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Commonly in survey research, multiple, different analyses are conducted by one or more than one researcher on the same data set. The conclusions from these analyses should be consistent despite the presence of missing data. Multiple imputation is frequently used to ensure consistency of analyses. Two methods for multiple impu- tation of missing data are a combination of hot deck and regression imputation, and multivariate normal multiple imputation. It is un- known whether these methods will give similar results in practical situations with large numbers of variables. We applied both mul- tiple imputation methods to a cancer screening survey data with 2 continuous, 48 Likert scale items, and 74 binary response items. Correlations and variances of imputated data sets were compared in a first attempt to investigate similarity of the imputation meth- ods. The results of both methods were found to be similar; either of the two methods are endorsed for surveys similar to the data set presented.

The Institute of Medicine recommends that cancer patients receive survivorship care plans (SCP) summarizing information important to the individual’s long-term care. The various components of SCPs have varying levels of evidence supporting their impact. We surveyed medical oncologists to better understand how they perceived the relative value of different SCP components. Medical oncologists caring for patients in diverse US practice settings were surveyed (357 respondents; participation rate 52.9%) about their perceptions of the usefulness of various components of SCPs to both patients and primary care physicians (PCPs). Oncologists perceived treatment summaries as “very useful” for PCPs but were less likely to perceive them as “very useful” for patients (55% vs. 40%, p

Latino adolescent and young adult (AYA) cancer survivors represent a growing population given the changing demographics in the United States. They experience significant health care disparities and barriers that warrant age-specific and culturally appropriate interventions to improve their clinical and psychosocial outcomes. This single-arm pilot study evaluated a novel intervention – a photonovela – on its ability to educate Latino AYA survivors and their family members and engage them in survivorship care. Ninety-seven participants (Latino AYA survivors and their family members) were recruited for this study. Three surveys assessing survivorship care confidence, cancer stigma, and survivorship care knowledge were administered to families before they received the photonovela, after the intervention, and at a booster phone call session. Mixed effects models were used to evaluate differences in scores at the three time points while accounting for repeated measures and family clustering. Results show the photonovela was effective in improving survivorship care confidence and knowledge of Latino AYA survivors and their families. This pilot study indicates the photonovela has potential to be a useful intervention for improving confidence and knowledge regarding the need to seek survivorship care for Latino AYA cancer survivors.

We examine whether primary care continuity of care (PCCOC) improved for Medicare beneficiaries under a 3-year demonstration to help federally qualified health centers (FQHCs) become patient-centered medical homes (PCMH). We used a difference-in-differences analysis to compare changes over time in PCCOC for beneficiaries in 503 demonstration sites to those in 827 comparison sites. We measured PCCOC using the claims-based usual provider of care (UPC) index (range 0–1) indicating the proportion of visits to the most commonly seen provider or practice over a 1-year period. Average baseline UPC index values were 0.77 at the provider level and 0.88 at the practice level, with similar values for demonstration and comparison sites. UPC decreased more over time in demonstration clinics than comparison clinics, but the magnitude of these changes were small. FQHCs already have high levels of PCCOC. These levels did not increase in association with the 3-year PCMH demonstration. Continuity for practices is higher than for providers, suggesting that Medicare beneficiaries may see multiple providers within one FQHC.

Background Chronic kidney disease (CKD) is a leading cause of healthcare morbidity, utilization, and expenditures nationally, and caring for late-stage CKD populations is complex. Improving health system efficiency could mitigate these outcomes and, in the COVID-19 era, reduce risks of viral exposure. Objective As part of a system-wide transformation to improve healthcare value among populations with high healthcare utilization and morbidity, UCLA Health evaluated a new patient-centered approach that we hypothesized would reduce inpatient utilization for CKD patients. Design For 18 months in 2015–2016 and 12 months in 2017, we conducted an interrupted time series regression analysis to evaluate the intervention’s impact on inpatient utilization. We used internal electronic health records and claims data across six payers. Participants A total of 1442 stage 4–5 CKD patients at a large academic medical center. Intervention Between October and December 2016, the organization implemented a Population Health Value CKD intervention for the CKD stages 4–5 population. A multispecialty leadership team risk stratified the population and identified improvement opportunities, redesigned multispecialty care coordination pathways across settings, and developed greater ambulatory infrastructure to support care needs. Main Measures Outcomes included utilization of hospitalizations, emergency department (ED) visits, inpatient bed days, and 30-day all-cause readmissions. Key Results During the 12 months following intervention implementation, the monthly estimated rate of decline for hospitalizations was 5.4% (95% CI: 3.4–7.4%), which was 3.4 percentage points faster than the 18-month pre-intervention decline of 2.0% (95% CI: 1.0–2.2%) per month (p = 0.004). Medicare CKD patients’ monthly ED visit rate of decline was 3.0% (95% CI: 1.2–4.8%) after intervention, which was 2.6 percentage points faster than the pre-intervention decline of 0.4% (95% CI: − 0.8 to 1.6%) per month (p = 0.02). Conclusions By creating care pathways that link primary and specialty care teams across settings with increased ambulatory infrastructure, healthcare systems have potential to reduce inpatient healthcare utilization. Electronic supplementary material The online version of this article (10.1007/s11606-020-06272-5) contains supplementary material, which is available to authorized users.

Background Minority adolescent and young adult (AYA) cancer survivors experience disparities in receipt of survivorship care. Objective This study describes the infrastructure of a community-partnered participatory research (CPPR) project between a community-based organization and a National Cancer Institute (NCI)-designated cancer center to develop culturally-tailored interventions to improve Latino AYA cancer survivor knowledge regarding their need for survivorship care. Methods Research team participants included the community organization and NCI cancer center directors, research coordinators, a community liaison, and cross-training program interns. Through use of Jones’ theoretical framework, additional stakeholders from academic and community settings were identified and invited to participate in the research team. A process evaluation and qualitative interviews were conducted to assess equal partnership between community and academic stakeholders and determine if the infrastructure followed the five core principles of CPPR. A grounded theory approach was used to analyze qualitative data. Conclusions CPPR between an NCI-designated cancer center and a community-based organization is a new research model for conducting minority AYA cancer survivor outreach. Open communication was critical in engaging the Latino community to discuss their survivorship needs. Community stakeholders were key to infrastructure success through fostering a cohesive partnership with and acting as the voice of the Latino community. Implementing a cross-training program promoted continued engagement of community members with academic partners. Proper infrastructure development is critical to building successful research partnerships in order to develop culturally-tailored interventions to improve survivorship care knowledge.

