To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs.Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases.Most (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers.This is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.The online version of this article (10.1186/s12913-019-3980-x) contains supplementary material, which is available to authorized users. Around the world, healthcare systems are experiencing significant pressures in coping with rapidly aging populations and growing multi-morbidity. Like other developed countries, Singapore’s population is also aging quickly, accompanied by the mounting prevalence of co-morbidities . Multi-mSince 2011, the Regional Health Systems (RHSs) have been established in various geographical regions in Singapore to build partnerships between different care providers, within and across care settings. Led by the acute hospital within each region, each RHS aims to foster integration and deliver seamless care for the population within the respective catchment areas in a cost-effective way , 8.Among all patients cared for under the RHS, frequent admitters (FAs)  consume a disproportionally high share of healthcare resources. In 2013, within the National University Health System (NUHS)-RHS, FAs accounted for only 1% of all patients, yet generated about 27% of all inpatient episodes and incurring higher average costs compared to those who were not FAs . A sub-oTransitional care is a set of multi-disciplinary interventions aimed at improving care coordination when patients transit between different healthcare settings . DischarIn 2012, the NUHS-RHS initiated a transitional care program for elderly patients and/or those with complex healthcare needs who had previously consumed high levels of hospital resources . ElderlyTo facilitate further development of the NUHS transitional care program, a rigorous and practical evaluation strategy was required to examine progress and identify insights for improvement and scaling-up. One way to achieve this was by assessing implementation fidelity. Implementation fidelity, the degree in which a program is implemented as intended, acts as a potential mediator of the relationship between programs and their intended outcomes . Higher To address this gap, we aimed to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program. The program had been demonstrated to result in lower mortality among FAs and higher healthcare utilization and cost compared to their matched controls .Furthermore, the study also aim to inform further development of the program. Since this gap is present in other countries too, this study may provide relevant insights to those involved in the development, implementation and/or evaluation of transitional care programs as part of integrated care initiatives beyond Singapore.The modified version of the Conceptual Framework of Implementation Fidelity (CFIF) was used in this study . The modParticipant responsiveness refers to how well participants (users receiving the program and providers delivering program) respond to, or are engaged by the program. If participants do not value the program, they will not be engaged in the program, thereby making implementation difficult. Program complexity refers to the comprehensiveness of the program as evaluated through descriptions of the program and the actual implementation. Simple but specific programs were found to be more likely implemented with high fidelity than complex and/or vaguely described programs. Adequate facilitation is expected to optimize fidelity. Quality of delivery describes whether a program is delivered appropriately to achieve what was intended. A poorly delivered program contributes to lower implementation fidelity overall. In assessing participant recruitment, the modified CFIF proposes to assess the reasons for non-participation among potential participants and subgroups that were less likely to participate. Finally, context considers surrounding social system, for example social structures and cultures.Guided by a set of selection criteria, eligible patients were recruited mainly from the inpatient wards through referrals from the physicians, nurses and other allied health professionals. Then, needs assessments were conducted and personalized care plans were developed accordingly. One or a group of dedicated CCs was assigned to every patient enrolled into the program. Every CC assumed the role of an integrator, responsible for coordinating the delivery of services through communication with patients, their families, and the various professionals and services that the healthcare users come into contact with throughout their period of enrolment in the program. The transitional care program started after patients were discharged from the hospital.The study is a part of the realist evaluation of the NUHS-RHS . In thisData were collected between June 2016 to June 2017. Components of adherence including content, frequency, and duration were assessed using non-participatory observations, reviews of medical records and program databases. We were unable to examine coverage as there was no documentation of the total number of people who were offered the program. Moderating factors were examined using interviews with healthcare providers and healthcare users (patients and caregivers). Caregivers were interviewed as proxies to patients. As there was no benchmarking available within Singapore, we did not assess the quality of delivery and comprehensiveness of policy.Program protocols were initially reviewed by study team members to provide an understanding of the program and how it aimed to achieve targeted outcomes. The intended components of the program identified were then validated against the program’s logic model, components of case management as proposed by the Kings’ Fund , and thrStudy team members conducted non-participatory observations of home visits and telephone monitoring – the core components of the program. Content of care delivery, interactions between healthcare users and providers, together with users’ responses to the service were observed and observation notes were taken. Medical records of patients enrolled into the programs were reviewed to provide a comprehensive picture of the services delivered throughout a patient’s healthcare journey from enrolment to discharge. Program databases comprised of records of patients enrolled in the program was reviewed to gather insights on the dose of the program.Then, observation notes and reviews of medical records were assessed using the checklist by study team members. Program components were scored as “yes” or “no” for whether they were conducted or not. After which, level of adherence for each component of the program was calculated as the percentage of the number of cases in which specific component was scored with “yes” over the total number of observations conducted and medical records reviewed. Levels of adherence for specific component that fall within the 80–100% range were categorised as “high”, within 51–79% as ‘moderate’ and 0–50% as ‘low’ fidelity , 31. In A convenience sampling of healthcare providers who were involved in the planning, development, and implementation of the program were recruited into the study. A contact list of all healthcare providers involved in the program was first obtained from the program manager. Based on which, invitation emails were sent out to recruit study participants. Only those who responded to the email invitations and agreed to be audio-recorded were interviewed by the study team member(s). In every interview session, an interview guide developed for the study  to take part in the interviews. Eligible healthcare users who agreed to be audio recorded were eventually interviewed. In every interview session, content of program and their responses to program were assessed using an interview guide for healthcare users  non-participatory observations were conducted, 29 at first-time home visits, 11 during follow-up visit and 2 during phone monitoring to assess adherence. For the same reason, medical records of 44 patients who were enrolled into the program were also reviewed. Out of the records reviewed, documentations regarding the program could not be found in 11 of them. Therefore, only 33 reviews of medical records were included in the assessment of adherence. Program databases containing a total of 2705 records were reviewed to determine the dose (frequency and duration) of the program.For the assessment of moderating factors influencing program implementation, 25 healthcare providers including CCs, managers, and physicians involved in the implementation of the program and 45 healthcare users (patient/caregiver) enrolled in the transitional care program were interviewed.As illustrated in Table The frequency of actualization of program specific activities was found to vary according to the needs of users, availability of CCs, and their confidence in delivering particular program components. For the period of program enrolment, a median frequency of 2 and 7 were found for home-visits and phone-monitoring respectively. Time spent on home visits was not explicitly tracked while a median of 10 min were found to be spent on every phone call monitoring. Patients were found to be enrolled in the NUHS-RHS post-discharge care program for a mean duration of 112.8 days with a standard deviation of 145.9 days.Our study findings confirmed interrelated influence of moderating factors identified by the modified CFIF on implementation fidelity of the NUHS transitional care program Fig. . A summaappreciation of the program and viewed the convenience of having empathetic, caring, proactive and knowledgeable CC visiting them at home to be most valuable. Nonetheless, the extent of responsiveness was found to fluctuate according to level of awareness. Some healthcare users were found to have limited awareness of the specific services the program offered, its goals and the role of the CC. Therefore, there was misconception; users regarded home visits as “disruptions” with little value and CCs as “doctors’ assistants” with limited capability, leading to lowered perceived value of the