Duration of New-Onset Depressive Symptoms During Medical Residency.

Importance: The implications of new-onset depressive symptoms during residency, particularly for first-year physicians (ie, interns), on the long-term mental health of physicians are unknown. Objective: To examine the association between and persistence of new-onset and long-term depressive symptoms among interns. Design, Setting, and Participants: The ongoing Intern Health Study (IHS) is a prospective annual cohort study that assesses the mental health of incoming US-based resident physicians. The IHS began in 2007, and a total of 105 residency programs have been represented in this national study. Interns enrolled sequentially in annual cohorts and completed follow-up surveys to screen for depression using the 9-item Patient Health Questionnaire-9 (PHQ-9) throughout and after medical training. The data were analyzed from May 2023 to March 2024. Exposure: A positive screening result for depression, defined as an elevated PHQ-9 score of 10 or greater (indicating moderate to severe depression) at 1 or more time points during the first postgraduate year of medical training (ie, the intern year). Main Outcomes and Measures: The main outcomes assessed were mean PHQ-9 scores (continuous) and proportions of physicians with an elevated PHQ-9 score (≥10; categorical or binary) at the time of the annual follow-up survey. To account for repeated measures over time, a linear mixed model was used to analyze mean PHQ-9 scores and a generalized estimating equation (GEE) was used to analyze the binary indicator for a PHQ-9 score of 10 or greater. Results: This study included 858 physicians with a PHQ-9 score of less than 10 before the start of their internship. Their mean (SD) age was 27.4 (9.0) years, and more than half (53.0% [95% CI, 48.5%-57.5%]) were women. Over the follow-up period, mean PHQ-9 scores did not return to the baseline level assessed before the start of the internship in either group (those with a positive depression screen as interns and those without). Among interns who screened positive for depression (PHQ-9 score ≥10) during their internship, mean PHQ-9 scores were significantly higher at both 5 years (4.7 [95% CI, 4.4-5.0] vs 2.8 [95% CI, 2.5-3.0]; P < .001) and 10 years (5.1 [95% CI, 4.5-5.7] vs 3.5 [95% CI, 3.0-4.0]; P < .001) of follow-up. Furthermore, interns with an elevated PHQ-9 score (≥10) demonstrated a higher likelihood of meeting this threshold during each year of follow-up. Conclusions and Relevance: In this cohort study of IHS participants, a positive depression screening result during the intern year had long-term implications for physicians, including having persistently higher mean PHQ-9 scores and a higher likelihood of meeting this threshold again. These findings underscore the pressing need to address the mental health of physicians who experience depressive symptoms during their training and to emphasize the importance of interventions to sustain the health of physicians throughout their careers.

Racialization processes and depressive symptoms among pregnant Mexican-origin immigrant women.

This study examines how racialization processes (conceptualized as multilevel and dynamic processes) shape prenatal mental health by testing the association of discrimination and the John Henryism hypothesis on depressive symptoms for pregnant Mexican-origin immigrant women. We analyzed baseline data (n = 218) from a healthy lifestyle intervention for pregnant Latinas in Detroit, Michigan. Using separate multiple linear regression models, we examined the independent and joint associations of discrimination and John Henryism with depressive symptoms and effect modification by socioeconomic position. Discrimination was positively associated with depressive symptoms (ß = 2.84; p < .001) when adjusting for covariates. This association did not vary by socioeconomic position. Women primarily attributed discrimination to language use, racial background, and nativity. We did not find support for the John Henryism hypothesis, meaning that the hypothesized association between John Henryism and depressive symptoms did not vary by socioeconomic position. Examinations of joint associations of discrimination and John Henryism on depressive symptoms indicate a positive association between discrimination and depressive symptoms (ß = 2.81; p < .001) and no association of John Henryism and depressive symptoms (ß = -0.83; p > .05). Results suggest complex pathways by which racialization processes affect health and highlight the importance of considering experiences of race, class, and gender within racialization processes.

Making Choices: A Multi-institutional, Longitudinal Cohort Study Assessing Changes in Treatment Outcome Valuation for Low-Risk Thyroid Cancer.