Latinas in the United States are more likely to be diagnosed with late-stage breast cancer (BC) compared to non-Latinas. Literacy-appropriate and culturally sensitive cancer communication interventions can help address existing racial/ethnic BC disparities. We formatively developed a new BC prevention brochure for Spanish-speaking Latinas (≥35 years). Eligible women ( n = 240) from a large public hospital in California were randomly assigned to one of three study arms: Group 1 received the new brochure, Group 2 included a community health worker (CHW) who delivered the new brochure’s content, and a control group received a standard educational brochure. Participants completed three surveys (baseline, postintervention, 3-month follow-up) with a 100% completion rate for the first two surveys and 80.4% completion after 3 months. We assessed the difference in outcomes for BC risk knowledge, perceived BC susceptibility, and BC information self-efficacy between groups. Participant mean age was 52.3 years, and 82.1% reported low English proficiency. Mean knowledge scores increased and perceived BC susceptibility improved for all groups ( p ≤ .05), yet treatment effects were not significant between groups for these outcomes. BC information self-efficacy also increased from baseline to postintervention for all groups to >80%. After 3 months, only Group 2 and the control group retained their increases and treatment effects were significant only for Group 2 compared to other groups in unadjusted and adjusted models. A CHW-delivered intervention may be more effective in improving BC information self-efficacy among Latinas compared to print material alone. More research is needed to examine the efficacy of CHW-delivered interventions.

IMPORTANCE: Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. OBJECTIVE: To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type. EXPOSURES: Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively. MAIN OUTCOMES AND MEASURES: Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. RESULTS: More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P

OBJECTIVE: To understand the process of practice transformation by identifying pathways for attaining patient‐centered medical home (PCMH) recognition. DATA SOURCES/STUDY SETTING: The CMS Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration was designed to help FQHCs achieve NCQA Level 3 PCMH recognition and improve patient outcomes. We used a stratified random sample of 20 (out of 503) participating sites for this analysis. STUDY DESIGN: We developed a conceptual model of structural, cultural, and implementation factors affecting PCMH transformation based on literature and initial qualitative interview themes. We then used conventional cross‐case analysis, followed by qualitative comparative analysis (QCA), a cross‐case method based on Boolean logic algorithms, to systematically identify pathways (i.e., combinations of factors) associated with attaining—or not attaining—Level 3 recognition. DATA COLLECTION METHODS: Site‐level indicators were derived from semistructured interviews with site leaders at two points in time (mid‐ and late‐implementation) and administrative data collected prior to and during the demonstration period. PRINCIPAL FINDINGS: The QCA results identified five distinct pathways to attaining PCMH recognition and four distinct pathways to not attaining recognition by the end of the demonstration. Across these pathways, one condition (change leader capacity) was common to all pathways for attaining recognition, and another (previous improvement or recognition experience) was absent in all pathways for not attaining recognition. In general, sites could compensate for deficiencies in one factor with capacity in others, but they needed a threshold of strengths in cultural and implementation factors to attain PCMH recognition. CONCLUSIONS: Future efforts at primary care transformation should take into account multiple pathways sites may pursue. Sites should be assessed on key cultural and implementation factors, in addition to structural components, in order to differentiate interventions and technical assistance.

The Institute of Medicine recommends that cancer patients receive survivorship care plans (SCP) summarizing information important to the individual's long-term care. The various components of SCPs have varying levels of evidence supporting their impact. We surveyed medical oncologists to better understand how they perceived the relative value of different SCP components.Medical oncologists caring for patients in diverse US practice settings were surveyed (357 respondents; participation rate 52.9%) about their perceptions of the usefulness of various components of SCPs to both patients and primary care physicians (PCPs).Oncologists perceived treatment summaries as "very useful" for PCPs but were less likely to perceive them as "very useful" for patients (55% vs. 40%, p 0.001). Information about the psychological effects of cancer (41% vs. 29%; p 0.001) and healthy behaviors (67% vs. 41%; p 0.001) were considered more useful to patients than to PCPs. From 3 to 20% of oncologists believed that any given component of the SCP was not useful to either PCPs or patients. Oncologists who perceived SCPs to be more useful tended to be female or to practice in settings with a fully implemented electronic health record.Oncologists do not perceive all components of SCPs to be equally useful to both patients and PCPs. To be successfully implemented, the SCP should be efficiently tailored to the unique needs and knowledge of patients and their PCPs. A minority of oncologists appear to be late adopters, suggesting that some resistance to the adoption of SCPs remains.

PurposeAdolescent and young adult (AYA) cancer survivors experience unique barriers that compromise receipt of survivorship care; therefore, development of innovative educational interventions to improve rates of AYA survivorship care is needed. The efficacy of text-messaging and peer navigation interventions was compared to standard-of-care survivorship educational materials to increase AYAs' (1) late effects knowledge and (2) knowledge, attitudes, and self-efficacy towards seeking survivor-focused care.MethodsThis was a three-armed, prospective, randomized controlled trial with one control group and two intervention groups. The control group received current standard-of-care educational materials. One intervention group participated in a text-messaging program, and the second participated in a peer navigator program. Participants completed pre- and post-intervention questionnaires. Study outcome variables were quantified using Fisher exact tests, two-sample t tests, exact McNemar tests, conditional logistic regression models, and analysis of covariance.ResultsSeventy-one survivors completed the study (control n = 24; text-messaging n = 23; peer navigation n = 24). Late effects knowledge was high at baseline for all groups. The text-messaging group had increased survivorship care knowledge compared to the control group (p

Background Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low-value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. Methods We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced-based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline-based (1) short-term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long-term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger-Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low-value PPI prescription prevalence. Results Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%-40.7%) were potentially low value-of which 82% began appropriately (eg, GERD) but then continued long term without a guideline-based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low-value prescriptions. Conclusion One in eight older adults were prescribed a PPI, and over one-third of prescriptions were potentially low-value. Most often, appropriate short-term prescriptions became potentially low value because they lacked long-term indications. With most potentially low-value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR-based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600-2604, 2019.

