A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol.

BACKGROUND: Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices. METHODS: We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data. DISCUSSION: Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities. TRIAL REGISTRATION: NCT05591586.

Prioritizing rural populations in state comprehensive cancer control plans: a qualitative assessment.

PURPOSE: The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) requires that states develop comprehensive cancer control (CCC) plans and recommends that disparities related to rural residence are addressed in these plans. The objective of this study was to explore rural partner engagement and describe effective strategies for incorporating a rural focus in CCC plans. METHODS: States were selected for inclusion using stratified sampling based on state rurality and region. State cancer control leaders were interviewed about facilitators and barriers to engaging rural partners and strategies for prioritizing rural populations. Content analysis was conducted to identify themes across states. RESULTS: Interviews (n = 30) revealed themes in three domains related to rural inclusion in CCC plans. The first domain (barriers) included (1) designing CCC plans to be broad, (2) defining "rural populations," and (3) geographic distance. The second domain (successful strategies) included (1) collaborating with rural healthcare systems, (2) recruiting rural constituents, (3) leveraging rural community-academic partnerships, and (4) working jointly with Native nations. The third domain (strategies for future plan development) included (1) building relationships with rural communities, (2) engaging rural constituents in planning, (3) developing a better understanding of rural needs, and (4) considering resources for addressing rural disparities. CONCLUSION: Significant relationship building with rural communities, resource provision, and successful strategies used by others may improve inclusion of rural needs in state comprehensive cancer control plans and ultimately help plan developers directly address rural cancer health disparities.

Financial navigation: Staff perspectives on patients' financial burden of cancer care.

PURPOSE: To describe perceptions of financial navigation staff concerning patients' cancer-related financial burden. METHODS: This qualitative descriptive study used a semi-structured interview guide to examine perceptions of financial navigation staff concerning patients' cancer-related financial burden. Staff who provided financial navigation support services to cancer patients were interviewed from different types of cancer programs across seven states representing rural, micropolitan, and urban settings. Interviews lasted approximately one hour, were audio recorded, and transcribed. Transcripts were double coded for thematic analysis. RESULTS: Thirty-five staff from 29 cancer centers were interviewed. The first theme involved communication issues related to patient and financial navigation staff expectations, timing and the sensitive nature of financial discussions. The second theme involved the multi-faceted impact of financial burden on patients, including stress, difficulty adhering to treatments, and challenges meeting basic, non-medical needs. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Cancer-related financial burden has a profound impact on cancer survivors' health and non-health outcomes. Discussions regarding cancer-related costs between cancer survivors and healthcare team members could help to normalize conversations and mitigate the multi-faceted determinants and effects of cancer-related financial burden. As treatment may span months and years and unexpected costs arise, having this discussion regularly and systematically is needed.

Patient Perspectives on Longitudinal Adherence to Lung Cancer Screening.

BACKGROUND: Annual lung cancer screening (LCS) has mortality benefits for eligible participants; however, studies demonstrate low adherence to follow-up LCS. RESEARCH QUESTION: What are patients' perspectives on barriers and facilitators to adherence to annual LCS? STUDY DESIGN AND METHODS: Forty participants enrolled in the University of Washington/Seattle Cancer Care Alliance LCS program completed a demographic questionnaire and a semistructured interview based on the Tailored Implementation in Chronic Diseases framework to determine attitudes, barriers, and facilitators to longitudinal LCS. Interviews were coded using principles of framework analysis to identify and compare themes between adherent and nonadherent participants. RESULTS: The 40 participants underwent initial LCS in 2017 with negative results. Seventeen were adherent to follow-up annual LCS, whereas 23 were not. Seven overall themes emerged from qualitative analysis, which are summarized as follows: (1) screening experiences are positive and participants have positive attitudes toward screening; (2) provider recommendation is a motivator and key facilitator for most patients; (3) many patients are influenced by personal factors and symptoms and do not understand the importance of asymptomatic screening; (4) common barriers to longitudinal screening include cost, insurance coverage, accessibility, and other medical conditions; (5) patients have variable preferences about how they receive their screening results, and many have residual questions about their results and future screening; (6) reminders are an important facilitator of annual screening; and (7) most patients think a navigator would be beneficial to the screening process, with different aspects of navigation thought to be most helpful. Those who were not adherent more commonly reported individual barriers to screening, competing health concerns, and less provider communication. INTERPRETATION: Key facilitators (eg, patient reminders, provider recommendations) may improve long-term screening behavior, and a number of barriers to the screening process could be addressed through patient navigation.

