Five Dimensions of Needs for Help: The Efficacy of a Technology-Based Intervention Among Asian American Breast Cancer Survivors

Cancer survivors including Asian American breast cancer survivors have reported their high needs for help during their survivorship process. With the COVID-19 pandemic, the necessity of technology-based programs to address their needs for help without face-to-face interactions has been highlighted. The purpose of this randomized intervention study was to determine the efficacy of a technology-based program in reducing various types of needs for help among this specific population. This was a randomized clinical trial with repeated measures. A total of 199 participants were included in the data analysis. The recruitment settings included both online and offline communities/groups for Asian Americans. The needs for help were assessed using the Support Care Needs Survey-34 Short Form (SCNS) subscales measuring psychological, information, physical, support, and communication needs. Data analysis was conducted through an intent-to-treat approach. In the mixed effect models, psychological needs, information needs, physical needs, and communication needs decreased over time (P < .001). However, there were no significant group * time effects. Social support significantly mediated the effects of a technology-based intervention on psychological, information, and support needs at the pre-test and the post-1 month. This study supported significant decreases in the needs for help of Asian American breast cancer survivors by a technology-based intervention. Further studies are needed with other racial/ethnic groups of cancer survivors to confirm the efficacy of a technology-based intervention in reducing cancer survivors' needs for help during their survivorship process.

Benefits, Harms, and Stakeholder Perspectives Regarding Opioid Therapy for Pain in Individuals With Metastatic Cancer: Protocol for a Descriptive Cohort Study

BACKGROUND

Opioids are a key component of pain management among patients with metastatic cancer pain. However, the evidence base available to guide opioid-related decision-making in individuals with advanced cancer is limited. Patients with advanced cancer or cancer that is unlikely to be cured frequently experience pain. Opioids are a key component of pain management among patients with metastatic cancer pain. Many individuals with advanced cancer are now living long enough to experience opioid-related harm. Emerging evidence from chronic noncancer pain literature suggests that longer-term opioid therapy may have limited benefits for pain and function, and opioid-related harms are also a major concern. However, whether these benefits and harms of opioids apply to patients with cancer-related pain is unknown.

OBJECTIVE

This manuscript outlines the protocol for the "Opioid Therapy for Pain in Individuals With Metastatic Cancer: The Benefits, Harms, and Stakeholder Perspectives (BEST) Study." The study aims to better understand opioid decision-making in patients with advanced cancer, along with opioid benefits and harms, through prospective examination of patients' pain experiences and opioid side effects and understanding the decision-making by patients, care partners, and clinicians.

METHODS

This is a multicenter, prospective cohort study that aims to enroll 630 patients with advanced cancer, 20 care partners, and 20 clinicians (670 total participants). Patient participants must have an advanced solid cancer diagnosis, defined by the American Cancer Society as cancer that is unlikely to be cured. We will recruit patient participants within 12 weeks after diagnosis so that we can understand opioid benefits, harms, and perspectives on opioid decision-making throughout the course of their advanced cancer (up to 2 years). We will also specifically elicit information regarding long-term opioid use (ie, opioids for ≥90 consecutive days) and exclude patients on long-term opioid therapy before an advanced cancer diagnosis. Lived-experience perspectives related to opioid use in those with advanced cancer will be captured by qualitative interviews with a subset of patients, clinicians, and care partners. Our data collection will be grounded in a behavioral decision research approach that will allow us to develop future interventions to inform opioid-related decision-making for patients with metastatic cancer.

RESULTS

Data collection began in October 2022 and is anticipated to end by November 2024.

CONCLUSIONS

Upon successful execution of our study protocol, we anticipate the development of a comprehensive evidence base on opioid therapy in individuals with advanced cancer guided by the behavioral decision research framework. The information gained from this study will be used to guide interventions to facilitate opioid decisions among patients, clinicians, and care partners. Given the limited evidence base about opioid therapy in people with cancer, we envision this study will have significant real-world implications for cancer-related pain management and opioid-related clinical decision-making.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54953.

