Perioperative mental health intervention for depression and anxiety symptoms in older adults study protocol: design and methods for three linked randomised controlled trials.

INTRODUCTION: Preoperative anxiety and depression symptoms among older surgical patients are associated with poor postoperative outcomes, yet evidence-based interventions for anxiety and depression have not been applied within this setting. We present a protocol for randomised controlled trials (RCTs) in three surgical cohorts: cardiac, oncological and orthopaedic, investigating whether a perioperative mental health intervention, with psychological and pharmacological components, reduces perioperative symptoms of depression and anxiety in older surgical patients. METHODS AND ANALYSIS: Adults ≥60 years undergoing cardiac, orthopaedic or oncological surgery will be enrolled in one of three-linked type 1 hybrid effectiveness/implementation RCTs that will be conducted in tandem with similar methods. In each trial, 100 participants will be randomised to a remotely delivered perioperative behavioural treatment incorporating principles of behavioural activation, compassion and care coordination, and medication optimisation, or enhanced usual care with mental health-related resources for this population. The primary outcome is change in depression and anxiety symptoms assessed with the Patient Health Questionnaire-Anxiety Depression Scale from baseline to 3 months post surgery. Other outcomes include quality of life, delirium, length of stay, falls, rehospitalisation, pain and implementation outcomes, including study and intervention reach, acceptability, feasibility and appropriateness, and patient experience with the intervention. ETHICS AND DISSEMINATION: The trials have received ethics approval from the Washington University School of Medicine Institutional Review Board. Informed consent is required for participation in the trials. The results will be submitted for publication in peer-reviewed journals, presented at clinical research conferences and disseminated via the Center for Perioperative Mental Health website. TRIAL REGISTRATION NUMBERS: NCT05575128, NCT05685511, NCT05697835, pre-results.

A Perioperative Mental Health Intervention for Depressed and Anxious Older Surgical Patients: Results From a Feasibility Study.

OBJECTIVES: The perioperative period is challenging and stressful for older adults. Those with depression and/or anxiety have an increased risk of adverse surgical outcomes. We assessed the feasibility of a perioperative mental health intervention composed of medication optimization and a wellness program following principles of behavioral activation and care coordination for older surgical patients. METHODS: We included orthopedic, oncologic, and cardiac surgical patients aged 60 and older. Feasibility outcomes included study reach, the number of patients who agreed to participate out of the total eligible; and intervention reach, the number of patients who completed the intervention out of patients who agreed to participate. Intervention efficacy was assessed using the Patient Health Questionnaire for Anxiety and Depression (PHQ-ADS). Implementation potential and experiences were collected using patient surveys and qualitative interviews. Complementary caregiver feedback was also collected. RESULTS: Twenty-three out of 28 eligible older adults participated in this study (mean age 68.0 years, 65% women), achieving study reach of 82% and intervention reach of 83%. In qualitative interviews, patients (n = 15) and caregivers (complementary data, n = 5) described overwhelmingly positive experiences with both the intervention components and the interventionist, and reported improvement in managing depression and/or anxiety. Preliminary efficacy analysis indicated improvement in PHQ-ADS scores (F = 12.13, p <0.001). CONCLUSIONS: The study procedures were reported by participants as feasible and the perioperative mental health intervention to reduce anxiety and depression in older surgical patients showed strong implementation potential. Preliminary data suggest its efficacy for improving depression and/or anxiety symptoms. A randomized controlled trial assessing the intervention and implementation effectiveness is currently ongoing.

Parenting practices and interventions during the COVID-19 pandemic lockdown: an exploratory cross-sectional study of caregivers in Brazil, Mexico, and the United States

Abstract Introduction The COVID-19 pandemic led countries' governments to rapidly establish lockdowns and social distancing, which altered family routines and the quality of family relationships worldwide. Objectives This exploratory cross-sectional study aimed to identify the impacts of the social distancing and lockdown in parenting practices of caregivers from Brazil, Mexico, and the USA, and to analyze the continuity of parenting intervention support for children and their families at the beginning of the pandemic in these countries. Methods The sample consisted of 704 caregivers of children (286 from Brazil, 225 from Mexico, and 193 from the USA) who answered an online survey about parenting practices before/after quarantine, caregiver/child routines, feelings related to quarantine, changes in everyday life since the beginning of the COVID-19 pandemic, contact with health professionals, and sources of parenting information. Results Data indicate that caregivers from the three countries experienced similar parenting practices during this time, and did not report significant changes before and after the lockdown. They sought information about parenting predominantly via social media. Those receiving previous mental health care perceived the transition from in-person to telehealth services during the pandemic as feasible and acceptable. Conclusion This study will be helpful for clinicians and parents to contextualize their practices amid long-standing effects that the COVID-19 pandemic can have on children and their families during and post-pandemic from multiple cultural backgrounds.

