Geographic Accessibility and Completion of Initial Low-Dose CT-Based Lung Cancer Screening in an Urban Safety-Net Population

BACKGROUND

Recent modifications to low-dose CT (LDCT)-based lung cancer screening guidelines increase the number of eligible individuals, particularly among racial and ethnic minorities. Because these populations disproportionately live in metropolitan areas, we analyzed the association between travel time and initial LDCT completion within an integrated, urban safety-net health care system.

METHODS

Using Esri's StreetMap Premium, OpenStreetMap, and the r5r package in R, we determined projected private vehicle and public transportation travel times between patient residence and the screening facility for LDCT ordered in March 2017 through December 2022 at Parkland Memorial Hospital in Dallas, Texas. We characterized associations between travel time and LDCT completion in univariable and multivariable analyses. We tested these associations in a simulation of 10,000 permutations of private vehicle and public transportation distribution.

RESULTS

A total of 2,287 patients were included in the analysis, of whom 1,553 (68%) completed the initial ordered LDCT. Mean age was 63 years, and 73% were underrepresented minorities. Median travel time from patient residence to the LDCT screening facility was 17 minutes by private vehicle and 67 minutes by public transportation. There was a small difference in travel time to the LDCT screening facility by public transportation for patients who completed LDCT versus those who did not (67 vs 66 min, respectively; P=.04) but no difference in travel time by private vehicle for these patients (17 min for both; P=.67). In multivariable analysis, LDCT completion was not associated with projected travel time to the LDCT facility by private vehicle (odds ratio, 1.01; 95% CI, 0.82-1.25) or public transportation (odds ratio, 1.14; 95% CI, 0.89-1.44). Similar results were noted across travel-type permutations. Black individuals were 29% less likely to complete LDCT screening compared with White individuals.

CONCLUSIONS

In an urban population comprising predominantly underrepresented minorities, projected travel time is not associated with initial LDCT completion in an integrated health care system. Other reasons for differences in LDCT completion warrant investigation.

Effect of Patient Navigation on Completion of Lung Cancer Screening in Vulnerable Populations

BACKGROUND

Although low-dose, CT-based lung cancer screening (LCS) can decrease lung cancer mortality in high-risk individuals, the process may be complex and pose challenges to patients, particularly those from minority underinsured and uninsured populations. We conducted a randomized controlled trial of telephone-based navigation for LCS within an integrated, urban, safety-net health care system.

PATIENTS AND METHODS

Patients eligible for LCS were randomized (1:1) to usual care with or without navigation at Parkland Health in Dallas, Texas. The primary endpoint was completion of the first 3 consecutive steps in a patient's LCS process. We explored differences in completion of LCS steps between navigation and usual care groups, controlling for patient characteristics using the chi-square test.

RESULTS

Patients (N=447) were randomized to either navigation (n=225) or usual care (n=222). Mean patient age was 62 years, 46% were female, and 69% were racial/ethnic minorities. There was no difference in completion of the first 3 steps of the LCS algorithm between arms (12% vs 9%, respectively; P=.30). For ordered LCS steps, completion rates were higher among patients who received navigation (86% vs 79%; P=.03). The primary reason for step noncompletion was lack of order placement.

CONCLUSIONS

In this study, lack of order placement was a key reason for incomplete LCS steps. When orders were placed, patients who received navigation had higher rates of completion. Clinical team education and enhanced electronic health record processes to simplify order placement, coupled with patient navigation, may improve LCS in safety-net health care systems.

The financial burden after liver transplantation is significant among commercially insured adults: A large US National Cohort

Liver transplantation (LT) is lifesaving for patients with cirrhosis; however, the resultant financial burden to patients has not been well characterized. We aimed to provide a nationally representative portrayal of patient financial burden after LT. Adult recipients of LT from 2006 to 2021 were identified using IQVIA PharMetrics® Plus for Academics-a large nationally representative claims database of commercially insured Americans. Patient financial liability (ie, what patients owe) was estimated using the difference between allowed and paid costs for adjudicated medical/pharmacy claims. Descriptive statistics were provided stratified by the financial liability group within 1 year after LT. Multivariable logistic regression modeling identified factors associated with high/extreme liability adjusting for covariates. Potential indirect costs of post-LT care were estimated based on hourly wages lost for care. Among 1412 recipients of LT, financial liability was heterogeneous-~3% had no liability and 21% had extreme liability > $10K for 1-year post-LT care; most (69%) paid between $1 and 10K, with 48% having liability >$5K. Factors associated with >$5K liability included older age, insurance/enrollment type, US region, history of HCC, and simultaneous liver-kidney transplant (for liability >$10K). Medication costs comprised ~30% of outpatient financial liability. Potential indirect costs from wages lost were $2,201-$6,073 per person, depending on an hourly wage. In a large national cohort of commercially insured recipients of LT, financial liability was highly variable across sociodemographic and clinical characteristics; nearly 1 out of 2 recipients of LT owed >$5K for 1 year of post-LT care. Transplant programs should help patients anticipate potential costs and identify vulnerable populations who would benefit from enhanced financial counseling.

Characteristics of self-triaged emergency department visits by adults with cancer

OBJECTIVES

Adults with a new diagnosis of cancer frequently visit emergency departments (EDs) for disease- and treatment-related issues, although not exclusively. Many cancer care providers have 24/7 clinician phone triage available, but initial recorded phone messages tend to advise patients to go to the nearest ED if they are "experiencing a medical emergency." It is unclear how well patients triage themselves to the optimal site of care.

STUDY DESIGN

Cross-sectional study of tumor registry records (university patients diagnosed 2008-2018 and safety-net patients diagnosed 2012-2018) identifiably linked to electronic health records and a regional health information exchange.

METHODS

We geoprocessed addresses to calculate driving time distance from the patient's home to the ED. We used mixed-effects regression to predict the diagnosis code-based severity for ED visits within 6 months of diagnosis, clustering visits within patients and hospitals.

RESULTS

A total of 39,498 adults made 38,944 ED visits to 67 different hospitals. Patients self-referred for 85.5% of visits and bypassed a median (IQR) of 13 (4-33) closer EDs. Visits closer to home were not significantly more clinically severe; visits were significantly less severe if the patient self-referred (adjusted odds ratio [AOR], 0.89; 95% CI, 0.81-0.97) or they were on weekends (AOR, 0.93; 95% CI, 0.87-0.99). Reanalyzing within each individual health system also showed similar findings.

CONCLUSIONS

Adults with cancer infrequently use available clinician advice before visiting the ED and may use factors other than clinical severity to determine their need for emergency care. Future work should explore the challenges that patients face navigating unplanned acute care, including reasons for underusing existing resources.

Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention

Low-dose computed tomography-based lung cancer screening represents a complex clinical undertaking that could require multiple referrals, appointments, and time-intensive procedures. These steps may pose difficulties and raise concerns among patients, particularly minority, under-, and uninsured populations. The authors implemented patient navigation to identify and address these challenges. They conducted a pragmatic randomized controlled trial of telephone-based navigation for lung cancer screening in an integrated, urban safety-net health care system. Following standardized protocols, bilingual (Spanish and English) navigators educated, motivated, and empowered patients to traverse the health system. Navigators made systematic contact with patients, recording standardized call characteristics in a study-specific database. Call type, duration, and content were recorded. Univariable and multivariable multinomial logistic regression was performed to investigate associations between call characteristics and reported barriers. Among 225 patients (mean age 63 years, 46% female, 70% racial/ethnic minority) assigned navigation, a total of 559 barriers to screening were identified during 806 telephone calls. The most common barrier categories were personal (46%), provider (30%), and practical (17%). System (6%) and psychosocial (1%) barriers were described by English-speaking patients, but not by Spanish-speaking patients. Over the course of the lung cancer screening process, provider-related barriers decreased 80% (P = 0.008). The authors conclude that patients undergoing lung cancer screening frequently report personal and health care provider-related barriers to successful participation. Barrier types may differ among patient populations and over the course of the screening process. Further understanding of these concerns may increase screening uptake and adherence. Clinical Trial Registration number: (NCT02758054).