program. In contrast, those who valued team-based and patient-centric care were more responsive.The majority of healthcare users were observed to be responsive and had good rapport with CCs during home visits. They expressed confusion created by lack of well-developed program direction and protocols. Expectation to cope with increasing workload, yield positive outcomes within a short time and lack of training, created anxiety among healthcare providers. Uncertainty surrounding the future direction of the program and job security of the CCs perpetuated frustrations among them. Altogether, these factors lowered morale and lowered providers’ responsiveness.Healthcare providers reported initial excitement about the prospects of the program and believed that the program would enhance transition and recovery of patients. However, the level of healthcare providers’ responsiveness changed over time due to myriad complex needs driving the development of the program, heterogeneity within the healthcare users that the program serves, detail of program components, and involvement of numerous actors with different perspectives rendered the program complicated. While it would have been ideal to have a simple, standardized, and specific program protocol, it was impossible to do so given many moving parts. Changes in leadership were found to shape the behaviour of different actors of the program, requiring successive adaptations throughout the implementation. For example, throughout the short implementation period, revisions to enrolment criteria, recruitment strategies, and roles of different providers were made due to the change in leadership.The a common information system, guiding protocols and financial support were found to facilitate the implementation of the transitional care program.The use of time-consuming additional administrative work, and hence not prioritized. Besides the common EMR, a standardized care needs assessment and referral system was implemented to help facilitate appropriate placement of patients for intermediate and long-term care (ILTC) in the community. However, healthcare providers experienced difficulties in using this system, forcing them to manually search for and refer patients to ILTC after the program.All healthcare providers involved were granted access to the common electronic medical records (EMR) which functions to systematically consolidate medical information and allows sharing of information between actors across disciplines and care settings. Although the shared EMR has successfully facilitated information continuity to a great extent, its wider adoption remained a work in progress. Having to manage other work pressures, documentation was perceived by healthcare providers as Guiding protocols describing selection criteria and key steps to be taken in delivering program were developed at the beginning of the program. Protocols guided healthcare providers to standardize the delivery of program and manage patients at home independently or as a team. However, there were different levels of granularity in the details available for various program components within the protocols. Detailed description was available only for needs assessments, development of care plans, and promotion of self-care. Consequently, healthcare providers had to improvise for other components and dose of the program based on their experiences. This caused discomfort among healthcare providers as many of them were used to working within the hospitals where standard operating procedures (SOPs) were clearly defined. The lack of specific details related to referrals to other services had also resulted in difficulties in referring users to other community services.Our study revealed that block funding provided by the Ministry of Health (MOH) Singapore which covered healthcare manpower costs, transport fees, training expenses, and service costs of providing the program facilitated the implementation of the program. Subsidies available for running the program lowered the barrier for adoption as users had to pay minimal fees for the program.difficulty in reconciling the differences between their professional opinions and the program selection criteria in recruitment of patients. In response to this, exceptions with justification often had to be made.Wrong and late referrals were noted to adversely affect recruitment in the early phase of the program. This was quickly resolved through continuous engagement of healthcare providers who refer patients by the program team and clarification of selection criteria. Later, healthcare providers experienced privacy concerns, were reported to more likely to decline participation. Out of pocket costs were also found to be the other reason for patient refusal.Approximately 10–20% of the eligible patients refused to participate in the program. Those who did not appreciate the value of the program and had were also often perceived as inferior to doctors working in the hospitals. This was perpetuated with passive culture among users which contributed to the belief that it was providers’ responsibility to assist in the management of their health.At users’ level, having been used to a largely hospital-centric system with easy access to specialist care, the healthcare users preferred to be cared for in the hospitals. Hospital care was highly subsidized, making it more appealing to users compared to community care. Non-doctors and professionals providing care outside of hospitals multidisciplinary collaboration in the delivery of the program was noted where physicians, nurses, and allied health professionals worked well together. This, in turn, contributed positively to the implementation of the program. Conversely, even with the focus to provide holistic care for individuals with complex needs, the phenomena of “super specialization” in which healthcare providers specialize in an organ or certain aspect of patient care persisted. There was limited interdisciplinary training among providers. This was problematic as diversification of professions and their specialized tasks contributed to slow progress towards provision of holistic care. Also, this affected providers’ ability to adequately manage individuals with multiple needs, causing delays in care. In many occasions, CCs had to seek help from social workers from the hospitals as they were not trained and therefore not confident in managing social issues and advocating for users.At the providers level, good progress in Requirements to document on multiple systems was a great concern to healthcare providers as it consumed more time. Fragmentation in care capabilities among providers were also observed. This was largely contributed by resource constraints at the community level. In addition, the formal organization of and practices within community care in Singapore were less developed compared to the hospitals, affecting their capability to collaborate. In many instances, CCs could not discharge patients to the community providers within the NUHS-RHS after the planned program period as the community care providers did not have the capability to continue management of care.At the organization level, fragmentation was found in information systems, with varied level of adoption and sub-systems adopted by different healthcare providers. We examined the implementation fidelity of a transitional care program to integrate services for high need individuals in Singapore after discharge from hospital, using the modified version of CFIF.Our findings revealed several contributing factors to variability in implementation fidelity of components of the NUHS-RHS transitional care program. These included: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers. Our results showed these factors influenced implementation fidelity of the program in an interrelated manner.We found that healthcare providers experienced the program as a complex intervention predominantly due to difficulties faced in its implementation and its intention to be “patient-centric”- i.e. designed and organized around the needs of the healthcare users (patients and caregivers). Findings highlighted heterogeneity within the users in terms of needs and responsiveness, making it impossible to standardize program implementation. Changes that occurred over time always required personalization of care. Personalization actualized in the form of continuous adaptations in response to changing needs through revising goals and working towards what is best for and preferred by users. This was reflected as variation in implementation fidelity of the program. Similar findings were reported by Muntinga et al. , who assThe high level of fidelity found for needs assessment, development of care plans, symptoms management and promotion of self-care was due to the availability of detailed description of protocols for these program components. Providing care outside of the hospitals was new for most CCs involved in the program, thus, detailed protocols gave guidance for CC to confidently deliver care on their own and to standardize delivery of care. This finding is in line with prior studies which suggested that detailed protocols facilitated implementation of program. Another explanation for high implementation fidelity is CCs’ training and confidence. CCs were trained in the hospitals and therefore familiar with medically-oriented tasks such as needs assessment, development of care plans, symptoms management, and promotion of self-care. It was not surprising that CCs naturally prioritized tasks which they were familiar with.Low implementation fidelity found for psychological support can be explained primarily by the lack of interdisciplinary training and experience among providers involved in the program in providing this support. CCs were found to be still accustomed to providing medical care in the hospital environment and lacked training in management of psychological issues. As highlighted by Ong et al. , this isThe Singapore mental health study revealed a huge treatment gap for mental illnesses . ResultsOur results showed a lack of referrals to other services by CCs was due to: i) the lack of specific details guiding