Cultivating an ecosystem: A qualitative exploration of sustainability in long-standing community-based participatory research (CBPR) partnerships.

Background: While sustainability is crucial to the success of community-based participatory research (CBPR) partnerships, there is a lack of conceptual clarity on what defines sustainability and what characterizes sustainability-promoting practices in long-standing (in existence ≥ 6 years) CBPR partnerships. Objectives: The aim of this article is to explore the definition of sustainability, as well as practices that influence sustainability from the perspectives of academic and community experts in long-standing CBPR partnerships. Methods: This qualitative analysis is part of Measurement Approaches to Partnership Success (MAPS), a participatory mixed methods validity study that examined "success" and its contributing factors in long-standing CBPR partnerships. Thematic analysis of 21 semi-structured interviews was conducted, including 10 academic and 11 community experts of long-standing CBPR partnerships. Results: The key defining components of sustainability we identified include: distinguishing between sustaining the work of the partnership and ongoing relationships among partners; working towards a common goal over time; and enduring changes that impact the partnership. We further identified strengthening and capacity building practices at multiple levels of the partnership that served to promote the sustainability of the partnership's work and of ongoing relationships among partners. Conclusions: Sustainability can be understood as supporting an ecosystem that surrounds the beneficial relationships between academic and community partners. Ongoing evaluation and application of practices that promote the sustainability of partnership activities and relationships may strengthen the long-term effectiveness of CBPR partnerships in advancing health equity.

Cultivating an Ecosystem: A Qualitative Exploration of Sustainability in Long-Standing Community-Based Participatory Research Partnerships.

BACKGROUND: While sustainability is crucial to the success of community-based participatory research (CBPR) partnerships, there is a lack of conceptual clarity on what defines sustainability and what characterizes sustainability-promoting practices in long-standing (in existence 6 years or longer) CBPR partnerships. OBJECTIVES: The aim of this article is to explore the definition of sustainability, as well as practices that influence sustainability from the perspectives of academic and community experts in long-standing CBPR partnerships. METHODS: This qualitative analysis is part of Measurement Approaches to Partnership Success, a participatory mixed methods validity study that examined "success" and its contributing factors in long-standing CBPR partnerships. Thematic analysis of 21 semistructured interviews was conducted, including 10 academic and 11 community experts of long-standing CBPR partnerships. RESULTS: The key defining components of sustainability we identified include: distinguishing between sustaining the work of the partnership and ongoing relationships among partners; working towards a common goal over time; and enduring changes that impact the partnership. We further identified strengthening and capacity building practices at multiple levels of the partnership that served to promote the sustainability of the partnership's work and of ongoing relationships among partners. CONCLUSIONS: Sustainability can be understood as supporting an ecosystem that surrounds the beneficial relationships between academic and community partners. Ongoing evaluation and application of practices that promote the sustainability of partnership activities and relationships may strengthen the long-term effectiveness of CBPR partnerships in advancing health equity.

Virtual Implementation of a Photovoice Project With Youth in Baltimore During the COVID-19 Pandemic.

This article describes the virtual implementation of Photovoice activities conducted as part of a project that sought to gather youths' perspectives on neighborhood and housing conditions, community redevelopment, and health and well-being in Baltimore. We discuss the original in-person design and how activities were implemented virtually, in light of coronavirus disease 2019 (COVID-19) physical distancing guidelines. Challenges to virtual implementation included establishing rapport with youth and families during recruitment and data collection, encouraging active participation during discussion sessions, and varying technological skills among youth. Facilitators of virtual implementation included partnering with a community organization, piloting virtual sessions to assess participant's technology skills, and providing various ways for youth to participate during discussion sessions, engage in group activities, and receive hands-on instruction. This article showcases the ways in which virtual implementation of Photovoice activities can be successfully implemented with youth and provides recommendations for future Photovoice projects that include virtual activities.

Examining ACCURE's Nurse Navigation Through an Antiracist Lens: Transparency and Accountability in Cancer Care.

