Smoking Status, Nicotine Medication, Vaccination, and COVID-19 Hospital Outcomes: Findings from the COVID EHR Cohort at the University of Wisconsin (CEC-UW) Study.

INTRODUCTION: Available evidence is mixed concerning associations between smoking status and COVID-19 clinical outcomes. Effects of nicotine replacement therapy (NRT) and vaccination status on COVID-19 outcomes in smokers are unknown. METHODS: Electronic health record data from 104 590 COVID-19 patients hospitalized February 1, 2020 to September 30, 2021 in 21 U.S. health systems were analyzed to assess associations of smoking status, in-hospital NRT prescription, and vaccination status with in-hospital death and ICU admission. RESULTS: Current (n = 7764) and never smokers (n = 57 454) did not differ on outcomes after adjustment for age, sex, race, ethnicity, insurance, body mass index, and comorbidities. Former (vs never) smokers (n = 33 101) had higher adjusted odds of death (aOR, 1.11; 95% CI, 1.06-1.17) and ICU admission (aOR, 1.07; 95% CI, 1.04-1.11). Among current smokers, NRT prescription was associated with reduced mortality (aOR, 0.64; 95% CI, 0.50-0.82). Vaccination effects were significantly moderated by smoking status; vaccination was more strongly associated with reduced mortality among current (aOR, 0.29; 95% CI, 0.16-0.66) and former smokers (aOR, 0.47; 95% CI, 0.39-0.57) than for never smokers (aOR, 0.67; 95% CI, 0.57, 0.79). Vaccination was associated with reduced ICU admission more strongly among former (aOR, 0.74; 95% CI, 0.66-0.83) than never smokers (aOR, 0.87; 95% CI, 0.79-0.97). CONCLUSIONS: Former but not current smokers hospitalized with COVID-19 are at higher risk for severe outcomes. SARS-CoV-2 vaccination is associated with better hospital outcomes in COVID-19 patients, especially current and former smokers. NRT during COVID-19 hospitalization may reduce mortality for current smokers. IMPLICATIONS: Prior findings regarding associations between smoking and severe COVID-19 disease outcomes have been inconsistent. This large cohort study suggests potential beneficial effects of nicotine replacement therapy on COVID-19 outcomes in current smokers and outsized benefits of SARS-CoV-2 vaccination in current and former smokers. Such findings may influence clinical practice and prevention efforts and motivate additional research that explores mechanisms for these effects.

TrueNTH Sexual Recovery Intervention for couples coping with prostate cancer: Randomized controlled trial results.

BACKGROUND: Despite significant sexual dysfunction and distress after localized prostate cancer treatment, patients typically receive only physiologic erectile dysfunction management. The authors performed a randomized controlled trial of an online intervention supporting couples' posttreatment recovery of sexual intimacy. METHODS: Patients treated with surgery, radiation, or combined radiation and androgen deprivation therapy who had partners were recruited and randomized to an online intervention or a control group. The intervention, tailored to treatment type and sexual orientation, comprised 6 modules addressing expectations for sexual and emotional sequelae of treatment, rehabilitation, and guidance toward sexual intimacy recovery. Couples, recruited from 6 sites nationally, completed validated measures at the baseline and 3 and 6 months after treatment. Primary outcome group differences were assessed with t tests for individual outcomes. RESULTS: Among 142 randomized couples, 105 patients (mostly surgery) and 87 partners completed the 6-month survey; this reflected challenges with recruitment and attrition. There were no differences between the intervention and control arms in Patient-Reported Outcomes Measurement Information System Global Satisfaction With Sex Life scores 6 months after treatment (the primary outcome). Three months after treatment, intervention patients and partners reported more engagement in penetrative and nonpenetrative sexual activities than controls. More than 73% of the intervention participants reported high or moderate satisfaction with module content; more than 85% would recommend the intervention to other couples. CONCLUSIONS: Online psychosexual support for couples can help couples to connect and experience sexual pleasure early after treatment despite patients' sexual dysfunction. Participants' high endorsement of the intervention reflects the importance of sexual health support to couples after prostate cancer treatment. LAY SUMMARY: This study tested a web-based program supporting couples' sexual recovery of sexual intimacy after prostate cancer treatment. One hundred forty-two couples were recruited and randomly assigned to the program (n = 60) or to a control group (n = 82). The program did not result in improvements in participants' satisfaction with their sex life 6 months after treatment, but couples in the intervention group engaged in sexual activity sooner after treatment than couples in the control group. Couples evaluated the program positively and would recommend it to others facing prostate cancer treatment.

