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PubMed2000

Smoking cessation programs for adolescents.

Many smoking cessation programs for adult smokers are described in the medical and nursing literature. Programs designed to prevent smoking among adolescents and children also are prevalent in the literature. Despite these prevention programs, many adolescents choose to start smoking. Once adolescents begin smoking, it is difficult to find ways to help them quit. Few programs exist that are targeted to help this population with smoking cessation. This article provides an in-depth review of 5 smoking cessation programs designed for adolescents. Each of the programs presents unique strategies for helping teenage smokers quit. Techniques used in these programs include peer leadership, nicotine patch therapy, peer support, computer instruction, and one-on-one counseling with a nurse practitioner. Each program was studied for efficacy with adolescents. Although none of the programs reviewed showed remarkable success, they serve as guides for future program development. Additional programs need to be developed and studied with larger, more diverse populations. Nurses must identify or develop smoking cessation programs that meet the needs of all types of adolescents and are effective in helping them to quit. Once designed, these smoking cessation programs should be made accessible to adolescents in a variety of settings.

Adolescent↗
PubMed2001

Dilemmas of Program Directors: Then and Now.

OBJECTIVE: To describe the current roles and responsibilities of program directors of athletic training education programs accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and to address the dilemmas of program directors' credibility with student athletic trainers, tenure and promotion, and clinical involvement in athletics. DESIGN AND SETTING: We sent a survey to all program directors who direct CAAHEP athletic training education programs. SUBJECTS: Eighty-three of 113 program directors of undergraduate programs participated in the study-a response rate of 73.4%. MEASUREMENTS: The survey consisted of demographic data: degree, age, major, years of experience as program director, and route to certification and questions concerning title, job responsibilities, expectations, and academic appointment. RESULTS: Most respondents (72%) indicated that their title was program director, and they had a median of 9 years of experience. Sixty-two percent had been certified as an athletic trainer for a median of 18.5 years. Forty-three percent had doctoral degrees and held the rank of assistant professor. Ninety-six percent indicated teaching was the primary duty and expectation of their program director's position. CONCLUSIONS: The dilemmas of tenure and promotion, decreased clinical involvement, and student athletic trainers' perceptions of program directors remain problematic. The dilemmas still exist as they did 12 years ago and are becoming more involved due to educational reform. Program directors must be able to communicate their roles and responsibilities to their administrators.

Journal Article↗
PubMed2004

Athletic Training Education Program Directors' Perceptions on Job Selection, Satisfaction, and Attrition.

OBJECTIVE: To determine the potential reasons for becoming a program director and reasons for leaving the program director position within athletic training education programs accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP); in addition, to describe the most and least beneficial and satisfying aspects of the program director position. DESIGN AND SETTING: In 1999, we sent a validated survey to athletic training education program directors of CAAHEP-accredited athletic training education programs. SUBJECTS: Of 113 athletic training education program directors of accredited undergraduate programs, 83 participated, for a response rate of 73.4%. MEASUREMENTS: The survey consisted of open-ended questions regarding potential reasons for becoming a program director and possibly leaving the program direction position and most and least beneficial and satisfying aspects of the position. We used inductive content analysis to determine themes for the responses to the open-ended questions. Descriptive statistics, including percentages, were calculated to report the data. RESULTS: Academic environment was the primary theme for becoming an athletic training education program director and professional appointment was the primary theme for possibly leaving the position. Professional advancement and student growth and success were the primary themes for the most beneficial and satisfying aspects. Workload and student issues and discipline were the primary themes for the least beneficial and satisfying aspects. CONCLUSIONS: Factors that affect job selection, satisfaction, and attrition are related to academic environment, teaching, students, professional advancement, program development/advancement, workload, personal issues, and athletics.

Journal Article↗
PubMed2005

A cost evaluation of the Georgia Stroke and Heart Attack Prevention Program.

