Key Informants' Perceptions of Health Equity and Racial Justice Impacts of the 2019 Massachusetts An Act Modernizing Tobacco Control.

INTRODUCTION: The Massachusetts legislature passed An Act Modernizing Tobacco Control in November 2019 to restrict retail sales of flavored commercially manufactured tobacco products including menthol products, increase penalties for violating the law's provisions, and provide health insurance coverage for tobacco treatment. AIMS AND METHODS: This study explores key informants' perceptions of intended and unintended impacts of implementation of the 2019 Massachusetts statewide law through a health equity and racial justice lens. We conducted in-depth interviews with 25 key informants from three key informant groups (public health officials and advocates, clinicians, and school staff) between March 2021 and April 2022. Using deductive codes on unintended impacts of the implementation of the law's policies, we conducted a focused analysis to identify impacts that were perceived and observed by informants from different key informant groups. RESULTS: Perceived or observed impacts of the law were identified across multiple levels by key informants and included concerns related to three broad themes: 1) intended impacts on health equity and racial justice, 2) ongoing availability of restricted products undermining the intended impact of the law, and 3) inequitable targeting by the policies and enforcement among communities of color. CONCLUSIONS: Future evaluation is needed to assess the intended and unintended impacts of implementation of the Massachusetts law to maximize the potential of the policies to reduce tobacco-related health disparities. We discuss implications and recommendations for achieving a national policy and equitable enforcement of flavored tobacco sales restrictions. IMPLICATIONS: This qualitative study among 25 key informants including public health and tobacco control advocates, clinicians, and school staff obtained perspectives of intended and unintended health equity and racial justice impacts of the 2019 Massachusetts An Act Modernizing Tobacco Control. Findings and recommendations from this study can inform monitoring efforts to assess the law's impacts in Massachusetts and the adoption of similar flavored tobacco sales restrictions and other tobacco control policies in other states to maximize the health equity benefits and minimize unintended impacts.

Do no harm: the impact of implementing cancer prevention strategies on other preventive health measures.

BACKGROUND: Translational efforts to increase uptake of evidence-based practices typically look at those outcomes in isolation of their impact on other aspects of care delivery. If we are in fact to "do no harm", we must consider the possible negative impact of improving use of one practice on other quality measures. Alternatively, a focus on one practice could lead to spread of effective strategies to other practices, which would be highly beneficial. We studied the impact of a colorectal cancer (CRC) screening initiative on delivery of other preventive care measures. METHODS: We used an interrupted time series design with implementation year as the interruption point. The initiative was conducted between 2015 and 2020, with three staggered cohorts. Main outcomes were quality measures for colorectal cancer screening, cervical cancer screening, hypertension management, diabetes management, weight screening and follow-up, tobacco use screening and cessation treatment, and depression screening and follow-up. RESULTS: The initiative was associated with an increase in CRC screening (OR = 1.67, p ≤ 0.01; average marginal effect = 12.2% points), and did not reduce performance on other quality measures in the year of CRC program implementation or a change in their respective secular trends. CONCLUSIONS: The initiative led to a clinically meaningful increase in CRC screening and was not associated with reductions in delivery of six other preventive services. Quality improvement (QI) initiatives typically approach implementation with an eye towards reducing unintended impact and leveraging existing staff and resources. Implementation research studies may benefit from considering how QI initiatives factor in the local context in implementation efforts.

Dual-Vaping of Nicotine and Cannabis among Adults who Currently Use Tobacco Products in Five New England States.

