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PURPOSE: Healthy cancer survivorship involves patients' active engagement with preventative health behaviors and follow-up care. While clinicians and patients have typically held dual responsibility for activating these behaviors, transitioning some clinician effort to technology and health coaches may enhance guideline implementation. This paper reports on the acceptability of the Shared Healthcare Actions & Reflections Electronic systems in survivorship (SHARE-S) program, an entirely virtual multicomponent intervention incorporating e-referrals, remotely-delivered health coaching, and automated text messages to enhance patient self-management and promote healthy survivorship. METHODS: SHARE-S was evaluated in single group hybrid implementation-effectiveness pilot study. Patients were e-referred from the clinical team to health coaches for three health self-management coaching calls and received text messages to enhance coaching. Semi-structured qualitative interviews were conducted with 21 patient participants, 2 referring clinicians, and 2 health coaches to determine intervention acceptability (attitudes, appropriateness, suitability, convenience, and perceived effectiveness) and to identify important elements of the program and potential mechanisms of action to guide future implementation. RESULTS: SHARE-S was described as impactful and convenient. The nondirective, patient-centered health coaching and mindfulness exercises were deemed most acceptable; text messages were less acceptable. Stakeholders suggested increased flexibility in format, frequency, timing, and length of participation, and additional tailored educational materials. Patients reported tangible health behavior changes, improved mood, and increased accountability and self-efficacy. CONCLUSIONS: SHARE-S is overall an acceptable and potentially effective intervention that may enhance survivors' self-management and well-being. Alterations to tailored content, timing, and dose should be tested to determine impact on acceptability and outcomes.
Subject(s)
Cancer Survivors , Mentoring , Qualitative Research , Humans , Female , Male , Middle Aged , Cancer Survivors/psychology , Mentoring/methods , Aged , Pilot Projects , Survivorship , Adult , Neoplasms/therapy , Neoplasms/psychology , Self-Management/methods , Text Messaging , Patient Acceptance of Health Care/psychology , Health Behavior , TelemedicineABSTRACT
BACKGROUND: serious illness conversations (SIC), particularly for persons living with cognitive impairment (PLCI), inconsistently happen in primary care. Pragmatic, scalable strategies are needed to promote SIC for PLCI. DESIGN: Pragmatic, prospective single-arm pilot study that occurred between July 1, 2021 and May 30, 2022 across seven primary care practices in North Carolina. PARTICIPANTS: Community-dwelling patients aged 65 and older with known or probable mild cognitive impairment or dementia (with decision-making capacity) and their care partners (if available). INTERVENTION: SIC telehealth intervention (TeleVoice) via video or telephone to assist PLCI in discussing their current goals, values, and future medical preferences, while facilitating documentation within the EHR. MAIN OUTCOMES: Main feasibility outcomes included reach/enrollment, intervention completion, and adoption rates at the clinic and provider level. Primary effectiveness outcomes included SIC documentation and quality within the EHR and usage of advance care planning billing (ACP) codes. RESULTS: Of the 163 eligible PLCI approached, 107 (66%) enrolled (mean age 83.7 years, 68.2% female, 16.8% Black, 22% living in a geographic area of high socioeconomic disadvantage) and 81 (76%) completed the SIC telehealth intervention; 45 care partners agreed to participate (mean age 71.5 years, 80% female). Adoption at clinic level was 50%, while 75% of providers within these clinics participated. Among PLCI that completed the intervention, SIC documentation and usage of ACP billing codes was 100% and 96%, respectively, with 96% (n = 78) having high-quality SIC documentation. No significant differences were observed between telephone and video visits. CONCLUSION: These findings provide preliminary evidence to support the feasibility of conducting SICs through telehealth to specifically meet the needs of community-dwelling PLCI. Further investigation of the sustainability of the intervention and its long-term impact on patient and caregiver outcomes is needed.
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BACKGROUND: Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients. METHODS: An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients). DISCUSSION: Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers. TRIAL REGISTRATION: Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.
