Concurrent bronchoscopy using radial probe and convex endobronchial ultrasound (RP‐ and CP‐EBUS) is used to simultaneously evaluate both peripheral lung lesions for the histological diagnosis of the primary tumor and mediastinal lymph nodes for mediastinal staging. So far, little is known about the combined procedure with RP‐ and CP‐EBUS.Between January 2020 and March 2021, the bronchoscopy database was reviewed to identify the clinical outcomes of the combined procedure with RP‐ and CP‐EBUS. Patients who underwent transbronchial biopsy using RP‐EBUS alone were classified as the RP‐EBUS group, while those who underwent a combined procedure with RP‐ and CP‐EBUS were classified as the combination group.p < 0.001). CP‐EBUS increased the diagnostic yield of the bronchoscopic procedure in the combination group by 9.3%. Although the mean procedure time was significantly longer, and the mean doses of midazolam and fentanyl were significantly higher in the combination group (p < 0.001), there were no differences in the overall complication rates between the two study groups .The overall diagnostic yield of the bronchoscopic procedure in the combination group was significantly higher than the RP‐EBUS group (90.7% vs. 70.0%, Combined bronchoscopy using RP‐ and CP‐EBUS is feasible and safe. In addition to mediastinal staging, CP‐EBUS increased the overall diagnostic yield of the bronchoscopic procedure by 9.3%. The combined procedure with radial probe TBLB and convex probe endobronchial ultrasound is feasible and safe. The combined procedure increased the overall diagnostic yield of bronchoscopy, besides concurrent diagnosis and mediastinal staging. Endobronchial ultrasound (EBUS) techniques expand the view of bronchoscopy beyond the central airway using convex probe EBUS (CP‐EBUS), and allow the investigation of peripheral lung lesions (PLLs), where conventional bronchoscopy is not possible, using radial probe EBUS (RP‐EBUS).The introduction of low‐dose computed tomography (CT) screening for lung cancer in high‐risk individuals has increased the detection rate of small PLLs.Between January 2020 and March 2021, the bronchoscopy database at Pusan National University Hospital, Republic of Korea, was used to identify the clinical outcomes of the combined procedure with RP‐ and CP‐EBUS. During the study period, 617 patients received RP‐EBUS‐TBB to evaluate PLLs. Two of these patients were excluded because PET was performed at another hospital, and could not be analyzed by nuclear radiologists. Another 12 patients were excluded because RP‐EBUS‐TBB was performed for a rebiopsy to detect genetic mutations in the lung cancer.PLLs were defined as any lung lesion existing beyond the segmental bronchus in the axial plane of the thin‐section CT scan.All procedures were performed under conscious sedation with intravenous midazolam and fentanyl. RP‐EBUS‐TBB was performed according to Kurimoto's standard technique, with or without virtual bronchoscopy navigation .When mediastinal LN sampling using CP‐EBUS was required, based on the CT scan or PET, it was followed by a RP‐EBUS‐TBB procedure. Using an ultrasound bronchoscope , CP‐EBUS‐TBNA was performed at the mediastinal LNs with a clinical suspicion of metastasis. A representative case of the combined procedure with RP‐ and CP‐EBUS is shown in Figure When bronchoscopy procedures using RP‐EBUS, with or without CP‐EBUS, failed to confirm the diagnosis, an additional surgical biopsy, percutaneous needle aspiration, or repeat bronchoscopy was performed after obtaining consent. Benign lesions, not otherwise specified, were defined as inflammatory cells only or a benign pathology, such as anthracotic pigmentation, on the biopsy specimen, with no changes on CT over at least 12 months of follow‐up.t‐test or Wilcoxon rank‐sum test for continuous variables. The diagnostic yield of the EBUS procedure was calculated by dividing the number of successful diagnoses by the total number of procedures. SPSS Statistics for Windows version 22.0 (IBM Corp.) was used for statistical analyses.All results are reported as numbers (percentages) for categorical variables and as the mean ± standard deviation for continuous variables. Data were compared using the chi‐squared or Fisher's exact test for categorical variables, and independent p < 0.001; mean age: 68.1 vs. 70.4 years, p = 0.021). Compared to the RP‐EBUS group, the combination group had larger mean PLL diameters , a greater proportion had a positive bronchus sign , and a greater proportion had solid PLLs  on thin‐section CT.The RP‐EBUS and combination groups consisted of 506 (83.9%) and 97 16.1%) participants, respectively. The baseline characteristics of the two study groups are shown in Table 6.1% partp = 0.021). The overall diagnostic yields of bronchoscopic procedure in the RP‐EBUS and combination groups were 70.0 and 90.7%, respectively (p < 0.001) . The mean doses of midazolam and fentanyl, administered for conscious sedation, were significantly lower in the RP‐EBUS than the combination group . However, there were no differences in the overall complication rates between the RP‐EBUS and combination groups  , 32 (33.0%), and nine (9.3%) participants, respectively , respectively. In total, 19 patients underwent thoracoscopic surgery with LN dissection, and four of the 32 LNs, aspirated using CP‐EBUS, were found to be false‐negatives. Unexpected N2 LN metastasis was found in the surgical specimen in one patient. In group B, three patients were diagnosed with SCLC, two with limited stage SCLC and one with extensive stage SCLC.In group C, nine patients were diagnosed using CP‐EBUS‐TBNA only, and all RP‐EBUS‐TBB results were found to be false‐negative. Among the seven NSCLC patients in group C, the number of aspirated N1, N2, and N3 LNs were two, eight, and one, respectively. All patients were eventually diagnosed with clinical stage III NSCLC. Thoracoscopic surgery was performed in five patients, and there were no false‐negative or ‐positive results in the eight LNs examined using CP‐EBUS.In the combination group, 41 NSCLC patients (54.7%) underwent surgery. Using the surgical specimen as the reference, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CP‐EBUS‐TBNA were determined to be 86.2, 100, 100, 87.5, and 93.0%, respectively.In the present study, we demonstrated that a combined procedure with RP‐ and CP‐EBUS was feasible for both histological diagnoses of primary tumors and mediastinal staging for suspected lung cancer. Our results demonstrate that CP‐EBUS‐TBNA, performed after RP‐EBUS‐TBB, improves the diagnostic yield of bronchoscopy. In addition, there was no difference in complication rates between the RP‐EBUS and combination groups (1.4% vs. 1.0%). To the best of our knowledge, this is the first study to investigate the clinical use and safety of the combined procedure with RP‐ and CP‐EBUS.Adenocarcinoma is known for early spread to adjacent LNs; the risk of occult LN metastases is reported to be more than twice as high as other histologies.In addition to mediastinal staging, our results show that CP‐EBUS‐TBNA, performed after RP‐EBUS‐TBB, increased the diagnostic yield of bronchoscopy. Previous studies reported that the diagnostic yield of RP‐EBUS‐TBB was 70%–80%,Previous studies have reported that the sensitivity and specificity of CP‐EBUS‐TBNA were 89–99% and 100%, respectively.Çağlayan et al.This study has some limitations. First, it was a retrospective study conducted at a single institute. Although the bronchoscopy database collected information for consecutive patients, potential selection bias could have influenced our results. In particular, there were significant differences in the baseline characteristics of the two groups. Second, RP‐EBUS‐TBB was performed conventionally, without the assistance of advanced bronchoscopy modalities, such as robotic bronchoscopy and cone‐beam CT, which could increase the diagnostic yield of the procedure. Third, the number of patients in the combination group, subgroup C was relatively small; thus, the findings may not be generalizable. Multicenter prospective studies with a larger number of participants are required to verify our findings.In conclusion, the combined procedure with RP‐ and CP‐EBUS is feasible and safe. In addition to mediastinal staging, additional CP‐EBUS‐TBNA increased the overall diagnostic yield of bronchoscopic procedures by 9.3%.All authors declare that they have no conflicts of interest relevant to this study.


