Association of food insecurity with overall and disease-specific mortality among cancer survivors in the US.

PURPOSE: To investigate the association of food insecurity with overall and disease-specific mortality among US cancer survivors. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES 1999-2018) were used to examine the impact of food insecurity on mortality risks among cancer survivors in the US. Study participants aged ≥ 20 years who had a history of cancer and completed the Adult Food Security Survey Module were included. Mortality data [all-cause, cancer, and cardiovascular (CVD) specific] through December 31, 2019 were obtained through linkage to the National Death Index. Using multivariable Cox proportional hazard regression, hazard ratios of mortality based on food security status were estimated. RESULTS: Among 5032 cancer survivors (mean age 62.5 years; 58.0% women; 86.2% non-Hispanic White), 596 (8.8%) reported food insecurity. Overall, 1913 deaths occurred (609 cancer deaths and 420 CVD deaths) during the median follow-up of 6.8 years. After adjusting for age, food insecurity was associated with a higher risk of overall (HR = 1.93; 95% CI = 1.56-2.39), CVD-specific (HR = 1.95; 95% CI = 1.24-3.05), and cancer-specific (HR = 1.70; 95% CI = 1.20-2.42) mortality (P < 0.001). However, after adjusting for socioeconomic characteristics and health-related factors (physical activity, diet quality measured by healthy eating index), the association between food insecurity and overall mortality was no longer statistically significant. CONCLUSIONS: Food insecurity was associated with a greater risk of overall mortality among cancer survivors. Further studies are needed to confirm these findings and evaluate whether the observed association represents a causal phenomenon and, if so, whether the effect is modifiable with food assistance programs.

Mobile Postoperative Symptom Intervention Tool and Biometric Monitoring After Radical Cystectomy: Pilot Study Evaluating Feasibility, Usability, and Potential Utility.

PURPOSE: Mobile health technology and integration of patient-reported outcome measures into clinical interventions have the potential to transform patient care. Though patient-reported outcome measure management has been shown to improve outcomes in ambulatory care settings, few studies have examined remote patient-reported outcome measure assessment after major cancer surgery. MATERIALS AND METHODS: A multiphased feasibility and usability study was designed. A mobile app-based postoperative symptom intervention tool was developed and evaluated by a focus group of bladder cancer patients and caregivers. Patients were prospectively accrued prior to cystectomy and asked to complete the daily mobile postoperative symptom intervention tool and wear biometric monitoring devices for 30 days post discharge. Retention, postoperative symptom intervention tool completion, and usability were assessed. Exploratory analysis of daily symptoms and patient-generated health information correlated signals with postsurgical complications and hospital readmission. RESULTS: Fifteen patients with a median age of 72 years completed 78% of daily surveys over the 30-day recovery period. Average time to complete the postoperative symptom intervention tool was 152 seconds. All patients agreed that the daily survey was easy to use, and most reported it would be a better way to communicate with the care team about symptoms than calling the clinic. Frequency and severity of patient-reported symptoms appeared to cluster prior to or at the time of complication or unplanned health care encounters on visual-analogue mapping. CONCLUSIONS: Using smartphone and wearable technology to capture patient-reported symptoms and biometric data is feasible and rated as highly usable by bladder cancer patients after cystectomy. Symptom scores may signal developing complications and help clinicians identify postsurgical patients who may benefit from intervention.

Telemedicine Adoption in an NCI-Designated Cancer Center During the COVID-19 Pandemic: A Report on Patient Experience of Care.

BACKGROUND: Patients with cancer require timely access to care so that healthcare providers can prepare an optimal treatment plan with significant implications for quality of life and mortality. The COVID-19 pandemic spurred rapid adoption of telemedicine in oncology, but study of patient experience of care with telemedicine in this population has been limited. We assessed overall patient experience of care with telemedicine at an NCI-designated Comprehensive Cancer Center during the COVID-19 pandemic and examined changes in patient experience over time. PATIENTS AND METHODS: This was a retrospective study of outpatient oncology patients who received treatment at Moffitt Cancer Center. Press Ganey surveys were used to assess patient experience. Data from patients with appointments between April 1, 2020, and June 30, 2021, were analyzed. Patient experience was compared between telemedicine and in-person visits, and patient experience with telemedicine over time was described. RESULTS: A total of 33,318 patients reported Press Ganey data for in-person visits, and 5,950 reported Press Ganey data for telemedicine visits. Relative to patients with in-person visits, more patients with telemedicine visits gave higher satisfaction ratings for access (62.5% vs 75.8%, respectively) and care provider concern (84.2% vs 90.7%, respectively) (P<.001). When adjusted for age, race/ethnicity, sex, insurance, and clinic type, telemedicine visits consistently outperformed in-person visits over time regarding access and care provider concern (P<.001). There were no significant changes over time in satisfaction with telemedicine visits regarding access, care provider concern, telemedicine technology, or overall assessment (P>.05). CONCLUSIONS: In this study, a large oncology dataset showed that telemedicine resulted in better patient experience of care in terms of access and care provider concern compared with in-person visits. Patient experience of care with telemedicine visits did not change over time, suggesting that implementing telemedicine was effective.

