Challenges and opportunities using online portals to recruit diverse patients to behavioral trials.

We describe the use of an online patient portal to recruit and enroll primary care patients in a randomized trial testing the effectiveness of a colorectal cancer (CRC) screening decision support program. We use multiple logistic regression to identify patient characteristics associated with trial recruitment, enrollment, and engagement. We found that compared to Whites, Blacks had lower odds of viewing the portal message (OR = 0.46, 95% CI = 0.37-0.57), opening the attached link containing the study material (OR = 0.75, 95% CI = 0.62-0.92), and consenting to participate in the trial (OR = 0.85, 95% CI = 0.67-0.93). We also found that compared to Whites, Asians had lower odds of viewing the portal message (OR = 0.53, 95% CI = 0.33-0.64), opening the attached link containing the study material (OR = 0.76, 95% CI = 0.54-0.97), consenting to participate in the trial (OR = 0.68, 95% CI = 0.53-0.95), and completing the trial's baseline questionnaire (OR = 0.59, 95% CI = 0.36-0.90). While portals offer an opportunity to mitigate human bias in trial invitations, because of racial disparities-not only in who has a portal account, but in how they interact with trial recruitment and enrollment material within the portal-using portals alone for trial recruitment may generate study samples that are not racially diverse.

Bayesian deprivation index models for explaining variation in elevated blood lead levels among children in Maryland.

Lead exposure adversely affects children's health. Exposure in the United States is highest among socioeconomically disadvantaged individuals who disproportionately live in substandard housing. We used Bayesian binomial regression models to estimate a neighborhood deprivation index and its association with elevated blood lead level (EBLL) risk using blood lead level testing data in Maryland census tracts. Our results show the probability of EBLL was spatially structured with high values in Baltimore city and low values in the District of Columbia suburbs and Baltimore suburbs. The association between the neighborhood deprivation index and EBLL risk was statistically significant after accounting for spatial dependence in probability of EBLL. The percent of houses built before 1940, African Americans, and renter occupied housing were the most important variables in the index. Bayesian models provide a flexible one-step approach to modeling risk associated with neighborhood deprivation while accounting for spatially structured and unstructured heterogeneity in risk.

Patient-Reported Needs Following a Referral for Colorectal Cancer Screening.

INTRODUCTION: Patient-physician communication about colorectal cancer screening can affect screening use, but discussions often lack information that patients need for informed decision making and seldom address personal preferences or barriers. To address this gap, a series of patient focus groups was conducted to guide the development of an online, interactive decision support program. This article presents findings on patient information needs and barriers to colorectal cancer screening after receiving a screening recommendation from a physician, and their perspectives on using electronic patient portals as platforms for health-related decision support. METHODS: Primary care patients with recent colonoscopy or stool testing orders were identified via the centralized data repository of a large Midwestern health system. Seven gender-stratified focus groups (N=45 participants) were convened between April and July 2016. Sessions were audio recorded, transcribed, coded, and analyzed for commonly expressed themes beginning in August 2016. RESULTS: Findings reveal a consistent need for simple and clear information on colorectal cancer screening. Participants desired step-by-step explanations of the colonoscopy procedure and information about bowel preparation options/alternatives. The desired level of additional information varied: some patients wanted to know about and act on test options, whereas others preferred following their physician-recommended testing path. Fears and concerns were prevalent, particularly about colonoscopy, and patients reported challenges getting these concerns and their informational needs addressed. Finally, they expressed consistent support for using the patient portal to gather additional information from their physician. CONCLUSIONS: Patient portals may offer an opportunity to build sustainable programs for decision support and assistance that are integrated with clinic workflows and processes.

Explaining variation in elevated blood lead levels among children in Minnesota using neighborhood socioeconomic variables.

BACKGROUND: Childhood lead exposure is linked to numerous adverse health effects and exposure in the United States is highest among people living in substandard housing, which is disproportionately inhabited by socioeconomically disadvantaged individuals. In this paper, we compared the Vox lead exposure risk score and concentrated disadvantage based on principal component analysis (PCA) to weighted quantile sum (WQS) regression to determine which method was best able to explain variation in elevated blood lead levels (EBLLs). METHODS: We constructed indices for census tracts in Minnesota and used them in Poisson regression models to identify the best socioeconomic measure for explaining EBLL risk. RESULTS: All indices had a significant association with EBLL in separate models. The WQS index had the best goodness-of-fit, followed next by the Vox index, and then the concentrated disadvantage index. Among the most important variables in the WQS index were percent of houses built before 1940, percent renter occupied housing, percent unemployed, and percent African American population. CONCLUSIONS: The WQS approach was best able to explain variation in EBLL risk and identify census tracts where targeted interventions should be focused to reduce lead exposure.

Estimating an area-level socioeconomic status index and its association with colonoscopy screening adherence.

