Development and Validation of a Kidney-Transplant Specific Measure of Treatment Burden.

BACKGROUND: Treatment burden refers to the work involved in managing one's health and its impact on well-being and has been associated with nonadherence in patients with chronic illnesses. No kidney transplant (KT)-specific measure of treatment burden exists. The aim of this study was to develop a KT-specific supplement to the Patient Experience with Treatment and Self-Management (PETS), a general measure of treatment burden. METHODS: After drafting and pretesting KT-specific survey items, we conducted a cross-sectional survey study involving KT recipients from Mayo Clinic in Minnesota, Arizona, and Florida. Exploratory factor analysis (EFA) was used to identify domains for scaling the KT-specific supplement. Construct and known-groups validity were determined. RESULTS: Survey respondents (n = 167) had a mean age of 61 years (range 22-86) and received a KT on average 4.0 years ago. Three KT-specific scales were identified (transplant function, self-management, adverse effects). Higher scores on the KT-specific scales were correlated with higher PETS treatment burden, worse physical and mental health, and lower self-efficacy (p < 0.0001). Patients taking more medications reported higher transplant self-management burden. CONCLUSIONS: We developed a KT-specific supplement to the PETS general measure of treatment burden. Scores may help providers identify recipients at risk for nonadherence.

Responsibilities, Strategies, and Practice Factors in Clinical Cost Conversations: a US Physician Survey.

BACKGROUND: Physicians play a key role in mitigating and managing costs in healthcare which are rising. OBJECTIVE: Conduct a cross-sectional survey in 2017, comparing results to a 2012 survey to understand US physicians' evolving attitudes and strategies concerning healthcare costs. PARTICIPANTS: Random sample of 1200 US physicians from the AMA Masterfile. MEASURES: Physician views on responsibility for costs of care, enthusiasm for cost-saving strategies, cost-consciousness scale, and practice strategies on addressing cost. KEY RESULTS: Among 1200 physicians surveyed in 2017, 489 responded (41%). In 2017, slightly more physicians reported that physicians have a major responsibility for addressing healthcare costs (32% vs. 27%, p = 0.03). In 2017, more physicians attributed "major responsibility" for addressing healthcare costs to pharmaceutical companies (68% vs. 56%, p < 0.001) and hospital and health systems (63% vs. 56%%, p = 0.008) in contrast to 2012. Fewer respondents in 2017 attributed major responsibility for addressing costs to trial lawyers (53% vs. 59%, p = 0.007) and patients (42% vs. 52%, p < 0.0001) as compared to 2012. Physician enthusiasm for patient-focused cost-containment strategies like high deductible health plans and higher co-pays (62% vs. 42%, p < 0.0001 and 62% vs. 39%, p < 0.0001, not enthusiastic, respectively) declined. Physicians reported that when they discussed cost, it resulted in a change in disease management 56% of the time. Cost-consciousness within surveyed physicians had not changed meaningfully in 2017 since 2012 (31.7 vs. 31.2). Most physicians continued to agree that decision support tools showing costs would be helpful in their practice (> 70%). After adjusting for specialty, political affiliation, practice setting, age, and gender, only democratic/independent affiliation remained a significant predictor of cost-consciousness. CONCLUSIONS AND RELEVANCE: US physicians increasingly attribute responsibility for rising healthcare costs to organizations and express less enthusiasm for strategies that increase patient out-of-pocket cost. Interventions that focus on physician knowledge and communication strategies regarding cost of care may be helpful.

The Impact of Stigma on Community Reintegration of Veterans With Traumatic Brain Injury and the Well-Being of Their Caregivers.

