Cancer care coordination in rural Hawaii: a focus group study

BACKGROUND

Rural populations consistently experience a disproportionate burden of cancer, including higher incidence and mortality rates, compared to the urban populations. Factors that are thought to contribute to these disparities include limited or lack of access to care and challenges with care coordination (CC). In Hawaii, many patients residing in rural areas experience unique challenges with CC as they require inter-island travel for their cancer treatment. In this focus group study, we explored the specific challenges and positive experiences that impact the CC in rural Hawaii cancer patients.

METHODS

We conducted two semi-structured focus group interviews with cancer patients receiving active treatment for any type of cancer (n = 8). The participants were recruited from the rural areas of Hawaii, specifically the Hawaii county and Kauai. Rural was defined using the Rural-Urban Commuting Area Codes (RUCA; rural ≥ 4). The focus group discussions were facilitated using open-ended questions to explore patients' experiences with CC.

RESULTS

Content analysis revealed that 47% of the discussions were related to CC-related challenges, including access to care (27.3%), insurance (9.1%), inter-island travel (6.1%), and medical literacy (4.5%). Other major themes from the discussions focused on facilitators of CC (30.3%), including the use of electronic patient portal (12.1%), team-based approach (9.1%), family caregiver support (4.5%), and local clinic staff (4.5%).

CONCLUSION

Our findings indicate that there are notable challenges in rural patients' experiences regarding their cancer care coordination. Specific factors such as the lack of oncologist and oncology services, fragmented system, and the lack of local general medical providers contribute to problems with access to care. However, there are also positive factors found through the help of facilitators of CC, notability the use of electronic patient portal, team-based approach, family caregiver support, and local clinic staff. These findings highlight potential targets of interventions to improve cancer care delivery for rural patients.

TRIAL REGISTRATION

Not required.

Patient reports of cancer care coordination in rural Hawaii

PURPOSE

Rural residents experience disproportionate burdens of cancer, and poorer cancer health outcomes in rural populations are partly attributed to care delivery challenges. Cancer patients in rural areas often experience unique challenges with care coordination. In this study, we explored patient reports of care coordination among rural Hawaii patients with cancer and compared rural and urban patients' perceptions of cancer care coordination.

METHODS

80 patients receiving active treatment for cancer from rural Hawaii participated in a care coordination study in 2020-2021. Participants completed the Care Coordination Instrument, a validated oncology patient questionnaire.

FINDINGS

Mean age of rural cancer patients was 63.0 (SD = 12.1), and 57.7% were female. The most common cancer types were breast and GI. Overall, rural and urban patients' perceptions of care coordination were comparable (p > 0.05). There were statistically significant differences between rural and urban patients' perceptions in communication and navigation aspects of care coordination (p = 0.02 and 0.04, respectively). Specific differences included a second opinion consultation, clinical trial considerations, and after-hours care. 43% of rural patients reported traveling by air for part or all of their cancer treatment.

CONCLUSIONS

Findings suggest that while overall perceptions of care coordination were similar between rural and urban patients, differential perceptions of specific care coordination areas between rural and urban patients may reflect limited access to care for rural patients. Improving access to cancer care may be a potential strategy to enhance care coordination for rural patients and ultimately address rural-urban cancer health disparities.

Through the Lens of Patient Partners: Challenges in Accrual of Older Adults to NCI Clinical Trials

The workshop "Engaging Older Adults in Cancer Clinical Trials Conducted in the NCI Clinical Trials Network: Challenges and Opportunities" included a Patient Stakeholder Workgroup that explored the needs and concerns of older adults with cancer regarding clinical trials. To accomplish this, the workgroup conducted patient focus groups in which participants were interviewed, recorded conversations were analyzed and coded, and salient themes were identified. The focus groups identified general barriers to accrual such as complex consent forms, general communication, restrictive eligibility, nonreferrals, patient costs, cultural insensitivity, limited accessibility in community settings, and transportation issues. They also identified the influence of knowledgeable information presenters, improved care, family or caregiver support, and the desire to help others as drivers or reasons to participate in clinical trials. The workshop concluded that multi-level interventions could be used to increase the accrual of older adults to National Cancer Institute clinical trials as well as others.