INTRODUCTION: Current measures of vaping behaviors do not distinguish what substances participants are vaping and to what extent they are dual-vaping nicotine and cannabis. This study describes the use of new survey questions that more specifically ask whether participants who vape are vaping nicotine, cannabis, CBD, or another substance. METHODS: Adults, who reported any past-30-day tobacco use, from five New England states participated in an online survey from April 2021 to July 2022. Participants who vaped were asked, "Have you used any of the following vape substances in the past 30 days?" with the possible responses of nicotine, cannabis, CBD, other, and "don't know." Dual-use of both nicotine and cannabis was defined as the vaping of both nicotine and cannabis and/or CBD in the past-30-days, operationalized as a dichotomous outcome. Data were collected in monthly, repeated cross-sectional waves. Multinomial logistic regression was used to examine correlates of dual-vaping. RESULTS: The analytic sample included 1547 adults who reported past-30-day tobacco use (mean age 42.9 years, 62.8% female, 85.4% White, 48.5% income of less than $50,000). Over one-quarter (26.1%) reported dual-vaping in the past-30-days. Identifying as male (p=0.002) and self-rated anxiety (p=0.043) were associated with a higher odds of dual-vaping. CONCLUSIONS: Our findings show that a sizable proportion of a sample of New England adults who have used tobacco in the past-30-days are dual-vaping nicotine and cannabis. Adequate survey measures for assessing the vaping of multiple substances can help in better screening and characterization of health behaviors around dual-use. IMPLICATIONS: This study addresses a key gap in adequate survey measures for assessing vaping of multiple substances. We found that among adults with past 30-day tobacco use, dual-vaping was prevalent and associated with different correlates, such as self-reported anxiety and education level, compared to sole-vaping of nicotine or cannabis. Our findings may help in characterizing and targeting future population-level surveillance and intervention efforts for multiple substance use behaviors.

Bundling Colorectal Cancer Screening Outreach with Screening for Social Risk in Federally Qualified Health Centers: A Stepped-Wedge Implementation-Effectiveness Study.

BACKGROUND: Bundling is combining individual interventions to meet quality metrics. Bundling offers of cancer screening with screening for social determinants of health (SDOH) may enable health centers to assist patients with social risks and yield efficiencies. OBJECTIVE: To measure effects of bundling fecal immunochemical testing (FIT) and SDOH screening in federally qualified health centers (FQHCs). DESIGN: Clustered stepped-wedge trial. PARTICIPANTS: Four Massachusetts FQHCs randomized to implement bundled FIT-SDOH over 8-week "steps." INTERVENTION: Outreach to 50-75-year-olds overdue for CRC screening to offer FIT with SDOH screening. The implementation strategy used facilitation and training for data monitoring and reporting. MAIN MEASURES: Implementation process descriptions, data from facilitation meetings, and CRC and SDOH screening rates. Rates were compared between implementation and control FQHCs in each "step" by fitting generalized linear mixed-effects models with random intercepts for FQHCs, patients, and "step" by FQHC. KEY RESULTS: FQHCs tailored implementation processes to their infrastructure, workflows, and staffing and prioritized different groups for outreach. Two FQHCs used population health outreach, and two integrated FIT-SDOH within established programs, such as pre-visit planning. Of 34,588 patients overdue for CRC screening, 54% were female; 20% Black, 11% Latino, 10% Asian, and 47% white; 32% had Medicaid, 16% Medicare, 32% private insurance, and 11% uninsured. Odds of CRC screening completion in implementation "steps" compared to controls were higher overall and among groups prioritized for outreach (overall: adjusted odds ratio (aOR) 2.41, p = 0.005; prioritized: aOR 2.88, p = 0.002). Odds of SDOH screening did not differ across "steps." CONCLUSIONS: As healthcare systems are required to conduct more screenings, it is notable that outreach for a long-standing cancer screening requirement increased screening, even when bundled with a newer screening requirement. This outreach was feasible in a real-world safety-net clinical population and may conserve resources, especially compared to more complex or intensive outreach strategies. CLINICAL TRIALS REGISTRATION: NCT04585919.

Participatory logic modeling in a multi-site initiative to advance implementation science.

