MigraineTracker: Examining Patient Experiences with Goal-Directed Self-Tracking for a Chronic Health Condition.

Self-tracking and personal informatics offer important potential in chronic condition management, but such potential is often undermined by difficulty in aligning self-tracking tools to an individual's goals. Informed by prior proposals of goal-directed tracking, we designed and developed MigraineTracker, a prototype app that emphasizes explicit expression of goals for migraine-related self-tracking. We then examined migraine patient experiences in a deployment study for an average of 12+ months, including a total of 50 interview sessions with 10 patients working with 3 different clinicians. Patients were able to express multiple types of goals, evolve their goals over time, align tracking to their goals, personalize their tracking, reflect in the context of their goals, and gain insights that enabled understanding, communication, and action. We discuss how these results highlight the importance of accounting for distinct and concurrent goals in personal informatics together with implications for the design of future goal-directed personal informatics tools.

Pakikisama: Filipino Patient Perspectives on Health Care Access and Utilization.

PURPOSE: Filipinos have unique social determinants of health, cultural values, and beliefs that contribute to a higher prevalence of cardiovascular comorbidities such as hypertension, diabetes, and dyslipidemia. We aimed to identify Filipino values, practices, and belief systems that influenced health care access and utilization. METHODS: We conducted 1-on-1 semistructured interviews with self-identified Filipino patients. Our qualitative study utilized a constant-comparative approach for data collection, thematic coding, and interpretive analysis. RESULTS: We interviewed 20 Filipinos in a remote rural community to assess structural and social challenges experienced when interacting with the health care system. Our results suggest that Filipinos regard culture and language as pillars of health access. Filipinos trust clinicians who exhibited positive tone and body language as well as relatable and understandable communication. These traits are features of Pakikisama, a Filipino trait/value of "comfortableness and getting along with others." Relatability and intercultural values familiarity increased Filipino trust in a health care clinician. Filipinos may lack understanding about how to navigate the US Health care system, which can dissuade access to care. CONCLUSIONS: For the Filipino community, culture and language are fundamental components of health access. Health care systems have the opportunity to both improve intercultural clinical training and increase representation among clinicians and support staff to improve care delivery and navigation of health services. Participants reported not routinely relying on health care navigators.

Colonoscopy Outreach for Rural Communities (CORC): A study protocol of a pragmatic randomized controlled trial of a patient navigation program to improve colonoscopy completion for colorectal cancer screening.

BACKGROUND: Colonoscopy is one of the primary methods of screening for colorectal cancer (CRC), a leading cause of cancer mortality in the United States. However, up to half of patients referred to colonoscopy fail to complete the procedure, and rates of adherence are lower in rural areas. OBJECTIVES: Colonoscopy Outreach for Rural Communities (CORC) is a randomized controlled trial to test the effectiveness of a centralized patient navigation program provided remotely by a community-based organization to six geographically distant primary care organizations serving rural patients, to improve colonoscopy completion for CRC. METHODS: CORC is a type 1 hybrid implementation-effectiveness trial. Participants aged 45-76 from six primary care organizations serving rural populations in the northwestern United States are randomized 1:1 to patient navigation or standard of care control. The patient navigation is delivered remotely by a trained lay-person from a community-based organization. The primary effectiveness outcome is completion of colonoscopy within one year of referral to colonoscopy. Secondary outcomes are colonoscopy completion within 6 and 9 months, time to completion, adequacy of patient bowel preparation, and achievement of cecal intubation. Analyses will be stratified by primary care organization. DISCUSSION: Trial results will add to our understanding about the effectiveness of patient navigation programs to improve colonoscopy for CRC in rural communities. The protocol includes pragmatic adaptations to meet the needs of rural communities and findings may inform approaches for future studies and programs. TRIAL REGISTRATION: National Clinical Trial Identifier: NCT05453630. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT05453630. Registered July 6, 2022.

Association of Maternal Cervical Cancer Screening Adherence with Adolescent HPV Vaccination Among Adolescent-Mother Pairs.

