Feasibility and acceptability of chaplain decision coaching on Periviable resuscitation decision quality: A pilot study.

Objective: To pilot test and assess the feasibility and acceptability of chaplain-led decision coaching alongside the GOALS (Getting Optimal Alignment around Life Support) decision support tool to enhance decision-making in threatened periviable delivery. Methods: Pregnant people admitted for threatened periviable delivery and their 'important other' (IO) were enrolled. Decisional conflict, acceptability, and knowledge were measured before and after the intervention. Chaplains journaled their impressions of training and coaching encounters. Descriptive analysis and conventional content analysis were completed. Results: Eight pregnant people and two IOs participated. Decisional conflict decreased by a mean of 6.7 (SD = 9.4) and knowledge increased by a mean of 1.4 (SD = 1.8). All rated their experience as "good" or "excellent," and the amount of information was "just right." Participants found it "helpful to have someone to talk to" and noted chaplains helped them reach a decision. Chaplains found the intervention a valuable use of their time and skillset. Conclusion: This is the first small-scale pilot study to utilize chaplains as decision coaches. Our results suggest that chaplain coaching with a decision support tool is feasible and well-accepted by parents and chaplains. Innovations: Our findings recognize chaplains as an underutilized, yet practical resource in value-laden clinical decision-making.

Comparative effectiveness of two interventions to increase colorectal cancer screening among females living in the rural Midwest.

PURPOSE: To assess the comparative effectiveness of a tailored, interactive digital video disc (DVD) intervention versus DVD plus patient navigation (PN) intervention versus usual care (UC) on the uptake of colorectal cancer (CRC) screening among females living in Midwest rural areas. METHODS: As part of a larger study, 663 females (ages 50-74) living in rural Indiana and Ohio and not up-to-date (UTD) with CRC screening at baseline were randomized to one of three study groups. Demographics , health status/history, and beliefs and attitudes about CRC screening were measured at baseline. CRC screening was assessed at baseline and 12 months from medical records and self-report. Multivariable logistic regression was used to determine whether females in each group were UTD for screening and which test they completed. RESULTS: Adjusted for covariates, females in the DVD plus PN group were 3.5× more likely to complete CRC screening than those in the UC group (odds ratio [OR] 3.62; 95% confidence interval [CI]: 2.09, 6.47) and baseline intention to receive CRC screening (OR 3.45, CI: 2.21,5.42) at baseline. Adjusting for covariates, there was no difference by study arm whether females who became UTD for CRC screening chose to complete a colonoscopy or fecal occult blood test/fecal immunochemical test. CONCLUSIONS: Many females living in the rural Midwest are not UTD for CRC screening. A tailored intervention that included an educational DVD and PN improved knowledge, addressed screening barriers, provided information about screening test options, and provided support was more effective than UC and DVD-only to increase adherence to recommended CRC screening.

Unpacking the relationship between shared decision-making and decisional quality, decision to screen, and screening completion in lung cancer screening.

OBJECTIVES: Lung cancer screening is a complex and individualized decision. To understand how best to support patients in this decision, we must understand how shared decision-making is associated with both decisional and behavioral outcomes. METHODS: Observational cohort study combining patient survey data with electronic health record data of lung screening-eligible patients who recently engaged in a shared decision-making discussion about screening with a primary care clinician. RESULTS: Using multivariable analysis (n = 529), factors associated with higher lung cancer screening decisional quality include higher knowledge (OR = 1.33, p < .0001), lower perceived benefits (OR = 0.90, p = .0004), higher perceived barriers (OR = 1.07, p < .0001), higher self-efficacy (OR = 1.13, p < .0001), and higher levels of perceiving the discussion was shared (OR = 1.04, p < .0001). Factors associated with the patient's decision to screen include older age (OR = 1.12, p = .0050) and higher self-efficacy (OR = 1.11, p = .0407). Factors associated with screening completion included older age (OR = 1.05, p = .0050), higher knowledge (OR = 1.24, p = .0045), and higher self-efficacy (OR = 1.12, p = .0003). CONCLUSIONS: Shared decision-making in lung cancer screening is a dyadic process between patient and clinician. As we continue to strive for high-quality patient-centered care, patient decision quality may be enhanced by targeting key factors such as high-quality knowledge, self-efficacy, and fostering a shared discussion to support patient engagement in lung cancer screening decisions.

Comparable Minimally Important Differences and Responsiveness of Brief Pain Inventory and PEG Pain Scales across 6 Trials.

