader healthcare sector) were major influences on practice ability to negotiate the pandemic.ConclusionsThis study demonstrates the complex influences on primary care practices, and reinforces the strengths of clinician participation in research design, conduct and analysis. Two implications are: telehealth, triage and infection management innovations are likely to continue; the existing payment system provides inadequate support to primary care in a global pandemic.

Identifying the sources of ongoing and novel disease outbreaks is critical for understanding the diffusion of epizootic diseases. Identifying infection sources is difficult when few physical differences separate individuals with different origins. Genetic assignment procedures show great promise for assessing transmission dynamics in such situations. Here, we use genetic assignment tests to determine the source of chronic wasting disease infections in free‐ranging white‐tailed deer (Odocoileus virginianus) populations. Natural dispersal is thought to facilitate the geographic diffusion of chronic wasting disease, but egression from captive cervid populations represents an alternative source of infection that is difficult to detect due to physical similarities with wild deer. Simulated reference populations were created based on allele frequencies from 1,912 empirical microsatellite genotypes collected in four sampling subregions and five captive facilities. These reference populations were used to assess the likelihood of ancestry and assignment of 1,861 free‐ranging deer (1,834 noninfected and 27 infected) and 51 captive individuals to captive or wild populations. The ancestry (Q) and assignment scores (A) for free‐ranging deer to wild populations were high (average Q wild = 0.913 and average A wild = 0.951, respectively), but varied among subregions (Q wild = 0.800–0.947, A wild = 0.857–0.976). These findings suggest that captive egression and admixture are rare, but risk may not be spatially uniform. Ancestry and assignment scores for two free‐ranging deer with chronic wasting disease sampled in an area where chronic wasting disease was previously unobserved in free‐ranging herds indicated a higher likelihood of assignment and proportion of ancestry attributable to captive populations. While we cannot directly assign these individuals to infected facilities, these findings suggest that rare egression events may influence the epizootiology of chronic wasting disease in free‐ranging populations. Continued disease surveillance and genetic analyses may further elucidate the relative disease risk attributable to captive and wild sources.

The article of record may be found at https://doi.org/10.1575/1912/27821 The Surface Ocean – Lower Atmosphere Study (SOLAS) (http://www.solas-int.org/) is an international research initiative focused on understanding the key biogeochemical-physical interactions and feedbacks between the ocean and atmosphere that are critical elements of climate and global biogeochemical cycles. Following the release of the SOLAS Decadal Science Plan (2015-2025) (Brévière et al., 2016), the Ocean-Atmosphere Interaction Committee (OAIC) was formed as a subcommittee of the Ocean Carbon and Biogeochemistry (OCB) Scientific Steering Committee to coordinate US SOLAS efforts and activities, facilitate interactions among atmospheric and ocean scientists, and strengthen US contributions to international SOLAS. In October 2019, with support from OCB, the OAIC convened an open community workshop, Ocean-Atmosphere Interactions: Scoping directions for new research with the goal of fostering new collaborations and identifying knowledge gaps and high-priority science questions to formulate a US SOLAS Science Plan. Based on presentations and discussions at the workshop, the OAIC and workshop participants have developed this US SOLAS Science Plan. The first part of the workshop and this Science Plan were purposefully designed around the five themes of the SOLAS Decadal Science Plan (2015-2025) (Brévière et al., 2016) to provide a common set of research priorities and ensure a more cohesive US contribution to international SOLAS. This report was developed with federal support of NSF (OCE-1558412) and NASA (NNX17AB17G). This report was developed with federal support of NSF (OCE-1558412) and NASA (NNX17AB17G).

