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1.
Genet Med ; 2021 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-33603197

RESUMO

PURPOSE: We sought to determine preferences of biobank participants whose samples were tested for clinically actionable variants but did not respond to an initial invitation to receive results. METHODS: We recontacted a subsample of participants in the Kaiser Permanente Washington/University of Washington site of the Electronic Medical Records and Genomics (eMERGE3) Network. The subsample had provided broad consent for their samples to be used for research but had not responded to one initial mailed invitation to receive their results. We sent a letter from the principal investigators with phone outreach. If no contact was made, we sent a certified letter stating our assumption that participant had actively refused. We collected reasons for declining. RESULTS: We recontacted 123 participants. Response rate was 70.7% (n = 87). Of these, 62 (71.3%) declined the offer of returned results and 25 (28.7%) consented. The most common reasons provided for refusal included not wanting to know (n = 22) and concerns about insurability (n = 28). CONCLUSION: Efforts to recontact biobank participants can yield high response. Though active refusal upon recontact was common, our data do not support assuming initial nonresponse to be refusal. Future research can work toward best practices for reconsenting, especially when clinically actionable results are possible.

2.
BMC Med Genomics ; 14(1): 10, 2021 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-33407467

RESUMO

BACKGROUND: Genetic testing allows patients and clinicians to understand the risk of hereditary diseases. By testing early, individuals can make informed medical decisions about management which may minimize the risk of developing certain diseases. Importantly, genetic test results may also be applicable to patients' biological relatives; thus, these results could also lead to minimizing their risk of disease. However, sharing genetic test results between patients and their relatives is scarce. The most frequently reported problems are that patients cannot clearly explain this information and relatives misinterpret the results. Smartphone apps in the healthcare field are a possible solution as they allow patients to accurately share sensitive information to others, while providing educational material to support understanding the information. However, these apps may not provide security to protect patients' identifiable information. We developed ShareDNA, a smartphone app that (1) allows patients to securely share their genetic test results with others, (2) provides information on how to interpret these results, and (3) minimizes the amount of patient information needed to use the service. RESULTS: We recruited thirteen participants to test the usability of our app and provide feedback. We found overall that participants were comfortable with using this app and could easily learn each app function when filling out our questionnaire. Additionally, based on vocalized impressions of the usefulness of the app, participants indicated that the user-interface could be more intuitive and that we needed to add more text within the app to explain why ShareDNA is a secure service. CONCLUSIONS: ShareDNA is a free smartphone app that allows patients to share their genetic test results with others, including their biological relatives. Sharing these results along with educational material will enable relatives to share accurate information and discuss their possible risk for disease with their clinical providers. As a result, appropriate testing in relatives could be improved.

3.
Transl Behav Med ; 10(4): 902-904, 2020 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-33030528

RESUMO

The Society of Behavioral Medicine (SBM) Leadership Institute provides leadership training for mid-career behavioral medicine scientists. As an institute fellow, I explored the experiences of social scientists working in healthcare settings. Exploratory research to describe the experiences, barriers, and facilitators social scientists face working in a healthcare delivery and research system. Our research questions were exploratory, focused on understanding (a) the experiences of social scientists working in a healthcare delivery and research system, (b) barriers that social scientists face working in a healthcare delivery and research system, (c) perceived value of sociological and anthropologic methods to clinicians and other health researchers, and (4) to understand the landscape of organizational models that feature social scientists as part of a larger scientific enterprise. We developed a plan for needs assessment activities. We conducted a design workshop of social scientists (n = 11). Using human-centered design methods, we elicited experiences and asked participants to develop a prototype model where social scientists could find career fulfillment with minimal structural barriers. We found that social scientists feel a strong sense of pride in their social science training and passion for the work they do. They reported occupying multiple disciplines at once, including multiple promotion and reputational expectations. Participants commonly reported that they themselves, as well as collaborators, viewed social science work, particularly qualitative research, as supplemental to quantitative work. Participants described perceptions that social science research is less rigorous or requires less training compared with other disciplines. Participants identified several contextual factors that influenced the perceived value of social science research in healthcare, including the focus of external funding priorities on larger clinical questions, organizational structure, and tangible leadership support of social science. The SBM Leadership Institute created a space for preliminary research into an area that could improve the experiences and research impact of social and behavioral scientists.

