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Author(s): Matthew R. Dunn 1,2,*, Didong Li 3, Marc A. Emerson 1,2, Caroline A. Thompson 1,2, Hazel B. Nichols 1,2, Sarah C. Van Alsten 1,2, Mya L. Roberson 2,4, Stephanie [...], Background Delays in breast cancer diagnosis and treatment lead to worse survival and quality of life. Racial disparities in care timeliness have been reported, but few studies have examined access at multiple points along the care continuum (diagnosis, treatment initiation, treatment duration, and genomic testing). Methods and findings The Carolina Breast Cancer Study (CBCS) Phase 3 is a population-based, case-only cohort (n = 2,998, 50% black) of patients with invasive breast cancer diagnoses (2008 to 2013). We used latent class analysis (LCA) to group participants based on patterns of factors within 3 separate domains: socioeconomic status ('SES'), 'care barriers,' and 'care use.' These classes were evaluated in association with delayed diagnosis (approximated with stages III-IV at diagnosis), delayed treatment initiation (more than 30 days between diagnosis and first treatment), prolonged treatment duration (time between first and last treatment-by treatment modality), and receipt of OncotypeDx genomic testing (evaluated among patients with early stage, ER+ (estrogen receptor-positive), HER2- (human epidermal growth factor receptor 2-negative) disease). Associations were evaluated using adjusted linear-risk regression to estimate relative frequency differences (RFDs) with 95% confidence intervals (CIs). Delayed diagnosis models were adjusted for age; delayed and prolonged treatment models were adjusted for age and tumor size, stage, and grade at diagnosis; and OncotypeDx models were adjusted for age and tumor size and grade. Overall, 18% of CBCS participants had late stage/delayed diagnosis, 35% had delayed treatment initiation, 48% had prolonged treatment duration, and 62% were not OncotypeDx tested. Black women had higher prevalence for each outcome. We identified 3 latent classes for SES ('high SES,' 'moderate SES,' and 'low SES'), 2 classes for care barriers ('few barriers,' 'more barriers'), and 5 classes for care use ('short travel/high preventive care,' 'short travel/low preventive care,' 'medium travel,' 'variable travel,' and 'long travel') in which travel is defined by estimated road driving time. Low SES and more barriers to care were associated with greater frequency of delayed diagnosis (RFD.sub.adj = 5.5%, 95% CI [2.4, 8.5]; RFD.sub.adj = 6.7%, 95% CI [2.8,10.7], respectively) and prolonged treatment (RFD.sub.adj = 9.7%, 95% CI [4.8 to 14.6]; RFD.sub.adj = 7.3%, 95% CI [2.4 to 12.2], respectively). Variable travel (short travel to diagnosis but long travel to surgery) was associated with delayed treatment in the entire study population (RFD.sub.adj = 10.7%, 95% CI [2.7 to 18.8]) compared to the short travel, high use referent group. Long travel to both diagnosis and surgery was associated with delayed treatment only among black women. The main limitations of this work were inability to make inferences about causal effects of individual variables that formed the latent classes, reliance on self-reported socioeconomic and healthcare history information, and generalizability outside of North Carolina, United States of America. Conclusions Black patients face more frequent delays throughout the care continuum, likely stemming from different types of access barriers at key junctures. Improving breast cancer care access will require intervention on multiple aspects of SES and healthcare access.