Integrating a focus on health equity in implementation science: Case examples from the national cancer institute's implementation science in cancer control centers (ISC3) network.

Background: A Health Equity Task Force (HETF) of members from seven Centers funded by the National Cancer Institute's (NCI) Implementation Science in Cancer Control Centers (ISC3) network sought to identify case examples of how Centers were applying a focus on health equity in implementation science to inform future research and capacity-building efforts. Methods: HETF members at each ISC3 collected information on how health equity was conceptualized, operationalized, and addressed in initial research and capacity-building efforts across the seven ISC3 Centers funded in 2019-2020. Each Center completed a questionnaire assessing five health equity domains central to implementation science (e.g., community engagement; implementation science theories, models, and frameworks (TMFs); and engaging underrepresented scholars). Data generated illustrative examples from these five domains. Results: Centers reported a range of approaches focusing on health equity in implementation research and capacity-building efforts, including (1) engaging diverse community partners/settings in making decisions about research priorities and projects; (2) applying health equity within a single TMF applied across projects or various TMFs used in specific projects; (3) evaluating health equity in operationalizing and measuring health and implementation outcomes; (4) building capacity for health equity-focused implementation science among trainees, early career scholars, and partnering organizations; and (5) leveraging varying levels of institutional resources and efforts to engage, include, and support underrepresented scholars. Conclusions: Examples of approaches to integrating health equity across the ISC3 network can inform other investigators and centers' efforts to build capacity and infrastructure to support growth and expansion of health equity-focused implementation science.

A multi- and mixed-method adaptation study of a patient-centered perioperative mental health intervention bundle.

BACKGROUND: Anxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients' unique needs. As part of the feasibility trial, we developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery. METHODS: We used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications - Expanded. RESULTS: Adaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: (1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). (2) Cohort-specific adaptations were recommended based on differing patient needs. (3) Compassion was identified by patients as the most important element. CONCLUSIONS: We identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations. CLINICAL TRIALS REGISTRATION: NCT05110690 (11/08/2021).

Return visit rates after an emergency department discharge for children with sickle cell pain episodes.

BACKGROUND: High return visit rates after hospitalization for people with sickle cell disease (SCD) have been previously established. Due to a lack of multicenter emergency department (ED) return visit rate data, the return visit rate following ED discharge for pediatric SCD pain treatment is currently unknown. PROCEDURE: A seven-site retrospective cohort study of discharged ED visits for pain by children with SCD was conducted using the Pediatric Emergency Care Applied Research Network Registry. Visits between January 2017 and November 2021 were identified using previously validated criteria. The primary outcome was the 14-day return visit rate, with 3- and 7-day rates also calculated. Modified Poisson regression was used to analyze associations for age, sex, initial hospitalization rate, and a visit during the COVID-19 pandemic with return visit rates. RESULTS: Of 2548 eligible ED visits, approximately 52% were patients less than 12 years old, 50% were female, and over 95% were non-Hispanic Black. The overall 14-day return visit rate was 29.1% (95% confidence interval [CI]: 27.4%-30.9%; site range 22.7%-31.7%); the 7- and 3-day return visit rates were 23.0% (95% CI: 21.3%-24.6%) and 16.7% (95% CI: 15.3%-18.2%), respectively. Younger children had slightly lower 14-day return visit rates (27.3% vs. 31.1%); there were no associations for site hospitalization rate, sex, and a visit occurring during the pandemic with 14-day returns. CONCLUSION: Nearly 30% of ED discharged visits after SCD pain treatment had a return visit within 14 days. Increased efforts are needed to identify causes for high ED return visit rates and ensure optimal ED and post-ED care.

Protocol for a scoping review of health equity frameworks and models applied in empirical studies of chronic disease prevention and control.

