Wait Time and Engagement While Waiting, and (2) Interview program management and staff about program structures and processes that may contribute to performance on these metrics. The first aim sought to supplement the VA’s existing facility-level performance metrics with SUD program-level metrics in order to identify high-value targets for quality improvement. The second aim recognized that not all key processes are reflected in the administrative data, and even when they are, new insight may be gained from viewing these data in the context of day-to-day clinical practice.In the U.S. Department of Veterans Affairs (VA), residential treatment programs are an important part of the continuum of care for patients with a substance use disorder (SUD). However, a limited number of program-specific measures to identify quality gaps in SUD residential programs exist. This study aimed to: (1) Develop metrics for two pre-admission processes: VA administrative data from fiscal year 2012 were used to calculate pre-admission metrics for 97 programs ; 34 Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) with a SUD track). Interviews were then conducted with management and front-line staff to learn what factors may have contributed to high or low performance, relative to the national average for their program type. We hypothesized that speaking directly to residential program staff may reveal innovative practices, areas for improvement, and factors that may explain system-wide variability in performance.Average wait time for admission was 16 days , with 60% of Veterans waiting longer than 7 days. For these Veterans, engagement while waiting occurred in an average of 54% of the waiting weeks (range 3–100% across programs). Fifty-nine interviews representing 44 programs revealed factors perceived to potentially impact performance in these domains. Efficient screening processes, effective patient flow, and available beds were perceived to facilitate shorter wait times, while lack of beds, poor staffing levels, and lengths of stay of existing patients were thought to lengthen wait times. Accessible outpatient services, strong patient outreach, and strong encouragement of pre-admission outpatient treatment emerged as facilitators of engagement while waiting; poor staffing levels, socioeconomic barriers, and low patient motivation were viewed as barriers.Metrics for pre-admission processes can be helpful for monitoring residential SUD treatment programs. Interviewing program management and staff about drivers of performance metrics can play a complementary role by identifying innovative and other strong practices, as well as high-value targets for quality improvement. Key facilitators of high-performing facilities may offer programs with lower performance useful strategies to improve specific pre-admission processes. In the United States Department of Veterans Affairs (VA), residential rehabilitation treatment programs are an integral part of the continuum of care for patients with a mental health or substance use disorder (SUD) . ResearcDespite their place in the continuum of care, residential programs are resource-intensive and costly, with associated health care costs (including indirect costs) estimated to be roughly $210 million for VA in FY 2014, posing a fiscal challenge for a capitated healthcare system with competing demands . PatientIn order to reduce undesirable variability in quality of care across VA residential SUD treatment programs, core standards and practices for these programs have been codified in two VA handbooks, the Uniform Mental Health Services Handbook (revised in 2008) and the MH RRTP Handbook (published in 2010) . These hresidential SUD treatment: (a) an access measure—the proportion of patients with a SUD diagnosis that receive care in a residential SUD treatment program, and (b) average length of stay in a residential SUD treatment program among patients admitted. While these measures are useful, VA would benefit from a comprehensive suite of measures to monitor other important structures, processes and outcomes of residential SUD treatment programs.VA Mental Health Services and the VA Office of Mental Health Operations have made adhering to these standard requirements for care delivery, managing costs, and improving outcomes their highest priority. Recognizing the need for a mechanism to routinely monitor the performance of all mental health services, including those provided in residential treatment programs, the Office of Mental Health Operations developed the Mental Health Information System (MHIS) . The MHIPre-Admission domain and the corresponding qualitative data which describe factors that may explain observed variability, in order to learn about potential innovative practices, and identify possible areas for improvement.Therefore, we sought to develop metrics using electronic health records data for VA residential SUD treatment programs in three key domains: pre-admission , in-treatment , and post-discharge . After calculating the metrics for all programs, we interviewed residential SUD treatment program management and front-line staff. This enabled us to validate that the metric data corresponded with their day-to-day experience, and to learn their impressions regarding the facilitators and/or challenges that may have impacted their program’s performance on metrics for which the program was substantially higher or lower than the VA national average. In this paper, we focus on the National data collected by the VA Northeast Program Evaluation Center (NEPEC) were used to identify 97 VA residential SUD treatment programs . Patients receiving treatment from these programs were then located in VA electronic health records data using combinations of station and specialty treatment (bed section) codes.Quality measures prioritized for metric development were chosen in collaboration with our operational partners in VA Mental Health Services (MHS) and the Office of Mental Health Operations (OMHO). The selected metrics include SUD-specific versions of other Mental Health Information System (MHIS) metrics, and processes of care emphasized in program evaluation reports  , 8. Thespre-admission processes are the focus of this paper—wait time (two metrics) and engagement while waiting for admission (three metrics). Descriptions of how these metrics were operationalized are presented in Table Two Drug and Alcohol Program Survey (DAPS) and NEPEC’s MH RRTP Annual Survey for FY 2012 to create individualized program profile reports. Each report summarized the program’s performance on the Pre-Admission metrics compared to the national average for similar VA residential SUD treatment programs . See Table Metrics data from FY 2012 were linked to the VA Program Evaluation and Resource Center’s FY 2012 DAPS and NEPEC databases and invited to participate in a telephone interview to discuss their program. First, a flyer describing the study was e-mailed to potential participants. If no response was received, a follow-up e-mail was sent a week later which featured select performance data for their program, highlighting both an area of success and an area for improvement (if applicable). A week later, a follow-up telephone call was made to the potential participant to answer any questions about the study. If the point-of-contact could not be reached, a telephone message was left and a subsequent follow-up call was made. To supplement initial recruitment efforts, research staff announced the study on VA-wide SUD representative calls and sent the recruitment flyer to several national VA e-mail groups. At scheduled telephone interviews, participants provided informed consent and were asked permission for interviews to be audiotaped. If the person declined to be audiotaped, then notes were taken. At the end of the interview, participants were asked to recommend front-line staff from their program who might be interested in participating in the study to provide additional perspectives. Interviews were conducted from March 2014 to August 2014. The study protocol was approved by the Stanford University Institutional Review Board.Program managers from the 97 programs were identified using The interview guide was developed by an interdisciplinary project team with input and feedback from our VA operational partners. It consisted of reviewing a “snapshot” of the program , followed by questions about the program’s clinical processes  and metric performance within the pre-admission, in-treatment, and post-discharge domains. We used a unique data collection technique which combined a semi-structured telephone interview (60–75 min) with Microsoft Lync computer screen-sharing. This method allowed the interviewer to walk the participant, point by point, through the individualized profile report that included their program’s performance relative to the national average for each metric. Participants were asked if the metric data seemed realistic given their knowledge of the program, and what factors may have contributed to their program’s high or low performance on specific metrics. For example, high performers were asked if there is anything they would like to share with other programs on how they achieved success on the metric, whereas low performers were asked if there were barriers and/or resource needs that impacted their performance.individually developed lists of barrier themes and facilitator themes, and met to resolve discrepancies and jointly arrive at a consensus of the major facilitator themes, major barrier themes, and their illustrative text components.The interviews were transcribed, cleaned for quality control, and imported into the qualitative data analysis software, ATLAS.ti (Version 7.5.7) . A codinThe total number of admissions in FY12 for all programs combined was 14,281 . Among all programs combined, there were 6330 patients with a pre-admission screening . The wait time and engagement while waiting metrics were not calculated if the percentage of patients with a pre-admission screening visit was less than 25%. Roughly a third of the programs (36 out of 97), failed to meet this threshold and, therefore are not included in the summary statistics presented here. In 27 programs, less than 25% of patients had a pre-admission screening visit. For 9 programs, there were no pre-admission screening data.During FY 2012, the average number of days that a Veteran waited from pre-admission screening to admission into a residential SUD treatment program (“average wait time”) was 17 days for SUD RRTPs  ranged from 0 to 100% .A total of 59 interviews were conducted, representing 63 participants  from 44 unique treatment programs . The interviewees were from 17 of the 21 VA networks and included four joint interviews . The majority of providers either had some type of social work degree (40%) or a PhD (35%). MDs and some type of nursing degree each comprised 5%. Program management comprised 37 providers . Similar to the overall providers interviewed, the majority of program management either had some type of social work degree (41%) or a PhD (41%). Four participants declined to be audio-taped but agreed that notes could be taken during the interview. In these cases, an electronic copy of the notes was then uploaded into ATLAS.ti.Wait Time metrics were asked if they had advice for other programs that may struggle with longer wait times. In response, program staff described process and structural factors that may have contributed to shorter wait times. Several interrelated key facilitators were identified and are described below, with supporting quotations listed in Table Participants at 11 programs with high performance on either of the two Many participants described ways in which they optimized efficiency in their screening and assessment processes, which in turn may have contributed to shorter wait times for Veterans waiting to enter the program. Among the strategies employed by programs were (a) keeping the number of assessments or screening appointments per patient to a minimum, and (b) flexibility in scheduling screening appointments or other processes to accommodate more timely screenings.The residential treatment program process includes waiting for admission, going through the process of being admitted, working through the components of the program, and the discharge process. In some cases, these processes overlap. Effectively managing patient flow, whether at an individual, team, or facility level, appeared to be integral in efforts at keeping program wait times below the national average. Key facilitators included: (a) regularly-scheduled meetings to review patient status to make sure they are not unnecessarily stalled between processes and (b) flexible admissions processes and requirements.The availability of beds was another factor that was commonly attributed to