A Randomized Crossover Trial Evaluating the Impact of Cultural Dexterity Training on Surgical Residents' Knowledge, Cross-Cultural Care, Skills, and Beliefs: The Provider Awareness and Cultural Dexterity Training for Surgeons (PACTS) Trial.

OBJECTIVES: This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs. BACKGROUND: Cross-cultural training of providers may reduce health care outcome disparities, but its effectiveness in surgical trainees is unknown. METHODS: PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between periods 1 and 2, while the Delayed group ("Delayed") received PACTS between periods 2 and 3. Residents were assessed preintervention and postintervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. χ 2 and Fisher exact tests were conducted to evaluate within-intervention and between-intervention group differences. RESULTS: Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6%-88.2%, P <0.0001), Self-Assessed Skills (74.5%--85.0%, P <0.0001), and Beliefs (89.6%-92.4%, P =0.0028) improved after PACTS; knowledge scores (71.3%-74.3%, P =0.0661) were unchanged. Delayed resident scores pre-PACTS to post-PACTS showed minimal improvements in all domains. When comparing the 2 groups in period 2, Early residents had modest improvement in all 4 assessment areas, with a statistically significant increase in Beliefs (92.4% vs 89.9%, P =0.0199). CONCLUSIONS: The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations.

Interaction of Insurance and Neighborhood Income on Operative Colorectal Cancer Outcomes Within a National Database.

INTRODUCTION: Sociodemographic disparities in colorectal cancer (CRC) surgical patients are known. Few studies, however, have examined the intersection of insurance type and median household income (MHI). METHODS: In this retrospective analysis of the National Inpatient Sample from 2000 to 2019, all CRC surgery patients between 50 and 64 y old were included. Patients were further stratified based on insurance type (commercial, Medicaid, and uninsured) as well as county-level MHI quartiles. Outcomes included nonelective surgery (primary outcome), inpatient mortality, complications, and blood transfusions. Multivariate logistic regression adjusted for sociodemographic variables, medical comorbidities, and hospital-level factors. RESULTS: Of 108,606 patients, 80.5% of patients had commercial insurance, while 5.8% were uninsured. On multivariate analysis, Medicaid or no insurance, especially when living in a lower-income community, were associated with significantly higher odds of nonelective surgery (ORs: 1.11-4.54). There was a stepwise effect on nonelective surgery by insurance type (uninsured with lower odds than insured) and MHI (each lower quartile had higher odds). There were similar trends for inpatient blood transfusions, but there were no significant differences in mortality or complications. CONCLUSIONS: Especially when considered together, noncommercial insurance and lower MHI were associated with worse outcomes in CRC patients. Insurance was more protective than MHI against worse outcomes. These findings among a screening-aged cohort have policy planning implications for insurance expansions and healthcare funding allocations. Further research is needed to understand the complex underlying mechanisms that create this interaction between insurance and MHI.

Mental health disorders as a risk factor in young patients with rectal prolapse.

BACKGROUND: Rectal prolapse (RP) typically presents in the elderly, though it can present in younger patients lacking traditional risk factors. The current study compares medical and mental health history, presentation, and outcomes for young and older patients with RP. METHODS: This is a single-center retrospective review of patients who underwent abdominal repair of RP between 2005 and 2019. Individuals were dichotomized into two groups based on age greater or less than 40 years. RESULTS: Of 156 patients, 25 were < 40. Younger patients had higher rates of diagnosed mental health disorders (80% vs 41%, p < 0.001), more likely to take SSRIs (p = .02), SNRIs (p = .021), anxiolytics (p = 0.033), and antipsychotics (p < 0.001). Younger patients had lower preoperative incontinence but higher constipation. Both groups had low rates of recurrence (9.1% vs 11.6%, p = 0.73). CONCLUSIONS: Young patients with RP present with higher concomitant mental health diagnoses and represent unique risk factors characterized by chronic straining compared to pelvic floor laxity.

A Conduit for a Culturally Competent Consent: Medical Interpreters' Perspectives on Surgical Informed Consent Discussions.

