Bidirectional associations between alcohol drinking and depressive symptom scores among US older adults.

BACKGROUND: This study examines the bidirectional associations between alcohol drinking and depression in which low to moderate alcohol drinking may reduce the risk of depression, while the occurrence of depression may increase the amount of alcohol drinking as a coping strategy. METHOD: Data for the community-dwelling older adults from the Medicare Current Beneficiary Survey (MCBS) 2016 to 2019 were analyzed using random intercept cross-lagged panel models to explore the within-individual causal associations for males and females separately. Socioeconomic status (SES), smoking and comorbidities were adjusted in the models. RESULTS: Among 3388 older adults with three measures for the number of alcohol drinks and Patient Health Questionnaire (PHQ) depression scores, a prior increase in the number of drinks was related to a moderate non-significant decrease in PHQ scores in the follow-up, but a previous increase in the PHQ scores was significantly associated with a decrease in the number of drinks at the follow-up visit in the adjusted models (regression coefficient = -0.144, p = 0.017 for males; and coefficient = -0.11, p < 0.001 for females). CONCLUSION: Prior depression may lead to reduced drinking in the follow up visits, but no bidirectional association was found among US older adults.

Disparities in E-Cigarette Harm and Addiction Perceptions Among Adolescents in the United States: a Systematic Review of the Literature.

BACKGROUND: Health disparities associated with e-cigarette use are increasingly apparent among US adolescents. Perceptions of e-cigarette harm and addiction play an important role in understanding adolescents' e-cigarette use behavior. The objective of this systematic review is to examine racial/ethnic and socio-economic disparities in e-cigarette harm and addiction perceptions among US adolescents. METHODS: We searched five databases to identify cross-sectional or longitudinal studies that focused on adolescents (≤ 18 years of age) who were ever, current, or never e-cigarettes users; we then examined how race/ethnicity and/or socio-economic status (SES) impacted e-cigarette harm and/or addiction perceptions. Two co-authors independently identified relevant studies, extracted data, and assessed the risk of bias. RESULTS: Adhering to PRISMA guidelines, eight of 226 identified studies met the inclusion criteria. These eight studies examined either perceptions regarding absolute e-cigarette harm and/or addiction (i.e., assessing perception of only e-cigarette) or relative e-cigarette harm and/or addiction (i.e., comparative perceptions to traditional cigarettes) by race and ethnicity. Two of the eight studies assessed absolute harm and/or addiction perceptions of e-cigarettes by SES. Our results indicate that, compared to all other racial/ethnic groups, relative e-cigarette harm and addiction perceptions were lower among Non-Hispanic White adolescents; however, absolute e-cigarette harm perception was higher among these groups. No clear patterns of racial/ethnic differences in absolute e-cigarette addiction perceptions and SES differences in absolute e-cigarette harm perceptions were reported. CONCLUSION: More research is needed to explicitly assess perceptions of e-cigarette harm and addiction among US adolescents by race/ethnicity and SES to develop subgroup appropriate public health messaging.

Factors Associated with E-Cigarette Quit Intention Among Adolescents in the United States.

Background: Given increasing use of e-cigarettes among adolescents in the United States and its potential for nicotine addiction, encouraging adolescents to quit using these products has become a public health priority. This study examined factors at various socio-ecological levels associated with e-cigarette quit intention (pre-contemplation, contemplation, or preparation) using the Stages of Change of the Trans-theoretical Model among the U.S. adolescents. Methods: We used cross-sectional data from the past 30-day adolescent exclusive e-cigarette users participating in Wave 4 of the Population Assessment of Tobacco and Health study (n = 349). Weighted adjusted multinomial logistic regression models were used to analyze the data. Results: Compared to pre-contemplators and contemplators, preparators were more likely to believe that nicotine in e-cigarettes was "very/extremely harmful" (vs. "not at all harmful") to health (p < 0.001) and people cause a "lot of harm" (vs. "no harm") to themselves when they use e-cigarettes (p < 0.001). In comparison to pre-contemplators, contemplators and preparators were more likely to report that their parents/guardians talked with them about not using e-cigarettes than those whose parents/guardians did not talk with them (p < 0.001). Additionally, contemplators and preparators were also more likely to report that they "often/very often" (vs. never) noticed health warnings on e-cigarette packages (p < 0.001). Conclusion: Our findings suggest that harm perception, influence of family, and e-cigarette health warnings are some of the important factors associated with the stages of change for intention to quit among adolescent e-cigarette users. This study will help public health practitioners and researchers design multi-level e-cigarette cessation interventions for adolescents.