lower wait times. How long a Veteran waits to enter the program may be reflected, in part by the sheer number of beds that a residential treatment program has available at any given time. Several participants described how their program’s high capacity may have positively influenced their program’s performance on the wait time metrics.Wait Time metrics reported the following reasons and challenges. See Table Participants at 14 programs with low performance on either of the two Many participants indicated that the lack of available beds impacted how long Veterans waited to enter their program in FY 2012. Key factors affecting bed availability were high demand and reduction of bed availability.Participants indicated that staff shortages  at the residential programs hindered their ability to admit patients more quickly and having fewer staff at the smaller Community Based Outpatient Clinics (CBOCs) delayed important processes such as medical clearances.Several participants acknowledged that program length or extending a Veteran’s length of stay after program completion when warranted can unintentionally lead to some Veterans waiting longer to enter the program.The programs in which we interviewed program management and front-line staff were more likely to be low performers on the 7-day wait metric. However, among these programs in which patients waited longer than 7 days to be admitted, they were more likely to be high performers with respect to the proportion of waiting weeks with at least one SUD/mental health outpatient encounter .Engagement While Waiting metrics were asked if there were particular aspects of their pre-admission processes that may have facilitated the provision of outpatient SUD and/or MH treatment while Veterans were waiting to enter the program. Several interrelated key factors were identified and are described below, with supporting quotations listed in Table Participants at 17 programs with high performance on any of the three Programs that were successful at engaging Veterans pre-admission leveraged their ability to offer and connect Veterans to SUD and mental health outpatient services within and/or outside the VA. In addition, some participants emphasized to Veterans the importance of staying connected to their outpatient providers if they were already accessing VA outpatient services. Fourteen of the 17 programs with high performance on this metric tried to engage Veterans waiting for admission in treatment groups such as pre-existing groups within the VA residential treatment program and VA intensive outpatient programs. Eight of the 17 high performing sites offered Veterans the opportunity to attend an established pre-admission group.In general, participants described a variety of motivational and outreach strategies believed to be instrumental in successfully engaging Veterans in treatment activities while waiting for admission. Program staff commonly reached out to and followed up with Veterans by telephone .Strongly encouraging pre-admission group participation was perceived to have a favorable impact on the degree to which Veterans engaged in treatment activities prior to admission. One participant illustrated how the staff incentivized Veterans to attend outpatient treatment by letting them know that pre-admission group participation would “improve their chance of getting into the program quicker” Table .Engagement While Waiting metrics, relative to the national average for their program type, were asked about barriers they faced in facilitating pre-admission engagement. The most commonly-cited barriers are described below, with corresponding supporting quotations listed in Table Participants at 14 programs with low performance on any of the three One of the primary obstacles voiced by participants was staffing constraints, which can make it difficult for program staff to provide optimal access to outpatient treatment.Participants also noted that due to socioeconomic factors, Veterans themselves find it difficult to access outpatient treatment even when it is available. The most common socioeconomic barriers voiced by participants were (a) geographic location/driving distance to outpatient treatment, (b) lack of public transportation, and (c) financial constraints, such as lacking money to buy gas.Fewer participants perceived that Veterans themselves may hinder their own opportunities to engage in treatment. In other words, some Veterans do not avail themselves of outpatient services.Wait Time and Engagement While Waiting, and (2) Interview program management and staff about program structures and processes that may contribute to performance on these metrics. The first aim sought to close a gap in the VA’s existing performance metrics in order to identify high-value targets for quality improvement. The second aim recognized that not all key processes are reflected in the administrative data, and even when they are, new insight may be gained from viewing these data in the context of day-to-day clinical practice. We hypothesized that speaking directly to residential program staff may reveal innovative practices, areas for improvement, and factors that may explain system-wide variability in performance.This study aimed to: (1) Develop metrics for two pre-admission processes: In this project, we learned that program-level performance on the pre-admission metrics was highly variable. Across programs, 0–100% of Veterans waited longer than 7 days to be admitted (average: 60%). For these Veterans, at least one SUD or mental health contact occurred in 3–100% of the waiting weeks (average: 54%). This degree of clinical variability is consistent with previous studies and evaluative reports of SUD treatment in VA SUD RRTPs , 12.We found that program management and staff shared common perceptions of the structures and processes that may have contributed to their program’s high or low performance on the pre-admission metrics. This information can be useful for designing interventions to improve access to residential SUD treatment and reduce system-wide variability. Efficient screening processes and effective patient flow are processes that theoretically could be implemented across programs to help reduce wait times if there is good communication among all levels of staff. The availability of beds which emerged as a key determinant (barrier and facilitator) of wait times is structural, more static and largely dependent upon factors external to the program .Given resource constraints, it may be tempting to concentrate efforts on other processes such as efficient screening and effective patient flow to reduce wait times, rather than increasing number of beds. However, systems can only become so efficient and resources spent on efficiency may take away resources from more beds. In addition, effective patient flow often depends upon sufficient staffing within the program itself and its ancillary components, which can be costly depending on the program’s needs. When staffing levels are suboptimal, this can potentially impact how quickly Veterans can be admitted to and discharged from the program. Most of the interview comments related to staffing levels were general in nature, although some respondents mentioned specific staffing needs. As noted in Table We found that successfully engaging Veterans in outpatient treatment while they wait appears to depend heavily on efforts by staff, at the individual provider, program, and facility level. Overall, good internal and inter-facility communication appears vital to providing Veterans with timely access to residential treatment, and may also have positive ripple effects .Poor staffing levels and socioeconomic barriers  which were often perceived to be beyond the staff’s control may be difficult to surmount as they are dependent on sufficient financial resources at the medical center. Yet, they are important to address as they potentially affect quality of care. As noted in Table Some programs however, showed resiliency and creativity in the face of these challenges. For instance, several programs were in the midst of advocating for transportation “workarounds” or creating their own . Another program had not yet set up a group for Veterans who are waiting, but found peer support specialists to be particularly helpful in the interim. Others cited strategies  that their program would benefit from having.While some patients who do not engage in outpatient treatment may truly lack motivation, it is possible that some factors perceived as low motivation , may stem from things beyond their control. Veterans struggling with issues such as transportation/housing may not be able to avail themselves of outpatient care, and for some, these factors may have been the driving force for seeking residential care in the first place. As such, these Veterans would also be precluded from an improved chance of getting into a residential program if they are incentivized to attend outpatient treatment—a strategy previously indicated by one provider as facilitating engagement while waiting. Any unintended consequences like this deserve attention to ensure equitability in access to services.The potential value of these pre-admission metrics is significant given that they provide VA leadership, as well as program management and staff, with a way to easily monitor the access, quality, and efficiency of residential SUD treatment programs. In response to an identified need to rapidly develop metrics for monitoring access to residential treatment, MHS and OMHO built upon the initial metrics developed by this study and implemented wait time metrics for the residential programs in October of 2014. These metrics continue to be refined with quarterly updates provided to the field and are part of a broader set of metrics that have been developed to understand access to residential treatment. By operationalizing this wait time metric, residential SUD treatment staff can view their program’s performance over time and identify opportunities for implementation and quality improvement efforts. It has been a critical component to ensuring a clear understanding of residential access and guiding strategic planning efforts at the regional and local level to improve access. Further, MHS and OMHO are working towards refinement and implementation of the remaining metrics. The initial data provided by this study serves as baseline data and a point of comparison as new metrics are implemented.The identification of common perceived facilitators and barriers offer opportunities for clinical leadership and health services researchers to craft interventions to improve timely access to services and disseminate “best practices” to the field. Although some of the identified “best practices” may appear to simply be the expected standard of care, the responses from interview participants reflect how a Veteran’s quality of care is critically tied to the consistent execution of these tasks. In addition, the support, cooperation, and communication among program staff and facility-wide appeared to play a vital role.We recognize some limitations of this study. We did not interview peripheral VA staff members  that are located at another site/campus within the facility, nor did we interview Veterans. In addition, less than half of the VA’s residential SUD programs were represented in the interviews, so our findings may not be generalizable to all VA residential SUD programs or to residential SUD programs outside the VA system. Moreover, there was substantially less representation from MH RRTPs with a SUD track (20%), compared to SUD RRTPs (80%). While we believe that provider interviews can be a beneficial component of quality improvement, we did not evaluate the effect of conveying what we learned back to our stakeholders. The next step would be to assess the potential value of interviewing program management and front-line staff while developing performance metrics. Since this endeavor can be labor-intensive, this reaffirms the need for evaluation. Despite these limitations, this study successfully created new metrics to monitor performance and identify areas for improvement, as well as an inventory of potential solutions informed by residential program management and front-line staff.Pre-admission process metrics developed in this study have been refined and are proving to be helpful for monitoring residential SUD treatment programs within the VA. Interviewing program management and staff about drivers of performance metrics can play a critical and complementary role by identifying innovative and other strong practices, as well as high-value targets for quality improvement. Key facilitators of pre-admission processes in high-performing facilities may offer programs with lower performance useful strategies to improve the quality of their pre-admission processes.