Time to diagnosis and treatment initiation during the COVID-19 pandemic among rural patients with cancer

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Background: Time to diagnosis (TTD) and treatment initiation (TTI) are important measures of access and quality of cancer care, but little is known about TTD and TTI for rural cancer patients. Rural residents experience disproportionate burdens of cancer including higher incidence and mortality, and many rural patients face challenges in health care access. Further understanding of TTD and TTI in rural areas is essential to improving the quality of cancer care delivery and cancer outcomes in rural areas. In this study, we describe TTD and TTI among rural cancer patients in Hawaii during the COVID-19 pandemic. Methods: Information about TTD and TTI was collected from 80 rural cancer patients enrolled on a care coordination study between Sept. 2020 and Dec. 2021. Participants were receiving active treatment for any cancer and residing in rural areas in Hawaii. We used descriptive statistics to describe TTD and TTI for the overall sample and specifically for those with breast and GI cancers, the two most common cancers in this study sample. Results: Participants were 56% female, with the mean age of 63 (SD = 12.1). 43% were White/Caucasian, 30% Native Hawaiian, and 25% two or more race. Reporting of symptoms to a healthcare provider led to diagnosis for 61.6% of the overall sample, whereas 38.4% received diagnosis following screening. For breast cancer, 36.8% indicated symptoms led to diagnosis, and 63.2% by screening. Among those with GI cancer, 76.5% reported symptoms led to diagnosis, and 23.5% by screening. Overall, 62.5% of participants reported TTD of within one month (< = 30 days) of screening or reporting symptoms to a healthcare provider (30-day TTD 62.5% for breast and 60.0% for GI). Median TTI for the overall sample was 60.6 days (IQR 30-62). For those with breast and GI cancers, median TTI was 61.0 (IQR 31-70) and 31.0 (IQR 0-61) days, respectively. Conclusions: Our results demonstrate that although TTD in this rural sample was comparable to other studies, TTI overall, and particularly for those with breast cancer, was nearly twice the TTI reported in other population-based studies. Delays in cancer treatment initiation have been associated with worse survival for breast and other cancers, especially among underserved populations. Our findings indicate that during the COVID-19 pandemic, rural residents in Hawaii experienced substantial delays in cancer treatment initiation. This study highlights the importance of addressing timely healthcare system access to minimize delays in treatment initiation and to improve health outcomes for rural cancer patients.

Clinical Research Professional Providing Care Coordination Support: A Study of Hawaii Minority/Underserved NCORP Community Site Trial Participants

PURPOSE

Although effective care coordination (CC) is recognized as a vital component of a patient-centered, high-quality cancer care delivery system, CC experiences of patients who enroll and receive treatment through clinical trials (CTs) are relatively unknown. Using mixed methods, we examined perceptions of CC among patients enrolled onto therapeutic CTs through the Hawaii Minority/Underserved National Cancer Institute Community Oncology Research Program.

METHODS

The Care Coordination Instrument, a validated instrument, was used to measure patients' perceptions of CC among CT participants (n = 45) and matched controls (n = 45). Paired t-tests were used to compare overall and three CC domain scores (Communication, Navigation, and Operational) between the groups. Semistructured focus group interviews were conducted virtually with 14 CT participants in 2020/2021.

RESULTS

CT participants reported significantly higher total CC scores than non-CT participants (P = .0008). Similar trends were found for Navigation and Operational domain scores (P = .007 and .001, respectively). Twenty-nine percent of CT participants reported receiving high-intensity CC assistance from their clinical research professionals (CRPs). Content analysis of focus group discussions revealed that nearly half of the focus group discussions centered on CRPs (47%), including CC support provided by CRPs (26%). Other key themes included general CT experiences (22%) and CRP involvement as an additional benefit to CT participation (15%).

CONCLUSION

Our results show that patients on CTs in this study had a more positive CC experience. This may be attributable in part to CC support provided by CRPs. These findings highlight both the improved experience of treatment for patients participating in a trial and the generally unrecognized yet integral role of CRPs as part of a cancer CT care team.