OBJECTIVE: To understand medical interpreter's perspectives on surgical informed consent discussions and provide feedback for surgeons on improving these conversations. SUMMARY BACKGROUND DATA: Informed consent is a critical component of patient-centered surgical decision-making. For patients with limited English proficiency (LEP), this conversation may be less thorough, even with a medical interpreter, leaving patients with an inadequate understanding of their diagnosis or treatment options. METHODS: A semi-structured interview guide was developed with input from interpreters and a qualitative research expert. We purposively sampled medical interpreters representing multiple languages until thematic saturation was achieved. Participants discussed their experience with the surgical consent discussion and process. Interview transcripts were analyzed using emergent thematic analysis. RESULTS: Among 22 interpreters, there were ten languages represented and an average experience of 15 years (range 4-40 y). Four major themes were identified. First, interpreters consistently described their roles as patient advocates and cultural brokers. Second, interpreters reported unique patient attributes that influence the discussion, often based on patients' cultural values/expectations, anticipated decisional autonomy, and family support. Third, interpreters emphasized the importance of surgeons demonstrating compassion and patience, using simple terminology, conversing around the consent, providing context about the form/process, and initiating a pre-encounter discussion. Finally, interpreters suggested reducing legal terminology on consent forms and translation into other languages. CONCLUSIONS: Experienced interpreters highlighted multiple factors associated with effective and culturally tailored informed consent discussions. Surgeons should recognize interpreters' critical and complex roles, be cognizant of cultural variations among patients with LEP, and improve interpersonal and communication skills to facilitate effective understanding.

Association between Surgery, Anesthesia, and Obstetric Workforce and Emergent Surgical and Obstetric Mortality among United States Hospital Referral Regions.

OBJECTIVE: To determine the association between SAO workforce and mortality from emergent surgical and obstetric conditions within US HR Rs. BACKGROUND: SAO workforce per capita has been identified as a core metric of surgical capacity by the Lancet Commission on Global Surgery, but its utility has not been assessed at the subnational level for a high-income country. METHODS: The number of practicing surgeons, anesthesiologists, and obstetricians per capita was estimated for all HRRs using the US Health Resources & Services Administration Area Health Resource File Database. Deaths due to emergent general surgical and obstetric conditions were determined from the Center for Disease Control and Prevention WONDER database. We utilized B-spline quantile regression to model the relationship between SAO workforce and emergent surgical mortality at different quantiles of mortality and calculated the expected change in mortality associated with increases in SAO workforce. RESULTS: The median SAO workforce across all HRRs was 74.2 per 100,000 population (interquartile range 33.3-241.0). All HRRs met the Lancet Commission on Global Surgery lower target of 20 SAO per 100,000, and 97.7% met the upper target of 40 per 100,000. Nearly 2.8 million Americans lived in HRRs with fewer than 40 SAO per 100,000. Increases in SAO workforce were associated with decreases in surgical mortality in HRRs with high mortality, with minimal additional decreases in mortality above 60 to 80 SAO per 100,000. CONCLUSIONS: Increasing SAO workforce capacity may reduce emergent surgical and obstetric mortality in regions with high surgical mortality but diminishing returns may be seen above 60 to 80 SAO per 100,000. Trial Registration: N/A.

Thromboprophylaxis Timing After Blunt Solid Organ Injury: A Systematic Review and Meta-analysis.

INTRODUCTION: Trauma patients with blunt abdominal solid organ injuries are at high risk for venous thromboembolism (VTE), but the optimal time to safely administer chemical thromboprophylaxis is controversial, especially for patients who are managed nonoperatively due to increased risk of hemorrhage. We sought to compare failure of nonoperative management (NOM) and VTE events based on timing of chemical thromboprophylaxis initiation. METHODS: A systematic review was conducted in PubMed and Embase databases. Studies were included if they evaluated timing of initiation of chemical thromboprophylaxis in trauma patients who underwent NOM of blunt solid organ injuries. Outcomes included failure of NOM and incidence of VTE. A random-effects meta-analysis was performed comparing patients who received late (>48 h) versus early thromboprophylaxis initiation. RESULTS: Twelve retrospective cohort studies, comprising 21,909 patients, were included. Three studies, including 6375 patients, provided data on adjusted outcomes. Pooled adjusted analysis demonstrated no difference in failure of NOM in patients receiving late versus early thromboprophylaxis (odds ratio [OR] 0.92, 95% confidence interval [CI]:0.4-2.14). When including all unadjusted studies, even those at high risk of bias, there remained no difference in failure of NOM (OR 1.16, 95% CI:0.72-1.86). In the adjusted analysis for VTE events, which had 6259 patients between two studies, patients receiving late chemical thromboprophylaxis had a higher risk of VTE compared with those who received early thromboprophylaxis (OR 1.89, 95% CI:1.15-3.12). CONCLUSIONS: Based on current observational evidence, initiation of prophylaxis before 48 h is associated with lower VTE rates without higher risk of failure of NOM.

