A quantitative feedback intervention to reduce binge drinking in young adults.

OBJECTIVE: Existing binge drinking reduction interventions such as brief intervention and personalized normative feedback have shown modest impact. The purpose of this study was to evaluate the feasibility (recruitment and retention rates), acceptability, and preliminary efficacy testing of a short-term "know your numbers (KYN)" intervention on motivating young adults to reduce their engagement in binge drinking. METHOD: Young adults (N=94, mean age 21 years) with a history of binge drinking received a 4-week KYN intervention that included information about their U.S. Alcohol Use Disorders Test (USAUDIT) scores and the alcohol biomarker phosphatidylethanol (PEth) level in relationship to different risk levels of alcohol use. At baseline and 4-weeks, measures included USAUDIT scores, PEth levels, motivation (Alcohol Contemplation Ladder) and other drinking measures. Focus groups were conducted at 4-weeks for feedback on the KYN approach. RESULTS: The recruitment rate was 82.26% (retention rate 76.9%). At 4-weeks there was a 62% increase in contemplation scores (indicating higher motivation), a decrease in USADUIT scores with an increase in the percent of participants classified as low-risk drinkers. No differences were found between baseline and 4-week PEth levels or number of binge episodes. Focus group results revealed satisfaction with the KYN approach but the need to understand how PEth levels and USAUDIT scores corresponded to health consequences and alcohol use levels. CONCLUSIONS: Results from this pilot study support the acceptability and potential use of a KYN approach in helping young adults understand their drinking levels.

A multiple technology-based and individually-tailored Sit Less program for people with cardiovascular disease: A randomized controlled trial study protocol.

Sedentary behavior, a key modifiable risk factor for cardiovascular disease, is prevalent among cardiovascular disease patients. However, few interventions target sedentary behavior in this group. This paper describes the protocol of a parallel two-group randomized controlled trial for a novel multi-technology sedentary behavior reduction intervention for cardiovascular disease patients (registered at Clinicaltrial.gov, NCT05534256). The pilot trial (n = 70) will test a 12-week "Sit Less" program, based on Habit Formation theory. The 35 participants in the intervention group will receive an instructional goal-setting session, a Fitbit for movement prompts, a smart water bottle (HidrateSpark) to promote hydration and encourage restroom breaks, and weekly personalized text messages. A control group of 35 will receive the American Heart Association's "Answers by Heart" fact sheets. This trial will assess the feasibility and acceptability of implementing the "Sit Less" program with cardiovascular disease patients and the program's primary efficacy in changing sedentary behavior, measured by the activPAL activity tracker. Secondary outcomes include physical activity levels, cardiometabolic biomarkers, and patient-centered outcomes (i.e. sedentary behavior self-efficacy, habit strength, and fear of movement). This study leverages commonly used mobile and wearable technologies to address sedentary behavior in cardiovascular disease patients, a high-risk group. Its findings on the feasibility, acceptability and primary efficacy of the intervention hold promise for broad dissemination.

Small Patients but a Heavy Lift: Workload and Burnout of Advanced Practice Providers and Physicians in a Level IV Neonatal Intensive Care Unit.

OBJECTIVE: This study explored the association between workload and the level of burnout reported by clinicians in our neonatal intensive care unit (NICU). A qualitative analysis was used to identify specific factors that contributed to workload and modulated clinician workload in the NICU. STUDY DESIGN: We conducted a study utilizing postshift surveys to explore workload of 42 NICU advanced practice providers and physicians over a 6-month period. We used multinomial logistic regression models to determine associations between workload and burnout. We used a descriptive qualitative design with an inductive thematic analysis to analyze qualitative data. RESULTS: Clinicians reported feelings of burnout on nearly half of their shifts (44%), and higher levels of workload during a shift were associated with report of a burnout symptom. Our study identified 7 themes related to workload in the NICU. Two themes focused on contributors to workload, 3 themes focused on modulators of workload, and the final 2 themes represented mixed experiences of clinicians' workload. CONCLUSION: We found an association between burnout and increased workload. Clinicians in our study described common contributors to workload and actions to reduce workload. Decreasing workload and burnout along with improving clinician well-being requires a multifaceted approach on unit and systems levels.

