Social determinants of health and treatment center affiliation: analysis from the sickle cell disease implementation consortium registry

BACKGROUND

Adults with sickle cell disease (SCD) suffer early mortality and high morbidity. Many are not affiliated with SCD centers, defined as no ambulatory visit with a SCD specialist in 2 years. Negative social determinants of health (SDOH) can impair access to care.

HYPOTHESIS

Negative SDOH are more likely to be experienced by unaffiliated adults than adults who regularly receive expert SCD care.

METHODS

Cross-sectional analysis of the SCD Implementation Consortium (SCDIC) Registry, a convenience sample at 8 academic SCD centers in 2017-2019. A Distressed Communities Index (DCI) score was assigned to each registry member's zip code. Insurance status and other barriers to care were self-reported. Most patients were enrolled in the clinic or hospital setting.

RESULTS

The SCDIC Registry enrolled 288 Unaffiliated and 2110 Affiliated SCD patients, ages 15-45y. The highest DCI quintile accounted for 39% of both Unaffiliated and Affiliated patients. Lack of health insurance was reported by 19% of Unaffiliated versus 7% of Affiliated patients. The most frequently selected barriers to care for both groups were "previous bad experience with the healthcare system" (40%) and "Worry about Cost" (17%). SCD co-morbidities had no straightforward trend of association with Unaffiliated status. The 8 sites' results varied.

CONCLUSION

The DCI economic measure of SDOH was not associated with Unaffiliated status of patients recruited in the health care delivery setting. SCDIC Registrants reside in more distressed communities than other Americans. Other SDOH themes of affordability and negative experiences might contribute to Unaffiliated status. Recruiting Unaffiliated SCD patients to care might benefit from systems adopting value-based patient-centered solutions.

Parental Experiences With Access to Care for Obstructive Sleep-Disordered Breathing: A Qualitative Study

OBJECTIVE

Despite evidence-based guidelines for obstructive sleep-disordered breathing (SDB), recent studies continue to highlight treatment inequities. We used qualitative research methods to examine parental facilitators and barriers to SDB treatment.

STUDY DESIGN

Qualitative interviews.

SETTING

Tertiary care center.

METHODS

Semistructured interviews were conducted (January-April 2022) with parents of children with SDB who underwent tonsillectomies to understand the processes of SDB detection and accessing specialty care. Interviews were conducted until thematic saturation was reached and coded using NVivo software.

RESULTS

Of the 17 parents who completed the key informant interviews, 6 (35%) were of non-Hispanic black race, and 3 (17.6%) interviews were conducted in Spanish. Parents noted that the more knowledge their primary care provider (PCP) had about SDB, the easier it was to obtain a diagnostic workup (41%). The most common barrier included difficulty obtaining a specialist (otolaryngology or sleep medicine) referral from their PCP and encountering providers who were dismissive of parent-reported symptoms related to SDB, leading them to seek a second opinion or self-refer (53%). Medicaid coverage was a strong facilitator to receipt of care (59%). Three (17.6%) parents noted alienation in the process due to racial bias or language barriers.

CONCLUSION

Parental interviews revealed that facilitators of SDB treatment included high clinician knowledge and perceived importance of SDB as well as Medicaid insurance which decreased financial strain. Parents also cited the attainment of referrals as a significant barrier to obtaining specialty evaluation. These findings identify potential modifiable areas to tailor future interventions for timely and equitable SDB care.

Identifying barriers to obstructive sleep-disordered breathing care: Parental perspectives

OBJECTIVE

Despite established clinical practice guidelines for pediatric obstructive sleep-disordered breathing (SDB), disparities persist for this common condition. Few studies have investigated parental experiences about challenges faced in obtaining SDB evaluation and tonsillectomy for their children. To better understand parent-perceived barriers to treatment of childhood SDB, we administered a survey to assess parental knowledge of this condition.

MATERIALS & METHODS

A cross-sectional survey was designed to be completed by parents of children diagnosed with SDB. Two validated surveys were administered: 1) Barriers to Care Questionnaire and 2) Obstructive Sleep-Disordered Breathing and Adenotonsillectomy Knowledge Scale for Parents. Logistic regression modeling was performed to assess for predictors of parental barriers to SDB care and knowledge.

RESULTS

Eighty parents completed the survey. Mean patient age was 7.4 ± 4.6 years, and 48 (60%) patients were male. The survey response rate was 51%. Patient racial/ethnic categories included 48 (60.0%) non-Hispanic White, 18 (22.5%) non-Hispanic Black, and 14 (17.5%) Other. Parents reported challenges in the 'Pragmatic' domain, including appointment availability and cost of healthcare, as the most frequently described barrier to care. Adjusting for age, sex, race, and education, parents in the middle-income bracket ($26,500 - $79,500) had higher odds of reporting greater barriers to care than parents in the highest (>$79,500) income tier (OR 5.536, 95% CI 1.312-23.359, P = 0.020) and lowest income tier (<$26,500) (OR 3.920, 95% CI 1.096-14.020). Parents whose children had tonsillectomy (n = 40) answered only a mean 55.7% ± 13.3% of questions correctly on the knowledge scale.

CONCLUSION

Pragmatic challenges were the most encountered barrier that parents reported in accessing SDB care. Families in the middle-income tier experienced the greatest barriers to SDB care compared to lower and higher income families. In general, parental knowledge of SDB and tonsillectomy was relatively low. These findings represent potential areas of improvement to target interventions to promote equitable care for SDB.

The Cost Impact of Telehealth Interventions in Pediatric Surgical Specialties: A Systematic Review

BACKGROUND

Telehealth is a rapidly expanding care modality in the United States. Pediatric surgical patients often require complex care which can incur significant expenses, some of which may be alleviated by telehealth. We performed a systematic review comparing telehealth and in-person visits, and telehealth's impacts on the cost of healthcare across pediatric surgical specialties.

METHODS

A systematic review was performed using the following databases: PubMed (MEDLINE), Scopus (Elsevier), and CINAHL (EBSCOHost), searched from inception to July 10th, 2022. Studies were included per the following criteria: (1) investigated a telehealth intervention for pediatric surgical care and (2) provided some metric of telehealth cost compared to an in-person visit. Non-English or studies conducted outside of the U.S. were excluded.

RESULTS

Fourteen manuscripts met inclusion criteria and presented data on 7992 visits, including patients with a weighted average age of 7.5 ± 3.5 years. Most (11/14) studies used telehealth in a synchronous, or "real-time" context. Of the studies which calculated dollar cost savings for telehealth visits compared to in-person appointments we found a substantial range of savings per visit, from $48.50 to $344.64. Cost savings were frequently realized in terms of reduced travel expenditures, lower opportunity costs (e.g. lost wages), and decreased hospital labor requirements.

CONCLUSIONS

This review suggests that telehealth provides cost incentives to pediatric surgical care in many scenarios, including post-operative visits and some routine clinic visits. Future work should focus on standardizing the metrics by which cost impacts are analyzed and detailing which visits are most appropriately facilitated by telehealth.

LEVEL OF EVIDENCE

V.

Anticipating adaptation: tracking the impact of planned and unplanned adaptations during the implementation of a complex population-based genomic screening program

In 2021, the Medical University of South Carolina (MUSC) launched In Our DNA SC. This large-scale initiative will screen 100,000 individuals in South Carolina for three preventable hereditary conditions that impact approximately two million people in the USA but often go undetected. In anticipation of inevitable changes to the delivery of this complex initiative, we developed an approach to track and assess the impact of evaluate adaptations made during the pilot phase of program implementation. We used a modified version of the Framework for Reporting Adaptations and Modification-Enhanced (FRAME) and Adaptations to code adaptations made during the 3-month pilot phase of In Our DNA SC. Adaptations were documented in real-time using a REDCap database. We used segmented linear regression models to independently test three hypotheses about the impact of adaptations on program reach (rate of enrollment in the program, rate of messages viewed) and implementation (rate of samples collected) 7 days pre- and post-adaptation. Effectiveness was assessed using qualitative observations. Ten adaptations occurred during the pilot phase of program implementation. Most adaptations (60%) were designed to increase the number and type of patient contacted (reach). Adaptations were primarily made based on knowledge and experience (40%) or from quality improvement data (30%). Of the three adaptations designed to increase reach, shortening the recruitment message potential patients received significantly increased the average rate of invitations viewed by 7.3% (p = 0.0106). There was no effect of adaptations on implementation (number of DNA samples collected). Qualitative findings support improvement in effectiveness of the intervention after shortening the consent form and short-term positive impact on uptake of the intervention as measured by team member's participation. Our approach to tracking adaptations of In Our DNA SC allowed our team to quantify the utility of modifications, make decisions about pursuing the adaptation, and understand consequences of the change. Streamlining tools for tracking and responding to adaptations can help monitor the incremental impact of interventions to support continued learning and problem solving for complex interventions being delivered in health systems based on real-time data.

Examining Mental Health, Education, Employment, and Pain in Sickle Cell Disease

Importance

Pain related to sickle cell disease (SCD) is complex and associated with social determinants of health. Emotional and stress-related effects of SCD impact daily quality of life and the frequency and severity of pain.

