Factors associated with prior completion of colorectal cancer and hepatitis C virus screenings among community health center patients: a cross-sectional study to inform a multi-behavioral educational intervention.

BACKGROUND: Colorectal cancer (CRC) and liver cancer are two of the leading causes of cancer death in the United States and persistent disparities in CRC and liver cancer incidence and outcomes exist. Chronic hepatitis C virus (HCV) infection is one of the main contributors to liver cancer. Effective screening for both CRC and HCV exist and are recommended for individuals based upon age, regardless of gender or sex assigned at birth. Recommendations for both screening behaviors have been recently updated. However, screening rates for both CRC and HCV are suboptimal. Targeting adoption of multiple screening behaviors has the potential to reduce cancer mortality and disparities. OBJECTIVE: To examine psychosocial factors associated with completion of CRC and HCV screenings in order to inform a multi-behavioral educational intervention that pairs CRC and HCV screening information. METHODS: A cross-sectional survey was conducted with participants (N = 50) recruited at two community health centers in Florida (United States). Kruskal-Wallis and Fisher's exact tests were used to examine associations between completion of both CRC and HCV screening, CRC and HCV knowledge, Preventive Health Model constructs (e.g., salience and coherence, response efficacy, social influence), and sociodemographic variables. RESULTS: Most participants were White (84%), female (56%), insured (80%), and reported a household income of $25,000 or less (53%). 30% reported ever previously completing both CRC and HCV screenings. Prior completion of both screening behaviors was associated with higher educational attainment (p = .014), having health insurance (p = .022), being U.S.-born (p = .043), and higher salience and coherence scores for CRC (p = .040) and HCV (p = .004). CONCLUSIONS: Findings demonstrate limited uptake of both CRC and HCV screenings among adults born between 1945 and 1965. Uptake was associated with multiple sociodemographic factors and health beliefs related to salience and coherence. Salience and coherence are modifiable factors associated with completion of both screening tests, suggesting the importance of incorporating these health beliefs in a multi-behavioral cancer education intervention. Additionally, health providers could simultaneously recommend and order CRC and HCV screening to improve uptake among this age cohort.

Longitudinal adherence to annual colorectal cancer screening among Black persons living in the United States enrolled in a community-based randomized trial.

BACKGROUND: This study examined repeat colorectal cancer screening rates at 12 and 24 months as part of a randomized intervention trial among Black persons living in the United States and factors associated with screening adherence. METHODS: Participants completed a survey assessing demographics and Preventive Health Model (PHM) factors (e.g., self efficacy, susceptibility) and received either a culturally targeted photonovella plus free fecal immunochemical test (FIT) kits (intervention group) or a standard educational brochure plus free FIT kits (comparison group). FIT return was assessed at 6, 12, and 24 months. Descriptive statistics summarized patterns of repeat screening. Logistic regression models assessed FIT uptake overtime, and demographic and PHM factors associated with screening adherence. RESULTS: Participants (N = 330) were U.S.-born (93%), non-Hispanic (97%), and male (52%). Initial FIT uptake within 6 months of enrollment was 86.6%, and subsequently dropped to 54.5% at 12 months and 36.6% at 24 months. Higher FIT return rates were observed for the brochure group at 24 months (51.5% vs 33.3% photonovella, p = .023). Multiple patterns of FIT kit return were observed: 37% completed FIT at all three time points (full adherence), 22% completed two of three (partial adherence), 29% completed one of three (partial adherence), and 12% did not return any FIT kits (complete nonadherence). Predictors of full adherence were higher levels of education and self-efficacy. CONCLUSIONS: Full adherence to repeat screening was suboptimal. Most participants had partial adherence (one or two of three) to annual FIT screening. Future studies should focus on strategies to support repeat FIT screening.

Skin cancer prevention behaviors, beliefs, distress, and worry among hispanics in Florida and Puerto Rico.