Subject(s)
Multicenter Studies as Topic , Renal Dialysis , Humans , Treatment Outcome , Time Factors , Comparative Effectiveness Research , Randomized Controlled Trials as Topic , Equivalence Trials as Topic , United States , Kidney Failure, Chronic/therapy , Kidney Failure, Chronic/diagnosisABSTRACT
Social determinants of health and unmet social needs are directly related to cancer outcomes, from diagnosis to survivorship. If identified, unmet social needs can be addressed in oncology care by changing care plans in collaboration with patients' preferences and accounting for clinical practice guidelines (eg, reducing the frequency of appointments, switching treatment modalities) and connecting patients to resources within healthcare organizations (eg, social work support, patient navigation) and with community organizations (eg, food banks, housing assistance programs). Screening for social needs is the first step to identifying those who need additional support and is increasingly recognized as a necessary component of high-quality cancer care delivery. Despite evidence about the relationship between social needs and cancer outcomes and the abundance of screening tools, the implementation of social needs screening remains a challenge, and little is known regarding the adoption, reach, and sustainability of social needs screening in routine clinical practice. We present data on the adoption and implementation of social needs screening at two large academic cancer centers and discuss three challenges associated with implementing evidence-based social needs screening in clinical practice: (1) identifying an optimal approach for administering social needs screening in oncology care, (2) adequately addressing identified unmet needs with resources and support, and (3) coordinating social needs screening between oncology and primary care.
Subject(s)
Needs Assessment , Neoplasms , Social Determinants of Health , Humans , Neoplasms/therapy , Medical Oncology , Social Support , Social Work/organization & administration , Health Services Needs and Demand , Professional Practice Gaps , Cancer Care Facilities/organization & administrationSubject(s)
Child Health Services , Smoking Cessation , Child , Female , Pregnancy , Humans , Pregnant Women , Smoking/epidemiology , Tobacco SmokingABSTRACT
BACKGROUND: Numerous prior opinion papers, administrative electronic health record data studies, and cross-sectional surveys of telehealth during the pandemic have been published, but none have combined assessments of video visit success monitoring with longitudinal assessments of perceived challenges to the rapid adoption of video visits during the pandemic. OBJECTIVE: This study aims to quantify (1) the use of video visits (compared with in-person and telephone visits) over time during the pandemic, (2) video visit successful connection rates, and (3) changes in perceived video visit challenges. METHODS: A web-based survey was developed for the dual purpose of monitoring and improving video visit implementation in our health care system during the COVID-19 pandemic. The survey included questions regarding rates of in-person, telephone, and video visits for clinician-patient encounters; the rate of successful connection for video visits; and perceived challenges to video visits (eg, software, hardware, bandwidth, and technology literacy). The survey was distributed via email to physicians, advanced practice professionals, and clinicians in May 2020. The survey was repeated in March 2021. Differences between the 2020 and 2021 responses were adjusted for within-respondent correlation across surveys and tested using generalized estimating equations. RESULTS: A total of 1126 surveys were completed (511 surveys in 2020 and 615 surveys in 2021). In 2020, only 21.7% (73/336) of clinicians reported no difficulty connecting with patients during video visits and 28.6% (93/325) of clinicians reported no difficulty in 2021. The distribution of the percentage of successfully connected video visits ("Over the past two weeks of scheduled visits, what percentage did you successfully connect with patients by video?") was not significantly different between 2020 and 2021 (P=.74). Challenges in conducting video visits persisted over time. Poor connectivity was the most common challenge reported by clinicians. This response increased over time, with 30.5% (156/511) selecting it as a challenge in 2020 and 37.1% (228/615) in 2021 (P=.01). Patients not having access to their electronic health record portals was also a commonly reported challenge (109/511, 21.3% in 2020 and 137/615, 22.3% in 2021, P=.73). CONCLUSIONS: During the pandemic, our health care delivery system rapidly adopted synchronous patient-clinician communication using video visits. As experience with video visits increased, the reported failure rate did not significantly decline, and clinicians continued to report challenges related to general network connectivity and patient access to technology.
