Factors influencing implementation of a care coordination intervention for cancer survivors with multiple comorbidities in a safety-net system: an application of the Implementation Research Logic Model.

BACKGROUND: Under- and uninsured cancer survivors have significant medical, social, and economic complexity. For these survivors, effective care coordination between oncology and primary care teams is critical for high-quality, comprehensive care. While evidence-based interventions exist to improve coordination between healthcare teams, testing implementation of these interventions for cancer survivors seen in real-world safety-net settings has been limited. This study aimed to (1) identify factors influencing implementation of a multicomponent care coordination intervention (nurse coordinator plus patient registry) focused on cancer survivors with multiple comorbidities in an integrated safety-net system and (2) identify mechanisms through which the factors impacted implementation outcomes. METHODS: We conducted semi-structured interviews (patients, providers, and system leaders), structured observations of primary care and oncology operations, and document analysis during intervention implementation between 2016 and 2020. The practice change model (PCM) guided data collection to identify barriers and facilitators of implementation; the PCM, Consolidated Framework for Implementation Research, and Implementation Research Logic Model guided four immersion/crystallization data analysis and synthesis cycles to identify mechanisms and assess outcomes. Implementation outcomes included appropriateness, acceptability, adoption, and penetration. RESULTS: The intervention was appropriate and acceptable to primary care and oncology teams based on reported patient needs and resources and the strength of the evidence supporting intervention components. Active and sustained partnership with system leaders facilitated these outcomes. There was limited adoption and penetration early in implementation because the study was narrowly focused on just breast and colorectal cancer patients. This created barriers to real-world practice where patients with all cancer types receive care. Over time, flexibility intentionally designed into intervention implementation facilitated adoption and penetration. Regular feedback from system partners and rapid cycles of implementation and evaluation led to real-time adaptations increasing adoption and penetration. DISCUSSION: Evidence-based interventions to coordinate care for underserved cancer survivors across oncology and primary care teams can be implemented successfully when system leaders are actively engaged and with flexibility in implementation embedded intentionally to continuously facilitate adoption and penetration across the health system.

Adaptation of Screening Tools for Social Determinants of Health in Pregnancy: A Pilot Project.

OBJECTIVES: Social determinants of health (SDOH) and stress during pregnancy may contribute to adverse pregnancy outcomes. The objective of this in the field pilot project was to develop a comprehensive screening tool by combining existing validated screeners. Additionally, implement use of this tool within routine prenatal visits and assess feasibility. METHODS: Pregnant patients accessing prenatal care at a single site of an urban Federally Qualified Health Center were recruited during prenatal visits to complete a Social Determinants of Health in Pregnancy Tool (SIPT). SIPT combines a series of questions from existing and well-validated tools and consists of five domains: (1) perceived stress, (2) relationship and family stress, (3) domestic violence, (4) substance abuse, and (5) financial stress. RESULTS: Between April 2018 and March 2019, 135 pregnant participants completed SIPT. Ninety-one percent of patients scored positive on at least one screener, 54% to three or more screeners. CONCLUSIONS: Despite guidelines to screen for SDOH during pregnancy there is no universal tool. Our pilot project demonstrated the concurrent use of adapted screening tools where participants reported at least one area of potential stress, and that linking to resources at the time of a visit is plausible. Future work should examine if screening and point of care linkages of services improves maternal child outcomes.

Supportive Care Needs Among Head and Neck Cancer Patients Prior to Oncologic Treatment: A Prospective, Nested Cross-Sectional Qualitative Analysis.

OBJECTIVES: To qualitatively characterize pretreatment head and neck cancer (HNC) patients' supportive care (SC) needs, attitudes toward SC, and barriers to SC utilization. MATERIALS AND METHODS: A prospective, nested, bi-institutional, cross-sectional pilot study design was employed. Participants were sub-selected from a representative sample of 50 patients newly diagnosed with mucosal or salivary gland HNC or sarcoma of the head and neck. Eligibility criteria included reporting ≥2 unmet needs (according to the Supportive Care Needs Survey-Short Form 34) or clinically-significant distress (National Comprehensive Cancer Network Distress Thermometer score ≥4). Semi-structured interviews were performed prior to initiation of oncologic treatment. Audio-recorded interviews were transcribed and thematically analyzed using NVivo 12.0 (QSR Australia). Thematic findings and representative quotes were interpreted by the entire research team. RESULTS: Twenty-seven patients were interviewed. One-third were treated at the county safety-net hospital and the remainder were treated at the university health system. An equal proportion of patients presented with oral cavity, oropharyngeal, and laryngeal or other tumors. Two significant findings were identified on semi-structured interviews. First, patients did not perceive the relevance of SC prior to treatment. Second, anxiety surrounding the HNC diagnosis and impending treatment dominated in the pretreatment phase. CONCLUSION: Improved HNC patient education about the relevance and importance of SC in the pretreatment setting is needed. Integration of social work or psychological services in HNC clinics is warranted to address patients' cancer-related worry-a discrete, dominant pretreatment SC need.