BACKGROUND: Logic models map the short-term and long-term outcomes that are expected to occur with a program, and thus are an essential tool for evaluation. Funding agencies, especially in the United States (US), have encouraged the use of logic models among their grantees. They also use logic models to clarify expectations for their own funding initiatives. It is increasingly recognized that logic models should be developed through a participatory approach which allows input from those who carry out the program being evaluated. While there are many positive examples of participatory logic modeling, funders have generally not engaged grantees in developing the logic model associated with their own initiatives. This article describes an instance where a US funder of a multi-site initiative fully engaged the funded organizations in developing the initiative logic model. The focus of the case study is Implementation Science Centers in Cancer Control (ISC3), a multi-year initiative funded by the National Cancer Institute. METHODS: The reflective case study was collectively constructed by representatives of the seven centers funded under ISC3. Members of the Cross-Center Evaluation (CCE) Work Group jointly articulated the process through which the logic model was developed and refined. Individual Work Group members contributed descriptions of how their respective centers reviewed and used the logic model. Cross-cutting themes and lessons emerged through CCE Work Group meetings and the writing process. RESULTS: The initial logic model for ISC3 changed in significant ways as a result of the input of the funded groups. Authentic participation in the development of the logic model led to strong buy-in among the centers, as evidenced by their utilization. The centers shifted both their evaluation design and their programmatic strategy to better accommodate the expectations reflected in the initiative logic model. CONCLUSIONS: The ISC3 case study demonstrates how participatory logic modeling can be mutually beneficial to funders, grantees and evaluators of multi-site initiatives. Funded groups have important insights about what is feasible and what will be required to achieve the initiative's stated objectives. They can also help identify the contextual factors that either inhibit or facilitate success, which can then be incorporated into both the logic model and the evaluation design. In addition, when grantees co-develop the logic model, they have a better understanding and appreciation of the funder's expectations and thus are better positioned to meet those expectations.

Forms or Free-Text? Measuring Advance Care Planning Activity Using Electronic Health Records.

Advance care planning (ACP) discussions seek to guide future serious illness care. These discussions may be recorded in the electronic health record by documentation in clinical notes, structured forms and directives, and physician orders. Yet, most studies of ACP prevalence have only examined structured electronic health record elements and ignored data existing in notes. We sought to investigate the relative comprehensiveness and accuracy of ACP documentation from structured and unstructured electronic health record data sources. We evaluated structured and unstructured ACP documentation present in the electronic health records of 435 patients with cancer drawn from three separate healthcare systems. We extracted structured ACP documentation by manually annotating written documents and forms scanned into the electronic health record. We coded unstructured ACP documentation using a rule-based natural language processing software that identified ACP keywords within clinical notes and was subsequently reviewed for accuracy. The unstructured approach identified more instances of ACP documentation (238, 54.7% of patients) than the structured ACP approach (187, 42.9% of patients). Additionally, 16.6% of all patients with structured ACP documentation only had documents that were judged as misclassified, incomplete, blank, unavailable, or a duplicate of a previously entered erroneous document. ACP documents scanned into electronic health records represent a limited view of ACP activity. Research and measures of clinical practice with ACP should incorporate information from unstructured data.

Advancing health equity through implementation science: Identifying and examining measures of the outer setting.

BACKGROUND: Implementation science (IS) could accelerate progress toward achieving health equity goals. However, the lack of attention to the outer setting where interventions are implemented limits applicability and generalizability of findings to different populations, settings, and time periods. We developed a data resource to assess outer setting across seven centers funded by the National Cancer Institute's IS Centers in Cancer Control (ISC3) Network Program. OBJECTIVE: To describe the development of the Outer Setting Data Resource and characterize the county-level outer context across Centers. METHODS: Our Data Resource captures seven key environments, including: (1) food; (2) physical; (3) economic; (4) social; (5) health care; (6) cancer behavioral and screening; and (7) cancer-related policy. Data were obtained from public sources including the US Census and American Community Survey. We present medians and interquartile ranges based on the distribution of all counties in the US, all ISC3 centers, and within each Center for twelve selected measures. Distributions of each factor are compared with the national estimate using single sample sign tests. RESULTS: ISC3 centers' catchment areas include 458 counties and over 126 million people across 28 states. The median percentage of population living within ½ mile of a park is higher in ISC3 counties (38.0%, interquartile range (IQR): 16.0%-59.0%) compared to nationally (18.0%, IQR: 7.0%-38.0%; p < 0.0001). The median percentage of households with no broadband access is significantly lower in ISC3 counties (28.4%, IQR: 21.4%-35.6%) compared the nation overall (32.8%, IQR: 25.8%-41.2%; p < 0.0001). The median unemployment rate was significantly higher in ISC3 counties (5.2%, IQR: 4.1%-6.4%) compared to nationally (4.9%, 3.6%-6.3%, p = 0.0006). CONCLUSIONS: Our results indicate that the outer setting varies across Centers and often differs from the national level. These findings demonstrate the importance of assessing the contextual environment in which interventions are implemented and suggest potential implications for intervention generalizability and scalability.

