Papel de la persona navegadora del paciente en el cáncer de pulmón / The Role of the Navigator Person for a Patient with Lung Cancer

Introducción: la medicina basada en el valor ha logrado mejorar la calidad de atención del paciente y/o la satisfacción de las personas, reduciendo costos y obteniendo mejores resultados. Se apoya sobre tres pilares básicos: la medicina basada en la evidencia, la atención centralizada en el paciente, y la sustentabilidad. Sin embargo, existen pocas publicaciones sobre la estrategia de personas navegadoras para pacientes con cáncer de pulmón, que podrían ser una herramienta clave para brindar apoyo, asegurando que tengan acceso al conocimiento y los recursos necesarios a fin de completar la vía de atención clínica recomendada. Estado del arte: se trata de una intervención en salud cuyo objetivo principal es lograr vencer las barreras relacionadas con la atención (p. ej., logísticas, burocrático-administrativas, de comunicación y financieras) para poder mejorar la calidad y el acceso a la salud en el marco de la atención del cáncer. Estas personas cumplen un papel de guía para pacientes durante el proceso de diagnóstico y tratamiento activo. Su labor consiste en vincular al paciente con los proveedores clínicos, brindar un sistema de apoyo, asegurar un acompañamiento individualizado, garantizar que tengan acceso al conocimiento y a los recursos necesarios para completar el seguimiento y/o tratamiento adecuado. Discusión/Conclusión: indudablemente, es un elemento cada vez más reconocido en los programas de cáncer, centrado en el paciente y de alta calidad. Su implementación será de especial interés en la Unidad de Práctica Integrada para personas con cáncer de pulmón. (AU)

Introduction: Value-based medicine has succeeded in improving the quality of patient care and or patient satisfaction, reducing costs, and obtaining better outcomes. It rests on three fundamental pillars: evidence-based medicine, patient-centered care, and sustainability. However, there are few publications on the people navigator strategy for lung cancer patients, which could be a crucial tool for providing support, ensuring that they have access to the knowledge and resources needed to complete the recommended clinical care pathway. State of the art: It is a health intervention whose main objective is to overcome care-related barriers (e.g., logistical, bureaucratic-administrative, communication, and financial) to improve quality and access to health in the context of cancer care. These individuals play a guiding role for patients during the diagnostic and active treatment process. Their job is to link the patient with clinical providers, provide a support system, ensure individualized accompaniment, and guarantee that they get access to the knowledge and resources necessary to complete the appropriate follow-up and, or treatment. Discussion/Conclusion: Undoubtedly, patient navigators represent an increasingly recognized element of high-quality, patient-centered cancer programs. Its implementation will be of specific interest in the Integrated Practice Unit for people with lung cancer. (AU)

A rede de cuidados à saúde para a população transexual / The Health Care Network for the Transsexual Population

Resumo O SUS trouxe os princípios de universalidade, integralidade e equidade para nortear as ações e os serviços de saúde, que devem ser livres de preconceito e discriminação. A rede formal de cuidados foi compreendida como a que está institucionalizada e a rede informal é uma rede afetiva. O objetivo da pesquisa foi compreender o acesso à rede de cuidados à saúde na percepção de transexuais em um município da Zona da Mata mineira, por meio da abordagem metodológica qualitativa com estudo descritivo. Foram realizadas entrevistas semiestruturadas com oito pessoas transexuais. As informações foram analisadas por meio da hermenêutica-dialética. Foram identificadas como barreiras à rede formal de cuidados o desrespeito ao uso do nome social nos serviços de saúde e o preconceito dos profissionais. Buscam-se cuidados e informações sobre uso de hormônios nas redes informais. A rede informal acolhe, mas a busca por cuidados somente nessas redes pode trazer riscos à saúde. A pesquisa evidenciou a existência de uma forte rede afetiva no município e a necessidade do estabelecimento de uma sólida rede formal de cuidados para a população transexual com ampla participação da rede informal. A rede formal é instável e não atende as necessidades de saúde dessa população.

