"It's Incapacitated Me in so Many Ways": Older Adults' Lived Experience With Postoperative Symptoms at Home After Major Elective Surgery.

OBJECTIVE: This qualitative study aimed to explore the challenges faced by older adults regarding the postoperative symptom experience after major elective surgery. BACKGROUND: Although extensively studied in oncology settings, the impact of postoperative symptom burden remains largely underexplored in elective major surgery among older adults. METHODS: We employed convenience sampling to recruit adults aged 65 years or above undergoing major elective surgery at the University of California, San Francisco. Semistructured interviews regarding the surgical experience were conducted at 1 and 3 months postoperatively. An inductive qualitative approach was used to identify emerging themes. Symptoms revealed by participants during interviews were also captured. RESULTS: Nineteen participants completed a 1-month postoperative interview, and 17 additionally completed a 3-month interview. Three themes emerged: (1) postoperative symptoms significantly impacted valued life activities and psychosocial well-being, (2) participants felt "caught off guard" by the intensity and duration of postoperative symptoms, and (3) participants expressed the need for additional support, resources, and education on symptom management. The most frequently mentioned symptoms were postoperative pain (n=12, 63.1%), gastrointestinal discomfort (n=8, 42.1%), and anxiety/stress (n=8, 42.1%) at 1-month postsurgery compared with pain and depression (both n=6, 35.3%) at 3 months. CONCLUSIONS: Study participants were surprised by the negative impact of postoperative symptoms on their psychosocial well-being and ability to engage in valued life activities. Symptom burden is an important patient-reported outcome that should be assessed postoperatively. Interventions to minimize postoperative symptom burden in older adults could optimize quality of life and participation in meaningful activities during surgical recovery.

"There's So Much That They're Enduring": Experiences of Older Adults Undergoing Major Elective Surgery.

OBJECTIVE: This qualitative study aimed to explore the psychosocial experience of older adults undergoing major elective surgery from the perspective of both the patient and family caregiver. SUMMARY BACKGROUND DATA: Older adults face unique psychological and social vulnerabilities that can increase susceptibility to poor health outcomes. How these vulnerabilities influence surgical treatment and recovery is understudied in the geriatric surgical population. METHODS: Adults aged 65 and older undergoing a high-risk major elective surgery at the University of California, San Francisco and their caregivers were recruited. Semi-structured interviews were conducted at three time points: 1-2 weeks before surgery, and at 1- and 3-months following surgery. An inductive qualitative approach was used to identify underlying themes. RESULTS: Twenty-five older adult patients (age range 65-82 years, 60% male) and 11 caregivers (age range 53-78 years, 82% female) participated. Three themes were identified. First, older surgical patients experienced significant challenges to emotional well-being both before and after surgery, which had a negative impact on recovery. Second, older adults relied on a combination of personal and social resources to navigate these challenges. Lastly, both patients and caregivers desired more resources from the healthcare system to address "the emotional piece" of surgical treatment and recovery. CONCLUSIONS: Older adults and their caregivers described multiple overlapping challenges to emotional well-being that spanned the course of the perioperative period. Our findings highlight a critical component of perioperative care with significant implications for the recovery of older surgical patients.

Public Opinions About Surgery in Older Adults: A Thematic Analysis.

OBJECTIVE: To examine public opinions of surgery in older adults. BACKGROUND: Increasing numbers of older adults are undergoing surgery. National healthcare organizations recognize the increased risks of postoperative complications and mortality in the older surgical population and have made efforts to improve the care of older adults undergoing surgery through hospital-level programs. However, limited research has explored the opinions and responses of the wider U.S. public regarding surgery in older adults. METHODS: We performed a qualitative, thematic analysis of reader comments posted in response to online newspaper articles relating to surgery in older adults. Articles were published in 2019-2020 and targeted for a popular press audience. RESULTS: Nine hundred eight reader comments posted in response to 6 articles relating to surgery in older adults were identified. Articles were published in online editions of print newspapers with a digital circulation between 1.3 and 5.7 million subscribers. Three themes were identified: (1) wariness/distrust towards healthcare: including general distrust of medicine and distrust of surgery, (2) problems experienced: ineffective communication and unrealistic expectations, and (3) recommended solutions: the need for multidisciplinary teams and patient-centered communication. CONCLUSIONS: Overall, the public viewed surgery in older adults with wariness/distrust due to ineffective communication and unrealistic expectations. Specialized surgical care tailored to the unique needs of older adults is needed. The public perspective suggests that U.S. health systems should strongly consider adopting programs that provide care to meet the unique needs of older adults undergoing surgery and ultimately improve both patient outcomes and their surgical experience.