Subject(s)
COVID-19 , Communications Media , Humans , COVID-19/epidemiology , Pandemics , Cross-Sectional Studies , CommunicationABSTRACT
BACKGROUND: Low-dose computed tomography (lung cancer screening) can reduce lung cancer-specific mortality by 20-24%. Based on this evidence, the United States Preventive Services Task Force recommends annual lung cancer screening for asymptomatic high-risk individuals. Despite this recommendation, utilization is low (3-20%). Lung cancer screening may be particularly beneficial for African American patients because they are more likely to have advanced disease, lower survival, and lower screening rates compared to White individuals. Evidence points to multilevel approaches that simultaneously address multiple determinants to increase screening rates and decrease lung cancer burden in minoritized populations. This study will test the effects of provider- and patient-level strategies for promoting equitable lung cancer screening utilization. METHODS: Guided by the Health Disparities Research Framework and the Practical, Robust Implementation and Sustainability Model, we will conduct a quasi-experimental study with four primary care clinics within a large health system (MedStar Health). Individuals eligible for lung cancer screening, defined as 50-80 years old, ≥ 20 pack-years, currently smoking, or quit < 15 years, no history of lung cancer, who have an appointment scheduled with their provider, and who are non-adherent to screening will be identified via the EHR, contacted, and enrolled (N = 184 for implementation clinics, N = 184 for comparison clinics; total N = 368). Provider participants will include those practicing at the partner clinics (N = 26). To increase provider-prompted discussions about lung screening, an electronic health record (EHR) clinician reminder will be sent to providers prior to scheduled visits with the screening-eligible participants. To increase patient-level knowledge and patient activation about screening, an inreach specialist will conduct a pre-visit phone-based educational session with participants. Patient participants will be assessed at baseline and 1-week post-visit to measure provider-patient discussion, screening intentions, and knowledge. Screening referrals and screening completion rates will be assessed via the EHR at 6 months. We will use mixed methods and multilevel assessments of patients and providers to evaluate the implementation outcomes (adoption, feasibility, acceptability, and fidelity). DISCUSSION: The study will inform future work designed to measure the independent and overlapping contributions of the multilevel implementation strategies to advance equity in lung screening rates. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04675476. Registered December 19, 2020.
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INTRODUCTION: Policies that reduce tobacco retail density to decrease tobacco use among the youth are critical for the tobacco endgame. This paper reviews a Hungarian tobacco regulatory measure, which, since 2013, has confined the sale of tobacco products exclusively to so-called National Tobacco Shops, summarises the changes in the national tobacco retail marketplace and reports on analyses of the impact of this intervention on illegal sales to minors and adolescent smoking behaviour. METHODS: We reviewed the available national statistical data on the structure and dynamics of the tobacco retail market. Changes in lifetime and current (past 30 days) use of cigarettes among Hungarian adolescents aged 13-17 years were assessed using data from international youth surveys on health behaviours collected in 2010-2020. RESULTS: Since the start of policy implementation, the density of tobacco shops in Hungary decreased by 85%, from 4.1 to 0.6 per 1000 persons. The prevalence of lifetime and current cigarette smoking among adolescents declined by 13-24 percentage points (pp) and by 4.8-15 pp, respectively. The rate of illegal sales of tobacco products to minors decreased by 27.6 pp, although the prevalence of compensatory access strategies, especially asking others to buy cigarettes for minors, increased. CONCLUSIONS: After a significant decrease in the nationwide availability of licensed tobacco retailers, Hungary experienced short-term reductions in youth smoking prevalence. However, the sporadic implementation of complementary, evidence-based tobacco control strategies might limit further declines in youth smoking initiation and tobacco product use.
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PURPOSE: (1) Identify the proportion of primary care visits in which American Indian/Alaska Native (AI/AN) men receive a prostate-specific antigen test (PSAT)and/or a digital rectal exam (DRE), (2) describe characteristics of primary care visits in which AI/AN receive PSA and/or DRE, and (3) identify whether AI/AN receive PSA and/or DRE less often than non-Hispanic White (nHW) men. METHODS: This was a secondary analysis of the National Ambulatory Medical Care Survey (NAMCS) during 2013-2016 and 2018 and the NAMCS Community Health Center (CHC) datasets from 2012-2015. Weighted bivariate and multivariable tests analyzed the data to account for the complex survey design. RESULTS: For AI/AN men, 1.67 per 100 visits (95% CI = 0-4.24) included a PSATs (or PSAT) and 0 visits included a DRE between 2013-2016 and 2018. The rate of PSA for non-AI/AN men was 9.35 per 100 visits (95% CI = 7.78-10.91) and 2.52 per 100 visits (95% CI = 1.61-3.42) for DRE. AI/AN men were significantly less likely to receive a PSA than nHW men (aOR = 0.09, 95% CI = 0.01-0.83). In CHCs, AI/AN men experienced 4.26 PSAT per 100 visits (95% CI = 0.96-7.57) compared to 5.00 PSAT per 100 visits (95% CI = 4.40-5.68) for non-AI/AN men. DRE rates for AI/AN men was 0.63 per 100 visits (95% CI = 0-1.61) compared to 1.05 per 100 (95% CI = 0.74-1.37) for non-AI/AN men. There was not a statistically significant disparity in the CHC data regarding PSA (OR = 0.91, 95% CI = 0.42-1.98) or DRE (OR = 0.75, 95% CI = 0.15-3.74), compared to nHW men. CONCLUSION: Efforts are needed to better understand why providers may not use PSA and DRE with AI/AN men compared to nHW men.