The 3-item pain intensity (P), interference with the enjoyment of life (E), and interference with general activity (G), or PEG, has become one of the most widely used measures of pain severity and interference. The minimally important differences (MID) and responsiveness of the PEG are essential metrics for solidifying its role in research and clinical care. The current study aims to establish the MID and responsiveness of the PEG by synthesizing data from 1,710 participants across 6 controlled trials. MIDs were estimated using absolute score changes among individuals reporting their pain was "a little better" on a retrospective global change anchor as well as distribution-based estimates using standard deviation thresholds and 1 and 2 standard errors of measurement. Responsiveness was assessed using standardized response means, area under the curve, and treatment effect sizes. MID estimates for the PEG ranged from 0.60 to 1.1 when using 0.35 SD, and 0.78 to 1.22 using 1 standard error of measurement. MID estimates using the global anchor had somewhat more variability but most estimates ranged from 1.0 to 1.75. Responsiveness effect sizes were generally large (>.80) for standardized response means and moderate (>.50) for treatment effect. Similarly, the most area under the curve values demonstrated an acceptable level of scale responsiveness (≥.70). Importantly, MID estimates and responsiveness of the PEG and BPI scales were largely comparable when aggregating data across trials. Our synthesis indicates that 1 point is a reasonable MID estimate on these 0- to 10-point pain scales, with 2 points being an upper bound. PERSPECTIVE: This article synthesizes data from 6 clinical trials to establish the minimally important difference (MID) and responsiveness of the 3-item PEG pain scale. The PEG demonstrated good responsiveness, and 1 to 2 points proved to be reasonable estimates for the lower and upper bounds of the MID.

Impact of Pain and Adverse Health Outcomes on Long-term U.S. Testicular Cancer Survivors.

PURPOSE: No study has quantified the impact of pain and other adverse health outcomes (AHOs) on global physical/mental health in long-term U.S. testicular cancer survivors (TCS) or evaluated patient-reported functional impairment due to pain. METHODS: TCS given cisplatin-based chemotherapy completed validated surveys, including PROMIS-v1.2 Global-Physical-and-Mental-Health, PROMIS pain questionnaires, and others. Multivariable linear regression examined relationships between 25 AHOs with Global-Physical (GPH) and Mental-Health (GMH) scores, and Pain-Interference Scores. AHOs with ß > 2 are clinically important and reported below. RESULTS: Among 358 TCS [median age: 46 (IQR: 38-53); median time-since-chemotherapy: 10.7 years; IQR = 7.2-16.0)], median AHO number was 5 (IQR = 3-7). 12% TCS had ≥10 AHOs, and 19% reported chemotherapy-induced neuropathic pain. Increasing AHO numbers were associated with decreases in physical and mental health (P < 0.0001 each). In multivariable analyses, chemotherapy-induced neuropathic pain (ß = -3.72; P = 0.001), diabetes (ß = -4.41; P = 0.037), obesity (ß = -2.01; P = 0.036) and fatigue (ß = -8.58; P < 0.0001) were associated with worse GMH, while being married/living-as-married benefitted GMH (ß = 3.63; P = 0.0006). Risk factors for pain-related functional-impairment included lower extremity location (ß = 2.15; P = 0.04) and concomitant peripheral artery disease (ß = 4.68; P < 0.001). GPH-score reductions were associated with diabetes (ß = -3.81; P = 0.012), balance/equilibrium problems (ß = -3.82; P = 0.003), cognitive-dysfunction (ß = -4.43; P < 0.0001), obesity (ß = -3.09; P < 0.0001), peripheral-neuropathy-score (ß = -2.12; P < 0.0001), and depression (ß = -3.17; P < 0.0001). CONCLUSIONS: TCS suffer AHOs that negatively impact long-term GMH, GPH, and pain-related functional-status. IMPLICATIONS FOR CANCER SURVIVORS: Clinically important factors associated with worse physical/mental health identify TCS requiring closer monitoring, counseling, and interventions. Chemotherapy-induced neuropathic pain must be addressed, given its detrimental impact on patient-reported functional-status and mental health 10+ years after treatment.

Receipt, uptake, and satisfaction with tailored DVD and patient navigation interventions to promote cancer screening among rural women.