Colorectal cancer screening in a safety-net health system: The intersectional impact of race, ethnicity, language, and mental health.

Though rates of colorectal cancer (CRC) screening continue to improve with increased advocacy and awareness, there are numerous disparities that continue to be defined within different health systems and populations. We aimed to define associations between patients' socio-demographic characteristics and CRC screening in a well-resourced safety-net health system. A retrospective review was performed from 2018 to 2019 of patients between 50 and 75-years-old who had a primary care visit within the last two years. Numerous patient characteristics were extracted from the medical record, including self-reported race, self-reported ethnicity, insurance, preferred language, severe mental health diagnoses (SMHD), and substance use disorder (SUD). Multivariate logistic regression assessed characteristics associated with CRC screening. Of 22,145 included patients, 16,065 (72.5%) underwent CRC screening. <40% of the population was White or of North American/European ethnicity and 38% had limited English proficiency. Hispanic patients had the highest screening rate while White patients had the lowest among races (78.1% vs 68.5%, respectively). White patients had higher rates of SMHD and SUD (p < 0.001). In multivariable analysis, most other races (Black, Asian, and Hispanic), ethnicities, and languages had significantly higher odds of screening, ranging from 20% to 55% higher, when White, North American/European, English-speakers are used as reference. In a well-resourced safety-net health system, patients who were non-White, non-North American/European, and non-English-speaking, had higher odds of CRC screening. This data from a unique health system may better guide screening outreach and implementation strategies in historically under-resourced communities, leading to strategies for equitable colorectal cancer screening.

Early C-reactive protein after colorectal surgery is not predictive of anastomotic leak: a retrospective cohort study.

PURPOSE: Prior studies suggest postoperative C-reactive protein (CRP) trends are sensitive for predicting anastomotic leak (AL) after elective colorectal surgery. However, in the setting of enhanced recovery pathways, multi-day CRP trends may not be feasible. This study aimed to assess the realistic and clinical utility of CRP in prediction of AL. METHODS: A retrospective review of patients who underwent elective colectomy or proctectomy from January 2019 to October 2020 at a single institution was performed. Comorbidities, operative characteristics, and perioperative outcomes were recorded. CRP was checked routinely on POD1 and on a clinical basis subsequently. The association between 10-point change in CRP-POD1 and AL was evaluated using multivariable logistic regression. The relationships between CRP-POD3, CRP-POD1, and AL were assessed using exploratory analyses. RESULTS: Among 332 patients, 23 (6.9%) developed AL, of which 9 cases (39%) were diagnosed upon readmission. AL was not associated with mortality. Median length of stay was 3 days (IQR 2-5). Median days to AL diagnosis was 7 (IQR 4-15). Adjusting for diverting stoma, steroid use, diagnosis, and open surgery, each 10-point increase in CRP was associated with increased odds of AL (OR 1.12, 95% CI 1.03-1.21, p=0.008). CRP-POD1 had poor discriminant utility for detecting AL (AUC 0.62, 95% CI = 0.494-0.746; p=0.061). CONCLUSION: CRP on POD1 is not a reliable method to predict a leak, and trending CRP may not be practical with decreasing lengths of stay in colorectal surgery.

Preoperative statin therapy is associated with higher 5-year survival after thoracic endovascular aortic repair.