BACKGROUND: Incidence of skin cancer has been increasing among U.S. Hispanics, who often are diagnosed with larger lesions and at later stage disease. Behaviors to decrease exposure to ultraviolet radiation can reduce risk of skin cancer. We describe skin cancer prevention behaviors and psychosocial variables among Hispanic participants recruited into a skin cancer prevention trial. METHODS: Self-reported Hispanic participants from eight primary care clinics in Tampa, Florida and Ponce, Puerto Rico were recruited into a randomized controlled prevention trial. Information on demographics, sun-related behaviors, and psychosocial variables were collected before intervention materials were provided. Multivariable regression models were used to compare baseline sun-related behaviors and psychosocial variables across groups defined by geographic location and language preference. RESULTS: Participants reported low levels of intentional outdoor tanning, weekday and weekend sun exposure, and very low levels of indoor tanning. However, only a minority of participants practiced sun-protective behaviors often or always, and about 30% experienced a sunburn in the past year. Participants had low levels of recent worry and concern about skin cancer, modest levels of perceived risk and severity, and high levels of response efficacy and self-efficacy. When comparing across groups defined by geographic location and language preference, English-preferring Tampa residents (hereafter referred to as Tampeños) had the highest proportion who were sunburned (35.9%) and tended toward more risky behavior but also had higher protective behavior than did Spanish-preferring Tampeños or Puerto Ricans. Spanish-preferring Puerto Ricans had higher recent concern about skin cancer, comparative chance of getting skin cancer, and response efficacy compared to either English- or Spanish-preferring Tampeños. Spanish-preferring Tampeños had the highest levels of familism and recent distress about skin cancer. CONCLUSIONS: Our results mirror previous observations of low levels of sun-protective behavior among U.S. Hispanics compelling the need for culturally appropriate and translated awareness campaigns targeted to this population. Because Hispanics in Tampa and Puerto Rico reported modest levels of perceived risk and severity, and high levels of response efficacy and self-efficacy, interventions aiming to improve skin cancer prevention activities that are anchored in Protection Motivation Theory may be particularly effective in this population subgroup.

Sharing and seeking information about skin cancer risk and prevention among Hispanic people from Florida and Puerto Rico.

Objective: To explore factors associated with communication and information-seeking after receipt of skin cancer prevention information among Hispanic individuals. Methods: Multivariable logistic regression was used to analyze existing data on demographics, personal experience, salience, and beliefs variables collected from Hispanic individuals to determine independent associations with sharing and seeking information about skin cancer prevention. Results: Of 578 participants, 53% reported any communication about skin cancer prevention behaviors or skin cancer genetic risk; and 31% and 21% sought additional information about preventive behaviors or genetic risk, respectively. Female sex, greater perceived severity, higher comparative chance of getting skin cancer, and lower health literacy were associated with greater communication, while having no idea of one's own skin cancer risk was related to less communication. Greater health numeracy and higher cancer worry were associated with information-seeking about prevention behaviors and genetic risk. Conclusion: Up to half of participants reported communication or information-seeking, although factors associated with specific activities differed. Future studies should evaluate how to promote communication behaviors in the Hispanic community and how sharing and seeking information influence an individual's network prevention practices. Innovation: Several factors related to communication behaviors among Hispanic people after obtaining skin cancer prevention information were identified.Trial registration: This trial was registered on clinicaltrials.gov (NCT03509467).

Predictors of correct recall of genetic risk information among Hispanic individuals in Florida and Puerto Rico.

OBJECTIVE: To identify predictors of genetic risk recall and examine whether recall influences adoption of skin cancer preventive behaviors among Hispanic individuals. METHODS: Hispanic participants randomized to intervention arms (n = 463) of a precision prevention trial were provided MC1R risk information (average, higher) and asked to recall their risk after 3 and 9 months. Predictors of recall (correct versus did not recall/misremembered) were determined by backwards stepwise logistic regression. Intervention effects on preventive behaviors were estimated within strata of 3-month recall. RESULTS: Age inversely predicted correct recall in both risk groups (average: OR3-months(3)= 0.97, 95%CI:0.94-1.01, OR9-months(9)= 0.96, 95%CI:0.93-0.99; higher: OR3 = 0.98, 95%CI:0.95-1.01, OR9 = 0.98, 95%CI:0.95-1.00). Education positively predicted recall among participants at average risk (OR3 =1.64, 95%CI:1.06-2.63, OR9 =1.73, 95%CI:1.12-2.81). Darker untanned skin color inversely predicted recall among participants at higher risk (OR3 =0.68, 95%CI:0.45-0.99, OR9 =0.74, 95%CI:0.50-1.09). Intervention effects for routine sunscreen use and undergoing a clinical skin exam were stronger among participants at higher risk who correctly recalled at 3 months than those who did not recall/misremembered. CONCLUSIONS: Younger age, higher education, and lighter untanned skin color predicted correct recall. Better recall may improve skin cancer prevention outcomes. PRACTICE IMPLICATIONS: Additional strategies are needed to boost recall among Hispanic individuals who are older, less educated, and darker-skinned.

