Timothy W. Farrell

The OXR domain defines a conserved family of eukaryotic oxidation resistance proteins.

BackgroundThe NCOA7 gene product is an estrogen receptor associated protein that is highly similar to the human OXR1 gene product, which functions in oxidation resistance. OXR genes are conserved among all sequenced eukaryotes from yeast to humans. In this study we examine if NCOA7 has an oxidation resistance function similar to that demonstrated for OXR1. We also examine NCOA7 expression in response to oxidative stress and its subcellular localization in human cells, comparing these properties with those of OXR1.ResultsWe find that NCOA7, like OXR1 can suppress the oxidative mutator phenotype when expressed in an E. coli strain that exhibits an oxidation specific mutator phenotype. Moreover, NCOA7s oxidation resistance function requires expression of only its carboxyl-terminal domain and is similar in this regard to OXR1. We find that, in human cells, NCOA7 is constitutively expressed and is not induced by oxidative stress and appears to localize to the nucleus following estradiol stimulation. These properties of NCOA7 are in striking contrast to those of OXR1, which is induced by oxidative stress, localizes to mitochondria, and appears to be excluded, or largely absent from nuclei.ConclusionNCOA7 most likely arose from duplication. Like its homologue, OXR1, it is capable of reducing the DNA damaging effects of reactive oxygen species when expressed in bacteria, indicating the protein has an activity that can contribute to oxidation resistance. Unlike OXR1, it appears to localize to nuclei and interacts with the estrogen receptor. This raises the possibility that NCOA7 encodes the nuclear counterpart of the mitochondrial OXR1 protein and in mammalian cells it may reduce the oxidative by-products of estrogen metabolite-mediated DNA damage.

Organizational Culture Associated With Provider Satisfaction

Background: Organizational culture is key to the successful implementation of major improvement strategies. Transformation to a patient-centered medical home (PCHM) is such an improvement strategy, requiring a shift from provider-centric care to team-based care. Because this shift may impact provider satisfaction, it is important to understand the relationship between provider satisfaction and organizational culture, specifically in the context of practices that have transformed to a PCMH model. Methods: This was a cross-sectional study of surveys conducted in 2011 among providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design. Measures included the Organizational Culture Assessment Instrument and the American Medical Group Association provider satisfaction survey. Results: Providers were most satisfied with quality of care (mean, 4.14; scale of 1–5) and interactions with patients (mean, 4.12) and were least satisfied with time spent working (mean, 3.47), paperwork (mean, 3.45), and compensation (mean, 3.35). Culture profiles differed across clinics, with family/clan and hierarchical cultures the most common. Significant correlations (P ≤ .05) between provider satisfaction and clinic culture archetypes included family/clan culture negatively correlated with administrative work; entrepreneurial culture positively correlated with the Time Spent Working dimension; market/rational culture positively correlated with how practices were facing economic and strategic challenges; and hierarchical culture negatively correlated with the Relationships with Staff and Resource dimensions. Conclusions: Provider satisfaction is an important metric for assessing experiences with features of a PCMH model. Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.

Connecting the Dots and Merging Meaning: Using Mixed Methods to Study Primary Care Delivery Transformation

OBJECTIVE To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. DATA SOURCE/STUDY SETTING An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. STUDY DESIGN Convergent case study mixed methods design. DATA COLLECTION/EXTRACTION METHODS Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. PRINCIPAL FINDINGS Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. CONCLUSIONS Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence.

AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults

In this position statement, we define unbefriended older adults as patients who: (1) lack decisional capacity to provide informed consent to the medical treatment at hand; (2) have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so; and (3) lack family, friends or a legally authorized surrogate to assist in the medical decision‐making process. Given the vulnerable nature of this population, clinicians, health care teams, ethics committees and other stakeholders working with unbefriended older adults must be diligent when formulating treatment decisions on their behalf. The process of arriving at a treatment decision for an unbefriended older adult should be conducted according to standards of procedural fairness and include capacity assessment, a search for potentially unidentified surrogate decision makers (including non‐traditional surrogates) and a team‐based effort to ascertain the unbefriended older adults preferences by synthesizing all available evidence. A concerted national effort is needed to help reduce the significant state‐to‐state variability in legal approaches to unbefriended patients. Proactive efforts are also needed to identify older adults, including “adult orphans,” at risk for becoming unbefriended and to develop alternative approaches to medical decision making for unbefriended older adults. This document updates the 1996 AGS position statement on unbefriended older adults.