INTRODUCTION: Hypertension is a leading cause of stroke, coronary artery disease, heart attack, and heart and kidney failure in the United States, all of which contribute to the rising costs of health care. The Georgia Stroke and Heart Attack Prevention Program is an education and direct service program for low-income patients with hypertension. This project evaluated the cost-effectiveness of the program compared with the following two alternative scenarios: no treatment for high blood pressure and the typical hypertension treatment received in the private sector nationwide (usual care). METHODS: We estimated the preventive treatment costs and number of adverse health events averted (hemorrhagic and ischemic stroke, heart disease, and kidney failure) associated with the Georgia Stroke and Heart Attack Prevention Program in two Georgia health districts. We used program cost and service usage data obtained from the Georgia Department of Human Resources and probabilities and costs of expected adverse events published in peer-reviewed sources. We compared program costs and number of expected adverse health events averted with those expected from 1) no preventive care and 2) usual care for high blood pressure. RESULTS: The Georgia Stroke and Heart Attack Prevention Program was less costly and resulted in better health outcomes than either no preventive care or usual care. Compared with no preventive care in the two districts, the program was estimated to result in 54% fewer expected adverse events; compared with usual care, the program was estimated to result in 46% fewer expected adverse events. Combining the costs of preventive treatment with the costs of expected adverse events, the Georgia Stroke and Heart Attack Prevention Program cost an average of 486 dollars per patient annually, compared with average annual costs of 534 dollars for no care and 624 dollars for usual care. CONCLUSION: Maintaining a publicly financed stroke and heart attack prevention program is more cost-effective and results in greater health benefits than other plausible scenarios. Because the benefits of this program accrue to both the state and federal governments through reduced Medicaid and indigent care expenditures, both the state and federal governments have a financial incentive to support the program.

Antihypertensive Agents↗
PubMed1992

Use of mentor programs in dietetic education.

Persons entering their first professional position can benefit from the career guidance and role models provided by a mentor program. To determine whether mentor programs were being used in dietetic education programs, surveys were mailed to all 667 program directors listed in The American Dietetic Association (ADA) Directory of Dietetic Programs, 1990-1991. Of the 329 (49%) directors who responded, approximately half (47%) reported that their program had never considered including a mentor program. Nonetheless, directors from each of the six dietetic education options reported that their program included a mentor program. Respondents were generous with their comments. Directors identified limited time as the greatest obstacle for implementing mentor programs. Changes in curricular demands were also cited. Program directors indicated a need for more information and models of mentor programs. Networks linking the dietetic practice groups of the ADA Council on Practice and research on mentor programs' effect on retention of dietitians in professional practice are needed.

Data Collection↗
PubMed1991

Comparison of MS-DOS and Macintosh pharmacokinetic analysis programs using a two-compartment, two-infusion dosing scheme.

Pharmacokinetic values derived by three nonlinear least-squares regression computer programs for sets of serum drug concentration data were compared. The three programs selected for comparison were the MS-DOS-based programs PCNONLIN and ADAPT and the Macintosh program BOOMER. Data on serum recainam hydrochloride concentration in 10 patients given an i.v. loading dose followed by a maintenance infusion were fitted by the appropriate models in each program. Samples had been subjected to reverse-phase isocratic high-performance liquid chromatography with ultraviolet light detection; intraday and interday coefficients of variation were less than 8% over the range of concentrations measured. A two-compartment model was used for all regressions. Each program was given identical initial estimates, and the simplex minimization algorithm of each program was used to fit the model to the data. An identical weighting scheme was used for all three programs. The mean pharmacokinetic values estimated by each program for the 10 data sets were essentially identical. Slightly larger rate constants and smaller volume terms were derived by BOOMER. BOOMER yielded the lowest weighted sum of squares and the highest correlation coefficient. A mean concentration-time plot showed that the programs all produced values that described the data very well. The three computer programs used in this analysis derived essentially the same pharmacokinetic values to describe sets of serum drug concentration data. The BOOMER program provides an acceptable alternative to MS-DOS-based programs for pharmacokinetic analysis.

Chromatography, High Pressure Liquid↗
PubMed1997

Family practice residency program directors' views on research.

BACKGROUND AND OBJECTIVES: The culture of family practice training programs does little to convince residents that research is a worthwhile and important activity. The traditional dichotomy between research and clinical medicine persists today, despite an identified clinical mission for research. METHODS: As part of an effort to build the research capacity of family practice training programs, a telephone survey was administered in August 1995 to the program directors of all residency programs listed in the American Academy of Family Physicians 1995 Directory of Family Practice Residency Programs. The directors were asked about their program's research environment, features designed to promote research activity, and the level of resident research productivity. RESULTS: More than half (53.6%) of the program directors felt that their training program actively promotes research. Three out of four indicated that involving residents in research is a goal of their program. However, only four of 10 (40.8%) programs provide specific time for research, and family practice residents appear to be relatively inactive by conventional measures of research productivity. CONCLUSIONS: Research appears to be developing a limited role in family practice training programs. Resident research productivity remains relatively low and may be a result of residency programs not providing specific time for participating in research. However, the program directors' supportive attitudes may contribute to research and scholarly activity becoming an integral part of a family physician's training.