Improving the delivery of team-based survivorship care after primary breast cancer treatment through a multi-level intervention: a pilot randomized controlled trial.

PURPOSE: We developed and tested a multi-level intervention, ConnectedCancerCare (CCC), which includes a tailored website and appointment reminder system for women with early-stage breast cancer and a provider summary letter sent to their medical oncologist and primary care provider to improve the delivery of team-based survivorship care. METHODS: We conducted a pilot randomized controlled trial to establish the feasibility and acceptability of CCC. Women diagnosed with stages 0-II breast cancer within one year of completing primary treatment were randomized to CCC (intervention) or a static online survivorship care plan (control). Participants completed baseline and 3-month follow-up surveys online. Post-trial interviews with 5 PCPs, 6 oncology providers, and 8 intervention patients were conducted. RESULTS: Of the 160 eligible women invited to participate, 66 completed the baseline survey and were randomized (41%) and 54 completed a follow-up survey (83%). Participants in the intervention arm found the CCC content to be acceptable, with 82% reporting it was easy to use and 86% reporting they would recommend it to other patients. Women randomized to CCC (vs. control) more often reported scheduling a PCP follow-up visit (64% vs. 42%), communicating with their PCP about provider roles (67% vs. 18%), and higher mean team-based cancer care knowledge scores (3.7 vs. 3.4). CONCLUSION: Deploying CCC in medical oncology practices was feasible, and the intervention content was acceptable. CCC shows promise for improving patient knowledge and patient-provider communication about provider roles in team-based cancer care and encouraging patients to engage with their PCP early in the survivorship period.

Neural Mechanisms of Emotion Regulation Moderate the Predictive Value of Affective and Value-Related Brain Responses to Persuasive Messages.

Emotionally evocative messages can be an effective way to change behavior, but the neural pathways that translate messages into effects on individuals and populations are not fully understood. We used a human functional neuroimaging approach to ask how affect-, value-, and regulation-related brain systems interact to predict effects of graphic anti-smoking messages for individual smokers (both males and females) and within a population-level messaging campaign. Results indicated that increased activity in the amygdala, a region involved in affective reactivity, predicted both personal quit intentions and population-level information-seeking and this was mediated by activity in ventromedial prefrontal cortex (vmPFC), a region involved in computing an integrative value signal. Further, the predictive value of these regions was moderated by expression of a meta-analytically defined brain pattern indexing emotion regulation. That is, amygdala and vmPFC activity strongly tracked with population behavior only when participants showed low recruitment of this brain pattern, which consists of regions involved in goal-driven regulation of affective responses. Overall, these findings suggest that affective and value-related brain responses can predict the success of persuasive messages and that neural mechanisms of emotion regulation can shape these responses, moderating the extent to which they track with population-level message impact.SIGNIFICANCE STATEMENT People and organizations often appeal to our emotions to persuade us, but how these appeals engage the brain to drive behavior is not fully understood. We present an fMRI-based model that integrates affect-, control-, and value-related brain responses to predict the impact of graphic anti-smoking stimuli within a small group of smokers and a larger-scale public messaging campaign. This model indicated that amygdala activity predicted the impact of the anti-smoking messages, but that this relationship was mediated by ventromedial prefrontal cortex and moderated by expression of a distributed brain pattern associated with regulating emotion. These results suggest that neural mechanisms of emotion regulation can shape the extent to which affect and value-related brain responses track with population behavioral effects.

Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial.

STUDY OBJECTIVE: We evaluated a strategy to increase use of the test (Dix-Hallpike's test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits. METHODS: We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head computed tomography (CT) use, length of stay, admission, and 90-day stroke events. The analysis was multilevel logistic regression with intervention, month, and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews. RESULTS: We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 95% confidence interval 3% to 4%; difference 2%, 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits (44.0% [1,352/3,077] versus 36.9% [1,682/4,558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program. CONCLUSION: These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low, which relates in part to our broad inclusion criteria for dizziness visits.