OBJECTIVE: To evaluate the relative importance of treatment outcomes to patients with low-risk thyroid cancer (TC). SUMMARY BACKGROUND DATA: Overuse of total thyroidectomy (TT) for low-risk TC is common. Emotions from a cancer diagnosis may lead patients to choose TT resulting in outcomes that do not align with their preferences. METHODS: Adults with clinically low-risk TC enrolled in a prospective, multi-institutional, longitudinal cohort study from 11/2019-6/2021. Participants rated treatment outcomes at the time of their surgical decision and again 9 months later by allocating 100 points amongst 10 outcomes. T-tests and Hotelling's T 2 statistic compared outcome valuation within and between subjects based on chosen extent of surgery (TT vs. lobectomy). RESULTS: Of 177 eligible patients, 125 participated (70.6% response) and 114 completed the 9-month follow-up (91.2% retention). At the time of the treatment decision, patients choosing TT valued the risk of recurrence more than those choosing lobectomy and the need to take thyroid hormone less ( P <0.05). At repeat valuation, all patients assigned fewer points to cancer being removed and the impact of treatment on their voice, and more points to energy levels ( P <0.05). The importance of the risk of recurrence increased for those who chose lobectomy and decreased for those choosing TT ( P <0.05). CONCLUSION: The relative importance of treatment outcomes changes for patients with low-risk TC once the outcome has been experienced to favor quality of life over emotion-related outcomes. Surgeons can use this information to discuss the potential for asthenia or changes in energy levels associated with total thyroidectomy.

Close distal margin is associated with locoregional rectal cancer recurrence: A multicenter study.

BACKGROUND AND OBJECTIVES: The importance of the radial margin for rectal cancer resection is well understood. However, surgeons have deemphasized the distal margin, accepting very close distal margins to perform sphincter-preserving surgery. We hypothesized that distal margins < 1 cm would be an independent risk factor for locoregional recurrence. The objective was to determine whether close distal margins are associated with increased locoregional recurrence risk. METHODS: This was a multi-institutional retrospective cohort study conducted at six academic medical centers including patients who received low anterior resection surgery for primary rectal cancer between 2007 and 2018. RESULTS: Of 556 low anterior resection patients, the rate of close distal margin was 12.8% (n = 71), and the locoregional recurrence rate was 5.0% (n = 28). The locoregional recurrence rate for close distal margin cases was 9.9% (n = 7) compared to 4.3% (n = 21) for distal margins ≥1.0 cm. In multivariable analysis, the only factor significantly associated with locoregional recurrence was close distal margin (adjusted odds ratio: 2.80, confidence interval: 1.08-7.25, p = 0.035). CONCLUSIONS: Rectal cancer patients with close distal margins (<1 cm) following low anterior resection had a significantly higher risk for locoregional recurrence. Therefore, the decision to perform low anterior resection with margins < 1 cm should be taken with caution.

Elucidating academic surgical staff perspectives of medical student learning in the operating room: An embedded mixed methods study.

BACKGROUND: The operating room (OR) is a complex environment for medical students. Little is known about the OR staff's perception of medical students. METHODS: We utilized an embedded mixed methods design to characterize surgical staff perceptions of students at an academic institution. We surveyed 408 OR nursing/technician staff with 16 follow-up interviews. RESULTS: 139 respondents. 91.3% reported having daily-to-weekly interactions with medical students. Yet, only 37.9% agreed that "patient care is better when medical students are part of the team." 25.2% felt confident that they knew what a student's education entails outside the OR. 93.5% agreed that interprofessional training between physicians and OR staff should be included in educational programs. 54% agreed that their responsibilities include medical student training in the OR setting. CONCLUSIONS: Despite an overall desire for teamwork, this study highlights a lack of knowledge of each others' roles. To improve OR culture and team dynamics, concerted efforts need to be made around interprofessional training.

Examining National Guideline Changes Association With Hemithyroidectomy Rates by Surgeon Volume.

INTRODUCTION: The 2015 American Thyroid Association (ATA) guidelines established that hemithyroidectomy (HT) is an appropriate treatment for patients with low-risk thyroid cancer. HT rates increased since the ATA guidelines were released; however, the relationship between surgeon volume and the initial extent of surgery has not been established. METHODS: A statewide database was used to identify patients with thyroid cancer who underwent initial thyroidectomy from 2013 to 2020. High-volume thyroid surgeons were defined as those who performed >25 thyroid procedures per year. A mixed-effect logistic model was used to compare low- and high-volume surgeons' initial extent of surgery pre-2015 and post-2015 ATA guidelines. Descriptive statistics were used to describe other surgical outcomes. RESULTS: The analysis included 3199 patients with thyroid cancer who underwent initial thyroidectomy. Twenty-four surgeons (6%) were considered high-volume; they performed 48% (n = 1349) of the operations. After the 2015 ATA guidelines were released, the rate of HT increased significantly for low- (23% to 28%, P = 0.042) but not high-volume (19% to 23%, P = 0.149) surgeons. Low-volume surgeons had significantly higher rates of readmission (P = 0.008), re-operation (P = 0.030), complications (P < 0.001), and emergency room visits (P = 0.002) throughout the entire study period. CONCLUSIONS: The publication of the 2015 ATA guidelines was associated with a significant increase in HT rates, primarily in low-volume thyroid surgeons. While low-volume surgeons began performing more HTs, they continued to have higher rates of readmission, reoperations, complications, and emergency room visits than high-volume surgeons.