Qualitative assessment of uptake retention and evaluation of prevention materials for skin cancer among Hispanics.

OBJECTIVE: Examine retention and evaluation of incorporating melanocortin-1 receptor genetic risk information materials in a skin cancer prevention intervention conducted in Hispanics living near Tampa, Florida and Ponce, Puerto Rico. METHODS: Two researchers applied thematic content analysis to identify major themes of open-ended responses (n = 1689) from 489 participants. RESULTS: Five major thematic categories emerged: 1) intervention comments; 2) tips and tricks; 3) cancer prevention; 4) general information; and 5) risk factors and genetics. Responses captured under intervention comments (e.g., information was clear, easy to understand) and tips and tricks for sun protection (e.g., using sunscreen, wearing protective clothing) were most frequent. Participants noted the importance of conducting skin exams professionally or at home. English-preferring Tampa residents stated their individual risk factors, especially race and/or ethnicity, more frequently than Ponce residents and Spanish-preferring Tampa residents. Ponce residents were more likely to comment on wanting to share intervention materials with family and friends. CONCLUSION: Findings suggest Hispanic participants implemented sun safety activities.

Engaging Physicians and Systems to Improve Hepatitis C Virus Testing in Baby Boomers.

Approximately three million people in the United States have been exposed to the hepatitis C virus (HCV), with two-thirds of these having chronic HCV infection. Baby boomers (those born 1945-1965) have nearly five times the prevalence of HCV infection compared with other age groups. Despite clinical practice guidelines that recommend HCV testing in baby boomers, the testing rates remain low. We developed and tested a multilevel intervention to increase orders for HCV testing that included integrated clinical decision support within the electronic health record (EHR) and a physician education session to improve HCV physician knowledge in one Florida academic health system. In the year prior to the intervention, test order rates for encounters with baby boomers was 11.9%. During the intervention period (August 2019-July 2020) for providers that viewed a best practice alert (BPA), the ordering increased to 59.2% in Family Medicine and 64.6% in Internal Medicine. The brief physician education intervention improved total HCV knowledge and increased self-efficacy in knowledge of HCV risk factors. These findings suggest that interventions at the system and physician levels hold promise for increasing HCV testing rates. Future studies are needed to evaluate this intervention in additional clinical settings and to test the benefit of adding additional intervention components that are directed at patients.

Predictors of genetic risk recall among the participants of a randomized controlled precision prevention trial against melanoma.

PURPOSE: Inherited variation in MC1R imparts low to moderate risk of melanoma. Research on genetic risk recall, factors predicting recall, and whether recall influences adoption of preventive behaviors is limited. METHODS: Participants (n = 447) enrolled in a melanoma precision prevention trial were provided with MC1R risk information (average or higher) and after 6 and 12 months, were asked to recall their genetic risk. Predictors of recall were identified using backward stepwise selection. Intervention effects were reassessed after stratifying by recall. RESULTS: Participants at higher risk were 2 to 3 times more likely to misremember or not recall than participants with average risk. Misremembering was almost exclusively observed among participants at higher risk. Among the participants with average risk, lower health numeracy and not completing the telephone follow-up were associated with not recalling or misremembering. Among the participants at higher risk, lower education was associated with not recalling and lower perceived comparative chance of developing melanoma was associated with misremembering. In general, participants at higher risk who correctly recalled had modestly stronger intervention effects on sun protection behaviors than those who misremembered or did not recall. CONCLUSION: Future studies should examine different strategies to increase genetic risk recall, which may result in improved behavioral outcomes, especially among participants with lower education and health numeracy.

