A Systems Approach to Evaluation Metrics: A Case Study of Salvation Farms

This paper examines how integrating systems thinking into nonprofit work and evaluation metrics can help to advance an organization’s mission and clarify that mission to the public. The researcher will utilize her practicum site at Salvation Farms, a small nonprofit in northern Vermont, as a case study to observe the extent to which this organization utilizes systems thinking and how current evaluation metrics can be improved to more effectively inform and involve the community. Salvation Farms’ mission, after all, is to build greater resilience into Vermont’s food system through agricultural surplus management. The researcher offers a literature review on systems thinking and performance measurement and analyzes the results of a mixed methods evaluation of 8 participants through interviews, surveys, and focus groups to answer the research question: to what extent can systems thinking and approaches help redesign performance measurement at Salvation Farms and ultimately help to clarify its mission to the public? Initial findings indicate that while Salvation Farms is growing its programs and community presence, there is still only a superficial understanding of its work, both by those close to the organization and by the general public. Often Salvation Farms’ specific programs are more easily understood or relatable than the overarching philosophy of resource management. This suggests that, even though Salvation Farms is having a meaningful impact on the community, the organization can expand its evaluation metrics, further define its indicators for success, and connect more with state-wide and regional partners to further clarify its role in Vermont’s food system. Improving the systemic linkage with other stakeholders, including the immediate community Salvation Farms operates in, will not only help the organization grow but also help advance the conversation in Vermont regarding how to strengthen the food system

Optimism and Risk of Incident Hypertension: A Target for Primordial Prevention

Aims Optimism is associated with reduced cardiovascular disease risk; however, few prospective studies have considered optimism in relation to hypertension risk specifically. We investigated whether optimism was associated with a lower risk of developing hypertension in U.S. service members, who are more likely to develop high blood pressure early in life. We also evaluated race/ethnicity, sex and age as potential effect modifiers of these associations. Methods Participants were 103 486 hypertension-free U.S. Army active-duty soldiers (mean age 28.96 years, 61.76% White, 20.04% Black, 11.01% Hispanic, 4.09% Asian, and 3.10% others). We assessed optimism, sociodemographic characteristics, health conditions, health behaviours and depression status at baseline (2009–2010) via self-report and administrative records, and ascertained incident hypertension over follow-up (2010–2014) from electronic health records and health assessments. We used Cox proportional hazards regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), and adjusted models for a broad range of relevant covariates. Results Over a mean follow-up of 3.51 years, 15 052 incident hypertension cases occurred. The highest v. lowest optimism levels were associated with a 22% reduced risk of developing hypertension, after adjusting for all covariates including baseline blood pressure (HR = 0.78; 95% CI = 0.74–0.83). The difference in hypertension risk between the highest v. lowest optimism was also maintained when we excluded soldiers with hypertension in the first two years of follow-up and, separately, when we excluded soldiers with prehypertension at baseline. A dose–response relationship was evident with higher optimism associated with a lower relative risk (p \u3c 0.001). Higher optimism was consistently associated with a lower risk of developing hypertension across sex, age and most race/ethnicity categories. Conclusions In a diverse cohort of initially healthy male and female service members particularly vulnerable to developing hypertension, higher optimism levels were associated with reduced hypertension risk independently of sociodemographic and health factors, a particularly notable finding given the young and healthy population. Results suggest optimism is a health asset and a potential target for public health interventions

Relation Between Optimism and Lipids in Midlife

This research examined optimism’s relationship with total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol, and triglycerides. The hypothesis that optimism is associated with a healthier lipid profile was tested. Participants were 990 mostly white men and women from the Midlife in the United States study who were on average 55.1 years old. Optimism was assessed by self-report with the Life Orientation Test. A fasting blood sample was used to assess serum lipid levels. Linear and logistic regression models examined the cross-sectional association between optimism and lipids accounting for covariates such as demographic characteristics (e.g., education) and health status (e.g., chronic medical conditions). After adjusting for covariates, results suggested that greater optimism was associated with higher HDL cholesterol and lower triglycerides. Optimism was not associated with LDL or total cholesterol. Findings were robust to a variety of modeling strategies that took into consideration the effect of treatment for cholesterol problems. Results further indicated that diet and body mass index may link optimism with lipids. In conclusion, this is the first study to suggest that optimism is associated with a healthy lipid profile; moreover, these associations may be explained, in part, by having healthier behaviors and a lower body mass index

