Talking, not training, increased the accuracy of physicians' diagnosis of their patients' preferences for colon cancer screening.

OBJECTIVE: Identify if primary care physicians (PCPs) accurately understand patient preferences for colorectal cancer (CRC) testing, whether shared decision making (SDM) training improves understanding of patient preferences, and whether time spent discussing CRC testing improves understanding of patient preferences. METHODS: Secondary analysis of a trial comparing SDM training plus a reminder arm to a reminder alone arm. PCPs and their patients completed surveys after visits assessing whether they discussed CRC testing, patient testing preference, and time spent discussing CRC testing. We compared patient and PCP responses, calculating concordance between patient-physician dyads. Multilevel models tested for differences in preference concordance by arm or time discussing CRC. RESULTS: 382 PCP and patient survey dyads were identified. Most dyads agreed on whether CRC testing was discussed (82%). Only 52% of dyads agreed on the patient's preference. SDM training did not impact accuracy of PCPs preference diagnoses (55%v.48%,p = 0.22). PCPs were more likely to accurately diagnose patient's preferences when discussions occurred, regardless of length. CONCLUSION: Only half of PCPs accurately identified patient testing preferences. Training did not impact accuracy. Visits where CRC testing was discussed resulted in PCPs better understanding patient preferences. PRACTICE IMPLICATIONS: PCPs should take time to discuss testing and elicit patient preferences.

"I know my body better than anyone else": a qualitative study of perspectives of people with lived experience on antimicrobial treatment decisions for injection drug use-associated infections.

Background: People who inject drugs (PWID) are at risk for severe bacterial and fungal infections including skin and soft tissue infections, endocarditis, and osteomyelitis. PWID have high rates of self-directed discharge and are often not offered outpatient antimicrobial therapies, despite studies showing their efficacy and safety in PWID. This study fills a gap in knowledge of patient and community partner perspectives on treatment and discharge decision making for injection drug use (IDU)-associated infections. Methods: We conducted semi-structured interviews with patients (n = 10) hospitalized with IDU-associated infections and community partners (n = 6) in the Portland, Maine region. Community partners include peer support workers at syringe services programs (SSPs) and outreach specialists working with PWID. We transcribed and thematically analyzed interviews to explore perspectives on three domains: perspectives on long-term hospitalization, outpatient treatment options, and patient involvement in decision making. Results: Participants noted that stigma and inadequate pain management created poor hospitalization experiences that contributed to self-directed discharge. On the other hand, patients reported hospitalization provided opportunities to connect to substance use disorder (SUD) treatment and protect them from outside substance use triggers. Many patients expressed interest in outpatient antimicrobial treatment options conditional upon perceived efficacy of the treatment, perceived ability to complete treatment, and available resources and social support. Finally, both patients and community partners emphasized the importance of autonomy and inclusion in medical decision making. Although some participants acknowledged their SUD, withdrawal symptoms, or undertreated pain might interfere with decision making, they felt these medical conditions were not justification for health care professionals withholding treatment options. They recommended open communication to build trust and reduce harms. Conclusion: Patients with IDU-associated infections desire autonomy, respect, and patient-centered care from healthcare workers, and may self-discharge when needs or preferences are not met. Involving patients in treatment decisions and offering outpatient antimicrobial options may result in better outcomes. However, patient involvement in decision making may be complicated by many contextual factors unique to each patient, suggesting a need for shared decision making to meet the needs of hospitalized patients with IDU-associated infections.

'I feel like they're actually listening to me': a pilot study of a hospital discharge decision-making conversation guide for patients with injection drug use-associated infections.