Important elements of programs that train and support infection control link nurses (ICLN) are the engagement of stakeholders, support from hospital and ward management and a structure for iterative improvement. The effects of programs, that combine all these elements, are unknown. We evaluated such a comprehensive program to explore its impact on link nurses and infection prevention practices and routines.We used the RE-AIM framework, a robust, evidence-based framework within the field of Implementation Science, to evaluate the impact of our ICLN training and support program. We used a mixed methods approach and organized the outcomes along its five dimensions: Reach, Effectiveness, Adoption, Implementation and Maintenance.Between 2014 and 2018, on average 91% of the inpatient wards and 58% of the outpatient clinics participated in the program (Reach) and impacted guideline adherence in inpatient wards. Link nurses felt engaged and empowered, and perceived their contribution to these results as pivotal. Ward managers confirmed the value of ICLN to help with implementing IPC practices (Effectiveness). The program was adopted both at the hospital and at the ward level (Adoption). Based on ongoing evaluations, the program was adapted by refining education, training and support strategies with emphasis on ward specific aspects (Implementation). The ICLN program was described as a key component of the infection prevention policy to sustain its effects (Maintenance).Our infection control link nurse program helped ICLN to improve infection prevention practices, especially in inpatient wards. The key to these improvements lay within the adaptability of our link nurse program. The adjustments to the program led to a shift of focus from hospital goals to goals tailored to the ward level. It allowed us to tailor activities to align them with the needs specific to each ward.The online version contains supplementary material available at 10.1186/s12913-023-09111-5. Infection control link nurses (ICLN) serve as role models in providing safe care; they are trained to monitor infection prevention-related issues on their ward and to inform and facilitate their peers so they can improve their clinical practice , 2. Sinchttps://re-aim.org/). RE-AIM has proven to be applicable in the evaluation of prevention programs; it can help to understand the efficacy and effectiveness of these programs implemented in real-world settings I followed a workshop on how to provide constructive feedback … After this workshop I realized I was communicating a bit too direct... So, because I was trained in measuring hand hygiene and in providing feedback to my peers I gained expertise in observing and dealing with non-compliance. From the interviews it transpired that ICLN perceived their contribution to the improvement in guideline adherence as pivotal. They felt that the knowledge and skills that they had learned and tools that were provided by the program contributed to their link nurse activities. Working side by side with their peers enabled ICLN to observe non-compliance, to provide direct feedback and to provide them with solutions to overcome barriers (e.g. suggest placing extra dispensers).With many different disciplines working in our outpatient clinic there might be different needs, too. I can't oversee all of these needs. In contrast, being the only nurse in a multiprofessional team working in an outpatient setting made it more complicated to take action.Surveyed ward managers underpinned the impact of their link nurses on infection prevention practices and valued them with a median score of 4 (IQR 3–4) out of 5 .In 2017, the link nurses perceived themselves as highly engaged with the link nurse role, with a median work engagement score of 5 (IQR 4.1–5.3). This dedication sustained during 2018; ICLN reported a median score of 5.1 (IQR 4.9–5.6) , goals were formulated per ward  together with the ward management, ICLN and the infection control practitioner. These plans also described the tasks and responsibilities for the ICLN, the ward manager and the infection control practitioner and the scheduled moments to discuss the progress of the plan. This way a bespoke plan of action was created to fit the local context and infection prevention issues of each ward. ICLN felt these plans helped to structure their tasks.The ICLN program was described as a key component of the infection prevention policy and the link nurse role was incorporated in the Infection Prevention Plan of the hospital. This plan described the organization and aims of infection control and prevention at the hospital level. Since its effectuation it facilitated and guided activities of the Hospital Infection Prevention Committee in supervising and coordinating infection prevention policies and reporting to the executive board.ICLN on all inpatient wards were trained by infection control practitioners; the training continuously offered to refresh skills or to train new ICLN. ICLN continued to measure hand hygiene compliance on a regular basis. Additionally, ICLN were taken up in the list of stakeholders in outbreak management, and were assigned a key role in the dissemination of local outbreak information at the ward level.The role of the link nurse and outcomes of the ward-based plans of action were discussed by ward managers and nursing directors during quarterly meetings. Ward managers were committed to provide the ICLN sufficient time to observe hand hygiene practices.In this study we evaluated an infection control link nurse program that was developed in our academic hospital; this evaluation was performed according to the RE-AIM framework. The results contribute to the understanding of the relation between how an ICLN program is implemented and its sustained effectiveness , 28. Str. stated that infection control practitioners also have an important leadership role in implementing safe practices; positive interactions with staff, enthusiasm and communicating the end goals of the program are powerful skills [Strong adoption of the program by hospital and ward management highlights the well-known importance of support for effective implementation of safe practices. A ward manager that supports and inspires staff to excel and forms partnerships across disciplines is more likely to succeed in the implementation of safe practices , 30. Sail skills . Thus, tPsychological empowerment of the link nurses and their engagement likely contributed to the adoption and success of our program. Psychological empowerment of nurses is associated with the provision of safe care . EmpowerRomijn et al. found discrepancies in the perceptions of several groups of health care workers on interprofessional collaboration, especially between physicians and other professionals (e.g. nurses). These discrepancies were most apparent with respect to the discussion of new practices and sharing of opinions [Our program had relatively low reach in the outpatient clinics. Link nurses from outpatient clinics in our study mentioned, apart from the lack of management support, a lack of resources as a barrier to take action, as observed in other studies . In ordeopinions . In thisopinions .Although case study results have limited generalizability, they yield the unique opportunity to evaluate interventions in their natural context. Key strengths of this evaluation included the use of multiple data sources and of a robust evaluation framework. It provides rich information on strategies to implement and sustain link nurse programs in acute care hospitals.The main limitation of this study is the absence of formal and systematic data collection. For example, baseline PES and UWES scores were not assessed. We therefore cannot link engagement and empowerment of the link nurses to our program activities. Potentially, link nurses entered the link nurse program because of their work engagement, their interest in infection prevention and their enthusiasm and competences to engage in program activities. The secondary analysis of the interviews was done by only one researcher. This limitation was partially addressed by team discussions with all authors that were also involved in the primary analyses; the data was discussed on multiple occasions. During these sessions reflexivity was encouraged. It reduced the risk of interpretation of the data being guided by team members’ knowledge, experiences and expectations . SelecteWhile we show here that an ICLN program can reach and influence ICLN, and can help to improve safe practices, especially in inpatient wards of acute care hospitals, it is possible that we did not capture all specific pitfalls and benefits of our program. A prospectively designed evaluation of this program in multiple organizations may be needed to showcase the true values of ICLN programs. Patient care shifts from inpatient care to the outpatient environment, leading to more complex care and treatment of more vulnerable patients in outpatient clinics. Increased attention for infection prevention in this part of hospitals is therefore important , 43. FutThe adaptability of link nurse programs allows the development of program activities that fit the needs of ICLN and allows to tailor program goals and to align these with the goals specific to each ward. Context specific plans of action can be an appropriate and valuable addition to ICLN programs. This implementation approach was found valuable to provide the program with reach, and to make it effective, adoptable, and maintainable.Additional file 1. StaRI-checklist.Additional file 2. Interview codes.


Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) is an innovative pilot program to provide supportive resources for veterans with interests in agricultural vocations. Implemented at 10 pilot sites, VA FARMS will provide mental health services and resources for veterans while supporting training in gardening and agriculture. As each pilot site project has unique goals, outreach strategies, and implementation efforts based on the local environment and veteran population, evaluating the pilot program provides a unique challenge for evaluators. This paper describes the protocol to evaluate VA FARMS, which was specifically designed to enable site variation by providing both site-specific and cross-site understanding of site implementation processes and outcomes.The objectives of this paper are to (1) describe the protocol used for evaluating VA FARMS, as an innovative Department of Veterans Affairs (VA) agriculturally based, mental health, and employment pilot program serving veterans at 10 pilot sites across the Veterans Health Administration enterprise; and (2) provide guidance to other evaluators assessing innovative programs.This evaluation uses the context, inputs, process, product (CIPP) model, which evaluates a program’s content and implementation to identify strengths and areas for improvement. Data collection will use a concurrent mixed methods approach. Quantitative data collection will involve quarterly program surveys, as well as three individual veteran participant surveys administered upon the veteran’s entrance and exit of the pilot program and 3 months postexit. Quantitative data will include baseline descriptive statistics and follow-up statistics on veteran health care utilization, health care status, and agriculture employment status. Qualitative data collection will include participant observation at each pilot site, and interviews with participants, staff, and community stakeholders. Qualitative data will provide insights about pilot program implementation processes, veterans’ experiences, and short-term participation outcomes.Evaluation efforts began in December 2018 and are ongoing. Between October 2018 and September 2020, 494 veterans had enrolled in VA FARMS and 1326 veterans were reached through program activities such as demonstrations, informational presentations, and town-hall discussions. A total of 1623 community members and 655 VA employees were similarly reached by VA FARMS programming during that time. Data were collected between October 2018 and September 2020 in the form of 336 veteran surveys, 30 veteran interviews, 27 staff interviews, and 11 community partner