CCs on where to refer patients to, and ii) difficulties faced by CCs in using the common referral system. This was worsened by providers’ diminishing responsiveness to the program. As providers became less responsive, they were less likely to take a proactive role in overcoming the issues faced. Furthermore, suboptimal capabilities found among community providers were found to deter referrals to other services. For this reason, CCs were often forced to continue to manage patients after the planned program duration. A study by Hasson et al. suggested that providers’ responsiveness is a key driving force for achieving high implementation fidelity. In their study, frustrations associated with limited facilitation in the study was found to ease quickly with high providers’ responsiveness .We found the lack of interdisciplinary training and diminishing responsiveness among CCs to be the main reason behind low implementation fidelity of advocacy and appointment management. With the lack of interdisciplinary training, CCs were not comfortable in delivering these services as they were traditionally specialized by other providers. Advocacy was typically delivered by social workers while appointments were managed by other designated operation teams in the hospitals. Consequently, CCs often had to rely on the assumptions that advocacy and appointment management would have been delivered by other providers , since patients enrolled in the program continued to receive care from the hospitals.Based on our study findings, we propose several generalizable recommendations for decision makers to consider when designing and implementing a transitional care program as part of a strategy for integration of healthcare services. Firstly, ex-ante, efforts should be put in place to improve the responsiveness of both healthcare users and providers about the program. There should be better alignment in expectations between both parties. Secondly, the capability building of community care providers should be prioritized.For better alignment of expectations between users and providers, efforts can be put into increasing users’ awareness of the program and addressing misconceptions, roles of CC and community care. Thorough explanation by the CCs about the program and their roles together with intentional involvement of users in making shared decision related to their care can be the potential solutions. However, as the willingness, readiness, and ability of healthcare users to participate were demonstrated to be the pre-requisites required for engaging patients who were receiving transitional care programs , future In addressing the diminishing responsiveness of providers, appropriate incentives  can be put in place to motivate healthcare providers. Emphasis should also be made for providers to have more active involvement in the design and development of programs. Such a strategy was found to secure the commitment of providers, improve motivation, and ensure sustainability in implementation of a similar program . It can To further develop capability among community providers, the hospitals that have more resources can possibly take a more pro-active role in training the community care providers. Community care providers could also be empowered by making changes to the current healthcare financing model to support integrated care interventions like transitional care programs. Rather than charging patients based on episodes of care and provider type, a financing mechanism that follows the patient and incentivizes quality and continuity of care should be put in place to pool charges across services and providers.To the best of our knowledge, this is the first study that has taken the opportunity to assess context-specific implementation process of a transitional care program in the context of Southeast Asia. Particularly in the context of Singapore, where most of previously conducted evaluation on similar programs evaluation , 24–26 fWe used a validated framework, the modified CFIF, which has been used to assess implementation fidelity of complex healthcare programs , 22. ConMeasurement of adherence was challenging as the basis of assessment could not be standardised and explicitly defined due to the nature of the program. This is consistent with other studies that have attempted to examine the implementation fidelity without clearly defined reference points of measurements , 34. KeeComprehensive and accurate data gathered using multiple methods during implementation of the program added increased credibility to the study findings as they reflect the actual circumstances in which the program was being implemented. Nevertheless, it must be acknowledged that because this study is a cross-sectional study, it did not take into account the changes of the program over time. We learned that changes occurred but details of the changes remained unknown. Therefore, we were unable to explicitly point out the effects of the evolution on implementation fidelity of the program. For a more comprehensive assessment of implementation fidelity, longitudinal investigations should be conducted in the future to understand how implementation of the program changes over time.In addition, only users who were part of the program were interviewed as it was operationally challenging to recruit those who rejected enrolment into the program. For simplicity, we combined findings from patients and their caregivers. The literature highlighted distinction between the roles of patients and caregivers in transitional care , therefoIn assessing the implementation fidelity of the NUHS-RHS transitional program, we found detailed protocols coupled with CCs’ level of confidence and familiarity in specific program components to contribute to high implementation fidelity. In contrast, program complexity, diminishing participant responsiveness, lack of specific training for CCs, and limited capability of community providers have observably made the implementation of the program challenging. Such findings highlighted the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with relevant skills required for their jobs, and further development of the capability of the community providers. Finally, as illustrated by the Rainbow Model of Integrated Care , our stuOther health and social care networks within Singapore and abroad, alike to the NUHS-RHS, are experimenting with new integrated care models including transitional care programs. Findings from existing research of the (cost-)effectiveness of integrated care are to a major extent inconsistent because of the variations in the strategic outcomes, methods of implementation, contexts (i.e. system and policy) and/or applied evaluation measures . The finAdditional file 1:Topic Guide for Interviews. (DOCX 18 kb)


OBJECTIVES/SPECIFIC AIMS: Leadership is an essential and recognized team science competency. Modeled after the successful LEAD (Leadership in Emerging Academic Departments) program at University of Texas Southwestern (UTSW), ConduITS LEAD Program is designed to: (1) provide personal and professional development opportunities for participants; (2) promote organizational change through applied leadership skills; (3) provide a platform for integrating multiple disciplines and fostering interprofessional relationships among investigators and clinicians. METHODS/STUDY POPULATION: The 1-year structured LEAD program curriculum includes monthly interactive seminars covering: personal and situational leadership; unconscious bias; communication and influence; navigating personal conflict; negotiation and networking; selecting and managing the right team; teamwork; financing the academic mission, budgets and business plan development; strategic planning and vision; presentation skills. To foster the development of leadership skills participants engage in Hogan Assessments, individual and peer mentoring from an executive coach and self-directed learning activities and assignments. Completion of an individual Capstone leadership project empowers learners to enact practice change through the implementation of leadership concepts in practice. RESULTS/ANTICIPATED RESULTS: In collaboration with the Office of Academic Enrichment & Development (OADE), the first competitive RFA was issued in November of 2016. In total, 63 applications were received including: gender: 29 M: 34 F; URM: 10; Degrees: M.D. (40); Ph.D. (11); M.D./Ph.D. (6); M.D./M.P.H. (3); M.D./M.S.C.R. (2); PharmD (1); Departments: 19; Institutes/Centers: 12; MSHS: 3 sites. Through a competitive and rigorous application process, 24 junior faculty with evidence of leadership potential and trajectory were chosen to participate. The current cohort of LEAD participants joined in February 2017, and will complete the program in January 2018. Using qualitative and quantitative survey methodology, participants will be evaluated for self-reported change to attitudes, belief, skills and development of new relationships and collaborations. Submitted Capstone projects were mainly focused on implementing situational and personal leadership concepts to practice, with one additionally focused on the use of behavioral interviewing techniques to optimize team building and teamwork. At the time of abstract submission 30% of the cohort has implemented their Capstone project in practice. Participants will be followed-up in 6 months’ time to evaluate the impact of the LEAD program on their practice. Following a second RFA, 24/52 candidates have been selected as our next cohort, and will start in February 2018. DISCUSSION/SIGNIFICANCE OF IMPACT: Leadership is known to be a core component of team science, and the ability to implement leadership into practice may advance personal and professional change. This program addresses the need to empower Junior Faculty to engage in leadership in practice. In addition, this program is able to provide added value to extend the reach of the OADE, promote new individual collaborations and facilitate additional leadership training efforts at our Institution. Future collaborative studies will focus on common outcomes as well as institutional differences between these 2 CTSA institutions.