Patient and caregiver experience with telehealth for surgical cancer care: A qualitative study.

INTRODUCTION: The COVID-19 pandemic led to telemedicine adoption for many medical specialties, including surgical cancer care. To date, the evidence for patient experience of telemedicine among patients with cancer undergoing surgery is limited to quantitative surveys. Thus, this study qualitatively assessed the patient and caregiver experience of telehealth visits for surgical cancer care. METHODS: We conducted semistructured interviews with 25 patients with cancer and three caregivers who had completed a telehealth visit for preanesthesia or postoperative visits. Interviews covered visit descriptions, overall satisfaction, system experience, visit quality, what roles caregivers had, and thoughts on what types of surgery-related visits would be appropriate through telehealth versus in-person. RESULTS: Telehealth delivery for surgical cancer care was generally viewed positively. Multiple factors influenced the patient experience, including prior experience with telemedicine, ease of scheduling visits, smooth connection experiences, having access to technical support, high communication quality, and visit thoroughness. Participants identified use cases on telehealth for surgical cancer care, including postoperative visits for uncomplicated surgical procedures and educational visits. CONCLUSIONS: Patient experiences with telehealth for surgical care are influenced by smooth system experiences, high-quality patient-clinician communications, and a patient-centered focus. Interventions are needed to optimize telehealth delivery (e.g., improve telemedicine platform usability).

Qualitative evaluation of the implementation and future sustainability of an e-referral system for smoking cessation at a US NCI-designated comprehensive cancer center: lessons learned.

BACKGROUND: Promoting smoking cessation is recognized as an essential part of cancer care. Moffitt Cancer Center, supported by the National Cancer Institute Cancer Moonshot Cancer Center Cessation Initiative, developed and implemented an opt-out-based automatic electronic health record (EHR)-mediated referral (e-referral) system for Tobacco Quitline services along with options for local group cessation support and an in-house tobacco treatment specialist. This study evaluated barriers and facilitators for implementation of the e-referral system. METHOD: Steering committee members (N=12) responsible for developing and implementing the new clinical workflow and nurses (N=12) who were expected to use the new e-referral system completed semi-structured interviews. Qualitative thematic content analyses were conducted. RESULTS: Interviewees perceived the e-referral system as an effective strategy for identifying and referring smokers to cessation services. However, barriers were noted including competing demands and perceptions that smoking cessation was a low priority and that some patients were likely to have low motivation to quit smoking. Suggestions to improve future implementation and sustainability included providing regular trainings and e-referral outcome reports and increasing the visibility of the e-referral system within the EHR. CONCLUSION: Initial implementation of the e-referral system was perceived as successful; however, additional implementation strategies are needed to ensure sustainability at both the clinician and system levels. Recommendations for future modifications include providing regular clinician trainings and developing a fully closed-loop system. Implications for cancer survivors Initial implementation of an e-referral system for smoking cessation for cancer patients revealed opportunities to improve the smoking cessation referral process at cancer centers.

Adoption of emergency department crowding interventions among US hospitals between 2007 and 2020.