Feasibility of a Smartphone-Based Tobacco Treatment for HIV-Infected Smokers.

BACKGROUND: Cigarette smoking is common among persons living with HIV (PLWH) in the United States. It is the leading cause of mortality in this group, and efforts to promote cessation have been largely unsuccessful. METHODS: From 2015 to 2017, we performed a randomized controlled trial of Positively Smoke Free-Mobile (PSF-M) versus standard care. PSF-M is a mobile Web site that offers a 42-day text message-based quit-smoking program with smartphone features including quit-day selection/calendar, educational/motivational videos, and HELP button for cravings. RESULTS: One hundred individuals enrolled, 48 were randomized to PSF-M (mean age = 45 years, 54% male, 81% black, 31% Latino) and 52 to the standard care condition. All participants were offered a 3-month supply of nicotine patches. Participants randomized to the mobile intervention visited the PSF-M home page a mean of 83 times, viewed 5.6/8 videos, logged in on 13 of 42 possible days, and received 131 texts. Among them, 77% tapped HELP for cravings, and craving response options were used by the following proportions: phone-a-friend, 58%; play-a-game, 29%; play-a-song, 4%. Older age and nonblack race were both associated with higher levels of engagement with the site. Of participants, 61% rated PSF-M very or extremely helpful, and 98% would recommend PSF-M to PLWH family or friends. Abstinence at 3 months, quit attempts, and daily cigarette intake all favored PSF-M over standard care but did not achieve statistical significance in our pilot sample. CONCLUSIONS: Smartphone-based tobacco treatment for PLWH was feasible and achieved moderate-high rates of engagement and satisfaction in a middle-aged, ethnic or racial minority group in the poorest urban community in the United States. IMPLICATIONS: Cigarette smoking has emerged as the leading killer of PLWH. Behavioral interventions have achieved only limited success in promoting cessation in this population. In this study, we explore the feasibility and preliminary efficacy of a multimodal, Web-based, quit-smoking intervention delivered to PLWH smokers via their smartphones.

Knowledge regarding and patterns of genetic testing in patients newly diagnosed with breast cancer participating in the iCanDecide trial.

BACKGROUND: The current study reports rates of knowledge regarding the probability of a BRCA1 and/or S pathogenic variant and genetic testing in patients with breast cancer, collected as part of a randomized controlled trial of a tailored, comprehensive, and interactive decision tool (iCanDecide). METHODS: A total of 537 patients newly diagnosed with early-stage breast cancer were enrolled at the time of their first visit in 22 surgical practices, and were surveyed 5 weeks (496 patients; Response Rate [RR], 92%) after enrollment after treatment decision making. Primary outcomes included knowledge regarding the probability of carrying a BRCA1 and/or BRCA2 pathogenic variant and genetic testing after diagnosis. RESULTS: Overall knowledge regarding the probability of having a BRCA1 and/or BRCA2 pathogenic variant was low (29.8%). Significantly more patients in the intervention group compared with the control group had knowledge regarding the probability of a BRCA1 and/or BRCA2 pathogenic variant (35.8% vs 24.4%; P <.006). In multivariable logistic regression, the intervention arm remained significantly associated with knowledge regarding the probability of having a BRCA1 and/or BRCA2 pathogenic variant (odds ratio, 1.79; 95% confidence interval, 1.18-2.70). CONCLUSIONS: The results of the current study suggest that although knowledge concerning the probability of having a BRCA1 and/or BRCA2 pathogenic variant remains low in this patient population, the interactive decision tool improved rates compared with a static Web site. As interest in genetic testing continues to rise, so will the need to integrate tools into the treatment decision process to improve informed decision making.

Decision-support networks of women newly diagnosed with breast cancer.