Objective

To explore the association of educational attainment, employment status, and mental health with pain episode frequency and severity among individuals with SCD.

Design, Setting, and Participants

This is a cross-sectional analysis of patient registry data collected at baseline (2017-2018) from patients treated at 8 sites of the US Sickle Cell Disease Implementation Consortium. Data analysis was performed from September 2020 to March 2022.

Main Outcomes and Measures

Electronic medical record abstraction and a participant survey provided demographic data, mental health diagnosis, and Adult Sickle Cell Quality of Life Measurement Information System pain scores. Multivariable regression was used to examine the associations of education, employment, and mental health with the main outcomes (pain frequency and pain severity).

Results

The study enrolled a total of 2264 participants aged 15 to 45 years (mean [SD] age, 27.9 [7.9] years; 1272 female participants [56.2%]) with SCD. Nearly one-half of the participant sample reported taking daily pain medication (1057 participants [47.0%]) and/or hydroxyurea use (1091 participants [49.2%]), 627 participants (28.0%) received regular blood transfusion, 457 (20.0%) had a depression diagnosis confirmed by medical record abstraction, 1789 (79.8%) reported severe pain (rated most recent pain crises as ≥7 out of 10), and 1078 (47.8%) reported more than 4 pain episodes in the prior 12 months. The mean (SD) pain frequency and severity t scores for the sample were 48.6 (11.4) and 50.3 (10.1), respectively. Educational attainment and income were not associated with increased pain frequency or severity. Unemployment (β, 2.13; 95% CI, 0.99 to 3.23; P < .001) and female sex (β, 1.78; 95% CI, 0.80 to 2.76; P < .001) were associated with increased pain frequency. Age younger than 18 years was inversely associated with pain frequency (β, -5.72; 95% CI, -7.72 to -3.72; P < .001) and pain severity (β, 5.10; 95% CI, -6.70 to -3.51; P < .001). Depression was associated with increased pain frequency (β, 2.18; 95% CI, 1.04 to 3.31; P < .001) but not pain severity. Hydroxyurea use was associated with increased pain severity (β, 1.36; 95% CI, 0.47 to 2.24; P = .003), and daily use of pain medication was associated with both increased pain frequency (β, 6.29; 95% CI, 5.28 to 7.31; P < .001) and pain severity (β, 2.87; 95% CI, 1.95 to 3.80; P < .001).

Conclusions and Relevance

These findings suggest that employment status, sex, age, and depression are associated with pain frequency among patients with SCD. Depression screening for these patients is warranted, especially among those experiencing higher pain frequency and severity. Comprehensive treatment and pain reduction must consider the full experiences of patients with SCD, including impacts on mental health.

Barriers and Facilitators to Chronic Red Cell Transfusion Therapy in Pediatric Sickle Cell Anemia

Background: Chronic red cell transfusion (CRCT) therapy is one of a few effective disease-modifying therapies for children with sickle cell anemia (SCA). CRCT is recommended for primary and secondary stroke prevention for at-risk children with SCA and is sometimes used for other disease-related complications. However, CRCT can be resource- and time-intensive for patients/families, providers, and organizations. This study was conducted to provide a comprehensive, multilevel examination of barriers and facilitators to transfusion therapy in children with SCA from health care provider and caregiver perspectives. Methods: A qualitative descriptive approach was used to conduct key informant interviews in a sample of 26 caregivers and 25 providers across the United States. Interviews were analyzed using directed content analysis with the Multilevel Ecological Model of Health as an initial coding framework and the constant comparison method. Results: Ten barrier themes and 10 facilitator themes emerged across all ecological levels. Themes most commonly occurred on the patient and organizational levels. Key barriers themes included Logistical Challenges, Obtaining and Maintaining Venous Access, Alloantibodies/Alloimmunization and Reactions, and Iron Overload and Adherence to Chelation Therapy. Key facilitator themes included Nursing and Non-nursing Staff Support, Positive Child/Family Experiences, Logistical Help and Social Resources, Blood Bank and Access to Blood, and Transfusion-Specific Resources. Discussion: The comprehensive understanding of multilevel barriers and facilitators to transfusion therapy, including the role of nursing, in children with SCA can inform strategies to improve CRCT for patients/families and providers and can also be applied by organizations seeking to implement transfusion services for SCA.

Perspectives of individuals with sickle cell disease on barriers to care

INTRODUCTION

Sickle cell disease (SCD) is an inherited hemoglobinopathy that predominantly affects African Americans in the United States. The disease is associated with complications leading to high healthcare utilization rates, including emergency department (ED) visits and hospitalizations. Optimal SCD care requires a multidisciplinary approach involving SCD specialists to ensure preventive care, minimize complications and prevent unnecessary ED visits and hospitalizations. However, most individuals with SCD receive sub-optimal care or are unaffiliated with care (have not seen an SCD specialist). We aimed to identify barriers to care from the perspective of individuals with SCD in a multi-state sample.

METHODS

We performed a multiple methods study consisting of surveys and interviews in three comprehensive SCD centers from March to June 2018. Interviews were transcribed and coded, exploring themes around barriers to care. Survey questions on the specific themes identified in the interviews were analyzed using summary statistics.

RESULTS

We administered surveys to 208 individuals and conducted 44 in-depth interviews. Barriers to care were identified and classified according to ecological level (i.e., individual, family/interpersonal, provider, and socio-environmental/organizational level). Individual-level barriers included lack of knowledge in self-management and disease severity. Family/interpersonal level barriers were inadequate caregiver support and competing life demands. Provider level barriers were limited provider knowledge, provider inexperience, poor provider-patient relationship, being treated differently, and the provider's lack of appreciation of the patient's SCD knowledge. Socio-environmental/organizational level barriers included limited transportation, lack of insurance, administrative barriers, poor care coordination, and reduced access to care due to limited clinic availability, services provided or clinic refusal to provide SCD care.

CONCLUSION

Participants reported several multilevel barriers to SCD care. Strategies tailored towards reducing these barriers are warranted. Our findings may also inform interventions aiming to locate and link unaffiliated individuals to care.

Patient-reported neurocognitive symptoms influence instrumental activities of daily living in sickle cell disease

Individuals with sickle cell disease (SCD) experience neurocognitive decline, low medication adherence, increased unemployment, and difficulty with instrumental activities of daily living (IADL). The relationship between self-perceived cognitive difficulties and IADLs, including employment, school enrollment, independence, engagement in leisure activities, and medication adherence is unknown. We hypothesized that self-reported difficulties across neurocognitive areas would predict lower IADL skills. Adolescent and adult participants of the multi-site Sickle Cell Disease Implementation Consortium (SCDIC) (n = 2436) completed patient-reported outcome (PRO) measures of attention, executive functioning, processing speed, learning, and comprehension. Cognitive symptoms were analyzed as predictors in multivariable modeling. Outcome variables included 1) an IADL composite that consisted of employment, participation in school, reliance on others, and leisure pursuits, and 2) hydroxyurea adherence. Participants reported cognitive difficulty across areas of attention (55%), executive functioning (51%), processing speed (57%), and reading comprehension (65%). Executive dysfunction (p < 0.001) and sometimes or often experiencing learning difficulties (p < 0.001 and p = 0.04) and poor comprehension (p = 0.000 and p = 0.001), controlled for age (p < 0.001), pain (p < 0.001), and hydroxyurea use (p = 0.001), were associated with poor IADL skills. Executive functioning difficulties (p = 0.021), controlled for age (p = 0.013 for ages 25-34), genotype (p = 0.001), and hemoglobin (p = 0.004), predicted hydroxyurea non-adherence. Analysis of PRO measures indicated that cognitive dysfunction is prevalent in adolescents and adults with SCD. Cognitive dysfunction translated into clinically meaningful outcomes. PRO of cognitive symptoms can be used as an important adjunct clinical tool to monitor symptoms that impact functional skills, including engagement in societal activities and medication adherence.

Identified barriers and facilitators to stroke risk screening in children with sickle cell anemia: results from the DISPLACE consortium

Background

Children with sickle cell anemia are at risk for stroke. Ischemic stroke risk can be identified among children ages 2–16 years with sickle cell anemia using transcranial Doppler ultrasound. Despite strong recommendations for transcranial Doppler screening in guidelines released by the National Heart, Lung, and Blood Institute, implementation of transcranial Doppler screening in sickle cell anemia remains suboptimal. The purpose of this study was to identify barriers and facilitators to transcranial Doppler screening in a large national consortium to inform subsequent implementation interventions.

Methods

A qualitative descriptive approach was used to conduct 52 semi-structured interviews with a sample of patients with sickle cell anemia, their parents or primary caregivers, and healthcare providers dispersed across the United States. Interviews took place from September 2018 through March 2019. Directed content analysis was conducted with an adapted version of the Multilevel Ecological Model of Health as an initial coding framework, completed July 2019. Frequency analysis was conducted to determine predominant barrier and facilitator themes.

Results

Fourteen barrier themes and 12 facilitator themes emerged representing all levels of the ecological framework. Two barrier themes (Logistical Difficulties and Competing Life Demands and Gaps in Scheduling and Coordination), and 5 facilitator themes (Coordination, Scheduling and Reminders; Education and Information; Provider and Staff Investment and Assistance; Positive Patient Experience; and Convenient Location) were predominant.