Participatory Logic Modeling in a Multi-Site Initiative to Advance Implementation Science.

Background: It is increasingly being recognized that logic models should be developed through a participatory approach which allows input from those who carry out the program being evaluated. While there are many positive examples of participatory logic modeling, funders have generally not used this approach in the context of multi-site initiatives. This article describes an instance where the funder and evaluator of a multi-site initiative fully engaged the funded organizations in developing the initiative logic model. The focus of the case study is Implementation Science Centers in Cancer Control (ISC 3 ), a multi-year initiative funded by the National Cancer Institute (NCI). Methods: The case study was collectively constructed by representatives of the seven centers funded under ISC 3 . Members of the Cross-Center Evaluation (CCE) Work Group jointly articulated the process through which the logic model was developed and refined. Individual Work Group members contributed descriptions of how their respective centers reviewed and used the logic model. Cross-cutting themes and lessons emerged through CCE Work Group meetings and the writing process. Results: The initial logic model for ISC 3 changed in significant ways as a result of the input of the funded groups. Authentic participation in the development of the logic model led to strong buy-in among the centers, as evidenced by their utilization. The centers shifted both their evaluation design and their programmatic strategy to better accommodate the expectations reflected in the initiative logic model. Conclusions: The ISC 3 case study provides a positive example of how participatory logic modeling can be mutually beneficial to funders, grantees and evaluators of multi-site initiatives. Funded groups have important insights about what is feasible and what will be required to achieve the initiative's stated objectives. They can also help identify the contextual factors that either inhibit or facilitate success, which can then be incorporated into both the logic model and the evaluation design. In addition, when grantees co-develop the logic model, they have a better understanding and appreciation of the funder's expectations, and thus are better positioned to meet those expectations.

Embedding community-engaged research principles in implementation science: The implementation science center for cancer control equity.

Gaps in the implementation of effective interventions impact nearly all cancer prevention and control strategies in the US including Massachusetts. To close these implementation gaps, evidence-based interventions must be rapidly and equitably implemented in settings serving racially, ethnically, socioeconomically, and geographically diverse populations. This paper provides a brief overview of The Implementation Science Center for Cancer Control Equity (ISCCCE) and describes how we have operationalized our commitment to a robust community-engaged center that aims to close these gaps. We describe how ISCCCE is organized and how the principles of community-engaged research are embedded across the center. Principles of community engagement have been operationalized across all components of ISCCCE. We have intentionally integrated these principles throughout all structures and processes and have developed evaluation strategies to assess whether the quality of our partnerships reflects the principles. ISCCCE is a comprehensive community-engaged infrastructure for studying efficient, pragmatic, and equity-focused implementation and adaptation strategies for cancer prevention in historically and currently disadvantaged communities with built-in methods to evaluate the quality of community engagement. This engaged research center is designed to maximize the impact and relevance of implementation research on cancer control in community health centers.

Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors.

PURPOSE: Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors. METHODS: During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity. RESULTS: The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed. CONCLUSION: In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.

Barriers and facilitators to address vaping in Massachusetts schools: a mixed-methods study of school-based stakeholders.