OBJECTIVE: Statin use is associated with higher long-term survival after abdominal aortic aneurysm repair. However, the association between statin use and survival after thoracic endovascular aortic repair (TEVAR) has not been established. METHODS: We performed a review of prospectively collected data of all patients who had undergone TEVAR in the Vascular Quality Initiative between 2014 and 2020. We excluded patients aged <18 years, those who had presented with trauma, and those who had received custom-manufactured or physician-modified devices. We evaluated the association between preoperative statin therapy and in-hospital mortality and complications and 5-year mortality. We also analyzed the trend of preoperative statin use in elective cases for the previous 7 years. To account for nonrandom assignment to treatment, we used propensity score matching of patient characteristics, comorbidities, pathology, and urgency for preoperative statin use. We used logistic regression and Cox regression for the short-term and 5-year outcomes, respectively. RESULTS: Of 6266 patients who had undergone TEVAR and met the inclusion criteria, 3331 (53%) patients had been taking a statin preoperatively, including 1148 of 2267 (64%) treated for aneurysmal disease. After propensity score matching, 1875 patients were in each cohort. Preoperative statin use was associated with lower rates of any perioperative complication (16.7% vs 19.6%; odds ratio, 0.82; 95% confidence interval [CI] 0.69-0.97; P = .022). Overall, preoperative statin use was also associated with lower 5-year mortality (18.8% vs 24.5%; hazard ratio [HR], 0.74; 95% CI, 0.63-0.89; P = .001). When stratified by urgency, preoperative statin use was associated with lower 5-year mortality after elective TEVAR (14.9% vs 22.4%; HR, 0.62; 95% CI, 0.49-0.79; P < .001) but not after urgent or emergent TEVAR (27.4% vs 29.1%; HR, 0.89; 95% CI, 0.70-1.14; P = .37). When stratified by pathology, preoperative statin use was associated with significantly lower 5-year mortality for patients with aneurysms (HR, 0.63; 95% CI, 0.48-0.83; P = .001). Although the mortality was also lower for patients with dissection and "other" pathology, these differences did not reach statistical significance. Between 2014 and 2019, a significant increase had occurred in statin use among patients undergoing elective TEVAR, from 56% in 2014 to 64% in 2019 (P = .007). CONCLUSIONS: Preoperative statin therapy is associated with lower perioperative complication rates and 5-year mortality for patients undergoing TEVAR. All patients with known thoracic aortic pathology should receive statin therapy unless contraindications for the drug are present. For patients undergoing elective TEVAR, the statin prescription percentage should be considered a quality metric, and further implementation research should occur to improve preoperative statin use.

Non-English Primary Language is Associated with Emergency Surgery for Diverticulitis.

BACKGROUND: Language barriers can limit access to care for patients with a non-English primary language (NEPL). The objective of this study was to define the association between primary language and emergency versus elective surgery among diverticulitis patients. MATERIALS AND METHODS: Retrospective cohort study of adult patients from the 2009-2014 New Jersey State Inpatient Database. Patients were included if they had primary language data and underwent a partial colon resection for diverticulitis. Primary language was dichotomized into NEPL versus English primary language (EPL). The primary outcome was surgical admission type - urgent/emergent (referred to as "emergency") versus elective. Descriptive and multivariable analyses were performed. RESULTS: A total of 9,453 patients underwent surgery for diverticulitis, of which 592 (6.3%) had NEPL. Among NEPL patients, 300 (51%) had Spanish as primary language and 292 (49%) had another non-Spanish primary language. Patients with NEPL and EPL were similar in age (median age 58 versus 59 years; P = 0.54) and sex (52% versus 53% female; P = 0.45). Patients with NEPL were less likely to have commercial insurance (45% versus 59%; P <0.001). On multivariable analysis, compared to patients with EPL, NEPL was associated with increased odds of emergency surgery for diverticulitis (OR 1.35; 95% Confidence Interval 1.13-1.62; P = 0.001) CONCLUSION: Patients with NEPL have higher odds of emergency versus elective surgery for diverticulitis compared to patients with EPL. Further research is needed to examine differences in referral pathways, patient-provider communication, and health literacy that may hinder access to elective surgery in patients with diverticulitis.

Sclerotherapy for Aneurysmal Bone Cysts: Scale for Response.