Perceptions of cancer care coordination among rural patients in Hawaii

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Background: Rural residents experience disproportionate burdens of cancer including higher incidence and mortality than urban residents. Disparities in rural cancer health outcomes are partially attributed to limited access to specialty care and care coordination challenges in rural areas. To date, little is known about rural cancer patients’ perceptions of care coordination (CC). In this study, we examined rural patients’ perceptions of cancer CC and compared rural and urban patients’ perceptions of cancer CC using the Care Coordination Instrument (CCI), a validated patient-report measure of CC. Methods: 80 rural patients receiving active treatment for any cancer residing in rural areas of Hawaii (Hawaii Island, Kauai) completed the CCI from Sept. 2020 to Dec. 2021. These rural areas are on separate islands from Oahu (urban) where tertiary care hospitals in Hawaii are located. Data for the urban cohorts ( n = 220) were derived from our archival data. The CCI assesses overall patients’ perceptions of CC (Total) and includes subscales that evaluate CC across three domains (Communication, Navigation, Operational). We used descriptive statistics to describe rural patients’ CC details and linear regression models to compare CCI scores between rural and urban patients. Results: Among 300 patients, demographic and clinical characteristics were similar between the rural and urban cohorts (mean age = 63.6, 56% female, most common cancer type: 28% breast and 25% GI). Patients were racially diverse, with 25% White/Caucasian, 24% Japanese, 16% Native Hawaiian, and 24% two or more race. Among rural patients, 43% indicated having traveled by air to another island (Oahu; urban) for cancer treatment (50% surgery). Of these patients, 38% indicated having paid out-of-pocket for cancer care-related travel costs. 65% of these patients reported travel costs as a burden, with 6% of patients having canceled or delayed treatment due to costs. Overall, there were no differences on the Total CCI scores between rural and urban patients ( p = 0.73). However, significant differences were found for Communication and Navigation ( p = 0.02 and p = 0.04, respectively), with rural patients reporting lower scores on these domains. No differences were found for the Operational domain scores. Conclusions: Our results demonstrate that that while rural patients’ overall perceptions of CC were similar to their urban cohorts, rural patients perceived greater CC challenges related to the communication and navigation aspects of CC. Off-island cancer care-related travel costs were reported as a significant burden for rural patients who must travel to another island for their cancer treatment. These findings highlight the need for interventions to address financial, communication and navigation challenges for rural patients in order to improve the quality of cancer care delivery in rural areas.

Applying ideation-to-action theories to predict suicidal behavior among adolescents

BACKGROUND

Although many risk factors for adolescent suicidal behavior have been identified, less is known about distinct risk factors associated with the progression from suicide ideation to attempts. Based on theories grounded in the ideation-to-action framework, we used structural equation modeling to examine risk and protective factors associated with the escalation from suicide ideation to attempts in adolescents.

METHODS

In this cross-sectional study, data from the 2013 and 2015 Hawaii High School Youth Risk Behavior Surveys (N = 8,113) were analyzed. The sample was 54.0% female and racially/ethnically diverse. Risk factors included depression, victimization, self-harm, violent behavior, disinhibition, and hard substance use, and protective factors included adult support, sports participation, academic achievement and school safety.

RESULTS

One in 6 adolescents (16.4%) reported suicide ideation, and nearly 1 in 10 (9.8%) adolescents had made a suicide attempt. Overall, disinhibition predicted the escalation to attempts among adolescents with suicide ideation, and higher academic performance was associated with lower suicide attempt risk. Depression and victimization were associated with suicide ideation.

LIMITATIONS

This study examined data from the Youth Risk Behavior Survey, and other known risk factors such as anxiety and family history of suicide were not available in these data.

CONCLUSIONS

Findings provide guidance for targets for clinical interventions focused on suicide prevention. Programs that incorporate behavioral disinhibition may have the greatest potential for reducing suicide attempt risk in adolescents with suicidal thoughts.

Effect of COVID-19-related reductions in cancer screening in Native Hawaiians and across urban and rural communities in Hawaii