There are persistent disparities in the delivery of cancer treatment, with Black patients receiving fewer of the recommended cancer treatment cycles than their White counterparts on average. To enhance racial equity in cancer care, innovative methods that apply antiracist principles to health promotion interventions are needed. The parent study for the current analysis, the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) intervention, was a system-change intervention that successfully eliminated the Black-White disparity in cancer treatment completion among patients with early-stage breast and lung cancer. The intervention included specially trained nurse navigators who leveraged real-time data to follow-up with patients during their treatment journeys. Community and academic research partners conducted thematic analysis on all clinical notes (n = 3,251) written by ACCURE navigators after each contact with patients in the specialized navigation arm (n = 162). Analysis was informed by transparency and accountability, principles adapted from the antiracist resource Undoing Racism and determined as barriers to treatment completion through prior research that informed ACCURE. We identified six themes in the navigator notes that demonstrated enhanced accountability of the care system to patient needs. Underlying these themes was a process of enhanced data transparency that allowed navigators to provide tailored patient support. Themes include (1) patient-centered advocacy, (2) addressing system barriers to care, (3) connection to resources, (4) re-engaging patients after lapsed treatment, (5) addressing symptoms and side effects, and (6) emotional support. Future interventions should incorporate transparency and accountability mechanisms and examine the impact on racial equity in cancer care.

Reconsidering Community-Engaged Research Through a Syndemic Theoretical Framework: Lessons from COVID-19.

BACKGROUND: Community-engaged research is a well-established approach to tackling health disparities in communities of color. However, the devastation caused by coronavirus disease 2019 (COVID-19) calls for a reexamination of the practice of community-engaged research. Syndemic framework characterizes the clustering and synergistic interactions between two or more diseases amid an underlay of social and environmental threats. This framework has been used to explain the disproportionately higher rates of COVID-19 in communities of color and may have utility in guiding future community-engaged research. OBJECTIVES: This article describes the process by which a syndemic framework was used to generate discussions on lessons learned from COVID-19 and describes the ensuing collaborative writing process that emerged from this discourse. METHODS: This article was developed by the Community Engagement Working Group (CEWG) of the Jackson Heart Study, a community-based epidemiologic study focused on cardiovascular disease among African Americans in the Jackson, Mississippi Metropolitan Area. By drawing upon a syndemic framework and lessons from COVID-19, the CEWG identified gaps and opportunities to enhance community-engaged research. CONCLUSIONS: Using syndemic framework as a starting point, the CEWG identified the following as aspects of community-engaged research that may warrant further consideration: 1) the need to examine multiple dimensions and assets of a community, 2) the need to view communities through an intersectionality lens, 3) the need to acknowledge the impact of historical and current trauma on the community, and 4) the need to provide support to community-engaged researchers who may be members of minoritized groups themselves and therefore, experience similar trauma.

Effect of an Antiracism Intervention on Racial Disparities in Time to Lung Cancer Surgery.

PURPOSE: Timely lung cancer surgery is a metric of high-quality cancer care and improves survival for early-stage non-small-cell lung cancer. Historically, Black patients experience longer delays to surgery than White patients and have lower survival rates. Antiracism interventions have shown benefits in reducing racial disparities in lung cancer treatment. METHODS: We conducted a secondary analysis of Accountability for Cancer Care through Undoing Racism and Equity, an antiracism prospective pragmatic trial, at five cancer centers to assess the impact on overall timeliness of lung cancer surgery and racial disparities in timely surgery. The intervention consisted of (1) a real-time warning system to identify unmet care milestones, (2) race-specific feedback on lung cancer treatment rates, and (3) patient navigation. The primary outcome was surgery within 8 weeks of diagnosis. Risk ratios (RRs) and 95% CIs were estimated using log-binomial regression and adjusted for clinical and demographic factors. RESULTS: A total of 2,363 patients with stage I and II non-small-cell lung cancer were included in the analyses: intervention (n = 263), retrospective control (n = 1,798), and concurrent control (n = 302). 87.1% of Black patients and 85.4% of White patients in the intervention group (P = .13) received surgery within 8 weeks of diagnosis compared with 58.7% of Black patients and 75.0% of White patients in the retrospective group (P < .01) and 64.9% of Black patients and 73.2% of White patients (P = .29) in the concurrent group. Black patients in the intervention group were more likely to receive timely surgery than Black patients in the retrospective group (RR 1.43; 95% CI, 1.26 to 1.64). White patients in the intervention group also had timelier surgery than White patients in the retrospective group (RR 1.10; 95% CI, 1.02 to 1.18). CONCLUSION: Accountability for Cancer Care through Undoing Racism and Equity is associated with timelier lung cancer surgery and reduction of the racial gap in timely surgery.

Expanding the Reach of an Evidence-Based, System-Level, Racial Equity Intervention: Translating ACCURE to the Maternal Healthcare and Education Systems.