Enhancing access to and diversity in cancer clinical trials through a financial reimbursement program: Protocol to evaluate a novel program

As clinical trials have become more complex, with increasing numbers of required procedures and clinic visits, gaining access to promising new treatments has become even more challenging for many individuals. To address these barriers, we implemented a financial reimbursement and outreach program designed to increase the number and diversity of participants in cancer clinical trials at centers in Dallas, Houston, and Philadelphia. As endorsed by U.S. Food and Drug Administration (FDA) and the Texas and Pennsylvania State Legislatures, the program provides financial reimbursement for non-clinical costs (e.g., travel, lodging) to patients on cancer clinical trials with household income up to 700% the Federal poverty rate. The research study described here, centered at the Dallas site, evaluates program impact by assessing (1) numbers and diversity of patients enrolled to cancer clinical trials before and after program implementation; (2) characteristics of patients offered participation in the program who do versus do not enroll; (3) characteristics of patients enrolled in the program who do versus do not complete the reimbursement process. To evaluate perceived barriers and facilitators of program participation, we will conduct semi-structured interviews and administer the Comprehensive Score for Financial Toxicity Patient Reported Outcome Measure (COST PROM) and the Short Assessment of Health Literacy (SAHL). This program will examine how reimbursement of non-clinical costs can improve access to cancer clinical trials, with the eventual goal of increasing trial enrollment, diversity, representativeness, and generalizability.

Colorectal Cancer Incidence, Inequalities, and Prevention Priorities in Urban Texas: Surveillance Study With the "surveil" Software Package

BACKGROUND

Monitoring disease incidence rates over time with population surveillance data is fundamental to public health research and practice. Bayesian disease monitoring methods provide advantages over conventional methods including greater flexibility in model specification and the ability to conduct formal inference on model-derived quantities of interest. However, software platforms for Bayesian inference are often inaccessible to nonspecialists.

OBJECTIVE

To increase the accessibility of Bayesian methods among health surveillance researchers, we introduce a Bayesian methodology and open source software package, surveil, for time-series modeling of disease incidence and mortality. Given case count and population-at-risk data, the software enables health researchers to draw inferences about underlying risk and derivative quantities including age-standardized rates, annual and cumulative percent change, and measures of inequality.

METHODS

We specify a Poisson likelihood for case counts and model trends in log-risk using the first-difference (random-walk) prior. Models in the surveil R package were built using the Stan modeling language. We demonstrate the methodology and software by analyzing age-standardized colorectal cancer (CRC) incidence rates by race and ethnicity for non-Latino Black (Black), non-Latino White (White), and Hispanic/Latino (of any race) adults aged 50-79 years in Texas's 4 largest metropolitan statistical areas between 1999 and 2018.

RESULTS

Our analysis revealed a cumulative decline of 31% (95% CI -37% to -25%) in CRC risk among Black adults, 17% (95% CI -23% to -11%) for Latino adults, and 35% (95% CI -38% to -31%) for White adults from 1999 to 2018. None of the 3 observed groups experienced significant incidence reduction in the final 4 years of the study (2015-2018). The Black-White rate difference (per 100,000) was 44 (95% CI 30-57) in 1999 and 35 (95% CI 28-43) in 2018. Cumulatively, the Black-White gap accounts for 3983 CRC cases (95% CI 3746-4219) or 31% (95% CI 29%-32%) of total CRC incidence among Black adults in this period.

CONCLUSIONS

Stalled progress on CRC prevention and excess CRC risk among Black residents warrant special attention as cancer prevention and control priorities in urban Texas. Our methodology and software can help the public and health agencies monitor health inequalities and evaluate progress toward disease prevention goals. Advantages of the methodology over current common practice include the following: (1) the absence of piecewise linearity constraints on the model space, and (2) formal inference can be undertaken on any model-derived quantities of interest using Bayesian methods.

Long-term Mammography Adherence among Uninsured Women Enrolled in the Breast Screening and Patient Navigation (BSPAN) Program

BACKGROUND

The Breast Screening and Patient Navigation (BSPAN) Program provides access to no-cost breast cancer screening services to uninsured women in North Texas. Using data from the longitudinal BSPAN program (2012-2019), we assessed prevalence and correlates of (i) baseline adherence and (ii) longitudinal adherence to screening mammograms.

METHODS

Outcomes were baseline adherence (adherent if women received second mammogram 9-30 months after the index mammogram) and longitudinal adherence (assessed among baseline adherent women and defined as being adherent 39 months from the index mammogram). We used multivariable logistic regression and multivariable Cox proportional hazards model to assess associations of sociodemographic and clinical characteristics with baseline and longitudinal adherence, respectively.

RESULTS

Of 19,292 women, only 5,382 (27.9%) were baseline adherent. Baseline adherence was more likely among women who were partnered, preferred speaking Spanish, had poor reading ability, had prior Papanicolaou (PAP) testing, and prior screening mammograms, compared with women who were non-partnered, preferred speaking English, had good reading ability, had no prior PAP testing, and no prior screening mammograms, respectively. Of those who were baseline adherent, 4,364 (81.1%) women demonstrated longitudinal adherence. Correlates of longitudinal adherence were similar to those from baseline adherence.

CONCLUSIONS

A large proportion of baseline adherent women (>80%) achieved longitudinal adherence, which highlights the importance of concentrating resources during the second mammogram in the progression toward continued adherence.

IMPACT

Results from our unique dataset provide realistic mammography adherence rates and may be generalizable to other areas introducing no-cost screening to low-income women, independent of any regular patient-centered medical home.

Longitudinal Experience With and Impressions of COVID-19-Related Clinical Research Changes

PURPOSE

The COVID-19 pandemic has led to profound changes in clinical research, including remote consent, telehealth, off-site procedures, shipment of therapy, and remote study monitoring. We assessed longitudinal perceptions of these adjustments among clinical research professionals.

METHODS

We distributed an anonymous survey assessing experiences, perceptions, and recommendations regarding COVID-19-related clinical research adjustments to cancer clinical research office personnel in May 2020 and again in November 2020. Responses were compared using Fisher's exact and Mann-Whitney U tests.

RESULTS

A total of 90 of 102 invited research personnel (88%) responded. Fifty-three (59%) reported participating in both initial and follow-up surveys. The proportion of respondents reporting personal experience with COVID-19-related adjustments increased over time, particularly for remote initial consent (29% v 4%), remote reconsent (24% v 9%), and remote study monitoring (36% v 22%). Perceived impact of COVID-19-related adjustments on data quality (P = .02) and patient experience (P = .002) improved significantly. However, perceived effect on patient safety (P = .02) and respondent's experience (P = .09) became less favorable. Individuals with personal experience with the adjustment were more likely to recommend continuing remote consent (62% v 38%; P = .04), remote monitoring (69% v 45%; P = .05), and therapy shipment (67% v 35%; P = .01) after the COVID-19 pandemic, with nonsignificant trends for off-site diagnostics (44% v 24%; P = .13) and telehealth visits (66% v 45%; P = .08).

CONCLUSION

More than 6 months into the global pandemic, perceptions of COVID-19-related clinical research changes remain favorable. Experienced individuals are more likely to recommend that these changes continue in the future.

Cancer prevention, risk reduction, and control: opportunities for the next decade of health care delivery research

In this commentary, we discuss opportunities to optimize cancer care delivery in the next decade building from evidence and advancements in the conceptualization and implementation of multi-level translational behavioral interventions. We summarize critical issues and discoveries describing new directions for translational behavioral research in the coming decade based on the promise of the accelerated application of this evidence within learning health systems. To illustrate these advances, we discuss cancer prevention, risk reduction (particularly precision prevention and early detection), and cancer treatment and survivorship (particularly risk- and need-stratified comprehensive care) and propose opportunities to equitably improve outcomes while addressing clinician shortages and cross-system coordination. We also discuss the impacts of COVID-19 and potential advances of scientific knowledge in the context of existing evidence, the need for adaptation, and potential areas of innovation to meet the needs of converging crises (e.g., fragmented care, workforce shortages, ongoing pandemic) in cancer health care delivery. Finally, we discuss new areas for exploration by applying key lessons gleaned from implementation efforts guided by advances in behavioral health.

Reimbursement Matters: Overcoming Barriers to Clinical Trial Accrual

BACKGROUND

Accrual to cancer clinical trials is suboptimal. Few data exist regarding whether financial reimbursement might increase accruals.

