A point-of-care pilot randomized intervention to connect patients with cancer-induced financial toxicity to telehealth financial counseling.

PURPOSE: Elevated costs of cancer treatment can result in economic and psychological "financial toxicity" distress. This pilot study assessed the feasibility of a point-of-care intervention to connect adult patients with cancer-induced financial toxicity to telehealth-delivered financial counseling. METHODS: We conducted a three-armed parallel randomized pilot study, allocating newly referred patients with cancer and financial toxicity to individual, group accredited telehealth financial counseling, or usual care with educational material (1:1:1). We assessed the feasibility of recruitment, randomization, retention, baseline and post-intervention COmprehensive Score for Financial Toxicity (COST), and Telehealth Usability Questionnaire (TUQ) scores. RESULTS: Of 382 patients screened, 121 were eligible and enrolled. 58 (48%) completed the intervention (9 individual, 9 group counseling, 40 educational booklet). 29 completed follow-up surveys: 45% female, 17% African American, 79% white, 7% Hispanic, 55% 45-64 years old, 31% over 64, 34% lived in rural areas, 24% had cancer stage I, 21% II, 7% III, 31% IV. Baseline characteristics were balanced across arms, retention status, surveys completion. Mean (SD) COST was 12.4 (6.1) at baseline and 16.0 (8.4) post-intervention. Mean (SD) COST score differences were 6.3 (11.6) after individual counseling, 5.8 (8.5) after group counseling, and 2.5 (6.4) after usual care. Mean TUQ score among nine counseling participants was 5.5 (0.9) over 7.0. Non-parametric comparisons were not statistically meaningful. CONCLUSION: Recruitment and randomization were feasible, while study retention presented challenges. Nine participants reported good usability and satisfaction with telehealth counseling. Larger-scale trials focused on improving participation, retention, and impact of financial counseling among patients with cancer are justified.

Prevalence of Underreported Nicotine Exposure Among US Nonsmoking Adults: A Comparison of Self-Reported Exposure and Serum Cotinine Levels From NHANES 2013-2020.

INTRODUCTION: Secondhand smoke (SHS) poses a significant health risk. However, individuals who do not smoke may be unaware of their exposure, thereby failing to take protective actions promptly. AIMS AND METHODS: We assessed the prevalence of underreported nicotine exposure in a nationally representative sample of US nonsmoking adults using data from the US National Health and Examination Survey. Individuals with underreported nicotine exposure were defined as those who reported no exposure to all tobacco products (traditional tobacco, nicotine replacements, and e-cigarettes) or SHS, yet had detectable levels of serum cotinine (>0.015 ng/mL). We fitted logistic regression models to determine sociodemographic and chronic condition factors associated with underreported nicotine exposure. RESULTS: Our analysis included 13 503 adults aged 18 years and older. Between 2013 and 2020, the prevalence of self-reported SHS exposure, serum cotinine-assessed nicotine exposure, and underreported nicotine exposure among US nonsmokers were 22.0%, 51.2%, and 34.6%, respectively. Remarkably, 67.6% with detectable serum cotinine reported no SHS exposure. Males, non-Hispanic blacks, individuals of other races (including Asian Americans, Native Americans, and Pacific Islanders), and those without cardiovascular diseases were more likely to underreport nicotine exposure than their counterparts. The median serum cotinine value was higher in respondents who reported SHS exposure (0.107 ng/mL) than in those who reported no exposure (0.035 ng/mL). We estimate that approximately 56 million US residents had underreported nicotine exposure. CONCLUSIONS: Over a third of US nonsmokers underreport their nicotine exposure, underlining the urgent need for comprehensive public awareness campaigns and interventions. Further research into sociodemographic determinants influencing this underreporting is needed. IMPLICATIONS: Understanding the extent of underreported nicotine exposure is crucial for developing effective public health strategies and interventions. It is imperative to bolster public consciousness about the risks associated with SHS. Additionally, surveillance tools should also incorporate measures of exposure to outdoor SHS and e-cigarette vapor to enhance the quality of data monitoring. Findings from this study can guide tobacco control initiatives and inform smoke-free air legislation.

