Comparing COVID-19 Response Behaviors between a Cancer Patient Sample and a Population-Based Cancer-Free Sample in a Rural Midwestern State.

INTRODUCTION: The COVID-19 pandemic caused an increase in fear, anxiety, and depressive symptoms globally. For populations at increased risk for adverse outcomes due to illness, such as cancer patients, these worries may have been exacerbated. Understanding how the pandemic impacted cancer patients will inform better preparation for future events that cause disturbances to cancer care delivery. METHODS: This study analyzed data from two surveys to determine whether cancer patients' responses differed from a cancer-free population-based sample in terms of concerns, preventive behaviors, and thoughts on their healthcare provider's communication regarding COVID-19 in a US Midwestern state. In August 2020, a survey was sent to 10,009 Iowans aged 18 and older, randomly selected from the 2018 Iowa voter registration file. In September 2020, a survey was emailed to 2,954 cancer patients aged 18 and older who opted into the University of Iowa Holden Comprehensive Cancer Center's Patients Enhancing Research Collaborations at Holden program. Previously validated and pretested Likert-type and multiple-choice items assessed concern regarding COVID-19, social distancing perception and behaviors, and demographic characteristics of respondents. We used χ2 tests and logistic regression to examine differences between the cancer patient and general population survey responses. RESULTS: We included 3,622 responses from the general population survey and 780 responses from the cancer patient survey in this analysis. Cancer patient survey respondents were more frequently older, lived in urban areas, had Medicare insurance coverage, had a college degree or higher, and were married. Cancer patients were more likely to report engaging in social distancing behaviors and greater concern regarding the pandemic. CONCLUSION: This study suggests differences in the impact of the COVID-19 pandemic on cancer patients compared to cancer-free members of the general population. These results indicate the need for consideration of cancer patients' physical and mental health during large-scale disruptions to cancer care.

Referrals and Decision-Making Considerations Involved in Selecting a Surgeon for Rectal Cancer Treatment in the Midwestern United States.