BACKGROUND: Chronic diseases, such as cancers and cardiovascular diseases, present the greatest burden of morbidity and mortality worldwide. This burden disproportionately affects historically marginalized populations. Health equity is rapidly gaining increased attention in public health, health services, and implementation research, though many health inequities persist. Health equity frameworks and models (FM) have been called upon to guide equity-focused chronic disease and implementation research. However, there is no clear synthesis of the health equity FM used in chronic disease research or how these are applied in empirical studies. This scoping review seeks to fill this gap by identifying and characterizing health equity FM applied in empirical studies along the chronic disease prevention and control continuum, describing how these FM are used, and exploring potential applications to the field of implementation science. METHODS: We follow established guidance for conducting scoping reviews, which includes six stages: (1) identify the research question; (2) identify relevant studies; (3) select studies for inclusion; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) consultation. This protocol presents the iterative, collaborative approach taken to conceptualize this study and develop the search strategy. We describe the criteria for inclusion in this review, methods for conducting two phases of screening (title and abstract, full text), data extraction procedures, and quality assurance approaches taken throughout the project. DISCUSSION: The findings from this review will inform health-equity focused chronic disease prevention and control research. FM identified through this review will be added to an existing website summarizing dissemination and implementation science frameworks, and we will offer case examples and recommendations for utilizing a health equity FM in empirical studies. Our search strategy and review methodology may serve as an example for scholars seeking to conduct reviews of health equity FM in other health disciplines. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework Registration https://doi.org/10.17605/OSF.IO/SFVE6.

Leveraging health infrastructure to optimize HPV vaccination for adolescents in Zambia: Protocol for an implementation study.

BACKGROUND: Cervical cancer is the leading cause of cancer death in Zambia, where HIV prevalence is also high (11.3%). HIV heightens the risk of developing and dying from cervical cancer. The human papillomavirus (HPV) vaccine can prevent 90% of cervical cancers, and in Zambia is recommended for adolescent girls ages 14-15 years, including those with HIV. Currently they mainly deliver HPV vaccination via school-based campaigns, which may exclude the most vulnerable adolescents-those out-of-school or who irregularly attend. Adolescents living with HIV (ALHIV) are more likely to have these vulnerabilities. Further, school-based campaigns are not tailored to the WHO-recommended HPV vaccination schedule for ALHIV (3 versus 2 doses). Integrating HPV vaccination into routine care in adolescent HIV clinics may ensure that ALHIV have access to vaccine at the WHO-recommended schedule. Such integration requires a multilevel approach, stakeholder engagement, and diversified implementation strategies, given known challenges of providing the HPV vaccine in LMICs, including Zambia. METHODS: Our study aims to integrate HPV vaccination into routine care in adolescent HIV clinics. To achieve success, we will co-design a package of implementation strategies using a previously successful implementation research approach developed for cervical cancer prevention in LMICs: the Integrative Systems Praxis for Implementation Research (INSPIRE). INSPIRE is a novel, comprehensive approach to develop, implement, and evaluate implementation science efforts. Following key elements of INSPIRE, our specific aims are to: 1) Identify the unique multilevel contextual factors (barriers and facilitators) across HIV settings (rural, urban, peri-urban) that influence HPV vaccine uptake; 2) Use Implementation Mapping to translate stakeholder feedback and findings from Aim 1 into a package of implementation strategies to integrate HPV vaccine into HIV clinics; 3) Conduct a Hybrid Type 3 effectiveness-implementation trial to evaluate the package of multilevel implementation strategies for integrating HPV vaccine into HIV clinics. DISCUSSION: Our research team has strong support, technical expertise, and resources (e.g., vaccines) from the Zambian Ministry of Health; and political will for scale-up. This stakeholder-based implementation model has the potential to be transported to HIV clinics across Zambia and serve as a model to address cancer prevention priorities for those with HIV in other LMICs. TRIAL REGISTRATION: To be registered prior to Aim 3, when implementation strategies finalized.

Association Between Surgical Quality Metric Adherence and Overall Survival Among US Veterans With Early-Stage Non-Small Cell Lung Cancer.