Pediatric primary care provider and staff perspectives on the implementation of electronic health record-based social needs interventions: A mixed-methods study.

Introduction: Interventions to address social needs in clinical settings can improve child and family health outcomes. Electronic health record (EHR) tools are available to support these interventions but are infrequently used. This mixed-methods study sought to identify approaches for implementing social needs interventions using an existing EHR module in pediatric primary care. Methods: We conducted focus groups and interviews with providers and staff (n = 30) and workflow assessments (n = 48) at four pediatric clinics. Providers and staff completed measures assessing the acceptability, appropriateness, and feasibility of social needs interventions. The Consolidated Framework for Implementation Research guided the study. A hybrid deductive-inductive approach was used to analyze qualitative data. Results: Median scores (range 1-5) for acceptability (4.9) and appropriateness (5.0) were higher than feasibility (3.9). Perceived barriers to implementation related to duplicative processes, parent disclosure, and staffing limitations. Facilitators included the relative advantage of the EHR module compared to existing documentation practices, importance of addressing social needs, and compatibility with clinic culture and workflow. Self-administered screening was seen as inappropriate for sensitive topics. Strategies identified included providing resource lists, integrating social needs assessments with existing screening questionnaires, and reducing duplicative documentation. Conclusions: This study offers insight into the implementation of EHR-based social needs interventions and identifies strategies to promote intervention uptake. Findings highlight the need to design interventions that are feasible to implement in real-world settings. Future work should focus on integrating multiple stakeholder perspectives to inform the development of EHR tools and clinical workflows to support social needs interventions.

Type, Timing, Frequency, and Durability of Outcome of Physical Therapy for Parkinson Disease: A Systematic Review and Meta-Analysis.

Importance: Parkinson disease (PD) is a neurodegenerative syndrome affecting approximately 1% of the population older than 60 years, and a major goal of treatment is preservation of physical function through physical therapy (PT). Although PT outcomes for PD are well documented, aggregate information on the parameters of PT are needed to guide implementation. Objective: To evaluate current evidence on the types, timing, frequency, duration, and outcomes of PT regimens applied for PD. Data Sources: PubMed, Embase, Medline, and the Web of Science Core Collection were searched for articles published from January 1, 2000, to August 10, 2022. Search terms included terms related to Parkinson disease, PT interventions, and PT-related outcomes. Study Selection: Included studies were peer-reviewed randomized clinical trials available in English of any PT intervention for patients with PD that included PT-related outcomes. The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed. Data Extraction and Synthesis: Two reviewers extracted data and assessed quality using the Cochrane Risk of Bias Tool. Data were analyzed using a random-effects model. Main Outcomes and Measures: A meta-analysis compared outcomes of nonstandard PT vs standard PT and standard PT vs no intervention for Unified Parkinson's Disease Rating Scale (UPDRS) score and measures of gait and balance. Results: A total of 46 trials with 3905 patients were included (range of mean ages, 61-77 years). Ten trials (22%) compared 2 types of nonstandard PT interventions; 26 (57%), nonstandard PT vs standard PT; and 10 (22%), PT vs no intervention. The most common nonconventional PT intervention was aquatic physiotherapy (5 trials [11%]). Durations of PT regimen ranged from 2 to 12 weeks in 39 trials (85%), and PT was most commonly performed with frequencies of either twice or 3 times weekly (27 [59%]). In most trials (39 [85%]), PT session length ranged from 30 to 60 minutes. Across trials, PT outcomes were reported for gait (14 trials [30%]), balance (10 [22%]), quality of life (3 [9%]), and cognition (1 [2%]). Approximately half of the trials (22 [48%]) documented durability of some level of benefit after completion of the prescribed regimen. Meta-analysis showed no significant difference for PT vs no intervention in UPDRS scores (standardized mean difference [SMD], -1.09; 95% CI, -2.50 to 0.33) or for nonstandard PT vs standard PT in measures of gait (SMD, 0.03; 95% CI, -0.53 to 0.59), balance (SMD, 0.54; 95% CI, -0.03 to 1.12), and UPDRS score (SMD, -0.49; 95% CI, -1.04 to 0.06). Meta-analytic regression of moderators revealed no significant differences in outcomes by frequency of PT per week (SMD, 0.17; 95% CI, -0.03 to 0.36). Conclusions and Relevance: The findings suggest that although a wide range of types and regimens of PT for PD have been tested, comparative effectiveness of different models of care and implementation strategies as well as long-term durability of their outcomes remain undetermined.

