"You start feeling comfortable, you just start sharing:" A qualitative study of patient distress screening in Black and White patients with endometrial cancer.

OBJECTIVES: Black patients with endometrial cancer are less likely to express distress and receive referrals for support services compared to White patients. We aim to characterize patient perceptions of the National Comprehensive Cancer Network Distress Thermometer and Problem List (NCCN DT & PL), a common distress screening tool, among Black and White patients with endometrial cancer and determine strategies to improve equity in referral to appropriate support services. METHODS: We conducted semi-structured interviews with 15 Black and 15 White patients with endometrial cancer who reported varying levels of distress on the NCCN DT & PL. Interviews were audio-recorded, transcribed, evaluated through staged content analysis, and salient themes were compared by patient race. RESULTS: The NCCN DT & PL was generally considered understandable, however the word "distress" could be alienating to participants who considered their stress to be less "drastic." Black participants mentioned fewer negative emotions such as worry and sadness in describing distress and spoke more often of a positive outlook. Additionally, Black participants emphasized the importance of relationship-building with clinicians for open communication on the NCCN DT & PL and clinical encounter. Finally, participants were divided on whether they would alter the way they completed the NCCN DT & PL given more information on cut off scores for referrals, but generally expressed a desire for more direct offers of support services. CONCLUSIONS: Relationship-building, open communication around emotion, and longitudinal direct offers of support emerged as avenues to reduce inequities in referral to supportive services for patients with endometrial cancer.

Digital Medicine System in Veterans With Severe Mental Illness: Feasibility and Acceptability Study.

BACKGROUND: Suboptimal medication adherence is a significant problem for patients with serious mental illness. Measuring medication adherence through subjective and objective measures can be challenging, time-consuming, and inaccurate. OBJECTIVE: The primary purpose of this feasibility and acceptability study was to evaluate the impact of a digital medicine system (DMS) among Veterans (patients) with serious mental illness as compared with treatment as usual (TAU) on medication adherence. METHODS: This open-label, 2-site, provider-randomized trial assessed aripiprazole refill adherence in Veterans with schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder. We randomized 26 providers such that their patients either received TAU or DMS for a period of 90 days. Semistructured interviews with patients and providers were used to examine the feasibility and acceptability of using the DMS. RESULTS: We enrolled 46 patients across 2 Veterans Health Administration sites: 21 (46%) in DMS and 25 (54%) in TAU. There was no difference in the proportion of days covered by medication refill over 3 and 6 months (0.82, SD 0.24 and 0.75, SD 0.26 in DMS vs 0.86, SD 0.19 and 0.82, SD 0.21 in TAU, respectively). The DMS arm had 0.85 (SD 0.20) proportion of days covered during the period they were engaged with the DMS (mean 144, SD 100 days). Interviews with patients (n=14) and providers (n=5) elicited themes salient to using the DMS. Patient findings described the positive impact of the DMS on medication adherence, challenges with the DMS patch connectivity and skin irritation, and challenges with the DMS app that affected overall use. Providers described an overall interest in using a DMS as an objective measure to support medication adherence in their patients. However, providers described challenges with the DMS dashboard and integrating DMS data into their workflow, which decreased the usability of the DMS for providers. CONCLUSIONS: There was no observed difference in refill rates. Among those who engaged in the DMS arm, the proportion of days covered by refills were relatively high (mean 0.85, SD 0.20). The qualitative analyses highlighted areas for further refinement of the DMS. TRIAL REGISTRATION: ClinicalTrials.gov NCT03881449; https://clinicaltrials.gov/ct2/show/NCT03881449.

eConsults' Impact on Care Access and Wait Times in Rheumatology.