Unmet Needs and Receipt of Supportive Care Services in Head and Neck Cancer Patients Prior to Oncologic Treatment: A Prospective, Cross-Sectional Pilot Study.

OBJECTIVE: To characterize the supportive care (SC) needs and receipt of SC services among head and neck cancer (HNC) patients prior to oncologic treatment and to explore the influence of social determinants of health on these outcomes. MATERIALS AND METHODS: Newly diagnosed HNC patients were surveyed via telephone prior to oncologic treatment between 10/2019 and 1/2021 using a prospective, cross-sectional, bi-institutional, pilot study design. The primary study outcome was unmet SC needs (Supportive Care Needs Survey-Short Form34 [SCNS-SF34]). Hospital type (university- vs county safety-net) was explored as an exposure. Descriptive statistics were performed using STATA16 (College Station, TX). RESULTS: Among 158 potentially eligible patients, 129 were successfully contacted, 78 met the study criteria, and 50 completed the survey. The mean age was 61, 58% exhibited clinical stage III-IV disease, and 68% and 32% were treated at the university and county safety-net hospital, respectively. Patients were surveyed a median of 20 days after their first oncology visit and 17 days prior to initiation of oncology treatment. They had a median of 24 total needs (11 were met and 13 were unmet) and preferred to see a median of 4 SC services but received care from none. County safety-net patients had comparatively more unmet needs than university patients (14.5 vs 11.5, P = .04). CONCLUSION: Pretreatment HNC patients at a bi-institutional academic medical center report a high number of unmet SC needs with corollary poor receipt of available SC services. Novel interventions to address this significant gap in care are needed.

Substance use and mental health burden in head and neck and other cancer survivors: A National Health Interview Survey analysis.

BACKGROUND: Tobacco dependence, alcohol abuse, depression, distress, and other adverse patient-level influences are common in head and neck cancer (HNC) survivors. Their interrelatedness and precise burden in comparison with survivors of other cancers are poorly understood. METHODS: National Health Interview Survey data from 1997 to 2016 were pooled. The prevalence of adverse patient-level influences among HNC survivors and matched survivors of other cancers were compared using descriptive statistics. Multivariable logistic regressions evaluating covariate associations with the primary study outcomes were performed. These included 1) current cigarette smoking and/or heavy alcohol use (>14 drinks per week) and 2) high mental health burden (severe psychological distress [Kessler Index ≥ 13] and/or frequent depressive/anxiety symptoms). RESULTS: In all, 918 HNC survivors and 3672 matched survivors of other cancers were identified. Compared with other cancer survivors, more HNC survivors were current smokers and/or heavy drinkers (24.6% [95% CI, 21.5%-27.7%] vs 18.0% [95% CI, 16.6%-19.4%]) and exhibited a high mental health burden (18.6% [95% CI, 15.7%-21.5%] vs 13.0% [95% CI, 11.7%-14.3%]). In multivariable analyses, 1) a high mental health burden predicted for smoking and/or heavy drinking (odds ratio [OR], 1.4; 95% CI, 1.0-1.9), and 2) current cigarette smoking predicted for a high mental health burden (OR, 1.7; 95% CI, 1.2-2.3). Furthermore, nonpartnered marital status and uninsured/Medicaid insurance status were significantly associated with both cigarette smoking and/or heavy alcohol use (ORs, 1.9 [95% CI, 1.4-2.5] and 1.5 [95% CI, 1.0-2.1], respectively) and a high mental health burden (ORs, 1.4 [95% CI, 1.1 -1.8] and 3.0 [95% CI, 2.2-4.2], respectively). CONCLUSIONS: Stakeholders should allocate greater supportive care resources to HNC survivors. The interdependence of substance abuse, adverse mental health symptoms, and other adverse patient-level influences requires development of novel, multimodal survivorship care interventions.