4.
Future Oncol ; 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32976048

RESUMO

Current models of financial burden after cancer do not adequately define types of financial burden, moderators or causes. We propose a new theoretical model to address these gaps. This model delineates the components of financial burden as material and psychological as well as healthcare-specific (affording treatment) versus general (affording necessities). Psychological financial burden is further divided into worry about future costs and rumination about past and current financial burden. The model hypothesizes costs and employment changes as causes, and moderators include precancer socioeconomic status and post-diagnosis factors. The model outlines outcomes affected by financial burden, including depression and mortality. Theoretically derived measures of financial burden, interventions and policy changes to address the causes of financial burden in cancer are needed.

5.
JCO Oncol Pract ; 16(9): e912-e921, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32379563

RESUMO

PURPOSE: Cost of care (CoC) conversations should occur routinely in oncology practice. However, patient preferences about with whom, when, and how to have these conversations are missing and preferences may vary across patient populations. METHODS: We performed a secondary qualitative analysis of quotes from interviews with 28 cancer survivors from two health care settings (Kaiser Permanente Washington and O'Neal Comprehensive Cancer Center at University of Alabama at Birmingham [UABCCC]). A targeted approach searched for three constructs: (1) Who should have CoC conversations with patients? (2) When should CoC conversations occur? and (3) How should CoC conversations happen? RESULTS: Interviewees were similar in age and education, but UABCCC participants had more racial/ethnic minority representation and financial distress. Within each construct, themes were similar across both groups. As to who should have CoC conversations, we found that (1) providers' main role is medical care, not CoC; and (2) care team staff members are a more appropriate choice to address CoC needs. About the question of when, we found that (3) individuals have strong convictions about when and if they want to discuss CoC; and (4) CoC information and resources need to be available when patients are ready. About the question of how, themes were (5) provide estimates of anticipated out-of-pocket costs and insurance coverage; (6) provide reassurance, sympathy, and concrete solutions; and (7) because of their sensitivity, conduct CoC conversations in a comfortable, private space. CONCLUSION: These findings offer general guidance as to who should conduct CoC conversations and when and how they should occur, with applicability across different patient populations.

8.
JNCI Cancer Spectr ; 4(1): pkz086, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32025627

RESUMO

Background: Although uniform colonoscopy screening reduces colorectal cancer (CRC) mortality, risk-based screening may be more efficient. We investigated whether CRC screening based on polygenic risk is a cost-effective alternative to current uniform screening, and if not, under what conditions it would be. Methods: The MISCAN-Colon model was used to simulate a hypothetical cohort of US 40-year-olds. Uniform screening was modeled as colonoscopy screening at ages 50, 60, and 70 years. For risk-stratified screening, individuals underwent polygenic testing with current and potential future discriminatory performance (area under the receiver-operating curve [AUC] of 0.60 and 0.65-0.80, respectively). Polygenic testing results were used to create risk groups, for which colonoscopy screening was optimized by varying the start age (40-60 years), end age (70-85 years), and interval (1-20 years). Results: With current discriminatory performance, optimal screening ranged from once-only colonoscopy at age 60 years for the lowest-risk group to six colonoscopies at ages 40-80 years for the highest-risk group. While maintaining the same health benefits, risk-stratified screening increased costs by $59 per person. Risk-stratified screening could become cost-effective if the AUC value would increase beyond 0.65, the price per polygenic test would drop to less than $141, or risk-stratified screening would lead to a 5% increase in screening participation. Conclusions: Currently, CRC screening based on polygenic risk is unlikely to be cost-effective compared with uniform screening. This is expected to change with a greater than 0.05 increase in AUC value, a greater than 30% reduction in polygenic testing costs, or a greater than 5% increase in adherence with screening.

9.
Front Psychol ; 10: 2622, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31824388

RESUMO

This study adapted a measure on worry about affording healthcare. The financial costs of healthcare are increasingly being shifted to patients. Financial burden from healthcare costs can be material (such as bankruptcy) or psychological. Psychological distress can be either worry about affording future care or distress due to material consequences and, despite evidence from clinical psychology that differentiates these types of emotional symptoms, this distinction has largely been ignored for financial burden in healthcare. We adapted a worry about affording healthcare scale for use in the general population (n = 398) to facilitate comparisons between disease groups and across countries. Participants completed a survey through an online platform. The worry about affording healthcare measure showed good reliability and validity through associations with quality of life (QOL) and measures of other types of financial burden. Worry about affording healthcare was also associated with cost-related non-adherence to medical care. Future research on patient QOL should consider worry about affording healthcare.