Factors Associated With E-Cigarette Quitting Behavior Among Adolescents in the United States: A Prospective Observational Study.

PURPOSE: This prospective observational study examined the association of socioecological factors with quitting behavior among US adolescents who exclusively use electronic cigarettes (e-cigarettes). METHODS: We used data from past 30-day adolescent exclusive e-cigarette users (n = 243) participating in Wave 3 of the Population Assessment of Tobacco and Health study, who were then followed-up with approximately 12 months later for Wave 4. Weighted unadjusted and adjusted multivariate logistic regression models and structural equation modeling were performed to analyze the data. RESULTS: Adolescents were significantly less likely to quit e-cigarettes if they perceived that nicotine in e-cigarettes was "slightly/somewhat harmful" to health (adjusted odds ratio [aOR] = 0.38; 95% confidence interval [CI]: 0.16-0.90, p = .02). Similarly, adolescents who reported that someone else in their home owned an e-cigarette (aOR = 0.43 [95% CI: 0.19-0.94], p = .03) or important people in their life used e-cigarettes (aOR = 0.45 [95% CI: 0.21-0.95], p = .03) were significantly less likely to quit e-cigarettes. The structural equation modeling showed a direct significant relationship of individual-level (b = 0.206, p = .02) and interpersonal-level factors (b = 0.170, p = .04) with e-cigarette quitting behavior. DISCUSSION: Our findings suggest that individual-level (harm perception) and interpersonal-level (e-cigarette use at home and by important people) factors may play a significant role in e-cigarette quitting behavior among US adolescents.

Effectiveness of Interventions to Improve Oral Cancer Knowledge: a Systematic Review.

Oral cancer is prone to late-stage diagnosis, and subsequent low five-year survival rates. A small number of interventions or campaigns designed to enhance knowledge of risk factors and symptoms associated with oral cancer have been attempted in the UK, US, and some other countries. The purpose of this systematic review is to assess the effectiveness of interventions designed to improve oral cancer knowledge. We searched five databases to identify randomized controlled trials (RCTs) and non-randomized/quasi-experimental (NR/QE) studies targeting the general population or high-risk groups (tobacco users or alcohol consumers), aged ≥15 years, and reporting the outcomes of individual and/or community level interventions. Two co-authors independently identified relevant studies, extracted data, and assessed the risk of bias. Adhering to PRISMA guidelines, 27 (eight RCTs and 19 NR/QE studies) of the 551 studies identified from the five databases met the inclusion criteria. All RCTs and nine NR/QE studies used either printed materials, health education sessions, multimedia aids, or some combinations of these tools. The other ten NR/QE studies were community-based and used mass media campaigns to increase oral cancer awareness. Overall, the majority of studies significantly improved oral cancer knowledge; however, heterogeneity in study design and variation in measurement tools made it difficult to compare outcomes. Findings suggest that individual and/or community level interventions are generally effective in increasing knowledge of oral cancer risk factors, signs and symptoms, and/or its early diagnosis and prevention strategies among the general population or high-risk groups. However, the long-term benefits of these interventions are understudied.

Smoking Cessation among Pregnant and Postpartum Women from Low-Income Groups in the United States.