Background: The prevalence of injection drug use (IDU)-associated infections and associated hospitalizations has been increasing for nearly two decades. Due to issues ranging from ongoing substance use to peripherally inserted central catheter safety, many clinicians find discharge decision-making challenging. Typically, clinicians advise patients to remain hospitalized for several weeks for intravenous antimicrobial treatment; however, some patients may desire other antimicrobial treatment options. A structured conversation guide, delivered by infectious disease physicians, intended to inform hospital discharge decisions has the potential to enhance patient participation in decisions. We developed a conversation guide in order to: (1) investigate its feasibility and acceptability and (2) examine experiences, outcomes, and lessons learned from use of the guide. Methods: We interviewed physicians after they each piloted the conversation guide with two patients. We interviewed patients immediately after the conversation and again 4-6 weeks later. Two analysts indexed transcriptions and used the framework method to identify and organize relevant information. We conducted retrospective chart review to corroborate and contextualize qualitative data. Results: Eight patients and four infectious disease physicians piloted the conversation guide. All patients (N = 8) completed antimicrobial treatment. Nearly all participants believed the conversation guide was important for incorporating patient values and preferences. Patients reported an increased sense of autonomy, but felt post-discharge needs could be better addressed. Physician participants identified the guide's long length and inclusion of pain management as areas for improvement. Conclusions: A novel conversation guide to inform hospital discharge decision-making for patients with IDU-associated infections was feasible, acceptable, and fostered the incorporation of patient preferences and values into decisions. While we identified areas for improvement, overall participants believed that this novel conversation guide helped to improve patient care and autonomy.

Decisions about adopting novel COVID-19 vaccines among White adults in a rural state, USA: A qualitative study.

PURPOSE: Many people, especially in rural areas of the United States, choose not to receive novel COVID-19 vaccinations despite public health recommendations. Understanding how people describe decisions to get vaccinated or not may help to address hesitancy. METHODS: We conducted semistructured interviews with 17 rural inhabitants of Maine, a sparsely populated state in the northeastern US, about COVID-19 vaccine decisions during the early rollout (March-May 2021). We used the framework method to compare responses, including between vaccine Adopters and Non-adopters. FINDINGS: Adopters framed COVID-19 as unequivocally dangerous, if not personally, then to other people. Describing their COVID concerns, Adopters emphasized disease morbidities. By contrast, Non-adopters never mentioned morbidities, referencing instead mortality risk, which they perceived as minimal. Instead of risks associated with the disease, Non-adopters emphasized risks associated with vaccination. Uncertainty about the vaccine development process, augmented by social media, bolstered concerns about the long-term unknown risks of vaccines. Vaccine Adopters ultimately described trusting the process, while Non-adopters expressed distrust. CONCLUSION: Many respondents framed their COVID vaccination decision by comparing the risks between the disease and the vaccine. Associating morbidity risks with COVID-19 diminishes the relevance of vaccine risks, whereas focusing on low perceived mortality risks heightens their relevance. Results could inform efforts to address COVID-19 vaccine hesitancy in the rural US and elsewhere. PATIENT OR PUBLIC CONTRIBUTION: Members of Maine rural communities were involved throughout the study. Leaders of community health groups provided feedback on the study design, were actively involved in recruitment, and reviewed findings after analysis. All data produced and used in this study were co-constructed through the participation of community members with lived experience.

Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED Study): a Physician Cluster Randomized Trial.

BACKGROUND: For adults aged 76-85, guidelines recommend individualizing decision-making about whether to continue colorectal cancer (CRC) testing. These conversations can be challenging as they need to consider a patient's CRC risk, life expectancy, and preferences. OBJECTIVE: To promote shared decision-making (SDM) for CRC testing decisions for older adults. DESIGN: Two-arm, multi-site cluster randomized trial, assigning physicians to Intervention and Comparator arms. Patients were surveyed shortly after the visit to assess outcomes. Analyses were intention-to-treat. PARTICIPANTS AND SETTING: Primary care physicians affiliated with 5 academic and community hospital networks and their patients aged 76-85 who were due for CRC testing and had a visit during the study period. INTERVENTIONS: Intervention arm physicians completed a 2-h online course in SDM communication skills and received an electronic reminder of patients eligible for CRC testing shortly before the visit. Comparator arm received reminders only. MAIN MEASURES: The primary outcome was patient-reported SDM Process score (range 0-4 with higher scores indicating more SDM); secondary outcomes included patient-reported discussion of CRC screening, knowledge, intention, and satisfaction with the visit. KEY RESULTS: Sixty-seven physicians (Intervention n=34 and Comparator n=33) enrolled. Patient participants (n=466) were on average 79 years old, 50% with excellent or very good self-rated overall health, and 66% had one or more prior colonoscopies. Patients in the Intervention arm had higher SDM Process scores (adjusted mean difference 0.36 (95%CI (0.08, 0.64), p=0.01) than in the Comparator arm. More patients in the Intervention arm reported discussing CRC screening during the visit (72% vs. 60%, p=0.03) and had higher intention to follow through with their preferred approach (58.0% vs. 47.1, p=0.03). Knowledge scores and visit satisfaction did not differ significantly between arms. CONCLUSION: Physician training plus reminders were effective in increasing SDM and frequency of CRC testing discussions in an age group where SDM is essential. TRIAL REGISTRATION: The trial is registered on clinicaltrials.gov (NCT03959696).