The abundance of literature documenting the impact of racism on health disparities requires additional theoretical, statistical, and conceptual contributions to illustrate how anti-racist interventions can be an important strategy to reduce racial inequities and improve population health. Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) was an NIH-funded intervention that utilized an antiracism lens and community-based participatory research (CBPR) approaches to address Black-White disparities in cancer treatment completion. ACCURE emphasized change at the institutional level of healthcare systems through two primary principles of antiracism organizing: transparency and accountability. ACCURE was successful in eliminating the treatment completion disparity and improved completion rates for breast and lung cancer for all participants in the study. The structural nature of the ACCURE intervention creates an opportunity for applications in other health outcomes, as well as within educational institutions that represent social determinants of health. We are focusing on the maternal healthcare and K-12 education systems in particular because of the dire racial inequities faced by pregnant people and school-aged children. In this article, we hypothesize cross-systems translation of a system-level intervention exploring how key characteristics of ACCURE can be implemented in different institutions. Using core elements of ACCURE (i.e., community partners, milestone tracker, navigator, champion, and racial equity training), we present a framework that extends ACCURE's approach to the maternal healthcare and K-12 school systems. This framework provides practical, evidence-based antiracism strategies that can be applied and evaluated in other systems to address widespread structural inequities.

How Can We PrEP? Exploring Black MSM's Experiences With Pre-Exposure Prophylaxis Through Photovoice.

Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV infection by over 90% among those at high risk via sexual transmission. PrEP acceptance and adherence remains low among those at highest risk of HIV, including Black men who have sex with men (MSM) in the southern U.S. This community-based participatory research project explored Black MSM's experiences with PrEP in North Carolina through photovoice, a methodology using photography and discussion. Our findings highlighted challenges and opportunities with PrEP, including intersectional stigma, the need for improved patient-provider education, and the role of community-based organizations in closing patient-provider gaps. This work is a first step towards understanding the daily lives of Black MSM on PrEP in the Triangle Region of North Carolina, including barriers and facilitators to PrEP use. Implications for public health practice highlight the need for conducting community-level interventions, integrating PrEP into primary care, and normalizing PrEP through community conversations.

Behaviour adoption approaches during public health emergencies: implications for the COVID-19 pandemic and beyond.

Human behaviour will continue to play an important role as the world grapples with public health threats. In this paper, we draw from the emerging evidence on behaviour adoption during diverse public health emergencies to develop a framework that contextualises behaviour adoption vis-à-vis a combination of top-down, intermediary and bottom-up approaches. Using the COVID-19 pandemic as a case study, we operationalise the contextual framework to demonstrate how these three approaches differ in terms of their implementation, underlying drivers of action, enforcement, reach and uptake. We illustrate how blended strategies that include all three approaches can help accelerate and sustain protective behaviours that will remain important even when safe and effective vaccines become more widely available. As the world grapples with the COVID-19 pandemic and prepares to respond to (re)emerging public health threats, our contextual framework can inform the design, implementation, tracking and evaluation of comprehensive public health and social measures during health emergencies.

'It's like you don't have a roadmap really': using an antiracism framework to analyze patients' encounters in the cancer system.

Background: Cancer patients can experience healthcare system-related challenges during the course of their treatment. Yet, little is known about how these challenges might affect the quality and completion of cancer treatment for all patients, and particularly for patients of color. Accountability for Cancer Care through Undoing Racism and Equity is a multi-component, community-based participatory research intervention to reduce Black-White cancer care disparities. This formative work aimed to understand patients' cancer center experiences, explore racial differences in experiences, and inform systems-level interventions.Methods: Twenty-seven breast and lung cancer patients at two cancer centers participated in focus groups, grouped by race and cancer type. Participants were asked about what they found empowering and disempowering regarding their cancer care experiences. The community-guided analysis used a racial equity approach to identify racial differences in care experiences.Results: For Black and White patients, fear, uncertainty, and incomplete knowledge were disempowering; trust in providers and a sense of control were empowering. Although participants denied differential treatment due to race, analysis revealed implicit Black-White differences in care.Conclusions: Most of the challenges participants faced were related to lack of transparency, such that improvements in communication, particularly two-way communication could greatly improve patients' interaction with the system. Pathways for accountability can also be built into a system that allows patients to find solutions for their problems with the system itself. Participants' insights suggest the need for patient-centered, systems-level interventions to improve care experiences and reduce disparities.

Harnessing "Scale-Up and Spread" to Support Community Uptake of the HoMBReS por un Cambio Intervention for Spanish-Speaking Men: Implementation Science Lessons Learned by a CBPR Partnership.