Relationships and resilience at work and at home: Impact of relational coordination on clinician work-life balance and well-being in times of crisis.

BACKGROUND: The COVID-19 pandemic has been an unusually comprehensive crisis that has taken a toll on people in their roles both at work and at home, giving rise to a new normal. PURPOSE: Relational coordination theory shows how communicating and relating for the purpose of task integration drives positive outcomes for workers, their clients, and their employers. The ecological theory of work-family spillover shows how relational dynamics from work spillover into family life, and vice versa. We build upon these two theories to understand how relationships at work impact work-life balance and worker well-being, especially in times of crisis. METHODOLOGY: This study was based on surveys of clinicians affiliated with a large California health system during the COVID-19 pandemic. Mediation and multilevel logistic regression models were used to assess how relational coordination among colleagues impacts well-being (job satisfaction and lack of burnout) through its effects on work-life balance (schedule control and personal time). RESULTS: A 1-point increase in relational coordination tripled clinician odds of having schedule control ( OR = 3.33, p < .001) and nearly doubled the odds of having adequate personal time ( OR = 1.83, p < .001). A 1-point increase in relational coordination nearly quadrupled odds of being satisfied with their job ( OR = 3.92, p < .001) and decreased odds of burnout by 64% ( OR = 0.36, p < .001). The impact of relational coordination on worker well-being was mediated by greater schedule control and personal time. CONCLUSION: Relational coordination among colleagues impacts worker well-being by enabling greater control over one's schedule and more personal time, thus creating a positive spillover from work to home in times of crisis. PRACTICE IMPLICATIONS: In times of crisis, leaders should prioritize relational coordination among colleagues in order to support their resilience both at work and at home.

Women, Younger Clinicians', and Caregivers' Experiences of Burnout and Well-being During COVID-19 in a US Healthcare System.

BACKGROUND: The COVID-19 pandemic brought rapid changes to the work and personal lives of clinicians. OBJECTIVE: To assess clinician burnout and well-being during the COVID-19 pandemic and guide healthcare system improvement efforts. DESIGN: A survey asking about clinician burnout, well-being, and work experiences. PARTICIPANTS: Surveys distributed to 8141 clinicians from June to August 2020 in 9 medical groups and 17 hospitals at Sutter Health, a large healthcare system in Northern California. MAIN MEASURES: Burnout was the primary outcome, and other indicators of well-being and work experience were also measured. Descriptive statistics and multivariate logistic regression analyses were performed. All statistical inferences were based on weighted estimates adjusting for response bias. KEY RESULTS: A total of 3176 clinicians (39.0%) responded to the survey. Weighted results showed 29.2% reported burnout, and burnout was more common among women than among men (39.0% vs. 22.7%, p<0.01). In multivariate models, being a woman was associated with increased odds of reporting burnout (OR=2.19, 95% CI: 1.51-3.17) and being 55+ years old with lower odds (OR=0.54, 95% CI: 0.34-0.87). More women than men reported that childcare/caregiving was impacting work (32.9% vs. 19.0%, p<0.01). Even after controlling for age and gender, clinicians who reported childcare/caregiving responsibilities impacted their work had substantially higher odds of reporting burnout (OR=2.19, 95% CI: 1.54-3.11). Other factors associated with higher burnout included worrying about safety at work, being given additional work tasks, concern about losing one's job, and working in emergency medicine or radiology. Protective factors included believing one's concerns will be acted upon and feeling highly valued. CONCLUSIONS: This large survey found the pandemic disproportionally impacted women, younger clinicians, and those whose caregiving responsibilities impacted their work. These results highlight the need for a holistic and targeted strategy for improving clinician well-being that addresses the needs of women, younger clinicians, and those with caregiving responsibilities.