Getting patients back for routine colorectal cancer screening: Randomized controlled trial of a shared decision-making intervention.

Thousands of colonoscopies were canceled during the initial surge of the COVID-19 pandemic. As facilities resumed services, some patients were hesitant to reschedule. The purpose of this study was to determine whether a decision aid plus telephone coaching would increase colorectal cancer (CRC) screening and improve patient reports of shared decision making (SDM). A randomized controlled trial assigned adults aged 45-75 without prior history of CRC who had a colonoscopy canceled from March to May 2020 to intervention (n = 400) or usual care control (n = 400) arms. The intervention arm received three-page decision aid and call from decision coach from September 2020 through November 2020. Screening rates were collected at 6 months. A subset (n = 250) in each arm was surveyed 8 weeks after randomization to assess SDM (scores range 0-4, higher scores indicating more SDM), decisional conflict, and screening preference. The sample was on average, 60 years old, 53% female, 74% White, non-Hispanic, and 11% Spanish speaking. More intervention arm patients were screened within 6 months (35% intervention vs 23% control, p < 0.001). The intervention respondents reported higher SDM scores (mean difference 0.7 [0.4, 0.9], p < 0.001) and less decisional conflict than controls (-21% [-35%, -7%], p = 0.003). The majority in both arms preferred screening versus delaying (68% intervention vs. 65% control, p = 0.75). An SDM approach that offered alternatives and incorporated patients' preferences resulted in higher screening rates. Patients who are overdue for CRC screening may benefit from proactive outreach with SDM support.

Cross-sectional Survey Examining Patient Attitudes and Preferences for Rescheduling Screening Colonoscopies Canceled due to the COVID-19 Pandemic.

Background. Early in the COVID-19 pandemic colonoscopies for colorectal cancer (CRC) screening were canceled. Patient perceptions of the benefits and risks of routine screening relative to health concerns associated with the COVID-19 pandemic were unknown. Purpose. Assess patient anxiety, worry, and interest in CRC screening during the COVID-19 pandemic. Methods. A random sample of 200 patients aged 45 to 75 y with colonoscopy cancellation due to COVID-19 in March to May 2020 were surveyed. Anxiety, COVID-19 and CRC risk perceptions, COVID-19 and CRC worry, likelihood of following through with colonoscopy in the next month, and interest in alternatives to colonoscopy were assessed. Subsequent screening was tracked for 12 mo. Results. Respondents (N = 127/200, 63.5%) were on average 60 y old, female (59%), college educated (62% college degree or more), and White (91%). A substantial portion of patients (46%) stated they may not follow through with a colonoscopy in the next month. There was greater interest in stool-based testing than in delaying screening (48% v. 26%). Women, older patients, and patients indicating tolerance of uncertainty due to complexity reported they were less likely to follow through with colonoscopy in the next month. Greater interest in stool-based testing was related to lower perceptions of CRC risk. Greater interest in delaying screening was related to less worry about CRC and less tolerance of risk. Over 12 mo, 60% of participants completed screening. Patients who stated they were more likely to screen in the next month were more likely to complete CRC screening (P = 0.01). Conclusions. Respondents who had a colonoscopy canceled during the COVID-19 pandemic varied in interest in rescheduling the procedure. A shared decision-making approach may help patients address varying concerns and select the best approach to screening for them. Highlights: In the wake of the first wave of the COVID-19 pandemic, almost half of patients stated they were not likely to follow through with a colonoscopy in the short term, about half were interested in screening with a stool-based test, and only one-quarter were interested in delaying screening until next year.Patients who perceived themselves at higher risk of colorectal cancer were less interested in stool-based testing, and patients who were more worried about colorectal cancer were less interested in delaying screening.A shared decision-making approach may be necessary to tailor screening discussions for patients during subsequent waves of the pandemic, other occasions where resources are limited and patient preferences vary, or where patients hold conflicting views of screening.

Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections.

Background: Patients with injection drug use (IDU)-associated infections traditionally experience prolonged hospitalizations, which often result in negative experiences and bad outcomes. Harm reduction approaches that value patient autonomy and shared decision-making regarding outpatient treatment options may improve outcomes. We sought to identify health care professionals (HCPs) perspectives on the barriers to offering four different options to hospitalized people who use drugs (PWUD): long-term hospitalization, oral antibiotics, long-acting antibiotics at an infusion center, and outpatient parenteral antibiotics. Methods: We recruited HCPs (n = 19) from a single tertiary care center in Portland, Maine. We interviewed HCPs involved with discharge decision-making and other HCPs involved in the specialized care of PWUD. Semi-structured interviews elicited lead HCP values, preferences, and concerns about presenting outpatient antimicrobial treatment options to PWUD, while support HCPs provided contextual information. We used the iterative categorization approach to code and thematically analyze transcripts. Results: HCPs were willing to present outpatient treatment options for patients with IDU-associated infections, yet several factors contributed to reluctance. First, insufficient resources, such as transportation, may make these options impractical. However, HCPs may be unaware of existing community resources or viable treatment options. They also may believe the hospital protects patients, and that discharging patients into the community exposes them to structural harms. Some HCPs are concerned that patients with substance use disorder will not make 'good' decisions regarding outpatient antimicrobial options. Finally, there is uncertainty about how responsibility for offering outpatient treatment is shared across changing care teams. Conclusion: HCPs perceive many barriers to offering outpatient care for people with IDU-associated infections, but with appropriate interventions to address their concerns, may be open to considering more options. This study provides important insights and contextual information that can help inform specific harm reduction interventions aimed at improving care of people with IDU-associated infections.

Association of Vitamin D Prescribing and Clinical Outcomes in Adults Hospitalized with COVID-19.

It is unclear whether vitamin D benefits inpatients with COVID-19. Objective: To examine the relationship between vitamin D and COVID-19 outcomes. Design: Cohort study. Setting: National COVID Cohort Collaborative (N3C) database. Patients: 158,835 patients with confirmed COVID-19 and a sub-cohort with severe disease (n = 81,381) hospitalized between 1 January 2020 and 31 July 2021. Methods: We identified vitamin D prescribing using codes for vitamin D and its derivatives. We created a sub-cohort defined as having severe disease as those who required mechanical ventilation or extracorporeal membrane oxygenation (ECMO), had hospitalization >5 days, or hospitalization ending in death or hospice. Using logistic regression, we adjusted for age, sex, race, BMI, Charlson Comorbidity Index, and urban/rural residence, time period, and study site. Outcomes of interest were death or transfer to hospice, longer length of stay, and mechanical ventilation/ECMO. Results: Patients treated with vitamin D were older, had more comorbidities, and higher BMI compared with patients who did not receive vitamin D. Vitamin D treatment was associated with an increased odds of death or referral for hospice (adjusted odds ratio (AOR) 1.10: 95% CI 1.05−1.14), hospital stay >5 days (AOR 1.78: 95% CI 1.74−1.83), and increased odds of mechanical ventilation/ECMO (AOR 1.49: 95% CI 1.44−1.55). In the sub-cohort of severe COVID-19, vitamin D decreased the odds of death or hospice (AOR 0.90, 95% CI 0.86−0.94), but increased the odds of hospital stay longer >5 days (AOR 2.03, 95% CI 1.87−2.21) and mechanical ventilation/ECMO (AOR 1.16, 95% CI 1.12−1.21). Limitations: Our findings could reflect more aggressive treatment due to higher severity. Conclusion: Vitamin D treatment was associated with greater odds of extended hospitalization, mechanical ventilation/ECMO, and death or hospice referral.

The impact of the COVID-19 pandemic on people who inject drugs accessing harm reduction services in an rural American state.

