Lessons From an Implementation Evaluation of a Real-World Multi-City Initiative to Address COVID-19 Vaccination Inequities

Background: The COVID-19 pandemic shed light on stark racial and ethnic inequities in access to care and accurate health information in the U.S. When COVID-19 vaccines became available, communities of color faced multiple barriers that contributed to low vaccine rates. To address this gap, the Equity-First Vaccination Initiative supported community organizations in five demonstration cities to plan and implement hyper-local strategies to increase COVID-19 vaccine access and uptake among communities of color.Purpose: To draw learnings from the experiences of the participating organizations, we applied a framework that integrated implementation science and health equity principles.Design and sample: In this commentary, we describe how we used this framework to guide qualitative interviews with community organizations, focusing on insights across five implementation elements (reach, design, implementation, adaptation, implementation outcomes).Conclusions: Learnings from this evaluation may help guide future implementation of similarly complex initiatives involving multiple organizations and sites to advance health equity during a public health crisis.

Effects of a Faith-Based Obesity Intervention on African American and Latino Adults' Children

BACKGROUND

Faith-based interventions are promising for promoting healthy behaviors among adults, but their ripple effects on participants' children are unknown. This study is one of the first to assess the effects of a faith-based multilevel obesity intervention on adult participants' children.

METHODS

We analyzed quantitative data from a cluster randomized controlled trial with two African American and two Latino churches in South Los Angeles, California, which invited adult participants to enroll one child (5-17 years) in a sub-study. At baseline and 6-7 months follow-up, parents completed a child health survey, which included the family nutrition and physical activity screening tool, and child height and weight were measured (n = 50).

RESULTS

Results from linear regression models showed children of intervention participants, compared to control, had significantly better dietary patterns at follow-up.

CONCLUSIONS

Findings suggest the health benefits of a faith-based multilevel obesity intervention for adults can extend to children and may help address obesity disparities.

Lessons Learned about Developing Faith and Public Health Partnerships to Address Health Disparities

Partnerships between public health and faith-based organizations draw on the strengths of both sectors to achieve a shared interest in promoting health and reducing disparities. However, information about implementation of faith and public health partnerships-particularly those involving diverse racial-ethnic groups-is limited. This paper reports on findings from qualitative interviews conducted with 16 public health and congregational leaders around the country as part of the early phase of the development of a faith and public health partnership to address health disparities in Los Angeles, CA. We identified eight themes regarding the barriers and facilitators to building faith and public health partnerships and distilled these into 10 lessons for developing such approaches. These interviews identified that engaging religious organizations often requires building congregational capacity of the congregation to participate in health programs; and that trust is a critically important element of these relationships. Further, trust is closely related to how well each organization involved in the partnership understands their partners' belief structures, approaches to addressing health and well-being and capacities to contribute to the partnership. Tailoring congregational health programs to match the interests, needs and capacity of partners was identified as an important approach to ensuring that the partnership is successful. But, this is complicated by working across multiple faith traditions and the racial-ethnic backgrounds, thus requiring increased and diverse communication strategies on the part of the partnership leadership. These lessons provide important information for faith and public health leaders interested in developing partnered approaches to address health in diverse urban communities.

Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending: A Randomized Clinical Trial

Importance

The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown.

Objective

To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years.

Design, Setting, and Participants

This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018.

Intervention

Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%).

Main Outcomes and Measures

Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021.

Results

High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85).

Conclusions and Relevance

The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention.

Trial Registration

ClinicalTrials.gov Identifier: NCT04047147.

The U.S. Equity-First Vaccination Initiative: Impacts and Lessons Learned

The one-year U.S. Equity-First Vaccination Initiative (EVI), launched in April 2021, aimed to reduce racial inequities in coronavirus disease 2019 (COVID-19) vaccination across five demonstration cities (Baltimore, Chicago, Houston, Newark, and Oakland) and over the longer term strengthen the United States' public health system to achieve more-equitable outcomes. This initiative comprised nearly 100 community-based organizations (CBOs), who led hyper-local work to increase vaccination access and confidence in communities of individuals who identify as Black, Indigenous, and People of Color. In this study, the second of two on the initiative, the authors examine the results of the EVI. They look at the initiative's activities, effects, and challenges, and provide recommendations for how to support and sustain this hyper-local community-led approach and strengthen the public health system in the United States.

The association of strained ICU capacity with hospital patient racial and ethnic composition and federal relief during the COVID-19 pandemic

OBJECTIVE

To identify the association between strained intensive care unit (ICU) capacity during the COVID-19 pandemic and hospital racial and ethnic patient composition, federal pandemic relief, and other hospital characteristics.

DATA SOURCES

We used government data on hospital capacity during the pandemic and Provider Relief Fund (PRF) allocations, Medicare claims and enrollment data, hospital cost reports, and Social Vulnerability Index data.

STUDY DESIGN

We conducted cross-sectional bivariate analyses relating strained capacity and PRF award per hospital bed with hospital patient composition and other characteristics, with and without adjustment for hospital referral region (HRR).

DATA COLLECTION

We linked PRF data to CMS Certification Numbers based on hospital name and location. We used measures of racial and ethnic composition generated from Medicare claims and enrollment data. Our sample period includes the weeks of September 18, 2020 through November 5, 2021, and we restricted our analysis to short-term, general hospitals with at least one intensive care unit (ICU) bed. We defined "ICU strain share" as the proportion of ICU days occurring while a given hospital had an ICU occupancy rate ≥ 90%.

PRINCIPAL FINDINGS

After adjusting for HRR, hospitals in the top tercile of Black patient shares had higher ICU strain shares than did hospitals in the bottom tercile (30% vs. 22%, p < 0.05) and received greater PRF amounts per bed ($118,864 vs. $92,407, p < 0.05). Having high versus low ICU occupancy relative to pre-pandemic capacity was associated with a modest increase in PRF amounts per bed after adjusting for HRR ($107,319 vs. $96,627, p < 0.05), but there were no statistically significant differences when comparing hospitals with high versus low ICU occupancy relative to contemporaneous capacity.

CONCLUSIONS

Hospitals with large Black patient shares experienced greater strain during the pandemic. Although these hospitals received more federal relief, funding was not targeted overall toward hospitals with high ICU occupancy rates.

Church-based interventions to address obesity among African Americans and Latinos in the United States: a systematic review

CONTEXT

Multilevel church-based interventions may help address racial/ethnic disparities in obesity in the United States since churches are often trusted institutions in vulnerable communities. These types of interventions affect at least two levels of socio-ecological influence which could mean an intervention that targets individual congregants as well as the congregation as a whole. However, the extent to which such interventions are developed using a collaborative partnership approach and are effective with diverse racial/ethnic populations is unclear, and these crucial features of well-designed community-based interventions.