Process evaluation is essential to understanding and interpreting the results of randomized trials testing the effects of behavioral interventions. A process evaluation was conducted as part of a comparative effectiveness trial testing a mailed, tailored interactive digital video disc (DVD) with and without telephone-based patient navigation (PN) to promote breast, cervical and colorectal cancer screening among rural women who were not up-to-date (UTD) for at least one screening test. Data on receipt, uptake, and satisfaction with the interventions were collected via telephone interviews from 542 participants who received the tailored interactive DVD (n = 266) or the DVD plus telephone-based PN (n = 276). All participants reported receiving the DVD and 93.0% viewed it. The most viewed sections of the DVD were about colorectal, followed by breast, then cervical cancer screening. Most participants agreed the DVD was easy to understand, helpful, provided trustworthy information, and gave information needed to make a decision about screening. Most women in the DVD+PN group, 98.2% (n = 268), reported talking with the navigator. The most frequently discussed cancer screenings were colorectal (86.8%) and breast (71.3%); 57.5% discussed cervical cancer screening. The average combined length of PN encounters was 22.2 minutes with 21.7 additional minutes spent on coordinating activities. Barriers were similar across screening tests with the common ones related to the provider/health care system, lack of knowledge, forgetfulness/too much bother, and personal issues. This evaluation provided information about the implementation and delivery of behavioral interventions as well as challenges encountered that may impact trial results.

Two interventions to promote cervical, breast, and colorectal cancer screening among rural women who were not up-to-date (UTD) for at least one screening test were evaluated by rural women who received them as part of the randomized trial. Participants who received the tailored interactive digital video disc (DVD; n = 266) or the DVD plus telephone-based patient navigation (PN; n = 276) were interviewed by phone about their engagement and satisfaction with the interventions. All participants reported receiving the DVD and 93.0% viewed it. Most agreed the DVD was easy to understand, helpful, provided trustworthy information, and gave information needed to get screened. Almost all women in the DVD+PN group, 98.2% (n = 268) talked with the navigator. The most common cancer screenings discussed with navigators were colorectal (86.8%), followed by breast (71.3%) and cervical (57.5%). The average length of encounters with the navigators was 22.2 minutes; navigators spent 21.7 additional minutes on coordinating activities. Barriers discussed were similar across screening tests. The most common were related to the healthcare provider/system, lack of knowledge, forgetfulness/too much bother, and personal issues. This study provided important information about receipt, uptake, and satisfaction with two behavioral interventions, along with challenges encountered that may impact results.

Patient awareness, perceptions, and attitudes towards pharmacists prescribing tobacco cessation medications.

BACKGROUND: Recent legislative advances now permit pharmacists to prescribe tobacco cessation medications in 17 states. While national initiatives are underway to prepare the pharmacy profession for this expanded role, patient perceptions of this role have not been explored. OBJECTIVE: The objective of this study was to characterize patient perceptions, attitudes, and awareness of pharmacists prescribing for tobacco cessation medications. METHODS: A cross-sectional survey of English and Spanish-speaking patients was conducted at 12 locations of a federally-qualified health center in Northwest Indiana. Survey measures assessed sociodemographics, tobacco use history and interest in quitting, prior interactions with pharmacists and awareness of pharmacists' ability to prescribe tobacco cessation medications, and perceptions of pharmacists assisting with cessation. The Theory of Planned Behavior (TPB) served as a framework for item development. Multivariable logistic regression was used for modeling. RESULTS: A total of 2082 individuals (1878 English, 204 Spanish) completed the survey (42.4%). Among current users (n = 592; 28.4%), 46.2% had made a quit attempt in the past year, and 41.0% reported having used a tobacco cessation medication in the past. Over half (60.5%) of current users would be comfortable talking with a pharmacist about quitting, 31.9% intended to talk with a pharmacist about quitting, and 31.7% intended to ask a pharmacist to prescribe a medicine to help with quitting. In multivariable modeling, intention to (a) talk with a pharmacist about quitting and (b) ask a pharmacist to prescribe a medication were significantly associated with TPB constructs. Current tobacco users were receptive to pharmacist-facilitated assistance with quitting, including prescribing of tobacco cessation medications. CONCLUSIONS: Patients' attitudes, subjective norms, and perceived behavioral control, from the Theory of Planned Behavior, were important predictors of intention to engage with pharmacists for quitting and intention to ask a pharmacist to prescribe a cessation medication.

The Quick FICS: 5 and 10 Item Versions of the Family Inpatient Communication Survey.

