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In 2021, the Medical University of South Carolina (MUSC) launched In Our DNA SC. This large-scale initiative will screen 100,000 individuals in South Carolina for three preventable hereditary conditions that impact approximately two million people in the USA but often go undetected. In anticipation of inevitable changes to the delivery of this complex initiative, we developed an approach to track and assess the impact of evaluate adaptations made during the pilot phase of program implementation. We used a modified version of the Framework for Reporting Adaptations and Modification-Enhanced (FRAME) and Adaptations to code adaptations made during the 3-month pilot phase of In Our DNA SC. Adaptations were documented in real-time using a REDCap database. We used segmented linear regression models to independently test three hypotheses about the impact of adaptations on program reach (rate of enrollment in the program, rate of messages viewed) and implementation (rate of samples collected) 7 days pre- and post-adaptation. Effectiveness was assessed using qualitative observations. Ten adaptations occurred during the pilot phase of program implementation. Most adaptations (60%) were designed to increase the number and type of patient contacted (reach). Adaptations were primarily made based on knowledge and experience (40%) or from quality improvement data (30%). Of the three adaptations designed to increase reach, shortening the recruitment message potential patients received significantly increased the average rate of invitations viewed by 7.3% (p = 0.0106). There was no effect of adaptations on implementation (number of DNA samples collected). Qualitative findings support improvement in effectiveness of the intervention after shortening the consent form and short-term positive impact on uptake of the intervention as measured by team member’s participation. Our approach to tracking adaptations of In Our DNA SC allowed our team to quantify the utility of modifications, make decisions about pursuing the adaptation, and understand consequences of the change. Streamlining tools for tracking and responding to adaptations can help monitor the incremental impact of interventions to support continued learning and problem solving for complex interventions being delivered in health systems based on real-time data.

PURPOSE: More than half of patients with head and neck squamous cell carcinoma (HNSCC) experience a delay initiating guideline-adherent postoperative radiation therapy (PORT), contributing to excess mortality and racial disparities in survival. However, interventions to improve the delivery of timely, equitable PORT among patients with HNSCC are lacking. This study (1) describes the development of NDURE (Navigation for Disparities and Untimely Radiation thErapy), a navigation-based multilevel intervention (MLI) to improve guideline-adherent PORT and (2) evaluates its feasibility, acceptability, and preliminary efficacy. METHODS: NDURE was developed using the six steps of intervention mapping (IM). Subsequently, NDURE was evaluated by enrolling consecutive patients with locally advanced HNSCC undergoing surgery and PORT (n = 15) into a single-arm clinical trial with a mixed-methods approach to process evaluation. RESULTS: NDURE is a navigation-based MLI targeting barriers to timely, guideline-adherent PORT at the patient, healthcare team, and organizational levels. NDURE is delivered via three in-person navigation sessions anchored to case identification and surgical care transitions. Intervention components include the following: (1) patient education, (2) travel support, (3) a standardized process for initiating the discussion of expectations for PORT, (4) PORT care plans, (5) referral tracking and follow-up, and (6) organizational restructuring. NDURE was feasible, as judged by accrual (88% of eligible patients [100% Blacks] enrolled) and dropout (n = 0). One hundred percent of patients reported moderate or strong agreement that NDURE helped solve challenges starting PORT; 86% were highly likely to recommend NDURE. The rate of timely, guideline-adherent PORT was 86% overall and 100% for Black patients. CONCLUSION: NDURE is a navigation-based MLI that is feasible, is acceptable, and has the potential to improve the timely, equitable, guideline-adherent PORT.

Background Family members of patients admitted to the ICU experience a constellation of sequelae described as postintensive care syndrome-family. The influence that an inter-ICU transfer has on psychological outcomes is unknown. Research Question Is inter-ICU transfer associated with poor psychological outcomes in families of patients with acute respiratory failure? Study Design and Methods Cross-sectional observational study of 82 families of patients admitted to adult ICUs (tertiary hospital). Data included demographics, admission source, and outcomes. Admission source was classified as inter-ICU transfer (n = 39) for patients admitted to the ICU from other hospitals and direct admit (n = 43) for patients admitted from the ED or the operating room of the same hospital. We used quantitative surveys to evaluate psychological distress (Hospital Anxiety and Depression Scale [HADS]) and posttraumatic stress (Post-Traumatic Stress Scale; PTSS) and examined clinical, family, and satisfaction factors associated with psychological outcomes. Results Families of transferred patients travelled longer distances (mean ± SD, 109 ± 106 miles) compared with those of patients directly admitted (mean ± SD, 65 ± 156 miles; P ≤ .0001). Transferred patients predominantly were admitted to the neuro-ICU (64%), had a longer length of stay (direct admits: mean ± SD, 12.7 ± 9.3 days; transferred patients: mean ± SD, 17.6 ± 9.3 days; P Interpretation In this exploratory study, posttraumatic stress measured by the PTSS was higher in the transferred families, but these findings will need to be replicated to infer clinical significance.

People with HIV (PWH) have higher rates of tobacco use compared to their societal counterparts and are disproportionately affected by tobacco-related morbidity and mortality. A needs assessment was conducted to assess provider beliefs and opinions on tobacco treatment barriers and treatment approaches. The results highlighted a disconnect between the known importance of quitting smoking and barriers in linking patients to treatment, such as lack of patient interest and other patient issues being a higher priority. Using this assessment data, a treatment delivery approach, Proactive Outreach with Medication Opt-out for Tobacco Treatment Engagement (PrOMOTE), was devised and piloted. PrOMOTE consisted of an outpatient clinical pharmacist trained in tobacco treatment proactively contacting patients for counseling and to prescribe smoking cessation pharmacotherapy (varenicline or dual nicotine replacement therapy (NRT)) using an opt-out approach. The pilot was conducted with 10 PWH and patient reach and opt-out rates were evaluated. Of the 10 patients contacted, 7 were reached and none opted out of the pharmacotherapy prescription (varenicline = 6; NRT = 1). Providers know the importance of smoking cessation for PWH but encounter several barriers to implementing treatment. Using PrOMOTE methods to deliver tobacco treatment increased the reach and pharmacotherapy acceptance rate of PWH who smoke.