INTRODUCTION: Pregnancy creates a unique window of opportunity for smoking cessation. However, pregnant women from underserved groups can face personal, social, and environmental challenges that impede quitting. This study draws upon the socioecological framework to explore perspectives on smoking cessation among pregnant and postpartum women from low-income groups in the mid-South of the United States. METHODS: Semistructured interviews were conducted with 60 women who were pregnant or postpartum. Data were analyzed in Dedoose qualitative software using the directed content analysis approach. RESULTS: Findings reveal that at the individual level, motivations for smoking cessation included the fact of being pregnant, risks associated with the infant's health, and desire to breastfeed. However, some pregnant women perceived that slowing down on smoking during pregnancy was adequate to prevent harm to their fetuses. Individual-level factors that made smoking cessation difficult included nicotine addiction and habit, boredom, stressful life circumstances, fear of weight gain, and perceived lack of willpower. At the interpersonal level, living in a smoke-free environment where loved ones do not smoke and emotional and practical support from social network members including partners and family members were thought to facilitate smoking cessation. At the organizational level, access to nicotine replacement therapies and counseling aided in their abilities to quit smoking. At the policy level, pregnant women viewed increase in cigarette prices, warning labels on the cigarette pack, and the potential for a ban on cigarette sales as having some effect in helping them quit smoking. DISCUSSION: This study offers theoretical insights into factors that function as barriers or facilitators of smoking cessation among pregnant and postpartum women from low-income groups in the United States. Designing multilevel smoking cessation interventions while considering the interplay of individual, interpersonal, organizational, and policy level factors may lead to better cessation outcomes.

Perception and intention of using less harmful and less addictive hypothetical modified risk tobacco products among never tobacco users in the united states.

AIMS: There is limited research focusing on how never tobacco users respond to claims associated with modified risk tobacco products (MRTPs). The purpose of the present study is twofold: (1) to identify how never tobacco users perceive hypothetical modified risk tobacco product (MRTP) claims; and (2) to assess whether these perceptions impact their intentions of using MRTPs described as "less harmful" and "less addictive." METHOD: The present study draws upon a nationally representative dataset of US adults aged ≥ 18 years (n = 850) from a cross-sectional survey (HINTS-FDA, Cycle 2, 2017). Weighted unadjusted and adjusted logistic regression analyses were performed to analyze the data. RESULTS: Participants who perceived tobacco products labeled as having "no additives" to be less harmful were close to three times more likely to report intentions of using "less harmful" (Adjusted OR = 2.93 [95% CI: 1.12-7.65]) and "less addictive" (Adjusted OR = 2.72 [95% CI: 1.03-7.21]) tobacco products than those who perceived them to be more/equally harmful. Participants who believed that tobacco products could be manufactured without some chemicals were over five and six times more likely to report intentions of using "less harmful" (Adjusted OR = 5.53 [95% CI: 1.59-19.25]) and "less addictive" (Adjusted OR = 6.60 [95% CI: 2.65-16.46]) tobacco products than those who were unlikely to believe it. CONCLUSIONS: Our findings have implications for FDA's regulation of MRTPs and provides insights regarding how the marketing of authorized MRTPs could impact population health in the future.

Post-liver transplant outcomes in patients with major psychiatric diagnosis in the United States.

INTRODUCTION AND OBJECTIVES: Higher rates of psychiatric disorders are reported among cirrhotic patients. This study examines the demographic and clinical outcomes post-liver transplant (LT) among cirrhotic patients with a major psychiatric diagnosis (cases) compared to those without psychiatric diagnosis (controls). MATERIALS AND METHODS: Retrospective case control design was used among 189 cirrhotic patients who had undergone LT at Methodist University Hospital Transplant Institute, Memphis, TN between January 2006 and December 2014. Multivariable regression and Cox proportional hazard regression were conducted to compare allograft loss and all-cause mortality. RESULTS: The study sample consisted of a matched cohort of 95 cases and 94 controls with LT. Females and those with Hepatic Encephalopathy (HE) were more likely to have psychiatric diagnosis. Patients with hepatocellular carcinoma (HCC) were twice as likely to have allograft loss. Psychiatric patients with HCC had two and a half times (HR 2.54; 95% CI: 1.20-5.37; p = 0.015) likelihood of all-cause mortality. Data censored at 1-year post-LT revealed that patients with psychiatric diagnosis have a three to four times higher hazard for allograft loss and all-cause mortality compared to controls after adjusting for covariates, whereas when the data is censored at 5 year, allograft loss and all-cause mortality have two times higher hazard ratio. CONCLUSIONS: The Cox proportional hazard regression analysis of censored data at 1 and 5 year indicate higher allograft loss and all-cause mortality among LT patients with psychiatric diagnosis. Patients with well-controlled psychiatric disorders who undergo LT need close monitoring and medication adherence.