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Background: The COVID-19 pandemic has disrupted medical care in all areas of the US and had a profound impact on cancer screening, with a concern that this may lead to excess cancer-related deaths over the next decade. There are existing disparities in cancer mortality among rural US residents and Native Hawaiians (NHs) due to access issues, lower socioeconomic status and lack of a sufficient provider workforce. A reduction in cancer screening may therefore have an oversized impact on these populations. In this study, we examine the effects of the COVID-19 pandemic on cancer screening frequency among NHs and in urban and rural populations in Hawaii. Methods: De-identified data on the frequencies of breast cancer (BCS), cervical cancer (CCS) and colorectal cancer (CRCS) screenings for 2019 and 2020 were obtained for Hawaii residents from several sources, including Hawaii Medical Services Association, the largest private and Medicaid provider in Hawaii, and the two largest state-wide health systems, Queen’s Health Systems and Hawaii Pacific Health. Data was analyzed using Rural-Urban Continuum Codes (RUCC) and Rural-Urban Commuting Area (RUCA) codes to define rurality and, along with health system facility location, to ascertain whether there was a differential impact on cancer screening rates for rural populations due to the pandemic. Cancer screening data for NHs in comparison to other groups was analyzed separately. Results: Overall, reductions in cancer screening during the pandemic were seen, with the degree of reduction varying widely across regions of the state and among different ethnic populations. Annual reductions in BCS, CCS and CRCS ranged from 4.0-30.2%, 2.7-3.0% and 9.4-13.2%, respectively, depending on the data source. BCS reductions were greatest in rural areas (p = 0.09) and among NHs (p = 0.0005). The island of Kauai, which is rural but was minimally affected by COVID-19, saw no reduction in BCS. CCS reductions had a reverse urban vs. rural pattern, with reductions of 4.5% urban and 0.8% rural (p = 0.02). CRCS reductions were most profound in rural residents (17.1%; p = 0.0001); reductions in CRCS among NHs were 1.5x greater than other groups. The differential impact across urban and rural areas was consistent for both RUCC and RUCA analysis. The extent of reduction was most significant for CRCS and was directly proportional to the degree of rurality. Conclusions: BCS and CRCS were impacted more significantly by the COVID-19 pandemic than CCS. For BCS and CRCS, greater reductions were seen in rural compaed to urban populations and in NHs. The lack of correlation with rurality for CCS may be because this population is generally younger and screening is often provided as a component of primary care. The greater pandemic-related reduction in screening among rural residents and Native Hawaiians may exacerbate existing cancer mortality disparities in these vulnerable populations.

Mixed-methods research to assess care coordination experiences among NCORP clinical trial participants

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Background: According to the Institute of Medicine, care coordination (CC) is a critical component of high-quality cancer care; however, many patients with cancer continue to experience fragmented care. CC experiences among cancer clinical trial (CT) participants are relatively unknown. Using mixed methods, we examined perceptions of CC among patients enrolled on therapeutic CTs conducted through the Hawaii Minority/Underserved NCI Community Oncology Research Program (NCORP). Methods: Forty-five CT participants completed the validated Care Coordination Instrument (CCI). The CCI assesses cancer patients’ perceptions of CC overall and across Communication, Navigation, and Operational domains. Data from 45 non-CT participants matched by age, gender, cancer type (breast, GI, other), and clinical stage from our prior studies served as a control group. Paired t-tests were used to compare the CCI scores between the two groups. Three semi-structured focus group interviews were conducted with 14 CT participants in 2020 and 2021. Results: The mean age of CT participants was 61.7 ( SD = 9.4), with the majority being female (67%) and Asian (56%). The most common cancer disease sites were breast (27%) and GI (16%). CT participants reported significantly higher total CC scores than non-participants ( p =.0008). Similar trends were found for Navigation ( p =.007) and Operational ( p =.001) domain scores. 56% of CT participants reported receiving moderate to high-intensity CC assistance from their clinical research professionals (CRPs). Content analysis of focus group discussions revealed that the majority of CT participants’ comments aligned with CC domains; 42% Communication, 30% Navigation, and 28% Operational. Nearly half of focus group discussions centered on CRPs (47%), including CC support provided by CRPs (26%). Other key themes that emerged from the focus groups included general CT experiences (22%) and CRP involvement as an additional benefit to CT participation (15%). Conclusions: Clinical trial participants perceive better CC than non-CT participants, partly attributed to CC support provided by CRPs. Our findings highlight a generally unrecognized yet integral role of CRPs as part of a cancer clinical trial care team. CRP involvement may be an additional benefit of CT participation and contribute to improved quality and value for patient-centered cancer care.