Evidence-based practices in the workplace can increase levels of healthy eating, cancer screening, physical activity, and tobacco cessation but are underused, even in large workplaces. This report summarizes an evaluation of the first year of The CEOs Challenge, a program developed by the American Cancer Society to promote implementation and maintenance of health-promoting, evidence-based workplace practices by large companies.Use of 17 evidence-based practices by 17 companies in the Washington State Chapter of the American Cancer Society’s CEOs Against Cancer network was assessed via survey and scored from 0 to 100. Companies received a written report of their baseline performance, followed by at least quarterly consultations with American Cancer Society staff members trained to assist in implementation of these practices. Follow-up performance was measured at 1 year.At baseline, implementation scores were 54.8 for cancer screening, 46.5 for healthy eating, 59.8 for physical activity, and 68.2 for tobacco cessation. At follow-up, scores increased by 19.6 for cancer screening, 19.4 for healthy eating, 16.0 for physical activity, and 9.4 points for tobacco cessation.The CEOs Challenge is a promising approach to chronic disease prevention via the workplace. It brings together one of the nation’s largest health-promoting voluntary agencies with the nation’s largest employers to promote evidence-based practices targeted at the most common causes of disease and death. The program increased the adoption of these practices and was well-accepted. Chronic diseases are rampant in the United States , and worTo disseminate health-promoting EBPs to large workplaces, the American Cancer Society (ACS) and the University of Washington’s Health Promotion Research Center (HPRC) developed the Workplace Solutions program . The EBPMeanwhile, ACS developed its Chief Executive Officers (CEOs) Against Cancer network, which organizes executives of large companies  into regional chapters to take action in cancer prevention and control . The netThe updated program was called The CEOs Challenge. CEOs provide leadership that is crucial to the success of workplace health programs  and ofteThe Chapter comprises 26 active member companies, employing a total of 348,527 people. Executives  gather at Chapter meetings 3 times per year. Although Workplace Solutions was designed for companies with 5,000 employees or more, the companies in the Chapter vary widely in size, and all were welcome to participate in The CEOs Challenge. The October 2013 meeting served as the kickoff. At this meeting, executives learned about the program and, if they chose, made an official commitment to participate. The CEOs Challenge was presented as a continuous program, with an annual cycle, to support companies in their efforts to improve employee health.Because company representatives reported on company-level activities, the University of Washington’s institutional review board did not consider these activities subject to review for human subjects research.The CEOs Challenge is a unique intervention in that assessment measures are a key part of the intervention and are reported to participants. Baseline survey. Participating executives delegated a company representative, almost always from Human Resources, to serve as manager of The CEOs Challenge program. At baseline, this manager completed the 41-item Workplace Solutions survey  would be scored as “partially implemented,” and a company with a program meeting all best-practice criteria would be scored as “fully implemented.” Individual best-practice scores in each of the 4 health-related categories were totaled and weighted with a multiplier to provide a numerical score (0–100). Category scores were averaged to provide an overall company score . Category scores were presented to executives and managers in an intuitive bar-chart format . After survey completion, new score reports were presented to companies, new or ongoing health promotion focus areas were identified for the coming year, and company engagement continued in the same way as in the first year. Follow-up score reports highlighted changes in best practices during the first year. Moving forward, the intent is to continue conducting annual follow-up surveys and delivering reports to participating companies.Recognition. Various forms of public recognition were used. At baseline, we aggregated company scores and presented them to executives at a Chapter meeting, allowing each company to compare its status against other participating companies. At each Chapter meeting during the year, executives were asked to share success stories. At follow-up, we again aggregated company data and presented Chapter-wide scores. Each company was thus able to see its own progress during the year and to compare its progress with that of the Chapter as a whole.Company managers also received recognition. All were invited to participate in a half-day CEOs Challenge Wellness Workshop organized by ACS. Managers of particularly successful programs were invited to make a presentation, and awards of recognition were given to all participants.t test was run to assess whether average changes in aggregate overall company best-practice scores from baseline to 12-month follow-up were different from zero. A signed rank test was also performed as confirmatory analysis in response to the skewness of change-score data. The aggregate scores for best-practice categories were presented descriptively without P values, because Bonferroni adjustments for multiple measurements were underpowered and statistically unreliable in this sample. Analysis was completed using Stata version 11.2 (StataCorp LP).We analyzed data only for the 17 companies that had complete baseline and follow-up data. Descriptive statistics were computed for the characteristics of employees in participating companies. A 2-sided, paired Data from qualitative program-satisfaction items were analyzed by 3 team members: one team member (M.K.) systematically reviewed the data to derive and classify themes and subthemes. Two other team members (A.T.P. and J.R.H.) reviewed the data and confirmed themes and subthemes.Median company size was 3,744 employees, and mean employee salary was $56,200 . Most emAt baseline, companies performed best in tobacco cessation best practices; this performance was driven by high levels of coverage for nicotine-replacement therapy and tobacco-cessation counseling . CompaniP < .001). Cancer screening practices improved 19.6 points with improvements in screening reminders in health insurance contracts. Healthy eating scores increased an average of 19.4 points, with companies increasingly posting nutritional content, labeling healthy choices, and adhering to healthy catering guidelines for meetings and events. Improvements in physical activity and tobacco cessation best practices were driven by improved communications with employees. Corporate philanthropy efforts were strong at baseline and improved slightly at 12-month follow-up.Scores improved between baseline and 12-month follow-up , with agAt 12-month follow-up, company experience with the program was positive, according to the qualitative portion of the survey. Managers noted that the health promotion focus of the program built on existing company initiatives and offered insight into areas where companies could expand and improve wellness efforts. “This has been a great eye-opening program to our company. It has opened our eyes to things that we really need to be working on, as well as what we do well” (Company C). “The program helped us identify where we could expand our wellness offerings and provided us the tools/support to do so” (Company F).Managers found most helpful the direct support from the ACS team and the ability to see how their own company compared with peer companies: “The ACS team was the best part of [The CEOs Challenge]. They helped suggest ways to improve [our] employee health and provided resources to help make it happen” (Company H). “We tend to be a little competitive, so establishing a challenge like this with other large local companies was fun for us” (Company L). “We liked seeing where other companies are excelling and even struggling. It helps to give us a . . . direction of where we need to be focusing” (Company C).Managers wanted additional online resources for employees, regular updates to leadership to aid best-practice improvements, and help in focusing on a particular aspect of cancer prevention, such as cancer screening. One manager asked to have more interaction between the executives in the Chapter and the human resources staff members who run their company programs. We found a substantial increase in the use of best EBPs by the 17 companies that completed baseline and follow-up measurements in The CEOs Challenge in its first year. At baseline, implementation scores were lower for practices that promote healthy eating and cancer screening than for practices that promote physical activity or tobacco cessation. Healthy eating and cancer screening practices had the greatest improvement at 1-year follow-up. At both baseline and follow-up, all practice categories had room for improvement, even among these relatively large companies that were interested enough in health promotion to actively partner with the ACS. The participating companies were positive about the program and were poised for further participation.t test. However, the results from a signed rank test were confirmatory, and t test results were retained for greater statistical power. Additional t tests on the changes in the health-related best-practice categories were not conducted because of limitations of the sample; multiple tests could not be appropriately adjusted without losing so much power as to render the tests unreliable. Fourth, all practices were assessed by company managers and reflect their best knowledge, but the data may be incomplete.We intended this evaluation as a feasibility-oriented pilot study rather than a trial of The CEOs Challenge. A limitation of the evaluation is its pre–post design and lack of a comparison group. A second limitation is that several participating companies were represented by local or regional offices rather than national headquarters offices, and local knowledge of the workplace-health–promotion practices of the national company may have been incomplete. Third, power for statistical testing may have been limited because of the small sample size. The distribution of change in overall company score from baseline to 12-month follow-up was somewhat skewed to the right, potentially violating the assumptions for the paired The CEOs Challenge model also has several strengths. First, it addresses the 3 leading behavioral causes of death in the United States — tobacco use, physical inactivity, and unhealthy eating . So, sucThe CEOs Challenge had little effect on the participating employers’ corporate philanthropy for ACS, at least as we measured it. Readers may question the appropriateness of including philanthropy as an explicit part of The CEOs Challenge. Public–private partnerships to improve the public’s health are most durable and effective when they address the needs of all partners . ACS, a The CEOs Challenge is a promising approach to chronic disease prevention in the workplace. It brings together one of the nation’s largest health-promoting voluntary agencies with the nation’s largest employers to promote EBPs targeted at the most common causes of disease and death. The program appears to have increased the adoption of these practices and to have been well-accepted in one local chapter, and additional chapters could implement this approach or support a larger study of The CEOs Challenge with a comparison group. Both broader implementation and a larger study have the potential to significantly improve evidence-based health promotion opportunities for thousands of US employees and inform the science of organization-level adoption and implementation of EBPs.