Abstract SUS brought the principles of universality, integrality, and equity to guide health actions and services, which must be free from any form of prejudice and discrimination. The formal care network was understood as the one that is institutionalized, and the informal network is an affective network. This research aimed to understand the access to the health care network in the perception of transsexuals in a municipality in Zona da Mata, Minas Gerais, through the qualitative methodological approach with descriptive study. Semi-structured interviews were conducted with eight transsexual people. The information was analyzed using hermeneutics-dialectics. Barriers to the formal care network were disrespect to the use of the social name in health services, prejudice, and unpreparedness of professionals. Therefore, care and information on hormone use are sought in informal networks. The informal network welcomes, but the search for care only in these networks can bring health risks. The research showed the existence of a strong affective network in the municipality and the need to establish a solid formal care network for the transsexual population with wide participation in the informal network, since the formal network is unstable and does not meet health needs of that population.

Plano EVA-TO: plano de enfrentamento à violência autoprovocada do Estado do Tocantins com ênfase na atenção integral à saúde / EVA-TO Plan: plan to face self-inflicted violence in the State of Tocantins with an emphasis on comprehensive health care

O Plano de Enfrentamento à Violência Autoprovocada do Estado do Tocantins com Ênfase na Atenção Integral à Saúde foi desenvolvido para fortalecer a rede de atenção psicossocial, em colaboração com o Sistema Único de Saúde (SUS) e o Sistema Único de Assistência Social (SUAS). Elaborado pelo Grupo de Trabalho "Flor de Pequi", o plano tem como objetivo qualificar a Rede de Atenção à Saúde, orientando gestores e profissionais de saúde na prevenção da violência autoprovocada, automutilação e suicídio, além de promover o acolhimento e compartilhamento do cuidado na rede de atenção à saúde. O documento foi elaborado em resposta a demandas relacionadas aos dados de violência autoprovocada, solicitações do Conselho Estadual de Defesa de Direitos da Criança e do Adolescente e do Conselho Regional de Psicologia. A metodologia, discussão, metas, ações e monitoramento também são abordados no plano.

The Plan for Confronting Self-Inflicted Violence in the State of Tocantins with an Emphasis on Comprehensive Health Care was developed to strengthen the psychosocial care network in collaboration with the Unified Health System (SUS) and the Unified Social Assistance System (SUAS). Elaborated by the "Flor de Pequi" Working Group, the plan aims to enhance the Health Care Network by providing guidance to managers and health professionals in the prevention of self-inflicted violence, self-harm, and suicide, while promoting care and support within the health care system. The document was created in response to demands related to self-inflicted violence data, requests from the State Council for the Defense of the Rights of Children and Adolescents, and the Regional Psychology Council. The plan also addresses methodology, discussion, goals, actions, and monitoring.

El Plan de Enfrentamiento a la Violencia Autoinfligida en el Estado de Tocantins con Énfasis en la Atención Integral de Salud fue desarrollado para fortalecer la red de atención psicosocial en colaboración con el Sistema Único de Salud (SUS) y el Sistema Único de Asistencia Social (SUAS). Elaborado por el Grupo de Trabajo "Flor de Pequi", el plan tiene como objetivo calificar la Red de Atención a la Salud, brindando orientación a los gestores y profesionales de la salud en la prevención de la violencia autoinfligida, la automutilación y el suicidio, además de promover el cuidado y apoyo dentro de la red de atención sanitaria. El documento fue elaborado en respuesta a demandas relacionadas con datos de violencia autoinfligida, solicitudes del Consejo Estatal para la Defensa de los Derechos de la Niñez y la Adolescencia y del Consejo Regional de Psicología. El plan también aborda la metodología, la discusión, las metas, las acciones y el monitoreo

Trends in Reported Health Care Affordability for Men and Women With Employer-Sponsored Health Insurance Coverage in the US, 2000 to 2020.

This study uses National Health Interview Survey data from 2000 to 2020 to examine reported differences between US men and women aged 19 to 64 years with employer-sponsored insurance in obtaining affordable health care.

Zambia Assessment of Tuberculosis (TB) and HIV in the Mines (ZATHIM): implications for programs and policies.