OBJECTIVES: Ambient clinical documentation technology uses automatic speech recognition (ASR) and natural language processing (NLP) to turn patient-clinician conversations into clinical documentation. It is a promising approach to reducing clinician burden and improving documentation quality. However, the performance of current-generation ASR remains inadequately validated. In this study, we investigated the impact of non-lexical conversational sounds (NLCS) on ASR performance. NLCS, such as Mm-hm and Uh-uh, are commonly used to convey important information in clinical conversations, for example, Mm-hm as a yes response from the patient to the clinician question are you allergic to antibiotics? MATERIALS AND METHODS: In this study, we evaluated 2 contemporary ASR engines, Google Speech-to-Text Clinical Conversation (Google ASR), and Amazon Transcribe Medical (Amazon ASR), both of which have their language models specifically tailored to clinical conversations. The empirical data used were from 36 primary care encounters. We conducted a series of quantitative and qualitative analyses to examine the word error rate (WER) and the potential impact of misrecognized NLCS on the quality of clinical documentation. RESULTS: Out of a total of 135 647 spoken words contained in the evaluation data, 3284 (2.4%) were NLCS. Among these NLCS, 76 (0.06% of total words, 2.3% of all NLCS) were used to convey clinically relevant information. The overall WER, of all spoken words, was 11.8% for Google ASR and 12.8% for Amazon ASR. However, both ASR engines demonstrated poor performance in recognizing NLCS: the WERs across frequently used NLCS were 40.8% (Google) and 57.2% (Amazon), respectively; and among the NLCS that conveyed clinically relevant information, 94.7% and 98.7%, respectively. DISCUSSION AND CONCLUSION: Current ASR solutions are not capable of properly recognizing NLCS, particularly those that convey clinically relevant information. Although the volume of NLCS in our evaluation data was very small (2.4% of the total corpus; and for NLCS that conveyed clinically relevant information: 0.06%), incorrect recognition of them could result in inaccuracies in clinical documentation and introduce new patient safety risks.

Abstract Background Clinical practice guidelines recommend colonoscopies at regular intervals for colorectal cancer (CRC) survivors. Using data from a large, multi-regional, population-based cohort, we describe the rate of surveillance colonoscopy and its association with geographic, sociodemographic, clinical, and health services characteristics. Methods We studied CRC survivors enrolled in the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Eligible survivors were diagnosed between 2003 and 2005, had curative surgery for CRC, and were alive without recurrences 14 months after surgery with curative intent. Data came from patient interviews and medical record abstraction. We used a multivariate logit model to identify predictors of colonoscopy use. Results Despite guidelines recommending surveillance, only 49% of the 1423 eligible survivors received a colonoscopy within 14 months after surgery. We observed large regional differences (38% to 57%) across regions. Survivors who received screening colonoscopy were more likely to: have colon cancer than rectal cancer (OR = 1.41, 95% CI: 1.05-1.90); have visited a primary care physician (OR = 1.44, 95% CI: 1.14-1.82); and received adjuvant chemotherapy (OR = 1.75, 95% CI: 1.27-2.41). Compared to survivors with no comorbidities, survivors with moderate or severe comorbidities were less likely to receive surveillance colonoscopy (OR = 0.69, 95% CI: 0.49-0.98 and OR = 0.44, 95% CI: 0.29-0.66, respectively). Conclusions Despite guidelines, more than half of CRC survivors did not receive surveillance colonoscopy within 14 months of surgery, with substantial variation by site of care. The association of primary care visits and adjuvant chemotherapy use suggests that access to care following surgery affects cancer surveillance.

Background: Many consensus guidelines recommend routine surveillance to detect recurrent disease among cancer survivors. We compare surveillance care receipt to guideline recommendations.Methods: Cohorts of patients aged 30 years or older diagnosed with breast, colorectal, endometrial, lung, or prostate cancer between 1990 and 1995 and treated with curative intent were identified (n = 100 per site). Receipt and indications for examinations and procedures were abstracted from medical records for as long as 5 years after treatment. Kaplan-Meier product estimates were used to estimate time to initial and subsequent service receipt.Results: Most cancer patients received the recommended minimum number of physical examinations after treatment. In fact, a sizable number of cancer survivors received physical examinations at a frequency in excess of what is currently recommended. Similarly, most of these cancer survivors received recommended testing for local recurrence. Yet, less than two thirds of colorectal cancer patients received recommended colon examinations in the initial year after treatment. Among colorectal, lung, and prostate cancer patients who received recommended initial local recurrence testing, repeat testing tended to occur more frequently than what is currently recommended. The use of testing for metastatic disease that is not recommended in guidelines is also commonplace among these cancer survivors.Conclusions: Among cohorts of cancer patients, we found wide variation in the use of surveillance care, including patterns of care receipt reflective of both underuse and overuse relative to guideline recommendations. Clinical reasons for these variations and the cost and health implications deserve further study. [ABSTRACT FROM AUTHOR]