Parent Perspectives on Electronic Health Record-Based Social Needs Screening and Documentation: A Qualitative Study.

OBJECTIVE: Social needs interventions in clinical settings can improve child health outcomes; however, they are not routinely delivered in routine pediatric care. The electronic health record (EHR) can support these interventions, but parent engagement in the development of EHR-based social needs interventions is lacking. The aim of this study was to assess parent perspectives on EHR-based social needs screening and documentation and identify family-centered approaches for screening design and implementation. METHODS: We enrolled 20 parents from four pediatric primary care clinics. Parents completed a social risk questionnaire from an existing EHR module and participated in qualitative interviews. Parents were asked about the acceptability of EHR-based social needs screening and documentation and preferences for screening administration. A hybrid deductive-inductive approach was used to analyze qualitative data. RESULTS: Parents identified the benefits of social needs screening and documentation but expressed concerns related to privacy, fear of negative outcomes, and use of outdated documentation. Some felt self-administered electronic questionnaires would mitigate parent discomfort and encourage disclosure of social needs, while others felt face-to-face screening would be more effective. Parents stressed the importance of transparency on the purpose of social needs screening and the use of data. CONCLUSIONS: This work can inform the design and implementation of EHR-based social needs interventions that are acceptable and feasible for parents. Findings suggest strategies such as clear communication and multi-modal delivery methods may enhance intervention uptake. Future work should integrate feedback from multiple stakeholders to design and evaluate interventions that are family-centered and feasible to implement in clinical settings.

An effectiveness-implementation hybrid trial of phone-based tobacco cessation interventions in the Lebanese primary healthcare system: protocol for project PHOENICS.

BACKGROUND: Tobacco use remains the leading cause of preventable disease, disability, and death in the world. Lebanon has an exceptionally high tobacco use burden. The World Health Organization endorses smoking cessation advice integrated into primary care settings as well as easily accessible and free phone-based counseling and low-cost pharmacotherapy as standard of practice for population-level tobacco dependence treatment. Although these interventions can increase access to tobacco treatment and are highly cost-effective compared with other interventions, their evidence base comes primarily from high-income countries, and they have rarely been evaluated in low- and middle-income countries. Recommended interventions are not integrated as a routine part of primary care in Lebanon, as in other low-resource settings. Addressing this evidence-to-practice gap requires research on multi-level interventions and contextual factors for implementing integrated, scalable, and sustainable cessation treatment within low-resource settings. METHODS: The objective of this study is to evaluate the comparative effectiveness of promising multi-component interventions for implementing evidence-based tobacco treatment in primary healthcare centers within the Lebanese National Primary Healthcare Network. We will adapt and tailor an existing in-person smoking cessation program to deliver phone-based counseling to smokers in Lebanon. We will then conduct a three-arm group-randomized trial of 1500 patients across 24 clinics comparing (1) ask about tobacco use; advise to quit; assist with brief counseling (AAA) as standard care; (2) ask; advise; connect to phone-based counseling (AAC); and (3) AAC + nicotine replacement therapy (NRT). We will also evaluate the implementation process to measure factors that influence implementation. Our central hypothesis is that connecting patients to phone-based counseling with NRT is the most effective alternative. This study will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, supported by Proctor's framework for implementation outcomes. DISCUSSION: The project addresses the evidence-to-practice gap in the provision of tobacco dependence treatment within low-resource settings by developing and testing contextually tailored multi-level interventions while optimizing implementation success and sustainability. This research is significant for its potential to guide the large-scale adoption of cost-effective strategies for implementing tobacco dependence treatment in low-resource settings, thereby reducing tobacco-related morbidity and mortality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05628389, Registered 16 November 2022.