OBJECTIVE: To assess the association between perceived stigma and discrimination and caregiver strain, caregiver well-being, and patient community reintegration. DESIGN: A cross-sectional survey study of 564 informal caregivers of U.S. military service veterans of wars in Iraq and Afghanistan who experienced traumatic brain injuries or polytrauma (TBI/PT). SETTING: Care settings of community-dwelling former inpatients of U.S. Department of Veterans Affairs Polytrauma Rehabilitation Centers. PARTICIPANTS: Caregivers of former inpatients (N=564), identified through next-of-kin records and subsequent nominations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Caregiver strain, depression, anxiety, loneliness, and self-esteem; as well as care recipient community reintegration, a key aspect of TBI/PT rehabilitation. RESULTS: Family stigma was associated with strain, depression, anxiety, loneliness, lower self-esteem, and less community reintegration. Caregiver stigma-by-association was associated with strain, depression, anxiety, loneliness, and lower self-esteem. Care recipient stigma was associated with caregiver strain, depression, anxiety, loneliness, lower self-esteem, and less community reintegration. CONCLUSIONS: Perceived stigma may be a substantial source of stress for caregivers of U.S. military veterans with TBI/PT, and may contribute to poor outcomes for the health of caregivers and for the community reintegration of the veterans for whom they provide care.

Clinical, Biochemical, and Histopathology Features of Patients With Glycogenic Hepatopathy.

BACKGROUND & AIMS: Glycogenic hepatopathy, a syndrome characterized by hepatomegaly and increased liver transaminases in patients with type 1 diabetes, has not been well characterized in adults. We describe the clinical, biochemical, and histopathology profile of a cohort of patients with glycogenic hepatopathy. We also examined differences between patients with type 1 diabetes with versus without glycogenic hepatopathy. METHODS: We performed a case-control study of patients with type 1 diabetes diagnosed with glycogenic hepatopathy and patients with type 1 diabetes without glycogenic hepatopathy (control subjects). Cases were identified in the database of electronic medical records at Mayo Clinic, Rochester from January 1, 1998, through January 1, 2014. Age- and sex-matched control subjects were identified from a Mayo Clinic registry of patients with type 1 diabetes who had normal levels of liver enzymes. Demographic, clinical, laboratory, and histopathology data were collected and compared between cases and control subjects. The primary outcome was difference in frequency of diabetic ketoacidosis episodes and hemoglobin (Hb) A1c levels between cases and control subjects. RESULTS: Among the 36 patients diagnosed with glycogenic hepatopathy, 20 had undergone liver biopsy analysis. Most cases were female (n = 28; 77.8%). Abdominal pain was the most common symptom (n = 23; 63.9%); 28 patients (77.8%) had hepatomegaly. All patients had poor control of diabetes (mean HbA1c level, 11.2 ± 2.4%). A higher proportion of cases had recurrent episodes of diabetic ketoacidosis (61%) than control subjects (9%) (P = .009), and cases had a higher mean level of HbA1c (11.2 ± 2.4% vs 9.0 ± 2.2% in control subjects; P = .0004). Adult cases had higher levels of aspartate transaminase (312.5 IU/L; range, 245.5-775 IU/L) than pediatric cases (157; range, 104-267 IU/L; P = .02) and lower serum levels of albumin (3.7 ± 0.5 g/dL vs 4.3 ± 0.4 g/dL for pediatric cases; P = .008). Only 16.7% of pediatric patients with glycogenic hepatopathy had growth retardation. Levels of liver transaminases were normalized at follow-up examinations of 18 of 21 adult or pediatric patients with glycogenic hepatopathy. CONCLUSIONS: More than half of patients with glycogenic hepatopathy and type 1 diabetes have recurrent episodes of diabetic ketoacidosis, and these patients have higher levels of HbA1c than patients with type 1 diabetes without glycogenic hepatopathy. We observed growth retardation in only about 17% of pediatric patients with glycogenic hepatopathy.

Dermatopathologists' concerns and challenges with clinical information in the skin biopsy requisition form: a mixed-methods study.

BACKGROUND: Communication failures between clinicians and dermatopathologists are prevalent. Our primary objective was to characterize the concerns and challenges of dermatopathologists posed by incomplete or inaccurate clinical information in the skin biopsy requisition form. METHODS: An explanatory sequential, mixed-methods study design comprised of a survey sent to 1103 members of the American Society of Dermatopathology (ASDP), followed by two focus group sessions. RESULTS: A total of 54% (598/1103) of dermatopathologists completed the questionnaire. Most dermatopathologists (80%; 436/548) viewed their roles to be providers of histopathological diagnosis and a report that is clinically meaningful. Paper or electronic requisition forms were the most common communication method (85%; 458/541) and were associated with the highest rates of dissatisfaction in 36% (193/537) of respondents. Inadequacy of specimens emerged as an important factor influencing judgment of the quality of provided clinical information. 44.7% (261/584) of dermatopathologists spent 30 minutes or more on average every day searching for relevant clinical information to assist with their histopathologic interpretation. CONCLUSION: ASDP dermatopathologists expressed significant dissatisfaction with the quality of clinical information in the requisition form and the time spent gathering information necessary for accurate, timely and clinically meaningful diagnosis. These findings have implications for the quality, safety and efficiency of dermatologic care.