BACKGROUND: The objective of this study was to develop a response scale for aneurysmal bone cysts (ABCs) treated with sclerotherapy and determine its inter-rater reproducibility. METHODS: Patients treated with sclerotherapy for an ABC between 1993 and 2014 were identified. An attending orthopaedic surgeon and an attending interventional radiologist independently reviewed the radiographic series for each patient and determined response to treatment using a novel grading system. Pain scores were collected from each visit. Inter-rater reliability was assessed using the intraclass correlation coefficient (ICC). General estimating equations analysis was used to evaluate the relationship between radiographic and pain scores and outcome, to develop an algorithm for the study patient population. A receiver operating characteristic curve was constructed to evaluate the diagnostic performance of the radiographic and pain scores in identifying the necessity of further treatment. To quantify the diagnostic utility, the area under the receiver operating characteristic curve was estimated along with a 95% confidence interval (CI). RESULTS: The inter-rater reliability was excellent for magnetic resonance imaging (ICC=0.83; 95% CI=0.74-0.89) and good for computed tomography/x-ray (ICC=0.69; 95% CI=0.51-0.81). The radiographic and pain scores proved to be independent predictors of treatment (P<0.001 and 0.004, respectively). An algorithm to determine the predictive probability for treatment versus observation in the study population was developed and tested based on these assessments. The area under the receiver operating characteristic curve of 0.85 (95% CI=0.79-0.92) indicated the good diagnostic performance of the algorithm. CONCLUSIONS: This novel grading system for radiographic response to sclerotherapy treatment demonstrates excellent to good inter-rater reliability giving providers a platform for discussion among themselves and with patients/parents. When incorporated with an assessment of pain, a predictive algorithm shows how this information could be used to determine the next steps after sclerotherapy treatment. LEVEL OF EVIDENCE: Level IV-case series.

ST Segment Elevation Caused by Artifact From Cylindrical Battery Ingestion.

BACKGROUND: Ingestion of cylindrical batteries is uncommon. Management can include removal via upper endoscopy, surgical excision, or observation. This case demonstrates the rare phenomenon of cylindrical battery ingestion causing an electrocardiogram (ECG) artifact that mimics ST segment myocardial infarction (STEMI). CASE REPORT: A 51-year-old man who ingested 13 small pencils and 18 AA batteries was found to have ST segment elevation in the inferior leads of the ECG. Further cardiac workup including cardiac biomarkers and transthoracic echocardiogram was negative, and his ECG changes resolved after extraction of the batteries. The ST segment changes were most likely caused by electrical artifact from battery ingestion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When faced with an ECG finding that is unexpected and that does not fit the patient's overall clinical picture, emergency physicians should consider artifact as a possible cause. Recognition of artifact as the cause of an ECG abnormality can obviate the need for a prolonged and potentially invasive cardiac workup.

Measuring the Reliability and Construct Validity of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) in Children With Cerebral Palsy.

OBJECTIVE: The purpose of this study was to (1) investigate the construct validity and (2) test-retest reliability of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) in children with cerebral palsy (CP). DESIGN: A prospective convenience cross-sectional sample. SETTING: Multidisciplinary CP clinic in a tertiary level pediatric children's hospital. PARTICIPANTS: English- and Spanish-speaking school-aged children (N=101) with a diagnosis of CP, stratified by Gross Motor Function Classification System level, who presented to our multidisciplinary clinic. Participants were excluded if they underwent recent surgery (<6mo) or botulinum neurotoxin A injection (<3mo). A subset of 17 families participated in retest reliability. MAIN OUTCOME MEASURES: Convergent and divergent validity were evaluated using Spearman correlation coefficient analysis; test-retest reliability was assessed using intraclass correlation coefficients (ICCs). RESULTS: Mean age was 12±3.7 years. Convergent validity was established between Mobility (PEDI-CAT) and Functional Mobility Scale (FMS) (5 m, r=0.85; 50 m, r=0.84; 500 m, r=0.76; P<.001). In ambulant children, convergent validity was established between Daily Activities (PEDI-CAT vs Pediatric Quality of Life CP [PedsQL-CP] [r=0.85, P<.001]) and between Social/Cognitive (PEDI-CAT) and Speech and Communication (PedsQL-CP) (r=0.42, P<.001). In nonambulant children, convergent validity was established between Daily Activities (PEDI-CAT) and Personal Care (Caregiver Priorities and Child Health Index of Life with Disabilities [CPCHILD]) (r=0.44, P<.001) and between social/cognitive (PEDI-CAT) and Communication (CPCHILD) (r=0.64, P<.001). A lack of correlation between Daily Activities, Social/Cognitive, and Responsibility (PEDI-CAT) and FMS and between the Mobility (PEDI-CAT) and Communication (PedsQL) domains confirmed divergent validity. Test-retest reliability was excellent for all domains of the PEDI-CAT (ICC=0.96-0.99). CONCLUSIONS: The PEDI-CAT is an outcome measure that demonstrates strong construct validity and reliability in children with CP.