Study protocol of a telephone problem-solving intervention for Spanish-speaking caregivers of veterans post-stroke: an 8-session investigator-blinded, two-arm parallel (intervention vs usual care), randomized clinical trial.

BACKGROUND: Stroke is one of the leading causes of death and the main cause of long-term disability in the United States. The significant risk factors of stroke among Hispanics are well-documented. The majority of stroke survivors return home following a stroke and are cared for by family caregivers. Due to the abrupt nature of strokes, caregivers experience unexpected changes and demands that oftentimes lead to caregiver burden and depression. Given the significant risk factors for stroke in Hispanics and the influence of culture in family norms and family management, we developed a telephone and online problem-solving intervention for Spanish-speaking stroke caregivers. This study tests the impact of a telephone and online problem-solving intervention for Spanish-speaking stroke caregivers on caregiver outcomes. METHODS: The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 290 caregivers from 3 Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a problem-solving intervention that uses telephone and online education and care management tools on the previously developed and nationally available RESCUE en Español Caregiver website. In the usual care group, participants receive the information and/or support caregivers of veterans with stroke normally receive through existing VA resources (e.g., stroke-related information and support). The primary outcome is change in caregiver's depressive symptoms at 1- and 12-weeks post-intervention. Secondary outcomes include changes in stroke caregivers' burden, self-efficacy, problem-solving, and health-related quality of life (HRQOL) and veterans' functional abilities. We will also determine the budgetary impact, the acceptability of the intervention and participation barriers and facilitators for Spanish-speaking stroke caregivers. DISCUSSION: This is an ongoing study. It is the first known randomized controlled trial testing the effect of a telephone and online problem-solving intervention in Spanish for caregivers of veterans post-stroke. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post-stroke. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03142841- Spanish Intervention for Caregivers of Veterans with Stroke (RESCUE Español). Registered on February 23, 2018. Protocol version 8. 08.11.2022.

Implementation of a novel emergency department pain coach educator program: First year experience and evaluation.

Background: The ongoing opioid epidemic and rising number of patients with chronic pain have highlighted the need for alternative and integrative pain management approaches. A number of evidence-based nonpharmacologic pain management strategies are available; however, these approaches remain underutilized due to barriers such as time limitations, cost, and lack of clinician training. The aim of this work was to implement a nonpharmacologic pain coach educator program that addresses these barriers. We report an evaluation of the first year of program implementation in the emergency department of a large safety-net hospital. Methods: We implemented a multimodal pain coach educator program that included education on pain neuroscience and over-the-counter analgesic options, demonstration of integrative techniques, and nonpharmacologic toolkits for home use. Implementation strategies included electronic health record tools, training and promotion, clinical champions, and clinician recognition. We used the RE-AIM framework to guide evaluation of the first year of program implementation using data from the electronic health record, quantitative and qualitative program records, and patient-reported outcomes. Results: In the first year of program implementation 550 pain coach educator sessions were conducted. Upon immediate session completion, 61% of patients felt the program was helpful, 39% were unsure at the time, and none reported session was not helpful. Clinician feedback was overwhelmingly positive. Program cost per patient was $344.35. Adaptations to first year intervention and implementation strategies included modifications of session delivery timing for accommodation of clinical workflows, additions to program content to align with patient characteristics, and changes to patient identification strategies in response to the coronavirus 19 pandemic. Conclusions: The PAMI pain coach educator program provides a model for nonpharmacologic pain management programs which can be scaled up and adapted for other settings. This work demonstrates the importance of intervention and implementation strategy adaptations to enhance program reach and effectiveness.

Effect of a telephone and web-based problem-solving intervention for stroke caregivers on stroke patient activities of daily living: A randomized controlled trial.