10.
Am J Prev Med ; 57(6 Suppl 1): S13-S24, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31753276

RESUMO

CONTEXT: Health systems increasingly are exploring implementation of standardized social risk assessments. Implementation requires screening tools both with evidence of validity and reliability (psychometric properties) and that are low cost, easy to administer, readable, and brief (pragmatic properties). These properties for social risk assessment tools are not well understood and could help guide selection of assessment tools and future research. EVIDENCE ACQUISITION: The systematic review was conducted during 2018 and included literature from PubMed and CINAHL published between 2000 and May 18, 2018. Included studies were based in the U.S., included tools that addressed at least 2 social risk factors (economic stability, education, social and community context, healthcare access, neighborhood and physical environment, or food), and were administered in a clinical setting. Manual literature searching was used to identify empirical uses of included screening tools. Data on psychometric and pragmatic properties of each tool were abstracted. EVIDENCE SYNTHESIS: Review of 6,838 unique citations yielded 21 unique screening tools and 60 articles demonstrating empirical uses of the included screening tools. Data on psychometric properties were sparse, and few tools reported use of gold standard measurement development methods. Review of pragmatic properties indicated that tools were generally low cost, written for low-literacy populations, and easy to administer. CONCLUSIONS: Multiple low-cost, low literacy tools are available for social risk screening in clinical settings, but psychometric data are very limited. More research is needed on clinic-based screening tool reliability and validity as these factors should influence both adoption and utility. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.


Assuntos
Programas de Rastreamento , Psicometria , Medição de Risco , Determinantes Sociais da Saúde , Humanos , Reprodutibilidade dos Testes , Inquéritos e Questionários
11.
JAMA ; 322(5): 445-454, 2019 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-31386140

RESUMO

Importance: Pancreatic adenocarcinoma is the third most common cause of cancer death among men and women in the United States. Objective: To systematically review benefits and harms of screening for pancreatic adenocarcinoma to inform the US Preventive Services Task Force. Data Sources: MEDLINE, PubMed, and the Cochrane Collaboration Registry of Controlled Trials, from January 2002 through April 27, 2018; surveillance through March 22, 2019. Study Selection: Studies of adults with or without risk factors for pancreatic adenocarcinoma (eg, family history of pancreatic cancer, personal history of new-onset diabetes) undergoing imaging-based screening; studies of treatment for adults with screen-detected or asymptomatic pancreatic adenocarcinoma. Included study designs were randomized clinical trials, nonrandomized controlled intervention studies, diagnostic accuracy studies with a reference standard, cohort studies, and case-control studies (for evaluation of harms only). Studies consisting entirely of populations with known genetic syndromes associated with pancreatic cancer were excluded. Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and rated included studies for quality; data were quantitatively analyzed to calculate a pooled diagnostic yield and narratively synthesized. Main Outcomes and Measures: Mortality, morbidity, or quality of life; diagnostic accuracy of screening tests; any harm of screening or treatment. Results: Thirteen fair-quality prospective cohort screening studies (N = 1317) conducted predominantly in populations at high familial risk for pancreatic adenocarcinoma were included. No studies reported on the effect of screening on morbidity or mortality or on the effectiveness of treatment for screen-detected pancreatic adenocarcinoma. Although no studies evaluated the diagnostic accuracy of screening tests, all 13 studies reported the diagnostic yield. Yields ranged from 0 to 75 cases per 1000 persons in studies using endoscopic ultrasound, magnetic resonance imaging, and/or computed tomography-based screening. In total, 18 cases of pancreatic adenocarcinoma were detected in 1156 adults at increased familial risk and 0 cases were detected in 161 average-risk adults. In 8 studies (n = 675) assessing procedural harms of screening, no serious harms from initial screening were reported. Two studies (n = 271) found no evidence of psychosocial harms related to screening. Evidence of surgical harms was limited. Conclusions and Relevance: Imaging-based screening in groups at high familial risk can detect pancreatic adenocarcinoma with limited evidence of minimal harms. However, the effect of screening on morbidity and mortality in groups at high familial risk has not been studied, and no data are available in average-risk populations. There is limited evidence to assess benefits or harms of surgical intervention for screen-detected pancreatic adenocarcinoma.