interviews. Data analysis is expected to be completed by October 2022.This evaluation protocol will provide guidance to other evaluators assessing innovative programs. In its application to the VA FARMS pilot, the evaluation aims to add to existing literature on nature-based therapies and the rehabilitation outcomes of agricultural training programs for veterans. Results will provide programmatic insights on the implementation of pilot programs, along with needed improvements and modifications for the future expansion of VA FARMS and other veteran-focused agricultural programs.DERR1-10.2196/40496 In a health care organization as large and complex as the Veterans Health Administration (VHA), successful innovations are a strategic priority . Health VHA’s Office of Rural Health (ORH) was established by US Congress in 2006 with a mission to improve health outcomes and increase access to care for the 2.7 million rural veterans enrolled in VHA care . Given OThe goal of the VA FARMS pilot program is to provide supportive resources to veterans who desire agricultural-based treatment activities, specifically targeted to veterans diagnosed with posttraumatic stress disorder (PTSD) to complement evidence-based standard care approaches. Due to high rates of PTSD and suicide among veterans of all service eras , the VHAThe VA FARMS pilot program combines the benefits of nature-based therapies (NBTs) for veterans experiencing PTSD and other mental health issues with opportunities for vocational rehabilitation and training. This is in line with the Department of Veteran Affairs (VA)’s prioritization of the diagnosis and treatment of PTSD in veterans and their efforts to improve access to VA benefits to treat PTSD symptoms -12. VA FFacilitation of community reintegration (CR) is part of the mission of the VA . VeteranVHA’s commitment to veteran-centered care has improved veteran access to complementary and integrative health approaches . One sucNBTs are not new treatment options for veterans. Historically, they were used to treat “shell shock,” war-related stress, traumatic stress, and PTSD among veterans returning from combat ,31,32. AEvaluating the VA FARMS pilot program will be challenging, in part because of its novelty. The rollout will be purposefully broad, allowing each pilot site’s goals, outreach, and implementation to differ based on the local environment and the unique needs of their veteran population. While mandated to provide training in agricultural vocations and access to behavioral health care services by licensed providers, each VA FARMS pilot site project is unique in its design and tailored to provide agricultural opportunities that meet local veteran needs. The evaluation protocol described herein will evaluate VA FARMS as a mechanism that supports tailored approaches to agricultural vocational training. The protocol allows for a site-specific and cross-site understanding of pilot project design and implementation processes. Programmatic data will provide a broad understanding of administrative logistics, promising practices, and modifications that may be needed to improve VA FARMS models. The protocol includes an assessment of the feasibility of measuring individual participant outcomes over time. By describing the protocol, this paper aims to provide guidance to other evaluators who are assessing innovative programs.The specific objectives of this evaluation are to: (1) identify barriers and strategies to implement sustainable ORH-funded agritherapy pilot site projects; (2) identify best practices that can be used to inform future VA agritherapy programing; (3) describe barriers, benefits, and personal experiences of veterans who participated in VA FARMS programming; and (4) assess pilot program implementation processes, barriers, facilitators, strategies, and outcomes for providing mental health care referrals and developing pathways toward employment in the agricultural sector.The context, inputs, process, product (CIPP) model  is well-context) were outlined in the congressional legislation. The pilot sites proposed unique approaches (input) in their funding applications to ORH. For example, they outlined budget and staffing needs, partnerships, and implementation strategies. The evaluation will record each pilot site program model and the degree to which this approach helped them achieve their goals; however, the primary focus will be to assess pilot program processes and products to suggest optimal models and promising practices. The process evaluation will document pilot program activities and strategic refinements. The product evaluation will assess the impact of participating in VA FARMS on veterans. The VA FARMS’s goals  participant observation of activities at planned yearly site visits; and (4) program implementation interviews with VA FARMS pilot site staff and community stakeholders.This 3-year evaluation will use a concurrent mixed methods approach to collect process and product data . VA FARMveteran participant surveys administered by each pilot site at baseline , at exit (when a VA FARMS veteran participant ends their training activities), and at 3 months after the exit survey; and (2) veteran voice interviews with veteran participants who completed an individual veteran participant survey at baseline and/or exit. Interviews will be collected via telephone in years 2 and 3 of the pilot. The activities of data collection and the associated timeline are summarized in Products of VA FARMS will be evaluated by assessing the individual impact of participating in the pilot site projects. These data will be collected through (1) Individual Individual veteran participant surveys see  will be Individual veteran participant surveys that are administered at exit and 3 months postexit will also include a 20-item satisfaction survey.Throughout the pilot period, quarterly program data will be reported to ORH electronically. Awardee sites will report the number of veteran participants recruited, attrition, completion, number of referrals for mental health services, number of participants who gained employment in agriculture, type and amount of service use/referrals made, and number and type of outreach events see . The evaEvaluators will attend annual site visits lasting approximately 2.5 days. Site visits will include participant observation of classes, demonstrations, and field activities. This method will allow evaluators to participate in VA FARMS activities and observe the day-to-day operations from both a programmatic and veteran participant perspective. A field notes template see  will capimplementation interviews .Interview guides will be developed iteratively based on pilot program goals and site-specific context, as well as evaluation survey results and conversations with VA FARMS program staff and ORH partners during monthly project status update calls. All interview guides will be based on 30-minute semistructured interviews. In Year 1, iews See  will be implementation interviews with VA FARMS pilot site staff will focus on VA FARMS program modifications and lessons learned that were driven by implementation needs and barriers. Veteran voice interviews .In year 3, final implementation interviews. Participants will be recruited based on exit survey data where veterans will indicate a willingness to participate in an interview discussing their experiences in the VA FARMS pilot program at each site. In years 2 and 3, veteran voice interview participants will be recruited based on exit survey data where veterans will indicate a willingness to participate in an interview discussing their experiences in the VA FARMS pilot program at each site.Evaluation participants will be recruited from each of the 10 local VA FARMS pilot project sites. Pilot project site directors will be required to provide quarterly pilot program data as a condition of funding. All other evaluation activities will be voluntary. A convenience sample of pilot project staff, partners, and veteran participants of VA FARMS pilot projects will be invited to take part in t-tests , Wilcoxon signed-rank tests , or repeated-measures analysis of variance (RMANOVA) will be used to compare changes in continuous outcomes over multiple measurement time points.Descriptive statistics will be provided for all quantitative measures, which will include frequencies and percentages for categorical variables, as well as means, medians, standard deviations, and ranges for continuous variables. For variables measured over multiple time points, statistics will be provided both cumulatively and per time point . Where appropriate, paired To understand implementation processes , quarterly pilot program surveys will be analyzed using descriptive statistics, and information will be presented both per quarter and cumulatively. In addition, data about veteran enrollments, outreach activities, and community partnerships will be collected to describe the number of participants who receive VA and non-VA health care and resource referrals, and the number of participants who became employed in agriculture.To understand implementation products , baseline descriptive statistics will be provided for veteran demographics, previous experience with gardening or agriculture, health care utilization, and PTSD and associated factors. Demographics will include gender, age, race/ethnicity, education, baseline employment and student status, military service branch, military service era, and service-connected disability rating. Previous experience with gardening or agriculture will be quantified in months. Health care utilization will include frequency of primary care visits, specialist visits, other provider visits, and hospital stays. Factors associated with PTSD will include reintegration, global physical health, and global mental health .t-tests, or Wilcoxon signed-rank tests—depending on the data distribution and satisfaction of analysis assumptions such as normality and sphericity—will be performed to compare baseline to exit scores and to compare exit scores to 3 months postexit scores. Participants will also be asked about their agriculture employment status.In addition to baseline descriptive statistics, follow-up statistics on participant outcomes will be obtained from self-reports and validated measures . Veterans will report on health care utilization, PTSD, and PTSD-related symptoms. It is important to note that the selected measures are not diagnostic but allow veterans to self-report the presence of the 20 DSM-5 symptoms of PTSD. Descriptive statistics will be provided for scores at pilot program exit and at 3 months postexit. Additionally, RMANOVA, paired Note-taking templates will be created to structure notes from project status update calls and observations from site visits. Project status call templates will include sections to record information about reported implementation activities, successes, and challenges. Field note templates see  will incData will be analyzed using a matrix analysis process . Notes wSemistructured interviews with VA FARMS staff, community stakeholders, and veteran participants will be conducted primarily over the phone, except during site visits where interviews will be conducted in person. In both cases, two experienced qualitative evaluation team members will conduct the interviews in tandem, one as the primary facilitator and the other as the notetaker and timekeeper. Detailed notes and an overall summary of the interview will be completed using the interview summary template. This template will be used as a first-level analysis document that will be integrated into the principal analysis effort using ATLAS.ti v8.0 .Data collection and analysis will occur concurrently allowing for insights from data analysis to iteratively guide subsequent data collection . The detailed note summaries will be uploaded into ATLAS.ti v8.0. Interview data will be analyzed using the noticing, collecting, and thinking (NCT) analysis model . As defiThis evaluation has been determined by the local VA Research and Development Service at the James A Haley Veterans’ Hospital to be a quality improvement project and will thus not be subject to the Institutional Review Board review for research . Given