A randomized controlled trial testing a virtual program for Asian American women breast cancer survivors

A culturally tailored virtual program could meet the survivorship needs of Asian American women breast cancer survivors (AABC). This study aims to determine the efficacy of a culturally tailored virtual information and coaching/support program (TICAA) in improving AABC's survivorship experience. A randomized clinical trial (NCT02803593) was conducted from January 2017 to June 2020 among 199 AABC. The intervention group utilized TICAA and the American Cancer Society [ACS] website while the control group used only ACS website for 12 weeks. The outcomes were measured using the SCNS-34SF (needs; primary), the MSAS-SF (symptoms; secondary), and the FACT-B (quality of life; secondary). The data were analyzed using an intent-to-treat approach. The intervention group showed significant reductions in their needs from the baseline (T0) to post 4 weeks (T1) and to post 12 weeks (T2). Although the changes were not statistically significant, the intervention group had decreased symptoms from T0 to T2 while the control group had an increase in their symptoms. The intervention group had a significant increase in their quality of life from T0 to T2. A culturally tailored virtual program could therefore improve quality of life in AABC patients. Trial Registration: To Enhance Breast Cancer Survivorship of Asian Americans (TICAA), NCT02803593, https://clinicaltrials.gov/ct2/show/NCT02803593?titles=TICAA&draw=2&rank=1.

Coping Skills Interventions for Fatigue in Adults with Hematologic Malignancies: A Systematic Review

Background: Persons with hematologic malignancies have a high symptom burden throughout the illness journey. Coping skills interventions effectively reduce fatigue for other cancer patients. The purpose of this systematic review is to identify if coping interventions can reduce fatigue in patients with hematologic malignancies. Methods: A search of PubMed, Embase, CINAHL, APA Psych INFO, Scopus, Cochrane, and non-traditional publications was performed in June 2021 for studies introducing coping interventions for adults with hematological cancers within the past 20 years. The Transactional Model of Stress and Coping was used as a framework with fatigue as the primary outcome. The Johns Hopkins Nursing Evidence Based Practice Appraisal tool was used for quality appraisal. Results: Twelve interventional studies met criteria for inclusion. Four studies significantly reduced fatigue, with an additional 3 showing a reduction in fatigue. Interventions that utilized both problem and emotion-focused coping were more effective at reducing fatigue compared to interventions that only used emotion or problem-focused coping. Conclusion: This systematic review found moderate-strength evidence to support that coping interventions can reduce fatigue, with mixed, but mostly beneficial results. Clinicians caring for patients with hematologic malignancies should consider using coping interventions to reduce fatigue.

Segregation Predicts COVID-19 Fatalities in Less Densely Populated Counties

Aim

It is well known that social determinants of health (SDoH) have affected COVID-19 outcomes, but these determinants are broad and complex. Identifying essential determinants is a prerequisite to address widening health disparities during the evolving COVID-19 pandemic.

Methods

County-specific COVID-19 fatality data from California, Illinois, and New York, three US states with the highest county-cevel COVID-19 fatalities as of June 15, 2020, were analyzed. Twenty-three county-level SDoH, collected from County Health Rankings & Roadmaps (CHRR), were considered. A median split on the population-adjusted COVID-19 fatality rate created an indicator for high or low fatality. The decision tree method, which employs machine learning techniques, analyzed and visualized associations between SDoH and high COVID-19 fatality rate at the county level.

Results

Of the 23 county-level SDoH considered, population density, residential segregation (between white and non-white populations), and preventable hospitalization rates were key predictors of COVID-19 fatalities. Segregation was an important predictor of COVID-19 fatalities in counties of low population density. The model area under the curve (AUC) was 0.79, with a sensitivity of 74% and specificity of 76%.

Conclusion

Our findings, using a novel analytical lens, suggest that COVID-19 fatality is high in areas of high population density. While population density correlates to COVID-19 fatality, our study also finds that segregation predicts COVID-19 fatality in less densely populated counties. These findings have implications for COVID-19 resource planning and require appropriate attention.

What’s Race got to do With it? How Palliative Care Consultation may Mitigate Racial Disparities in Future Care

It is unknown if care and cost outcomes differ by race and ethnicity following discharge from a hospitalization involving palliative care consultation to discuss goals-of-care (PCC). In this secondary analysis of 1,390 seriously-ill patients age 18+ alive at discharge who self-identified as Black, Hispanic, Asian, white, or other race and received PCC at an urban, academic medical center, we used binomial logistic regression and multiple linear regression controlling for demographic and clinical variables to identify factors associated with care experiences and costs following discharge from a hospitalization with PCC. In adjusted analyses, discharge to hospice was associated with Medicaid (p=0.016). Thirty-day readmission was associated with age 75+ (P=0.015), Medicaid (P=0.004), admission 30 days prior (P<0.0001), and Black race compared to white (P=0.016). Number of future days hospitalized was associated with Medicaid (P=0.001), admission 30 days prior (P=0.017), and Black race compared to white (P=0.012). Having any future hospitalization cost was associated with patient ages 65-74 (P=0.022) and 75+ (P=0.023), Medicaid (P=0.014), admission 30-days prior (P<0.0001), and Black race compared to white (P=0.021). Total future hospitalization costs were associated with female gender (P=0.025), Medicaid (P=0.009), admission 30 days prior (P=0.040), and Black race compared to white (P=0.037). Race or ethnicity was not a predictor of hospice enrollment. Randomized controlled trials are needed to understand if PCC is an intervention that reduces racial disparities in end-of-life care. Qualitative insights are needed to explain how PCC and socioeconomic factors such as Medicaid may mitigate future acute care use among racial and ethnic groups.

