Skin Cancer Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Skin cancer is the most common cancer type and is a major cause of morbidity. Objective: To systematically review the benefits and harms of screening for skin cancer to inform the US Preventive Services Task Force. Data Sources: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from June 1, 2015, through January 7, 2022; surveillance through December 16, 2022. Study Selection: English-language studies conducted in asymptomatic populations 15 years or older. Data Extraction and Synthesis: Two reviewers independently appraised the articles and extracted relevant data from fair- or good-quality studies; results were narratively summarized. Main Outcomes and Measures: Morbidity; mortality; skin cancer stage, precursor lesions, or lesion thickness at detection; harms of screening. Results: Twenty studies in 29 articles were included (N = 6 053 411). Direct evidence on screening effectiveness was from 3 nonrandomized analyses of 2 population-based skin cancer screening programs in Germany (n = 1 791 615) and suggested no melanoma mortality benefit at the population level over 4 to 10 years' follow-up. Six studies (n = 2 935 513) provided inconsistent evidence on the association between clinician skin examination and lesion thickness or stage at diagnosis. Compared with usual care, routine clinician skin examination was not associated with increased detection of skin cancer or precursor lesions (5 studies) or stage at melanoma detection (3 studies). Evidence on the association between clinician skin examination and lesion thickness at detection was inconsistent (3 studies). Nine studies (n = 1 326 051) found a consistent positive association between more advanced stage at melanoma detection and increasing risk of melanoma-associated and all-cause mortality. Two studies (n = 232) found little to no persistent cosmetic or psychosocial harms associated with screening. Conclusions and Relevance: A substantial nonrandomized evidence base suggests a clear association between earlier stage at skin cancer detection and decreased mortality risk. However, nonrandomized studies suggest little to no melanoma mortality benefit associated with skin cancer screening with visual skin examination in adolescents or adults and no association between routine clinician skin examination and earlier stage at melanoma detection. Evidence is inconsistent regarding whether clinician skin examination is associated with thinner melanoma lesions at detection.

Human-Centered Design Study to Inform Traceback Cascade Genetic Testing Programs at Three Integrated Health Systems.

INTRODUCTION: A traceback genetic testing program for ovarian cancer has the potential to identify individuals with hereditary breast and ovarian cancer and their relatives. Successful implementation depends on understanding and addressing the experiences, barriers, and preferences of the people served. METHODS: We conducted a remote, human-centered design research study of people with ovarian, fallopian tube, or peritoneal cancer (probands) and people with a family history of ovarian cancer (relatives) at three integrated health systems between May and September 2021. Participants completed activities to elicit their preferences about ovarian cancer genetic testing messaging and to design their ideal experience receiving an invitation to participate in genetic testing. Interview data were analyzed using a rapid thematic analysis approach. RESULTS: We interviewed 70 participants and identified five preferred experiences for a traceback program. Participants strongly prefer discussing genetic testing with their doctor but are comfortable discussing with other clinicians. The most highly preferred experience for both probands and relatives was to discuss with a knowledgeable clinician who could answer questions, followed by directed (sent directly to specific people) or passive (shared in a public area) communication. Repeated contact was acceptable for reminders. CONCLUSION: Participants were open to receiving information about traceback genetic testing and recognized its value. Participants preferred discussing genetic testing with a trusted clinician. Directed communication was preferable to passive communication. Other valued information included how genetic tests help their family and the cost of genetic testing. These findings are informing traceback cascade genetic testing programs at all three sites.

Feasibility of using an app-based coaching intervention to improve provider communication about HPV vaccination.

