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Summary Background Seasonal influenza vaccine (SIV) uptake among US adults aged 65 years or older remains suboptimal and stagnant. Further, there is growing concern around racial and ethnic disparities in uptake. We aimed to assess racial and ethnic disparities in overall SIV and in high-dose vaccine (HDV) uptake among Medicare beneficiaries during the 2015–16 influenza season and sought to identify possible mediators for observed disparities. Methods We did a historical record-linkage cohort study using Medicare (a US national health insurance programme) databases, which included all older adults (≥65 years) enrolled in Medicare during the study period (July 1, 2015, to June 30, 2016). We excluded beneficiaries of Medicare Part C (managed care offered by private companies), and residents of long-term care facilities. The primary outcome was SIV receipt during the study period, classified into receipt of HDV and standard-dose vaccines (SDVs, representing all other SIVs). SIV uptake probabilities were estimated using competing-risk survival analysis methods. Mediation analyses were done to investigate potential mediators of the association between race and ethnicity and uptake. Findings During the study period, of 26·5 million beneficiaries in the study cohort, 47·4% received a SIV, 52·7% of whom received HDV. Compared with white beneficiaries (49·4%), Hispanic (29·1%), Black (32·6%), and Asian (47·6%) beneficiaries were less likely to be vaccinated and, when vaccinated, were less likely to receive HDV (37·8% for Hispanic people, 41·1% for Black people, and 40·3% for Asian people, compared with 53·8% of white people who received HDV). Among those vaccinated, after accounting for region, income, chronic conditions, and health-care use, minority groups were 26–32% less likely to receive HDV, relative to white people (odds ratio [OR] 0·68 [95% CI 0·68–0·69] for Black people; OR 0·71 [0·71–0·72] for Asian people; and OR 0·74 [0·73–0·74] for Hispanic people). Interpretation Substantial racial and ethnic disparities in SIV uptake among Medicare beneficiaries aged 65 years or older are evident. New legislative, fiscal, and educational strategies are urgently needed to address these inequities. Funding Sanofi Pasteur.

Background: Asymptomatic patients with atrial fibrillation (AF) pose challenges to diagnosis. Early diagnosis can reduce morbidity and mortality. Systematic screening in primary care may result in early intervention. Objectives: We sought to examine the implementation outcomes of a systematic, team-based quality improvement education (QIE) intervention for AF screening in primary care during the COVID-19 pandemic. Methods: QIE intervention was implemented in academic-based (n=4) and community-based (n=2) practices to address COVID-19 challenges. Surveys administered by site identified existing approaches and provider teams developed screening protocol based on targeted education, deploying a mobile ECG device (Kardiamobile™). Patient charts were reviewed (Dec 2020 - May 2021) to determine eligibility, i.e., patients aged 65–74 (with prior stroke/TIA or two other risk factors) or aged ≥75 (with one other risk factor) without prior AF. Patient EHR data were examined for demographic/clinical data and screening outcome. Provider interviews (n=12) and validation from representative patients (n=2) accounted for sustainability of outcomes. Results: A total of 1,221 patients were evaluated for AF risk, with 408 eligible for screening. Of these, 277 (68%) were female and CHA 2 DS 2 -VASc varied -score=3 (45%); score=4 (24%); score=5+ (31%). Patients (n=7; 2%) who screened positive for AF were referred or started on anticoagulation, like other primary care studies. Figure 1 shows how systematic screening was re-imagined and implemented Satisfaction and engagement increased among providers and patients - attributed, in part, to benefits of team-based planning and targeted education. Conclusion: An AF screening program was adapted to improve patient care despite COVID-19 related challenges. A QIE toolkit was launched to assist primary care practices with implementing streamlined, sustainable, and patient-engaging strategies to reduce stroke.

Introduction Despite improved understanding of the risks of influenza and better vaccines for older patients, influenza vaccination rates remain subpar, including in high-risk groups such as older adults, and demonstrate significant racial and ethnic disparities. Methods This study considers demographic, clinical, and geographic correlates of influenza vaccination among Medicare Fee-for-Service (FFS) beneficiaries in 2015–2016 and maps the data on a geographic information system (GIS) at the zip code level. Results Analyses confirm that only half of the senior beneficiaries evidenced a claim for receiving an inactivated influenza vaccine (IIV), with significant disparities observed among black, Hispanic, rural, and poorer beneficiaries. More extensive disparities were observed for the high-dose (HD) vaccine, with its added protection for older populations and confirmed economic benefit. Most white beneficiaries received HD; no non-white subgroup did so. Mapping of the data confirmed subpar vaccination in vulnerable populations with wide variations at the zip code level. Conclusion Urgent and targeted efforts are needed to equitably increase IIV rates, thus protecting the most vulnerable populations from the negative health impact of influenza as well as the tax-paying public from the Medicare costs from failing to do so. Electronic supplementary material The online version of this article (10.1007/s12325-020-01324-y) contains supplementary material, which is available to authorized users.

Background: Hypertension (HTN) is the most potent cardiovascular disease worldwide and a major public health concern in the U.S. Although Social Determinants of Health (SDoH) are associated with HTN, it is unclear whether these indicators are routinely captured in the primary care setting. We sought to examine the prevalence of any HTN and its association with captured SDoH for new patients (pts) presenting to an urban community primary care clinic for 2019 and 2020. Methods and Results: We identified a cohort-based, cross-sectional sample of 2,577 new pts ≥ 18 years of age in a community clinic in Atlanta, GA, between Jan 2019 and Dec 2020. Electronic health records were reviewed to determine the rate of selected SDoH indicators (financial strain, transportation, medical transportation, and food insecurity) captured at any time and the presenting blood pressure for all new patients. Blood pressure was classified as follows: normal, systolic BP/diastolic BP (SBP/DBP) ≤120/80 mmHg, elevated SBP 120-129mmHg and DBP Conclusion: Routine assessments of SDoH for African American pts presenting for new pt visits are suboptimal in the primary care setting. However, financial strain and food insecurity are significantly associated with stage 1 and 2 HTN in this population. Standardization of intake processes is essential to increase the collection of SDoH indicators and may ultimately guide secondary prevention strategies for HTN interventions.