CONTEXT: Communication quality in the hospital impacts outcomes like satisfaction, depression, and anxiety for families, and assessment tools must be efficient and reliable. OBJECTIVES: We developed the Quick FICS-5 and -10, shorter versions of the 30-item Family Inpatient Communication Survey (FICS). METHODS: The Quick FICS were developed from the original FICS study of hospitalized patients 65+ and their surrogates. The development sample came from the original FICS-30 scale. The validation sample came from a randomized controlled trial of surrogates for adult ICU patients. Participants were family members of patients on medical ICU or inpatient medicine services at three hospitals in a Midwest metropolitan area. We evaluated validity and reliability using factor analysis, internal consistency, and associations with surrogate psychological and decision-making outcomes. RESULTS: In the development sample of 364 patient/surrogate dyads, most surrogates were adult children (66.8%), female (70.9%), and white (68.9%). We identified 5-item and 10-item surveys. Exploratory factor analysis supported an overall communication score for the FICS-5 and FICS-10, as well as information and emotional support subscales for the FICS-10. There was high internal reliability (Cronbach's alpha was 0.83 for the FICS-5 and 0.90 for the FICS-10; information and emotional support subscales were 0.89 and 0.75 respectively). There was good predictive validity when comparing FICS scores to outcomes six to eight weeks after discharge, including anxiety (P = -0.13; P = 0.0234), and satisfaction with the hospital stay (P = 0.48; P < 0.0001). Similarly, the validation sample (n = 188) revealed Cronbach's alpha ranging from 0.81 to 0.93 and significant correlations (P < 0.05) with concurrent distress, anxiety, depression, and decision regret. CONCLUSIONS: The Quick FICS offers efficient, valid, and reliable evaluation of communication quality in the hospital that can be useful for research and quality improvement.

Racial disparities in cascade testing for cancer predisposition genes.

We sought to determine whether there are racial disparities in cascade testing rates and whether providing testing at no-charge impacts rates in Black and White at-risk-relatives (ARR). Probands with a pathogenic/likely pathogenic germline variant in a cancer predisposition gene were identified up to one year before and up to one year after cascade testing became no-charge in 2017. Cascade testing rates were measured as the proportion of probands who had at least one ARR obtain genetic testing through one commercial laboratory. Rates were compared between self-reported Black and White probands using logistic regression. Interaction between race and cost (pre/post policy) was tested. Significantly fewer Black probands than White probands had at least one ARR undergo cascade genetic testing (11.9% versus 21.7%, OR 0.49, 95% CI 0.39-0.61, p < 0.0001). This was seen both before (OR 0.38, 95% CI 0.24-0.61, p < 0.001) and after (OR 0.53, 95% CI 0.41-0.68, p < 0.001) the no-charge testing policy. Rates of an ARR undergoing cascade testing were low overall, and significantly lower in Black versus White probands. The magnitude of difference in cascade testing rates between Blacks and Whites did not significantly change with no-charge testing. Barriers to cascade testing in all populations should be explored in order to maximize the benefits of genetic testing for both treatment and prevention of cancer.

Leveraging social media to increase lung cancer screening awareness, knowledge and uptake among high-risk populations (The INSPIRE-Lung Study): Study protocol of design and methods of a community-based randomized controlled trial.

Background. Lung cancer is the leading cause of cancer death for both men and women in the United States. The National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (LDCT) screening can reduce lung cancer mortality among high-risk individuals, but uptake of lung screening remains low. Social media platforms have the potential to reach a large number of people, including those who are at high risk for lung cancer but who may not be aware of or have access to lung screening. Methods. This paper discusses the protocol for a randomized controlled trial (RCT) that leverages FBTA to reach screening-eligible individuals in the community at large and intervene with a public-facing, tailored health communication intervention ( LungTalk ) to increase awareness of, and knowledge about, lung screening. Discussion. This study will provide important information to inform the ability to refine implementation processes for national population efforts to scale a public-facing health communication focused intervention using social media to increase screening uptake of appropriate, high-risk individuals. Trial Registration : The trial is registered at clinicaltrials.gov (#NCT05824273).

PROMIS Profile-29 is a valid instrument with distinct advantages over legacy instruments for measuring the quality of life in chronic liver disease.