BACKGROUND: To deal with emergency department (ED) crowding, the American College of Emergency Physicians (ACEP) established a task force to develop a list of low-cost, high-impact solutions. In this study, we report on the trend in the adoption rate of ACEP-recommended ED crowding interventions by US hospitals. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey data from 2007 to 2020 (N = 3874 hospitals). The primary outcome was whether a hospital adopted each of the ACEP-recommended interventions, which were grouped into three overlapping categories: technology-based, flow modifications, and physical-based (e.g., changing ED layout). RESULTS: On average, the most frequently adopted intervention was bedside registration (85.1%) and the least frequently adopted intervention was kiosk check-in (8.3%). The adoption of ED crowding interventions increased significantly between 2007 and 2020, except for expanding ED treatment space which declined by 45.0% from 30.3% in 2007 to 15.7% in 2020. The largest adoption rate increase occurred in having a separate operating room for ED cases with a 188.5% increase in adoption rate followed by radio-frequency identification (RFID) tracking (151.2%), and kiosk check-in (144.2%). CONCLUSIONS: The adoption rate of ED crowding interventions by hospitals has risen, however most effective ED crowding interventions are still underutilized. The trends for each intervention did not always increase linearly, with certain periods showing greater fluctuations in adoption rate. Hospitals tend to implement technology-based interventions, compared to physical-based interventions and flow modification interventions.

Patient and caregiver experience with telepharmacy in cancer care to support beginning systemic therapy: A qualitative study.

INTRODUCTION: Although the COVID-19 pandemic spurred telehealth adoption for many specialties and care team roles, the patient and caregiver experience for telepharmacy visits has been relatively understudied. To our knowledge, there is a paucity of studies that have attempted to qualitatively evaluate this. This study aimed to qualitatively assess the patient and caregiver experience of telepharmacy visits in a cancer center. METHODS: Semistructured interviews were conducted with 21 patients with cancer and seven caregivers that had attended a telepharmacy visit between December 1, 2021, and May 24, 2022. The interviews assessed visit content, overall satisfaction, system experience, visit quality, and future preferences for pharmacy visits as telehealth versus in-person. We used both deductive and inductive coding to identify themes. RESULTS: Telepharmacy delivery was generally well-received. Reasons for having the telepharmacy visit included reviewing chemotherapy procedures, side effects to expect during treatment, providing education on recently prescribed medications, offering dietary recommendations (e.g., avoiding grapefruit juice), and performing medication reconciliation. Participants were receptive to having pharmacy visits through telehealth due to the perceived lack of a need to have a physical exam and prior relationship with the pharmacist. Participants also highlighted the main reason for the telepharmacy visits was primarily to provide patient education, which participants felt was suitable for telehealth. CONCLUSIONS: The patient and caregiver experience of telepharmacy is influenced by several factors, such as ease of connectivity, communicating effectively with the pharmacist, and timing of the telepharmacy visit (e.g., immediately after picking up medications from the pharmacy). Participants' recommendations to improve telepharmacy delivery included health systems raising awareness of telepharmacy services and providing a list of questions to patients to guide discussions.

Early Performance of the Patients Over Paperwork Initiative among Family Medicine Physicians.

OBJECTIVES: In 2019, the Centers for Medicare & Medicaid Services began implementing the Patients Over Paperwork (POP) initiative in response to clinicians reporting burdensome documentation regulations. To date, no study has evaluated how these policy changes have influenced documentation burden. METHODS: Our data came from the electronic health records of an academic health system. Using quantile regression models, we assessed the association between the implementation of POP and clinical documentation word count using data from family medicine physicians in an academic health system from January 2017 to May 2021 inclusive. Studied quantiles included the 10th, 25th, 50th, 75th, and 90th quantiles. We controlled for patient-level (race/ethnicity, primary language, age, comorbidity burden), visit-level (primary payer, level of clinical decision making involved, whether a visit was done through telemedicine, whether a visit was for a new patient), and physician-level (sex) characteristics. RESULTS: We found that the POP initiative was associated with lower word counts across all of the quantiles. In addition, we found lower word counts among notes for private payers and telemedicine visits. Conversely, higher word counts were observed in notes that were written by female physicians, notes for new patient visits, and notes involving patients with greater comorbidity burden. CONCLUSIONS: Our initial evaluation suggests that documentation burden, as measured by word count, has declined over time, particularly following implementation of the POP in 2019. Additional research is needed to see whether the same occurs when examining other medical specialties, clinician types, and longer evaluation periods.

Utilization of inpatient palliative care services among adolescents and young adults with cancer: Evidence from National Inpatient Sample 2016-2019.

