Osteopathic physician (D.O.) residency programs that do not achieve accreditation under the new Single Accreditation System (SAS) standards by June 30, 2020 will lose access to their share of more than $9,000,000,000 of public tax dollars. This U.S. Centers for Medicare & Medicaid Services (CMS) funding helps sponsoring institutions cover direct and indirect resident physician training expenses. A significant financial burden would then be shifted to marginal costs of the residency program’s sponsoring institution in the absence of CMS funding. The sponsoring institution’s ability or willingness to bare these costs occurs during a time when hospital operating margins are at historic lows (Advisory.com /Daily Briefing /May 18, 2017 | The Daily Briefing / Hospital profit margins declined from 2015 to 2016, Moody's finds). Loss of access to CMS funding may result in potentially cataclysmic reductions in the production and availability of primary care physicians for rural and urban underserved populations. Which osteopathic residency programs will be able to survive the new accreditation requirement changes by the 2020 deadline? What are some of the defining attributes of those programs that already have achieved “initial accreditation” under the new SAS requirements? How can the osteopathic programs in the process of seeking the new accreditation more effectively “pivot” by learning from those programs that have succeeded? What are the potential implications of SAS to both access and quality of health care to millions of Americans? This report is based upon a study that examined and measured how osteopathic physician residency programs in the U.S. are accommodating the substantive structural, financial, political and clinical requirements approximately half way through a five-year adaptation period. In 2014, US Graduate Medical Education (GME) physician program accreditation systems formally agreed to operate under a single accreditation system for all osteopathic (D.O) and allopathic (M.D.) programs in the U.S. Since July 1, 2015, the American Osteopathic Association (AOA) accredited training programs have been eligible to apply for Accreditation Council for Graduate Medical Education (ACGME) accreditation. This agreement to create a Single Accreditation System (SAS) was consummated among the AOA, the American Association of Colleges of Osteopathic Medicine (AACOM) and ACGME with a memorandum of understanding. As this research is published, the ACGME is transitioning to be the single accreditor for all US GME programs by June 30, 2020. At that time, the AOA would fully relinquish all its GME program accreditation responsibilities. The new SAS operates under published ACGME guidelines and governance. Business policy and health care resource allocation question motivated this research. Failure of osteopathic programs to “pivot” to the new standards could result in fewer licensed physicians being produced in the high demand primary care field. Potential workforce shortage areas include urban and especially rural populations (CRS Report 7-5700 R44376 Feb 12, 2016). Large physician shortages already have been projected to care for a rapidly aging US population without considering the impact of the GME accreditation changes currently underway (Association of American Medical Colleges 2017 Key Findings report www.aamc.org/2017projections). The goal of this research is to provide osteopathic GME programs practical insights into characteristics of a sample of osteopathic GME programs that have successfully made the “pivot” into SAS requirements and been accredited by ACGME and those that have not. The study seeks to better understand the experiences, decisions, challenges and expectations directly from osteopathic programs directors as they strive to meet the realities of the new SAS requirements. Do programs that are already accredited differ significantly from those that have not? How do characteristics such as program size, geographic locations, clinical program components, program sponsor structure, number and experience of faculty and administration, cost planning and perceived benefits of the movement to SAS factor into successfully meeting the new requirements before the 2020 closing date? A cross-sectional research survey was designed, tested and deployed to a national sample of currently serving osteopathic GME program directors. The survey elicited data about each program’s “pivot” from AOA GME accreditation practices and guidelines to the new Single Accreditation System (SAS). The survey instrument was designed to obtain information about patterns in osteopathic GME program curricula, administrative support functions, faculty training, compliance requirements and program director characteristics shared by those programs that have been granted “initial accreditation” by the Accreditation Council for Graduate Medical Education (ACGME) who administer SAS. Thirty five (35) osteopathic GME program directors responded to the 26 question survey in June 2017. Descriptive statistics were applied and central tendency measures determined. The majority of survey respondents were Doctors of Osteopathic Medicine (D.O.s) from specialty residency programs sponsoring an average of 16 residents. Respondents were mostly non-profit, urban, multi-facility health system locations with an existing affiliation with a research college or university. About half of the programs had completed some form of fiscal due diligence related to the potential cost impact of SAS. None of those surveyed reported utilizing outside consultants to assist in the SAS “pivot” process. Most programs plan to keep the same number of residents while others expressed an interest in expanding or contracting. None of the respondents planned to close their program. The dichotomous dependent variable (DV) was whether or not the Osteopathic GME program had “achieved or not yet achieved initial SAS accreditation” at the time of the survey. A cross tabulation analysis of the DV with potential predictive variables (IV) was conducted and Chi-square and various exact significance tests were applied to gage goodness of fit. Results were grouped into categories that aligned with the five research questions and hypotheses. Several characteristics were shared by those programs that achieved SAS. GME sponsor institutions that currently have dually accredited programs by the AOA and ACGME seemed to be at a distinct advantage. Although they represented a smaller number of total survey respondents (20%), all primary care program participants reported SAS achievement. Directors reported an average of six (6) full-time paid faculty members teaching in their programs and twice that number of preceptor volunteers in the total sample. Realization of any operational cost savings or efficiencies as a result of moving to a single accreditation system was a principle concern for the majority (86%) of GME program director respondents, regardless of current accreditation status, although most felt SAS would result in offering medical student graduates access to all accredited US GME residency and fellowships programs.