Importance: Surgical resection remains the preferred treatment for functionally fit patients diagnosed with early-stage non-small cell lung cancer (NSCLC). Process-based intraoperative quality metrics (QMs) are important for optimizing long-term outcomes following curative-intent resection. Objective: To develop a practical surgical quality score for patients diagnosed with clinical stage I NSCLC who received definitive surgical treatment. Design, Setting, and Participants: This retrospective cohort study used a uniquely compiled data set of US veterans diagnosed with clinical stage I NSCLC who received definitive surgical treatment from October 2006 through September 2016. The data were analyzed from April 1 to September 1, 2022. Based on contemporary treatment guidelines, 5 surgical QMs were defined: timely surgery, minimally invasive approach, anatomic resection, adequate lymph node sampling, and negative surgical margin. The study developed a surgical quality score reflecting the association between these QMs and overall survival (OS), which was further validated in a cohort of patients using data from the National Cancer Database (NCDB). The study also examined the association between the surgical quality score and recurrence-free survival (RFS). Exposures: Surgical treatment of early-stage NSCLC. Main Outcomes and Measures: Overall survival and RFS. Results: The study included 9628 veterans who underwent surgical treatment between 2006 and 2016. The cohort consisted of 1446 patients who had a mean (SD) age of 67.6 (7.9) years and included 9278 males (96.4%) and 350 females (3.6%). Among the cohort, 5627 individuals (58.4%) identified as being smokers at the time of surgical treatment. The QMs were met as follows: timely surgery (6633 [68.9%]), minimally invasive approach (3986 [41.4%]), lobectomy (6843 [71.1%]) or segmentectomy (532 [5.5%]), adequate lymph node sampling (3278 [34.0%]), and negative surgical margin (9312 [96.7%]). The median (IQR) follow-up time was 6.2 (2.5-11.4) years. An integer-based score (termed the Veterans Affairs Lung Cancer Operative quality [VALCAN-O] score) from 0 (no QMs met) to 13 (all QMs met) was constructed, with higher scores reflecting progressively better risk-adjusted OS. The median (IQR) OS differed substantially between the score categories (score of 0-5 points, 2.6 [1.0-5.7] years of OS; 6-8 points, 4.3 [1.7-8.6] years; 9-11 points, 6.3 [2.6-11.4] years; and 12-13 points, 7.0 [3.0-12.5] years; P < .001). In addition, risk-adjusted RFS improved in a stepwise manner between the score categories (6-8 vs 0-5 points, multivariable-adjusted hazard ratio [aHR], 0.62; 95% CI, 0.48-0.79; P < .001; 12-13 vs 0-5 points, aHR, 0.39; 95% CI, 0.31-0.49; P < .001). In the validation cohort, which included 107 674 nonveteran patients, the score remained associated with OS. Conclusions and Relevance: The findings of this study suggest that adherence to intraoperative QMs may be associated with improved OS and RFS. Efforts to improve adherence to surgical QMs may improve patient outcomes following curative-intent resection of early-stage lung cancer.

Uma revisão de escopo do uso excessivo de mamografia de rastreamento / Una revisión de alcance del uso excesivo de mamografía de tamizaje / A scoping review of excessive use of mammography screening

Resumo Objetivos Identificar como os estudiosos definem o rastreamento excessivo para mulheres sem risco de desenvolver câncer de mama, examinar os determinantes (barreiras e facilitadores) do uso excessivo da mamografia de rastreamento e descrever as taxas de observação do uso excessivo da mamografia de rastreamento. Métodos Revisão de escopo baseada em busca realizada em maio de 2022 em seis bancos de dados e bibliotecas eletrônicas de saúde. Artigos revisados por pares em qualquer idioma e ano de publicação foram incluídos. Resultados Na amostra de 18 artigos publicados a partir de 1991, a maioria deles dos Estados Unidos, o uso excessivo de mamografia foi definido como a intenção ou realização de mamografia fora da faixa etária ou intervalo recomendado, entre mulheres com expectativa de vida limitada, em programas, organizados e oportunísticos, coexistentes. As taxas de observação do uso excessivo de mamografia de rastreamento nos estudos selecionados variaram de 1,4% a 87,2%. Os facilitadores da mamografia excessiva são preocupações relacionadas ao câncer; a recomendação médica, especialmente de especialistas; e ao maior acesso a exames. As mais expostas ao rastreamento excessivo são as mulheres com maior escolaridade e renda. As barreiras para o excesso de mamografia incluíram orientações nas consultas sobre os malefícios da mamografia e a expectativa de vida, por médicos generalistas, principalmente os da atenção primária. Conclusão Nosso estudo identificou que o uso excessivo da mamografia de rastreamento tem alta prevalência quando realizado como rastreamento e é permeado por fatores multiníveis. Nossa lista de determinantes pode fornecer algumas orientações para estudos futuros com o objetivo de desimplementar o cuidado de baixo valor do uso excessivo da mamografia de rastreamento.