tInterviews will be audio-recorded with the permission of each participant, including veterans, VA FARMS staff, administrative leadership, and community stakeholders. All data will be kept in a secured folder behind the VHA firewall. The folder will only be accessible to members of the evaluation team. After interviews have been summarized, audio recordings will be deleted.Interview guides and recruitment invitations will be drafted at a sixth-grade reading level using “plain language” principles for clear communication . These mAn advisory board of subject matter experts (SMEs) will assist the evaluation team in quarterly meetings as well as on an as-needed basis. Advisory board participants will include SMEs in farm safety, PTSD, veteran farming programs, and disability and farming issues. They will assist with instrument development, face validity, pilot testing, and technical and agricultural issues that may arise during the evaluation, along with data collection and interpretation questions. Additionally, they will be available for general technical and programmatic issues that may arise for awardee sites. They will not see any data, and any information provided will be in aggregate or deidentified form.In July 2018, a total of 10 sites were awarded with funding to implement their proposed pilot projects  and wereAgricultural programs have been found to provide physical and behavioral health benefits to veterans who are struggling to transition from military to civilian life. European studies on the impact of horticulture and agriculture on the health and well-being of veterans and service members have found positive benefits for veteran participants with PTSD, including feeling relaxed, secure, and safe; having a sense of purpose; a decrease in PTSD symptoms; and learning new skills -52. In tDespite a long history of farming as therapy for veterans ,14,52,60Notably, there are no validated quantitative measures that capture CR or rehabilitation outcomes of agricultural training programs in the civilian or veteran population . The neeThis 3-year evaluation will employ a concurrent mixed methods approach and a CIPP model to collect process and product data. The evaluation will allow for a site-specific and cross-project understanding of project designs and implementation processes, as well as an assessment of the feasibility of measuring individual participant outcomes over time. Results of this evaluation will contribute rigorous evaluation findings of veteran agritherapy programs to the literature, an area that is notably sparse. Additionally, this evaluation will address the lack of measurement tools and poor descriptions of the therapeutic approach used in the NBT literature . Program


The presence of os acromiale is of clinical relevance before performing shoulder surgery but ethnic differences and little information regarding associated factors seem to be present. Population-based studies to clarify these topics are essential so the purpose of this study was to assess the prevalence, anatomy, and associations of os acromiale in a general adult population.Both shoulders of 3050 participants from the population-based Study of Health in Pomerania (SHIP) were assessed on magnetic resonance imaging (MRI). Associations with the os acromiale were calculated for sex, age, body height, body weight, and heavy mechanical oscillations on the upper extremity.p = 0.037, left side: p = 0.005). Overall, no differences in sides (p = 0.808), to participants’ age , body height , and the exposure to heavy mechanical oscillations on the upper extremity  were detected.In total, 1.9% (58/3050) had an os acromiale, while 21 were unilateral left, 23 were unilateral right, and 14 were bilateral. Sixty-eight meso-acromions, three pre-acromions, and one meta-acromion were detected. Os acromiale were more frequent in men  and the lacking association to lifestyle, age, gender, or sides. Additionally, it is important to be aware of possible os acromiale before surgery. The os acromiale is an accessory bone of the acromion, resulting from a failure of fusion during the development of the acromial process. The acromion is already formed in the early development. Fealy et al. documented its consistent cartilaginous shape throughout all gestational periods starting from gestational week 13 –4. RecenDuring fusion-failures, seven types of os acromiale are possible . HoweverThe exact aetiology and associated factors of the os acromiale are not completely resolved. One hypothesis suggests a genetic predisposition , 14. AnoRegarding further associations, various results are described: association with the dominant side , 16, 17,In respect of the clinical relevance of the os acromiale, associations with various shoulder pathologies were described. Older studies determined an association between os acromiale and subacromial impingement as well as rotator cuff pathology and subacromial bursitis , 18, 19.However, sometimes os acromiale is a possible cause for pain . There aGiven the importance to not overlook an existing os acromiale, the lack of population-based values and knowledge on influencing factors, population-based studies are crucial. Therefore, the aim of this study was to assess the frequency, anatomy, and associations of os acromiale in a general adult population.Data from the Study of Health in Pomerania (SHIP) was examined. The study is an ongoing population-based project with two independent cohorts, SHIP-START and SHIP-TREND. To achieve the population-based approach, participants were recruited randomly from official resident registry office files of a defined region in north-eastern Germany and stratified by sex, age, and city of residence. All participants were of Caucasian ethnicity.n = 3300) and from 2008 to 2012 , two follow-ups took place. The second cohort  was examined baseline from 2008 to 2012. A high response rate was achieved by three written invitations, phone calls, and one personal contact. The local ethics commission approved the study and each participant gave written informed consent. Further study details have already been published [As baseline (SHIP-START-0), 6265 eligible adults were chosen with a response of 68.8% in 1997. Between 2002 and 2006  underwent the MRI examination, whereof 266 participants dropped-out because of claustrophobia, acute problems, metal implants, or personal reasons. One data was missing. In total, MRI of 3050 participants were investigated in the current analysis . All MRIs were performed by four trained technicians. To assess the os acromiale, axial T1 volume interpolated breath hold examination sequences , an axial T2 Half Fourier-Acquired Single shot Turbo spin Echo sequence , and an coronal turbo inversion recovery magnitude sequence  were used.All MRI were examined by two trained examiners . The observers were blinded to all clinical information of the participants, while using the OsiriX  software. Since the axial plane is best to identify the “double joint” sign of an os acromiale , 8, 27, As patient-related parameters, the participants’ age, gender, body height, and body weight were determined. Additionally, shoulder pain on the visual analog scale (VAS) in the last seven days, proximal humeral fracture in the patients’ medical history, and the exposure to heavy mechanical oscillations on the upper extremity  at the workplace and the amount of years were assessed. Moreover, seeing a surgeon or orthopedist in the last 12 months and the number of visits were documented.t-test was used for numerical variables; continuous variables were analyzed by Wilcoxon tests while categorical data was examined with Chi2-tests. A p value of < 0.05 was considered as statistically significant. Associations of demographic and anamnestic data with the os acromiale were analyzed by univariate logistic regression models. The statistical analysis was performed using Stata 16.1 .Descriptive statistics such as mean values, standard deviations (SD), ranges, and percentiles were used to describe the sample. Student’s Out of the 3,050 participants 52% were females while the mean age was 52.8 ± 13.8 years with marginal differences between the sexes. The mean values of body height, body weight, and BMI were higher in males than in females . No differences in sides were detected (p = 0.808). Two out of the 20 left-handed participants had an os acromiale but on the right side. Participants with os acromiale had a greater body height than participants without, but after adjusting the results on gender no significant differences were found . Gender-adjusted body weight analyses showed a significant association to right os acromiale (p = 0.016), whereas no significant results occurred for the left side (p = 0.132).In total, 72 os acromiale were found in 58 different participants. Therefore, 1.9% of the whole sample showed an os acromiale, while 21 36%) were unilateral left, 23 (40%) were unilateral right, and 14 (24%) were bilateral. Sixty-eight meso-acromions, three pre-acromions, and one meta-acromion were detected , shoulder pain , visiting a surgeon  or orthopedist , and to heavy mechanical oscillations on the upper extremity  were detected.No associations to participants’ age (right: The os acromiale is mostly investigated by studies on skeletons or cadavers. Only few authors published results in vivo using hospital-based data to conduct these studies Table . In addiIn this large population-based study, 1.9% of the 3050 participants had at least one os acromiale. The frequency of bilaterality was 24%.As described in earlier studies –12, mostSince Angel et al.  proposedMoreover, no differences regarding sides were detected. A conclusive calculation regarding the dominant side was not possible because only 20 left-handed participants were present in our study sample. However, a correlation to the dominant side seems unlikely because the two left-handed participants with os acromiale were os acromiale on the right side. In previous works, Aibinder et al. discovered os acromiale more frequently on the dominant side , while oGumina et al. suggested in 2003 that the frequency of os acromiale increases with increasing distance between the anterior aspect of the acromion and the acromioclavicular joint . HoweverRegarding associations to os acromiale, a higher prevalence for men was detected, while no associations for age and body height were present. The significant association between body weight and the os acromiale on the right side seems to be coincidentally. Previous studies revealed a higher prevalence of os acromiale in men , 16 as wGiven that stable and asymptomatic os acromiale can become unstable and symptomatic due to trauma or surgical interventions, e.g., subacromial decompression , 33, it Regarding treatment of symptomatic os acromiale, there is no consensus until today. Usually, a conservative approach is used as first-line therapy for at least six months. Afterwards, surgical intervention should be considered . The disA limitation of our study might be how representative our sample is. Due to selection by response to the baseline SHIP-TREND-0, to the baseline and follow-up examinations of SHIP-START-2 as well as to the MRI subproject, representativeness might have been diminished. Moreover, our study consists of an exclusively Caucasian population. With respect to known ethnic differences , 12, ourA last limitation might be the already mentioned inclusion of participants from the age of 18 which could lead to a degree of bias with falsely diagnosed os acromiale since some authors stated that the os acromiale should only be diagnosed after the age of 25 . In MRI In conclusion, the prevalence of 1.9% of os acromiale in north-eastern Germany is relatively low comparing to the worldwide prevalence of 7%. This may be based on the genetic pool in this area. Additionally, no other association to lifestyle, age, gender, or sides was detected so our study supports the genetic theory for the etiology of the os acromiale. Despite the low prevalence, it is important to be aware of potential os acromiale before surgery, so MRI are advised. Since therapy on symptomatic os acromiale depends on the size of the os acromiale, current measurements were given.