Assuntos
Adenocarcinoma/diagnóstico por imagem , Detecção Precoce de Câncer , Neoplasias Pancreáticas/diagnóstico , Adenocarcinoma/genética , Adenocarcinoma/mortalidade , Adenocarcinoma/cirurgia , Adulto , Detecção Precoce de Câncer/efeitos adversos , Feminino , Humanos , Masculino , Programas de Rastreamento/efeitos adversos , Pâncreas/diagnóstico por imagem , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias , Qualidade de Vida , Fatores de Risco , Sensibilidade e Especificidade
12.
Pediatrics ; 144(2)2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31270139

RESUMO

OBJECTIVES: To explore parent attitudes toward discussing their child's health care costs in the inpatient setting and to identify strategies for health care providers to engage in cost discussions with parents. METHODS: Using purposeful sampling, we conducted semistructured interviews between October 2017 and February 2018 with parents of children with and without chronic disease who received care at a tertiary academic children's hospital. Researchers coded the data using applied thematic analysis to identify salient themes and organized them into a conceptual model. RESULTS: We interviewed 42 parents and identified 2 major domains. Categories in the first domain related to factors that influence the parent's desire to discuss health care costs in the inpatient setting, including responsibility for out-of-pocket expenses, understanding their child's insurance coverage, parent responses to financial stress, and their child's severity of illness on hospital presentation. Categories in the second domain related to parent preference regarding the execution of cost discussions. Parents felt these discussions should be optional and individualized to meet the unique values and preferences of families. They highlighted concerns regarding physician involvement in these discussions; their preference instead was to explore financial issues with a financial counselor or social worker. CONCLUSIONS: Parents recommended that cost discussions in the inpatient setting should be optional and based on the needs of the family. Families expressed a desire for physicians to introduce rather than conduct cost discussions. Specific recommendations from parents for these discussions may be used to inform the initiation and improvement of cost discussions with families during inpatient encounters.


Assuntos
Comportamento do Consumidor/economia , Custos de Cuidados de Saúde , Hospitalização/economia , Hospitais Pediátricos/economia , Pais/psicologia , Adulto , Feminino , Custos de Cuidados de Saúde/tendências , Gastos em Saúde/tendências , Hospitalização/tendências , Hospitais Pediátricos/tendências , Humanos , Pacientes Internados , Cobertura do Seguro/economia , Cobertura do Seguro/tendências , Masculino , Pessoa de Meia-Idade , Adulto Jovem
13.
J Empir Res Hum Res Ethics ; 14(3): 286-295, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31113270

RESUMO

In 2016, the U.S. National Institutes of Health (NIH) announced a new policy requiring single institutional review board (sIRB) review for multisite studies. However, adherence to the new policy requires the separation of regulatory institutional review board (IRB) work per Federal guidance from site-specific local compliance concerns. In particular, genomic research is subject to a wide range of state laws, institutional requirements, and local population preferences. In this qualitative study, we explored the anticipated needs of genomics researchers and IRB administrators around implementing the policy. We observed multiple uncertainties, particularly about intersite communication processes, sIRB selection processes, and roles of the reviewing IRB and local sites regarding local context information relevant to genomics. Optimal implementation of the NIH policy may require additional guidance for researchers and IRB administrators.


Assuntos
Comitês de Ética em Pesquisa , Pesquisa em Genética , Genômica , Estudos Multicêntricos como Assunto , Políticas , Humanos , National Institutes of Health (U.S.) , Estados Unidos
14.
Ann Intern Med ; 170(9_Suppl): S70-S78, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-31060061