BACKGROUND: Mineworkers in Southern Africa have the highest rates of tuberculosis (TB) among working populations in the world (The World Bank, Benefits and costs associated with reducing tuberculosis among Southern Africa's mineworkers, 2014), making mineworkers a key population for TB program efforts. The current evaluation aimed to characterize mineworkers and former (ex-) mineworkers, and assess knowledge, attitudes and practices related to TB and HIV care among mineworkers and healthcare workers (HCWs) in Zambia. METHODS: A mixed-methods evaluation of current and former (ex-) mineworkers and HCWs was conducted in the Copperbelt and North-Western provinces, Zambia. Knowledge, attitudes and practices (KAPs) related to TB care and policies were assessed using a structured survey. Focus Group Discussions (FGDs) were conducted with current and ex-mineworkers to understand perceptions, practices, and barriers related to accessing healthcare for TB. RESULTS: Overall, 2,792 mineworkers and 94 HCWs completed the KAP survey, and 206 (171 current, 71 ex-) mineworkers participated in FGDs. Mineworkers and ex-mineworkers were knowledgeable about TB symptoms (cough; 94%), transmission (81.7%) and treatment (99.2%). Yet, barriers to seeking care were evident with 30% of mineworkers experiencing cough, and 19% reporting 2 or more TB symptoms at the time of the survey. The majority of mineworkers (70.9%) were aware of policies barring persons from working after a diagnosis of TB, and themes from FGDs and HCW comments (n = 32/62; 51.6%) recognized fear of job loss as a critical barrier to providing timely screening and appropriate care for TB among mineworkers. The majority (76.9%) of mineworkers indicated they would not disclose their TB status to their supervisor, but would be willing to share their diagnosis with their spouse (73.8%). CONCLUSION: Fear of job loss, driven by governmental policy and mistrust in mining companies, is a major barrier to healthcare access for TB among mineworkers in Zambia. As a result of these findings, the government policy prohibiting persons from working in the mines following TB disease is being repealed. However, major reforms are urgently needed to mitigate TB among mineworkers, including ensuring the rights of mineworkers and their communities to healthy living and working environments, improved social responsibility of mining companies, and facilitating choice and access to affordable, timely, and high-quality healthcare services.

Understanding the Tradeoffs Between Travel Burden and Quality of Care for In-center Hemodialysis Patients.

BACKGROUND: Renal dialysis is a lifesaving but demanding therapy, requiring 3 weekly treatments of multiple-hour durations. Though travel times and quality of care vary across facilities, the extent to which patients are willing and able to engage in weighing tradeoffs is not known. Since 2015, Medicare has summarized and reported quality data for dialysis facilities using a star rating system. We estimate choice models to assess the relative roles of travel distance and quality of care in explaining patient choice of facility. RESEARCH DESIGN: Using national data on 2 million patient-years from 7198 dialysis facilities and 4-star rating releases, we estimated travel distance to patients' closest facilities, incremental travel distance to the next closest facility with a higher star rating, and the difference in ratings between these 2 facilities. We fit mixed effects logistic regression models predicting whether patients dialyzed at their closest facilities. RESULTS: Median travel distance was 4 times that in rural (10.9 miles) versus urban areas (2.6 miles). Higher differences in rating [odds ratios (OR): 0.56; 95% confidence interval (CI): 0.50-0.62] and greater area deprivation (OR: 0.50; 95% CI: 0.48-0.53) were associated with lower odds of attending one's closest facility. Stratified models were also fit based on urbanicity. For rural patients, excess travel was associated with higher odds of attending the closer facility (per 10 miles; OR: 1.05; 95% CI: 1.04-1.06). Star rating differences were associated with lower odds of receiving care from the closest facility among urban (OR: 0.57; 95% CI: 0.51-0.63) and rural patients (OR: 0.18; 95% CI: 0.08-0.44). CONCLUSIONS: Most dialysis patients have higher rated facilities located not much further than their closest facility, suggesting many patients could evaluate tradeoffs between distance and quality of care in where they receive dialysis. Our results show that such tradeoffs likely occur. Therefore, quality ratings such as the Dialysis Facility Compare (DFC) Star Rating may provide actionable information to patients and caregivers. However, we were not able to assess whether these associations reflect a causal effect of the Star Ratings on patient choice, as the Star Ratings served only as a marker of quality of care.