Impact of self-assessed health status and physical and functional limitations on healthcare utilization and mortality among older cancer survivors in US.

PURPOSE: The purpose of this study was to examine the impact of physical limitations, functional limitations and self-assessed health status on mortality and healthcare utilization among older cancer survivors. METHODS: National Medicare Current Beneficiary Survey (MCBS) cost and use data from 2008 to 2013 were used for analysis. Physical limitations, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL) were assessed on multiple questions, and self-assessed health was measured on a five-point scale (1-5: Excellent-Poor). Multivariable logistic regression and Poisson regression models were used for hospitalization, re-hospitalization and mortality rates based on three follow up years. RESULTS: This study included 17,715 cancer patients with a mean age of 75 years and 57% females. Cancer survivors with poor self-assessed health had a higher rate of hospitalizations (adjusted Odds Ratio: aOR: 1.60, 95% Confidence Interval: CI: 1.47-1.72, p < 0.001) relative to non-cancer participants. Compared to participants with no history of cancer, cancer survivors with IADL (aOR: 1.41, 95% CI: 1.25-1.58, p < 0.001) or with poor self-assessed health (aOR: 1.39, 95% CI: 1.21-1.60, p < 0.001) were more likely to have a higher number of hospital readmissions within 30 days of a prior hospitalization. Three-year mortality rate was significantly higher among cancer survivors with poor self-assessed health (Hazard Ratio: 2.81, 95% CI: 2.81-2.82, p < 0.001). CONCLUSION: Self-assessed health and physical and functional limitations significantly and independently impact healthcare utilization and mortality among older cancer survivors. Healthcare providers should incorporate formal assessments of both self-assessed health and functional status among older cancer survivors in their clinical practice. IMPLICATION FOR CANCER SURVIVORS: Self-reported health status is a valuable and independent predictor of healthcare utilization and mortality among cancer survivors.

Effect of opioid treatment on clinical outcomes among cirrhotic patients in the United States.

BACKGROUND: Opioid medications are frequently used to address pain among patients with cirrhosis, including those on the liver transplant (LT) waitlist and after transplantation. However, opioid use has been associated with poor allograft outcomes and reduced transplant survival. We examined the impact of opioid use across the spectrum of advanced liver disease, from the initial hepatology consultation for cirrhosis through transplant referral, listing, and the post-LT process. METHODS: The study includes all patients referred for cirrhosis management in a single healthcare system in the United States. Data were extracted retrospectively through medical chart review. RESULTS: Of 414 patients included in the study, 104 (25%) were treated with opioid. Patients on opioids were more likely to be White, have body mass indices (BMI) >30, have HCV, suffer from hepatic encephalopathy, cigarette smokers, and use benzodiazepines concurrently. Higher doses of opioids were associated with multiple emergency department (ED). Eighty-nine underwent LT, including 20 opioid-treated patients. There was no difference found between the opioid and non-opioid groups with regard to allograft loss, ED visits, and hospital readmissions at 2 years post-LT follow-up. CONCLUSIONS: Opioid treatment was common among patients with cirrhosis. We did not find increased negative outcomes among opioid users across the spectrum of cirrhosis. However, the sample for LT patients was small.

Impact of Physical and Functional Limitations on Health Care Utilization in Older Cancer Survivors: A Medicare Current Beneficiary Survey.