To describe the medical care use and costs associated with migraine.Retrospective case-control design in which migraine case status was ascertained via validated telephone interview and linked with comprehensive claims data. Unadjusted and adjusted use and cost differences by migraine status were evaluated using exponential score tests and generalized estimating equations.We interviewed 8,579 individuals to identify migraine cases (N= 1,265) and a random sample of nonmigraine controls (N= 1,178) among eligible health plan enrollees aged 18 to 55.Survey responses were used to categorize individuals meeting the International Headache Society's diagnostic criteria for migraine with or without aura as migraine cases and to collect information on comorbid psychiatric symptoms. Claims data were used to compile annual medical and pharmaceutical use and costs, presence of migraine diagnosis, and other diagnosed comorbidities.Interview-ascertained migraine cases used more outpatient visits (9.1 vs 6.8;P<.01), were more likely to be seen in the emergency department (20.7% vs 17.6%;P < .05), and were admitted to the hospital more (4.5% vs 2.8%;P < .05) compared to nonmigraine controls. Cases incurred significantly higher medical care costs ($2,761 vs$2,064;P<.01). Multivariable model results indicate that much of this increase in costs is due to the presence of major depressive symptoms as well as other diagnosed comorbidities that are more common among those with migraine.By combining validated telephone survey information to identify migraine cases and controls with comprehensive claims data, we found migraine cases incur higher medical care costs compared to controls. These increased costs are associated with the presence of psychiatric symptoms and other comorbidities.J GEN INTERN MED 2004;19:1005 –1012. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Text messaging could be effective for determining patient eligibility for lung cancer screening (LCS). We explored people's willingness to share their tobacco use history via text message among diverse groups. STUDY DESIGN: Cross-sectional survey. METHODS: In 2020, we conducted a cross-sectional survey asking respondents about cellular phone usage, smoking habits, sociodemographic characteristics, and the likelihood of responding to a text message from their health care provider's office about tobacco use. We used χ² and analysis of variance tests for.comparisons. RESULTS: Among 745 respondents, 90% used text messaging casually. Overall, 54% never smoked, 33% currently smoked, and 13% previously smoked. Six percent were LCS eligible, and 20% used both cigarettes and e-cigarettes (dual users). Current smokers were significantly younger, less likely to be female, and more likely to use text messaging. LCS-eligible respondents were older and less likely to have a high income. Dual users were younger, less likely to report female gender and live in rural areas, and more likely to have a college education and high income. Most respondents (83%) indicated they were likely to respond to text message inquiries regarding smoking status. Middle-aged respondents (mean age, 37 years) were significantly more willing to report smoking status than younger or older respondents (91% vs 84% and 84%, respectively). Respondents with no college education (83% vs 88%) or with a low income vs a middle or high income (81% vs 86% and 88%, respectively) were significantly less willing to report smoking status via text messages. CONCLUSIONS: Text messaging showed promise for evaluating smoking history and for simplifying the process of identifying LCS-eligible individuals. However, achieving equity in identifying eligibility for LCS requires the implementation of multimodal strategies. [ABSTRACT FROM AUTHOR]

The article discusses research done on colon cancer screening. It references the study "Increasing Colon Cancer Screening in African Americans" by R. E. Myers and colleagues, published within the issue. Topics discussed include the higher rates of colon cancer screening among African Americans in Philadelphia, Pennsylvania.

