Importance of primary care for underserved cancer patients with multiple chronic conditions.

PURPOSE: To understand the impact of pre-existing conditions on healthcare utilization among under- and uninsured patients in the transition from cancer treatment to post-treatment survivorship. METHODS: Using electronic health record data, we constructed a cohort of patients seen in an integrated county health system between 1/1/2010 and 12/31/2016. Six hundred thirty-one adult patients diagnosed with non-metastatic breast or colorectal cancer during this period (cases) were matched 1:1 on sex and Charlson comorbidity index to non-cancer patients who had at least two chronic conditions and with at least one visit to the health system during the study period (controls). Conditional fixed effects Poisson regression models compared number of primary care and emergency department (ED) visits and completed [vs. no show or missed] appointments between cancer and non-cancer patients. RESULTS: Cancer patients had significantly lower number of visits compared with non-cancer patients (N = 46,965 vs. 85,038). Cancer patients were less likely to have primary care (IRR = 0.25; 95% CI: 0.24, 0.27) and ED visits (IRR = 0.57; 95% CI: 0.50, 0.64) but more likely to complete a scheduled appointment (AOR = 4.83; 95% CI: 4.32, 5.39) compared with non-cancer patients. Cancer patients seen in primary care at a higher rate were more likely to visit the ED (IRR = 2.06; 95% CI: 1.52, 2.80) than those seen in primary care at a lower rate. CONCLUSION: Health systems need to find innovative, effective solutions to increase primary care utilization among cancer patients with chronic care conditions to ensure optimal management of both chronic conditions and cancer. IMPLICATIONS FOR CANCER SURVIVORS: Maintaining regular connections with primary care providers during active cancer treatment should be promoted.

Restricting Tobacco Retail Outlets Around Middle and High Schools as a Way to Reduce Tobacco Marketing Disparities: A Simulation Study.

INTRODUCTION: Communities with more people of color and economically disadvantaged residents are disproportionately exposed to tobacco marketing from tobacco companies. This study examined if banning tobacco retail outlets (TROs) within 1000 ft of schools would reduce these marketing disparities through a greater reduction in the amount of tobacco advertising around schools in these communities. METHODS: Data from objectively audited advertisement data from 106 convenience stores and gas stations around 42 middle and high schools located in the four major metropolitan areas of Texas were linked with schools' enrollment data. ArcGIS (Aeronautical Reconnaissance Coverage Geographic Information System) was used to simulate a 1000-ft ban of tobacco sales around the schools. Independent sample T-tests and Mann-Whitney U tests were used to test mean differences where appropriate. RESULTS: Schools with a higher enrollment of Hispanic/Latino (mean = 171.6, SD = 96.9) and economically disadvantaged students (mean = 168.9, SD = 102.3) were surrounded with significantly greater advertising at TROs than schools with lower enrollment of these groups (mean = 82.8, SD = 49.1 and mean = 89.2, SD = 50.6, respectively). A simulated 1000 ft ban of TROs around schools led to greater advertising reduction around schools with a higher enrollment of Hispanic/Latino students (13.3%-29.4% reductions) in comparison to schools with lower Hispanic/Latino student enrollment. However, the more economically disadvantaged schools had a smaller reduction in the number of advertisements (5.9%-21.9% reductions) in comparison to schools with less economically disadvantaged students. CONCLUSION: The implementation of a ban of tobacco sales at TROs within 1000 ft of schools is one policy approach to reduce youth exposure to tobacco marketing, particularly among students of color. STUDY IMPLICATION: Tobacco retail outlets (TROs) around schools with a higher enrollment of Hispanic/Latino and economically disadvantaged students had significantly more tobacco advertisements in comparison to schools with lower enrollment of these student groups. A simulated ban of TROs within 1000 ft of schools led to greater advertising reduction around schools with a higher enrollment of Hispanic/Latino students. For schools with more economically disadvantaged students, the ban led to a smaller reduction in advertisements in comparison to schools with less economically disadvantaged students. This proposed place-based strategy could be a successful means to reduce tobacco advertising and marketing disparity among communities of color.

A Simulation of the potential impact of restricting tobacco retail outlets around middle and high schools on tobacco advertisements.