OBJECTIVE

The objective of this study was to assess perceptions about reimbursement to overcome barriers to trial accrual.

RESEARCH DESIGN

This was a cross-sectional survey.

SUBJECTS

Oncologists identified from the American Medical Association Physician Masterfile.

MEASURES

We report descriptive statistics, associations of physician characteristics with perceptions of reimbursement, domains, and subthemes of free-text comments.

RESULTS

Respondents (n=1030) were mostly medical oncologists (59.4%), ages 35-54 (67%), and male (75%). Overall, 30% reported discussing trials with >25% of patients. Barriers perceived were administrative/regulatory, physician/staff time, and eligibility criteria. National Cancer Institute cooperative group participants and practice owners were more likely to endorse higher reimbursement. Respondents indicated targeted reimbursement would help improve infrastructure, but also noted potential ethical problems with reimbursement for discussion (40.7%) and accrual (85.9%). Free-text comments addressed reimbursement sources, recipients, and concerns about the real and apparent conflict of interest.

CONCLUSIONS

Though concerns about a potential conflict of interest remain paramount and must be addressed in any new system of reimbursement, oncologists believe reimbursement to enhance infrastructure could help overcome barriers to trial accrual.

Patterns and Results of Triage Advice Before Emergency Department Visits Made by Patients With Cancer

PURPOSE

Patients with cancer undergoing treatment frequently visit the emergency department (ED) for commonly anticipated complaints (eg, pain, nausea, and vomiting). Nearly all Medicare Oncology Care Model (OCM) participants prioritized ED use reduction, and the OCM requires that patients have 24-hour telephone access to a clinician, but actual reductions in ED visits have been mixed. Little is known about the use of telephone triage for acute care.

METHODS

We identified adults aged 18+ years newly diagnosed with cancer, linked to ED visits from a single institution within 6 months after diagnosis, and then analyzed the telephone and secure electronic messages in the preceding 24 hours. We coded interactions to classify the reason for the call, the main ED referrer, and other attempted management. We compared the acuity of patient self-referred versus clinician-referred ED visits by modeling hospitalization and ED visit severity.

RESULTS

From 2011 to 2018, 3,247 adults made 5,371 ED visits to the university hospital and self-referred to the ED 58.5% of the time. Clinicians referred to outpatient or oncology urgent care for 10.3% of calls but referred to the ED for 61.3%. Patient self-referred ED visits were likely to be hospitalized (adjusted Odds Ratio [aOR], 0.89, 95% CI, 0.64 to 1.22) and were not more severe (aOR, 0.75, 95% CI, 0.55 to 1.02) than clinician referred.

CONCLUSION

Although patients self-referred for six of every 10 ED visits, self-referred visits were not more severe. When patients called for advice, clinicians regularly recommended the ED. More should be done to understand barriers that patients and clinicians experience when trying to access non-ED acute care.

Current Practices for Screening and Addressing Financial Hardship within the NCI Community Oncology Research Program

BACKGROUND

Cancer-related financial hardship is associated with poor care outcomes and reduced quality of life for patients and families. Scalable intervention development to address financial hardship requires knowledge of current screening practices and services within community cancer care.

METHODS

The NCI Community Oncology Research Program (NCORP) 2017 Landscape Assessment survey assessed financial screening and financial navigation practices within U.S. community oncology practices. Logistic models evaluated associations between financial hardship screening and availability of a cancer-specific financial navigator and practice group characteristics (e.g., safety-net designation, critical access hospital, proportion of racial and ethnic minority patients served).

RESULTS

Of 221 participating NCORP practice groups, 72% reported a financial screening process and 50% had a cancer-specific financial navigator. Practice groups with more than 10% of new patients with cancer enrolled in Medicaid (_adjOR = 2.81, P = 0.02) and with less than 30% racial/ethnic minority cancer patient composition (_adjOR = 3.91, P < 0.01) were more likely to screen for financial concerns. Practice groups with less than 30% racial/ethnic minority cancer patient composition (_adjOR = 2.37, P < 0.01) were more likely to have a dedicated financial navigator or counselor for patients with cancer.

CONCLUSIONS

Most NCORP practice groups screen for financial concerns and half have a cancer-specific financial navigator. Practices serving more racial or ethnic minority patients are less likely to screen and have a designated financial navigator.

IMPACT

The effectiveness of financial screening and navigation for mitigating financial hardship could be tested within NCORP, along with specific interventions to address cancer care inequities.See related commentary by Yabroff et al., p. 593.

Clinician Variation in Ordering and Completion of Low-Dose Computed Tomography for Lung Cancer Screening in a Safety-Net Medical System

BACKGROUND

Less than 5% of eligible individuals in the United States undergo lung cancer screening. Variation in clinicians' participation in lung cancer screening has not been determined.

PATIENTS AND METHODS

We studied medical providers who ordered ≥ 1 low-dose computed tomography (LDCT) for lung cancer screening from February 2017 through February 2019 in an integrated safety-net healthcare system. We analyzed associations between provider characteristics and LDCT orders and completion using chi-square, Fisher exact, and Student t tests, as well as ANOVA and multinomial logistic regression.

RESULTS

Among an estimated 194 adult primary care physicians, 144 (74%) ordered at least 1 LDCT, as did 39 specialists. These 183 medical providers ordered 1594 LDCT (median, 4; interquartile range, 2-9). In univariate and multivariate models, family practice providers (P < .001) and providers aged ≥ 50 years (P = .03) ordered more LDCT than did other clinicians. Across providers, the median proportion of ordered LDCT that were completed was 67%. The total or preceding number of LDCT ordered by a clinician was not associated with the likelihood of LDCT completion.

CONCLUSION

In an integrated safety-net healthcare system, most adult primary care providers order LDCT. The number of LDCT ordered varies widely among clinicians, and a substantial proportion of ordered LDCT are not completed.

Assessment of patient and provider attitudes towards therapeutic drug monitoring to improve medication adherence in low-income patients with hypertension: a qualitative study

OBJECTIVES

Previous studies have implicated therapeutic drug monitoring (TDM), by measuring serum or urine drug levels, as a highly reliable technique for detecting medication non-adherence but the attitudes of patients and physicians toward TDM have not been evaluated previously. Accordingly, we solicited input from patients with uncontrolled hypertension and their physicians about their views on TDM.

DESIGN

Prospective analysis of responses to a set of questions during semistructured interviews.

SETTING

Outpatient clinics in an integrated health system which provides care for a low-income, uninsured population.

PARTICIPANTS

Patients with uncontrolled hypertension with either systolic blood pressure of at least 130 mm Hg or diastolic blood pressure of at least 80 mm Hg despite antihypertensive drugs and providers in the general cardiology and internal medicine clinics.

PRIMARY AND SECONDARY OUTCOME MEASURES

Attitudes towards TDM and the potential impact on physician-patient relationship.

RESULTS

We interviewed 11 patients and 10 providers and discussed the findings with 13 community advisory panel (CAP) members. Of the patients interviewed, 91% (10 of 11) and all 10 providers thought TDM was a good idea and should be used regularly to better understand the reasons for poorly controlled hypertension. However, 63% (7 of 11) of patients and 20% of providers expressed reservations that TDM could negatively impact the physician-patient relationship. Despite some concerns, the majority of patients, providers and CAP members believed that if test results are communicated without blaming patients, the potential benefits of TDM in identifying suboptimal adherence and eliciting barriers to adherence outweighed the risks.

CONCLUSION

The idea of TDM is well accepted by patients and their providers. TDM information if delivered in a non-judgmental manner, to encourage an honest conversation between patients and physicians, has the potential to reduce patient-physician communication obstacles and to identify barriers to adherence which, when overcome, can improve health outcomes.

Experience, Perceptions, and Recommendations Concerning COVID-19-Related Clinical Research Adjustments

BACKGROUND

During the COVID-19 public health emergency, the FDA and NIH altered clinical trial requirements to protect participants and manage study conduct. Given their detailed knowledge of research protocols and regular contact with patients, clinicians, and sponsors, clinical research professionals offer important perspectives on these changes.

METHODS

We developed and distributed an anonymous survey assessing COVID-19-related clinical trial adjustment experiences, perceptions, and recommendations to Clinical Research Office personnel at the Harold C. Simmons Comprehensive Cancer Center. Responses were compared using the Fisher exact test.