Assessment of skin cancer precision prevention materials among Hispanics in Florida and Puerto Rico.

OBJECTIVE: To assess Hispanic participants' ratings of intervention materials and examine differences by language preference. METHODS: Participants on a skin cancer prevention trial were randomized to receive generic (n = 457) or precision prevention materials conveying average (n = 195) or higher genetic risk (n = 268) based on MC1R genotype. Three months after receiving either English or Spanish language prevention materials, participants reported amount read, believability and clarity of materials, and intention to change preventive behavior. RESULTS: Participants reported high levels on all four outcomes, but the precision prevention groups noted lower clarity than the generic group (p = 3.2 ×10-6). Participants preferring Spanish provided consistently higher scores than those preferring English. Among English-preferring participants, those in the precision prevention groups scored lower on all measures than those in the generic group. CONCLUSIONS: Skin cancer prevention materials were well-received by Hispanic participants. Higher scores among participants preferring Spanish may indicate acquiescence bias, or that translated prevention materials met their linguistic needs. Participants in the precision prevention groups with English language preference may have challenges in the uptake of genetic risk results. PRACTICE IMPLICATIONS: Availability of Spanish materials may have facilitated higher scores. Additional strategies should be explored to optimize participants' believability and clarity of precision prevention materials.

Hepatitis C virus (HCV) seroprevalence, RNA detection, and genotype distribution across Florida, 2015-2018.

Chronic hepatitis C virus (HCV) infection is a leading cause of hepatocellular carcinoma (HCC) in the U.S. Due to high rates of HCV among baby boomers (born 1945-1965), it was recommended they receive universal screening. This was expanded to all U.S. adults in 2020 due to evidence of increasing rates of chronic HCV in younger adults. An assessment of HCV burden across demographics is crucial to understand the future burden of HCC and target under-screened adults for HCV. Using the OneFlorida Clinical Research Consortium, of more than one million individuals in Florida, all HCV antibody and viral RNA tests completed from 2015 to 2018 were identified. HCV seroprevalence, HCV viral load (active infection), and HCV genotype distribution by risk groups were assessed. Overall, HCV seroprevalence and active infection were highest among White non-Hispanic individuals, males, and baby boomers. However, odds of a positive HCV antibody test were higher among Black non-Hispanic individuals born before 1945 (aOR: 2.74; 95% CI: 1.98-3.78) or 1945-1965 (aOR: 1.46; 95% CI: 1.36-1.56) compared to White non-Hispanic individuals. In contrast, among individuals born after 1965, Black non-Hispanics were less likely than White non-Hispanics to test HCV antibody positive (aOR of 0.5-0.28). A similar age/race pattern was observed for active HCV infection. There was a higher prevalence of genotype 1A and 3 and lower prevalence of 1B in younger adults. Patterns of HCV seroprevalence and active HCV infection identified in our study support the recent shift from age and risk-based screening guidelines to universal adult screening.

A randomized clinical trial of precision prevention materials incorporating MC1R genetic risk to improve skin cancer prevention activities among Hispanics.

Purpose: Skin cancer incidence is increasing among Hispanics, who experience worse outcomes than non-Hispanic Whites. Precision prevention incorporating genetic testing for MC1R, a skin cancer susceptibility marker, may improve prevention behavior. Patients and Methods: Hispanic participants (n=920) from Tampa, FL and Ponce, PR, were block-randomized within MC1R higher- and average-risk groups to precision prevention or generic prevention arms. We collected baseline information on demographics, family history of cancer, phenotypic characteristics, health literacy, health numeracy, and psychosocial measures. Participants reported weekday and weekend sun exposure (in hours), number of sunburns, frequency of five sun protection behaviors, intentional outdoor and indoor tanning, and skin examinations at baseline, three months, and nine months. Participants also reported these outcomes for their eldest child ≤10 years old. Results: Among MC1R higher-risk participants, precision prevention increased sunscreen use (OR=1.74, p=0.03) and receipt of a clinical skin exam (OR=6.51, p=0.0006); and it decreased weekday sun exposure hours (ß=-0.94, p=0.005) and improved sun protection behaviors (ß=0.93, p=0.02) in their children. There were no significant intervention effects among MC1R average risk participants. The intervention did not elevate participant cancer worry. We also identified moderators of the intervention effect among both average- and higher-risk participants. Conclusions: Receipt of MC1R precision prevention materials improved some skin cancer prevention behaviors among higher-risk participants and their children and did not result in reduced prevention activities among average-risk participants. Despite these encouraging findings, levels of sun protection behaviors remained suboptimal among participants, warranting more awareness and prevention campaigns targeted to Hispanics.