How cancer programs identify and address the financial burdens of rural cancer patients.

PURPOSE: Financial toxicity is associated with negative patient outcomes, and rural populations are disproportionately affected by the high costs of cancer care compared to urban populations. Our objective was to (1) understand cancer programs' perceptions of rural-urban differences in cancer patients' experiences of financial hardship, (2) evaluate the resources available to cancer patients across the rural-urban continuum, and (3) determine how rural and urban health care teams assess and address financial distress in cancer patients. METHODS: Seven research teams within the Cancer Prevention and Research Control Network conducted semi-structured interviews with cancer program staff who have a role in connecting cancer patients with financial assistance services in both rural and urban counties. Interviews were audio-recorded and transcribed. We identified themes using descriptive content and thematic analysis. RESULTS: We interviewed 35 staffs across 29 cancer care programs in seven states, with roughly half of respondents from programs in rural counties. Participants identified differences in rural and urban patients' experiences of financial hardship related to distance required to travel for treatment, underinsurance, and low socioeconomic status. Insufficient staffing was an identified barrier to addressing rural and urban patients' financial concerns. CONCLUSIONS: Improved financial navigation services could mitigate the effects of financial toxicity experienced by cancer patients, particularly rural patients, throughout treatment and survivorship. Future research is needed to improve how cancer programs assess financial hardship in patients and to expand financial navigation services to better serve rural cancer patients.

Design of a study to implement population-based risk assessment for hereditary cancer genetic testing in primary care.

Identifying patients with high genetic risk for cancer has important clinical ramifications, but hereditary cancer risk is often not identified because of testing barriers at both the provider and patient level. It is unknown how to best implement appropriate genetic testing and follow-up care into an operating primary care clinic. Implementation studies to date have been conducted in high resourced facilities under optimal conditions, often not at the clinic level. This study aims to compare and evaluate two population-wide engagement strategies for identifying members of a primary care clinic's population with a family or personal history of cancer and offering high-risk individuals genetic testing for cancer susceptibility mutations. The two engagement strategies are: 1) point of care screening (POC), conducted when a patient is scheduled for an appointment and 2) direct patient engagement (DPE), where outreach provides the patient an opportunity to complete screening online on their own time. The study will identify changes, problems, and inefficiencies in clinical flow during and after the implementation of risk assessment and genomic testing for cancer risk across primary care clinics. It will also evaluate the effects of the two engagement strategies on patient, provider, and clinic leader outcomes, including perceptions of benefits, harms, and satisfaction with the engagement strategy and process of cancer risk assessment and genetic testing, across gender, racial/ethnic, socioeconomic, and genetic literacy divides. Finally, the study will evaluate the cost-effectiveness and budget impact of each engagement strategy.

Qualitative Assessment of Washington State Medicaid Health Plan Readiness to Implement Systems-Based Approaches to Colorectal Cancer Screening.

Implementation of population-based colorectal cancer screening programs by Medicaid health plans could address colorectal cancer screening disparities. Our objective is to identify facilitators and barriers to implementation of a population-based colorectal cancer screening program by Washington State Medicaid health plans. We conducted semi-structured interviews with leadership from 2 statewide and 3 national Medicaid plans. We organized the interview questions around the Consolidated Framework for Implementation Research (CFIR). We analyzed interview transcripts, guided by directed content analysis, and identified facilitators and barriers to Medicaid health plan implementation of population-based colorectal cancer screening programs. Robust health plan (inner setting) quality improvement infrastructures were facilitators. Lack of statewide Medicaid policy incentives (external setting) to increase colorectal cancer screening were barriers to potential implementation. Efforts to address identified barriers through local and national policies and statewide data sharing efforts may support Medicaid health plan implementation of population-based colorectal cancer screening programs.

Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs.

Few data are available on patient navigators (PNs) across diverse roles and organizational settings that could inform optimization of patient navigation models for cancer prevention. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the Colorectal Cancer and Control Program (CRCCP) are two federally-funded screening programs that support clinical- and community-based PNs who serve low-income and un- or underinsured populations across the United States. An online survey assessing PN characteristics, delivered activities, and patient barriers to screening was completed by 437 of 1002 identified PNs (44%). Responding PNs were racially and ethnically diverse, had varied professional backgrounds and practice-settings, worked with diverse populations, and were located within rural and urban/suburban locations across the U.S. More PNs reported working to promote screening for breast/cervical cancers (BCC, 94%) compared to colorectal cancer (CRC, 39%). BCC and CRC PNs reported similar frequencies of individual- (e.g., knowledge, motivation, fear) and community-level patient barriers (e.g., beliefs about healthcare and screening). Despite reporting significant patient structural barriers (e.g., transportation, work and clinic hours), most BCC and CRC PNs delivered individual-level navigation activities (e.g., education, appointment reminders). PN training to identify and champion timely and patient-centered adjustments to organizational policies, practices, and norms of the NBCCEDP, CRCCP, and partner organizations may be beneficial. More research is needed to determine whether multilevel interventions that support this approach could reduce structural barriers and increase screening and diagnostic follow-up among the marginalized communities served by these two important cancer-screening programs.

Conflicts of Interest and Distribution of Resources to Community Partners: An Organizational Ethics Dilemma.

BACKGROUND: Conflicts of interest can arise when faculty and staff administer programs that distribute research funds, training opportunities, and other resources across academic and community partners. We describe the ethical concerns encountered by a Clinical Translational Science Award (CTSA) program in administering its community-focused pilot grant program and how its Research Bioethics Consultation service helped to address them.Ethical Concerns: CTSA program faculty and staff identified ethical concerns in several areas, including appropriateness of including Regional Research Collaborations (RRC) faculty as principal or co-investigators on applications, determining how much help RRC faculty and staff should provide to prospective applicants, and creating a fair and effective application review process. DISCUSSION: The CTSA program identified common goals and values for its community-focused pilot grant program, and resolved the conflicts of interest with the new pilot grant policies. This approach could generalize to conflicts of interest that arise in other academic-community partnerships.

Racial and Ethnic Health Disparities Curricula in US Medical Schools: A CERA Study.

INTRODUCTION: Health disparities among African Americans are an historic and pervasive problem in US health care. We examined the presence, requirements, and content of curricula in US medical schools dedicated to racial and ethnic health disparities. METHODS: We conducted a national CERA survey of Family Medicine department chairs. Chairs were asked about disparities curricula in their institutions. RESULTS: Ninety-two percent reported that their medical school curriculum included focus on racial and ethnic disparities. However, many were dissatisfied with the content and quality of their curricular offerings. There were no significant departmental predictors of the quality of health disparities curricula. CONCLUSION: The majority of medical schools address health disparities in their curricula, but optimally covering this important content remains a persistent challenge in medical school education.

Primary Care Patients' Willingness to Participate in Comprehensive Weight Loss Programs: From the WWAMI Region Practice and Research Network.

PURPOSE: In the United States, 69% of adults are overweight or obese, as defined by a body mass index (BMI) ≥25 kg/m(2). The US Preventive Services Task Force recommends screening all adult patients for obesity and referring obese patients to intensive, multicomponent behavioral weight loss programs comprising 12 to 26 yearly sessions. The objective of this study is to determine the degree to which overweight and obese primary care patients report willingness to participate in these intensive weight loss programs and to identify the patient factors associated with reported willingness to participate. METHODS: This 2013 cross-sectional survey was offered to all adult patients seen for an office visit at 1 of 12 primary care clinics in the Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) Region Practice and Research Network (WPRN). Patients self-reported both their health information and their willingness to participate in a comprehensive weight loss program. Respondents were characterized by descriptive statistics. We compared reported rates of willingness to participate by patient factors and assessed which patient factors were independently associated with reported willingness using bivariate analysis and logistic regression, respectively. RESULTS: Of overweight and obese respondents, 63% reported willingness to participate in comprehensive weight loss programs. Age, sex, race/ethnicity, insurance status, BMI, and reason for wanting to lose weight were all significantly and independently associated with reported willingness to participate. CONCLUSIONS: Reported willingness to participate in comprehensive weight loss programs suggests that additional resources are needed to understand strategies for disseminating and implementing effective comprehensive weight loss programs.