Purpose: Genomic testing improves outcomes for many at-risk individuals and patients with cancer; however, little is known about how genomic testing for non–small-cell lung cancer (NSCLC) and colorectal cancer (CRC) is used in clinical practice. Patients and Methods: In 2012 to 2013, we surveyed medical oncologists who care for patients in diverse practice and health care settings across the United States about their use of guideline- and non–guideline-endorsed genetic tests. Multivariable regression models identified factors that are associated with greater test use. Results: Of oncologists, 337 completed the survey (participation rate, 53%). Oncologists reported higher use of guideline-endorsed tests (eg, KRAS for CRC; EGFR for NSCLC) than non–guideline-endorsed tests (eg, Onco typeDX Colon; ERCC1 for NSCLC). Many oncologists reported having no patients with CRC who had mismatch repair and/or microsatellite instability (24%) or germline Lynch syndrome (32%) testing, and no patients with NSCLC who had ALK testing (11%). Of oncologists, 32% reported that five or fewer patients had KRAS and EGFR testing for CRC and NSCLC, respectively. Oncologists, rather than pathologists or surgeons, ordered the vast majority of tests. In multivariable analyses, fewer patients in nonprofit integrated health care delivery systems underwent testing than did patients in hospital or office-based single-specialty group settings (all P < .05). High patient volume and patient requests (CRC only) were also associated with higher test use (all P < .05). Conclusion: Genomic test use for CRC and NSCLC varies by test and practice characteristics. Research in specific clinical contexts is needed to determine whether the observed variation reflects appropriate or inappropriate care. One potential way to reduce unwanted variation would be to offer widespread reflexive testing by pathology for guideline-endorsed predictive somatic tests.

Background Clinical decision support is increasingly used to enhance clinicians' exposure to established evidence and patient information during an episode of patient care. Pending legislation specifies clinical decision support before performing advanced imaging at emergency department (ED) visits. Purpose To estimate the volume of advanced imaging tests (CT and MRI) that would require use of clinical decision support to achieve Protecting Access to Medicare Act (PAMA) compliance in the ED. Materials and Methods A retrospective, cross-sectional analysis of ED visits was conducted by using data from the 2012-2015 National Hospital Ambulatory Care Survey. PAMA-related visits were identified by selecting the patient reasons for visit (RFVs) related to the eight clinical conditions. Results Among the adult ED visits, 26.7% (20 506 of 77 299, representing 113 000 000 visits across 4 years, or 28 000 000 visits annually) patients presented with a RFV consistent with a PAMA priority clinical area (PCA). Among visits in which a patient described an RFV code consistent with a PAMA PCA, up to 22.9% (4681 of 20 506; 95% confidence interval: 21.8%, 24.1%) patients underwent advanced imaging, translating to approximately 6 000 000 visits annually. Conclusion Protecting Access to Medicare Act legislation targets eight priority clinical areas, estimated to be prevalent among one in four adult emergency department visits. CT and/or MRI studies are performed during up to 23% of these visits. Depending on the particular clinical decision support systems selected within a health system, and how they are implemented, the potential volume of studies in which clinicians must interact with clinical decision support system may either exceed or fall short of these estimates. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Forman in this issue.

The Global Payment Program (GPP) seeks to improve health care for California's uninsured by using federal funds to make prospective payments to public health care systems for providing inpatient, outpatient, and nontraditional services. This report presents the final evaluation of the program. Through the GPP, public health care systems have put in place a variety of strategies and offered a wider range of services during its first three years.

RESEARCH OBJECTIVE:Care coordination among health care providers is essential for high-quality care and it is strongly associated with overall ratings of doctors. Care coordination may be especially important for sicker and chronically ill patients because of the multiple providers involved in their care. This study examines whether the association of care coordination with global ratings of one's personal doctor varies by number of chronic conditions and self-rated health. STUDY DESIGN:We used nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data to evaluate care coordination, doctor communication, getting needed care, getting care quickly, count of 6 chronic conditions (angina, cancer, chronic obstructive pulmonary disease, diabetes, heart attack, stroke), self-rated general health (5-point scale, poor to excellent, scored linearly), and interactions among them as predictors of the CAHPS global rating of personal doctor (scored 0-100 with 100 being best possible personal doctor) using linear regression models. The analytic sample included 242,871 Medicare fee-for-service and managed care beneficiaries in 2013: 56% female; 14% 18-64, 47% 65-74, 27% 75-84, and 11% 85 and older; and 48% high school education or less. RESULTS:The CAHPS composites (of care coordination, doctor communication, getting needed care, and getting care quickly) and number of chronic conditions were significantly positively associated with ratings of personal doctor (P

We examined differences in patient outcomes associated with 3 patient-centered medical home (PCMH) recognition programs-National Committee for Quality Assurance (NCQA) Level 3, The Joint Commission (TJC), and Accreditation Association for Ambulatory Health Care (AAAHC)-among Medicare beneficiaries receiving care at federally qualified health centers (FQHCs).We used data from CMS' FQHC Advanced Primary Care Practice Demonstration, in which participating FQHCs received assistance to achieve NCQA Level 3 PCMH recognition. We assessed the impact of the 3 recognition programs on utilization, quality, and Medicare expenditures using a sample of 1108 demonstration and comparison FQHCs.Using propensity-weighted difference-in-differences analyses, we compared changes in outcomes over 3 years for beneficiaries attributed to FQHCs that achieved each type of recognition relative to beneficiaries attributed to FQHCs that did not achieve recognition.Recognized FQHCs, compared with nonrecognized FQHCs, were associated with significant 3-year changes in FQHC visits, non-FQHC primary care visits, specialty visits, emergency department (ED) visits, hospitalizations, a composite diabetes process measure, and Medicare expenditures. Changes varied in direction and strength by recognition type. In year 3, compared with nonrecognized sites, NCQA Level 3 sites were associated with greater increases in ambulatory visits and quality and greater reductions in hospitalizations and expenditures (P .01), TJC sites were associated with significant reductions in ED visits and hospitalizations (P.01), and AAAHC sites had changes in the opposite direction of what we anticipated.Heterogeneous changes in beneficiary utilization, quality, and expenditures by recognition type may be explained by differences in recognition criteria, evaluation processes, and documentation requirements.