Background: The therapeutic benefits of β-blockers are well established in left heart failure. The Pulmonary Arterial Hypertension Treatment with Carvedilol for Heart Failure [PAHTCH] study showed safety and possible benefit of carvedilol in pulmonary arterial hypertension (PAH) associated right heart failure over 6 months. This study aims at evaluating the short-term cardiovascular effects and early mechanistic biomarkers of carvedilol therapy.Methods: Thirty patients with pulmonary hypertension (PH) received low dose carvedilol (3.125 mg twice daily) for 1 week prior to randomization to placebo, low-dose, or dose-escalating carvedilol therapy. Echocardiography was performed at baseline and 1 week. Exercise capacity was assessed by 6 min walk distance (6MWD). The L-arginine/nitric oxide pathway and other biological markers of endothelial function were measured.Results: All participants tolerated 1 week of carvedilol without adverse effects. After 1 week of carvedilol, 6MWD and heart rate at peak exercise did not vary (both p > 0.1). Heart rate at rest and 1 min post walk dropped significantly (both p < 0.05) with a trend for increase in heart rate recovery (p = 0.08). Right ventricular systolic pressure (RVSP) decreased by an average of 13 mmHg (p = 0.002). Patients who had a decrease in RVSP of more than 10 mm Hg were defined as responders (n = 17), and those with a lesser drop as non-responders (n = 13). Responders had a significant drop in pulmonary vascular resistance (PVR) after 1 week of carvedilol (p = 0.004). In addition, responders had a greater decrease in heart rate at rest and 1 min post walk compared to non-responders (both p < 0.05). Responders had higher plasma arginine and global bioavailability of arginine at baseline compared to non-responders . After 1 week of carvedilol, responders had greater increase in urinary nitrate (p = 0.04). Responders treated with carvedilol had a sustained drop in RVSP and PVR after 6 months of carvedilol with no change in cardiac output.Conclusions: Low-dose carvedilol for 1 week can potentially identify a PH responder phenotype that may benefit from β-blockers that is associated with less endothelial dysfunction.Clinical Trial Registration:http://www.clinicaltrials.gov. identifier: NCT01586156. Pulmonary arterial hypertension (PAH) is a progressive pulmonary vascular disease defined by elevated pulmonary arterial pressure leading to right-sided heart failure. Recent studies have investigated the safety and potential benefits of β-blockers in pulmonary arterial hypertension (PAH) related heart failure , 2. WherPrior studies of the short-term effects of β-blockade did not evaluate cardiac function and/or pulmonary pressures, or biologic markers of disease pathway activation. The L-arginine/nitric oxide (NO) pathway is abnormal in PAH. L-arginine, the substrate for synthesis of the vasodilator NO, is consumed by arginase to produce ornithine and urea, and/or altered by methylation pathways that inhibit NO production . In PAH,Here, the cardiovascular effects of short-term (1 week) use of carvedilol at low dose were evaluated in patients with PH, in order to assess clinical and biological markers that might identify those with an acute beneficial response to β-blockers. To study the short-term effects of carvedilol, the PAHTCH cohort was analyzed for clinical characteristics and echocardiographic measures as well as biomarkers of endothelial function, including the arginine/NO pathway, BNP, and endothelin-1 at baseline prior to drug and at 1 week of low-dose carvedilol. In contrast to the prior PAHTCH report, this study provides new information on the 1 week low-dose carvedilol intervention evaluating both clinical measures and mechanistic biomarkers.The Pulmonary Arterial Hypertension Treatment with Carvedilol for Heart Failure (PAHTCH) clinical trial was approved by the Institutional Review Board at the Cleveland Clinic. A total of 30 PH patients and 12 healthy participants were consented and enrolled. PH patients started with a 1 week open-label low-dose carvedilol at 3.125 mg twice daily, followed by double-blinded randomization to placebo, low-fixed dose or escalating dose arms. Study design and participants have been previously described in detail .All echocardiograms and Doppler examinations were performed on a General Electric (GE) Ultrasound system (models E95 and E9), by an advanced cardiac sonographer (MP). Analysis was performed offline via Syngo Dynamics Cardio PACS system, Siemens Healthcare and EchoPAC Clinical workstation, GE Medical Imaging. Transthoracic echocardiograms were performed after 1 week of carvedilol to assess acute changes in cardiac structure and function as safety measures . For theThe same method was applied to the RV for analysis of peak global RV longitudinal strain. The spectral Doppler waveform recorded at the level of the right ventricular outflow tract was used to identify the timing of pulmonic valve opening and closing times. An RV focused, or modified view was captured during breath hold and analyzed. RV peak global RV longitudinal strain values for the base, mid and apical RV lateral wall segments were recorded as well as the global 6-wall strain, which also included the interventricular base, mid, and apical segments.Continuous wave (CW) Doppler of the peak tricuspid valve regurgitant (TR) jet was used to calculate RV systolic pressure using the Bernoulli equation. For weak and insufficient TR jets, agitated saline contrast was used to enhance the TR jet signal. A peak TR Doppler jet of good quality was obtainable on all study subjects. Right atrial pressure was calculated from the change in inferior vena cava collapse during respiration and with the sniff test as reported. Two-dimensional echo analysis included LV end diastolic and systolic diameters measured from the parasternal long axis view, LV end diastolic and systolic volume assessment (biplane method of disc) for LV ejection fraction (LVEF), cardiac output (CO), and stroke volume (SV). The pulmonary vascular resistance (PVR) was calculated by: Peak TV velocity/time velocity integral of the RVOT x 10 + 0.16 = PVR in Woods .Plasma NT-proBNP was measured by an electrochemiluminescence immunoassay using the Roche Cobas e411 analyzer as previously described , symmetric dimethyl arginine (SDMA), and monomethyl arginine (MMA) were performed by stable-isotope-dilution High-performance liquid chromatography (HPLC) with online tandem mass spectometry as previously described . These mAll values of urine samples were normalized by urine creatinine to account for differences in hydration and urine volume. Creatinine concentrations were measured with the Abbott Architect machine according to manufacturer's instructions. All samples tested negative for nitrite using the Griess reaction. Nitrate  according to the manufacturer's protocol at baseline and 3 and 6-months visits.t-test was used for quantitative values with natural log transformation used for values with skewed distributions. Associations among quantitative measures were assessed using Pearson correlations. Statistical significance was accepted at a level of p ≤ 0.05.All analyses were performed using JMP Pro, version 13.1 (SAS Institute). One-tail Fisher's Exact (for 2 × 2 tables) or Likelihood Ratio chi-square test was used for comparison of categorical variables. One-tail Student's N = 30) and healthy controls (N = 12) were enrolled in the study. The study population was described in a prior report (N = 26) with 2 patients with chronic thromboembolic PH (WHO group 4) and 2 with PH associated with lung diseases (WHO group 3). Among the 30 PH participants, 24 were taking phosphodiesterase type 5 inhibitors, 19 endothelin receptor antagonists, and 16 prostacyclin analogs. Healthy controls and PH patients were ethnically similar. There were no differences in age or gender