BACKGROUND/OBJECTIVE: A growing number of health systems have implemented eConsults to improve access to specialty advice, but few studies have described their use in rheumatology or impact on visit wait times. We evaluated the uptake of an eConsult program and its impact on wait times for in-person rheumatology visits. METHODS: In this quality improvement project, we analyzed electronic health record data from 4 intervention clinics and 4 comparison clinics, 12 months before and after implementation of an eConsult program. We compared median wait time for rheumatology appointments using a pre-post difference-in-differences analysis and quantile regression, adjusting for patient age, race, sex, clinic pair, and primary insurance payer. We also interviewed 11 primary care providers from the intervention clinics and conducted a rheumatology provider focus group (n = 4) to elucidate experiences with the program. RESULTS: Rheumatologists recommended management in primary care or referral to another specialty for 41% of eConsults, reducing initial demand for in-person visits. The median wait times dropped in the intervention and the comparison clinics (42 and 25 days, respectively). Intervention clinic median wait time dropped 17 days more than comparison clinics, and this was nonstatistically significant (p = 0.089). eConsults fit provider care tasks best for triage or initial workup for diagnosis, and less well when tests required interpretation, or when back and forth communication was needed to manage the patient's condition. CONCLUSIONS: Implementation of eConsults for rheumatology was associated with reduced wait times for rheumatology appointments and supported primary care providers in the triage and workup for a substantial portion of patients.

MedFit App, a Behavior-Changing, Theoretically Informed Mobile App for Patient Self-Management of Cardiovascular Disease: User-Centered Development.

BACKGROUND: The MedFit app is designed to facilitate participation of people with cardiovascular disease (CVD) in an exercise-based rehabilitation program remotely. This paper details the development for the MedFit app. OBJECTIVE: The aim of this research was to develop a behavior change, theoretically informed exercise rehabilitation mobile app for adults with CVD by following the early stages of the formative research: development and feasibility testing. METHODS: Adhering to the mobile health (mHealth) development evaluation framework, the stages of the formative research process including (1) development and (2) feasibility were undertaken. The content and format of the MedFit app were developed based on (1) theory, (2) usability testing, and (3) content design. RESULTS: A systematic review of the literature was undertaken to identify the most appropriate theories from which to develop the app. This led to the creation of the MedFit app. The app went through iterative rounds of usability focus group testing with adults with CVD to provide feedback on the app. This process was framed by the unified theory of acceptance and use of technology model. Feedback was then translated into feasible technical improvements to be executed through close collaboration with the technical team, who adapted and made modifications to the app based on this codesign process. CONCLUSIONS: The formative research process of the app development involved theoretical underpinning, usability testing, and content design. mHealth interventions may play a key role in the future of health care, potentially addressing the barriers to participation in cardiac rehabilitation. This work will provide guidance for future research aiming to develop mobile apps by incorporating a best practice framework for mHealth intervention development and a user-centered design approach.

Knowledge, attitude, and practice of the use of irradiated meat among respondents to the FoodNet Population Survey in Connecticut and New York.

Irradiation of fresh meat to control microbial pathogens received approval from the federal government in February 2000. Food irradiation is a useful, albeit underutilized, process that can help protect the public from foodborne illnesses. The objective of this study was to determine consumer knowledge, attitudes, and practices toward irradiated meat products. Data were obtained from a single-stage random-digit dialing telephone survey of residents of the Foodborne Diseases Active Surveillance Network (FoodNet) sites conducted in 2002 to 2003, which included supplemental questions about food safety and irradiated meat for residents of the Connecticut and New York sites. Thirty-seven percent of 3,104 respondents knew that irradiated fresh meat was available for purchase; however, only 2% found the product where they shopped. Knowledge of product availability was significantly influenced by whether a respondent lived in a county with one or more grocery stores operated by chain A, which had actively promoted the sale of irradiated fresh ground beef during the survey period. In a logistic regression model, after adjusting for other factors, respondents living in a county with chain A were more likely to know that irradiated products could be purchased than respondents living in other counties (odds ratio 2.0; 95% confidence interval 1.5 to 2.5). This finding suggests that public education efforts by an individual grocery store chain can have an important effect on knowledge of irradiated food.

Social and geographic distance in HIV risk.