OBJECTIVE: To examine (1) if tobacco retail outlets (TROs) closer to middle and high schools have more tobacco advertisements than TROs farther away and (2) the potential impact of two place-based tobacco control strategies on tobacco advertisements: a simulated ban of TROs (1) within 1000ft of schools and (2) within 500 ft of other TROs. METHODS: TROs within half-mile of 53 middle and high schools in the four largest Metropolitan areas in Texas were audited for all tobacco marketing. ArcGIS was used for mapping and grouping TROs by distance from the schools and simulating the ban. Mean differences in the number of tobacco advertisements were examined with t-tests. Percentage reductions in tobacco advertisements were calculated after simulation of both bans, reported by school type and by location, product and flavour. RESULTS: TROs within 1000 ft of schools had significantly more tobacco advertisements as compared with TROs located within 1000-2000 ft (p=0.03) for all schools combined and middle schools. Simulation of the 1000 ft ban of TROs led to a slightly greater reduction in advertisements (19.4%) as compared with the 500 ft ban of TROs from other TROs (17.9%). The reduction in all advertisement types was greater around middle schools and greatest for e-cigarettes (23.6%). CONCLUSION: Students can be exposed to a great deal of tobacco advertising in TROs around their schools. The implementation of a 1000 ft ban of TROs, or at minimum a ban on tobacco advertising outside and within these outlets, is one way to prevent or reduce the use of tobacco among adolescents.

Benign, Borderline, and Malignant Pediatric Adnexal Masses: A 10-Year Review.

STUDY OBJECTIVE: To investigate the incidence, clinical features, tumor markers, radiologic findings, types of surgeries, and histologies for adnexal masses in female pediatric and adolescent patients. DESIGN: Retrospective chart review. SETTING: Children's Health in Dallas and Plano, Texas from 2009 to 2018. PARTICIPANTS: Female patients younger than 19 years old who underwent surgical management of an adnexal mass. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Imaging characteristics, tumor markers, surgical procedures, and histopathology. RESULTS: In total, 752 patients (mean age, 13.7 years) underwent 756 surgical procedures for 781 adnexal masses. Of these, 732/781 (93.7%) were benign, 7/781 (0.9%) were borderline, and 42/781 (5.4%) were malignant. Of all 781 masses, 520/781 (66.6%) were ovarian and 261/781 (33.4%) were paratubal or tubal. Benign masses were associated with Hispanic race, pain, simple or cystic characteristics on imaging, and negative tumor markers. Borderline and malignant masses were associated with white race, pain, mass or distension, larger size, and heterogeneous appearance on imaging. Borderline masses were associated with negative tumor markers. Malignant masses were associated with elevated alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. CONCLUSION: Most adnexal masses in the pediatric and adolescent population are benign. Benign masses were significantly smaller, more likely to have negative tumor markers, and appear simple or cystic. There is little standardization with respect to preoperative tumor markers for adnexal masses. High-yield tumor markers for malignancy include alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. Low-yield tumor markers include inhibin A and B. Gynecologists performed more fertility-preserving surgeries including mini-laparotomies and fewer laparotomies for benign masses than pediatric surgeons.

The impact of intimate partner violence on breast and cervical cancer survivors in an integrated, safety-net setting.

PURPOSE: Characterize prevalence of intimate partner violence (IPV) among breast and cervical survivors receiving care in an urban safety-net healthcare system; Examine the relationship between IPV and clinical characteristics, receipt of cancer treatment, and guideline-recommended survivorship care. METHODS: From 2010 to 2017, breast and cervical cancer survivors were identified and recruited from a large, integrated, safety-net hospital system. Electronic health records (EHR; to measure survivorship care), cancer registry (to measure clinical characteristics), and patient telephone surveys (to measure IPV) were triangulated among 312 survivors. Bivariate and multivariable models assessed the relationship between victimization and clinical characteristics, cancer treatment, and guideline-recommended survivorship care. RESULTS: Among the 312 participants, 54% identified as IPV+. Among breast cancer, IPV+ cancer participants were twice more likely to develop estrogen receptor negative ER- and/or progesterone receptor negative PR- tumor receptors compared with IPV- cancer participants (AOR = 2.31; 95% CI, 1.20, 4.44). IPV+ breast cancer participants were less likely to have surgery and less likely to have hormone therapy as a first course of treatment compared with IPV- participants. There was no relationship between IPV and adherence to guideline-recommended cancer survivorship care. CONCLUSIONS: This study expands our current knowledge on how victimization, and specifically IPV, impact health among specialty care. Future research should determine the feasibility of implementing Trauma-Informed Care in oncology practices to better optimize care. IMPLICATIONS FOR CANCER SURVIVORS: At integrated hospital systems, IPV+ cancer participants should utilize social workers, within their oncology clinics, to connect to victim services.

Patient-Reported Barriers to Completing a Diagnostic Colonoscopy Following Abnormal Fecal Immunochemical Test Among Uninsured Patients.