Early life adversity can significantly impact child development and health outcomes throughout the life course. With the COVID-19 pandemic exacerbating preexisting and introducing new sources of toxic stress, social programs that foster resilience are more necessary now than ever. The Helping Us Grow Stronger (HUGS/Abrazos) program fills a crucial need for protective buffers during the COVID-19 pandemic, which has escalated toxic stressors affecting pregnant women and families with young children. HUGS/Abrazos combines patient navigation, behavioral health support, and innovative tools to ameliorate these heightened toxic stressors. We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, to evaluate the implementation of the HUGS/Abrazos program at Massachusetts General Hospital from 6/30/2020–8/31/2021. Results of the quality improvement evaluation revealed that the program was widely adopted across the hospital and 392 unique families were referred to the program. The referred patients were representative of the communities in Massachusetts disproportionately affected by the COVID-19 pandemic. Furthermore, 79% of referred patients followed up with the initial referral, with sustained high participation rates throughout the program course; and they were provided with an average of four community resource referrals. Adoption and implementation of the key components in HUGS/Abrazos were found to be appropriate and acceptable. Furthermore, the implemented program remained consistent to the original design. Overall, HUGS/Abrazos was well adopted as an emergency relief program with strong post-COVID-19 applicability to ameliorate continuing toxic stressors while decreasing burden on the health system. Early life adversity, defined as recurrent stressful events that occur during sensitive periods of development, can have profound impact on child development and health outcomes throughout the life course –4. PregnThe COVID-19 pandemic exacerbated preexisting and introduced new sources of toxic stress for families with young children. Specifically, the newfound challenges of at-home parenting , financiGiven the quickly evolving public health crisis, analytical methods that can assess public health interventions without delaying implementation are crucial. RE-AIM – Reach, Effectiveness, Adoption, Implementation, and Maintenance – provides an evaluation framework that assesses the delivery of public health interventions while bridging the gap between practice and research –30. The The design and implementation of the HUGS/Abrazos program has been previously described . HUGS/AbWe used a mixed methods approach, guided by the RE-AIM framework, to evaluate the implementation and delivery of HUGS/Abrazos . QuantitTo evaluate adoption, defined as the representativeness of settings that implement a new program , we utilTo evaluate reach, defined as the participation rate and characteristics of the program-eligible population , we utilTo evaluate the effectiveness, defined as the impact of the program for the participating population , we utilWe calculated descriptive statistics for the number of referred patients, unique referrals to HUGS/Abrazos, touchpoints completed, and the referrals to community resources. We performed statistical analyses using RStudio 1.4.1717 (R Core Team) .n = 6). The second focus group session involved all members of the behavioral health team, who provided stress reduction strategies, mindfulness techniques, and cognitive behavioral therapy to alleviate acute behavioral health needs (n = 3). Finally, the third focus group session involved primary care physicians (PCP), who were part of the program's initial conception and design team and served as clinician champions heralding the program's launch (n = 2). The focus group interview guide was developed according to the sustainability-enhanced RE-AIM framework with questions tailored to evaluate implementation outcomes, which included appropriateness, acceptability, penetration, fidelity to program design, and sustainability , Obstetrics (31.1%), Family Medicine (11.7%), and Behavioral Health/Psychiatry (6.6%) which correlates well with the HUGS/Abrazos intended patient population of pregnant women and families with children under 6 years old. Remaining referrals to HUGS/Abrazos originated from department categories that include but are not limited to emergency medicine, care coordination, social services, and more. Referring providers included physicians, midwives, psychologists, social workers, nurse practitioners, and others.The MGH HealthCare Centers in Chelsea and Revere were the most common referral sites, making up 42.6 and 23.5%, respectively, of parent referrals and 62.4 and 22.0%, respectively, of child referrals. This correlates well with Chelsea and Revere being the primary sites of HUGS/Abrazos' initial design and implementation. However, 33.9 and 15.6% for parent and child referrals, respectively, originated from MGH main hospital and other MGH affiliated community-based health centers, suggesting successful widespread multi-site adoption of HUGS/Abrazos in the MGH hospital system.A total of 6,267 women and 8,055 children under 6 years old were seen for obstetric and pediatric care, respectively, at practices participating in HUGS/Abrazos since its implementation. A total of 551 referrals were made for HUGS/Abrazos, and of this, 392 referrals were made for unique families during the evaluation period (ex. one family may be referred for both food insecurity and baby supplies). The racial and ethnic demographics of referred patients were comparable to the racial and ethnic demographics of the communities in which we targeted our outreach efforts. For example, the racial and ethnic demographics of parents in the HUGS/Abrazos program included 64.2, 22.9, and 8.5% of Hispanic, non-Hispanic Whites, and non-Hispanic Blacks in comparison to 67.0, 20.6, and 5.4% of the same racial and ethnic groups, respectively, in Chelsea, MA (A total of 392 unique families were referred to HUGS/Abrazos see . Of thesSeveral key findings emerged when assessing HUGS/Abrazos program using the RE-AIM framework. First, patients referred to HUGS/Abrazos were representative – racially, ethnically, and socioeconomically – of the communities that were disproportionately affected by the COVID-19 pandemic, demonstrating that we are effectively reaching families in need of support. Second, there were high participation rates by referred families throughout the program, illustrating that HUGS/Abrazos filled a crucial need for patient navigation of resources and acute behavioral health support. Third, the adoption and implementation of the key components in HUGS/Abrazos were appropriate and acceptable, and they remained faithful to its original design. Finally, there is overwhelming stakeholder support in maintaining HUGS/Abrazos beyond the COVID-19 pandemic, as it has proved to be an effective delivery model in mitigating acute exacerbations of toxic stress. Taken together, these results suggest that the implementation of HUGS/Abrazos was effective in providing emergency relief to help decrease the burden on the health system.Short-term behavioral health interventions have been shown to be effective in mitigating mental health needs during the perinatal period and among adolescents –44. MoreSeveral factors contributed to successful reach, adoption, and implementation of the HUGS/Abrazos program. Little is known about factors that support program uptake. By using the RE-AIM framework, we can begin to elucidate these factors and thereby improve the sustainability and diffusion of this innovative program and provide a roadmap for other public health innovations , 50. BasThe strengths and limitations of program design has been discussed in detail in a prior publication . For ourIn conclusion, the HUGS/Abrazos program is an emergency relief program that provides patient navigation of resources and acute behavioral health services to support vulnerable patient populations while reducing burden on an overwhelmed health system. HUGS/Abrazos serves as a protective buffer for vulnerable pregnant women and families with young children against toxic stressors exacerbated by the COVID-19 pandemic while also fostering resilience. Our evaluation of this quality improvement program, guided by the RE-AIM Framework, demonstrates that HUGS/ Abrazos was successfully adopted, reached its intended population, was effective in sustaining high participation rates and providing needed services, was acceptable, and maintained high fidelity. Next steps should focus on objective assessments of program efficacy, such as usage of validated mental health assessment instruments. Integration of social and behavioral health supports, multidisciplinary collaboration, and use of innovative tools that streamlined workflow are the basic principles that empowered the rapid implementation and effectiveness of HUGS/Abrazos, making the program an exemplary delivery model for future similar programs.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.MLi, MSi, MPe, and ET contributed to the conceptualization and design of the implementation evaluation process. MLu performed the quantitative statistical analysis and assisted with the interpretation of the data. MLi, MSi, MPe, SP, VC, and S-YTC conducted the qualitative analysis and/or assisted with the interpretation of the data. MSe, AE, CT, GK, AB, MH, MPa, WL, and ET assisted with interpretation of all data and critically reviewed the manuscript for important intellectual content. MLi and MSi drafted the first version of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.Program funding was provided by the Boston Foundation to the Kraft Center for Community Health at MGH and through support by Grant no. R01HD100022 from Eunice Kennedy Shriver National Institute of Child health and Human Development awarded to Andrea G. Edlow. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. The sponsors had no role in the evaluation, collection, analysis, and interpretation of data, writing of report, or decision to submit for publication.The 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


What strategies and best practices do US graduate medical education (GME) programs use to improve diversity, equity, and inclusion (DEI) in residency?In this qualitative study of the Accreditation Council of Graduate Medical Education’s Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion Award submissions, foundational and aspirational DEI strategies used by exemplar GME programs were identified. Foundational strategies included mission-driven holistic review for admissions and selection, interviewer trainings on implicit bias mitigation and on how racism and discrimination affect admission processes and advancement, inclusive selection and DEI committees, mission statements that include DEI, and retention efforts to improve faculty diversity.These findings suggest that GME programs might adopt strategies of exemplar programs to improve DEI in residency, ensure compliance with accreditation standards, and improve health outcomes for all. Closing the diversity gap is critical to ensure equity in medical education and health care quality. Nevertheless, evidence-based strategies and best practices to improve diversity, equity, and inclusion (DEI) in the biomedical workforce remain poorly understood and underused. To improve the culture of DEI in graduate medical education (GME), in 2020 the Accreditation Council of Graduate Medical Education (ACGME) launched the Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion Award to recognize exceptional DEI efforts in US residency programs.To identify strategies and best practices that exemplary US GME programs use to improve DEI.This qualitative study performed an exploratory content analysis of award applications submitted to the ACGME over 2 cycles in 2020 and 2021, using the constant comparative method. The research team first acknowledged their own biases related to DEI, used caution to not overinterpret the data, and performed several cross-checks during data analysis to ensure confirmability of the results. A preliminary codebook was developed and used during regular adjudication