BACKGROUND: Regular primary care visits may allow an opportunity to deliver high-value, proactive care. However, no previous study has examined whether more temporally regular primary care visits predict better outcomes. OBJECTIVE: To examine the relationship between the temporal regularity of primary care (PC) visits and outcomes. DESIGN: Retrospective cohort study. PARTICIPANTS: We used Medicare claims for 378,862 fee-for-service Medicare beneficiaries, who received PC at 1328 federally qualified health centers from 2010 to 2014. MAIN MEASURES: We created five beneficiary groups based upon their annual number of PC visits. We further subdivided those groups according to whether PC visits occurred with more or less regularity than the median value. We compared these 10 subgroups on three outcomes, adjusting for beneficiary characteristics: emergency department (ED) visits, hospitalizations, and total Medicare expenditures. We also aggregated to the clinic level and divided clinics into tertiles of more, less, and similarly regular to predicted. We compared these three groups of clinics on the same three outcomes of care. KEY RESULTS: Within each visit frequency group, beneficiaries in the subgroup with fewer regular visits had more ED visits, more hospitalizations, and higher costs. Among beneficiaries with the most frequent PC visits, the less regular subgroup had more ED visits (1.70 vs. 1.31 per person-year), more hospitalizations (0.69 vs. 0.57), and greater Medicare expenditures ($20,731 vs. $17,430, p

Much of dissemination, implementation, and improvement (DII) science is conducted by social scientists, healthcare practitioners, and biomedical researchers. While each of these groups has its own venues for sharing methods and findings, forums that bring together the diverse DII science workforce provide important opportunities for cross-disciplinary collaboration and learning. In particular, such forums are uniquely positioned to foster the sharing of three important components of research. First: they allow the sharing of conceptual frameworks for DII science that focus on the use and spread of innovations. Second: they provide an opportunity to share strategies for initiating and governing DII research, including approaches for eliciting and incorporating the research priorities of patients, study participants, and healthcare practitioners, and decision-makers. Third: they allow the sharing of outcome measures well-suited to the goals of DII science, thereby helping to validate these outcomes in diverse contexts, improving the comparability of findings across settings, and elevating the study of the implementation process itself.

© 2015 Wiley Periodicals, Inc. Background: This study used Community Partnered Participatory Research (CPPR) to address low participation of racial and ethnic minorities in medical research and the lack of trust between underrepresented communities and researchers. Methods: Using a community and academic partnership in July 2012, residents of a South Los Angeles neighborhood were exposed to research recruitment strategies: referral by word-of-mouth, community agencies, direct marketing, and extant study participants. Results: Among 258 community members exposed to recruitment strategies, 79.8% completed the study. Exposed individuals identified their most important method for learning about the study as referral by study participants (39.8%), community agencies (30.6%), word-of-mouth (17.5%), or direct marketing promotion (12.1%). Study completion rates varied by recruitment method: referral by community agencies (88.7%), referral by participants (80.4%), direct marketing promotion (86.2%), word of mouth (64.3%). Conclusions: Although African American and Latino communities are often described as difficult to engage in research, we found high levels of research participation and completion when recruitment strategies emerged from the community itself. This suggests recruitment strategies based on CPPR principles represent an important opportunity for addressing health disparities and our high rates of research completion should provide optimism and a road map for next steps.

Multidisciplinary tumor board meetings are common in cancer care, but limited evidence is available about their benefits. We assessed the associations of tumor board participation and structure with care delivery and patient outcomes.As part of the CanCORS study, we surveyed 1,601 oncologists and surgeons about participation in tumor boards and specific tumor board features. Among 4,620 patients with lung or colorectal cancer diagnosed from 2003 to 2005 and seen by 1,198 of these physicians, we assessed associations of tumor board participation with patient survival, clinical trial enrollment, guideline-recommended care, and patient-reported quality, adjusting for patient and physician characteristics.Weekly physician tumor board participation (v participation less often or never) was not associated with patient survival, although in exploratory subgroup analyses, weekly participation was associated with lower mortality for extensive-stage small-cell lung cancer and stage IV colorectal cancer. Patients treated by the 54% of physicians participating in tumor boards weekly (v less often or never) were more likely to enroll onto clinical trials (odds ratio [OR], 1.6; 95% CI, 1.1 to 2.2). Patients with stage I to II non-small-cell lung cancer (NSCLC) whose physicians participated in tumor boards weekly were more likely to undergo curative-intent surgery (OR, 2.9; 95% CI, 1.3 to 6.8), although those with stage I to II NSCLC whose physicians' meetings reviewedone cancer site were less likely to undergo curative-intent surgery (OR, 0.1; 95% CI, 0.03 to 0.4).Among patients with lung or colorectal cancer, frequent physician tumor board engagement was associated with patient clinical trial participation and higher rates of curative-intent surgery for stage I to II NSCLC but not with overall survival.