Less than two-thirds of US adolescents are up-to-date with HPV vaccination. While mothers engaged in preventive care are more likely to seek preventive care for their children, current studies on associations between maternal cervical cancer screening (CCS) and adolescent HPV vaccination are needed. We assessed associations between maternal preventive service utilization and adolescent HPV vaccination using electronic health record data from a healthcare system in Washington State. We included adolescents (11-17 years) and their mothers with ≥ 1 primary care visit between 2018 and 2020. Outcomes were HPV vaccine initiation and completion. The primary exposure was maternal adherence to guideline-recommended CCS. Secondary exposures were maternal breast cancer screening adherence (for mothers ≥ 52 years) and ≥ 1 wellness visit ≤ 2 years. We used Generalized Estimating Equations to estimate prevalence ratios, and explore effect modification by adolescent sex, adolescent provider characteristics, and maternal language interpreter use. Of 4121 adolescents, 66% had a CCS-adherent mother, 82% initiated HPV vaccination, and 49% completed the series. CCS adherence was associated with higher initiation (adjusted prevalence ratio (APR):1.10, 95%CI:1.06-1.13) and completion (APR:1.16, 95%CI:1.08-1.23). Associations were stronger for male vs. female adolescents, adolescents who had a primary care provider in family practice vs. pediatrics, and adolescents who had the same primary care provider as their mother vs. not. Recent maternal wellness visit was also associated with higher initiation (APR:1.04, 95%CI:1.01-1.07) and completion (APR:1.12, 95%CI:1.05-1.20). Results suggest that delivering healthcare through a family-centered approach and engaging mothers in broad preventive care could increase adolescent HPV vaccination coverage.

Provider Perspectives on Addressing Firearm Safety with Older Adults in Primary Care.

OBJECTIVES: Chronic conditions, including mild cognitive impairment and depression, place older adults at high risk of firearm suicide. Approximately 40% of older adults have access to a firearm, and many do not store their firearms safely. However, firearm counseling occurs infrequently in clinical settings. Using by the Ottawa Decision Support Framework (ODSF) to conceptualize the decisional support needed by patients and their providers to facilitate firearm counseling, we explore provider perspectives on desired resources for addressing firearm safety with older adult patients. METHODS: From March - August 2022, we conducted 21 semi-structured interviews with primary care providers caring for older adults. We report deductive concepts as well as emergent themes. RESULTS: Major themes were identified from the three components of the ODSF; decisional needs, decision support and decisional outcomes. Themes included: provider self-efficacy to conduct firearm counseling, clinical workflow considerations, stories for change, patient diagnosis implications, and caregiver involvement. CONCLUSIONS: There is a need for decision aids in the clinical setting that facilitate firearm counseling and promotes shared decision-making about firearm storage. CLINICAL IMPLICATIONS: Implementing a decision aid in the clinical setting can improve provider self-efficacy to conduct firearm counseling and help reduce risk factors associated with firearm-related harm among older adults.

A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol.

BACKGROUND: Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices. METHODS: We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data. DISCUSSION: Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities. TRIAL REGISTRATION: NCT05591586.

Measuring the Impact of the COVID-19 Pandemic on Health Behaviors and Health Care Utilization in Rural and Urban Patients with Cancer and Cancer Survivors.

Healthcare access and health behaviors differ between those living in urban and rural communities and contribute to inequitable cancer health outcomes. The COVID-19 pandemic led to significant disruptions in daily life and healthcare delivery. This cross-sectional survey aimed to measure the impact of the COVID-19 pandemic on the health behaviors of cancer patients and survivors, comparing outcomes for urban and rural respondents. Survey was administered from January 2021-June 2021 to cancer patients or survivors (treated within the last 5 years) at one of six cancer centers in Washington and Idaho. Respondent ZIP code was used to assess rurality using Rural-Urban Commuting Area designation. 515 rural (43.5% of those contacted) and 146 urban (40% of those contacted) cancer patients and survivors participated. Few differences between urban and rural cancer patients and cancer survivors were noted. Rural residents were older (69.2 years vs. 66.9 years). Rural respondents had higher mean alcohol consumption than urban respondents (4.4 drinks per week vs. 2.7 drinks per week). 12.2% of those who reported drinking in the last 30 days also reported increased alcohol consumption since the start of the pandemic, with no difference in reported increased alcohol consumption in rural vs. urban respondents. 38.5% reported decreased physical activity. 20.5% reported cancelling or delaying cancer care due to the COVID-19 pandemic. Delays in cancer healthcare services and worsening health behaviors due to the COVID-19 pandemic may contribute to poorer health outcomes, with few differences between rural and urban cancer patients and cancer survivors.