sessions. Disagreements were discussed until agreements were reached.Foundational  and aspirational  DEI strategies used by exemplary GME programs.This qualitative study included 29 award applications submitted between August 17, 2020, and January 11, 2022. Strategies spanned the education continuum from premedical students through faculty. Foundational strategies included working with schools, community colleges, and 4-year college campuses; providing structured support for visiting students; mission-driven holistic review for admissions and selection; interviewer trainings on implicit bias mitigation and on how racism and discrimination impact admission processes and advancement; interview-day DEI strategies; inclusive selection and DEI committees; mission statements that include DEI; and retention efforts to improve faculty diversity. Aspirational strategies included development of longitudinal bidirectional collaborations  with organizations working with applicants who were historically excluded and underrepresented in medicine, blinding metrics in residency applications, longitudinal curricula on DEI and health equity, and faculty mentoring such as affinity groups, mentored research, and joint academic-community recruitments. Findings provide residency program leadership with a menu of options at various inflection points to foster DEI within their programs.The findings of this qualitative study suggest that GME programs might adopt strategies of exemplary programs to improve DEI in residency, ensure compliance with accreditation standards, and improve health outcomes for all. This qualitative study performs an exploratory content analysis to investigate what strategies and best practices are used by graduate medical education programs to improve diversity, equity, and inclusion in their programs with detailed narratives from residency program applicants. This policy standard mandates that all GME training programs engage in “practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce6 Using the detailed narratives from ACGME-accredited residency programs applying for the Barbara Ross-Lee, DO, Diversity, Equity, and inclusion award, we performed an exploratory content analysis to investigate the following research question: “What strategies and best practices do GME programs use to improve DEI in their programs?”To recognize efforts to achieve DEI, the ACGME launched the Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion Award.SRQR) reporting guideline and was deemed exempt from further review by the Institutional Review Board at the Yale University School of Medicine because it was not considered human participant research. Each winter starting in 2020, the ACGME issues a call for applications for the Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion Award.6 US residency programs, sponsoring institutions, and specialty organizations are eligible to apply. Applicants describe program efforts to increase diversity in GME and pre-GME (inclusive of any level of learner before they enter GME) and assessment of their impact . In consultation with the ACGME’s Department of DEI, a research task force led by two of us (D.B. and T.L.F.) analyzed all applications submitted by GME programs (only) in 2020 (n = 22) and 2021 (n = 7) to develop a roadmap of strategies and best practices. Applications ranged from 9 to 152 pages in length. The research team was unaware of which applicants received awards and reviewed all applications as self-nominated exemplars.This qualitative study followed the Standards for Reporting Qualitative Research (underrepresented minority (URM) and underrepresented in medicine (URiM) to describe communities involved in their efforts. We retained terms used by each program and preferentially used the phrases historically excluded and UriM when making overarching comments about the study findings.Programs used the terms 7; our analytic approach included these 4 categories in our analysis. Three members of the research team with prior experience in qualitative research  led the analytical approach. Members of the team had expertise in ACGME (W.M.), GME (S.S.), workforce diversity (T.L.F.), and pre-GME DEI (M.L. and A.J.S.).Since limited literature exists regarding a cohesive framework of strategies for GME programs, we used an inductive approach. Although we were open to exploratory and yet-to-be identified results, we were sensitized in our approach to the Kellogg Logic Model framework, which allows for the systematic identification of activities, outputs, outcomes, and impact of any program development or implementation8 Therefore, we used caution to not overinterpret the data, and we sought to ask neutral questions during research team adjudication sessions. We additionally performed several cross-checks during data analysis to ensure confirmability of our results.At the beginning of our analysis, our research team acknowledged our own biases related to DEI, inclusive of our preconceived notions about the importance and benefit of pursuing improvements in DEI, strategies that may work best, and/or the limitations of pursuing DEI initiatives based on our own experience in local environments.9 First, to develop a preliminary codebook, all investigators independently reviewed 2 award submissions  to identify general categories. In 2 subsequent team meetings, a preliminary codebook of categories was identified and subsequently used in the analysis. Two investigators (M.L. and M.W.) then analyzed a small sample of the applications , further identifying examples within each category and initial themes and modifying the codebook. The research team held regular adjudication sessions to discuss the categories and themes. Pairs of investigators then independently analyzed all data, with continued adjudication sessions . In these meetings, initial categories and themes were compared for consistency and agreement, and disagreements were discussed until agreements were reached. The discussions also allowed for the deliberation over disagreements, collapsing and modification of codes and categories, and the creation of a conceptual model related to the time phases of DEI strategies, all of which enhanced the credibility of this work.8 Consensus for all disagreements and findings was reached through group discussion. All investigators agreed on final categories, themes, and conceptual models. A web application for managing, analyzing, and presenting qualitative research data  was used for data management.10 The investigators categorized strategies as foundational or aspirational. Strategies were considered foundational if they were commonly cited and had the potential for high impact with small effort, and thereby achievable by all GME programs. The remaining strategies were considered aspirational, with the potential for high impact but requiring greater effort and investment.We approached the data using the constant comparative method.11 Of the 23 programs affiliated with a medical school, 10 were ranked among the top 20 schools with National Institutes of Health funding by the Blue Ridge Institute for Medical Research.12 Programs described DEI efforts focused on residents who were racially or ethnically underrepresented (URM or URiM) and less commonly described efforts focused on LGBTQAI  communities.16 There were no thematic differences in the approach to DEI across specialties. Our analysis identified a phase-based sequence of DEI efforts across the educational continuum. Below we highlight common themes and practices among 15 foundational and 18 aspirational strategies and offer suggestions that all GME programs might consider to promote DEI.Between August 17, 2021, and January 11, 2022, a total of 29 applications were available for analysis, including 4 applications in 2022 submitted by residency programs that also applied in 2021 (25 programs). Of these applications, 17 were from primary care GME programs , 3 were from surgical GME programs , and 5 were from other GME programs  . ProgramOur analysis identified numerous foundational and aspirational strategies used by GME programs to address and improve DEI in their local environments . All proGraduate medical education programs augmented their outreach efforts to focus on growing the number of historically excluded and URiM students. Residency programs were active in prehealth pathway programs and kindergarten through grade 12 schools with teaching in health classes, participating in career fairs and shadowing, or offering workshops in first aid or suturing.23Practices included outreach to community college students, college and university students, and students enrolled in postbaccalaureate programs. One residency cohosted a day-long premedical conference on a community college campus in partnership with MESA , a statewide college and career preparation engine that propels student diversity and achievement in science, technology, engineering, and math.18 Latino Medical Student Association (LMSA),19 Asian Pacific American Medical Student Association (APAMSA),20 and Health Professionals Advancing LGBTQ Equality .21Residents and faculty participated in outreach at events with large numbers of historically excluded and URiM medical  students. These included annual or regional meetings of the Student National Medical Association (SNMA),17 Mentorship with these students and organizations frequently continued after the meetings. Often residency programs used social media platforms to reach a wide audience.22One program made annual recruitment trips to historically Black colleges and universities with medical schools.Several programs reported highly successful funded visiting internship and/or subinternship programs for visiting students. Trainees described the funding for travel, housing, and meals as vital to allowing them to choose visiting internships away from their home institution. Funded visiting internships and/or subinternships both increased the programs’ visibility and served as a successful recruitment strategy for the visiting students. Successful visiting programs included clinical immersions, faculty mentorship, and support for students to envision themselves in academic careers. As many as 25% of the visiting students subsequently matched into the residency program.Many GME programs cited improvements in their review of applicants as critical to the successful recruitment of historically excluded and URiM residents. Programs described using mission-driven holistic approaches to review applications. For example, one program increased emphasis on the “road traveled,” that is, life experiences and community leadership while de-emphasizing numeric metrics . Another program specifically focused on applicants committed to providing medical care to the diverse populations served by the program by examining applicants’ history of service, leadership, and advocacy.Once selected for an interview, several strategies were used to improve the interview experience for historically excluded and URiM applicants. In almost all cases, implicit bias training was required for all interviewers. Some programs additionally required interviewer training on how racism and discrimination impact admission processes and advancement in medical training. In some cases, interviewers were blinded to applicant metrics  or intentionally matched to applicants based on shared background, interests, or experiences. At one program, LGBTQIA and pronoun pins were given to applicants as they began the interview day.To align with the program’s mission statement and to minimize bias in interviews, one program used behavioral interviewing techniques focused on the behaviors the program seeks in residents. Many programs offered an interview day with an intentional DEI and/or inclusion theme. For example, a residency hosted diversity interview days when applicants can opt for a day focused on Black or African American and Latinx applicants. During these expanded interview days, applicants have an opportunity to meet with racial and ethnic minority residents, alumni, and faculty to help them start to build a network of support and encourage them to choose to train there. Other programs used interview questions on DEI and health equity, offered interview day dinners with historically excluded and URiM residents and faculty, and moved away from unstructured interviews to include standard questions that reflect the program’s values, patient population, and clinical practice environment.Graduate medical education programs with diverse resident cohorts ensured that selection committees were populated with historically excluded and URiM faculty, residents, and other stakeholders such as nurses, patients, and community members. At least 1 program paid stipends to URiM committee members.Following the interview, some programs reached out to URiM applicants and/or sponsored second-look events. One program created and supported a group of residents and faculty to focus on the recruitment of individuals who define themselves as URM applicants.