OBJECTIVE

The present systematic literature review of church-based interventions was conducted to assess their efficacy for addressing obesity across different racial/ethnic groups (eg, African Americans, Latinos).

DATA SOURCES AND EXTRACTION

In total, 43 relevant articles were identified using systematic review methods developed by the Center for Disease Control and Prevention (CDC)'s Task Force on Community Preventive Services. The extent to which each intervention was developed using community-based participatory research principles, was tailored to the particular community in question, and involved the church in the study development and implementation were also assessed.

DATA ANALYSIS

Although 81% of the studies reported significant results for between- or within-group differences according to the study design, effect sizes were reported or could only be calculated in 56% of cases, and most were small. There was also a lack of diversity among samples (eg, few studies involved Latinos, men, young adults, or children), which limits knowledge about the ability of church-based interventions to reduce the burden of obesity more broadly among vulnerable communities of color. Further, few interventions were multilevel in nature, or incorporated strategies at the church or community level.

CONCLUSIONS

Church-based interventions to address obesity will have greater impact if they consider the diversity among populations burdened by this condition and develop programs that are tailored to these different populations (eg, men of color, Latinos). Programs could also benefit from employing multilevel approaches to move the field away from behavioral modifications at the individual level and into a more systems-based framework. However, effect sizes will likely remain small, especially since individuals only spend a limited amount of time in this particular setting.

Feasibility and acceptability of a mobile messaging program within a church-based healthy living intervention for African Americans and Latinos

Church-based programs can act on multiple levels to improve dietary and physical activity behaviors among African Americans and Latinos. However, the effectiveness of these interventions may be limited due to challenges in reaching all congregants or influencing behavior outside of the church setting. To increase intervention impact, we sent mobile messages (text and email) in English or Spanish to congregants (n = 131) from predominantly African American or Latino churches participating in a multi-level, church-based program. To assess feasibility and acceptability, we collected feedback throughout the 4-month messaging intervention and conducted a process evaluation using the messaging platform. We found that the intervention was feasible to implement and acceptable to a racially ethnically diverse study sample with high obesity and overweight rates. While the process evaluation had some limitations (e.g. low response rate), we conclude that mobile messaging is a promising, feasible addition to church-based programs aiming to improve dietary and physical activity behaviors.

Eat, Pray, Move: A Pilot Cluster Randomized Controlled Trial of a Multilevel Church-Based Intervention to Address Obesity Among African Americans and Latinos

PURPOSE

To implement a multilevel, church-based intervention with diverse disparity populations using community-based participatory research and evaluate feasibility, acceptability, and preliminary effectiveness in improving obesity-related outcomes.

DESIGN

Cluster randomized controlled trial (pilot).

SETTING

Two midsized (∼200 adults) African American baptist and 2 very large (∼2000) Latino Catholic churches in South Los Angeles, California.

PARTICIPANTS

Adult (18+ years) congregants (n = 268 enrolled at baseline, ranging from 45 to 99 per church).

INTERVENTION

Various components were implemented over 5 months and included 2 sermons by pastor, educational handouts, church vegetable and fruit gardens, cooking and nutrition classes, daily mobile messaging, community mapping of food and physical activity environments, and identification of congregational policy changes to increase healthy meals.

MEASURES

Outcomes included objectively measured body weight, body mass index (BMI), and systolic and diastolic blood pressure (BP), plus self-reported overall healthiness of diet and usual minutes spent in physical activity each week; control variables include sex, age, race-ethnicity, English proficiency, education, household income, and (for physical activity outcome) self-reported health status.

ANALYSIS

Multivariate linear regression models estimated the average effect size of the intervention, controlling for pair fixed effects, a main effect of the intervention, and baseline values of the outcomes.

RESULTS

Among those completing follow-up (68%), the intervention resulted in statistically significantly less weight gain and greater weight loss (-0.05 effect sizes; 95% confidence interval [CI] = -0.06 to -0.04), lower BMI (-0.08; 95% CI = -0.11 to -0.05), and healthier diet (-0.09; 95% CI = -0.17 to -0.00). There was no evidence of an intervention impact on BP or physical activity minutes per week.

CONCLUSION

Implementing a multilevel intervention across diverse congregations resulted in small improvements in obesity outcomes. A longer time line is needed to fully implement and assess effects of community and congregation environmental strategies and to allow for potential larger impacts of the intervention.

A Community-Partnered Approach to Developing Church-Based Interventions to Reduce Health Disparities Among African-Americans and Latinos

Faith and public health partnerships offer promise to addressing health disparities, but examples that incorporate African-Americans and Latino congregations are lacking. Here we present results from developing a multi-ethnic, multi-denominational faith and public health partnership to address health disparities through community-based participatory research (CBPR), focusing on several key issues: (1) the multi-layered governance structure and activities to establish the partnership and identify initial health priority (obesity), (2) characteristics of the congregations recruited to partnership (n = 66), and (3) the lessons learned from participating congregations' past work on obesity that informed the development of a multi-level, multi-component, church-based intervention. Having diverse staff with deep ties in the faith community, both among researchers and the primary community partner agency, was key to recruiting African-American and Latino churches. Involvement by local health department and community health clinic personnel provided technical expertise and support regarding health data and clinical resources. Selecting a health issue-obesity-that affected all subgroups (e.g., African-Americans and Latinos, women and men, children and adults) garnered high enthusiasm among partners, as did including some innovative aspects such as a text/e-mail messaging component and a community mapping exercise to identify issues for advocacy. Funding that allowed for an extensive community engagement and planning process was key to successfully implementing a CBPR approach. Building partnerships through which multiple CBPR initiatives can be done offers efficiencies and sustainability in terms of programmatic activities, though long-term infrastructure grants, institutional support, and non-research funding from local foundations and health systems are likely needed.

Stakeholder Perspectives on a Culture of Health: Key Findings

Since 2013, the Robert Wood Johnson Foundation (RWJF) has embarked on a pioneering effort to advance a Culture of Health. The Culture of Health action framework is founded on a vision in which "everyone in our diverse society leads healthier lives now and for generations to come." To put the Culture of Health vision into action, RWJF asked RAND Health to support the development of an action framework and measurement strategy. This article summarizes the stakeholder engagement efforts that RAND used to inform this work. It draws on a series of interviews and focus groups that RAND researchers conducted with stakeholders both within and outside the United States. It should be of interest to RWJF, as well as to those individuals and organizations interested in advancing the Culture of Health action framework. Given that RWJF is focused on using the Culture of Health action framework and measures to catalyze national dialogue about content and investments to improve population health and well-being, the study should be beneficial to a range of national, state, and local leaders across a variety of sectors that contribute to health as described by the Culture of Health action framework.

