Correction: Improving the Engagement of Underrepresented People in Health Research Through Equity-Centered Design Thinking: Qualitative Study and Process Evaluation for the Development of the Grounding Health Research in Design Toolkit.

[This corrects the article DOI: 10.2196/43101.].

Tools to measure barriers to medication management capacity in older adults: a scoping review.

BACKGROUND: Medication management capacity is a crucial component of medication adherence, particularly among older adults. Various factors, including physical abilities, cognitive functions, sensory capabilities, motivational, and environmental factors, influence older adults' ability to manage medications. It is, therefore, crucial to identify appropriate tools that allow clinicians to determine which factors may impact medication management capacity and, consequently, nonadherence to medications. PURPOSE: 1)To identify tools that measure physical, cognitive, sensory (vision, hearing, touch), motivational, and environmental barriers to medication self-management in older adults, and 2) to understand the extent to which these tools assess various barriers. METHODS: The scoping review was conducted using Arksey and O'Malley's scoping review framework and the PRISMA Extension for Scoping Reviews checklist. In June 2022, the relevant literature was identified by searching PubMed (MEDLINE), Ovid Embase, Ovid IPA, EBSCOhost CINAHL, APA PsycINFO, and Scopus. RESULTS AND DISCUSSION: In total, 7235 studies were identified. Following the removal of duplicates, 4607 articles were screened by title and abstract, of which 4253 did not meet the inclusion criteria. Three reviewers reviewed the full texts of the remaining 354 articles; among them, 41 articles, 4 theses and 1 conference abstract met the inclusion criteria. From the included studies, 44 tools were identified that measured a combination of physical, cognitive, sensory, motivational, and environmental barriers (n=19) or only cognition (n=13), vision (n=5), environmental factors (n=3), auditory (n=1), and motivational factors (n=1). The review also examined the psychometric properties of the identified tools and found that most of them had reported validity and reliability data. Several tools have demonstrated promise in assessing a combination of barriers with validity and reliability. These tools include the Self-Medication Assessment Tool (SMAT), ManageMed Screening (MMS), Self-Medication Risk Assessment Tool (RAT), HOME-Rx revised, and Medication Management Ability Assessment (MMAA). CONCLUSION: This scoping review identified 44 validated tools to measure various challenges that older adults encounter with medication management. However, no tool measures all five barriers (physical, cognitive, sensory, motivational, and environmental) to medication-taking at home. Therefore, utilizing a combination of tools would be most appropriate to measure these different aspects comprehensively. Further research is needed to develop a new comprehensive tool that simultaneously measures various barriers to medication self-management.

Cost-utility analysis of a multispecialty interprofessional team dementia care model in Ontario, Canada.

OBJECTIVES: To examine the cost-effectiveness of Multi-specialty INterprofessional Team (MINT) Memory Clinic care in comparison to the provision of usual care. DESIGN: Using a Markov-based state transition model, we performed a cost-utility (costs and quality-adjusted life years, QALY) analysis of MINT Memory Clinic care and usual care not involving MINT Memory Clinics. SETTING: A primary care-based Memory Clinic in Ontario, Canada. PARTICIPANTS: The analysis included data from a sample of 229 patients assessed in the MINT Memory Clinic between January 2019 and January 2021. PRIMARY OUTCOME MEASURES: Effectiveness as measured in QALY, costs (in Canadian dollars) and the incremental cost-effectiveness ratio calculated as the incremental cost per QALY gained between MINT Memory Clinics versus usual care. RESULTS: MINT Memory Clinics were found to be less expensive ($C51 496 (95% Crl $C4806 to $C119 367) while slightly improving quality of life (+0.43 (95 Crl 0.01 to 1.24) QALY) compared with usual care. The probabilistic analysis showed that MINT Memory Clinics were the superior treatment compared with usual care 98% of the time. Variation in age was found to have the greatest impact on cost-effectiveness as patients may benefit from the MINT Memory Clinics more if they receive care beginning at a younger age. CONCLUSION: Multispecialty interprofessional memory clinic care is less costly and more effective compared with usual care and early access to care significantly reduces care costs over time. The results of this economic evaluation can inform decision-making and improvements to health system design, resource allocation and care experience for persons living with dementia. Specifically, widespread scaling of MINT Memory Clinics into existing primary care systems may assist with improving quality and access to memory care services while decreasing the growing economic and social burden of dementia.