Prioritizing rural populations in state comprehensive cancer control plans: a qualitative assessment.

PURPOSE: The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) requires that states develop comprehensive cancer control (CCC) plans and recommends that disparities related to rural residence are addressed in these plans. The objective of this study was to explore rural partner engagement and describe effective strategies for incorporating a rural focus in CCC plans. METHODS: States were selected for inclusion using stratified sampling based on state rurality and region. State cancer control leaders were interviewed about facilitators and barriers to engaging rural partners and strategies for prioritizing rural populations. Content analysis was conducted to identify themes across states. RESULTS: Interviews (n = 30) revealed themes in three domains related to rural inclusion in CCC plans. The first domain (barriers) included (1) designing CCC plans to be broad, (2) defining "rural populations," and (3) geographic distance. The second domain (successful strategies) included (1) collaborating with rural healthcare systems, (2) recruiting rural constituents, (3) leveraging rural community-academic partnerships, and (4) working jointly with Native nations. The third domain (strategies for future plan development) included (1) building relationships with rural communities, (2) engaging rural constituents in planning, (3) developing a better understanding of rural needs, and (4) considering resources for addressing rural disparities. CONCLUSION: Significant relationship building with rural communities, resource provision, and successful strategies used by others may improve inclusion of rural needs in state comprehensive cancer control plans and ultimately help plan developers directly address rural cancer health disparities.

Tacedinaline (CI-994), a class I HDAC inhibitor, targets intrinsic tumor growth and leptomeningeal dissemination in MYC-driven medulloblastoma while making them susceptible to anti-CD47-induced macrophage phagocytosis via NF-kB-TGM2 driven tumor inflammation.

BACKGROUND: While major advances have been made in improving the quality of life and survival of children with most forms of medulloblastoma (MB), those with MYC-driven tumors (Grp3-MB) still suffer significant morbidity and mortality. There is an urgent need to explore multimodal therapeutic regimens which are effective and safe for children. Large-scale studies have revealed abnormal cancer epigenomes caused by mutations and structural alterations of chromatin modifiers, aberrant DNA methylation, and histone modification signatures. Therefore, targeting epigenetic modifiers for cancer treatment has gained increasing interest, and inhibitors for various epigenetic modulators have been intensively studied in clinical trials. Here, we report a cross-entity, epigenetic drug screen to evaluate therapeutic vulnerabilities in MYC amplified MB, which sensitizes them to macrophage-mediated phagocytosis by targeting the CD47-signal regulatory protein α (SIRPα) innate checkpoint pathway. METHODS: We performed a primary screen including 78 epigenetic inhibitors and a secondary screen including 20 histone deacetylase inhibitors (HDACi) to compare response profiles in atypical teratoid/rhabdoid tumor (AT/RT, n=11), MB (n=14), and glioblastoma (n=14). This unbiased approach revealed the preferential activity of HDACi in MYC-driven MB. Importantly, the class I selective HDACi, CI-994, showed significant cell viability reduction mediated by induction of apoptosis in MYC-driven MB, with little-to-no activity in non-MYC-driven MB, AT/RT, and glioblastoma in vitro. We tested the combinatorial effect of targeting class I HDACs and the CD47-SIRPa phagocytosis checkpoint pathway using in vitro phagocytosis assays and in vivo orthotopic xenograft models. RESULTS: CI-994 displayed antitumoral effects at the primary site and the metastatic compartment in two orthotopic mouse models of MYC-driven MB. Furthermore, RNA sequencing revealed nuclear factor-kB (NF-κB) pathway induction as a response to CI-994 treatment, followed by transglutaminase 2 (TGM2) expression, which enhanced inflammatory cytokine secretion. We further show interferon-γ release and cell surface expression of engulfment ('eat-me') signals (such as calreticulin). Finally, combining CI-994 treatment with an anti-CD47 mAb targeting the CD47-SIRPα phagocytosis checkpoint enhanced in vitro phagocytosis and survival in tumor-bearing mice. CONCLUSION: Together, these findings suggest a dynamic relationship between MYC amplification and innate immune suppression in MYC amplified MB and support further investigation of phagocytosis modulation as a strategy to enhance cancer immunotherapy responses.