Highly Conformal Craniospinal Radiotherapy Techniques Can Underdose the Cranial Clinical Target Volume if Leptomeningeal Extension through Skull Base Exit Foramina is not Contoured

AIMS

Craniospinal irradiation (CSI) remains a crucial treatment for patients with medulloblastoma. There is uncertainty about how to manage meningeal surfaces and cerebrospinal fluid (CSF) that follows cranial nerves exiting skull base foramina. The purpose of this study was to assess plan quality and dose coverage of posterior cranial fossa foramina with both photon and proton therapy.

MATERIALS AND METHODS

We analysed the radiotherapy plans of seven patients treated with CSI for medulloblastoma and primitive neuro-ectodermal tumours and three with ependymoma (total n = 10). Four had been treated with a field-based technique and six with TomoTherapy™. The internal acoustic meatus (IAM), jugular foramen (JF) and hypoglossal canal (HC) were contoured and added to the original treatment clinical target volume (Plan_CTV) to create a Test_CTV. This was grown to a test planning target volume (Test_PTV) for comparison with a Plan_PTV. Using Plan_CTV and Plan_PTV, proton plans were generated for all 10 cases. The following dosimetry data were recorded: conformity (dice similarity coefficient) and homogeneity index (D₂ - D₉₈/D₅₀) as well as median and maximum dose (D_2%) to Plan_PTV, V_95% and minimum dose (D_99.9%) to Plan_CTV and Test_CTV and Plan_PTV and Test_PTV, V_95% and minimum dose (D_98%) to foramina PTVs.

RESULTS

Proton and TomoTherapy™ plans were more conformal (0.87, 0.86) and homogeneous (0.07, 0.04) than field-photon plans (0.79, 0.17). However, field-photon plans covered the IAM, JF and HC PTVs better than proton plans (P = 0.002, 0.004, 0.003, respectively). TomoTherapy™ plans covered the IAM and JF better than proton plans (P = 0.000, 0.002, respectively) but the result for the HC was not significant. Adding foramen CTVs/PTVs made no difference for field plans. The mean D_min dropped 3.4% from Plan_PTV to Test_PTV for TomoTherapy™ (not significant) and 14.8% for protons (P = 0.001).

CONCLUSIONS

Highly conformal CSI techniques may underdose meninges and CSF in the dural reflections of posterior fossa cranial nerves unless these structures are specifically included in the CTV.

Acculturation and Drug Use Stigma Among Latinos and African Americans: An Examination of a Church-Based Sample

Substance use patterns among Latinos likely reflect changes in attitudes resulting from acculturation, but little is known about Latinos' attitudes regarding drug addiction. We surveyed a church-based sample of Latinos and African Americans (N = 1,235) about attitudes toward drug addiction and socio-demographics. Linear regression models compared Latino subgroups with African-Americans. In adjusted models, Latinos had significantly higher drug addiction stigma scores compared to African Americans across all subgroups (US-born Latinos, β = 0.22, p < .05; foreign-born Latinos with high English proficiency, β = 0.30, p < .05; and foreign-born Latinos with low English proficiency, β = 0.49, p < .001). Additionally, Latinos with low English proficiency had significantly higher mean levels of drug use stigma compared Latinos with high proficiency (both foreign-born and US-born). In this church-affiliated sample, Latinos' drug addiction stigma decreases with acculturation, but remains higher among the most acculturated Latinos compared to African-Americans. These attitudes may pose a barrier to treatment for Latino drug users.

Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage: A Case Study on Tacoma-Pierce County, Washington

The Patient Protection and Affordable Care Act (ACA) laid the groundwork for a substantial increase in the number of people who have access to health insurance through Medicaid expansion or health insurance marketplaces. During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible people. Typically, they used federal and state funding to develop navigator programs. Program design differed by location, and, although many stakeholders were involved in these efforts, state and local health departments (LHDs) were, and remain, a relatively untapped resource. This article is one in a series designed to highlight innovative models and best practices that leverage LHD involvement in ACA outreach and enrollment and to facilitate knowledge transfer to other geographic regions looking to leverage the full range of roles for LHDs in ACA outreach and enrollment. Each case study was designed to capture nuanced differences in how health departments support these efforts in their communities, identify facilitators and barriers to these approaches, and develop lessons learned from these activities. These studies identify compelling models for how state and local health departments can implement similar activities in their own communities. Further, they provide guidance and insight into the role LHDs can play now, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage moving forward. This article focuses on a case study on Tacoma-Pierce County, Washington.

Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage: A Case Study on New Orleans, Louisiana

The Patient Protection and Affordable Care Act (ACA) laid the groundwork for a substantial increase in the number of people who have access to health insurance through Medicaid expansion or health insurance marketplaces. During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible people. Typically, they used federal and state funding to develop navigator programs. Program design differed by location, and, although many stakeholders were involved in these efforts, state and local health departments (LHDs) were, and remain, a relatively untapped resource. This article is one in a series designed to highlight innovative models and best practices that leverage LHD involvement in ACA outreach and enrollment and to facilitate knowledge transfer to other geographic regions looking to leverage the full range of roles for LHDs in ACA outreach and enrollment. Each case study was designed to capture nuanced differences in how health departments support these efforts in their communities, identify facilitators and barriers to these approaches, and develop lessons learned from these activities. These studies identify compelling models for how state and local health departments can implement similar activities in their own communities. Further, they provide guidance and insight into the role LHDs can play now, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage moving forward. This article focuses on a case study on New Orleans, Louisiana.

Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage: A Case Study on Boston and Massachusetts

The Patient Protection and Affordable Care Act (ACA) laid the groundwork for a substantial increase in the number of people who have access to health insurance through Medicaid expansion or health insurance marketplaces. During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible people. Typically, they used federal and state funding to develop navigator programs. Program design differed by location, and, although many stakeholders were involved in these efforts, state and local health departments (LHDs) were, and remain, a relatively untapped resource. This article is one in a series designed to highlight innovative models and best practices that leverage LHD involvement in ACA outreach and enrollment and to facilitate knowledge transfer to other geographic regions looking to leverage the full range of roles for LHDs in ACA outreach and enrollment. Each case study was designed to capture nuanced differences in how health departments support these efforts in their communities, identify facilitators and barriers to these approaches, and develop lessons learned from these activities. These studies identify compelling models for how state and local health departments can implement similar activities in their own communities. Further, they provide guidance and insight into the role LHDs can play now, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage moving forward. This article focuses on a case study on Boston and Massachusetts.

Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage: A Case Study on West Virginia

The Patient Protection and Affordable Care Act (ACA) laid the groundwork for a substantial increase in the number of people who have access to health insurance through Medicaid expansion or health insurance marketplaces. During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible people. Typically, they used federal and state funding to develop navigator programs. Program design differed by location, and, although many stakeholders were involved in these efforts, state and local health departments (LHDs) were, and remain, a relatively untapped resource. This article is one in a series designed to highlight innovative models and best practices that leverage LHD involvement in ACA outreach and enrollment and to facilitate knowledge transfer to other geographic regions looking to leverage the full range of roles for LHDs in ACA outreach and enrollment. Each case study was designed to capture nuanced differences in how health departments support these efforts in their communities, identify facilitators and barriers to these approaches, and develop lessons learned from these activities. These studies identify compelling models for how state and local health departments can implement similar activities in their own communities. Further, they provide guidance and insight into the role LHDs can play now, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage moving forward. This article focuses on a case study on West Virginia.

Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage: A Case Study on Illinois

The Patient Protection and Affordable Care Act (ACA) laid the groundwork for a substantial increase in the number of people who have access to health insurance through Medicaid expansion or health insurance marketplaces. During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible people. Typically, they used federal and state funding to develop navigator programs. Program design differed by location, and, although many stakeholders were involved in these efforts, state and local health departments (LHDs) were, and remain, a relatively untapped resource. This article is one in a series designed to highlight innovative models and best practices that leverage LHD involvement in ACA outreach and enrollment and to facilitate knowledge transfer to other geographic regions looking to leverage the full range of roles for LHDs in ACA outreach and enrollment. Each case study was designed to capture nuanced differences in how health departments support these efforts in their communities, identify facilitators and barriers to these approaches, and develop lessons learned from these activities. These studies identify compelling models for how state and local health departments can implement similar activities in their own communities. Further, they provide guidance and insight into the role LHDs can play now, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage moving forward. This article focuses on a case study on Illinois.

Church-Based HIV Screening in Racial/Ethnic Minority Communities of California, 2011-2012

Community-based human immunodeficiency virus (HIV) testing at religious congregations has been proposed as a potentially effective way to increase screening among disproportionately affected populations, such as those self-identifying as African American and Latino. Although congregations may provide reach into these communities, the extent to which church-based HIV testing alleviates access barriers, identifies new cases, and reaches people at increased risk for HIV is not well documented. We examined the results of an HIV testing program that was conducted as part of a larger intervention aimed at reducing HIV stigma at five churches in Los Angeles County, California, in 2011-2012. HIV screening identified one positive result in 323 tests but reached a substantial proportion of people who had not been tested before, including many who lacked health insurance. Although this approach may not be an efficient way to identify cases of previously unknown HIV infection, it could help achieve universal testing goals.

Effects of a Pilot Church-Based Intervention to Reduce HIV Stigma and Promote HIV Testing Among African Americans and Latinos

HIV-related stigma and mistrust contribute to HIV disparities. Addressing stigma with faith partners may be effective, but few church-based stigma reduction interventions have been tested. We implemented a pilot intervention with 3 Latino and 2 African American churches (4 in matched pairs) in high HIV prevalence areas of Los Angeles County to reduce HIV stigma and mistrust and increase HIV testing. The intervention included HIV education and peer leader workshops, pastor-delivered sermons on HIV with imagined contact scenarios, and HIV testing events. We surveyed congregants at baseline and 6 month follow-up (n = 1235) and found statistically significant (p < 0.05) reductions in HIV stigma and mistrust in the Latino intervention churches but not in the African American intervention church nor overall across matched African American and Latino pairs. However, within matched pairs, intervention churches had much higher rates of HIV testing (p < 0.001). Stigma reduction and HIV testing may have synergistic effects in community settings.

Predictors of HIV-related stigmas among African American and Latino religious congregants

OBJECTIVES

To inform church-based stigma interventions by exploring dimensions of HIV stigma among African American and Latino religious congregants and determining how these are related to drug addiction and homosexuality stigmas and knowing someone HIV-positive.

METHOD

In-person, self-administered surveys of congregants 18+ years old across 2 African American and 3 Latino churches (n = 1,235, response rate 73%) in a western U.S. city with high HIV prevalence. Measures included 12 items that captured dimensions of HIV stigma, a 5-item scale that assessed attitudes toward people who are addicted to drugs, a 7-item scale assessing attitudes toward homosexuality, and questions regarding sociodemographics and previous communication about HIV.

RESULTS

Of the survey participants, 63.8% were women, mean age was 40.2 years, and 34.4% were African American, 16.8% were U.S.-born Latinos, 16.0% were foreign-born, English-speaking Latinos, and 32.9% were foreign-born, Spanish-speaking Latinos. Exploratory and confirmatory factor analyses identified 4 dimensions of HIV stigma: discomfort interacting with people with HIV (4 items, α = .86), feelings of shame "if you had HIV" (3 items, α = .78), fears of rejection "if you had HIV" (3 items, α = .71), and feelings of blame toward people with HIV (2 items, α = .65). Across all dimensions, after controlling for sociodemographic characteristics and previous communication about HIV, knowing someone with HIV was associated with lower HIV stigma, and greater stigma concerning drug addiction and homosexuality were associated with higher HIV stigma.

CONCLUSIONS

Congregation-based HIV stigma reduction interventions should consider incorporating contact with HIV-affected people. It may also be helpful to address attitudes toward drug addiction and sexual orientation. (PsycINFO Database Record

Do Experiences with Medicare Managed Care Vary According to the Proportion of Same-Race/Ethnicity/Language Individuals Enrolled in One's Contract?

OBJECTIVE

To examine whether care experiences and immunization for racial/ethnic/language minority Medicare beneficiaries vary with the proportion of same-group beneficiaries in Medicare Advantage (MA) contracts.

DATA SOURCES/STUDY SETTING

Exactly 492,495 Medicare beneficiaries responding to the 2008-2009 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey.

DATA COLLECTION/EXTRACTION METHODS

Mixed-effect regression models predicted eight CAHPS patient experience measures from self-reported race/ethnicity/language preference at individual and contract levels, beneficiary-level case-mix adjustors, along with contract and geographic random effects.