The Social Ecology of Burnout: A framework for research on nurse practitioner burnout.

BACKGROUND: The U.S. health system is burdened by rising costs, workforce shortages, and unremitting burnout. Well-being interventions have emerged in response, yet data suggest that the work environment is the problem. Nurse practitioner (NP) burnout is associated with structural and relational factors in the work environment, practice autonomy, and hierarchical leadership. PURPOSE: We explore the unique social, cultural, and political environment in which NPs work through the lens of social ecology and present the Social Ecology of Burnout (SEB) framework. METHODS: We review current burnout frameworks in the context of the NP practice environment and discuss the SEB, specifically exploring psychological safety and its influence on burnout. FINDINGS: Psychological safety, work environment, and policy are presented within the SEB and solutions which empower NPs are considered. DISCUSSION: Our framework can serve as a guide for future nursing research, practice, and policy.

Using the Age-Friendly Environment Framework to Assess Advance Care Planning Factors Among Older Adults with Limited Income: A Cross-sectional, Descriptive Survey Study.

BACKGROUND AND OBJECTIVES: The World Health Organization created the Age-Friendly Environment (AFE) framework to design communities that support healthy aging and equitable decision-making. This framework's resource domains may account for disparately lower advance care planning (ACP) among older adults with limited incomes compared to those with high incomes. We aimed to describe and examine associations of AFE factors with ACP. RESEARCH DESIGN AND METHODS: We recruited and conducted cross-sectional surveys among older adults with limited incomes in seven community-based settings in Nashville, Tennessee. ACP and AFE item scales were dichotomized and analyzed with unadjusted phi correlation coefficients. RESULTS: Survey participants (N=100) included 59 women, 70 Black/African American, and 70 ≥60 years old. Most participants agreed that their community was age-friendly (≥58%) and varied in ACP participation (22-67%). Participants who perceived easy travel and service access and sufficient social isolation outreach were more likely to have had family or doctor quality-of-life discussions (phi=.22 to .29, p<.05). Having a healthcare decision-maker was positively associated with age-friendly travel, housing, and meet-up places (phi=.20-.26, p<.05). DISCUSSION AND IMPLICATIONS: The AFE Framework is useful for exploring the environmental factors of ACP, but further research is warranted to identify specific and immediate resources to support successful ACP among populations with socioeconomic disadvantage.

Implicit and Explicit Weight Bias among Midwives: Variations Across Demographic Characteristics.

INTRODUCTION: Weight bias toward individuals with higher body weights is present in health care settings. However, there has been limited quantitative exploration into weight bias among perinatal care providers and its potential variations based on demographic characteristics. The aim of this study was to examine if the direction and extent of weight bias among midwives certified by the American Midwifery Certification Board (AMCB) varied across age, years since certification, body mass index (BMI), race, ethnicity, and US geographic region. METHODS: Through direct email listservs, postcard distribution, social media accounts, and professional networks, midwives were invited to complete an online survey of their implicit weight bias (using the Implicit Association Test) and their explicit weight bias using the Anti-Fat Attitudes Questionnaire (AFA), Fat Phobia Scale (FPS), and Preference for Thin People (PTP) measure. RESULTS: A total of 2106 midwives who identified as Black or White and resided in one of 4 US geographic regions participated in the survey. Midwives with a lower BMI expressed higher levels of implicit (P <.01) and explicit (P ≤.01) weight bias across all 4 measures except for the AFA Fear of Fat Subscale. Implicit weight bias levels also varied by age (P <.001) and years since certification (P <.001), with lower levels among younger midwives (vs older) and those with fewer years (vs more) since certification. Only age and BMI remained significant (P <.001) after adjusting for other demographic characteristics. Lower explicit weight bias levels were found among midwives who identified as Black (vs White) on 2 measures (FPS: adjusted ß = -0.07, P = .004; PTP: P = .01). DISCUSSION: This was the first quantitative study of how weight bias varies across demographic characteristics among a national sample of midwives. Further exploration is needed in more diverse samples. In addition, research to determine whether weight bias influences clinical decision-making and quality of care is warranted.