Submitted by LORENA MENDES DE CARVALHO LUCIO null (limcarvalho@yahoo.com.br) on 2016-09-12T13:56:26Z No. of bitstreams: 1 TESE FINAL LORENA POS BANCA Repositorio UNESP 12.09.16.pdf: 1673690 bytes, checksum: 578ad77e846c1bc6a83776f9b4d1b8bf (MD5) / Approved for entry into archive by Felipe Augusto Arakaki (arakaki@reitoria.unesp.br) on 2016-09-14T18:44:12Z (GMT) No. of bitstreams: 1 lucio_lmc_dr_bot.pdf: 1673690 bytes, checksum: 578ad77e846c1bc6a83776f9b4d1b8bf (MD5) / Made available in DSpace on 2016-09-14T18:44:12Z (GMT). No. of bitstreams: 1 lucio_lmc_dr_bot.pdf: 1673690 bytes, checksum: 578ad77e846c1bc6a83776f9b4d1b8bf (MD5) Previous issue date: 2016-08-25 / Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / O presente estudo objetivou determinar as concentrações dos resíduos de gases anestésicos (RGA) em salas de operação (SO) e o impacto dessa exposição ocupacional em relação aos danos genômicos e estresse oxidativo em profissionais recém-expostos. O estudo foi conduzido no Hospital das Clínicas, Faculdade de Medicina de Botucatu-UNESP. As concentrações de isoflurano, sevoflurano e óxido nitroso (N2O) foram medidas nas SO por espectrofotometria infravermelha, com equipamento portátil. Sessenta e três médicos residentes, ao final de três anos do Programa de Residência Médica, foram alocados em dois grupos: exposto (Anestesiologia e Cirurgia, n=32) e controle (Clínica Médica, n=31). Amostras de sangue periférico e células bucais foram coletadas e protegidas da luz. Avaliaram-se danos no material genético (teste do cometa - danos basais, purinas e pirimidinas oxidadas em linfócitos; 8-hidroxi-2’-desoxiguanosina no plasma), micronúcleo (MN) em células bucais, proteínas carboniladas, marcadores de lipoperoxidação (malonaldeído e 4-hidroxinonenal) e capacidade antioxidante plasmática (ferric reducing antioxidant power, oxygen radical absorbance capacity e total antioxidant performance). As concentrações médias dos RGA foram superiores aos limites internacionalmente recomendados (2,7 vezes: isoflurano; 4,9 vezes: sevoflurano; 7,2 vezes: N2O). Os grupos não diferiram quanto aos dados demográficos (p>0,05). Detectou-se aumento significativo de danos basais no DNA (p=0,01) e maior frequência de MN em células bucais (2,3 vezes; p=0,07) no grupo exposto em relação ao grupo controle, mas não houve diferença (p>0,05) entre os grupos em relação a todos os marcadores de estresse oxidativo. Em conclusão, o estudo mostra que médicos residentes expostos a altas concentrações de RGA apresentam aumento significativo de danos sistêmicos no DNA e frequência aumentada de instabilidade genômica (MN bucais), mas não de estresse oxidativo. Portanto, este estudo mostra que jovens profissionais já apresentam alterações genômicas, o que reforça a importância do biomonitoramento e da diminuição da exposição aos RGA. / This study determined the waste anesthetic gases (WAG) in operating rooms (OR) and evaluated the impact of the occupational exposure in genetic damage and oxidative stress in medical residents. The study was performed at “Hospital das Clínicas, Faculdade de Medicina de Botucatu-UNESP”. The concentrations of isoflurane, sevoflurane and nitrous oxide (N2O) were measured in ORs. Sixty-three medical residents completing their three-year Medical Residency Program were recruited for the study and were assigned to two groups: exposed group (n=32) of Anesthesiology and Surgery areas and control group (n=31) of Internal Medicine area. Blood and buccal cells were concomitantly collected from both groups and protected from light to measure genetic instability by buccal micronucleus (MN), basal and oxidized DNA damage (comet assay and 8-hydroxy-2′-deoxyguanosine), biomarkers of protein and lipid oxidation, and three different assays for plasma antioxidant activity. Mean WAG concentrations were above international thresholds (2.7-fold: isoflurane; 4.9-fold: sevoflurane; 7.2-fold: N2O). There was