International Center-Level Variation in Utilization of Completion Lymph Node Dissection and Adjuvant Systemic Therapy for Sentinel Lymph Node-Positive Melanoma at Major Referral Centers.

OBJECTIVE: The aim of this study was to determine overall trends and center-level variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy for sentinel lymph node (SLN)-positive melanoma. SUMMARY BACKGROUND DATA: Based on recent clinical trials, management options for SLN-positive melanoma now include effective adjuvant systemic therapy and nodal observation instead of CLND. It is unknown how these findings have shaped practice or how these contemporaneous developments have influenced their respective utilization. METHODS: We performed an international cohort study at 21 melanoma referral centers in Australia, Europe, and the United States that treated adults with SLN-positive melanoma and negative distant staging from July 2017 to June 2019. We used generalized linear and multinomial logistic regression models with random intercepts for each center to assess center-level variation in CLND and adjuvant systemic treatment, adjusting for patient and disease-specific characteristics. RESULTS: Among 1109 patients, performance of CLND decreased from 28% to 8% and adjuvant systemic therapy use increased from 29 to 60%. For both CLND and adjuvant systemic treatment, the most influential factors were nodal tumor size, stage, and location of treating center. There was notable variation among treating centers in management of stage IIIA patients and use of CLND with adjuvant systemic therapy versus nodal observation alone for similar risk patients. CONCLUSIONS: There has been an overall decline in CLND and simultaneous adoption of adjuvant systemic therapy for patients with SLN-positive melanoma though wide variation in practice remains. Accounting for differences in patient mix, location of care contributed significantly to the observed variation.

Prophylactic mastectomy and occult malignancy: Surgical and imaging considerations.

BACKGROUND: Sentinel node biopsy (SLNB) is not routinely recommended for patients undergoing prophylactic mastectomy (PM), yet omission remains a subject of debate among surgeons. A modern patient cohort was examined to determine occult malignancy (OM) incidence within PM specimens to reinforce current recommendations. METHODS: All PM performed over a 5-year period were retrospectively identified, including women with unilateral breast cancer who underwent synchronous or delayed contralateral PM or women with elevated cancer risk who underwent bilateral PM. RESULTS: The study population included 772 patients (598 CPM, 174 BPM) with a total of 39 OM identified: 17 invasive cancers (14 CPM, 3 BPM) and 22 DCIS (19 CPM, 3 BPM). Of the 86 patients for whom SLNB was selectively performed, 1 micrometastasis was identified. In the CPM cohort, risk of OM increased with age, presence of LCIS of either breast, or presence of a non-BRCA high-penetrance gene mutation, while preoperative magnetic resonance imaging was associated with lower likelihood of OM. CONCLUSIONS: Given the low incidence of invasive OM in this updated series, routine SLNB is of low value for patients undergoing PM. For patients with indeterminate radiographic findings, discordant preoperative biopsies, LCIS, or non-BRCA high-penetrance gene mutations, selective SLNB implementation could be considered.

Using Path Analysis and Linear Regression to Test for Gender and Participation: Effects in a Culturally Tailored Diabetes Intervention for Latino Adults.