BACKGROUND: Little is known about the size and characteristics of the decision-support networks of women newly diagnosed with breast cancer and whether their involvement improves breast cancer treatment decisions. METHODS: A population-based sample of patients newly diagnosed with breast cancer in 2014 and 2015, as reported to the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries, were surveyed approximately 7 months after diagnosis (N = 2502; response rate, 68%). Network size was estimated by asking women to list up to 3 of the most important decision-support persons (DSPs) who helped them with locoregional therapy decisions. Decision deliberation was measured using 4 items assessing the degree to which patients thought through the decision, with higher scores reflecting more deliberative breast cancer treatment decisions. The size of the network (range, 0-3 or more) was compared across patient-level characteristics, and adjusted mean deliberation scores were estimated across levels of network size using multivariable linear regression. RESULTS: Of the 2502 women included in this analysis, 51% reported having 3 or more DSPs, 20% reported 2, 18% reported 1, and 11% reported not having any DSPs. Married/partnered women, those younger than 45 years, and black women all were more likely to report larger network sizes (all P < .001). Larger support networks were associated with more deliberative surgical treatment decisions (P < .001). CONCLUSIONS: Most women engaged multiple DSPs in their treatment decision making, and involving more DSPs was associated with more deliberative treatment decisions. Future initiatives to improve treatment decision making among women with breast cancer should acknowledge and engage informal DSPs. Cancer 2017;123:3895-903. © 2017 American Cancer Society.

The impact of doctor-patient communication on patients' perceptions of their risk of breast cancer recurrence.

PURPOSE: Doctor-patient communication is the primary way for women diagnosed with breast cancer to learn about their risk of distant recurrence. Yet little is known about how doctors approach these discussions. METHODS: A weighted random sample of newly diagnosed early-stage breast cancer patients identified through SEER registries of Los Angeles and Georgia (2013-2015) was sent surveys about ~2 months after surgery (Phase 2, N = 3930, RR 68%). We assessed patient perceptions of doctor communication of risk of recurrence (i.e., amount, approach, inquiry about worry). Clinically determined 10-year risk of distant recurrence was established for low and intermediate invasive cancer patients. Women's perceived risk of distant recurrence (0-100%) was categorized into subgroups: overestimation, reasonably accurate, and zero risk. Understanding of risk and patient factors (e.g. health literacy, numeracy, and anxiety/worry) on physician communication outcomes was evaluated in multivariable regression models (analytic sample for substudy = 1295). RESULTS: About 33% of women reported that doctors discussed risk of recurrence as "quite a bit" or "a lot," while 14% said "not at all." Over half of women reported that doctors used words and numbers to describe risk, while 24% used only words. Overestimators (OR .50, CI 0.31-0.81) or those who perceived zero risk (OR .46, CI 0.29-0.72) more often said that their doctor did not discuss risk. Patients with low numeracy reported less discussion. Over 60% reported that their doctor almost never inquired about worry. CONCLUSIONS: Effective doctor-patient communication is critical to patient understanding of risk of recurrence. Efforts to enhance physicians' ability to engage in individualized communication around risk are needed.

Sexual Health Concerns Among Cancer Survivors: Testing a Novel Information-Need Measure Among Breast and Prostate Cancer Patients.

While it is recognized that cancer treatment can contribute to problems in sexual function, much less is currently known about the specific sexual health concerns and information needs of cancer survivors. This study tested a new instrument to measure cancer survivors' sexual health concerns and needs for sexual information after cancer treatment. The Information on Sexual Health: Your Needs after Cancer (InSYNC), developed by a multidisciplinary team of experts, is a novel 12-item questionnaire to measure sexual health concerns and information needs of cancer survivors. We tested the measure with a sample of breast and prostate cancer survivors. A convenience sample of 114 cancer survivors (58 breast, 56 prostate) was enrolled. Results of the InSYNC questionnaire showed high levels of sexual concern among cancer survivors. Areas of concern differed by cancer type. Prostate cancer survivors were most concerned about being able to satisfy their partners (57 %) while breast cancer survivors were most concerned with changes in how their bodies worked sexually (46 %). Approximately 35 % of all cancer survivors wanted more information about sexual health. Sexual health concerns and unmet information needs are common among breast and prostate cancer survivors, varying in some aspects by type of cancer. Routine screening for sexual health concerns should be included in comprehensive cancer survivorship care to appropriately address health care needs. The InSYNC questionnaire is one tool that may help clinicians identify concerns facing their patients.