Resumen Objetivos Identificar cómo los académicos definen el tamizaje excesivo en mujeres sin riesgo de presentar cáncer de mama, examinar los determinantes (barreras y facilitadores) del uso excesivo de mamografía de tamizaje y describir los índices de observación del uso excesivo de mamografía de tamizaje. Métodos Revisión de alcance basada en una búsqueda realizada en mayo de 2022 en seis bases de datos y bibliotecas electrónicas de salud. Se incluyeron artículos revisados por pares en cualquier idioma o año de publicación. Resultados En la muestra de 18 artículos publicados a partir de 1991, la mayoría de Estados Unidos, el uso excesivo de mamografía fue definido como la intención o realización de mamografía fuera del grupo de edad o intervalo recomendado, en mujeres con expectativa de vida limitada, en programas coexistentes, organizados y oportunistas. Los índices de observación del uso excesivo de mamografía de tamizaje en los estudios seleccionados varían de 1,4 % a 87,2 %. Los facilitadores de la mamografía excesiva son las preocupaciones relacionadas con el cáncer, las recomendaciones médicas, especialmente de especialistas, y el mayor acceso al examen. Las personas más expuestas al tamizaje excesivo son las mujeres con mayor escolaridad e ingresos. Las barreras para el exceso de mamografías incluyeron orientaciones en consultas sobre los maleficios de la mamografía y expectativa de vida, por parte de médicos generales, principalmente los de atención primaria. Conclusión El estudio identificó que el uso excesivo de mamografía de tamizaje tiene alta prevalencia cuando se realiza como tamizaje y está impregnado de factores multinivel. La lista de determinantes puede ofrecer algunas orientaciones para estudios futuros con el objetivo de dejar de implementar esta atención de escaso valor que es el uso excesivo de mamografía de tamizaje.

Abstract Objectives To identify how scholars define excessive screening for women without risk of developing breast cancer, examine the determinants (barriers and facilitators) of excessive use of mammography screening, and describe the rates of observations of excessive use mammography screening. Methods Scoping review based on a search in May 2022 in six electronic health databases and libraries. Articles included were peer-reviewed articles, in any language and year of publication. Results In a sample of 18 articles, published from 1991 onwards, most of them from the United States, the excessive use of mammography were defined as the intention or performance of mammography outside the recommended age or interval range, among women with limited life expectancy, in coexisting, organized and opportunistic programs. The rates of observations of excessive use of mammography screening in the selected studies ranged from 1.4% to 87,2%. Facilitators for excessive mammography are related concerns of getting cancer; to the medical advice, especially from specialists; and to the increased access to tests. The most exposed to excessive screening are women with higher levels of education and income. Barriers for excessive mammography included guidance in consultations about the harm of mammography and life expectancy by general practitioners, particularly those in primary care. Conclusion Our study identified that the excessive use of mammography screening has a high prevalence when done as screening and is permeated by multi-level factors. Our list of determinants can provide some guidance for future studies aiming to de-implement the low-value care of excessive mammography screening.

A case study of adapting a health insurance decision intervention from trial into routine cancer care.

OBJECTIVE: This study adapted Improving Cancer Patients' Insurance Choices (I Can PIC), an intervention to help cancer patients navigate health insurance decisions and care costs. The original intervention improved knowledge and confidence making insurance decisions, however, users felt limited by choices provided in insurance markets. Using decision trees and frameworks to guide adaptations, we modified I Can PIC to focus on using rather than choosing health insurance. The COVID-19 pandemic introduced unforeseen obstacles, prompting changes to study protocols. As a result, we allowed users outside of the study to use I Can PIC (> 1050 guest users) to optimize public benefit. This paper describes the steps took to conduct the study, evaluating both the effectiveness of I Can PIC and the implementation process to improve its impact. RESULTS: Although I Can PIC users had higher knowledge and health insurance literacy compared to the control group, results were not statistically significant. This outcome may be associated with systems-level challenges as well as the number and demographic characteristics of participants. The publicly available tool can be a resource for those navigating insurance and care costs, and researchers can use this flexible approach to intervention delivery and testing as future health emergencies arise.

Perioperative mental health intervention bundle for older surgical patients: protocol for an intervention development and feasibility study.