Yoga and Mindfulness for Social-Emotional Development and Resilience in 3-5 Year-Old Children: Non-Randomized, Controlled Intervention.

Background: Early childhood is the key life course period for development of social-emotional skills, providing the foundation for school readiness and resilience in later life. Age-appropriate yoga and mindfulness programs may contribute to the development of critical skills in children. Young children from minoritized communities that face structural racism and health disparities may benefit from programs that support social-emotional development and contribute to future academic success. Systematic reviews of yoga interventions for young children have indicated the potential for effectiveness in supporting social-emotional development, executive function, and physical activity. However, studies of yoga and mindfulness with non-White children are sparse and, overall, the evidence base to date for such programs remains limited by non-controlled studies and the variable quality of studies evaluating programs in early childhood settings. Methods: The analysis of data from a non-randomized, controlled intervention aimed to assess the effect of exposure to a yoga and mindfulness program for early childhood development of social-emotional skills in a majority Black/African American urban preschool setting in southeastern US. Children in the intervention received group yoga and mindfulness led by a certified children's yoga teacher who also had training and experience as a school teacher. Intervention participants engaged in activities for 20 minutes once per week for 32 weeks, while the control group had no yoga. The final sample included 579 in the historical control group and 122 in the intervention group. Results: Results indicated that children who participated in the yoga and mindfulness program had higher total protective factor (TPF) subscores on the Devereux Early Childhood Assessment over time than children who did not receive yoga and mindfulness programming, and that the difference was statistically significant (P<0.05). Participation in the intervention group significantly predicted increases in initiative score, self-control score, and TPF score, as well as a decrease in the behavioral concerns. Discussion: School based yoga and mindfulness programming can support social-emotional skills and resilience in young children. Additional studies with larger sample sizes and randomization are needed on use of yoga and mindfulness in young children for social-emotional development, particularly for Black/African American children and others from minoritized communities.

Improving the Engagement of Underrepresented People in Health Research Through Equity-Centered Design Thinking: Qualitative Study and Process Evaluation for the Development of the Grounding Health Research in Design Toolkit.

BACKGROUND: Health inequalities are rooted in historically unjust differences in economic opportunities, environment, access to health care services, and other social determinants. Owing to these health inequalities, the COVID-19 pandemic has disproportionately affected underserved populations, notably people of color, incarcerated and formerly incarcerated individuals, and those unable to physically distance themselves from others. However, people most strongly impacted by health disparities, and the pandemic, are not frequently engaged in research, either as researchers or as participants, resulting in slow progress toward improving health equity. Establishing ways to foster the engagement of historically excluded people is crucial to improving health equity through patient-centered health research. OBJECTIVE: This study aimed to assess the use of equity-centered design thinking (EDT) for engaging community members in research prioritization related to COVID-19. The co-design methods and subsequent production of a toolkit that can be used for engagement were assessed through process evaluation and qualitative methods. METHODS: Process evaluation and qualitative inquiry, using reflexive thematic analysis, were undertaken to examine the use of EDT. Patient community members and stakeholders remotely partnered with design and health researchers in a year-long digital process to cocreate capacity-building tools for setting agenda for research regarding the impact of COVID-19 on health outcomes. Through a series of 3 workshops, 5 community partners engaged in EDT activities to identify critical challenges for the health and well-being of their communities. The subsequent tools were tested with 10 health researchers who provided critical input over the course of 2 workshops. Interviews with co-designers, project materials, and feedback sessions were used in the process evaluation and finalization of an equity-centered toolkit for community engagement in research. Data from the co-design process, meetings, workshops, and interviews were analyzed using reflexive thematic analysis to identify salient themes. RESULTS: Process evaluation illustrated how the EDT co-design process offered an approach to engage patient partners and community stakeholders in health-related research around COVID-19. The participants expressed satisfaction with design thinking approaches, including creative activities and iterative co-design, as a means of working together. Thematic analysis identified 3 key themes: the value of authentic partnerships, building trust and empathy through design, and fostering candid dialogue around health and social issues impacting historically underrepresented and underinvested communities. CONCLUSIONS: The project addressed the need to test EDT strategies for fostering inclusive community engagement in health research agenda setting and provided an alternative to traditional top-down models. Despite the increasing use of human-centered design in health, few projects explicitly include equity in design thinking approaches. The use of methods and tools to intentionally engage underrepresented stakeholders in the process of research agenda setting and equitably sharing power between researchers and community members may improve health research, ultimately improving health equity.