The sometimes-paradoxical emergent behavior of complex systems may be explained by the interaction of simple rules. The paradox of primary care—that systems based on primary care have healthier populations, fewer health inequities, lower health care expenditures, and better system-level evidence-based disease care, despite less evidence-based care for individual diseases—may be explained by the iterative interaction among three simple rules that describe the generalist approach: (1) Recognize a broad range of problems/opportunities; (2) Prioritize attention and action with the intent of promoting health, healing, and connection; and (3) Personalize care based on the particulars of the individual or family in their local context. These are complemented by three simple rules for specialist care that represent current approaches to quality and health care system improvement: (1) Identify and classify disease for management; (2) Interpret through specialized knowledge; (3) Generate and carry out a management plan. Health care systems that support the enactment of the simple rules of the generalist approach are likely to have more effective primary and specialty care, and greater population health, equity, quality, and sustainable cost.

BackgroundManagement of care transitions from primary care into and out of oncology is critical for optimal care of cancer patients and cancer survivors. There is limited understanding of existing primary care-oncology relationships within the context of the changing health care environment.MethodsThrough a comparative case study of 14 innovative primary care practices throughout the United States (U.S.), we examined relationships between primary care and oncology settings to identify attributes contributing to strengthened relationships in diverse settings. Field researchers observed practices for 10–12 days, recording fieldnotes and conducting interviews. We created a reduced dataset of all text related to primary care-oncology relationships, and collaboratively identified patterns to characterize these relationships through an inductive “immersion/crystallization” analysis process.ResultsNine of the 14 practices discussed having either formal or informal primary care-oncology relationships. Nearly all formal primary care-oncology relationships were embedded within healthcare systems. The majority of private, independent practices had more informal relationships between individual primary care physicians and specific oncologists. Practices with formal relationships noted health system infrastructure that facilitates transfer of patient information and timely referrals. Practices with informal relationships described shared commitment, trust, and rapport with specific oncologists. Regardless of relationship type, challenges reported by primary care settings included lack of clarity about roles and responsibilities during cancer treatment and beyond.ConclusionsWith the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate strengths of informal primary care-oncology relationships in addition to formal system driven relationships.

Observers of the past 10 to 15 years have witnessed the simultaneous growth of dramatic changes in the practice of primary care and the emergence of a new field of dissemination and implementation science (D&I). Most current implementation science research in primary care assumes practices are not meeting externally derived standards and need external support to meet these demands. After a decade of initiatives, many stakeholders now question the return on their investments. Overall improvements in quality metrics, utilization cost savings, and patient experience have been less than anticipated. While recently conducting a research project in primary care practices, we unexpectedly discovered 3 practices that profoundly shifted our thinking about the sources and directionality of practice change and the underlying assumptions of D&I. Inspired by these practices—along with systems thinking, complexity theory, action research, and the collaborative approaches of community-based participatory research—we propose a reimagining of D&I theory to empower practices. We shift the emphasis regarding the source and direction of change from outside-in to inside-out. Such a shift has the potential to open a new frontier in the science of dissemination and implementation and inform better health policy.

Genetic variability in the prion protein (Prnp) gene influences host susceptibility to many pathogenic prion diseases. Understanding the distribution of susceptible Prnp variants and determining factors influencing spatial genetic patterns are important components of many chronic wasting disease mitigation strategies. Here, we describe Prnp variability in white-tailed deer (Odocoileus virginianus) from the Mid-Atlantic region of the United States of America, an area with a recent history of infection and low disease incidence. This population is characterized by lower rates of polymorphism and significantly higher frequencies of the more susceptible 96GG genotype compared to previously surveyed populations. The prevalence of the most susceptible genotypes at disease-associated loci did vary among subregions, indicating that populations have innate differences in genotype-dictated susceptibility.

Knowledge of light partitioning into different optically active constituents, particularly chromophoric dissolved organic matter (CDOM) in the ultraviolet (UV) is indispensable for understanding UV dependent biogeochemical issues including photochemical processes in optically complex waters. Herein a new approach is presented to investigate photochemistry by blending two ocean color algorithms, namely the composite SeaUV (Cao et al., 2014) and the SeaCDOM (Cao and Miller, 2015) algorithms, and applying them to visible remote sensing reflectance (Rrs) measured using the Hyperspectral Imager for the Coastal Ocean (HICO). As illustrated using photochemical carbon monoxide (CO) production from CDOM, this model approach allows high resolution examination of UV optical details with estimates of both depth-specific and depth-integrated photoproduction rates in a dynamic estuarine/coastal environment. Decoupled retrievals of inherent and apparent optical properties (i.e. diffuse attenuation coefficient (Kd) and CDOM absorption coefficient (ag)) using two distinct ocean color algorithms over the entire UV spectrum allow a synoptically dynamic view of CDOM's contribution to light attenuation (ag/Kd). This provides new potential to probe UV processes in complex coastal waters on regional as well as global scales using remote sensing of ocean color.