We assessed vaping behaviors, environments, COVID-19 influences, and barriers and facilitators of existing approaches that address adolescent vaping in Massachusetts middle and high schools. Findings from this study will provide considerations for individual schools or districts as they advance adolescent vaping prevention and treatment efforts. We analyzed 310 open-ended comments from Massachusetts school administrators who completed a survey between November 2020 and January 2021. Further, we analyzed nine semi-structured interviews with administrators (e.g., principals, vice principals, school nurses) from Massachusetts school systems (n = 6) and school-based anti-tobacco advocates (n = 3); interviews took place between May and December 2021. Informed by Green's PRECEDE model, we conducted a framework analysis using deductive codes based on the model constructs (enabling, reinforcing, and predisposing factors) and inductive codes of key themes emerging from the interviews. Challenges to addressing adolescent vaping included staff capacity, funding, and lack of mental health and counseling supports. The COVID-19 pandemic was a major barrier to conducting usual in-person vaping programs, but also reduced student vaping at school due to new social distancing practices and bathroom use policies. Facilitators of vaping interventions included peer-led initiatives and parental involvement. Participants discussed the importance of educating adolescents on the harms of vaping and the move toward alternatives-to-suspension programs rather than disciplinary action. School-based anti-vaping program implementers-such as school districts, state departments of education, or local health departments-will need to leverage facilitators such as peer-led initiatives, alternatives-to-suspension approaches, and parental involvement, to increase the potential impact of these programs.

The purpose of this study was to understand challenges that school administrators faced in their approaches to address adolescent vaping in Massachusetts middle and high schools. We analyzed open-ended comments from Massachusetts school administrators who completed a survey between November 2020 and January 2021. Further, we analyzed nine interviews with administrators (e.g., principals, vice principals, school nurses) from Massachusetts school systems (n = 6) and school-based anti-tobacco advocates (n = 3); interviews took place between May and December 2021. We found that challenges to addressing adolescent vaping included school personnel capacity, funding, and lack of mental health and counseling supports. The COVID-19 pandemic was a major barrier to conducting usual in-person vaping programs, but also reduced student vaping at school due to new social distancing practices and bathroom use policies. Successful approaches included peer-led initiatives and parental involvement, and participants discussed the importance of educating adolescents on the harms of vaping. Based on our findings, school-based anti-vaping program practitioners­such as school districts, state departments of education, or local health departments­should leverage peer-led initiatives, alternatives-to-suspension approaches, and parental involvement, to increase the potential impact of adolescent vaping prevention and treatment efforts.

The Colocation Model in Community Cancer Care: A Description of Patient Clinical and Demographic Attributes and Referral Pathways.

PURPOSE: Cancer disparities are well documented among Black, Indigenous, and People of Color, yet little is known about the characteristics of programs that serve these populations. Integrating specialized cancer care services within community settings is important for addressing the needs of historically marginalized populations. Our National Cancer Institute-Designated Cancer Center initiated a clinical outreach program incorporating cancer diagnostic services and patient navigation within a Federally Qualified Health Center (FQHC) to expedite evaluation and resolution of potential cancer diagnoses with the goal of collaboration between oncology specialists and primary care providers in a historically marginalized community in Boston, MA. MATERIALS AND METHODS: Sociodemographic and clinical characteristics were analyzed from patients who were referred to the program for cancer-related care between January 2012 and July 2018. RESULTS: The majority of patients self-identified as Black (non-Hispanic) followed by Hispanic (Black and White). Twenty-two percent of patients had a cancer diagnosis. Treatment and surveillance plans were established for those with and without cancer at a median time to diagnostic resolution of 12 and 28 days, respectively. The majority of patients presented with comorbid health conditions. There was a high prevalence of self-reported financial distress among patients seeking care through this program. CONCLUSION: These findings highlight the wide spectrum of cancer care concerns in historically marginalized communities. This review of the program suggests that integrating cancer evaluation services within community-based primary health care settings offers promise for enhancing the coordination and delivery of cancer diagnostic services among historically marginalized populations and could be a method to address clinical access disparities.

Breast cancer knowledge and understanding treatment rationales among diverse breast cancer survivors.

PURPOSE: The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care. METHODS: We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013-2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt. RESULTS: During 2018-2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4-76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; > 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination. CONCLUSIONS: Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer.

Collaboration networks of the implementation science centers for cancer control: a social network analysis.

