Racial and ethnic differences in disease course Medicare expenditures for beneficiaries with dementia

BACKGROUND

Research on racial and ethnic disparities in costs of care during the course of dementia is sparse. We analyzed Medicare expenditures for beneficiaries with dementia to identify when during the course of care costs are the highest and whether they differ by race and ethnicity.

METHODS

We analyzed data from the 2000-2016 Health and Retirement Study (HRS) linked with corresponding Medicare claims to estimate total Medicare expenditures for four phases: (1) the year before a dementia diagnosis, (2) the first year following a dementia diagnosis, (3) ongoing care for dementia after the first year, and (4) the last year of life. We estimated each patient's phase-specific and disease course Medicare expenditures by using a race-specific survival model and monthly expenditures adjusted for patient characteristics. We investigated healthcare utilization by service type across races/ethnicities and phases of care.

RESULTS

Adjusted mean total Medicare expenditures for non-Hispanic (NH) Black ($165,730) and Hispanic beneficiaries with dementia ($160,442) exceeded corresponding expenditures for NH Whites ($136,326). In the year preceding and immediately following initial dementia diagnosis, mean Medicare expenditures for NH Blacks ($26,337 and $20,429) exceeded expenditures for Hispanics and NH Whites ($21,399-23,176 and 17,182-18,244). The last year of life was responsible for the greatest cost contribution: $51,294 (NH Blacks), $47,469 (Hispanics), and $39,499 (NH Whites). These differences were driven by greater use of high-cost services (e.g., emergency department, inpatient and intensive care), especially during the last year of life.

CONCLUSIONS

NH Black and Hispanic beneficiaries with dementia had higher disease course Medicare expenditures than NH Whites. Expenditures were highest for NH Black beneficiaries in every phase of care. Further research should address mechanisms of such disparities and identify methods to improve communication, shared decision-making, and access to appropriate services for all populations.

Evaluating the Impact of a Pediatric Inpatient Social Care Program in a Community Hospital

OBJECTIVES

To evaluate the impact of implementing a stakeholder-informed social risk screening and social service referral system in a community hospital setting.

METHODS

We implemented a stakeholder-informed social care program at a community hospital in April 2022. The evaluation included patients aged 0 to 17 years admitted to the pediatric unit between April 2021 and March 2022 (1 year preimplementation) and between April 2022 and March 2023 (1 year postimplementation). For a random subset of 232 preimplementation and 218 postimplementation patients, we performed manual data extraction, documenting program process measures and preliminary effectiveness outcomes. We used χ square and Wilcoxon rank tests to compare outcomes between the preimplementation and postimplementation groups. Multivariable logistic regression was used to assess the preliminary effectiveness of the social care program in identifying social risks.

RESULTS

Screening rates were higher in the postimplementation group for nearly all social domains. Compared with preimplementation, the postimplementation group had higher rates of social risks identified (17.4% vs 7.8% [P < .01]: adjusted odds ratio 2.9 [95% confidence interval 1.5-5.5]) on multivariate testing. Social work consults were completed more frequently and earlier for the postimplementation group (13.8.% vs 5.6% [P < .01]) and median (19 hours vs 25 hours [P = .03]), respectively. Rates of communication of social risks in discharge summaries were higher in the postimplementation group (46.8% vs 8.2% [P < .001]).

CONCLUSIONS

The implementation of a stakeholder-informed social care program within a community hospital setting led to the increased identification of social risks and social work consultations and improved timeliness of social work consultations and written communication of social risks in discharge summaries for primary care providers.

Racial differences in testing for infectious diseases: An analysis of jail intake data

HIV and hepatitis C virus (HCV) testing for all people in jail is recommended by the CDC. In the community, there are barriers to HIV and HCV testing for minoritized people. We examined the relationship between race and infectious diseases (HIV, HCV, syphilis) testing in one Massachusetts jail, Middlesex House of Corrections (MHOC). This is a retrospective analysis of people incarcerated at MHOC who opted-in to infectious diseases testing between 2016-2020. Variables of interest were race/ethnicity, self-identified history of psychiatric illness, and ever having experienced restrictive housing. Twenty-three percent (1,688/8,467) of people who were incarcerated requested testing at intake. Of those, only 38% received testing. Black non-Hispanic (25%) and Hispanic people (30%) were more likely to request testing than white people (19%). Hispanic people (16%, AOR 1.69(1.24-2.29) were more likely to receive a test result compared to their white non-Hispanic (8%, AOR 1.54(1.10-2.15)) counterparts. Black non-Hispanic and Hispanic people were more likely to opt-in to and complete infectious disease testing than white people. These findings could be related to racial disparities in access to care in the community. Additionally, just over one-third of people who requested testing received it, underscoring that there is room for improvement in ensuring testing is completed. We hope our collaborative efforts with jail professionals can encourage other cross-disciplinary investigations.

Nurse navigation, symptom monitoring and exercise in vulnerable patients with lung cancer: feasibility of the NAVIGATE intervention

We developed the Navigate intervention to improve survival among vulnerable lung cancer patients. In this intervention-only study, we examined feasibility in terms of recruitment, retention, attendance, adherence, and acceptability to specify adjustments to study procedures and intervention components prior to a randomized trial. The Navigate intervention includes nurse navigation, patient-reported outcomes, and physical exercise. Patients ≥ 18 years old, diagnosed with non-small cell lung cancer at any stage, with performance status ≤ 2, eligible for cancer treatment and vulnerable according to a screening instrument were included. The recruitment goal of eligible patients was 40% while the retention goal was 85%. The predefined cut-offs for sufficient attendance and adherence were ≥ 75%. Acceptability was evaluated by semi-structured interviews with participants, nurse navigators, and physiotherapists. Seventeen (56%) out of 30 screened patients were considered vulnerable and eligible for the study, 14 (82%) accepted participation, and 3 (21%) were subsequently excluded due to ineligibility, leaving 11 patients. Four patients dropped out (36%) and four patients died (36%) during follow-up and 3 (27%) were retained. All 11 patients participated in nurse sessions (mean 16, range 1-36) with 88% attendance and dialogue tools being applied in 68% of sessions. Ninety-one percent of patients responded to PROs (mean of 9 PROs, range 1-24) with 76% of the PRO questionnaires used (attendance) and 100% adherence (completion of all questions in PRO questionnaires), and 55% participated in exercise sessions with 58% attendance and 85% adherence. We identified important barriers primarily related to transportation, but overall acceptability was high. The Navigate intervention was feasible with high participation, acceptability and satisfactory adherence. Retention and exercise attendance were low, which resulted in adjustments.Trial registration: The feasibility study was initiated prior to the multicenter randomized controlled trial registered by ClinicalTrials.gov (number: NCT05053997; date 23/09/2021).

Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC): a study protocol for a hybrid type 1 randomized controlled trial

BACKGROUND

There are persistent racial and ethnic health disparities in end-of-life health outcomes in the United States. African American patients are less likely than White patients to access palliative care, enroll in hospice care, have documented goals of care discussions with their healthcare providers, receive adequate symptom control, or die at home. We developed Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) to address these disparities. DeCIDE PC is an integrated community health worker (CHW) palliative care intervention that uses community health workers (CHWs) as care team members to enhance the receipt of palliative care for African Americans with advanced cancer. The overall objectives of this study are to (1) assess the effectiveness of the DeCIDE PC intervention in improving palliative care outcomes amongst African American patients with advanced solid organ malignancy and their informal caregivers, and (2) develop generalizable knowledge on how contextual factors influence implementation to facilitate dissemination, uptake, and sustainability of the intervention.