INTRODUCTION: The perioperative period is high risk for older adults. Depression and anxiety are common perioperative problems, frequently coexisting with cognitive impairment. Older patients with these conditions are more likely than younger patients to experience postoperative delirium, long hospital stays, poor quality of life and rehospitalisation. These experiences can, in turn, exacerbate anxiety and depressive symptoms. Despite these risks, little is known about how to treat perioperative anxiety and depression among older adults. METHODS AND ANALYSIS: We designed a feasibility study of a perioperative mental health intervention bundle to improve perioperative mental health, specifically depression and anxiety. The overarching goals of this study are twofold: first, to adapt and refine an intervention bundle comprised of behavioural activation and medication optimisation to meet the needs of older adults within three surgical patient populations (ie, orthopaedic, oncological and cardiac); and second, to test the feasibility of study procedures and intervention bundle implementation. Quantitative data on clinical outcomes such as depression, anxiety, quality of life, delirium, falls, length of stay, hospitalisation and pain will be collected and tabulated for descriptive purposes. A hybrid inductive-deductive thematic approach will be employed to analyse qualitative feedback from key stakeholders. ETHICS AND DISSEMINATION: The study received approval from the Washington University Institutional Review Board. Results of this study will be presented in peer-reviewed journals, at professional conferences, and to our perioperative mental health advisory board. TRIAL REGISTRATION NUMBER: NCT05110690.

Transition for Adolescents and Young Adults With Sickle Cell Disease in a US Midwest Urban Center: A Multilevel Perspective on Barriers, Facilitators, and Future Directions.

BACKGROUND: Sickle cell disease (SCD), an inherited red blood cell disorder, primarily affects African Americans in the United States. Adolescents and young adults with SCD (AYA-SCD) are at risk of high morbidity and mortality when transitioning from pediatric to adult care. The goal of this qualitative study was to understand factors associated with optimal implementation of the AYA-SCD transition. METHODS: Participants were recruited from a large hospital system and the community. Interview guides included topics on access to primary and specialized care, beliefs and practices related to pain control, transition from pediatric to adult care, and patient experiences in the emergency department. Data were coded and analyzed using an inductive thematic coding approach in combination with a deductive coding approach using domains from the Consolidated Framework for Implementation Research (CFIR). RESULTS: Fifty-nine participants, including 21 AYA-SCD from both the pediatric and adult clinics, 17 caregivers, 9 pediatric SCD providers, 6 adult SCD providers, and 6 emergency department providers, completed 11 focus groups and 5 semistructured interviews. Results identified multiple factors within the domains of CFIR including the outer setting, inner setting, individual characteristics, and intervention characteristics. Results were incorporated into a transition framework to inform local practice improvement. CONCLUSION: Our study highlights the importance of multilevel barriers and facilitators for AYA-SCD transition from pediatric to adult care. Future studies could use implementation science frameworks to understand local context and identify strategies and intervention characteristics to improve transition programming. These efforts will ultimately reduce health disparities and ensure health equity.

Racial Disparities in the Surgical Treatment of Clinical Stage I Non-Small Cell Lung Cancer Among Veterans.

BACKGROUND: Prior studies in the civilian population have reported racial disparities in lung cancer outcomes following surgical treatment, including inferior quality of care and worse survival. It is unclear if racial disparities exist in the Veterans Health Administration (VHA), the largest integrated health care system in the United States. RESEARCH QUESTION: Do racial disparities affect early-stage non-small cell lung cancer (NSCLC) outcomes following surgical treatment within the VHA? STUDY DESIGN AND METHODS: This retrospective cohort study was conducted in veterans with clinical stage I NSCLC undergoing surgical treatment in the VHA system. Demographic characteristics, access to care, surgical quality measures, and short- and long-term oncologic outcomes between White and Black veterans were evaluated. RESULTS: From 2006 to 2016, a total of 18,800 veterans with clinical stage I NSCLC were included. The rates of definitive surgical treatment were similar between Black (57.3%) and White (58.1%) veterans (P = .42). The final study cohort included 9,842 patients receiving surgical treatment, of whom 8,356 (84.9%) were White and 1,486 (15.1%) were Black. Black patients were younger and more likely to smoke, although comorbidities were similar between the two groups. Black patients were somewhat less likely to receive adequate lymph node sampling (30.6% vs 33.3%; P = .050); however, other access-to-care metrics and surgical quality measures, including rates of anatomic lobectomy (71.9% vs 69.4%; P = .189) and positive margins (3.2% vs 3.1%; P = .955), were similar between the two groups. Although Black veterans were less likely to experience major postoperative complications, there was no difference in 30-day readmission, 30-day mortality, or disease-free survival between the two groups. Black patients had significantly better risk-adjusted overall survival (hazard ratio, 0.802; 95% CI, 0.729-0.883; P < .001). INTERPRETATION: Among veterans with NSCLC undergoing surgical treatment through the VHA, Black patients received comparable care with equivalent if not superior outcomes compared with White patients.