BACKGROUND Antibiotic treatment decisions for medically complex patients are complicated, as the risk of undertreatment may be severe, whereas overtreatment may be associated with adverse effects and the emergence of antibiotic resistant pathogens. OBJECTIVE To determine the influence of patient complexities on providers’ decisions to prescribe antibiotics in 3 common hospital-based clinical vignettes. DESIGN A physician survey. SETTING Three urban medical centers in Los Angeles County, California. PARTICIPANTS Hospital-based physicians. MEASUREMENTS Physicians were presented 3 clinical vignettes, with variations by patient age, comorbidity burden, functional status, and follow-up, and asked to choose the best antibiotic regimen. We described the association of additional patient complexity on the proportion of guideline-adherent antibiotic choices. RESULTS In the survey, 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with either older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P

I n this issue of JGIM, Nguyen et al. present empirical evidence highlighting the potential value of using a patient’s instability at hospital discharge as a diagnostic test to predict the likelihood of future adverse events. Based upon prior empirical evidence regarding the role of abnormal vital signs in predicting vital status,, the authors define instability at hospital discharge as temperature ≥37.8 °C, heart rate ≥100 beats per minute, respiratory rate >24 breaths per minute, systolic blood pressure ≤90 mmHg, or oxygen saturation

The Global Payment Program seeks to improve health care for California's uninsured by providing funds to cover both traditional and non-traditional services, settings, and providers. The 12 participating public health care systems seek to reduce the use of services in high-intensity settings by designing systems of care that emphasize primary care and supportive services. This is the report of the midpoint evaluation of the program.

Objective To assess the extent to which patients self-refer to cancer specialists and whether self-referral is associated with better experiences and quality of care. Data Sources Data from surveys and medical record abstraction collected through the Cancer Care Outcomes Research and Surveillance Consortium. Study Design Observational study of patients with lung and colorectal cancer diagnosed from 2003 through 2005 in five geographically defined regions and five integrated health care delivery systems. Methods Multivariable logistic regression models used to assess factors associated with self-referral and propensity score-weighted doubly robust models to test the association between self-referral and experiences/quality of care. Principal Findings Among 5,882 patients, 9.7 percent of lung cancer patients and 14.9 percent of colorectal cancer patients self-referred to at least one cancer specialist. Black patients were less likely to self-refer than white patients (odds ratio: 0.48, 95 percent confidence interval: 0.35, 0.64); patients with high incomes (vs. low) and with a college degree (vs. non-high school graduates) were significantly more likely to self-refer. Self-referral was associated with lower ratings of overall physician communication for patients with lung cancer but, conversely, higher odds of curative surgery among patients with stage I/II lung cancer. Conclusions A small but significant proportion of patients self-referred to their cancer specialists; rates varied by patient race and socioeconomic status. To the extent that self-referral is associated with quality, it may reinforce disparities in care.

ContextRelatively few data are available about symptoms among cancer patients.ObjectivesTo describe the prevalence and severity of symptoms among a large, representative cohort of newly diagnosed cancer patients.MethodsWe collected survey data about symptoms (pain, fatigue, depression, nausea/vomiting, cough, dyspnea, and diarrhea) from 5422 patients with incident lung and colorectal cancer from the diverse, nationally representative Cancer Care Outcomes Research and Surveillance Consortium cohort. We described the prevalence of any symptoms and moderate/severe symptoms approximately four to six months after diagnosis. We used logistic regression to identify patient and clinical characteristics associated with symptoms, and calculated adjusted proportions of patients with symptoms.ResultsIn total, 5067 (93.5%) patients reported at least one symptom in the four weeks before their survey, with 51% reporting at least one moderate/severe symptom. Lung cancer patients reported more symptoms than colorectal cancer patients. Patients who received treatment or had more comorbidities were more likely to report symptoms. For example, after adjustment, patients who received chemotherapy during the six weeks before the survey were more likely than others to report at least one symptom (97.3% vs. 90.8%, P

Better working conditions for clinicians and staff could help primary care practices implement delivery system innovations and help sustain the US primary care workforce. Using longitudinal surveys, we assessed the experience of clinicians and staff in 296 clinical sites that participated in the Centers for Medicare and Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Participating FQHCs were expected to achieve, within three years, patient-centered medical home recognition at level 3-the highest level possible. During 2013-14, clinicians and staff in these FQHCs reported statistically significant declines in multiple measures of professional satisfaction, work environment, and practice culture. There were no significant improvements on any surveyed measure. These findings suggest that working conditions in FQHCs have deteriorated recently. Whether findings would be similar in other primary care practices is unknown. Although we did not identify the causes of these declines, possible stressors include the adoption of health information technology, practice transformation, and increased demand for services.

From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical-home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination.We examined the achievement of medical-home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients' experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference-in-differences analyses, we compared changes in outcomes in the two groups of sites during a 3-year period.Level 3 medical-home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures ($37 more per beneficiary per year, P=0.02). Demonstration-site participation was not associated with relative improvements in most measures of patients' experiences.Demonstration sites had higher rates of medical-home recognition and smaller decreases in the number of patients' visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.).

Patient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models.We measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes.Cross-sectional, propensity score-weighted, multivariable regression analysis.A convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites.PCMH capabilities were self-reported using the National Committee for Quality Assurance's (NCQA's) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011.Nearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)-but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures ($111 per beneficiary [95% CI: $61, $158]) and total Medicare expenditures of $353 [95% CI: $65, $614]).Implementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization.

Background Quality care for patients with cancer often requires access to specialty providers, but little is known about barriers to referring cancer patients for specialized care. Referral barriers may also lessen physician career satisfaction. We aimed to determine factors associated with these barriers and whether greater barriers are associated with low career satisfaction.

Purpose: The purpose of this study was to determine the prevalence of post-traumatic stress symptoms in a sample of cancer survivors and to investigate their association with the impact of cancer, depressive symptoms, and social support. Methods: We administered a survey to participants in a cancer survivor registry. It included: Post-Traumatic Stress Disorder Checklist-Civilian version (PCL-C), Impact of Cancer Scale (IOC) v.2, and measures of social support, income, and long-term effects of cancer. We performed multivariate analyses to estimate associations between PCL-C and other variables. PCL-C score was examined as a continuous dependent variable and categorically. Results: Responses were available from 162 cancer survivors. Mean age was 51years (standard deviation (SD) 16); mean time since diagnosis was 11years (SD 10). Mean PCL-C score was 27 (SD 9, range 17-64); 29% of the sample scored 30 and above, 13% scored 38 and above, 7% scored 44 and above. Linear regression indicated that PCL-C scores were significantly associated with the IOC negative impact scale (NIS) (p