METHODS

We will conduct a multicenter, randomized, assessor-blind, parallel-group, pragmatic, hybrid type 1 effectiveness-implementation trial at three cancer centers across the United States. The DeCIDE PC intervention will be delivered over 6 months with CHW support tailored to the individual needs of the patient and caregiver. The primary outcome will be advance care planning. The treatment effect will be modeled using logistic regression. The secondary outcomes are quality of life, quality of communication, hospice care utilization, and patient symptoms.

DISCUSSION

We expect the DeCIDE PC intervention to improve integration of palliative care, reduce multilevel barriers to care, enhance clinic and patient linkage to resources, and ultimately improve palliative care outcomes for African American patients with advanced cancer. If found to be effective, the DeCIDE PC intervention may be a transformative model with the potential to guide large-scale adoption of promising strategies to improve palliative care use and decrease disparities in end-of-life care for African American patients with advanced cancer in the United States.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov (NCT05407844). First posted on June 7, 2022.

Alzheimer's disease medication use and adherence patterns by race and ethnicity

BACKGROUND

We examined racial and ethnic differences in medication use for a representative US population of patients with Alzheimer's disease and related dementias (ADRD).

METHODS

We examined cholinesterase inhibitors and memantine initiation, non-adherence, and discontinuation by race and ethnicity, using data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims.

RESULTS

Among newly diagnosed ADRD patients (n = 1299), 26% filled an ADRD prescription ≤90 days and 36% ≤365 days after diagnosis. Among individuals initiating ADRD-targeted treatment (n = 1343), 44% were non-adherent and 24% discontinued the medication during the year after treatment initiation. Non-Hispanic Blacks were more likely than Whites to not adhere to ADRD medication therapy (odds ratio: 1.50 [95% confidence interval: 1.07-2.09]).

DISCUSSION

Initiation of ADRD-targeted medications did not vary by ethnoracial group, but non-Hispanic Blacks had lower adherence than Whites. ADRD medication non-adherence and discontinuation were substantial and may relate to cost and access to care.

HIGHLIGHTS

Initiation of anti-dementia medications among newly diagnosed Alzheimer's disease and related dementias (ADRD) patients was low in all ethnoracial groups. ADRD medication non-adherence and discontinuation were substantial and may relate to cost and access to care. Compared to Whites, Blacks and Hispanics had lower use, poorer treatment adherence, and more frequent discontinuation of ADRD medication, but when controlling for disease severity and socioeconomic factors, racial disparities diminish. Our findings demonstrate the importance of adjusting for socioeconomic characteristics and disease severity when studying medication use and adherence in ADRD patients.

Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life

BACKGROUND

Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits.

OBJECTIVE

This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia.

METHODS

This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions.

RESULTS

Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences.

CONCLUSIONS

Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.

NAVIGATE: improving survival in vulnerable patients with lung cancer through nurse navigation, symptom monitoring and exercise - study protocol for a multicentre randomised controlled trial

INTRODUCTION AND AIM

Low socioeconomic position (SEP) has been shown to be strongly associated with impaired lung cancer survival. Barriers related to receiving recommended treatment among patients with lung cancer with low SEP may include adverse health behaviour and limited physical and psychosocial resources influencing the ability to react on high-risk symptoms and to navigate the healthcare system. To address the underlying factors that drive both decisions of treatment, adherence to treatment and follow-up in vulnerable patients with lung cancer, we developed the Navigate intervention. The aim of this randomised controlled trial is to investigate the effect of the intervention on survival (primary outcome), lung cancer treatment adherence, health-related quality of life and other psychosocial outcomes as well as health costs and process evaluation (secondary outcomes) in a study population of vulnerable patients with lung cancer.

METHODS AND ANALYSIS

This two-armed multicentre randomised trial will recruit patients from five lung cancer clinics in Denmark identified as vulnerable according to a screening instrument with nine clinical and patient-reported vulnerability criteria developed for the study. We will enrol 518 vulnerable patients >18 years old diagnosed with non-small cell lung cancer at all stages with a performance status <2. Participants will be randomly allocated to either standard treatment and intervention or standard treatment alone. The Navigate intervention is based on principles from motivational interviewing and includes three components of nurse navigation, systematic monitoring of patient-reported outcomes (PROs) and physical exercise in a person-centred delivery model. Data will be collected at baseline and 3, 6, 12 months after randomisation using questionnaires, clinical data and physical function tests.

ETHICS AND DISSEMINATION

Ethics Committee, Region Zealand (SJ-884/EMN-2020-37380) and the Data Protection Agency in Region Zealand (REG-080-2021) approved the trial. Participants will provide written informed consent. Results will be reported in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05053997.

Parent Perspectives on Screening for Social Needs During Pediatric Hospitalizations

OBJECTIVES

Social determinants of health have been demonstrated to be important drivers of health outcomes and disparities. Screening for social needs has been routinely performed and shown to be beneficial in ambulatory settings, but little is known regarding parent perspectives on screening during pediatric hospitalizations. This study sought to determine parental attitudes surrounding inpatient screening and screening process preferences in the hospital setting.

METHODS

We conducted 17 semistructured interviews with English- and Spanish-speaking parents of hospitalized children at 1 tertiary and 2 community hospitals between July 2020 and February 2021, with questions probing opinions and experiences with social needs screening, comfort level with discussing social needs with hospital providers, and screening process preferences in the hospital setting. Interviews were recorded, professionally transcribed, and analyzed thematically.

RESULTS

Participants were median age 32 years, with majority female and English-speaking, and nearly one-half with children admitted to a community hospital. Emergent themes included (1) importance of screening for social needs across multiple health care settings, (2) hospitals viewed as capable systems to respond to social needs, (3) most parents comfortable discussing social needs with inpatient providers, (4) appreciation for providers expressing caring and desire to help during inpatient screening, and (5) importance of a family-centered approach to inpatient screening.

CONCLUSIONS

Parents reported positive perceptions regarding pediatric inpatient social needs screening importance and hospitals' ability to address social needs and identified multiple screening process preferences for the hospital setting that can inform the development of family-centered inpatient social needs screening strategies.

Using community-engaged methods to develop a study protocol for a cost analysis of a multi-site patient navigation intervention for breast cancer care

BACKGROUND

Patient navigation is an evidence-based intervention for reducing delays in oncology care among underserved populations. In order to address the financial sustainability of this intervention, information is needed on the cost of implementing patient navigation in diverse healthcare settings. Because patient navigation programs and care settings are highly variable, this paucity of cost data creates difficulties in identifying best practices and decisions about the feasibility of implementing navigation programs within a health care system. One barrier to collecting these cost data is the lack of assessment tools available to support patient navigation programs. These tools must be relevant to the wide variety of navigation activities that exist in health care settings, and be flexible enough to collect cost data important to stakeholders in fee-for-service and value-based care environments.

METHODS AND RESULTS

We present a novel approach and methods for assessing the cost of a patient navigation program implemented across six hospital systems to enhance timely entry and uptake of breast cancer care and treatment. These methods and tools were developed in partnership with breast oncology patient navigators and supervisors using principles of stakeholder engagement, with the goal of increasing usability and feasibility in the field.

CONCLUSIONS

This methodology can be used to strengthen cost analysis and assessment tools for other navigation programs for improving care and treatment for patients with chronic conditions.

TRIAL REGISTRATION

NCT03514433.

Development of a workflow process mapping protocol to inform the implementation of regional patient navigation programs in breast oncology

BACKGROUND

Implementing city-wide patient navigation processes that support patients across the continuum of cancer care is impeded by a lack of standardized tools to integrate workflows and reduce gaps in care. The authors present an actionable workflow process mapping protocol for navigation process planning and improvement based on methods developed for the Translating Research Into Practice study.

METHODS

Key stakeholders at each study site were identified through existing community partnerships, and data on each site's navigation processes were collected using mixed methods through a series of team meetings. The authors used Health Quality Ontario's Quality Improvement Guide, service design principles, and key stakeholder input to map the collected data onto a template structured according to the case-management model.