Background: With the COVID-19 pandemic came rapid uptake in virtual oncology care. During this, sociodemographic inequities in access to virtual visits (VVs) have become apparent. To better understand these issues, we conducted a qualitative study to describe the perceived usability and acceptability of VVs among Black adults diagnosed with cancer., Methods: Adults who self-identified as Black and had a diagnosis of prostate, multiple myeloma, or head and neck cancer were recruited from 2 academic medical centers, and their community affiliates to participate in a semi-structured interview, regardless of prior VV experience. A patient and family advisory board was formed to inform all components of the study. Interviews were conducted between September 2, 2021 and February 23, 2022. Transcripts were organized topically, and themes and subthemes were determined through iterative and interpretive immersion/crystallization cycles., Results: Of the 49 adults interviewed, 29 (59%) had participated in at least one VV. Three overarching themes were derived: (1) VVs felt comfortable and convenient in the right contexts; (2) the technology required for VVs with video presented new challenges, which were often resolved by an audio-only telephone call; and (3) participants reported preferring in-person visits, citing concerns regarding gaps in nonverbal communication, trusting providers, and distractions during VV., Conclusion: While VVs were reported to be acceptable in specific circumstances, Black adults reported preferring in-person care, in part due to a perceived lack of interpersonal connectedness. Nonetheless, retaining reimbursement for audio-only options for VVs is essential to ensure equitable access for those with less technology savvy and/or limited device/internet capabilities., (© The Author(s) 2023. Published by Oxford University Press.)

When facing a health decision, people tend to seek and access web-based information and other resources. Unfortunately, this exposes them to a substantial volume of misinformation. Misinformation, when combined with growing public distrust of science and trust in alternative medicine, may motivate people to make suboptimal choices that lead to harmful health outcomes and threaten public safety. Identifying harmful misinformation is complicated. Current definitions of misinformation either have limited capacity to define harmful health misinformation inclusively or present a complex framework with information characteristics that users cannot easily evaluate. Building on previous taxonomies and definitions, we propose an information evaluation framework that focuses on defining different shapes and forms of harmful health misinformation. The framework aims to help health information users, including researchers, clinicians, policy makers, and lay individuals, to detect misinformation that threatens truly informed health decisions., (©Ilona Fridman, Skyler Johnson, Jennifer Elston Lafata. Originally published in JMIR Medical Education (https://mededu.jmir.org), 07.06.2023.)

Objectives: We describe online portal account adoption and feature access among subgroups of patients who traditionally have been disadvantaged or represent those with high healthcare needs., Study Design: Retrospective cohort study of insured primary care patients 18 years and older (N = 20,282) receiving care from an integrated health system., Methods: Using data from an electronic health record repository, portal adoption was defined by 1 or more online sessions. Feature access (ie, messaging, appointment management, visit/admission summaries, and medical record access and management) was defined by user-initiated "clicks." Multivariable regression methods were used to identify patient factors associated with portal adoption and feature access among adopters., Results: One-third of patients were portal adopters, with African Americans (odds ratio [OR], 0.50; 95% CI, 0.46-0.56), Hispanics (OR, 0.63; 95% CI, 0.47-0.84), those 70 years and older (OR, 0.48; 95% CI, 0.44-0.52), and those preferring a language other than English (OR, 0.43; 95% CI, 0.31-0.59) less likely to be adopters. On the other hand, the likelihood of portal adoption increased with a higher number of comorbidities (OR, 1.04; 95% CI, 1.02-1.07). Among adopters, record access and management features (95.9%) were accessed most commonly. The majority of adopters also accessed appointment management (76.6%) and messaging (59.1%) features. Similar race and age disparities were found in feature access among adopters., Conclusions: The diversity of portal features accessed may bode well for the ability of portals to engage some patients, but without purposeful intervention, reliance on portals alone for patient engagement may exacerbate known social disparities-even among those with an activated portal account.