OBJECTIVE: To test for effects of a problem-solving intervention for stroke caregivers on stroke survivor activities of daily living. DESIGN: Two-arm parallel randomized clinical trial with repeated measures at 11 weeks and 19 weeks. SETTING: Medical centers for US military Veterans. SUBJECTS: Caregivers of stroke survivors. INTERVENTION: A registered nurse guided caregivers in using problem-solving strategies emphasizing creative thinking, optimism, planning, and expert information to address challenges associated with caregiving. Caregivers in the intervention completed one telephone orientation session followed by eight online, asynchronous messaging center sessions. The messaging center sessions involved (a) education on the Resources and Education for Stroke Caregivers' Understanding and Empowerment website (https://www.stroke.cindrr.research.va.gov/en/), (b) supportive communication between the nurse and caregiver, (c) nurse and caregiver interactions to improve problem-solving, and (d) maintain adherence to discharge planning instructions. MAIN OUTCOME: The Barthel Index was used to measure activities of daily living. RESULTS: 174 participants (standard care n = 88, intervention n = 86) were enrolled at baseline. There were no significant differences between groups at baseline. Change scores in activities of daily living between baseline and 11 weeks were significantly higher in the intervention group than the standard care group (group difference = 6.43, 95% confidence interval: 1.28, 11.58). Group differences in change scores between baseline and 19 weeks were not statistically significant (group difference = 3.89, 95% confidence interval: -3.58, 11.36). CONCLUSIONS: This web-based caregiver intervention improved stroke survivor activities of daily living by 11 weeks, but intervention effects were undetectable after 19 weeks.

Mixed methods evaluation of vaping and tobacco product use prevention interventions among youth in the Florida 4-H program.

INTRODUCTION: Novel prevention programs are developed to address the increase in e-cigarette use (vaping) among children. However, it remains paramount to test their feasibility in rural settings. This pilot study implemented and evaluated the feasibility and outcomes of two innovative programs, CATCH My Breath and smokeSCREEN, among youth in rural settings in Florida. METHODS: We conducted four focus groups with youth aged 11-17 recruited from 4-H rural clubs in Florida. In a subsequent randomized trial, we recruited 82 youth participants and assigned them to one of three arms: CATCH My Breath, smokeSCREEN, or control. CATCH My Breath and smokeSCREEN participants attended online group intervention sessions while the control group received educational material. Pre- and post-surveys were administered to all participants to assess knowledge, susceptibility, perceived positive outcomes and risk perceptions related to tobacco and e-cigarette use. Other feasibility parameters were also assessed. RESULTS: Focus group discussions provided insights about feasibility and informed the implementation of both interventions in terms of delivery format, scheduling of sessions and incentives. After the intervention, CATCH My Breath participants significantly improved their general tobacco-related knowledge (post-pre = 16.21-12.92 = 3.3, p <.01) and risk perceptions towards other flavored tobacco products (post-pre = 19.29-17.71 = 1.6, p <.05). smokeSCREEN participants significantly improved their general tobacco knowledge (post-pre = 18.77-13.77 = 5.0, p <.01), knowledge about e-cigarettes (post-pre = 9.08-6.31 = 2.8, p <.01) and risk perception towards e-cigarettes (post-pre = 24.69-21.92 = 2.8, p <.05). CONCLUSIONS: This study demonstrated feasibility of delivering the interventions via participant engagement, participants' willingness to be randomized, assessment of outcome measures, and exploration of different recruitment methods. Despite the potential positive influence of CATCH My Breath and smokeSCREEN on youth participants, further evaluation with larger samples is needed.

Developing Capacity in Dissemination and Implementation Research in the Eastern Mediterranean Region: Evaluation of a Training Workshop.