Review of a Geriatric Health Literacy Workshop for Medical Students and Residents

The “Geriatric Health Literacy Workshop for Medical Students and Residents” developed by Seema Limaye, MD, introduces medical students and residents to important concepts in communicating with older adults with low health literacy through a variety of teaching modalities. The workshop is available on the Portal of Geriatric Online Education (POGOe) and includes a didactic session, role‐playing exercises, and a critique of patient education handouts. A preworkshop health literacy module and postworkshop clinical observation sessions reinforce the workshop content. The activity is designed to take approximately 2.5 hours to administer to small groups of three to five learners and is also suitable for interdisciplinary teams of health professions trainees. This POGOe product review highlights important features of the workshop and suggests opportunities for improvement.

Review of “Depression in the Elderly—Simulated Patient Small Group Activity”

This activity teaches knowledge and skills regarding the assessment and management of geriatric depression to second‐year medical students. Students actively participate in a standardized patient scenario with a “collateral source,” which the authors define as a relative, friend, neighbor, healthcare power of attorney, or healthcare provider of a cognitively impaired patient who can provide additional history that might be more accurate than that obtained from the patient. Students also discuss proposed physical examination items, formulate a management plan with assistance from a handout on geriatric depression and facilitation by a faculty member, and receive feedback from the standardized patient and a “collateral source.” This activity is designed to take c approximately 2 hours to administer to small groups of learners and emphasizes that depression often presents atypically in older adults.

Implementation of Care Management: An Analysis of Recent AHRQ Research.

Care management (CM) is a promising team-based, patient-centered approach “designed to assist patients and their support systems in managing medical conditions more effectively.” As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality–sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

Professional Development and Exposure to Geriatrics: Medical Student Perspectives From Narrative Journals

Teaching professionalism is an important goal in American medical education. With the aging of the U.S. population, it is critical to understand how medical students develop professional behaviors when caring for older adults. Exposure to geriatrics and older patients can enhance students’ professional development with patients of all ages and across different specialties. Medical students learn explicit and implicit messages during their education. In addition to helping to evaluate curricula, reflective journaling encourages individual development and helps in revealing how medical students become professionals. In this study, medical student volunteers described their responses to new geriatrics content in their curriculum, encounters with older patients in clinical settings, and their evolving physician identities. Multidisciplinary team analysis elicited 10 themes regarding: evaluation of geriatrics within the curriculum, recognition of geriatrics principles, and attitudes regarding aging and professional development over time. This article focuses on the impact of geriatrics exposure on students’ professional development, revealing ways that students think about professionalism and older patients. Medical educators should consider journaling to help foster and gauge students’ professional development.

Individual versus interprofessional team performance in formulating care transition plans: A randomised study of trainees from five professional groups

ABSTRACT Health professions trainees’ performance in teams is rarely evaluated, but increasingly important as the healthcare delivery systems in which they will practice move towards team-based care. Effective management of care transitions is an important aspect of interprofessional teamwork. This mixed-methods study used a crossover design to randomise health professions trainees to work as individuals and as teams to formulate written care transition plans. Experienced external raters assessed the quality of the written care transition plans as well as both the quality of team process and overall team performance. Written care transition plan quality did not vary between individuals and teams (21.8 vs. 24.4, respectively, p = 0.42). The quality of team process did not correlate with the quality of the team-generated written care transition plans (r = −0.172, p = 0.659). However, there was a significant correlation between the quality of team process and overall team performance (r = 0.692, p = 0.039). Teams with highly engaged recorders, performing an internal team debrief, had higher-quality care transition plans. These results suggest that high-quality interprofessional care transition plans may require advance instruction as well as teamwork in finalising the plan.