112 Background: Prostate cancer (PC) screening guidelines differ in recommended age at screening and varying emphasis on risk factors (e.g., race, family history), leading to lack of clarity among healthcare providers (HCPs). Research has highlighted a higher risk for Black patients, and the importance for at-risk patients to undergo screening at an earlier age and receive appropriate follow-up. A system-based Quality Improvement Education (QIE) intervention was developed to increase screening and referrals for PC especially among higher risk subgroups. The QIE aimed to increase awareness of the burden and consequences of racial disparities while mobilizing a team-focused approach. Methods: QIE intervention was deployed at 3 practice sites that provide community-based primary care services to Black populations (72% Black patients). The sites differed in patient capacity, staff, challenges faced, and pre-intervention screening practices. Practice assessments were completed pre-intervention by site representatives (n = 3) and individual baseline surveys were filled out by HCPs (n = 24). The 12-week intervention included educational materials from Prostate Health Education Network (PHEN) and deployment of an updated screening protocol within each clinic to raise PC awareness to staff and patients. Post-intervention evaluation was based on qualitative interviews (n = 5) and feedback from the QIE coaches. Patient data from electronic health records (EHR) on PC screening and referrals was collected post-initiative and divided a posteriori into 3 sub-groups, pre, during and post-intervention (n = 6662). Results: QIE led to increased awareness of barriers to access faced by patients from diverse communities. The QIE also led to increased awareness among team members regarding the need for screening at-risk groups at an earlier age and the importance of follow-up with patients. Online education materials made available to HCPs raised patient awareness. Table highlights an increase in PC screening during the intervention, but limited sustainability post-intervention. Interviewees reported increases in patient education, referrals and follow-up action. Conclusions: Increase in percentage of patients screened during the intervention phase was potentially due to added attention during the initiative, while limited sustainability post-intervention might be due to the brief intervention period, reliance on retrospective data and inability to fully leverage EHR data. Based on this project’s learnings, similar initiatives should seek organizational support for data analytics and process documentation to ensure consistent data standards and overall success.[Table: see text]

120 Background: According to the American Cancer Society, prostate cancer is the second most common cause of cancer death in Black men. Between 2014–2018, the prostate cancer incidence rate among Black men was 73% higher than that in white men. Approximately 6,040 Black men are projected to die of prostate cancer in 2022. Many disparities contribute to prostate cancer mortality in Black men, including missed genitourinary (GU) referral appointments. Research has shown that patient navigation can be an effective, evidence-based intervention to improve health outcomes. Improving completion of GU referrals through navigation may advance equity in continuity of care. Methods: An algorithm was integrated into electronic medical records (EMR) to identify Black men eligible for prostate cancer screening in primary care practices of a health system North Carolina. An assessment was adapted for community-facing navigators using existing literature on patient navigation practices. Navigators were trained on culturally responsive prostate cancer education and a plan-do-study-act quality improvement (QI) model. A notice to navigate alert was implemented into the navigation workflow to alert staff of Black men with prostate-specific antigen (PSA) levels of 10 or greater. Results: At baseline, perceived barriers to entering the continuum of care were related to the social determinants of health, as noted by navigators. During the intervention, navigators were alerted of 25 Black men 49 – 74 years of age with PSA levels of 10 and above. Initial PSA results ranged from 10.55 to 101.61 (ng/ml). Twenty-three of them agreed to accept navigation services and were scheduled appointments to follow up with GU. Of the completed appointments, 15 were diagnosed with prostate cancer. Post-intervention, navigators noted barriers to completing GU appointments included health literacy/education, work schedules, transportation, lack of responsiveness to female navigators, the digital divide, social support, and denial of prognosis. Conclusions: Providing Black men with navigation services allowed common barriers to be eliminated, increased GU appointment completion, identified men with prostate cancer at earlier stages, and assisted with earlier initiation of treatment by conducting a warm handoff to clinical navigators. Future studies may seek to understand implementation of the EMR algorithm across all primary care practices, integrating the use of navigators as an intervention, and supplementing culturally—tailored patient education materials to include a digital component.

Highlights • A thoughtful vaccination campaign is critical to ensure COVID-19 vaccine uptake. • Social, behavioral, and communication science is essential to such a campaign. • Meaningful messages from trusted spokespersons can crowd out misinformation. • COVID-19 vaccines must be available at familiar, convenient locations that feel safe. • Transparent decisions and public oversight mechanisms strengthen vaccine confidence., Given the social and economic upheavals caused by the COVID-19 pandemic, political leaders, health officials, and members of the public are eager for solutions. One of the most promising, if they can be successfully developed, is vaccines. While the technological development of such countermeasures is currently underway, a key social gap remains. Past experience in routine and crisis contexts demonstrates that uptake of vaccines is more complicated than simply making the technology available. Vaccine uptake, and especially the widespread acceptance of vaccines, is a social endeavor that requires consideration of human factors. To provide a starting place for this critical component of a future COVID-19 vaccination campaign in the United States, the 23-person Working Group on Readying Populations for COVID-19 Vaccines was formed. One outcome of this group is a synthesis of the major challenges and opportunities associated with a future COVID-19 vaccination campaign and empirically-informed recommendations to advance public understanding of, access to, and acceptance of vaccines that protect against SARS-CoV-2. While not inclusive of all possible steps than could or should be done to facilitate COVID-19 vaccination, the working group believes that the recommendations provided are essential for a successful vaccination program.