Euglycemic Diabetic Ketoacidosis Caused by Alcoholic Pancreatitis and Starvation Ketosis.

Starvation ketosis and pancreatitis are uncommon and underrecognized etiologies of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is associated commonly with pregnancy, use of insulin en route to the hospital, and use of sodium-glucose cotransporter-2 (SGLT-2) inhibitors. A 58-year-old male with past medical history of type II diabetes mellitus and alcoholism presented with chief complaint of nausea, vomiting, and poor oral intake for several weeks. Despite extensive history of diabetes and no recent SGLT-2 inhibitor use, his labs were consistent with euglycemic DKA. His imaging and clinical history also confirmed alcoholic pancreatitis. The patient was admitted for euglycemic DKA secondary to starvation ketosis and alcoholic pancreatitis. His anion gap and beta-hydroxybutyrate rapidly cleared with initiation of the DKA protocol. This case teaches us that clinicians should consider early initiation of the DKA protocol even in the setting of euglycemia, when a patient presents with high-anion-gap metabolic acidosis, a high beta-hydroxybutyrate level, and a clinical picture of pancreatitis and starvation.

Feasibility of delivering survivorship care via lay health educators: A pilot randomized controlled trial among rural cancer survivors.

PURPOSE: We tested the feasibility of survivorship care plan (SCP) delivery with/without a lay health educator (LHE) telephone-delivered information session among rural cancer survivors, and their effects on health-related self-efficacy and knowledge of cancer history. METHODS: Randomized trial of cancer survivors from 3 rural oncology clinics featuring either SCP alone (control) or SCP plus LHE-delivered information session (intervention). Participants completed a questionnaire on health-related self-efficacy and knowledge of cancer-specific medical history. Responses were compared to medical records for accuracy. SCPs were then mailed to participants. Approximately 5 months later, participants completed a follow-up questionnaire. A subset of participants took part in subsequent qualitative interviews about their study experience. FINDINGS: Of 301 survivors approached, 72 (23.9%) were randomized (mean age 66.4 years; 3.1 years from diagnosis; 62.5% female), and 65 (90.3%) completed the study. Global mental and physical health or self-efficacy scores did not change significantly from baseline to follow-up for either group. In exploratory analyses, self-efficacy increased in participants with inadequate/marginal health literacy in the intervention arm (+0.7, 95% CI = 0.1-1.2; P = .01). Accuracy of knowledge did not improve but was high at baseline (mean 76.0±14.5%). 60.1% and 48.4% of control and intervention participants, respectively, found SCPs definitely/somewhat useful. Qualitative data (n = 20) suggested that SCPs were helpful to patients when primary and oncology care were less integrated. CONCLUSIONS: An LHE-delivered informational session was feasible but had limited benefit to rural cancer survivors versus delivery of SCP alone but may be of benefit to patients with low health literacy or with less integrated care.

Patient concerns about accessing sexual and reproductive health services outside of primary care: A survey in rural and urban settings in the Pacific Northwest.