BACKGROUND: Despite evidence of superior outcomes for rectal cancer at high-volume, multidisciplinary cancer centers, many patients undergo surgery in low-volume hospitals. OBJECTIVE: This study aimed to examine considerations of former patients with rectal cancer when selecting their surgeon and to evaluate which considerations were associated with surgery at high-volume hospitals. DESIGN: In this retrospective cohort study, patients were surveyed about what they considered when selecting a cancer surgeon. SETTINGS: Study data were obtained via survey and the statewide Iowa Cancer Registry. PATIENTS: All eligible individuals diagnosed with invasive stages II/III rectal cancer from 2013 to 2017 identified through the registry were invited to participate. MAIN OUTCOME MEASURES: The primary outcomes were the characteristics of the hospital where they received surgery (ie, National Cancer Institute designation, Commission on Cancer accreditation, and rectal cancer surgery volume). RESULTS: Among respondents, 318 of 417 (76%) completed surveys. Sixty-nine percent of patients selected their surgeon based on their physician's referral/recommendation, 20% based on surgeon/hospital reputation, and 11% based on personal connections to the surgeon. Participants who chose their surgeon based on reputation had significantly higher odds of surgery at National Cancer Institute-designated (OR 7.5; 95% CI, 3.8-15.0) or high-volume (OR 2.6; 95% CI, 1.2-5.7) hospitals than those who relied on referral. LIMITATIONS: This study took place in a Midwestern state with a predominantly white population, which limited our ability to evaluate racial/ethnic associations. CONCLUSION: Most patients with rectal cancer relied on referrals in selecting their surgeon, and those who did were less likely to receive surgery at a National Cancer Institute-designated or high-volume hospitals compared to those who considered reputation. Future research is needed to determine the impact of these decision factors on clinical outcomes, patient satisfaction, and quality of life. In addition, patients should be aware that relying on physician referral may not result in treatment from the most experienced or comprehensive care setting in their area. See Video Abstract at http://links.lww.com/DCR/B897.REMISIONES Y CONSIDERACIONES PARA LA TOMA DE DECISIONES RELACIONADAS CON LA SELECCIÓN DE UN CIRUJANO PARA EL TRATAMIENTO DEL CÁNCER DE RECTO EN EL MEDIO OESTE DE LOS ESTADOS UNIDOSANTECEDENTES:A pesar de la evidencia de resultados superiores para el tratamiento del cáncer de recto en centros oncológicos de gran volumen y multidisciplinarios, muchos pacientes se someten a cirugía en hospitales de bajo volumen.OBJETIVOS:Examinar las consideraciones de los antiguos pacientes con cáncer de recto al momento de seleccionar a su cirujano y evaluar qué consideraciones se asociaron con la cirugía en hospitales de gran volumen.DISEÑO:Encuestamos a los pacientes sobre qué aspectos consideraron al elegir un cirujano oncológico para completar este estudio de cohorte retrospectivo.AJUSTE:Los datos del estudio se obtuvieron mediante una encuesta y el Registro de Cáncer del estado de Iowa.PACIENTES:Se invitó a participar a todas las personas elegibles diagnosticadas con cáncer de recto invasivo en estadios II/III entre 2013 y 2017 identificadas a través del registro.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados principales fueron las características del hospital donde fue realizada la cirugía (es decir, designación del Instituto Nacional del Cáncer, acreditación de la Comisión de Cáncer y volumen de cirugía del cáncer de recto).RESULTADOS:Hubo 318 de 417 (76%) encuestas completadas. El sesenta y nueve por ciento seleccionó a su cirujano en función de la referencia / recomendación de su médico, el 20% por la reputación del cirujano/hospital, y el 11% por sus conexiones personales con el cirujano. Los participantes que eligieron a su cirujano en función a la reputación tuvieron probabilidades significativamente más altas de cirugía en el Instituto Nacional del Cáncer designado (OR = 7,5, IC del 95%: 3,8-15,0) o en hospitales de alto volumen (OR = 2,6, IC del 95%: 1,2-5,7) que aquellos que dependían de la derivación.LIMITACIONES:Este estudio se llevó a cabo en un estado del medio oeste con una población predominantemente blanca, lo que limitó nuestra capacidad para evaluar las asociaciones raciales/étnicas.CONCLUSIONES:La mayoría de los pacientes con cáncer de recto dependían de las derivaciones para seleccionar a su cirujano, y los que lo hacían tenían menos probabilidades de recibir cirugía en un hospital designado por el Instituto Nacional del Cáncer o en hospitales de gran volumen en comparación con los que consideraban la reputación. Se necesitan investigaciones a futuro para determinar el impacto de estos factores de decisión en los resultados clínicos, la satisfacción del paciente y la calidad de vida. Además, los pacientes deben ser conscientes de que depender de la remisión de un médico puede no resultar en el tratamiento más experimentado o integral en su área. Consulte Video Resumen en http://links.lww.com/DCR/B897. (Traducción-Dr Osvaldo Gauto).

Variation in coordination of care reported by breast cancer patients according to health literacy.

BACKGROUND: Health literacy is the ability to perform basic reading and numerical tasks to function in the healthcare environment. The purpose of this study is to describe how health literacy is related to perceived coordination of care reported by breast cancer patients. METHODS: Data were retrieved from the Patient-Centered Outcomes Research Institute-sponsored "Share Thoughts on Breast Cancer" Study including demographic factors, perceived care coordination and responsiveness of care, and self-reported health literacy obtained from a mailed survey completed by 62% of eligible breast cancer survivors (N = 1221). Multivariable analysis of variance was used to characterize the association between presence of a single healthcare professional that coordinated care ("care coordinator") and perceived care coordination, stratified by health literacy level. RESULTS: Health literacy was classified as low in 24% of patients, medium in 34%, and high in 42%. Women with high health literacy scores were more likely to report non-Hispanic white race/ethnicity, private insurance, higher education and income, and fewer comorbidities (all p < 0.001). The presence of a care coordinator was associated with 17.1% higher perceived care coordination scores among women with low health literacy when compared to those without a care coordinator, whereas a coordinator modestly improved perceived care coordination among breast cancer survivors with medium (6.9%) and high (6.2%) health literacy. CONCLUSION: The use of a single designated care coordinator may have a strong influence on care coordination in patients with lower levels of health literacy.

