Geriatric Assessment-Driven Intervention (GAIN) on Chemotherapy-Related Toxic Effects in Older Adults With Cancer: A Randomized Clinical Trial.

IMPORTANCE: Although geriatric assessment-driven intervention improves patient-centered outcomes, its influence on chemotherapy-related toxic effects remains unknown. OBJECTIVE: To assess whether specific geriatric assessment-driven intervention (GAIN) can reduce chemotherapy-related toxic effects in older adults with cancer. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial enrolled 613 participants from a National Cancer Institute-designated cancer center between 2015 and 2019. Patients were 65 years and older with a solid malignant neoplasm, were starting a new chemotherapy regimen, and completed a geriatric assessment. Patients were followed up until chemotherapy completion or 6 months after initiation, whichever occurred first. Data analysis was done by intention-to-treat principle. INTERVENTIONS: Patients were randomized (2:1) to either the GAIN (intervention) or standard of care (SOC) arm. In the GAIN arm, a geriatrics-trained multidisciplinary team composed of an oncologist, nurse practitioner, social worker, physical/occupation therapist, nutritionist, and pharmacist reviewed geriatric assessment results and implemented interventions based on prespecified thresholds built into the geriatric assessment's domains. In the SOC arm, geriatric assessment results were sent to treating oncologists for consideration. MAIN OUTCOMES AND MEASURES: The primary outcome was incidence of grade 3 or higher chemotherapy-related toxic effects (graded using National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0). Secondary outcomes included advance directive completion, emergency department visits, unplanned hospitalizations, average length of stay, unplanned hospital readmissions, chemotherapy dose modifications, and early discontinuation. Overall survival analysis was performed up to 12 months after chemotherapy initiation. RESULTS: Among the 605 eligible participants for analysis, median (range) age was 71 (65-91) years, 357 (59.0%) were women, and 432 (71.4%) had stage IV disease. Cancer types included gastrointestinal (202 [33.4%]), breast (136 [22.5%]), lung (97 [16.0%]), genitourinary (91 [15.0%]), gynecologic (54 [8.9%]), and other (25 [4.1%]). Incidence of grade 3 or higher chemotherapy-related toxic effects was 50.5% (95% CI, 45.6% to 55.4%) in the GAIN arm and 60.6% (95% CI, 53.9% to 67.3%) in the SOC arm, resulting in a significant 10.1% reduction (95% CI, -1.5 to -18.2%; P = .02). A significant absolute increase in advance directive completion of 28.4% with GAIN vs 13.3% with SOC (P < .001) was observed. No significant differences were observed in emergency department visits, unplanned hospitalizations, average length of stay, unplanned readmissions, chemotherapy dose modifications or discontinuations, or overall survival. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, integration of multidisciplinary GAIN significantly reduced grade 3 or higher chemotherapy-related toxic effects in older adults with cancer. Implementation of GAIN into oncology clinical practice should be considered among older adults receiving chemotherapy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02517034.

Commitment to health theory: a graphic model.

Graphic models can improve understanding of theoretical concepts and the relationship between concepts. This article introduces a model of Commitment to Health Theory, which describes the process of behavior change from action to the maintenance stage of change. Commitment to health means that a new or modified health behavior will be used regardless of socioeconomic factors, race, gender, employment category, and age. Findings were based on three cross-sectional survey studies of approximately 1,085 predominantly manufacturing workers sampled from across the United States. Commitment to Health Theory was used to identify those in the action stage of change with mid-level commitment and predict the likelihood of successfully changing health behavior. Monitoring levels of commitment to health can determine appropriate intervention strategies to assist clients who currently exhibit unhealthy diet and exercise behaviors.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative.

OBJECTIVES: We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS: Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS: In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS: Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

Measuring the distribution of health behaviors in working populations--the needs assessment.

In this study, 79% of employees had one or more unhealthy behaviors that could result in disease or injury. needs assessment can be used to identify individual employees who have unhealthy behaviors and may be ready for behavior change. Focused health behavior interventions for employees who are ready to make a behavior change are more effective than generalized health promotion.

Providing asthma care in elementary schools: understanding barriers to determine best practices.

School nurses play a critical role in the management of children's asthma, yet they face barriers in their efforts to deliver quality care. In this qualitative study involving focus groups with school nurses, we identified key barriers in order to inform best practices. School nurses identified 4 main barriers to effective asthma care in elementary schools: lack of education, lack of communication, lack of resources, and lack of respect. An analysis of the barriers suggests that best practices for asthma care in elementary school settings require collaborative strategies that involve schools, families, the community, and the healthcare profession.

Health planning that magnifies the community's voice: allies against asthma.

Allies Against Asthma, a working group of the Consortium for Infant and Child Health (CINCH), conducted a comprehensive asthma needs assessment in Hampton Roads, Virginia, in 2001. Results from extant data and parent surveys indicated that asthma prevalence was high (15% to 18%), 45% to 50% of children received primary care for asthma in the emergency department, 30% had been recently hospitalized, and most children were not adequately medicated. Focus groups revealed inadequate asthma education, low income, lack of resources and consistent care, disparities in insurance coverage, and noncompliance with national asthma guidelines. An integrated community asthma action plan was developed and funded. Members were satisfied with the planning process--88% felt the plan reflected the needs assessment, and 86% agreed the plan would effectively improve asthma management. Interventions commenced in January 2002. The inclusive process that led to these interventions will ensure that the project is successful and sustainable.

Commitment to Health Scale.

The Commitment to Health Scale (CHS) was developed to predict likelihood of clients being able to permanently adopt new health-promoting behaviors. Commitment is based on the association between starting new health behaviors and long-term performance of those behaviors. The CHS evolved from an examination of Prochaska and DiClemente's Stages of Change Algorithm, Decisional Balance Scale, and Strong and Weak Principle (Velicer, Rossi, Prochaska, & DiClemente, 1996). Scale items were assessed by classical and Rasch measurement methods. The research was performed in three separate studies at various locations in the United States and included approximately 1100 subjects. A new unidimensional variable was identified called Commitment to Health. Internal consistency reliability of the scale was .94 (Cronbach's alpha). External validity and reliability were assessed based on expected and observed ordering and between known groups. Scale scores predicted self-reported health behaviors and body mass index.