“Our first month of residency training at ___ was devoted solely to understanding the historic context of social injustice and civil unrest that resulted in the founding of the institution and its hospital.”—from a GME programEfforts of GME programs focused on the resident experience and retention of residents as faculty were of equal importance. All programs offered curricula on DEI and health equity for some or all residents. Key features included longitudinal (months to years) curricula and didactics, facilitated dialogues, and skill-building sessions on topics such as microaggressions, systemic racism, and the burden of underrepresentation. Programs frequently engaged residents to lead new initiatives. For example, one residency’s LGBTQIA residency group identified and helped fill a critical and underrecognized gap in the training of residents and fellows by providing formal LGBTQIA health competencies training, creating an inclusive forum for LGBTQIA trainees, formally engaging  trainees in an annual Pride event, and contributing to the recruitment of LGBTQIA residents and fellows.Clinical rotations in medically underserved communities were a common intentional strategy. In some programs, these longitudinal experiences were core to the program mission. For example, 1 program embedded community partnerships and advocacy into the entirety of the clinical experiences. Other programs offered shorter tracks  and/or research opportunities on health equity and health disparities. In addition to academic enhancements, programs provided support for historically excluded and URiM residents through peer groups, conferences, book clubs, grand rounds, and wellness programming focused on equity and inclusion.In recognizing the continuing impact of racism and discrimination on its residents, 1 program created resident-led working groups focused on recruitment and representation, resident education, research, resident well-being, advocacy for underresourced patients and families, and community partnerships. This program has led to system-wide efforts to formalize reporting structures and policies surrounding personally experienced and witnessed discrimination and bias.One program compensated residents for DEI work. Another program made efforts to acknowledge the holy days of the various faiths represented by their trainees, faculty, and staff.Most programs had diversity committees composed of residents, faculty, and staff. Some committees were longstanding, but many had been recently developed at the request of trainees. Well-developed diversity committees were actively engaged in outreach, recruitment, and retention efforts. Committee members were included in interview and ranking committees and often offered personalized outreach to interviewees—an effort that was referenced as critical to enhancing inclusion among many of the historically excluded and URiM trainees. Many residency programs and institutions provided financial and logistical support for resident diversity committees.Programs offered historically excluded and URiM trainee leadership opportunities, DEI excellence awards, and program or institution-wide DEI days. These efforts recognized the unique importance of DEI in their program, institution, or specialty society.Programs that reported successful retention of residents as faculty were intentional in their efforts to support trainees through mentorship, inclusion on research projects, and sponsorship for leadership positions (and through creating positions if they did not yet exist). Programs supported faculty to conduct research in and attend professional development offerings related to DEI and health equity. Faculty mentoring included affinity groups such as Minority Men’s Night, mentored research, and joint academic-community recruitments.24 on residency applicants from US doctor of medicine degree–granting medical schools to ACGME-accredited programs by specialty and self-identified race or ethnicity to compare their percentage of all URiM applicants who applied to their residency program.A key feature of successful programs was using a data-driven continuous quality improvement approach to measuring, monitoring, and disseminating DEI efforts. Most programs tracked the characteristics of applicants, interviewees, interns, and program graduates to monitor the program’s success in recruiting and retaining for diversity, while others modified their DEI practices only after a single self-review or sentinel event leading to self-review. Strategies included surveys to measure GME graduates’ knowledge, self-efficacy, and self-confidence; to monitor their premedical participants’ transitions into medical school or other health professions careers; and to track GME graduates into practice . Another strategy used publicly available data from the Association of American Medical Colleges’s Electronic Residency Application ServiceMany programs disseminated their successes in meetings and peer-reviewed publications. Many URiM GME program faculty are engaged in national organizations focused on diversity and equity  or through specialty societies to provide a national focus on recruiting a diverse physician workforce.Review of applications to the ACGME’s Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion Award identified strategies, themes, and practices for growing the pool of applicants, improving resident recruitment and selection, and enhancing the residency environment. Fifteen strategies were identified as foundational for all programs to consider implementing. Eighteen additional strategies were identified as aspirational targets for programs to consider implementing as part of their robust DEI commitment.Based on the data reviewed from these exemplars in DEI, GME programs should carefully consider adopting the practices outlined herein. Programs might implement 1 or more foundational strategies targeting each group  along the continuum. Alternatively, programs with areas of strength might focus on aspirational strategies in their areas of need. Concurrent focus on recruitment, retention, and inclusion is critical. All efforts require institutional commitment to catalyze and sustain program-level practices, particularly in creating resource-intensive continuous quality improvement strategies. US GME programs deserve recognition for innovative efforts to improve DEI in their programs, yet much work remains to be done, particularly in understanding how sponsoring institution policies and practices impede or facilitate GME diversity.This study has several limitations. First, the applications were from GME programs that self-identified as exemplars in DEI, raising the possibility of selection bias. However, given the limited information in the literature regarding best and emerging strategies used across multiple GME programs, we believe these results have credibility and can be applied to other US GME programs. The number of applications declined from 22 in year 1 to 7 in year 2 for unclear reasons, but in total represent a small but diverse range of specialties, locations, and settings across the US. In addition, there were several areas where promising practices were mentioned but details were lacking, such as reporting discrimination, efforts to retain residents who may experience challenges during training, efforts focused on ethnic populations , or disabled communities. Furthermore, as these were award applications, there was no mention of lessons learned along the way to becoming exemplars, which merits further study with a potential for broad applicability to the numerous GME programs that may not have considered themselves competitive for this award.In this qualitative study of ACGME DEI award applications, we found that GME programs made great efforts to improve DEI. While GME programs attend to their unique strengths and needs, in review of the data and in the opinion of the authors, all GME programs should consider implementing at least 1 foundational effort for each target population, with particular attention to the experience for applicants and interviewees.


While hypertension, diabetes, hypercholesterolemia and high-risk of cardiovascular disease can be easily diagnosed and treated with cost-effective medicines, a large proportion of people remain undiagnosed. We assessed the potential effectiveness, cost, and distributional impact of opportunistically screening for these chronic conditions at outpatient patient departments in Sri Lanka.We used nationally representative data on biomarkers and healthcare utilization in 2019 to model the screening of people aged 40+ without preexisting CVD and without a reported diagnosis of hypertension, diabetes, or hypercholesterolemia. We modelled an intensive one month program that would screen a proportion of those making an outpatient visit to a public or private clinic and follow-up a proportion of those screened to confirm diagnoses. We also modelled a less intensive one year program. The main outcomes were the new diagnoses of any of the chronic conditions. Program costs were calculated and the socioeconomic distributions of individuals screened, new cases diagnosed, and treatments delivered were estimated. Sensitivity analyses varied the probability of screening and follow-up.Using data on 2,380 survey participants who met the inclusion criteria, we estimated that the one month program would diagnose 8.2%  of those with a chronic condition who would remain undiagnosed without the program. The one year program would diagnose 26.9%  of the otherwise undiagnosed and would have a cost per person newly diagnosed of USD 6.82  in the public sector and USD 16.92  in the private sector. New diagnoses would be evenly distributed over the socioeconomic distribution, with public (private) clinics diagnosing a higher proportion of poorer (richer) individuals. Both programs would reduce underdiagnosis among males relative to females.Opportunistic screening for cardiovascular diseases at outpatient clinics in Sri Lanka could be cost-effective and equitable. In most low- and middle-income countries (LMICs), the burden of cardiovascular diseases is increasing , reachinIn 2016, Sri Lanka’s Ministry of Health (MOH) set targets to reduce the prevalence of hypertension by 25% and to reduce mortality due to diabetes and CVD by 20% by 2025 89. The s8Despite the potential for opportunistic screening for cardiovascular disease risk factors at routine medical consultations to deliver cost-effective interventions that help reorient primary care toward management of chronic diseases, it is not common in LMICs 10. In SrThis study aimed to assess the effectiveness, cost, and distributional impact of an opportunistic screening program for high-risk of CVD, along with hypertension, diabetes and hypercholesterolemia, implemented through OP visits of Sri Lankans aged 40 years and older without pre-existing CVD, and without a previous diagnosis of hypertension, diabetes or hypercholesterolemia.We modelled the screening program using data on prevalence of CVD-related chronic conditions, their diagnoses, and healthcare utilization from the 2018/2019 Sri Lanka Health and Ageing Study (SLHAS). This was a nationally representative, stratified, multi-stage cluster random sample of adults aged 18 years and older. Participants attended a field clinic close to their residence where a questionnaire was completed and biomarkers were