Survey mode and asking about future intentions did not impact self-reported colorectal cancer screening accuracy.

BACKGROUND: Self-reported colorectal cancer (CRC) screening behavior is often subject to over-reporting bias. We examined how the inclusion of a future intention to screen item (viz. asking about future intentions to get screened before asking about past screening) and mode of survey administration impacted the accuracy of self-reported CRC screening. METHODS: The target population was men and women between 49 and 85 years of age who lived in Olmsted County, MN, for at least 10 years at the time of the study. Eligible residents were randomized into four groups representing the presence or absence the future intention to screen item in the questionnaire and administration mode (mail vs. telephone). A total of 3,638 cases were available for analysis with 914, 838, 956, and 930 in the mail/future intention, mail/no future intention, telephone/future intention, and telephone/no future intention conditions, respectively. False positives were defined as self-reporting being screened among those with no documented history of screening in medical records and false negatives as not self-reporting screening among those with history of screening. RESULTS: Comparing false positive and false negative reporting rates for each specific screening test among the responders at the bivariate level, regardless of mode, there were no statistically significant differences by the presence or absence of a preceding future intention question. When considering all tests combined, the percentage of false negatives within the telephone mode was slightly higher for those with the future intention question (6.7% vs 4.2%, p = 0.04). Multivariate models that considered the independent impact of the future intention question and mode, affirmed the results observed at the bivariate level. However, individuals in the telephone arm (compared to mail) were slightly (though not significantly) more likely to report a false positive (36.4% vs 31.8%, OR = 1.11, p = 0.55). CONCLUSION: It may be that in the context of a questionnaire that is clearly focused on CRC and with specific descriptions of the various CRC screening tests, certain design features such as including intention to screen items or mode of administration will have very little impact on the accuracy of self-reported CRC screening.

Is patient assessment of asthma care delivery associated with publicly reported performance measures?

OBJECTIVE: To determine the association between patient assessment of healthcare delivery and publicly reported asthma performance measures. METHODS: We identified individuals 5-50 years old who had asthma quality measures reported to the Minnesota Community Measurement© (MCM©) by their clinic and sent them a postal survey which included within it the Patient Assessment of Chronic Illness care (PACIC), a validated measure of patient perception of the quality of healthcare delivery. We performed a multivariable analysis to examine the association between PACIC scores and achievement of asthma care quality measures. RESULTS: The response rate for the ACS was 102/367 (28%); a non-response bias analysis revealed no differences between responders and non-responders for age, gender and asthma control. Most responders (73%) reported taking asthma medications daily and most (71%) had poorly controlled asthma. The PACIC score was not associated with any of the asthma quality measures based on the data reported to MCM© by the clinic. A higher PACIC score was, however, associated with having an asthma action plan based on patient-reported data in the ACS (p < 0.0001) but not with patient-reported asthma control or emergency department/hospitalizations for asthma. CONCLUSIONS: Patient assessment of high quality asthma care delivery was associated with patient self-report of having an asthma action plan but was not associated with any of the publicly reported asthma performance measures.

Differences in Cannabidiol-Related Attitudes and Practice Behaviors Between U.S. Primary Care Physicians Practicing in a Single Health Care System Across States With and Without Marijuana Legalization.