Conclusions

Barriers and facilitators to transcranial Doppler screening in children with sickle cell anemia are complex and occur across multiple ecological levels. One barrier theme and 3 facilitator themes were found to be optimal to address in subsequent implementation interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00192-z.

Electronic Health Record-Embedded Individualized Pain Plans for Emergency Department Treatment of Vaso-occlusive Episodes in Adults With Sickle Cell Disease: Protocol for a Preimplementation and Postimplementation Study

Background

Individuals living with sickle cell disease often require aggressive treatment of pain associated with vaso-occlusive episodes in the emergency department. Frequently, pain relief is poor. The 2014 National Heart, Lung, and Blood Institute evidence-based guidelines recommended an individualized treatment and monitoring protocol to improve pain management of vaso-occlusive episodes.

Objective

This study will implement an electronic health record–embedded individualized pain plan with provider and patient access in the emergency departments of 8 US academic centers to improve pain treatment for adult patients with sickle cell disease. This study will assess the overall effects of electronic health record–embedded individualized pain plans on improving patient and provider outcomes associated with pain treatment in the emergency department setting and explore barriers and facilitators to the implementation process.

Methods

A preimplementation and postimplementation study is being conducted by all 8 sites that are members of the National Heart, Lung, and Blood Institute–funded Sickle Cell Disease Implementation Consortium. Adults with sickle cell disease aged 18 to 45 years who had a visit to a participating emergency department for vaso-occlusive episodes within 90 days prior to enrollment will be eligible for inclusion. Patients will be enrolled in the clinic or remotely. The target analytical sample size of this study is 160 patient participants (20 per site) who have had an emergency department visit for vaso-occlusive episode treatment at participating emergency departments during the study period. Each site is expected to enroll approximately 40 participants to reach the analytical sample size. The electronic health record–embedded individualized pain plans will be written by the patient’s sickle cell disease provider, and sites will work with the local informatics team to identify the best method to build the electronic health record–embedded individualized pain plan with patient and provider access. Each site will adopt required patient and provider implementation strategies and can choose to adopt optional strategies to improve the uptake and sustainability of the intervention. The study is informed by the Technology Acceptance Model 2 and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Provider and patient baseline survey, follow-up survey within 96 hours of an emergency department vaso-occlusive episode visit, and selected qualitative interviews within 2 weeks of an emergency department visit will be performed to assess the primary outcome, patient-perceived quality of emergency department pain treatment, and additional implementation and intervention outcomes. Electronic health record data will be used to analyze individualized pain plan adherence and additional secondary outcomes, such as hospital admission and readmission rates.

Results

The study is currently enrolling study participants. The active implementation period is 18 months.

Conclusions

This study proposes a structured, framework-informed approach to implement electronic health record–embedded individualized pain plans with both patient and provider access in routine emergency department practice. The results of the study will inform the implementation of electronic health record–embedded individualized pain plans at a larger scale outside of Sickle Cell Disease Implementation Consortium centers.

Trial Registration

ClinicalTrials.gov NCT04584528; https://clinicaltrials.gov/ct2/show/NCT04584528.

International Registered Report Identifier (IRRID)

DERR1-10.2196/24818

Rural Barriers to Surgical Care for Children With Sleep-Disordered Breathing

OBJECTIVE

To assess the impact of rural-urban residence on children with obstructive sleep-disordered breathing (SDB) who were candidates for tonsillectomy with or without adenoidectomy (TA).

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary children's hospital.

METHODS

A cohort of otherwise healthy children aged 2 to 18 years with a diagnosis of obstructive SDB between April 2016 and December 2018 who were recommended TA were included. Rural-urban designation was defined by ZIP code approximation of rural-urban commuting area codes. The main outcome was association of rurality with time to TA and loss to follow-up using Cox and logistic regression analyses.

RESULTS

In total, 213 patients were included (mean age 6 ± 2.9 years, 117 [55%] male, 69 [32%] rural dwelling). Rural-dwelling children were more often insured by Medicaid than private insurance (P < .001) and had a median driving distance of 74.8 vs 16.8 miles (P < .001) compared to urban-dwelling patients. The majority (94.9%) eventually underwent recommended TA once evaluated by an otolaryngologist. Multivariable logistic regression analysis did not reveal any significant predictors for loss to follow-up in receiving TA. Cox regression analysis that adjusted for age, sex, insurance, and race showed that rural-dwelling patients had a 30% reduction in receipt of TA over time as compared to urban-dwelling patients (hazard ratio, 0.7; 95% CI, 0.50-0.99).

CONCLUSION

Rural-dwelling patients experienced longer wait times and driving distance to TA. This study suggests that rurality should be considered a potential barrier to surgical intervention and highlights the need to further investigate geographic access as an important determinant of care in pediatric SDB.

Racial Disparities in Pediatric Endoscopic Sinus Surgery

OBJECTIVE

To determine the impact of race and ethnicity on 30-day complications following pediatric endoscopic sinus surgery (ESS).

STUDY DESIGN

Cross-sectional cohort study.

SUBJECTS AND METHODS

Patients ≤ 18 years of age undergoing ESS from 2015 to 2017 were identified in the Pediatric National Surgical Improvement Program-Pediatric database. Patient demographics, comorbidities, surgical indication, and postoperative complications were extracted. Patient race/ethnicity included non-Hispanic black, non-Hispanic white, Hispanic, and other. Multivariable logistic regression was performed to determine if race/ethnicity was a predictor of postoperative complications after ESS.

RESULTS

A total of 4,337 patients were included in the study. The median age was 10.9 (interquartile range: 14.5-6.7) years. The cohort was comprised of 68.3% non-Hispanic white, 13.9% non-Hispanic black, 9.7% Hispanic, and 2.1% other. The 30-day complication rate was 3.2%, and the mortality rate was 0.3%. The rate of reoperation was 3.8%, and readmission was 4.1%. Black and Hispanic patients had higher rates of urgent operations (P = .003 and P < .001, respectively), and black patients had a higher incidence of emergent operations (P < .001) compared to their white peers. For elective ESS cases, multivariable analysis adjusting for sex, age, comorbidities, and surgical indication indicated that children of Hispanic ethnicity had increased postoperative complications (odds ratio: 1.57, 95% confidence interval: 1.04-2.37).

CONCLUSION

This analysis demonstrated that black and Hispanic children disproportionately undergo more urgent and emergent ESS. Hispanic ethnicity was associated with increased 30-day complications following elective pediatric ESS. Further studies are needed to elucidate potential causes of these disparities and identify areas for improvement.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1369-E1374, 2021.

Publication of data collection forms from NHLBI funded sickle cell disease implementation consortium (SCDIC) registry

BACKGROUND

Sickle cell disease (SCD) is an autosomal recessive blood disorder affecting approximately 100,000 Americans and 3.1 million people globally. The scarcity of relevant knowledge and experience with rare diseases creates a unique need for cooperation and infrastructure to overcome challenges in translating basic research advances into clinical advances. Despite registry initiatives in SCD, the unavailability of descriptions of the selection process and copies of final data collection tools, coupled with incomplete representation of the SCD population hampers further research progress. This manuscript describes the SCDIC (Sickle Cell Disease Implementation Consortium) Registry development and makes the SCDIC Registry baseline and first follow-up data collection forms available for other SCD research efforts.

RESULTS

Study data on 2400 enrolled patients across eight sites was stored and managed using Research Electronic Data Capture (REDCap). Standardized data collection instruments, recruitment and enrollment were refined through consensus of consortium sites. Data points included measures taken from a variety of validated sources (PHENX, PROMIS and others). Surveys were directly administered by research staff and longitudinal follow-up was coordinated through the DCC. Appended registry forms track medical records, event-related patient invalidation, pregnancy, lab reporting, cardiopulmonary and renal functions.

CONCLUSIONS

The SCDIC Registry strives to provide an accurate, updated characterization of the adult and adolescent SCD population as well as standardized, validated data collecting tools to guide evidence-based research and practice.

Designs and methods for implementation research: Advancing the mission of the CTSA program

INTRODUCTION

The US National Institutes of Health (NIH) established the Clinical and Translational Science Award (CTSA) program in response to the challenges of translating biomedical and behavioral interventions from discovery to real-world use. To address the challenge of translating evidence-based interventions (EBIs) into practice, the field of implementation science has emerged as a distinct discipline. With the distinction between EBI effectiveness research and implementation research comes differences in study design and methodology, shifting focus from clinical outcomes to the systems that support adoption and delivery of EBIs with fidelity.

METHODS

Implementation research designs share many of the foundational elements and assumptions of efficacy/effectiveness research. Designs and methods that are currently applied in implementation research include experimental, quasi-experimental, observational, hybrid effectiveness-implementation, simulation modeling, and configurational comparative methods.

RESULTS

Examples of specific research designs and methods illustrate their use in implementation science. We propose that the CTSA program takes advantage of the momentum of the field's capacity building in three ways: 1) integrate state-of-the-science implementation methods and designs into its existing body of research; 2) position itself at the forefront of advancing the science of implementation science by collaborating with other NIH institutes that share the goal of advancing implementation science; and 3) provide adequate training in implementation science.