How, when, and why individuals with stage IV cancer seen in an outpatient setting are referred to palliative care: a mixed methods study.

PURPOSE: Early palliative care (PC) for individuals with advanced cancer improves patient and family outcomes and experience. However, it is unknown when, why, and how in an outpatient setting individuals with stage IV cancer are referred to PC. METHODS: At a large multi-specialty group in the USA with outpatient PC implemented beginning in 2011, clinical records were used to identify adults diagnosed with stage IV cancer after January 1, 2012 and deceased by December 31, 2017 and their PC referrals and hospice use. In-depth interviews were also conducted with 25 members of medical oncology, gynecological oncology, and PC teams and thematically analyzed. RESULTS: A total of 705 individuals were diagnosed and died between 2012 and 2017: of these, 332 (47%) were referred to PC, with 48.5% referred early (within 60 days of diagnosis). Among referred patients, 79% received hospice care, versus 55% among patients not referred. Oncologists varied dramatically in their rates of referral to PC. Interviews revealed four referral pathways: early referrals, referrals without active anti-cancer treatment, problem-based referrals, and late referrals (when stopping treatment). Participants described PC's benefits as enhancing pain/symptom management, advance care planning, transitions to hospice, end-of-life experiences, a larger team, and more flexible patient care. Challenges reported included variation in oncologist practices, patient fears and misconceptions, and access to PC teams. CONCLUSION: We found high rates of use and appreciation of PC. However, interviews revealed that exclusively focusing on rates of referrals may obscure how referrals vary in timing, reason for referral, and usefulness to patients, families, and clinical teams.

The Relationship Between Primary Care Physician Burnout and Patient-Reported Care Experiences: a Cross-sectional Study.

BACKGROUND: Primary care physician (PCP) burnout is prevalent and on the rise. Physician burnout may negatively affect patient experience of care. OBJECTIVE: To identify the direct impact of PCP burnout on patient experience in various domains of care. DESIGN: A cross-sectional observational study using physician well-being (PWB) surveys collected in 2016-2017, linked to responses from patient experience of care surveys. Patient demographics and practice characteristics were derived from the electronic health record. Linked data were analyzed at the physician level. SETTING: A large non-profit multi-specialty ambulatory healthcare organization in northern California. PARTICIPANTS: A total of 244 physicians practicing internal medicine or family medicine who responded to the PWB survey (response rate 72%), and 30,701 completed experience surveys from patients seeing these physicians. MEASUREMENTS: Burnout was measured with a validated single-item question with a 5-point scale ranging from (1) enjoy work to (5) completely burned out and seeking help. Patient experience of patient-provider communication, access, and overall rating of provider was measured with Clinician & Group Consumer Assessment of Healthcare Providers & Systems (CG-CAHPS) survey. Patient experience scores (0-100 scale) were adjusted for age, gender, race/ethnicity, and English proficiency. RESULTS: Physician burnout had a negative impact on patient-reported experience of patient-provider communication but not on access or overall rating of providers. A one-level increase in burnout was associated with 0.43 decrease in adjusted patient-provider communication experience score (P < 0.01). LIMITATIONS: Data came from a single large healthcare organization. Patterns may differ for small- and mid-sized practices. CONCLUSION: Physician burnout adversely affects patient-provider communication in primary care visits. Efforts to improve physician work environments could have a meaningful positive impact on patient experience as well as physician well-being.

Frontline Perspectives on Physician Burnout and Strategies to Improve Well-Being: Interviews with Physicians and Health System Leaders.