Popliteal artery entrapment syndrome (PAES), a condition predominantly affecting young individuals, is a rare clinical entity that can result in significant morbidity. The presence of lower limb pain and claudication in young, physically active individuals should prompt consideration for PAES. Early diagnosis and management is crucial to prevent long-term complications; however, diagnosis is fraught with challenges due to the rarity of the disease and its similar clinical presentation with more common conditions. We present a case of a young female with PAES who was misdiagnosed and underwent a tarsal tunnel release for suspected tarsal tunnel syndrome and subsequent fasciotomies for presumed chronic exertional compartment syndrome (CECS) without any relief. We outline the insidious undiagnosed course of her condition over a period of 12 years, discuss teaching points of how to recognize key differences of PAES and associated conditions, and provide recommendations for how to make the right diagnosis. Popliteal artery entrapment syndrome (PAES), a consequence of aberrant positioning of structures surrounding the popliteal artery within the popliteal fossa, may present due to a variety of anatomical differences. The classification scheme is summarized in Classically, the condition affects young men and those individuals who are highly physically active, including military personnel and long-distance runners , 2. ProlA 30-year-old female presented following a fall during a workout session, when her leg “gave out.” As an avid runner, she noted progressive worsening of her daily activities and exercise intolerance due to pain, numbness, and a burning sensation in her right lower extremity, symptoms that had been present for 12 years. She worked as a physical therapist and while assessing her pulse a decreased ankle-brachial index was noted. She had a history of a tarsal tunnel release 14 years ago for presumed tarsal tunnel syndrome followed by a four-compartment fasciotomy for supposed chronic exertional compartment syndrome (CECS) 10 years ago.Physical exam of the right leg demonstrated a normal femoral pulse, while the popliteal pulse was absent with diminished posterior tibial and dorsalis pedis pulses. Tenderness to palpation was elicited overlying the right tibia.Radiographs showed no evidence of a fracture. A duplex ultrasound demonstrated normal triphasic waveforms extending from the right superficial femoral artery caudally to the proximal popliteal artery. Distally, the native popliteal artery was not clearly identified. Multiple collaterals within the popliteal fossa were visualized . CT angiBased on these findings, the entrapment was not amenable to endovascular repair with minimally invasive techniques. Vascular surgery recommended right popliteal artery entrapment release coupled with popliteal-to-popliteal artery bypass and right lower extremity venous mapping. The two heads of the gastrocnemius muscles were split to expose the distal aspect of the popliteal artery. Small fibrous bands were removed off the popliteal artery followed by insertion of a bypass graft . Flow toPopliteal artery entrapment syndrome is a rare clinical entity affecting young individuals, causing symptoms of vascular compromise. Delay in diagnosis or misdiagnosis occurs commonly as patients lack vascular risk factors that would otherwise predispose them to symptoms associated with atherosclerosis and claudication . FurtherOne of the challenges faced in diagnostic medicine is differentiating disease processes that overlap in clinical presentation. In the case of PAES, its clinical presentation and patient population closely mirror those of CECS; both conditions predominantly affect young, well-conditioned, physically active individuals who present with exercise-induced claudication or paresthesia –13. HoweObtaining a good history of symptom onset and exacerbations along with a proper physical exam assessing lower extremity pulses can aid in diagnosis. Doppler ultrasonography is a useful inexpensive and noninvasive initial investigation to suggest the diagnosis , 15. HowFurther testing can be done with CTA. MRI/MRA also helps to evaluate the vasculature, delineate the surrounding musculature, and provide an alternative for patients with contraindications to CTA –20. ThisThe insidious course of PAES may have serious long-term ramifications in an otherwise healthy individual. The abnormal anatomy of the popliteal fossa can produce continual compression of the popliteal artery, causing endothelial damage resulting in the formation of aneurysm, thrombosis, or embolism. Any of these sequelae in a patient can trigger ischemia and potentially threaten limb viability . Early iAlso in consideration is gender predilection of PAES towards males. Further investigative efforts should be geared towards discovering the underlying etiology as to why this disease manifests with a higher incidence in males. The overall incidence of PAES in the general population has been reported to be between 0.17% and 3.5%, with up to 85% of patients diagnosed clinically being males –25. We pDiagnosis of popliteal artery entrapment syndrome is fraught with difficulty due to the rarity of the condition and its overlap with other more common diseases. Awareness of key characteristics along with appropriate use of imaging modalities greatly increases the likelihood of making the proper diagnosis. Timely diagnosis is extremely important, both for symptom management and to avoid long-term morbidity. PAES, though predominantly affecting males, should also be considered in young females presenting with a history of exercise-induced claudication.


