The Effect of a Translating Research into Practice (TRIP)‐Cancer Intervention on Cancer Pain Management in Older Adults in Hospice

Background.  Pain is a major concern for individuals with cancer, particularly older adults who make up the largest segment of individuals with cancer and who have some of the most unique pain challenges. One of the priorities of hospice is to provide a pain‐free death, and while outcomes are better in hospice, patients still die with poorly controlled pain. Objective.  This article reports on the results of a Translating Research into Practice intervention designed to promote the adoption of evidence‐based pain practices for older adults with cancer in community‐based hospices. Setting.  This Institutional Human Subjects Review Board‐approved study was a cluster randomized controlled trial implemented in 16 Midwestern hospices. Methods.  Retrospective medical records from newly admitted patients were used to determine the intervention effect. Additionally, survey and focus group data gathered from hospice staff at the completion of the intervention phase were analyzed. Results.  Improvement on the Cancer Pain Practice Index, an overall composite outcome measure of evidence‐based practices for the experimental sites, was not significantly greater than control sites. Decrease in patient pain severity from baseline to post‐intervention in the experimental group was greater; however, the result was not statistically significant ( P  = 0.1032). Conclusions.  Findings indicate a number of factors that may impact implementation of multicomponent interventions, including unique characteristics and culture of the setting, the level of involvement with the change processes, competing priorities and confounding factors, and complexity of the innovation (practice change). Our results suggest that future study is needed on specific factors to target when implementing a community‐based hospice intervention, including determining and measuring intervention fidelity prospectively.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/93516/1/j.1526-4637.2012.01405.x.pd

REDUCTIONS WITHOUT REGRET: DETAILS - AVOIDING BOX CANYONS, ROACH MOTELS, AND WRONG TURNS

The United States is concurrently pursuing the goals of reducing the size of its nuclear weapons force – strategic and non-strategic, deployed and non-deployed – and of modernizing the weapons it continues to possess. Many of the existing systems were deployed 30 to 50 years ago, and the modernization process can be expected to extend over the next decade or more. Given the impossibility of predicting the future over the lifetime of systems that could extend to the end of this century, it is essential that dead ends in force development be avoided, and the flexibility and availability of options be retained that allow for • Scalability downward in the event that further reductions are agreed upon; • Reposturing to respond to changes in threat levels and to new nuclear actors; and • Breakout response in the event that a competitor significantly increases its force size or force capability, In this paper, we examine the current motivations for reductions and modernization; review a number of historical systems and the attendant capabilities that have been eliminated in recent decades; discuss the current path forward for the U.S. nuclear force; provide a view of the evolving deterrence situation and our assessment of the uncertainties involved; and present examples of possibly problematic directions in force development. We close with our thoughts on how to maintain flexibility and the availability of options for which a need might recur in the future

REDUCTIONS WITHOUT REGRET: DETAILS - AVOIDING BOX CANYONS, ROACH MOTELS, AND WRONG TURNS

The United States is concurrently pursuing the goals of reducing the size of its nuclear weapons force – strategic and non-strategic, deployed and non-deployed – and of modernizing the weapons it continues to possess. Many of the existing systems were deployed 30 to 50 years ago, and the modernization process can be expected to extend over the next decade or more. Given the impossibility of predicting the future over the lifetime of systems that could extend to the end of this century, it is essential that dead ends in force development be avoided, and the flexibility and availability of options be retained that allow for • Scalability downward in the event that further reductions are agreed upon; • Reposturing to respond to changes in threat levels and to new nuclear actors; and • Breakout response in the event that a competitor significantly increases its force size or force capability, In this paper, we examine the current motivations for reductions and modernization; review a number of historical systems and the attendant capabilities that have been eliminated in recent decades; discuss the current path forward for the U.S. nuclear force; provide a view of the evolving deterrence situation and our assessment of the uncertainties involved; and present examples of possibly problematic directions in force development. We close with our thoughts on how to maintain flexibility and the availability of options for which a need might recur in the future