BACKGROUND: Nationally over 50% of physicians report symptoms of burnout. OBJECTIVE: To understand the perspectives of health system leaders and frontline physicians on contributors to physician burnout and strategies to improve well-being. DESIGN: We conducted in-depth interviews with health system leaders and frontline physicians at a large, predominantly fee-for-service, multispecialty group practice with approximately 1300 physicians. PARTICIPANTS: The 17 participants included 15 physicians, (12 Internal Medicine and Family Medicine physicians and 3 from other specialties), 11 individuals in leadership roles, and 11 women. APPROACH: Interviews included a review of factors associated with burnout at the organization, asking participants which factors they believed contributed to burnout, questions about experiences of burnout, and what specific changes would improve well-being. KEY RESULTS: All 17 participants agreed that organizational factors were key contributors to burnout, while only 9 mentioned the salience of individual factors: "It does not matter how resilient or positive you are, the work environment, especially in primary care will eventually be a problem." An increasing workload associated with the electronic health record (EHR) and a culture focused on productivity were cited as contributing to burnout, especially among physicians in Internal Medicine and Family Medicine (primary care) departments. Physicians in primary care, women, and leaders described multiple barriers to well-being. Participants described responding to increased workloads by reducing clinical work hours. Participants suggested reducing and compensating EHR work, expanding care teams/support staff, reducing use of metrics, providing more support to leaders, changing the business model, and increasing positivity and collegiality, as essential to improving well-being. CONCLUSION: Interviews reveal a variety of interacting factors contributing to physician burnout. Reducing clinical work hours has become a coping strategy. Changes recommended to improve physician well-being include increasing support staff, reducing EHR workload, changing revenue generation and compensation approaches, and shifting organizational culture to place more value on physician wellness.

How home hospice care facilitates patient and family engagement.

Little is known about how patient and family engagement manifests in home hospice care. This qualitative study included interviews and observation of home hospice care with 18 patients, 11 caregivers, and 26 hospice workers in the United States. Structural factors (e.g., home setting, ample time, personal relationships), hospice worker strategies (e.g., patient education and presenting choices), and family member support facilitated engagement. Barriers to engagement included difficult relationships and unavailable or unwilling family members. Home hospice care demonstrates potential strategies for continuous, informed, and holistic engagement. These engagement strategies may translate to other arenas of health care.

Analysis of Hospitals Switching From a "Danger to Self" Question to Universal Columbia-Suicide Severity Rating Scale Screening: Impact on Screenings, Identification of Suicide Risk, and Documented Psychiatric Care.

Objective: Sutter Health launched system-wide general population standardized suicide screening with the Columbia-Suicide Severity Rating Scale (C-SSRS) screen (triage) version in 23 hospitals in 2019, replacing a one-question "danger to self" (DTS) assessment. This study analyzed the impact of C-SSRS implementation on screening rates, positive screenings, and documented psychiatric care within 90 days for all patients and a subgroup diagnosed with Major Depressive Disorder (MDD). Methods: Adults seen at hospitals in the pre-period (July 1, 2017-June 30, 2019) and post-period (July 1, 2019-December 31, 2020) were identified using electronic health records. Outcomes were compared using chi-square statistics and interrupted time series (ITS) models. Results: Pre-period, 92.8% (740,984/798,653) of patients were screened by DTS versus 84.6% (504,015/595,915) by C-SSRS in the post-period. Positive screening rates were 1.5% pre-period and 2.2% post-period, and 9.2% pre-period versus 10.8% post-period for those with MDD. Among individuals with positive screenings, 64.0% (pre-period) had documented follow-up psychiatric care versus 52.5% post-period and 66.4% of those with moderate or high-risk. Among all patients seen there was an overall increase in documentation of psychiatric care within 90 days (0.87% pre- to 0.96% post-period). ITS models revealed a 9.6% decline in screening, 1.3% increase in positive screenings, and 12.9% decline in documented psychiatric care following C-SSRS implementation (all p < 0.01). Conclusions: Following implementation, there was meaningful increase in suicide risk identification, and an increase in the proportion of patients with documented psychiatric care. Observed relative declines in screening warrant future research examining opportunities and barriers to general population C-SSRS use.