Assessment of the Prevalence and Trajectory of Depressive Symptoms by Sexual Orientation During Physician Training.

This cohort study uses survey data to assess the prevalence and development of depressive symptoms among sexual minority and heterosexual physicians during residency training.

Examining the Implementation of Conditional Financial Incentives Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework to Improve HIV Outcomes among Persons Living with HIV (PLWH) in Louisiana.

Economic strengthening interventions are needed to support HIV outcomes among persons living with HIV (PLWH). The Baton Rouge Positive Pathway Study (BRPPS), a mixed method implementation science study, was conducted to assess key RE-AIM components tied to the provision of conditional financial incentives among PLWH in Baton Rouge, Louisiana. Seven hundred and eighty-one (781) PLWH enrolled at four HIV clinic sites were included in the final analyses. Participants completed an initial baseline survey, viral load test, and were contacted at 6 and 12 months (±1 month) post-enrollment for follow-up labs to monitor viral load levels. Participants received up to USD140 in conditional financial incentives. The primary analyses assessed whether participation in the BRPPS was associated with an increase in the proportion of participants who were: (a) engaged in care, (b) retained in care and (c) virally suppressed at baseline to 6 and 12 months post-baseline. We constructed a longitudinal regression model where participant-level outcomes at times t0 (baseline) and t1 (6- or 12-month follow-up) were modeled as a function of time. A secondary analysis was conducted using single-level regression to examine which baseline characteristics were associated with the outcomes of interest at 12-month follow-up. Cost analyses were also conducted with three of the participating clinics. Most participants identified as Black/African American (89%). Fewer than half of participants reported that they were unemployed or made less than USD5000 annually (43%). Over time, the proportion of participants engaged in care and retained in care significantly increased (70% to 93% and 32% to 64%, p < 0.00). However, the proportion of virally suppressed participants decreased over time (59% to 34%, p < 0.00). Implementation costs across the three sites ranged from USD17,198.05 to USD396,910.00 and were associated with between 0.37 and 1.34 HIV transmissions averted at each site. Study findings provide promising evidence to suggest that conditional financial incentives could help support engagement and retention in HIV care for a high need and at risk for falling out of HIV care population.

Mapping of head and neck cancer patient concerns inventory scores on to Euroqol-Five Dimensions-Five Levels (EQ-5D-5L) health utility scores.

BACKGROUND: The purpose of this paper is to map the number of concerns on the dimensions in Head and Neck Patient Concerns Inventory (PCI) on to the health utility (HU) index scores on Euroqol-Five Dimensions-Five levels {EQ-5D-5L) . METHODS: This is a cross-sectional survey conducted in patients who have completed their treatment. Four candidate models were considered, three based on ordinary least squares regression (OLS) and one two-parts model. RESULTS: A reduced OLS model based on 'Physical and functional', 'Treatment-related', and 'Psychological, emotional and spiritual well-being' domains was found best on the estimation sample. This was validated externally on a separate sample. CONCLUSIONS: This is the first study that mapped a non-QOL tool to generate HU scores on EQ-5D-5L. The proposed mapping algorithm can estimate the cost-utility in economic evaluation studies when HU scores are not directly available. The algorithm will be best suited for studies in low-middle income countries.