OBJECTIVES: Palliative care can improve the quality of life of adolescents and young adults (AYA) with cancer. However, little is known about the utilization of palliative care among AYA cancer patients. Identifying factors associated with the utilization of palliative care could inform efforts to improve palliative care access among AYA patients living with cancer. METHODS: Using data from the National Inpatient Sample 2016-2019, a representative sample of US hospitalizations, we examined palliative care encounters and associated characteristics among hospitalizations of AYA with cancer and high inpatient mortality risk. Survey design-adjusted bivariate and multivariable logistic regression models were used to examine associations of patient- and hospital-level characteristics with palliative care. RESULTS: Of 10,979 hospitalizations by AYA cancer patients with high mortality risk, 19.9% received palliative care services between 2016 and 2019. After adjusting for all characteristics, independent predictors of palliative care use were as follows: older age (25-39 years old vs. 25-39 years; odds ratio [OR] 1.31, 95% confidence interval [CI] 1.15-1.49), Hispanic/Latinx (vs. non-Hispanic White; OR 1.16, 95% CI 1.01-1.34), female (vs. male; OR 1.27, 95% CI 1.14-1.41), public insurance (vs. private insurance; OR 1.23, 95% CI 1.10-1.38), hospital location in the US South (vs. Northeast; OR 0.78, 95% CI 0.66-0.94), and a large hospital (vs. small; OR 0.83, 95% CI 0.72-0.96). SIGNIFICANCE OF RESULTS: Less than 20% of AYAs with cancer and high risk of mortality received inpatient palliative care services. Further research is needed to explore the reasons for lower palliative care utilization in the younger age groups.

Metagenomics and chemotherapy-induced nausea: A roadmap for future research.

Uncontrolled chemotherapy-induced nausea and vomiting can reduce patients' quality of life and may result in premature discontinuation of chemotherapy. Although nausea and vomiting are commonly grouped together, research has shown that antiemetics are clinically effective against chemotherapy-induced vomiting (CIV) but less so against chemotherapy-induced nausea (CIN). Nausea remains a problem for up to 68% of patients who are prescribed guideline-consistent antiemetics. Despite the high prevalence of CIN, relatively little is known regarding its etiology independent of CIV. This review summarizes a metagenomics approach to the study and treatment of CIN with the goal of encouraging future research. Metagenomics focuses on genetic risk factors and encompasses both human (ie, host) and gut microbial genetic variation. Little work to date has focused on metagenomics as a putative biological mechanism of CIN. Metagenomics has the potential to be a powerful tool in advancing scientific understanding of CIN by identifying new biological pathways and intervention targets. The investigation of metagenomics in the context of well-established demographic, clinical, and patient-reported risk factors may help to identify patients at risk and facilitate the prevention and management of CIN.

Rapid adaptation of cancer screening practices during COVID-19: A multi-state qualitative study.

Context: The COVID-19 pandemic required primary care practices to rapidly adapt cancer screening procedures to comply with changing guidelines and policies. Objective: This study sought to: 1) identify cancer screening barriers and facilitators during the COVID-19 pandemic; 2) describe cancer screening adaptations; and 3) provide recommendations. Study design: A qualitative study was conducted (n= 42) with primary care staff. Individual interviews were conducted through videoconference from August 2020 - April 2021 and recorded, transcribed, and analyzed for themes using NVivo 12 Plus. Setting: Primary care practices included federally qualified health centers, tribal health centers, rural health clinics, hospital/health system-owned, and academic medical centers located across ten states including urban (55%) and rural (45%) sites. Population studied: Primary care staff included physicians (n=13), residents (n=10), advanced practice providers (n=9), and administrators (n=10). Outcome measures: The interviews assessed perceptions about cancer screening barriers and facilitators, necessary adaptations, and future recommendations. Results: Barriers to cancer screening included delays in primary and specialty care, staff shortages, lack of personal protective equipment, patient hesitancy to receive in-person care, postal service delays for mail-home testing, COVID-19 travel restrictions (for Mexico-US border-crossing patients) and organizational policies (e.g., required COVID-19 testing prior to screening). Facilitators included better care coordination and collaboration due to the pandemic and more time during telehealth visits to discuss cancer screening compared to in-person visits. Adaptations included delayed screening, patient triage (e.g., prioritizing patients overdue for screening), telehealth visits to discuss cancer screening, mail-home testing, coordinating cancer screenings (e.g., providing fecal immunochemical test materials during cervical cancer screening) and same-day cancer screening. Recommendations included more public health education about the importance of cancer screening during COVID-19, more mail-home testing, and expanded healthcare access (e.g., weekend clinic) to address patient backlogs for cancer screening. Conclusions: Primary care staff developed innovative strategies to adapt cancer screening during the COVID-19 pandemic. Unresolved challenges (e.g., patient backlogs) will require additional implementation stra.