Weight Bias Among Certified Nurse-Midwives and Certified Midwives: Findings From a National Sample.

INTRODUCTION: Weight bias toward individuals with higher body weights permeates health care settings in the United States and has been associated with poor weight-related communication and quality of care as well as adverse health outcomes. However, there has been limited quantitative investigation into weight bias among perinatal care providers. Certified nurse-midwives (CNMs)/certified midwives (CMs) attend approximately 11% of all births in the United States. The aims of this study were to measure the direction and extent of weight bias among CNMs/CMs and compare their levels of weight bias to the US public and other health professionals. METHODS: Through direct postcard distribution, social media accounts, professional networks, and email listservs, American Midwifery Certification Board (AMCB)-certified midwives were solicited to complete an online survey of their implicit weight bias using the Implicit Association Test and their explicit weight bias using the Antifat Attitudes Questionnaire, Fat Phobia Scale, and Preference for Thin People measure. RESULTS: A total of 2257 midwives participated in the survey, yielding a completion rate of 17.7%. Participants were mostly White and female, with a median age of 46 years and 11 years since AMCB certification. More than 70% of midwives have some level of implicit weight bias, although to a lesser extent compared with previously published findings among the US public (P < .01) and other health professionals (P < .01). In a subsample comparison of female midwives to female physicians, implicit weight bias levels were similar (P > .05). Midwives also express explicit weight bias, but at lower levels than the US public and other health professionals (P < .05). DISCUSSION: This study provides the first quantitative research documenting weight bias among a national US sample of perinatal care providers. Findings can inform educational efforts to mitigate weight bias in the perinatal care setting and decrease harm.

Life-Stage and Contextual Factors of Advance Care Planning Among Older Adults With Limited Income.

Patient perspectives are essential to understand healthcare disparities such as low rates of advance care planning (ACP) among adults with limited income. We completed twenty semi-structured interviews using purposive and snowball sampling. Initial and final themes emerged from inductive inclusion of recurring codes and deductive application of the cumulative disadvantage theory. Four themes emerged: (1) structural, (2) life-stage, (3) social stressors and resources, and (4) individual stress responses and ACP readiness. ACP resources among participants included positive structural and social support and previous familial death experiences that were mitigated by stress avoidance and competing priorities. Structural resources and healthcare stressors should be addressed with policy and research to improve continuous healthcare participation and support early, comprehensive ACP.

A Brief Intervention in Primary Care to Improve Parents' Discipline Practices and Reach Other Caregivers.

Parents (N = 599) of 6-month-old to 10-year-old children were given a handbook intervention that educates about healthy discipline in a pediatric clinic serving low-income families in Nashville, Tennessee. A research assistant spent approximately 1 minute introducing the intervention. A total of 440 parents (73.4%) responded to a follow-up survey 2 to 4 months later. Most parents (88%) who completed the follow-up survey had read at least part of the handbook. Of parents who received the handbook, 63% reported that the handbook helped them discipline their children. Half of parents reported specific changes they made because of the handbook. The most frequently reported changes were more talking/explaining/communicating (25%), more redirecting (7.8%), more patience/listening (6.0%), less anger/yelling (10.8%), and less spanking (7.5%). 42% of parents reported that they shared the handbook with other caregivers, friends, relatives, and children. A brief clinic intervention improves parents' discipline practices and reaches other caregivers.

Endovascular Detection of Catheter-Thrombus Contact by Vacuum Excitation.