Tobacco Cessation Motivations, Preferences, and Barriers Among Rural Smokers: Implications for Optimizing Referrals in Clinical Practice.

Introduction: Rural‒urban smoking disparities have widened in recent years because smoking prevalence reductions have been experienced disproportionately among urban adults. Tobacco cessation programs that work in urban settings may not be reaching rural smokers or may need tailoring to be effective. Identifying smoking cessation preferences and barriers among rural smokers can facilitate the implementation of acceptable programs to address rural smoking-related disparities. Thus, the aim of this study was to examine tobacco cessation motivations, preferences, and barriers among rural smokers and to assess smokers' likelihood to use various types of tobacco cessation programs. Methods: Using a cross-sectional study design, we distributed a self-administered survey to 100 smokers during regularly scheduled healthcare appointments at 3 rural Michigan practices from June to August 2019. We examined differences in participant characteristics by the readiness to quit using chi-square/Fisher's exact tests and described cessation motivations, preferences, and barriers to tobacco cessation among rural smokers. Results: Participants reporting readiness to quit were less likely to have smoking allowed in their home (31.7% vs. 75.0%; p=0.003) and had a higher prevalence of anxiety (62.1% vs. 6.3%; p=0.0001) and depression (49.2% vs. 18.8%; p=0.04) than those not ready to quit. Preferences were higher for nicotine replacement medications and reward-based approaches, with only 10% of participants being likely to use telephone-based quitlines. Conclusions: These findings suggest that provider referrals to nicotine replacement medications and reward-based approaches can be used to enhance tobacco cessation among rural smokers.

Cascade Genetic Risk Education and Testing in Families With Hereditary Cancer Syndromes: A Pilot Study.

PURPOSE: Cascade genetic risk evaluation in families with hereditary cancer can reduce the burden of disease but the rate of germline genetic testing in relatives of patients at risk is low. METHODS: We identified all 277 women diagnosed with breast cancer in Georgia in 2017 who linked to a clinically actionable germline pathogenic variant through a Surveillance, Epidemiology, and End Results registry-variant linkage initiative. We surveyed them, and then invited eligible respondents to an online platform hosted by a navigator that offered cancer genetic risk education and germline genetic testing to untested relatives. We randomly assigned patient-family clusters at the time of the patient enrollment offer to free versus $50 (USD) test cost. Patients invited relatives to join the study through personalized e-mail. Enrolled relatives received online cancer genetic education and the opportunity to order clinical germline genetic testing through the platform. The primary outcome was the number of relatives who ordered genetic testing. RESULTS: One hundred twenty-five of 277 patients completed surveys (45.2%). Most respondents were eligible for the trial offer (113 of 125; 90.4%). In the free testing arm, 20 of 56 eligible patients participated (35.7% of eligible respondents) and they invited 28 relatives: 12 relatives enrolled and 10 ordered testing. In the $50 (USD) arm, 16 of 57 eligible patients participated (28.1%) and they invited 38 relatives: 18 relatives enrolled and 17 ordered testing. CONCLUSION: Cascade genetic testing in families with hereditary cancer syndromes accrued through a population-based cancer registry can be achieved through an online platform that offers genetic risk education and low-cost testing to relatives. A modest charge did not appear to influence the percentage of participating patients, numbers of participating relatives, and numbers of relatives who received genetic testing.

Relations of Current and Past Cancer with Severe Outcomes among 104,590 Hospitalized COVID-19 Patients: The COVID EHR Cohort at the University of Wisconsin.