In-home medication management by older adults: a modified ethnography study using digital photography walkabouts.

BACKGROUND: Medication mismanagement can lead to non-optimal management of chronic diseases and poor health outcomes. OBJECTIVE: The purpose of this study was to better understand meanings associated with in-home medication management and storage practices of older adults with chronic diseases. METHODS: A modified ethnographic approach using digital photography walkabouts, observation protocols and field notes were used to document in-home medication organisation and storage locations. Thematic analysis was used to generate themes and sub-themes. RESULTS: Data from multiple home visits of 10 participants (mean age = 76 years; 80% females) including 30 photographs, 10 observation protocols and field notes were analysed. The average number of medications used was reported to be 11.1 (range: 5-20). Themes and sub-themes include choice of storage location (sub-themes: impact on medication behaviour, visibility of medications and storage with other items), knowledge regarding appropriate medication storage conditions (sub-themes: impact on safety of patient and impact on stability of medications) and systems to manage in-home medication intake. DISCUSSION: In-home medication management reflects older adults perspectives regarding privacy, medication taking routine, knowledge about safe and effective storage and organisation systems. The lack of knowledge causing inappropriate medication storage not only impacts the stability of medications, but also increases risk of medication errors and safety, ultimately affecting medication intake behaviours.

Assessing the prevalence and correlates of prenatal cannabis consumption in an urban Canadian population: a cross-sectional survey.

BACKGROUND: Recreational cannabis use was legalized in Canada in October 2018. We aimed to determine the prevalence and correlates of cannabis consumption among pregnant individuals in a single Canadian city following national legalization. METHODS: Over the period May to October 2019, we distributed an anonymous cross-sectional survey to pregnant patients attending family practice, midwifery, and low-risk and high-risk obstetrics clinics in Hamilton, Ontario. Eligibility was based on English literacy and current pregnancy. The survey included questions regarding lifetime and in-pregnancy cannabis use, intent for postpartum use and patterns of use. We also collected demographic information. We calculated descriptive statistics and performed logistic regression analyses to explore the relations between cannabis consumption and demographic characteristics. RESULTS: Of 531 pregnant individuals approached, 478 agreed and were able to participate, for a 90% participation rate. Among these 478 respondents, 54 (11%) reported consuming cannabis at some point during the pregnancy and 20 (4%) reported currently consuming cannabis. Among the 460 respondents who intended to breastfeed, 23 (5%) planned to consume cannabis during the postpartum period. Of 20 current users, 13 (65%) reported consuming cannabis at least weekly and 19 (95%) reported nausea, sleep problems or anxiety as reasons for use. Respondents without postsecondary education had 10.0-fold (95% confidence interval [CI] 4.6-23.5) greater odds of prenatal cannabis consumption than university-educated respondents. In addition, respondents who reported that their partners used cannabis had 3.9-fold (95% CI 2.2-7.3) greater odds of prenatal cannabis consumption than those who reported that their partners did not use cannabis. INTERPRETATION: Lower educational attainment and partners' cannabis consumption were associated with greater odds of inpregnancy cannabis use. These results may help to inform early intervention strategies to decrease cannabis consumption during this vulnerable period of fetal and neonatal development.

Medical Complications and Prognostic Factors for Medically Unstable Conditions During Acute Inpatient Cancer Rehabilitation.