Health Care Providers' and Professionals' Experiences With Telehealth Oncology Implementation During the COVID-19 Pandemic: A Qualitative Study.

BACKGROUND: Rapid implementation of telehealth for cancer care during COVID-19 required innovative and adaptive solutions among oncology health care providers and professionals (HPPs). OBJECTIVE: The aim of this qualitative study was to explore oncology HPPs' experiences with telehealth implementation during the COVID-19 pandemic. METHODS: This study was conducted at Moffitt Cancer Center (Moffitt), an NCI (National Cancer Institute)-Designated Comprehensive Cancer Center. Prior to COVID-19, Moffitt piloted telehealth visits on a limited basis. After COVID-19, Moffitt rapidly expanded telehealth visits. Telehealth visits included real-time videoconferencing between HPPs and patients and virtual check-ins (ie, brief communication with an HPP by telephone only). We conducted semistructured interviews with 40 oncology HPPs who implemented telehealth during COVID-19. The interviews were recorded, transcribed verbatim, and analyzed for themes using Dedoose software (version 4.12). RESULTS: Approximately half of the 40 participants were physicians (n=22, 55%), and one-quarter of the participants were advanced practice providers (n=10, 25%). Other participants included social workers (n=3, 8%), psychologists (n=2, 5%), dieticians (n=2, 5%), and a pharmacist (n=1, 3%). Five key themes were identified: (1) establishing and maintaining patient-HPP relationships, (2) coordinating care with other HPPs and informal caregivers, (3) adapting in-person assessments for telehealth, (4) developing workflows and allocating resources, and (5) future recommendations. Participants described innovative strategies for implementing telehealth, such as coordinating interdisciplinary visits with multiple HPPs and inviting informal caregivers (eg, spouse) to participate in telehealth visits. Health care workers discussed key challenges, such as workflow integration, lack of physical exam and biometric data, and overcoming the digital divide (eg, telehealth accessibility among patients with communication-related disabilities). Participants recommended policy advocacy to support telehealth (eg, medical licensure policies) and monitoring how telehealth affects patient outcomes and health care delivery. CONCLUSIONS: To support telehealth growth, implementation strategies are needed to ensure that HPPs and patients have the tools necessary to effectively engage in telehealth. At the same time, cancer care organizations will need to engage in advocacy to ensure that policies are supportive of oncology telehealth and develop systems to monitor the impact of telehealth on patient outcomes, health care quality, costs, and equity.

Telestroke Infrastructure, Processes, and Support Needs: A Survey of Hospitals in Five States.

Introduction: Telestroke has been shown to be a cost-effective approach to promoting use and timeliness of evidence-based treatment. However, adoption of telestroke has been relatively low. Several barriers to telestroke implementation have been previously identified in the literature. These barriers, and the strategies needed to overcome them, may vary across hospitals. Our study aimed to examine telestroke programs to identify opportunities for future research and efforts to promote effective implementation and sustainment of telestroke services. Methods: We surveyed hospitals in five states to capture information about the current status of the hospital's telestroke program; the model(s) of delivery being used (e.g., hub-and-spoke and third-party vendor); and telestroke infrastructure, processes, and implementation strategies. The survey included both closed-ended and open-ended response options. Descriptive results are presented, complemented with illustrative examples of open-ended responses. Results: We received 89 responses, each representing a different hospital. Approximately one-third of telestroke programs in our sample began between 2018 and 2020. More than two-thirds reported participating in a collaboration with other organizations to improve telestroke services. The most commonly reported, high-priority topics for additional guidance involved monitoring process measures, using performance indicators for improvement, and sharing data from measures with physicians. Discussion: Results complement prior studies, specifically about impacts of COVID-19 on telestroke programs and capabilities that hospitals most need assistance with. Challenges faced and guidance needed differ across hospitals, suggesting a need for a tailored support. The results also suggest more work is needed to understand factors that threaten sustainability of telestroke programs.

Association of Financial Factors and Telemedicine Adoption for Heart Attack and Stroke Care Among Rural and Urban Hospitals: A Longitudinal Study.