measured . A medicEach participant had their blood pressure (BP) measured, fasting blood glucose, and lipid profiles (see Supplement 1). Most participants were asked how many OP visits they made to various types of healthcare facilities in a 28-day recall period. Others were randomly assigned to report OP visits in one of two other recall periods.For the modelling exercise, we used the data on biomarkers, reported diagnoses and medication, medical records and criteria given in We identified OP visits to public and private specialist clinics, public and private general clinics, and public Medical Officer of Health clinics as those at which opportunistic screening could potentially be initiated.We modelled a screening process , respectively. This program would place less demands on the day-to-day operation of clinics, but it would run over a longer period.We assumed that 60% of those who would be screened in both the 28-day and one-year programs would attend a follow-up visit irrespective of health status, sociodemographic characteristics, and type of facility initially visited, with this parameter varied in sensitivity analyses from 40% to 80%. A small intervention trial in the US, found that over 60% of participants who were screened and had been told they were at elevated risk for CVD had visited a doctor within three months .The main outcomes were the number of people newly diagnosed with any of the three chronic conditions, this number as a proportion of those who would remain undiagnosed without the program, and the cost per person newly diagnosed. In secondary analysis, we estimated the number and proportion newly diagnosed for each of the three conditions separately.We used binomial probabilities to calculate the probability that a participant would get the initial screen based on the number of OP visits reported over a 28-day period (Supplement 1). For the one-year program, we did not have data on OP visits over a one-year period. Separately for public and private OP visits and by age, sex, and socioeconomic group, we estimated the proportion of participants that would have an OP visit in a year by extrapolating from a model of how the probability of having an OP visit varied for a seven-day, a 14-day and a 28-day recall period (see Supplement 1).The number of patients screened was calculated by multiplying each participant’s sample weight  by their probability of being screened  and summing over all participants. The weights scale the sample and make it representative of the population of Sri Lanka aged 40 years and over. We then calculated the number of patients followed-up by multiplying the number screened by the probability of follow-up (0.6). For each of the chronic conditions, the number of people that would be newly diagnosed by the screening program was the number followed-up who were identified to have that condition using the biomarker data but who were previously undiagnosed . We alsoFollowing the same general procedure, we calculated the number of newly diagnosed cases identified through opportunistic screening at OP visits to public and private facilities separately. The weight of a participant who visited both sectors was distributed proportionately based on the number of visits to each sector and the respective probability of screening. Costs were calculated separately for the public and private sectors. Costs for the public sector were from a government budgetary perspective, and covered consumable, reagent and labour costs for laboratory testing and the cost for a follow-up visit. Costs for the private sector were from a patient perspective, covering prices of laboratory tests and the cost for a follow-up visit, although private sector doctors often do not charge when followingup reports ordered at a previous appointment. Costs were based on prices quoted in the public and private sectors in 2021, which were converted to December 2021 US dollars (US$1 = LKR 201.40) .We used concentration curves and concentration indices  to assesFor both the 28-day and one-year programs, we evaluated the impact of varying the assumed probability of follow-up from 60% to 80% and 40%. We also modelled a one-year program that would have the same screening probabilities and so be as intensive as the 28-day program.Out of 6,668 participants aged 18+, 4,564 were aged 40+, and 4,035 of those in this age group had no history of CVD . After tOver 25% of those who had any undiagnosed chronic condition had an OP visit in the past 28 days . Among pOut of the 3,972 participants used to model the 1-year program—that is, people with no CVD and had data on whether they had a OP visit in the past seven, 14 or 28 days—31%  had an undiagnosed chronic condition. From the model, over half (59%) of those with an undiagnosed chronic condition would have at least one OP visit in a year.Scaled to the Sri Lankan population, we estimated that there would be 2.32 million people  without a previous diagnosis of CVD with an OP visit within a 28-day period that would be eligible for opportunistic screening . Using tWith a less intensive one-year program that would screen lower proportions of those with OP visits, we estimated that about 4.5 million  patients would be eligible for screening, and 3.7 million  of them would be assessed, with 17.0%  of those assessed  being newly diagnosed with at least one chronic condition .The 28-day program would identify 8.0%  of undiagnosed hypertensives, 7.4%  of undiagnosed diabetics and 8.7%  of those with undiagnosed hypercholesterolemia or high CVD risk, in the population aged 40 years or more , and the cost per person diagnosed was US$7.05  . The cosEstimates for the sensitivity analyses are shown in Supplementary Table 5 and 6. The cost per person diagnosed ranged from US$6.44 to US$7.73 in the public sector and US$15.03 to US$25.75 in the private sector. A more intensive one-year program, where probability of assessment was doubled to 60% in the public sector and 55% in the private sector, marginally increased the percentage of newly diagnosed cases from 27% to 32%, with the total cost to the government increasing by a similar amount (16%). The program with the most impact is a one-year program with high probabilities of screening per encounter (60% in the public sector and 55% in the private sector), as well as a high follow-up rate of 80%. Such a program would newly diagnose 42% of undiagnosed cases; the costs per person diagnosed is similar to the one-year base case, and the total cost for the public health sector would be 0.31% of the 2019 annual expenditure on health by the government. The cost per person diagnosed in the government sector reduced by 5% if the follow-up rate increased from 60% to 80%, and increased by about 10% if the follow-up rate reduced from 60% to 40% in both the 28-day and one-year scenarios. For example, in the one-year scenario where the probability of being screened is 30% in the public sector and 28% in the private sector, if the probability of follow-up was lowered from 60% to 40%, the proportion of undiagnosed people that would be newly diagnosed over the course of the year reduces from 27% to 18%, with a 10% increase in the cost per diagnosis from US$6.82 to US$7.53.Opportunistic screening at healthcare encounters has been proposed to increase detection of chronic conditions in LMICs 19. HowevOur study finds that opportunistic screening could moderately increase the detection of people with undiagnosed chronic conditions. With a pragmatic 28-day program in which 60% of OP patients at public clinics and 55% of OP patients at private clinics would be assessed, and only 60% followed-up, we estimated that 8% of people with an undiagnosed chronic condition would be detected. With a one-year program in which the probabilities of assessment on a single encounter were lowered to 30% and 20% for public and private clinics, respectively, 27% of those with an undiagnosed chronic condition would be detected. Furthermore, the distribution of new diagnoses was broadly distributionally neutral: overall, the distribution of people with an undiagnosed chronic condition would become slightly less skewed towards the poor. The detection of new diagnoses would be slightly pro-poor at public clinics and slightly pro-rich at private clinics. Whilst the government could introduce screening that is pro-poor in the public sector, it is likely that there will be spill-on effects in the private sector since most physicians in the private sector are government doctors engaged in dual practice .A major advantage of opportunistic screening over community-based screening is that it makes use of doctors and facilities that are already available. Although such a screening program would require additional resources at several stages, most requirements are likely to be manageable. First, the initial assessment, which involves asking patients a simple set of questions, taking physical measurements, and arranging laboratory tests and follow-up, would require only a slight lengthening of the duration of existing consultations, and could potentially be carried out by several types of healthcare staff, particularly in the public sector . Further9Even in the intensive one-year screening program, the total cost to the government was estimated at USD 3,745,000, which is 0.31% of the total annual public health expenditure for 2019 . A one-yWe modelled a uniform follow-up rate by disease condition because the conditions considered are largely asymptomatic, and there is no disease-based reason to expect a differential in follow-up visit rates. However, follow-up rates may vary, particularly by gender and socioeconomic status. In the sensitivity analysis, higher follow-up rates would reduce the cost per person diagnosed and proportionately increase the percentage of new diagnoses. However, even a one-year program with a probability of screening of 30% and 28% per public and private sector encounter, and a low follow-up rate of 40%, would still newly diagnose 18% of undiagnosed people, with a marginal increase in cost per diagnosed person in the public sector compared to the base case. To increase the impact of the program, reduce cost per diagnosis, and ensure that any expansion of the health system is fully utilized, it is imperative the follow-up rates be increased as much as possible.Whilst richer people were more likely to have a chronic condition, poorer people were more likely be undiagnosed. This is similar to other LMICs 23 with aThere are several limitations to this study. The estimates of doctor visits for the one-year program relied on modelling, although a subanalysis suggests that our model gives a conservative estimate of the number of people who had an OP visit in the past year (Supplement 1). As Sri Lanka undergoes an economic crisis with a depreciating currency and foreign exchange shortage resulting in medicine shortages, advocating for screening programs may be challenging in the short-term , given tThe current community-based screening program for chronic conditions is problematic with limited penetration and systematic difficulty in reaching men. A key strength of this study is that it demonstrates that in a country with relatively low health spending, and where each person on average visits a doctor seven to eight times a year (similar to the OECD average ), and 30The modelling exercise showed that it would be affordable, likely feasible and effective to screen opportunistically for people at high-risk for CVD. Furthermore, such a screening program would address a gender disparity diagnosis by increasing the diagnosis of males disproportionately, and it would slightly reduce socioeconomic inequality in diagnosis. It is important to assess whether the public health system would be able to absorb an estimated 2% increase in outpatient visits arising from the program.The data used in this article are subject to an embargo until late-2022 in accordance with the overall Sri Lanka Health and Ageing Study Open Data policy. Once the embargo expires the data will be shared on reasonable request to the corresponding author.The additional file for this article can be found as follows:10.5334/gh.1174.s1Supplemental Material.Supplement 1 to 3.