Four antecedents  exhibited favorable effects on customer loyalty. Among these four factors, the positively perceived CSR initiatives had a greater impact on customer loyalty. In addition, according to our findings, female participants were more likely to have a positive perception of the four antecedents than males.This research explored a conceptual framework incorporating interrelationships among corporate social responsibility (CSR), corporate ability (CA), corporate reputation (CR), and CSR-related transparency on customer loyalty within the hotel context. In this study, we also analyzed consumers’ propensity to support CSR initiatives through the socio-demographic indicator of gender. We used independent sample  The hotel industry is one of the world’s fastest-growing business spheres  has been an important topic studied by both scholars and practitioners in recent decades. CSR is related to a company’s commitment to its societal obligations. Recently, researchers have begun to include CSR in loyalty behavior models. A socially responsible image can differentiate a brand and enhance customer loyalty. Corporate social responsibility helps to enhance sustainability of the hospitality industry and retain customers (Gao and Mattila Corporate Ability (CA) is also an important differentiator in this competitive business environment. CA is defined as “the company’s expertise in producing and delivering products and services”  between genders.First, we checked the reliability and validity of the measurement model. Then, we performed Confirmatory Factor Analysis (CFA), using AMOS. In order to study cause and effect, we employed a multiple regression model to evaluate the impact of the four elements on customer loyalty. Multiple regression analysis is the concurrent grouping of multiple factors to measure how and to what degree they affect a certain result . We used an independent sample The demographic profiles of the respondents are presented in Table χ2 = 1376.434, df = 303, p < .001), CFI = .90, IFI = .90, and RMSEA = .08). Factor loadings for the indicators for each construct were all significant (p < .01) and sufficiently high. To evaluate the internal consistency of the multi-item measures for each construct, we conducted a composite-reliability test for which all values ranged from .726 to .922, and were greater than the recommended threshold of .60 , CA , CR , and CSR related transparency . Therefore, hypotheses 1, 2, 3, and 4 were supported, as expected. The findings indicated that CSR, CA, CR, and CSR-related transparency (the independent variables) were generally associated with customer loyalty (the dependent variable). The results of the comparisons among the beta coefficients and the t-values revealed that CSR had a greater impact on customer loyalty toward a hotel. The regression results that we used to evaluate the hypotheses are presented in Table Overall CSR  for all the analyzed variables, so the assumption of variance equality was not rejected. The significant differences between the means of the two groups on perceived CSR, CA, CR, and transparency (t(485) = −3.114; t(485) = −4.175; t(485) = −4.074; t(485) = −2.921, p < .01). Overall, mean scores and standard deviations for all variables were higher among female respondents . Thus, hypotheses 5, 6, 7, and 8 were supported.Then, we utilized an independent sample Attracting profitable customers and retaining them is always a key element of a successful business. Both those in the industry and academia are consistently seeking ways to increase customer loyalty. Although this is a popular topic, there has been no agreement on the factors that generate superior loyalty on the part of consumers , whereas some researchers have found small or irrelevant changes  to customer loyalty have been inconclusive . There is ongoing research on the presumed differences between men and women  with regard to purchase behaviors. Our study will contribute to this type of research by focusing specifically on the hotel context.From a practical perspective, while CSR efforts may simply be window dressing and propaganda, they do have a significant impact on customers—much like a marketing or advertising campaign. There has been discussion about whether hospitality companies should become involved in CSR activities  (Loureiro and Kastenholz The association between consumers and companies is influenced not only by the transparent actions of the company but also by consumers’ personal approximations of how the company reacts in circumstances in which its activities cannot be transparent Kitchin . TherefoFrom a demographic standpoint, our findings will help hospitality marketers to effectively target certain segments of the population and provide clearer insights into formulating more effective marketing strategies. Understanding how to successfully target individuals—irrespective of whether that approach is based on demographic characteristics—with appropriate message content is paramount. Thus, to attract/retain more customers, hotel marketers should provide a learning opportunity to this group of customers by delivering various information/knowledge about their programs/activities/services.A loyalty program that benefits a charity can be a notable differentiator for an industry and produce considerable public relations benefits and opportunities for favorable publicity. These can be critical assets in today’s environment in which CSR activities are gaining more attention from customers. Since the business environment has become increasingly competitive, maintaining loyal customer relationships remains an essential element of business strategies. Thus, a loyalty program that can help a company distinguish itself, increase customer spending, and transmit a positive CSR message is essential to success (Eason et al. In conclusion, corporate social responsibility enhances customer loyalty because consumers typically have positive responses toward companies that are socially accountable (Pomering and Dolnicar Our research has certain limitations which future researchers could work to overcome. For example, they could employ our model with a larger random sample or in other contexts. In addition, the representativeness of the samples collected from Amazon Mechanical Turk is debatable (Paolacci and Chandler This research contends that corporate ability and reputation, perceived corporate social responsibility, and CSR-related transparency should be concurrently applied by hotel executives to develop an effective and valued company plan that provides sustainable competitive benefits.


Discs of gas and dust around million-year-old stars are a by-product of the star formation process and provide the raw material to form planets. Hence, their evolution and dispersal directly impact what type of planets can form and affect the final architecture of planetary systems. Here, we review empirical constraints on disc evolution and dispersal with special emphasis on transition discs, a subset of discs that appear to be caught in the act of clearing out planet-forming material. Along with observations, we summarize theoretical models that build our physical understanding of how discs evolve and disperse and discuss their significance in the context of the formation and evolution of planetary systems. By confronting theoretical predictions with observations, we also identify the most promising areas for future progress. These discs are a natural consequence of the star-formation process, implying that all young stars have the potential to host a planetary system. Circumstellar discs are observed to evolve and finally disperse over a timescale of a few million years §, which iyoung circumstellar discs is controlled by viscous accretion while the late evolution and final dispersal by star-driven photoevaporation  or weak-line (W) T Tauri stars (TTs) mostly based on the strength of the Hα emission line  forbidden lines  line at 6300 Å  12.8 μm emission, most of which arises beyond the dust cavity [b). All other observables are consistent with the gap being opened by star-driven photoevaporation [Stronger evidence for thermally driven winds comes from mid-infrared high-resolution spectra of [NeII] at 12.8 μm. The low-velocity emission has blueshifts between 2 and 12 km s. 3.2 in  and refe. 3.2 in . Direct t cavity   component whose intensity decreases while the opening angle increases going from the Class 0 through to the Class II phase  12.8 μm line profiles for an EUV-driven wind  and an X M⊙ yr−1 . Similar M⊙ yr−1 . This is M⊙ yr−1 . Some st M⊙ yr−1 ,143. In 4.Before comparing observations and theory to identify discs that are truly caught in the act of dispersing, we briefly summarize the salient results discussed in previous sections. We also schematically illustrate the three main stages of disc evolution and dispersal in While theoretical models combining accretion and disc winds are consistent with these basic observations and reproduce the lifetime and dispersal of discs, several authors have pointed out that the theory fails to explain a subset of the observed transition discs . But areSpitzer and complementary long-wavelength photometry, to identify different populations of transition discs in the mass accretion rate (Rhole) plot [Rhole from SED modelling, which is insensitive to Rhole≤1 AU, and total disc masses (assuming a gas-to-dust ratio of 100), also obtained from SED modelling  plot . Stellarle) plot , includile) plot ), an este A.3 of ). From te A.3 of .4 Objectng discs  while grng discs . The solng discs .Figure 5 years. Once the inner disc has drained onto the central star, stage 3 in α EW but no upper limit on the mass accretion rate [Twenty-nine out of 72 discs (approx. 40%) fall in the area covered by grey squares and within the solid grey lines and, as such, are consistent with cavities being opened by photoevaporation. If these are the only discs caught in the act of dispersing, the disc dispersal timescale is about 40% of that measured from counting all transition discs. However, this number should be taken as a lower limit as upper limits on mass accretion rates are more rarely reported in the literature than mass accretion rate measurements. Overall, these results confirm previous reports that the dispersal timescale is short, of order 10ion rate . In addi−8 M⊙ yr−1 [α-type accretion is assumed in the inner disc, meaning that large gas surface densities are required at the low velocities implied by typical α values. It has recently been proposed that gas accreting at transsonic speeds may help in solving this problem [nH∼108 cm−3) are required in the inner disc, which may be consistent with recent observational constraints [The population of discs that is most difficult to explain, not only via photoevaporation models, is that of discs that have large dust cavities (greater than 20 AU) and are accreting vigorously, at rates not too dissimilar from those of full discs  conference proceedings . In what5.1.One aspect of the influence of photoevaporation on the formation of planetesimals which was considered in the PPVI review is the selective removal of virtually dust free material. Grains in the wind launching region will be lifted in the wind according to the force balance between the drag force , gravityElements of a one-dimensional dust evolution model  have bee−2, Stokes numbers of order 10−2 are sufficient to trigger the instability [−3 for similar metallicities [−4 instead of the canonical ∼10−2) is due to radial drift which has removed the large particles (which contain most of the dust mass) from the disc. The gap opens shortly after 3 Myr and creates a region of pressure maximum inside the gas-rich inner edge of the outer disc where the conditions may become favourable for triggering the streaming instability. This region moves out as the hole grows, possibly leaving behind a population of planetesimals which may provide the seeds for a terrestrial planetary system in tight configuration, reminiscent of the compact multi-transiting planet systems discovered by Kepler  also plays an important role. It has been shown that for metallicities (column integrated dust-to-gas ratios) approximately greater than 10tability . More relicities . Very relicities  suggest licities ,164. Figrocesses ). More drocesses , radial rocesses ,167.FigFurther effects of internal EUV and external FUV photoevaporation on the chemical composition of the material in the disc available for planet formation have also been explored ,169. The5.2.Trapping dust particles by vortices in discs is an attractive avenue to create ‘hotspots’ for planet formation. The possibility of vortices created at the gap edges in transitional discs by planet formation or photoevaporation has recently been investigated ,173. In The removal of gas from the protoplanetary disc spells the end for gas giant formation, and it provides a natural stop to migration processes involving exchange of angular momentum between the planets and the gas in the disc. The general consequences of gas removal for the formation and evolution of planetary systems have been explored in a number of seminal works reviewed during PPVI . In the Moving onto later times of dynamical evolution, recent work has shown that the disc dispersal mechanism can influence migration histories of planeatary embryos, finally determining the formation of hot super-Earths versus giant planet cores . This reMore recent works also highlight the importance of disc dispersal in understanding the migration histories of planetary embryos ,183.6.We have summarized empirical constraints on the evolution and dispersal of planet-forming discs and discussed theoretical models that offer a physical interpretation. Particular emphasis was placed on the subset of discs that may be caught in the act of dispersing, often called transition discs. As it transpires from this review, observations and theory have advanced significantly in just the past few years and are challenging classical views of disc evolution and dispersal. By confronting theory with observations we can draw the following main conclusions:— Current data are consistent with accretion being the main disc dispersal mechanism on ∼Myr timescales but cannot prove whether disc viscosity or MHD winds drive accretion.5 yr) can be explained by: (i) photoevaporation taking over long-lived viscously evolving discs, (ii) MHD winds if the inner disc can retain most of its magnetic flux while the outer disc loses it during evolution, or (iii) a combination of the two, where a thermally driven wind, threaded by magnetic lines, exerts a torque on the gas remaining in the disc and drives accretion.— The relatively long disc lifetime (a few Myr) but short disc, dispersal timescale  and disc masses, might not be truly dispersing discs and remain difficult to account for in the classical α disc paradigm.— The SED-identified transition discs are a heterogeneous group of systems. About 50% of them can be explained by models that include viscous evolution and photoevaporation. The other 50%, those that have large mass accretion rates (approx. 10— Gas diagnostics are starting to reveal cavities and gaps at radial distances comparable to dust cavities in transition discs providing valuable constraints on the ways discs evolve and disperse.At this stage, clarifying the role of accretion and disc winds in the evolution and dispersal of planet-forming discs is critical to make progress in the field and connect the first stages of planet formation to mature planetary systems. Measurements of turbulence in discs will be key to assess the role of viscous accretion. Luckily, they are becoming possible thanks to the sensitivity and spatial resolution of ALMA and multiple approaches are being tested to understand uncertainties and biases . ExpandiFrom the theory side, there are also several important directions that need to be pursued. As discussed in §3.2, photoevaporative models are mature but still incomplete. A longer-term but challenging goal would be to build models that include all stellar heating sources, treat disc chemistry and dust evolution, and include hydrodynamics to properly determine wind rates and profiles as well as to predict emission line profiles. Global MHD disc simulations, with enough vertical extent, are still needed to demonstrate that MHD winds can drive accretion and disc dispersal. Predictions that could distinguish this mode of evolution from viscously evolving photoevaporating discs are also necessary to make progress in the field. The relative extent of the gas and dust and gas depletions are some of the diagnostics that are becoming accessible to observers and might be promising to establish how discs evolve and disperse.Finally, the last few years have seen several attempts at quantitatively accounting for disc dispersal in planet formation and evolution models. What is apparent is that disc dispersal is not only a boundary condition to planet formation models, but many of the processes involved can play a powerful role in the assembly of material to make planetesimals, as well as in the evolution of young planetary systems. Thus, the era of quantitative planet formation modelling can only truly begin once a more quantitative picture of disc dispersal is established via comprehensive and observationally constrained theoretical modelling.