Retention and Evaluation of Precision and Generic Prevention Materials for Melanoma: A Qualitative Study Comparing Young Adults and Adults.

A randomized trial was conducted to examine whether providing precision prevention materials incorporating melanocortin-1 receptor genetic risk information would increase intention to practice melanoma preventive behaviors. Here, we determine retention/evaluation of prevention materials for adolescent and young adults (AYA) 18 to 39 years old versus adults aged 40+ at 6 and 12 months as an a priori adjunct analysis to the primary research question. Using qualitative methodology, open-ended questions probing most important information from prevention materials and additional comments were collected at 6 and 12 months after baseline. Descriptive statistics were performed on demographic/self-reported characteristics. Two independent researchers applied qualitative thematic content analysis to identify major themes in open-ended questions. Of the 1,134 participants randomized, 906 completed at least one of the follow-up surveys and contributed to analyses of intervention efficacy. Five major thematic categories emerged from the open-ended response data: (i) tips and tricks for sun protection; (ii) cancer prevention; (iii) risk factors and genetics; (iv) general information; and (v) intervention comments. Across all ages, the most important information retained were sun protection techniques in the generic prevention materials group and identifying the importance of genetic risk factors/implementing lifestyle behavior changes in the precision prevention materials group. For additional comments, AYA participants in the generic prevention materials group preferred more scientific information including statistics and citations for references while adults were more likely to state they already knew cancer prevention techniques. Results provide unique qualitative evaluation of AYA versus adult retention of prevention materials for melanoma that enhance quantitative findings. PREVENTION RELEVANCE: It is important to evaluate information within groups defined by periods of the life trajectory, e.g., AYA and adults, to best inform preferences, knowledge, and motivation for behavior change. By assessing retention, evidence-based interventions can be designed to better support public health messaging and encourage positive health behaviors.

Assessment of melanoma precision prevention materials incorporating MC1R genetic risk information.

Few studies have examined cognitive responses to mailed precision prevention materials. MC1R is a robust, well-described melanoma susceptibility marker. The purpose was to assess cognitive responses to generic or precision prevention materials incorporating MC1R genetic risk. Non-Hispanic White participants (n = 1134) enrolled in a randomized controlled trial received either precision prevention materials incorporating MC1R genetic risk (higher/average) or generic prevention (standard) materials. Six months after baseline, 808 (71.3%) participants reported on the amount of prevention materials read (5-point scale); believability and clarity of materials; intention to change preventive behaviors (7-point Likert scale); and recall of their MC1R genetic risk. Comparisons were conducted using Kruskal-Wallis and chi-squared tests. Overall, participants read most to all (Mdn = 4, IQR = 2) of the prevention materials, reported high believability (Mdn = 7, IQR = 1) and clarity (Mdn = 7, IQR = 1), and moderate intention to change preventive behaviors (Mdn = 5, IQR = 2). Higher-risk participants reported slightly less clarity (Mdn = 6, IQR = 2) than either average-risk (Mdn = 6, IQR = 1, p = 2.50 × 10-3) or standard participants (Mdn = 7, IQR = 1, p = 2.30 × 10-5); and slightly less believability (Mdn = 6, IQR = 1) than standard participants (Mdn = 7, IQR = 1, p = .005). Higher-risk participants were 2.21 times as likely (95% CI = 1.43-3.43) to misremember or forget their risk compared to average-risk participants; misremembering was observed only among higher-risk participants (14%). Mailed precision prevention information were mostly read, highly believable and clear, and resulted in moderate levels of intention to change sun protection behaviors, bolstering the feasibility of population-level precision prevention. Defensive reactions may explain lower clarity, believability, and higher incorrect risk recall among higher-risk participants.