Subject(s)
Healthcare Disparities , Physical Examination , Prostate-Specific Antigen , Prostatic Neoplasms , Humans , Male , American Indian or Alaska Native , Physical Examination/methods , Primary Health Care , Prostate-Specific Antigen/blood , Prostatic Neoplasms/blood , Prostatic Neoplasms/diagnosis , Prostatic Neoplasms/ethnology , Rectum , WhiteABSTRACT
BACKGROUND: Screening for colorectal cancer (CRC) is widely recommended but underused, even though CRC is the third most diagnosed cancer and the second leading cause of cancer death in the USA. The mPATH™ program is an iPad-based application designed to identify patients due for CRC screening, educate them on the commonly used screening tests, and help them select their best option, with the goal of increasing CRC screening rates. METHODS: The mPATH™ program consists of questions asked of all adult patients at check-in (mPATH™-CheckIn), as well as a module specific for patients due for CRC screening (mPATH™-CRC). In this study, the mPATH™ program is evaluated through a Type III hybrid implementation-effectiveness design. Specifically, the study consists of three parts: (1) a cluster-randomized controlled trial of primary care clinics comparing a "high touch" evidence-based implementation strategy with a "low touch" implementation strategy; (2) a nested pragmatic study evaluating the effectiveness of mPATH-CRC™ on completion of CRC screening; and (3) a mixed-methods study evaluating factors that facilitate or impede the maintenance of interventions like mPATH-CRC™. The primary objective is to compare the proportion of patients aged 50-74 who are eligible for CRC screening who complete mPATH™-CRC in the 6th month following implementation between the "high touch" and "low touch" implementation strategies. Effectiveness of mPATH™-CRC is evaluated by comparing the proportion who complete CRC screening within 16 weeks of their visit to the clinic between a pre-implementation cohort (8 months before implementation) and a post-implementation cohort (8 months after implementation). DISCUSSION: This study will provide data on both the implementation of the mPATH™ program and its effectiveness in improving screening rates for CRC. In addition, this work has the potential to have an even broader impact by identifying strategies to support the sustained use of other similar technology-based primary care interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT03843957. Registered on 18 February 2019.
Subject(s)
Colorectal Neoplasms , Early Detection of Cancer , Adult , Humans , Early Detection of Cancer/methods , Colorectal Neoplasms/diagnosis , Colorectal Neoplasms/prevention & control , Mass Screening/methods , Government Programs , ColonoscopyABSTRACT
INTRODUCTION: Initial cancer survivorship care planning efforts focused on information sharing demonstrated limited impact on patient health outcomes. We designed the Shared Healthcare Actions & Reflections Electronic Systems in survivorship (SHARE-S) program to enhance survivorship guideline implementation by transitioning some effort from clinicians to technology and patients through supporting health self-management (e.g., healthy lifestyles). METHODS: We conducted a single-group hybrid implementation-effectiveness pilot study. SHARE-S incorporated three strategies: (1) e-referral from the clinical team for patient engagement, (2) three health self-management coach calls, and (3) text messages to enhance coaching. Our primary implementation measure was the proportion of patients e-referred who enrolled (target >30%). Secondary implementation measures assessed patient engagement. We also measured effectiveness by describing changes in patient health outcomes. RESULTS: Of the 118 cancer survivor patients e-referred, 40 engaged in SHARE-S (proportion enrolled = 34%). Participants had a mean age of 57.4 years (SD = 15.7), 73% were female, 23% were Black/African American, and 5 (12.5%) were from a rural location. Patient-level adherence to coach calls was >90%. Changes from baseline to follow-up showed at least a small effect (Cohen's d = 0.2) for improvements in: mindful attention, alcohol use, physical activity, fruit and vegetable intake, days of mindfulness practice, depressive symptoms, ability to participate in social roles and activities, cancer-specific quality of life, benefits of having cancer, and positive feelings. CONCLUSION: The SHARE-S program successfully engaged cancer survivor patients. Once enrolled, patients showed promising improvements in health outcomes. Supporting patient self-management is an important component of optimizing delivery of cancer survivorship care.