Introduction. This study aimed to examine how well an evidence-based physical activity program could be translated for wide scale dissemination and adoption to increase physical activity among community-dwelling older adults. Methods. Between October 2009 and December 2012, reach, fidelity, dosage, ease of implementation, and barriers to translation of EnhanceFitness (EF) were assessed. To assess effectiveness, a pretest-posttest design was used to measure increases in functional fitness . Results. Fourteen community-based agencies offered 126 EF classes in 83 different locations and reached 4,490 older adults. Most participants were female (72%). Thirty-eight percent of participants did not complete the initial 16-week EF program. The 25% who received the recommended dose experienced an increase in upper and lower body strength and mobility. Further, participants reported high satisfaction with the program. Conclusion. EF was successfully implemented in a variety of settings throughout South Florida and reached a large number of older adults. However, challenges were encountered in ensuring that those who participated received a program dose that would lead to beneficial gains in functional fitness.  Regular physical activity can promote physical and psychological wellbeing and reduce risk of disability and vulnerability to chronic diseases in older adults –5. NeverThe Healthy Aging Regional Collaborative (HARC) was established by the Health Foundation of South Florida (HFSF) to increase the adoption of evidence-based programs that promote and preserve the health of older adults in South Florida. Among the programs selected was EnhanceFitness (EF), which is an evidence-based group exercise program for older adults of all fitness levels , 14. EF The Healthy Aging Regional Collaborative was created to increase local community capacity to offer accessible health promotion programs to older adults in South Florida. HARC was established by the HFSF and was designed to (1) disseminate evidence-based health promotion programs to address inactivity and chronic health conditions in older adults in South Florida; (2) establish a local group of trained professionals and lay leaders with the capacity to provide a range of evidence-based health promotion programs to older adults on an ongoing basis; and (3) provide a foundation for planning, coordination, technical assistance, and peer learning for present and future collaborative members. Community-based agencies that were interested in participating in HARC had to apply to HFSF and received funding to offer evidence-based programs, including EF. Funding covered licensing for use of the selected evidence-based program, instructor training, program implementation materials and equipment, and support for the administrative costs of implementation, including procurement of sites, instructors and participants, data collection, and data entry. Funded agencies were responsible for delivering EF. Agencies identified suitable sites to offer EF classes  as well as recruited program participants.A one-hour EF class includes a 5-minute warm-up, a 20-minute low impact aerobic workout, a 5-minute cooldown, a 20-minute strength training workout, and 10 minutes of stretching and is offered three times per week. Instructors who were certified by a nationally recognized fitness organization  and who received training in EF procedures at a two-day training conducted by EF program developers and EF master trainers led classes. All instructors were required to teach EF as outlined in EF training materials provided by the program developer. Individuals over the age of 50 who were interested in participating in EF were enrolled by agencies as long as they were cognitively and physically able to participate in the EF program.Multiple sources of data were collected to evaluate how well HARC agencies were able to implement EF. Descriptive/demographic data form, a health history, a fitness check (FC), and program satisfaction survey were collected. Participant data were collected at enrollment, with a second FC and the evaluation scheduled to be completed 16 weeks after enrollment as prescribed by the EF program. Program managers and instructors collected all participant data. All staff who administered the forms and collected data were trained regarding the meaning and importance of the items and shown the correct way to administer the three functional tests included on the FC during EF training sessions. Program managers submitted class registrations, new and ongoing participant data, and participant attendance records to HARC's evaluation team. An annual survey of program managers was also conducted online. Program fidelity was monitored by trained observers who observed randomly selected classes and then completed a fidelity observation checklist aimed at identifying implementation issues.Prior to receiving any data from agencies, HARC's evaluation team received approval from the Institutional Review Board at Florida International University to conduct the evaluation of HARC.The number of agencies, sites, classes, and participants were tracked as measures of EF implementation. Demographic characteristics of participants were self-identified on a form that included questions regarding gender, age, race and ethnicity, highest level of education, annual personal income, living situation , marital status, and primary spoken language. Participant satisfaction was measured using the satisfaction survey developed and provided by EF.Effectiveness of the EF program was assessed based on changes in measures of functional fitness , self-reported general health, and self-reported frequency (days per week) of exercise of at least 30-minute duration.Additional measures included (1) the BRFSS general health measure, with a response scale from 1 = poor to 5 = excellent ; (2) selThe annual survey of HARC program coordinators served as a process evaluation tool and identified implementation issues that agencies in HARC experienced. Questions specific to implementing EF were included each year and only agencies who offered the EF program completed these items. Items assessed ease of implementing the EF program, challenges with implementation, assessed participant recruitment activities, and also assessed long-term adoption and sustainability.Observations of 30% of randomly selected classes assessed fidelity to the program design. Observers were staff members of the evaluation team and were trained on program specifications through a detailed review of the instructor manual. As part of the training, observers would accompany an experienced observer and interrater reliability would be assessed. Observers used a structured checklist that was based on the instructor manual and was developed by the evaluation team, EF master trainers, and HARC member agencies. The checklist specified observable elements related to the class environment, instructor, duration, and site. Each element was marked as observed or not observed. Discrepancies from the prescribed exercise routine were noted in a comment section.Of the 4,490 enrolled participants, 1,146 received the dose of the intervention proposed by Belza and colleagues  Figure . ExclusiData were extracted from the online database and imported into SPSS 22.0 for analysis. Data was first assessed for normality and outliers. Data on participant satisfaction, self-reported improvement in physical abilities, participant characteristics, participant attendance metrics, and program manager survey and fidelity observation data were analyzed using descriptive statistics. To test specific hypotheses about program effectiveness, the general linear model (GLM) was chosen to assess within-subject changes in outcome measures  at baseline and 6 weeks and controlled for potential differences in performance site .A total of 4,490 older adults enrolled and attended at least one EF session between October 1, 2009, and December 31, 2012. The majority of enrolled participants were women. Participant ages ranged from 29 to 107, with a mean age of 74.8 years (SD ± 9.9). The racial/ethnic composition of participants was diverse, with non-Hispanic whites and Hispanics making up the two largest groups . The numSixty-nine EF classes were observed for fidelity by the evaluation team between, accounting for nearly 33% of all EF classes offered during the time period. Almost half of the observed classes, 47.8%, had no significant fidelity concerns in the measured dimensions. The most frequently cited concerns related to instructors not using key phrases developed to ensure participant safety, including checking if participants could see and hear the instructor (30%), and reminding participants not to do exercises their physician advised against (30%), not to do any exercises that were painful (16%), and to exercise at a pace that was comfortable (14%). Additionally, 41% of observed sessions lasted less than 60 minutes .Of 4,490 participants enrolled in the HARC EF program between October 1, 2009, and December 31, 2012, who attended at least one session, an average of 26% received the minimum recommended dose  Table 2Table 2. In the Year 1 program manager survey, six of seven program managers responsible for implementing EF reported that implementation was difficult or very difficult on a five-point scale from very easy to very difficult. In the Year 2 and Year 3 surveys, more than half of the program managers indicated that implementation was moderate, that is, half-way between very easy and very difficult on the measurement scale, showing that ease of implementation improved over time. Implementation barriers most frequently cited over the three years remained relatively constant and included funding, inadequate