Direct and indirect effect of the COVID-19 pandemic on patients with cardiomyopathy.

OBJECTIVES: (1) To evaluate the prevalence and hospitalisation rate of COVID-19 infections among patients with dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM) in the Royal Brompton and Harefield Hospital Cardiovascular Research Centre (RBHH CRC) Biobank. (2) To evaluate the indirect impact of the pandemic on patients with cardiomyopathy through the Heart Hive COVID-19 study. (3) To assess the impact of the pandemic on national cardiomyopathy-related hospital admissions. METHODS: (1) 1236 patients (703 DCM, 533 HCM) in the RBHH CRC Biobank were assessed for COVID-19 infections and hospitalisations; (2) 207 subjects (131 cardiomyopathy, 76 without heart disease) in the Heart Hive COVID-19 study completed online surveys evaluating physical health, psychological well-being, and behavioural adaptations during the pandemic and (3) 11 447 cardiomyopathy-related hospital admissions across National Health Service (NHS) England were studied from NHS Digital Hospital Episode Statistics over 2019-2020. RESULTS: A comparable proportion of patients with cardiomyopathy in the RBHH CRC Biobank had tested positive for COVID-19 compared with the UK population (1.1% vs 1.6%, p=0.14), but a higher proportion of those infected were hospitalised (53.8% vs 16.5%, p=0.002). In the Heart Hive COVID-19 study, more patients with cardiomyopathy felt their physical health had deteriorated due to the pandemic than subjects without heart disease (32.3% vs 13.2%, p=0.004) despite only 4.6% of the cardiomyopathy cohort reporting COVID-19 symptoms. A 17.9% year-on-year reduction in national cardiomyopathy-related hospital admissions was observed in 2020. CONCLUSION: Patients with cardiomyopathy had similar reported rates of testing positive for COVID-19 to the background population, but those with test-proven infection were hospitalised more frequently. Deterioration in physical health amongst patients could not be explained by COVID-19 symptoms, inferring a significant contribution of the indirect consequences of the pandemic. TRIAL REGISTRATION NUMBER: NCT04468256.

Consequences of the COVID-19 pandemic on lung cancer care and patient health in a German lung cancer center: results from a cross-sectional questionnaire.

BACKGROUND: The novel coronavirus SARS-CoV-2 has caused a global COVID-19 pandemic, leading to worldwide changes in public health measures. In addition to changes in the public sector (lockdowns, contact restrictions), hospitals modified care to minimize risk of infection and to mobilize resources for COVID-19 patients. Our study aimed to assess the impact of these measures on access to care and behaviour of patients with thoracic malignancies. METHODS: Thoracic oncology patients were surveyed in October 2020 using paper-based questionnaires to assess access to ambulatory care services and tumor-directed therapy during the COVID-19 pandemic. Additionally, behaviour regarding social distancing and wearing of face masks were assessed, as well as COVID-19 exposure, testing and vaccination. Results are presented as absolute and relative frequencies for categorical variables and means with standard deviation for numerical variables. We used t-test, and ANOVA to compare differences in metric variables and Chi2-test to compare proportions between groups. RESULTS: 93 of 245 (38%) patients surveyed completed the questionnaire. Respiration therapy and physical therapy were unavailable for 57% to 70% of patients during March/April. Appointments for tumor-directed therapy, tumor imaging, and follow-up care were postponed or cancelled for 18.9%, 13.6%, and 14.8% of patients, respectively. Patients reported their general health as mostly unaffected. The majority of patients surveyed did not report reducing their contacts with family. The majority reduced contact with friends. Most patients wore community masks, although a significant proportion reported respiratory difficulties during prolonged mask-wearing. 74 patients (80%) reported willingness to be vaccinated against SARS-CoV-2. CONCLUSIONS: This survey provides insights into the patient experience during the second wave of the COVID-19 pandemic in Munich, Germany. Most patients reported no negative changes to cancer treatments or general health; however, allied health services were greatly impacted. Patients reported gaps in social distancing, but were prepared to wear community masks. The willingness to get vaccinated against SARS-CoV-2 was high. This information is not only of high relevance to policy makers, but also to health care providers.