Patients’ perceptions of care coordination among NCORP therapeutic clinical trial participants: A matched case-control study

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Background: Effective coordination of care (CC) is a critical component of high-quality cancer care; however, many patients with cancer continue to receive poorly coordinated care. CC experiences among therapeutic clinical trial (CT) participants are relatively unknown. We examined cancer patients’ perceptions of CC among CT participants using a validated Care Coordination Instrument (CCI). Methods: The study sample (N = 90) consisted of 45 CT participants and 45 matched non-participants from archival data from our prior CC studies. 171 patients who participated in therapeutic cancer clinical trials through the Hawaii Minority/Underserved NCI Community Oncology Research Program (NCORP) between 2015 and 2020 were contacted for study participation, and 26% completed the CCI. The CCI measures overall perceptions of CC and across 3 domains (Communication, Navigation, Operational). Paired t-tests were used to compare overall and domain scores between CT participants and non-participants. The two groups were matched by age, gender, cancer type (breast, GI, other), and clinical stage. Results: Among CT participants, the mean age was 61.7 ( SD = 9.4), and the majority were female (67%) and Asian (56%). The most common cancer types were breast (27%) and GI (16%), with 24% with stage III disease. CT participants reported significantly higher total CC scores than non-participants (62.5 vs. 55.8; p = .0008). Similar trends were found for Navigation ( p = .007) and Operational ( p = .001) domain scores. 29% of CT participants reported receiving high-intensity CC assistance from their clinical research associates (CRAs), and 27% indicated receiving moderate-level CC assistance. Responses to open-ended questions regarding CC revealed that CT participants received assistance with a variety of CC activities from their CRAs, including scheduling appointments and explaining test results and procedures. Conclusions: Patients who participate in therapeutic cancer clinical trials report more positive perceptions of CC compared to non-participants. Qualitative data suggest that significant care coordination support is provided by the clinical research associate. The results underscore the importance of CC support provided by CRAs who may be an unrecognized component of the healthcare delivery team. CC provided by CRAs may contribute to improved quality and value of cancer care for patients enrolled on therapeutic clinical trials.

Differences in rural versus urban cancer patients’ perception of care coordination

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Background: Although advances in anticancer treatment have improved survival of patients with cancer overall, cancer mortality rates remain disproportionately high in rural areas. Disparities in rural cancer health outcomes are partially attributed to challenges with care coordination in rural areas. However, little is known about rural-urban differences in patients’ perception of cancer care coordination. In this exploratory study, we compared rural and urban cancer patients’ perception of care coordination (CC) using a Care Coordination Instrument (CCI), a validated self-report measure. Methods: We conducted a secondary analysis of cross-sectional survey data from two community-based cancer care delivery studies from 2018 and 2019 focused on cancer patients’ perception of CC. Patients receiving active therapy for any cancer completed a 29-item CCI. The CCI assesses overall perceptions of CC (Total) and across 3 domains: Communication, Navigation, and Operational. The rural patient cohort was derived from the American Cancer Society Hope Lodge Hawaii, which provides lodging for patients from neighbor islands (rural) receiving cancer care on Oahu (urban). The urban comparison group included patients residing on Oahu. Multivariate regression analyses were conducted to compare rural and urban patients’ perception of CC with adjustment for age, gender, and cancer type. Results: Data from 243 patients were analyzed; 23 (9.5%) were rural and 220 (90.5%) were urban. The rural and urban groups were similar with respect to patient demographics (age, gender) and clinical status. Rural patients reported significantly lower overall mean CCI scores than urban patients (54.7 vs 61.6; p = .02). Rural-urban differences in patients’ perception of CC were found for Communication (29.5 vs 35.1; p = .004) and Operational (19.7 vs 22.0; p = .02) domains. There were no rural-urban differences for Navigation. Conclusions: Our results demonstrate that rural patients had significantly poorer perception of care coordination overall than urban patients. Specifically, the observed rural vs urban differences in patients’ perception of care coordination were related to communication and operational challenges. Required coordination with a patient navigator to facilitate access to Hope Lodge may have confounded analysis in the Navigation domain. These findings highlight the need for interventions to address communication and operational CC challenges for rural patients in order to improve the quality of cancer care and reduce health disparities for rural cancer patients.