Introduction: Dramatic shifts in marijuana laws, along with federal deregulation of hemp with the 2018 Farm Bill, have resulted in increased availability and use of cannabidiol (CBD) supplements throughout the United States (US). Given the rapid increase in CBD use in the U.S. general population, in this study, we aim to characterize primary care physician (PCP) attitudes and practice behaviors and to assess whether differences in provider attitudes and behaviors vary as a function of marijuana legalization (ML) status in the state of practice. Materials and Methods: Data are from an online provider survey on CBD supplement-related attitudes, beliefs, and behaviors administered to 508 PCPs as part of a larger mixed methods study. Participating PCPs were recruited from the Mayo Clinic Healthcare Network and provided medical care in primary care settings across four U.S. states (Minnesota, Wisconsin, Florida, and Arizona). Results: The survey response rate was 45.4% (n=236/508). According to providers, CBD was frequently brought up in PCP settings, typically by patients. PCPs were generally hesitant to screen for or discuss CBD with their patients and identified multiple barriers to open patient-provider dialogue about CBD. PCPs practicing in states that had passed ML were more receptive to patients using CBD supplements, whereas PCPs practicing in states that had not passed ML were more concerned about CBD-related side effects. Regardless of state ML status, most PCPs did not feel that they should be recommending CBD supplements to their patients. Most PCPs reported believing that CBD was unhelpful for most conditions for which it is marketed, with chronic non-cancer pain and anxiety/stress being exceptions. PCP respondents generally felt that they had insufficient knowledge/training around CBD. Conclusions: Results from this mixed methods study show that PCPs practicing in the U.S. rarely screen for or discuss CBD use with their patients and report several barriers to engage in proactive CBD-focused practice behaviors. Furthermore, survey results show that some PCP attitudes, practice behaviors, and barriers vary as a function of state ML status. These findings may guide medical education efforts and inform primary care practice modifications aimed at enhancing screening and monitoring of patient CBD use by PCPs.

Temporal Trends in Use of Complementary Therapies Among Patients With Cardiovascular Disorders.

This study aimed to evaluate the use and frequency of complementary and integrative medicine (CIM) therapies in an outpatient cohort with cardiovascular disease (CVD) and compare trends over time. This cross-sectional point-of-care prospective study assessed patients attending a cardiology outpatient clinic. As in our 2009 cohort, data were collected with a 17-question survey on demographic characteristics, CVD history, current use and future interest in CIM. In total, 964 patients completed the survey. CIM use continues to be high (2009 vs 2018, 83.4% vs 81.8%) (p = 0.34), with dietary supplements the most common therapy (75% in both studies). We observed increased use of mind-body therapies (28.5% vs 23.9%, p = 0.02), especially meditation, yoga, and tai chi. Of the patients receiving CIM therapies, 41.9% reported using CIM for heart-related symptoms. Relaxation, stress management, and meditation were the top three mind-body therapies for CVD-related symptoms in both cohorts. Reporting of CIM use to clinicians is low (15%) and interest on future use is high (47%). In conclusion, CIM is highly used in cardiology patients-4 of 10 patients use CIM for CVD-related symptoms. Most take dietary supplements, with an increased use of mind-body therapies. Our data highlight the importance of documenting CIM use in practice and the need for research to document efficacy.

Health Care Costs and Utilization Predictions by the Skilled Nursing Facility Readmission Risk Instrument.

OBJECTIVES: Health care providers at hospitals and skilled nursing facilities (SNFs) are increasingly expected to optimize care of post-acute patients to reduce hospital readmissions and contain costs. To achieve these goals, providers need to understand their patients' risk of hospital readmission and how this risk is associated with health care costs. A previously developed risk prediction model identifies patients' probability of 30-day hospital readmission at the time of discharge to an SNF. With a computerized algorithm, we translated this model as the Skilled Nursing Facility Readmission Risk (SNFRR) instrument. Our objective was to evaluate the relationship between 30-day health care costs and hospital readmissions according to the level of risk calculated by this model. DESIGN: This retrospective cohort study used SNFRR scores to evaluate patient data. SETTING AND PARTICIPANTS: The patients were discharged from Mayo Clinic Rochester hospitals to 11 area SNFs. METHODS: We compared the outcomes of all-cause 30-day standardized direct medical costs and hospital readmissions between risk quartiles based on the distribution of SNFRR scores for patients discharged to SNFs for post-acute care from April 1 through November 30, 2017. RESULTS: Mean 30-day all-cause standardized costs were positively associated with SNFRR score quartiles and ranged from $9199 in the fourth quartile (probability of readmission, 0.27-0.66) to $2679 in the first quartile (probability of readmission, 0.07-0.13) (P ≤ .05). Patients in the fourth SNFRR score quartile had 5.68 times the odds of 30-day hospital readmission compared with those in the first quartile. CONCLUSIONS AND IMPLICATIONS: The SNFRR instrument accurately predicted standardized direct health care costs for patients on discharge to an SNF and their risk for 30-day hospital readmission. Therefore, it could be used to help categorize patients for preemptive interventions. Further studies are needed to confirm its validity in other institutions and geographic areas.