School-based telehealth (SBTH) offers an opportunity to overcome traditional barriers to providing comprehensive asthma care for children. Guided by an implementation science framework considering factors internal and external to the school setting, we characterized barriers and facilitators to asthma care within an existing SBTH program available in over 50 under-resourced South Carolina schools.This cross-sectional study assessed barriers and facilitators to SBTH asthma care delivery using web-based surveys of school nurses, specifically addressing school implementation of telehealth methods. Surveys evaluated practices and nurse and school-specific factors related to telehealth implementation including perceived barriers, organizational readiness and self-efficacy. Utilizers were schools who completed 1-10 average visits per month while non-utilizers completed less than 1 average visit per month. Descriptive statistics were performed to characterize perceptions in utilizers versus non-utilizers.Of 53 surveys distributed, 36 were completed (68% response rate). Commonly cited barriers included inadequate time due to competing tasks in both utilizers (65%) and non-utilizers (74%) as well as lack of caregiver involvement in care planning (94% of utilizers and 84% of non-utilizers). Of those utilizing specific, relevant telehealth services, schools scored high in perceptions of organizational readiness (We identified inadequate nurse time and challenges engaging caregivers as key barriers to implementation of a school-based telehealth asthma program providing care to an under-resourced population. Addressing these barriers when expanding telehealth services may promote utilization of telehealth.

EXECUTIVE SUMMARY Intensive care unit (ICU) telemedicine has grown exponentially to the point that approximately 10% of U.S. hospitals use such programs. However, no studies have focused on strategic decision tools in the context of rural hospitals. We applied the pervasive balanced scorecard framework and used a sequential, mixed methods design with qualitative and quantitative data sources. We then triangulated them to generate value scorecards for four rural South Carolina hospitals. Four domains, each with numerous components, were identified and compiled to create a composite value scorecard. Domains and numbers of components included organizational (n = 10), clinical (n = 5), financial (n = 8), and strategic (n = 3) effects of ICU telemedicine. When weighting each component within domains and then comparing across hospitals, we identified substantial variation in the relative value derived from ICU telemedicine. Our novel, multidimensional value scorecard could be prospectively applied by hospitals seeking a structured approach to decision-making for ICU telemedicine investments.

Head and neck cancer (HNC) survivors and caregivers face significant challenges after treatment. This study's objective was to evaluate the effects of a dyadic survivorship care planning (SCP) intervention on survivor and caregiver outcomes.This randomized controlled trial enrolled HNC survivors and caregivers within 18 months post-treatment, randomized dyads to SCP (one-session with written SCP and follow-up telephone call) or usual care and administered baseline and 6-month surveys. Multivariable linear regression examined intervention effects on depression and unmet needs in dyads and burden on caregiverss and a set of secondary outcomes. Rating scales and open-ended questions assessed acceptability.We randomized 89 survivor-caregiver dyads (42 usual care, 47 SCP dyads). Fidelity to SCP was high for most survivorship domains except discussing care barriers (13%). The most commonly discussed referrals included nutrition (83%) and behavioral medicine (38%), but referral uptake was low. The SCP intervention did not improve depression or unmet needs among dyads or burden among caregivers at 6 months relative to usual care (p's .05). Nurses and dyads rated SCP favorably with 80% positive ratings for session length and care plan content. Qualitative findings highlighted that SCP helped consolidate complex clinical information and strengthened survivor-caregiver-clinician relationships.An HNC SCP intervention was acceptable but ineffective in improving dyads' outcomes.Post-treatment SCP in HNC dyads was ineffective in improving outcomes in survivors and caregivers as delivered in this study. More research is needed to understand how to capitalize on the acceptability of the SCP approach and enhance its effectiveness to support dyads.

PURPOSE: Delays initiating guideline-adherent postoperative radiation therapy (PORT) in head and neck squamous cell carcinoma (HNSCC) are common, contribute to excess mortality, and are a modifiable target for improving survival. However, the barriers that prevent the delivery of timely, guideline-adherent PORT remain unknown. This study aims to identify the multilevel barriers to timely, guideline-adherent PORT and organize them into a conceptual model. MATERIALS AND METHODS: Semi-structured interviews with key informants were conducted with a purposive sample of patients with HNSCC and oncology providers across diverse practice settings until thematic saturation (n = 45). Thematic analysis was performed to identify the themes that explain barriers to timely PORT and to develop a conceptual model. RESULTS: In all, 27 patients with HNSCC undergoing surgery and PORT were included, of whom 41% were African American, and 37% had surgery and PORT at different facilities. Eighteen clinicians representing a diverse mix of provider types from 7 oncology practices participated in key informant interviews. Five key themes representing barriers to timely PORT were identified across 5 health care delivery levels: (1) inadequate education about timely PORT, (2) postsurgical sequelae that interrupt the tight treatment timeline (both intrapersonal level), (3) insufficient coordination and communication during care transitions (interpersonal and health care team levels), (4) fragmentation of care across health care organizations (organizational level), and (5) travel burden for socioeconomically disadvantaged patients (community level). CONCLUSION: This study provides a novel description of the multilevel barriers that contribute to delayed PORT. Interventions targeting these multilevel barriers could improve the delivery of timely, guideline-adherent PORT and decrease mortality for patients with HNSCC.

Distress with self-perceived changes in appearance and function can result in body image disturbance (BID), which is common in head and neck cancer (HNC) survivors and a major source of psychosocial morbidity. To address the lack of psychometrically sound patient-reported outcome measures (PROMs) of HNC-related BID, we aim to create and validate the Inventory to Measure and Assess imaGe disturbancE-HeadNeck (IMAGE-HN).Survey study.Multiple academic centers.Following item development, HNC survivors from 4 academic centers completed the IMAGE-HN. Item responses were psychometrically analyzed using confirmatory factor analysis (CFA) and Rasch analysis.Item development resulted in a 31-item PROM consisting of 5 individual domains and a global domain. In total, 305 HNC survivors of diverse ages, HNC subsites, and reconstructive paradigms completed the initial items. After removal of 3 items for local dependence, CFA confirmed the unidimensionality and local independence (item residual correlations|0.20|) for each domain. Rasch analysis indicated acceptable fit (infit and outfit mean squares2.0), monotonicity of all rating scale categories, and low person misfit (4%). Person separation indices and person reliability were adequate for each domain except appearance concealment, which was removed (4 items). This resulted in the IMAGE-HN, a psychometrically acceptable 24-item PROM of HNC-related BID consisting of a global scale and 4 subscales measuring unique constructs and comprised independent items.IMAGE-HN is a novel, psychometrically sound, multidomain PROM of HNC-related BID for use in clinical and research settings.