RESULTS

A total of 94 of 109 contacted research personnel (87%) responded. Among these individuals, 58% had >5 years' professional experience in clinical research, and 56% had personal experience with a COVID-19-related change. Respondents perceived that these changes had a positive impact on patient safety; treatment efficacy; patient and staff experience; and communication with patients, investigators, and sponsors. More than 90% felt that positive changes should be continued after COVID-19. For remote consent, telehealth, therapy shipment, off-site diagnostics, and remote monitoring, individuals with personal experience with the specific change and individuals with >5 years' professional experience were numerically more likely to recommend continuing the adjustment, and these differences were significant for telehealth (P=.04) and therapy shipment (P=.02).

CONCLUSIONS

Clinical research professionals perceive that COVID-19-related clinical trial adjustments positively impact multiple aspects of study conduct. Those with greatest experience-both specific to COVID-19-related changes and more generally-are more likely to recommend that these adjustments continue in the future.

Mobile Device Applications for Electronic Patient Portals in Oncology

PURPOSE

Mobile devices provide individuals with rapid and frequent access to electronic patient portals. We investigated how oncology patients use this technology to review test results and communicate with providers.

PATIENTS AND METHODS

We performed a retrospective study of patients enrolled in the MyChart electronic health portal associated with the Epic electronic medical record at the Harold C. Simmons Comprehensive Cancer Center from 2012 to 2017. We recorded type of portal access according to year and patient characteristics. Associations among patient characteristics and types of portal access were tested using Mann-Whitney U test, χ² test, and linear Gaussian regression models.

RESULTS

Since the availability of a mobile device application in 2012, 2,524 patients with cancer accessed MyChart from a mobile device at least once, which accounted for 291,526 mobile log-ins. The number of patients with MyChart mobile application log-ins increased from 4% in 2012 to 13% in 2017 ( P = .004). Among these patients, the median proportion of log-ins that occurred through mobile device use increased from 22% to 72% during this time period ( P < .001). Mobile access occurred more frequently among younger ( P < .001), black ( P = .002), and Hispanic ( P = .004) patients. Since 2012, total portal log-in frequency increased approximately 110% among patients who used the mobile application compared with 25% among those who did not use the mobile application ( P < .001).

CONCLUSION

Mobile access to electronic health portals has increased patient portal use, particularly among traditionally underserved populations. How this widely and immediately available technology affects patient expectations and experiences warrants additional study.

A randomized trial of mail and email recruitment strategies for a physician survey on clinical trial accrual

Background

Patient participation in cancer clinical trials is suboptimal. A challenge to capturing physicians’ insights about trials has been low response to surveys. We conducted a study using varying combinations of mail and email to recruit a nationally representative sample of medical, surgical, and radiation oncologists to complete a survey on trial accrual.

Methods

We randomly assigned eligible physicians identified from the American Medical Association MasterFile (n = 13,251) to mail- or email-based recruitment strategies. Mail-based recruitment included a survey packet with: (1) cover letter describing the survey and inviting participation; (2) paper copy of the survey and postage-paid return envelope; and (3) a web link for completing the survey online. Email-based recruitment included an e-mail describing the survey and inviting participation, along with the web link to the survey, and a reminder postcard 2 weeks later.

Results

Response was higher for mail-based (11.8, 95% CI 11.0–12.6%) vs. email-based (4.5, 95% CI 4.0–5.0%) recruitment. In email-based recruitment, only one-quarter of recipients opened the email, and even fewer clicked on the link to complete the survey. Most physicians in mail-based recruitment responded after the first invitation (362 of 770 responders, 47.0%). A higher proportion of responders vs. non-responders were young (ages 25–44 years), men, and radiation or surgical (vs. medical) oncologists.

Conclusions

Most physicians assigned to mail-based recruitment actually completed the survey online via the link provided in the cover letter, and those in email-based recruitment did not respond until they received a reminder postcard by mail. Providing the option to return a paper survey or complete it online may have further increased participation in the mail-based group, and future studies should examine how combinations of delivery mode and return options affect physicians’ response to surveys.

Tracking the Nonenrolled: Lung Cancer Screening Patterns Among Individuals not Accrued to a Clinical Trial

INTRODUCTION

For lung cancer screening, the available data are often derived from patients enrolled prospectively in clinical trials. We, therefore, investigated lung cancer screening patterns among individuals eligible for, but not enrolled in, a screening trial.

PATIENTS AND METHODS

From February 2017 through February 2019, we enrolled subjects in a trial examining telephone-based navigation during low-dose computed tomography (LDCT) for lung cancer screening. We identified patients for whom LDCT was ordered and who were approached, but not enrolled, in the trial. We categorized nonenrollment as the patient had declined or could not be reached. We compared the characteristics and LDCT completion rates among these groups and the enrolled population using the 2-sample t test and χ² test.

RESULTS

Of 900 individuals approached for participation (mean age, 62 years; 45% women, 53% black), 447 were enrolled in the screening clinical trial. No significant demographic differences were found between the enrolled and nonenrolled cohorts. Of the 453 individuals not enrolled, 251 (55%) had declined participation and 202 (45%) could not be reached, despite up to 6 attempts. LDCT completion was significantly associated with enrollment status: 81% of enrolled individuals, 73% of individuals who declined participation, and 49% of those who could not be reached (P < .001).

CONCLUSIONS

In the present single-center study, demographic factors did not predict for participation in a lung cancer screening trial. Lung cancer screening adherence rates were substantially lower for those not enrolled in a screening trial, especially for those who could not be contacted. These findings may inform the broader implementation of screening programs.

Patient and provider perspectives on delivery of oral cancer therapies

OBJECTIVE

The introduction of oral cancer therapies presents new challenges to delivery of quality cancer care. Little is known about how patients and providers address and overcome these challenges. We conducted a qualitative study exploring the range of patient and provider perspectives on oral cancer therapies.

METHODS

We conducted semi-structured interviews with patients and providers at a tertiary referral center and county safety-net hospital in Dallas, TX. Interviews probed perspectives on differences between parenteral chemotherapy and oral therapies, adherence, communication, and cost/insurance. Interview transcripts were analyzed thematically using a deductively-driven coding scheme corresponding to the interview guide.

RESULTS

We conducted 22 patient (13 at tertiary referral center, 9 at safety-net hospital) and 10 provider (7 oncologists, 2 nurses, 1 pharmacist) interviews. Key themes from interviews included: (1) differences in parenteral chemotherapy vs. oral therapy; (2) adherence and dosing; and (3) experiences related to cost and communication.

CONCLUSIONS

Nearly all providers described challenges engaging with and educating patients about oral cancer therapies. Despite our initial hypothesis, safety-net patients encountered few barriers accessing oral therapies compared to patients receiving care in the tertiary referral center.

PRACTICE IMPLICATIONS

Our findings will guide future interventions to monitor and support cancer patients receiving oral therapies.

Definition and Coordination of Roles and Responsibilities Among Cancer Center Clinic and Research Personnel

PURPOSE

Effective enrollment and treatment of patients in cancer clinical trials require definition and coordination of roles and responsibilities among clinic and research personnel.

MATERIALS AND METHODS

We developed a survey that incorporated modified components of the Survey of Physician Attitudes Regarding the Care of Cancer Survivors. Surveys were administered to clinic nursing staff and research personnel at a National Cancer Institute-designated comprehensive cancer center. Results were analyzed using χ²-tests, t tests, and analyses of variance.

RESULTS

Surveys were completed by 105 staff members (n = 50 research staff, n = 55 clinic staff; 61% response rate). Research staff were more likely to feel that they had the skills to answer questions, convey information, and provide education for patients on trials (all P < .05). Both clinic and research staff reported receipt of communication about responsibilities in fewer than 30% of cases, although research staff reported provision of such information in more than 60% of cases. Among 20 tasks related to care of patients in trials, no single preferred model of responsibility assignment was selected by the majority of clinic staff for nine tasks (45%) or by research staff for three tasks (15%). Uncertainty about which team coordinates care was reported by three times as many clinic staff as research staff (P = .01). There was also substantial variation in the preferred model for delivery of care to patients in trials (P < .05).