Background Healthcare-associated infections (HAIs) have long been the subject of research and prevention practice. When findings show potential to significantly impact outcomes, clinicians, policymakers, safety experts, and stakeholders seek to bridge the gap between research and practice by identifying mechanisms and assigning responsibility for translating research to practice. Objectives This paper describes progress and challenges in HAI research and prevention practices, as explained through an examination of Health and Human Services (HHS) Action Plan's goals, inputs, and implementation in each area. Research design We used the Context-Input-Process-Product evaluation model, together with an HAI prevention system framework, to assess the transformative processes associated with HAI research and adoption of prevention practices. Results Since the introduction of the Action Plan, HHS has made substantial progress in prioritizing research projects, translating findings from those projects into practice, and designing and implementing research projects in multisite practice settings. Research has emphasized the basic science and epidemiology of HAIs, the identification of gaps in research, and implementation science. The basic, epidemiological, and implementation science communities have joined forces to better define mechanisms and responsibilities for translating HAI research into practice. Challenges include the ongoing need for better evidence about intervention effectiveness, the growing implementation burden on healthcare providers and organizations, and challenges implementing certain practices. Conclusions Although these HAI research and prevention practice activities are complex spanning multiple system functions and properties, HHS is making progress so that the right methods for addressing complex HAI problems at the interface of patient safety and clinical practice can emerge.

BACKGROUND In response to the growing concern about healthcare-associated infections (HAIs), US Department of Health and Human Services (HHS) developed the National Action Plan to Prevent Healthcare-associated Infections. A key focus of the Action Plan is the setting of HAI metrics and targets and the enhancement and development of data systems to support HAI surveillance. OBJECTIVES To identify and assess the strengths and weaknesses of HHS data systems available for surveillance of catheter-associated urinary tract infections, surgical site infections, and Clostridium difficile infections. To present national data from each of the data systems and assess concordance in trends over time. RESEARCH DESIGN Literature review on data system characteristics and HAI measurement. Graphical and descriptive analyses of longitudinal HAI rates from HHS data systems. MEASURES HAI rate information expressed as prevalence rates or standardized infection ratios. RESULTS We identified four HHS data systems--Medicare claims data, Healthcare Cost and Utilization Project, Medicare Patient Safety Monitoring System, and National Healthcare Safety Network--capable of surveillance of at least one of the HAIs under study. Surgical site infection and Clostridium difficile infection rates display concordance in trends, although there is no evidence of concordance in catheter-associated urinary tract infections rates. We have identified a number of desirable HAI data system characteristics: clinically valid; provide information on a broad range of HAIs; have large sample size to support statistical inference; be representative of the United States; and display consistency in cohort, surveillance protocols, and data collection methodology. CONCLUSIONS Although the data systems included in this study vary along the desirable data system dimensions we identified, trends in HAI rates are generally concordant across the data systems. This increases confidence in observed trends.

BACKGROUND The development of the Health and Human Services (HHS) Action Plan to eliminate healthcare-associated infections (HAIs) and the coordinated efforts of the federal and private sectors to address this patient safety problem present an unprecedented effort to "bend the cost curve" of delivering care through improving quality. Key to this strategy was a multipronged approach at the federal, state, and regional levels. OBJECTIVES To examine the impact of HHS's Regional Office projects in support of the implementation of the National Action Plan to Eliminate HAIs and to clarify the role played by HHS regions in the multipronged federal effort to combat HAIs. RESEARCH DESIGN Qualitative; 13 individual semistructured interviews with representatives from 9 regions. Eight interviews were conducted initially and follow-up interviews were conducted 1-year later with original participants. MEASURES Evaluated results against the modified Context-Input-Process-Product system functions and properties used to evaluate the HAI National Action Plan, including: HAI data and monitoring, knowledge development, infrastructure development, HAI prevention and practice adoption, prioritization, coordination and alignment, accountability and incentives, stakeholder engagement, and resources. RESULTS Results from the interviews were systematically coded against a framework that documents specific system and properties that characterize the roadmap laid out by the Action Plan. This review assesses progress toward Action Plan goals achieved by these OASH-funded regional projects and finds that these regional activities furthered the National Action Plan goals by addressing the key regional needs. CONCLUSIONS Key to the success of the National Action Plan was the multilevel approach to implementation of initiatives at the federal, regional, and state levels.

Post-treatment cancer care is often fragmented and of suboptimal quality. We explored factors that may affect cancer survivors' post-treatment care coordination, including oncologists' use of electronic technologies such as e-mail and integrated electronic health records (EHRs) to communicate with primary care physicians (PCPs). We used data from a survey (357 respondents; participation rate 52.9%) conducted in 2012-2013 among medical oncologists caring for patients in a large US study of cancer care delivery and outcomes. Oncologists reported their frequency and mode of communication with PCPs, and role in providing post-treatment care. Seventy-five per cent said that they directly communicated with PCPs about post-treatment status and care recommendations for all/most patients. Among those directly communicating with PCPs, 70% always/usually used written correspondence, while 36% always/usually used integrated EHRs; telephone and e-mail were less used. Eighty per cent reported co-managing with PCPs at least one post-treatment general medical care need. In multivariate-adjusted analyses, neither communication mode nor intensity were associated with co-managing survivors' care. Oncologists' reliance on written correspondence to communicate with PCPs may be a barrier to care coordination. We discuss new research directions for enhancing communication and care coordination between oncologists and PCPs, and to better meet the needs of cancer survivors post-treatment.