Provider communication training is effective for increasing HPV vaccination rates among U.S. adolescents. However, such trainings often rely on in-person meetings, which can be burdensome for providers and costly to implement. To evaluate the feasibility of Checkup Coach, an app-based coaching intervention, to improve provider communication about HPV vaccination. In 2021, we offered Checkup Coach to providers in 7 primary care clinics in a large integrated delivery system. Participating providers (n = 19) attended a 1-h interactive virtual workshop that taught 5 high-quality practices for recommending HPV vaccination. Providers then had 3 months of access to our mobile app, which offered ongoing communication assessments, tailored tips for addressing parents' concerns, and a dashboard of their clinic's HPV vaccination coverage. Online surveys assessed pre-/post-intervention changes in providers' perceptions and communication behaviors. Compared to baseline, more providers reported high-quality HPV vaccine recommendation practices at 3-month follow-up (47% vs. 74%, p < .05). Providers' knowledge, self-efficacy, and shared commitment to improving HPV vaccination also improved (all p < .05). Although we found improvements in several other cognitions after the workshop, these changes did not retain statistical significance at 3 months. About three-quarters (78%) of providers used the mobile app, logging 2.3 sessions on average. Most providers agreed the app was easy to use (mean = 4.7/5.0), a convenient way to get vaccination data (mean = 4.6/5.0), and a tool they would recommend (mean = 4.3/5.0). Our app-based coaching intervention demonstrated feasibility and warrants additional evaluation as a novel mode for training providers to improve their HPV vaccine communication.

The aim of this study was to evaluate the feasibility of Checkup Coach, an app-based coaching intervention to improve provider communication about HPV vaccination, by offering the app to providers in 7 primary care clinics in a large integrated delivery system. Participating providers attended a 1-h interactive virtual workshop that taught high-quality HPV vaccine recommendation practices. For the following 3 months, providers used the app for ongoing communication assessments, tailored tips for addressing parents' concerns, and a dashboard of their clinic's HPV vaccination rates. Online surveys assessed pre- and post-intervention changes in providers' perceptions and communication practices. The percentage of providers reporting high-quality HPV vaccine recommendation practices increased from baseline to follow-up. Providers also reported higher HPV vaccine-related knowledge, self-efficacy, and shared commitment at 3 months. Providers agreed that the app was easy to use, a convenient way to get vaccination data, and a tool they would recommend. Our app-based coaching intervention demonstrated feasibility and warrants additional evaluation as a novel mode for training providers to improve their HPV vaccine communication.

Feasibility, acceptability, and limited efficacy of health system-led familial risk notification: protocol for a mixed-methods evaluation.

BACKGROUND: Genetic testing for pathogenic variants associated with hereditary breast and ovarian cancer risk can improve cancer outcomes through enhanced preventive care in both people with known variants and their biologic relatives. Cascade screening-the process of case-finding in relatives by notifying and inviting them to consider testing-currently relies on the patient to notify their own at-risk relatives. However, many of these relatives never learn they might be at risk. We developed and implemented a new health system-led familial genetic risk notification process where the care team offers to contact at-risk relatives directly. This protocol describes a study to assess the feasibility, acceptability, and limited efficacy of this intervention. METHODS: This feasibility study will use a single-arm, nonrandomized, mixed-methods prospective design. We will enroll two groups of participants: probands and relatives of probands. Eligible probands are currently enrolled Kaiser Permanente Washington (KPWA) members with an upcoming appointment for pre-test genetic counseling for hereditary Lynch syndrome, breast, or ovarian cancer. Eligible relatives, who do not have to be KPWA members, are first-and second-degree relatives of probands. During the appointment with the proband, the genetic counselor will determine whether the proband is appropriate for genetic testing and if so, which relatives might benefit from cascade testing. The genetic counselor then will offer to contact any or all identified relatives directly to discuss genetic risk and testing. The primary outcome of this study is the feasibility of the implemented familial notification process, which we will measure using quantitative and qualitative data on intervention reach, intervention acceptability, and limited efficacy. Analyses will be primarily descriptive and exploratory, with the intent of preparing for a future, larger trial of direct contact interventions. DISCUSSION: Our findings will provide new, foundational evidence for the creation of US-based familial notification systems that directly address logistical and ethical challenges while prioritizing the preferences of patients and families.

Pragmatic Randomized Study of Targeted Text Message Reminders to Reduce Missed Clinic Visits.