CONCLUSION

Knowledge, attitudes, and perception of care and responsibilities for patients on clinical trials differ between and among clinic and research personnel. Additional research about how these findings affect efficiency and quality of care on clinical trials is needed.

Impact of a Cancer Urgent Care Clinic on Regional Emergency Department Visits

PURPOSE

Did the creation of an urgent care clinic specifically for patients with cancer affect emergency department visits among adults newly diagnosed with cancer?

PATIENTS AND METHODS

We applied an interrupted time series analysis to adjusted monthly emergency department visits made by adults age 18 years or older who were diagnosed with cancer between 2009 and 2016 at a comprehensive cancer center. Cancer registry patients were linked to a longitudinal regional database of emergency department and hospital visits. Because the urgent care clinic was closed on weekends, we took advantage of the natural experiment by comparing weekend visits as a control group. Our primary outcome was emergency department visits within 180 days after a cancer diagnosis, compiled as adjusted monthly rates of emergency department visits per 1,000 patient-months. We analyzed subsequent hospitalizations as a secondary outcome.

RESULTS

The rate of weekday emergency department visits was increasing at a rate of 0.43 visits (95% CI, 0.29 to 0.57 visits) per month before May 2012, then fell in half to a rate of 0.19 visits (95% CI, 0.11 to 0.28 visits) per month (P = .007) after the urgent care clinic was established. In contrast, the weekend visit rate was growing at a rate of 0.08 visits (95% CI, -0.03 to 0.19 visits) per month before May 2012 and 0.05 (95% CI, -0.02 to 0.13 visits; P = .533) afterward. By the end of 2016, there were 15.3 fewer monthly weekday emergency department visits than expected (P = .005). Trends in weekday hospitalizations were not significantly changed.

CONCLUSION

Although only one in eight emergency department-visiting patients also used the urgent care clinic, the growth rate of emergency department visits fell by half after the urgent care clinic was established.

Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol

BACKGROUND

The growing numbers of cancer survivors challenge delivery of high-quality survivorship care by healthcare systems. Innovative ways to improve care coordination for patients with cancer and multiple chronic conditions ("complex cancer survivors") are needed to achieve better care outcomes, improve patient experience of care, and lower cost. Our study, Project CONNECT, will adapt and implement three evidence-based care coordination strategies, shown to be effective for primary care conditions, among complex cancer survivors. Specifically, the purpose of this study is to: 1) Implement a system-level EHR-driven intervention for 500 complex cancer survivors at Parkland; 2) Test effectiveness of the strategies on system- and patient-level outcomes measured before and after implementation; and 3) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer.

METHODS

Project CONNECT is a quasi-experimental implementation study among 500 breast and colorectal cancer survivors with at least one of the following chronic conditions: diabetes, hypertension, chronic lung disease, chronic kidney disease, or heart disease. We will implement three evidence-based care coordination strategies in a large, county integrated safety-net health system: 1) an EHR-driven registry to facilitate patient transitions between primary and oncology care; 2) co-locating a nurse practitioner trained in care coordination within a complex care team; 3) and enhancing teamwork through coaching. Segmented regression analysis will evaluate change in system-level (i.e. composite care quality score) and patient-level outcomes (i.e. self-reported care coordination). To evaluate implementation, we will merge quantitative findings with structured observations and physician and patient interviews.

DISCUSSION

This study will result in an evaluation toolkit identifying key model elements, barriers, and facilitators that can be used to guide care coordination interventions in other safety-net settings. Because Parkland is a vanguard of safety-net healthcare nationally, findings will be widely applicable as other safety-nets move toward increased integration, enhanced EHR capability, and experience with growing patient diversity. Our proposal recognizes the complexity of interventions and scaffolds evidence-based strategies together to meet the needs of complex patients, systems of care, and service integration.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02943265 . Registered 24 October 2016.

Development and Preliminary Psychometric Evaluation of a Patient-Reported Outcome Measure for Lung Cancer Stigma: The Lung Cancer Stigma Inventory (LCSI)

INTRODUCTION

Among patients with lung cancer, stigma is associated with negative psychosocial and behavioral outcomes. There is a need to develop psychometrically robust patient-reported outcome (PRO) measures for stigma that incorporate perspectives of patients diagnosed with lung cancer. As part of our multi-phase process of measure development and validation, we report on scale formation and preliminary psychometric evaluation of the Lung Cancer Stigma Inventory (LCSI).

METHOD

Building on previously reported concept elicitation (Phase I) work, Phase II of LCSI development involved item generation and refinement, informed by literature review, provider input, and patient (N=20) feedback. Phase III focused on initial psychometric scale evaluation in a unique sample of 231 lung cancer patients.

RESULTS

Based on provider input and patient cognitive interviews, 49 items were included in a preliminary measure. In an exploratory factor analysis (EFA) of the 37 retained items, three factors emerged: Perceived Stigma, Internalized Stigma, and Constrained Disclosure. Internal consistency of the final, 25-item LCSI scale was high (Cronbach's alpha= 0.89) and the three subscales demonstrated good internal consistency. The test-retest correlation was high (r = 0.91), suggesting strong stability of measurement over time. There was good convergent validity between the LCSI and an existing measure of lung cancer stigma, the Cataldo Lung Cancer Stigma Scale (CLCSS; r= 0.58, p< 0.001).

DISCUSSION

In a multi-phase process, we have developed a reliable, multi-dimensional measure of lung cancer stigma, the Lung Cancer Stigma Inventory (LCSI). Subsequent work will be conducted to establish further evidence of validity and clinically meaningful change.

Polypharmacy and patterns of prescription medication use among cancer survivors

BACKGROUND

The population of cancer survivors is rapidly growing in the United States. Long-term and late effects of cancer, combined with the ongoing management of other chronic conditions, make survivors particularly vulnerable to polypharmacy and its adverse effects. In the current study, the authors examined patterns of prescription medication use and polypharmacy in a population-based sample of cancer survivors.

METHODS

Using data from the Medical Expenditure Panel Survey (MEPS), the authors matched cancer survivors (5216 survivors) with noncancer controls (19,588 controls) by age, sex, and survey year. Polypharmacy was defined as ≥5 unique medications. The authors estimated the percentage of respondents prescribed medications within therapeutic classes and total prescription expenditures.

RESULTS

A higher percentage of cancer survivors were prescribed ≥5 unique medications (64.0%; 95% confidence interval [95% CI], 62.3%-65.8%) compared with noncancer controls (51.5%; 95% CI, 50.4%-52.6%), including drugs with abuse potential. Across all therapeutic classes, a higher percentage of newly (≤1 year since diagnosis) and previously (>1 years since diagnosis) diagnosed survivors were prescribed medications compared with controls, with large differences observed with regard to central nervous system agents (65.8% [95% CI, 62.3%-69.3%] vs 57.4% [95% CI, 55.3%-59.5%] vs 46.0% [95% CI, 45.0%-46.9%]). Specifically, nearly 10% of survivors were prescribed benzodiazepines and/or opioids compared with approximately 5% of controls. Survivors had more than double the prescription expenditures (median of $1633 vs $784 among controls). Findings persisted across age and comorbidity categories.

CONCLUSIONS

Cancer survivors were prescribed a higher number of unique medications, including drugs with abuse potential, thereby increasing their risk of adverse drug events, financial toxicity, poor adherence, and drug-drug interactions. Cancer 2018;124:2850-2857. © 2018 American Cancer Society.

County-level outcomes of a rural breast cancer screening outreach strategy: a decentralized hub-and-spoke model (BSPAN2)

Rural mammography screening remains suboptimal despite reimbursement programs for uninsured women. Networks linking non-clinical community organizations and clinical providers may overcome limited delivery infrastructure in rural areas. Little is known about how networks expand their service area. To evaluate a hub-and-spoke model to expand mammography services to 17 rural counties by assessing county-level delivery and local stakeholder conduct of outreach activities. We conducted a mixed-method evaluation using EMR data, systematic site visits (73 interviews, 51 organizations), 92 patient surveys, and 30 patient interviews. A two-sample t test compared the weighted monthly average of women served between hub- and spoke-led counties; nonparametric trend test evaluated time trend over the study period; Pearson chi-square compared sociodemographic data between hub- and spoke-led counties. From 2013 to 2014, the program screened 4603 underinsured women. Counties where local "spoke" organizations led outreach activities achieved comparable screening rates to hub-led counties (9.2 and 8.7, respectively, p = 0.984) and did not vary over time (p = 0.866). Qualitative analyses revealed influence of program champions, participant language preference, and stakeholders' concerns about uncompensated care. A program that leverages local organizations' ability to identify and reach rural underserved populations is a feasible approach for expanding preventive services delivery.