PURPOSE: Acute inpatient rehabilitation provides concurrent medical care and intensive rehabilitation. We sought to describe the nature of types of medical complications and to identify the more frequent types of medical complications management in patients with cancer undergoing acute inpatient rehabilitation. METHODS: We reviewed the records of all consecutive patients admitted to acute inpatient rehabilitation from September 1, 2017, through February 28, 2018. Presenting problem noted to be a significant change in medical status using the Centers for Medicare & Medicaid Services' Evaluation and Management Service Guide was defined as a medical complication. We recorded demographic and clinical characteristics. Multivariable logistic regression analysis was performed to assess prognostic factors for returning to acute care. RESULTS: Among 165 evaluable patients, 158 (96%) had at least one medical complication, and 31 (19%) had an unplanned return to acute care. After excluding three patients who had planned return to acute care, there was a cohort of 162 patients and the most common medical complication categories were electrolyte abnormalities 81 (50%), musculoskeletal 70 (43%), genitourinary or renal 61 (38%), hematologic 58 (36%), and cardiovascular problems 46 (28%). Multivariable analysis showed that tachycardia (odds ratio [OR], 7.83; 95% CI, 2.23 to 27.54; P = .001) and weekly or more frequent RBC transfusions (OR, 5.23; 95% CI, 1.39 to 19.64; P = .014) were independently associated with unplanned return to acute care. CONCLUSION: A high frequency and wide range of medical complications and interventions occur in patients with cancer undergoing acute inpatient rehabilitation. Close monitoring and expertise are needed for this patient population.

Estimation of Health Utility and Quality Adjusted Life Years in Bilateral Hand Transplantation: A Time Trade-off Study.

BACKGROUND: Hand transplantation and advances in the field of prostheses have opened new frontiers in the restoration of hand function among bilateral hand amputees (BHA). There is only scarce literature evaluating the health utility (HU) and quality adjusted life years (QALY) gained by bilateral hand composite tissue allotransplantation (CTA) or prosthesis over amputation. The study was focused on BHA restored with prosthesis or CTA. METHODS: The HU of three different health states (HS) namely, BHA, using prosthesis or with CTA and net QALYs gained by hand transplantation or prosthesis over amputation were computed by time trade-off (TTO) method among 236 study participants. RESULTS: Among 236 study participants, medical professional (120), general public (89), BHA (23), and bilateral hand transplant recipients (4) were included. The mean HU by TTO method among the study participants (n = 232) as BHA, using prosthesis or CTA was 0.34 (±0.24), 0.50 (±0.26) and 0.69 (±0.26) respectively. Bilateral hand CTA imparted an expected gain of 12.57 (±11.43) mean QALYs over amputation among the study participants. The subgroup analysis displayed higher mean HU in hand CTA recipient HS along with maximum QALY gained by CTA over amputation. CONCLUSIONS: Bilateral hand CTA HS stands above the other 2 HSs, namely BHA and prosthesis, in terms of the health utility. As demonstrated by QALY gain of 12.57, participants' valuation of health utility is notably higher for CTA with acceptance of lifelong immunosuppressant rather than for a state of uncompromised physical health with a bilateral hand amputation.

"The strategies are the same, the problems may be different": a qualitative study exploring the experiences of healthcare and service providers with medication therapy management for individuals with spinal cord injury/dysfunction.

BACKGROUND: Persons with spinal cord injury/dysfunction (SCI/D) often take multiple medications to treat their secondary complications and chronic conditions (multimorbidity). Multiple healthcare and service providers are often involved in care, which can result in increased risk of fragmentation of care. Optimal medication therapy management (MTM) is essential to ensure therapeutic benefit from medication regimens. However, little is known about the experiences of providers in supporting persons with SCI/D with MTM. METHODS: Telephone interviews were conducted to explore healthcare and service providers' experiences with MTM for persons with SCI/D. Participants were recruited through clinical organizations and researchers' personal contacts. Participants were purposefully selected for diversity in profession and were required to be English speaking and to have provided care to at least one person with SCI/D. The qualitative interviews followed a semi-structured interview guide. Data display matrices were used in a constant comparative process for descriptive and interpretive analysis. RESULTS: Thirty-two interviews were conducted from April to December 2018. Each profession had distinct views on their roles in facilitating MTM for persons with SCI/D, which aligned with their respective scopes of practice. Shared provider tasks included tailoring medications, providing education, and exploring medication alternatives. Most participants felt that the care they provided for persons with SCI/D was similar to the care that they provided to other patients, with some differences relating to the physical limitations and medical complexity associated with SCI/D. Five factors were identified that impacted participants' abilities to provide MTM for persons with SCI/D: patient self-management skills, provider knowledge and confidence, provider-patient relationships, interprofessional collaboration, and provider funding models including the use of technology-supported consultations. CONCLUSION: While participants described commonalities in the barriers and enablers associated with providing MTM to persons with SCI/D and other populations, there were unique considerations identified. These SCI/D-specific considerations resulted in recommendations for improvements in MTM for this population. Future research should include perspectives from persons with SCI/D.