Microbial pathogen contamination is a leading cause of impairment for urban rivers and streams in Michigan. Reports on the ability of green infrastructure best management practices to remove microbial pathogens have been highly variable. This study evaluated the influence of a detention basin (Kreiser Pond) on microbial dynamics in the Plaster Creek watershed in West Michigan. High levels of fecal indicator bacteria and coliphage were documented in influent and effluent water, with significant increases in indicator microbe concentrations during storm events. In dry conditions, Kreiser Pond efficiently reduced the number of indicator microbes flowing through the basin. Rainfall volume had a greater influence on the diversity of bacteria than sampling location. Antibiotic resistance was prevalent in culturable E. coli from Kreiser Pond, demonstrating a potential public health risk and highlighting the need for identifying the ultimate sources of microbial pollution.

Collection of biological samples for DNA is necessary in a variety of disciplines including disease epidemiology, landscape genetics, and forensics. Quantity and quality of DNA varies depending on the method of collection or media available for collection (e.g., blood, tissue, fecal). Blood is the most common sample collected in vials or on Whatman Flinders Technology Associates (FTA) cards with short- and long-term storage providing adequate DNA for study objectives. The focus of this study was to determine if biological samples stored on Whatman FTA Elute cards were a reasonable alternative to traditional DNA sample collection, storage, and extraction. Tissue, nasal swabs, and ocular fluid were collected from white-tailed deer (Odocoileus virginianus). Tissue samples and nasal swabs acted as a control to compare extraction and DNA suitability for microsatellite analysis for nasal swabs and ocular fluid extracted from FTA Elute cards. We determined that FTA Elute cards improved the extraction time and storage of samples and that nasal swabs and ocular fluid containing pigmented fluid were reasonable alternatives to traditional tissue DNA extractions.

Multilevel perspectives across communities, medical systems and policy environments are needed, but few methods are available for health services researchers with limited resources. We developed a mixed methods health policy approach, the focused Rapid Assessment Process (fRAP), that is designed to uncover multilevel modifiable barriers and facilitators contributing to public health issues. We illustrate with a study applying fRAP to the issue of cancer survivorship care. Through this multilevel investigation we identified two major modifiable areas affecting high-quality cancer survivorship care: (1) the importance of cancer survivorship guidelines/data and (2) the need for improved oncology–primary care relationships. This article contributes to the mixed methods literature by coupling geospatial mapping to qualitative rapid assessment to efficiently identify policy change targets.

Background: There is no commonly accepted comprehensive framework for describing the practical specifics of external support for practice change. Our goal was to develop such a taxonomy that could be used by both external groups or researchers and health care leaders. Methods: The leaders of 8 grants from Agency for Research and Quality for the EvidenceNOW study of improving cardiovascular preventive services in over 1500 primary care practices nationwide worked collaboratively over 18 months to develop descriptions of key domains that might comprehensively characterize any external support intervention. Combining literature reviews with our practical experiences in this initiative and past work, we aimed to define these domains and recommend measures for them. Results: The taxonomy includes 1 domain to specify the conceptual model(s) on which an intervention is built and another to specify the types of support strategies used. Another 5 domains provide specifics about the dose/mode of that support, the types of change process and care process changes that are encouraged, and the degree to which the strategies are prescriptive and standardized. A model was created to illustrate how the domains fit together and how they would respond to practice needs and reactions. Conclusions: This taxonomy and its use in more consistently documenting and characterizing external support interventions should facilitate communication and synergies between 3 areas (quality improvement, practice change research, and implementation science) that have historically tended to work independently. The taxonomy was designed to be as useful for practices or health systems managing change as it is for research.