Attitude of Health Personnel↗
PubMed1996

Quality of care at school-aged child-care programs: regulatable features, observed experiences, child perspectives, and parent perspectives.

This study investigates children's experiences at 30 school-aged child-care (SACC) programs. Regulatable features such as total enrollment, child-staff ratio, and staff education were assessed via director report. Observers recorded positive/neutral and negative staff-child interactions, and rated programs in terms of flexibility and age appropriateness. Negative staff-child interactions were more frequent when child-staff ratios were larger and when staff had less formal education. The presence of a greater number of different types of program activities was associated with staff having more frequent positive interactions with children and with observers rating programs as flexible and age appropriate. These regulatable and observed features were examined in relation to children's (N = 180) and parents' (N = 152) perceptions of program psychosocial climate. Children's reports of overall climate, emotional support from staff, and autonomy/privacy provisions were predicted by program features. Children reported poorer program climate when programs had larger enrollments and when observers recorded more frequent negative staff-child interactions. Children had more positive program perceptions when programs offered a greater variety of activities. Children's reports of program climate in addition to observed child-staff ratios were associated with parental perceptions of the programs. Parents had more positive perceptions when child-adult ratios were smaller and when their children reported more positive climates. This study suggests a convergence between observer, child, and parent about factors contributing to quality of after-school programs.

Attitude↗
PubMed2005

Nutrition behavior change among EFNEP participants is higher at sites that are well managed and whose front-line nutrition educators value the program.

Effective programs to promote improved dietary practices among low-income families depend on the motivation and performance of front-line nutrition educators, yet little is known about the work context experienced by nutrition workers or how their perceptions of work context relate to program effectiveness. This research examined the perceived work context of nutrition educators, a multidimensional construct developed through formative research, in the Expanded Food and Nutrition Education Program (EFNEP) in New York State. We proposed that work context, program management, and program and educator characteristics would be related to program effectiveness (reported behavior change among participants). A state-wide survey of paraprofessional Community Nutrition Educators (CNEs) in 30 program sites was conducted and analyzed in relation to program monitoring data. Greater behavior change was reported by participants in sites whose CNEs gave positive ratings to the value of EFNEP (P < 0.02) and to the managerial practices of their supervisors (P < 0.001). To our knowledge, this is the first time that an association was demonstrated between perceived work context at the front lines and effectiveness of a nutrition program. Higher behavior change scores were also reported at sites in which a greater proportion of participants received individual rather than group instruction (P < 0.001). Associations between participants' reported behavior change and CNEs' perceptions of program value and program management suggest that improvements in these areas could enhance nutrition program success.

Attitude of Health Personnel↗
PubMed2006

Educational fellowship programs: common themes and overarching issues.

The trend toward intensive faculty development programs has been driven by a variety of factors, including institutional needs for educational expertise and leadership, as well as individual faculty members' motivation to augment their educational expertise, teaching skills, and leadership skills. The nine programs described in this issue possess several common features that can be ascribed to shared perceptions of pervasive needs coupled with feasible educational resources and strategies to meet these needs. All programs identify a clear set of goals and objectives for their respective curricula. Curriculum domains include not only teaching skills but also educational research, curriculum development, and educational leadership. In spite of many similarities, each program reflects the unique character of its home institution, the faculty, educational resources, and the specific goals of the program. Each program has documented gains in such key outcomes as participant promotions, new leadership positions both locally and nationally, and scholarly productivity in the form of peer-reviewed papers and presentations. Evidence of institutional benefits includes the production of innovative curricula and a pool of educational leaders. The programs have also developed a community of knowledgeable scholars who interact with each other and serve as a catalyst for continuing change and educational improvement. Although each program was developed largely independently of the others, the common elements in their design provide opportunities to evaluate collaboratively the successful aspects of such programs and to share ideas and resources for program curricula between existing programs and with institutions considering implementing new programs.