Identifying quality improvement targets to facilitate colorectal cancer screening completion

The colorectal cancer (CRC) screening process involves multiple interfaces (communication exchanges and transfers of responsibility for specific actions) among primary care and gastroenterology providers, laboratory, and administrative staff. After a retrospective electronic health record (EHR) analysis discovered substantial clinic variation and low CRC screening prevalence overall in an urban, integrated safety-net system, we launched a qualitative analysis to identify potential quality improvement targets to enhance fecal immunochemical test (FIT) completion, the system's preferred screening modality. Here, we report examination of organization-, clinic-, and provider-level interfaces over a three-year period (December 2011–October 2014).

We deployed in parallel 3 qualitative data collection methods: (1) structured observation (90+ hours, 10 sites); (2) document analysis (n > 100); and (3) semi-structured interviews (n = 41) and conducted iterative thematic analysis in which findings from each method cross-informed subsequent data collection. Thematic analysis was guided by a conceptual model and applied deductive and inductive codes.

There was substantial variation in protocols for distributing and returning FIT kits both within and across clinics. Providers, clinic and laboratory staff had differing access to important data about FIT results based on clinical information system used and this affected results reporting. Communication and coordination during electronic referrals for diagnostic colonoscopy was suboptimal particularly for co-morbid patients needing anesthesia clearance.

Our multi-level approach elucidated organizational deficiencies not evident by quantitative analysis alone. Findings indicate potential quality improvement intervention targets including: (1) best-practices implementation across clinics; (2) detailed communication to providers about FIT results; and (3) creation of EHR alerts to resolve pending colonoscopy referrals before they expire.

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Multi-level qualitative approach identified challenges to 3 clinical processes

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Variation in fecal immunochemical testing (FIT) kit distribution and return

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Incomplete transfer of key FIT result data across clinical information systems

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Suboptimal communication and coordination during colonoscopy referrals

Cancer Center Clinic and Research Team Perceptions of Identity and Interactions

PURPOSE

Conduct of cancer clinical trials requires coordination and cooperation among research and clinic teams. Diffusion of and confusion about responsibility may occur if team members' perceptions of roles and objectives do not align. These factors are critical to the success of cancer centers but are poorly studied.

METHODS

We developed a survey adapting components of the Adapted Team Climate Inventory, Measure of Team Identification, and Measure of In-Group Bias. Surveys were administered to research and clinic staff at a National Cancer Institute-designated comprehensive cancer center. Data were analyzed using descriptive statistics, t tests, and analyses of variance.

RESULTS

Responses were received from 105 staff (clinic, n = 55; research, n = 50; 61% response rate). Compared with clinic staff, research staff identified more strongly with their own group ( P < .01) but less strongly with the overall cancer center ( P = .02). Both clinic staff and research staff viewed their own group's goals as clearer than those of the other group ( P < .01) and felt that members of their groups interacted and shared information within ( P < .01) and across ( P < .01) groups more than the other group did. Research staff perceived daily outcomes as more important than did clinic staff ( P = .05), specifically research-related outcomes ( P = .07).

CONCLUSION

Although there are many similarities between clinic and research teams, we also identified key differences, including perceptions of goal clarity and sharing, understanding and alignment with cancer center goals, and importance of outcomes. Future studies should examine how variation in perceptions and group dynamics between clinic and research teams may impact function and processes of cancer care.

Family and Social Context Contributes to the Interplay of Economic Insecurity, Food Insecurity, and Health

In this study, we show how household health, economic instability, and food insecurity are inextricably linked; disruptions in individual health or income create cumulative and interdependent challenges faced by multiple household members. Drawing upon semi-structured focus groups with English- and Spanish-speaking clients of an urban food pantry, we demonstrate: (1) the impact of economic scarcity on health, (2) the impact of one household member's health on the health and food security of all household members, and (3) food sharing behaviors among family and social networks, including multi-generational families and non-kin individuals. We identify the gap between household-level assessments of food insecurity and individual-level health reports, which may obscure poor health among other household members. Understanding the social and family context of health and food insecurity may inform future interventions that address the interrelated challenges of diverse and disadvantaged households and communities.

Patient navigation for lung cancer screening in an urban safety-net system: Protocol for a pragmatic randomized clinical trial

The National Lung Screening Trial demonstrated improved lung cancer mortality with annual low-dose computed tomography (CT) screening, leading to lung cancer screening endorsement by the United States Preventive Services Task Force and coverage by the Centers for Medicare and Medicaid. Adherence to annual CT screens in that trial was 95%, which may not be representative of real-world, particularly medically underserved populations. This pragmatic trial will determine the effect of patient-focused, telephone-based patient navigation on adherence to CT-based lung cancer screening in an urban safety-net population. 340 adults who meet standard eligibility for lung cancer screening (age 55-77years, smoking history≥30 pack-years, quit within 15years if former smoker) are referred through an electronic medical record-based order by physicians in community- and hospital-based primary care settings within the Parkland Health and Hospital System in Dallas County, Texas. Eligible patients are randomized to usual care or patient navigation, which addresses adherence, patient-reported barriers, smoking cessation, and psycho-social concerns related to screening completion. Patients complete surveys and semi-structured interviews at baseline, 6-month, and 18-month follow-ups to assess attitudes toward screening. The primary endpoint of this pragmatic trial is adherence to three sequential, prospectively defined steps in the screening protocol. Secondary endpoints include self-reported tobacco use and other patient-reported outcomes. Results will provide real-world insight into the impact of patient navigation on adherence to CT-based lung cancer screening in a medically underserved population. This study was registered with the NIH ClinicalTrials.gov database (NCT02758054) on April 26, 2016.

Assessing local capacity to expand rural breast cancer screening and patient navigation: An iterative mixed-method tool

BACKGROUND

Despite federal funding for breast cancer screening, fragmented infrastructure and limited organizational capacity hinder access to the full continuum of breast cancer screening and clinical follow-up procedures among rural-residing women. We proposed a regional hub-and-spoke model, partnering with local providers to expand access across North Texas. We describe development and application of an iterative, mixed-method tool to assess county capacity to conduct community outreach and/or patient navigation in a partnership model.

METHODS

Our tool combined publicly-available quantitative data with qualitative assessments during site visits and semi-structured interviews.

RESULTS

Application of our tool resulted in shifts in capacity designation in 10 of 17 county partners: 8 implemented local outreach with hub navigation; 9 relied on the hub for both outreach and navigation. Key factors influencing capacity: (1) formal linkages between partner organizations; (2) inter-organizational relationships; (3) existing clinical service protocols; (4) underserved populations. Qualitative data elucidate how our tool captured these capacity changes.

CONCLUSIONS

Our capacity assessment tool enabled the hub to establish partnerships with county organizations by tailoring support to local capacity and needs. Absent a vertically integrated provider network for preventive services in these rural counties, our tool facilitated a virtually integrated regional network to extend access to breast cancer screening to underserved women.

Oncology Nursing Perceptions of Patient Electronic Portal Use: A Qualitative Analysis

PURPOSE/OBJECTIVES

To identify nursing staff reactions to and perceptions of electronic portal use in a cancer setting.
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RESEARCH APPROACH

Qualitative.
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SETTING

Outpatient clinic at the Harold C. Simmons Comprehensive Cancer Center of the University of Texas Southwestern Medical Center in Dallas.
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PARTICIPANTS

13 nurses with a range of credentials and experience, representing infusion, medical oncology, and bone marrow transplantation clinics.
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METHODOLOGIC APPROACH

Two focus groups were conducted. Theoretical thematic content analysis of data was performed.
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FINDINGS

Key themes that emerged for consideration of electronic portals included work volume and flow, patient expectations and safety, variation in use of communication technologies, and education and management.
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INTERPRETATION

The current study provides insight into the implications of electronic portals by identifying nursing staff reactions to this technology. These reactions are predominantly related to the impact on clinical workload and patient safety and expectations.
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IMPLICATIONS FOR NURSING

As clinical cancer facilities incorporate electronic portal technology into their operations, attention to the impact on staff workload, division of labor, patient safety, and patient expectations should be considered.