Background: Study populations in clinical research must reflect US changing demographics, especially with the rise of precision medicine. However, racial and ethnic minority groups (REMGs) have low rates of participation in cancer clinical trials. Methods: Criteria were developed to identify cancer centers able to accrue a higher than average proportion of REMGs into clinical trials. Comprehensive interviews were conducted with leaders of these cancer centers to identify operational strategies contributing to enhanced accrual of REMGs. Results: Eight US cancer centers reported a REMG accrual rate range in cancer research between 10 and 50% in a 12-month reporting period and met other criteria for inclusion. Fourteen leaders participated in this assessment. Key findings were that centers: had a metric collection and reporting approach; routinely captured race and ethnicity data within databases accessible to research staff; had operational standards to support access and inclusion; developed practices to facilitate sustained patient participation during clinical trials; had strategies to decrease recruitment time and optimize clinical study design; and identified low-resource strategies for REMG accrual. There was also a clear commitment to establish processes that support the patient's provider as the key influencer of patient recruitment into clinical trials. Conclusion: We have identified operational practices that facilitate increased inclusion of REMGs in cancer trials. In order to establish a sustainable cancer center inclusion research strategy, it is valuable to include an operational framework that is informed by leading US cancer centers of excellence. Keywords: Cancer research, Clinical trials, Operations, Disparities, Diversity and inclusion, Racial and ethnic minority groups

140 Background: Black men are disparately affected by prostate cancer (PC). They are more likely to develop PC and at an earlier age when the disease is more advanced at diagnosis. As a result, Black men are two to three times more likely to die from PC than white men. Given these disparities, experts increasingly promote screening for PC in Black men at a younger age. Methods: To inform implementation of a quality improvement education (QIE) project in three primary care practices in Maryland, a zip code analysis of the prevalence of PC was performed. Maryland practices were selected due to higher rates of PC in regions of the state and significant Black populations (Table). The QIE initiative started with a baseline practice assessment survey (including information on panel size, patient demographics, PC screening/treatment approaches, and barriers) and an analysis of current PC screening rates. Health system leaders and champions from the practice sites received training on patient-centered conversations with high-risk Black patients and concerning QIE planning. The champions developed rapid cycle improvement plans to implement increased screening using a patient-oriented online educational platform ( Dr. PSA ), as well as posters, and placards for patient education. Results: The overall national prevalence of PC in Medicare Fee-for-Service Program beneficiaries in 2018 was 2.65%. For Black beneficiaries the overall prevalence was 2.89%. Prevalence for beneficiaries in specific Maryland zip codes are detailed in Table. *Data not available; Source: NMQF Prostate Cancer Index Baseline practice assessment data revealed that patient panels ranged from 4,000 to 58,163 patients, with Black patients accounting for 50% or more of two of the practices and 25 to 50% of the third practice. Barriers to screening identified include financial issues, insurance restrictions, and lack of knowledge about PC and screening. Baseline screening rates are approximately 75%. Conclusions: Zip code prevalence analysis and baseline practice assessment data confirmed the relevance of implementing a QIE initiative in the three selected sites. Through a mixed-methods evaluation study, practice staff knowledge, attitudes, and self-reported practices will be assessed pre- and post-QIE initiative to assess impact of the initiative and determine opportunities for further improvement in PC screening practices.[Table: see text]

Background Seasonal influenza vaccine (SIV) uptake in the United States remains suboptimal, requiring new and innovative strategies. Objective To evaluate the impact of a behavioral peer comparison (PC) intervention on SIV uptake in community pharmacies across the United States. Methods A cluster randomized study was conducted across a national network of Walmart community pharmacies (> 4500 sites) during the 2019-2020 influenza season. The clusters consisted of 416 markets, each containing an average of 11 pharmacies. All pharmacies in a market were randomly assigned to either no intervention or the PC intervention, a software-delivered communication informing on-site staff, including pharmacists and pharmacy technicians, of their pharmacy’s weekly performance, measured as SIV doses administered, compared with that of peer pharmacies within their market. The outcome was the pharmacy-level cumulative SIV doses administered during the intervention period (September 1, 2019,-February 29, 2020). Linear regression models were used to estimate the PC impact, with multiway cluster-robust SEs estimated by market and state. Results A total of 4589 pharmacies were enrolled in the study, with 2297 (50.1%) randomized to the control group and 2292 (49.9%) randomized to the PC intervention group. Overall, compared with the control pharmacies, the PC pharmacies administered 3.7% (95% CI –0.3% to 7.9%) additional SIV doses. Among large-format pharmacies, the PC pharmacies administered 4.1% (95% CI 0.1%–8.3%) additional SIV doses compared with the controls. Historically low-performing large-format PC pharmacies administered 6.1% (95% CI 0.5%–11.9%) additional SIV doses compared with the controls. No statistically significant treatment effects were observed among small-format pharmacies. Conclusion Our findings demonstrate that PCs can improve SIV uptake among large-format community pharmacies, with historically low-performing pharmacies potentially exhibiting the greatest relative impact. Wide-scale implementation of PCs in community pharmacies may help to further improve SIV uptake in these settings.