Latinx men in the southern United States are affected disproportionately by HIV and other sexually transmitted infections (STIs). However, few evidence-based prevention interventions exist to promote health equity within this population. Developed by a well-established community-based participatory research partnership, the HoMBReS por un Cambio intervention decreases sexual risk among Spanish-speaking, predominately heterosexual Latinx men who are members of recreational soccer teams in the United States. Scale-up and spread, an implementation science framework, was used to study the implementation of this evidence-based community-level intervention within three community organizations that represent typical community-based providers of HIV and STI prevention interventions (i.e., an AIDS service organization, a Latinx-serving organization, and a county public health department). Archival and interview data were analyzed, and 24 themes emerged that mapped onto the 12 scale-up and spread constructs. Themes included the importance of strong and attentive leadership, problem-solving challenges early, an established relationship between innovation developers and implementers, organizational capacity able to effectively work with men, trust building, timelines and incremental deadlines, clear and simple guidance regarding all aspects of implementation, appreciating the context (e.g., immigration-related rhetoric, policies, and actions), recognizing men's competing priorities, and delineated supervision responsibilities. Scale-up and spread was a useful framework to understand multisite implementation of a sexual risk reduction intervention for Spanish-speaking, predominately heterosexual Latinx men. Further research is needed to identify how constructs, like those within scale-up and spread, affect the process across the implementation continuum, given that the uptake and implementation of an innovation is a process, not an event.

The Other Side of Through: Young Breast Cancer Survivors' Spectrum of Sexual and Reproductive Health Needs.

The long-term reproductive health impact of cancer treatments is a concern for premenopausal women with a history of breast cancer. This study examined the unmet sexual and reproductive health needs of breast cancer survivors, as well as concordances and discordances in needs by childbearing status and race. We interviewed 17 women diagnosed with breast cancer between the ages of 18 and 45 years and living in North Carolina. To analyze these data, we used the Sort and Sift, Think and Shift© method, a multidimensional qualitative analysis approach. We learned that breast cancer survivors (a) received limited reproductive health information, (b) desired realistic expectations of conceiving postcancer, (c) struggled with adjusting to their altered physical appearance, and (d) had menopause symptoms that led to sexual health and quality of life issues. Breast cancer survivors are in need of and desire more education and resources to address their sexual and reproductive health concerns.

Racial Differences in the Influence of Health Care System Factors on Informal Support for Cancer Care Among Black and White Breast and Lung Cancer Survivors.

This retrospective, secondary qualitative analysis investigates whether health system factors influence social support among Black and white breast and lung cancer survivors and racial differences in support. These data come from race- and cancer-stratified focus groups (n = 6) and interviews (n = 2) to inform a randomized controlled trial utilizing antiracism and community-based participatory research approaches. Findings indicate social support was helpful for overcoming treatment-related challenges, including symptom management and patient-provider communication; racial differences in support needs and provision were noted. Resources within individual support networks reflect broader sociostructural factors. Reliance on family/friends to fill gaps in cancer care may exacerbate racial disparities.

A peer navigation intervention to prevent HIV among mixed immigrant status Latinx GBMSM and transgender women in the United States: outcomes, perspectives and implications for PrEP uptake.

The Latinx population in the United States is disproportionately affected by HIV. Our community-based participatory research partnership developed, implemented and evaluated a Spanish-language peer navigation intervention designed to increase HIV testing and condom use among social networks of immigrant Spanish-speaking Latinx gay, bisexual and other men who have sex with men (GBMSM) and transgender women (TW). We randomized 21 social networks of Latinx GBMSM and TW, ages 18-55 years, to the intervention, known as HOLA, or a waitlist control group. Social network participants (n = 166) completed structured assessments at baseline and 12-month follow-up (24 months after baseline). Follow-up retention was 95%. Individual in-depth interviews with a sample of participants documented their intervention-related experiences, needs, and priorities to inform future research. At follow-up, HOLA participants reported increased HIV testing (adjusted odds ratio = 8.3; 95% CI = 3.0-23.0; P < 0.0001). All study participants reported increased condom use; there was no significant difference between HOLA and waitlist control participants. In-depth interviews identified critical intervention elements and impacts and community needs and priorities. The HOLA intervention is effective for increasing HIV testing among Latinx GBMSM and TW, an initial step within the HIV prevention and care continua, and may be adaptable to promote pre-exposure prophylaxis uptake.

A Multi-faceted Intervention Aimed at Black-White Disparities in the Treatment of Early Stage Cancers: The ACCURE Pragmatic Quality Improvement trial.