INTRODUCTION: Missed clinic appointments ("no-shows") waste health system resources, decrease physician availability, and may worsen patient outcomes. Appointment reminders reduce no-shows, though evidence on the optimal number of reminders is limited and sending multiple reminders for every visit is costly. Risk prediction models can be used to target reminders for visits that are likely to be missed. METHODS: We conducted a randomized quality improvement project at Kaiser Permanente Washington among patients with primary care and mental health visits with a high no-show risk comparing the effect of one text message reminder (sent 2 business days prior to the appointment) with 2 text message reminders (sent 2 and 3 days prior) on no-shows and same-day cancellations. We estimated the relative risk (RR) of an additional reminder using G-computation with logistic regression adjusted for no-show risk. RESULTS: Between February 27, 2019 and September 23, 2019, a total of 125,076 primary care visits and 33,593 mental health visits were randomized to either 1 or 2 text message reminders. For primary care visits, an additional text message reduced the chance of no-show by 7% (RR = 0.93, 95% CI: 0.89-0.96) and same-day cancellations by 6% (RR = 0.94, 95% CI: 0.90-0.98). In mental health visits, an additional text message reduced the chance of no-show by 11% (RR = 0.89, 95% CI: 0.86-0.93) but did not impact same-day cancellations (RR = 1.02, 95% CI: 0.96-1.11). We did not find effect modification among subgroups defined by visit or patient characteristics. CONCLUSION: Study findings indicate that using a prediction model to target reminders may reduce no-shows and spend health care resources more efficiently.

Feasibility and Assessment of a Cascade Traceback Screening Program (FACTS): Protocol for a Multisite Study to Implement and Assess an Ovarian Cancer Traceback Cascade Testing Program.

Ovarian cancer (OVCA) patients may carry genes conferring cancer risk to biological family; however, fewer than one-quarter of patients receive genetic testing. "Traceback" cascade testing -outreach to potential probands and relatives-is a possible solution. This paper outlines a funded study (U01 CA240747-01A1) seeking to determine a Traceback program's feasibility, acceptability, effectiveness, and costs. This is a multisite prospective observational feasibility study across three integrated health systems. Informed by the Conceptual Model for Implementation Research, we will outline, implement, and evaluate the outcomes of an OVCA Traceback program. We will use standard legal research methodology to review genetic privacy statutes; engage key stakeholders in qualitative interviews to design communication strategies; employ descriptive statistics and regression analyses to evaluate the site differences in genetic testing and the OVCA Traceback testing; and assess program outcomes at the proband, family member, provider, system, and population levels. This study aims to determine a Traceback program's feasibility and acceptability in a real-world context. It will account for the myriad factors affecting implementation, including legal issues, organizational- and individual-level barriers and facilitators, communication issues, and program costs. Project results will inform how health care providers and systems can develop effective, practical, and sustainable Traceback programs.

Patient and Family Preferences on Health System-Led Direct Contact for Cascade Screening.

Health benefits to relatives of people at known genetic risk for hereditary cancer syndromes is key to realizing the promise of precision medicine. We conducted a qualitative study to design a patient- and family-centered program for direct contact of relatives to recommend cascade genetic testing. We conducted two rounds of data collection using focus groups followed by individual interviews with patients with HBOC or Lynch syndrome and a separate sample of people with a family history of hereditary cancers. Results indicate that U.S.-based health system-led direct contact of relatives is acceptable to patients and families, should take a programmatic approach, include consent of relatives before proband testing, complement to existing patient-mediated disclosure, and allow for relative control of information. Our findings suggest a set of requirements for U.S.-based direct contact programs that could ultimately benefit more relatives than current approaches.

Barriers to Human Papillomavirus Vaccine Series Completion among Insured Individuals in an Integrated Healthcare Setting.

INTRODUCTION: Infection with certain types of human papillomavirus (HPV) can lead to cervical cancer as well as other cancers in both men and women. However, the requirement for multiple doses may limit the vaccine's effectiveness for cancer prevention. We conducted a pilot study to investigate barriers to HPV vaccine series completion among members of an integrated healthcare system with clinical documentation of only 1 dose. METHODS: We surveyed parents or legal guardians of 11-17-year-old girls (n = 10) and boys (n = 18), as well as 18-31-year-old women (n = 20) and men (n = 9), about their reasons for not completing the HPV vaccine series. RESULTS: Most participants (70.2%) were non-Hispanic white. Among parents of children, commonly reported barriers to HPV vaccine series completion included not being aware or informed of the need for additional doses (28.6%), as well as the inconvenience of returning for additional doses (17.9%). Concerns about the HPV vaccine or vaccines in general were more common among parents of girls (30.0%) compared with parents of boys (16.7%). Among adults, barriers to HPV vaccine series completion included the inconvenience of returning for additional doses (31.0%), not being aware or informed of the need for additional doses (10.3%), and forgetting (10.3%). CONCLUSION: Our findings suggest that clinicians and healthcare systems can play a greater role in promoting awareness of the multiple-dose requirement, addressing vaccine concerns, and increasing opportunistic vaccination in a variety of settings. Increasing these efforts may facilitate HPV vaccine completion and increase its effectiveness in cancer prevention.

Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Colorectal cancer (CRC) remains a significant cause of morbidity and mortality in the US. Objective: To systematically review the effectiveness, test accuracy, and harms of screening for CRC to inform the US Preventive Services Task Force. Data Sources: MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant studies published from January 1, 2015, to December 4, 2019; surveillance through March 26, 2021. Study Selection: English-language studies conducted in asymptomatic populations at general risk of CRC. Data Extraction and Synthesis: Two reviewers independently appraised the articles and extracted relevant study data from fair- or good-quality studies. Random-effects meta-analyses were conducted. Main Outcomes and Measures: Colorectal cancer incidence and mortality, test accuracy in detecting cancers or adenomas, and serious adverse events. Results: The review included 33 studies (n = 10 776 276) on the effectiveness of screening, 59 (n = 3 491 045) on the test performance of screening tests, and 131 (n = 26 987 366) on the harms of screening. In randomized clinical trials (4 trials, n = 458 002), intention to screen with 1- or 2-time flexible sigmoidoscopy vs no screening was associated with a decrease in CRC-specific mortality (incidence rate ratio, 0.74 [95% CI, 0.68-0.80]). Annual or biennial guaiac fecal occult blood test (gFOBT) vs no screening (5 trials, n = 419 966) was associated with a reduction of CRC-specific mortality after 2 to 9 rounds of screening (relative risk at 19.5 years, 0.91 [95% CI, 0.84-0.98]; relative risk at 30 years, 0.78 [95% CI, 0.65-0.93]). In observational studies, receipt of screening colonoscopy (2 studies, n = 436 927) or fecal immunochemical test (FIT) (1 study, n = 5.4 million) vs no screening was associated with lower risk of CRC incidence or mortality. Nine studies (n = 6497) evaluated the test accuracy of screening computed tomography (CT) colonography, 4 of which also reported the test accuracy of colonoscopy; pooled sensitivity to detect adenomas 6 mm or larger was similar between CT colonography with bowel prep (0.86) and colonoscopy (0.89). In pooled values, commonly evaluated FITs (14 studies, n = 45 403) (sensitivity, 0.74; specificity, 0.94) and stool DNA with FIT (4 studies, n = 12 424) (sensitivity, 0.93; specificity, 0.85) performed better than high-sensitivity gFOBT (2 studies, n = 3503) (sensitivity, 0.50-0.75; specificity, 0.96-0.98) to detect cancers. Serious harms of screening colonoscopy included perforations (3.1/10 000 procedures) and major bleeding (14.6/10 000 procedures). CT colonography may have harms resulting from low-dose ionizing radiation. It is unclear if detection of extracolonic findings on CT colonography is a net benefit or harm. Conclusions and Relevance: There are several options to screen for colorectal cancer, each with a different level of evidence demonstrating its ability to reduce cancer mortality, its ability to detect cancer or precursor lesions, and its risk of harms.

Transitioning patients from outpatient mental health services to primary care: A rapid literature review.