OBJECTIVE: The objective of this study was to examine the relationship between social distance (measured as the geodesic, or shortest distance, between 2 people in a connected network) and geographic distance (measured as the actual distance between them in kilometers [km]). STUDY: We used data from a study of 595 persons at risk for HIV and their sexual and drug-using partners (total N = 8920 unique individuals) conducted in Colorado Springs, Colorado, from 1988 to 1992--a longitudinal cohort study that ascertained sociodemographic, clinical, behavioral, and network information about participants. We used place of residence as the geographic marker and calculated distance between people grouped by various characteristics of interest. RESULTS: Fifty-two percent of all dyads were separated by a distance of 4 km or less. The closest pairs were persons who both shared needles and had sexual contact (mean = 3.2 km), and HIV-positive persons and their contacts (mean = 2.9). The most distant pairs were prostitutes and their paying partners (mean = 6.1 km). In a connected subset of 348 respondents, almost half the persons were between 3 and 6 steps from each other in the social network and were separated by a distance of 2 to 8 km. Using block group centroids, the mean distance between all persons in Colorado Springs was 12.4 km compared with a mean distance of 5.4 km between all dyads in this study (P <0.0001). The subgroup of HIV-positive people and their contacts was drawn in real space on a map of Colorado Springs and revealed tight clustering of this group in the downtown area. CONCLUSION: The association of social and geographic distance in an urban group of people at risk for HIV provides demonstration of the importance of geographic clustering in the potential transmission of HIV. The proximity of persons connected within a network, but not necessarily known to each other, suggests that a high probability of partner selection from within the group may be an important factor in maintenance of HIV endemicity.

Who's calling the shots? Pediatricians' adherence to the 2001-2003 pneumococcal conjugate vaccine-shortage recommendations.

BACKGROUND: A national shortage of heptavalent pneumococcal conjugate vaccine (PCV7) occurred from September 2001 through May 2003. In December 2001 and January 2002, the Advisory Committee on Immunization Practices and the American Academy of Pediatrics (AAP) issued PCV7-shortage recommendations, emphasizing that all health care providers decrease the number of doses for healthy children so that more children could receive some PCV7. OBJECTIVES: We assessed (1) how the PCV7 shortage affected pediatricians, (2) whether children in the public and private sectors were vaccinated differently during the shortage, (3) pediatricians' knowledge of and adherence to the Advisory Committee on Immunization Practices/AAP recommendations, (4) and what factors were associated with nonadherence to the recommendations. METHODS: We conducted a cross-sectional mail survey of 2500 US physician-members of the AAP from November 2002 through March 2003; physicians providing childhood immunizations were eligible. We asked about PCV7-shortage experience, assessed recommendation adherence through clinical scenarios, and modeled potential factors associated with reported nonadherence to the recommendation to defer the fourth PCV7 dose. RESULTS: Of 2478 surveys sent to valid addresses, 1412 (57%) completed surveys were received; 946 (67%) of these were from eligible pediatricians. Overall, 79% experienced a PCV7 shortage, 94% reported being aware of the recommendations, and 42% reported barriers to recommendation adherence. Ninety-four percent reported vaccinating 6-month-old infants with private or public insurance in the same manner. As recommended, 91% reported fully vaccinating high-risk patients. Contrary to recommendations, 49% reported sometimes or always administering the fourth PCV7 dose to healthy children 12 to 15 months old; their reasons included recurrent otitis media, childcare attendance, and parental desire. Controlling for other characteristics, pediatricians who had no PCV7 shortage in their practices were significantly more likely to report administering the fourth dose than pediatricians who had a shortage (odds ratio [OR]: 3.67; 95% confidence interval [CI]: 2.40-5.63). Other factors associated with nonadherence were being in solo private practice (OR: 2.18; 95% CI: 1.26-3.77) or being male (OR: 1.51; 95% CI: 1.08-2.12). Among pediatricians deferring PCV7, 36% reported having no system to track children for whom PCV7 was deferred. CONCLUSIONS: Many pediatricians, both with and without a PCV7 shortage, administered more PCV7 doses than recommended. Pediatricians without a shortage were less likely to limit use, which suggests that they might have focused on the perceived value of administering the full schedule to their patients in preference to broader public health goals. Providing more information to physicians on the effectiveness of a fewer-dose schedule and the risk of disease when vaccine is deferred and educating parents might increase adherence to recommendations and achieve more equitable coverage during vaccine shortages.