BACKGROUND: For colorectal cancer (CRC) screening to improve survival, patients with an abnormal fecal immunochemical test (FIT) must follow-up with a diagnostic colonoscopy. Adherence to follow-up is low and patient-level barriers for suboptimal adherence have yet to be explored. OBJECTIVE: To characterize barriers for non-completion of diagnostic colonoscopy after an abnormal FIT reported by under- and uninsured patients receiving care in a safety-net health system. DESIGN: A longitudinal, cohort study of CRC screening outreach to 8565 patients using mailed FIT kits. Patients with abnormal FIT results received telephonic navigation to arrange for a no-cost diagnostic colonoscopy. PATIENTS: Adults aged 50-64 years receiving care at a North Texas safety-net health system. APPROACH: Descriptive analyses characterized the patient sample and reasons for lack of follow-up after abnormal FIT over the 3-year outreach program. Thematic qualitative analyses characterized reasons for lack of follow-up with a colonoscopy after the abnormal FIT. KEY RESULTS: Of 689 patients with an abnormal FIT, 45% (n = 314) did not complete a follow-up colonoscopy. Among the 314 non-completers, 184 patients reported reasons for not completing a follow-up colonoscopy included health insurance-related challenges (38%), comorbid conditions (37%), social barriers such as transportation difficulties and lack of social support (29%), concerns about FIT/colonoscopy process (12%), competing life priorities (12%), adverse effects of bowel preparation (3%), and poor health literacy (3%). Among the 314 non-completers, 131 patients did not report a barrier, as 51% reported that that had completed a previous colonoscopy in the past 10 years, 10% refused with no reason, and 10% were never reached by phone. CONCLUSIONS: Future studies aimed at improving FIT screening and subsequent colonoscopy rates need to address the unique needs of patients for effective and sustainable screening programs. TRIAL REGISTRATION: NCT01946282.

Pilot testing the detection of elder abuse through emergency care technicians (DETECT) screening tool: results from the DETECT pilot project.

OBJECTIVE: To pilot test the feasibility of implementing an elder abuse (EA) screening tool (DETECT) designed for medics. METHODS: Testing occurred between September 17th, 2015 and October 26th, 2015. MedStar Mobile Healthcare medics completed the DETECT tool when responding to calls for community-dwelling patients 65 years of age or older. RESULTS: The DETECT tool was used 1,248 times by 97% of medics responding to an eligible 911 call. Medics responded affirmatively to at least one screening item on 209 of the completed screenings (16.8%). Immediately following the introduction of the DETECT tool, there was an increase of 5.4 (226% above baseline) reports per month (p = 0.0056). CONCLUSIONS: The DETECT tool was easily incorporated into medic's field-based practice and resulted in an increase in medic generated reports of EA to APS. Future research designed to evaluate the tool's validity and reliability are warranted.

Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol.

BACKGROUND: The growing numbers of cancer survivors challenge delivery of high-quality survivorship care by healthcare systems. Innovative ways to improve care coordination for patients with cancer and multiple chronic conditions ("complex cancer survivors") are needed to achieve better care outcomes, improve patient experience of care, and lower cost. Our study, Project CONNECT, will adapt and implement three evidence-based care coordination strategies, shown to be effective for primary care conditions, among complex cancer survivors. Specifically, the purpose of this study is to: 1) Implement a system-level EHR-driven intervention for 500 complex cancer survivors at Parkland; 2) Test effectiveness of the strategies on system- and patient-level outcomes measured before and after implementation; and 3) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer. METHODS: Project CONNECT is a quasi-experimental implementation study among 500 breast and colorectal cancer survivors with at least one of the following chronic conditions: diabetes, hypertension, chronic lung disease, chronic kidney disease, or heart disease. We will implement three evidence-based care coordination strategies in a large, county integrated safety-net health system: 1) an EHR-driven registry to facilitate patient transitions between primary and oncology care; 2) co-locating a nurse practitioner trained in care coordination within a complex care team; 3) and enhancing teamwork through coaching. Segmented regression analysis will evaluate change in system-level (i.e. composite care quality score) and patient-level outcomes (i.e. self-reported care coordination). To evaluate implementation, we will merge quantitative findings with structured observations and physician and patient interviews. DISCUSSION: This study will result in an evaluation toolkit identifying key model elements, barriers, and facilitators that can be used to guide care coordination interventions in other safety-net settings. Because Parkland is a vanguard of safety-net healthcare nationally, findings will be widely applicable as other safety-nets move toward increased integration, enhanced EHR capability, and experience with growing patient diversity. Our proposal recognizes the complexity of interventions and scaffolds evidence-based strategies together to meet the needs of complex patients, systems of care, and service integration. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02943265 . Registered 24 October 2016.

Surveillance for colorectal cancer survivors in an integrated safety-net health system in the United States.