Establishing Sickle Cell Disease Stroke Prevention Teams in Africa is Feasible: Program Evaluation Using the RE-AIM Framework.

We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate a Stroke Prevention Team's readiness to prevent strokes in children with sickle cell anemia living in northern Nigeria. The NIH sponsored Stroke Prevention Trial in Nigeria included a goal of a sustainable stroke prevention program. The program's 1-year reach for transcranial Doppler screening was 14.7% (4710/32,000) of which 6.0% (281/4710) had abnormal velocities (≥200 cm/s). All participants with abnormal transcranial Doppler velocities were started on hydroxyurea (effectiveness). The leaders of all 5 hospitals agreed to adopt the program. After 1 year, program-implementation and maintenance rates were 100%, demonstrating the program's feasibility and short-term sustainability.

Promoting Physical Activity in Rural Settings: Effectiveness and Potential Strategies.

PURPOSE: Implementing efficacious physical activity interventions in real-world rural settings is needed because rural cancer survivors are more physically inactive and experience poorer health. To address this gap, this study evaluated effectiveness of an evidenced-based physical activity program (Better Exercise Adherence after Treatment for Cancer [BEAT Cancer]) for rural women cancer survivors when implemented by community-based, non-research staff. METHODS: 16 rural women cancer survivors received BEAT Cancer implemented by a rural, community organization and non-research staff; physical activity, patient-reported outcomes, and social cognitive constructs were measured at baseline and post-program. Cancer survivors and interventionists completed program evaluations post-program. RESULTS: Cancer survivor mean age was 58±12 years; 62% were White. Mean months since diagnosis was 54±72; 69% had breast cancer. Significant improvements from pre- to post-program occurred for self-report weekly minutes of moderate-to-vigorous physical activity (mean change [M] = 146±186, p = 0.009), anxiety (M = -1.3±1.8, p = 0.016), depression (M = -2.1±2.0, p = 0.001), self-efficacy (M = 20.9±30.5, p = 0.019), barriers interference (M = -15.0±14.1, p = 0.001), and social support (M = 5.0±7.4, p = 0.02). Cancer survivors ranked the program highly, identified strategies that were helpful (e.g., group activities, personalized exercise plan, etc.), and suggested additional implementation strategies (e.g., guide for home-based phase, etc.). Interventionists identified strategies (e.g., logistics, staff training and certification, cost, etc.) for enhancing organizational readiness for program delivery. CONCLUSION: Evidence-based physical activity programs can be effective when implemented by non-research staff in rural settings. Further research testing strategies that improve implementation is needed. PRACTICAL IMPLICATIONS: Effectiveness and identified strategies supporting delivery when implemented by a rural organization can improve physical activity promotion for rural, at-risk populations.

Genetic Counseling and Testing in African American Patients With Breast Cancer: A Nationwide Survey of US Breast Oncologists.

PURPOSE: To determine if physicians' self-reported knowledge, attitudes, and practices regarding genetic counseling and testing (GCT) vary by patients' race. METHODS: We conducted a nationwide 49-item survey among breast oncology physicians in the United States. We queried respondents about their own demographics, clinical characteristics, knowledge, attitudes, practices, and perceived barriers in providing GCT to patients with breast cancer. RESULTS: Our survey included responses from 277 physicians (females, 58.8%; medical oncologists, 75.1%; academic physicians, 61.7%; and Whites, 67.1%). Only 1.8% indicated that they were more likely to refer a White patient than refer an African American patient for GCT, and 66.9% believed that African American women with breast cancer have lower rates of GCT than White women. Regarding perceived barriers to GCT, 63.4% of respondents indicated that African American women face more barriers than White women do and 21% felt that African American women require more information and guidance during the GCT decision-making process than White women. Although 32% of respondents indicated that lack of trust was a barrier to GCT in all patients, 58.1% felt that this was a greater barrier for African American women (P < .0001). Only 13.9% believed that noncompliance with GCT is a barrier for all patients, whereas 30.6% believed that African American women are more likely than White women to be noncompliant (P < .0001). CONCLUSION: We demonstrated that racial differences exist in oncology physicians' perceived barriers to GCT for patients with breast cancer. This nationwide survey will serve as a basis for understanding physicians' determinants of GCT for African American women and highlights the necessity of education and interventions to address bias among physicians. Awareness of such physician biases can enable further work to address inequities, ultimately leading to improved GCT equity for African American women with breast cancer.