Unique Breast Cancer Screening Disparities in a Safety-Net Health System.

INTRODUCTION: Breast cancer screening (BCS) disparities leave historically underserved groups more vulnerable to adverse outcomes. This study explores granular associations between BCS and patient sociodemographic factors in a large urban safety-net health system. METHODS: A retrospective review among female patients ages 50-74 within an urban safety-net health system was conducted in 2019. All patients had a primary care visit in the past 2 years. Multiple patient health and sociodemographic characteristics were reviewed, as well as provider gender and specialty. Bivariate analyses and multivariable logistic regression were performed in 2022. RESULTS: The BCS rate among 11,962 women was 69.7%. Over half of patients were non-White (63.6%) and had public insurance (72.3%). Patients with limited English proficiency made up 44.3% of the cohort. Compared to their sociodemographic counterparts, patients with White race, English proficiency, and Medicare insurance had the lowest rates of BCS. Serious mental illness and substance use disorder were associated with lower odds of BCS. In multivariable analysis, when using White race and English speakers as a reference, most other races (Black, Hispanic, and Other) and languages (Spanish, Portuguese, and Other) had significantly higher odds of screening ranging from 8% to 63% higher, except Asian race and Haitian Creole language. Female (versus male) and internal medicine-trained providers were associated with higher screening odds. CONCLUSIONS: Multiple unique variables contribute to BCS disparities, influenced by patient and health system factors. Defining and understanding the interplay of these variables can guide policymaking and identify avenues to improve BCS for vulnerable or traditionally under-resourced populations.

Factors Affecting Colorectal Cancer Screening in Primary Care Physician Practices in Ukraine.

PURPOSE: This study aims to identify the factors influencing colorectal cancer (CRC) screening practices, along with the barriers and facilitators from the perspective of primary care physicians (PCPs) in Ukraine. Considering health care system challenges, including those posed by the ongoing war, this research seeks to inform improvements in CRC screening and outcomes in Ukraine and other low- and middle-income countries (LMICs). METHODS: A survey was designed and distributed electronically to Ukrainian PCPs, focusing on CRC screening practices, beliefs, and barriers. The survey incorporated questions adapted from established cancer screening surveys and frameworks. Complete responses were collected from 740 PCPs. Sample statistics were computed, and population-level perceptions and associations with CRC screening practices were estimated by standardizing responses to national PCP demographics. RESULTS: The majority of respondents were women (91%) and specialized in family medicine (84%). Respondents believed in the effectiveness of colonoscopy for reducing CRC mortality (80%), with 75% of PCPs referring patients for this screening modality. Major barriers identified include inadequate training of PCPs in screening and lack of resources. Respondents reported high utilization of fecal occult blood test and colonoscopy for screening when these tests were said to be available in their practices. Self-reported familiarity with CRC screening guidelines and participation in educational workshops were positively associated with screening referrals. CONCLUSION: The study highlights the role of access to CRC screening tests and awareness of screening guidelines in enhancing CRC screening practices among Ukrainian PCPs. Addressing training and resource barriers, alongside public health interventions targeting patient-related barriers, is essential. These findings offer valuable insights for LMICs facing similar challenges, emphasizing the need for tailored strategies to improve cancer screening in these health care settings.