RESULTS

Data collection and process mapping exercises resulted in a 10-step protocol that includes: 1) workflow mapping procedures to guide data collection on the series of activities performed by health care personnel that comprise a patient's navigation experience, 2) a site survey to assess program characteristics, 3) a semistructured interview guide to assess care coordination workflows, 4) a site-level swim lane workflow process mapping template, and 5) a regional high-level process mapping template to aggregate data from multiple site-level process maps.

CONCLUSIONS

This iterative, participatory approach to data collection and process mapping can be used by improvement teams to streamline care coordination, ultimately improving the design and delivery of an evidence-based navigation model that spans multiple treatment modalities and multiple health systems in a metropolitan area. This protocol is presented as an actionable toolkit so the work may be replicated to support other quality-improvement initiatives and efforts to design truly patient-centered breast cancer treatment experiences.

LAY SUMMARY

Evidence-based patient navigation in breast cancer care requires the integration of services through each phase of cancer treatment. The Translating Research Into Practice study aims to implement patient navigation for patients with breast cancer who are at risk for delays and are seeking care across 6 health systems in Boston, Massachusetts. The authors designed a 10-step protocol outlining procedures and tools that support a systematic assessment for health systems that want to implement breast cancer patient navigation services for patients who are at risk for treatment delays.

Evaluating the sustainability of patient navigation programs in oncology by length of existence, funding, and payment model participation

BACKGROUND

For this study, the authors examined whether specific programmatic factors were associated with the sustainability of patient navigation programs.

METHODS

This cross-sectional survey explored navigation programmatic factors associated with 3 measures of sustainability: 1) length of program existence, 2) reliance on sustainable funding, and 3) participation in alternative payment models. In total, 750 patient navigators or program administrators affiliated with oncology navigation programs in clinical-based and community-based settings completed the survey between April and July 2019.

RESULTS

Associations were observed between both accreditation and work setting and measures of program sustainability. Accredited programs and larger, more resourced clinical institutions were particularly likely to exhibit multiple measures of sustainability. The results also identified significant gaps at the programmatic level in data collection and reporting among navigation programs, but no association was observed between programmatic data collection/reporting and sustainability.

CONCLUSIONS

Navigation is not currently a reimbursable service and has historically been viewed as value-added in oncology settings. Therefore, factors associated with sustainability are critical to understand how to build a framework for successful navigation programs within the current system and also to develop the case for potential reimbursement in the future.

Racial and Ethnic Differences in Hospice Use and Hospitalizations at End-of-Life Among Medicare Beneficiaries With Dementia

IMPORTANCE

The pool of studies examining ethnic and racial differences in hospice use and end-of-life hospitalizations among patients with dementia is limited and results are conflicting, making it difficult to assess health care needs of underresourced racial and ethnic groups.

OBJECTIVE

To explore differences in end-of-life utilization of hospice and hospital services among patients with dementia by race and ethnicity.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used national survey data from the Health and Retirement Study linked with Medicare and Medicaid claims that reflected a range of socioeconomic, health, and psychosocial characteristics. Eligible participants were Medicare fee-for-service beneficiaries aged 65 years or older diagnosed with dementia who died between 2000 and 2016. Analyses were performed from June to December 2021.

EXPOSURES

Race and ethnicity.

MAIN OUTCOMES AND MEASURES

We examined the frequency and costs of hospice care, emergency department (ED) visits, and hospitalizations during the last 180 days of life among Medicare decedents with dementia. We analyzed the proportion of dementia decedents with advance care planning and their end-of-life care preferences.

RESULTS

The cohort sample included 5058 beneficiaries with dementia (mean [SD] age, 85.5 [8.0] years; 3038 women [60.1%]; 809 [16.0%] non-Hispanic Black, 357 [7.1%] Hispanic, and 3892 non-Hispanic White respondents [76.9%]). In adjusted analysis, non-Hispanic Black decedents (odds ratio [OR], 0.65; 95% CI, 0.55-0.78), nursing home residents (OR, 0.81; 95% CI, 0.71-0.93), and survey respondents represented by a proxy (OR, 0.84; 95% CI, 0.71-0.99) were less likely to use hospice, whereas older decedents (age 75-84 vs 65-74 years: OR, 1.39; 95% CI, 1.12-1.72; age ≥85 vs 65-74 years: OR, 1.39; 95% CI, 1.13-1.71), women (OR, 1.19; 95% CI, 1.05-1.35), and decedents with higher education (high school vs less than high school: OR, 1.17; 95% CI, 1.01-1.36; more than high school vs less than high school: OR, 1.32; 95% CI, 1.13-1.54), more severe cognitive impairment (OR, 1.51; 95% CI, 1.02-2.23), and more instrumental activities of daily living limitations (OR, 1.07; 95% CI, 1.01-1.12) were associated with higher hospice enrollment. A higher proportion of Black and Hispanic decedents with dementia used ED (645 of 809 [79.7%] and 274 of 357 [76.8%] vs 2753 of 3892 [70.7%]; P < .001) and inpatient services (625 of 809 [77.3%] and 275 of 357 [77.0%] vs 2630 of 3892 [67.5%]; P < .001) and incurred roughly 60% higher inpatient expenditures at the end of life compared with White decedents (estimated mean: Black, $23 279; 95% CI, $20 690-$25 868; Hispanic, $23 471; 95% CI, $19 532-$27 410 vs White, $14 609; 95% CI, $13 800-$15 418). A higher proportion of Black and Hispanic than White beneficiaries with dementia who were enrolled in hospice were subsequently admitted to the ED (56 of 309 [18.1%] and 22 of 153 [14.4%] vs 191 of 1967 [9.7%]; P < .001) or hospital (48 of 309 [15.5%] and 17 of 153 [11.1%] vs 119 of 1967 [6.0%]; P < .001) before death. The proportion of dementia beneficiaries completing advance care planning was lower among Black (146 of 704 [20.7%]) and Hispanic (66 of 308 [21.4%]) beneficiaries compared with White beneficiaries (1871 of 3274 [57.1%]). A higher proportion of Black and Hispanic decedents with dementia had written instructions choosing all care possible to prolong life (30 of 144 [20.8%] and 12 of 65 [18.4%] vs 72 of 1852 [3.9%]), whereas a higher proportion of White decedents preferred to limit care in certain situations (1708 of 1840 [92.8%] vs 114 of 141 [80.9%] and 51 of 64 [79.7%]), withhold treatments (1448 of 1799 [80.5%] vs 87 of 140 [62.1%] and 41 of 62 [66.1%]), and forgo extensive life-prolonging measures (1712 of 1838 [93.1%] vs 120 of 138 [87.0%] and 54 of 65 [83.1%]).

CONCLUSIONS AND RELEVANCE

The results of this cohort study highlight unique end-of-life care utilization and treatment preferences across racial and ethnic groups among patients with dementia. Medicare should consider alternative payment models to promote culturally competent end-of-life care and reduce low-value interventions and costs among the population with dementia.

Hypertensive diseases of pregnancy and risk of breast cancer in the Black Women's Health Study

PURPOSE

Compared to white women, Black women have increased risk of developing hypertensive diseases of pregnancy (HDOP) and have a higher incidence of aggressive breast cancer subtypes. Few studies of HDOP and breast cancer risk have included large numbers of Black women. This study examined the relation of HDOP to incidence of breast cancer overall and by estrogen receptor (ER) status in Black women.

METHODS

We followed 42,982 parous women in the Black Women's Health Study, a nationwide prospective study of Black women. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) to assess associations of self-reported HDOP, including preeclampsia and gestational hypertension, with breast cancer incidence overall and by ER subtype, adjusted for age and established breast cancer risk factors.