BACKGROUND: Reports continue to show that Blacks with curable lung or breast cancer complete treatment less often than similar Whites contributing to worse survival. ACCURE is an intervention trial designed to address this problem. PATIENTS AND METHODS: A pragmatic, quality improvement trial comparing an intervention group to retrospective and concurrent controls. Patients with early stage breast or lung cancer aged 18 to 85 were enrolled (N = 302) at 2 cancer centers between April 2013 and March 2015 for the intervention component. Data from patients seen between January 2007 and December 2012 with these diagnoses were obtained to establish control completion rates. Concurrent data for non-study patients were used to identify secular trends. The intervention included: a real time registry derived from electronic health records of participants to signal missed appointments or unmet care milestones, a navigator, and clinical feedback. The primary outcome was "Treatment Complete", a composite variable representing completion of surgery, recommended radiation and chemotherapy for each patient. RESULTS: The mean age in the intervention group was 63.1 years; 37.1% of patients were Black. Treatment completion in retrospective and concurrent controls showed significant Black-White differences (Blacks (B) 79.8% vs. Whites (W) 87.3%, p < 0.001; 83.1% B vs. 90.1% W, p < 0.001, respectively). The disparity lessened within the intervention (B 88.4% and W 89.5%, p = 0.77). Multivariate analyses confirmed disparities reduction. OR for Black-White disparity within the intervention was 0.98 (95% CI 0.46-2.1); Black completion in the intervention compared favorably to Whites in retrospective (OR 1.6; 95% CI 0.90-2.9) and concurrent (OR 1.1; 95% CI 0.59-2.0) controls. CONCLUSION: A real time registry combined with feedback and navigation improved completion of treatment for all breast and lung cancer patients and narrowed disparities. Similar multi-faceted interventions could mitigate disparities in the treatment of other cancers and chronic conditions.

The role of patient-physician relationship on health-related quality of life and pain in cancer patients.

PURPOSE: Health-related quality of life (HRQOL) and pain are important supportive cancer care outcomes. The patient-provider relationship, a modifiable care experience, has been linked to healthcare outcomes; however, less is known about associations between patient-provider relationship and supportive care outcomes in cancer patients. We examined the role of multiple aspects of the patient-provider relationship in explaining patterns of HRQOL and pain among breast and lung cancer patients. METHODS: Our analysis included 283 breast and lung cancer patients from two cancer centers. Clinical data and survey data on patient sociodemographic factors, physical and mental HRQOL, pain, and patient-physician relationship (i.e., doctor's respectfulness, time spent with doctors, patient involvement in decision-making, satisfaction with care, and following doctor's advice/treatment plan) were collected at baseline and during treatment. We estimated adjusted modified Poisson regression models to assess associations between patient-physician relationship factors and physical and mental HRQOL and pain. RESULTS: Compared with patients reporting suboptimal respect from doctors, patients reporting optimal respect were less likely to report below average physical HRQOL (adjusted risk ratio (ARR), 0.73; 95%CI, 0.62-0.86), below average mental HRQOL (ARR, 0.71; 95%CI, 0.54-0.93), and moderate-to-severe pain (ARR, 0.53; 95%CI, 0.35-0.79). Patients reporting optimal involvement in care decision-making and patients who reported following their doctor's advice/treatment plan were less likely to report below average mental HRQOL than their respective counterparts (ARR, 0.64; 95%CI, 0.50-0.83; ARR, 0.65; 95%CI, 0.48-0.86). CONCLUSION: Multiple patient-physician relationship factors account for variations in HRQOL and pain in cancer patients. These findings provide insight into potential targets for improving the patient-provider relationship and supportive cancer care outcomes.

"They were just waiting for me to mess up": A critical discourse analysis of immigrant Latinx teens' perceptions of power dynamics.

This paper explores Latinx adolescents' perceptions of power dynamics with authority around them. We seek to inform how community-based professionals engage with and seek to understand members of this population. We conducted a critical discourse analysis of data collected during a community action photovoice project with 13 Latinx adolescents living in a metropolitan region of the southeastern United States. Participants felt they were under greater surveillance scrutiny by authority figures in social and academic spaces than their non-Latino peers. They discussed ways their movements were at times constrained because others presumed they were deviant, and how that affected their identity development. Judgments and assumptions held by both powerful adults and oppressed groups alike serve to reinscribe social stratification that places Latinx adolescents at a power disadvantage relative to their white peers. These experiences and understandings of power relations shape the circuitous racial dispossession of youth.