BACKGROUND: There is mixed evidence about the relations of current versus past cancer with severe COVID-19 outcomes and how they vary by patient and cancer characteristics. METHODS: Electronic health record data of 104,590 adult hospitalized patients with COVID-19 were obtained from 21 United States health systems from February 2020 through September 2021. In-hospital mortality and ICU admission were predicted from current and past cancer diagnoses. Moderation by patient characteristics, vaccination status, cancer type, and year of the pandemic was examined. RESULTS: 6.8% of the patients had current (n = 7,141) and 6.5% had past (n = 6,749) cancer diagnoses. Current cancer predicted both severe outcomes but past cancer did not; adjusted odds ratios (aOR) for mortality were 1.58 [95% confidence interval (CI), 1.46-1.70] and 1.04 (95% CI, 0.96-1.13), respectively. Mortality rates decreased over the pandemic but the incremental risk of current cancer persisted, with the increment being larger among younger vs. older patients. Prior COVID-19 vaccination reduced mortality generally and among those with current cancer (aOR, 0.69; 95% CI, 0.53-0.90). CONCLUSIONS: Current cancer, especially among younger patients, posed a substantially increased risk for death and ICU admission among patients with COVID-19; prior COVID-19 vaccination mitigated the risk associated with current cancer. Past history of cancer was not associated with higher risks for severe COVID-19 outcomes for most cancer types. IMPACT: This study clarifies the characteristics that modify the risk associated with cancer on severe COVID-19 outcomes across the first 20 months of the COVID-19 pandemic. See related commentary by Egan et al., p. 3.

Adapting an in-person patient-caregiver communication intervention to a tailored web-based format.

BACKGROUND: Interventions that target cancer patients and their caregivers have been shown to improve patient-caregiver communication, support, and emotional well-being. OBJECTIVE: To adapt an in-person communication intervention for cancer patients and caregivers to a web-based format, and to examine the usability and acceptability of the web-based program among representative users. METHODS: A tailored, interactive web-based communication program for cancer patients and their family caregivers was developed based on an existing in-person, nurse-delivered intervention. The development process involved: (1) building a multidisciplinary team of content and web design experts, (2) combining key components of the in-person intervention with the unique tailoring and interactive features of a web-based platform, and (3) conducting focus groups and usability testing to obtain feedback from representative program users at multiple time points. RESULTS: Four focus groups with 2-3 patient-caregiver pairs per group (n = 22 total participants) and two iterations of usability testing with four patient-caregiver pairs per session (n = 16 total participants) were conducted. Response to the program's structure, design, and content was favorable, even among users who were older or had limited computer and Internet experience. The program received high ratings for ease of use and overall usability (mean System Usability Score of 89.5 out of 100). CONCLUSIONS: Many elements of a nurse-delivered patient-caregiver intervention can be successfully adapted to a web-based format. A multidisciplinary design team and an iterative evaluation process with representative users were instrumental in the development of a usable and well-received web-based program.

Leveraging EHR data for outcomes and comparative effectiveness research in oncology.

Along with the increasing adoption of electronic health records (EHRs) are expectations that data collected within EHRs will be readily available for outcomes and comparative effectiveness research. Yet the ability to effectively share and reuse data depends on implementing and configuring EHRs with these goals in mind from the beginning. Data sharing and integration must be planned both locally as well as nationally. The rich data transmission and semantic infrastructure developed by the National Cancer Institute (NCI) for research provides an excellent example of moving beyond paper-based paradigms and exploiting the power of semantically robust, network-based systems, and engaging both domain and informatics expertise. Similar efforts are required to address current challenges in sharing EHR data.

Ethnic group differences in the relationship between depressive symptoms and smoking.

OBJECTIVES: A relationship between depression and smoking has been documented; however, little attention has focused on ethnic variability in how this relationship is manifested. Thus, we examined the interaction between ethnicity and significant depressive symptoms on smoking status. DESIGN: A random digit dial survey (Minnesota Needs Assessment Survey) that oversampled ethnic minorities assessed demographics, smoking status, and depressive symptoms (Patient Health Questionnaire-2 [PHQ-2]). We examined the prevalence of current smoking between individuals with and without depressive symptoms within ethnic group and the interaction of depressive symptoms by ethnic group on smoking status. RESULTS: Of 16,981 participants, 20.8% were current smokers, and 7.7% reported significant depressive symptoms on the PHQ-2 (score ≥3). Ethnic differences were observed in smoking rates (Asians 17.2%, Latinos 19.0%, whites 20.4%, African-Americans 23.4%, American Indians 51.2%) and depressive symptoms (Asians 4.9%, Latinos 13.1%, whites 7.0%, African-Americans 19.1%, American Indians 12.5%). Depressive symptoms were associated with a higher prevalence of smoking among Whites (34.5% vs. 19.4%), African-Americans (43.6% vs. 18.9%), and American Indians (81.9% vs. 47.1%), but not among Latinos (14.5% vs. 19.7%) or Asians (19.6% vs. 17.1%). The interaction between ethnicity and depressive symptomatology on current smoking was significant (p=0.02) among Latinos relative to Whites, controlling for other demographics. CONCLUSION: The relationship between depressive symptoms and smoking differs by ethnicity, particularly for Latinos. Understanding these differences may contribute to the development of culturally specific interventions.