Adult↗
PubMed1996

A community development and outreach program in geriatric mental health: four years' experience.

OBJECTIVES: To describe a geriatric mental health outreach program based on a community development model and to review 4 years of experience with this program. DESIGN: Program model and description of implementation experience. SETTINGS: A geriatric mental health outreach program of a regional psychiatric hospital, serving a primarily non-urban area, with offices in the community it serves. PARTICIPANTS: The program targets community-dwelling or institutionalized older persons with late-onset mental health problems and/or behavioral disturbances, persons with long-standing psychiatric disorders with age-related changes, and their caregivers. INTERVENTION: The program is a geriatric mental health outreach and consultation service that emphasizes community development and caregiver education. Program components include an interprofessional consultation team, a specialized information and resource service, educational service initiatives, and an ongoing role in planning and coordination activity in the local health care system. MEASUREMENTS: Program monitoring, including a patient database and a description of program activities. RESULTS: Cognitive impairment, behavioral disturbance, physical/medical problems and depression are the most common reasons for referral to the outreach program. Referred patients (mean age 78; 65% female) have usually (almost 90% of cases) been managed at a similar or lower level of care. Program activities have included focused educational initiatives in community and institutional settings and have emphasized the involvement and development of community caregivers and other local resources. CONCLUSION: The program is a multifaceted effort to make efficient use of scarce specialized resources in a manner that is sensitive and responsive to local circumstances and needs. Experience to date has shown evidence of the feasibility and potential benefits of a comprehensive approach to community development and outreach in geriatric mental health.

Aged↗
PubMed2004

International pediatric cardiac assistance in Croatia: results of the 10 year program.

AIM: In an effort to help alleviate the lack of an adequate pediatric cardiac surgical service that existed in Croatia following 1991 the International Childrens Heart Foundation (ICHF) was asked to provide the necessary surgery. Initially, this project was undertaken as a humanitarian program to provide pediatric cardiac operations. After 5 years, the Republic of Croatia financially sponsored the program. The intended purpose of the Government Sponsored Program was to provide staff education, clinical services, and the development of an organized pediatric cardiac service team in country. The surgical results of the humanitarian program and the educational and surgical results of the Government sponsored program are reported. METHODS: Review of 3 separate databases maintained in country and the database of the ICHF in Memphis, Tennessee, was undertaken. Risk classification of the operations performed was performed using the Risk Adjustment in Congenital Heart Surgery method. RESULTS: A total of 32 trips (11 during the Humanitarian Program, and 21 during the Government Sponsored Program) were made between April 1993 and July 2003. A total of 601 primary operations (151 - Humanitarian Program, 450 - Government Sponsored Program) were preformed. Overall mortality in the cardiac surgical department for the Government Sponsored Program was 11%, non-risk adjusted. There were 4 senior surgeons, 3 surgical residents, 6 cardiac anesthesiologists, 2 pediatric intensivists, and 3 pediatric cardiologists involved in the educational program. CONCLUSIONS: The combination of humanitarian and government sponsored pediatric cardiac surgical missions provided 601 Croatian children with operations. Substantial progress was made in the areas of anesthesia, perfusion, and postoperative care in the cardiac surgical intensive care unit. Despite these improvements a number of issues still exist that prevent the development of an independently functioning full service pediatric cardiac program.

Altruism↗
PubMedDate not supplied

Evaluating the impact of a theory-based sexuality and contraceptive education program.

A controlled field study involving 1,444 adolescent males and females 13-19 years of age was performed to compare a sexuality education program based on the health belief model and social learning theory with several publicly funded community-based and school-based interventions. Among males who had never had intercourse prior to participating in the study, those in the experimental program were more likely than those in the comparison programs to maintain abstinence over the next year; there was no program effect, however, among females. Among female adolescents who initiated intercourse after the start of the study, attendees of the comparison programs were more likely to have used an effective contraceptive at most recent intercourse and to have used an effective method more consistently than were those who attended the experimental program; no such association was seen among comparable young men. Both experimental and comparison programs significantly increased the consistent use of effective methods among teenagers who had been coitally active before attending the programs. Among males, however, when preintervention contraceptive efficiency was held constant, the experimental program led to significantly greater contraceptive efficiency during the follow-up year than did the comparison programs; among females, the two approaches produced an equivalent degree of improvement. Finally, prior exposure to sexuality education was associated with greater contraceptive efficiency at the one-year follow-up among almost all sexual-experience and gender groups, regardless of the type of intervention program attended.