Emergency department involvement in the diagnosis of cancer among older adults: a SEER-Medicare study.

BACKGROUND: Internationally, 20% to 50% of cancer is diagnosed through emergency presentation, which is associated with lower survival, poor patient experience, and socioeconomic disparities, but population-based evidence about emergency diagnosis in the United States is limited. We estimated emergency department (ED) involvement in the diagnosis of cancer in a nationally representative population of older US adults, and its association with sociodemographic, clinical, and tumor characteristics. METHODS: We analyzed Surveillance, Epidemiology, and End Results Program-Medicare data for Medicare beneficiaries (≥66 years old) with a diagnosis of female breast, colorectal, lung, and prostate cancers (2008-2017), defining their earliest cancer-related claim as their index date, and patients who visited the ED 0 to 30 days before their index date to have "ED involvement" in their diagnosis, with stratification as 0 to 7 or 8 to 30 days. We estimated covariate-adjusted associations of patient age, sex, race and ethnicity, marital status, comorbidity score, tumor stage, year of diagnosis, rurality, and census-tract poverty with ED involvement using modified Poisson regression. RESULTS: Among 614 748 patients, 23% had ED involvement, with 18% visiting the ED in the 0 to 7 days before their index date. This rate varied greatly by tumor site, with breast cancer at 8%, colorectal cancer at 39%, lung cancer at 40%, and prostate cancer at 7%. In adjusted models, older age, female sex, non-Hispanic Black and Native Hawaiian or Other Pacific Islander race, being unmarried, recent year of diagnosis, later-stage disease, comorbidities, and poverty were associated with ED involvement. CONCLUSIONS: The ED may be involved in the initial identification of cancer for 1 in 5 patients. Earlier, system-level identification of cancer in non-ED settings should be prioritized, especially among underserved populations.

The Unmet Needs of Breast Cancer Navigation Services: Reconciling Clinical Care With the Emotional and Logistical Challenges Experienced by Younger Women with Breast Cancer in a Healthcare Delivery System.

This study explores the experience of the breast cancer journey for younger women receiving patient navigation services in a healthcare delivery system and any remaining challenges that navigation services may leave unaddressed. In this qualitative analysis, we used a purposeful sampling approach to conduct a semistructured in-person interview with 19 younger women (under 50 years at the time of diagnosis) at various stages of breast cancer treatment and receiving care that included some form of patient navigation services/within the Sutter Health system. Thematic analysis was performed using an inductive grounded theory approach. The patient experience revealed that women receiving navigation services throughout their cancer journey had little concern related to clinical decision-making and treatment. Rather, emotional, and logistical challenges dominate their experience and perceptions of the cancer journey. Managing day-to-day life and the emotional aspects of a cancer diagnosis cannot be disentangled from clinical care. Navigating the emotional and logistical aspects of the cancer journey is an ongoing unmet need for women under age 50, and navigation services can potentially be enhanced to help address these specific needs. Women with breast cancer may benefit from navigation programs focused not only on clinically related challenges but also on recognizing the daily needs of younger women and guiding them through family and job-related obstacles encountered while navigating cancer care. Health systems could enhance existing nurse navigation programs and redesign other aspects of care to focus on meeting these needs.

Implementing universal suicide screening in a large healthcare system's hospitals: rates of screening, suicide risk, and documentation of subsequent psychiatric care.