Purpose: Only 2% to 5% of adult patients with cancer enroll onto clinical trials. We assessed simultaneously characteristics of patients and their physicians that may be independently associated with participation. Methods: CanCORS, a National Cancer Institute (NCI) –funded population-based observational cohort study of newly diagnosed patients with lung and colorectal cancers, sampled patients across five geographic areas, five health care delivery systems, and 15 Veterans Administration hospitals. We linked patient survey and medical record data with physician survey data to examine correlates of trial enrollment. Results: Among 9,901 patients, 5.3% enrolled onto trials. Of the 9,901 patients, we linked 6,506 patients to one medical oncologist, surgeon, or radiation oncologist (physicians, N 1,325) who responded to the physician survey and was considered their primary cancer clinician decision maker. Patient age, race, disease stage, geographic region, and health insurance were independently associated with trial enrollment. Physician factors independently associated with patient trial enrollment were being a medical oncologist, practicing at an NCI-designated cancer center, taking the lead in discussing trials with patients, and receiving increased income from trial enrollment. After simultaneously adjusting for patient and physician characteristics, only being a physician practicing at an NCI-designated cancer center (odds ratio [OR], 1.65; 95% CI, 1.19 to 2.27) and patient female sex (OR, 1.36; 95% CI, 1.10 to 1.68), age 70 versus 50 years (OR, 0.28; 95% CI, 0.16 to 0.48), and advanced disease (OR, 1.85; 95% CI, 1.45 to 2.37) remained independently associated with trial enrollment. Conclusion: Both practice environment and patient clinical and demographic characteristics are associated with cancer clinical trial enrollment; simultaneous intervention may be required when trying to increase enrollment rates.

Purpose: Chemotherapy prolongs survival in patients with advanced non–small-cell lung cancer. However, few studies have included patients with poor performance status. This study examined rates of oncologists’ recommendations for chemotherapy by patient performance status and symptoms and how physician characteristics influence chemotherapy recommendations. Methods: We surveyed medical oncologists involved in the care of a population-based cohort of patients with lung cancer from the CanCORS (Cancer Care Outcomes Research and Surveillance) study. Physicians were queried about their likelihood to recommend chemotherapy to patients with stage IV lung cancer with varying performance status (Eastern Cooperative Oncology Group performance status 0 [good] v 3 [poor]) and presence or absence of tumor-related pain. Repeated measures logistic regression was used to estimate the independent associations of patients’ performance status and symptoms and physicians’ demographic and practice characteristics with chemotherapy recommendations. Results: Nearly all physicians (adjusted rate, 97% to 99%) recommended chemotherapy for patients with good performance status, and approximately half (adjusted rate, 38% to 53%) recommended chemotherapy for patients with poor performance status (P < .001). Compared with patient factors, physician and practice characteristics were less strongly associated with chemotherapy recommendations in adjusted analyses. Conclusion: Strong consensus among oncologists exists for chemotherapy in patients with advanced non–small-cell lung cancer and good performance status. However, the relatively high rate of chemotherapy recommendations for patients with poor performance status despite the unfavorable risk–benefit profile highlights the need for ongoing work to define high-value care in oncology and to implement and evaluate strategies to align incentives for such care.

Given the growing concern about CT overutilization, we provide a descriptive trend analysis of CT studies ordered in U.S. emergency departments by nonphysician health care providers and examine whether there is a significant difference in ordering patterns between nonphysicians and physicians.We used a nationally representative data sample for 2001-2008 to describe trends in CT studies ordered in U.S. emergency departments by nonphysician health care providers. We performed a multivariate logistic regression with hospital fixed effects on the most recently available data to determine whether there is a difference in ordering patterns between the two provider groups.From 2001 to 2008, the number of emergency department visits associated with CT studies managed solely by nonphysician health care providers increased from 100,626 to 620,296. Over this same period, the proportion of emergency department visits associated with CT managed solely by nonphysician providers grew from 1.5% to 3.6%. Controlling for hospital-level and patient-level variables, patient visits managed solely by nonphysician providers had 0.38 times the odds of CT utilization compared with patient visits managed by physicians.Although both the total number and the proportion of emergency department visits managed independently by nonphysician providers and associated with CT have grown rapidly in the past decade, nonphysician health care providers are less likely to order CT compared with physicians. The types of ordering providers and their differing practices should become part of the discourse regarding appropriate CT utilization.

The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving1 line of chemotherapy and receiving combination chemotherapy.Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of1 line of chemotherapy or combination chemotherapy.The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens.

When the clinical center of the National Institutes of Health (NIH) opened more than a half a century ago, its director required that independent committees review any research that posed high or unusual risks for its human subjects. In 1966 the requirement for independent review was extended to all human subjects research funded by the NIH, and in 1974, this was codified as federal law by the National Research Act. The law required organizations seeking funding from the U.S. Public Health Service to form committees that would review the adequacy of protections for human subjects. The committees—which came to be known as “institutional review boards,” or IRBs—were specifically charged with assessing the safety of the proposed research and the adequacy of the consent to be obtained from the research participants. A survey conducted the year after the new law was enacted found overwhelming support for IRBs among researchers, with 91 percent of the respondents agreeing that IRBs protect patients and 70 percent supporting the statement that IRB review improves the overall quality of research (Gray, Cooke, and Tannenbaum 1978). The researchers did have some reservations, however. Approximately half the respondents (43 percent of biomedical and 54 percent of behavioral and social scientists) believed that the need to obtain IRB review impeded their research to some extent, and a small number (8 percent) even concluded that the difficulties associated with IRB review outweighed its benefits. In the time since that survey, both the volume of research and the number of IRBs have grown. Between 1995 and 2009, the NIH's research budget increased almost fourfold, from $7.7 billion to almost $30 billion (US DHHS 2009), while the number of IRBs grew at more than double that rate, from 491 in 1995 to almost 4,000 by 2008 (Catania et al. 2008). During this interval, there also were a number of government-commissioned evaluations of IRBs, as well as the wider system for protecting human research participants, which largely concluded that reforms were necessary to ensure adequate protections (Bell, Whiton, and Connelly 1998; Federman et al. 2003; NBAC 2001; US DHHS 1998; US GAO 1996). Although there has not been any broad-based effort to examine the corollary impacts that IRB review might have on research, the U.S. Department of Health and Human Services (US DHHS) recently announced its intention to reform the regulations that govern such review (US DHHS 2011). Editorials and commentaries from a wide range of clinical and research disciplines characterize IRBs as “slow and cumbersome [and] inconsistent” (Straight 2009, 376) and claim that they unduly delay research (Marsh et al. 2008), create disincentives for research participation (Infectious Diseases Society of America 2009), do not have the requisite expertise needed for review (Emanuel et al. 2004), and, more generally, impose a “staggering” cost on the research (Gordon et al. 2003). More pointedly, some people have argued that even though many of the costs and constraints resulting from IRB review are necessary, other costs constitute an unnecessary “burden” because they do not increase the research participants’ protections.