RESULTS

Over 20 years of follow-up, we identified 2376 incident breast cancer cases. History of HDOP (11.7%) was not associated with breast cancer risk overall (HR 0.98; 95% CI 0.87, 1.11). HRs for invasive ER+ and ER- breast cancer were 1.11 (95% CI 0.93, 1.34) and 0.81 (95% CI 0.61, 1.07), respectively.

CONCLUSIONS

HDOP was not associated with risk of overall breast cancer in Black women. A suggestive inverse association with ER- breast cancer may reflect an anti-tumorigenic hormone profile in HDOP, but those results require confirmation in other studies.

Clinical Stakeholder Perspectives on Pediatric Inpatient Screening for Social Needs

OBJECTIVES

Social determinants of health are major drivers of health outcomes and quality of life. While several social needs screening tools have been created for use in primary care settings, the best procedures to incorporate these tools into hospital workflow remain unclear. This study aimed to elicit clinical stakeholder perspectives on proposed screening for social needs during pediatric hospitalizations, with particular focus on informing implementation strategies.

METHODS

We conducted 23 semistructured interviews with pediatric clinical stakeholders (physicians, nurses, social workers, and case managers) at 1 tertiary and 2 community hospitals between July 2020 and January 2021, on topics including social needs screening practices, benefits and challenges to inpatient screening, and optimal screening and referral processes within hospital workflow. Interviews were recorded, professionally transcribed, and analyzed thematically.

RESULTS

Participants ranged in age from 25 to 62 years, with nearly half working in community hospitals. Regarding inpatient social needs screening, themes emerged about benefits, including enabling clinicians to identify vulnerable patients/moments, and providing clinicians with comprehensive understanding of social context; barriers, including prioritization of medical needs, lack of clinician education surrounding screening, and lack of pre-established relationships; facilitators, including duration of time spent with families, and multidisciplinary clinicians; screening process preferences, including verbal screening, and integration into pre-existing systems; and referral process preferences, including resource provision with family empowerment, and care transition to outpatient clinicians.

CONCLUSIONS

Clinical stakeholders identified multiple barriers, facilitators, and process preferences for pediatric inpatient social needs screening, which may inform the future development of feasible and sustainable implementation strategies.

Development and validation of assessments of adolescent health literacy: a Rasch measurement model approach

BACKGROUND

Health literacy (HL) is implicated in improved health decision-making and health promotion, and reduced racial, ethnic, and socioeconomic health disparities. Three major areas of HL include functional, interactive, and critical HL. HL skills develop throughout the lifespan as individuals' psychosocial and cognitive capacities develop and as they accumulate experiences with navigating health systems. Though adolescence is marked by increased involvement in health decision-making, most HL studies and measures of HL have focused on adults. Both the adult and adolescent HL literature are also limited by the paucity of validated test-based measures for assessing HL. The existing test-based validated HL measures for adolescents were originally designed for adults. However, adolescents are at an earlier phase of developing their HL skills (e.g., fewer experiences navigating the health system) compared to adults and measures originally designed for adults may assume prior knowledge that adolescents may lack therein underestimating adolescents' HL. This study developed and validated test-based assessments of adolescents' functional, interactive, and critical HL.

METHODS

Items were generated in an iterative process: focus groups with adolescents informed item content, cognitive interviews with adolescents and expert consultation established content and face validity of the initial items, and items were revised or removed where indicated. High school students (n = 355) completed a measurement battery including the revised HL items. The items were evaluated and validated using Rasch measurement models.

RESULTS

The final 6-item functional, 10-item interactive, and 7-item critical HL assessments and their composite (23 items) fit their respective Rasch models. Item-level invariance was established for gender (male vs. female), age (12-15-year-olds vs. 16-18-year-olds), and ethnicity in all assessments. The assessments had good convergent validity with an established measure of functional HL and scores on the assessments were positively related to reading instructions before taking medicine and questioning the truthfulness of health information found online.

CONCLUSIONS

These assessments are the first test-based measures of adolescents' interactive and critical HL, the first test-based measure of functional HL designed for adolescents, and the first composite test-based assessment of all three major areas of HL. These assessments should be used to inform strategies for improving adolescents' HL, decision-making, and behaviors.

Implementation of a Patient-Provider Agreement to Improve Healthcare Delivery for Patients With Substance Use Disorder in the Inpatient Setting

OBJECTIVES

Inpatient healthcare delivery to people who use drugs is an opportunity to provide acute medical stabilization and offer treatment for underlying substance use disorder (SUD). The process of delivering quality healthcare to people with SUD can present challenges.

METHODS

We convened a group of stakeholders to discuss challenges and opportunities for improving healthcare safety and employee satisfaction when providing inpatient care to people with SUD.

RESULTS

We developed, implemented, and evaluated a "Pain and Addiction Agreement" tool, a document to guide discussions between providers and patients about expectations and policies for inpatient care.

CONCLUSIONS

In this article, we share our experience of working closely with stakeholders. We hope that our project can serve as a blueprint motivating other centers to pursue quality improvement initiatives to improve healthcare for people with SUD and support the people who take care of them in the hospital.

Assessment of patient navigation programs for breast cancer patients across the city of Boston

PURPOSE

Healthcare systems contribute to disparities in breast cancer outcomes. Patient navigation is a widely cited system-based approach to improve outcomes among populations at risk for delays in care. Patient navigation programs exist in all major Boston hospitals, yet disparities in outcomes persist. The objective of this study was to conduct a baseline assessment of navigation processes at six Boston hospitals that provide breast cancer care in preparation for an implementation trial of standardized navigation across the city.

METHODS

We conducted a mixed methods study in six hospitals that provide treatment to breast cancer patients in Boston. We administered a web-based survey to clinical champions (n = 7) across six sites to collect information about the structure of navigation programs. We then conducted in-person workflow assessments at each site using a semi-structured interview guide to understand site-specific implementation processes for patient navigation programs. The target population included administrators, supervisors, and patient navigators who provided breast cancer treatment-focused care.

RESULTS

All sites offered patient navigation services to their patients undergoing treatment for breast cancer. We identified wide heterogeneity in terms of how programs were funded/resourced, which patients were targeted for navigation, the type of services provided, and the continuity of those services relative to the patient's cancer treatment.

CONCLUSIONS

The operationalization of patient navigation varies widely across hospitals especially in relation to three core principles in patient navigation: providing patient support across the care continuum, targeting services to those patients most likely to experience delays in care, and systematically screening for and addressing patients' health-related social needs. Gaps in navigation across the care continuum present opportunities for intervention.

TRIAL REGISTRATION

Clinical Trial Registration Number NCT03514433, 5/2/2018.

Dementia Diagnosis Disparities by Race and Ethnicity

BACKGROUND

Dementia is often underdiagnosed and this problem is more common among some ethnoracial groups.

OBJECTIVE

The objective of this study was to examine racial and ethnic disparities in the timeliness of receiving a clinical diagnosis of dementia.

RESEARCH DESIGN

This was a prospective cohort study.

SUBJECTS

A total of 3966 participants age 70 years and above with probable dementia in the Health and Retirement Study, linked with their Medicare and Medicaid claims.

MEASURES

We performed logistic regression to compare the likelihood of having a missed or delayed dementia diagnosis in claims by race/ethnicity. We analyzed dementia severity, measured by cognition and daily function, at the time of a dementia diagnosis documented in claims, and estimated average dementia diagnosis delay, by race/ethnicity.

RESULTS

A higher proportion of non-Hispanic Blacks and Hispanics had a missed/delayed clinical dementia diagnosis compared with non-Hispanic Whites (46% and 54% vs. 41%, P<0.001). Fully adjusted logistic regression results suggested more frequent missed/delayed dementia diagnoses among non-Hispanic Blacks (odds ratio=1.12; 95% confidence interval: 0.91-1.38) and Hispanics (odds ratio=1.58; 95% confidence interval: 1.20-2.07). Non-Hispanic Blacks and Hispanics had a poorer cognitive function and more functional limitations than non-Hispanic Whites around the time of receiving a claims-based dementia diagnosis. The estimated mean diagnosis delay was 34.6 months for non-Hispanic Blacks and 43.8 months for Hispanics, compared with 31.2 months for non-Hispanic Whites.