Implementation of suicide risk screening may improve prevention and facilitate mental health treatment. This study analyzed implementation of universal general population screening using the Columbia-Suicide Severity Rating Scale (C-SSRS) within hospitals. The study included adults seen at 23 hospitals from 7/1/2019-12/31/2020. We describe rates of screening, suicide risk, and documented subsequent psychiatric care (i.e., transfer/discharge to psychiatric acute care, or referral/consultation with system-affiliated behavioral health providers). Patients with suicide risk (including those with Major Depressive Disorder [MDD]) were compared to those without using Wilcoxon rank-sum -tests for continuous variables and χ2 tests for categorical variables. Results reported are statistically significant at p < 0.05 level. Among 595,915 patients, 84.5% were screened by C-SSRS with 2.2% of them screening positive (37.6% low risk [i.e., ideation only], and 62.4% moderate or high risk [i.e., with a plan, intent, or suicidal behaviors]). Of individuals with suicide risk, 52.5% had documentation of psychiatric care within 90 days. Individuals with suicide risk (vs. without) were male (48.1% vs 43.0%), Non-Hispanic White (55.0% vs 47.8%), younger (mean age 41.0 [SD: 17.7] vs. 49.8 [SD: 20.4]), housing insecure (12.5% vs 2.6%), with mental health diagnoses (80.3% vs 25.1%), including MDD (41.3% vs 6.7%). Universal screening identified 2.2% of screened adults with suicide risk; 62.4% expressed a plan, intent or suicidal behaviors, and 80.3% had mental health diagnoses. Documented subsequent psychiatric care likely underestimates true rates due to care fragmentation. These findings reinforce the need for screening, and research on whether screening leads to improved care and fewer suicides.

This study reported outcomes of standardized suicide screening using the Columbia-Suicide Severity Rating Scale among adults in 23 hospitals in a large health system in northern California between 7/1/2019 and 12/31/2020. Out of 595,915 patients seen in hospital inpatient or emergency departments, 84.5% were screened and among them 2.2% had suicide risk, 41.3% of whom had a diagnosis of Major Depressive Disorder. Compared to patients without suicide risk, a higher proportion of patients who screened positive for suicide risk were male, Non-Hispanic White, younger, recently homeless, and had co-occurring mental health diagnoses. Overall, 52.5% of those screening positive for suicide risk had documentation of subsequent psychiatric care within the health system within 90 days and this rate was even higher (73%) for individuals whose screenings indicated the highest risk. These findings reinforce the need for increased screening, and research to determine whether screening leads to improved care and fewer suicides.

Lean Practices for Resource Use, Timeliness, and Coordination of Care in Breast Cancer Navigation.

BACKGROUND: Cancer care is described as insufficiently patient-centered, requiring improved accessibility and coordination. Breast oncology nurse navigators may help provide timely patient care by improving care coordination. OBJECTIVES: This study evaluated a breast cancer navigation (BCN) program in a large ambulatory healthcare system. It examined measures related to quality and value, including timely service delivery, appropriate use of resources, and care coordination. METHODS: Using Lean methods, a BCN program focused on women receiving a breast biopsy was developed at a pilot site and later implemented throughout the healthcare system. Study data evaluated timely disclosure of biopsy results, prompt scheduling of initial consultations, outpatient use of cancer specialists, and coordination between primary care and oncology practices. FINDINGS: After implementing the BCN program, more timely biopsy results were delivered to patients. Patients were more likely to complete an initial consultation within two weeks of biopsy and made fewer outpatient visits. Referrals to cancer specialists within a month of biopsy increased, and primary care encounters with patients decreased.

The Healthcare Journey of Women With Advanced Gynecological Cancer From Diagnosis Through Terminal Illness: Qualitative Analysis of Progress Note Data.

OBJECTIVE: To examine women's journeys with gynecologic cancer from before diagnosis through death and identify elements of their healthcare experience that warrant improvement. METHODS: This exploratory study used longitudinal progress notes data from a multispecialty practice in Northern California. The sample included women with stage IV gynecological cancer diagnosed after 2011 and who died before 2018. Available progress notes from prior to diagnosis to death were qualitatively analyzed. RESULTS: We identified 32 women, (median age 61 years) with mostly uterine (n=17) and ovarian (n=9) cancers and median survival of 9.2 months (min:2.9 and max:47.5). Sixteen (50%) received outpatient palliative care and 18 (56%) received hospice care. The analysis found wide variation in documentation about communication about diagnosis, prognosis, goals of care, stopping treatment, and starting hospice care. Challenges included escalating/severe symptoms, repeated urgent care/emergency department/hospital encounters, and lack of or late access to palliative and hospice care. Notes also illustrated how patient background and goals influenced care trajectory and communication. Documentation styles varied substantially, with palliative care notes more consistently documenting conversations about goals of care and psychosocial needs. CONCLUSION: This analysis of longitudinal illness experience of women with advanced gynecological cancer suggests that clinicians may want to (1) prioritize earlier discussion about goals of care; (2) provide supplemental support to patients with higher needs, possibly through palliative care or navigation; and (3) write notes to enhance patient understanding now that patients may access all notes.