staff, inadequate client interest, cultural norms of the community, and difficulty in recruiting class instructors. The most frequent barriers identified for recruiting participants included difficulty maintaining consistent participation and the seasonal residence of some participants in the South Florida area. The most frequent barriers to instructor recruitment included availability for the three weekly one-hour sessions, finding individuals who were committed to the EF program, and lack of transportation.Analysis revealed that participants who completed the recommended dose and received a posttest after participating in the program for four months significantly improved their scores on the three physical ability measures, self-reported general health, and frequency of daily exercise of at least 30-minute duration after participating in EF program .When asked on the second FC about improvements in physical abilities as a result of their EF participation, 71.5% of participants indicated improvement. Among the 2,565 EF participants who completed a program evaluation, 89% were satisfied or highly satisfied with the program. Additionally, 97% responded that they would take the class again and 92% would recommend the class to a friend.The HARC initiative described here is the largest scale translation of EF to a broad cross section of community agencies and settings within the same geographical area to date in the United States. Data reported here suggest that HARC was able to successfully implement EF throughout South Florida and reach a large number of older adults over the three-year period. These findings indicate that this effort to form a collaborative, sharing resources, training, and knowledge, was an effective approach for translating an evidence-based program to a wide array of community settings and sites.Unlike controlled trials of EF, data reported here are based on the real world implementation of EF in a variety of community settings throughout South Florida. It was important to investigate if the community-based EF implementation produced participant changes similar to those reported in controlled EF efficacy studies. Our findings are consistent with prior controlled studies of EF and other fitness programs , 15, 16.As with any adoption of a health promotion program, the potential for changes and deviations in the curriculum is a concern. Adaptation is a normal process, yet it can cause a program to be less effective if changes are made that undermine the program's effectiveness. In our evaluation, we assessed fidelity to determine how accurately EF agencies and instructors implemented the program. Surprisingly, very few concerns were identified for the core elements of the program. The majority of observed concerns involved safety warnings that instructors are supposed to use throughout the class.Our evaluation did identify several areas that warrant comment and further investigation. A participant recruitment challenge relating to male participants existed. Only about 15% of participants were male, while the percentage of males in the total population in the three targeted Florida counties is much higher, at nearly 44% . This raAlthough findings show that EF can be effectively implemented by a collaborative in South Florida and that participants can achieve benefits consistent with clinical trials if they participate regularly, this evaluation has certain limitations. As this was a community-based implementation and not a controlled research study, a randomized design could not be used. Participants self-selected into the program, so they may not be representative of the larger older adult population in South Florida. Bias could also be an issue if functional test results reflect the impact of health-promoting activities that participants engaged in other than EF. A large number of participants did not have documented follow-up measures, which reduced data available for analysis of fitness test results. Finally, functional test data are potentially subject to measurement bias because different instructors collected data on outcome measures. However, the rigorous training on data collection tools prior to being certified to teach an EF class, use of the same tool, and ongoing fidelity monitoring of instructors reduces the chances of measurement bias.Even with these limitations, this study had strengths. The program was implemented by multiple agencies, and the diverse racial/ethnic mix of the South Florida participants is likely different than demographic profiles found in previously described evaluations. Many measures of implementation used indicated successful introduction of the programs and ongoing fidelity to program design. A longer-term retrospective study of sustained fidelity and the program's impact on participant physical fitness, health status, frequency of exercise, and healthcare costs is needed to confirm that outcomes reported here endure over longer time periods.Health promotion efforts targeting older adults are essential for improvement in quality of life, functional ability, and healthcare cost savings. HARC's innovative approach to rapid EF implementation on a wide scale shows that EF can be introduced in many different settings and delivered successfully. Moreover, there is reason to believe that community-based EF programs have the potential to offer access to an evidence-based physical activity with proven health benefits to a large percentage of older adults in the community. However, efforts are needed to ensure that community-based agencies that offer EF reinforce the importance of continued attendance to ensure the most benefit to program participants and that implementers continue to assess implementation fidelity of the program to the original design tested in controlled trials.


Decoy receptor 3 (DcR3), a member of the tumor necrosis factor receptor (TNFR) superfamily, shows inhibitory effects on Fas-mediated apoptosis. Currently, data are lacking on the correlation between DcR3 and the recurrence of breast cancer. The authors examined DcR3 mRNA expression and genomic amplification in breast cancer, and investigated the effect of DcR3 gene amplification on prognosis of patients.in situ hybridization. DcR3 gene amplification was examined by quantitative polymerase chain reaction. The correlation between DcR3 gene amplification status and clinicopathological factors was examined and also the relationship between DcR3-Amp and relapse and survival.A total of 95 patients formed the basis of the current retrospective study. DcR3 mRNA expression in breast cancer tissues was examined by RNase protection assay and The relative copy numbers of DcR3 genomic DNA correlated significantly with the levels of DcR3 mRNA expression . In addition, lymphatic invasion correlated significantly with DcR3 gene amplification (P = 0.012). However, there was no correlation between the remaining clinicopathological factors and DcR3 gene amplification. In the univariate analysis, the recurrence-free survival (RFS) rate of patients who were positive for DcR3 gene amplification was significantly lower than that of patients who were negative for DcR3 gene amplification (P = 0.0271). Multivariate analysis showed that DcR3 gene amplification (P = 0.028) and disease stage (P < 0.001) remained significant independent predictors of RFS.DcR3 gene amplification was significantly correlated with lymphatic invasion, and also DcR3 gene amplification predicts recurrence after resection, which may be an important prognostic factor in breast cancer patients. Humans have several defence mechanisms to prevent tumor progression, with the Fas/Fas ligand (Fas/FasL) system being one of the major and best-known mechanisms for evading tumor cells. The Fas/FasL system plays an important role in tumor cell death caused by cytotoxic lymphocytes . HoweverDcR3 overexpression may occur without genomic amplification , whereasThe present study comprised 100 consecutive Japanese patients who underwent surgical resection for primary breast cancer during the 5-year period between January 1996 and December 2000. Four patients with distant metastases and one patient with inflammatory breast cancer who underwent neoadjuvant chemotherapy resulting in the absence of cancer cells in the resected specimens were excluded. The remaining 95 patients (94 women and 1 man) with median age of 56 years  formed the basis of the current retrospective study. Consent was obtained from all individuals who participated in the study.Surgical resection procedures depended mainly on the size of the primary tumor. We decided that patients with tumors larger than 3 cm should undergo modified radical mastectomy, while patients with tumors ≤ 3 cm but without wide intraductal spreading or multicentric lesions should receive breast-conserving surgery. Patients with DCIS, advanced age or poor general condition were not subjected to axillary lymph node dissection.Sixty-five patients underwent modified radical mastectomy, 22 patients received breast-conserving surgery, three patients underwent mastectomy without axillary dissection, three patients underwent wide resection without axillary dissection and two patients underwent radical mastectomy.In all, 72 patients received some form of adjuvant therapy after resection: 50 patients received hormone therapy , nine patients received chemotherapy (CMF and CAF) and 13 patients received chemohormonal therapy. Only one patient received neoadjuvant chemotherapy (CAF).After surgical resection, the patients were followed up every 3 - 6 months in outpatient clinics and were monitored for disease recurrence by means of physical examinations and laboratory tests. The patients underwent routine imaging (mammography and/or