INTRODUCTION: Guideline-recommended surveillance reduces likelihood of colorectal cancer (CRC) recurrence, yet surveillance rates are low in the United States (US). Little is known about CRC surveillance rates among patients without health insurance and their primary care clinicians/oncologists' attitudes towards surveillance care. METHODS: A retrospective study of 205 patients diagnosed with Stage I-III CRC from 2008-2010 was conducted in an integrated system with a network of providers delivering care to patients lacking health insurance coverage. Surveillance patterns were characterized from medical records and logistic regression models examined correlates of guideline-concordant surveillance. 41 Parkland primary care physicians (PCPs) and 24 oncologists completed surveys to assess their attitudes and practices regarding CRC surveillance. RESULTS: 38% of CRC patients received guideline-concordant surveillance; those with early stage cancers were less likely to receive surveillance (OR=0.35; 95 CI: 0.14, 0.87). PCPs and oncologists differed markedly on who is responsible for cancer surveillance care. 77% of oncologists responded that PCPs evaluated patients for cancer recurrence while 76% of PCPs responded that these services were either ordered by oncologists or shared with PCPs. 67% of oncologists said they rarely provide a treatment and surveillance care plan to survivors and over half said that they infrequently communicate with patients' other physicians about who will follow patients for their cancer and other medical issues. DISCUSSION: Care coordination between PCP and oncologist is needed to improve CRC surveillance. New models of shared care clearly delineating roles for oncologists and PCPs are needed to improve CRC survivorship care.

Violence against women increases cancer diagnoses: Results from a meta-analytic review.

The purpose of this project was to assess the magnitude of the relationship between violence against women and cancer; to identify the exposures and cancers for which this relationship was particularly robust; to identify the effect of violence exposure on cancer screening. We conducted a meta-analysis of 36 studies to determine the relationship between violence against women and cancer outcomes, including screening, in 2017. Results from this review provide evidence of a significant, positive relationship between violence and cancer diagnoses, particularly for cervical cancer. Women who were victims of intimate partner violence and sexual abuse were more likely to be diagnosed with cancer compared with non-victims. Violence against women did not appear to be related to cancer screening practices and routine clinical service utilization; however, violence was associated with greater odds of abnormal pap test results. Victims of intimate partner violence and women who suffered physical abuse were more likely to have abnormal pap test results. In conclusion, use of screening tools for violence against women in clinical settings may improve the breadth and quality of research on violence against women and cancer. Investigators should consider how to creatively apply case-control and retrospective cohort designs to investigate the complex mechanisms and moderators of the relationship between violence against women and cancer.

Towards the development of a screening tool to enhance the detection of elder abuse and neglect by emergency medical technicians (EMTs): a qualitative study.

BACKGROUND: To develop a screening tool to enhance elder abuse and neglect detection and reporting rates among emergency medical technicians (EMTs). Our primary aim was to identify the most salient indicators of elder abuse and neglect for potential inclusion on a screening tool. We also sought to identify practical elements of the tool that would optimize EMT uptake and use in the field, such as format, length and number of items, and types of response options available. METHODS: Qualitative data were collected from 23 EMTs and Adult Protective Services (APS) caseworkers that participated in one of five semi-structured focus groups. Focus group data were iteratively coded by two coders using inductive thematic identification and data reduction. Findings were subject to interpretation by the research team. RESULTS: EMTs and APS caseworks identified eight domains of items that might be included on a screening tool: (1) exterior home condition; (2) interior living conditions; (3) social support; (4) medical history; (5) caregiving quality; (6) physical condition of the older adult; (7) older adult's behavior; and, (8) EMTs instincts. The screening tool should be based on observable cues in the physical or social environment, be very brief, easily integrated into electronic charting systems, and provide a decision rule for reporting guidance to optimize utility for EMTs in the field. CONCLUSIONS: We described characteristics of a screening tool for EMTs to enhance detection and reporting of elder abuse and neglect to APS. Future research should narrow identified items and evaluate how these domains positively predict confirmed cases of elder abuse and neglect.

The long-term effects of school dropout and GED attainment on substance use disorders.

BACKGROUND: Epidemiologic research suggests that 14% of the population do not complete high school, and dropout has been linked to mental health conditions, substance use, chronic health problems, and criminal behavior. Few studies have assessed whether attainment of the general education development (GED) credential is protective from substance use. PURPOSE: To assess the long-term outcomes of school dropout and GED attainment on past year substance use disorders, age of onset, and current smoking status. METHODS: Longitudinal data were included for lifetime substance users who participated in the National Epidemiological Survey on Alcohol and Related Conditions (Waves I and II). Eligible participants (N=30,608) were classified as having completed high school, dropped out of high school and did not complete a GED, or completed GED at Wave I. Survey logistic regression analyses were used to determine whether high school graduation status was associated with substance use disorders and smoking at Wave II. RESULTS: Multivariate results suggest that participants who dropped out of high school (OR=1.53; p<.01) or attained a GED were more likely to have a past year marijuana use disorder (OR=1.62 p<.01) compared to high school graduates. High school dropouts were also more likely to be current smokers (OR=1.88; p<.05) than graduates. CONCLUSIONS: High school dropouts have higher long-term rates of marijuana use disorder and smoking in adulthood than graduates. Attainment of a GED does not appear to be protective from marijuana use disorders in adulthood.