BACKGROUND: Multi-center research initiatives offer opportunities to develop and strengthen connections among researchers. These initiatives often have goals of increased scientific collaboration which can be examined using social network analysis. METHODS: The National Cancer Institute (NCI)-funded Implementation Science Centers in Cancer Control (ISC3) initiative conducted an online social network survey in its first year of funding (2020) to (1) establish baseline network measures including the extent of cross-center collaboration and (2) assess factors associated with a network member's access to the network such as one's implementation science (IS) expertise. Members of the seven funded centers and NCI program staff identified collaborations in planning/conducting research, capacity building, product development, scientific dissemination, and practice/policy dissemination. RESULTS: Of the 192 invitees, 182 network members completed the survey (95%). The most prevalent roles were faculty (60%) and research staff (24%). Almost one-quarter (23%) of members reported advanced expertise in IS, 42% intermediate, and 35% beginner. Most members were female (69%) and white (79%). One-third (33%) of collaboration ties were among members from different centers. Across all collaboration activities, the network had a density of 14%, suggesting moderate cohesion. Degree centralization (0.33) and betweenness centralization (0.07) measures suggest a fairly dispersed network (no single or few central member(s) holding all connections). The most prevalent and densely connected collaboration was in planning/conducting research (1470 ties; 8% density). Practice/policy dissemination had the fewest collaboration, lowest density (284 ties' 3% density), and the largest number of non-connected members (n=43). Access to the ISC3 network varied significantly depending on members' level of IS expertise, role within the network, and racial/ethnic background. Across all collaboration activities, most connected members included those with advanced IS expertise, faculty and NCI staff, and Hispanic or Latino and white members. CONCLUSIONS: Results establish a baseline for assessing the growth of cross-center collaborations, highlighting specific areas in need of particular growth in network collaborations such as increasing engagement of racial and ethnic minorities and trainees or those with less expertise in IS.

Beyond Educating the Masses: The Role of Public Health Communication in Addressing Socioeconomic- and Residence-based Disparities in Tobacco Risk Perception.

Public health communication has long been a key component of tobacco control efforts. However, little is known whether and how such an effort could address disparities in tobacco risk perceptions among population subgroups. In this study, using data from the Global Adult Tobacco Survey of Ethiopia, we examined if tobacco risk perceptions varied across socioeconomic and urban vs. rural population subgroups, and whether and how exposure to anti-smoking message was associated with disparities in risk perceptions across socioeconomic and urban-rural subgroups. The results indicated that health risk perceptions of smoking and secondhand smoke exposure were significantly lower among rural, less educated and less affluent population subgroups. Controlling for age, gender, education, wealth, place of residence, and pro-smoking message exposure, anti-smoking message exposure was associated with greater risk perceptions of smoking. Moreover, anti-smoking message exposure moderated the associations of place of residence and education with risk perceptions of smoking and secondhand smoke exposure, respectively. The probability of risk perception of smoking associated with anti-smoking message exposure was higher among the rural populace compared to urbanites. Similarly, the probability of risk perception of secondhand smoke exposure associated with anti-smoking message exposure was the highest among individuals without formal education compared to those with primary, secondary, and college-level education. The findings suggest that efforts should be made to make sure adequate anti-smoking message exposure among less educated and rural audiences so as to reduce disparities in tobacco risk perceptions.

The Use of Multimode Data Collection in Random Digit Dialing Cell Phone Surveys for Young Adults: Feasibility Study.