CONCLUSIONS

As implementation methodologies mature, both implementation science and the CTSA program would greatly benefit from cross-fertilizing expertise and shared infrastructures that aim to advance healthcare in the USA and around the world.

Putting Evidence Academies into action: Prostate cancer, nutrition, and tobacco control science

A well-documented challenge in moving public health research into practice is the extended time it takes to implement findings in clinical practice and communities. The Evidence Academy model (Rohweder et al., 2016), developed and first used in North Carolina, is a pragmatic, action-oriented model that aims to shorten this timeline by communicating cutting-edge findings directly to those who can use them and convening individuals working in a single topic area to network and plan activities for the future. The University of Pennsylvania Collaborating Center of the Cancer Prevention and Control Research Network (CPCRN) held three conferences based on the Evidence Academy model: one about prostate cancer in 2015, a second on food access and obesity prevention in 2017, and a third about tobacco control science in 2018. A diverse planning committee of stakeholders helped shape the content, focus,and format of each conference. Local and national experts presented findings to regional audiences of researchers, practitioners, government leaders, and community members. Each Evidence Academy included collaborators and speakers from other Prevention Research Centers (PRCs) and CPCRN network sites. Evaluations and outcomes indicated that the events were successful in achieving their goals and fostered ongoing relationships among attendees. This paper illustrates how the Evidence Academy model was used in a different region and describes lessons learned and follow-up activities that were initiated via the Evidence Academy and with input from participants. Lessons learned may be helpful in developing and evaluating future adaptations of the Evidence Academy model and/or the effectiveness of its components.

Formative Research on Knowledge and Preferences for Stool-based Tests compared to Colonoscopy: What Patients and Providers Think

The rates of colorectal cancer (CRC) screening in the U.S. remain below national targets, so many people at risk are not being screened. The objective of this qualitative research project was to assess patient and provider knowledge and preferences about CRC screening modalities and specifically the use of the fecal immunochemical test (FIT) as a first line screening choice. Nine focus groups were conducted with a medically underserved patient population and qualitative interviews were administered to their medical providers. Thematic analysis was used to synthesize key findings. Both providers and patients thought that the FIT would be a good option for CRC screening both as an individual choice and for an overall program approach. The test is less expensive and therefore more readily available for patients compared to colonoscopy. Overall, there was consensus that the FIT offers a reasonably priced, simple approach to CRC screening which has broad appeal to both providers and patients. Concerns identified by patients and providers included the possibility of false positives with the FIT which could be caused by test contamination or failing to perform the test properly. Patients also described feelings of disgust toward performing the FIT and difficulties in following the instructions. Study findings indicate provider and patient support for using the FIT for CRC screening at both the individual and system-wide levels of implementation. While barriers to the use of the FIT were listed, benefits of using the FIT were perceived as positive motivators to engage previously unscreened and uninsured or under-insured individuals in CRC screening.

Implementing a small media intervention to increase colorectal cancer screening in primary care clinics

Colorectal cancer (CRC) is one of the most common cancers in the USA. In 2017, an estimated 135,420 people were diagnosed with CRC and 50,260 people died from CRC. Several screening modalities are recommended by the United States Preventive Services Task Force (USPSTF), including annual stool tests that are usually completed at home and under-used compared with colonoscopy despite stated patient preferences for an alternative to colonoscopy. The Community Preventive Services Task Force recommends use of small media interventions (SMIs) to increase CRC screening and calls for a greater understanding of its independent impact on screening participation. This study tested whether a SMI increased the likelihood of participant return of a USPSTF recommended Fecal Immunochemical Test (FIT). In total, 804 individuals participated in a two-group, prospective randomized controlled trial. Descriptive statistics with chi-square tests compared differences in participant characteristics and return rates. Multivariable log-binomial modeling estimated combined effects of patient characteristics with FIT return rates. No differences in return rates were observed overall or by participant characteristics other than the year of enrollment. A multivariable model controlling for all covariates, found gender, insurance type, and regular place for healthcare to be significantly associated with return rates. Receipt of the SMI did not independently increase overall return rates but it may have improved the ease of completing the FIT by some participants, particularly women, those with insurance, and those with a regular place for healthcare.

Project ACCRUE: Exploring Options to Increase Awareness of AIDS Malignancy Consortium Clinical Trials in North Carolina

BACKGROUND Longer lifespans conferred by antiretroviral therapy result in more time exposed to cancer risk for people living with HIV/AIDS (PLWHA). Given limited diversity in AIDS Malignancy Consortium (AMC) clinical trials, there is need for new approaches to educate PLWHA in order to improve awareness and participation in AMC trials.METHODS With input from a community advisory board, Project ACCRUE (AMC Clinical Trials at Carolina Ramp Up Enrollment) conducted a key informant interview with service providers; online organizational surveys of AMC trial awareness and resource needs; and "lunch and learn" educational sessions, including pre- and post-intervention knowledge assessments.RESULTS Providers indicated that transportation, mistrust of the medical community, and affordability were barriers to trial participation, while printed educational materials could facilitate trial recruitment. Providers indicated that their clients had concerns about participating in trials, but also recognized several benefits of participation including access to medical personnel and treatment, receipt of monetary incentives, and a feeling of satisfaction from helping others. In lunch and learn sessions, use of an audience response system to collect questionnaire data improved scores on knowledge-based items [S(55) = 460; P < .0001] compared to a pencil and paper test [S(20) = 12.5; P = .6541].LIMITATIONS Generalizability may have been compromised by the small sample size. Long-term recall was not measured, and the short retest interval may have impacted post-intervention assessments.CONCLUSIONS Service providers recognize the benefits of working with researchers to educate patients about HIV-related cancers and participation in clinical trials. Lunch and learn sessions improved knowledge and perceptions about clinical trials for PLWHA.

Weight loss attempts in a racially diverse sample of primary care patients

Despite efforts to promote healthy weight, obesity is at epidemic levels among adults in the US. We examined the prevalence of weight loss attempts among a racially diverse sample of overweight and obese primary care patients (n = 274) based on sociodemographic, clinical and psychological factors, and shared decision-making (SDM) about weight loss/management. This observational study was conducted from December 2015 through January 2017. Data were obtained by self-report via survey. Overall, 64% of participants were attempting to lose weight at the time of survey. No significant differences in current weight loss attempts were found based on racial background, sociodemographic characteristics, or clinical factors. Participants who believed they were obese/overweight (OR = 6.70, 95% CI = 2.86, 15.72, p < 0.0001) or who were ready to lose/manage their weight (OR = 4.50, 95% CI = 1.82, 11.09, p = 0.001) had an increased likelihood of attempting to lose weight. The likelihood of attempting to lose weight increased with greater SDM with providers (OR = 1.54, 95% CI = 1.06, 2.22, p = 0.02). Patient perceptions about their weight, their readiness for weight loss/management, and SDM were associated significantly with weight loss attempts.

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Obesity is a significant clinical and public health issue.

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64% of obese/overweight primary care patients was trying to lose weight.

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Weight loss attempts did not differ based on race, SES, or clinical factors.

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Weight loss efforts were associated with perceived obesity status and readiness.

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Greater shared decision-making was associated with making weight loss efforts.

Use of Adult Patient Focus Groups to Develop the Initial Item Bank for a Cochlear Implant Quality-of-Life Instrument

Importance

No instrument exists to assess quality of life (QOL) in adult cochlear implant (CI) users that has been developed and validated using accepted scientific standards.

Objective

To develop a CI-specific QOL instrument for adults in accordance with the Patient Reported Outcomes Measurement Information System (PROMIS) guidelines.

Design, Setting, and Participants

As required in the PROMIS guidelines, patient focus groups participated in creation of the initial item bank. Twenty-three adult CI users were divided into 1 of 3 focus groups stratified by word recognition ability. Three moderator-led focus groups were conducted based on grounded theory on December 3, 2016. Two reviewers independently analyzed focus group recordings and transcripts, with a third reviewer available to resolve discrepancies. All data were reviewed and reported according to the Consolidated Criteria for Reporting Qualitative Research. The setting was a tertiary referral center.

Main Outcomes and Measures

Coded focus group data.

Results

The 23 focus group participants (10 [43%] female; mean [range] age, 68.1 [46.2-84.2] years) represented a wide range of income levels, education levels, listening modalities, CI device manufacturers, duration of CI use, and age at implantation. Data saturation was determined to be reached before the conclusion of each of the focus groups. After analysis of the transcripts, the central themes identified were communication, emotion, environmental sounds, independence and work function, listening effort, social isolation and ability to socialize, and sound clarity. Cognitive interviews were carried out on 20 adult CI patients who did not participate in the focus groups to ensure item clarity. Based on these results, the initial QOL item bank and prototype were developed.

Conclusions and Relevance

Patient focus groups drawn from the target population are the preferred method of identifying content areas and domains for developing the item bank for a CI-specific QOL instrument. Compared with previously used methods, the use of patient-centered item development for a CI-specific QOL instrument will more accurately reflect patient experience and increase our understanding of how CI use affects QOL.

