Explore the vast range of titles available.

Manchester is among the most socially deprived areas in the UK leading to increased comorbidities, hospital attendances, admissions and deaths.1 Deaths will increase to the levels seen in the pandemic by 20402 3 with 75–90% benefitting from palliative care4 5 and many more home deaths expected.6 In 2015, North Manchester successfully piloted the ‘Midhurst Model’ of community palliative care.7 8 In 2018 this was extended citywide with extra funding from Macmillan, co-produced with service users.9 MethodA service evaluation using qualitative and quantitative data in order to see if the model was successful and met the original aims and objectives.ResultsAims and objectives were mainly achieved. Patients, carers and community staff valued the regular support, 7-day service, single point of access and rapid access to support by appropriate staff. Patients/carers felt supported, respected and listened to, with less need to call other services. GPs and external staff rated the care highly. More time is needed to embed the service for district nurses. A reduction in bed days and preventable admissions was shown, with 90% of admissions deemed appropriate. More patients on the caseload were able to die at home with 89% achieving their preferred place of death. Timely identification of patients, discharge from hospital and advance care planning was promoted. Numbers on the caseloads and contacts increased exponentially. Remote reviews helped protect vulnerable patients. Work with ‘hard to reach’ (e.g. homeless) groups was undertaken. Patients were given bisphosphonates at home for malignant hypercalcaemia. Gaps identified were spiritual and level three psychological support and over representation of cancer and ‘white British’ patients on caseloads.ConclusionThe model of care worked well despite the effects of the pandemic. Financial savings are likely. Investment in community care is required going forwards.ReferencesBuild Back Fairer in Greater Manchester (2021) UCL Institute of Health Equity. Available at: https://www.instituteofhealthequity.org/resources-reports/build-back-fairer-in-greater-manchester-health-equity-and-dignified-lives/build-back-fairer-in-greater-manchester-main-report.pdf (Accessed 10th Aug 2021).Raleigh Veena for the King’s Fund. Invisible deaths: understanding why deaths at home increased during the Covid-19 pandemic. [Online] June 5th, 2021. Available at: https://www.kingsfund.org.uk/blog/2021/06/understanding-why-deaths-home-increased-covid-19-pandemic (Accessed June 10th 2021).ONS Mortality Data. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity (Accessed Aug 10th 2021).Modelling Demand for Palliative Care Service in England (2021) Sue Ryder Available at: https://www.sueryder.org/sites/default/files/2021-03/Modelling_Demand_and_Costs_for_Palliative_Care_Services_in_England%20%281%29.pdf (Accessed Aug 10th 2021).Etkind SN, Bone AE, Gomes B, et al. How many people will need palliative care in 2040? Past trends, future projections and implications for services. BMC Med 2017;15:102. Available at: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0860-2#:~:text=Based%20on%20projection%20method%202,2040%20from%206465%20to%203891 (Accessed June 10th 2021).Bone AE, Gomes B, Etkind SN, et al. What is the impact of population ageing on the future provision of end-of-life care? Population-based projections of place of death. Palliative Medicine 2018;32(2):329–336. Available at: https://journals.sagepub.com/doi/pdf/10.1177/0269216317734435 (Accessed 8th June 2021).Noble B, King N, Hughes P, Winslow M, Melvin J, Brooks J, Bravington A, Ingleton C, Bath P. (2012) Evaluation of the midhurst macmillan specialist palliative care service (real choice project): a community consultant led palliative care service. Macmillan Cancer Support.Yorke J, Prof. A Qualitative Evaluation Report regarding North Manchester Macmillan Palliative Care Support Service (2016). Available at: https://www.mhcc.nhs.uk/wp-content/uploads/2018/08/NMMPCSS-Qualitative_report_FINAL.pdf (Accessed 8th June 2021).Atak, M. Macmillan Supportive and Palliative Care Programme. Service User Report 2019–21. Available at: https://www.manchesterlco.org/app/uploads/2020/08/MMSPCP-User-Involvement-Report-Mid-Programme.pdf (Accessed 8th June 2021).National Palliative and End of Life Care Partnership. 2015. Ambitions for Palliative and End of Life Care: A national framework for local action 2015–2020 and 2021–2026. Available at: https://acpopc.csp.org.uk/system/files/documents/2021-05/FINAL_Ambitions-for-Palliative-and-End-of-Life-Care_2nd_edition.pdf (Accessed Aug 10th 2021).

