Self-management support for chronic disease in primary care: frequency of patient self-management problems and patient reported priorities, and alignment with ultimate behavior goal selection.

BACKGROUND: To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients' identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients' reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal. METHODS: CTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet (fruits and vegetables, salt, fat, sugar sweetened beverages), physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic. RESULTS: 446 participants with ≥ one chronic diseases (mean age 55.4 ± 12.6; 58.5% female) participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas. CONCLUSION: Participants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT01945918 .

Trends and Implications of Adjuvant Systemic Therapy for Head and Neck Cancer Without High-Risk Features.

OBJECTIVE: Determine trends and survival implications of adjuvant systemic therapy use for lower risk head and neck cancer. STUDY DESIGN: Retrospective cohort study. SETTING: US National Cancer Database, 2010 to 2019. METHODS: Patients with mucosal head and neck squamous cell carcinoma treated with surgery and postoperative radiation therapy were identified. Adjuvant systemic therapy trends in those with and without extranodal extension or positive margins were assessed as annual percent change by JoinPoint analysis. Factors associated with adjuvant systemic therapy and overall survival were assessed with multivariable models and cox proportional hazard models, respectively. RESULTS: From 2010 to 2019, approximately one-third of head and neck cancer patients without extranodal extension or positive margins received adjuvant systemic therapy. This rate decreased throughout the study period, with the highest annual percent change from 2016 to 2019 (12.21%; 95% confidence interval: 3.73%-19.95%). Younger age, male sex, Hispanic ethnicity, community program setting, advanced stage, and lymphovascular invasion increased the odds a patient would receive adjuvant systemic therapy. Adjuvant systemic therapy was associated with inferior overall survival when used in those without extranodal extension or positive margins after controlling for covariates. CONCLUSION: Though decreasing, adjuvant systemic therapy use is still common in the absence of extranodal extension and positive margins, and a variety of patient, provider, and oncologic factors may influence its use. The inferior overall survival after adjuvant systemic therapy in the absence of high-risk features suggests any oncologic benefit may not outweigh the costs and morbidity of the therapy.

Demographic predictors of head and neck cancer survival differ in the elderly.

OBJECTIVES/HYPOTHESIS: Head and neck squamous cell carcinoma (HNSCC) prognosis strongly correlates with demographic factors. This study aimed to determine whether demographic predictors of HNSCC survival differ between age cohorts, with an emphasis on the growing elderly demographic. STUDY DESIGN: Outcomes research. METHODS: Adults with squamous cell carcinoma of the upper aerodigestive tract were identified from the Surveillance, Epidemiology and End Results 18 database. Demographic and oncologic factors were compared between three age groups: 18 to 49, 50 to 74, and >75 years. Factors associated with cancer-specific survival were assessed in each cohort using subdistribution hazard ratio (sHR) and 95% confidence interval (CI) produced by multivariate competing risk models. RESULTS: A cohort of 69,098 patients included 10,588 (15.3%) 75 years or older and 9,882 (14.3%) less than 50 years old. Older patients were more often female (35.4% vs. 25.1% aged 18-49 years and 20.4% aged 50-74 years), white (78.7% vs. 69.4% and 75.9%), insured (63.5% vs. 46.5% and 56.8%), and married (56.6% vs. 53% and 51.1%), but received adequate treatment less often (72.0% vs. 86.3% and 82.7%). In the older cohort, male sex was associated with lower mortality (sHR: 0.92, 95% CI: 0.85-1.00), and unlike the younger cohorts, black race was no longer associated with mortality (sHR: 1.07, 95% CI: 0.94-1.22). Marriage was associated with lower mortality in all age groups but with diminishing effects (single sHR: young 1.52, middle 1.31, older 1.14). CONCLUSIONS: Elderly HNSCC patients have distinct effects from demographic prognostic factors and should be considered a separate subgroup with unique epidemiology, risks, and preferences. LEVEL OF EVIDENCE: 2c Laryngoscope, , 129:146-153, 2018.