Background: A lack of access to mental health services is a critical barrier to obtaining evidence-based care. One strategy to improve access is to transition stable patients out of mental health specialty services and into primary care, thus opening availability for new patients and those with acute mental health needs. To support these transitions, organizations might explore a range of new practices and implementation strategies. Methods: We conducted a rapid literature review to summarize descriptions from the research literature about practices for transitioning stable patients from outpatient mental health services to primary care, as well as implementation strategies to enhance the adoption and sustainment of these practices. We searched PsycINFO and Cumulated Index to Nursing and Allied Health Literature (CINAHL) for articles published between January 2000 and August 2019. For articles meeting inclusion criteria, we abstracted data on study characteristics, transition practices, and implementation strategies. Results: We included 11 articles representing diverse study designs, settings, and health care organizations. Across these articles, we identified six categories of commonly described transition practices, with patient engagement appearing the most frequently (10 articles), followed by shared treatment planning (eight articles), assessment of recovery and stability, care coordination, follow up and support, and medication management (seven articles each). Less frequently, articles included descriptions of implementation strategies, with five articles describing efforts to train and educate stakeholders and four articles describing the use of evaluative and iterative strategies. Conclusions: We identified descriptions of several common practices to help patients transition from mental health specialty services to primary care, but there are opportunities for an increased focus on implementation strategies to enhance the adoption and sustainment of these transition practices. More research is needed to better understand the effectiveness of specific transition interventions and the feasibility of deploying these interventions in heterogeneous health care settings.

Impact of a novel oral health promotion program on routine oral hygiene among socioeconomically disadvantaged smokers: results from a randomized semi-pragmatic trial.

Smokers are at high risk of oral disease and report sub-optimal oral hygiene. Improving smokers' oral hygiene could reduce their future disease risk. The purpose of this study is to assess the effects of a novel, multi-modal oral health promotion program (Oral Health 4 Life; OH4L) targeted to socioeconomically disadvantaged smokers and delivered through state-funded tobacco quitlines. Smokers (n = 718) were randomized to standard quitline care or standard care plus OH4L. OH4L recipients received a comprehensive behavioral intervention and were advised of the benefits of routine oral hygiene, encouraged to brush and floss daily (for better oral health and to manage cigarette cravings), and provided a toothbrush and floss. Participants were followed for 6 months to assess the intervention effects on routine oral hygiene (brushing and flossing) and changes in motivation and self-efficacy. Data were collected between 2015 and 2017. At 2-month follow-up, OH4L participants were more likely to meet the American Dental Association (ADA) recommendations for brushing twice daily (adjusted RR = 1.15 [1.04, 1.27], p = .006), flossing daily (adjusted RR = 1.20 [1.03, 1.39], p = .02), and for both brushing and flossing (adjusted RR = 1.33 [1.10, 1.61], p = .003). Daily flossing was more likely at 6-month follow-up (adjusted RR = 1.21 [1.04, 1.42], p = .02) among OH4L participants. The change in self-efficacy and motivation for daily flossing from baseline to 2 months was significantly greater among OH4L participants and mediated the intervention effect on flossing at 6 months. Integrating oral hygiene promotion with standard tobacco quitline services improved oral health self-care.

Psychometric and Pragmatic Properties of Social Risk Screening Tools: A Systematic Review.