Hispanic and Immigrant Paradoxes in U.S. Breast Cancer Mortality: Impact of Neighborhood Poverty and Hispanic Density

To test the Hispanic and Immigrant Paradoxes-i.e., survival advantages despite a worse risk factor profile-and the modifying role of neighborhood context, we examined associations between patient ethnicity, birthplace, neighborhood Hispanic density and neighborhood poverty among 166,254 female breast cancer patients diagnosed 1995-2009 in Texas, U.S. Of all, 79.9% were non-Hispanic White, 15.8% Hispanic U.S.-born, and 4.2% Hispanic foreign-born. We imputed birthplace for the 60.7% of Hispanics missing birthplace data using multiple imputation. Shared frailty Cox proportional hazard models (patients nested within census tracts) adjusted for age, diagnosis year, stage, grade, histology, urban/rural residence, and local mammography capacity. Whites (vs. U.S.-born Hispanics) had increased all-cause and breast cancer mortality. Foreign-born (vs. U.S.-born) Hispanics had increased all-cause and breast cancer mortality. Living in higher Hispanic density neighborhoods was generally associated with increased mortality, although associations differed slightly in magnitude and significance by ethnicity, birthplace, and neighborhood poverty. We found no evidence of an Immigrant Paradox and some evidence of a Hispanic Paradox where protective effects were limited to U.S.-born Hispanics. Contrary to prior studies, foreign birthplace and residence in higher Hispanic density neighborhoods were associated with increased mortality. More research on intersections between ethnicity, birthplace and neighborhood context are needed.

Achieving Coordinated Care for Patients With Complex Cases of Cancer: A Multiteam System Approach

Patients with cancer with multiple chronic conditions pose a unique challenge to how primary care and specialty care teams provide well-coordinated, patient-centered care. Effectiveness of these care teams in providing optimal health care depends on the extent to which they coordinate their goals and knowledge as components of a multiteam system (MTS). This article outlines challenges of care coordination in the context of an MTS, illustrated through the care experience of "Mr Fuentes," a patient in the Dallas County integrated safety-net system, Parkland. As a continuing patient with chronic illnesses, the patient being discussed is managed through one of the Parkland community-oriented primary care clinics. However, a cancer diagnosis triggered an additional need for augmented coordination between his different provider teams. Further research and practice should investigate the relationships of MTS coordination for shared care management, transfer to and from specialty care, treatment compliance, barriers to care, and health outcomes of chronic comorbid conditions, as well as cancer control and surveillance.

Increase in Cancer Center Staff Effort Related to Electronic Patient Portal Use

PURPOSE

Electronic portals provide patients with real-time access to personal health records. Use of this technology by individuals with cancer is particularly intensive. We therefore examined patterns of use of electronic portals by clinic staff at a National Cancer Institute-designated comprehensive cancer center.

METHODS

We identified and characterized cancer center providers and clinic staff who performed electronic activities related to MyChart, the institution's personal health records portal, from 2009 to 2014. Total MyChart actions and messages received were quantified and characterized according to type, timing, and staff category.

RESULTS

Two hundred eighty-nine employees were included in our analysis: 85 nurses (29%), 79 ancillary staff (27%), 49 clerical/managerial staff (17%), 47 physicians (16%), and 29 advanced practice providers (10%). These individuals performed 740,613 MyChart actions and received 117,799 messages. Seventy-seven percent of actions were performed by nurses, 11% by ancillary staff, 6% by advanced practice providers, 5% by physicians, and 1% by clerical/managerial staff. From 2011 to 2014, staff MyChart activity increased approximately 10-fold. On average, 6.3 staff MyChart actions were performed per patient-initiated message. In 2014, nurses performed an average of 3,838 MyChart actions and received an average of 589 messages, compared with 591 actions and 87 messages in 2011 ( P < .001). Sixteen percent of all actions occurred outside clinic hours.

CONCLUSION

Cancer center employee effort related to an electronic patient portal has increased markedly over time, particularly among nursing staff. Because further uptake of this technology is expected, it is critical to consider potential effects on clinical resources, employee and patient satisfaction, and patient safety.

Resolving Rivalries and Realigning Goals: Challenges of Clinical and Research Multiteam Systems

This article describes the care processes for a 64-year-old man with newly diagnosed advanced non-small-cell lung cancer who was enrolled in a first-line clinical trial of a new immunotherapy regimen. The case highlights the concept of multiteam systems in cancer clinical research and clinical care. Because clinical research represents a highly dynamic entity-with studies frequently opening, closing, and undergoing modifications-concerted efforts of multiple teams are needed to respond to these changes while continuing to provide consistent, high-level care and timely, accurate clinical data. The case illustrates typical challenges of multiteam care processes. Compared with clinical tasks that are routinely performed by single teams, multiple-team care greatly increases the demands for communication, collaboration, cohesion, and coordination among team members. As the case illustrates, the described research team and clinical team are separated, resulting in suboptimal function. Individual team members interact predominantly with members of their own team. A considerable number of team members lack regular interaction with anyone outside their team. Accompanying this separation, the teams enact rivalries that impede collaboration. The teams have misaligned goals and competing priorities that create competition. Collective identity and cohesion across the two teams are low. Research team and clinical team members have limited knowledge of the roles and work of individuals outside their team. Recommendations to increase trust and collaboration are provided. Clinical providers and researchers may incorporate these themes into development and evaluation of multiteam systems, multidisciplinary teams, and cross-functional teams within their own institutions.

Validity of Single-Item Screening for Limited Health Literacy in English and Spanish Speakers

OBJECTIVES

To evaluate 3 single-item screening measures for limited health literacy in a community-based population of English and Spanish speakers.

METHODS

We recruited 324 English and 314 Spanish speakers from a community research registry in Dallas, Texas, enrolled between 2009 and 2012. We used 3 screening measures: (1) How would you rate your ability to read?; (2) How confident are you filling out medical forms by yourself?; and (3) How often do you have someone help you read hospital materials? In analyses stratified by language, we used area under the receiver operating characteristic (AUROC) curves to compare each item with the validated 40-item Short Test of Functional Health Literacy in Adults.

RESULTS

For English speakers, no difference was seen among the items. For Spanish speakers, "ability to read" identified inadequate literacy better than "help reading hospital materials" (AUROC curve = 0.76 vs 0.65; P = .019).

CONCLUSIONS

The "ability to read" item performed the best, supporting use as a screening tool in safety-net systems caring for diverse populations. Future studies should investigate how to implement brief measures in safety-net settings and whether highlighting health literacy level influences providers' communication practices and patient outcomes.

Assessing race and ethnicity data quality across cancer registries and EMRs in two hospitals

BACKGROUND

Measurement of patient race/ethnicity in electronic health records is mandated and important for tracking health disparities.

OBJECTIVE

Characterize the quality of race/ethnicity data collection efforts.

METHODS

For all cancer patients diagnosed (2007-2010) at two hospitals, we extracted demographic data from five sources: 1) a university hospital cancer registry, 2) a university electronic medical record (EMR), 3) a community hospital cancer registry, 4) a community EMR, and 5) a joint clinical research registry. The patients whose data we examined (N = 17 834) contributed 41 025 entries (range: 2-5 per patient across sources), and the source comparisons generated 1-10 unique pairs per patient. We used generalized estimating equations, chi-squares tests, and kappas estimates to assess data availability and agreement.

RESULTS

Compared to sex and insurance status, race/ethnicity information was significantly less likely to be available (χ(2 )> 8043, P < .001), with variation across sources (χ(2 )> 10 589, P < .001). The university EMR had a high prevalence of "Unknown" values. Aggregate kappa estimates across the sources was 0.45 (95% confidence interval, 0.45-0.45; N = 31 276 unique pairs), but improved in sensitivity analyses that excluded the university EMR source (κ = 0.89). Race/ethnicity data were in complete agreement for only 6988 patients (39.2%). Pairs with a "Black" data value in one of the sources had the highest agreement (95.3%), whereas pairs with an "Other" value exhibited the lowest agreement across sources (11.1%).