While the incidence and prevalence of type 2 diabetes is higher among Latino/as, Latino men are disproportionately affected and have poorer outcomes. We aimed to determine whether gender impacted any outcomes in a culturally tailored type 2 diabetes (T2D) intervention and to evaluate the effects of gender and intervention participation intensity on outcomes at 6-month follow-up. Nested path and regression models were compared with the likelihood ratio test and information criteria in a sample of Latino/a adults with T2D (n = 222) participating in a T2D community health worker (CHW)-led intervention. Path analysis showed that the effect of the intervention did not vary by gender. The intervention was associated with significant improvements in knowledge of T2D management 0.24 (0.10); p = 0.014, diabetes distress, -0.26 (0.12); p = 0.023, and self-efficacy, 0.61 (0.21); p = 0.005. At 6-month follow-up, improved self-management was associated with greater self-efficacy and Hemoglobin A1c (HbA1c) was lower by -0.18 (0.08); p = 0.021 for each unit of self-management behavior. Linear regressions showed that class attendance and home visits contributed to positive intervention results, while gender was non-significant. Pathways of change in a CHW-led culturally tailored T2D intervention can have a significant effect on participant behaviors and health status outcomes, regardless of gender.

Facility-Level Variation of Low-Value Breast Cancer Treatments in Older Women with Early-Stage Breast Cancer: Analysis of a Statewide Claims Registry.

BACKGROUND: Since 2004, national guidelines have supported the omission of sentinel lymph node biopsy (SLNB) and radiotherapy for women ≥ 70 years of age with early-stage, hormone receptor-positive (HR+) breast cancer, but many women continue to receive at least one of these services. Provider- and patient-level factors may contribute to persistent utilization, but the role of facility-level factors is unknown. We aimed to determine facility-level variation of SLNB and adjuvant radiotherapy utilization in older women with early-stage, HR+ breast cancer undergoing breast-conserving surgery (BCS). Additionally, we aimed to explore factors associated with SLNB and radiotherapy utilization and the intra-facility correlation in their utilization. METHODS: We conducted a retrospective cohort study using a statewide registry of claims data. We included women ≥70 years of age diagnosed with breast cancer who underwent BCS from 2012 to 2019 at 80 hospitals in the Michigan Value Collaborative. The main outcome was inter-facility rates and variation of SLNB and radiotherapy, as well as intra-facility correlation in their utilization. RESULTS: The cohort included 7253 women (median age 77 years). Only 20% (n = 1440) underwent BCS alone, whereas 71% (n = 5122) underwent SLNB and 52% (n = 3793) received radiotherapy. Inter-facility rates of SLNB ranged from 35 to 82% (median 70%), and radiotherapy ranged from 19 to 72% (median 49%). SLNB and radiotherapy were positively correlated (r = 0.27, p = 0.016). CONCLUSIONS: SLNB and radiotherapy rates remain high with significant variation in utilization at the facility level. High utilizers of SLNB are likely to be high utilizers of radiotherapy, suggesting the opportunity for strategic targeting of these facilities and their clinicians.

Statewide Episode Spending Variation of Mastectomy for Breast Cancer.

BACKGROUND: Centralizing complex cancer operations, such as pancreatectomy and esophagectomy, has been shown to increase value, largely due to reduction in complications. For high-volume operations with low complication rates, it is unknown to what degree value varies between facilities, or by what mechanism value may be improved. To identify possible opportunities for value enhancement for such operations, we sought to describe variations in episode spending for mastectomy with a secondary aim of identifying patient- and facility-level determinants of variation. STUDY DESIGN: Using the Michigan Value Collaborative risk-adjusted, price-standardized claims data, we evaluated mean spending for patients undergoing mastectomy at 74 facilities (n = 7,342 patients) across the state of Michigan. Primary outcomes were 30- and 90-day episode spending. Using linear mixed models, facility- and patient-level factors were explored for association with spending variability. RESULTS: Among 7,342 women treated across 74 facilities, mean 30-day spending by facility ranged from $11,129 to $20,830 (median $14,935). Ninety-day spending ranged from $17,303 to $31,060 (median $23,744). Patient-level factors associated with greater spending included simultaneous breast reconstruction, bilateral surgery, length of stay, and readmission. Among women not undergoing reconstruction, variation persisted, and length of stay, bilateral surgery, and readmission were all associated with increased spending. CONCLUSION: Michigan hospitals have significant variation in spending for mastectomy. Reducing length of stay through wider adoption of same-day discharge for mastectomy and reducing the frequency of bilateral surgery may represent opportunities to increase value, without compromising patient safety or oncologic outcomes.

Incremental Spending Associated with Low-Value Treatments in Older Women with Breast Cancer.