RESUMO

Background: Patients prefer to discuss costs in the clinical setting, but physicians and teams may be unprepared to incorporate cost discussions into existing workflows. Objective: To understand and improve clinical workflows related to cost-of-care conversations. Design: Qualitative human-centered design study. Setting: 2 integrated health systems in the U.S. Pacific Northwest: a system-wide oncology service line and a system-wide primary care service line. Participants: Clinicians, clinical team members, operations staff, and patients. Measurements: Ethnographic observations were made at the integrated health systems, assessing barriers to and facilitators of discussing costs with patients. Three unique patient experiences of having financial concerns addressed in the clinic were designed. These experiences were refined after in-person interviews with patients (n = 20). Data were synthesized into a set of clinical workflow requirements. Results: Most patient cost concerns take 1 of 3 pathways: informing clinical care decision making, planning and budgeting concerns, and addressing immediate financial hardship. Workflow requirements include organizational recognition of the need for clinic-based cost-of-care conversations; access to cost and health plan benefit data to support each conversation pathway; clear team member roles and responsibilities for addressing cost-of-care concerns; a patient experience where cost questions are normal and each patient's preferences and privacy are respected; patients know who to go to with cost questions; patients' concerns are documented to minimize repetition to multiple team members; and patients learn their expected out-of-pocket costs before treatment begins. Limitation: Results may have limited generalizability to other health care settings, and the study did not test the effectiveness of the workflows developed. Conclusion: Clinic-based workflows for cost-of-care conversations that optimize patients' care experience require organizational commitment to addressing cost concerns, clear roles and responsibilities, appropriate and complete data access, and a team-based approach. Primary Funding Source: Robert Wood Johnson Foundation.


Assuntos
Assistência Ambulatorial/organização & administração , Comunicação , Gastos em Saúde , Neoplasias/economia , Relações Médico-Paciente , Atenção Primária à Saúde/organização & administração , Fluxo de Trabalho , Assistência Ambulatorial/economia , Efeitos Psicossociais da Doença , Humanos , Entrevistas como Assunto , Neoplasias/terapia , Atenção Primária à Saúde/economia , Pesquisa Qualitativa , Estados Unidos
15.
J Community Genet ; 10(4): 461-470, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30843145

RESUMO

Assess the feasibility and acceptability of health system-led genetic risk notification in a US integrated health system. We conducted semi-structured phone interviews with individuals age 40-64 years who had undergone genetic sequencing, but had not yet received their results, assessing attitudes to direct outreach to relatives. During each interview, we collected contact information for adult relatives identified as members of the same system and attempted to identify each relative in administrative data. We conducted 20 interviews. Most participants expressed support for Kaiser Permanente Washington involvement in familial risk notification. Direct outreach to relatives received the most unqualified support; outreach to the relatives' physician or interaction with the relatives' electronic medical record received more tempered support. Support was motivated by the desire to have risk communicated accurately and quickly. The most common caveat was a desire to alert relatives before the health system contacted them. Of 57 named relatives who were members of the same health system, we retrieved a single match for 40 (70.2%) based on name or birthdate. Health system involvement in familial risk notification received support in a sample of patients in a US integrated health system, and identification of relatives is feasible.

16.
Health Educ Behav ; 46(3): 445-453, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30616381

RESUMO

BACKGROUND: Parental trust in their child's health care provider and the number and type of vaccine information sources are important dimensions of vaccine hesitancy and may suggest intervention components for future research. METHOD: We conducted secondary analysis of survey data from mothers of healthy newborns in Washington State, and examined the association between parental trust in their child's health care provider and vaccine information sources. RESULTS: We found that mothers with less trust in their child's health care provider used more sources, more informal sources, and were less likely to consider their child's pediatrician their main source of vaccine information compared with more trusting mothers. However, less trusting mothers did not report more effort to read or watch stories about vaccines than more trusting mothers, nor were they more likely to report the internet as their main vaccine information source. CONCLUSIONS: Future interventions seeking to reduce parental vaccine hesitancy should consider intervention components focused on building or improving parent trust in their child's health care provider.


Assuntos
Educação em Saúde , Mães/educação , Mães/psicologia , Confiança/psicologia , Vacinação/psicologia , Adulto , Tomada de Decisões , Feminino , Humanos , Recém-Nascido , Masculino , Relações Profissional-Família , Inquéritos e Questionários , Washington
17.
Cancer ; 124(21): 4181-4191, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-30475400