BACKGROUND: The impact of public health policies during the COVID-19 pandemic on people who inject drugs (PWID) has varied across regions. In other countries, recent research has shown that PWID access to harm reduction services, despite rapid adaptations, has been negatively impacted. Our study describes these impacts in a rural state. METHODS: We conducted semi-structured interviews with PWID, community partners, and healthcare providers in the rural state of Maine (USA). We explored how changes made during the pandemic impacted access to harm reduction services, including basic services (i.e., shelter), syringe service programs, safe drug supply, low barrier treatment, and peer support. Interviews were analyzed using the framework method to apply Penchansky's model of access, with Saurman's modification, which includes six dimensions of access-accessibility, availability, acceptability, affordability, accommodation, awareness. RESULTS: We interviewed thirty-six stakeholders (N = 9 community partners, N = 9 healthcare providers, N = 18 PWID). Policies such as mobile outreach expansion, mail delivery of equipment, and relaxed telemedicine regulations facilitated accessibility to syringe service programs and low barrier buprenorphine treatment. Public health policies, such as social distancing and screening policies, reduced contact, which subsequently reduced acceptability and awareness of many services. Elimination of the one-for-one needle exchange in some areas increased, acceptability (i.e., perception of service), and affordability for PWID. However, some areas actually began enforcing a one-for-one needle exchange policy, which reduced affordability, acceptability, and awareness of services. CONCLUSIONS: Changes resulting from the COVID-19 pandemic have impacted all dimensions of access to harm reduction services among PWID. While some barriers to harm reduction services were unavoidable during the pandemic, we found that specific policy decisions mitigated service barriers, while other policies exacerbated them. Relaxing needle exchange policies were particularly helpful in facilitating access to harm reduction services by giving community organizations flexibility to adapt to the evolving needs of PWID. These results can inform policies and service delivery to optimally mitigate the negative impacts on PWID during, and beyond, the pandemic.

Understanding the Role of Misinformation in COVID-19 Vaccine Hesitancy in a Rural State.

Objective: to identify factors associated with COVID19 vaccine hesitancy, including sources of information among residents of Maine. Methods: 148 study participants, recruited through community partners and primary care offices in Maine, completed an anonymous 15 item online survey. Recruitment and data collection occurred from May to September, 2021. Hesitancy was determined through a single question, "Will you get one of the COVID vaccines when it is offered to you?" Results: vaccine hesitant respondents were younger than not hesitant respondents (p = 0.01). Hesitant individuals were significantly more likely to report concerns regarding the speed of COVID-19 vaccine production, vaccine efficacy, and potential vaccine side effects (p < 0.05 for each). Hesitant individuals were also significantly more likely to have discussed vaccination with their primary physician (p = 0.04). Conclusions: overall, hesitant individuals are more likely to be younger and had less trust in information from government sources, but they sought input from primary care. They were also more concerned about efficacy, side effects, and the rapid development of COVID-19 vaccines. Primary care physicians are in key positions to address these concerns due to contact with individuals who need accurate information.

Prescription opioid policies and associations with opioid overdose and related adverse effects.

BACKGROUND: United States (US) policies to mitigate the opioid epidemic focus on reducing access to prescription opioids to prevent overdoses. We examined the impact of state policies in Vermont (July 2017) and Maine (July 2016) on opioid overdoses and opioid-related adverse effects. METHODS: Study population included patients 15 years and older in all-payer claims of Vermont (N = 597,683; Jan.2016-Dec.2018) and Maine (N = 1,370,960; Oct.2015-Dec.2017). We used interrupted time series analyses to assess the impact of opioid prescribing policies on monthly opioid overdose rate and opioid-related adverse effects rate. We used the International Classification of Disease-10-CM to identify overdoses (T40.0 × 1-T40.4 × 4, T40.601-T40.604, T40.691-T40.694) and adverse effects (T40.0 × 5, T40.2 × 5-T40.4 × 5, T40.605, T40.695). RESULTS: Immediately after the policy, the level of Vermont's opioid overdose rate increased by 34% (95% confidence interval, CI: 1.09, 1.65) while the level of opioid-related adverse effects rate decreased by 29% (95% CI: 0.58, 0.87). In Maine, there was no level change in opioid overdose rate, but the slope of the adverse effects rate after the policy decreased by 3.5% (95% CI: 0.94, 0.99). These results varied within age and rurality subgroups in both states. CONCLUSION: While the decrease in rate of adverse effects following the policy changes is promising, the increase in Vermont's opioid overdose rate may suggest there is an association between policy implementation and short-term risk to public health.