CONTEXT: Health systems increasingly are exploring implementation of standardized social risk assessments. Implementation requires screening tools both with evidence of validity and reliability (psychometric properties) and that are low cost, easy to administer, readable, and brief (pragmatic properties). These properties for social risk assessment tools are not well understood and could help guide selection of assessment tools and future research. EVIDENCE ACQUISITION: The systematic review was conducted during 2018 and included literature from PubMed and CINAHL published between 2000 and May 18, 2018. Included studies were based in the U.S., included tools that addressed at least 2 social risk factors (economic stability, education, social and community context, healthcare access, neighborhood and physical environment, or food), and were administered in a clinical setting. Manual literature searching was used to identify empirical uses of included screening tools. Data on psychometric and pragmatic properties of each tool were abstracted. EVIDENCE SYNTHESIS: Review of 6,838 unique citations yielded 21 unique screening tools and 60 articles demonstrating empirical uses of the included screening tools. Data on psychometric properties were sparse, and few tools reported use of gold standard measurement development methods. Review of pragmatic properties indicated that tools were generally low cost, written for low-literacy populations, and easy to administer. CONCLUSIONS: Multiple low-cost, low literacy tools are available for social risk screening in clinical settings, but psychometric data are very limited. More research is needed on clinic-based screening tool reliability and validity as these factors should influence both adoption and utility. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Screening for Pancreatic Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Pancreatic adenocarcinoma is the third most common cause of cancer death among men and women in the United States. Objective: To systematically review benefits and harms of screening for pancreatic adenocarcinoma to inform the US Preventive Services Task Force. Data Sources: MEDLINE, PubMed, and the Cochrane Collaboration Registry of Controlled Trials, from January 2002 through April 27, 2018; surveillance through March 22, 2019. Study Selection: Studies of adults with or without risk factors for pancreatic adenocarcinoma (eg, family history of pancreatic cancer, personal history of new-onset diabetes) undergoing imaging-based screening; studies of treatment for adults with screen-detected or asymptomatic pancreatic adenocarcinoma. Included study designs were randomized clinical trials, nonrandomized controlled intervention studies, diagnostic accuracy studies with a reference standard, cohort studies, and case-control studies (for evaluation of harms only). Studies consisting entirely of populations with known genetic syndromes associated with pancreatic cancer were excluded. Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and rated included studies for quality; data were quantitatively analyzed to calculate a pooled diagnostic yield and narratively synthesized. Main Outcomes and Measures: Mortality, morbidity, or quality of life; diagnostic accuracy of screening tests; any harm of screening or treatment. Results: Thirteen fair-quality prospective cohort screening studies (N = 1317) conducted predominantly in populations at high familial risk for pancreatic adenocarcinoma were included. No studies reported on the effect of screening on morbidity or mortality or on the effectiveness of treatment for screen-detected pancreatic adenocarcinoma. Although no studies evaluated the diagnostic accuracy of screening tests, all 13 studies reported the diagnostic yield. Yields ranged from 0 to 75 cases per 1000 persons in studies using endoscopic ultrasound, magnetic resonance imaging, and/or computed tomography-based screening. In total, 18 cases of pancreatic adenocarcinoma were detected in 1156 adults at increased familial risk and 0 cases were detected in 161 average-risk adults. In 8 studies (n = 675) assessing procedural harms of screening, no serious harms from initial screening were reported. Two studies (n = 271) found no evidence of psychosocial harms related to screening. Evidence of surgical harms was limited. Conclusions and Relevance: Imaging-based screening in groups at high familial risk can detect pancreatic adenocarcinoma with limited evidence of minimal harms. However, the effect of screening on morbidity and mortality in groups at high familial risk has not been studied, and no data are available in average-risk populations. There is limited evidence to assess benefits or harms of surgical intervention for screen-detected pancreatic adenocarcinoma.

"You Really Do Have to Know the Local Context": IRB Administrators and Researchers on the Implications of the NIH Single IRB Mandate for Multisite Genomic Studies.

In 2016, the U.S. National Institutes of Health (NIH) announced a new policy requiring single institutional review board (sIRB) review for multisite studies. However, adherence to the new policy requires the separation of regulatory institutional review board (IRB) work per Federal guidance from site-specific local compliance concerns. In particular, genomic research is subject to a wide range of state laws, institutional requirements, and local population preferences. In this qualitative study, we explored the anticipated needs of genomics researchers and IRB administrators around implementing the policy. We observed multiple uncertainties, particularly about intersite communication processes, sIRB selection processes, and roles of the reviewing IRB and local sites regarding local context information relevant to genomics. Optimal implementation of the NIH policy may require additional guidance for researchers and IRB administrators.

"It would be so much easier": health system-led genetic risk notification-feasibility and acceptability of cascade screening in an integrated system.

Assess the feasibility and acceptability of health system-led genetic risk notification in a US integrated health system. We conducted semi-structured phone interviews with individuals age 40-64 years who had undergone genetic sequencing, but had not yet received their results, assessing attitudes to direct outreach to relatives. During each interview, we collected contact information for adult relatives identified as members of the same system and attempted to identify each relative in administrative data. We conducted 20 interviews. Most participants expressed support for Kaiser Permanente Washington involvement in familial risk notification. Direct outreach to relatives received the most unqualified support; outreach to the relatives' physician or interaction with the relatives' electronic medical record received more tempered support. Support was motivated by the desire to have risk communicated accurately and quickly. The most common caveat was a desire to alert relatives before the health system contacted them. Of 57 named relatives who were members of the same health system, we retrieved a single match for 40 (70.2%) based on name or birthdate. Health system involvement in familial risk notification received support in a sample of patients in a US integrated health system, and identification of relatives is feasible.