The first 20 months of the COVID-19 pandemic: Mortality, intubation and ICU rates among 104,590 patients hospitalized at 21 United States health systems.

MAIN OBJECTIVE: There is limited information on how patient outcomes have changed during the COVID-19 pandemic. This study characterizes changes in mortality, intubation, and ICU admission rates during the first 20 months of the pandemic. STUDY DESIGN AND METHODS: University of Wisconsin researchers collected and harmonized electronic health record data from 1.1 million COVID-19 patients across 21 United States health systems from February 2020 through September 2021. The analysis comprised data from 104,590 adult hospitalized COVID-19 patients. Inclusion criteria for the analysis were: (1) age 18 years or older; (2) COVID-19 ICD-10 diagnosis during hospitalization and/or a positive COVID-19 PCR test in a 14-day window (+/- 7 days of hospital admission); and (3) health system contact prior to COVID-19 hospitalization. Outcomes assessed were: (1) mortality (primary), (2) endotracheal intubation, and (3) ICU admission. RESULTS AND SIGNIFICANCE: The 104,590 hospitalized participants had a mean age of 61.7 years and were 50.4% female, 24% Black, and 56.8% White. Overall risk-standardized mortality (adjusted for age, sex, race, ethnicity, body mass index, insurance status and medical comorbidities) declined from 16% of hospitalized COVID-19 patients (95% CI: 16% to 17%) early in the pandemic (February-April 2020) to 9% (CI: 9% to 10%) later (July-September 2021). Among subpopulations, males (vs. females), those on Medicare (vs. those on commercial insurance), the severely obese (vs. normal weight), and those aged 60 and older (vs. younger individuals) had especially high mortality rates both early and late in the pandemic. ICU admission and intubation rates also declined across these 20 months. CONCLUSIONS: Mortality, intubation, and ICU admission rates improved markedly over the first 20 months of the pandemic among adult hospitalized COVID-19 patients although gains varied by subpopulation. These data provide important information on the course of COVID-19 and identify hospitalized patient groups at heightened risk for negative outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04506528 (https://clinicaltrials.gov/ct2/show/NCT04506528).

Trust in the internet as a health resource among older adults: analysis of data from a nationally representative survey.

BACKGROUND: Distrust in the Internet as a source of health information remains common among older adults. The influence of this distrust on Internet use for health-related purposes, however, is unclear. OBJECTIVE: The objective of our study was to explore how older adults' trust in the Internet influences their online health-related activities, and to identify potential targets for improving health-related Internet resources for older adults. METHODS: Data were obtained from a nationally representative, random digit-dial telephone survey of 1450 adults 50 years of age and older in the United States. A model was developed to conceptualize the hypothesized relationships among individual characteristics, distrust, and avoidance of the Internet as a health resource. Multivariate logistic regression analyses were conducted to examine the association between trust in online health information and use of the Internet for health-related purposes. Additional multivariate logistic regression analyses were conducted to identify the key characteristics associated with trust in online health information, adding sequentially the variables hypothesized to account for distrust among older adults: sociodemographic and health characteristics, inexperience and technical difficulties with the Internet, negative feelings toward the Internet, and lack of awareness about the sources providing the health information found online. RESULTS: The mean (SD) age of the study population was 63.7 (10.6) years. Of the 823 (56.8%) Internet users, 628 (76.3%) reported using the Internet as a health resource. Trust in the Internet as a source of health information was associated with using the Internet for a number of health activities, including searching for information about a specific health condition (adjusted OR 4.43, P < .001), purchasing prescription drugs (adjusted OR 2.61, P = .03), and talking with a health care provider about information found online (adjusted OR 2.54, P = .002). Older adults (age ≥ 65 years) were less likely to trust the Internet as a source of health information (OR 0.63, P = .04), even after adjusting for other sociodemographic characteristics and health and function. This age effect was only slightly attenuated (adjusted OR 0.69, P = .13) after adjusting for inexperience and technical difficulties with the Internet, but it disappeared entirely (adjusted OR 0.96, P = .91) after adjusting for other hypothesized contributors to distrust (including finding the Internet confusing because it provides "too much information," and lacking awareness about the source providing health information found online). CONCLUSIONS: Website design features that clearly identify the source and credibility of information and minimize confusion may build trust among older adults and offer an opportunity to increase the utility of the Internet as a health resource for this population.