Individualized supportive care is recommended to manage the debilitating effects of advanced prostate cancer and its treatments. Yet, the implementation of supportive care in practice remains inconsistent.The aim of this study was to synthesize the barriers and facilitators to implementing supportive care interventions after identifying supportive care interventions for advanced prostate cancer survivors.PubMed, SCOPUS, CINAHL Complete, ProQuest, and PsycINFO were searched for relevant studies published between 2011 and 2020. Studies were included if they reported on a supportive care intervention and included a description of implementation barriers and/or facilitators. The Theoretical Domains Framework was used to characterize implementation barriers and facilitators.Of the 620 articles identified, 13 met all prespecified inclusion criteria. Primary barriers were related to the domains of environmental context and resources (eg, limited resources), knowledge (eg, insufficient knowledge on efficacy of supportive care), and beliefs about capabilities (eg, lack of confidence in materials). Facilitators fell under environmental context and resources (partnerships with local services), reinforcement (eg, partners inclusion), and skills (eg, delivery by professionals).This scoping review highlights barriers and facilitators that affect supportive care implementation. Future research that focuses on overcoming barriers and maximizing facilitators is needed to improve, modify, or supplement existing supportive care implementation practices.As the number of advanced prostate cancer survivors continues to increase, supportive care must become the standard of care. Future interventions must incorporate increased knowledge and funding, alternative delivery models, and consistent use of specialty nurses.

IntroductionBreast cancer remains a leading cause of cancer deaths; however, recent improvements in treatment have improved survivorship. As a result of this improvement, more individuals are living with the long-term side effects of cancer treatment. Therefore, methods that incorporate lifestyle and mind-body approaches are becoming increasingly used in the patient treatment pathway.MethodsIn this study, PranaScience Institute will develop and test a group video mobile application for Yogic Breathing (YB). YB is shown to reduce symptomatic conditions associated with several conditions including breast cancer. For this initial feasibility study, PranaScience will collaborate with the Medical University of South Carolina to implement the study app-based program in breast cancer survivors. This research is aimed to understand if the YB could be delivered via an app, if participants are able to practice it satisfactorily, and if there is any symptom relief by the YB practice. In the control group, participants will be directed to the Attention Control (AC) feature of the app, which guides users to focus on a mindfulness activity not involving YB. Participants will be randomly assigned to the YB or AC study plan (N=20 per group). Breast cancer survivors who have completed radiation therapy within last 6 months will be recruited for this study and provided access to the app for a 12-week program. The study app will record total practice times. Virtual visits by a study yoga instructor during group video sessions will measure participant compliance with proper technique. Feasibility will be examined by evaluating intervention delivery factors and resource needs. Acceptability of using the mobile study app to support symptom management will be evaluated using a satisfaction and system usability scale. Behavioral survey measures will help guide effect sizes and power calculations for the next larger-scale study. Biomarkers in the saliva (tumor suppressors, cytokines), and fingernails (cortisol, differential proteomics) will be measured at baseline and end of study at 12 weeks.DiscussionAll findings from this pilot study will be synthesized to refine the mobile study app in preparation for large-scale evaluation in Phase II involving all-study site participants with cancer. ClinicalTrials.gov Identifier NCT05161260.

ImportanceAlthough 1 in 4 head and neck cancer (HNC) survivors experience clinically significant body image distress (BID), a psychosocial morbidity that adversely affects quality of life, effective interventions for these patients are lacking.ObjectiveTo evaluate the acceptability and preliminary efficacy of BRIGHT (Building a Renewed ImaGe after Head and neck cancer Treatment), a brief tele–cognitive behavioral therapy, at reducing BID among HNC survivors.Design, Setting, and ParticipantsThis parallel-group pilot randomized clinical trial recruited adult HNC survivors with BID between August 13, 2020, and December 9, 2021, from the Medical University of South Carolina HNC clinic during a routine survivorship encounter. Data were analyzed from May 3 to June 16, 2022.InterventionsBRIGHT consisted of 5 weekly psychologist-led video tele–cognitive behavioral therapy sessions. Attention control (AC) consisted of dose- and delivery-matched survivorship education.Main Outcomes and MeasuresChange in HNC-related BID was assessed using IMAGE-HN (Inventory to Measure and Assess imaGe disturbancE–Head and Neck), a validated patient-reported outcome (score range, 0-84, with higher scores indicating greater HNC-related BID). Clinical response rate was measured as the proportion of patients with a clinically meaningful change in IMAGE-HN scores.ResultsOf the 44 HNC survivors with BID allocated to BRIGHT (n = 20) or AC (n = 24), the median (range) age was 63 (41-80) years, and 27 patients (61%) were female. Patients rated BRIGHT’s acceptability highly (all metrics had a mean rating of ≥4.5/5), and 19 of 20 patients (95%) receiving BRIGHT were likely or highly likely to recommend it to other HNC survivors with BID. BRIGHT decreased HNC-related BID from baseline to 1 month postintervention relative to AC (mean model-based difference in change in IMAGE-HN score, –7.9 points; 90% CI, –15.9 to 0.0 points) and from baseline to 3 months postintervention relative to AC (mean model-based difference in change in IMAGE-HN score, –17.1 points; 90% CI, −25.6 to −8.6 points). At 3 months postintervention, the clinical response rate of BRIGHT was 6.6-fold higher than AC (model-based odds ratio, 6.6; 90% CI, 2.0-21.8). The improvement in HNC-related BID for BRIGHT vs AC at 3 months was clinically significant, and the effect size was large (Cohen d, −0.9; 90% CI, −1.4 to −0.4).Conclusions and RelevanceIn this pilot randomized clinical trial, BRIGHT was acceptable, may result in a clinically meaningful improvement in HNC-related BID, and showed a high clinical response rate. These promising preliminary data support conducting a large efficacy trial to establish BRIGHT as the first evidence-based treatment for HNC survivors with BID.Trial RegistrationClinicalTrials.gov Identifier: NCT03831100

Background: Supportive care interventions can improve quality of life and health outcomes of advanced prostate cancer survivors. Despite the high prevalence of unmet needs, supportive care for this population is sparse. Methods: The databases PubMed, SCOPUS, CINAHL, and ProQuest were searched for relevant articles. Data were extracted, organized by thematic matrix, and categorized according to the seven domains of the Supportive Care Framework for Cancer Care. Results: The search yielded 1678 articles, of which 18 were included in the review and critically appraised. Most studies were cross-sectional with small, non-diverse samples. Supportive care interventions reported for advanced prostate cancer survivors are limited with some positive trends. Most outcomes were symptom-focused and patient self-reported (e.g., anxiety, pain, self-efficacy) evaluated by questionnaires or interview. Interventions delivered in group format reported improvements in more outcomes. Conclusions: Additional supportive care intervention are needed for men with advanced prostate cancer. Because of their crucial position in caring for cancer patients, nurse scientists and clinicians must partner to research and develop patient-centered, culturally relevant supportive care interventions that improve this population’s quality of life and health outcomes. Efforts must concentrate on sampling, domains of needs, theoretical framework, guidelines, and measurement instruments.