BACKGROUND AND AIMS: The Patient-Reported Outcomes Measurement Information System (PROMIS) is increasingly used to measure health-related quality of life, yet, it has not been well-studied in chronic liver disease (CLD). This study compares PROMIS Profile-29 to Short-Form Health Survey (SF-36) and Chronic Liver Disease Questionnaire (CLDQ) in patients with CLD. APPROACH AND RESULTS: In all, 204 adult outpatients with CLD completed PROMIS-29, CLDQ, SF-36 and usability questionnaires. Mean scores were compared between groups, the correlation between domain scores was assessed, and floor/ceiling effects were calculated. Etiologies of CLD were NAFLD (44%), hepatitis C (16%), and alcohol (16%). Fifty-three percent had cirrhosis and 33% were Child-Pugh B/C with a mean model for end-stage liver disease score of 12.0. In all 3 tools, the poorest scores were in physical function and fatigue. The presence of cirrhosis or complications was associated with worse scores in most PROMIS Profile-29 domains, indicating known group validity. Strong correlations ( r ≥ 0.7) were present between Profile-29 and SF-36 or CLDQ domains measuring similar concepts, indicating strong convergent validity. Profile-29 was completed faster than SF-36 and CLDQ (5.4 ± 3.0, 6.7 ± 3.3, 6.5 ± 5.2 min, p = 0.003) and rated equally on usability. All CLDQ and SF-36 domains reached the floor or ceiling, while none were noted for Profile-29. These floor/ceiling effects were magnified when assessed in those with and without cirrhosis, indicating the improved depth of measurement by Profile-29. CONCLUSIONS: Profile-29 is a valid, more efficient, well-received tool that provides an improved depth of measurement when compared to SF-36 and CLDQ and, therefore, an ideal tool to measure general health-related quality of life in CLD.

Leveraging social media to increase lung cancer screening awareness, knowledge and uptake among high-risk populations (The INSPIRE-Lung Study): study protocol of design and methods of a community-based randomized controlled trial.

BACKGROUND: Lung cancer is the leading cause of cancer death for both men and women in the United States. The National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (LDCT) screening can reduce lung cancer mortality among high-risk individuals, but uptake of lung screening remains low. Social media platforms have the potential to reach a large number of people, including those who are at high risk for lung cancer but who may not be aware of or have access to lung screening. METHODS: This paper discusses the protocol for a randomized controlled trial (RCT) that leverages FBTA to reach screening-eligible individuals in the community at large and intervene with a public-facing, tailored health communication intervention (LungTalk) to increase awareness of, and knowledge about, lung screening. DISCUSSION: This study will provide important information to inform the ability to refine implementation processes for national population efforts to scale a public-facing health communication focused intervention using social media to increase screening uptake of appropriate, high-risk individuals. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov (#NCT05824273).

Mortality After Postcolonoscopy Colorectal Cancer in the Veterans Affairs Health Care System.

Importance: Postcolonoscopy colorectal cancer (PCCRC) refers to colorectal cancer (CRC) diagnosed after a colonoscopy in which no cancer was found and is reflective of colonoscopy quality at the individual and system levels. Colonoscopy is widely performed in the Veterans Affairs (VA) health care system, but the prevalence of PCCRC and its associated mortality are unknown. Objective: To examine PCCRC prevalence and its all-cause mortality (ACM) and CRC-specific mortality (CSM) within the VA health care system. Design, Setting, and Participants: This retrospective cohort study used VA-Medicare administrative data to identify 29 877 veterans aged 50 to 85 years with newly diagnosed CRC between January 1, 2003, and December 31, 2013. Patients whose colonoscopy occurred less than 6 months before CRC diagnosis with no other colonoscopy within the previous 36 months were categorized as having detected CRC (DCRC). Those who had a colonoscopy that did not detect CRC between 6 and 36 months before CRC diagnosis were categorized as having postcolonoscopy CRC (PCCRC-3y). A third group included patients with CRC and no colonoscopy within the prior 36 months. The final analysis of the data was performed in September 2022. Exposures: Prior receipt of colonoscopy. Main Outcomes and Measures: Cox proportional hazards regression (with censoring, last follow-up December 31, 2018) analyses were conducted to compare PCCRC-3y and DCRC for 5-year ACM and CSM after CRC diagnosis. Results: Of 29 877 patients with CRC (median [IQR] age, 67 [60-75] years; 29 353 [98%] male; 5284 [18%] Black, 23 971 [80%] White, and 622 [2%] other), 1785 (6%) were classified as having PCCRC-3y and 21 811 (73%) as having DCRC. The 5-year ACM rates were 46% vs 42% for patients with PCCRC-3y vs patients with DCRC. The 5-year CSM rates were 26% vs 25% for patients with PCCRC-3y vs patients with DCRC. In multivariable Cox proportional hazards regression analysis, there was no significant difference in ACM and CSM between patients with PCCRC-3y (adjusted hazard ratio [aHR], 1.04; 95% CI, 0.98-1.11; P = .18) and patients with DCRC (aHR, 1.04; 95% CI, 0.95-1.13; P = .42). However, compared with patients with DCRC, patients with no prior colonoscopy had significantly higher ACM (aHR, 1.76; 95% CI, 1.70-1.82; P < .001) and CSM (aHR, 2.22; 95% CI, 2.12-2.32; P < .001). Compared with patients with DCRC, patients with PCCRC-3y had significantly lower odds of having undergone colonoscopy performed by a gastroenterologist (odds ratio, 0.48; 95% CI, 0.43-0.53; P < .001). Conclusions and Relevance: This study found that PCCRC-3y constituted 6% of CRCs in the VA system, which is similar to other settings. Compared with patients with CRC detected by colonoscopy, those with PCCRC-3y have comparable ACM and CSM.