Introduction: To examine trends in telemedicine adoption for stroke and cardiac care among U.S. hospitals, specifically associations between hospital financial indicators and adoption of these telemedicine services. Methods: This is a retrospective analysis of data from the Health Information Management and System Society Dorenfest Database and Healthcare Cost Report Information System from 2012 to 2017. We used a pooled ordinary least squares model and reported results as average marginal effects (AMEs). Results: The number of hospitals with stroke or cardiac telemedicine services in urban and rural areas increased through our study period from 153 (7.30%) to 407 (19.42%) and from 127 (6.31%) to 331 (16.45%), respectively. In rural hospitals, being a for-profit hospital (AME = -10.49, 95% confidence interval [CI] = -14.01 to -6.98) and having an increase in Medicare inpatient mix (AME = -0.31, 95% CI = -0.42 to -0.20) were associated with the probability of telemedicine adoption for heart attack and stroke care. A couple of nonfinancial variables included in the model also were associated with adoption, specifically having one more licensed bed (AME = -0.02, 95% CI = -0.04 to -0.00) and higher number of emergency department visits (AME = 5.64, 95% CI = 2.83 to 7.20). In urban hospitals, being a for-profit hospital (AME = -8.94, 95% CI = -11.76 to -6.11) and having a higher total margin (AME = 0.17, 95% CI = 0.08 to 0.26) were associated with the probability of telemedicine adoption for heart attack and stroke care. Two nonfinancial variables also were statistically significant: having one more licensed bed (AME = 0.01, 95% CI = 0.041 to 0.02) and being closer to another telemedicine hospital (AME = 0.81, 95% CI = -1.62 to 0.01). Discussions: Telemedicine adoption rate for cardiac and stroke care has increased significantly in recent years. Financial status may be a bigger driver of adoption for urban hospitals than rural hospitals.

Patient-Level Factors Associated with Utilization of Telemedicine Services from a Free Clinic During COVID-19.

Background: Disparities in telemedicine use by race, age, and income have been consistently documented. To date, research has focused on telemedicine use among patients with adequate insurance coverage. To address this gap, this study identifies patient-level factors associated with telemedicine use during the coronavirus (COVID-19) pandemic among one free clinic network's patients who are underinsured or uninsured. Methods: Electronic health record data were reviewed for patient-level data on patients seen from March 2020 to September 2020. Patients were grouped by telemedicine use history. We controlled for sociodemographic factors (e.g., age, race/ethnicity) and comorbidities. Logistic regression analyses were conducted. Results: Across 198 adult patients, 56.6% received telemedicine care. Of these, 99.1% elected for audio-only telemedicine instead of video telemedicine. Telemedicine use was more likely among those living within 15 miles of their clinic (adjusted odds ratio [aOR] = 4.43, 95% confidence interval [CI] 1.70-11.53). It was less likely to be used by older patients (aOR = 0.97, 95% CI 0.94-1.00), patients of male sex (aOR = 0.85, 95% CI 0.18-0.92), and those establishing care as a new patient (aOR = 0.01, 95% CI 0.00-0.07). Conclusion: The moderate usage of telemedicine suggests that its implementation in free clinics may be feasible. Solutions specific to patients with smartphone-only internet access are needed to improve the use of video telemedicine as smartphone-specific factors (e.g., data use limits) may influence the ability for underserved patients to receive video telemedicine.

Geographic variation in palliative care delivery among patients diagnosed with metastatic lung cancer in the USA: Medicare population-based study.

PURPOSE: The USA has observed a significant increase in the use of palliative care for patients diagnosed with advanced cancer. However, it is unknown how geographic variation affects patients' use of palliative care services. We examined temporal and demographic trends in receipt of and timing of palliative care by state and region. METHODS: A retrospective cohort study of the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Study sample included community-dwelling patients aged ≥ 65 years with metastatic lung cancer who were diagnosed between 2001 and 2015. Cochran-Armitage trend test was used to evaluate temporal trends in receipt of and timing of palliative care by states and census region. RESULTS: The proportion of metastatic lung cancer patients who received palliative care ranged from 16.4% in Washington and 16.3% in Connecticut to 6.4% in Louisiana. From 2001 to 2015, use of palliative care increased from 3.2 to 29.8% in the West region, from 3.3 to 31.9% in the Northeast region, from 3.8 to 36.2% in the Midwest region, and from 0.9 to 23.3% in the South region (all P < 0.001). The median time from the date of cancer diagnosis to the date of first palliative care visit varied geographically, from 44 days in Utah to 66 days in California. Hospital-based palliative care was most common in these states. CONCLUSION: The substantial geographic variation in the use of palliative care suggesting a need for additional research on geographic disparities in palliative care and strategies that might improve state-level palliative care delivery.