Cluster-Randomized Trial to Evaluate a Centralized Clinical Pharmacy Service in Private Family Medicine Offices.

BACKGROUND: The use of clinical pharmacists in primary care has improved the control of several chronic cardiovascular conditions. However, many private physician practices lack the resources to implement team-based care with pharmacists. The purpose of this study was to evaluate whether a centralized, remote, clinical pharmacy service could improve guideline adherence and secondary measures of cardiovascular risk in primary care offices in rural and small communities. METHODS AND RESULTS: This study was a prospective trial in 12 family medicine offices cluster randomized to either the intervention or usual care. The intervention was delivered for 12 months, and subjects had research visits at baseline and 12 months. The primary outcome was adherence to guidelines, and secondary outcomes included changes in key cardiovascular risk factors and preventative health measures. We enrolled 302 subjects. There was no improvement in the Guideline Advantage score from baseline to 12 months in the control group (64.7% versus 63.1%, respectively; P=0.21). There was a statistically significant improvement in the intervention group from 63.3% at baseline to 67.8% at 12 months (P=0.02). The estimated benefit of the intervention was 5.0%±2.4% (95% confidence interval=-0.5% to 10.4%; P=0.07). Several criteria were significantly better for intervention subjects, including appropriate statin therapy (P<0.001), body mass index, screening (P<0.001), and alcohol screening (P<0.001). Only 13.7% of subjects with diabetes mellitus had hemoglobin A1c at goal at baseline, and this increased to 30.8% and 21.0% in the intervention and control group, respectively, at 12 months (P=0.10). CONCLUSIONS: The centralized, remote pharmacist intervention was successfully implemented. The improvements in outcomes were modest, in part because of higher than expected baseline guideline adherence. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT 01983813.

Efficacy and safety of nighttime dosing of antihypertensives: review of the literature and design of a pragmatic clinical trial.

Blood pressure exhibits circadian variability, and nighttime blood pressure is one of the best predictors of cardiovascular (CV) events. Adults with hypertension who lack a nighttime dipping pattern are at particularly high risk. Several studies have found that bedtime dosing of antihypertensive agents reduces sleep blood pressure and improves the dipping pattern in nondippers. One small study and 2 substudies of diabetes and chronic kidney disease suggest that bedtime dosing of ≥ 1 antihypertensives significantly reduced CV events. A Cochrane review of 5 studies found no difference in adverse events between morning and evening dosing. However, several evaluations in ophthalmology have found that nocturnal arterial hypotension precipitated ocular vascular disorders such as ischemic optic neuropathy. Some authors have suggested that additional studies of nighttime dosing of antihypertensive agents that evaluate CV events need to be conducted. The authors describe a randomized controlled pragmatic trial that is being planned at the University of Iowa and Duke University. Patients with hypertension and other comorbid conditions will be randomized to either continue morning dosing of all antihypertensive agents or to switch their nondiuretic medications to bedtime dosing. Patients will be followed for 36 to 42 months. This study will determine whether nighttime dosing reduces CV risk when compared with traditional morning dosing of antihypertensive agents.

Adjuvant chemotherapy use and adverse events among older patients with stage III colon cancer.