OBJECTIVES: While primary care providers are a major source of sexual and reproductive health (SRH) services in the United States, particularly in rural areas, not all primary care settings offer a full range of SRH services. We aimed to understand primary care patient concerns regarding accessing SRH services, including abortion care, outside of their primary care clinic and if those concerns differed by urban or rural setting. STUDY DESIGN: An anonymous survey was distributed over a 2-week period between December 2019 to March 2020 to all adult patients in four primary care clinics in Idaho, Washington, and Wyoming. The survey assessed patient concerns regarding accessing SRH services outside of their primary care clinic and their willingness to travel to access SRH services. RESULTS: The overall response rate was 69% (745/1086). Over 85% of respondents identified at least one concern to seeking SRH services outside of a primary care setting, with cost, insurance coverage, length of wait time, and lack of an established relationship being the most frequently reported concerns. A majority of respondents were willing to travel a maximum of 1 hour for most SRH services. Respondents from rural-serving clinics were significantly more likely to be willing to travel longer amounts of time for medication abortion, aspiration abortion, and intrauterine device placement. CONCLUSION: Our findings highlight that a majority of both urban and rural primary care patients have concerns regarding accessing SRH services outside of their primary care clinic and are unwilling to travel more than 1 hour to access most SRH services. IMPLICATIONS: A majority of primary care patients have concerns regarding accessing SRH services outside of primary care settings. Health care policy changes should aim to strengthen the SRH services available in primary care settings to alleviate the burdens primary care patients face in accessing SRH services outside of their primary care clinic, particularly for rural populations.

Patient and Clinician Recommendations to Improve Communication and Understanding of Lung Cancer Screening Results.

BACKGROUND: Patient understanding of chest low-dose CT (LDCT) scan results for lung cancer screening (LCS) may impact outcomes. RESEARCH QUESTION: What are patient- and clinician-identified gaps in understanding and communication of LCS results and how might communication be improved through a patient-oriented tool? STUDY DESIGN AND METHODS: We performed a mixed-methods study of participants recruited from a multisite LCS program to understand knowledge gaps after receiving LCS results and to guide development of a commonly asked questions (CAQ) after LCS information sheet. Initial patient surveys assessed understanding and reactions to LCS results (n = 190). We then conducted patient interviews and focus group discussions (n = 31) to understand experiences receiving LDCT scan results and reactions to results letters and the proposed CAQ; we also interviewed clinicians (n = 6) for feedback on these resources. We summarized survey responses and used thematic analysis to identify major themes in focus groups and interviews. RESULTS: Of 190 survey respondents (43% response rate), although 88% agreed that they "understood" their LCS results, only 55% reported understanding what a lung nodule is. Approximately two-thirds thought it was "very important" to receive more information regarding lung nodules and incidental lung and heart disease. In interviews and focus groups, although patients believed that brief results letters for normal LDCT scan results generally were acceptable, most found letters explaining abnormal LDCT scan and incidental findings to be concerning and not a substitute for discussion with their clinician. Nearly all patients expressed that the CAQ sheet provided helpful information on nodules, results reporting and incidental findings, and helped them form questions to ask their clinicians. INTERPRETATION: We identified patient-reported information needs regarding LCS results and developed a CAQ information sheet that was refined with patient and clinician input. The CAQ may represent a simple and feasible way to improve LCS results reporting and to augment clinician-patient discussions.

Financial navigation: Staff perspectives on patients' financial burden of cancer care.

PURPOSE: To describe perceptions of financial navigation staff concerning patients' cancer-related financial burden. METHODS: This qualitative descriptive study used a semi-structured interview guide to examine perceptions of financial navigation staff concerning patients' cancer-related financial burden. Staff who provided financial navigation support services to cancer patients were interviewed from different types of cancer programs across seven states representing rural, micropolitan, and urban settings. Interviews lasted approximately one hour, were audio recorded, and transcribed. Transcripts were double coded for thematic analysis. RESULTS: Thirty-five staff from 29 cancer centers were interviewed. The first theme involved communication issues related to patient and financial navigation staff expectations, timing and the sensitive nature of financial discussions. The second theme involved the multi-faceted impact of financial burden on patients, including stress, difficulty adhering to treatments, and challenges meeting basic, non-medical needs. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Cancer-related financial burden has a profound impact on cancer survivors' health and non-health outcomes. Discussions regarding cancer-related costs between cancer survivors and healthcare team members could help to normalize conversations and mitigate the multi-faceted determinants and effects of cancer-related financial burden. As treatment may span months and years and unexpected costs arise, having this discussion regularly and systematically is needed.