RESUMO

BACKGROUND: Cancer costs should be discussed by patients and providers, but information is not readily available. Results from recently published studies (in the last 5 years) on direct and indirect cancer costs may help guide these discussions. METHODS: The authors reviewed studies published between 2013 and 2017 that reported direct health care costs and indirect (productivity losses) costs. The annual mean total and net costs of cancer were summarized for all payers and for survivors only by age (ages 18-64 and ≥65 years), by phase of care (initial [ie, 12 months from diagnosis], continuing, and end-of-life [ie, 12 months before death]), or for recently diagnosed (within 1-2 years of diagnosis) and longer term survivors. RESULTS: For all payers combined, costs for cancers like breast, prostate, colorectal, and lung cancers were $20,000 to $100,000 in the initial phase, $1000 to $30,000 annually in the continuing phase, and ≥$60,000 in the end-of-life phase. Annual out-of-pocket costs to recently diagnosed survivors were >$1000 for medical care and time costs, approximately $2000 for productivity losses, and from $2500 to >$4000 for employment disability, depending on age. For longer term survivors, the cost of medical care was approximately $1500 for older survivors and $747 for younger survivors, time costs were $831 to $955 for older survivors and $459 to $630 for younger survivors, and productivity losses were approximately $800. Disability among long-term survivors was similar to that among short-term survivors. Limitations of the reviewed studies included older data and under-representation of higher cost cancers. CONCLUSIONS: Frequently updated cost information for all cancer types is needed to guide discussions of anticipated short-term and long-term cancer-related costs with survivors. Cancer 2018;000:000-000. © 2018 American Cancer Society.


Assuntos
Continuidade da Assistência ao Paciente/economia , Procedimentos Clínicos/economia , Emprego/economia , Custos de Cuidados de Saúde , Neoplasias/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Sobreviventes de Câncer/estatística & dados numéricos , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Efeitos Psicossociais da Doença , Procedimentos Clínicos/estatística & dados numéricos , Eficiência , Emprego/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Adulto Jovem
18.
Clin Pediatr (Phila) ; 57(13): 1523-1531, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30003794

RESUMO

This study evaluated the impact of health system-based outreach and reminders on human papillomavirus (HPV) vaccine series initiation and completion. Parents of 10 to 12 year olds (n = 1805) were randomized to receive either (1) an outreach letter and brochure recommending HPV vaccination followed by automated HPV vaccine reminders or (2) usual care. We interviewed a subset of 50 parents to assess program acceptability. Outcomes were HPV vaccine initiation during the study period and on-time series completion. Rates of HPV vaccine initiation during the study period (July 2015 to August 2016) were similar between the intervention and control groups, but initiation within 120 days of randomization was higher in the intervention group (23.6% and 18.8%, P = .04) as was completion during the study period (10.3% vs 6.8%, P = .04). Reminders for doses 2 and 3 did not affect completion. The program was acceptable to parents. This study provides evidence that health system-based outreach and reminders can improve HPV vaccination.


Assuntos
Relações Comunidade-Instituição , Prestação Integrada de Cuidados de Saúde , Vacinas contra Papillomavirus , Aceitação pelo Paciente de Cuidados de Saúde , Sistemas de Alerta , Vacinação , Adulto , Criança , Feminino , Humanos , Masculino , Infecções por Papillomavirus/prevenção & controle , Pais
19.
JAMA ; 319(11): 1143-1157, 2018 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-29558557

RESUMO

Importance: Exposure to UV radiation, especially in childhood, increases skin cancer risk. Objective: To systematically review the evidence on the benefits and harms of behavioral counseling for skin cancer prevention to inform the US Preventive Services Task Force (USPSTF). Data Sources: Cochrane Central Register of Controlled Trials, MEDLINE, and PubMed were searched for studies published from January 2009 to March 31, 2016, for skin cancer prevention and from August 2005 to March 31, 2016, for skin self-examination. Surveillance in targeted publications was conducted through February 14, 2018. Studies included in previous USPSTF reports were reevaluated for inclusion. Study Selection: Fair- and good-quality studies of primary care-relevant behavioral interventions focused on improving skin cancer outcomes, intermediate outcomes, or skin cancer prevention and self-examination behaviors. Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and extracted data into evidence tables. Results were qualitatively summarized but not pooled because of heterogeneity of measures. Main Outcomes and Measures: Skin cancer, sunburn, precursor skin lesions, sun protection behaviors, and any harms from interventions. Results: Twenty-one trials in 27 publications were included (N = 20 561). No studies assessed skin cancer outcomes in pediatric populations; 1 adult trial (n = 1356) promoting skin self-examination found no significant difference in participants diagnosed with melanoma in the intervention group vs the control group at 12-month follow-up (0 vs 1 diagnosis). There was no consistent improvement in prevention of sunburn for children (3 trials [n = 2508]) or adults (6 trials [n = 3959]). There were small to moderate increases in sun protection behavior in pediatric populations (6 trials [n = 4252]) and adults (12 trials [n = 13 099]) and small increases in skin self-examination in adults (11 trials [n = 7771]; odds ratios, 1.16-2.6). One of 3 trials of indoor tanning found an intervention effect; an appearance-focused intervention (n = 430) resulted in a smaller increase in mean indoor tanning sessions at 6 months in the intervention group vs the control group. Harms were rarely reported: 1 trial of skin self-examination (n = 1356) found an increase in skin procedures in the intervention group vs the control group at 6 months (8.0% vs 3.6%, P < .001) but not between 6 and 12 months (3.9% vs 3.3%, P = .50), and 1 trial (n = 217) found no between-group difference in skin cancer worry (28.9% vs 18.4%, P = .16). Conclusions and Relevance: Behavioral interventions can increase sun protection behavior, but there is no consistent evidence that interventions are associated with a reduction in the frequency of sunburn in children or adults and minimal evidence on skin cancer outcomes. Intervention can increase skin self-examination in adults but may lead to increased skin procedures without detecting additional atypical nevi or skin cancers.