BACKGROUND: Young adults' early adoption of new cell phone technologies have created challenges to survey recruitment but offer opportunities to combine random digit dialing (RDD) sampling with web mode data collection. The National Young Adult Health Survey was designed to test the feasibility of this methodology. OBJECTIVE: In this study, we compared response rates across the telephone mode and web mode, assessed sample representativeness, examined design effects (DEFFs), and compared cigarette smoking prevalence to a gold standard national survey. METHODS: We conducted a survey experiment where the sampling frame was randomized to single-mode telephone interviews, telephone-to-web sequential mixed mode, and single-mode web survey. A total of 831 respondents aged 18 to 34 years were recruited via RDD at baseline. A soft launch was conducted prior to main launch. We compared the web mode to the telephone modes (ie, single-mode and mixed mode) at wave 1 based on the American Association for Public Opinion Research response rate 3 for screening and extended surveys. Base-weighted demographic distributions were compared to the American Community Survey. The sample was calibrated to the US Census Bureau's American Community Survey to calculate DEFFs and to compare cigarette smoking prevalence to the National Health Interview Survey. Prevalence estimates are estimated with sampling weights and are presented with unweighted sample sizes. Consistency of estimates was judged by 95% CI. RESULTS: The American Association for Public Opinion Research response rate 3 was higher in the telephone mode than in the web mode (24% and 30% vs 6.1% and 12.5%, for soft launch and main launch, respectively), which was reflected in response rate 3 for screening and extended surveys. During the soft launch, the extended survey and eligibility rate were low for respondents pushed to the web mode. To boost productivity and survey completes for the web condition, the main launch used cell phone numbers from the sampling frame where the sample vendor matched the number to auxiliary data, which suggested that the number likely belonged to an adult in the target age range. This increased the eligibility rate, but the screener response rate was lower. Compared to population distribution from the US Census Bureau, the telephone mode overrepresented men (57.1% [unweighted n=412] vs 50.9%) and those enrolled in college (40.3% [unweighted n=269] vs 23.8%); it also underrepresented those with a Bachelor of Arts or Science (34.4% [unweighted n=239] vs 55%). The web mode overrepresented White, non-Latinos (70.7% [unweighted n=90] vs 54.4%) and those with some college education (30.4% [unweighted n=40] vs 7.6%); it also underrepresented Latinos (13.6% [unweighted n=20] vs 20.7%) and those with a high school or General Education Development diploma (15.3% [unweighted n=20] vs 29.3%). The DEFF measure was 1.28 (subpopulation range 0.96-1.93). The National Young Adult Health Survey cigarette smoking prevalence was consistent with the National Health Interview Survey overall (15%, CI 12.4%-18% [unweighted 149/831] vs 13.5%, CI 12.3%-14.7% [unweighted 823/5552]), with notable deviation among 18- to 24-year-olds (15.6%, CI 11.3%-22.2% [unweighted 51/337] vs 8.7%, CI 7.1%-10.6% [unweighted 167/1647]), and those with education levels lower than Bachelor of Arts or Science (24%, CI 19.3%-29.4% [unweighted 123/524] vs 17.1%, CI 15.6%-18.7% [unweighted 690/3493]). CONCLUSIONS: RDD sampling for a web survey is not feasible for young adults due to its low response rate. However, combining this methodology with RDD telephone surveys may have a great potential for including media and collecting autophotographic data in population surveys.

A Yet Unrealized Promise: Structured Advance Care Planning Elements in the Electronic Health Record.

Background: Electronic health records (EHRs) may help enable reliable, rapid data management for many uses, such as facilitating communication of advance care planning (ACP). However, issues with validity and accuracy of EHRs hinder the use of ACP information for practical applications. Design: We present a cross-sectional pilot study of 433 older adults with cancer from three large health care systems, participating in an ongoing multisite pragmatic trial (4UH3AG060626-02). We compared data extracted from dedicated structured EHR fields for ACP to a chart review of corresponding ACP documentation contained in the medical chart. Results: Structured ACP data existed for 43.2% of patients and varied by site (25.7% -48.9%). Of the identified structured ACP data elements, 59.2% of recorded elements were correct, 23.7% were incorrect, and 17.1% were duplicates with heterogeneity across sites. Conclusion: Structured ACP data in EHRs were frequently incorrect. This represents a problem for patients and their families, as well as quality improvement and research efforts. Clinical Trials Registration: NCT03609177.

Primary Addiction Medicine Skills for Hospice and Palliative Medicine Physicians: A Modified Delphi Study.