Subject(s)
Neoplasms , Survivorship , Humans , Female , Middle Aged , Male , Pilot Projects , Quality of Life , Neoplasms/therapy , Patient ParticipationABSTRACT
Many head acceleration events (HAEs) observed in youth football emanate from a practice environment. This study aimed to evaluate HAEs in youth football practice drills using a mouthpiece-based sensor, differentiating between inertial and direct HAEs. Head acceleration data were collected from athletes participating on 2 youth football teams (ages 11-13 y) using an instrumented mouthpiece-based sensor during all practice sessions in a single season. Video was recorded and analyzed to verify and assign HAEs to specific practice drill characteristics, including drill intensity, drill classification, and drill type. HAEs were quantified in terms of HAEs per athlete per minute and peak linear and rotational acceleration and rotational velocity. Mixed-effects models were used to evaluate the differences in kinematics, and generalized linear models were used to assess differences in HAE frequency between drill categories. A total of 3237 HAEs were verified and evaluated from 29 football athletes enrolled in this study. Head kinematics varied significantly between drill categorizations. HAEs collected at higher intensities resulted in significantly greater kinematics than lower-intensity drills. The results of this study add to the growing body of evidence informing evidence-based strategies to reduce head impact exposure and concussion risk in youth football practices.
Subject(s)
Brain Concussion , Football , Humans , Adolescent , Head , AccelerationABSTRACT
BACKGROUND: Clinical decision support (CDS) tools in electronic health records (EHRs) are often used as core strategies to support quality improvement programs in the clinical setting. Monitoring the impact (intended and unintended) of these tools is crucial for program evaluation and adaptation. Existing approaches for monitoring typically rely on health care providers' self-reports or direct observation of clinical workflows, which require substantial data collection efforts and are prone to reporting bias. OBJECTIVE: This study aims to develop a novel monitoring method leveraging EHR activity data and demonstrate its use in monitoring the CDS tools implemented by a tobacco cessation program sponsored by the National Cancer Institute's Cancer Center Cessation Initiative (C3I). METHODS: We developed EHR-based metrics to monitor the implementation of two CDS tools: (1) a screening alert reminding clinic staff to complete the smoking assessment and (2) a support alert prompting health care providers to discuss support and treatment options, including referral to a cessation clinic. Using EHR activity data, we measured the completion (encounter-level alert completion rate) and burden (the number of times an alert was fired before completion and time spent handling the alert) of the CDS tools. We report metrics tracked for 12 months post implementation, comparing 7 cancer clinics (2 clinics implemented the screening alert and 5 implemented both alerts) within a C3I center, and identify areas to improve alert design and adoption. RESULTS: The screening alert fired in 5121 encounters during the 12 months post implementation. The encounter-level alert completion rate (clinic staff acknowledged completion of screening in EHR: 0.55; clinic staff completed EHR documentation of screening results: 0.32) remained stable over time but varied considerably across clinics. The support alert fired in 1074 encounters during the 12 months. Providers acted upon (ie, not postponed) the support alert in 87.3% (n=938) of encounters, identified a patient ready to quit in 12% (n=129) of encounters, and ordered a referral to the cessation clinic in 2% (n=22) of encounters. With respect to alert burden, on average, both alerts fired over 2 times (screening alert: 2.7; support alert: 2.1) before completion; time spent postponing the screening alert was similar to completing (52 vs 53 seconds) the alert, and time spent postponing the support alert was more than completing (67 vs 50 seconds) the alert per encounter. These findings inform four areas where the alert design and use can be improved: (1) improving alert adoption and completion through local adaptation, (2) improving support alert efficacy by additional strategies including training in provider-patient communication, (3) improving the accuracy of tracking for alert completion, and (4) balancing alert efficacy with the burden. CONCLUSIONS: EHR activity metrics were able to monitor the success and burden of tobacco cessation alerts, allowing for a more nuanced understanding of potential trade-offs associated with alert implementation. These metrics can be used to guide implementation adaptation and are scalable across diverse settings.