Influence of Opioid Prescription Policy on Overdoses and Related Adverse Effects in a Primary Care Population.

BACKGROUND: In response to the opioid epidemic, many states have enacted policies limiting opioid prescriptions. There is a paucity of evidence of the impact of opioid prescribing interventions in primary care populations, including whether unintended consequences arise from limiting the availability of prescribed opioids. OBJECTIVE: Our aim was to compare changes in opioid overdose and related adverse effects rate among primary care patients following the implementation of state-level prescribing policies. DESIGN: A cohort of primary care patients within an interrupted time series model. PARTICIPANTS: Electronic medical record data for 62,776 adult (18+ years) primary care patients from a major medical center in Vermont from January 1, 2016, to June 30, 2018. INTERVENTIONS: State-level opioid prescription policy changes limiting dose and duration. MAIN MEASURES: Changes in (1) opioid overdose rate and (2) opioid-related adverse effects rate per 100,000 person-months following the July 1, 2017, prescription policy change. KEY RESULTS: Among primary care patients, there was no change in opioid overdose rate following implementation of the prescribing policy (incidence rate ratio; IRR: 0.64, 95% confidence interval; CI: 0.22-1.88). There was a 78% decrease in the opioid-related adverse effects rate following the prescribing policy (IRR: 0.22, 95%CI: 0.09-0.51). This association was moderated by opioid prescription history, with decreases observed among opioid-naïve patients (IRR: 0.18, 95%CI: 0.06-0.59) and among patients receiving chronic opioid prescriptions (IRR: 0.17, 95%CI: 0.03-0.99), but not among those with intermittent opioid prescriptions (IRR: 0.51, 95%CI: 0.09-2.82). CONCLUSIONS: Limiting prescription opioids did not change the opioid overdose rate among primary care patients, but it reduced the rate of opioid-related adverse effects in the year following the state-level policy change, particularly among patients with chronic opioid prescription history and opioid-naïve patients. Limiting the quantity and duration of opioid prescriptions may have beneficial effects among primary care patients.

Variation in additional testing and patient outcomes after stress echocardiography or myocardial perfusion imaging, according to accreditation status of testing site.

BACKGROUND: The purpose of the present study was to determine whether patients receiving a stress echocardiogram or myocardial perfusion imaging (MPI) test have differences in subsequent testing and outcomes according to accreditation status of the original testing facility. METHODS AND RESULTS: An all-payer claims dataset from Maine Health Data Organization from 2012 to 2014 was utilized to define two cohorts defined by an initial stress echocardiogram or MPI test. The accreditation status (Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) or none) of the facility performing the index test was known. Descriptive statistics and multivariate regression were used to examine differences in subsequent diagnostic testing and cardiac outcomes. We observed 4603 index stress echocardiograms and 8449 MPI tests. Multivariate models showed higher odds of subsequent MPI testing and hospitalization for angina if the index test was performed at a non-accredited facility in both the stress echocardiogram cohort and the MPI cohort. We also observed higher odds of percutaneous coronary interventions (PCI) performed (OR 1.68, 95% CI 1.13-2.50), if the initial MPI test was done in a non-accredited facility. CONCLUSION: Cardiac testing completed in non-accredited facilities were associated with higher odds of subsequent MPI testing, hospitalization for angina, and PCI.

Area Deprivation Index and Rurality in Relation to Lung Cancer Prevalence and Mortality in a Rural State.