A Deep Learning-Based Decision Support Tool for Precision Risk Assessment of Breast Cancer.

PURPOSE: The Breast Imaging Reporting and Data System (BI-RADS) lexicon was developed to standardize mammographic reporting to assess cancer risk and facilitate the decision to biopsy. Because of substantial interobserver variability in the application of the BI-RADS lexicon, the decision to biopsy varies greatly and results in overdiagnosis and excessive biopsies. The false-positive rate from mammograms is estimated to be 7% to approximately 10% overall, but within the BI-RADS 4 category, it is greater than 70%. Therefore, we developed the Breast Cancer Risk Calculator (BRISK) to target a well-characterized and specific patient subgroup (BI-RADS 4) rather than a broad heterogeneous group in assessing breast cancer risk. METHODS: BRISK provides a novel precise risk assessment model to reduce overdiagnosis and unnecessary biopsies. It was developed by applying natural language processing and deep learning methods on 5,147 patient records archived in the Houston Methodist systemwide data warehouse from 2006 to May 2015, including imaging and pathology reports, mammographic images, and patient demographics. Key characteristics for BI-RADS 4 patients were collected and computed to output an index measure for biopsy recommendation that is clinically relevant and informative and improves upon the traditional BI-RADS 4 scores. RESULTS: For the validation set, we assessed data from 1,247 BI-RADS 4 patients, including mammographic images and medical reports. The BRISK model sensitivity to predict malignancy was 100%, whereas the specificity was 74%. The total accuracy of our implemented model in BRISK was 81%. Overall area under the curve was 0.93. CONCLUSION: BRISK for abnormal mammogram uses integrative artificial intelligence technology and has demonstrated high sensitivity in the prediction of malignancy. Prospective evaluation is under way and can lead to improvement in patient-physician engagement in making informed decisions with regard to biopsy.

Optimizing medications in older adults with cognitive impairment: Considerations for primary care clinicians.

OBJECTIVE: To provide primary care physicians with an approach to medication optimization in older adults with cognitive impairment. SOURCES OF INFORMATION: The approach is based on an accredited memory clinic training program developed by the Centre for Family Medicine Primary Care Collaborative Memory Clinic. MAIN MESSAGE: Dementia increases the risk of medication-related adverse events and adds to the complexity and challenge of providing optimal care for these older adults. Considerations include medication adherence, appropriate therapeutic targets for comorbid conditions, minimized use of medications with potentially adverse cognitive effects, and rational use and monitoring of cognition-enhancing drugs. Medication management plans must be individualized and based on goals of care. CONCLUSION: Primary care physicians must consider many factors in optimizing medications for those with cognitive impairment.

Study protocol for a randomized, controlled, superiority trial comparing the clinical and cost- effectiveness of integrated online mental health assessment-referral-care in pregnancy to usual prenatal care on prenatal and postnatal mental health and infant health and development: the Integrated Maternal Psychosocial Assessment to Care Trial (IMPACT).