Background Germline genetic testing is recommended by the National Comprehensive Cancer Network (NCCN) for individuals including, but not limited to, those with a personal history of ovarian cancer, young-onset (< 50 years) breast cancer, and a family history of ovarian cancer or male breast cancer. Genetic testing is underused overall, and rates are consistently lower among Black and Hispanic populations. Behavioral economics-informed implementation strategies, or nudges, directed towards patients and clinicians may increase the use of this evidence-based clinical practice. Methods Patients meeting eligibility for germline genetic testing for breast and ovarian cancer will be identified using electronic phenotyping algorithms. A pragmatic cohort study will test three sequential strategies to promote genetic testing, two directed at patients and one directed at clinicians, deployed in the electronic health record (EHR) for patients in OB-GYN clinics across a diverse academic medical center. We will use rapid cycle approaches informed by relevant clinician and patient experiences, health equity, and behavioral economics to optimize and de-risk our strategies and methods before trial initiation. Step 1 will send patients messages through the health system patient portal. For non-responders, step 2 will reach out to patients via text message. For non-responders, Step 3 will contact patients’ clinicians using a novel “pend and send” tool in the EHR. The primary implementation outcome is engagement with germline genetic testing for breast and ovarian cancer predisposition, defined as a scheduled genetic counseling appointment. Patient data collected through the EHR (e.g., race/ethnicity, geocoded address) will be examined as moderators of the impact of the strategies. Discussion This study will be one of the first to sequentially examine the effects of patient- and clinician-directed strategies informed by behavioral economics on engagement with breast and ovarian cancer genetic testing. The pragmatic and sequential design will facilitate a large and diverse patient sample, allow for the assessment of incremental gains from different implementation strategies, and permit the assessment of moderators of strategy effectiveness. The findings may help determine the impact of low-cost, highly transportable implementation strategies that can be integrated into healthcare systems to improve the use of genomic medicine. Trial registration ClinicalTrials.gov. NCT05721326. Registered February 10, 2023. https://www.clinicaltrials.gov/study/NCT05721326

Background Increased breast density augments breast cancer risk and reduces mammography sensitivity. Supplemental breast MRI screening can significantly increase cancer detection among women with dense breasts. However, few women undergo this exam, and screening is consistently lower among racially minoritized populations. Implementation strategies informed by behavioral economics (“nudges”) can promote evidence-based practices by improving clinician decision-making under conditions of uncertainty. Nudges directed toward clinicians and patients may facilitate the implementation of supplemental breast MRI. Methods Approximately 1600 patients identified as having extremely dense breasts after non-actionable mammograms, along with about 1100 clinicians involved with their care at 32 primary care or OB/GYN clinics across a racially diverse academically based health system, will be enrolled. A 2 × 2 randomized pragmatic trial will test nudges to patients, clinicians, both, or neither to promote supplemental breast MRI screening. Before implementation, rapid cycle approaches informed by clinician and patient experiences and behavioral economics and health equity frameworks guided nudge design. Clinicians will be clustered into clinic groups based on existing administrative departments and care patterns, and these clinic groups will be randomized to have the nudge activated at different times per a stepped wedge design. Clinicians will receive nudges integrated into the routine mammographic report or sent through electronic health record (EHR) in-basket messaging once their clinic group (i.e., wedge) is randomized to receive the intervention. Independently, patients will be randomized to receive text message nudges or not. The primary outcome will be defined as ordering or scheduling supplemental breast MRI. Secondary outcomes include MRI completion, cancer detection rates, and false-positive rates. Patient sociodemographic information and clinic-level variables will be examined as moderators of nudge effectiveness. Qualitative interviews conducted at the trial’s conclusion will examine barriers and facilitators to implementation. Discussion This study will add to the growing literature on the effectiveness of behavioral economics-informed implementation strategies to promote evidence-based interventions. The design will facilitate testing the relative effects of nudges to patients and clinicians and the effects of moderators of nudge effectiveness, including key indicators of health disparities. The results may inform the introduction of low-cost, scalable implementation strategies to promote early breast cancer detection. Trial registration ClinicalTrials.gov NCT05787249. Registered on March 28, 2023.

Background Serious illness conversations (SICs) are an evidence-based approach to eliciting patients’ values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics (“nudges”) that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion—either alone or in combination with clinician nudges that additionally compare performance relative to peers—may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. Methods We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity. Discussion This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies. Trial registration ClinicalTrials.gov , NCT04867850 . Registered on April 30, 2021. Funding National Cancer Institute P50CA244690

Background Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. Methods A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or “nudges”) promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. Discussion This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. Trial registration Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021.

Sheep Farming for Meat and Wool contains practical, up-to-date information on sheep production and management for producers throughout temperate Australia. It is based on research and extension projects conducted over many years by the Department of Primary Industries and its predecessors and the University of Melbourne. The book covers business management, pasture growth and management, nutrition and feed management, drought management, reproductive management, disease management, genetic improvement, animal welfare and working dog health. It also gives seasonal reminders for a spring lambing wool-producing flock, for autumn lambing Merino ewes joined to Border Leicester rams, and for winter lambing crossbred ewes joined to terminal sires. It will guide new and established farmers, students of agriculture and service providers with detailed information on the why and how of sheep production, and will assist farmer groups to initiate activities aimed at increasing their efficiency in specific areas of sheep production.

Angela Mazur makes some great points regarding overweight children and dieting [letter, Aug. 21, \"Don't put children on quick-fix diets\"].