no significant difference between groups regarding demographic data. Basal DNA damage (p=0.01) and buccal MN frequency (by 2.3-fold; p=0.07) were increased in the exposed group compared to the control group. Results showed no significant difference for oxidative stress biomarkers between groups. In conclusion, this study shows that medical residents exposed to high WAG concentrations have increased systemic DNA damage and genomic instability (buccal MN), but not oxidative stress. Thus, these young professionals already have genetic damage in the beginning of their career. Our results reinforce the importance of the biomonitoring and also the adequate measures to decrease ambient air pollution in the OR. / FAPESP: 2013/21130-0 / CNPq: 472453/2013-0 / CAPES/PGCI: 14527-13-8

Orientador: Leandro Gobbo Braz / Resumo: O presente estudo objetivou determinar as concentrações dos resíduos de gases anestésicos (RGA) em salas de operação (SO) e o impacto dessa exposição ocupacional em relação aos danos genômicos e estresse oxidativo em profissionais recém-expostos. O estudo foi conduzido no Hospital das Clínicas, Faculdade de Medicina de Botucatu-UNESP. As concentrações de isoflurano, sevoflurano e óxido nitroso (N2O) foram medidas nas SO por espectrofotometria infravermelha, com equipamento portátil. Sessenta e três médicos residentes, ao final de três anos do Programa de Residência Médica, foram alocados em dois grupos: exposto (Anestesiologia e Cirurgia, n=32) e controle (Clínica Médica, n=31). Amostras de sangue periférico e células bucais foram coletadas e protegidas da luz. Avaliaram-se danos no material genético (teste do cometa - danos basais, purinas e pirimidinas oxidadas em linfócitos; 8-hidroxi-2’-desoxiguanosina no plasma), micronúcleo (MN) em células bucais, proteínas carboniladas, marcadores de lipoperoxidação (malonaldeído e 4-hidroxinonenal) e capacidade antioxidante plasmática (ferric reducing antioxidant power, oxygen radical absorbance capacity e total antioxidant performance). As concentrações médias dos RGA foram superiores aos limites internacionalmente recomendados (2,7 vezes: isoflurano; 4,9 vezes: sevoflurano; 7,2 vezes: N2O). Os grupos não diferiram quanto aos dados demográficos (p>0,05). Detectou-se aumento significativo de danos basais no DNA (p=0,01) e maior frequê... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: This study determined the waste anesthetic gases (WAG) in operating rooms (OR) and evaluated the impact of the occupational exposure in genetic damage and oxidative stress in medical residents. The study was performed at “Hospital das Clínicas, Faculdade de Medicina de Botucatu-UNESP”. The concentrations of isoflurane, sevoflurane and nitrous oxide (N2O) were measured in ORs. Sixty-three medical residents completing their three-year Medical Residency Program were recruited for the study and were assigned to two groups: exposed group (n=32) of Anesthesiology and Surgery areas and control group (n=31) of Internal Medicine area. Blood and buccal cells were concomitantly collected from both groups and protected from light to measure genetic instability by buccal micronucleus (MN), basal and oxidized DNA damage (comet assay and 8-hydroxy-2′-deoxyguanosine), biomarkers of protein and lipid oxidation, and three different assays for plasma antioxidant activity. Mean WAG concentrations were above international thresholds (2.7-fold: isoflurane; 4.9-fold: sevoflurane; 7.2-fold: N2O). There was no significant difference between groups regarding demographic data. Basal DNA damage (p=0.01) and buccal MN frequency (by 2.3-fold; p=0.07) were increased in the exposed group compared to the control group. Results showed no significant difference for oxidative stress biomarkers between groups. In conclusion, this study shows that medical residents exposed to high WAG concentrations have increase... (Complete abstract click electronic access below) / Doutor