A systematic review of lifestyle counseling for diverse patients in primary care

Prior research and systematic reviews have examined strategies related to weight management, less is known about lifestyle and behavioral counseling interventions optimally suited for implementation in primary care practices generally, and among racial and ethnic patient populations. Primary care practitioners may find it difficult to access and use available research findings on effective behavioral and lifestyle counseling strategies and to assess their effects on health behaviors among their patients. This systematic review compiled existing evidence from randomized trials to inform primary care providers about which lifestyle and behavioral change interventions are shown to be effective for changing patients' diet, physical activity and weight outcomes. Searches identified 444 abstracts from all sources (01/01/2004-05/15/2014). Duplicate abstracts were removed, selection criteria applied and dual abstractions conducted for 106 full text articles. As of June 12, 2015, 29 articles were retained for inclusion in the body of evidence. Randomized trials tested heterogeneous multi-component behavioral interventions for an equally wide array of outcomes in three population groups: diverse patient populations (23 studies), African American patients only (4 studies), and Hispanic/Mexican American/Latino patients only (2 studies). Significant and consistent findings among diverse populations showed that weight and physical activity related outcomes were more amenable to change via lifestyle and behavioral counseling interventions than those associated with diet modification. Evidence to support specific interventions for racial and ethnic minorities was promising, but insufficient based on the small number of studies.

Provider Advice About Weight Loss in a Primary Care Sample of Obese and Overweight Patients

Objective: Primary care providers play an important role in obesity prevention and reduction by advising patients about weight loss strategies. This study examined receipt of provider advice to lose weight among primary care patients who were overweight and obese. Methods: Observational study conducted among primary care patients (n = 282) who completed a survey that measured receipt of provider advice about weight loss/management, chronic health conditions, perceived weight status, and perceptions about shared decision making about weight loss/management. Results: Fifty-nine percent of participants had been advised by their physician to lose weight. Participants who were obese were more likely than those who were overweight to report provider advice (odds ratio [OR] = 1.31, 95% CI = 1.25-4.34, P = .001). Similarly, participants who believed they were obese/overweight had a greater likelihood of reporting provider advice compared with those who did not believe they were obese/overweight (OR = 1.40, 95% CI = 2.43-6.37, P = .0001). Shared decision making about weight loss/management was associated with an increased likelihood of reporting provider advice (OR = 3.30, 95% CI = 2.62-4.12, P = .0001). Conclusions: Patient beliefs about their weight status and perceptions about shared decision-making are important to receiving provider advice about weight loss/management among primary care patients. Practice Implications: Continued efforts are needed to enhance provider advice about weight loss/management among obese/overweight patients.

A Comprehensive View of Frequent Emergency Department Users Based on Data from a Regional HIE

OBJECTIVES

A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a unique health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize all frequent ED users in our region, regardless of hospital visited or payer class. The objective of our study was to use data from an HIE to characterize patients in a region who are frequent ED users (FEDUs).

METHODS

We constructed a database from a cohort of adult patients (18 years old or older) with information in a regional HIE for a 1-year period beginning in April 2012. Patients were defined as FEDUs (those who made four or more visits during the study period) and non-FEDUs (those who made fewer than four ED visits during the study period). Predictor variables included age, race, sex, payer class, county of residence, and International Classification of Diseases, Ninth Revision codes. Bivariate (χ(2)) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being a FEDU.

RESULTS

The database contained 127,672 patients, 12,293 (9.6%) of whom were FEDUs. Logistic regression showed the following patient characteristics to be significantly associated with the outcome of being a FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and International Classification of Diseases, Ninth Revision codes 630 to 679 (complications of pregnancy, childbirth, and puerperium), 780 to 799 (ill-defined conditions), 280 to 289 (diseases of the blood), 290-319 (mental disorders), 680 to 709 (diseases of the skin and subcutaneous tissue), 710 to 739 (musculoskeletal and connective tissue disease), 460 to 519 (respiratory disease), and 520 to 579 (digestive disease). No significant differences were noted between men and women.

CONCLUSIONS

Data from an HIE can be used to describe all of the patients within a region who are FEDUs, regardless of the hospital system they visited. This information can be used to focus care coordination efforts and link appropriate patients to a medical home. Future studies can be designed to learn the reasons why patients become FEDUs, and interventions can be developed to address deficiencies in health care that result in frequent ED visits.

Health Information Exchange in the ED: What Do ED Clinicians Think?

OBJECTIVES

Our regional health information exchange (HIE), known as Carolina eHealth Alliance (CeHA)-HIE, serves all major hospital systems in our region and is accessible to emergency department (ED) clinicians in those systems. We wanted to understand reasons for low CeHA-HIE utilization and explore options for improving it.

METHODS

We implemented a 24-item user survey among ED clinician users of CeHA-HIE to investigate their perceptions of system usability and functionality, the quality of the information available through CeHA-HIE, the value of clinician time spent using CeHA-HIE, the ease of use of CeHA-HIE, and approaches for improving CeHA-HIE.

RESULTS

Of the 231 ED clinicians surveyed, 51 responded, and among those, 48 reported having used CeHA-HIE and completed the survey.

CONCLUSIONS

Results show most ED clinicians believed that CeHA-HIE was easy to use and added value to their work, but they also desired better integration of information available from CeHA-HIE into their system's electronic medical record.

Predictors of Participation in Mammography Screening among Non-Hispanic Black, Non-Hispanic White, and Hispanic Women

INTRODUCTION

Many factors influence women's decisions to participate in guideline-recommended screening mammography. We evaluated the influence of women's socioeconomic characteristics, health-care access, and cultural and psychological health-care preferences on timely mammography screening participation.

MATERIALS AND METHODS

A random digit dial survey of United States non-Hispanic Black, non-Hispanic White, and Hispanic women aged 40-75, from January to August 2009, determined self-reported time of most recent mammogram. Screening rates were assessed based on receipt of a screening mammogram within the prior 12 months, the interval recommended at the time by the American Cancer Society.

RESULTS

Thirty-nine percent of women reported not having a mammogram within the last 12 months. The odds of not having had a screening mammography were higher for non-Hispanic White women than for non-Hispanic Black (OR = 2.16, 95% CI = 0.26, 0.82, p = 0.009) or Hispanic (OR = 4.17, 95% CI = 0.12, 0.48, p = 0.01) women. Lack of health insurance (OR = 3.22, 95% CI = 1.54, 6.73, p = 0.002) and lack of usual source of medical care (OR = 3.37, 95% CI = 1.43, 7.94, p = 0.01) were associated with not being screened as were lower self-efficacy to obtain screening (OR = 2.43, 95% CI = 1.26, 4.73, p = 0.01) and greater levels of religiosity and spirituality (OR = 1.42, 95% CI = 1.00, 2.00, p = 0.05). Neither perceived risk nor present temporal orientation was significant.

DISCUSSION

Odds of not having a mammogram increased if women were uninsured, without medical care, non-Hispanic White, older in age, not confident in their ability to obtain screening, or held passive or external religious/spiritual values. Results are encouraging given racial disparities in health-care participation and suggest that efforts to increase screening among minority women may be working.

When Should ED Physicians Use an HIE? Predicting Presence of Patient Data in an HIE

OBJECTIVES

Health information exchanges (HIEs) make possible the construction of databases to characterize patients as multisystem users (MSUs), those visiting emergency departments (EDs) of more than one hospital system within a region during a 1-year period. HIE data can inform an algorithm highlighting patients for whom information is more likely to be present in the HIE, leading to a higher yield HIE experience for ED clinicians and incentivizing their adoption of HIE. Our objective was to describe patient characteristics that determine which ED patients are likely to be MSUs and therefore have information in an HIE, thereby improving the efficacy of HIE use and increasing ED clinician perception of HIE benefit.

METHODS

Data were extracted from a regional HIE involving four hospital systems (11 EDs) in the Charleston, South Carolina area. We used univariate and multivariable regression analyses to develop a predictive model for MSU status.

RESULTS

Factors associated with MSUs included younger age groups, dual-payer insurance status, living in counties that are more rural, and one of at least six specific diagnoses: mental disorders; symptoms, signs, and ill-defined conditions; complications of pregnancy, childbirth, and puerperium; diseases of the musculoskeletal system; injury and poisoning; and diseases of the blood and blood-forming organs. For patients with multiple ED visits during 1 year, 43.8% of MSUs had ≥4 visits, compared with 18.0% of non-MSUs (P < 0.0001).

CONCLUSIONS

This predictive model accurately identified patients cared for at multiple hospital systems and can be used to increase the likelihood that time spent logging on to the HIE will be a value-added effort for emergency physicians.

Abstract A08: Concordance in patient and provider priorities and preferences to address behavioral risk factors for cancer health disparities interventions

Purpose: Actively engaging key stakeholders in the development of interventions is necessary to address cancer health disparities. While lay community residents are often included in these efforts, the preferences of patients and providers in primary care settings are often not elicited. We used focus groups and key informant interviews to identify priorities and preferences for lifestyle modification and health behavior change interventions among primary care patients and providers.

Methods: Patients (n=35) and providers (n=18) from 3 rural and 5 urban primary care practices that were part of a practice-based research network were recruited to participate in a 60-90 minute focus group or 20-30 minute key informant interview, respectively. Focus groups and key informant interviews were facilitated using a semi-structured discussion guide that asked patients and providers to identify barriers and facilitators to lifestyle modification and health behavior change among patients and implementation of interventions in the practice, the interventions that are preferred by patients, and interventions that can be implemented in the practice. Data were analyzed using NVivo 10 to identify emergent themes.