Comparative Effectiveness of 2 Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Among Women in the Rural US: A Randomized Clinical Trial.

Importance: Women living in rural areas have lower rates of breast, cervical, and colorectal cancer screening compared with women living in urban settings. Objective: To assess the comparative effectiveness of (1) a mailed, tailored digital video disc (DVD) intervention; (2) a DVD intervention plus telephonic patient navigation (DVD/PN); and (3) usual care with simultaneously increased adherence to any breast, cervical, and colorectal cancer screening that was not up to date at baseline and to assess cost-effectiveness. Design, Setting, and Participants: This randomized clinical trial recruited and followed up women from rural Indiana and Ohio (community based) who were not up to date on any or all recommended cancer screenings. Participants were randomly assigned between November 28, 2016, and July 1, 2019, to 1 of 3 study groups (DVD, DVD/PN, or usual care). Statistical analyses were completed between August and December 2021 and between March and September 2022. Intervention: The DVD interactively assessed and provided messages for health beliefs, including risk of developing the targeted cancers and barriers, benefits, and self-efficacy for obtaining the needed screenings. Patient navigators counseled women on barriers to obtaining screenings. The intervention simultaneously supported obtaining screening for all or any tests outside of guidelines at baseline. Main Outcomes and Measures: Receipt of any or all needed cancer screenings from baseline through 12 months, including breast, cervical, and colorectal cancer, and cost-effectiveness of the intervention. Binary logistic regression was used to compare the randomized groups on being up to date for all and any screenings at 12 months. Results: The sample included 963 women aged 50 to 74 years (mean [SD] age, 58.6 [6.3] years). The DVD group had nearly twice the odds of those in the usual care group of obtaining all needed screenings (odds ratio [OR], 1.84; 95% CI, 1.02-3.43; P = .048), and the odds were nearly 6 times greater for DVD/PN vs usual care (OR, 5.69; 95% CI, 3.24-10.5; P < .001). The DVD/PN intervention (but not DVD alone) was significantly more effective than usual care (OR, 4.01; 95% CI, 2.60-6.28; P < .001) for promoting at least 1 (ie, any) of the needed screenings at 12 months. Cost-effectiveness per woman who was up to date was $14 462 in the DVD group and $10 638 in the DVD/PN group. Conclusions and Relevance: In this randomized clinical trial of rural women who were not up to date with at least 1 of the recommended cancer screenings (breast, cervical, or colorectal), an intervention designed to simultaneously increase adherence to any or all of the 3 cancer screening tests was more effective than usual care, available at relatively modest costs, and able to be remotely delivered, demonstrating great potential for implementing an evidence-based intervention in remote areas of the midwestern US. Trial Registration: ClinicalTrials.gov Identifier: NCT02795104.

Associations between outpatient treatment and the use of intensive psychiatric healthcare services.

The current manuscript examines concurrent and longitudinal associations between the utilization of outpatient and intensive psychiatric services among Medicaid-enrolled youth. Using an administrative dataset of Medicaid claims from 2007 to 2017, youth were included if they were between the ages of 10-18 (M = 13.4, SD = 2.6) and had a psychiatric Medicaid claim (N = 33,590). Psychiatric services were coded as outpatient, emergency department (ED), inpatient, or residential based on Medicaid codes. Logistic regression analyses indicated that the receipt of even one outpatient visit significantly reduced the odds of having an ED, inpatient, and residential visit within 60-, 90-, and 120-day windows. Survival analyses indicated most youth did not have any ED, inpatient, or residential visit following their first outpatient visit. For remaining youth, having an outpatient visit significantly increased the risk of having an ED, inpatient, and residential visit following their initial appointment, which may suggest these youth are being triaged to a more appropriate level of care. Classification accuracy analyses indicated a cutoff of 2 outpatient visits yielded maximum accuracy in determining youth with ED, inpatient, and residential visits. Findings highlight use of outpatient-level services in reducing risk of more intensive service utilization.