Precision prevention uses an individual's genetics, environment, and/or lifestyle to promote prevention behaviors. However, if materials incorporating precision prevention information are not easily accessible, individuals may misinterpret or distrust findings. Few studies have examined participant-reported believability and clarity of mailed precision prevention materials, how much they read, and whether they intend to change preventive behaviors. We assessed genetic risk for melanoma by determining DNA variation at the MC1R gene, a known melanoma risk marker. Participants were mailed either precision prevention materials conveying their MC1R genetic risk or generic (without genetic risk information) prevention materials. Overall, participants read most of the materials, gave high believability and clarity scores, and reported moderate levels of intention to change preventive behavior. However, participants at higher genetic risk had slightly lower believability and clarity scores than the generic group and were more likely to forget or misremember their genetic risk than participants at average genetic risk. Among participants who correctly recalled their genetic risk, differences in believability diminished, while differences in clarity remained. We conclude that precision prevention materials are highly believable and clear, but additional strategies may be necessary to maximize believability, clarity, and risk recall for individuals at a higher genetic risk.

Preventative Cancer Screening Rates Among Uninsured Patients in Free Clinics: A Retrospective Cohort Study of Cancer Survivors and Non-cancer Survivors.

BACKGROUND: There is limited research on screening rates among uninsured cancer survivors. Uninsured cancer survivors are at higher risk of poorer health outcomes than the insured due to limited access to preventative screening for secondary cancers. This study examines the rates of surveillance and screening of uninsured cancer survivors and compares to uninsured patients without a cancer history seen in free clinics. METHODS: Data were collected retrospectively from electronic medical records and paper charts of patients from 10 free clinics between January 2016 and December 2018 in the Tampa Bay area. The prevalence of socioeconomic characteristics, cancer diagnoses, and screening practices were compared for cancer survivors and free clinic patients without a history of cancer. Study participants were determined to be eligible for cancer screenings based on the United States Preventive Services Task Force guidelines. RESULTS: Out of 13 982 uninsured patients frequenting free clinics between 2016 and 2018, 402 (2.9%) had a documented history of cancer. Out of the 285 eligible cancer survivors, 44 (15.4%) had completed age-appropriate colon cancer screening. Among the 170 female cancer survivors, 75 (44.1%) had completed breast cancer screenings, and only 5.9% (59/246) had completed cervical cancer screenings. After adjusting for age, gender, race, salary, employment status, and household size, cancer survivors were more likely to undergo colorectal cancer screening (OR: 3.59, 95% CI: 2.10-6.15) and breast cancer screening (OR: 2.13, 95% CI: 1.30-3.84) than patients without a cancer history. This difference was not seen for cervical cancer screening (OR: 0.99, 95% CI: .62-1.58). CONCLUSIONS: Uninsured cancer survivors frequenting free clinics represent a unique population that is underrepresented in the medical literature. Our results suggest that uninsured survivors use screening services at higher rates when compared to uninsured patients without a reported cancer diagnosis. However, these rates are suboptimal when compared to national screening rates of insured cancer survivors.

Using the Electronic Health Record to Characterize the Hepatitis C Virus Care Cascade.

OBJECTIVES: Chronic hepatitis C virus (HCV) infection is one of the main causes of hepatocellular carcinoma. Before initiating a multilevel HCV screening intervention, we sought to (1) describe concordance between the electronic health record (EHR) data warehouse and manual medical record review in recording aspects of HCV testing and treatment and (2) estimate the percentage of patients with chronic HCV infection who initiated and completed HCV treatment using manual medical record review. METHODS: We examined the medical records for 177 patients (100 randomly selected patients born during 1945-1965 without evidence of HCV testing and 77 adult patients of any birth cohort who had completed HCV testing) with a primary care or relevant specialist visit at an academic health care system in Tampa, Florida, from 2015 through 2018. We used the Cohen κ coefficient to examine the degree of concordance between the searchable data warehouse and the medical record review abstractions. Descriptive statistics characterized referral to and receipt of treatment among patients with chronic HCV infection from medical record review. RESULTS: We found generally good concordance between the data warehouse abstraction and medical record review for HCV testing data (κ ranged from 0.66 to 0.87). However, the data warehouse failed to capture data on HCV treatment variables. According to medical record review, 28 patients had chronic HCV infection; 16 patients were prescribed treatment, 14 initiated treatment, and 9 achieved and had a reported posttreatment undetected HCV viral load. CONCLUSIONS: Using data warehouse data provides generally reliable HCV testing information. However, without the use of natural language processing and purposeful EHR design, manual medical record reviews will likely be required to characterize treatment initiation and completion.