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BACKGROUND: One-half of all people who undergo lung cancer screening (LCS) currently use tobacco. However, few published studies have explored how to implement effective tobacco use treatment optimally during the LCS encounter. RESEARCH QUESTION: Was the Optimizing Lung Screening intervention (OaSiS) effective at reducing tobacco use among patients undergoing LCS in community-based radiology facilities? STUDY DESIGN AND METHODS: The OaSiS study (National Cancer Institute [NCI] Protocol No.: WF-20817CD) is an effectiveness-implementation hybrid type II cluster randomized trial of radiology facilities conducted in partnership with the Wake Forest National Cancer Institute Community Oncology Research Program research base. We randomly assigned 26 radiology facilities in 20 states to the intervention or usual care group. Staff at intervention facilities implemented a variety of strategies targeting the clinic and care team. Eligible patient participants were aged 55 to 77 years undergoing LCS and currently using tobacco. Of 1,094 who completed a baseline survey (523 intervention group, 471 control group) immediately before the LCS appointment, 956 completed the 6-month follow-up (86% retention rate). Fifty-four percent of those who reported not using tobacco at 6 months completed biochemical verification via mailed cotinine assay. Generalized estimating equation marginal models were used in an intention-to-treat analysis to predict 7-day tobacco use abstinence. RESULTS: The average self-reported abstinence among participants varied considerably across facilities (0%-27%). Despite a significant increase in average cessation rate over time (0% at baseline to approximately 13% at 6 months; P < .0001), tobacco use did not differ by trial group at 14 days (OR, 0.96; 95% CI, 0.46-1.99; P = .90), 3 months (OR, 1.17; 95% CI, 0.69-1.99; P = .56), or 6 months (OR, 0.97; 95% CI, 0.65-1.43; P = .87). INTERPRETATION: The OaSiS trial participants showed a significant reduction in tobacco use over time, but no difference by trial arm was found. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03291587; URL: www. CLINICALTRIALS: gov.
Subject(s)
Lung Neoplasms , Smoking Cessation , Tobacco Use Cessation , Humans , Smoking Cessation/methods , Early Detection of Cancer , Lung Neoplasms/diagnosis , LungABSTRACT
Purpose: Costs of Papanicolaou (Pap) tests and mammograms are a primary barrier for women aged 18-39 seeking screening and diagnostic services. Race/ethnicity and rural/border resident status compound their risks for delayed diagnosis, possibly resulting in higher mortality. Methods: We analyzed cross-sectional data from young adult (YA) women (aged 18-39) from a cancer education and patient navigation (PN) program in rural and border Texas from 2012 to 2016. Descriptive statistics, Chi-square tests, and logistic regressions summarized sociodemographic variables and receipt of PN, Pap tests, and mammograms. Results: The sample consisted of 1181 women aged 31.8 years (standard deviation 5.5) on average. A total of 795 (67.3%) received PN, 494 (41.8%) received a Pap test, and 121 (10.3%) received a mammogram. The YA women attending the program due to cost (odds ratio [OR]: 7.24; confidence interval [CI]: 4.74-11.05) and reporting 1 (OR: 3.84; CI: 2.40-6.14) or 2+ barriers (OR: 6.00; CI: 3.61-9.99) had higher odds of being navigated than those not concerned about cost and not identifying a barrier. The YA women attending due to cost (OR: 2.22, CI: 1.61-3.05) and receiving navigation (OR: 1.92; CI: 1.29-2.84) had higher odds of receiving a Pap test than their counterparts. The majority receiving a mammogram were worried about cost (85.1%); 40.5% had a family history of breast cancer, and a doctor or nurse recommended a mammogram for 15.7%. Conclusion: Detection of cervical and breast cancer in YA women residing in rural and border Texas may be improved with PN to assist with financial barriers to care and service coordination.
