Are primary care providers prepared to care for survivors of breast cancer in the safety net?

BACKGROUND: With the growing number of survivors of breast cancer outpacing the capacity of oncology providers, there is pressure to transition patients back to primary care. Primary care providers (PCPs) working in safety-net settings may have less experience treating survivors, and little is known about their knowledge and views on survivorship care. The current study was performed to determine the knowledge, attitudes, and confidence of PCPs in the safety net at delivering care to survivors of breast cancer. METHODS: A modified version of the National Cancer Institute's Survey of Physician Attitudes Regarding Care of Cancer Survivors was given to providers at 2 county hospitals and 5 associated clinics (59 providers). Focus groups were held to understand barriers to survivorship care. RESULTS: Although the majority of providers believed PCPs have the skills necessary to provide cancer-related follow-up, the vast majority were not comfortable providing these services themselves. Providers were adherent to American Society of Clinical Oncology recommendations for mammography (98%) and physical examination (87%); less than one-third were guideline-concordant for laboratory testing and only 6 providers (10%) met all recommendations. PCPs universally requested additional training on clinical guidelines and the provision of written survivorship care plans before transfer. Concerns voiced in qualitative sessions included unfamiliarity with the management of endocrine therapy and confusion regarding who would be responsible for certain aspects of care. CONCLUSIONS: Safety-net providers currently lack knowledge of and confidence in providing survivorship care to patients with breast cancer. Opportunities exist for additional training in evidence-based guidelines and improved coordination of care between PCPs and oncology specialists.

Could Nonenhanced Computer Tomography Suffice as the Imaging Study of Choice for the Screening of Asymptomatic Microscopic Hematuria?

OBJECTIVE: To compare the diagnostic accuracy of the noncontrast and contrast-enhanced phases of computed tomographic urography for detection of upper urinary tract findings in adults undergoing initial evaluation of newly diagnosed asymptomatic microscopic hematuria to determine if less-intensive noncontrast imaging has the potential to become a suitable imaging alternative in the work-up of this common condition. MATERIALS AND METHODS: Retrospective review from 2010-2015 for adults who underwent computed tomographic urography for initial evaluation of asymptomatic microscopic hematuria. Three nonblinded physicians independently categorized the upper urinary tract findings described in the computed tomography reports into one of three groups: normal, benign, or suspicious for malignancy. The noncontrast images of a randomized portion of the studies categorized as normal and all studies categorized as suspicious and benign were submitted to two blinded radiologists who independently classified each study into one of the aforementioned categories. RESULTS: The noncontrast images for 475 subjects were blindly reviewed. When compared to the computed tomographic urography reports, the negative predictive values of noncontrast images were 97.25% and 94.92% for radiologist 1 and radiologist 2, respectively, with an associated specificity of 88.6% and 97.95%. Of the 5 true upper tract malignancies, both blinded radiologists correctly identified 4 of the 5. CONCLUSION: Contrast imaging added little diagnostic value when compared with noncontrast imaging for most subjects undergoing initial evaluation for asymptomatic microscopic hematuria. Less-intensive imaging with nonenhanced computed tomography could reduce the nontrivial risks associated with multiphasic contrast imaging but further work is necessary to identify risk-stratifying criteria.

A real-time mobile web-based module promotes bidirectional feedback and improves evaluations of the surgery clerkship.

BACKGROUND: We implemented a real-time mobile web-based reporting module for students in our surgery clerkship and evaluated its effect on student satisfaction and perceived abuse. METHODS: Third-year medical students in the surgery clerkship received surveys regarding intimidation, perceived abuse, satisfaction with clerkship resources, and interest in a surgical career. Survey data were analyzed to assess differences after implementing the mobile reporting system and to identify independent predictors of perceived abuse. RESULTS: With the reporting module, students perceived less intimidation by residents (P < .001) and by faculty (P = .008), greater satisfaction reporting feedback (P < .001), and greater interest in surgical careers (P = .003). Perceived abuse decreased without reaching statistical significance (P = .331). High ratings of intimidation by faculty independently predicted perceived abuse (odds ratio = 1.3), and satisfaction with anonymous reporting was a negative predictor (odds ratio = .2). CONCLUSIONS: A mobile web-based system for real-time reporting fosters open communication and bidirectional feedback and promotes greater satisfaction with the surgery clerkship and interest in a surgical career.

Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture.

OBJECTIVES: To define the target domains of culture-improvement interventions, to assess the impact of these interventions on surgical culture and to determine whether culture improvements lead to better patient outcomes and improved healthcare efficiency. BACKGROUND: Healthcare systems are investing considerable resources in improving workplace culture. It remains unclear whether these interventions, when aimed at surgical care, are successful and whether they are associated with changes in patient outcomes. METHODS: PubMed, Cochrane, Web of Science and Scopus databases were searched from January 1980 to January 2015. We included studies on interventions that aimed to improve surgical culture, defined as the interpersonal, social and organisational factors that affect the healthcare environment and patient care. The quality of studies was assessed using an adapted tool to focus the review on higher-quality studies. Due to study heterogeneity, findings were narratively reviewed. FINDINGS: The 47 studies meeting inclusion criteria (4 randomised trials and 10 moderate-quality observational studies) reported on interventions that targeted three domains of culture: teamwork (n=28), communication (n=26) and safety climate (n=19); several targeted more than one domain. All moderate-quality studies showed improvements in at least one of these domains. Two studies also demonstrated improvements in patient outcomes, such as reduced postoperative complications and even reduced postoperative mortality (absolute risk reduction 1.7%). Two studies reported improvements in healthcare efficiency, including fewer operating room delays. These findings were supported by similar results from low-quality studies. CONCLUSIONS: The literature provides promising evidence for various strategies to improve surgical culture, although these approaches differ in terms of the interventions employed as well as the techniques used to measure culture. Nevertheless, culture improvement appears to be associated with other positive effects, including better patient outcomes and enhanced healthcare efficiency. TRIAL REGISTRATION NUMBER: CRD42013005987.

Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events.

IMPORTANCE: Serious, preventable surgical events, termed never events, continue to occur despite considerable patient safety efforts. OBJECTIVE: To examine the incidence and root causes of and interventions to prevent wrong-site surgery, retained surgical items, and surgical fires in the era after the implementation of the Universal Protocol in 2004. DATA SOURCES: We searched 9 electronic databases for entries from 2004 through June 30, 2014, screened references, and consulted experts. STUDY SELECTION: Two independent reviewers identified relevant publications in June 2014. DATA EXTRACTION AND SYNTHESIS: One reviewer used a standardized form to extract data and a second reviewer checked the data. Strength of evidence was established by the review team. Data extraction was completed in January 2015. MAIN OUTCOMES AND MEASURES: Incidence of wrong-site surgery, retained surgical items, and surgical fires. RESULTS: We found 138 empirical studies that met our inclusion criteria. Incidence estimates for wrong-site surgery in US settings varied by data source and procedure (median estimate, 0.09 events per 10,000 surgical procedures). The median estimate for retained surgical items was 1.32 events per 10,000 procedures, but estimates varied by item and procedure. The per-procedure surgical fire incidence is unknown. A frequently reported root cause was inadequate communication. Methodologic challenges associated with investigating changes in rare events limit the conclusions of 78 intervention evaluations. Limited evidence supported the Universal Protocol (5 studies), education (4 studies), and team training (4 studies) interventions to prevent wrong-site surgery. Limited evidence exists to prevent retained surgical items by using data-matrix-coded sponge-counting systems (5 pertinent studies). Evidence for preventing surgical fires was insufficient, and intervention effects were not estimable. CONCLUSIONS AND RELEVANCE: Current estimates for wrong-site surgery and retained surgical items are 1 event per 100,000 and 1 event per 10,000 procedures, respectively, but the precision is uncertain, and the per-procedure prevalence of surgical fires is not known. Root-cause analyses suggest the need for improved communication. Despite promising approaches and global Universal Protocol evaluations, empirical evidence for interventions is limited.

The impact of continuous Medicaid enrollment on diagnosis, treatment, and survival in six surgical cancers.

OBJECTIVE: To examine the effect of Medicaid enrollment on the diagnosis, treatment, and survival of six surgically relevant cancers among poor and underserved Californians. DATA SOURCES: California Cancer Registry (CCR), California's Patient Discharge Database (PDD), and state Medicaid enrollment files between 2002 and 2008. STUDY DESIGN: We linked clinical and administrative records to differentiate patients continuously enrolled in Medicaid from those receiving coverage at the time of their cancer diagnosis. We developed multivariate logistic regression models to predict death within 1 year for each cancer after controlling for sociodemographic and clinical variables. DATA COLLECTION/EXTRACTION METHODS: All incident cases of six cancers (colon, esophageal, lung, pancreas, stomach, and ovarian) were identified from CCR. CCR records were linked to hospitalizations (PDD) and monthly Medicaid enrollment. PRINCIPAL FINDINGS: Continuous enrollment in Medicaid for at least 6 months prior to diagnosis improves survival in three surgically relevant cancers. Discontinuous Medicaid patients have higher stage tumors, undergo fewer definitive operations, and are more likely to die even after risk adjustment. CONCLUSIONS: Expansion of continuous insurance coverage under the Affordable Care Act is likely to improve both access and clinical outcomes for cancer patients in California.

Age, poverty, acculturation, and gastric cancer.

BACKGROUND: Gastric cancer is an aggressive disease, and overall changes in incidence rates have been noted. There are conflicting data on whether young patients have worse outcomes than older patients; the roles of tumor biology and access to care are critical to answering this question. Our objectives were to explore how gastric cancer rates, receipt of care, and outcomes are affected by age, poverty, and acculturation. METHODS: A total of 42,187 patients were identified from the 1980-2009 Surveillance, Epidemiology, and End Results registry. We compared trends in incidence rates between patients <40, 40-64, and ≥65 years using ordinary least-squares regression. Separate multivariate regression models were used to evaluate the impact of age, poverty, and acculturation on receipt of cancer-directed therapy and hazard of mortality. RESULTS: Patients <40 years had stable incidence rates over the 3-decade period compared with decreases for patients 40-64 and ≥65 years. They are also more likely to present with aggressive, advanced disease (P < .0001 for both). On unadjusted and adjusted analyses, patients <40 years were more likely to receive cancer-directed therapies and have better survival than those ≥65 years. Residing in high poverty areas was associated with not receiving appropriate cancer-directed therapy; the adjusted hazard ratio of mortality for surgically resected patients was, however, not affected by poverty. Residing in high immigration areas was associated with a low hazard ratio (HR, 0.74; 95% confidence interval [CI], 0.7-0.79) of mortality. Foreign-born patients also had a low hazard ratio (HR, 0.87; 95% CI, 0.83-0.91) of mortality. CONCLUSION: Although trends in incidence rates for patients <40 years remain unchanged and their disease is aggressive and advanced at presentation, they do not experience disparities in gastric cancer-directed therapies and survival after resection. For patients residing in impoverished areas or high immigration communities, operative resection and adjustment for appropriate aftercare is associated with comparable or better survival when compared with those living in low poverty or low immigration areas. Disparities remain in receipt of appropriate cancer-directed therapies, and future efforts should focus on decreasing structural variations in care and unconscious biases regarding patients from these vulnerable communities.