OBJECTIVE: The objective of this work is to introduce and demonstrate the effectiveness of a novel sensing modality for contact detection between an off-the-shelf aspiration catheter and a thrombus. METHODS: A custom robotic actuator with a pressure sensor was used to generate an oscillatory vacuum excitation and sense the pressure inside the extracorporeal portion of the catheter. Vacuum pressure profiles and robotic motion data were used to train a support vector machine (SVM) classification model to detect contact between the aspiration catheter tip and a mock thrombus. Validation consisted of benchtop accuracy verification, as well as user study comparison to the current standard of angiographic presentation. RESULTS: Benchtop accuracy of the sensing modality was shown to be 99.67%. The user study demonstrated statistically significant improvement in identifying catheter-thrombus contact compared to the current standard. The odds ratio of successful detection of clot contact was 2.86 (p = 0.03) when using the proposed sensory method compared to without it. CONCLUSION: The results of this work indicate that the proposed sensing modality can offer intraoperative feedback to interventionalists that can improve their ability to detect contact between the distal tip of a catheter and a thrombus. SIGNIFICANCE: By offering a relatively low-cost technology that affords off-the-shelf aspiration catheters as clot-detecting sensors, interventionalists can improve the first-pass effect of the mechanical thrombectomy procedure while reducing procedural times and mental burden.

Impact of Animal-Assisted Interaction on Anxiety in Children With Advanced Cancer and Their Caregivers.

Background: Pediatric patients with advanced cancer and their caregivers have unique psychosocial needs. Anxiety often worsens throughout treatment for both patients and parents, and, if undertreated, can cause suffering. Animal-assisted interaction (AAI) incorporates animals into patient care in a structured manner for the purpose of therapeutic benefit. Objective: To evaluate feasibility of incorporating AAI into patient care and to assess AAI effectiveness in decreasing patient and caregiver anxiety in pediatric patients with advanced cancer, defined by relapsed or refractory disease. Design: Randomized controlled study. Setting/Subjects: Participants were children (n = 19) and parents (n = 21) who were randomized to AAI group or usual care (UC) group. Measures: Participants completed weekly measures to assess anxiety, including the 20-question State-Trait Anxiety Inventory (STAI). Results: Our results demonstrated feasibility of the use of AAI in children with advanced cancer. While they did not reveal a significant difference in anxiety scores over the four sessions in either group, parents randomized to the AAI group had lower STAI State subscores at initial visit in comparison to the UC group. The difference in initial STAI State anxiety scores for caregivers may indicate a positive effect of AAI in reducing anxiety surrounding appointments through anticipation of seeing a therapy dog. Conclusion: Further research is needed to determine the effectiveness of AAI in pediatric patients with advanced cancer and their caregivers, but results are promising that participation in AAI may lessen caregiver anxiety. Clinical Trial Registration Number is: NCT03765099.

Longitudinal Pattern of Lymphedema and Fibrosis in Patients With Oral Cavity or Oropharyngeal Cancer: A Prospective Study.

PURPOSE: The study aimed to describe the prevalence, severity, and trajectory of internal lymphedema, external lymphedema, and fibrosis in patients with oral cavity or oropharyngeal (OCOP) cancer. METHODS AND MATERIALS: One hundred twenty patients with newly diagnosed OCOP cancer were enrolled in a prospective longitudinal study. Recruitment was conducted at a comprehensive medical center. Participants were assessed pretreatment; at end of treatment; and at 3, 6, 9, and 12 months post-cancer treatment. Validated clinician-reported measures and computed tomography were used to assess the study outcomes. RESULTS: Seventy-six patients who completed the 9- or 12-month assessments were included in this report. Examination of the external lymphedema and fibrosis trajectories revealed that the total severity score peaked between the end of treatment and 3 months posttreatment and then decreased gradually over time but did not return to baseline by 12 months posttreatment (P < .001). The longitudinal patterns of severity scores for patients treated with surgery only or with multimodality therapy were similar. Examination of the internal swelling trajectories revealed that all patients experienced a significant increase in sites with swelling immediately posttreatment. For patients treated with surgery only, swelling was minimal and returned to baseline by 9 to 12 months posttreatment. Patients receiving multimodal treatment experienced a gradual decrease in number of sites with swelling during the 12-month posttreatment period that remained significantly above baseline (P < .05). Computed tomography revealed different patterns of changes in prevertebral soft tissue and epiglottic thickness in the surgery-only and multimodality treatment groups during the 12-month posttreatment period. There were minimal changes in thickness in both regions in the surgery-only group. Patients with multimodal treatment had significant increases in thickness in both regions 3 months posttreatment that remained thicker at 12 months than at baseline (P < .001). CONCLUSIONS: Lymphedema and fibrosis are the common complications of OCOP cancer therapy. Routine assessment, monitoring, and timely treatment of lymphedema and fibrosis are critical.