distribution. However, PH patients had overall higher body mass index and lower oxygen saturation. Indicators of RV and pulmonary vascular function as measured by right ventricular systolic pressure (RVSP), plasma NT-proBNP and endothelin-1 were higher in PH patients compared to controls. In addition, urinary cGMP was higher in PH compared to healthy controls. Plasma arginine levels and global arginine bioavailability (ratio of arginine to ornithine and citrulline) and citrulline were lower in PH, whereas the plasma level of MMA, an endogenous inhibitor of nitric oxide synthase, was higher  and in PH   and in PH  and in PH . Similarly, plasma NT-proBNP directly correlated with RVSP in PH . Heart rate at maximum exertion at 6 min did not vary on carvedilol therapy (p = 0.3); however heart rate at 1 min recovery post walk dropped significantly  and heart rate recovery (HRR) tended to increase .All patients tolerated 1 week of carvedilol at 3.125 mg twice daily. Exercise capacity as measured by 6 min walk distance did not vary after 1 week of low dose carvedilol. Heart rate at rest dropped by an average of 6 beats/minute  had a drop in RVSP of ≥ 10 mmHg, and were defined as responders . Responders had significantly lower RVSP at 1 week compared to non-responders  and the change in RVSP from baseline was significant . Heart rate measured during echocardiography was not significantly reduced (p = 0.4) but stroke volume was decreased compared to baseline (p < 0.0001). Systolic and diastolic blood pressures dropped with carvedilol therapy . Pulmonary vascular resistance (PVR) did not change significantly (paired t-test > 0.1). The drop in stroke volume was associated with a decrease in left ventricle end diastolic volume . There was a non-significant drop in LV ejection fraction (LVEF) . Despite these changes, LV and RV strains did not vary significantly (both p > 0.1). Both responders and non-responders had a decrease in CO   and a non-significant increase in PVR . The drop in LVESV was not significant (p = 0.09). There was no change in LVEF. On the other hand, in the responder group, the drop in CO was associated with a drop in PVR  and a decrease in LVEF . There were no differences in gender, race, or WHO classification between responders and non-responders. Functional class as measured by New York Heart Association (NYHA) classification was not different between the 2 groups . There was no difference in PH therapy at baseline between the 2 groups (p > 0.1). Baseline biomarkers of disease severity, NT-proBNP and endothelin-1 were similar . There were no significant differences between the 2 groups at baseline based on 6 min walk distance or echocardiography (Table We further compared responders and non-responders at baseline. Both groups had similar age . After 1 week of low-dose carvedilol treatment, urinary nitrate/creatinine increased in responders compared to non-responders . These findings suggest that responders had recovery of L-arginine–nitric oxide pathway whereas non-responders did not.To identify the possible mechanisms of action of carvedilol, we compared features between responders and non-responders Table . At baset-test p = 0.05]. Responders on carvedilol at 6 months had higher arginine and arginine biovailability compared to non-responders on carvedilol . Responders on carvedilol had lower SDMA and ADMA at 6 months of therapy compared to non-responders . These results suggest that the drop in RVSP after 1 week of therapy might predict patients who will maintain a drop in RVSP over time and that the response is related in part to recovery of the endothelial arginine/NO pathway.The PAHTCH study design offered an ideal opportunity to determine if the early response to carvedilol predicted sustained response over time. After 1 week open-label carvedilol, 5 of the 17 PH responders were randomized to the placebo arm, 7 to the low-fixed dose carvedilol and 5 to the escalating dose carvedilol. Of the 13 non-responders, 5 were randomized to the placebo arm, 3 to the low-fixed dose carvedilol and 5 to the escalating dose carvedilol. There were no significant differences in the clinical parameters between responders and non-responders assigned to carvedilol at the 3 and 6-months visits. Responders on carvedilol had a sustained response to carvedilol at 6 months. In fact, RVSP and PVR were lower in responders at 6 months compared to baseline with no change in cardiac output  and carry better prognosis –28. DuriThe drop in stroke volume and contractility described is similar to what is described in earlier studies in left heart failure , 31. In ad-hoc investigation of the PAHTCH study limits the power of the analyses. The echocardiogram performed at the 1-week visit was a limited study performed to assess safety. However, a single expert sonographer who was blind to the randomization scheme performed all echocardiograms. Another limitation is the sample size. Dividing participants into responders and non-responders led to smaller subgroups in placebo, low-dose and dose-escalating carvedilol groups, decreasing the power for detection of significant changes. We were able to detect differences over time between responders and non-responders who continued on carvedilol when assignment was characterized by any carvedilol therapy  vs. no therapy (placebo). The difference in weight between responders and non-responders and the possibility of insufficient dosing of carvedilol might have affected the long-term findings. Based on good clinical practice, all patients were started on a low initial dose of 3.125 mg twice daily regardless of weight  trial is a double-blinded, randomized, controlled intervention with three arms preceded by an open-label 1-week run-in period (NCT01586156). It was conducted from 2012 to 2016 at the Cleveland Clinic. The Institutional Review Board at Cleveland Clinic approved the study (IRB number # 11-1198). All participants provided informed consent prior to their participation in the study.SF conducted the study, analyzed and interpreted the data, and wrote the manuscript. DS conducted study and collected and analyzed the data. MP performed and read the echocardiography and collected the data. JT read the echocardiography and reviewed the manuscript. HC performed the research experiment and analyzed and interpreted the data. SC collected the data and samples and put in place database. JS recruited the patient. KH conducted the study and reviewed the manuscript. WT analyzed the data and reviewed the manuscript. SE designed the research, analyzed the data, and wrote the manuscript.KH has grants and contracts, consult or is on the speaker's bureau of Actelion Pharmaceuticals, Arena Healthcare, Bayer Healthcare, Boehringer Ingelheim, Eiger Pharmaceuticals, Gilead Sciences, Reata Pharmaceuticals, and United Therapeutics. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


VA mental health self-management mobile applications (apps) teach evidence-based skills such as mindfulness and behavior activation. Older Veterans are likely to benefit from learning these skills, but many need assistance learning to use their mobile devices. To bridge this knowledge gap, we developed a clinical program  and accompanying patient education materials to help older Veterans use apps to meet their mental health and well-being goals. The program provides personalized coaching support consisting of (1) teaching basic mobile device use; (2) selecting a goal-consistent app; and (3) encouraging behavior change using the app. The presentation will describe the preliminary outcomes and implementation process. Initial results suggest that the program is feasible, acceptable, and may increase mobile device proficiency for novice users. Additionally, we disseminated 1,418 sets of education materials to providers in 21 states. Challenges and successes at the local and national levels will be discussed.