Adolescent↗
PubMed2005

Development, implementation, and evaluation of a community- and hospital-based respiratory syncytial virus prophylaxis program.

PURPOSE: To implement and deliver a respiratory syncytial virus prophylaxis (RSVP) program in response to the Canadian Pediatric Society recommendations. METHODS: A novel program was designed to provide inpatient RSVP for at-risk infants cared for in 1 tertiary care newborn intensive care unit (NICU). This inpatient program was part of a coordinated approach to RSVP, designed and implemented by 3 hospitals. An RSVP program logic model was created and used by a multidisciplinary team to evaluate the in-house program and identify areas of program activity requiring improvement. RESULTS: Following the 2000 to 2001 RSV season, a compliance and outcomes audit was performed in the tertiary center; 193 infants were enrolled in the RSVP program and 162 infants had received RSVP in the NICU [Mean = 1.64 doses]. Telephone follow-up with the parents of discharged infants identified that 159 infants (98%) had successfully completed their full course of RSVP. Using the RSVP program logic model, 5 areas for program improvement were identified including infant recruitment, patient transfer/discharge processes, product procurement, preparation/distribution/administration of doses, and healthcare team communication. CONCLUSIONS: Interdisciplinary collaboration is an important factor in the success of the RSVP program and has supported a consistent model of care for the delivery of RSVP. The program logic model provided a useful structure to systematically review the RSVP program in this organization.

Antibiotic Prophylaxis↗
PubMed2005

Variations in adult congenital heart disease training in adult and pediatric cardiology fellowship programs.

OBJECTIVES: The purpose of this study was to evaluate adult congenital heart disease (CHD) training among U.S. cardiology fellowship programs. BACKGROUND: Although training recommendations for caring for adults with CHD exist, the educational patterns and numbers of specialists remain unknown. METHODS: We surveyed U.S. directors of 170 adult cardiology and 45 pediatric cardiology (PC) fellowship programs. Adult program surveys contained 1 single-response and 10 multiple-choice questions; pediatric program surveys contained 1 single-response and 13 multiple-choice questions. RESULTS: Ninety-four adult cardiology fellowship directors (55%) and 34 PC directors (76%) responded. Of adult programs, 70% were in university hospitals and 40% were associated with PC groups. Those with PC-affiliation had more adult CHD clinics (p < 0.02) and more adult CHD inpatient (p < 0.02) and outpatient (p < 0.002) visits than those without PC affiliation. Most PC programs were in children's hospitals (38%) or children's hospitals within adult hospitals (50%). Eighty-two percent had associated adult cardiology programs. Pediatric programs followed adult CHD patients in various care settings. Over one-third of adult and pediatric programs had < or = 3 lectures annually regarding adult CHD. Nine adult and 2 pediatric programs offered adult CHD fellowships, and only 31 adult and 11 pediatric fellows pursued advanced CHD training in the last 10 years. CONCLUSIONS: Adult CHD didactic and clinical experiences for cardiology fellows vary widely. Few programs offer advanced CHD training, and the number of specially trained physicians is unlikely to meet projected workforce requirements. Adult cardiology programs with PC affiliation have increased CHD experience and might provide good educational models.

Adult↗
PubMed2000

Mortality impact of an integrated community cardiovascular health program.