Gender Differences in Pain Threshold, Unpleasantness, and Descending Pain Modulatory Activation Across the Adult Life Span: A Cross Sectional Study.

The neurobiological underpinnings of gender differences in pain perception, and how these differences may be modified by age, are incompletely understood, placing patients at risk of suboptimal pain management. Using functional magnetic resonance imaging, we examined brain responses in the descending pain modulatory system (DPMS, specifically, dorsolateral prefrontal cortex, anterior cingulate cortex, insula, hypothalamus, amygdala, and periaqueductal gray, during an evoked pain task. We investigated the interaction of age and gender in our sample of healthy adults (27 females, 32 males, 30-86 years) on DPMS response. In a perceptually matched thermal pain paradigm, we investigated pain unpleasantness and neural responses for 3 heat pain percepts: just noticeable pain, weak pain, and moderate pain (MP). Females reported just noticeable pain at a lower temperature, but reported less unpleasantness at weak pain and MP percepts, compared to males. There was a significant age-by-gender interaction during moderate pain in the right anterior cingulate cortex and bilateral insula, such that, males had a stronger positive relationship between DPMS response and age compared to females in these regions. Our results indicate that differences in DPMS responses may explain some gender differences in pain perception and that this effect may change across the adult lifespan. PERSPECTIVE: Gender differences in pain have been well-documented but the brain mechanisms for these differences are still unclear. This article describes potential differences in brain functioning during different levels of pain that could explain differences in pain responses between men and women across the adult lifespan.

Effects of a medication adherence app among medically underserved adults with chronic illness: a randomized controlled trial.

For individuals living with a chronic illness who require use of long-term medications, adherence is a vital aspect of successful symptom management and outcomes. This study investigated the effect of a smartphone app on adherence, self-efficacy, knowledge, and medication social support in a medically underserved adult population with various chronic illnesses. Participants were randomized to a group who used the app for one month or a control group provided with a printed medication list. Compared to the control group, participants receiving the intervention had significantly greater medication adherence (Cohen's d = -0.52, p = .014) and medication self-efficacy (Cohen's d = 0.43, p = .035). No significant effects were observed related to knowledge or social support. The findings suggest use of the app could positively impact chronic disease management in a medically underserved population in the United States.

Effect of a Medication Adherence Mobile Phone App on Medically Underserved Patients with Chronic Illness: Preliminary Efficacy Study.

BACKGROUND: Medication adherence is vital in the treatment of patients with chronic illness who require long-term medication therapies to maintain optimal health. Medication adherence, a complex and widespread problem, has been difficult to solve. Additionally, lower-income, medically underserved communities have been found to have higher rates of inadequate adherence to oral medications. Even so, this population has been underrepresented in studies using mobile medication adherence app interventions. Federally qualified health centers provide care for medically underserved populations, defined as communities and populations where there is a demonstrable unmet need for health services. These centers have been reporting an increase in a more complex chronic disease population. Including medically underserved individuals in mobile health studies provides opportunities to support this disproportionately affected group, work toward reducing health disparities in access to health care, and understand barriers to mobile health uptake. OBJECTIVE: The aim of this preliminary efficacy study was to evaluate the effects and feasibility of a commercially available medication adherence app, Medisafe, in a medically underserved adult population with various chronic illnesses seeking care in a federally qualified health center. METHODS: Participants in this single-arm pre-post intervention preliminary efficacy study (N=10) completed a baseline survey, used the app for 2 weeks, and completed an end-of-study survey. The primary outcome measures were medication adherence and medication self-efficacy. Feedback on the use of the app was also gathered. RESULTS: A statistically significant median increase of 8 points on the self-efficacy for adherence to medications scale was observed (P=.03, Cohen d=0.69). Though not significant, the adherence to refills and medications scale demonstrated a median change of 2.5 points in the direction of increased medication adherence (P=.21, Cohen d=0.41). Feedback about the app was positive. CONCLUSIONS: Use of the Medisafe app is a viable option to improve medication self-efficacy and medication adherence in medically underserved patients in an outpatient setting with a variety of chronic illnesses.