IntroductionThe Kingdom of Saudi Arabia (KSA) is in a unique position and different from other nations that periodically host an event, such as the World Cup or the Olympics. The KSA is faced annually with millions of pilgrims coming from around the world to participate in the Hajj, Umrah, and Ziarah rituals. Continuously hosting such huge mass gatherings poses overwhelming challenges to the Saudi healthcare system. Consequently, an additional specialized cadre of qualified public health personnel is needed. The purpose of this article is to describe the establishment of an academic public health program that addresses this need.Materials & MethodsIn response to the dire need for public health specialists, a landmark project was launched in 2013 at Alfaisal University (AU). The project aimed to establish a Master of Public Health (MPH) program with a concentration in the health aspects of mass gatherings. The MPH program was created in collaboration with the United States-based Partners HealthCare International (PHI), the Saudi Global Center for Mass Gatherings Medicine (GCMGM) at the Ministry of Health (MOH), the Ministry of Education (MOE), and the Ministry of Hajj and Umrah (MOHU). A needs assessment was conducted to help in the program development. The needs assessment drew on the unpublished findings of an institutional review board (IRB)-approved anonymous market survey that was administered to prospective students of the MPH program.ResultsThe needs assessment study revealed the need for an MPH program with concentrations in mass gatherings health, health policy and management, and biostatistics and epidemiology. Consequently, we designed an MPH program to include these three concentrations. In particular, the mass gatherings health concentration aimed at preparing qualified public health specialists to help manage risks to the Saudi public health system, to analyze health data, and to recommend policies associated with the continuous mass gatherings events. Challenges to program development included working with multiple governmental agencies, absence of a frame of reference to develop a program curriculum, a lack of qualified faculty, lengthy and tedious government approval procedures, and inadequate funding. After obtaining the required approvals, the MPH program with a concentration in mass gatherings health was inaugurated in the fall of 2016. This program is accredited by the Saudi government to prepare public health specialists trained and locally certified in mass gatherings health issues.ConclusionsThe public health experts of the AU have established what may be the first MPH program with a concentration in mass gatherings health. The main challenges to program development were identified, and appropriate actions to meet these challenges were taken. This innovative MPH produces certified specialists equipped with the analytical and policy-making tools necessary to continuously monitor and improve the public health aspects of mass gatherings. Besides, the program provides a frame of reference for the development of unique public health programs, not only in the KSA but worldwide. The Kingdom of Saudi Arabia (KSA) has extensive experience managing the yearly tradition of hosting millions of Muslim pilgrims from all over the world to the Two Holy Mosques: The Sacred Mosque in Mecca for Hajj and Umrah and the Prophet’s Mosque in Medina for Ziarah. These events fit the World Health Organization’s (WHO) definition of mass gatherings . It is cHajj, the pilgrimage to the city of Mecca, is one of the five pillars of Islam. Muslims worldwide who can afford to perform Hajj and who are healthy are required to complete it once at some point during their lifetime . Mecca  approval, this study was conducted to describe the establishment of an MPH program with a concentration in mass gatherings health. Located in Riyadh, Saudi Arabia, Alfaisal University (AU) is a private, non-profit, multicultural university with over 3,000 students representing over 40 nations .Each year, several million pilgrims from all over the world come to the KSA to perform Hajj, Umrah, or Ziarah rituals. Hence, there is a demand for qualified public health specialists who observe health events, trends, and concerns to ensure quality public health programs for the protection of the pilgrims, as well as the health of the Kingdom’s inhabitants. In response to this demand, a landmark academic project was launched in 2013 at AU to establish an MPH program with a concentration in mass gatherings health.This innovative academic program was established in close collaboration with the United States-based Partners HealthCare International (PHI). The MPH program was later launched with the support of the Global Center for Mass Gatherings Medicine (GCMGM) at the Ministry of Health (MOH), the Ministry of Education (MOE), the MOHU, and the WHO. The involvement of these entities, especially the Saudi government, is vital for success. This new MPH program was designed to produce specialists equipped with the analytical and policy-making tools necessary to continuously monitor and improve the public health aspects of mass gatherings.Establishing a graduate program, especially in public health, can be a complicated and challenging task. It entails comprehensive planning and coordination . To deve1. Draft the initial proposal 2. Conduct a needs assessment3. Team building 4. Prepare and officially submit the program application to the MOE5. Acquisition of required approvals to start the program6. Develop a plan for the admission process7. Program initiation and follow-up Program development began in 2013 with an idea proposed in writing by this study author to the Dean of the College of Medicine (COM) at AU. After proposal approval, a needs assessment was conducted to find out if there was a local need for an MPH program concentrated on the health aspects of mass gatherings. The assessment was done, in part, using reports, findings, and information available at the WHO, the Saudi MOE, MOH, MOHU, and the United States Center for Disease Control and Prevention’s website . The neeIn conducting the needs assessment, the results of the market survey supplemented other sources of information, including our observations and experiences and guided our actions. The findings of the market survey are presented in Table Of the market survey participants, 38.8% were females, 22.4% were Saudi citizens, and 76.5% were medical students. The ages of 76.5% of the participants ranged from 18 - 24 years. Moreover, 78.8% of the participants reported interest in the proposed MPH program. Most of the respondents preferred the health policy and management concentration, and a quarter was interested in the mass gatherings health concentration.Moreover, up until a few years ago, only a small number of specialists worked in the Kingdom’s public health sector. In 2014, for example, only 3,704 public health specialists were working for the MOH . DespiteOnce the need for such an MPH program was established, the next stage was team building. An extensive search was conducted for national and international public health experts with experience in mass gatherings health and related areas. Since 2008, AU has an ongoing affiliation with Partners Harvard Medical International (PHMI), now called Partners HealthCare International (PHI), for the establishment of a state-of-the-art COM.During the COM program development, the PHI joined the AU leadership and faculty in the medical program’s strategic planning and implementation. These activities included faculty and curriculum development, assessment of students, faculty, and program, as well as advice on infrastructure and governance. PHI experts also participated in similar oversight and advisory roles in establishing the MPH Program. In January of 2017, the GCMGM collaborated with the WHO to lead a global consultation on risk assessment tools for mass gatherings health in Jeddah, Saudi Arabia. The newly established MPH team and PHI were invited to participate and interact with world experts on this topic .The next stage was to complete and submit a program approval form to the MOE. The form included sections