Assuntos
Aconselhamento/métodos , Comportamentos Relacionados com a Saúde , Neoplasias Cutâneas/prevenção & controle , Queimadura Solar/prevenção & controle , Adolescente , Adulto , Criança , Humanos , Lesões Pré-Cancerosas/prevenção & controle , Fatores de Risco , Autoexame/efeitos adversos , Pigmentação da Pele , Protetores Solares
20.
JAMA ; 319(2): 173-187, 2018 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-29318283

RESUMO

Importance: Adolescent idiopathic scoliosis (AIS), a spinal curvature of 10° or more, is the most common form of scoliosis, with a prevalence of 1% to 3%. Curves progress in approximately two-thirds of patients with AIS before skeletal maturity, and large curves (>50°) may be associated with adverse health outcomes. Objective: To systematically review evidence on benefits and harms of AIS screening for the US Preventive Services Task Force (USPSTF). Data Sources: Cochrane Central Register of Controlled Trials, MEDLINE, ERIC, PubMed, CINAHL, and relevant systematic reviews were searched for studies published from January 1966 to October 20, 2016; studies included in a previous USPSTF report were also reviewed. Surveillance was conducted through July 24, 2017. Study Selection: Fair- and good-quality studies that evaluated the accuracy of screening children and adolescents aged 10 to 18 years for AIS, the benefits of AIS treatment, the harms of AIS screening or treatment, or long-term health outcomes. Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and extracted data into evidence tables. Results were qualitatively summarized. Main Outcomes and Measures: Health outcomes and spinal curvature in adolescence and adulthood, accuracy of screening for AIS, any harm of AIS screening or treatment. Results: Fourteen studies (N = 448 276) in 26 articles were included. Accuracy of AIS screening was highest (93.8% sensitivity; 99.2% specificity) in a cohort study of a clinic-based program using forward bend test, scoliometer, and Moiré topography screening (n = 306 082); accuracy was lower in cohort studies of 6 programs using fewer modalities (n = 141 161). Four controlled studies (n = 587) found evidence for benefit of bracing on curve progression compared with controls. A randomized clinical trial and a nonrandomized trial of exercise treatment (N = 184) found favorable reductions in Cobb angle of 0.67° to 4.9° in the intervention group compared with increases of 1.38° to 2.8° in the control group. Two cohort studies (n = 339) on long-term outcomes found that braced participants reported more negative treatment experience and body appearance compared with surgically treated or untreated participants. A study that combined a randomized clinical trial and cohort design (n = 242) reported harms of bracing, which included skin problems on the trunk and nonback body pains. There was no evidence on the effect of AIS screening on adult health outcomes. Conclusions and Relevance: Screening can detect AIS. Bracing and possibly exercise treatment can interrupt or slow progression of curvature in adolescence. However, there is little or no evidence on long-term outcomes for AIS treated in adolescence, the association between curvature at skeletal maturity and adult health outcomes, the harms of AIS screening or treatment, or the effect of AIS screening on adult health outcomes.


Assuntos
Braquetes , Terapia por Exercício , Programas de Rastreamento , Medicina Preventiva , Escoliose/diagnóstico , Adolescente , Adulto , Braquetes/efeitos adversos , Criança , Progressão da Doença , Feminino , Humanos , Masculino , Programas de Rastreamento/efeitos adversos , Guias de Prática Clínica como Assunto , Escoliose/cirurgia , Escoliose/terapia , Sensibilidade e Especificidade , Resultado do Tratamento
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