Factors associated with future dental care utilization among low-income smokers overdue for dental visits.

BACKGROUND: Smokers are at increased risk of oral disease. While routine dental care can help prevent and treat oral health problems, smokers have far lower rates of dental care utilization compared with non-smokers. We sought to better understand which factors may facilitate or hinder dental care utilization among low-income smokers participating in a randomized intervention trial in order to inform future intervention planning. METHODS: This is a secondary analysis of data collected between 2015 and 2017 as part of the OralHealth4Life trial. Participants were eligible callers to the Louisiana, Nebraska, and Oregon state tobacco quitlines who had no dental appointment in the prior or upcoming six months. We examined the association between participants' baseline characteristics and their receiving professional dental care between baseline and the 6-month follow-up survey. RESULTS: Participants were racially diverse (42% non-White) and two-thirds had an annual household income under $20,000. Most (86.7%) had not had a dental cleaning in more than one year. Commonly cited barriers to dental care included cost (83.7%) and no dental insurance (78.1%). Those with dental insurance were more likely to see a dentist at follow-up (RR 1.66). Similarly, those reporting a dental insurance barrier to care were less likely to see a dentist at follow-up (RR 0.69); however, there was no significant utilization difference between those reporting a cost barrier vs. those who did not. After controlling for these financial factors, the following baseline characteristics were significantly associated with a higher likelihood of dental care utilization at 6 months: higher motivation (RR 2.16) and self-efficacy (RR 1.80) to visit the dentist, having a disability (RR 1.63), having a higher education level (RR 1.52), and having perceived gum disease (RR 1.49). Factors significantly associated with a lower likelihood of dental care utilization included being married (RR 0.68) and not having a last dental cleaning within the past year (RR 0.47). CONCLUSIONS: Our findings provide important insight into factors that may facilitate or deter use of professional dental care among low-income smokers. This information could inform the development of future interventions to promote dental care utilization. TRIAL REGISTRATION: ClinicalTrials.gov : NCT02347124 ; registered 27 January 2015.

Mobile Apps for Oral Health Promotion: Content Review and Heuristic Usability Analysis.

BACKGROUND: There has been an increase in consumer-facing mobile health (mHealth) apps in recent years. Prior reviews have characterized the availability, usability, or quality of popular mHealth apps targeting a range of health behaviors, but none has examined apps that promote better oral health care. Oral disease affects billions of people worldwide and mobile phone use is on the rise, so the market for well-designed and effective oral health apps is substantial. OBJECTIVE: We examined the content and usability of popular oral health promotion apps to better understand the current state of these self-help interventions and inform the need and opportunity for future app development. METHODS: Between February and March 2018, we identified oral health-focused apps that were designed for Android or iOS, available in English, and targeted adult consumers (as opposed to children or dental health professionals). The sample was limited to the most popular and highly rated apps on each platform. For each app reviewed, we assessed its basic descriptive characteristics (eg, platform, cost), evidence of a theoretical basis or empirical validation, key program functionality, and the extent to which the app addressed diet and tobacco and alcohol use as risk factors for oral disease. We characterized the framing (ie, gain vs loss) of all persuasive messaging and conducted a heuristic analysis to assess each app's usability as a persuasive health technology. RESULTS: Thirty-three apps were eligible for review based on the selection criteria. Two-thirds (22/33, 67%) were geared toward the general public as opposed to dental clinic patients, insurance plan members, or owners of specific electric toothbrushes. Most (31/33, 94%) were free to download, and a majority (19/33, 58%) were sponsored by software developers as opposed to oral health experts. None offered any theoretical basis for the content or had been empirically validated. Common program features included tools for tracking or reminding one to brush their teeth and assistance scheduling dental appointments. Nineteen apps (58%) included educational or persuasive content intended to influence oral health behavior. Only 32% (6/19) of these included a larger proportion of gain-framed than loss-framed messaging. Most of the apps did not mention diet, alcohol or tobacco-important risk factors for oral disease. Overall, the apps performed poorly on standard usability heuristics recommended for persuasive health technologies. CONCLUSIONS: The quality of the reviewed apps was generally poor. Important opportunities exist to develop oral health promotion apps that have theoretically grounded content, are empirically validated, and adhere to good design principles for persuasive health technologies.