As the demand for dissemination and implementation (D&I) research grows globally, there is a need for D&I capacity building in regions where D&I science is underrepresented. The Workshop on Dissemination and Implementation Research in Health (WONDIRH) was aimed for participants in the Eastern Mediterranean region to (1) appreciate the complex process of bridging research and practice in a variety of real-world settings, and (2) develop research that balances rigor with relevance and employs study designs and methods appropriate for the complex processes involved in D&I. The present exploratory study investigates participants' satisfaction with the workshop, the enhancement of their self-rated confidence in D&I skills, as well as their intention to apply the learned content into practice. The workshop included four weekly 90-min virtual interactive training sessions in conjunction with open access content from the National Cancer Institute Training Institute in Implementation and Dissemination Research in Cancer (TIDIRC). We applied a one-group pre-post design for the evaluation of workshop. Participants were invited to self-rate their confidence in D&I competencies (15 items, pre and post workshop). At the end of the workshop, participants additionally were asked to rate their satisfaction (5 items, 1-5 scales), and their intention to apply the learned content into practice (4 items, 1-5 scales). Of the 77 workshop participants, 34 completed the evaluation. Confidence improved between pre- and post-workshop assessments in all 15 self-rated D&I competencies. Respondents were generally satisfied with the workshop (mean satisfaction range 3.82-4.26 across the 5 items) and endorsed intentions to apply workshop topics (mean intention range 4.03-4.35 across the 4 items). This initial workshop demonstrated the ability to attract and engage participants to enhance their confidence in D&I research competencies and skills and to build capacity in D&I research. Future efforts should consider offering targeted training for researchers at different stages and to clearly articulate learning objectives. Supplementary Information: The online version contains supplementary material available at 10.1007/s43477-022-00067-y.

Feasibility of a primary care patient decision aid for smoking cessation with information about e-cigarettes.

Decision aids can promote shared decision making and behavior change and may be effective in helping patients quit smoking. Patients are increasingly using e-cigarettes for smoking cessation; however, little is known about the impact of including e-cigarette information in smoking cessation decision aids. Our objective was to assess the feasibility and acceptability of a smoking cessation decision aid including e-cigarette information. This study was conducted at one family medicine clinic in the United States. We used a pre-post design. In Phase I, the decision aid presented information about approved cessation methods. In Phase II, current e-cigarette users and patients with no intention of quitting received additional information on switching to e-cigarettes. We assessed the impact of the decision aids on quit attempts and abstinence, confidence and readiness to quit, confidence and readiness to switch to e-cigarettes, and patient satisfaction. We enrolled 60 patients in each phase (N = 120). Patients reported higher confidence and readiness to quit after viewing the decision aids and consulting with their physician (p < 0.01). Patients reported the decision aid helped prepare them to make a decision about quitting smoking and expressed satisfaction with the decision aid and clinician consultation. We did not observe an impact of including e-cigarette information. Smoking cessation decision aids are acceptable to patients and may promote behavior change. Future studies should explore the impact of providing patients e-cigarette information using larger sample sizes and rigorous designs. Further research is needed to identify strategies to promote shared decision-making regarding e-cigarettes.

Implementation strategies for integrating tobacco cessation treatment in cancer care: A qualitative study.

Purpose: The objective of this study was to determine how to optimize implementation of tobacco cessation treatment interventions in cancer care by (1) investigating the feasibility and acceptability of a multi-level approach to tobacco cessation treatment intervention, (2) identifying barriers and facilitators to implementation, and (3) eliciting additional strategies to improve implementation of the intervention. Methods: We conducted qualitative interviews with oncologists (n = 15) from one large academic health center in the Southeastern United States. We asked about their knowledge, attitudes, and current practices regarding tobacco use screening and treatment. We also asked about two proposed strategies to support implementation of tobacco cessation treatment: (1) developing a registry of tobacco users in collaboration with the state-run tobacco cessation program, and (2) providing on-site tobacco cessation counseling from trained professionals. Results: Oncologists saw addressing tobacco use as valuable; however, they felt restricted from consistently addressing tobacco use by multi-level barriers such as workload, electronic health record (EHR) design, patient anxiety, and low self-efficacy for treating tobacco dependence. Oncologists responded positively to on-site treatment and felt this strategy would increase treatment accessibility and enhance engagement. Reaction to developing a registry of tobacco users was mixed, with concerns regarding lack of oncologist involvement and patient privacy expressed. Other suggested strategies for supporting implementation of tobacco cessation treatment included reducing referral complexity, establishing financial or quality incentives for oncologists, and leveraging existing EHR tools to facilitate integration of cessation interventions into clinic workflows. Conclusion: We identified several challenges to implementing tobacco use treatment in cancer care; however, we considered strategies to overcome these barriers that were viewed as feasible and acceptable. Our work highlights the importance of engaging stakeholders in implementation efforts. Future work should explore the impact of the implementation strategies identified in this study.