Affordable Care Act Impact on Community Health Center Staffing and Enrollment: A Cross-Sectional Study.

Over 500 000 Washingtonians gained health insurance under the Affordable Care Act (ACA). As more patients gain insurance, community health centers (CHCs) expect to see an increase in demand for their services. This article studies the CHCs in Washington State to examine how the increase in patients has been impacting their workload and staffing. We found a reported mean increase of 11.7% and 5.4% in new Medicaid and Exchange patients, respectively. Half of the CHCs experienced large or dramatic workload impact from the ACA. Our findings suggest that CHCs need further workforce support to meet the expanding patient demand.

Evaluating the Development, Implementation and Dissemination of a Multisite Card Study in the WWAMI Region Practice and Research Network.

BACKGROUND: Practice-based research networks (PBRNs) promote the conduct of research in real-world settings by engaging primary care clinicians as champion research collaborators. Card studies are brief surveys administered to patients or clinicians at the point of care. The objective of this paper is to describe the design and evaluation of a card study methodology that the WWAMI Region Practice and Research Network (WPRN) used to develop research partnerships across multiple member sites. METHODS: We used a collaborative model to develop, implement and disseminate the results of a network-wide card study to assess patient preferences for weight loss in primary care. After the card study data collection was completed, we conducted individual and focus group interviews and a brief survey of participating practice champions. RESULTS: Increased research engagement and personal and professional developments were the primary motivators for participating in the development of the card study. Increasing research activity at practices and learning information about patients were motivators for implementing the study. Their participation resulted in champions reporting increased confidence in collaborating on research projects as well as the development of new clinical services for patients. DISCUSSION: This collaborative model positively influenced research capacity in the WPRN and may be a useful strategy for helping PBRNs conducted translational research.

Satisfaction of family physicians working in community health centers.

BACKGROUND: Community health centers (CHCs) receive $2.9 billion in federal funding to provide primary care to 20 million people annually, and these numbers are increasing. Understanding of physician satisfaction in CHCs may help guide recruitment and retention efforts aimed at expanding CHC programs. The objective of this study was to contrast the satisfaction of family physicians working in CHCs with the satisfaction of family physicians working in other practice settings. METHODS: Analysis of 4 cross-sectional surveys of recent residency graduates from the Washington, Wyoming, Alaska, Montana, and Idaho Family Medicine Residency Network. Surveys were conducted approximately every 3 years from 2000 to 2010. Main outcome measures included self-reported satisfaction with residency training, practice, and specialty on a 1 (low) to 5 (high) scale. RESULTS: Eight hundred ninety-three family physician responded (response rate, 61%), of whom 129 were CHC physicians and 764 were non-CHC physicians. Compared with non-CHC physicians, higher proportions of CHC physicians reported being highly satisfied with their residency training (79% vs 61%; P < .01) and choice of specialty (74% vs 60%; P < .01). In contrast, lower proportions of CHC physicians were highly satisfied with their employers (62% vs 72%; P = .05). [corrected]. There were no differences in satisfaction with practice partners, income, practice location, or work hours. After adjustment for physician, practice, and community characteristics, CHC physicians were more likely to be highly satisfied with their residency training (odds ratio, 2.6; P = .001) and their choice of specialty (odds ratio, 1.7; P = .03). CHC physicians were less likely to be highly satisfied with their employers (odds ratio, 0.5; P < .01). CONCLUSIONS: The lower level of satisfaction reported by CHC physicians has implications for workforce recruitment and retention in CHC settings. In an era of CHC growth, efforts to improve physician relationships with employers may be a potential target for enhancing the physician workforce in CHCs.