Results: There was concordance between patients and providers in terms of wanting interventions that address diet and physical activity to manage chronic conditions. Patients and providers also identified similar barriers to implementing interventions to address these behaviors: lack of patient motivation and knowledge and limited capacity and knowledge among providers to deliver intensive interventions. Both patients and providers indicated that tailored interventions are most likely to be effective, but resource constraints in the practice were potential barriers to implementation of these types of programs. Despite concordance in preferences for diet and physical activity interventions between patients and providers, there was disagreement about how the effects of these interventions should be monitored. Patients wanted to be held accountable to providers, but providers wanted patients to be accountable to themselves.

Conclusions: Our findings emphasize the importance of actively engaging patient and provider stakeholders in efforts to develop interventions that address behavioral risk factors for cancer health disparities. While there is concordance between patients and providers in terms of the behavioral focus of interventions and barriers and facilitators to implementation, there may be discordance in terms of how the effects of interventions are monitored. Efforts to disseminate and implement evidence-based interventions into primary care should consider the preferences of both patients and providers.

Citation Format: LaShanta J. Rice, Melanie Jefferson, Cathy L. Melvin, Chanita Hughes Halbert. Concordance in patient and provider priorities and preferences to address behavioral risk factors for cancer health disparities interventions. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A08.

Race and Prevalence of Large Bowel Polyps Among the Low-Income and Uninsured in South Carolina

BACKGROUND

Compared to whites, blacks have higher colorectal cancer incidence and mortality rates and are at greater risk for early-onset disease. The reasons for this racial disparity are poorly understood, but one contributing factor could be differences in access to high-quality screening and medical care.

AIMS

The present study was carried out to assess whether a racial difference in prevalence of large bowel polyps persists within a poor and uninsured population (n = 233, 124 blacks, 91 whites, 18 other) undergoing screening colonoscopy.

METHODS

Eligible patients were uninsured, asymptomatic, had no personal history of colorectal neoplasia, and were between the ages 45-64 years (blacks) or 50-64 years (whites, other). We examined the prevalence of any adenoma (conventional, serrated) and then difference in adenoma/polyp type by race and age categories.

RESULTS

Prevalence for ≥1 adenoma was 37 % (95 % CI 31-43 %) for all races combined and 36 % in blacks <50 years, 38 % in blacks ≥50 years, and 35 % in whites. When stratified by race, blacks had a higher prevalence of large conventional proximal neoplasia (8 %) compared to whites (2 %) (p value = 0.06) but a lower prevalence of any serrated-like (blacks 18 %, whites 32 %; p value = 0.02) and sessile serrated adenomas/polyps (blacks 2 %, whites 8 % Chi-square p value; p = 0.05).

CONCLUSIONS

Within this uninsured population, the overall prevalence of adenomas was high and nearly equal by race, but the racial differences observed between serrated and conventional polyp types emphasize the importance of taking polyp type into account in future research on this topic.

Dental opioid prescribing practices and risk mitigation strategy implementation: Identification of potential targets for provider-level intervention

BACKGROUND

Given the regular use of immediate-release opioids for dental pain management, as well as documented opioid misuse among dental patients, the dental visit may provide a viable point of intervention to screen, identify, and educate patients regarding the risks associated with prescription opioid misuse and diversion. The aims of this statewide survey of dental practitioners were to assess (a) awareness of the scope of prescription opioid misuse and diversion; (b) current opioid prescribing practices; (c) use of and opinions regarding risk mitigation strategies; and (d) use and perceived utility of drug monitoring programs.

METHODS

This cross-sectional study surveyed dentists (N = 87) participating in statewide professional and alumni organizations. Dentists were invited via e-mail and listserv announcement to participate in a one-time, online, 59-item, self-administered survey.

RESULTS

A majority of respondents reported prescribing opioids (n = 66; 75.8%). A minority of respondents (n = 38; 44%) reported regularly screening for current prescription drug abuse. Dentists reported low rates of requesting prior medical records (n = 5; 5.8%). Only 38% (n = 33) of respondents had ever accessed a prescription drug monitoring program (PDMP), and only 4 (4.7%) consistently used a PDMP. Dentists reporting prior training in drug diversion were significantly more likely to have accessed their PDMP, P < .01. Interest in continuing education regarding assessment of prescription drug abuse/diversion and use of drug monitoring programs was high.

CONCLUSIONS

Although most dentists received training related to prescribing opioids, findings identified a gap in existing dental training in the assessment/identification of prescription opioid misuse and diversion. Findings also identified gaps in the implementation of recommended risk mitigation strategies, including screening for prescription drug abuse, consistent provision of patient education, and use of a PDMP prior to prescribing opioids.

Promoting public health through state cancer control plans: a review of capacity and sustainability

The Centers for Disease Prevention and Control's National Comprehensive Cancer Control (CCC) Program oversee CCC programs designed to develop and implement CCC plans via CCC coalitions, alliances, or consortia of program stakeholders. We reviewed 40 up-to-date plans for states and the District of Columbia in order to assess how capacity building and sustainability, two evidence-based practices necessary for organizational readiness, positive growth, and maintenance are addressed. We employed an electronic key word search, supplemented by full text reviews of each plan to complete a content analysis of the CCC plans. Capacity is explicitly addressed in just over half of the plans (53%), generally from a conceptual point of view, with few specifics as to how capacity will be developed or enhanced. Roles and responsibilities, timelines for action, and measurements for evaluation of capacity building are infrequently mentioned. Almost all (92%) of the 40 up-to-date plans address sustainability on at least a cursory level, through efforts aimed at funding or seeking funding, policy initiatives, and/or partnership development. However, few details as to how these strategies will be implemented are found in the plans. We present the Texas plan as a case study offering detailed insight into how one plan incorporated capacity building and sustainability into its development and implementation. Training, technical assistance, templates, and tools may help CCC coalition members address capacity and sustainability in future planning efforts and assure the inclusion of capacity building and sustainability approaches in CCC plans at the state, tribal, territorial, and jurisdiction levels.

Promotion of tobacco use cessation for lesbian, gay, bisexual, and transgender people: a systematic review

CONTEXT

Lesbian, gay, bisexual, and transgender (LGBT) people are at increased risk for the adverse effects of tobacco use, given their high prevalence of use, especially smoking. Evidence regarding cessation is limited. To determine if efficacious interventions are available and to aid the development of interventions, a systematic review was conducted of grey and peer-reviewed literature describing clinical, community, and policy interventions, as well as knowledge, attitudes, and behaviors regarding tobacco use cessation among LGBT people.

EVIDENCE ACQUISITION

Eight databases for articles from 1987 to April 23, 2014, were searched. In February-November 2013, authors and researchers were contacted to identify grey literature.

EVIDENCE SYNTHESIS

The search identified 57 records, of which 51 were included and 22 were from the grey literature; these were abstracted into evidence tables, and a narrative synthesis was conducted in October 2013-May 2014. Group cessation curricula tailored for LGBT populations were found feasible to implement and show evidence of effectiveness. Community interventions have been implemented by and for LGBT communities, although these interventions showed feasibility, no rigorous outcome evaluations exist. Clinical interventions show little difference between LGBT and heterosexual people. Focus groups suggest that care is needed in selecting the messaging used in media campaigns.

CONCLUSIONS

LGBT-serving organizations should implement existing evidence-based tobacco-dependence treatment and clinical systems to support treatment of tobacco use. A clear commitment from government and funders is needed to investigate whether sexual orientation and gender identity moderate the impacts of policy interventions, media campaigns, and clinical interventions.

The cancer prevention and control research network: An interactive systems approach to advancing cancer control implementation research and practice

BACKGROUND

Although cancer research has advanced at a rapid pace, a gap remains between what is known about how to improve cancer prevention and control (CPC) and what is implemented as best practices within health care systems and communities. The Cancer Prevention and Control Research Network (CPCRN), with more than 10 years of dissemination and implementation research experience, aims to accelerate the uptake and use of evidence-based CPC interventions.

METHODS

The collective work of the CPCRN has facilitated the analysis and categorization of research and implementation efforts according to the Interactive Systems Framework for Dissemination and Implementation (ISF), providing a useful heuristic for bridging the gap between prevention research and practice. The ISF authors have called for examples of its application as input to help refine the model.

RESULTS

We provide examples of how the collaborative activities supported by the CPCRN, using community-engaged processes, accelerated the synthesis and translation of evidence, built both general and innovation-specific capacity, and worked with delivery systems to advance cancer control research and practice.

CONCLUSIONS

The work of the CPCRN has provided real-world examples of the application of the ISF and demonstrated that synthesizing and translating evidence can increase the potential that evidence-based CPC programs will be used and that capacity building for both the support system and the delivery system is crucial for the successful implementation and maintenance of evidence-based cancer control.

IMPACT

Adoption and implementation of CPC can be enhanced by better understanding ISF systems and intervening to improve them.