BACKGROUND: We sought to describe lung cancer prevalence and mortality in relation to socioeconomic deprivation and rurality. METHODS: We conducted a population-based cross-sectional analysis of prevalent lung cancers from a statewide all-payer claims dataset from 2012 to 2016, lung cancer deaths in Maine from the state death registry from 2012 to 2016, rurality, and area deprivation index (ADI), a geographic area-based measure of socioeconomic deprivation. Analyses examined rate ratios for lung cancer prevalence and mortality according to rurality (small and isolated rural, large rural, or urban) and ADI (quintiles, with highest reflecting the most deprivation) and after adjusting for age, sex, and area-level smoking rates as determined by the Behavioral Risk Factor Surveillance System. RESULTS: Among 1 223 006 adults aged 20 years and older during the 5-year observation period, 8297 received lung cancer care, and 4616 died. Lung cancer prevalence and mortality were positively associated with increasing rurality, but these associations did not persist after adjusting for age, sex, and smoking rates. Lung cancer prevalence and mortality were positively associated with increasing ADI in models adjusted for age, sex, and smoking rates (prevalence rate ratio for ADI quintile 5 compared with quintile 1 = 1.41, 95% confidence interval [CI] =1.30 to 1.54) and mortality rate ratio = 1.59, 95% CI = 1.41 to 1.79). CONCLUSION: Socioeconomic deprivation, but not rurality, was associated with higher lung cancer prevalence and mortality. Interventions should target populations with socioeconomic deprivation, rather than rurality per se, and aim to reduce lung cancer risk via tobacco treatment and control interventions and to improve patient access to lung cancer prevention, screening, and treatment services.

Association between the food and physical activity environment, obesity, and cardiovascular health across Maine counties.

BACKGROUND: Accounting for nearly one-third of all deaths, cardiovascular disease is the leading cause of mortality and morbidity in the United States. Adverse health behaviors are major determinants of this high incidence of disease. Examining local food and physical activity environments and population characteristics in a poor, rural state may highlight underlying drivers of these behaviors. We aimed to identify demographic and environmental factors associated with both obesity and overall poor cardiovascular health (CVH) behaviors in Maine counties. METHODS: Our cross-sectional study analyzed 40,398 Behavioral Risk Factor Surveillance System (BRFSS) 2011-2014 respondents alongside county-level United States Department of Agriculture (USDA) Food Environment Atlas 2010-2012 measures of the built environment (i.e., density of restaurants, convenience stores, grocery stores, and fitness facilities; food store access; and county income). Poor CVH score was defined as exhibiting greater than 5 out of the 7 risk factors defined by the American Heart Association (current smoking, physical inactivity, obesity, poor diet, hypertension, diabetes, and high cholesterol). Multivariable logistic regression models described the contributions of built environment variables to obesity and overall poor CVH score after adjustment for demographic controls. RESULTS: Both demographic and environmental factors were associated with obesity and overall poor CVH. After adjustment for demographics (age, sex, personal income, and education), environmental characteristics most strongly associated with obesity included low full-service restaurant density (OR 1.34; 95% CI 1.24-1.45), low county median household income (OR 1.31; 95% CI 1.21-1.42) and high convenience store density (OR 1.21; 95% CI 1.12-1.32). The strongest predictors of overall poor CVH behaviors were low county median household income (OR 1.30; 95% CI 1.13-1.51), low full-service restaurant density (OR 1.38; 95% CI 1.19-1.59), and low fitness facility density (OR 1.27; 95% CI 1.11-1.46). CONCLUSIONS: In a rural state, both demographic and environmental factors predict overall poor CVH. These findings may help inform communities and policymakers of the impact of both social determinants of health and local environments on health outcomes.

Association Between Rurality and Lung Cancer Treatment Characteristics and Timeliness.

BACKGROUND: Lung cancer is the leading cause of cancer-related mortality in the United States, and rural states bear a greater burden of disease. METHODS: We analyzed tumor registry data to examine relationships between rurality and lung cancer stage at diagnosis and treatment. Cases were from the Maine Cancer Registry from 2012 to 2015, and rurality was defined using rural-urban commuting areas. Multivariable models were used to examine the relationships between rurality and treatment, adjusting for age, sex, poverty, education, insurance status, and cancer stage. RESULTS: We identified 5,338 adults with incident lung cancer; 3,429 (64.2%) were diagnosed at a late stage (III or IV). Rurality was not associated with stage at diagnosis. For patients with early-stage disease (I or II), rurality was not associated with receipt of treatment. However, for patients with late-stage disease, residents of large rural areas received more surgery (10%) compared with metropolitan (9%) or small/isolated rural areas (6%), P = .01. In multivariable analyses, patients in large rural areas received more chemotherapy (OR 1.48; 95% CI: 1.08-2.02) than those in metropolitan areas. Patients with early-stage disease residing in small/ isolated rural areas had delays in treatment (median time to first treatment = 43 days, interquartile range [IQR] 22-68) compared with large rural (34 days, IQR 17-55) and metropolitan areas (35 days, IQR 17-60), P = .0009. CONCLUSION: Rurality is associated with differences in receipt of specific lung cancer treatments and in timeliness of treatment.