Disparities in Pediatric Patient Portal Activation and Feature Use.

OBJECTIVE: Disparities in adult patient portal adoption are well-documented; however, less is known about disparities in portal adoption in pediatrics. This study examines the prevalence and factors associated with patient portal activation and the use of specific portal features in general pediatrics. MATERIALS AND METHODS: We analyzed electronic health record data from 2012 to 2020 in a large academic medical center that offers both parent and adolescent portals. We summarized portal activation and use of select portal features (messaging, records access and management, appointment management, visit/admissions summaries, and interactive feature use). We used logistic regression to model factors associated with patient portal activation among all patients along with feature use and frequent feature use among ever users (ie, ≥1 portal use). RESULTS: Among 52 713 unique patients, 39% had activated the patient portal, including 36% of patients aged 0-11, 41% of patients aged 12-17, and 62% of patients aged 18-21 years. Among activated accounts, ever use of specific features ranged from 28% for visit/admission summaries to 92% for records access and management. Adjusted analyses showed patients with activated accounts were more likely to be adolescents or young adults, white, female, privately insured, and less socioeconomically vulnerable. Individual feature use among ever users generally followed the same pattern. CONCLUSIONS: Our findings demonstrate that important disparities persist in portal adoption in pediatric populations, highlighting the need for strategies to promote equitable access to patient portals.

Concordance Between Electronic Health Record and Tumor Registry Documentation of Smoking Status Among Patients With Cancer.

PURPOSE: Patients with cancer who use tobacco experience reduced treatment effectiveness, increased risk of recurrence and mortality, and diminished quality of life. Accurate tobacco use documentation for patients with cancer is necessary for appropriate clinical decision making and cancer outcomes research. Our aim was to assess agreement between electronic health record (EHR) smoking status data and cancer registry data. MATERIALS AND METHODS: We identified all patients with cancer seen at University of Florida Health from 2015 to 2018. Structured EHR smoking status was compared with the tumor registry smoking status for each patient. Sensitivity, specificity, positive predictive values, negative predictive values, and Kappa statistics were calculated. We used logistic regression to determine if patient characteristics were associated with odds of agreement in smoking status between EHR and registry data. RESULTS: We analyzed 11,110 patient records. EHR smoking status was documented for nearly all (98%) patients. Overall kappa (0.78; 95% CI, 0.77 to 0.79) indicated moderate agreement between the registry and EHR. The sensitivity was 0.82 (95% CI, 0.81 to 0.84), and the specificity was 0.97 (95% CI, 0.96 to 0.97). The logistic regression results indicated that agreement was more likely among patients who were older and female and if the EHR documentation occurred closer to the date of cancer diagnosis. CONCLUSION: Although documentation of smoking status for patients with cancer is standard practice, we only found moderate agreement between EHR and tumor registry data. Interventions and research using EHR data should prioritize ensuring the validity of smoking status data. Multilevel strategies are needed to achieve consistent and accurate documentation of smoking status in cancer care.

Mixed-methods economic evaluation of the implementation of tobacco treatment programs in National Cancer Institute-designated cancer centers.