breast ultrasonography (US), chest X-rays, abdominal US/CT and bone scintigraphy) every 12 months. When tumor recurrences were detected, the patients were administered either hormone therapy  or chemotherapy . In some cases of brain and/or bone metastasis, radiation therapies, including gamma-knife, were also introduced. For some of the patients with locoregional recurrence in the breast or axilla, local resection was performed.The follow-up period after surgical resection was defined as the interval between the date of initial treatment and that of the last follow-up, which ranged from 4 to 105 months  in the current series.in vitro transcription of [32P]- or [35S]-labeled antisense cRNA probes, which were used in the RNase protection assay (RPA) or in situ hybridization (ISH) experiments, respectively.The cDNA fragments for human Fas , human FasL , human DcR3  and human glyceraldehyde-3-phosphate dehydrogenase (115 bp) were derived from human oesophageal cancer cells by RT-PCR cloning and inserted into the pGEM 3Z vector . The recombinant plasmids were linearized with the appropriate restriction enzymes and used as templates for 32P]-labeled Fas, FasL or DcR3 probe combined with the GAPDH probe at the specific radioactivity level of 1 × 104 cpm, overnight at 48 °C. Then, unhybridized probes were digested with ribonuclease A and ribonuclease T1 at 30 °C for 1 h, and the ribonucleases were digested with proteinase K at 37 °C for 30 min. After phenol/chloroform extraction, the hybridized probes were precipitated with ethanol, denatured at 85 °C and electrophoresed in 6% polyacrylamide gels. The dried gels were exposed to X-ray films for 3 days. The density of each band was analyzed by densitometry using the NIH Image software (version 1.59), and the expression of DcR3 mRNA was defined as the ratio of DcR3 mRNA to GAPDH mRNA band density, which was greater than 3% in the present study.The RPA was performed to detect and semi-quantitate the levels of DcR3, Fas and FasL mRNAs in the breast cancer tissues, as reported previously . In brie35S]-labeled cRNA probes (1 × 106 cpm/section) overnight at 55 °C. After washing with buffer at room temperature, the sections were treated with 20 mg/mL RNase A solution for 30 min at room temperature, followed by washing with buffer at 55 °C for 4 h and at room temperature. After dehydration, the sections were exposed to a photographic emulsion for 5 - 7 days in the dark at 4 °C, developed, counterstained with hematoxylin and observed by both bright- and dark-field microscopy.ISH was performed to determine the distribution of DcR3 mRNA in breast cancer tissues, as reported previously . In brieQuantitative PCR was used to measure DcR3 gene amplification, as reported previously . In brieFor DcR3 genomic DNA quantitation, the amplification reactions (25 mL) contained isolated genomic DNA (0.5 µL), 1 × TaqMan universal PCR master mix (Applied Biosystems), 900 nM DcR3 primer and 250 nM of the corresponding fluorogenic probe. For β-globin genomic DNA quantitation, the amplification reaction (25 µL) contained isolated genomic DNA (0.5 µL), 1 × TaqMan universal PCR master mix (Applied Biosystems), 900 nM β-globin primer and 250 nM of the corresponding fluorogenic probe. Two-step PCR was performed according to the manufacturer’s instructions under the following thermal cycler conditions: 50 °C for 2 min, 95 °C for 10 min, followed by 40 cycles of 95 °C for 15 s and 60 °C for 1 min. The colon adenocarcinoma cell line SW480 [The data were analyzed using the SDS software (Applied Biosystems) and are presented as the means of the DcR3 amplicon/β-globin amplicon ratios.In addition to DcR3 gene amplification, we included several clinicopathological factors in the analysis of prognosis. The clinicopathological factors employed in the present study were: age (≤ 50 years versus > 50 years), pT, pN, pStage, lymphatic invasion, venous invasion, estrogen receptor (ER), PgR, Her2 and adjuvant therapy. Information on these factors was obtained from the medical records of each patient. The causes of death were determined from the medical records, and deaths from other causes were treated as censored cases. The follow-up period was defined as the interval between the date of treatment and the last follow-up. The correlation between DcR3 gene amplification and other clinicopathological factors was also examined.Medical records and survival data were obtained for all 95 patients. Survival curves were constructed using the Kaplan-Meier method, and differences in survival were evaluated using the log-rank test. The Cox proportional hazards regression model was used to identify factors that were independently associated with RFS. In this model, a stepwise selection is used for variable selection, with entry and removal limits of P < 0.05 and P > 0.01, respectively. The stability of this model was confirmed using step-backward and step-forward fitting procedures; the variables identified as having an independent influence on survival were identical for both procedures. The clinical features and pathological tumor-related factors were compared between the two patient groups using Fisher’s exact test. All statistical evaluations were performed using the SPSS 12.0J software package . All tests were two-sided, and differences with P values of < 0.05 were considered statistically significant.DcR3 mRNA was prominently expressed in 50% (4/8) of the cases, as assessed by RPA. Fas mRNA was expressed in all of the cases, in which DcR3 mRNA expression was detected by RPA. In contrast, FasL mRNA was not detected in all of the cases, in which DcR3 mRNA expression was detected by RPA (data not shown).In the ISH using the antisense probe, DcR3 mRNA expression was found to be prominent in breast cancer cells. The signals were negligible in breast cancer cells and normal breast tissues tested with the sense probe or antisense probe. These results show that DcR3 mRNA is detectable in breast cancer cells by ISH .DcR3 mRNA expression was extensive in five cases and faint in nine cases, as assessed by RPA (data not shown). The five strong cases had higher relative copy numbers of DcR3 genomic DNA than the nine faint cases (data not shown). The relative copy number of DcR3 genomic DNA correlated significantly  with DcR3 mRNA expression .The median relative copy number of DcR3 in the 95 breast cancer tissues was 1.19. Therefore, in the present study, positive DcR3 gene amplification was defined as ≥ 1.2 DcR3 copies, whereas negative DcR3 gene amplification was defined as < 1.2 DcR3 copies. The median relative copy number of DcR3 in the 12 non-cancer tissues was 0.64 .The patients were subdivided into two groups according to DcR3 gene amplification status: 1) positive for DcR3 gene amplification (n = 47); and 2) negative for DcR3 gene amplification (n = 48). The clinicopathological characteristics were comparable for the two groups, with the exception that lymphatic invasion was observed more frequently (P = 0.012) in patients with positive DcR3 gene amplification .The cumulative RFS rate was 77.5% at 5 years post-resection. Univariate analyses revealed that stage (P < 0.0001), nodal status (P = 0.0018), ER status (P = 0.0269) and positive DcR3 gene amplification (P = 0.0271)  were staThe cumulative overall survival (OS) rate was 84.5% at 5 years post-resection. Univariate analyses revealed that stage (P = 0.0005), nodal status (P = 0.0030), venous invasion (P = 0.0111), ER status (P = 0.0155) and lymphatic invasion (P = 0.0206) were statistically significant prognostic factors for survival. All 11 variables were entered into multivariate analyses, which revealed that pStage III (relative risk (RR): 3.270; 95% confidence interval (CI): 1.162 - 9.200; P = 0.025; and ER-positive status  remained as significant independent predictors of survival.Twelve patients died of tumor relapse, four patients died of other causes , eight patients were alive with recurrent disease and the remaining 71 patients were alive without recurrence.Although DcR3 overexpression and gene amplification have been reported previously, the correlation between DcR3 expression and prognosis remains controversial. In gastric cancer patients, DcR3 overexpression is associated with significantly shortened OS , whereasThere are very few reports of DcR3 expression in breast cancer patients; a single report concluded that DcR3 mRNA overexpression does not occur in breast tumors . HoweverWe also examined the relationship between the DcR3 gene copy number and DcR3 mRNA expression, since it is easier to obtain genomic DNA from the paraffin-embedded samples of previously treated patients than to obtain mRNA, and analysis of prognosis is possible using the previous samples of patients, for which the clinical course is already apparent. Our results show that the relative copy number of DcR3 genomic DNA significantly correlates with DcR3 mRNA expression. Since we demonstrated a significant correlation between DcR3 gene amplification and DcR3 mRNA overexpression, we could introduce DcR3 gene amplification into further studies of the analysis of prognosis for breast cancer patients.Of the clinicopathological factors examined, DcR3 gene amplification showed a significant correlation only with lymphatic invasion. Since DcR3 has been shown to have an inhibitory effect on Fas-mediated apoptosis  and the In the present study, we also examined the effects of several clinicopathological factors on the RFS and OS of the breast cancer patients. Several clinicopathological factors are known to be important in the prognosis of breast cancer patients, including nodal status , 13, tumOur study has shown that amplification of the genomic DNA for DcR3 may be an important prognostic factor in breast cancer.