Improving Readiness to Manage Intimate Partner Violence in Family Medicine Clinics by Collaboration With a Community Organization.

BACKGROUND AND OBJECTIVES: Primary care clinicians are in a unique position to address intimate partner violence (IPV) in routine clinical practice. The purpose of this study was to improve clinician readiness to identify and manage IPV in four family medicine residency practice sites on the west side of Chicago by partnering with a local domestic violence organization. METHODS: Practice sites included three federally qualified health centers and one hospital-based office. Eligible clinicians included resident and faculty physicians, nurse practitioners, and certified nurse midwives. We assessed readiness using the validated Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS). We used initial survey results (n=53, 73%) to develop a targeted clinician educational intervention by a community organization. We administered the PREMIS tool postintervention at 1 and 6 months, measuring perceived and actual knowledge, preparedness, and practice issues. We performed comparison statistics to assess aggregate change. RESULTS: PREMIS response rates were n=53 (72%), n=32 (47%), and n=36 (49%), for preintervention, 1, and 6 months postintervention, respectively. Mean clinician preparedness score improved significantly at 1 and 6 months (P<.001, P<.009). Mean self-perceived knowledge score improved significantly at 1 month (P<.001) and trended toward improvement at 6 months (P=.07). Actual knowledge trended toward improvement at 1 month (P=.07) and after 6 months (P=.05). Mean practice issues scores did not improve significantly. CONCLUSIONS: Participation in a 45-minute targeted educational intervention improved clinician readiness to manage IPV. Collaborating with a community partner builds a relationship for further referrals and advocacy for patients.

Ready or not--intrapartum prevention of perinatal HIV transmission in Illinois.

OBJECTIVES: The overall readiness of Illinois birthing hospitals to comply with the 2003 Illinois HIV Perinatal Prevention Act and prevent perinatal HIV transmission, and the hospital characteristics that predict readiness were examined. METHODS: Nurse Managers of all 137 Illinois birthing hospitals were surveyed regarding current labor and delivery (L&D) practices for HIV status identification, documentation, testing and zidovudine (AZT) availability in March 2004. Bivariate and multivariable regression analysis was performed. RESULTS: All 137 hospitals returned the surveys. Almost forty seven percent of Illinois birthing hospitals had adequate maternal HIV status documentation on arrival in L&D, 72.3% documented prenatal HIV results in the L&D chart, 65.7% documented prenatal HIV in the newborn chart, 38.7% ordered HIV tests on L&D if no prenatal HIV status was available, and 61.3% had AZT available. Only 17 hospitals (12.4%) met requirements for overall readiness to prevent perinatal HIV transmission. Sixteen hospitals (11.6%) met a minimal level of readiness (prenatal HIV status documentation and AZT availability). CONCLUSIONS: Despite passage of legislation to increase perinatal HIV testing and reduce transmission, Illinois birthing hospitals had an overall low level of readiness to implement the intrapartum interventions that are an essential part of eradicating pediatric HIV infection. Perinatal reduction protocols and implementation guidelines would improve the overall readiness of Illinois birthing hospitals to prevent perinatal HIV transmission.

AZT Availability in Illinois birthing hospitals: is the perinatal HIV prevention safety net in place?

OBJECTIVES: To prevent perinatal HIV transmission, providers must identify HIV status for all women in labor and newborns, and provide timely antiretroviral therapy if necessary. The objective of this study is to evaluate the availability and accessibility of zidovudine (AZT) in Illinois birthing hospitals. METHODS: We surveyed all Illinois birthing hospital pharmacies by telephone in February 2005 regarding availability, accessibility, and protocols surrounding AZT use in the perinatal period. RESULTS: All 137 pharmacies participated. Only 43.1% reported having syrup and IV AZT available and only 37.2% indicated the ability to have AZT available on labor and delivery within 30 min during off hours. Protocols for treating HIV positive women in labor and exposed newborns were available in only 37.2% of pharmacies while 72.4% had protocols for antiretroviral therapy for occupational post-exposure prophylaxis. Variables associated with pharmacies having AZT available included being a major academic hospital and serving a predominately (greater than 96%) white patient population. Timely provision of AZT was more likely to occur in urban, major academic hospitals serving a predominately white population. CONCLUSIONS: In order to further reduce perinatal HIV transmission, availability and timely access to both syrup and IV AZT must be improved in Illinois birthing hospitals.