Shortening a survey and using alternative forms of prenotification: impact on response rate and quality.

BACKGROUND: Evidence suggests that survey response rates are decreasing and that the level of survey response can be influenced by questionnaire length and the use of pre-notification. The goal of the present investigation was determine the effect of questionnaire length and pre-notification type (letter vs. postcard) on measures of survey quality, including response rates, response times (days to return the survey), and item nonresponse. METHODS: In July 2008, the authors randomized 900 residents of Olmsted County, Minnesota aged 25-65 years to one of two versions of the Talley Bowel Disease Questionnaire, a survey designed to assess the prevalence of functional gastrointestinal disorders (FGID). One version was two pages long and the other 4 pages. Using a 2 x 2 factorial design, respondents were randomized to survey length and one of two pre-notification types, letter or postcard; 780 residents ultimately received a survey, after excluding those who had moved outside the county or passed away. RESULTS: Overall, the response rates (RR) did not vary by length of survey (RR = 44.6% for the 2-page survey and 48.4% for the 4-page) or pre-notification type (RR = 46.3% for the letter and 46.8% for the postcard). Differences in response rates by questionnaire length were seen among younger adults who were more likely to respond to the 4-page than the 2-page questionnaire (RR = 39.0% compared to 21.8% for individuals in their 20s and RR = 49.0% compared to 32.3% for those in their 30s). There were no differences across conditions with respect to item non-response or time (days after mailing) to survey response. CONCLUSION: This study suggests that the shortest survey does not necessarily provide the best option for increased response rates and survey quality. Pre-notification type (letter or postcard) did not impact response rate suggesting that postcards may be more beneficial due to the lower associated costs of this method of contact.

Monoclonal Gammopathy of Undetermined Significance: Indications for Prediagnostic Testing, Subsequent Diagnoses, and Follow-up Practice at Mayo Clinic.

OBJECTIVES: To determine the indications for prediagnostic testing, subsequent diagnoses found, and follow-up practices in patients who were incidentally diagnosed with monoclonal gammopathy of undetermined significance (MGUS). PATIENTS AND METHODS: From our prospective MGUS database, we identified 329 patients residing in southeastern Minnesota who were diagnosed from January 1, 2011, through December 31, 2014, and followed up at Mayo Clinic. RESULTS: Most test orders came from nonhematologists (n=310, 94.2%). The top 5 indications were neuropathy (n=65, 19.8%), renal disease (n=45, 13.7%), anemia (n=42, 12.8%), bone disorder or connective tissue pain (n=42, 12.8%), and cutaneous disease (n=19, 5.8%). Hypercalcemia was an infrequent indication (n=9, 2.7%). The final diagnosis for all neuropathy evaluations was sensory/motor neuropathy-not otherwise specified, with 18.7% having IgM MGUS. Chronic kidney disease-not otherwise specified, iron deficiency, and osteoporosis/osteopenia were the most common subsequent diagnoses for test indications of renal disease, anemia, and bone disorder or connective tissue pain, respectively. Most patients (n=213, 64.7%) had 1 or more follow-up visit during the study period. A minority were followed by hematologists (43.5%, n=143). Patients with low-risk MGUS comprised 45.0% (n=148) of the cohort. Male patients and younger patients were more likely to be followed up than their counterparts (P<.01). About one-third (n=27, 32.1%) of patients 80 years or older (n=84) continued to have regular follow-up visits. Hematologists were more likely to follow patients with MGUS more closely than nonhematologists (P<.001). However, the intensity of follow-up was not based on MGUS risk. CONCLUSION: Monoclonal protein testing is commonly performed for signs and symptoms not typically associated with lymphoplasmacytic malignancies. There is a significant variation in MGUS follow-up between hematologists and nonhematologists (P<.001) that is not based on risk factors or clinical practice guidelines.