The Tennessee Medicaid medication therapy management program: early stage contextual factors and implementation outcomes.

BACKGROUND: First investigated in the 1990s, medication therapy management (MTM) is an evidence-based practice offered by pharmacists to ensure a patient's medication regimen is individualized to include the safest and most effective medications. MTM has been shown to a) improve quality of patient care, b) reduces health care costs, and c) lead to fewer medication-related adverse effects. However, there has been limited testing of evidence-based, a-priori implementation strategies that support MTM implementation on a large scale. METHODS: The study has two objectives assessed at the organizational and individual level: 1) to determine the adoption, feasibility, acceptability and appropriateness of a multi-faceted implementation strategy to support the MTM pilot program in Tennessee; and 2) to report on the contextual factors associated with program implementation based on the Consolidated Framework for Implementation Research (CFIR). The overall design of the study was a hybrid type 2 effectiveness-implementation study reporting outcomes of Tennessee state Medicaid's (TennCare) MTM Pilot program. This paper presents early stage implementation outcomes (e.g., adoption, feasibility, acceptability, appropriateness) and explores implementation barriers and facilitators using the CFIR. The study was assessed at the (a) organizational and (b) individual level. A mixed-methods approach was used including surveys, claims data, and semi-structured interviews. Interview data underwent initial, rapid qualitative analysis to provide real time feedback to TennCare leadership on project barriers and facilitators. RESULTS: The total reach of the program from July 2018 through June 2020 was 2033 MTM sessions provided by 17 Medicaid credentialed pharmacists. Preliminary findings suggest participants agreed that MTM was acceptable (µ = 16.22, SD = 0.28), appropriate (µ = 15.33, SD = 0.03), and feasible (µ = 14.72, SD = 0.46). Each of the scales had an excellent level of internal (> 0.70) consistency (feasibility, α = 0.91; acceptability, α = 0.96; appropriateness, α = 0.98;). Eight program participants were interviewed and were mapped to the following CFIR constructs: Process, Characteristics of Individuals, Intervention Characteristics, and Inner Setting. Rapid data analysis of the contextual inquiry allowed TennCare to alter initial implementation strategies during project rollout. CONCLUSION: The early stage implementation of a multi-faceted implementation strategy to support delivery of Tennessee Medicaid's MTM program was found to be well accepted and appropriate across multiple stakeholders including providers, administrators, and pharmacists. However, as the early stage of implementation progressed, barriers related to relative priority, characteristics of the intervention (e.g., complexity), and workflow impeded adoption. Programmatic changes to the MTM Pilot based on early stage contextual analysis and implementation outcomes had a positive impact on adoption.

Impact of Asynchronous Electronic Communication-Based Visits on Clinical Outcomes and Health Care Delivery: Systematic Review.

BACKGROUND: Electronic visits (e-visits) involve asynchronous communication between clinicians and patients through a secure web-based platform, such as a patient portal, to elicit symptoms and determine a diagnosis and treatment plan. E-visits are now reimbursable through Medicare due to the COVID-19 pandemic. The state of evidence regarding e-visits, such as the impact on clinical outcomes and health care delivery, is unclear. OBJECTIVE: To address this gap, we examine how e-visits have impacted clinical outcomes and health care quality, access, utilization, and costs. METHODS: We conducted a systematic review; MEDLINE, Embase, and Web of Science were searched from January 2000 through October 2020 for peer-reviewed studies that assessed e-visits' impacts on clinical and health care delivery outcomes. RESULTS: Out of 1859 papers, 19 met the inclusion criteria. E-visit usage was associated with improved or comparable clinical outcomes, especially for chronic disease management (eg, diabetes care, blood pressure management). The impact on quality of care varied across conditions. Quality of care was equivalent or better for chronic conditions, but variable quality was observed in infection management (eg, appropriate antibiotic prescribing). Similarly, the impact on health care utilization varied across conditions (eg, lower utilization for dermatology but mixed impact in primary care). Health care costs were lower for e-visits than those for in-person visits for a wide range of conditions (eg, dermatology and acute visits). No studies examined the impact of e-visits on health care access. It is difficult to draw firm conclusions about effectiveness or impact on care delivery from the studies that were included because many used observational designs. CONCLUSIONS: Overall, the evidence suggests e-visits may provide clinical outcomes that are comparable to those provided by in-person care and reduce health care costs for certain health care conditions. At the same time, there is mixed evidence on health care quality, especially regarding infection management (eg, sinusitis, urinary tract infections, conjunctivitis). Further studies are needed to test implementation strategies that might improve delivery (eg, clinical decision support for antibiotic prescribing) and to assess which conditions can be managed via e-visits.