CONCLUSIONS

Non-Hispanic Blacks and Hispanics may experience a missed or delayed diagnosis of dementia more often and have longer diagnosis delays. When diagnosed, non-Hispanic Blacks and Hispanics may have more advanced dementia. Public health efforts should prioritize racial and ethnic underrepresented communities when promoting early diagnosis of dementia.

"I'm not gonna be able to do anything about it, then what's the point?": A broad group of stakeholders identify barriers and facilitators to HCV testing in a Massachusetts jail

BACKGROUND

Despite national guidelines promoting hepatitis C virus (HCV) testing in prisons, there is substantial heterogeneity on the implementation of HCV testing in jails. We sought to better understand barriers and opportunities for HCV testing by interviewing a broad group of stakeholders involved in HCV testing and treatment policies and procedures in Massachusetts jails.

METHODS

We conducted semi-structured interviews with people incarcerated in Middlesex County Jail (North Billerica, MA), clinicians working in jail and community settings, corrections administrators, and representatives from public health, government, and industry between November 2018-April 2019.

RESULTS

51/120 (42%) of people agreed to be interviewed including 21 incarcerated men (mean age 32 [IQR 25, 39], 60% non-White). Themes that emerged from these interviews included gaps in knowledge about HCV testing and treatment opportunities in jail, the impact of captivity and transience, and interest in improving linkage to HCV care after release. Many stakeholders discussed stigma around HCV infection as a factor in reluctance to provide HCV testing or treatment in the jail setting. Some stakeholders expressed that stigma often led decisionmakers to estimate a lower "worth" of incarcerated individuals living with HCV and therefore to decide against paying for HCV testing.".

CONCLUSION

All stakeholders agreed that HCV in the jail setting is a public health issue that needs to be addressed. Exploring stakeholders' many ideas about how HCV testing and treatment can be approached is the first step in developing feasible and acceptable strategies.

Diabetes Control During Massachusetts Insurance Reform

Racial/ethnic disparities in glycemic control-a key diabetes outcome measure-continue to widen, even though the overall prevalence of glycemic control in the US has improved. Health insurance coverage may be associated with improved glycemic control, but few studies examine effects during a period of policy change. We assessed changes in glycemic control by racial/ethnic groups following the Massachusetts Health Insurance Reform for patients at two urban safety-net academic health systems between January 2005 and December 2013. We analyzed outcomes for three measures of poor glycemic control: 1) lack of a hemoglobin A1C (A1C) measure during a 6-month period; 2) A1C >8%; 3) A1C >9% before, during, and after implementation of insurance reform. We did not find increased rates of A1C monitoring or control following insurance reform overall or for specific racial/ethnic groups. We found evidence of worsened, not improved, glycemic control in some racial/ethnic groups in the post-reform period. The expansion of affordable insurance coverage was not associated with improved glycemic control in vulnerable populations.

Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial

IMPORTANCE

Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results.

OBJECTIVE

To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020.

INTERVENTIONS

Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon's discretion.

MAIN OUTCOMES AND MEASURES

The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 [worst] to 100 [best]; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score.

RESULTS

Among 163 patients who were randomized (mean age, 62 years; 80 [49%] women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, -2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%).

CONCLUSIONS AND RELEVANCE

Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02076113.

Surgical Predictive Model for Breast Cancer Patients Assessing Acute Postoperative Complications: The Breast Cancer Surgery Risk Calculator

BACKGROUND

Prognostic tools, such as risk calculators, improve the patient-physician informed decision-making process. These tools are limited for breast cancer patients when assessing surgical complication risk preoperatively.

OBJECTIVE

In this study, we aimed to assess predictors associated with acute postoperative complications for breast cancer patients and then develop a predictive model that calculates a complication probability using patient risk factors.

METHODS

We performed a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2017. Women diagnosed with ductal carcinoma in situ or invasive breast cancer who underwent either breast conservation or mastectomy procedures were included in this predictive modeling scheme. Four models were built using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. Model performance, accuracy and calibration measures during internal/external validation included area under the curve, Brier score, and Hosmer-Lemeshow statistic, respectively.

RESULTS

A total of 163,613 women met the inclusion criteria. The area under the curve for each model was as follows: overall, 0.70; infectious, 0.67; hematologic, 0.84; and internal organ, 0.74. Brier scores were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values to be > 0.05. Using model coefficients, individualized risk can be calculated on the web-based Breast Cancer Surgery Risk Calculator (BCSRc) platform ( www.breastcalc.org ).

CONCLUSION

We developed an internally and externally validated risk calculator that estimates a breast cancer patient's unique risk of acute complications following each surgical intervention. Preoperative use of the BCSRc can potentially help stratify patients with an increased complication risk and improve expectations during the decision-making process.

The Influence of Health Insurance Stability on Racial/Ethnic Differences in Diabetes Control and Management

Objective

This study examined whether health insurance stability was associated with improved type 2 diabetes mellitus (DM) control and reduced racial/ethnic health disparities.

Methods

We utilized electronic medical record data (2005-2013) from two large, urban academic health systems with a racially/ethnically diverse patient population to examine insurance coverage, and three DM outcomes (poor diabetes control, A1c ≥8.0%; very poor diabetes control A1c >9.0%; and poor BP control, ≥ 130/80 mm Hg) and one DM management outcome (A1c monitoring). We used generalized estimating equations adjusting for age, sex, comorbidities, site of care, education, and income. Additional analysis examined if insurance stability (stable public or private insurance over the six-month internal) moderates the impact of race/ethnicity on DM outcomes.

Results

Nearly 50% of non-Hispanic (NH) Whites had private insurance coverage, compared with 33.5% of NH Blacks, 31.5% of Asians, and 31.1% of Hispanics. Overall, and within most racial/ ethnic groups, insurance stability was associated with better glycemic control compared with those with insurance switches or always being uninsured, with uninsured NH Blacks having significantly worse BP control. More NH Black and Hispanic patients had poorly controlled (A1c≥8%) and very poorly controlled (A1c>9%) diabetes across all insurance stability types than NH Whites or Asians. The interaction between insurance instability and race/ethnic groups was statistically significant for A1c monitoring and BP control, but not for glycemic control.

Conclusion

Stable insurance coverage was associated with improved DM outcomes for all racial / ethnic groups, but did not eliminate racial ethnic disparities.

Can Community Health Workers Increase Palliative Care Use for African American Patients? A Pilot Study

PURPOSE

African American patients with cancer underutilize advance care planning (ACP) and palliative care (PC). This feasibility study investigated whether community health workers (CHWs) could improve ACP and PC utilization for African American patients with advanced cancer.

METHODS

African American patients diagnosed with an advanced solid organ cancer (stage IV or stage III disease with a palliative performance score < 60%) were enrolled. Patients completed baseline surveys that assessed symptom burden and distress at baseline and 3 months post-CHW intervention. The CHW intervention consisted of a comprehensive assessment of multiple PC domains and social determinants of health. CHWs provided tailored support and education on the basis of iterative assessment of patient needs. Intervention feasibility was determined by patient and caregiver retention rate above 50% at 3 months.

RESULTS

Over a 12-month period, 24 patients were screened, of which 21 were deemed eligible. Twelve patients participated in the study. Patient retention was high at 3 months (75%) and 6 months (66%). Following the CHW intervention, symptom assessment as measured by Edmonton Symptom Assessment System improved from 33.8 at baseline to 18.8 (P = .03). Psychological distress improved from 5.5 to 4.7 (P = .36), and depressive symptoms from 42.2 to 33.6 (P = .09), although this was not significant. ACP documentation improved from 25% at baseline to 75% at study completion. Sixty-seven percentage of patients were referred to PC, with 100% of three decedents using hospice.