Measurement of Pharmacist-Physician Collaborative Care on Therapeutic Inertia in Patients With Type 2 Diabetes.

BACKGROUND: Team-based care practice models have been shown to improve diabetes-related therapeutic inertia, yet the method and type of antidiabetic treatment intensification (TI) leading to improvements in glycemic control are not well understood. OBJECTIVE: To evaluate time to TI in a pharmacist-physician practice model (PPM) as compared with usual medical care (UMC), explore the method and type of antidiabetic TI, and evaluate achievement of hemoglobin A1C (A1C) goal among each cohort. METHODS: This was a retrospective cohort study conducted between January 1, 2017, and December 31, 2018. Median time to TI was calculated and compared between patients in the PPM and UMC groups using the log rank test. Descriptive statistics were used to evaluate the method and type of TI and A1C goal achievement. RESULTS: A total of 56 patients were included. The median (interquartile range) time to antidiabetic TI among the PPM cohort was 37.5 days (8, 216.5), as compared with 142 days (16, 465) in the UMC cohort (P = 0.19). At 1 year post-index date, 25% of patients in the PPM cohort reached their A1C goal compared with 18.8% of patients in the UMC cohort. This effect was maintained in the subgroup (n = 49) of patients receiving TI (23.1% vs 17.8%). CONCLUSION AND RELEVANCE: A shorter time to TI and improvement in A1C goal achievement was observed with pharmacist-physician care compared with UMC. These findings suggest that pharmacist-physician care may be one of several interventions necessary to overcome therapeutic inertia in diabetes care.

The psychosocial needs of underserved breast cancer survivors and perspectives of their clinicians and support providers.

PURPOSE: Breast cancer survivors (BrCS) experience many psychosocial difficulties following treatment, leading to an increased risk of psychological distress compared to the general population. This is especially true for underserved BrCS whose unmet supportive care needs can result in worse physical and mental health outcomes. This qualitative study compared healthcare and support providers' perceptions of BrCS' needs to survivors' perceptions of their own needs. METHODS: Semi-structured in-depth interviews were conducted with 25 underserved BrCS and 20 cancer survivorship stakeholders identified using purposeful sampling. Using the constant comparison method and content analysis, data were analyzed via an iterative process of coding and discussion. Data were summarized according to three intermediate and proximal themes mentioned by both stakeholders and survivors: (1) psychosocial needs of cancer survivors, (2) support, and (3) benefit finding/positive feelings about cancer. Demographic data were analyzed by calculating descriptive statistics. RESULTS: There was consistency in providers' and survivors' perceptions of post-treatment mood changes, financial burden, familial stress, and physical changes. Providers and survivors differed in perceptions of BrCS' preferred sources of care and support, effects of cancer treatment on body image, the effects of fear of cancer recurrence on follow-up care, and benefit finding. CONCLUSIONS: This study provides valuable insight into areas in which healthcare and support providers' perceptions may differ from underserved BrCS' lived experiences. Results from this study can be used to develop interventions and inform healthcare and support providers on how to provide high-quality care to underserved BrCS.

Hepatitis C Virus Screening: Factors Associated With Test Completion in a Large Academic Health Care System.