Long-term primary results of accelerated partial breast irradiation after breast-conserving surgery for early-stage breast cancer: a randomised, phase 3, equivalence trial

BackgroundWhole-breast irradiation after breast-conserving surgery for patients with early-stage breast cancer decreases ipsilateral breast-tumour recurrence (IBTR), yielding comparable results to mastectomy. It is unknown whether accelerated partial breast irradiation (APBI) to only the tumour-bearing quadrant, which shortens treatment duration, is equally effective. In our trial, we investigated whether APBI provides equivalent local tumour control after lumpectomy compared with whole-breast irradiation.MethodsWe did this randomised, phase 3, equivalence trial (NSABP B-39/RTOG 0413) in 154 clinical centres in the USA, Canada, Ireland, and Israel. Adult women (>18 years) with early-stage (0, I, or II; no evidence of distant metastases, but up to three axillary nodes could be positive) breast cancer (tumour size ≤3 cm; including all histologies and multifocal breast cancers), who had had lumpectomy with negative (ie, no detectable cancer cells) surgical margins, were randomly assigned (1:1) using a biased-coin-based minimisation algorithm to receive either whole-breast irradiation (whole-breast irradiation group) or APBI (APBI group). Whole-breast irradiation was delivered in 25 daily fractions of 50 Gy over 5 weeks, with or without a supplemental boost to the tumour bed, and APBI was delivered as 34 Gy of brachytherapy or 38·5 Gy of external bream radiation therapy in 10 fractions, over 5 treatment days within an 8-day period. Randomisation was stratified by disease stage, menopausal status, hormone-receptor status, and intention to receive chemotherapy. Patients, investigators, and statisticians could not be masked to treatment allocation. The primary outcome of invasive and non-invasive IBTR as a first recurrence was analysed in the intention-to-treat population, excluding those patients who were lost to follow-up, with an equivalency test on the basis of a 50% margin increase in the hazard ratio (90% CI for the observed HR between 0·667 and 1·5 for equivalence) and a Cox proportional hazard model. Survival was assessed by intention to treat, and sensitivity analyses were done in the per-protocol population. This trial is registered with ClinicalTrials.gov, NCT00103181.FindingsBetween March 21, 2005, and April 16, 2013, 4216 women were enrolled. 2109 were assigned to the whole-breast irradiation group and 2107 were assigned to the APBI group. 70 patients from the whole-breast irradiation group and 14 from the APBI group withdrew consent or were lost to follow-up at this stage, so 2039 and 2093 patients respectively were available for survival analysis. Further, three and four patients respectively were lost to clinical follow-up (ie, survival status was assessed by phone but no physical examination was done), leaving 2036 patients in the whole-breast irradiation group and 2089 in the APBI group evaluable for the primary outcome. At a median follow-up of 10·2 years (IQR 7·5-11·5), 90 (4%) of 2089 women eligible for the primary outcome in the APBI group and 71 (3%) of 2036 women in the whole-breast irradiation group had an IBTR (HR 1·22, 90% CI 0·94-1·58). The 10-year cumulative incidence of IBTR was 4·6% (95% CI 3·7-5·7) in the APBI group versus 3·9% (3·1-5·0) in the whole-breast irradiation group. 44 (2%) of 2039 patients in the whole-breast irradiation group and 49 (2%) of 2093 patients in the APBI group died from recurring breast cancer. There were no treatment-related deaths. Second cancers and treatment-related toxicities were similar between the two groups. 2020 patients in the whole-breast irradiation group and 2089 in APBI group had available data on adverse events. The highest toxicity grade reported was: grade 1 in 845 (40%), grade 2 in 921 (44%), and grade 3 in 201 (10%) patients in the APBI group, compared with grade 1 in 626 (31%), grade 2 in 1193 (59%), and grade 3 in 143 (7%) in the whole-breast irradiation group.InterpretationAPBI did not meet the criteria for equivalence to whole-breast irradiation in controlling IBTR for breast-conserving therapy. Our trial had broad eligibility criteria, leading to a large, heterogeneous pool of patients and sufficient power to detect treatment equivalence, but was not designed to test equivalence in patient subgroups or outcomes from different APBI techniques. For patients with early-stage breast cancer, our findings support whole-breast irradiation following lumpectomy; however, with an absolute difference of less than 1% in the 10-year cumulative incidence of IBTR, APBI might be an acceptable alternative for some women.FundingNational Cancer Institute, US Department of Health and Human Services