Despite overwhelming burdens of disease, health care access in most developing countries is extremely low. As governments work toward achieving universal health coverage, evidence on appropriate interventions to expand access in rural populations is critical for informing policies. Using a combination of population and health system data, we evaluated the impact of two pilot fee exemption interventions in a rural area of Madagascar. We found that fewer than one-third of people in need of health care accessed treatment when point-of-service fees were in place. However, when fee exemptions were introduced for targeted medicines and services, the use of health care increased by 65 percent for all patients, 52 percent for children under age five, and over 25 percent for maternity consultations. These effects were sustained at an average direct cost of US$0.60 per patient. The pilot interventions can become a key element of universal health care in Madagascar with the support of external donors.

Evidence suggests that disparities in adult immunization (AI) rates are growing. Providers need adequate patient resources and information about successful interventions to help them engage in effective practices to reduce AI disparities. The primary purposes of this paper were to review and summarize the evidence base regarding interventions to reduce AI disparities and to scan for relevant resources that could support providers in their AI efforts to specifically target disparities. First, building on a literature review conducted by the U.S. Centers for Disease Control and Prevention, we searched the peer-reviewed literature to identify articles that either discussed interventions to reduce AI disparities or provided reasons and associations for disparities. We scanned the articles and conducted an internet search to identify tools and resources to support efforts to improve AI rates. We limited both searches to resources that addressed influenza, pneumococcal, hepatitis B, Tdap, and/or herpes zoster vaccinations. We found that most articles characterized AI disparities, but several discussed strategies for reducing AI disparities, including practice-based changes, communication and health literacy approaches, and partnering with community-based organizations. The resources we identified were largely fact sheets and handouts for patients and journal articles for providers. Most resources pertain to influenza vaccination and Spanish was the most prevalent language after English. More evaluation is needed to assess the health literacy levels of the materials. We conclude that additional research is needed to identify effective ways to reduce AI disparities and more resources are needed to support providers in their efforts. We recommend identifying best practices of high performers, further reviewing the appropriateness and usefulness of available resources, and prioritizing which gaps should be addressed.

The objective of this study is to test how the transfer of auditing knowledge, along with other variables, work together to impact the level of professional skepticism in auditors and answer the crucial question of how auditors' competencies and expertise jointly interact with the knowledge transfer process. The study attempts to test these components in an empirical model, decomposing them and showing how they affect skepticism by comparing how knowledge is transferred in experts as compared to novices. The results of this study show that the differences between the expert auditors and the novices strengthened support for the role of knowledge and expertise in improving skepticism in engagement planning. The results of our study illustrate that knowledge transfer plays an important role in enhancing auditor professional skepticism, thereby improving the accuracy of auditor judgments. Also, as suggested by Nelson (2009), expert knowledge, position, and judgment were significant factors in the planning of an audit engagement. However, trait effects (as captured by firm effects) were not significant in explaining auditors' judgments. These results are important in that they illustrate the significance of the role that knowledge transfer functions in facilitating auditors' exercise of appropriate professional skepticism in audit engagement planning. Explores how auditors' interact with the knowledge transfer process.Illustrates how knowledge transfer improves the accuracy of auditor judgments.Highlights the significance of knowledge transfer in audit engagement planning.Uses an empirical model to test how skepticism is utilized in experts vs novices.

Objective Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents. Methods This narrative review included articles from PubMed that were: 1) original research; 2) discussed near misses or adverse events in the ambulatory setting; 3) relevant to US health care; and 4) published between 2002 and 2013. After full text review, 38 studies were searched for information on near misses and associated factors. Additionally, we used expert opinion and current inpatient near miss registries to inform registry development. Results Studies included a variety of safety issues including diagnostic errors, treatment or management-related errors, communication errors, environmental/structural hazards, and health information technology (health IT)-related concerns. The registry, based on the results of the review, updates previous work by including specific sections for errors associated with diagnosis, communication, and environment structure and incorporates specific questions about the role of health information technology. Conclusions Through use of this registry or future registries that incorporate newly identified categories, near misses in the ambulatory setting can be accurately captured, and that information can be used to improve patient safety.

PURPOSE: Participation of racial and ethnic minority groups (REMGs) in cancer trials is disproportionately low despite a high prevalence of certain cancers in REMG populations. We aimed to identify notable practices used by leading US cancer centers that facilitate REMG participation in cancer trials. METHODS: The National Minority Quality Forum and Sustainable Healthy Communities Diverse Cancer Communities Working Group developed criteria by which to identify eligible US cancer centers—REMGs comprise 10% or more of the catchment area; a 10% to 50% yearly accrual rate of REMGs in cancer trials; and the presence of formal community outreach and diversity enrollment programs. Cancer center leaders were interviewed to ascertain notable practices that facilitate REMG accrual in clinical trials. RESULTS: Eight cancer centers that met the Communities Working Group criteria were invited to participate in in-depth interviews. Notable strategies for increased REMG accrual to cancer trials were reported across five broad themes: commitment and center leadership, investigator training and mentoring, community engagement, patient engagement, and operational practices. Specific notable practices included increased engagement of health care professionals, the presence of formal processes for obtaining REMG patient/caregiver input on research projects, and engagement of community groups to drive REMG participation. Centers also reported an increase in the allocation of resources to improving health disparities and increased dedication of research staff to REMG engagement. CONCLUSION: We have identified notable practices that facilitate increased participation of REMGs in cancer trials. Wide implementation of such strategies across cancer centers is essential to ensure that all populations benefit from advances in an era of increasingly personalized treatment of cancer.