212 Background: Nearly 1 in 3 head and neck cancer (HNC) survivors suffer from body image distress (BID), a source of devastating psychosocial morbidity that impairs quality of life. Evidence-based strategies to manage BID among HNC survivors are lacking. This trial evaluates the preliminary efficacy of BRIGHT (Building a Renewed ImaGe after Head & neck cancer Treatment), a brief tele-cognitive behavioral intervention, relative to attention control (AC), at reducing BID among HNC survivors. Methods: HNC survivors with clinically significant BID were randomized to BRIGHT (n = 20) or AC (n = 24). BRIGHT was delivered by a psychologist in 5 weekly video tele-medicine sessions. AC consisted of dose- and delivery-matched survivorship education. Changes in HNC-related BID and cancer-related BID were assessed using the IMAGE-HN and Body Image Scale (BIS), respectively. The effect of BRIGHT vs AC was analyzed using generalized linear models. Clinical response (proportion of patients with a clinically meaningful change in IMAGE-HN and BIS scores) for BRIGHT vs AC was analyzed with logistic regression. Results: The median age was 63 years (range 41-80) and 61% had stage III/IV HNC. BRIGHT decreased HNC-related BID from baseline to 1- and 3-months post-intervention relative to AC (Table). At 3-months post intervention, the response rate of BRIGHT on HNC-related BID was 6.6-fold higher than AC (OR = 6.6; 90% CI 2.0 to 21.8). BRIGHT decreased cancer-related BID from baseline to 3-months post-intervention vs AC (Table). The improvement in HNC-related BID and cancer-related BID for BRIGHT vs AC at 3-months was clinically significant and the effect size was large (Cohen’s d = -0.9, 90% CI -1.4 to -0.4 for each). Conclusions: In this pilot RCT, BRIGHT results in clinically meaningful improvements in BID among HNC survivors. These promising preliminary data support conducting a large efficacy trial to establish BRIGHT as the first evidence-based treatment for HNC survivors with BID. Clinical trial information: NCT03831100. [Table: see text]

Importance Body image–related distress (BID) is common among head and neck cancer (HNC) survivors and associated with significant morbidity. Risk factors for HNC-related BID remain poorly characterized because prior research has used outcome measures that fail to fully capture BID as experienced by HNC survivors. Objective To assess the association of demographic and oncologic characteristics with HNC-related BID using the Inventory to Measure and Assess imaGe disturbancE-Head & Neck (IMAGE-HN), a validated, multidomain, patient-reported outcome measure of HNC-related BID. Design, Setting, and Participants This cross-sectional study assessed 301 adult survivors of surgically managed HNC at 4 academic medical centers. Main Outcomes and Measures The primary outcome measure was IMAGE-HN scores, for which higher scores reflect more severe HNC-related BID. Multivariable linear regression analyses were performed to evaluate the association of patient characteristics with IMAGE-HN global and 4 subdomain (other-oriented appearance concerns, personal dissatisfaction with appearance, distress with functional impairments, and social avoidance) scores. Results Of the 301 participants (212 [70.4%] male; mean [SD] age, 65.3 [11.7] years), 181 (60.1%) underwent free flap reconstruction. Graduation from college (β = −9.6; 95% CI, −17.5 to −1.7) or graduate school (β = −12.6; 95% CI, −21.2 to −3.8) was associated with lower IMAGE-HN social avoidance scores compared with less than a high school education. Compared with paid work, unemployment was associated with higher IMAGE-HN other-oriented appearance (β = 10.7; 95% CI, 2.0-19.3), personal dissatisfaction with appearance (β = 12.5; 95% CI, 1.2-23.7), and global (β = 8.0; 95% CI, 0.6-15.4) scores. Compared with no reconstruction, free flap reconstruction was associated with higher IMAGE-HN global scores (β = 11.5; 95% CI, 7.9-15.0) and all subdomain scores (other-oriented appearance: β = 13.1; 95% CI, 8.6-17.6; personal dissatisfaction with appearance: β = 15.4; 95% CI, 10.0-20.7; distress with functional impairment: β = 12.8; 95% CI, 8.1-17.4; and social avoidance and isolation: β = 10.2; 95% CI, 5.8-14.6). Higher IMAGE-HN distress with functional impairment scores were found in those who received surgery and adjuvant radiation (β = 7.8; 95% CI, 2.9-12.7) or chemoradiotherapy (β = 6.5; 95% CI, 1.8-11.3) compared with surgery alone. The multivariable regression model accounted for a modest proportion of variance in IMAGE-HN global (R2 = 0.18) and subdomain scores (R2 = 0.20 for other-oriented appearance, 0.14 for personal dissatisfaction with appearance, 0.21 for distress with functional impairment, and 0.13 for social avoidance and isolation). Conclusions and Relevance In this cross-sectional study, factors associated with risk of HNC-related BID included free flap reconstruction, lower educational attainment, unemployment, and multiple treatment modalities. These characteristics explain a modest proportion of variance in IMAGE-HN scores, suggesting that other characteristics may be the major risk factors for HNC-related BID and should be explored in future studies.