BACKGROUND: The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications. METHODS: We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs. RESULTS: Median total monthly operating costs across funded centers were $11,045 (range: $5129-$20,751). The largest median operating cost category was personnel ($10,307; range: $4122-$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17-$573), materials ($6-$435), training ($96-$516), technology ($171-$2759), and equipment ($10-$620). Median cost-per-participant was $466 (range: $70-$2093) and cost-per-quit was $2688 (range: $330-$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications. CONCLUSIONS: Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Cost evaluation of tobacco control interventions in clinical settings: A systematic review.

Elucidating the cost implications of tobacco control interventions is a prerequisite to their adoption in clinical settings. This review fills a knowledge gap in characterizing the extent to which cost is measured in tobacco control studies. A search of English literature was conducted in the following electronic databases: MEDLINE, EconLit, PsychINFO, and CINAHL using MeSH terms from 2009 to 2018. Studies were reviewed by two independent reviewers and included if they were conducted in U.S. inpatient or outpatient facilities and reported costs associated with a tobacco control intervention. They were categorized according to evaluation type, clinical setting, target population, cost measures, and stakeholder perspective. Bias risk was evaluated for RCTs. Seventeen publications were included, representing counseling interventions (n = 8) and combination (i.e., counseling and pharmacotherapy) interventions (n = 9). Studies were categorized by evaluation type: cost-effectiveness analysis (n = 10), cost utility analysis (n = 3) and cost identification (n = 4). The selected studies targeted the following populations: general adults (n = 6), hospitalized/inpatient (n = 4), military/veterans (n = 4), individuals with low socioeconomic status (n = 4), mental health or medical comorbidities (n = 2), and pregnant women (n = 2). Intervention costs included personnel, medication, education material, technology, and overhead costs. Stakeholder perspectives included: healthcare organization (n = 10), payer (n = 8), patient (n = 2), and societal (n = 1). Few studies have reported the cost of tobacco control interventions in clinical settings. Cost is a critical outcome that should be consistently measured in evaluations of tobacco control interventions to promote their uptake in clinical settings.

Primary Care Physician Perspectives on Recommending E-cigarettes to Smokers: a Best-Worst Discrete Choice Experiment.

BACKGROUND: Recent clinical trials suggest that e-cigarettes may be more effective for smoking cessation than traditional cessation aids, yet primary care physician (PCP) practices regarding e-cigarette recommendations for smokers have not been studied in-depth. OBJECTIVE: To identify factors influencing PCP recommendation of e-cigarettes for smoking cessation. DESIGN: Discrete choice experiment and survey. PARTICIPANTS: Florida PCPs. MEASURES: The survey included a discrete choice experiment in which PCPs indicated whether they would recommend e-cigarettes for each of 8 hypothetical patient profiles with the following contrasting characteristics: e-cigarette use, interest in approved cessation methods, smoking intensity, prior experience with approved cessation medications, quit intention, age, and comorbidity. Responses were summarized using descriptive statistics and standardized scores (SS). KEY RESULTS: The sample (n = 216) was predominately male (76%), white (66%), and non-Hispanic (78%), and most respondents had held their medical degree for 20+ years (77%). The response rate was 28.7%. Most PCPs thought e-cigarettes were at least somewhat effective for smoking cessation (66%) and lowering disease risk (65%); 31% perceived e-cigarettes to be equally/more effective than traditional cessation aids. PCPs were split regarding whether e-cigarettes were less (50%) or equally harmful (38%) as cigarettes. Yet, few were very confident in their ability to counsel patients on e-cigarettes risks (27%) or benefits (15%). PCPs recommended e-cigarettes in 27% of patient profiles they evaluated. The most important factors influencing the decision to recommend or not recommend e-cigarette were patients' prior use of nicotine replacement therapy with (SS = 0.22, 95% CI = 0.17-0.27) and without use of other medications for cessation (SS = 0.18, 95% CI = 0.13-0.23), and being middle age (50 years old) with chronic obstructive pulmonary disease (SS = 0.16, 95% CI = 0.10-0.23). CONCLUSIONS: Considering the increased patient use of e-cigarettes and increasing use for cessation, this study highlights the need for guidelines and education to aid PCPs' counseling of patients about e-cigarette use.