Disparities in access to cancer care and treatment outcomes among racial, ethnic and underserved populations have been observed for decades. Despite a plethora of national and local initiatives aimed at addressing these disparities, progress to date has been limited. Guided by the domains of the cancer care continuum (CCC) established by the IOM/NASEM [1] the Diverse Cancer Communities Working Group [2] (CWG) will deliver a framework with domains, processes and activities which when disseminated and implemented in the US, will contribute in an impactful way to addressing cancer care disparities. To achieve our goal, we utilized methodology similar to that used to identify best practices in recruiting diverse patients into cancer clinical trials.[3] We conducted an environmental scan to identify strategies and associated experts who successfully provided community and/or patient-centric, IOM defined domain standards in our population of interest. The environmental scan was conducted between March and September 2018, resulting in the identification of 84 unique experts and 44 unique patient organizations. The identified experts had documented processes and best practices along the six CCC domains as follows: Prevention & Risk Reduction (29%); Screening (30%); Diagnosis (11%); Treatment (8%); Survivorship (18%); and End-of-Life (5%). Of the 84 participants, 26% are experts in all six domains, 36% are experts in multiple domains, and 14% are also experts in Patient Navigator Research Programs. Drawing from our environmental scan, the CWG engaged the experts and advocates to develop the foundation for a theoretical underpinning of an evidence-based, practical continuum of care framework. Highest cross-cancer-continuum areas of impact included 1) patient navigation which addresses barriers to enable patients to progress successfully along the cancer continuum of care, 2) excellence in community engagement, a necessary mandate to build trust in among minority and underserved populations, and 3) implementation of health care system changes based on real-world examples. Additionally, experts focused on opportunities to close gaps between the CCC domains with specific emphasis on screening, diagnosis, treatment, and survivorship, with the understanding that health care system change is often effectively sustained by long-term policy implementation that ultimately increases access, utilization and standardization across the continuum. This adapted framework is intended to guide researchers, health care leaders and policy leaders to promote health equity in cancer outcomes. References: [1] Institute of Medicine 2013. Delivering High-Quality Cancer Care; Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. https://doi.org/10.17226/18359; [2] URL: http://shcllc.info/cancer-working-group/ [3] URL: http://ascopubs.org/doi/full/10.1200/JOP.18.00638 Citation Format: Jeanne M. Regnante, Karen Winkfield, MD, PhD, Ellen Sonet, JD, MBA, Evelyn Gonzalez, Karen M. Freund, MD, Simon Craddock Lee, PhD, Scarlett Lin Gomez, PhD, MPH, Nina Bickell, MD, Lynette Bonar, PhD, Michelle Vichnin, MD, Nicole Richie, PhD, Richardae Araojo, PharmD, Andrea Ferris, MBA, Thomas Farrington, Linda Fleisher, PhD, MPH, Carolyn Fang, PhD, Laura Lee Hall, PhD, Renee Nicolas, Shyrea Thompson, Marilyn Metcalf, PhD, Patti Fine Jewell, PhD, Marianne Gandee, Anna Forte, PhD, Elizabeth Franklin. PhD, Patti Doykos, PhD. Securing the cancer continuum of care model for racially and ethnically diverse and medically underserved populations [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D080.

Racial and ethnic minority groups have low rates of inclusion in cancer clinical trials (CCTs). For example, African American patients comprise 5% of patients enrolled in CCTs that support US Food and Drug Administration approval of new drugs but represent 13.3% of the general US population. Though cancer is the leading cause of death for Asian Americans, only 3% of CCTs is composed of Asian American participants. With the promise and rise of precision medicine, it is critical that study populations in clinical research reflect the changing US demographics. Expanding access to health data and analytics empower stakeholders to better understand and advocate for equitable research and treatment access in cancer. Research question: To what extent does the current US CCT site placement for non-small cell lung cancer (NCSLC) and small cell lung cancer (SCLC) reflect the reality of lung cancer patient prevalence and demographics in the US? Methods: Researchers used the following two primary data sources: (1) Medicare Fee-for-Service (FFS) patient-level claims data from 2016, including the following data elements: prevalence, co-morbidities, hospital encounters, and costs for patients with ICD-10 codes for NCSLC and SCLC, by demographic (age, gender, race, and ethnicity). Locations were designated as high (greater than 0.87%) or low (less than 0.87%) prevalence, based on national average prevalence. (2) CCT placement data was sourced from 2018 Clinical Trials.gov to determine ongoing NCLSC and SCLC studies where there are US study sites. Data were mapped on the Lung Cancer Index™, a National Minority Quality Forum (NMQF) geographic information system (GIS) with an interactive data warehouse and data visualization system, including geomapping. Preliminary data conclusions: 1) Of the 2812 interventional CCTs, the study team mapped 495 therapeutic, interventional, currently enrolling CCTs (after excluding trials for behavioral interventions and palliative care). 2) Of the 10015 zip codes mapped, 58.8% of those were designated as zones of high prevalence (HP) of lung cancer. Of the 5888 HP zip codes, only 10.5% had NSCLC trials and 5.6% percent had SCLC trials. 3) When analyzed by counties, of the 59% of counties with high prevalence of African American patients, only 3% and 1% of counties had more than 10 NSCLC trials and 10 SCLC trials respectively. Similarly, of the 24% of counties with high prevalence of Asian American lung cancer patients, only 3% and 1% of counties had more than 10 NSCLC and 10 SCLC trials respectively. Implications: While additional analyses are ongoing, preliminary findings suggest that there is a major disconnect between US lung CCT placement and where patients live. The advent of precision medicine creates urgency to improve CCT enrollment of racial and ethnic minority groups, for equitable benefit of resulting innovation and access to optimal treatment. Lung cancer prevalence, including by population demographics, at the zip code and county level can be a critical guide to CCT site placement. Citation Format: Upal Basu Roy, Liou Xu, Laura Lee Hall, Gary Puckrein, Andrea Ferris, Jeanne Regnante. Geographic relationship between lung cancer clinical trial sites and patient prevalence and demographics in the Medicare Fee-for-service program [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D081.