Background: Black men are disproportionately impacted by prostate cancer (PrCa). Current guidelines recommend that all men make informed decisions about whether to be screened for PrCa. Little is known about the barriers and facilitators of informed decision-making (IDM) about PrCa screening in Black men. Methods: We conducted focus groups with a convenience sample of Black men aged 55 to 69 years from a primary care practice (n = 21). Template analysis was used to evaluate themes related to barriers and facilitators of IDM about PrCa screening. Results: IDM was impacted by external factors, intrinsic factors, and personal beliefs about PrCa screening. Family, friends, and clinicians played a paramount role in shaping attitudes about PrCa screening. Distrust of the medical community impaired IDM, and lack of clinician communication about PrCa screening further engendered mistrust. Participants felt they lacked adequate knowledge to make an informed decision about PrCa screening. Identified areas to promote IDM included education on racial disparities, education that screening is a personal choice, and differentiating PrCa screening from colon cancer screening. Conclusions: Our results indicate that Black men may lack the prerequisite information to make informed decisions about PrCa screening, which is notable in light of known PrCa racial disparities. Clinicians can play an important role in facilitating IDM through fostering discussions about the benefits and risks of PrCa screening and educating Black men about racial disparities.

Background/Purpose: Telehealth-delivered school-based asthma care offers an opportunity to overcome typical barriers to providing asthma care to children compared to the traditional setting. Exploring the key components of care and internal and external factors affecting delivery may facilitate implementation of these programs, which have been shown to expand care. We used a dissemination and implementation science approach to characterize barriers and facilitators to asthma care in a telehealth-delivered school-based program available in over 50 South Carolina schools, of which 91% serve students who qualify for free or reduced lunch. Methods: …

Objective Asthma is one of the most common chronic conditions of childhood, conferring an immense burden on children and their caregivers. School-based telehealth approaches for asthma care provide the opportunity to deliver convenient, cost-effective care to more children in the school setting. Our study objective was to characterize school-based telehealth asthma program delivery experiences and examine barriers and facilitators to telehealth program implementation. Methods Interviews were conducted with telehealth program staff and school stakeholders in nine schools engaged in a school-based telehealth asthma program. A structured interview guide was designed using the Exploration, Adoption/Preparation, Implementation, Sustainment (EPIS) framework. A template analysis qualitative approach was used to identify themes related to implementation processes. Results Interviews identified key telehealth implementation strategies including building relationships, marketing and provision of technical assistance, education and support to aid program delivery. Key facilitators to successful program implementation included strong partnerships between the telehealth and school teams, a shared commitment to enhancing access to asthma care for children, and strong nurse leadership. Primary barriers to implementation included lack of family/caregiver involvement and competing demands for nurses. Conclusions This study identified barriers and facilitators to implementing a school-based telehealth asthma program that can be used to guide education, training and support strategies to enhance program delivery. Recommended implementation strategies include building strong program-school partnerships, creating a shared vision to improve access to care, and building engagement in families and communities while supporting nurse leaders and family involvement with training and resources. These results can help guide future telehealth interventions.

Rationale: Evidence-based practices promote quality care for intensive care unit patients but chronic evidence-to-practice gaps limit their reach. Objectives: To characterize key determinants of evidence-based practice uptake in the rural intensive care setting. Methods: A parallel convergent mixed methods design was used with six hospitals receiving a quality improvement intervention. Guided by implementation science principles, we identified barriers and facilitators to uptake using clinician surveys (N = 90), key informant interviews (N = 14), and an implementation tracking log. Uptake was defined as completion of eight practice change steps within 12 months. After completing qualitative and quantitative data analyses for each hospital, site, staff, and program delivery factors were summarized within and across hospitals to identify patterns by uptake status. Results: At the site level, although structural characteristics (hospital size, intensivist staffing) did not vary by uptake status, interviews highlighted variability in staffing patterns and culture that differed by uptake status. At the clinician team level, readiness and self-efficacy were consistently high across sites at baseline with time and financial resources endorsed as primary barriers. However, interviews highlighted that as initiatives progressed, differences across sites in attitudes and ownership of change were key uptake influences. At the program delivery level, mixed methods data highlighted program engagement and leadership variability by uptake status. Higher uptake sites had better training attendance; more program activities completed; and a stable, engaged, collaborative nurse and physician champion team. Conclusions: Results provide an understanding of the multiple dynamic influences on different patterns of evidence-based practice uptake and the importance of implementation support strategies to accelerate uptake in the intensive care setting.

Importance The standard of care for initiation of postoperative radiotherapy (PORT) in head and neck squamous cell carcinoma (HNSCC) is within 6 weeks of surgical treatment. Delays in guideline-adherent PORT initiation are common, associated with mortality, and a measure of quality care, but patient-specific tools to estimate the risk of these delays are lacking. Objective To develop and validate 2 nomograms (that use presurgical and postsurgical data) for predicting delayed PORT initiation. Design, Setting, and Participants This cohort study obtained patient data from January 1, 2004, to December 31, 2015, from the National Cancer Database. Adults aged 18 years or older with a newly diagnosed HNSCC who underwent surgical treatment and PORT at a Commission on Cancer–accredited facility were included. Data analysis was conducted from June 2, 2019, to January 29, 2020. Exposures Surgical treatment and PORT. Main Outcomes and Measures The primary outcome measure was PORT initiation more than 6 weeks after the surgical intervention. Multivariable logistic regression models were created in a random selection of 80% of the sample (derivation cohort) and were internally validated with bootstrapping, assessed for discrimination by calibration plots and the concordance (C) index, and externally validated in the remaining 20% of the sample (validation cohort). Results The study included 60 766 adults with HNSCC who were grouped into derivation and validation cohorts. The derivation cohort comprised 48 625 patients (mean [SD] age, 59.59 [11.3] years; 36 825 men [75.7%]) selected randomly from the full sample, whereas 12 151 patients (mean [SD] age, 59.63 [11.2] years; 9266 men [76.3%]) composed the validation cohort. The rate of PORT delay was 55.8% (n=27140) in the derivation cohort and 56.7% (n=6900) in the validation cohort. Both nomograms created to predict the risk of PORT initiation delay used variables, including race/ethnicity, insurance type, tumor site, and facility type. The nomogram based on presurgical variables included clinical stage and severity of comorbidity, whereas the nomogram with postsurgical variables included US region, length of stay, and care fragmentation between surgical and radiotherapy facilities. For the presurgical nomogram, the concordance indices were 0.670 (95% CI, 0.664-0.676) in the derivation cohort and 0.674 (95% CI, 0.662-0.685) in the validation cohort. For the nomogram with postsurgical variables, the concordance indices were 0.691 (95% CI, 0.686-0.696) in the derivation cohort and 0.694 (95% CI, 0.685-0.704) in the validation cohort. Conclusions and Relevance This study found that a nomogram developed with presurgical data to generate personalized estimates of PORT initiation delay may improve pretreatment counseling and the delivery of interventions to patients at high risk for such a delay. A nomogram including postsurgical data can drive institutional quality improvement initiatives and enhance risk-adjusted comparisons of delay rates across facilities.