Tailoring Implementation Strategies for Cardiovascular Disease Risk Calculator Adoption in Primary Care Clinics.

INTRODUCTION: When implementing interventions in primary care, tailoring implementation strategies to practice barriers can be effective, but additional work is needed to understand how to best select these strategies. This study sought to identify clinicians' contributions to the process of tailoring implementation strategies to barriers in clinical settings. METHODS: We conducted a modified nominal group exercise involving 8 implementation scientists and 26 primary care clinicians in the WWAMI region Practice and Research Network. Each group identified implementation strategies it felt would best address barriers to using a cardiovascular disease (CVD) risk calculator previously identified across 44 primary care clinics from the Healthy Hearts Northwest pragmatic trial (2015 to 2018). These barriers had been mapped beforehand to the Consolidated Framework for Implementation Research (CFIR) domains. We examined similarities and differences in the strategies that 30% or more of each group identified (agreed-on strategies) for each barrier and for barriers in each CFIR domain. We used the results to demonstrate how strategies might be tailored to individual clinics. RESULTS: Clinicians selected 23 implementation strategies to address 1 or more of the 13 barriers; implementation scientists selected 35. The 2 groups agreed on at least 1 strategy for barriers in each CFIR domain: Inner Setting, Outer Setting, Intervention Characteristics, Characteristics of Individuals, and Process. Conducting local needs assessment and assessing for readiness/identifying barriers and facilitators were the 2 most common implementation strategies chosen only by clinicians. CONCLUSIONS: Clinician stakeholders identified implementation strategies that augmented those chosen by implementation scientists, suggesting that codesign of implementation processes between implementation scientists and clinicians may strengthen the process of tailoring strategies to overcome implementation barriers.

The relationship among social support, food insecurity and mental health for adults with severe mental illness and type 2 diabetes: A survey study.

OBJECTIVE: People living with severe mental illness are at increased risk of medical comorbidity as well as poverty, food insecurity, and inadequate social support in managing their mental and physical health conditions. Lack of access to sufficient food negatively affects a person's ability to manage health conditions, in particular diabetes, which is twice as common among people with severe mental illness as the general population. This study aimed to explore associations among food insecurity, social support, and psychiatric symptoms among adults with severe mental illness and diabetes. METHOD: A cross-sectional survey was conducted between January and May 2021 among adults (N = 156) with severe mental illness and type 2 diabetes who received primary care through a large academic health-care system (26% response rate). Valid and reliable questionnaires were implemented to measure food insecurity, social support, and mental health. Regression analysis was applied to examine the associations between food security status, social support, and mental health. RESULTS: Food insecurity and social support are both correlated with psychiatric symptom severity. Specifically, support from family members has the largest protective role against food insecurity. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This study found food insecurity is likely a critical issue to address whenever it is present in adults with severe mental illness (SMI) and type 2 diabetes. The presence of family support mitigates the need for addressing food insecurity. Practices and policies aimed at both addressing health inequities such as food insecurity and strengthening family support among people living with SMI and comorbid medical conditions are important adjuncts to self-management interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Patient opinions on sexual and reproductive health services in primary care in rural and urban clinics.