We commend Riddle et al. (1) for reviewing the potential and challenges of big data in modern health care, given its transformational power in predicting and improving care and outcomes. It is important, however, to recognize additional and evolving data sources as well as the equitable application of big data analytics. The meeting report focuses on three major sources of big data: the electronic medical record, national surveys and registries, and clinical trial databases. There …

164 Background: Kentucky is the epicenter of smoking and lung cancer in the U.S.: over half the population is a current or former smoker (second only to WV); and it has the highest annual lung cancer incidence—89.6 per 100,000 population—according to the most recent CDC data. While offering a significant, double-digit death benefit due to early recognition and improved therapies, LDCT lung cancer screening of at-risk individuals remains extremely low. Helping primary care practices identify their at-risk patients, promote reduced tobacco use, and refer for screening is critical. Methods: In this pilot, family practice and internal medicine practices, residency programs, and federally qualified health centers (FQHCs) were recruited in rural regions of Eastern Kentucky with populations at highest risk. The Sustainable Healthy Communities Quality Improvement Education (SHC-QIE) model—which engages multidisciplinary practice leaders, rapid cycle improvement or a PDSA approach to QI, geoanalytics, and community engagement support—was implemented to promote better screening while enhancing clinician satisfaction. Results: Each practice significantly improved their identification of smokers and patients qualifying for lung cancer screening in the Medicare program as well as screening referrals by nearly 2-fold. For example, in one FQHC, accurate reporting of tobacco history data in the medical record increased from 34.6% to 56.9%. Another example showed referrals for LDCTs increased from 230 in 2017 to 412 in 2018, with a 71% increase over baseline. While survey data from the participating clinics conceded challenges in implementing a QI initiative, significant satisfaction with the initiative, ongoing plans for activities building on the program, and community engagement were found as well. Pre-, post-survey data also revealed significant improvement in screening, tobacco counseling, and LDCT referral. Conclusions: In spite of EMR barriers, significant increases in smoking history taking, counseling for tobacco cessation, and referral for lung cancer screening was achieved over the course of 9 months.

Background: Racial and ethnic minority groups (REMGs) have low rates of inclusion in cancer trials. With the rise of precision medicine, it is critical that study populations in clinical research reflect the changing US demographics. Methods: Criteria were developed to identify cancer centers able to accrue a higher than average proportion of REMGs into clinical trials. Comprehensive interviews were conducted with leaders of identified cancer centers to ascertain operational strategies contributing to enhanced accrual of REMGs. Results: Eight representative centers reported a REMG accrual rate range in cancer research between 10-50% in a 12-month reporting period and met other criteria for inclusion, and 14 leaders participated in this assessment. Key findings were that centers: had a metric collection and reporting approach; routinely captured race and ethnicity data within databases accessible to research staff; had operational standards to support access and inclusion; developed practices to facilitate sustained patient participation during clinical trials; had strategies to decrease recruitment time and optimize clinical study design; and identified low-resource strategies for improving accrual. There was also a commitment to establish processes that support the patient’s provider as the key influencer of patient recruitment into clinical trials. Conclusion: Conduct of cancer research requires coordination of an operational framework governed by metrics in order to achieve high accrual of diverse populations in clinical trials. Leading US cancer centers have established key Operational Excellence practices and other notable practices which are critical for optimizing sustained inclusion of diverse populations in cancer clinical research. Citation Format: Jeanne M. Regnante, Nicole A. Richie, Lola Fashoyin-Aje, Laura Lee Hall, Quita Highsmith, J'Aimee A. Louis, Kenneth Turner, Spencer C. Hoover, Simon Craddock Lee, Erin L. Williams, Homer Adams, Coleman Obasaju, Ify Sargeant, Madeline Geday, Marianne Gandee, Rayneisha Watson, Moon S. Chen. US cancer centers of excellence coordination of operational strategies contribute to enhanced accrual of racial and ethnic minorities in clinical trials [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-012.

Chronic pain is a prevalent chronic condition with significant burden and economic impact in the United States. Chronic pain is particularly abundant in primary care, with an estimated 52% of chronic pain patients obtaining care from primary care physicians (PCPs). However, PCPs often lack adequate training and have limited time and resources to effectively manage chronic pain. Chronic pain management is complex in nature because of high co-occurrence of psychiatric disorders and other medical comorbidities in patients. This article describes a quality improvement initiative conducted by the American College of Physicians (ACP), in collaboration with the Kentucky ACP Chapter, and the Center for Health Services and Outcomes Research at the Johns Hopkins Bloomberg School of Public Health, to enhance chronic pain management in 8 primary care practices participating in Accountable Care Organizations in Kentucky, with a goal of enhancing the screening, diagnosis, and treatment of patients with chronic pain.

Sudden cardiac arrest (SCA) is the most common cause of death in the United States. Despite national guidelines, patients at risk for SCA often fail to receive evidence-based therapies. Racial and ethnic minorities and women are at particularly high risk for undertreatment. To address the persistent challenges in improving the quality of care for SCA, the Duke Center for the Prevention of Sudden Cardiac Death at the Duke Clinical Research Institute (Durham, NC) reconvened the Sudden Cardiac Arrest Thought Leadership Alliance. Experts from clinical cardiology, cardiac electrophysiology, health policy and economics, the US Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Health Care Research and Quality, and device and pharmaceutical manufacturers discussed the development of SCA educational tools for patients and providers, mechanisms of implementing successful tools to help providers identify patients in their practice at risk for SCA, disparities in SCA prevention, and performance measures related to SCA care. This article summarizes the discussions held at this meeting.