Trend and effects of high-deductible health insurance plans in the health care system: financial access problems in management of cognitive impairment.

BACKGROUND: High-deductible health plans (HDHPs) are characterized by higher deductibles and lower monthly premiums compared with a typical health plan. HDHPs may reduce, or delay, needed care, which will ultimately lead to poorer access to care for chronically affected participants. OBJECTIVES: To (1) investigate the HDHP enrollment trend and (2) determine the effects of HDHPs on financial access problems for individuals with self-reported cognitive impairment. METHODS: Data between 2010 and 2018 were obtained from the National Health Interview Survey (NHIS). Individuals with cognitive impairment were identified if they were limited by memory difficulties. Problems regarding financial access to health care were assessed based on 6 survey questions from the Centers for Disease Control and Prevention. Multivariable logistic regressions were implemented to evaluate the effects of HDHPs. RESULTS: This study identified 1,148 individuals with cognitive impairment, representing 3.9 million individuals in the United States from 2010 to 2018. A nearly 2-fold increase in HDHP enrollment with cognitive impairment was observed from 2010 (20.9%) to 2018 (41.9%). This increase is similar to that reported for noncognitively impaired individuals. After controlling for possible confounding variables, cognitively impaired individuals with HDPHs were more likely to have overall financial access difficulties compared with those without HDHPs (OR = 1.17, 95% CI = 0.88-1.56, P = 0.271), but this likelihood was not statistically significant. CONCLUSIONS: HDHPs are intended to support effective care options and reduce health care costs. However, our research found that among individuals with cognitive impairment, those with HDHPs experienced some financial access problems, such as affording medical care, follow-up care, and specialists, than those without HDHPs, indicating that HDHPs might have unintended consequences for health care usage. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest or financial interests to disclose.

Change in healthcare during Covid-19 pandemic was assessed through observational designs.

OBJECTIVE: Methodological challenges for investigating the changes in healthcare utilization during COVID-19 pandemic must be considered for obtaining unbiased estimates. STUDY DESIGN AND SETTING: A population-based study in the Lombardy region (Italy) measured the association between the level of epidemic restrictions (increasing exposure during pre-epidemic, post-lockdown, and lockdown periods) and the recommended healthcare (outcome) for patients with schizophrenia, heart failure, chronic obstructive pulmonary disease, breast cancer, and pregnancy women. Two designs are applied: the self-controlled case series (SCCS) and the usual cohort design. Adjustments for between-patients unmeasured confounders and seasonality of medical services delivering were performed. RESULTS: Compared with pre-epidemic, reductions in delivering recommended healthcare during lockdown up to 73% (95% confidence interval: 63%-80%) for timeliness of breast cancer surgery, and up to 20% (16%-23%) for appropriated gynecologic visit during pregnancy were obtained from SCCS and cohort design, respectively. Healthcare provision came back to pre-epidemic levels during the post-lockdown, with the exception of schizophrenic patients for whom the SCCS showed a reduction in continuity of care of 11% (11%-12%). CONCLUSION: Strategies for investigating the changes in healthcare utilization during pandemic must be implemented. Recommendations for taking into account sources of systematic uncertainty are discussed and illustrated by using motivating examples.

Racial and Socioeconomic Disparities in Utilization of Telehealth in Patients with Liver Disease During COVID-19.