CONCLUSION

Utilization of CHWs to address PC domains and social determinants of health is feasible. Although study enrollment was identified as a potential barrier, most recruited patients were retained on study.

Development of an Actionable Framework to Address Cancer Care Disparities in Medically Underserved Populations in the United States: Expert Roundtable Recommendations

Cancer disparities persist among medically underserved populations despite widespread efforts to address them. We describe the development of a framework for addressing cancer care disparities across the cancer care continuum (CCC), guided by the CCC domains established by the Institute of Medicine/National Academies of Sciences, Engineering, and Medicine (IOM/NAS).

Contributors to Independent Research Funding Success from the Perspective of K12 BIRCWH Program Directors

INTRODUCTION

Faculty training awards are an important means of advancing early career faculty in research. The National Institutes of Health (NIH) Building Interdisciplinary Research Careers in Women's Health (BIRCWH) is a long-running K12 career development program and has been integral in promoting the research success of faculty nationally. We surveyed BIRCWH program directors to understand factors likely to influence long-term research careers and funding success.

MATERIALS AND METHODS

We developed an online survey containing open-ended questions about individual and programmatic attributes and activities that promote success in achieving independent research funding. Domains of interest included: 1) strategies for funding success; 2) traits for predicting success; 3) groups considered vulnerable to attrition; and 4) existing resources and means of support.

RESULTS

Fifteen institutions (75%) were included in the final analysis. Passion for research, persistence, resilience, and strong mentorship relationships were identified by all directors as factors important to scholar success. Responses also revealed an important pattern: program directors attributed attrition either to individual or organizational characteristics. This distinction has meaningful consequences for framing efforts to diminish attrition. Faculty who were clinicians, women, parents and underrepresented minorities were identified as vulnerable to attrition from the research careers. Common perceived challenges in these groups included isolation/feeling alienated, juggling numerous priorities, inadequate research time, lack of role models, and work-life balance issues.

CONCLUSION

K12 BIRCWH directors identified persistence and resilience and developing community, networks, and other support opportunities as elements of scholar success. Programs and mentors can help early career faculty by teaching skills and providing tools they can use to maximize the value of these opportunities and expand their mentees' research relationships. Our study also highlights the importance of social factors, particularly isolation, on clinicians, women, and minoritized scholars on career success.

Evaluating the Role of Self-Esteem on Differential Career Outcomes by Gender in Academic Medicine

PURPOSE

Gender differences in faculty advancement persist in academic medicine. Understanding of what drives these differences remains limited. The relationship among self-esteem, gender, and career outcomes has not previously been explored.

METHOD

The authors evaluated the association between gender and 2012-2013 career outcomes, specifically, the number of publications, academic rank, leadership positions, and retention, and whether self-esteem as measured in the 1995 National Faculty Survey mediates this relationship. They measured self-esteem using the modified Rosenberg Self-Esteem Scale. The authors used multivariable logistic regression analysis to understand the association among gender, self-esteem, and the outcomes of rank, leadership, and retention, and negative binomial models for number of publications. Models were adjusted for race, specialty, effort distribution, and years since first faculty appointment. The authors performed a mediation analysis to understand whether self-esteem mediates the relationship between gender and these career outcomes.

RESULTS

Overall, self-esteem scores were high. Women had lower self-esteem in 1995 than their male colleagues. In adjusted models, female gender was associated with lower performance on all 4 career outcome metrics. While self-esteem scores were positively associated with all 4 outcomes, the authors' mediation analysis suggested that self-esteem did not mediate the relationship between gender and these 4 career metrics.

CONCLUSIONS

Female medical faculty members lag behind men on traditional metrics of faculty achievement. While higher self-esteem is positively associated with faculty achievement, it did not mediate the relationship between gender and career advancement over the 17 years of follow-up and, thus, may not be an ideal target for programs and policies to increase gender parity in academic medicine.

Late-afternoon communication and patient planning (CAPP) rounds: an intervention to allow early patient discharges

OBJECTIVE

Measure effect of late-afternoon communication and patient planning (CAPP) rounds to increase early electronic discharge orders (EDO).

METHODS

We enrolled 4485 patients discharged from six subspecialty medical services. We implemented late-afternoon CAPP rounds to identify patients who could have morning discharge the subsequent day. After an initial successful implementation of the intervention, we identified lack of sustainability. We made changes with sustained implementation of the intervention. This is a before-after study of a quality improvement intervention.

PROGRAM EVALUATION

Primary measures of intervention effectiveness were percentage of patients who received EDO by 11 am and patients discharged by noon. Additional measure of effectiveness were percent of patients admitted to the correct ward, emergency department (ED)-to-ward transfer time compared between intervention and nonintervention periods. We compared the overall expected LOS and the average weekly discharges to assess for comparability across the control and intervention time periods. We used the readmission rate as balancing measure to ensure that the intervention was not have unintended negative patients consequences.

RESULTS

Expected length of stay based upon discharge diagnosis/comorbidities and readmission rates were similar across the intervention and control time periods. The average weekly discharges were not statistically significant. Percentage of EDO by 11 am was higher in the first intervention period, second intervention period and combined intervention periods (28.9% vs. 21.8%, P < 0.001) compared with the respective control periods. Percent discharged before noon increased in the first intervention period, second intervention period and for the combined intervention periods (17 vs. 11.8%, P < 0.001). There was no difference in the percent admitted to the correct ward and ED-to-ward transfer time.

CONCLUSION

Afternoon CAPP rounds to identify early patient discharges the following day led to increase in EDO entered by 11 am and discharges by noon without an adverse change in readmission rates and LOS.

Theory-Based Development of an Implementation Intervention Using Community Health Workers to Increase Palliative Care Use

CONTEXT

Opportunities for the use of palliative care services are missed in African American (AA) communities, despite Level I evidence demonstrating their benefits.

OBJECTIVES

Single-institution and stakeholder-engaged study to design an intervention to increase palliative care use in AA communities.

METHODS

Two-phased qualitative research design guided by the Behavior Change Wheel and Theoretical Domains Framework models. In Phase 1, focus group sessions were conducted to identify barriers and facilitators of palliative care use and the viability of community health workers (CHWs) as a solution. After applying the Behavior Change Wheel and Theoretical Domains Framework to data gathered from Phase 1, Phase 2 consisted of a stakeholder meeting to select intervention content and prioritize modes of delivery.

RESULTS

A total of 15 stakeholders participated in our study. Target behaviors identified were for patients to gain knowledge about benefits of palliative care, physicians to begin palliative care discussions earlier in treatment, and to improve patient-physician interpersonal communication. The intervention was designed to improve patient capability, physician capability, patient motivation, physician motivation, and increase patient opportunities to use palliative care services. Strategies to change patient and physician behaviors were all facilitated by CHWs and included creation and dissemination of brochures about palliative care to patients, empowerment and activation of patients to initiate goals-of-care discussions, outreach to community churches, and expanding patient social support.

CONCLUSION

Use of a theory-based approach to facilitate the implementation of a multi-component strategy provided a comprehensive means of identifying relevant barriers and enablers of CHWs as an agent to increase palliative care use in AA communities.