CONTEXT: Randomized trials suggest adjuvant chemotherapy is effective for older patients with stage III colon cancer. However, older patients are less likely to receive this therapy than younger patients, perhaps because of concern about adverse effects. OBJECTIVE: To evaluate adjuvant chemotherapy use and outcomes for older patients with stage III colon cancer from well-defined population-based settings and health care systems. DESIGN: Observational study of adjuvant chemotherapy use and outcomes by age using Poisson regression to estimate the number of adverse events adjusted for demographic and clinical factors, including comorbid illness and specific elements of chemotherapy regimens documented with clinically detailed medical record reviews and patient and surrogate surveys. SETTING: Five geographically defined regions (Alabama, Iowa, Los Angeles County, northern California, and North Carolina), 5 integrated health care delivery systems, and 15 Veterans Affairs hospitals. PATIENTS: Six hundred seventy-five patients diagnosed with stage III colon cancer from 2003 through 2005 who underwent surgical resection and were followed up for as long as 15 months postdiagnosis. MAIN OUTCOME MEASURES: Chemotherapy regimen, dose, duration, and annualized mean number of adverse events stratified by age. RESULTS: Of 202 patients aged 75 years and older, 101 (50%) received adjuvant chemotherapy compared with 87% of 473 younger patients (difference, 37%; 95% confidence interval [CI], 30%-45%). Among patients who received adjuvant chemotherapy, 14 patients (14%) aged 75 years and older and 178 younger patients (44%) received a regimen containing oxaliplatin (difference, 30%; 95% CI, 21%-38%). Older patients were less likely to continue treatment, such that by 150 days, 99 patients (40%) aged 65 years and older and 68 younger patients (25%) had discontinued chemotherapy (difference, 15%; 95% CI, 7%-23%). Overall, 162 patients (24%) had at least 1 adverse clinical event, with more events among patients treated with vs without adjuvant chemotherapy (mean, 0.39 vs 0.16; difference, 0.23; 95% CI, 0.11-0.36; P < .001). Among patients receiving adjuvant chemotherapy, adjusted rates of late clinical adverse events were lower for patients 75 years and older (mean, 0.28) vs for younger patients (0.35 for ages 18-54 years, 0.52 for ages 55-64 years, and 0.45 for ages 65-74 years; P = .008 for any age effect). CONCLUSION: Among patients with stage III colon cancer who underwent surgical resection and received adjuvant chemotherapy, older patients in the community received less-toxic and shorter chemotherapy regimens, and those treated had fewer adverse events than younger patients.

Cost-effectiveness of tamsulosin, doxazosin, and terazosin in the treatment of benign prostatic hyperplasia.

OBJECTIVE: To evaluate the cost-effectiveness of tamsulosin, doxazosin, or terazosin as initial treatments for moderate benign prostatic hyperplasia (BPH) over a 3-year time horizon from a health-system-payer perspective. METHODS: A decision-analytic model is used to project the course of treatment at 6-month intervals over 3 years following initiation of therapy with tamsulosin, doxazosin, or terazosin. Treatment failure is defined as failure to attain and maintain a 25% improvement in the American Urological Association (AUA) symptom score from baseline. In the model, finasteride is added for patients who fail on their initial therapy and, in the event of finasteride treatment failure, patients progress to transurethral resection of the prostate (TURP) and, if needed, a second TURP. The ranges of values for treatment failure rates and clinical event cost parameters used in the decision model are derived from the literature. Only direct medical costs related to BPH and its treatment are included. Since 2 comparators are available generically (doxazosin and terazosin) drug acquisition costs are defined by the list prices at Drugstore.com. All costs are discounted by 3% per year. Effectiveness is measured as successful medical treatment without surgery over 3 years. RESULTS: For base-case model parameters, discounted BPH-related total direct medical costs over 3 years are 4084 dollars, 4323 dollars, and 4695 dollars for generic terazosin, generic doxazosin, and tamsulosin, respectively. The model estimates a medical treatment success rate (no TURP) at 3 years of 72.3% for tamsulosin, compared with 68.2% for both terazosin and doxazosin. The incremental cost for tamsulosin versus terazosin is 610 dollars over 3 years, which yields an incremental cost-effectiveness ratio of 14,609 dollars per success. Generic doxazosin is dominated (higher cost but equal effectiveness compared with terazosin). Higher rates of twice-daily (or 2 units per day) dosing are associated with higher incremental cost-effectiveness ratios. The decision-model results also are sensitive to the estimated costs of TURP and hypotensive adverse events. CONCLUSION: As an initial medical therapy for moderate BPH, tamsulosin is more effective than generic terazosin or doxazosin, with an incremental cost of about 203 dollars per year (or about 17 dollars per month) over 3 years.