DISCUSSION

Our findings suggest that high-quality race/ethnicity data are attainable. Many of the "errors" in race/ethnicity data are caused by missing or "Unknown" data values.

CONCLUSIONS

To facilitate transparent reporting of healthcare delivery outcomes by race/ethnicity, healthcare systems need to monitor and enforce race/ethnicity data collection standards.

Developing a Brief Suicide Prevention Intervention and Mobile Phone Application: a Qualitative Report

Suicide is the second leading cause of death among youth and has become a serious public health problem. There has been limited research on strategies to decrease the likelihood of reattempt in adolescents. As phase one of a treatment development study, clinicians, parents and adolescents participated in qualitative interviews in order to gain new perspectives on developing a targeted intervention and a safety plan phone application for suicide prevention. Participants indicated that transition of care, specific treatment targets and safety planning were important parts of treatment. In addition, all participants endorsed the use of a smartphone application for these purposes.

Multiple Comorbidities and Interest in Research Participation Among Clients of a Nonprofit Food Distribution Site

BACKGROUND

Persons accessing food from nonprofit distribution sites face numerous challenges and typically have significant unmet health needs. However, given limited and intermittent healthcare system engagement, this vulnerable population is underrepresented in clinical research. We sought to better understand the health needs of a nonclinical population to inform future research and interventions.

METHODS

Focus groups were conducted in English (n = 4) and Spanish (n = 4) with clients of Crossroads Community Services (CCS), the largest distributor of North Texas Food Bank. Discussions probed participants' health status, healthcare utilization, understanding and utilization of mammography, and attitudes toward participation in research.

RESULTS

Participants included 42 CCS clients, primarily Hispanic or African American women. Participants reported multiple comorbid conditions among household members, yet utilization of health services was often limited by cost. The majority expressed interest in participating in research to communicate their health concerns and obtain emotional support.

CONCLUSION

CCS clients represent a high-need, under-reached population willing to engage in health-related research that affords them opportunity to connect with peers in group settings and obtain information to improve management of daily life challenges. The Community Assistance Research (CARe) Initiative, a community-academic collaboration, establishes a much-needed opportunity for ongoing clinical research and intervention among this underserved population.

Residential racial segregation and mortality among black, white, and Hispanic urban breast cancer patients in Texas, 1995 to 2009

BACKGROUND

The authors investigated whether residential segregation (the degree to which racial/ethnic groups live separately from one another in a geographic area) 1) was associated with mortality among urban women with breast cancer, 2) explained racial/ethnic disparities in mortality, and 3) whether its association with mortality varied by race/ethnicity.

METHODS

Using Texas Cancer Registry data, all-cause mortality and breast-cancer mortality were examined among 109,749 urban black, Hispanic, and white women aged ≥50 years who were diagnosed with breast cancer from 1995 to 2009. Racial (black) segregation and ethnic (Hispanic) segregation of patient's neighborhoods were measured and were compared with the larger metropolitan statistical area using the location quotient measure. Shared frailty Cox proportional hazard models were used to nest patients within residential neighborhoods (census tract) and were controlled for race/ethnicity, age, diagnosis year, tumor stage, grade, histology, neighborhood poverty, and county-level mammography availability.

RESULTS

Greater black segregation and Hispanic segregation were adversely associated with cause-specific mortality and all-cause mortality. For example, in adjusted models, Hispanic segregation was associated with cause-specific mortality (adjusted hazard ratio, 1.24; 95% confidence interval, 1.05-1.46). Compared with whites, blacks had higher mortality for both outcomes, whereas Hispanics demonstrated equivalent (cause-specific) or lower (all-cause) mortality. Segregation did not explain racial/ethnic disparities in mortality. Within each race/ethnicity strata, segregation was either adversely associated with mortality or was not significant.

CONCLUSIONS

Among urban women with breast cancer in Texas, segregation has an independent, adverse association with mortality, and the effect of segregation varies by patient race/ethnicity. The novel application of a small-area measure of relative racial segregation should be examined in other cancer types with documented racial/ethnic disparities across varied geographic areas.

Effectiveness of a community research registry to recruit minority and underserved adults for health research

BACKGROUND

Recruiting minorities and underserved populations into population-based studies is a long standing challenge. This study examined the feasibility of recruiting adults from a community research registry.

METHODS

Ethnically diverse, bilingual staff attended health fairs, inviting adults to join a registry. We examined rates of successful contact, scheduling, and participation for studies that used the registry.

RESULTS

Five studies queried 6,886 research registry members (48% Hispanic and 38% black) and attempted to contact 2,301 potentially eligible participants; eligibility criteria varied across studies. We successfully contacted 1,130 members, 51.9% were scheduled to participate and of those, 60.8% completed their study appointment. Non-Hispanic whites were less likely than Hispanics to be interested, but among those scheduling an appointment, participation did not differ by race/ethnicity.

CONCLUSION

Community research registries are a feasible and efficient method for recruiting minority and underserved adults and may address disparities in access to and participation in health research.

Predictors and intensity of online access to electronic medical records among patients with cancer

INTRODUCTION

Electronic portals are secure Web-based servers that provide patients with real-time access to their personal health record (PHR). These applications are now widely used at cancer centers nationwide, but their impact has not been well studied. This study set out to determine predictors and patterns of use of a Web-based portal for accessing PHRs and communicating with health providers among patients with cancer.

METHODS

Retrospective analysis of enrollment in and use of MyChart, a PHR portal for the Epic electronic medical record system, among patients seen at a National Cancer Institute-designated cancer center. Predictors of MyChart use were analyzed through univariable and multivariable regression models.

RESULTS

A total of 6,495 patients enrolled in MyChart from 2007 to 2012. The median number of log-ins over this period was 57 (interquartile range 17-137). The most common portal actions were viewing test results (37%), viewing and responding to clinic messages (29%), and sending medical advice requests (6.4%). Increased portal use was significantly associated with younger age, white race, and an upper aerodigestive malignancy diagnosis. Thirty-seven percent of all log-ins and 31% of all medical advice requests occurred outside clinic hours. Over the study period, the average number of patient log-ins per year more than doubled.

CONCLUSIONS

Among patients with cancer, PHR portal use is frequent and increasing. Younger patients, white patients, and patients with upper aerodigestive malignancies exhibit the heaviest portal use. Understanding the implications of this new technology will be central to the delivery of safe and effective care.

Evaluating a De-Centralized Regional Delivery System for Breast Cancer Screening and Patient Navigation for the Rural Underserved

Providing breast cancer screening services in rural areas is challenging due to the fractured nature of healthcare delivery systems and complex reimbursement mechanisms that create barriers to access for the under- and uninsured. Interventions that reduce structural barriers to mammography, like patient navigation programs, are effective and recommended, especially for minority and underserved women. Although the literature on rural healthcare is significant, the field lacks studies of adaptive service delivery models and rigorous evaluation of evidence-based programs that facilitate routine screening and appropriate follow-up across large geographic areas.

OBJECTIVES

To better understand how to implement a decentralized regional delivery "hub & spoke" model for rural breast cancer screening and patient navigation, we have designed a rigorous, structured, multi-level and mixed-methods evaluation based on Glasgow's RE-AIM model (Reach, Effectiveness, Adoption, Implementation, and Maintenance).

METHODS AND DESIGN

The program is comprised of three core components: 1) Outreach to underserved women by partnering with county organizations; 2) Navigation to guide patients through screening and appropriate follow-up; and 3) Centralized Reimbursement to coordinate funding for screening services through a central contract with Medicaid Breast and Cervical Cancer Services (BCCS). Using Glasgow's RE-AIM model, we will: 1) assess which counties have the resources and capacity to implement outreach and/or navigation components, 2) train partners in each county on how to implement components, and 3) monitor process and outcome measures in each county at regular intervals, providing booster training when needed.

DISCUSSION

This evaluation strategy will elucidate how the heterogeneity of rural county infrastructure impacts decentralized service delivery as a navigation program expands. In addition to increasing breast cancer screening access, our model improves and maintains time to diagnostic resolution and facilitates timely referral to local cancer treatment services. We offer this evaluation approach as an exemplar for scientific methods to evaluate the translation of evidence-based federal policy into sustainable health services delivery in a rural setting.