BACKGROUND: In most women ≥ 70 years old with hormone-receptor-positive breast cancer, axillary staging and adjuvant radiotherapy provide no survival advantage over surgery and hormone therapy alone. Despite recommendations for their omission, sentinel lymph node biopsy (SLNB) and adjuvant radiotherapy rates remain high. While treatment side effects are well documented, less is known about the incremental spending associated with SLNB and adjuvant radiotherapy. METHODS: Using a statewide multipayer claims registry, we examined spending associated with breast cancer treatment in a retrospective cohort of women ≥ 70 years old undergoing surgery. RESULTS: 9074 women ≥70 years old underwent breast cancer resection between 2012 and 2019, with 78% (n = 7122) receiving SLNB and/or adjuvant radiotherapy within 90 days of surgery. Women undergoing SLNB were more likely to receive radiation (51% vs. 28%; p < 0.001 and OR = 2.68). Average 90-day spending varied substantially based upon treatment received, ranging from US$10,367 (breast-conserving surgery alone) to US$27,370 (mastectomy with SLNB and adjuvant radiotherapy). The relative increases in 90-day treatment spending in the breast-conserving surgery cohort was 65% for SLNB, 82% for adjuvant radiotherapy, and 120% for both treatments. CONCLUSIONS: SLNB and adjuvant radiotherapy have significant spending implications in older women with breast cancer, even though they are unlikely to improve survival.

Using path analysis to model the process of change in HbA1c among African Americans and Latinos in a community health worker diabetes intervention.

OBJECTIVE: To examine which components of a culturally tailored community health worker (CHW) intervention improved glycemic control and intermediate outcomes among Latina/o and African American participants with diabetes. METHODS: The sample included 326 African American and Latina/o adults with type 2 diabetes in Detroit, MI. CHWs provided interactive group diabetes self-management classes and home visits, and accompanied clients to a clinic visit during the 6-month intervention period. We used path analysis to model the processes by which each intervention component affected change in diabetes self-efficacy, diabetes-related distress, knowledge of diabetes management, and HbA1c. RESULTS: The group-based healthy lifestyle component was significantly associated with improved knowledge. The group-based self-management section was significantly associated with reduced diabetes-related distress. Intervention class attendance was positively associated with self-efficacy. Diabetes self-management mediated the reductions in HbA1c associated with reductions in diabetes distress. CONCLUSIONS: Path analysis allowed each potential pathway of change in the intervention to be simultaneously analyzed to identify which aspects of the CHW intervention contributed to changes in diabetes-related behaviors and outcomes among African Americans and Latinas/os. PRACTICE IMPLICATIONS: Findings reinforce the importance of interactive group sessions in efforts to improve diabetes management and outcomes among Latina/o and African American adults with diabetes.

Insult to injury: National analysis of return to work and financial outcomes of trauma patients.

BACKGROUND: While much of trauma care is rightly focused on improving inpatient survival, the ultimate goal of recovery is to help patients return to their daily lives after injury. Although the overwhelming majority of trauma patients in the United States survive to hospital discharge, little is known nationally regarding the postdischarge economic burden of injuries among trauma survivors. METHODS: We used the National Health Interview Survey from 2008 to 2017 to identify working-age trauma patients, aged 18 to 64 years, who sustained injuries requiring hospitalization. We used propensity score matching to identify noninjured respondents. Our primary outcome measure was postinjury return to work among trauma patients. Our secondary outcomes included measures of food insecurity, medical debt, accessibility and affordability of health care, and disability. RESULTS: A nationally weighted sample of 319,580 working-age trauma patients were identified. Of these patients, 51.7% were employed at the time of injury, and 58.9% of them had returned to work at the time of interview, at a median of 47 days postdischarge. Higher rates of returning to work were associated with shorter length of hospital stay, higher education level, and private health insurance. Injury was associated with food insecurity at an adjusted odds ratio (aOR) of 1.8 (95% confidence interval, 1.40-2.37), with difficulty affording health care at aOR of 1.6 (1.00-2.47), with medical debt at aOR of 2.6 (2.11-3.20), and with foregoing care due to cost at aOR of 2.0 (1.52-2.63). Working-age trauma patients had disability at an aOR of 17.6 (12.93-24.05). CONCLUSION: The postdischarge burden of injury among working-age US trauma survivors is profound-patients report significant limitations in employment, financial security, disability, and functional independence. A better understanding of the long-term impact of injury is necessary to design the interventions needed to optimize postinjury recovery so that trauma survivors can lead productive and fulfilling lives after injury. LEVEL OF EVIDENCE: Economic & Value-Based Evaluations, level II; Prognostic, level II.