To explore whether the variation in clinical response to immune checkpoint blockade (ICB) reflects intrinsic characteristics of tumor-infiltrating lymphocytes (TIL), TILs from multiple tumor types were analyzed by multiparameter flow cytometry. Recent work identified CD39+CD103+ double positive (DP) CD8 TIL as tumor-reactive, therefore we assessed this phenotype in primary NSCLC (n=28), BCa (n=23), HNSCC (n=23), and RCC (n=23) specimens. TILs from NSCLC and HNSCC had significantly higher frequencies of DP T cells than BCa and RCC (NSCLC: median=34.2, IQR=15.0–53.8%; HNSCC: median=28.6%, IQR=13.5–44.5%), while TILs from BCa and RCC had low frequencies of DP T cells (BCa: median=2.4%, IQR=1.1–3.9%; RCC: median=4.2%, IQR=1.5–16.6%). Additionally, DP cells in NSCLC and HNSCC were co-expressed immune checkpoint markers PD-1, TIM-3, and LAG-3 at a higher frequency than RCC or BCa (P Supported by GlaxoSmithKline and the Providence Portland Medical Foundation

The photobleaching of chromophoric dissolved organic matter (CDOM) is considered an important loss process for CDOM absorption in sunlit natural waters, where it can regulate the biota's exposure to sunlight, surface solar heating, and dissolved organic matter dynamics. Despite its importance, this sink remains poorly quantified, primarily because of the difficulty of determining photobleaching apparent quantum yields (AQYs) that capture the dual spectral dependency of this process and are applicable to polychromatic sunlight. Here, we present a simple method to determine a CDOM photobleaching AQY matrix (AQY-M) for natural water samples that does not require any a priori assumptions about the spectral dependency of photobleaching. It combines controlled irradiation experiments, a partial least-square regression, and an optimization procedure to produce AQY-Ms that are spectrally coherent and optimized for modeling accurate photobleaching rates in natural waters. Water temperature and the solar exposure history of CDOM had a major influence on the magnitude and spectral characteristics of the AQY-M. These factors should be considered when determining the AQY-M of samples and provide constraints when modeling photobleaching rates in natural waters. We expect that this effective method will provide future studies with a robust means to characterize and understand the variability of AQY-M in natural waters.

Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. Context Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. Methods A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. Findings We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. Conclusions Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

PURPOSE We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care. METHODS We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW—a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes. RESULTS In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system–owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system–owned practices that implemented these operational changes. CONCLUSIONS There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.

Objective To learn from the experiences of innovative primary care practices that have successfully developed care teams. Research design A 2½-day working conference was convened with representatives from 10 innovative primary care practices, content experts, and researchers to discuss experiences of developing care teams. Qualitative data included observation notes, transcripts of conference sessions and interviews, and narrative summaries of innovations. Case summaries of practices and an analysis matrix were created to identify common themes. Participants Ten practices known nationally for innovations in team-based care participated in the conference represented by 1 to 2 practice members. Results Two domains emerged related to creating effective teams and funding them. Participants emphasized the importance of making practice values explicit and involving everyone in the change process, standardizing routine processes, and mitigating resistance. They also highlighted that team-based care adds comprehensiveness, not necessarily productivity. They, thus, highlighted the need for a long-term financial vision, including resourcefulness and alternate funding. Conclusions Team-based care is possible and valuable in primary care. It is difficult to develop and sustain, however, and requires dedicated time and resources. The challenges these highly motivated practices described raise the question of feasibility for more average practices in the current funding environment.