Patient Preferences for Preventive Healthcare During the COVID-19 Pandemic in a Large Integrated Health System.

The COVID-19 pandemic caused healthcare systems and patients to cancel or postpone healthcare services, particularly preventive care. Many patients still have not received these services raising concerns about the potential for preventable morbidity and mortality. At Sutter Health, a large integrated healthcare system in Northern California, we conducted a population-based email survey in August 2020 to evaluate perceptions and preferences about where, when, and how healthcare is delivered during the COVID-19 pandemic. In total, 3351 patients completed surveys, and 42.6% reported that they would "wait until they felt safe" before receiving a colonoscopy as compared to 22.4% for a mammogram. The doctor's office was the most common preferred location for receiving vaccines/shots (79.9%), though many also reported preferring an outdoor setting or in a car (63.7%). With over 40% of patients reporting that they would "wait until they feel safe" for a colonoscopy, healthcare systems could focus on promoting other evidence-based options such a fecal-occult blood test to ensure timely colon cancer screening.

Evolving Goals of Care Discussions as Described in Interviews With Individuals With Advanced Cancer and Oncology and Palliative Care Teams.

BACKGROUND: Individuals with advanced cancer and their families have negative end-of-life experiences when the care they receive is not aligned with their values and preferences. OBJECTIVE: To obtain in-depth information on how patients with advanced cancer and the oncology and palliative care (PC) clinicians who care for them discuss goals of care (GoC). DESIGN: The research team conducted in-depth interviews and qualitative data analysis using open coding to identify how perspectives on GoC discussions vary by stage of illness, and experience with PC teams. SETTING/SUBJECTS: Twenty-five patients and 25 oncology and PC team members in a large multi-specialty group in Northern California. RESULTS: At the time of diagnosis participants described having establishing GoC conversations about understanding the goal of treatment (e.g. to extend life), and prognosis ("How much time do I have?"). Patients whose disease progressed or pain/symptoms increased reported changing GoC conversations about stopping treatment, introducing hospice care, prognostic awareness, quality of life, advance care planning, and end-of-life planning. Participants believed in the fluidity of prognosis and preferences for prognostic communication varied. Patients appreciated how PC teams facilitated changing GoC conversations. Timing was challenging; some patients desired earlier conversations and PC involvement, others wanted to wait until things were "going downhill." CONCLUSION: Patients and clinical teams acknowledged the complexity and importance of GoC conversations, and that PC teams enhanced conversations. The frequency, quality, and content of GoC conversations were shaped by patient receptivity, stage of illness, clinician attitudes and predispositions toward PC, and early integration of PC.

Breast Cancer Navigation: Using Physician and Patient Surveys to Explore Nurse Navigator Program Experiences.

BACKGROUND: Patient navigators can improve patient experiences of care and outcomes, but little is known about how navigation programs may affect physician workflows and experience. OBJECTIVES: This study aimed to understand patient and physician experiences with a breast cancer navigation (BCN) program using Lean design principles. METHODS: Surveys were developed and distributed from 2019 to 2020 to 255 patients diagnosed with breast cancer and 128 physicians in primary care and cancer-related specialties. Descriptive analyses were conducted. FINDINGS: Eighty-three physicians and 94 patients completed the survey. A large majority of physicians reported that the BCN program "made their day easier" and improved flow, care coordination, and patient experience. A large majority of patients reported receiving the right level of support during diagnosis communication and high satisfaction in other domains measured.

Differences in IgG Antibody Responses following BNT162b2 and mRNA-1273 SARS-CoV-2 Vaccines.