Objective: This study examines effects of physical and functional limitations on health care utilization among older cancer survivors, compared with those without cancer and without physical and functional limitations. Method: Medicare Current Beneficiary Survey data from 2008 to 2011 were used. Physical limitations (PL), activities of daily living (ADL), and instrumental activities of daily living (IADL) were measured on a 5-point scale. Propensity score weighting was developed using logistic regressions. Results: Older cancer survivors with physical and functional limitations had higher rate of emergency department visits than those without limitations (PL: 21.8% vs.17%, adjusted odds ratio [aOR]:1.72, 95% confidence interval [CI]: [1.26, 2.35], p < .05; ADL: 25.8% vs.17.4%, aOR: 2.68, 95% CI: [1.86, 3.86], p < .001), and higher cost of hospitalization (IADL: M = US$24,916, SD: 3,877.1). Conclusion: Older cancer survivors with physical and functional limitations had higher health care utilization compared with those without cancer. Addressing complex and unique health care needs in this population will help reduce excess burden on the health care system.

"All boats will rise": Physicians' perspectives on multidisciplinary lung cancer care in a community-based hospital setting.

PURPOSE: We explored the perceived strengths, barriers to implementation, and suggestions for sustainable implementation of a multidisciplinary model within a community-based hospital system from the physicians' perspectives. METHODS: We conducted 9 focus groups with 37 physicians involved in the care of lung cancer patients. Grounded theory methodology guided the identification of recurrent themes that emerged from the qualitative data analysis. RESULTS: The majority of study participants agreed that the multidisciplinary model could benefit patients by promoting high quality, efficient, and well-coordinated care. Co-location, financial disincentives, and time constraints were identified as major deterrents to full participation in a multidisciplinary clinic. Other perceived challenges were the integration of a multidisciplinary care model into the existing healthcare system, maintenance of referral streams, and designation of the physician primarily responsible for a patient's care. Educating physicians about the availability of a multidisciplinary clinic, establishing efficient processes for initial consultations, implementing technology for virtual participation, and using a nurse navigator with reliable closed-loop communication were suggested to improve the implementation of the multidisciplinary model. CONCLUSIONS: Physicians generally agreed that the multidisciplinary model could improve lung cancer care, but they perceived significant personal, institutional, and system-level barriers that need to be addressed for its successful implementation in a community healthcare setting.

Psychosocial interventions for informal caregivers of lung cancer patients: A systematic review.

OBJECTIVE: Caregivers of patients with lung cancer often face physical, emotional, and financial distress, which not only negatively affects the caregivers' mental health and quality of life but may also impact patients' well-being. The purpose of this systematic review is to examine the content, delivery, and efficacy of psychosocial interventions targeting caregivers of lung cancer patients. METHODS: Studies included in this systematic review assessed psychosocial interventions for caregivers of lung cancer patients that were published in English between January 2009 and December 2017. These interventions focused on burden, mental health, quality of life, self-efficacy, and/or coping as outcome measures. CINAHL, PubMed, PsycInfo, Science Direct, and Web of Science databases were searched using the terms (lung cancer OR lung neoplasms OR thoracic cancer) AND (caregiver OR caregiving) AND (intervention OR program) to systematically review the relevant literature on this topic. RESULTS: From the 22 studies included in this systematic review, interventions were classified into four categories: communication-based interventions, coping skills training interventions, multicomponent interventions, and stress reduction interventions. The majority of the interventions (especially communication-based and multicomponent) led to improvement, albeit not always statistically significant, in one or more outcomes; however, the most frequently reported improvements included, burden, distress, anxiety, depression, overall quality of life, self-efficacy, and coping abilities. CONCLUSIONS: The unmet needs of informal caregivers of lung cancer patients have a significant impact on their mental health and quality of life, but this burden can be alleviated by psychosocial interventions that offer appropriate support, education, and resources.

Pragmatic trial of a multidisciplinary lung cancer care model in a community healthcare setting: study design, implementation evaluation, and baseline clinical results.