Determining patient needs to enhance exercise program implementation and uptake in rural settings for women after a cancer diagnosis.

PURPOSE: To qualitatively explore exercise barriers and facilitators experienced by rural female cancer survivors from the program interventionist and recipient perspective for the purpose of enhancing exercise program implementation and uptake in rural settings. METHODS: A descriptive qualitative study design was utilized. Focus groups were conducted prior to implementation of an evidence-based exercise program by a rural non-research cancer clinical site. Nineteen rural female cancer survivors (mean age = 61.7 ± 10.9 years) and 11 potential interventionists (mean age = 42.3 ± 15.3 years) completed focus groups (stratified by participant role). Focus groups were audio recorded, transcribed, coded, and analyzed using inductive thematic analysis with NVivo 11. RESULTS: Cancer survivors identified 12 barrier themes (cancer specific adverse effects, lack of support, lack of knowledge, perceived negative aspects of exercise, cost, lack of resources, motivation, inconvenience, lack of program flexibility, time, weather, safety) and eight facilitator themes (knowledge, ease of access, resources, awareness, cost, options, organized, fun) related to exercise. Interventionists identified seven barrier themes (cost, transportation, lack of cancer survivor and interventionist knowledge, fear, motivation, lack of support, lack of resources) and four facilitator themes (resources, support, knowledge, motivation). Narratives revealed differing role-specific perspectives on shared themes between survivors and interventionists as well as potential implementation strategies for enhancing exercise participation and exercise program uptake among rural female cancer survivors. CONCLUSION: Exploring multi-level stakeholder perspectives on cancer survivors' exercise needs and related strategies yields important information for organizations to consider when implementing exercise programs in rural contexts.

Input from multiple stakeholder levels prioritizes targets for improving implementation of an exercise intervention for rural women cancer survivors.

BACKGROUND: Although evidence-based interventions for increasing exercise among cancer survivors (CSs) exist, little is known about factors (e.g., implementation facilitators) that increase effectiveness and reach of such interventions, especially in rural settings. Such factors can be used to design implementation strategies. Hence, our study purpose was to (1) obtain multilevel perspectives on improving participation in and implementation of a multicomponent exercise behavior change intervention for rural women CSs and (2) identify factors important for understanding the context using the Consolidated Framework for Implementation Research (CFIR) for comparison across three levels (CSs, potential interventionists, community/organizational stakeholders). METHODS: We conducted three nominal group technique meetings with rural women CSs, three with community/organizational stakeholders, and one with potential interventionists. During each meeting, participants were asked to respond silently to one question asking what would make a multicomponent exercise intervention doable from intervention participation (CSs) or implementation (potential interventionists, stakeholders) perspectives. Responses were shared, discussed to clarify meaning, and prioritized by group vote. Data was deductively coded using CFIR. RESULTS: Mean age of CSs (n = 19) was 61.8 ± 11.1 years, community stakeholders (n = 16) was 45.9 ± 8.1 years, and potential interventionists (n = 7) was 41.7 ± 15.2 years. There was considerable consensus among CSs, potential interventionists, and stakeholders in terms of CFIR domains and constructs, e.g., "Design quality and packaging" (Innovation Characteristics), "Patients needs and resources" (Outer Setting), "Available resources" (Inner Setting), and "Engaging" (Process). However, participant-specific CFIR domains and constructs were also observed, e.g., CSs endorsed "Knowledge and beliefs about the intervention," "Individual stage of change," and "Self-efficacy" (Characteristics of Individuals); potential interventionists valued "Tension for change" (Inner Setting) and "Innovation participants" and "Key stakeholder" (Process); stakeholders emphasized "Goals and feedback" and "Network and communication" (Inner Setting), and "Planning" (Process). How the three participant levels conceptualized the CFIR constructs demonstrated both similarities and differences. CONCLUSIONS: Multilevel input yielded diversity in type, relative priority, and conceptualization of implementation facilitators suggesting foci for future implementation strategy development and testing. Findings also reinforced the importance of multilevel implementation strategies for increasing exercise in an underserved, at-risk population.