OBJECTIVES: In 2012, onetime hepatitis C virus (HCV) screening was recommended for all baby boomers (people born during 1945-1965) in the United States, but only 4.0%-12.9% of baby boomers have ever had a screening ordered by a health care provider. This study examined the HCV screening prevalence among adult patients in a large academic health care system and assessed factors associated with the completion of screening when ordered for baby boomers. METHODS: We defined HCV screening completion as the completion of an HCV antibody test when it was ordered. We used electronic health records to examine HCV screening completion rates among adults (N = 106 630) from August 1, 2015, through July 31, 2020, by birth cohort. Among baby boomers whose health care provider ordered HCV screening, we examined frequency and percentages of HCV screening completion by sociodemographic and clinical characteristics. We conducted univariate and multivariable logistic regression analyses to assess factors associated with HCV screening completion among baby boomers. RESULTS: During the study period, 73.0% of baby boomers completed HCV screening when it was ordered. HCV completion did not differ by sex or race and ethnicity among baby boomers. Baby boomers with Medicare supplemental health insurance compared with commercial health insurance (adjusted odds ratio [aOR] = 1.87) and those seeing only advanced practice professionals compared with specialty care physicians (aOR = 2.24) were more likely to complete HCV screening when it was ordered. CONCLUSIONS: Noncompletion of HCV screening is one of many barriers along the HCV treatment continuum. Our findings suggest a need for interventions targeting systems, health care providers, and patients to increase HCV screening rates in the United States.

A Randomized Trial of Precision Prevention Materials to Improve Primary and Secondary Melanoma Prevention Activities among Individuals with Limited Melanoma Risk Phenotypes.

Inherited variation at MC1R is associated with elevated melanoma risk among non-Hispanic whites (NHWs). MC1R genetic testing may unmask previously unrecognized disease risk, especially among individuals with few melanoma phenotypic risk factors. We recruited NHW individuals with limited phenotypic risk factors from two primary care clinics in west-central Florida. Participants (n = 1134) were randomized within MC1R genotype risk group (average/higher) to receive mailed precision prevention (i.e., intervention) or generic prevention materials. Participants reported hours of weekday and weekend sun exposure, frequency of intentional outdoor tanning and sun protection behaviors, number of sunburns, indoor tanning episodes, and skin examinations at baseline, and after 6 and 12 months. Among MC1R higher-risk participants, the intervention increased the likelihood of often or always wearing a shirt with sleeves (OR = 1.49, p = 0.03) and seeking shade or using an umbrella (OR = 1.42, p = 0.046), and it decreased the number of sunburns among their young children (ß = -0.13, p = 0.03). Intervention effects were not noted among MC1R average-risk participants. Moderation analyses identified intervention effects within subgroups in average-risk and higher-risk participants. Precision prevention information conveying MC1R testing results can increase the practice of some sun protection behaviors among at-risk individuals with limited melanoma risk phenotypes and may provide a cross-generational tool to counteract increasing incidence of melanoma.

Distribution of Estimated Lifetime Breast Cancer Risk Among Women Undergoing Screening Mammography.

OBJECTIVE. Supplemental screening breast MRI is recommended for women with an estimated lifetime risk of breast cancer of greater than 20-25%. The performance of risk prediction models varies for each individual and across groups of women. The present study investigates the concordance of three breast cancer risk prediction models among women presenting for screening mammography. SUBJECTS AND METHODS. In this prospective study, we calculated the estimated lifetime risk of breast cancer using the modified Gail, Tyrer-Cuzick version 7, and BRCAPRO models for each woman who presented for screening mammography. Per American Cancer Society guidelines, for each woman the risk was categorized as less than 20% or 20% or greater as well as less than 25% or 25% or greater with use of each model. Venn diagrams were constructed to evaluate concordance across models. The McNemar test was used to test differences in risk group allocations between models, with p ≤ .05 considered to denote statistical significance. RESULTS. Of 3503 screening mammography patients who underwent risk stratification, 3219 (91.9%) were eligible for risk estimation using all three models. Using at least one model, 440 (13.7%) women had a lifetime risk of 20% or greater, including 390 women (12.1%) according to the Tyrer-Cuzick version 7 model, 18 (0.6%) according to the BRCAPRO model, and 141 (4.4%) according to the modified Gail model. Six women (0.2%) had a risk of 20% or greater according to all three models. Women were significantly more likely to be classified as having a high lifetime breast cancer risk by the Tyrer-Cuzick version 7 model compared with the modified Gail model, with thresholds of 20% or greater (odds ratio, 6.4; 95% CI, 4.7-8.7) or 25% or greater (odds ratio, 7.4; 95% CI, 4.7-11.9) used for both models. CONCLUSION. To identify women with a high lifetime breast cancer risk, practices should use estimates of lifetime breast cancer risk derived from multiple risk prediction models.