OBJECTIVES: Primary care providers are a major source of sexual and reproductive health care in the United States, particularly in rural areas, and not all providers offer the same services. This study aimed to understand patient preferences and expectations around reproductive health services including abortion care in a primary care setting and if those expectations differed by urban or rural setting. STUDY DESIGN: An anonymous survey was distributed to all patients 18 years or older in 4 primary care clinics in Idaho, Washington, and Wyoming over a 2-week period. The survey asked patients about which reproductive health services should be available in primary care. RESULTS: The overall response rate was 69% (745/1086). For all queried reproductive health services except for aspiration abortion, the majority of respondents reported that primary care clinics should have that service available. Forty-two percent of respondents reported that aspiration abortion should be available in primary care. Overall, most respondents reported that medication abortion (58%) and miscarriage management (65%) should be available in primary care. More respondents in urban clinics thought IUD services (84% vs 71%), medication abortion (74% vs 37%), and aspiration abortion (52% vs 28%) should be accessible in primary care compared to those in rural-serving clinics. CONCLUSIONS: This study of 4 primary care clinics in Idaho, Washington, and Wyoming, spanning urban and rural settings, highlights that most patients desire contraception services and miscarriage management to be available in primary care. IMPLICATIONS: Increasing training may help meet patient desires for access to reproductive services in primary care, however, further exploration of barriers to this care is warranted. High rates of respondents desiring miscarriage management access highlights the need to train more primary care clinicians to provide full spectrum miscarriage management options.

Early Response of Primary Care Practices to COVID-19 Pandemic.

INTRODUCTION: The emergence of the COVID-19 pandemic and subsequent public health mitigation strategies resulted in rapid and significant changes to delivery of primary care. The field of primary care faced an unprecedented dual challenge of providing routine care to patients while ensuring patient and staff safety and managing patients with a highly transmissible disease. This study describes how a diverse group of primary care practices addressed these challenges at the start of the COVID-19 pandemic, in Spring 2020. METHODS: A cross-sectional electronic survey of representatives from primary care practices in the WWAMI region Practice and Research Network (WPRN). Survey topics included clinical workforce, operations, and use of telemedicine in the first 3 months of the COVID-19 pandemic. RESULTS: To safely manage patients with COVID-19 symptoms all clinics modified operations; 81.3% diverted patients with respiratory symptoms to a telemedicine evaluation, 68.8% diverted these patients to be seen in-person at another location, and 75% made in-clinic changes to maintain safety. The set of operational changes employed by clinics was diverse. To continue to provide routine patient care, all clinics employed telemedicine. Over 80% of clinics had never used telemedicine prior to March 2020. CONCLUSIONS: A diverse group of primary care clinics all rapidly implemented a variety of operational adaptations to address patient needs and maintain patient and staff safety at the onset of the COVID- 19 pandemic. Telemedicine, together with other measures, provided critical pathways for maintaining delivery of care.

Patient navigation for hereditary colorectal cancer: Design of a randomized controlled trial to determine the effectiveness of pathways to genetic counseling.

BACKGROUND: Diagnosis of Lynch and other hereditary colorectal cancer (CRC) syndromes through germline genetic testing has important implications for treatment and risk-management, yet guideline-recommended genetic counseling referral and attendance is suboptimal. METHODS: Our team developed an adapted patient navigation program-Pathways to Genetic Counseling-to address multilevel barriers to genetic counseling referral and receipt. This paper describes the methods of a randomized controlled trial (RCT) testing Pathways to Genetic Counseling's effectiveness at increasing genetic counseling attendance in the University of Washington Medicine health system. We will identify CRC patients eligible for genetic counseling (diagnosed before age 50 or at any age with evidence of inherited mismatch repair deficiency) through a combination of structured electronic health record queries and manual chart review. Patients will be randomized 1:1 prior to consent and receive either care as usual (no contact) or be invited to participate in patient navigation. We will use chart review to compare rates of genetic counseling referral and attendance within six months of randomization, regardless of patients' engagement with navigation. We plan to identify and randomize 161 eligible CRC patients over a nine-month period beginning in late 2021. DISCUSSION: Our pragmatic RCT design will provide real-world data on the potential for patient navigation to address longstanding care gaps in preventive genomic medicine. If effective, we hope to pilot Pathways to Genetic Counseling in additional settings with a long-term goal of improving appropriate diagnosis of hereditary CRC syndromes and subsequent cascade screening of eligible family members.