Background Supportive care interventions have demonstrated benefits for both informal and/or family cancer caregivers and their patients, but uptake generally is poor. To the authors' knowledge, little is known regarding the availability of supportive care services in community oncology practices, as well as engagement practices to connect caregivers with these services. Methods Questions from the National Cancer Institute Community Oncology Research Program (NCORP)'s 2017 Landscape Survey examined caregiver engagement practices (ie, caregiver identification, needs assessment, and supportive care service availability). Logistic regression was used to assess the relationship between the caregiver engagement outcomes and practice group characteristics. Results A total of 204 practice groups responded to each of the primary outcome questions. Only 40.2% of practice groups endorsed having a process with which to systematically identify and document caregivers, although approximately 76% were routinely using assessment tools to identify caregiver needs and approximately 63.7% had supportive care services available to caregivers. Caregiver identification was more common in sites affiliated with a critical access hospital (odds ratio [OR], 2.44; P = .013), and assessments were less common in safety-net practices (OR, 0.41; P = .013). Supportive care services were more commonly available in the Western region of the United States, in practices with inpatient services (OR, 2.96; P = .012), and in practices affiliated with a critical access hospital (OR, 3.31; P = .010). Conclusions Although many practice groups provide supportive care services, fewer than one-half systematically identify and document informal cancer caregivers. Expanding fundamental engagement practices such as caregiver identification, assessment, and service provision will be critical to support recent calls to improve caregivers' well-being and skills to perform caregiving tasks.

Objectives The study aimed to evaluate the feasibility, acceptability, and preliminary clinical impact of BRIGHT (Building a Renewed ImaGe after Head & neck cancer Treatment), a novel telemedicine-based cognitive-behavioral intervention to manage body image disturbance (BID) in head and neck cancer (HNC) survivors. Methods Head and neck cancer survivors with BID were enrolled into a single-arm pilot trial. Participants completed study measures at baseline, 1- and 3-months post-BRIGHT to assess its acceptability and clinical impact. Participants completed semi-structured interviews to evaluate the feasibility and acceptability of BRIGHT and refine the intervention. Results Ten HNC survivors with BID were enrolled into the trial of tablet-based BRIGHT. BRIGHT was feasible, as judged by low dropout (n = 1), high session completion rates (100%; 45/45) and low rates of technical issues with the tablet-based delivery (11% minor; 0% major). Ninety percent of participants were highly likely to recommend BRIGHT, reflecting its acceptability. BRIGHT was associated with a 34.5% reduction in mean Body Image Scale scores at 1-month post-BRIGHT (mean difference from baseline = 4.56; 95% CI 1.55, 7.56), an effect that was durable at 3-months post-BRIGHT (mean decrease from baseline = 3.56; 95% CI 1.15-5.96). Program evaluation revealed high levels of satisfaction with BRIGHT, particularly the delivery platform. During the qualitative evaluation, participants highlighted that BRIGHT improved image-related coping behavior. Conclusions BRIGHT is feasible, acceptable to HNC survivors, and has significant potential as a novel approach to manage BID in HNC survivors. Additional research is necessary to refine BRIGHT and evaluate its clinical efficacy and scalability.

OBJECTIVES. To characterize the temporal trajectory of body image disturbance (BID) in patients with surgically treated head and neck cancer (HNC). STUDY DESIGN. Prospective cohort study. SETTING. Academic medical center. SUBJECTS AND METHODS: Patients with HNC who were undergoing surgery completed the Body Image Scale (BIS), a validated patient-reported outcome measure of BID, pretreatment and 1, 3, 6, 9, and 12 months posttreatment. Changes in BIS scores (ΔBIS) relative to pretreatment (primary endpoint) were analyzed with a linear mixed model. Associations between demographics, clinical characteristics, psychosocial attributes, and persistently elevated BIS scores and increases in BIS scores ≥5 points relative to pretreatment (secondary endpoints) were analyzed through logistic regression. RESULTS. Of the 68 patients, most were male (n = 43), had oral cavity cancer (n = 37), and underwent microvascular reconstruction (n = 45). Relative to baseline, mean ΔBIS scores were elevated at 1 month postoperatively (2.9; 95% CI, 1.3–4.4) and 3 (3.2; 95% CI, 1.5–4.9) and 6 (1.8; 95% CI, 0.02–3.6) months posttreatment before returning to baseline at 9 months posttreatment (0.9; 95% CI, −0.8 to 2.5). Forty-three percent of patients (19 of 44) had persistently elevated BIS scores at 9 months posttreatment relative to baseline, and 51% (31 of 61) experienced an increase in BIS scores ≥5 relative to baseline. CONCLUSIONS. In this cohort of patients surgically treated for HNC, BID worsens posttreatment before returning to pretreatment (baseline) levels at 9 months posttreatment. However, 4 in 10 patients will experience a protracted course with persistent posttreatment body image concerns, and half will experience a significant increase in BIS scores relative to pretreatment levels.

Advances in cancer prevention, screening and early detection, diagnosis, treatment, and care delivery have yielded significant improvements in survival for cancer patients and decreases in cancer-related treatment toxicity. However, these advances have been accompanied by an increasing financial burden to patient and their caregivers. Financial toxicity, which draws a parallel between the side effects of cancer treatment and the side effects of undue financial distress, is increasingly recognized as being common and a source of significant morbidity and decreased health-related quality of life for head and neck cancer (HNC) patients and their caregivers. This chapter will (1) define financial toxicity following cancer treatment, (2) estimate its incidence in HNC patients, (3) highlight key risk factors in HNC patients, (4) describe various tools for its measurement, (5) discuss the impact of financial toxicity on HNC patients, and (6) review resources on financial toxicity for patients and caregivers. Knowledge gaps and research opportunities to improve the delivery of patient-centered cancer care that is attentive to the complex issue of financial toxicity will be explored at the conclusion.