Delayed Urological Cancer Care during the COVID-19 Pandemic: Urologists' Experience.

INTRODUCTION: The arrival of coronavirus disrupted health care systems and forced delays in cancer treatment. We explored the experience of urologists who had to delay their patients' cancer care. METHODS: Urologists who treat prostate, bladder, and renal cancers, selected through purposive sampling, responded to a survey about cancer treatment delay. They were asked about their practice setting, decision making and interactions with patients, and they were asked to reflect on their personal experience. A 0 to 10 point scale, modeled on the National Comprehensive Cancer Network' Distress Thermometer (NCCN-DT), validated for cancer patients with cancer, was used to estimate physician distress. We used descriptive statistics to analyze survey results. RESULTS: Of the 64 participating urologists, 98% delayed surgical treatment; fewer delayed cases of advanced cancers (42% for ≥T3/T4 or Gleason ≥8 prostate cancers, 58% for muscle invasive bladder cancer, 61% for ≥T2 renal cancers). They reported feeling anxious (44%) and helpless (29%), and their median distress score was 5 (range 0-10). They relied on their own risk assessments (67%) and consulted colleagues (56%) and national guidelines (53%) when making treatment deferral decisions. They identified a number of concerns as they resumed surgeries. CONCLUSIONS: Based on a comparison to the NCCN-DT clinical cutoff distress level of 4, urologists experienced moderately high levels of distress as they delayed cancer care during the COVID-19 pandemic and expressed concerns going forward. While the focus on patient care is paramount in a pandemic, it is important to recognize physician distress and develop practical and psychological strategies for distress mitigation.

The comparative effectiveness of clinic, work-site, phone, and Web-based tobacco treatment programs.

INTRODUCTION: Tobacco treatment programs may be offered in clinical settings, at work-sites, via telephone helplines, or over the Internet. Little comparative data exist regarding the real-world effectiveness of these programs. This paper compares the reach, effectiveness, and costs of these different modes of cessation assistance. METHODS: This is an observational study of cohorts of participants in Minnesota's QUITPLAN programs in 2004. Cessation assistance was provided in person at 9 treatment centers, using group counseling at 68 work-sites, via a telephone helpline, or via the Internet. The main outcomes of the study are enrollment by current smokers, self-reported 30-day abstinence, and cost per quit. Reach was calculated statewide for the helpline and Web site, regionally for the treatment centers, and for the employee population for work-site programs. RESULTS: Enrollment was greatest for the Web site (n = 4,698), followed by the helpline (n = 2,351), treatment centers (n = 616), and work-sites (n = 479). The Web site attracted younger smokers. Smokers at treatment centers had higher levels of nicotine dependence. The helpline reached more socially disadvantaged smokers. Responder 30-day abstinence rates were higher for the helpline (29.3%), treatment centers (25.8%), and work-sites (19.6%) compared with the online program (12.5%). These differences persisted after controlling for baseline differences in participant characteristics and use of pharmacological therapy. The cost per quit was lowest for the Web site program ($291 per quit, 95% CI = $229-$372). DISCUSSION: Treatment center, work-site, helpline, and Web site programs differ in their reach, effectiveness, and estimated cost per quit. Each program plays a part in assisting populations of tobacco users in quitting.