BACKGROUND AND AIMS: The coronavirus disease 2019 (COVID-19) pandemic resulted in a rapid expansion of telehealth services in hepatology. However, known racial and socioeconomic disparities in internet access potentially translate into barriers for the use of telehealth, particularly video technology. The specific aim of this study was to determine if disparities in race or socioeconomic status exist among patients utilizing telehealth visits during COVID-19. METHODS: We performed a retrospective cohort study of all adult patients evaluated in hepatology clinics at Duke University Health System. Visit attempts from a pre-COVID baseline period (January 1, 2020 through February 29, 2020; n = 3328) were compared to COVID period (April 1, 2020 through May 30, 2020; n = 3771). RESULTS: On multinomial regression modeling, increasing age was associated with higher odds of a phone or incomplete visit (canceled, no-show, or rescheduled after May 30,2020), and non-Hispanic Black race was associated with nearly twice the odds of completing a phone visit instead of video visit, compared to non-Hispanic White patients. Compared to private insurance, Medicaid and Medicare were associated with increased odds of completing a telephone visit, and Medicaid was associated with increased odds of incomplete visits. Being single or previously married (separated, divorced, widowed) was associated with increased odds of completing a phone compared to video visit compared to being married. CONCLUSIONS: Though liver telehealth has expanded during the COVID-19 pandemic, disparities in overall use and suboptimal use (phone versus video) remain for vulnerable populations including those that are older, non-Hispanic Black, or have Medicare/Medicaid health insurance.

Trends in Cancer Treatment Service Availability Across Critical Access Hospitals and Prospective Payment System Hospitals.

BACKGROUND: Rural residents experience worse cancer prognosis and access to cancer care providers than their urban counterparts. Critical access hospitals (CAHs) represent over half of all rural community hospitals. However, research on cancer services provided within CAHs is limited. OBJECTIVE: The objective of this study was to investigate trends in cancer services availability in urban and rural Prospective Payment System (PPS) hospitals and CAHs. DESIGN: Retrospective, time-series analysis using data from 2008 to 2017 American Hospital Association Annual Surveys. Multivariable logistic regressions were used to examine differential trends in cancer services between urban PPS, rural PPS, and CAHs, overall and among small (<25 beds) hospitals. SUBJECTS: All US acute care and cancer hospitals (4752 in 2008 to 4722 in 2017). MEASURES: Primary outcomes include whether a hospital provided comprehensive oncology services, chemotherapy, and radiation therapy each year. RESULTS: In 2008, CAHs were less likely to provide all cancer services, especially chemotherapy (30.4%) and radiation therapy (2.9%), compared with urban (64.4% and 43.8%, respectively) and rural PPS hospitals (42.0% and 23.3%, respectively). During 2008-2017, compared with similarly sized PPS hospitals, CAHs were more likely to provide oncology services and chemotherapy, but with decreasing trends. Radiation therapy availability between small PPS hospitals and CAHs did not differ. CONCLUSIONS: Compared with all PPS hospitals, CAHs offered fewer cancer treatment services and experienced a decline in service capability over time. These differences in chemotherapy services were mainly driven by hospital size, as small urban and rural PPS hospitals had lower rates of chemotherapy than CAHs. Still, the lower rates of radiotherapy in CAHs highlight disproportionate challenges facing CAHs for some specialty services.

Undocumented Older Latino Immigrants in the United States: Population Projections and Share of Older Undocumented Latinos by Health Insurance Coverage and Chronic Health Conditions, 2018-2038.

OBJECTIVES: This article focuses on the older Latino undocumented population and anticipates how their current demographic characteristics and health insurance coverage might affect future population size and health insurance trends. METHODS: We use the 2013-2018 American Community Survey as a baseline to project growth in the Latino 55 and older undocumented population over the next 20 years. We use the cohort component method to estimate population size across different migration scenarios and distinguish between aging in place and new immigration. We also examine contemporary health insurance coverage and chronic health conditions among 55 and older undocumented Latinos from the 2003-2014 California Health Interview Survey. We then project health insurance rates in 2038 among Latino immigrants under different migration and policy scenarios. RESULTS: If current mortality, migration, and policy trends continue, projections estimate that 40% of undocumented Latino immigrants will be 55 years or older by 2038-nearly all of whom will have aged in place. Currently, 40% of older Latino undocumented immigrants do not have insurance. Without policies that increase access to insurance, projections estimate that the share who are uninsured among all older Latinos immigrants will rise from 15% to 21%, and the share who is both uninsured and living with a chronic health condition will rise from 5% to 9%. DISCUSSION: Without access to health care, older undocumented immigrants may experience delayed care and more severe morbidity. Our projections highlight the need to develop and enact policies that can address impending health access concerns for an increasingly older undocumented Latino population.