PURPOSE: This longitudinal study explores causal attributions in newly diagnosed head/neck cancer (HNC) patients and their caregivers. METHODS: Perceptions of causal attributions and associated level of responsibility regarding each patient’s HNC diagnosis at baseline (n=72 dyads) were described and then tested as predictors of depressive symptoms, cancer worry, and perceived support six months later. RESULTS: When causes were reported, tobacco and alcohol use topped the list of both patients and caregivers. Three-quarters of dyads agreed about perceptions of the patients’ responsibility in causing their HNC. Some dyad-level patterns of causal attribution were associated with patients’ and caregivers’ cancer worry (p

BACKGROUND: The number of colorectal cancer (CRC) survivors in the US is increasing and factors associated with CRC surveillance require attention. PURPOSE: This study examined the role of personal, provider, and practice-level factors on CRC survivor care surveillance experiences and outcomes. METHODS: A telephone survey, informed by the Chronic Care Model, was conducted over a one-year period with 150 CRC survivors identified via the South Carolina Central Cancer Registry. Participants were ages ≥21 years and diagnosed with stages I-III CRC within 1.5 years of study enrollment. Data were analyzed using descriptive statistics and logistic regression. Adherence was defined as receipt of surveillance colonoscopy at 13 months post-CRC surgery, as recommended by evidence-based guidelines. RESULTS: The majority of participants were male (55%) and white (86%), with a median age of 65 years (range 25–89). Almost half (43%) had attained a high school degree or less. Cancer stage was fairly evenly distributed, and 58% had received treatment by surgery alone (provider-level factor). Few participants (56%) received a survivorship care plan (practice-level factor), and adherence to surveillance colonoscopy was lowest (36%) among participants with more than one comorbidity (personal-level factor). Logistic regression models showed that the only significant effect of personal, provider, or practice-level factors on CRC surveillance adherence was related to type of health insurance coverage (Private/HMO vs. Other; p=0.04). DISCUSSION: This is one of the first studies to evaluate CRC surveillance in a socioeconomically diverse sample. The only associations found among the examined factors and adherence were related to type of health insurance coverage. Participants with private/HMO health insurance were significantly more likely than participants with “other” health insurance coverage types (i.e., none, Medicare without supplement, Medicare with supplement) to be adherent to the 13-month colonoscopy. Therefore, future education strategies and patient navigation interventions could focus on identifying and overcoming multi-level barriers to CRC surveillance services.

ObjectiveWe aimed to explore multiple perspectives regarding barriers to and facilitators of advance care planning (ACP) among African Americans to identify similarities or differences that might have clinical implications.MethodQualitative study with health disparities experts (n = 5), community members (n = 9), and seriously ill African American patients and caregivers (n = 11). Using template analysis, interviews were coded to identify intrapersonal, interpersonal, and systems-level themes in accordance with a social ecological framework.ResultParticipants identified seven primary factors that influence ACP for African Americans: religion and spirituality; trust and mistrust; family relationships and experiences; patient-clinician relationships; prognostic communication, care preferences, and preparation and control. These influences echo those described in the existing literature; however, our data highlight consistent differences by group in the degree to which these factors positively or negatively affect ACP. Expert participants reinforced common themes from the literature, for example, that African Americans were not interested in prognostic information because of mistrust and religion. Seriously ill patients were more likely to express trust in their clinicians and to desire prognostic communication; they and community members expressed a desire to prepare for and control the end of life. Religious belief did not appear to negate these desires.Significance of resultsThe literature on ACP in African Americans may not accurately reflect the experience of seriously ill African Americans. What are commonly understood as barriers to ACP may in fact not be. We propose reframing stereotypical barriers to ACP, such as religion and spirituality, or family, as cultural assets that should be engaged to enhance ACP. Although further research can inform best practices for engaging African American patients in ACP, findings suggest that respectful, rapport-building communication may facilitate ACP. Clinicians are encouraged to engage in early ACP using respectful and rapport building communication practices, including open-ended questions.

OBJECTIVE: To promote patient-centered oncology care through an in-depth analysis of the patient experience of body image disturbance (BID) following surgery for head and neck cancer (HNC). STUDY DESIGN: Qualitative methods approach using semistructured key informant interviews. SETTING: Academic medical center. SUBJECTS AND METHODS: Participants with surgically treated HNC underwent semistructured key informant interviews and completed a sociodemographic survey. Recorded interviews were transcribed, coded, and analyzed using template analysis to inform creation of a conceptual model. RESULTS: Twenty-two participants with surgically treated HNC were included, of whom 16 had advanced stage disease and 15 underwent free tissue transfer. Five key themes emerged characterizing the participants’ lived experiences with BID following HNC treatment: personal dissatisfaction with appearance, other-oriented appearance concerns, appearance concealment, distress with functional impairments, and social avoidance. The participant’s perceived BID severity was modified by preoperative patient expectations, social support, and positive rational acceptance. These 5 key themes and 3 experiential modifiers form the basis of a novel, patient-centered conceptual model for understanding BID in HNC survivors. CONCLUSION: A patient-centered approach to HNC care reveals that dissatisfaction with appearance, other-oriented appearance concerns, appearance concealment, distress with functional impairments, and social avoidance are key conceptual domains characterizing HNC-related BID. Recognition of these psychosocial dimensions of BID in HNC patients can inform development of HNC-specific BID patient-reported outcome measures to facilitate quantitative assessment of BID as well as the development of novel preventative and therapeutic strategies for those at risk for, or suffering from, BID.

Introduction This brief report examined prior cessation attempts, attitudes toward nicotine replacement therapy (NRT), and interests in cessation interventions among head and neck cancer (HNC) patients with a recent smoking history (current smokers and recent quitters). Methods Forty-two HNC patients scheduled for major surgery who reported current or recent (quit Results Patients attempted to quit smoking on average 3.2 times in the past 12 months. Most patients (65.8%) reported that NRT products help people quit, with 42.5% reporting ever using cessation aids/services. Most patients (81.8%) reported interest in a smoking cessation program. Current smokers and recent quitters reported similar cessation attempts, attitudes toward NRT, and interest in smoking cessation interventions. Discussion Cancer center-based smoking cessation interventions are needed for current smokers and recent quitters maintaining cessation.