The use of peer support groups for emergency physicians during the COVID-19 pandemic.

Objective: To test the feasibility, receptivity, and preliminary effectiveness of peer support groups for emergency medicine physicians during the COVID-19 pandemic and gain a better understanding of their experiences with peer support. Methods: This pilot study used a quasi-experimental design to assess change in symptoms of distress, anxiety, depression and burn-out before and after participating in a virtual, group-based peer support intervention for a duration of 8 weeks. Pre-post change analyses were performed using two-sided, paired t tests. Feasibility was measured by attendance data to demonstrate the use of the intervention. Receptivity was measured using a global change rating and net promoter score at the end of each session and 8-week period, respectively. During the final session, qualitative data on physician experience was collected and then analyzed using conventional content analysis. Results: Twenty-four emergency medicine physicians participated in the pilot study. The attendance goal was met by 20 (24, 83%) physicians and 19 (22, 86%) physicians reported they would recommend peer support groups to a friend of colleague. Positive standardized response mean effect sizes indicated modest improvement in nine of 12 symptom measurements with marginal significance (p < 0.10) for improvement in guilt [20, Effect Size (ES) = 0.45] and depression (21, ES = 0.39). Qualitative findings revealed high overall benefit with few adverse impacts of participation. Conclusions: Results demonstrate high physician receptivity, feasibility, and benefit from participation in peer support groups. Promising signs of improvement in distress, anxiety, depression, and burn out symptoms warrant additional studies with larger sample sizes and more robust research designs to establish the evidence base for peer support in the physician population.

CMS Practice Assessment Tool validity for alternative payment models.

OBJECTIVES: To study the predictive validity of the CMS Practice Assessment Tool (PAT) among 632 primary care practices. STUDY DESIGN: Retrospective observational study. METHODS: The study included primary care physician practices recruited by the Great Lakes Practice Transformation Network (GLPTN), 1 of 29 CMS-awarded networks, and used data from 2015 to 2019. At enrollment, trained quality improvement advisers scored each of the PAT's 27 milestones by its degree of implementation based on interviews with staff, review of documents, direct observation of practice activity, and professional judgment. The GLPTN also tracked each practice's status regarding alternative payment model (APM) enrollment. Exploratory factor analysis (EFA) was used to identify summary scores; mixed-effects logistic regression was used to assess the relationship between derived scores with APM participation. RESULTS: EFA revealed that the PAT's 27 milestones could be summed into 1 overall score and 5 secondary scores. By the end of the 4-year project, 38% of practices were enrolled in an APM. A baseline overall score and 3 secondary scores were associated with increased odds of joining an APM (overall score: odds ratio [OR], 1.06; 95% CI, 0.99-1.12; P = .061; data-driven care quality score: OR, 1.11; 95% CI, 1.00-1.22; P = .040; efficient care delivery score: OR, 1.08; 95% CI, 1.03-1.13; P = .003; collaborative engagement score: OR, 0.88; 95% CI, 0.80-0.96; P = .005). CONCLUSIONS: These results demonstrate that the PAT has adequate predictive validity for APM participation.

Patient-Reported Functional Impairment Due to Hearing Loss and Tinnitus After Cisplatin-Based Chemotherapy.

PURPOSE: Cisplatin is widely used and highly ototoxic, but patient-reported functional impairment because of cisplatin-related hearing loss (HL) and tinnitus has not been comprehensively evaluated. PATIENTS AND METHODS: Testicular cancer survivors (TCS) given first-line cisplatin-based chemotherapy completed validated questionnaires, including the Hearing Handicap Inventory for Adults (HHIA) and Tinnitus Primary Function Questionnaire (TPFQ), each of which quantifies toxicity-specific functional impairment. Spearman correlations evaluated associations between HL and tinnitus severity and level of functional handicap quantified with the HHIA and TPFQ, respectively. Associations between HL or tinnitus and five prespecified adverse health outcomes (cognitive dysfunction, fatigue, depression, anxiety, and overall health) were evaluated. RESULTS: HL and tinnitus affected 137 (56.4%) and 147 (60.5%) of 243 TCS, respectively. Hearing aids were used by 10% TCS (14/137). Of TCS with HL, 35.8% reported clinically significant functional impairment. Severe HHIA-assessed functional impairment was associated with cognitive dysfunction (odds ratio [OR], 10.62; P < .001), fatigue (OR, 5.48; P = .003), and worse overall health (OR, 0.19; P = .012). Significant relationships existed between HL severity and HHIA score, and tinnitus severity and TPFQ score (P < .0001 each). TCS with either greater hearing difficulty or more severe tinnitus were more likely to report cognitive dysfunction (OR, 5.52; P = .002; and OR, 2.56; P = .05), fatigue (OR, 6.18; P < .001; and OR, 4.04; P < .001), depression (OR, 3.93; P < .01; and OR, 3.83; P < .01), and lower overall health (OR, 0.39; P = .03; and OR, 0.46; P = .02, respectively). CONCLUSION: One in three TCS with HL report clinically significant functional impairment. Follow-up of cisplatin-treated survivors should include routine assessment for HL and tinnitus. Use of the HHIA and TPFQ permit risk stratification and referral to audiologists as needed, since HL adversely affects functional status and is the single largest modifiable risk factor for cognitive decline and dementia in the general population.