Cost-Effectiveness of a Diabetes Self-Management Education and Support Intervention Led by Community Health Workers and Peer Leaders: Projections From the Racial and Ethnic Approaches to Community Health Detroit Trial.

OBJECTIVE: To simulate the long-term cost-effectiveness of a peer leader (PL)-led diabetes self-management support (DSMS) program following a structured community health worker (CHW)-led diabetes self-management education (DSME) program in reducing risks of complications in people with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS: The trial randomized 222 Latino adults with T2D to 1) enhanced usual care (EUC); 2) a CHW-led, 6-month DSME program and 6 months of CHW-delivered monthly telephone outreach (CHW only); or 3) a CHW-led, 6-month DSME program and 12 months of PL-delivered weekly group sessions with telephone outreach to those unable to attend (CHW + PL). Empirical data from the trial and the validated Michigan Model for Diabetes were used to estimate cost and health outcomes over a 20-year time horizon from a health care sector perspective, discounting both costs and benefits at 3% annually. The primary outcome measure was the incremental cost-effectiveness ratio (ICER). RESULTS: Over 20 years, the CHW + PL intervention had an ICER of $28,800 and $5,900 per quality-adjusted life-year (QALY) gained compared with the EUC and CHW-only interventions, respectively. The CHW-only intervention had an ICER of $430,600 per QALY gained compared with the EUC intervention. In sensitivity analyses, the results comparing the CHW + PL with EUC and CHW-only interventions were robust to changes in intervention effects and costs. CONCLUSIONS: The CHW + PL-led DSME/DSMS intervention improved health and provided good value compared with the EUC intervention. The 6-month CHW-led DSME intervention without further postintervention CHW support was not cost effective in Latino adults with T2D.

Variations in Persistent Use of Low-Value Breast Cancer Surgery.

Importance: Through the Choosing Wisely campaign, surgical specialties identified 4 low-value breast cancer operations. Preliminary data suggest varying rates of deimplementation and have identified patient-level and clinician-level determinants of continued overuse. However, little information exists about facility-level variation or determinants of differential deimplementation. Objective: To identify variation and determinants of persistent use of low-value breast cancer surgical care. Design, Setting, and Participants: Retrospective cohort study in which reliability-adjusted facility rates of each procedure were calculated using random-intercept hierarchical logistic regression before and after evidence demonstrated that each procedure was unnecessary. The National Cancer Database is a prospective cancer registry of patients encompassing approximately 70% of all new cancer diagnoses from more than 1500 facilities in the United States. Data were analyzed from November 2019 to August 2020. The registry included women 18 years and older diagnosed as having breast cancer between 2004 and 2016 and meeting inclusion criteria for each Choosing Wisely recommendation. Main Outcomes and Measures: Rate of each low-value breast cancer procedure based on facility type and breast cancer volume categories before and after the release of data supporting each procedure's omission. Results: The total cohort included 920 256 women with a median age of 63 years. Overall, 86% self-identified as White, 10% as Black, 3% as Asian, and 4.5% as Hispanic. Most women in this cohort were insured (51% private and 47% public), were living in a metropolitan or urban area (88% and 11%, respectively), and originated from the top half of income-earning households (65.5%). While there was significant deimplementation of axillary lymph node dissection and lumpectomy reoperation in response to guidelines supporting omission of these procedures, rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy in older women increased during the study period. Academic research programs and high-volume facilities overall demonstrated the greatest reduction in use of these low-value procedures. There was significant interfacility variation for each low-value procedure. Facility-level axillary lymph node dissection rates ranged from 7% to 47%, lumpectomy reoperation rates ranged from 3% to 62%, contralateral prophylactic mastectomy rates ranged from 9% to 67%, and sentinel lymph node biopsy rates ranged from 25% to 97%. Pearson correlation coefficient for each combination of 2 of the 4 procedures was less than 0.11, suggesting that hospitals were not consistent in their deimplementation performance across all 4 procedures. Many were high outliers in one procedure but low outliers in another. Conclusions and Relevance: Interfacility variation demonstrates a performance gap and an opportunity for formal deimplementation efforts targeting each procedure. Several facility-level characteristics were associated with differential deimplementation and performance.

Trends in Contralateral Prophylactic Mastectomy Utilization for Small Unilateral Breast Cancer.