Due to increased anthropogenic pressures on many fish populations, supplementing wild populations with captive-raised individuals has become an increasingly common management practice. Stocking programs can be controversial due to uncertainty about the long-term fitness effects of genetic introgression on wild populations. In particular, introgression between hatchery and wild individuals can cause declines in wild population fitness, resiliency, and adaptive potential and contribute to local population extirpation. However, low survival and fitness of captive-raised individuals can minimize the long-term genetic consequences of stocking in wild populations, and to date the prevalence of introgression in actively stocked ecosystems has not been rigorously evaluated. We quantified the extent of introgression in 30 populations of wild brook trout (Salvelinus fontinalis) in a Pennsylvania watershed and examined the correlation between introgression and 11 environmental covariates. Genetic assignment tests were used to determine the origin (wild vs. captive-raised) for 1,742 wild-caught and 300 hatchery brook trout. To avoid assignment biases, individuals were assigned to two simulated populations that represented the average allele frequencies in wild and hatchery groups. Fish with intermediate probabilities of wild ancestry were classified as introgressed, with threshold values determined through simulation. Even with reoccurring stocking at most sites, over 93% of wild-caught individuals probabilistically assigned to wild origin, and only 5.6% of wild-caught fish assigned to introgressed. Models examining environmental drivers of introgression explained

PURPOSE Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODS In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from −28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTS The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system–owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores. CONCLUSION There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models.

IntroductionThe COVID-19 pandemic has transformed healthcare systems worldwide. Primary care providers have been at the forefront of the pandemic response and have needed to rapidly adjust processes and routines around service delivery. The pandemic provides a unique opportunity to understand how general practices prepare for and respond to public health emergencies. We will follow a range of general practices to characterise the changes to, and factors influencing, modifications to clinical and organisational routines within Australian general practices amidst the COVID-19 pandemic.Methods and analysisThis is a prospective case study of multiple general practices using a participatory approach for design, data collection and analysis. The study is informed by the sociological concept of routines and will be set in six general practices in Melbourne, Australia during the 2020–2021 COVID-19 pandemic. General practitioners associated with the Monash University Department of General Practice will act as investigators who will shape the project and contribute to the data collection and analysis. The data will include investigator diaries, an observation template and interviews with practice staff and investigators. Data will first be analysed by two external researchers using a constant comparative approach and then later refined at regular investigator meetings. Cross-case analysis will explain the implementation, uptake and sustainability of routine changes that followed the commencement of the pandemic.Ethics and disseminationEthics approval was granted by Monash University (23950) Human Research Ethics Committees. Practice reports will be made available to all participating practices both during the data analysis process and at the end of the study. Further dissemination will occur via publications and presentations to practice staff and medical practitioners.

Background Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform—the introduction of inter-professional teams into traditional PC settings—has been difficult to implement despite financial investment and enthusiasm. Objective To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices. Methods An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies. Results Seven common levers influence a jurisdiction’s ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations’ attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect. Conclusion The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Background Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit ‘between the lines’ knowledge generated during many research projects that are not intrinsic to the main objectives of studies. Objective To develop a novel approach to expand and deepen meta-syntheses using researchers’ experience, tacit knowledge and relevant unpublished materials. Methods We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants’ studies to identify new patterns and insights. Results CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions. Conclusions The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.

textabstractBackground. Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients' needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated. Objective. The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams. Methods. Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with faceto- face group retreats, using a Collaborative Reflexive Deliberative Approach. Results. Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team's production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team's activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts. Conclusion. The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes.

Photochemical reactions in natural waters are a sink for dissolved organic carbon (DOC) and a source of dissolved inorganic carbon (DIC). Although considered significant to the carbon budget of the oceans, DIC photoproduction rates remain poorly constrained due to the analytical challenge involved in accurately measuring very low production rates (likely sub-μM h− 1 for blue ocean waters) relative to high background DIC concentrations (~ 2 mM). In an attempt to overcome this analytical limitation, almost all previous DIC photoproduction studies in marine systems have relied on the stripping of background DIC prior to irradiation, with unknown consequences for the integrity of the DOC pool and its photoreactivity, and none have resulted in a satisfactory determination of photoproduced DIC in open ocean waters. Here, we use small additions of NaH13CO3 (

