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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.

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 (RFDadj = 5.5%, 95% CI [2.4, 8.5]; RFDadj = 6.7%, 95% CI [2.8,10.7], respectively) and prolonged treatment (RFDadj = 9.7%, 95% CI [4.8 to 14.6]; RFDadj = 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 (RFDadj = 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. Matthew R Dunn and colleagues use latent class methods to generate composite measures of access to healthcare, including socioeconomic status, care barriers and care use, to examine their association with timeliness of breast cancer care. Author summary: Why was this study done?: Delays in breast cancer care can lead to worse outcomes and there are documented racial disparities in who receives timely care. Few prior studies of breast cancer treatment timeliness have attempted to integrate the complex set of factors that shape patients' access to care. What did the researchers do and find?: We used latent class methods to generate composite measures of healthcare access that include socioeconomic status (SES), care barriers, and care use domains. These composite variables were evaluated in association with multiple markers of breast cancer care delays (diagnosis, treatment initiation, treatment duration). Patients with low SES and more barriers to care had greater frequency of delayed diagnosis and prolonged treatment duration. Longer driving time to care was associated with greater frequency of delayed treatment, particularly among black patients. What do these findings mean?: Different sets of healthcare access factors were associated with different markers of delay, highlighting how different barriers may be more salient at different stages of cancer care. Black women had greater frequency of each type of care delay, which suggest that eliminating racial disparities in breast cancer care will require intervening on multiple dimensions of access. Health system efforts to assess patient risk of delayed care (and refer high-risk patients to supportive services such as patient navigation) can be strengthened by consideration of multiple access factors rather than any one factor alone. A limitation of composite measures of healthcare access (e.g., SES) is that they do not assess the effect of specific factors (e.g., income) and further research is needed to understand which factors should be prioritized for intervention planning. [ABSTRACT FROM AUTHOR]

Lung cancer screening with low-dose computed tomography has been shown to reduce lung cancer mortality. Nevertheless, it may also lead to potential harms, including complications arising from downstream invasive procedures. However, the magnitude of such potential harms in real-world practice remains unknown. The current study evaluated downstream use of invasive procedures and procedural complications after lung cancer screening in 5 diverse U.S. health care systems. Visual Abstract. Downstream Procedures and Complications Associated With Lung Cancer Screening.: Lung cancer screening with low-dose computed tomography has been shown to reduce lung cancer mortality. Nevertheless, it may also lead to potential harms, including complications arising from downstream invasive procedures. However, the magnitude of such potential harms in real-world practice remains unknown. The current study evaluated downstream use of invasive procedures and procedural complications after lung cancer screening in 5 diverse U.S. health care systems. Background: Lung cancer screening (LCS) using low-dose computed tomography (LDCT) reduces lung cancer mortality but can lead to downstream procedures, complications, and other potential harms. Estimates of these events outside NLST (National Lung Screening Trial) have been variable and lacked evaluation by screening result, which allows more direct comparison with trials. Objective: To identify rates of downstream procedures and complications associated with LCS. Design: Retrospective cohort study. Setting: 5 U.S. health care systems. Patients: Individuals who completed a baseline LDCT scan for LCS between 2014 and 2018. Measurements: Outcomes included downstream imaging, invasive diagnostic procedures, and procedural complications. For each, absolute rates were calculated overall and stratified by screening result and by lung cancer detection, and positive and negative predictive values were calculated. Results: Among the 9266 screened patients, 1472 (15.9%) had a baseline LDCT scan showing abnormalities, of whom 140 (9.5%) were diagnosed with lung cancer within 12 months (positive predictive value, 9.5% [95% CI, 8.0% to 11.0%]; negative predictive value, 99.8% [CI, 99.7% to 99.9%]; sensitivity, 92.7% [CI, 88.6% to 96.9%]; specificity, 84.4% [CI, 83.7% to 85.2%]). Absolute rates of downstream imaging and invasive procedures in screened patients were 31.9% and 2.8%, respectively. In patients undergoing invasive procedures after abnormal findings, complication rates were substantially higher than those in NLST (30.6% vs. 17.7% for any complication; 20.6% vs. 9.4% for major complications). Limitation: Assessment of outcomes was retrospective and was based on procedural coding. Conclusion: The results indicate substantially higher rates of downstream procedures and complications associated with LCS in practice than observed in NLST. Diagnostic management likely needs to be assessed and improved to ensure that screening benefits outweigh potential harms. Primary Funding Source: National Cancer Institute and Gordon and Betty Moore Foundation. [ABSTRACT FROM AUTHOR]