This prospective cohort pilot study sought to characterize the short-term temporal trajectory of, and risk factors for, body image disturbance (BID) in patients with head and neck cancer (HNC). Most patients were male (35/56), had oral cavity cancer (33/56), and underwent microvascular reconstruction (37/56). Using the Body Image Scale (BIS), a validated patient-reported outcome measure of BID, the prevalence of BID (BIS ≥10) increased from 11% preoperatively to 25% at 1 month postoperatively and 27% at 3 months posttreatment (P < .001 and P = .0014 relative to baseline, respectively). Risk factors for BID included female sex (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.3-19.8), pT 3 to 4 tumors (OR, 8.9; 95% CI, 2.0-63.7), and more severe baseline shame and stigma (OR, 1.06; 95% CI, 1.01-1.13), depression (OR, 1.25; 95% CI, 1.06-1.51), and social isolation (OR, 1.21; 95% CI, 1.01-1.49). The prevalence and severity of BID increase immediately posttreatment. Demographic, oncologic, and psychosocial characteristics identify high-risk patients for targeted interventions.

Rationale: Implementation of evidence-based best practices is influenced by a variety of contextual factors. It is vital to characterize such factors to maintain high-quality care. Patients in the ...

OBJECTIVE. To synthesize published literature describing the severity of body image disturbance (BID) in patients with head and neck cancer (HNC) over time, its psychosocial and functional associations, and treatment strategies as assessed by patient-reported outcome measures (PROMs). DATA SOURCE. PubMed/MEDLINE, Scopus, PsycINFO, Web of Science, and Google Scholar. REVIEW METHODS. A systematic review of the English-language literature was performed to identify studies of BID in patients with HNC using psychometrically validated PROMs to assess (1) severity of BID over time, (2) psychosocial and functional associations, and (3) management strategies. RESULTS. A total of 17 studies met inclusion criteria. BID was assessed via 10 different PROMs, none of which were HNC-specific measures of BID. Two of 2 longitudinal studies (100%) reported that BID improved from pretreatment to posttreatment, and 2 of 3 longitudinal studies (67%) showed that the severity of BID decreased over time as survivors got further out from treatment. Seven of 17 studies (41%) described negative functional and psychosocial associations with BID, although study methodology limited conclusions about cause and effect. None of the studies assessing interventions to manage BID (0/2, 0%) demonstrated an improvement in BID relative to control. CONCLUSION. BID in patients with HNC has negative functional and psychosocial associations and lacks evidence-based treatment. Research is limited by the lack of an HNC-specific BID PROM. Further research should address knowledge gaps related to the lack of an HNC-specific BID PROM, longitudinal course of BID in patients with HNC, confusion with regards to risk factors and outcomes, and lack of prevention and treatment strategies.

PURPOSE: The objectives of this study were to test the acceptability and feasibility of a survivorship needs assessment planning (SNAP) tool for head and neck cancer (HNC) survivors and caregivers, evaluate short-term changes in psychosocial outcomes after completing the SNAP session and develop strategies for system refinement. METHODS: We used a prospective one-group design and mixed methods with HNC survivors and caregivers (N=25 dyads). Participants completed baseline and 6-week surveys before and after completing a SNAP clinic visit to assess psychosocial outcomes and acceptability. Intervention sessions included tablet-based needs assessments driving tailored care plans. Dyads’ open-ended feedback and clinician interviews (N=12) evaluated acceptability and feasibility. RESULTS: SNAP data collection time burden and technology challenges were minimal and care plans included messages (M=19), educational materials (M=13) and referrals (M=4.5; 86% Behavioral Medicine, 77% Nutrition, 65% Physical Therapy). Participants reported high satisfaction with the session and care plan, highlighting the key strengths of pulling complex medical information together and the focus on caregiver well-being, with multiple suggestions to facilitate clinic workflow. Depression and unmet needs decreased and survivorship knowledge increased significantly in survivors and caregivers (p

Objectives Ventilator dependent respiratory failure (VDRF) patients are seriously ill and often transferred between ICUs. Our objective was to obtain multi-stakeholder insights into the experiences of families during inter-ICU transfer. Methods We conducted a qualitative study using semi-structured interviews with family members of VDRF patients as well as clinicians that have received or transferred VDRF patients to our hospital. Interviews were transcribed and template analysis was used to identify themes within/across stakeholder groups. Results Patient, family, clinician and systems-level factors were identified as key themes during inter-ICU transfer. The main findings highlight that family members were rarely engaged in the decision to transfer as well as a lack of standardized communication between clinicians during care transitions. Family members were reassured with the care after transfer in spite of practical and financial challenges. Clinicians acknowledged the lack of a systematic approach for meeting the needs of families and suggested various resources. Conclusions This is one of the first qualitative studies to gather a multi-stakeholder perspective and identify problems faced by families during inter-ICU transfer of VDRF patients. Practice implications Our results provide a starting point for the development of family-centered support interventions which will need to be tested in future studies.

Objectives/Hypothesis Head and neck squamous cell carcinoma (HNSCC) patients who smoke are at risk for poor treatment outcomes. This study evaluated symptom burden and clinical, sociodemographic, and psychosocial factors associated with smoking in surgical patients to identify potential targets for supportive care services. Study Design Cross-sectional survey. Methods Individuals with HNSCC of the oral cavity, larynx, or pharynx were recruited from two cancer centers and completed questionnaires assessing smoking status (never, former, current/recent), patient characteristics, and symptoms before surgery. Results Of the 103 patients enrolled, 73% were male, 52% were stage IV, 41% reported current/recent smoking, and 37% reported former smoking. Current/recent smokers were less likely than former smokers to have adequate finances (53% vs. 89%, P = .001) and be married/partnered (55% vs. 79%, P = .03). Current/recent smokers were also more likely than both former and never smokers to be unemployed (49% vs. 40% and 13%, respectively, all P = .02) and lack health insurance (17% vs. 5% and 13%, respectively, all P ≤.04). Fatalistic beliefs (P = .03) and lower religiosity (P =.04) were more common in current/recent than never smokers. In models adjusted for sociodemographic/clinical factors, current/recent smokers reported more problems than former and never smokers with swallowing, speech, and cough (P ≤.04). Current/recent smokers also reported more problems than never smokers with social contact, feeling ill, and weight loss (P ≤ .02). Conclusions HNSCC patients reporting current/recent smoking before surgery have high-risk clinical and sociodemographic features that may predispose them to poor postoperative outcomes. Unique symptoms in HNSCC smokers may be useful targets for patient-centered clinical monitoring and intervention. Level of Evidence 4 Laryngoscope, 2016