Perceptions of cancer care coordination in patient-family caregiver dyads

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Background: Family caregivers (FCGs) can play a key role in coordinating care for cancer patients. However, little is known about FCGs’ perspectives of care coordination (CC). In this cross-sectional study, we evaluated perceptions of CC in cancer patient-family caregiver dyads using the Care Coordination Instrument (CCI), a validated self-report measure with excellent psychometric properties. Methods: Patients receiving active treatment for cancer and their primary FCGs ( N = 54 dyads) completed the 29-item CCI (patient) and the CCICG (a parallel FCG version) at private oncology practices or hospital-based facilities from June to Sept. 2019. The CCI and CCICG assess overall perceptions of CC (Total) and across 3 domains: Communication, Navigation, and Operational. The CCICG includes a supplemental questionnaire that assesses the degree of caregiver CC involvement on a 4-point Likert scale. Mixed regression models were used to examine differences between patients and FCGs’ perceptions of CC and to identify predictors of dyadic differences on the CCI scores. Pearson’s correlation was used to evaluate associations between FCGs’ perceptions of CC and the degree of caregiver involvement. Results: CCICG Total scores demonstrated a bimodal distribution, representing FCGs’ perceptions of CC in distinct high and low subgroups; thus, all analyses were conducted by subgroups (highCG, lowCG). Overall, no dyadic differences were found in the highCG group on the CCI scores. However, in the lowCG group, FCGs reported poorer Total ( p < .01), Communication ( p < .01), Navigation ( p < .01), and Operational ( p < .05) scores than patients. Provider setting (private practices) and the absence of an identified patient navigator significantly predicted poorer FCG Total scores compared to patients’ perceptions ( p < .05). FCGs’ Total scores were inversely associated with the degree of caregiver involvement among FCGs in the lowCG group ( p < .05) but not among FCGs in the highCG group. Conclusions: Our findings demonstrate that a subgroup of FCGs has poorer perceptions of CC that differ significantly from patient perceptions and is most apparent for patients receiving treatment in a private practice setting and in the absence of a patient navigator. These FCGs report a high degree of caregiver involvement and may be providing additional CC support that is not recognized by cancer patients. These findings underscore the need for interventions to support FCG CC involvement as a member of the care team in order to improve the quality and value of patient-centered cancer care delivery.

Assessing Patients' Perceptions of Cancer Care Coordination in a Community-Based Setting

PURPOSE

Effective care coordination (CC) is a hallmark of a high-quality cancer care. However, efforts to improve cancer care delivery are limited by the lack of a clinically useful tool to assess CC. In this study, we examined patients' perceptions of cancer CC using a novel tool, the Care Coordination Instrument (CCI), and evaluated the quality of the CCI.

METHODS

The CCI is a 29-item patient questionnaire that assesses CC across varied practice settings and patient populations overall and for three critical domains of CC: communication, navigation, and operational. We conducted univariable and multivariable regression analyses to identify patient clinical and practice characteristics associated with optimal versus suboptimal CC.

RESULTS

Two hundred patients with cancer completed the CCI questionnaire between October 2018 and January 2019, of whom 189 were used for the analysis. The presence of a family caregiver and a diagnosis of a blood cancer were correlated with overall positive reports of CC (P < .001 and P < .05, respectively). Poorer perceptions of CC were associated with having a head and neck cancer and the absence of family caregiver support. The effects of cancer disease stage and having access to a patient navigator on CC were not statistically significant.

CONCLUSION

Integrating a patient-centered tool to assess cancer CC can be a strategy to optimize cancer care delivery. Understanding factors associated with effective and ineffective CC can help inform efforts to improve overall quality of care and care delivery.

Development and psychometric evaluation of a questionnaire to measure cancer patients' perception of care coordination

BACKGROUND

Although the importance of care coordination (CC) is well-recognized, cancer patients often receive poorly coordinated care across varied care settings and different oncology providers. Efforts to improve cancer care are hampered by lack of adequate measures. In this two-part, mixed-method study, we describe the development, refinement, and validation of a new care coordination instrument (CCI) designed to assess cancer patients' perception of CC.

METHODS

In Study 1, an initial CCI was developed incorporating questions based on literature review. The items were then modified following four field tests conducted in a large academic hospital with oncology nurses (n = 20) and cancer patients (n = 120). This modified instrument was used to determine whether the CCI was able to distinguish CC between two practices (30 GI and 30 myeloma patients) within the same hospital setting. In Study 2, 68 patients receiving community-based care participated in seven focus groups. Based on these discussions, the CCI items were again refined, and psychometric evaluation was conducted to assess the quality of the instrument.

RESULTS

Based on field tests, 3 domains of the CCI, Communication, Navigation, and Operational, were defined as critical components of CC. The Operational domain evaluates efficiency of care and is unique to this CCI. The field test demonstrated that GI patients reported significantly better CC Overall and for the Communication and Navigation domains (all p < .05). In Study 2, patients expressed concordance with the CCI items and their CC experiences, establishing validity of the CCI. Qualitative analysis of the focus group discussions indicated that the items with the highest frequencies of participants' comments were related to the concepts of Navigator, Team, Survey, and Communication. Quantitative analysis identified items with a limited response range or high rates of "neutral" responses; accordingly, those items were removed. The final CCI survey is a 29 item, multiple-choice questionnaire with excellent reliability, Cronbach's α = .922.