Understanding the geographic extent and connectivity of wildlife populations can provide important insights into the management of disease outbreaks but defining patterns of population structure is difficult for widely distributed species. Landscape genetic analyses are powerful methods for identifying cryptic structure and movement patterns that may be associated with spatial epizootic patterns in such cases.We characterized patterns of population substructure and connectivity using microsatellite genotypes from 2,222 white‐tailed deer (Odocoileus virginianus) in the Mid‐Atlantic region of the United States, a region where chronic wasting disease was first detected in 2009. The goal of this study was to evaluate the juxtaposition between population structure, landscape features that influence gene flow, and current disease management units.Clustering analyses identified four to five subpopulations in this region, the edges of which corresponded to ecophysiographic provinces. Subpopulations were further partitioned into 11 clusters with subtle (F ST ≤ 0.041), but significant genetic differentiation. Genetic differentiation was lower and migration rates were higher among neighboring genetic clusters, indicating an underlying genetic cline. Genetic discontinuities were associated with topographic barriers, however.Resistance surface modeling indicated that gene flow was diffuse in homogenous landscapes, but the direction and extent of gene flow were influenced by forest cover, traffic volume, and elevational relief in subregions heterogeneous for these landscape features. Chronic wasting disease primarily occurred among genetic clusters within a single subpopulation and along corridors of high landscape connectivity.These results may suggest a possible correlation between population substructure, landscape connectivity, and the occurrence of diseases for widespread species. Considering these factors may be useful in delineating effective management units, although only the largest features produced appreciable differences in subpopulation structure. Disease mitigation strategies implemented at the scale of ecophysiographic provinces are likely to be more effective than those implemented at finer scales., We characterized the spatial population structure of white‐tailed deer in the Mid‐Atlantic region of the United States in order to evaluate the juxtaposition population structure, gene flow patterns, and chronic wasting disease cases in the region. We found evidence of four to five subpopulation units, the extents of which generally corresponded with ecophysiographic provinces, with 11 subtle genetic clusters nested hierarchically within subpopulation units. Landscape genetic analyses revealed corridors of high connectivity adjacent to ridges, roads, and open areas, which may indicate directed disease transmission in regions heterogeneous for these features.

Background Microsatellite loci have been used extensively over the past two decades to study the genetic characteristics of non-model species. The ease of microsatellite development and ability to adapt markers from related species has led to the proliferation of available markers for many commonly studied species. Because it is often infeasible to genotype individuals across all available loci, researchers generally rely on subsets of markers. Marker choice can bias inferences made using disparate suites of loci. This has been a primary motivation for efforts to identify uniform marker panels. Here, we use the geographic distribution of previous studies to identify microsatellite loci for white-tailed deer (Odocoileus virginianus) with the potential for widespread use, and we evaluate the effectiveness of this panel in a portion of the range where few previous studies have been conducted. The purpose was to consolidate the numerous genetic resources for this species into a manageable panel and to provide a uniform methodology that improves comparisons between past and future studies. Results We reviewed microsatellite panels from 58 previous or ongoing projects and identified 106 candidate loci. We developed a multiplex protocol and evaluated the efficacy of 17 of the most commonly used loci using 720 DNA samples collected from the Mid-Atlantic region of the United States of America. Amplification errors were detected in six of these loci. The 11 remaining loci were highly polymorphic, exhibited low frequencies of null alleles, and were easy to interpret with the aid of allele binning software. Conclusions The development of broadly-applicable, core microsatellite panels has the potential to improve repeatability and comparative ability for commonly studied species. The properties of the consolidated 11 microsatellite panel suggest that they are applicable for many common research objectives for white-tailed deer. The geographic distribution of previous studies using these markers provides a greater degree of confidence regarding the robustness to common sources of error related to amplification anomalies, such as null alleles, relative to loci with more limited use. While this does not replace further evaluation of genotyping errors, it does provide a common platform that benefits future research studies. Electronic supplementary material The online version of this article (10.1186/s12863-019-0750-z) contains supplementary material, which is available to authorized users.

PURPOSE Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors. METHODS We conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians’ perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process. RESULTS Divergent views exist regarding primary care’s role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology’s responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge. CONCLUSIONS This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.