e17501 Background: Coordination of care has grown in importance with the advent of new modalities of treatment requiring specialized expertise. In cancer care, multidisciplinary approaches have shown improvements in quality of care and patient satisfaction. Tumor boards provide a mechanism for improving coordination of care. We evaluated physician and practice characteristics that predict frequency of tumor board attendance. Methods: This cross-sectional study utilizes data obtained by surveying physicians of a population-based sample of women with incident breast cancer. Physicians were queried regarding tumor board attendance, specialty (medical oncologist [MO], radiation oncologist [RO], surgeon indicating that the hospital at which most breast cancer surgeries are performed has an American College of Surgeons accredited program [ACOSSg] and surgeon without such affiliation [non-ACOSSg]), physician characteristics (gender, race, teaching involvement, patient volume, number of offices, ownership interest), and practice setting (practice type, size, reimbursement). Univariate, bivariate, and multivariate analyses were performed for the dependent variable characterizing provider report of frequency of tumor board meeting attendance. Results: Most surveyed physicians (83%) report attending tumor board weekly (58%) or monthly (25%). Weekly participation was reported by 63%, 92%, 47%, and 32% of MOs, ROs, ACOSSgs, and non-ACOSSgs (p < 0.01). Specialty and higher patient volumes are significant predictors of more frequent attendance, after adjustment for practice size and type. In comparison to the most prevalent specialty category (low volume ACOSSgs), high volume MOs attend more (p = 0.01), and low volume non-ACOSSgs attend less frequently (p = 0.00). Conclusions: Tumor board attendance implies increased participation in multidisciplinary care, but specific subsets of providers are less frequent users. This not only has implications for choosing providers, but also for efforts to increase attendance. Tumor board agendas and formalized institution wide policies could be designed to further engage low frequency attendees as a means to promote multidisciplinary care and improve health outcomes. [Table: see text]

A great deal of clinical cancer care is delivered in the home by informal caregivers (e.g. family, friends), who are often untrained. Caregivers' context varies widely, with many providing care despite low levels of resources and high levels of additional demands. Background: Changes in health care have shifted much cancer care to the home, with limited data to inform this transition. We studied the characteristics, care tasks, and needs of informal caregivers of cancer patients. Methods: Caregivers of seven geographically and institutionally defined cohorts of newly diagnosed colorectal and lung cancer patients completed self-administered questionnaires (n = 677). We combined this information with patient survey and chart abstraction data and focused on caregivers who reported providing, unpaid, at least 50% of the patient's informal cancer care. Results: Over half of caregivers (55%) cared for a patient with metastatic disease, severe comorbidity, or undergoing current treatment. Besides assisting with activities of daily living, caregivers provided cancer-specific care such as watching for treatment side effects (68%), helping manage pain, nausea or fatigue (47%), administering medicine (34%), deciding whether to call a doctor (30%), deciding whether medicine was needed (29%), and changing bandages (19%). However, half of caregivers reported not getting training perceived as necessary. In addition, 49% of caregivers worked for pay, 21% reported poor or fair health, and 21% provided unpaid care for other individuals. One in four reported low confidence in the quality of the care they provided. Conclusions: Much assistance for cancer patients is delivered in the home by informal caregivers, often without desired training, with a significant minority having limited resources and high additional demands. Future research should explore the potentially high yield of addressing caregiver needs in improving quality of cancer care and both survivors' and caregivers' outcomes. Copyright © 2010 John Wiley & Sons, Ltd.

The continuum of breast cancer care requires multidisciplinary efforts. Patient navigators, who perform outreach, coordination, and education, have been shown to improve some areas of care. However, little research has assessed the impact of navigators on breast cancer treatment in uninsured populations. Our objective is to report on the impact of a patient navigator program on breast cancer quality of care at a public hospital. One hundred consecutive newly diagnosed patients with breast cancer (Stages I to III) were identified (2005 to 2007). Forty-nine patients were treated before the use of navigators and 51 after program implementation. Nine breast cancer quality indicators were used to evaluate quality of care. Overall adherence to the quality indicators improved from 69 to 86 per cent with the use of patient navigators ( P < 0.01). Only one individual indicator, use of surveillance mammography, improved significantly (52 to 76%, P < 0.05). All nine indicators reached 75 per cent or greater adherence rates after implementation of the navigator program compared with only four before implementation. Patient navigators appear to improve breast cancer quality of care in a public hospital. In populations in which cultural, linguistic, and financial barriers are prevalent, navigator programs can be effective in narrowing the observed gaps in the quality of cancer care.

Purpose The objective of this study was to evaluate the quality of care provided to uninsured women with breast cancer who received treatment through the Breast and Cervical Cancer Prevention Treatment Program (BCCTP). Methods Participants included women with stage I to III breast cancer (n = 658) from a consecutive sample of women 18 years or older who received coverage through the California BCCTP between February 2003 and September 2005 who consented to a survey and medical record review (61% response rate). Quality of breast cancer care was evaluated using 29 evidence-based quality measures developed for the National Initiative for Cancer Care Quality (NICCQ). NICCQ, a largely insured cohort of women diagnosed with stage I to III breast cancer in 1998, was used to benchmark the results. Results Twenty-three percent of women presented with stage III disease compared with fewer than 10% nationally. Patients received 93% of recommended care (95% CI, 92% to 93%). Adherence to recommended care within domains ranged from 87% for post-treatment surveillance (95% CI, 84% to 90%) to 97% for diagnostic evaluation (95% CI, 96% to 97%). Compared to the NICCQ cohort, adherence to quality measures was as good or better for the BCCPT cohort in all domains except post-treatment surveillance. Conclusion The BCCTP has made important inroads in providing poor, uninsured women with access to high quality care when faced with the diagnosis of breast cancer; however, many present at an advanced stage, which is associated with worse outcomes.