Early Performance of Hospital Value-based Purchasing Program in Medicare: A Systematic Review.

BACKGROUND: Under the Affordable Care Act, the Centers for Medicare and Medicaid Services has greatly expanded inpatient fee-for-value programs including the Hospital Value-based Purchasing (HVBP) program. Existing evidence from the HVBP program is mixed. There is a need for a systematic review of the HVBP program to inform discussions on how to improve the program's effectiveness. OBJECTIVE: To review and summarize studies that evaluated the HVBP program's impact on clinical processes, patient satisfaction, costs and outcomes, or assessed hospital characteristics associated with performance on the program. DESIGN: We searched the MEDLINE/PubMed, Scopus, ProQuest database for literature published between January 2013 and July 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS: Of 988 studies reviewed, 33 studies that met the selection criteria were included. A small group of studies (n=7) evaluated the impact of the HVBP program, and no impact on processes or patient outcomes was reported. None of the included studies evaluated the effect of HVBP program on health care costs. Other studies (n=28) evaluated the hospital characteristics associated with HVBP performance, suggesting that safety-net hospitals reportedly performed worse on several quality and cost measures. Other hospital characteristics' associations with performance were unclear. CONCLUSIONS: Our findings suggest that the current HVBP does not lead to meaningful improvements in quality of care or patient outcomes and may negatively affect safety-net hospitals. More rigorous and comprehensive adjustment is needed for more valid hospital comparisons.

Patient Portal Barriers and Group Differences: Cross-Sectional National Survey Study.

BACKGROUND: Past studies examining barriers to patient portal adoption have been conducted with a small number of patients and health care settings, limiting generalizability. OBJECTIVE: This study had the following two objectives: (1) to assess the prevalence of barriers to patient portal adoption among nonadopters and (2) to examine the association between nonadopter characteristics and reported barriers in a nationally representative sample. METHODS: Data from this study were obtained from the 2019 Health Information National Trends Survey. We calculated descriptive statistics to determine the most prevalent barriers and conducted multiple variable logistic regression analysis to examine which characteristics were associated with the reported barriers. RESULTS: The sample included 4815 individuals. Among these, 2828 individuals (58.73%) had not adopted a patient portal. Among the nonadopters (n=2828), the most prevalent barriers were patient preference for in-person communication (1810/2828, 64.00%), no perceived need for the patient portal (1385/2828, 48.97%), and lack of comfort and experience with computers (735/2828, 25.99%). Less commonly, individuals reported having no patient portal (650/2828, 22.98%), no internet access (650/2828, 22.98%), privacy concerns (594/2828, 21.00%), difficulty logging on (537/2828, 18.99%), and multiple patient portals (255/2828, 9.02%) as barriers. Men had significantly lower odds of indicating a preference for speaking directly to a provider compared with women (odds ratio [OR] 0.75, 95% CI 0.60-0.94; P=.01). Older age (OR 1.01, 95% CI 1.00-1.02; P<.001), having a chronic condition (OR 1.83, 95% CI 1.44-2.33; P<.001), and having an income lower than US $20,000 (OR 1.61, 95% CI 1.11-2.34; P=.01) were positively associated with indicating a preference for speaking directly to a provider. Hispanic individuals had significantly higher odds of indicating that they had no need for a patient portal (OR 1.59, 95% CI 1.24-2.05; P<.001) compared with non-Hispanic individuals. Older individuals (OR 1.05, 95% CI 1.04-1.06; P<.001), individuals with less than a high school diploma (OR 3.15, 95% CI 1.79-5.53; P<.001), and individuals with a household income of less than US $20,000 (OR 2.78, 95% CI 1.88-4.11; P<.001) had significantly higher odds of indicating that they were uncomfortable with a computer. CONCLUSIONS: The most common barriers to patient portal adoption are preference for in-person communication, not having a need for the patient portal, and feeling uncomfortable with computers, which are barriers that are modifiable and can be intervened upon. Patient characteristics can help predict which patients are most likely to experience certain barriers to patient portal adoption. Further research is needed to tailor implementation approaches based on patients' needs and preferences.