Studies examining antibody responses by vaccine brand are lacking and may be informative for optimizing vaccine selection, dosage, and regimens. The purpose of this study is to assess IgG antibody responses following immunization with BNT162b2 (30 µg mRNA) and mRNA-1273 (100 µg mRNA) vaccines. A cohort of clinicians at a nonprofit organization is being assessed clinically and serologically following immunization with BNT162b2 or mRNA-1273. IgG responses were measured at the Remington Laboratory by an IgG assay against the SARS-CoV-2 spike protein-receptor binding domain. Mixed-effect linear (MEL) regression modeling was used to examine whether the SARS-CoV-2 IgG level differed by vaccine brand, dosage, or number of days since vaccination. Among 532 SARS-CoV-2 seronegative participants, 530 (99.6%) seroconverted with either vaccine. After adjustments for age and gender, MEL regression modeling revealed that the average IgG antibody level increased after the second dose compared to the first dose (P < 0.001). Overall, titers peaked at week 6 for both vaccines. Titers were significantly higher for the mRNA-1273 vaccine on days 14 to 20 (P < 0.05), 42 to 48 (P < 0.01), 70 to 76 (P < 0.05), and 77 to 83 (P < 0.05) and higher for the BNT162b2 vaccine on days 28 to 34 (P < 0.001). In two participants taking immunosuppressive drugs, the SARS-CoV-2 IgG antibody response remained negative. mRNA-1273 elicited higher IgG antibody responses than BNT162b2, possibly due to the higher S-protein delivery. Prospective clinical and serological follow-up of defined cohorts such as this may prove useful in determining antibody protection and whether differences in antibody kinetics between the vaccines have manufacturing relevance and clinical significance. IMPORTANCE SARS-CoV-2 vaccines using the mRNA platform have become one of the most powerful tools to overcome the COVID-19 pandemic. mRNA vaccines enable human cells to produce and present the virus spike protein to their immune system, leading to protection from severe illness. Two mRNA vaccines have been widely implemented, mRNA-1273 (Moderna) and BNT162b2 (Pfizer/BioNTech). We found that, following the second dose, spike protein antibodies were higher with mRNA-1273 than with BNT162b2. This is biologically plausible, since mRNA-1273 delivers a larger amount of mRNA (100 µg mRNA) than BNT162b2 (30 µg mRNA), which is translated into spike protein. This difference may need to be urgently translated into changes in the manufacturing process and dose regimens of these vaccines.

Primary care nurse practitioner management of adolescent behavioral health.

OBJECTIVES: To determine the personnel costs and revenue generated by embedding a behavioral health nurse practitioner (BHNP) in primary care clinics to evaluate and manage adolescent behavioral health needs. STUDY DESIGN: We estimated personnel costs and revenue from a quality improvement project undertaken at 4 clinic sites between August 1, 2016, and July 31, 2018, at a large multispecialty medical group in northern California. METHODS: Costs were estimated by identifying the actual hours spent by the BHNP and for medical assistant (MA) support and using Bureau of Labor Statistics national data on wages and benefits. Revenue was estimated by analyzing Current Procedural Terminology (CPT) codes for BHNP visits from the Epic electronic health record and corresponding relative value units (RVUs), based on 135% of 2018 nationally unadjusted Medicare rates. RESULTS: We estimate 2-year revenue of $144,449 and personnel costs (salary + benefits) of $90,431. The BHNP work totaled 1083 hours, and MA support totaled 312 hours. Using a nurse practitioner wage of $53.70/hour and an MA wage of $16.95/hour, total salary costs were $63,451; we then added benefits costs. Using the CPT codes assigned to the 768 encounters with 207 unique patients, we estimated generation of 1640 RVUs and total revenue of $144,449. CONCLUSIONS: This analysis found that personnel costs ($90,514) of a primary care-embedded BHNP are 63% of the potential revenue generated ($144,449). This analysis suggests that a primary care BHNP could be a cost-saving and patient-centered way to reduce the burden on primary care providers while meeting the growing needs of adolescents with behavioral health needs.