Objectives: Periodic health examinations (PHEs) are the most common reason adults see primary care providers. It is unknown if PHEs serve as a "safe portal" for patients with mental health needs to initiate care. We examined how physician communication styles impact mental health service delivery in PHEs., Study Design: Retrospective observational study using audio-recordings of 255 PHEs with patients likely to need mental health care., Methods: Mixed-methods examined the timing of a mental health discussion (MHD), its quality, and the relationship between MHD quality and physician practice styles. MHD quality was measured against evidence-based practices as a 3-level variable (evidence-based, perfunctory, or absent). Physician practice styles were measured by: visit length, verbal dominance, and elicitation of a patient's agenda. A generalized ordered logit model was used., Results: Many patients came with mental health concerns, as over 50% of the MHDs occurred in the first 5 minutes of the visit. One-third of the 255 patients had an evidence-based MHD, another third had a perfunctory MHD, and the remaining had no MHD. MHD quality was significantly associated with physician communication styles. Visits with physicians who tend to spend more time with patients, fully elicit patients' agendas, and let patients talk (instead of being verbally dominant) were more likely to deliver evidence-based MHD., Conclusions: If done well, PHEs could be a safe portal for patients to seek mental health care, but most PHEs fell short. Improving PHE quality may require reimbursement for longer visits and coaching for physicians to more fully elicit patients' agendas and to listen more attentively.

Objective To evaluate associations between patients' preferences for attributes of different colorectal (CRC) screening modalities, physician CRC screening recommendations during periodic health exams, and subsequent utilization of screening 12 months later in a large health maintenance organization (HMO). Study Design Multi-method study including baseline surveys from average-risk HMO members joined with audio recordings of 415 periodic health exams (PHEs) and electronic medical record (EMR) data. Methods Patient ratings of test attributes were used to create an algorithm reflecting type and strength of CRC screening modality preference at baseline. Physician recommendations were obtained from audio recordings. Attribute-based test preferences and physician recommendations were compared with CRC test use using chisquare tests. Associations between attribute-based preferences and physician recommendations were assessed using logistic regression. Results Based on attribute rankings, most participants had a weak preference for colonoscopy (COL) (41%), an unclear preference (22.4%), or a weak preference for fecal occult blood testing (FOBT) (18.6%). About half (56%) of patients were screened at 12 months and there was no statistical association between attribute preferences and type of test received. Patients were significantly more likely to receive a recommendation including a test other than COL when they had an attribute-based test preference for FOBT (odds ratio [OR]: 2.17; 95% CI, 1.26-3.71; P < .01). Conclusions CRC screening test use in this large HMO was generally low. It was not associated with patients' preferences for different attributes of CRC screening tests but was associated with physician recommendations. Physicians may have better success in getting patients to screen if they consider preferences for test attributes.

Objectives: Examine association of comprehensiveness of colorectal cancer (CRC) screening discussion by primary care physicians (PCPs) with completion of CRC screening., Study Design: Observational study in Kaiser Permanente Northwest, a group-model health maintenance organization., Methods: A total of 883 participants overdue for CRC screening received an automated telephone call (ATC) between April and June 2009 encouraging CRC screening. Between January and March 2010, participants completed a survey on PCPs' discussion of CRC screening and patient beliefs regarding screening., Primary Outcome Measure: receipt of CRC screening (assessed by electronic medical record [EMR], 9 months after ATC). Primary independent variable: comprehensiveness of CRC screening discussion by PCPs (7-item scale). Secondary independent variables: perceived benefits of screening (4-item scale assessing respondents' agreement with benefits of timely screening) and primary care utilization (EMR; 9 months after ATC). The independent association of variables with CRC screening was assessed with logistic regression., Results: Average scores for comprehensiveness of CRC discussion and perceived benefits were 0.4 (range 0-1) and 4.0 (range 1-5), respectively. A total of 28.2% (n = 249) completed screening, 84% of whom had survey assessments after their screening date. Of screeners, 95.2% completed the fecal immunochemical test. More comprehensive discussion of CRC screening was associated with increased screening (odds ratio [OR] = 1.51, 95% confidence interval [CI] = 1.03-2.21). Higher perceived benefits (OR = 1.46, 95% CI = 1.13-1.90) and 1 or more PCP visits (OR = 5.82, 95% CI = 3.87-8.74) were also associated with increased screening., Conclusions: More comprehensive discussion of CRC screening was independently associated with increased CRC screening. Primary care utilization was even more strongly associated with CRC screening, irrespective of discussion of CRC screening.