Comparative Analysis of Health Domains for Neuropathic Pain Patients

Active duty military members have significant service-related risks for developing pain from injury. Although estimates for neuropathic pain (NP) are available for civilian populations, the incidence and prevalence for NP in military members is less clear. Understanding correlates of pain in military members is vital to improving their physical, mental, and social health. Using a comparative design, a secondary analysis was conducted on longitudinal PASTOR data from 190 pain management center patients. The objectives were to compare trends in patient-reported outcomes over time between those screening positive and negative for NP (NP+, NP-, respectively) based on PROMIS Neuropathic Pain Scale T-scores. Findings showed improvements in fatigue, sleep-related impairment, and anger over time. There was a difference between those screening NP+ and NP- for sleep-related impairment, and the cross-level interaction effect showed sleep-related impairment worsening over time. These results emphasize the need to identify NP and implement and evaluate targeted therapies.

Goals-of-Care Consult and Future Costs, Acute Care and Hospice Use in Matched Cohorts of African Americans and Whites

African Americans receive less hospice care and more aggressive end-of-life care than Whites. Little is known about how palliative care consultation to discuss goals-of-care (“PCC”) is associated with future acute care utilization and costs, or hospice use, by race. To compare future acute care costs and utilization and discharge to hospice between propensity-matched cohorts of African Americans with and without PCC, and Whites with and without PCC, we conducted a secondary analysis of 35,154 seriously-ill African American and White adults who had PCC at a high-acuity hospital and were discharged 2014-2016. We found no significant difference between African Americans with or without PCC in mean future acute care costs ($11,651 vs. $15,050, P=0.09), 30-day readmissions (P=0.58), future hospital days (P=0.34), future ICU admission (P=0.25), or future ICU days (P=0.30), but found greater discharge to hospice among African Americans with PCC (36.5% vs. 2.4%, P<0.0001). We found significant differences between Whites with PCC vs. without PCC in mean future acute care costs ($8,095 vs. $16,799, P<0.001), 30-day readmissions (10.2% vs. 16.7%, P<0.0001), future days hospitalized (3.7 vs. 6.3 days, P<0.0001), and discharge to hospice (42.7% vs. 3.0%, P<0.0001). Results suggest PCC decreases future acute care costs and utilization in Whites and, directionally but not significantly, in African Americans; and increases discharge to hospice in both races (15-fold in African Americans, 14-fold in Whites). Research is needed to understand how PCC supports end-of-life decision-making and hospice use across races and how systems and policies can enable effective goals-of-care consultations across settings.

Palliative Care Consult for Clinician Distress Through the Philosophical Lenses of Gender Norms and Phenomenology

The National Academy of Medicine has raised significant concerns on clinician health and well-being as many experiencing burnout, post-traumatic stress, and depression. Indeed, clinicians experience a range of human emotions when caring for older adults with severe, life-limiting illnesses. These emotions may manifest in multiple ways and from various sources. Uncertain of how to attend to such distress, clinicians may consult a trusted resource, including the palliative care team. Palliative care specialists are trained to support the complexities and needs of patients and families; increasingly, however, palliative care consults are rooted in clinician distress. This session uses clinical case examples to explore the palliative care consult for distressed clinicians from two different philosophical perspectives: (1) phenomenology and (2) the social construct of gender norms. A phenomenological lens respects the unique, subjective lived experience of each individual in their day-to-day interactions with patients, families, and health care systems. Therefore, when caring for seriously ill older adults, clinicians may bring their own subjective experiences to the patient encounter and react differently to ethical dilemmas and conflicts that arise. The social construct of gender norms asks us to examine clinician distress from a different perspective. Here, the postmodern rejection of gender binarism allows clinicians to experience a spectrum of emotions and distress regardless of gender. Exploration through clinical cases will highlight the unique, varied experience of clinician distress and offer opportunities for future research into the role of palliative care teams in supporting distressed clinicians who care for seriously ill older adults.