Impact of a health information exchange on resource use and Medicare-allowable reimbursements at 11 emergency departments in a midsized city

INTRODUCTION

Use clinician perceptions to estimate the impact of a health information exchange (HIE) on emergency department (ED) care at four major hospital systems (HS) within a region. Use survey data provided by ED clinicians to estimate reduction in Medicare-allowable reimbursements (MARs) resulting from use of an HIE.

METHODS

We conducted the study during a one-year period beginning in February 2012. Study sites included eleven EDs operated by four major HS in the region of a mid-sized Southeastern city, including one academic ED, five community hospital EDs, four free-standing EDs and 1 ED/Chest Pain Center (CPC) all of which participated in an HIE. The study design was observational, prospective using a voluntary, anonymous, online survey. Eligible participants included attending emergency physicians, residents, and mid-level providers (PA & NP). Survey items asked clinicians whether information obtained from the HIE changed resource use while caring for patients at the study sites and used branching logic to ascertain specific types of services avoided including laboratory/microbiology, radiology, consultations, and hospital admissions. Additional items asked how use of the HIE affected quality of care and length of stay. The survey was automated using a survey construction tool (REDCap Survey Software © 2010 Vanderbilt University). We calculated avoided MARs by multiplying the numbers and types of services reported to have been avoided. Average cost of an admission from the ED was based on direct cost trends for ED admissions within the region.

RESULTS

During the 12-month study period we had 325,740 patient encounters and 7,525 logons to the HIE (utilization rate of 2.3%) by 231 ED clinicians practicing at the study sites. We collected 621 surveys representing 8.25% of logons of which 532 (85.7% of surveys) reported on patients who had information available in the HIE. Within this group the following services and MARs were reported to have been avoided [type of service: number of services; MARs]: Laboratory/Microbiology:187; $2,073, Radiology: 298; $475,840, Consultations: 61; $6,461, Hospital Admissions: 56; $551,282. Grand total of MARs avoided: $1,035,654; average $1,947 per patient who had information available in the HIE (Range: $1,491 - $2,395 between HS). Changes in management other than avoidance of a service were reported by 32.2% of participants. Participants stated that quality of care was improved for 89% of patients with information in the HIE. Eighty-two percent of participants reported that valuable time was saved with a mean time saved of 105 minutes.

CONCLUSION

Observational data provided by ED clinicians practicing at eleven EDs in a mid-sized Southeastern city showed an average reduction in MARs of $1,947 per patient who had information available in an HIE. The majority of reduced MARs were due to avoided radiology studies and hospital admissions. Over 80% of participants reported that quality of care was improved and valuable time was saved.

Endocrine therapy initiation among Medicaid-insured breast cancer survivors with hormone receptor-positive tumors

PURPOSE

Hormone receptor-positive (HR+) cancers account for most breast cancer diagnoses and deaths. Among survivors with HR + breast cancers, endocrine therapy (ET) reduces 5-year risk of recurrence by up to 40%. Observational studies in Medicare- and privately-insured survivors suggest underutilization of ET. We sought to characterize ET use in a low-income Medicaid-insured population in North Carolina.

METHODS

Medicaid claims data were matched to state cancer registry records for survivors aging 18-64 diagnosed with stage 0-II HR + breast cancer from 2003 to 2007, eligible for ET, and enrolled in Medicaid for at least 12 of 15 months post-diagnosis. We used multivariable logistic regression to model receipt of any ET medication during 15 months post-diagnosis controlling for age, race, tumor characteristics, receipt of other treatments, comorbidity, residence, reason for Medicaid eligibility, involvement in the Breast and Cervical Cancer Control Program (BCCCP), and diagnosis year.

RESULTS

Of 222 women meeting the inclusion criteria, only 50% filled a prescription for ET. Involvement in the BCCCP and earlier year of diagnoses were associated with significantly higher odds of initiating guideline-recommended ET (adjusted odds ratio [AOR] for the BCCCP 3.76, 95% confidence interval [CI] 1.67-8.48; AOR for 2004 relative to 2007 2.80, 95% CI 1.03-7.62; AOR for 2005 relative to 2007 2.11, 95% CI 0.92-4.85).

CONCLUSIONS

Results suggest substantial underutilization of ET in this population. Interventions are needed to improve timely receipt of ET and to better support survivors taking ET.

IMPLICATIONS FOR CANCER SURVIVORS

Low-income survivors should be counseled on the importance of ET and offered support services to promote initiation and long-term adherence.

Communication and dissemination strategies to facilitate the use of health-related evidence

OBJECTIVES

This review examined how to best communicate and disseminate evidence, including uncertain evidence, to inform health care decisions. The review focused on three primary objectives--comparing the effectiveness of: (1) communicating evidence in various contents and formats that increase the likelihood that target audiences will both understand and use the information (KQ 1); (2) a variety of approaches for disseminating evidence from those who develop it to those who are expected to use it (KQ 2); and (3) various ways of communicating uncertainty-associated health-related evidence to different target audiences (KQ 3). A secondary objective was to examine how the effectiveness of communication and dissemination strategies varies across target audiences, including evidence translators, health educators, patients, and clinicians.

DATA SOURCES

We searched MEDLINE®, the Cochrane Library, Cochrane Central Trials Registry, PsycINFO®, and the Web of Science. We used a variety of medical subject headings (MeSH terms) and major headings, and used free-text and title and abstract text-word searches. The search was limited to studies on humans published from 2000 to March 15, 2013, for communication and dissemination, given the prior systematic reviews, and from 1966 to March 15, 2013, for communicating uncertainty.

REVIEW METHODS

We used standard Evidence-based Practice Center methods of dual review of abstracts, full-text articles, and abstractions, and quality ratings and group consensus to resolve disagreements. We used group consensus to grade strength of evidence.

RESULTS

The search identified 4,152 articles (after removing duplicates) for all three KQs. After dual review at the title/abstract stage and full-text review stage, we retained 61 articles that directly (i.e., head to head) compared strategies to communicate and disseminate evidence. Across the KQs, many of the comparisons yielded insufficient evidence to draw firm conclusions. For KQ 1, we found that investigators frequently blend more than one communication strategy in interventions. For KQ 2, we found that, compared with single dissemination strategies, multicomponent dissemination strategies are more effective at enhancing clinician behavior, particularly for guideline adherence. Key findings for KQ 3 indicate that evidence on communicating overall strength of recommendation and precision was insufficient, but certain ways of communicating directness and net benefit may be helpful in reducing uncertainty.

CONCLUSIONS

The lack of comparative research evidence to inform communication and dissemination of evidence, including uncertain evidence, impedes timely clinician, patient, and policymaker awareness, uptake, and use of evidence to improve the quality of care. Expanding investment in communication, dissemination, and implementation research is critical to the identification of strategies to accelerate the translation of comparative effectiveness research into community and clinical practice and the direct benefit of patient care.

Developing a research agenda for cardiovascular disease prevention in high-risk rural communities

The National Institutes of Health convened a workshop to engage researchers and practitioners in dialogue on research issues viewed as either unique or of particular relevance to rural areas, key content areas needed to inform policy and practice in rural settings, and ways rural contexts may influence study design, implementation, assessment of outcomes, and dissemination. Our purpose was to develop a research agenda to address the disproportionate burden of cardiovascular disease (CVD) and related risk factors among populations living in rural areas. Complementary presentations used theoretical and methodological principles to describe research and practice examples from rural settings. Participants created a comprehensive CVD research agenda that identified themes and challenges, and provided 21 recommendations to guide research, practice, and programs in rural areas.

Provider advice about weight loss and physical activity in the postpartum period

OBJECTIVE

To explore the association between healthcare provider advice about weight loss and physical activity in the postpartum period and weight retention and activity levels in women assessed at 3 months postpartum.

METHODS

Using data from a prospective cohort study, we explored the association of advice with postpartum weight retention and activity levels in 688 women at 3 months postpartum. Data from home visits included anthropometric measurements and information collected from sociodemographic, health behavior, and psychosocial questionnaires. Weight retention was calculated as weight at 3 months postpartum minus prepregnancy weight; activity levels and advice were based on maternal self-report. Linear regression and Poisson regression were used to explore associations.

RESULTS

The majority of the population was white (76%), had a greater than high school education (83%), and had an income >185% of the federal poverty level (81%). Women ranged in age from 17 to 48 years. Most women reported receiving no weight loss (89.1%) and no physical activity advice (77.4%) from a healthcare provider during the 3-month postpartum period. After adjustment, we found no association between provider advice and weight retention. When compared with those who reported no advice, following provider advice showed an association with recreational activity above the median (RR 1.50, 95% confidence interval [CI] 1.24, 1.80).

CONCLUSIONS

Provider advice may influence physical activity but may not be enough to help postpartum women lose pregnancy weight. Instead, women may benefit more from individualized counseling and follow-up beyond the usual 6-week postpartum visit.

Up in smoke: vanishing evidence of tobacco disparities in the Institute of Medicine's report on sexual and gender minority health

The Institute of Medicine (IOM) released a groundbreaking report on lesbian, gay, bisexual, and transgender (LGBT) health in 2011, finding limited evidence of tobacco disparities. We examined IOM search terms and used 2 systematic reviews to identify 71 articles on LGBT tobacco use. The IOM omitted standard tobacco-related search terms. The report also omitted references to studies on LGBT tobacco use (n = 56), some with rigorous designs. The IOM report may underestimate LGBT tobacco use compared with general population use.