Abstract D080: Securing the cancer continuum of care model for racially and ethnically diverse and medically underserved populations

Disparities in access to cancer care and treatment outcomes among racial, ethnic and underserved populations have been observed for decades. Despite a plethora of national and local initiatives aimed at addressing these disparities, progress to date has been limited. Guided by the domains of the cancer care continuum (CCC) established by the IOM/NASEM [1] the Diverse Cancer Communities Working Group [2] (CWG) will deliver a framework with domains, processes and activities which when disseminated and implemented in the US, will contribute in an impactful way to addressing cancer care disparities. To achieve our goal, we utilized methodology similar to that used to identify best practices in recruiting diverse patients into cancer clinical trials.[3] We conducted an environmental scan to identify strategies and associated experts who successfully provided community and/or patient-centric, IOM defined domain standards in our population of interest. The environmental scan was conducted between March and September 2018, resulting in the identification of 84 unique experts and 44 unique patient organizations. The identified experts had documented processes and best practices along the six CCC domains as follows: Prevention & Risk Reduction (29%); Screening (30%); Diagnosis (11%); Treatment (8%); Survivorship (18%); and End-of-Life (5%). Of the 84 participants, 26% are experts in all six domains, 36% are experts in multiple domains, and 14% are also experts in Patient Navigator Research Programs. Drawing from our environmental scan, the CWG engaged the experts and advocates to develop the foundation for a theoretical underpinning of an evidence-based, practical continuum of care framework. Highest cross-cancer-continuum areas of impact included 1) patient navigation which addresses barriers to enable patients to progress successfully along the cancer continuum of care, 2) excellence in community engagement, a necessary mandate to build trust in among minority and underserved populations, and 3) implementation of health care system changes based on real-world examples. Additionally, experts focused on opportunities to close gaps between the CCC domains with specific emphasis on screening, diagnosis, treatment, and survivorship, with the understanding that health care system change is often effectively sustained by long-term policy implementation that ultimately increases access, utilization and standardization across the continuum. This adapted framework is intended to guide researchers, health care leaders and policy leaders to promote health equity in cancer outcomes. References: [1] Institute of Medicine 2013. Delivering High-Quality Cancer Care; Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. https://doi.org/10.17226/18359; [2] URL: http://shcllc.info/cancer-working-group/ [3] URL: http://ascopubs.org/doi/full/10.1200/JOP.18.00638

Citation Format: Jeanne M. Regnante, Karen Winkfield, MD, PhD, Ellen Sonet, JD, MBA, Evelyn Gonzalez, Karen M. Freund, MD, Simon Craddock Lee, PhD, Scarlett Lin Gomez, PhD, MPH, Nina Bickell, MD, Lynette Bonar, PhD, Michelle Vichnin, MD, Nicole Richie, PhD, Richardae Araojo, PharmD, Andrea Ferris, MBA, Thomas Farrington, Linda Fleisher, PhD, MPH, Carolyn Fang, PhD, Laura Lee Hall, PhD, Renee Nicolas, Shyrea Thompson, Marilyn Metcalf, PhD, Patti Fine Jewell, PhD, Marianne Gandee, Anna Forte, PhD, Elizabeth Franklin. PhD, Patti Doykos, PhD. Securing the cancer continuum of care model for racially and ethnically diverse and medically underserved populations [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D080.

Translating research into practice: Protocol for a community-engaged, stepped wedge randomized trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative

BACKGROUND

Racial and socioeconomic disparities in breast cancer mortality persist. In Boston, MA, Black, Non-Hispanic women and Medicaid-insured individuals are 2-3 times more likely to have delays in treatment compared to White or privately insured women. While evidence-based care coordination strategies for reducing delays exist, they are not systematically implemented across healthcare settings.

METHODS

Translating Research Into Practice (TRIP) utilizes community engaged research methods to address breast cancer care delivery disparities. Four Massachusetts Clinical and Translational Science Institute (CTSI) hubs collaborated with the Boston Breast Cancer Equity Coalition (The Coalition) to implement an evidence-based care coordination intervention for Boston residents at risk for delays in breast cancer care. The Coalition used a community-driven process to define the problem of care delivery disparities, identify the target population, and develop a rigorous pragmatic approach. We chose a cluster-randomized, stepped-wedge hybrid type I effectiveness-implementation study design. The intervention implements three evidence-based strategies: patient navigation services, a shared patient registry for use across academic medical centers, and a web-based social determinants of health platform to identify and address barriers to care. Primary clinical outcomes include time to first treatment and receipt of guideline-concordant treatment, which are captured through electronic health records abstraction. We will use mixed methods to collect the secondary implementation outcomes of acceptability, adoption/penetration, fidelity, sustainability and cost.

CONCLUSION

TRIP utilizes an innovative community-driven research strategy, focused on interdisciplinary collaborations, to design and implement a translational science study that aims to more efficiently integrate proven health services interventions into clinical practice.

Racial and Ethnic Differences in Knowledge About One's Dementia Status

OBJECTIVES

To examine racial and ethnic differences in knowledge about one's dementia status.

DESIGN

Prospective cohort study.

SETTING

The 2000 to 2014 Health and Retirement Study.

PARTICIPANTS

Our sample included 8,686 person-wave observations representing 4,065 unique survey participants, aged 70 years or older, with dementia, as identified by a well-validated statistical prediction model based on individual demographic and clinical characteristics.

MEASUREMENTS

Primary outcome measure was knowledge of one's dementia status, as reported in the survey. Patient characteristics included race/ethnicity, age, sex, survey year, cognition, function, comorbidity, and whether living in a nursing home.

RESULTS

Among subjects identified as having dementia by the prediction model, 43.5% to 50.2%, depending on the survey year, reported that they were informed of the dementia status by their physician. This proportion was lower among Hispanics (25.9%-42.2%) and non-Hispanic blacks (31.4%-50.5%) than among non-Hispanic whites (47.7%-52.9%). Our fully adjusted regression model indicated lower dementia awareness among non-Hispanic blacks (odds ratio [OR] = 0.74; 95% confidence interval [CI] = 0.58-0.94) and Hispanics (OR = 0.60; 95% CI = 0.43-0.85), compared to non-Hispanic whites. Having more instrumental activity of daily living limitations (OR = 1.65; 95% CI = 1.56-1.75) and living in a nursing home (OR = 2.78; 95% CI = 2.32-3.32) were associated with increased odds of subjects reporting being told about dementia by a physician.

CONCLUSION

Less than half of individuals with dementia reported being told by a physician about the condition. A higher proportion of non-Hispanic blacks and Hispanics with dementia may be unaware of their condition, despite higher dementia prevalence in these groups, compared to non-Hispanic whites. Dementia outreach programs should target diverse communities with disproportionately high disease prevalence and low awareness. J Am Geriatr Soc 68:1763-1770, 2020.

Is insurance instability associated with hypertension outcomes and does this vary by race/ethnicity?

BACKGROUND

Stable health insurance is often associated with better chronic disease care and outcomes. Racial/ethnic health disparities in outcomes are prevalent and may be associated with insurance instability, particularly in the context of health insurance reform.

METHODS

We examined whether insurance instability was associated with uncontrolled blood pressure (UBP) and whether this association varied by race/ethnicity. We used a retrospective longitudinal observational cohort study of patients diagnosed with hypertension who obtained care within two health systems in Massachusetts. We measured the UBP, insurance instability, and race of 43,785 adult primary care patients, age 21-64 with visits from 1/2005-12/2013.

RESULTS

We found higher rates of UBP for blacks and Hispanics at each time point over the entire 9 years. Insurance instability was associated with greater rates of UBP. Always uninsured black patients fared worst, while white and Hispanic patients with consistent public insurance fared best.

CONCLUSIONS

Stable insurance of any type was associated with better hypertension control than no or unstable insurance.

Effects of sexual harassment on advancement of women in academic medicine: A multi-institutional longitudinal study

BACKGROUND

Sexual harassment of women in academic medicine may impede advancement and productivity. This study analyzes the longitudinal effects of sexual harassment on academic advancement and productivity among women.