CONCLUSIONS

We developed a novel, patient-centered tool with excellent psychometric properties that can be utilized across varied practice settings to assess patients' perception of cancer care coordination.

TRIAL REGISTRATION

Not required; retrospectively registered ClinicalTrials.gov NCT03594006 20 July 2018.

Mixed-methods research to evaluate a novel patient-centered cancer care coordination instrument

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Background: Effective care coordination (CC) is a critical component of high-quality cancer care; however, efforts to improve cancer care coordination are hampered by limited patient-centered measures. This mixed-methods research reports on patients’ feedback and the utility of a novel care coordination instrument (CCI) designed to assess cancer care coordination. Methods: 7 focus group discussions were conducted with 68 cancer patients receiving active therapy to evaluate validity of the CCI. Subsequently, the CCI was modified and administered to additional 200 cancer patients derived from community-based private and hospital clinics. The CCI is a 29-item, multiple-choice questionnaire and includes subscales that evaluate CC in 3 domains (Communication, Navigation, Operational) across 4 areas of CC (patient-physician; between providers; during inpatient-to-ambulatory care transitions; during transitions across phases of care). Results: Qualitative analysis of focus group discussions demonstrated that the CCI has good face and content validity. Content analysis identified the following themes: Survey, Education/Knowledge, Navigator, Communication, Support, Access, Providers, and Team. Questions with unclear wording or high proportions of not applicable or missing responses were refined or removed. Results of the revised survey indicated that the CCI is able to distinguish patient- and practice characteristics associated with optimal/poor CC. Specifically, cancer types (leukemia, myeloma) and having a patient navigator predicted high overall patients’ ratings of CC ( p < .05). Marginally significant differences were found for practice setting ( p = .085). A multiple regression model with all predictors entered simultaneously revealed that the presence of a family/friend caregiver significantly predicted better CC ( p < .001); however, the benefits of a patient navigator were no longer significant. Conclusions: This study demonstrates the utility of the CCI for assessing patients’ perspectives of cancer CC. Use and integration of this instrument in oncology practices/clinics can identify areas of potential interventions for CC improvement and lead to a better quality of care.

Validation of an oncology-specific instrument to measure cancer patients’ perception of care coordination

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Background: According to the IOM, effective coordination of care (CC) is a critical component of high-quality cancer care; however, lack of a reliable and validated measure limits our current understanding of cancer care coordination. We examined psychometric properties and utility of a Care Coordination Instrument (CCI), a survey developed to assess cancer patients’ perceptions of care coordination. Methods: The 29-item CCI was administered to 200 patients receiving active treatment for cancer at private oncology practices and hospital-based facilities from Oct. 2018 to Jan. 2019. The CCI includes subscales that evaluate CC in 3 domains (Communication, Navigation, Operational) across 4 areas of CC (patient-physician; between health providers; during inpatient-to-ambulatory care transitions; during transitions across different phases of care). All items were rated on a 4-point Likert scale. Results: Psychometric analyses of the CCI demonstrated that it has good internal consistency reliability (α = .917) and the three-factor solution was an acceptable fit (CFI = .853, SRMR = .065). Overall, cancer types (leukemia, myeloma) and having an identified patient navigator significantly predicted higher patients’ ratings of CC ( p < .05). Similar trends were found for Communication and Operation subscale scores ( p < .05). Having an identified navigator predicted higher Navigation scores ( p < .05). Marginally significant differences were found for practice setting, with patients receiving care in hospital-based facilities reporting better CC ( p = .085). Item-level analyses revealed significant differences in specific aspects of CC (e.g., physician-patient communication) across cancer type, presence/absence of a patient navigator, and practice setting. Conclusions: The results demonstrate that the CCI is a reliable and valid instrument for measuring cancer patients’ perceptions of care coordination. Perception of CC correlated with the presence of a navigator, underlying cancer type and (trending) practice setting. Use of this instrument may reveal important information about cancer care coordination and may identify areas of targets for improvement in patient-centered cancer care delivery.