BACKGROUND: Responsible for 25% of all US cancer deaths, lung cancer presents complex care-delivery challenges. Adoption of the highly recommended multidisciplinary care model suffers from a dearth of good quality evidence. Leading up to a prospective comparative-effectiveness study of multidisciplinary vs. serial care, we studied the implementation of a rigorously benchmarked multidisciplinary lung cancer clinic. METHODS: We used a mixed-methods approach to conduct a patient-centered, combined implementation and effectiveness study of a multidisciplinary model of lung cancer care. We established a co-located multidisciplinary clinic to study the implementation of this care-delivery model. We identified and engaged key stakeholders from the onset, used their input to develop the program structure, processes, performance benchmarks, and study endpoints (outcome-related process measures, patient- and caregiver-reported outcomes, survival). In this report, we describe the study design, process of implementation, comparative populations, and how they contrast with patients within the local and regional healthcare system. Trial Registration: ClinicalTrials.gov Identifier: NCT02123797. RESULTS: Implementation: the multidisciplinary clinic obtained an overall treatment concordance rate of 90% (target >85%). Satisfaction scores were high, with >95% of patients and caregivers rating themselves as being "very satisfied" with all aspects of care from the multidisciplinary team (patient/caregiver response rate >90%). The Reach of the multidisciplinary clinic included a higher proportion of minority patients, more women, and younger patients than the regional population. Comparative effectiveness: The comparative effectiveness trial conducted in the last phase of the study met the planned enrollment per statistical design, with 178 patients in the multidisciplinary arm and 348 in the serial care arm. The multidisciplinary cohort had older age and a higher percentage of racial minorities, with a higher proportion of stage IV patients in the serial care arm. CONCLUSIONS: This study demonstrates a comprehensive implementation of a multidisciplinary model of lung cancer care, which will advance the science behind implementing this much-advocated clinical care model.

Outcomes of Liver Transplant Recipients With Autoimmune Liver Disease Using Long-Term Dual Immunosuppression Regimen Without Corticosteroid.

BACKGROUND: Liver transplant (LT) recipients with autoimmune liver disease (primary sclerosing cholangitis, primary biliary cholangitis, autoimmune hepatitis) are at increased risk of developing acute cellular rejection (ACR), and in many cases graft failure due to recurrent disease. We describe our experience with dual immunosuppression without steroid maintenance and analyze its effect on disease recurrence; ACR; patient and graft survivals; and complications, such as sepsis and de novo malignancy. METHODS: We included 74 consecutive LT recipients (April 2006 to April 2013) with autoimmune liver disease (primary sclerosing cholangitis, 20; primary biliary cholangitis, 23; autoimmune hepatitis, 31) from a single transplant center. Immunosuppression protocol included rabbit antithymocyte globulin for induction and mycophenolate mofetil with tacrolimus or sirolimus/everolimus indefinitely for maintenance. RESULTS: Overall 1-, 3-, 5-, and 7-year patient survival was 95.9%, 90.4%, 82,2% and 74.9%, re-graft-free survival was 93.2%, 86.3%, 79.9%, and 72.8%, respectively (median follow-up, 5.5 years). In a multivariate Cox regression analysis, sepsis during post-LT period (P = 0.040; hazard ratio [HR], 2.52; 95% confidence interval [CI], 1.04-6.11), steroid use for ACR (P = 0.037; HR, 2.60; 95% CI, 1.06-6.34), and younger age (<40 years) at LT (P = 0.038; HR, 2.53; 95% CI, 1.05-6.10) predicted graft survival, whereas steroid use for ACR was the only variable that was predictive of overall patient survival (P = 0.004; HR, 4.10; 95% CI, 1.59-10.52). Overall, 34 biopsy-proven ACR was noted in 22 LT recipients (30%), 13 (17.5%) had disease recurrence, and 34 episodes of sepsis occurred in 19 patients. CONCLUSIONS: Dual immunosuppression protocol in LT recipients with autoimmune liver disease without corticosteroid maintenance had acceptable rates of survival and ACR without predisposing patients to the adverse effects of long-term steroid therapy.

Disparity in rates of HPV infection and cervical cancer in underserved US populations.

There is a higher rate of HPV infection and cervical cancer incidence and mortality in underserved US population who reside in Appalachian mountain region compared to Northern Plains. Social and behavioral factors such as smoking and alcohol consumption are for such a high incidence. However, by and large, the reasons for these discrepancies lie in the reluctance of the underserved population to adopt preventive measures such as prophylactic Human papilloma virus (HPV) vaccines and Pap smear screening that have significantly reduced the incidence and mortality rate of cervical cancer in Caucasian women. Thus, it is clear that drastic change in social behavior and implementation of preventive measures is required to effectively reduce the incidence and mortality from cervical cancer in this underserved population.