Background. Many factors contribute to oral anti-cancer therapy adherence, including counselling and educational support. Objective. We systematically review the literature evaluating the effectiveness of interpersonal communication-, counselling- and education-based interventions on patient adherence to oral anticancer therapy. Methods. Using search terms pertaining to medication adherence, oral anticancer therapy, and communication, education, and counselling, we conducted a systematic search for full-text, original research articles prior to 3/13/20. Two reviewers independently reviewed each paper for inclusion and charted study information. Results. Twenty-four articles were included. All considered the use of oral anticancer therapy between two defined time points. Four studies also considered the length of time a patient persisted on therapy. Half (n = 12) of the studies reported a statistically significant relationship between the intervention and medication adherence, with no consistent pattern among intervention structure/content and effectiveness. Programmes offering in-person counselling and those targeting patients with chronic myeloid leukemia (CML), tended to report positive findings. Most studies faced substantial risk of bias, and only two reported using a behavioural theory to guide interventional content. Conclusions. Findings highlight the infancy of evidence base and need for rigorous and large-scale studies grounded in established behavioural theories to advance patient-targeted educational and counselling practices supporting adherence to oral anti-cancer therapy. [ABSTRACT FROM AUTHOR]

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 The published literature provides few insights regarding how to develop or consider the effects of knowledge co-production partnerships in the context of delivery system science. Objective To describe how a healthcare organisation-university-based research partnership was developed and used to design, develop and implement a practice-integrated decision support tool for patients with a physician recommendation for colorectal cancer screening. Design Instrumental case study. Participants Data were ascertained from project documentation records and semistructured questionnaires sent to 16 healthcare organisation leaders and staff, research investigators and research staff members. Results Using a logic model framework, we organised the key inputs, processes and outcomes of a healthcare organisation-university-based research partnership. In addition to pragmatic researchers, partnership inputs included a healthcare organisation with a supportive practice environment and an executive-level project sponsor, a mid-level manager to serve as the organisational champion and continual access to organisational employees with relevant technical, policy and system/process knowledge. During programme design and implementation, partnership processes included using project team meetings, standing organisational meetings and one-on-one consultancies to provide platforms for shared learning and problem solving. Decision-making responsibility was shared between the healthcare organisation and research team. We discuss the short-term outcomes of the partnership, including how the partnership affected the current research team's knowledge and health system initiatives. Conclusion Using a logic model framework, we have described how a healthcare organisation-university-based research team partnership was developed. Others interested in developing, implementing and evaluating knowledge co-production partnerships in the context of delivery system science projects can use the experiences to consider ways to develop, implement and evaluate similar co-production partnerships. [ABSTRACT FROM AUTHOR]

Understanding how patients and physicians discuss screening barriers may illuminate reasons for non-adherence to recommended colorectal cancer (CRC) screening. The goal of the present study was to describe patients' reporting of and physicians' responses to CRC screening barriers and examine their associations with patients' CRC screening behaviors. Audio-recorded primary care consultations (N = 413) with patients due for CRC screening were used to identify CRC screening-related barrier talk and physician responses. Presence of barrier talk was associated with less patient adherence to CRC screening (OR = 0.568, p = 0.007). Neither CRC screening talk (n = 413) nor physician responses (n = 151) were associated with patients' CRC screening. Among the consultations in which barrier talk occurred (n = 151), patients most often reported test-related (28.9%) and psychological (26.1%) barriers. Barriers were most often reported in the context of CRC screening discussions (45.7%) or in direct response to a physician's question about CRC screening (48.6%). Results indicated that patients rarely raised CRC screening barriers unprompted and that presence of barrier talk was predictive of CRC screening behavior. These findings may help improve future clinical practice by highlighting that patients may benefit from physicians initiating and facilitating discussions of CRC screening barriers and directly helping patients overcome known barriers to CRC screening. [ABSTRACT FROM AUTHOR]