CONTEXT: Hospice and palliative medicine (HPM) physicians frequently care for patients with substance use disorders (SUDs), but there is no consensus on which primary addiction medicine (AM) skills are essential. OBJECTIVES: Identify key primary AM skills that physicians should acquire during an ACGME-accredited HPM fellowship program. METHODS: A modified Delphi study consisting of 18 experts on SUD in HPM and medical education. A literature review and expert input identified initial AM skills. In three Delphi rounds, participants rated each skill on a nine-point scale from "not at all important to include" to "crucial to include." We calculated medians (IQRs), analyzed panelists' comments, and grouped skills using the RAND / UCLA appropriateness method. RESULTS: Among 62 proposed AM skills, 53 skills were rated as appropriate to include (38 of which achieved agreement), and nine skills were rated as uncertain. AM skills most relevant to HPM included 1) defining chemical coping, median 8.5 (IQR 2); 2) balancing life expectancy with risks of opioid use for patients with SUD, 9 (IQR 0); 3) explaining best practices to dispose unused opioids postmortem, 8 (IQR 2); 4) managing pain for hospice patients with SUD, 9 (IQR 0.75); and 5) partnering with hospice to manage patients on methadone and buprenorphine, 9 (IQR 2). Experts did not achieve consensus on whether HPM physicians should be encouraged to learn to prescribe buprenorphine for patients with opioid use disorder, 6 (IQR 3). CONCLUSION: HPM fellowships should consider incorporating the primary AM skills identified in this study in their curricula.

Advance Care Planning: Promoting Effective and Aligned Communication in the Elderly (ACP-PEACE): the study protocol for a pragmatic stepped-wedge trial of older patients with cancer.

INTRODUCTION: Advance care planning (ACP) is associated with improved health outcomes for patients with cancer, and its absence is associated with unfavourable outcomes for patients and their caregivers. However, older adults do not complete ACP at expected rates due to patient and clinician barriers. We present the original design, methods and rationale for a trial aimed at improving ACP for older patients with advanced cancer and the modified protocol in response to changes brought by the COVID-19 pandemic. METHODS AND ANALYSIS: The Advance Care Planning: Promoting Effective and Aligned Communication in the Elderly study is a pragmatic, stepped-wedge cluster randomised trial examining a Comprehensive ACP Program. The programme combines two complementary evidence-based interventions: clinician communication skills training (VitalTalk) and patient video decision aids (ACP Decisions). We will implement the programme at 36 oncology clinics across three unique US health systems. Our primary outcome is the proportion of eligible patients with ACP documentation completed in the electronic health record. Our secondary outcomes include resuscitation preferences, palliative care consultations, death, hospice use and final cancer-directed therapy. From a subset of our patient population, we will collect surveys and video-based declarations of goals and preferences. We estimate 11 000 patients from the three sites will be enrolled in the study. ETHICS AND DISSEMINATION: Regulatory and ethical aspects of this trial include Institutional Review Board (IRB) approval via single IRB of record mechanism at Dana-Farber Cancer Institute, Data Use Agreements among partners and a Data Safety and Monitoring Board. We plan to present findings at national meetings and publish the results. TRIAL REGISTRATION NUMBER: NCT03609177; Pre-results.

Development and testing of the KnowGene scale to assess general cancer genetic knowledge related to multigene panel testing.

PURPOSE: To develop and evaluate a measure of cancer genetics knowledge relevant to multigene panel testing. METHODS: The instrument was developed using systematic input from a national panel of genetics experts, acceptability evaluation by patient advocates, and cognitive testing. Twenty-four candidate items were completed by 591 breast or gynecological patients who had undergone genetic counseling and multigene panel testing in the past 18 months. A unidimensional item response theory model was fit with a mix of 2-parameter logistic nested response (2 plnrm) and 2-parameter logistic (2 pl) items. RESULTS: Key domains addressing cancer genetics knowledge were found to be overlapping. Of the 24 candidate items, 8 items were removed due to poor discrimination or local dependence. The remaining 16 items had good fit (RMSEA = 0.045, CFI = 0.946) and discrimination parameters ranging from 0.49 to 1.60. The items specified as 2 plnrm distinguish between those answering incorrect versus don't know, with discrimination ranging from 0.51 to 1.02. Information curves were highest among those with lower knowledge. CONCLUSION: KnowGene is a rigorously developed and effective measure of knowledge after cancer genetic counseling and multigene panel testing. PRACTICE IMPLICATIONS: Measuring knowledge in a systematic way will inform practice and research initiatives in cancer genetics.