Objective: To compare colorectal cancer (CRC) screening use, including changes over time and demographic characteristics associated with screening receipt, between 2 insured primary care populations., Study Design: Clinical and administrative records from 2 large health systems, one in New Mexico and the other in Michigan, were used to determine use of CRC screening tests between 2004 and 2008 among patients aged 51 to 74 years., Methods: Generalized estimating equations were used to evaluate trends in CRC screening use over time and the association of demographic and other factors with screening receipt., Results: Rates of CRC screening use ranged from 48.1% at the New Mexico site to 68.7% at the Michigan site, with colonoscopy being the most frequently used modality. Fecal occult blood test was used inconsistently by substantial proportions of patients who did not meet the definition of screening users. Screening use was positively and significantly associated with older age, male sex, and more periodic health examinations and other types of primary care visits; at the Michigan site, it was also associated with African American race, married status, and higher annual estimated household income., Conclusions: Among insured primary care patients, CRC screening use falls short. Further research is needed to determine what factors are barriers to routine fecal occult blood test or colonoscopy use among insured patients who have access to and regularly use primary care and how those barriers can be eliminated.

Background: Many consensus guidelines recommend routine surveillance to detect recurrent disease among cancer survivors. We compare surveillance care receipt to guideline recommendations., Methods: Cohorts of patients aged 30 years or older diagnosed with breast, colorectal, endometrial, lung, or prostate cancer between 1990 and 1995 and treated with curative intent were identified (n = 100 per site). Receipt and indications for examinations and procedures were abstracted from medical records for as long as 5 years after treatment. Kaplan-Meier product estimates were used to estimate time to initial and subsequent service receipt., Results: Most cancer patients received the recommended minimum number of physical examinations after treatment. In fact, a sizable number of cancer survivors received physical examinations at a frequency in excess of what is currently recommended. Similarly, most of these cancer survivors received recommended testing for local recurrence. Yet, less than two thirds of colorectal cancer patients received recommended colon examinations in the initial year after treatment. Among colorectal, lung, and prostate cancer patients who received recommended initial local recurrence testing, repeat testing tended to occur more frequently than what is currently recommended. The use of testing for metastatic disease that is not recommended in guidelines is also commonplace among these cancer survivors., Conclusions: Among cohorts of cancer patients, we found wide variation in the use of surveillance care, including patterns of care receipt reflective of both underuse and overuse relative to guideline recommendations. Clinical reasons for these variations and the cost and health implications deserve further study.

Background: Economic analyses are increasingly important in medical research. Accuracy often requires that they include large, diverse populations, which requires data from multiple sources. The difficulty is in making the data comparable across different settings. This article focuses on how to create comparable measures of health care resource use and cost using data from seven health plans and delivery systems participating in the Cancer Research Network's HMOs Investigating Tobacco study., Methods: We used a data inventory to identify variation in data capture across sites and used data dictionaries to develop algorithms for assigning standardized cost to the three major components of health care use: outpatient, inpatient, and pharmacy., Results: The plans included in this study varied from fully integrated, closed-panel models to plans and delivery systems that include network or independent physician association components. Information derived from the data inventory and data dictionary instruments demonstrated a substantial variation in both the content and capture of data across all sites and across all components of usage. The methods we employed for cost allocation varied by usage component and were based on our ability to leverage the data points available to best reflect actual resource use., Conclusions: The importance of this article is the method of ascertaining, cataloging, and addressing the within- and between-plan differences in health care resource use. Second, the decisions we made to address the differences between health plans provide other researchers a starting point when creating a cost algorithm for multisite retrospective research.

Science is the basis of medicine. Good science leads to better decisions and more effective systems to support those decisions. Most individuals associate science primarily with academic institutions. However, top-quality research relevant to managing the health of populations and the care of specific clinical conditions is increasingly being carried out by investigators working in integrated healthcare systems. This introduction outlines the activities of the HMO Research Network, whose researchers have made and continue to make important contributions to the field of health research. Its objective is to inform readers of the activities and value of systems-based health research. We describe the importance and extent of the research conducted by HMO Research Network members, as well as the advantages of conducting research in such settings.