Approaches to Behavioral Health Integration at High Performing Primary Care Practices.

INTRODUCTION: Behavioral health (BH) integration has been proposed as an important strategy to help primary care practices meet the needs of their patient population, but there is little research on the ways in which practices are integrating BH services. This article describes the goals for BH integration at 30 high-performing primary care practices and strategies to operationalize these goals. METHODS: We conducted a qualitative analysis of BH integration at 30 US primary care practices that had been selected for the Learning from Effective Ambulatory Practices (LEAP) project following an interview-based assessment and rating process. Data collection included formal and informal interviews with practice leaders and staff, as well as observations of clinical encounters. We used a template analysis approach to thematically analyze data. RESULTS: Most LEAP practices looked to BH integration to help them provide timely BH care for all patients, share the work of providing BH-related care, meet the full spectrum of patient needs, and improve the capacity and functioning of care teams. Practices operationalized these goals in various ways, including universal BH screening and involving BH specialists in chronic illness care. As they worked toward their BH integration goals, LEAP practices faced common challenges related to staffing, health information technology, funding, and community resources. DISCUSSION: High-performing primary care practices share common goals for BH integration, as well as common challenges operationalizing these goals. As US residents increasingly receive BH services in primary care, it is critical to remove barriers to BH integration and support primary care practices in meeting a full spectrum of patient needs.

Behavioral Counseling for Skin Cancer Prevention: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Exposure to UV radiation, especially in childhood, increases skin cancer risk. Objective: To systematically review the evidence on the benefits and harms of behavioral counseling for skin cancer prevention to inform the US Preventive Services Task Force (USPSTF). Data Sources: Cochrane Central Register of Controlled Trials, MEDLINE, and PubMed were searched for studies published from January 2009 to March 31, 2016, for skin cancer prevention and from August 2005 to March 31, 2016, for skin self-examination. Surveillance in targeted publications was conducted through February 14, 2018. Studies included in previous USPSTF reports were reevaluated for inclusion. Study Selection: Fair- and good-quality studies of primary care-relevant behavioral interventions focused on improving skin cancer outcomes, intermediate outcomes, or skin cancer prevention and self-examination behaviors. Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and extracted data into evidence tables. Results were qualitatively summarized but not pooled because of heterogeneity of measures. Main Outcomes and Measures: Skin cancer, sunburn, precursor skin lesions, sun protection behaviors, and any harms from interventions. Results: Twenty-one trials in 27 publications were included (N = 20 561). No studies assessed skin cancer outcomes in pediatric populations; 1 adult trial (n = 1356) promoting skin self-examination found no significant difference in participants diagnosed with melanoma in the intervention group vs the control group at 12-month follow-up (0 vs 1 diagnosis). There was no consistent improvement in prevention of sunburn for children (3 trials [n = 2508]) or adults (6 trials [n = 3959]). There were small to moderate increases in sun protection behavior in pediatric populations (6 trials [n = 4252]) and adults (12 trials [n = 13 099]) and small increases in skin self-examination in adults (11 trials [n = 7771]; odds ratios, 1.16-2.6). One of 3 trials of indoor tanning found an intervention effect; an appearance-focused intervention (n = 430) resulted in a smaller increase in mean indoor tanning sessions at 6 months in the intervention group vs the control group. Harms were rarely reported: 1 trial of skin self-examination (n = 1356) found an increase in skin procedures in the intervention group vs the control group at 6 months (8.0% vs 3.6%, P < .001) but not between 6 and 12 months (3.9% vs 3.3%, P = .50), and 1 trial (n = 217) found no between-group difference in skin cancer worry (28.9% vs 18.4%, P = .16). Conclusions and Relevance: Behavioral interventions can increase sun protection behavior, but there is no consistent evidence that interventions are associated with a reduction in the frequency of sunburn in children or adults and minimal evidence on skin cancer outcomes. Intervention can increase skin self-examination in adults but may lead to increased skin procedures without detecting additional atypical nevi or skin cancers.