Bi-directional association between depression and HF: An electronic health records-based cohort study.

OBJECTIVE: To determine whether a bi-directional relationship exists between depression and HF within a single population of individuals receiving primary care services, using longitudinal electronic health records (EHRs). METHODS: This retrospective cohort study utilized EHRs for adults who received primary care services within a large healthcare system in 2006. Validated EHR-based algorithms identified 10,649 people with depression (depression cohort) and 5,911 people with HF (HF cohort) between January 1, 2006 and December 31, 2018. Each person with depression or HF was matched 1:1 with an unaffected referent on age, sex, and outpatient service use. Each cohort (with their matched referents) was followed up electronically to identify newly diagnosed HF (in the depression cohort) and depression (in the HF cohort) that occurred after the index diagnosis of depression or HF, respectively. The risks of these outcomes were compared (vs. referents) using marginal Cox proportional hazard models adjusted for 16 comorbid chronic conditions. RESULTS: 2,024 occurrences of newly diagnosed HF were observed in the depression cohort and 944 occurrences of newly diagnosed depression were observed in the HF cohort over approximately 4-6 years of follow-up. People with depression had significantly increased risk for developing newly diagnosed HF (HR 2.08, 95% CI 1.89-2.28) and people with HF had a significantly increased risk of newly diagnosed depression (HR 1.34, 95% CI 1.17-1.54) after adjusting for all 16 comorbid chronic conditions. CONCLUSION: These results provide evidence of a bi-directional relationship between depression and HF independently of age, sex, and multimorbidity from chronic illnesses.

Initial and subsequent 3-year cost after hospitalization for first acute ischemic stroke and intracerebral hemorrhage.

AIMS: To examine 1) the major drivers of index hospitalization and 3-year post-acute follow-up care, 2) cost for rehabilitation and homecare, and 3) indirect cost from lost productivity after acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH). METHODS: Retrospective study of adults hospitalized with AIS (n = 811) and ICH (N = 145) between 2003 and 2014. Direct costs standardized to Medicare reimbursement rates were captured for hospitalization and 3-year follow-up or death. Adjusted cost estimates were assessed using generalized linear modeling with gamma distribution. Costs for rehabilitation, home healthcare, and lost productivity were assessed using sets of cost captured through literature review. RESULTS: Calculated as mean cost per person: hospitalization $18,154 for AIS and $24,077 for ICH; monthly 3-year aggregate $5138 for AIS and $8172 for ICH; 3-year inpatient rehabilitation $4185 for AIS and $4196 for ICH; homecare $19,728 for AIS and $14,487 for ICH; indirect cost from lost productivity $77,078 for AIS and $56,601 for ICH. Age < 55 years, being non-white, and stroke severity were strongly associated with greater hospitalization cost for AIS and ICH. Hyperlipidemia incurred lower while cancer, coronary artery disease, asthma/chronic obstructive pulmonary disease, heart failure, and anemia incurred higher 3-year aggregate cost for AIS. Cancer and diabetes mellitus incurred higher 3-year aggregate cost for ICH. CONCLUSIONS: We provide estimates of direct and indirect costs incurred for acute and continuing post-acute care through a 3-year follow-up period after first-ever AIS and ICH with important comparisons for predictors between index hospitalization and 3-year post-stroke costs.

Impact of lymphoma survivorship clinic visit on patient-centered outcomes.