Subject(s)
Breast Neoplasms , Papanicolaou Test , Female , Young Adult , Humans , Texas , Vaginal Smears , Cross-Sectional Studies , Breast Neoplasms/diagnosisABSTRACT
BACKGROUND: Rural patients with ST-elevation myocardial infarction (STEMI) may be less likely to receive prompt reperfusion therapy. This study's primary objective was to compare rural versus urban time intervals among a national cohort of prehospital patients with STEMI. METHODS: The ESO Data Collaborative (Austin, TX), containing records from 1,366 emergency medical services agencies, was queried for adult 9-1-1 responses with suspected STEMI from 1/1/2018-12/31/2019. The scene address for each encounter was classified as either urban or rural using the 2010 US Census Urban Area Zip Code Tabulation Area relationship. The primary outcome was total EMS interval (9-1-1 call to hospital arrival); a key secondary outcome was the proportion of responses that had EMS intervals under 60 minutes. Generalized estimating equations were used to determine whether rural versus urban differences in interval outcomes occurred when adjusting for loaded mileage (distance from scene to hospital) and patient and clinical encounter characteristics. RESULTS: Of 15,915,027 adult 9-1-1 transports, 23,655 records with suspected STEMI were included in the analysis. Most responses (91.6%, n = 21,661) occurred in urban settings. Median EMS interval was 37.6 minutes (IQR 30.0-48.0) in urban settings compared to 57.0 minutes (IQR 46.5-70.7) in rural settings (p < 0.01). Urban responses more frequently had EMS intervals <60 minutes (89.5%, n = 19,130), compared to rural responses (55.5%, n = 1,100, p < 0.01). After adjusting for loaded mileage, age, sex, race/ethnicity, abnormal vital signs, pain assessment, aspirin administration, and IV/IO attempt, rural location was associated with a 5.8 (95%CI 4.2-7.4) minute longer EMS interval than urban, and rural location was associated with a reduced chance of achieving EMS interval < 60 minutes (OR 0.40; 95%CI 0.33-0.49) as compared to urban location. CONCLUSION: In this large national sample, rural location was associated with significantly longer EMS interval for patients with suspected STEMI, even after accounting for loaded mileage.
Subject(s)
Emergency Medical Services , ST Elevation Myocardial Infarction , Adult , Humans , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/therapy , Time Factors , Hospitals , Rural PopulationABSTRACT
Background: Patient portals can be an innovative and efficient way to engage patients in advance care planning (ACP). However, comprehension and judgment in older adults with cognitive impairment presents several barriers and challenges to engaging in new technology. Our objective was to develop an ACP portal-based tool (ACPVoice) for community-dwelling persons living with cognitive impairment (PLCI) by engaging end-users in the design process. Methods: Two rounds of cognitive interviews were conducted to identify and resolve cognitive issues related to comprehension, judgment, response, and to assess content validity. Purposive sampling was used with the goal of enrolling 15 different participants (five with mild cognitive impairment and five dyads (those with mild dementia and their care partner) in each round to assess respondents' understanding of questions related to advance care planning to be administered via the patient portal. Results: Twenty PLCI (mean age 78.4, 10 females [50%]) and ten care partners (mean age 60.9, 9 females [90%]) completed cognitive interviews between May 2021 and October 2021. The mean Mini-Mental State Examination score for PLCI was 25.6 (SD 2.6). Unclear wording and undefined vague and/or unfamiliar terms were the major issues identified. Revisions to item wording, response options, and instructions were made to improve question comprehension and response as well as navigational ease. Conclusion: Minor changes to the wording, format, and response options substantially improved respondents' ability to interpret the item content of the ACPVoice tool. Dissemination and implementation of the ACPVoice tool could help to engage community-dwelling PLCI in ACP discussions.
Subject(s)
Advance Care Planning , Cognitive Dysfunction , Dementia , Female , Humans , Aged , Independent Living , Cognitive Dysfunction/therapy , Dementia/psychologyABSTRACT
The National Cancer Institute's Implementation Science Centers in Cancer Control (ISC3) Network represents a large-scale initiative to create an infrastructure to support and enable the efficient, effective, and equitable translation of approaches and evidence-based treatments to reduce cancer risk and improve outcomes. This Cancer MoonshotSM-funded ISC3 Network consists of 7 P50 Centers that support and advance the rapid development, testing, and refinement of innovative approaches to implement a range of evidence-based cancer control interventions. The Centers were designed to have research-practice partnerships at their core and to create the opportunity for a series of pilot studies that could explore new and sometimes risky ideas and embed in their infrastructure a 2-way engagement and collaboration essential to stimulating lasting change. ISC3 also seeks to enhance capacity of researchers, practitioners, and communities to apply implementation science approaches, methods, and measures. The Organizing Framework that guides the work of ISC3 highlights a collective set of 3 core areas of collaboration within and among Centers, including to 1) assess and incorporate dynamic, multilevel context; 2) develop and conduct rapid and responsive pilot and methods studies; and 3) build capacity for knowledge development and exchange. Core operating principles that undergird the Framework include open collaboration, consideration of the dynamic context, and engagement of multiple implementation partners to advance pragmatic methods and health equity and facilitate leadership and capacity building across implementation science and cancer control.