Patient Risk Factor Profiles Associated With Timing of Goals-of-Care Consultation Before Death

Early palliative care consultation to discuss goals-of-care (“PCC”) benefits seriously ill patients. To identify risk factor profiles associated with inpatient PCC timing before death, we conducted a secondary analysis of seriously ill adults who had PCC at a high-acuity hospital and died 2014-2016. Of 1,141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15-60 days before death; 21% had PCC &gt;60 days before death (median 13 days). Classification and Regression Tree modeling showed Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%) were most likely to have PCC close to death, with age &lt;46 or &gt;75 increasing probability (98%). Among age groups, the highest proportion of patients with PCC close to death was &gt;75 years. Complex variable interactions associated with PCC timing suggests we need a systematic process for initiating PCC earlier and effective primary palliative training for providers across settings.

Emergency Transition to Virtual Education during COVID-19: Lessons and Opportunities for Experiential Learning and Practice Socialization

This article was migrated. The article was not marked as recommended. In response to COVID-19, health professional schools made an emergency transition to virtual learning. The speed and scope of virtual learning adoption is unprecedented and poses major challenges to health professional schools to maintain important elements of their curriculum and pedagogical structure. Some challenges include maintaining fidelity of experiential and bedside clinical learning, along with practice socialization. These challenges may be amplified in traditionally underrepresented and poor students. There are some practical solutions to minimize these challenges. For example, health professional schools can find new means of encouraging community engagement and mentor-mentee relationships such as using technology to connect students with faculty and patients to mitigate losses in clinical experiences, and using video-chat over speech only forms of communication that can help establish some sense of learning community while online. Health professional schools may also use the COVID-19 crisis to establish new norms in health profession education, by developing hybrid educational content between multiple programs or health professions, with the goal of establishing or strengthening interprofessional educational opportunities and increasing access to them.

Advance Care Planning Outcomes in African Americans: An Empirical Look at the Trust Variable

CONTEXT

Racial disparities in rates of hospice use, a marker of quality of end-of-life (EOL) care, have been a long-standing problem. Although distrust has been cited as a main reason for the preference of intensive EOL care among African Americans, the role of trust has not been closely analyzed in predicting EOL care in the context of advance care planning (ACP) outcomes.

OBJECTIVES

The goal of this review was to empirically examine the role of trust in ACP outcomes.

METHODS

For this systematic review, we utilized methods adapted from the GRADE process developed by the Cochrane Collaboration. The research question guiding this review was "What is the quantitative influence of trust in the health care system or health care providers on the ACP process for African Americans?" We searched Medline, Embase, and Web of Science for articles published between 1975 and 2016.

RESULTS

We identified nine quantitative studies that measured and evaluated trust as a predictor or correlate of ACP preferences. Of the studies, eight were observational and one was a pre-post-test study. Three studies were designated as low quality, and six studies were of moderate quality.

CONCLUSION

Distrust has been cited as a central reason for African Americans' tendency to choose life-sustaining treatments over comfort-focused care; however, our findings do not support this hypothesis. The majority of studies found no significant differences in trust between African Americans and their White counterparts. Further, we found that trust was not associated with ACP outcomes in the majority of studies.

Identifying distinct risk profiles to predict adverse events among community-dwelling older adults

Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong-Lo-Mendell-Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p < 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community-dwelling older adults.

The use of comorbidities among adults experiencing care transitions: a systematic review and evolutionary analysis of empirical literature

OBJECTIVE

To systematically review how comorbidities are employed in the empirical literature for adults coping with multiple chronic conditions during common episodes of acute illness that resulted in transition across health care setting.

METHODS

Evolutionary concept analysis inductively identifies current consensus regarding the usage of a concept and results in exploring attributes and clarification of the concept. Sixty studies from 1965 to 2009 identified from MEDLINE, CINAHL, PsychINFO, and ISI Web of Science databases were analysed.

RESULTS

Comorbidities were used heterogeneously among reviewed studies with most controlling for their presence (n=33) and lacking robust measurement (n=37). The designation of index or principal condition was equally heterogeneous with approximately half (n=26) representing the main disease or diagnosis of interest to the researcher. In this study comorbidities were associated with personal, disease or system level antecedents and consequences. A conceptual framework is proposed.

DISCUSSION

The impact of comorbidities on the care and outcomes of adults coping with multiple chronic conditions is limited by heterogeneous and ambiguous usage. While analytic techniques have become more sophisticated, continued lack of meaningful conceptualization and instrument use has limited maturation of this important concept for research, practice and policy purposes.