Examining Patterns of Psychotherapy Service Utilization Among Medicaid-Enrolled Adolescents.

OBJECTIVE: Adolescents with behavioral health disorders (i.e., mental health disorders and substance use) often experience frequent recurrence of symptoms, suggesting a need for an ongoing behavioral health intervention, rather than a single course of treatment. However, little is known about mental health care service use among adolescents over longer periods. The authors examined longitudinal patterns of outpatient behavioral health service utilization in a large sample of adolescents. METHODS: Medicaid claims for 8,197 adolescents (ages 10.0-13.9 years, mean±SD=11.5±1.2; 61% male) from one Indiana county between 2006 and 2017 were examined, with a focus on outpatient psychotherapy visits. Latent class analysis (LCA) was used to detect clusters of longitudinal patterns of outpatient psychotherapy visits across 5 years, beginning with an adolescent's first behavioral health visit. RESULTS: A five-class LCA model emerged with unique classes of service use based on duration and level of engagement (frequency) of monthly outpatient psychotherapy visits. Most adolescents fell in the nonuse class (38.7% of the sample). Additional classes were defined as late-onset low engagement (17.1%), early-onset high engagement (15.5%), early-onset moderate engagement (16.7%), and continuously high engagement (11.9%). Statistically significant differences were found across the classes in average duration and frequency of involvement (p<0.001), as well as in demographic characteristics (race, age, gender, and ethnicity) and behavioral health diagnoses (p<0.001). CONCLUSIONS: These findings confirm that adolescents with behavioral health diagnoses do not follow a uniform pattern of psychotherapy utilization. The distinct patterns of service use point toward the need to identify appropriate long-term service recommendations for adolescents.

Prevalence and risk factors for ototoxicity after cisplatin-based chemotherapy.

PURPOSE: Ototoxicity is a prominent side effect of cisplatin-based chemotherapy. There are few reports, however, estimating its prevalence in well-defined cohorts and associated risk factors. METHODS: Testicular cancer (TC) survivors given first-line cisplatin-based chemotherapy completed validated questionnaires. Descriptive statistics evaluated the prevalence of ototoxicity, defined as self-reported hearing loss and/or tinnitus. We compared patients with and without tinnitus or hearing loss using Chi-square test, two-sided Fisher's exact test, or two-sided Wilcoxon rank sum test. To evaluate ototoxicity risk factors, a backward selection logistic regression procedure was performed. RESULTS: Of 145 TC survivors, 74% reported ototoxicity: 68% tinnitus; 59% hearing loss; and 52% reported both. TC survivors with tinnitus were more likely to indicate hypercholesterolemia (P = 0.008), and difficulty hearing (P < .001). Tinnitus was also significantly related to age at survey completion (OR = 1.79; P = 0.003) and cumulative cisplatin dose (OR = 5.17; P < 0.001). TC survivors with hearing loss were more likely to report diabetes (P = 0.042), hypertension (P = 0.007), hypercholesterolemia (P < 0.001), and family history of hearing loss (P = 0.044). Risk factors for hearing loss included age at survey completion (OR = 1.57; P = 0.036), hypercholesterolemia (OR = 3.45; P = 0.007), cumulative cisplatin dose (OR = 1.94; P = 0.049), and family history of hearing loss (OR = 2.87; P = 0.071). CONCLUSIONS: Ototoxicity risk factors included age, cisplatin dose, cardiovascular risk factors, and family history of hearing loss. Three of four TC survivors report some type of ototoxicity; thus, follow-up of cisplatin-treated survivors should include routine assessment for ototoxicity with provision of indicated treatments. IMPLICATIONS FOR CANCER SURVIVORS: Survivors should be aware of risk factors associated with ototoxicity. Referrals to audiologists before, during, and after cisplatin treatment is recommended.