PURPOSE: Cancer survivors may experience physical, social, and emotional effects of cancer and its treatments. National Comprehensive Cancer Network (NCCN) guidelines recommend the development of a survivorship care plan (SCP) for cancer patients following completion of treatment with curative intent. Our institution developed a lymphoma survivorship clinic (SC) to assess patient needs, provide education, and create and deliver SCPs. This study analyzed the impact of a SC visit on patient-centered outcomes. METHODS: Surveys were sent to lymphoma patients at Mayo Clinic Rochester within 4 weeks of their post-treatment visit to the SC that queried patient-reported outcomes, including experience of care, quality of life (QOL), and distress. We compared survey responses between those who attended the SC and those who were eligible but did not attend. RESULTS: From November 2013 to May 2015, 236 lymphoma patients were surveyed, 96 of whom had a SC visit and 140 of who were eligible but did not attend. Those who attended the SC were more likely to "definitely" recall discussion on improving health, preventing illness, and making changes in habits/lifestyle, diet, and exercise. There were no differences in QOL or distress. Adjusted analyses revealed that SC attendance was associated with better self-reported overall health among younger patients and better physical well-being in Hodgkin lymphoma patients compared to those with other subtypes of lymphoma. CONCLUSIONS: Participation in the lymphoma SC improved patient education on survivorship issues, particularly health behaviors. There may be a particular benefit in younger patients. However, there were no differences in QOL or distress. Further study is needed to determine if improved survivorship education and SCP delivery leads to long-term health benefits in cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Our study evaluates the clinical impact of a SC in patients treated for lymphoma. We demonstrate that a SC visit improves patient education regarding health behaviors.

US Physicians' Reactions To ACA Implementation, 2012-17.

Physicians play a key role in implementing health policy, and US physicians were split in their opinions about the Affordable Care Act (ACA) soon after its implementation began. We readministered elements of a prior survey of US physicians to a similar sample to understand how US physicians' opinions of the ACA may have changed over a crucial five-year implementation period (2012-17), and we compared responses across both surveys. Of the 1,200 physicians to whom we sent a survey in the summer of 2017, 489 responded (a response rate of 41 percent). A majority of respondents (60 percent) believed that the ACA had improved access to care and insurance, yet many (43 percent) felt that it had reduced the affordability of coverage. More physicians agreed in 2017 than in 2012 that the ACA "would turn United States health care in the right direction" (53 percent versus 42 percent), despite reporting perceived worsening in several practice conditions over the same time period. After we adjusted for specialty, political party affiliation, practice setting type, perceived social responsibility, age, and sex, we found that only political party affiliation was a significant predictor of support for the ACA in the 2017 results.

Preventing cardiovascular disease: Participant perspectives of the FAITH! Program.

Striking cardiovascular health disparities exist among African-Americans in Minnesota compared to Whites; however, community-based interventions to address cardiovascular disease risk are lacking. This study explored participant perceptions of a culturally tailored, cardiovascular disease prevention program developed using a community-based participatory research process. Research participation perceptions, program benefits, and program satisfaction/acceptability were analyzed using a mixed-methods approach. Overall, acceptability was high. Findings highlight the favorable inclusion of African-Americans (research perception), knowledge gained about healthy lifestyle practices (benefits), and quality of the curriculum/speakers (satisfaction). Community-based participatory research may be useful in fostering the acceptability of behavior change interventions among marginalized African-American communities.

Portopulmonary Hypertension: A Survey of Practice Patterns and Provider Attitudes.

BACKGROUND: The role of liver transplantation (LT) in the management of portopulmonary hypertension (POPH) is poorly understood. The aim of this study was to better understand provider attitudes and practice patterns regarding the management of patients with POPH and to assess the concordance between clinical practice and current guidelines. METHODS: We performed a multicenter survey study of hepatologists and pulmonary hypertension (PH) physicians at US LT centers that performed >50 transplants per year. Survey responses are summarized as number (%). Associations were assessed using a Wilcoxon-rank sum, chi-square, or Fisher exact test, as appropriate. RESULTS: Seventy-four providers from 35 centers were included. There was marked variability regarding screening practices, management, and attitudes. Forty-two percent responded that POPH nearly always or often improves with LT, and 15.5% reported that POPH rarely or never improves. In contrast to current guidelines, 50.7% agreed that treated POPH should be an indication for LT in patients with compensated cirrhosis. Hepatologists were more likely than PH physicians to agree that POPH should be an indication for LT (P = 0.02). Forty-nine percent of respondents thought that the current POPH Model for End-stage Liver Disease exception criteria should be modified, and management of patients with an elevated mean pulmonary arterial pressure and normal pulmonary vascular resistance differed from current policies. CONCLUSIONS: There is marked variability in provider attitudes and practice patterns regarding the management of POPH. This study highlights the need for prospective studies to inform practice and for improved implementation of practice guidelines in order to standardize care.