METHODS

We undertook a longitudinal analysis to predict effects of sexual harassment reported in 1995 on career outcomes measured in 2012-13, among a sample of women in academic medicine (N = 1273) recruited from 24 U.S. medical schools. Measures included survey data from 1995 on sexual harassment (predictor), and 2012-2013 data on retention in academic medicine, rank, leadership positions, and refereed publications (outcomes), captured from surveys and public records. We used multivariable models to test effects of sexual harassment on study outcomes, adjusting for socio-demographics, employment-related variables, and gender discrimination.

FINDINGS

In 1995, 54% of women reported any workplace sexual harassment, and 32% of women reported severe harassment (e.g., threats or coercive sexual advances) in the workplace. Multivariable regression models showed no significant effects of sexual harassment. However, severe sexual harassment was associated with higher odds of attaining full professorship by 2012-2013 (AOR: 1·70; 95% CI 1·03, 2·80; p = 0·04).

INTERPRETATION

Contrary to our hypothesis, women reporting severe workplace harassment in 1995 were more rather than less likely to advance to full professor. Women seeking advancement may be more vulnerable to sexual harassment in academic medicine vis a vis greater exposure to those who abuse their position of authority.

FUNDING

NIvH R01GM088470; Doris Duke Foundation 2016D007145; BMGF OPP1163682.

Parent Perspectives During Hospital Readmissions for Children With Medical Complexity: A Qualitative Study

OBJECTIVES

Children with medical complexity (CMC) have high readmission rates, but relatively little is known from the parent perspective regarding care experiences surrounding and factors contributing to readmissions. We aimed to elicit parent perspectives on circumstances surrounding 30-day readmissions for CMC.

METHODS

We conducted 20 semistructured interviews with parents of CMC experiencing an unplanned 30-day readmission at 1 academic medical center between December 2016 and January 2018, asking about topics such as previous discharge experiences, medical services and resources, and home environment and social support. Interviews were recorded, professionally transcribed, and analyzed thematically by using a modified grounded theory approach.

RESULTS

Children ranged in age from 0 to 15 years, with neurologic complex chronic conditions being predominant (35%). Although the majority of parents did not identify any factors that they perceived to have contributed to readmission, themes emerged regarding challenges associated with chronicity of care and transitions of care that might influence readmissions, including frequency of hospital use, symptom confusion, lack of inpatient continuity, resources needed but not received, and difficulty filling prescriptions.

CONCLUSIONS

Parents identified multiple challenges associated with chronicity of medical management and transitions of care for CMC. Future interventions aiming to improve continuity and communication between admissions, ensure that home services are provided when applicable and prescriptions are filled, and provide comprehensive support for families in both the short- and long-term may help improve patient and family experiences while potentially decreasing readmissions.

Timeliness of Treatment Initiation in Newly Diagnosed Patients With Breast Cancer

BACKGROUND

Evidence-based timeliness benchmarks have been established to assess quality of breast cancer care, as delays in treatment are associated with poor clinical outcomes. However, few studies have evaluated how current breast cancer care meets these benchmarks and what factors may delay the timely initiation of treatment.

PATIENTS AND METHODS

Demographic and disease characteristics of 377 newly diagnosed patients with breast cancer who initiated treatment at Tufts Medical Center (2009-2015) were extracted from electronic medical records. Time from diagnosis to initial surgery and time from diagnosis to initiation of hormone therapy were estimated with Kaplan-Meier curves. Multivariable regression analysis was used to identify factors associated with treatment delays. Thematic analysis was performed to categorize reasons for delay.

RESULTS

Of 319 patients who had surgery recommended as the first treatment, 248 (78%) met the 45-day benchmark (median, 28 days; 25th-75th %, 19-43). After adjusting for potential confounders, multivariable regression analysis revealed that negative hormone receptor status (odds ratio, 3.48; 95% confidence interval, 1.44-8.43) and mastectomy (odds ratio, 4.07; 95% confidence interval, 2.10-8.06) were significantly associated with delays in surgery. Delays were mostly owing to clinical complexity or logistical/financial reasons. Of 241 patients eligible for hormone therapy initiation, 232 (96%) met the 1-year benchmark (median, 147 days; 25th-75th %, 79-217).

CONCLUSION

Most patients met timeliness guidelines for surgery and initiation of hormone therapy, although risk factors for delay were identified. Knowledge of reasons for breast cancer treatment delay, including clinical complexity and logistical/financial issues, may allow targeting interventions for patients at greatest risk of care delays.

Achieving Gender and Social Equality: More Than Gender Parity Is Needed

In this Perspective, the authors review Association of American Medical Colleges data on gender parity and intersectionality, consider the literature on gender parity in academic medicine and the underlying gender norms that explain these statistics, and offer recommendations for moving past indicators of parity to achieve gender and social equality.Improvements in gender parity among medical school graduates have not translated to gender parity among practicing physicians or medical school faculty, particularly for racial/ethnic minorities. Further, gender parity does not correspond to gender equality, such that gender-based disparities in salaries and advancement persist. In addition, social norms related to traditional gender role expectations reinforce existing biases and lead to sexual harassment and discrimination against women in the workplace.Building on their analysis of existing data and the literature, the authors offer concrete recommendations to achieve gender equality in academic medicine that not only improve parity but also support policies and practices to address the norms that further bias and discrimination. These recommendations include the collection, monitoring, and open reporting of data on salaries as well as on sex and race/ethnicity; stronger policies related to family leave and sexual discrimination and harassment; and accountability structures to ensure that policies are enforced. While these efforts alone cannot eliminate gender inequalities, academic medicine should be at the forefront of creating a climate in medicine that is supportive of gender equality as part of their larger goal of promoting social equality.

The Relationship Between Health Literacy, Cancer Prevention Beliefs, and Cancer Prevention Behaviors

While cancer prevention behaviors have been clearly defined, many people do not engage in these risk-reduction behaviors. Factors such as cancer prevention beliefs and limited health literacy may undermine cancer prevention behavior recommendations. This study explored the relationships between cancer prevention beliefs, health literacy, and cancer prevention behaviors. Data were analyzed from the 2013 Health Information National Trends Survey (n = 1675). Regression analyses for four cancer prevention belief (prevention is not possible, cancer is fatal, there are too many recommendations for prevention, everything causes cancer) statements were modeled, including health literacy and sociodemographic variables as predictors. In addition, separate regression analyses predicted four cancer prevention behaviors (fruit and vegetable consumption, physical activity, cigarette smoking) from cancer prevention beliefs, health literacy, and sociodemographic variables. Participants with low health literacy were more likely to hold fatalistic cancer prevention beliefs than those with higher health literacy. Cancer prevention beliefs were related to less fruit and vegetable consumption, fewer days of physical activity, and with being a nonsmoker after controlling for sociodemographic variables. Health literacy was not a significant predictor of cancer prevention behaviors. Given the relationship between health literacy and cancer prevention beliefs, research is needed to ascertain how to empower patients with low health literacy to have a more realistic understanding of cancer.

Standardized activities for lay patient navigators in breast cancer care: Recommendations from a citywide implementation study

BACKGROUND

There is a need for guidelines on patient navigation activities to promote both the quality of patient navigation and the standards of reimbursement for these services because a lack of reimbursement is a major barrier to the implementation, maintenance, and sustainability of these programs.

METHODS

A broad community-based participatory research process was used to identify the needs of patients for navigation. A panel of stakeholders of clinical providers was convened to identify specific activities for navigators to address the needs of patients and providers with the explicit goal of reducing delays in the initiation of cancer treatment and improving adherence to the care plan.

RESULTS

Specific activities were identified that could be generalized to all patient navigation programs for care during active cancer management to address the needs of vulnerable communities.

CONCLUSIONS

Oncology programs that seek to implement lay patient navigation may benefit from the adoption of these activities for quality monitoring. Such activities are necessary as we consider reimbursement strategies for navigators without clinical training or licensure.