on program justification, aims, curriculum development, admission requirements, description and justification of new courses that must be created, and a reference to the student manual that would be created. Once the form was completed, it was submitted for approvals by the COM Board, the University Board, and finally, by the MOE.The next stage was the acquisition of the required approvals of the new program. Obtaining approvals for a new graduate degree program in the KSA includes several stages. First, new degree programs require college and university board reviews and approvals. The second stage is to submit for MOE review, including evaluation by an external independent panel of subject experts - usually, another Saudi university that has experience in this area. Finally, apply for approval by the MOE. However, the external review process was the most demanding and time-consuming stage.This newly created MPH program adopted an innovative curriculum designed to serve the public health needs of the KSA. It provides quality education to English-speaking graduate students in the KSA and beyond. The program requires a minimum of 43 credits to be completed in two years, i.e., four semesters, with a maximum of 12 hours per semester. It includes a practicum followed by a thesis. Students can choose one of three tracks: mass gatherings health, healthcare policy and management, or biostatistics and epidemiology. In particular, the mass gatherings health track provides strong public health education and specialized training in mass gatherings health issues. It was quite a challenging task to develop a curriculum for this MPH program without a credible frame of reference. The principal consideration of the newly established curriculum was that the Saudi public health workforce requires intense preparation in analytical methods and research techniques.Next, the MPH team focused on the development of an admission process. Admission requirements included a baccalaureate degree from a regionally accredited college or university, a minimum undergraduate grade point average of 3.00 on a 4.00 scale, the Test of English as a Foreign Language (TOEFL®)  score of 500; and successful completion of an in-person interview with the program director or his designee. Students who do not meet some of these admission criteria are required to complete selected courses tailored towards improving English language proficiency or computer skills.During the MPH program development, the MPH team faced many challenges. These challenges included the absence of a frame of reference to develop program curriculum, a lack of qualified faculty, lengthy and tedious program approval procedures, limited graduates’ certification, and an inadequate number of scholarships for MPH students. Another encounter that we faced was a short time to plan the recruitment process properly. Only a few weeks before the scheduled starting date, we received the official program approval. As a result, insufficient time was available for proper planning and advertising.Additionally, the word was out that some of the government funding programs had expired. Consequently, the first cohort consisted of only four self-paid students. The main challenges of the program development and implemented actions to meet these challenges are presented in Table After the main challenges to program development were identified, the MPH team took appropriate actions to meet these challenges and receive the MOE program approval. The first mass gatherings health cohort was launched in the fall of 2016.Currently, the KSA offers the first MPH program with a concentration in mass gatherings health at AU. The immense need for public health specialists and the current scarcity of public health professionals underscored the rationale behind this newly created MPH program. This MPH program increases the capacity of the Saudi public health sector and prepares public health leaders to address some of the Kingdom’s mass gatherings health challenges of the 21st century. During the MPH program development, the MPH team faced many challenges, most of which were alleviated with the support of PHI and other governmental agencies. For example, the team was successful in convincing the local authority to shorten the program approval process by utilizing qualified international experts to review the program application. Also, the MPH team partnered with the MOH to sponsor applicants to the newly established MPH program. To deal with the issue of the lack of qualified faculty, the team collaborated with experts of the MOH, GCMGM, PHI, and WHO to help start the program. Moreover, we continue to work with the SCFHS to extend the certification process to include a full range of professionals, including those in the areas of healthy nutrition and health communication.In recognition for and support of the newly established MPH program, the MOH, represented by GCMGM and in collaboration with AU, organized the Third International Conference on Mass Gatherings Medicine. The conference was under the theme “From Mass Gatherings Medicine to Mass Gatherings Health: Evolving Perceptions and Practices” . The conThe new MPH program was constructed with an eye on the future. We planned to perform periodic evaluations of the program curriculum conducted by students, peers, and external experts. Also, we planned to conduct continuous improvement of the curriculum, including the flexibility to add new concentrations. The program was designed to attract strong candidates and train them to be recruited after graduation by local, regional, and international academic and public health organizations. These organizations are aware of the role that these qualified public health professionals play in maintaining and improving the public health sector and becoming the future leaders of the field. Creating a new generation of public health practitioners and scholars with expertise in mass gatherings health empowers the position of the KSA as a global leader in mass gatherings health, one of the main goals of the Saudi Vision 2030 .Finally, the expertise gleaned from this program might benefit international organizations as they share challenges and solutions, such as the United States Federal Emergency Management Agency (FEMA). While other experts involved in mass gatherings usually work with planned events that occur on a scheduled basis every two to 10 years, such as the Olympics, World Cup, and Kumbh Mela, the experience in KSA is a continuous flow of pilgrims all year long with a peak at the period of Hajj.Some limitations that might have impacted the needs assessment should be addressed. For example, the sample size for the market survey was small. Besides, the sample was chosen conveniently from prospective students of the MPH program. Consequently, this may impact the generalizability of survey results.The KSA is in a unique position as different from other nations that periodically host an event such as the World Cup or the Olympics KSA. The KSA is faced annually with millions of pilgrims coming from around the world to participate in the Hajj, Umrah, and Ziarah. In collaboration with several Saudi governmental agencies, the PHI, and the WHO, the public health experts of AU have established what may be the first MPH program with a concentration in mass gatherings health. The program was designed to provide the Saudi healthcare system with qualified public health professionals to cope with the recent expansion of the Two Holy Mosques. Besides, it empowers the position of the KSA as an international leader in mass gatherings health.The main challenges for program development included working with multiple governmental agencies, an insufficient number of faculty, absence of a frame of reference to develop program curriculum, and funding. Appropriate actions to meet the challenges that were taken included collaboration with the experts of the MOH, GCMGM, PHI, and WHO, as well as partnering with the MOH to sponsor applicants to the newly established MPH program. This innovative MPH program provides a frame of reference for the development of unique public health programs not only in the KSA but worldwide.