PRINCIPAL FINDINGS

As a contract's proportion of a given minority group increased, overall and non-Hispanic, white patient experiences were poorer on average; for the minority group in question, however, high-minority plans may score as well as low-minority plans. Spanish-preferring Hispanic beneficiaries also experience smaller disparities relative to non-Hispanic whites in plans with higher Spanish-preferring proportions.

CONCLUSIONS

The tendency for high-minority contracts to provide less positive patient experiences for others in the contract, but similar or even more positive patient experiences for concentrated minority group beneficiaries, may reflect cultural competency, particularly language services, that partially or fully counterbalance the poorer overall quality of these contracts. For some beneficiaries, experiences may be just as positive in some high-minority plans with low overall scores as in plans with higher overall scores.

Correlates of HIV testing among African American and Latino church congregants: the role of HIV stigmatizing attitudes and discussions about HIV

Faith-based organizations can be key settings in which to reach African Americans and Latinos for HIV prevention, but little is known regarding factors that predict congregants' HIV testing behaviors. We examined the extent to which sociodemographic factors, HIV-related cues to action (e.g., knowing someone who is HIV-positive), and the social climate surrounding HIV (stigma toward a hypothetical HIV-positive congregant, HIV-related discussions at church about abstinence, condoms, and testing) were associated with willingness to be tested in church and with ever having been tested among 1211 African American and Latino congregants. Multivariate analyses indicated that congregants were more open to church-based testing if they were younger and had discussed condoms at church. They were less open if they expressed stigmatizing attitudes toward a hypothetical congregant. Foreign-born Latinos with low English proficiency were more willing to be tested at church than were African Americans. Congregants were more likely to have ever been tested if they were younger, African American, female, or married; if they knew someone who was HIV-positive; and if they had discussed testing and condoms at church. They were less likely if they had discussed abstinence. Open dialogue around HIV may activate congregants to be more receptive to church-based prevention.

Quantifying uncertainty in radiotherapy demand at the local and national level using the Malthus model

The Malthus programme produces a model for the local and national level of radiotherapy demand for use by commissioners and radiotherapy service leads in England. The accuracy of simulation is dependent on the population cancer incidence, stage distribution and clinical decision data used by the model. In order to quantify uncertainty in the model, a global sensitivity analysis of the Malthus model was undertaken. As predicted, key decision points in the model relating to stage distribution and indications for surgical or non-surgical initial management of disease were observed to yield the strongest effect on simulated radiotherapy demand. The proportion of non-small cell lung cancer patients presenting with stage IIIB/IV disease had the largest effect on fraction burden in the four most common cancer types treated with radiotherapy, where a 1% change in stage IIIb/IV disease yielded a 1.3% change in fraction burden for lung cancer patients. A 1% change in mastectomy rate yielded a 0.37% change in fraction burden for breast cancer patients. The model is also highly sensitive to changes in the radiotherapy indications in colon and gastric cancer. Broadly, the findings of the sensitivity analysis mirror those previously published by other groups. Sensitivity analysis of the local-level population and cancer incidence data revealed that the cancer registration rate in the 50-64 year female population had the highest effect on simulation results. The analysis reveals where additional effort should be undertaken to provide accurate estimates of important parameters used in radiotherapy demand models.

Predictors of the Existence of Congregational HIV Programs: Similarities and Differences Compared With Other Health Programs

PURPOSE

Identify and compare predictors of the existence of congregational human immunodeficiency virus (HIV) and other health programs.

DESIGN

Cross-sectional study.

SETTING

United States.

SUBJECTS

A nationally representative sample of 1506 U.S. congregations surveyed in the National Congregations Study (2006-2007).

MEASURES

Key informants at each congregation completed in-person and telephone interviews on congregational HIV and other health programs and various congregation characteristics (response rate = 78%). County-level HIV prevalence and population health data from the Robert Wood Johnson Foundation's 2007 County Health Rankings were linked to the congregational data.

ANALYSIS

Multinomial logistic regression was used to assess factors that predict congregational health programs relative to no health programs; and of HIV programs relative to other health activities.

RESULTS

Most congregations (57.5%) had at least one health-related program; many fewer (5.7%) had an HIV program. Predictors of health vs. HIV programs differed. The number of adults in the congregation was a key predictor of health programs, while having an official statement welcoming gay persons was a significant predictor of HIV programs (p < .05). Other significant characteristics varied by size of congregation and type of program (HIV vs. other health).

CONCLUSION

Organizations interested in partnering with congregations to promote health or prevent HIV should consider congregational size as well as other factors that predict involvement. Results of this study can inform policy interventions to increase the capacity of religious congregations to address HIV and health.

An intervention to reduce HIV-related stigma in partnership with African American and Latino churches

HIV-related stigma negatively affects prevention and care, and community-based interventions are needed. Here we describe the development of a multi-ethnic, faith-based intervention to reduce HIV stigma that included: educational workshops on HIV, testing, and stigma; peer leader workshops using role plays and drawing on principles of motivational interviewing; a pastor-delivered sermon on HIV that incorporated theological reflection and an imagined contact scenario; and congregation-based HIV testing events. Lessons learned include: partnership development is essential and requires substantial investment; tailoring intervention components to single race-ethnic groups may not be preferable in diverse community settings; and adapting testing processes to be able to serve larger numbers of people in shorter time frames is needed for congregational settings. This development process successfully combined the rigorous application of social science theory and community engagement to yield a multifaceted HIV stigma reduction intervention appropriate for Protestant and Catholic churches in African American and Latino communities.

Breast cancer risk following Hodgkin lymphoma radiotherapy in relation to menstrual and reproductive factors

BACKGROUND

Women treated with supradiaphragmatic radiotherapy (sRT) for Hodgkin lymphoma (HL) at young ages have a substantially increased breast cancer risk. Little is known about how menarcheal and reproductive factors modify this risk.

METHODS

We examined the effects of menarcheal age, pregnancy, and menopausal age on breast cancer risk following sRT in case-control data from questionnaires completed by 2497 women from a cohort of 5002 treated with sRT for HL at ages <36 during 1956-2003.

RESULTS

Two-hundred and sixty women had been diagnosed with breast cancer. Breast cancer risk was significantly increased in patients treated within 6 months of menarche (odds ratio (OR) 5.52, 95% confidence interval (CI) (1.97-15.46)), and increased significantly with proximity of sRT to menarche (Ptrend<0.001). It was greatest when sRT was close to a late menarche, but based on small numbers and needing reexamination elsewhere. Risk was not significantly affected by full-term pregnancies before or after treatment. Risk was significantly reduced by early menopause (OR 0.55, 95% CI (0.35-0.85)), and increased with number of premenopausal years after treatment (Ptrend=0.003).