BACKGROUND: Stress, depression, and anxiety affect 15 to 25% of pregnant women. However, fewer than 20% of prenatal care providers assess and treat mental health problems and fewer than 20% of pregnant women seek mental healthcare. For those who seek treatment, the lack of health system integration and existing barriers frequently prevent treatment access. Without treatment, poor prenatal mental health can persist for years and impact future maternal, child, and family well-being. METHODS/DESIGN: The purpose of this randomized controlled trial is to evaluate the effectiveness of an integrated process of online psychosocial assessment, referral, and cognitive behavior therapy (CBT) for pregnant women compared to usual prenatal care (no formal screening or specialized care). The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6 to 8 weeks postrandomization. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. Pregnant women are eligible if they: 1) are <28 weeks gestation; 2) speak/read English; 3) are willing to complete email questionnaires; 4) have no, low, or moderate psychosocial risk on screening at recruitment; and 5) are eligible for CBT. A sample of 816 women will be recruited from large, urban primary care clinics and allocation is by computer-generated randomization. Women in the intervention group will complete an online psychosocial assessment, and those with mild or moderate depression, anxiety, or stress symptoms then complete six interactive cognitive behavior therapy modules. All women will complete email questionnaires at 6 to 8 weeks postrandomization and at 3, 6, and 12 months postpartum. Clinic-based providers and researchers conducting chart abstraction and analysis are blinded. Qualitative interviews with 8 to 10 healthcare providers and 15 to 30 intervention group women will provide data on feasibility and acceptability of the intervention. Results of this trial will determine the feasibility and effectiveness of an integrated approach to prenatal mental healthcare and the use of highly accessible computer-based psychosocial assessment and CBT on maternal, infant, and family-based outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01901796.

Breast cancer in Latinas: gene expression, differential response to treatments, and differential toxicities in Latinas compared with other population groups.

Disparities in clinical outcomes of breast cancer have been described among different racial and ethnic groups in the U.S. Convincing data exist showing that Latina women have a lower incidence of breast cancer but a higher breast cancer-related mortality rate compared with white women. Noticeable differences in breast cancer incidence are present even within different Latina subsets with a higher incidence in second- and third-generation women compared with foreign born. An increasing amount of data exists pointing to significant differences in the genetics and biology of breast cancer in Latinas as a significant contributor to the higher mortality, including a higher incidence of triple-negative breast cancers (which do not overexpress HER-2 protein and are negative for estrogen receptors and progesterone receptors). Other social and environmental factors are likely to play a significant role as well, including a lower rate of screening mammography, variable access to medical care, among others. Recent data are inconclusive regarding differences among racial/ethnic groups in the response to chemotherapy. Data on racial/ethnic variations in the pharmacogenomics of chemotherapy, endocrine treatments, and toxicity are more limited, with some data suggesting differences in frequencies of polymorphisms of genes involved in the metabolism of some of these agents. Further studies are needed on this subject.

Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.

BACKGROUND: Over the past five years, in most hospitals in England and Wales, incident reporting has become well established but it remains unclear how well reports match clinical adverse events. International epidemiological studies of adverse events are based on retrospective, multi-hospital case record review. In this paper the authors describe the use of incident reporting, pharmacist surveillance and local real-time record review for the recognition of clinical risks associated with hospital inpatient care. METHODOLOGY: Data on adverse events were collected prospectively on 288 patients discharged from adult acute medical and surgical units in an NHS district general hospital using incident reports, active surveillance of prescription charts by pharmacists and record review at time of discharge. RESULTS: Record review detected 26 adverse events (AEs) and 40 potential adverse events (PAEs) occurring during the index admission. In contrast, in the same patient group, incident reporting detected 11 PAEs and no AEs. Pharmacy surveillance found 10 medication errors all of which were PAEs. There was little overlap in the nature of events detected by the three methods. CONCLUSION: The findings suggest that incident reporting does not provide an adequate assessment of clinical adverse events and that this method needs to be supplemented with other more systematic forms of data collection. Structured record review, carried out by clinicians, provides an important component of an integrated approach to identifying risk in the context of developing a safety and quality improvement programme.