Subject(s)
Implementation Science , Neoplasms , United States , Humans , National Cancer Institute (U.S.) , Delivery of Health Care , Neoplasms/therapy , Capacity Building/methodsABSTRACT
Understanding characteristics of head acceleration events (HAEs) in youth football is vital in developing strategies to improve athlete safety. This study aimed to characterize HAEs in youth football using an instrumented mouthpiece. Youth football athletes (ages 11-13) participating on two teams were enrolled in this study for one season. Each athlete was instrumented with a mouthpiece-based sensor throughout the season. HAEs were verified on film to ensure that mouthpiece-based sensors triggered during contact. The number of HAEs, peak resultant linear and rotational accelerations, and peak resultant rotational velocity were quantified. Mixed effects models were used to evaluate differences in mean kinematic metrics among all HAEs for session type, athlete position, and contact surface. A total of 5,292 HAEs were collected and evaluated from 30 athletes. The median (95th percentile) peak resultant linear acceleration, rotational acceleration, and rotational velocity was 9.5 g (27.0 g), 666.4 rad s-2 (1863.3 rad s-2), and 8.5 rad s-1 (17.4 rad s-1), respectively. Athletes experienced six (22) HAEs per athlete per session (i.e., practice, game). Competition had a significantly higher mean number of HAEs per athlete per session and mean peak rotational acceleration. Peak resultant rotational kinematics varied significantly among athlete positions. Direct head impacts had higher mean kinematics compared to indirect HAEs, from body collisions. The results of this study demonstrate that session type, athlete position, and contact surface (i.e., direct, indirect) may influence HAE exposure in youth football.
Subject(s)
Brain Concussion , Football , Soccer , Adolescent , Humans , Child , Head Protective Devices , Acceleration , Athletes , Biomechanical Phenomena , HeadABSTRACT
Based on the findings from the National Lung Screening Trial, the U.S. Preventive Services Task Force recommends annual low dose computed tomography (LDCT) lung cancer screening (LCS) among high-risk adults. Approximately 54% of individuals seeking LCS report current cigarette smoking. Effective smoking cessation interventions, offered at the time of LCS, enhances the health benefits of screening that are attributable to reductions in lung cancer overall and tobacco-related mortality. Considering these data, the Centers for Medicare & Medicaid Services' (CMS) 2015 decision to cover LCS with LDCT required that radiology imaging facilities make tobacco cessation interventions available for people who smoke. In February 2022, CMS reversed their 2015 coverage requirement for delivering tobacco use treatment at the time of LDCT; CMS retained the requirement for counseling during the shared decision-making visit prior to the exam. The policy change does not diminish the importance of offering high-quality tobacco cessation services in conjunction with routine LDCT for LCS. However, LCS programs face a range of barriers to implementing tobacco use treatment in their settings. As a result, implementation has lagged. Closing the "evidence to practice" gap is the focus of implementation science, a field that offers a set of rigorous methods and a systematic approach to identifying and overcoming contextual barriers to implementing evidence-based guidelines in a range of clinical settings. In this paper, we describe how implementation science frameworks and methods can be used to help guide LCS programs in their efforts to integrate tobacco use treatment and discuss policy changes needed to further facilitate the delivery of TUT as an essential component of the LCS process.
Lung cancer is the leading cause of cancer death in the United States. There is strong evidence, from a large number of international studies, that lung cancer screening for people who meet specific criteria, can reduce lung cancer-related deaths. Based on these findings, the Centers for Medicare and Medicaid decided to provide insurance coverage for lung cancer screening for eligible patients. This includes people aged 5080 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Over 50% of people who seek lung cancer screening report current cigarette smoking. Studies show that offering these smokers support to quit at the time of screening can further increase survival rates by reducing both deaths from lung cancer and other tobacco-related diseases. Unfortunately, lung cancer screening programs do not consistently provide effective treatments to help smokers quit. This is a missed opportunity to engage smokers in quitting when the health risk of tobacco use is most salient, and therefore smokers may be more willing to engage in tobacco use treatment. This paper provides detailed guidance on how programs can implement high quality tobacco use treatment services in conjunction with lung cancer screening.