"I had no choice": A mixed-methods study on access to care for vaginal breech birth.

INTRODUCTION: Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth. METHODS: We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care. RESULTS: Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system. CONCLUSION: Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.

Trauma Patient Transitions From Critical Care: A Survey of U.S. Trauma Centers.

BACKGROUND: Transitions between clinical units are vulnerable periods for patients. A significant body of evidence describes the importance of structured transitions, but there is limited reporting of what happens. Describing transitions within a conceptual model will characterize the salient forces that interact during a patient transition and, perhaps, lead to improved outcomes. OBJECTIVE: To describe the processes and resources that trauma centers use to transition patients from critical care to nonintensive care units. METHODS: This cross-sectional study surveyed all Level I and II trauma centers listed in the American Trauma Society database from September 2020 to November 2020. Data were merged from the American Hospital Association 2018 Hospital Survey. RESULTS: A total of 567 surveys were distributed, of which 152 responded for a (27%) response rate. Results were organized in categories: capital input, organizational facets, employee behavior, employee terms/scope, and labor inputs. Resources and processes varied; the most important opportunities for transition improvement included: (1) handoff instruments were only reported at 36% (n = 27) of trauma centers, (2) mandatory resident education about transitions was only reported at 70% (n = 16) of trauma centers, and (3) only 6% (n = 4) of trauma centers reported electronic medical record applications that enact features to influence employee behavior. CONCLUSIONS: After years of focusing on transitions as a high-stake period, there remain many opportunities to develop resources and enact effective processes to address the variability in transition practice across trauma centers.

Caregiving self-efficacy and pain assessment by family caregivers of people living with dementia.

Like other older adults, people living with dementia (PLWD) experience pain, and the task of pain assessment often falls to family caregivers. In this study, we surveyed family caregivers of PLWD to determine the frequency with which they use different elements of pain assessment. We also determined correlations of family caregivers' characteristics (caregiving self-efficacy, relationship duration and type, mood, education level, and health literacy) with their use of the elements of pain assessment. Participants reported frequent use of many pain assessment elements. Statistically significant correlations were found between caregiving self-efficacy for obtaining respite and asking others about noticed behavior change (rho=.0.41, p=.007); and for responding to disruptive patient behaviors for multiple pain assessment elements including observing pain behaviors (rho=0.49, p<.001), asking others about noticed behavior change (rho=0.54, p<.001) and rechecking (rho=0.56, p<.001). Continued efforts are needed to describe pain assessments by family caregivers of PLWD.

Factors associated with quality of life among patients with a newly diagnosed oral cavity and oropharyngeal cancer.

PURPOSE: The objectives of this report were 1) to examine the quality of life (QOL) of patients with a newly diagnosed oral cavity or oropharyngeal (OCOP) cancer; and 2) to examine factors contributing to QOL before cancer treatment. METHODS: The sample included 115 participants with a new diagnosis of OCOP cancer. Participants completed the demographic form, oral cancer disease and treatment form, Hospital Anxiety and Depression Scale (HADS), Brief Health Literacy Screen (BHLS), and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Pearson correlations and linear regressions were used for data analysis. RESULTS: Participants had a median global health related QOL score of 66.7 (interquartile range, IQR = 50.0, 83.4) with median scores for the subdomains being generally high (all >80 of possible 100). Anxiety and depression were significantly inversely correlated with all areas of EORTC QOL (r = - 0.48 to -0.78, all p < .001). Multivariable associations were strongest with the physical functioning domain (R = 0.56, p < .001), with younger age, higher income, Stage I/II cancer (compared to Stage III/IV) significant contributors to the multiple correlation (beta > ± 0.20, p < .05). CONCLUSIONS: Health care providers should be attentive to OCOP cancer patients with older age, lower household income, advanced cancer stage, and presence of anxious and/or depressive symptoms for indicators of poor QOL. CLINICIANS SHOULD CONSIDER THE BENEFIT OF: initiating supportive interventions before cancer treatment among OCOP cancer patients with poor QOL.