Factor Analysis of Therapist-Identified Treatment Targets in Community-Based Children's Mental Health

The present study used exploratory and confirmatory factor analyses to identify underlying latent factors affecting variation in community therapists' endorsement of treatment targets. As part of a statewide practice management program, therapist completed monthly reports of treatment targets (up to 10 per month) for a sample of youth (n = 790) receiving intensive in-home therapy. Nearly 75 % of youth were diagnosed with multiple co-occurring disorders. Five factors emerged: Disinhibition, Societal Rules Evasion, Social Engagement Deficits, Emotional Distress, and Management of Biodevelopmental Outcomes. Using logistic regression, primary diagnosis predicted therapist selection of Disinhibition and Emotional Distress targets. Client age predicted endorsement of Societal Rules Evasion targets. Practice-to-research implications are discussed.

Positive and Negative Affect in Clinic-Referred Youth With ADHD

OBJECTIVE

To examine self-reported positive affect (PA) and negative affect (NA) among youth with ADHD (only and comorbid) and other non-ADHD-referred youth in an ethnically diverse clinical sample.

METHOD

Semi-structured interviews identified 80 pure ADHD, 284 ADHD plus one or more comorbidities, and 730 non-ADHD youth (e.g., other diagnoses or no diagnosis). The Positive and Negative Affect Scale-Children (PANAS-C) was used to assess affective states.

RESULTS

Even after controlling for the influence of potential confounds, youth with only ADHD reported higher PA and lower NA than other clinic-referred youth. The ADHD-comorbid group reported higher PA than the "non-ADHD" group, but these groups did not differ on level of NA. ADHD subtype did not influence results.

CONCLUSION

Among clinic-referred youth, ADHD is associated with higher levels of PA and when there are no comorbid disorders, lower levels of NA.

Isolation of Clostridium difficile from the feces and the antibody in sera of young and elderly adults

Attempts were made to isolate Clostridium difficile from a total of 431 fecal specimens from 149 young and 213 elderly healthy adults, and 69 elderly adults with cerebrovascular disease but no gastrointestinal disease. C difficile was isolated from 49 specimens, and the frequency of isolation was 15.4% in healthy young adults, 7.0% in healthy elderly adults, and 15.9% in elderly adults with cerebrovascular disease. Thirty-four (about 70%) of the 49 C. difficile strains isolated produced cytotoxin which was neutralized by Clostridium sordellii antitoxin in vitro; in both young and elderly adults approximately 30% of the C. difficile isolates were nontoxigenic. The mean concentration of C. difficile in feces was 10(4.1)/g in young adults and 10(4.6)/g in elderly adults, with a range of 10(2.0) to 10(6.9)/g. Antibody against C. difficile toxin was found in most of the sera obtained from young adults carrying toxigenic C. difficile, but not in sera of elderly adults, no matter how abundant was toxigenic C. difficile in the feces.

Taxonomy of Clostridium tetani and related species

Clostridium tetani and its related species C. tetanomorphum, C. cochlearium and C. lentoputrescens were examined for DNA-DNA homology and biochemical properties. Two distinctly different groups were included under the name of C. tetanomorphum: one was identical with C. cochlearium and the name C. tetanomorphum was applied to the other group with some amendment of biochemical properties. Comparison of the type strain of C. lentoputrescens with wild strains obtained from horse faeces indicated that the name C. lentoputrescens should be abolished as a later synonym of C. cochlearium. Liquefaction of gelatin and spore shape, which have been used as the important criteria for differentiation of C. tetani-related species, were genetically insignificant.

Clostridium sporogenes isolates and their relationship to C. botulinum based on deoxyribonucleic acid reassociation

Sixty-two isolates of Clostridium sporogenes from canned foods were examined for cultural properties, heat resistance and DNA-DNA homology to Clostridium botulinum type A190. Sporulation was observed in most of 21 umbonate and rhizoidal colony-forming strains (colony-type I strains), but not in most of the 41 strains with convex and circular or crenate colonies with a mat to semi-glossy surface (colony-type II strains). More than half of the latter strains showed much higher heat resistance than the rhizoidal colony-forming strains. The DNA isolated from colony-type II strains was 81% or more homologous to C. botulinum A190 DNA, forming duplexes which had thermostabilities similar to homologous duplexes of strain A190 DNA. Colony-type I strains differed from C. botulinum by 30 to 40% DNA homology and the DNA duplexes formed between these strains and strain A190 showed deltaT m(e) values of 7-0 degrees C when compared with the T m(e) of homologous DNA duplexes of strain A190.