CONCLUSION

In summary, this paper shows for the first time that sRT close to menarche substantially increases breast cancer risk. Careful consideration should be given to follow-up of these women, and to measures that might reduce their future breast cancer risk.

The value of image-guided intensity-modulated radiotherapy in challenging clinical settings

OBJECTIVE

To illustrate the wider potential scope of image-guided intensity-modulated radiotherapy (IG-IMRT), outside of the "standard" indications for IMRT.

METHODS

Nine challenging clinical cases were selected. All were treated with radical intent, although it was accepted that in several of the cases the probability of cure was low. IMRT alone was not adequate owing to the close proximity of the target to organs at risk, the risk of geographical miss, or the need to tighten planning margins, making image-guided radiotherapy an essential integral part of the treatment. Discrepancies between the initial planning scan and the daily on-treatment megavoltage CT were recorded for each case. The three-dimensional displacement was compared with the margin used to create the planning target volume (PTV).

RESULTS

All but one patient achieved local control. Three patients developed metastatic disease but benefited from good local palliation; two have since died. A further patient died of an unrelated condition. Four patients are alive and well. Toxicity was low in all cases. Without daily image guidance, the PTV margin would have been insufficient to ensure complete coverage in 49% of fractions. It was inadequate by >3 mm in 19% of fractions, and by >5 mm in 9%.

CONCLUSION

IG-IMRT ensures accurate dose delivery to treat the target and avoid critical structures, acting as daily quality assurance for the delivery of complex IMRT plans. These patients could not have been adequately treated without image guidance.

ADVANCES IN KNOWLEDGE

IG-IMRT can offer improved outcomes in less common clinical situations, where conventional techniques would provide suboptimal treatment.

Development of an electronic medical record based intervention to improve medical care of osteoporosis

Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. An EMR-based intervention (osteoporosis order set) was developed with physician and patient input. There was a trend toward greater calcium supplementation from July 2008 to April 2009 (s = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low.

INTRODUCTION

Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. The study population consisted of patients over 50 years of age.

METHODS

Northwestern Memorial Hospital is a tertiary care academic hospital in Chicago. This study was conducted from September 1, 2007 through June 30, 2009.

RESULTS

Physicians reported that barriers to care comprised nonacute nature of osteoporosis, belief that osteoporosis should be addressed by the PCP, low awareness of recurrent fractures, and radiographs with terms such as "compression deformity", "wedge deformity", or "vertebral height loss" which in their opinion were not clearly indicative of vertebral fractures. An EMR-based intervention was developed with physician and patient input. Over the evaluation period, 295 fracture cases in individuals over the age of 50 years in the medicine floors were analyzed. Mean age was 72 ± 11 years; 74% were female. Sites of fracture included hip n = 78 (27%), vertebral n = 87 (30%), lower extremity n = 61 (21%), upper extremity n = 43 (15%) and pelvis n = 26 (9%). There was no increase in documentation of osteoporosis in the medical record from pre- to post-EMR implementation (p = 0.89). There was a trend toward greater calcium supplementation from July 2008 to April 2009 (p = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low.

CONCLUSION

An electronic medical record intervention without electronic reminders created with physician input achieves an increase in calcium supplementation but fails to increase diagnosis or treatment for osteoporosis at the time of hospitalization for a fragility fracture.

Primary testicular lymphoma

Primary testicular non-Hodgkin lymphoma (PTL) comprises around 9% of testicular cancers and 1-2% of all non-Hodgkin lymphomas. Its incidence is increasing and it primarily affects older men, with a median age at presentation of around 67 years. By far the most common histological subtype is diffuse large B-cell lymphoma, accounting for 80-90% of PTLs. Most patients present with a unilateral testicular mass or swelling. Up to 90% of patients have stage I or II disease at diagnosis (60 and 30%, respectively) and bilateral testicular involvement is seen in around 35% of patients. PTL demonstrates a continuous pattern of relapse and propensity for extra-nodal sites such as the central nervous system and contralateral testis. Retrospective data have emphasised the importance of prophylactic radiotherapy in reducing recurrence rates within the contralateral testis. Recent outcome data from the prospective IELSG-10 trial have shown far better progression-free and overall survival than historical outcomes. This supports the use of orchidectomy followed by Rituximab- cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP), central nervous system prophylaxis and prophylactic radiotherapy to the contralateral testis with or without nodal radiotherapy in patients with limited disease. Central nervous system relapse remains a significant issue and future research should focus on identifying the best strategy to reduce its occurrence. Here we discuss the evidence supporting combination chemotherapy and radiotherapy in PTL.

Lung spirometry parameters and diffusion capacity are decreased in patients with Type 2 diabetes

AIMS

In cohort studies, Type 2 diabetes mellitus has been associated with decreased forced 1 s expiratory volume and forced vital capacity. We examined if forced vital capacity, forced 1 s expiratory volume and diffusion lung capacity correlate with diabetes mellitus across different races in a clinical setting.

METHODS

We examined the medical records of 19,882 adults 18-97 years of age in our centre from 1 January 2000 to 1 May 2009. After excluding patients with diseases causing abnormal lung function, 4164 subjects were available for analysis. We used multiple linear regressions to examine cross-sectional differences in forced vital capacity, forced 1 s expiratory volume and carbon monoxide diffusing capacity between patients with and without diabetes mellitus, after adjustment for age, sex, race, height, smoking, BMI and heart failure.

RESULTS

Patients with diabetes (n = 560) were older (62 ± 12 vs. 55 ± 16 years), more likely to be men (56 vs. 43%), overweight (BMI 31.7 ± 8.5 vs. 27.3 ± 6.7 kg/m2 ), have heart failure (33 vs. 14%) and less likely to be Caucasians (65 vs. 76%) and never smokers (66 vs. 72%) compared with patients without diabetes (n = 3604). The mean unadjusted values in patients with diabetes vs. those without were: forced vital capacity 2.78 ± 0.91 vs. 3.19 ± 1.03 l; forced 1 s expiratory volume 2.17 ± 0.74 vs. 2.49 ± 0.0.83; and carbon monoxide diffusing capacity 16.67 ± 5.53 vs. 19.18 ± 6.72 ml(-1) min(-1) mmHg, all P < 0.0001. These differences remained significant after adjustment for covariates. After race stratification, only Caucasians with diabetes had a significant decrease in all lung function measures.

CONCLUSIONS

Patients with diabetes have decreased lung function compared with those without diabetes. Caucasians with diabetes have more global lung function impairment compared with African-Americans and Hispanics.