Éxito! is modeled after the Minority Training Program in Cancer Control Research (MTPCCR), which found that Latino participants went on to doctoral programs at a lower rate (12%) than African American (36%) and Asian participants (33%). Éxito! Latino Cancer Research Leadership Training is designed to increase the number of Latinos who pursue doctoral degrees and careers in cancer health disparity (CHD) research. The program has three components: recruitment with partnering universities and associations, an ethnically tailored intensive 5-day summer institute (SI), and 6-month paid internships offered on a competitive basis. Up to 20 master’s level students/master’s level health professionals are selected annually to participate in the SI; faculty are leaders in Latino CHD research. Funded by the National Cancer Institute (NCI) from 2011 to 2015, Éxito! recruited 101 summer institute participants and awarded 21 internships. Analyses of pre- and post-institute surveys showed significant increases in confidence to apply to a doctoral program and academic self-efficacy among summer institute participants, and significantly increased research skills among interns. Forty-three percent of Éxito! program alumni applied to a doctoral program (our main outcome) and 29.7% were currently enrolled. This is nearly double the rate for MTPCCR Latino participants (17%) for the corresponding time period. Éxito! is a model pipeline program for encouragement of Latinos on to doctoral programs  with the potential to increase the pool of cancer health disparity researchers.Latinos lag behind other racial/ethnic groups in pursuit of master’s and doctoral degrees in public health and the health sciences.  Cancer has surpassed cardiovascular disease as the leading cause of death for Latinos in the USA . MoreoveAlthough there are growing numbers of Latinos at the undergraduate level, they lag behind Whites and other racial/ethnic groups in pursuit of master’s degrees and doctoral degrees in public health and the health sciences , 11. LatÉxito! Latino Cancer Research Leadership Training (Éxito!) program was created by the Institute for Health Promotion Research at UT Health San Antonio with funding from the National Cancer Institute (NCI). Éxito! conducts an annual 5-day summer institute and offers 6-month internships to encourage Latino master’s level students and graduates to pursue a doctoral degree and a career in cancer control research, with a focus on reduction of Latino cancer health disparities. Éxito! is modeled after the successful Minority Training Program in Cancer Control Research (MTPCCR) with sites at the University of California, San Francisco (UCSF) and UCLA, which seeks to increase diversity in public health and social/behavioral doctoral programs and cancer disparity research  reaffirmed my belief to apply to doctoral programs. It opened up my eyes to additional opportunities in cancer research that I may not have previously thought of. It was also a tremendous experience to be surrounded by people with your same interests and that motivated me even more to go into a career in cancer research.In the post-institute qualitative component of the survey, the vast majority of the participants’ open-ended responses lauded the program as very motivational and beneficial, as illustrated by the following comments:Éxito! awarded 21 internships from 2012 to 2014. Each project varied, with the majority of interns working on secondary data analysis (n = 15) using various cancer-related data sets and obesity-related data sets. Other projects included literature reviews (n = 4), community health education (n = 1), and original research (n = 1).Éxito! interns (n = 19) were asked about their interns’ motivation to apply to a doctoral program at the start of the internship and after. Before starting, 47% of mentors indicated that their intern was highly motivated, 37% somewhat motivated, and 16% neither motivated nor unmotivated. After internships, mentors indicated that their intern was highly (63%) or somewhat (37%) motivated. Throughout the 5 years of the program, two mentors provided mentorship two different years, resulting in a number of mentors (n = 19) that is less than the number of interns (n = 21).Based on findings from the pre- and post-internship surveys, interns’ research skills significantly improved across all measured domains Table . Confiden = 101) applied to doctoral programs and 29.7% (n = 30) are currently enrolled in a doctoral programs. Among the doctoral enrollees, 17% (n = 5) completed Éxito! internships. Further, 33.3% (n = 10) of currently enrolled/and accepted doctoral students indicated that their current job/research was directly related to cancer  and 36.7% (n = 11) indicated their job indirectly related to cancer . Similarly, when given the statement that they would pursue a career directly related to cancer after obtaining a doctoral degree, 53.3% (n = 16) of doctoral students indicated they either strongly agreed (30%) or agreed (23.3%). In addition, survey results indicated that, among current master’s students and master’s graduates (n = 54), 25.9% (n = 14) indicated they were confident (or very confident) they would apply to a doctoral program in the next year and 59.3% (n = 32) of alumni in the next 5 years.As of December 2015, 43% of all alumni  after 5 years is nearly double that for MTPCCR Latinos (17%) after 12 years [Éxito! is able to address issues specific to Latino students and recognize the value of their culture, helping them to see their potential roles in eliminating disparities, and giving them the support and confidence they need to take the next academic step. Exposure to successful Latino role models and like-minded peers were powerful forms of verbal persuasion. In Éxito!, students found a “sense of belonging” and viewed themselves as a larger force rather than simply a “minority.”The rollment 0% after Éxito! succeeded in improving participants’ confidence in their ability and desire to pursue and complete doctoral-level degrees and careers in cancer control research that focus on Latino cancer health disparities. The program addressed many of the barriers that Latinos face in attempting to rise to the doctoral level and thus to achieve greater representation as leaders in public health. The program will continue to offer the summer institute and internships for 125 master’s level students and professionals between 2015 and 2020 with support from a second round of NCI funding. Throughout, we will continue to modify the program based on participant feedback.The first 5 years of Éxito! results far exceeded those of the multi-ethnic MTPCCR using the same model but primarily targeting and tailoring for Latinos supports the strength of role modeling and cultural concordance in both encouraging Latino students to apply by increasing their self-efficacy in a highly supportive environment, and enabling them to overcome a broad range of barriers. This includes increasing their efficacy in communicating their needs, applying for financial assistance, gaining acceptance in campus environment and how to identify and incorporate mentorship as well as peer support. Some notable lessons were learned in our first 5 years. Importantly, Éxito! alumni and doctoral students continue to need support after attending the summer institute related to issues such as the doctoral application process, insufficient mentoring for doctoral students, and managing course work during their doctoral program. Because Éxito! has been renewed for another 5 years, we are able to address these needs in the new funding cycle (2015–2020) by focusing on two important constructs: doctoral level persistence and career development.The fact that Doctoral programs are described as consisting of three distinct stages: stage I is the first year of a doctoral program, stage II is the start of the second year through the completion of requirements for a doctoral degree, except for the dissertation, and stage III is the dissertation and defense , 24. PreÉxito! alumni currently enrolled in doctoral programs, we are developing a stage-based pipeline of support. We use social media outlets like Facebook and LinkedIn to encourage alumni to contact us so that we may provide further support and connect them with other alumni and current doctoral students who have faced similar challenges or concerns. These innovations will also help recent alumni connect with one another after attending the summer institute. This connection facilitates a more expansive network with individuals from similar cultural backgrounds who share concerns, challenges, and questions related to pursuing doctoral education. In addition, quarterly webinars are being presented on topics chosen in direct response to the needs voiced by current alumni, such as: (1) applying to a doctoral program , (2) how to succeed in a doctoral program , and (3) general career development . In addition, more tailored webinars will be offered for program alumni who are currently enrolled in doctoral programs. The content discussed during these webinars will be guided by the topics most important to the doctoral students.For Éxito! reflect what has been stated consistently in the literature: most Éxito! participants are the first in their family to pursue a higher education; among the most common educational barriers is the lack of adequate social support [Other lessons learned from  support , 14, 25, support , 27.Éxito! participants reported using loans and grants to fund their undergraduate and master’s degrees such that their greatest barrier to pursuit of a doctoral degree was the financial burden. Many students also lack the real-world experience and academic preparedness [Additionally, the majority of our aredness  needed tÉxito! program stands as a robust example of a strategy to strengthen the pipeline for Latino representation at the doctoral level so that the next generation of health practitioners and researchers is representative of the US population and that culturally relevant solutions can more effectively reduce health disparities and improve health equity.As the Latino population grows, Latino enrollment in post-secondary institutions will likely increase . HoweverÉxito! has added another replication, demonstrating the model’s adaptability to a different region of the country and its effectiveness in targeting a specific population, Latinos/Hispanics. Indeed, Éxito!’s results exceeded those for Latinos in the MTPCCR. The successful adaptation of Éxito! from the MTPCCR program is evidence that the basic program components can be disseminated and adapted to fit the needs of other research institutions. After 5 years, the evidence of its acceptance and value among the Latino/Hispanic population show that the program should be ready for further replication at Hispanic Serving Institutions (HSIs) and beyond the Southwestern region.The MTPCCR initially demonstrated the portability and replicability of its cancer control diversity pipeline program model to a second institution within California . Éxito!