BACKGROUND: Preventing cardiovascular disease through community interventions makes theoretical sense but has been difficult to demonstrate. We set out to determine whether a community cardiovascular health program had an impact on mortality. DESIGN: Program evaluation plus ecologic observational analysis of program encounters and mortality rates with external comparisons. SETTING: Franklin County and two comparison counties in rural Maine. PARTICIPANTS: Program encountered >50% of regional adults, broadly distributed by site, gender, and age. INTERVENTIONS: From 1974 to 1994, a community program, integrated with primary medical care and staffed by professional nurses, provided education, screening, counseling, referral, tracking, and follow-up for cardiovascular risk factors. MAIN OUTCOME MEASURES: Age-adjusted mortality rates (total, heart, coronary, cerebrovascular, cancer) for three counties and Maine, plus annual program encounters. RESULTS: Relative to Maine, the Franklin heart disease death rate was 0.97 at baseline (1960-1969; 95% confidence interval, 0.91 to 1.03), 0.91 during the program (0.85 to 0.97), 0.83 during the 11 years of program growth (0.78 to 0.88), but 1.0 during the 10 years of decreasing encounters. Franklin's total death rate was 1.01 at baseline, 0.95 during the program (0.92 to 0.98), and 0.90 during program growth (0.86 to 0. 94). Results were similar for coronary disease, stroke, and cancer. Relative death rates did not fall in either comparison county. Nurse-client encounters totaled 120,280 over 21 years. Relative to Maine, heart disease death rates correlated inversely with program encounters (r = -0.53) but not with unemployment or physician supply. CONCLUSIONS: Integrated with primary medical care, a comprehensive, nurse-mediated community cardiovascular health program in rural Maine has been associated with significant time-dependent and dose-dependent reductions in cardiovascular and total mortality.

Adult↗
PubMed1999

Staff compliance with and ratings of effectiveness of a prompted voiding program in a long-term care facility.

BACKGROUND: Despite findings that prompted voiding is effective in reducing urinary incontinent (UI) episodes, the prevalence of UI in this population has remained unchanged. It is estimated that 50% of all nursing home residents have UI. Staff involvement is considered a critical factor, yet little is known about staff perception of the effectiveness of prompted voiding. METHODS: This descriptive study of staff perceptions of a prompted voiding intervention was conducted at a university-affiliated 255-bed geriatrics center. A 12-week prompted voiding program was conducted with 17 residents with UI. Baseline continence status was compared with continence status at the end of the program, and a survey was conducted to assess staff perceptions of the program. The aims of the study were: (1) to determine effectiveness of a prompted voiding program, (2) to assess staff perception of overall effectiveness of the prompted voiding program, (3) to assess staff compliance with the prompted voiding program, and (4) to compare staff perception of prompted voiding effectiveness with actual continence outcomes. RESULTS: Overall UI status improved in 5 residents (31%), remained the same in 6 residents (38%), and declined in 5 residents (31%). Sixty-four (73%) of 88 staff members who participated in the program responded to a survey. Staff members were asked to rate their overall impressions of the prompted voiding program, and to rate improvement in continence status for specific residents who participated in the program. Ninety-five percent of staff members thought drier residents were happier; 80% thought the prompted voiding program should continue. Only 52% of staff thought residents participating in the prompted voiding program were better, and 43% perceived no change. A majority (58%) of staff thought compliance with prompted voiding was 80% to 90%; however, unobtrusive observations during the study revealed only 70% compliance. There was no correlation between staff ratings of improvement in continence and actual continence outcomes for individual residents (r = 0.02, P = .709). CONCLUSIONS: Staff reports of compliance with a prompted voiding program were inflated, and they were unable to determine which residents had actually improved and which residents had not improved with regard to UI. These findings suggest that nursing home staff, and particularly nursing assistants, need more meaningful definitions of UI and quantifiable evidence that residents benefit from prompted voiding.

Adult↗
PubMed1984

Perinatal outreach education. A continuation strategy for a basic program.

The Perinatal Continuing Education Program consists of a nine-month intervention with community hospital nurses, physicians, and support personnel. Components include a hospital self-inventory of resources, coordination by community hospital staff, a skills workshop, and self-instructional books. This article outlines a follow-up strategy to the basic program and describes changes in community hospital knowledge and care practices that occur between programs. The follow-up program presented includes a modified coordinators' workshop, identification of updated self-instructional materials for careful study by past participants, and a self-survey of "recommended routines" intended to facilitate change in hospital policies. Otherwise, except for the deletion of the resources inventory, the follow-up program is similar to the basic program. Testing of participants and detailed review of 1435 hospital charts at sequential time periods revealed a decline in mean knowledge scores between programs, higher scores by new participants before follow-up when compared to pre-basic program, a plateau of patient care quality between programs, and a further improvement in patient care quality after the follow-up program. We conclude that a follow-up program is best accepted after three years but that timing is not critical. Evaluation measures suggest that new knowledge and care practices become institutionalized as a result of this program and that altered care practices are not simply a result of improved performance by individuals.

Education, Medical, Continuing↗