Health Care Utilization Among Elderly Medicare Beneficiaries With Coexisting Dementia and Cancer.

Objective: The goal of this research is to delineate health care utilization among elderly Medicare beneficiaries with coexisting dementia and cancer compared with those with dementia alone, cancer alone, or neither condition. Method: The study cohort included 96,124 elderly patients aged 65 years and older who resided in the Mid-South region of the United States and were enrolled in Medicare during 2009. Multivariate regression analyses were used to examine health care utilizations while adjusting for sociodemographic characteristics. Results: Those with coexisting dementia and cancer diagnoses had higher rates of hospitalizations, hospital readmissions within 30 days, intensive care unit use, and emergency department visits compared with those with dementia only, cancer only, and those with neither condition. Patients with coexisting dementia and cancer also had a higher number of primary care visits and specialist visits. Conclusion: There is a greater need for developing tailored care plans for elderly with these two degenerative health conditions to address their unique health care needs and to reduce financial burden on the patients and the health care system.

Deploying Team Science Principles to Optimize Interdisciplinary Lung Cancer Care Delivery: Avoiding the Long and Winding Road to Optimal Care.

The complexity of lung cancer care mandates interaction between clinicians with different skill sets and practice cultures in the routine delivery of care. Using team science principles and a case-based approach, we exemplify the need for the development of real care teams for patients with lung cancer to foster coordination among the multiple specialists and staff engaged in routine care delivery. Achieving coordinated lung cancer care is a high-priority public health challenge because of the volume of patients, lethality of disease, and well-described disparities in quality and outcomes of care. Coordinating mechanisms need to be cultivated among different types of specialist physicians and care teams, with differing technical expertise and practice cultures, who have traditionally functioned more as coactively working groups than as real teams. Coordinating mechanisms, including shared mental models, high-quality communication, mutual trust, and mutual performance monitoring, highlight the challenge of achieving well-coordinated care and illustrate how team science principles can be used to improve quality and outcomes of lung cancer care. To develop the evidence base to support coordinated lung cancer care, research comparing the effectiveness of a diverse range of multidisciplinary care team approaches and interorganizational coordinating mechanisms should be promoted.

'One-stop shop': lung cancer patients' and caregivers' perceptions of multidisciplinary care in a community healthcare setting.

BACKGROUND: Multidisciplinary care is rarely practiced in community healthcare settings where the majority of patients receive lung cancer care in the US. We sought direct input from patients and their informal caregivers on their experience of lung cancer care delivery. METHODS: We conducted focus groups of patient and caregiver dyads. Patients had received care for lung cancer in or out of a multidisciplinary thoracic oncology clinic coordinated by a nurse navigator. Focus groups were audiotaped, transcribed, and analyzed using Creswell's 7-step process. Recurring overlapping themes were developed using constant comparative methods within the Grounded Theory framework. RESULTS: A total of 46 participants were interviewed in focus groups of 5 patient-caregiver dyads. Overlapping themes were a perception that multidisciplinary care improved physician collaboration, patient-physician communication, and patient convenience, while reducing redundancy in testing. Improved coordination decreased confusion, stress, and anxiety. Negative experience of serial care included poor communication among physicians, insensitive communication about illness, delays in diagnosis and treatment, misdiagnosis, and mistreatment. Physician-to-physician communication and patient education were suggested areas for improvement in the multidisciplinary model. CONCLUSIONS: Multidisciplinary care was perceived as more patient-centered, effective, safe, and efficient than standard serial care. It was also believed to improve the timeliness of care and equitable access to high quality care. Additional studies to compare these perspectives to those of other key stakeholders, including clinicians, hospital administrators and representatives of third party payers, will facilitate better understanding of the role of multidisciplinary care programs in lung cancer care delivery.