Socioeconomic status (SES) is often considered a risk factor for health outcomes. SES is typically measured using individual variables of educational attainment, income, housing, and employment variables or a composite of these variables. Approaches to building the composite variable include using equal weights for each variable or estimating the weights with principal components analysis or factor analysis. However, these methods do not consider the relationship between the outcome and the SES variables when constructing the index. In this project, we used weighted quantile sum (WQS) regression to estimate an area-level SES index and its effect in a model of colonoscopy screening adherence in the Minnesota-Wisconsin Metropolitan Statistical Area. We considered several specifications of the SES index including using different spatial scales (e.g., census block group-level, tract-level) for the SES variables. We found a significant positive association (odds ratio = 1.17, 95% CI: 1.15-1.19) between the SES index and colonoscopy adherence in the best fitting model. The model with the best goodness-of-fit included a multi-scale SES index with 10 variables at the block group-level and one at the tract-level, with home ownership, race, and income among the most important variables. Contrary to previous index construction, our results were not consistent with an assumption of equal importance of variables in the SES index when explaining colonoscopy screening adherence. Our approach is applicable in any study where an SES index is considered as a variable in a regression model and the weights for the SES variables are not known in advance.

Nourishing Our Understanding of Role Modeling to Improve Support and Health (NOURISH): design and methods.

Pediatric overweight is associated with numerous physical and psychological health risks, and overweight children are at significant risk for obesity in adulthood. African-American children are at particularly high risk for obesity and related health complications. However, this racial group has traditionally had limited access to obesity treatment and relatively few studies have included sufficient numbers of lower-SES, African American participants. Further, although parental involvement in treatment for pediatric overweight has been found to be beneficial, few studies have examined the efficacy of offering treatment exclusively to parents, a potentially cost-effective approach which could benefit the entire family. This pilot project will evaluate the efficacy of an intensive parenting intervention, (NOURISH; Nourishing Our Understanding of Role modeling to Improve Support and Health), targeting racially diverse parents of overweight children (ages 6-11). NOURISH addresses several urgent research priorities by targeting the underserved and addressing the significant disparity in obesity treatment services. Parents meeting study criteria (having a child between the ages of 6 and 11 with a BMI ≥ the 85th percentile) will be offered participation in the randomized trial comparing NOURISH with a control group. We hypothesize that children whose parents participate in NOURISH will manifest greater decreases in BMI, and greater improvements in dietary intake, and quality of life compared to children whose parents do not participate. This study is designed explicitly to gather preliminary feasibility, acceptability, and effectiveness data to inform a subsequent larger randomized controlled trial.

Patient costs as a barrier to intensive health behavior counseling.

BACKGROUND: Although intensive health behavior counseling has been demonstrated to help patients lose weight and quit smoking, many payers offer limited coverage for such counseling. PURPOSE: This mixed-methods case study examined how coverage affected utilization of an electronic linkage system (eLinkS) to help adult patients obtain intensive health behavior counseling, provided through a collaboration of primary care practices and community programs. METHODS: Grant support enabled patients to obtain counseling at no cost, but funds were exhausted within 5 weeks as a result of an overwhelming response. To study the influence of cost as a barrier, referrals were resumed for an additional 3 weeks, but patients were required to pay for them. Use of eLinkS, level of clinician counseling and referrals, and patient interest in referrals were measured using electronic medical record data and patient and clinician interviews. RESULTS: When counseling was free, approximately one in five patients with an unhealthy behavior and an eLinkS prompt was referred for intensive counseling. However, when patient charges were instituted, referrals decreased by 97% (from 21.8% to 0.7%, p<0.001); clinicians asked fewer patients about health behaviors (37% vs 29%, p<0.001); clinicians offered fewer patients referrals (29% vs 6%, p<0.001); and patients were less interested in accepting referrals (76% vs 14%, p<0.001). In interviews, patients and clinicians cited cost as a major barrier. CONCLUSIONS: Coverage for intensive health behavior counseling is important to utilization, particularly for interventions that involve clinician-community partnerships. The potential public health benefits of such collaborations to reduce unhealthy behaviors justify the elimination of financial barriers (e.g., copayments) by payers.

Mammography screening after risk-tailored messages: the women improving screening through education and risk assessment (WISER) randomized, controlled trial.

AIMS: A randomized trial investigated the impact of risk-tailored messages on mammography in diverse women in the Virginia Commonwealth University Health System's gynecology clinics. METHODS: From 2003 to 2005, 899 patients > or =40 years of age were randomized to receive risk-tailored information or general information about breast health. Multiple logistic regression analyses summarize their breast health practices at 18 months. RESULTS: At baseline, 576 (64%) women reported having a mammogram in the past year. At 18-month follow-up, mammography rates were 72.6% in the intervention group and 74.2% in the control group (N.S.). Women (n = 123) who reported worrying about breast cancer "often" or "all the time" had significantly higher mammography rates with the intervention (85.0%) vs. the controls (63.5%). No significant differences existed in clinical breast examination, self-examination, or mammography intentions between the two study arms. However, intervention women with lower education reported significantly fewer clinical breast examinations at follow-up. CONCLUSIONS: The brief intervention with a risk-tailored message did not have a significant effect overall on screening at 18 months. However, among those who worried, mammography rates in the intervention group were higher. Individual characteristics, such as worry about breast cancer and education status, may impact interventions to improve breast cancer prevention practices.