Chronic Disease Among African American Families: A Systematic Scoping Review.

INTRODUCTION: Chronic diseases are common among African Americans, but the extent to which research has focused on addressing chronic diseases across multiple members of African American families is unclear. This systematic scoping review summarizes the characteristics of research addressing coexisting chronic conditions among African American families, including guiding theories, conditions studied, types of relationships, study outcomes, and intervention research. METHODS: The literature search was conducted in PsycInfo, PubMed, Social Work Abstracts, Sociological Abstracts, CINAHL, and Family and Society Studies Worldwide to identify relevant articles published from January 2000 through September 2016. We screened the title and abstracts of 9,170 articles, followed by full-text screening of 530 articles, resulting in a final sample of 114 articles. Fifty-seven percent (n = 65) of the articles cited a guiding theory/framework, with psychological theories (eg, social cognitive theory, transtheoretical model) being most prominent. The most common conditions studied in families were depression (70.2%), anxiety (23.7%), and diabetes (22.8%), with most articles focusing on a combination of physical and mental health conditions (47.4%). RESULTS: In the 114 studies in this review, adult family members were primarily the index person (71.1%, n = 81). The index condition, when identified (79.8%, n = 91), was more likely to be a physical health condition (46.5%, n = 53) than a mental health condition (29.8%, n = 34). Among 343 family relationships examined, immediate family relationships were overwhelmingly represented (85.4%, n = 293); however, extended family (12.0%, n = 41) and fictive kin (0.6%, n = 2) were included. Most (57.0%, n = 65) studies focused on a single category of outcomes, such as physical health (eg, obesity, glycemic control), mental health (eg, depression, anxiety, distress), psychosocial outcomes (eg, social support, caregiver burden), or health behaviors (eg, medication adherence, disease management, health care utilization); however, 43.0% (n = 49) of studies focused on outcomes across multiple categories. Sixteen intervention articles (14.0%) were identified, with depression the most common condition of interest. CONCLUSION: Recognizing the multiple, simultaneous health issues facing families through a lens of family comorbidity and family multimorbidity may more accurately mirror the lived experiences of many African American families and better elucidate intervention opportunities than previous approaches.

A Person-Centered Approach to the Study of Black Adolescent Religiosity, Racial Identity, and Sexual Initiation.

Decreasing the number of adolescents who have never had sexual intercourse is one way to address sexual health disparities. We used intersectionality to explore the joint effects of religiosity and racial identity on Black adolescent sexual initiation. Data originated from the National Survey of American Life-Adolescent (n = 1,170), a nationally representative study of Black adolescents. Latent profile analysis and survival analysis were used to evaluate study hypotheses. Results showed four distinct profiles of religiosity and racial identity. These profiles explained 19% of the variability in sexual initiation. Additional analyses revealed sociodemographic differences in profile membership. Findings contribute to understanding ethnic heterogeneity among Black adolescents and racial identity and religiosity as sociocultural factors that influence sexual initiation; and support reconceptualizing Black adolescent religiosity.

A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: A pragmatic trial at five cancer centers.

BACKGROUND: Advances in early diagnosis and curative treatment have reduced high mortality rates associated with non-small cell lung cancer. However, racial disparity in survival persists partly because Black patients receive less curative treatment than White patients. METHODS: We performed a 5-year pragmatic, trial at five cancer centers using a system-based intervention. Patients diagnosed with early stage lung cancer, aged 18-85 were eligible. Intervention components included: (1) a real-time warning system derived from electronic health records, (2) race-specific feedback to clinical teams on treatment completion rates, and (3) a nurse navigator. Consented patients were compared to retrospective and concurrent controls. The primary outcome was receipt of curative treatment. RESULTS: There were 2841 early stage lung cancer patients (16% Black) in the retrospective group and 360 (32% Black) in the intervention group. For the retrospective baseline, crude treatment rates were 78% for White patients vs 69% for Black patients (P < 0.001); difference by race was confirmed by a model adjusted for age, treatment site, cancer stage, gender, comorbid illness, and income-odds ratio (OR) 0.66 for Black patients (95% CI 0.51-0.85, P = 0.001). Within the intervention cohort, the crude rate was 96.5% for Black vs 95% for White patients (P = 0.56). Odds ratio for the adjusted analysis was 2.1 (95% CI 0.41-10.4, P = 0.39) for Black vs White patients. Between group analyses confirmed treatment parity for the intervention. CONCLUSION: A system-based intervention tested in five cancer centers reduced racial gaps and improved care for all.