BACKGROUND: For average-risk women with unilateral breast cancer, contralateral prophylactic mastectomy (CPM) offers no survival benefit and contributes to increased costs and patient harm. Despite recommendations from professional societies against CPM, utilization of this service is increasing, partly due to patients' desire for breast symmetry when undergoing mastectomy. Most women with small tumors are candidates for breast-conserving surgery (BCS) and could avoid CPM. We describe CPM utilization in women with small, unilateral tumors, and identify determinants of possible overuse. METHODS: Using the National Cancer Database, we identified women with unilateral, T1 breast cancer. We evaluated utilization of BCS, unilateral mastectomy, and CPM and assessed patient, tumor, and facility factors associated with CPM. RESULTS: Of 765,487 women with small, unilateral breast cancer, 69% underwent BCS and 31% chose mastectomy. Of 176,673 women ≥70 y, 75% underwent BCS and 25% chose mastectomy. CPM rates in both cohorts have increased since 2006. Decreased adjuvant radiotherapy in older women was associated with increased BCS rates. Patient factors (younger age, white race, private insurance, and breast reconstruction), tumor factors (lobular histology, higher grade, and human epidermal growth factor receptor 2 positive/estrogen receptor negative status), and facility factors (type and geographic location) were associated with increased CPM rates compared with unilateral mastectomy in multivariable models. CONCLUSIONS: Most women with small unilateral breast cancer are candidates for BCS, yet one-third elects to undergo a mastectomy, of which a rising percentage opts for CPM. Tailoring deimplementation strategies to factors influencing treatment may help reduce CPM utilization and associated financial toxicity, pain, and disability.

Enhancing vocational training in corrections: A type 1 hybrid randomized controlled trial protocol for evaluating virtual reality job interview training among returning citizens preparing for community re-entry.

The Michigan Department of Corrections operates the Vocational Villages, which are skilled trades training programs set within prisons that include an immersive educational community using virtual reality, robotics, and other technologies to develop employable trades. An enhancement to the Vocational Villages could be an evidence-based job interview training component. Recently, we conducted a series of randomized controlled trials funded by the National Institute of Mental Health to evaluate the efficacy of virtual reality job interview training (VR-JIT). The results suggested that the use of VR-JIT was associated with improved job interview skills and a greater likelihood of receiving job offers within 6 months. The primary goal of this study is to report on the protocol we developed to evaluate the effectiveness of VR-JIT at improving interview skills, increasing job offers, and reducing recidivism when delivered within two Vocational Villages via a randomized controlled trial and process evaluation. Our aims are to: (1) evaluate whether services-as-usual in combination with VR-JIT, compared to services-as-usual alone, enhances employment outcomes and reduces recidivism among returning citizens enrolled in the Vocational Villages; (2) evaluate mechanisms of employment outcomes and explore mechanisms of recidivism; and (3) conduct a multilevel, mixed-method process evaluation of VR-JIT implementation to assess the adoptability, acceptability, scalability, feasibility, and implementation costs of VR-JIT.

Study protocol: A multisite trial of Work-Related Cognitive behavioral therapy for unemployed persons with social anxiety.

This paper provides a methodological description of a multi-site, randomized controlled trial (RCT) of a cognitive-behavioral intervention for enhancing employment success among unemployed persons whose employment efforts have been undermined by social anxiety disorder (SAD). SAD is a common and impairing condition, with negative impacts on occupational functioning. In response to these documented employment-related impairments, in a previous project, we produced and tested an eight-session work-related group cognitive-behavioral therapy provided alongside vocational services as usual (WCBT + VSAU). WCBT is delivered by vocational service professionals and is designed in a context and style that overcomes accessibility and stigma-related obstacles with special focus on employment-related targets. Our previous project found that WCBT + VSAU significantly improved social anxiety, depression, and a range of employment-related outcomes compared to a control group of socially anxious job-seekers who received vocational services as usual without WCBT (VSAU-alone). Participants in this study were all homeless, primarily African American job-seekers with high levels of psychiatric comorbidity and limited education and employment histories. The present, two-region study addresses whether WCBT + VSAU enhances job placement, job retention and mental health outcomes in a larger sample assessed over an extended follow-up period. In addition, this trial evaluates whether the effects of WCBT + VSAU generalize to a new population of urban-based, racially diverse job-seekers with vocational and educational histories that differ from our original sample. This study also investigates the system-effects of WCBT + VSAU in a new site that will be informative for broad implementation of WCBT + VSAU. Finally, this project involves a refined, technology-assisted form of WCBT + VSAU designed to be delivered more easily by vocational services professionals.