Accelerated BEP: a phase I trial of dose-dense BEP for intermediate and poor prognosis metastatic germ cell tumour

Background:

We used bleomycin, etoposide, cisplatin (BEP), the most effective regimen in the treatment of germ cell tumours (GCTs) and increased dose-density by using pegfilgrastim to shorten cycle length. Our aim was to assess safety and tolerability.

Methods:

Sixteen male patients with intermediate or poor prognosis metastatic GCT were treated with four cycles of 3-day BEP with G-CSF on a 14-day cycle for a planned relative dose-density of 1.5 compared with standard BEP.

Results:

Eleven intermediate and five poor prognosis patients were treated. In all, 14 of 16 patients completed the study treatment. Toxicities were comparable to previous studies using standard BEP, except for mucositis and haematological toxicity that were more severe. The overall relative dose-density for all 16 patients was mean 1.38 (range 0.72–1.5; median 1.46). Complete response was achieved after chemotherapy alone in two patients (13%) and following chemotherapy plus surgery in nine additional patients (56%). Four patients (25%) had a partial response and normalised their marker levels. At a median follow-up of 4.4 years (range 2.1–6.8) the estimated 5-year progression-free survival probability is 81% (95% CI 64–100%).

Conclusion:

Accelerated BEP is tolerable without major additional toxicity. A randomised controlled trial will be required to obtain comparative efficacy data.

Congregation-based programs to address HIV/AIDS: elements of successful implementation

Religious organizations may be uniquely positioned to address HIV by offering prevention, treatment, or support services to affected populations, but models of effective congregation-based HIV programs in the literature are scarce. This systematic review distils lessons on successfully implementing congregation HIV efforts. Peer-reviewed articles on congregation-based HIV efforts were reviewed against criteria measuring the extent of collaboration, tailoring to the local context, and use of community-based participatory research (CBPR) methods. The effectiveness of congregations' efforts and their capacity to overcome barriers to addressing HIV is also assessed. We found that most congregational efforts focused primarily on HIV prevention, were developed in partnerships with outside organizations and tailored to target audiences, and used CBPR methods. A few more comprehensive programs also provided care and support to people with HIV and/or addressed substance use and mental health needs. We also found that congregational barriers such as HIV stigma and lack of understanding HIV's importance were overcome using various strategies including tailoring programs to be respectful of church doctrine and campaigns to inform clergy and congregations. However, efforts to confront stigma directly were rare, suggesting a need for further research.

Organisational culture: variation across hospitals and connection to patient safety climate

CONTEXT

Bureaucratic organisational culture is less favourable to quality improvement, whereas organisations with group (teamwork) culture are better aligned for quality improvement.

OBJECTIVE

To determine if an organisational group culture shows better alignment with patient safety climate.

DESIGN

Cross-sectional administration of questionnaires. Setting 40 Hospital Corporation of America hospitals.

PARTICIPANTS

1406 nurses, ancillary staff, allied staff and physicians.

MAIN OUTCOME MEASURES

Competing Values Measure of Organisational Culture, Safety Attitudes Questionnaire (SAQ), Safety Climate Survey (SCSc) and Information and Analysis (IA).

RESULTS

The Cronbach alpha was 0.81 for the group culture scale and 0.72 for the hierarchical culture scale. Group culture was positively correlated with SAQ and its subscales (from correlation coefficient r = 0.44 to 0.55, except situational recognition), ScSc (r = 0.47) and IA (r = 0.33). Hierarchical culture was negatively correlated with the SAQ scales, SCSc and IA. Among the 40 hospitals, 37.5% had a hierarchical dominant culture, 37.5% a dominant group culture and 25% a balanced culture. Group culture hospitals had significantly higher safety climate scores than hierarchical culture hospitals. The magnitude of these relationships was not affected after adjusting for provider job type and hospital characteristics.

CONCLUSIONS

Hospitals vary in organisational culture, and the type of culture relates to the safety climate within the hospital. In combination with prior studies, these results suggest that a healthcare organisation's culture is a critical factor in the development of its patient safety climate and in the successful implementation of quality improvement initiatives.

Patterns of nurse-physician communication and agreement on the plan of care

BACKGROUND

Interdisciplinary communication is critically important to provide safe and effective care, yet it has been inadequately studied for hospitalised medical patients. Our objective was to characterise nurse-physician communication and their agreement on patients' plan of care.

METHODS

During a one-month period, randomly selected hospitalised patients, their nurses and their physicians were interviewed. Nurses and physicians were asked to identify one another, whether communication had occurred, and about six aspects of the plan of care. Two internists rated nurse-physician agreement on aspects of the plan of care as none, partial or complete agreement. Measures included the percentage of nurses and physicians able to identify one another and reporting communication and the percentage of nurse-physician pairs in agreement on aspects of the plan of care.

RESULTS

310 (91%) and 301 (88%) of 342 eligible nurses and physicians completed interviews. Nurses correctly identified patients' physicians 71% of the time and reported communicating with them 50% of the time. Physicians correctly identified the patients' nurses 36% of the time and reported communicating with them 62% of the time. Physicians and nurses showed no agreement on aspects of the plan of care ranging from 11% for planned procedures to 42% for medication changes.

CONCLUSIONS

Nurses and physicians did not reliably communicate with one another and were often not in agreement on the plan of care for hospitalised medical patients.

Geographical variation in radiotherapy services across the UK in 2007 and the effect of deprivation

AIMS

Modelling of demand has shown substantial underprovision of radiotherapy in the UK. We used national audit data to study geographical differences in radiotherapy waiting times, access and dose fractionation across the four countries of the UK and between English strategic health authorities.

MATERIALS AND METHODS

We used a web-based tool to collect data on diagnosis, dose fractionation and waiting times on all National Health Service patients in the UK starting a course of radiotherapy in the week commencing 24 September 2007. Cancer incidence for the four countries of the UK and for England by primary care trust was used to model demand for radiotherapy aggregated by country and by strategic health authority.

RESULTS

Across the UK, excluding skin cancer, 2504 patients were prescribed 33 454 fractions in the audit week. Waits for radical radiotherapy exceeded the recommended 4 week maximum for 31% of patients (range 0-62%). Fractions per million per year ranged from 17 678 to 36 426 and radical fractions per incident cancer ranged from 3.0 to 6.7. Patients who were treated received similar treatment in terms of fractions per radical course of radiotherapy (18.2-23.0). Access rates ranged from 25.2 to 48.8%, nearing the modelled optimum of 50.7% in three regions. Fractions per million prescribed as a first course of treatment varied from 43.9 to 90.3% of modelled demand. The percentage of patients failing to meet the 4 week Joint Council for Clinical Oncology target for radical radiotherapy rose as activity rates increased (r=0.834), indicating a mismatch of demand and capacity. In England, a comparison between strategic health authorities showed that increasing deprivation was correlated with lower rates of access to radiotherapy (r=-0.820).