This report reviews the rationale for the American College of Cardiology’s Coalition to Reduce Racial and Ethnic Disparities in Cardiovascular Disease Outcomes (credo) and the tools that will be made available to cardiologists and others treating cardiovascular disease (CVD) to better meet the needs of their diverse patient populations. Even as the patient population with CVD grows increasingly diverse in terms of race, ethnicity, age, and sex, many cardiologists and other health care providers are unaware of the negative influence of disparate care on CVD outcomes and do not have the tools needed to improve care and outcomes for patients from different demographic and socioeconomic backgrounds. Reviewed published reports assessed the need for redressing CVD disparities and the evidence concerning interventions that can assist cardiology care providers in improving care and outcomes for diverse CVD patient populations. Evidence points to the effectiveness of performance measure-based quality improvement, provider cultural competency training, team-based care, and patient education as strategies to promote the elimination of disparate CVD care and in turn might lead to better outcomes. credo has launched several initiatives built on these evidence-based principles and will be expanding these tools along with research. credo will provide the CVD treatment community with greater awareness of disparities and tools to help close the gap in care and outcomes for all patient subpopulations.

e18643Background: By 2050, racial and ethnic minorities (REMs) will constitute > 50% of the US population. Despite a high prevalence of certain cancers in REM populations, < 10% REMs diagnosed with...

Evidence-based practices represent an extremely important advance in the mental health system, and NAMI continues its support of efforts to develop and implement these interventions. Moving forward, the authors envision consumers and family members playing a much greater role in developing and promulgating EBP. Individually and corporately, consumers can: facilitate research that will expedite equitable implementation of existing and new EBPs; play a significant role in providing services; play a lead role in promoting policies that support EBP implementation through the development and use of advocacy toolkits; influence provider adaptation of EBP through the broad development and testing of resources that urge EBP consumerism; and, advance through the monitoring of EBP. These consumer-led activities generally have been relegated to a lower level of importance in the current research, policy, and funding environment leading to poorly developed partnerships and "buy in" from the consumer community. It is important that the level of importance of these activities and the role of consumers and families be rethought. Further advancement of EBP will require implementing a three-track program of research, including a much greater focus on action research and the involvement of consumers as research and evaluation partners. This is the fastest and most effective way to achieve breakthrough results in practices for treating people with serious mental illnesses and to address the serious and growing problem of racial and cultural disparities and the disconnect that causes between those individuals and the means to their recovery. The hope of consumers and families rest on the ability to initiate action now.

This study offers a comprehensive examination of hypothetical concepts related to the behaviors, attitudes, outcomes, processes, experiences, manifestations and indicators connected with an organization's design, implementation and management of a coherent set of policies, procedures and systems to manage risks to its information assets. We introduce network analysis tools as a novel approach to highlight the construct relationships found in Information Security Management Systems (ISMS) literature published in the new millennium. Descriptive results display a significant expansion in the research of ISMS-related phenomena. Network analyses showcase the critical influence of certain constructs in scholarly publications as well as the most salient relationships among these constructs. Our study provides a gap analysis that also underscores those constructs that may require further exploration by this stream of research.

With an estimated investment of over 1 trillion dollars to date on information technology (IT) products and applications, one would hope that there exists a corresponding improvement in organizational performance and productivity. The level of IT usage has widely been accepted as an important indicator of IT success within organizations. This research synthesizes and validates the construct of IT usage using a meta-analysis. It accomplishes that by analyzing the empirical results of various studies over a period of time covering a broad scope of characteristics of both users and information systems (IS), and it examines the relation between these characteristics and the level of IT usage within organizations. In general, the results of this meta-analysis lead to the conclusion that there exists a strong and significant positive relation between the perception of ease of use and the perceived usefulness of an IT system to the actual amount of usage. Another factor that indicates a high level of IT usage is...

Recovery in severe mental illness is a powerful concept for consumers, invoking a journey through understanding and acceptance of illness and disability, along with hope for a quality life, self-empowerment, and responsibility. Although not widely recognized, the journey toward recovery is also important for family members of individuals with severe mental illnesses, who often serve in a care-giving or supportive role for their loved ones. From the family perspective, to make recovery a real possibility, several issues must be confronted. First, progress toward recovery must acknowledge and involve care-giving and supportive family members, recognizing their significant role in the lives of many individuals with severe mental illnesses as well as the journey of family members in understanding and accepting a severe mental illness in a loved one. Second, a real, recovery-oriented system implements treatments and supports shown to be effective. In this day and age, the gap between research findings and ordinary care condemns too many consumers and their families to outcomes far short of what is possible. This includes not only medications, psychotherapy, employment services, dual diagnosis services, housing and other supports for consumers, but also family education, shown to be effective by a large body of research. Third, a recovery-oriented system of care cannot afford to dance around the thorniest and most controversial issues in severe mental illnesses-such as individuals with the most intractable forms of illness or the relatively infrequent but very real situations in which either consumers or family members are assaultive or abusive. All of these elements are essential if recovery is to be more than a slogan, but rather a true goal in a system of care that respects consumers with these disorders and their care-giving family members.

It is well known that families represent a major resource for people with severe mental illnesses. As many as 75% of persons discharged from psychiatric hospitals return home to live with their families [1,2], and as many as 90% of persons with severe mental illnesses stay in regular contact with their families as frequently as every day [2,3]. Families, in general, and the National Alliance for the Mentally 111 (NAMI), specifically, have long had an interest in psychosocial rehabilitation, and a variety of recent changes in mental health practice portend an increase in that interest. Over the last several years, investments in the public mental health system have decreased [4]. Often these decreases in expenditures occur with the introduction of managed care into that system. Thus, for example, in Iowa, Colorado, and Massachusetts, approximately 30% of the total state Medicaid expenditure on mental health care dollars were lost to service delivery as all three states moved to Medicaid managedcare plans [4]. Because managed care generally decreases hospi

Using 414 business undergraduates at two universities in the US, a 28-item computer self-efficacy scale is validated and used to examine the relationship between (a) training and computer self-efficacy and (b) user attitudes and computer self-efficacy. Survey responses were collected both at the beginning and end of an introductory computer course. A principal factor analysis of the computer self-efficacy scale supported a conceptually meaningful four-factor solution with high alpha reliabilities. Results suggest that training significantly improved the computer self-efficacy of males and females in this study for all factors. Training programs seemed more effective for male and female respondents with positive attitudes toward computers. Training programs seemed less effective for respondents with negative attitudes toward computers. Implications of these findings are discussed and research opportunities described.