Infant delivery costs related to maternal smoking: an update

INTRODUCTION

Adverse maternal and infant health outcomes due to maternal smoking are well known. Previous estimates of health care costs for infants at delivery attributable to maternal smoking were $366 million, $704 per smoker, in 1996 dollars. Changes in antenatal and neonatal care, medical care inflation, and declines in the prevalence of maternal smoking call for an updated analysis.

METHODS

We used Pregnancy Risk Assessment Monitoring System for 2001/2002 to estimate the association of maternal smoking to Neonatal Intensive Care Unit (NICU) admission and, in turn, the length of stay for infants admitted/not admitted. Models are then used with 2003 natality files to derive predicted expenses as is and "as if" mothers did not smoke. The difference in these predicted expenses is smoking attributable expenses (SAEs). The updated analysis incorporated Hispanic ethnicity as an additional variable, data from 27 as opposed to 13 states, and updated (2004) NICU costs per night.

RESULTS

In contrast to earlier work, we find no significant association of maternal smoking and NICU admission but rather, a positive effect on the length of stay of exposed infants once admitted to the NICU. SAEs were estimated at $122 million (CI = -$29m to $285m) nationally and $279 (CI = -$76 to $653) per maternal smoker in 2004 dollars.

CONCLUSIONS

Declines in maternal smoking prevalence between the mid-1990s and 2003 combined with a weaker relationship of maternal smoking to NICU admission offset medical care inflation such that infants' SAEs declined. Yet, these are significant in magnitude, incurred immediately and highly preventable.

Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review

OBJECTIVES

This paper examines the prevalence of tobacco use among sexual minorities in the US through a systematic review of literature from 1987 to May 2007.

METHODS

Seven databases were searched for peer-reviewed research (Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library via Wiley InterScience, Education Resources Information Center (ERIC), Health Source: Nursing/Academic, Institute for Scientific Information (ISI) Web of Science, PsycINFO via EBSCO Host and PubMed). No language restrictions were used. Abstracts were identified in the literature search (n = 734) and were independently read and coded for inclusion or exclusion by two reviewers. When agreement was not reached, a third reviewer acted as arbitrator. Abstracts were included if they presented data collected in the US from 1987 to May 2007 and reported prevalence or correlation of tobacco use with sexual minority status. Studies reporting data from HIV-positive samples were excluded. The identified articles (n = 46) were independently read by two reviewers who recorded key outcome measures, including prevalence and/or odds ratios of tobacco use, sample size and domain of sexuality (identity, behaviour, or desire). Factors relating to study design and methodology were used to assess study quality according to nine criteria.

RESULTS

In the 42 included studies, 119 measures of tobacco prevalence or association were reported. The available evidence points to disparities in smoking among sexual minorities that are significantly higher than among the general population.

CONCLUSIONS

Ongoing, targeted interventions addressing smoking among sexual minorities are warranted in tobacco control programs.

Best Practice Smoking Cessation Intervention and Resource Needs of Prenatal Care Providers

OBJECTIVE

To describe smoking cessation interventions by prenatal care providers and to identify factors associated with best practice.

METHODS

A mailed survey assessed implementation of the "5 A's" of best practice (Ask about smoking; Advise patients to quit; Assess willingness to quit; Assist with a cessation plan; and Arrange follow-up), practice characteristics, intervention training, resources, barriers, and attitudes toward reimbursement. Each factor in association with provider type and best practice implementation was analyzed.

RESULTS

Of 1,138 eligible North Carolina health professionals, 844 responded (74%); 549 were providing prenatal care and returned completed surveys. Most asked about smoking (98%) and advised cessation (100%). Across provider type, one third (31%) consistently implemented all "5 A's" of best practice. Most providers (90%) had at least one material resource (eg, pamphlets), which correlated with nearly 10 times the adjusted odds of best practice (odds ratio [OR] 9.6, 95% confidence interval [CI] 1.3-72.9). Seventy percent had at least one counseling resource. Having a counseling resource (OR 2.5, 95% CI 1.4-4.4) and a written protocol to identify staff responsibilities (OR 2.5, 95% CI 1.5-4.3) were equally associated with best practice. More than one half of providers endorsed reimbursement as influential on best practice.

CONCLUSION

Best practice is well-established to promote prenatal smoking cessation yet implemented by only one third of prenatal care providers in North Carolina. In this study, best practice was associated with resources, practice organization, and reimbursement. Augmented use of available resources (eg, toll-free hotlines) and adequate reimbursement may promote best practice implementation.

Medicaid reimbursement for prenatal smoking intervention influences quitting and cessation

BACKGROUND

40% of births in the USA are covered by Medicaid and smoking is prevalent among recipients. The objective of this study was to evaluate the association between levels of Medicaid coverage for prenatal smoking cessation interventions on quitting during pregnancy and maintaining cessation after delivery.

METHODS

Population based survey study of 7513 post-partum women from 15 states who: participated in Pregnancy Risk Assessment Monitoring System (PRAMS) during 1998-2000; smoked at the beginning of their pregnancy; and had Medicaid coverage. Participating states were categorised into three levels of Medicaid coverage for smoking cessation interventions during prenatal care: extensive (pharmacotherapies and counselling); some (pharmacotherapies or counselling); or none. Quit rates among women who smoked before pregnancy and rates of maintaining cessation were examined.

RESULTS

Higher levels of coverage during prenatal care for smoking cessation interventions were associated with higher quit rates; 51%, 43%, and 39% of women quit in states with extensive, some, and no coverage, respectively. Compared to women in states with no coverage, women in states with extensive coverage had 1.6 times the odds of quitting smoking (odds ratio (OR) 1.58, 95% confidence interval (CI) 1.00 to 2.49). Maintenance of cessation after delivery was associated with extensive levels of Medicaid coverage; 48% of women maintained cessation in states with extensive coverage compared to 37% of women in states with no coverage. Compared to women in states with no coverage, women with extensive coverage had 1.6 times the odds of maintaining cessation (OR 1.63, 95% CI 1.04 to 2.56).

CONCLUSIONS

Prenatal Medicaid coverage for both pharmacotherapies and counselling is associated with higher rates of quitting and continued cessation. This suggests policymakers can promote cessation by broadening smoking cessation services in Medicaid prenatal coverage.

Costs of a smoking cessation counseling intervention for pregnant women: comparison of three settings

OBJECTIVE

Although the rate of smoking among women giving birth in the United States has declined steadily from 19.5% in 1989 to 11.4% in 2002, it still far exceeds the Healthy People 2010 goal of 1%. The objective of this study was to estimate the costs of a recommended five-step smoking cessation counseling intervention for pregnant women.

METHODS

Costs were compared across three settings: a clinical trial, a quit line, and a rural managed care organization. Cost data were collected from August 2002 to September 2003. Intervention costs were compared with potential neonatal cost savings from averted adverse outcomes using data from the Centers for Disease Control and Prevention's Maternal and Child Health Smoking-Attributable Mortality, Morbidity, and Economics Costs software.

RESULTS

The costs of implementing the intervention ranged from dollar 24 to dollar 34 per pregnant smoker counseled across the three settings. Potential neonatal cost savings that could be accrued from women who quit smoking during pregnancy were estimated at dollar 881 per maternal smoker. Assuming a 30% to 70% increase over baseline quit rates, interventions could net savings up to dollar 8 million within the range of costs per pregnant smoker.

CONCLUSIONS

Costs may vary depending on the intensity and nature of the intervention; however, this analysis found a surprisingly narrow range across three disparate settings. Cost estimates presented here are shown to be low compared with potential cost savings that could be accrued across the quit rates that could be achieved through use of the 5A's smoking cessation counseling intervention.

Getting focused: missed opportunities for smoking interventions for pregnant women receiving Medicaid

BACKGROUND

The prevalence of smoking, and cessation and relapse rates for pregnant women have health and financial implications. Our objectives were to describe smoking among pregnant smokers receiving Medicaid including characteristics associated with reporting discussion of smoking with providers and the association between those discussions with quitting and maintenance.

METHODS

Analysis of Pregnancy Risk Assessment Monitoring System (PRAMS) data from 15 states for 20,287 women with Medicaid for prenatal care during 1998-2000.

RESULTS

Thirty-four percent of women smoked before pregnancy (N = 7,686). Most smokers (93%) and nonsmokers (88%) reported discussions about smoking during prenatal care. Women were less likely to have discussed smoking if they were lighter smokers (OR = 1.47; CI = 1.03, 2.12), or reported a previous low-birthweight infant (OR = 1.72; CI = 1.03-2.86). Women reporting discussions (compared to those not) were less likely to quit (ARR = 0.70: CI = 0.59-0.91). Quitters reporting discussions (compared to those not) were no more likely to maintain cessation (ARR = 0.89; CI = 0.7, 1.21).

CONCLUSIONS

Smoking cessation interventions can be improved for pregnant women receiving Medicaid, especially if focused to address individual needs of light smokers, those with previous low-birthweight infants, or those who find it most difficult to quit.