CONCLUSIONS

There are substantial differences across the UK in the radiotherapy provided to patients and its timeliness. Radiotherapy capacity does not reflect regional variations in cancer incidence across the UK (3618-5800 cases per million per year). In addition, deprivation is a major unrecognised influence on radiotherapy access rates. In regions with higher levels of deprivation, fewer patients with cancer receive radiotherapy and the proportion treated radically is lower. This probably reflects late presentation with advanced disease, poor performance status and co-morbid illness. To provide an equitable, evidence-based service, the needs of the local population should be assessed using demand modelling based on local cancer incidence. Ideally this should include data on deprivation, performance status and stage at presentation. The results should be compared with local radiotherapy activity data to understand waits, access and dose fractionation in order to plan adequate provision for the future. The development of a mandatory radiotherapy data set in England will facilitate this, but to assist change it is essential that the results are analysed and fed back to clinicians and commissioners.

Distinct clinical phenotypes of airways disease defined by cluster analysis

Airways disease is currently classified using diagnostic labels such as asthma, chronic bronchitis and emphysema. The current definitions of these classifications may not reflect the phenotypes of airways disease in the community, which may have differing disease processes, clinical features or responses to treatment. The aim of the present study was to use cluster analysis to explore clinical phenotypes in a community population with airways disease. A random population sample of 25-75-yr-old adults underwent detailed investigation, including a clinical questionnaire, pulmonary function tests, nitric oxide measurements, blood tests and chest computed tomography. Cluster analysis was performed on the subgroup with current respiratory symptoms or obstructive spirometric results. Subjects with a complete dataset (n = 175) were included in the cluster analysis. Five clusters were identified with the following characteristics: cluster 1: severe and markedly variable airflow obstruction with features of atopic asthma, chronic bronchitis and emphysema; cluster 2: features of emphysema alone; cluster 3: atopic asthma with eosinophilic airways inflammation; cluster 4: mild airflow obstruction without other dominant phenotypic features; and cluster 5: chronic bronchitis in nonsmokers. Five distinct clinical phenotypes of airflow obstruction were identified. If confirmed in other populations, these findings may form the basis of a modified taxonomy for the disorders of airways obstruction.

Waiting times for systemic cancer therapy in the United Kingdom in 2006

This audit was conducted to measure waiting times for systemic cancer therapy across the United Kingdom. All patients, aged 16 years or older, commencing their first course of systemic therapy between 13 November and 19 November 2006 were eligible for inclusion. Data on 936 patients from 81 hospital sources were collected. Systemic therapy is largely given in compliance with national waiting time targets. In terms of the Joint Council for Clinical Oncology (JCCO) targets, 84% of patients commence treatment within 21 days and 98% of patients complied with the Department of Health target that treatment should follow within 31 days of the decision being agreed with the patient. Only 76% complied with the Department of Health 62-day target from GP referral to first definitive treatment. However, the date of urgent referral by the GP was not submitted for most patients in our survey, leaving a sample of only 84 out of 936 patients (9% of total) suitable for this analysis. There was only a 3- to 5-day difference between the waiting times for systemic therapy for patients categorised as urgent compared with routine. Locally agreed definitions had little impact on patients' priority for treatment. This audit has established a baseline measurement of waiting times for systemic therapy across the United Kingdom. The continuing introduction of novel therapies is likely to have a significant effect on the service and we recommend that service managers model the likely impact on resource requirements. In addition, urgent treatment should be clearly defined as that required within 24 h (maximum 48 h) to avoid the risk of clinical deterioration, particularly in patients with acute leukaemia, lymphoma or germ cell tumour.

Proportional classifications of COPD phenotypes

BACKGROUND

Chronic obstructive pulmonary disease (COPD) encompasses a group of disorders characterised by the presence of incompletely reversible airflow obstruction with overlapping subsets of different phenotypes including chronic bronchitis, emphysema or asthma. The aim of this study was to determine the proportion of adult subjects aged >50 years within each phenotypic subgroup of COPD, defined as a post-bronchodilator ratio of forced expiratory volume in 1 s/forced vital capacity (FEV(1)/FVC) <0.7, in accordance with current international guidelines.

METHODS

Adults aged >50 years derived from a random population-based survey undertook detailed questionnaires, pulmonary function tests and chest CT scans. The proportion of subjects in each of 16 distinct phenotypes was determined based on combinations of chronic bronchitis, emphysema and asthma, with and without incompletely reversible airflow obstruction defined by a post-bronchodilator FEV(1)/FVC ratio of 0.7.

RESULTS

A total of 469 subjects completed the investigative modules, 96 of whom (20.5%) had COPD. Diagrams were constructed to demonstrate the relative proportions of the phenotypic subgroups in subjects with and without COPD. 18/96 subjects with COPD (19%) had the classical phenotypes of chronic bronchitis and/or emphysema but no asthma; asthma was the predominant COPD phenotype, being present in 53/96 (55%). When COPD was defined as a post-bronchodilator FEV(1)/FVC less than the lower limit of normal, there were one-third fewer subjects with COPD and a smaller proportion without a defined emphysema, chronic bronchitis or asthma phenotype.

CONCLUSION

This study provides proportional classifications of the phenotypic subgroups of COPD which can be used as the basis for further research into the pathogenesis and treatment of this heterogeneous disorder.

A radiotherapy technique to improve dose homogeneity around bone prostheses

Purpose. Following limb conserving surgery for bone or soft tissue sarcoma, patients may require post-operative radiotherapy to minimise the risk of local recurrence. In such circumstances the metal prosthesis reduces the dose in its shadow by approximately 10% when using opposed fields. We describe a technique to boost the underdosed area to overcome this problem.Patients or subjects. Seven sequential patients presenting between 1995 and 2001 had their treatment individualised because they had metal prosthesis in the treatment volume.Methods. To improve the target dose homogeneity we used a custom-made keyhole cutout to boost the area in the shadow of the prosthesis. The degree of attenuation caused by the metal prosthesis was estimated and a boost dose calculated. Exit thermoluminescent dosimetry (TLD) was used to confirm the estimates made.Results and discussion. Variation between patients was seen, demonstrating the need for exit TLD to individualise the treatment plan. The use of a boost field provides a method to overcome under-dosage in the shadow of a metal prosthesis. It improves dose homogeneity throughout the target volume and ensures adequate dose intensity around the prosthesis, the site most at risk of local recurrence.