This article reports on the National Alliance for the Mentally III (NAMI) national report card to examine quality of care under managed care. The national report card will provide a summary of state policies underpinning the move of managed care into the public mental health system, and directly probe consumer and family member perceptions and experiences of managed care and the policies and practices of managed care organizations.

This paper presents the work done by the ACM ITiCSE, 2013 Conference Working Group (WG) on Cybersecurity, Women and Minorities: How to Succeed in the Career! The ITiCSE 2013 conference was held July 1-3, 2013, in Canterbury, United Kingdom. The overall goal of the WG was to conduct a preliminary investigation into the reasons behind the lack of women and minorities within the field of Cybersecurity. This is not just an issue of academic or research interest, but is important in ensuring that a greater number of women and minorities progress through a full career in Cybersecurity. There are currently no statistics available on the numbers of women and minorities either currently enrolled in or graduated from these programs. There is a need to explore the full range of factors that influence women and minority's decisions not to consider a career in Cybersecurity.

As part of a performance improvement continuing medical education activity on atrial fibrillation (afib), cardiologists and other health care providers solicited baseline surveys to ascertain patient attitudes about quality of life and provider communication and behaviors. Using selected questions from the ambulatory CAHPS survey and internally developed afib-specific questions, surveys were collected from 1,385 patients. The sample included more males (n=757) than females (n=574) and was majority white (n=1207) and 55 or older (n=1200). A subset of the survey containing 7 CAHPS items (α = .88) assessed the extent to which their doctor explained things clearly, listened carefully, spent enough time with them, and other indicators of quality care. Items were scored using a 4-point Likert scale and responses were analyzed using ANOVA with two independent variables (sex and race/ethnicity) and their interaction term. For analysis purposes, race/ethnicity was re-coded into 2 groups: white and non-white. The main effects of sex, race/ethnicity, and their interaction term were significant (F (3,1327) = 23.77, p. = .00; F (3,1327) = 10.74, p. = .00; F (3,1327) = 28.66, p. = .00, respectively). Results indicated non-white males were least satisfied with care (see attached graph). While the results are preliminary and need further validation, reduced satisfaction with care among non-white males is consistent with recent results from focus groups conducted by Griffith and colleagues at the University of Michigan School of Public Health. As the project continues, educational interventions for physicians will highlight this disparity and potential changes over time will be examined.

This report reviews the rationale for the American College of Cardiology's Coalition to Reduce Racial and Ethnic Disparities in Cardiovascular Disease Outcomes (credo) and the tools that will be made available to cardiologists and others treating cardiovascular disease (CVD) to better meet the needs of their diverse patient populations. Even as the patient population with CVD grows increasingly diverse in terms of race, ethnicity, age, and sex, many cardiologists and other health care providers are unaware of the negative influence of disparate care on CVD outcomes and do not have the tools needed to improve care and outcomes for patients from different demographic and socioeconomic backgrounds. Reviewed published reports assessed the need for redressing CVD disparities and the evidence concerning interventions that can assist cardiology care providers in improving care and outcomes for diverse CVD patient populations. Evidence points to the effectiveness of performance measure-based quality improvement, provider cultural competency training, team-based care, and patient education as strategies to promote the elimination of disparate CVD care and in turn might lead to better outcomes. credo has launched several initiatives built on these evidence-based principles and will be expanding these tools along with research. credo will provide the CVD treatment community with greater awareness of disparities and tools to help close the gap in care and outcomes for all patient subpopulations.

The first nationwide survey on managed care's impact shows widespread concern among consumers with severe mental illnesses and their families.

Research involves people. People participate in research. People may benefit from research-driven improvements in clinical practice. And people face social perceptions and policies that stem from research.

A detailed morphometric evaluation of the somata and organelles of regenerating hypoglossal motoneurons from the rat was conducted. The volume of the hypoglossal nucleus and various parameters used to appraise neuronal size were estimated from 50 microns sections. The subcellular composition of randomly selected neurons was quantified from 1 micron and ultrathin sections. The volume of neuronal nuclei, nucleoli, mitochondria and lysosomes as well as the surface area of intracellular membranes were determined. Seven to 30 days following axotomy the volume of the hypoglossal nucleus was significantly diminished, undoubtedly reflecting dendritic retraction (P less than 0.05). Concomitantly, all estimates of neuronal size indicated significant neuronal enlargement (P less than 0.05). Ultrastructural alterations were most prominent 7 days following nerve transection: nucleolar volume was significantly increased, rough endoplasmic reticulum surface area was reduced, and non-Golgi smooth membrane surface area increased (P less than 0.05). In general, other organelles resisted the influence of axotomy and all ultrastructural parameters returned to control levels 21 to 30 days following the nerve transection. Functional recovery was detected in all animals 21 and 30 days following axotomy. The measured responses of axotomized hypoglossal motoneurons are similar to those reported for retinal ganglion cells of the goldfish (WhitnallGrafstein, 1982, 1983), suggesting common metabolic events among these distinct neuronal populations following axonal transection.