Behavioral Risk Factors and Regional Variation in Cardiovascular Health Care and Death.

INTRODUCTION: Reducing the burden of death from cardiovascular disease includes risk factor reduction and medical interventions. METHODS: This was an observational analysis at the hospital service area (HSA) level, to examine regional variation and relationships between behavioral risks, health services utilization, and cardiovascular disease mortality (the outcome of interest). HSA-level prevalence of cardiovascular disease behavioral risks (smoking, poor diet, physical inactivity) were calculated from the Behavioral Risk Factor Surveillance System; HSA-level rates of stress tests, diagnostic cardiac catheterization, and revascularization from a statewide multi-payer claims data set from Maine in 2013 (with 606,260 patients aged ≥35 years), and deaths from state death certificate data. Analyses were done in 2016. RESULTS: There were marked differences across 32 Maine HSAs in behavioral risks: smoking (12.4%-28.6%); poor diet (43.6%-73.0%); and physical inactivity (16.4%-37.9%). After adjustment for behavioral risks, rates of utilization varied by HSA: stress tests (28.2-62.4 per 1,000 person-years, coefficient of variation=17.5); diagnostic cardiac catheterization (10.0-19.8 per 1,000 person-years, coefficient of variation=17.3); and revascularization (4.6-6.2 per 1,000 person-years; coefficient of variation=9.1). Strong HSA-level associations between behavioral risk factors and cardiovascular disease mortality were observed: smoking (R2=0.52); poor diet (R2=0.38); and physical inactivity (R2=0.35), and no association between revascularization and cardiovascular disease mortality after adjustment for behavioral risk factors (R2=0.02). HSA-level behavioral risk factors were also strongly associated with all-cause mortality: smoking (R2=0.57); poor diet (R2=0.49); and physical inactivity (R2=0.46). CONCLUSIONS: There is substantial regional variation in behavioral risks and cardiac utilization. Behavioral risk factors are associated with cardiovascular disease mortality regionally, whereas revascularization is not. Efforts to reduce cardiovascular disease mortality in populations should focus on prevention efforts targeting modifiable risk factors.

Variations in Hospice Utilization and Length of Stay for Medicare Patients With Melanoma.

CONTEXT: Timely hospice referral is an indicator of high-quality end-of-life care for cancer patients. Variations in patient characteristics associated with hospice utilization and length of stay have been demonstrated in studies of other malignancies but not melanoma. OBJECTIVES: We sought to understand hospice utilization and patient characteristics associated with variability in use for the older melanoma population. METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify 13,393 melanoma patients aged 65+ years at time of diagnosis between 2000 and 2009, who died by 12/31/10. The primary outcome was enrollment in hospice with secondary outcome of hospice duration. Patient characteristics associated with variations in hospice enrollment were examined. RESULTS: Among 13,393 patients who died with melanoma, 5298 (40%) received hospice care. Of these, 17% were enrolled in hospice for three days or less, while 13% had ≥90 days of hospice care. Despite improvements over time in the proportion of patients who received hospice and those who received at least 90 days of hospice care, late hospice enrollments did not change. Multivariable analysis revealed that patients of older age, with distant disease at time of diagnosis, and residing in rural areas or in census tracts with higher rates of high school completion were more likely to enroll in hospice. CONCLUSION: Rates of hospice enrollment increased over time but remained under accepted quality benchmarks with variations evident in those who receive hospice services. Efforts to increase access to earlier hospice care for all patients dying with melanoma are essential.

Cancer Care Coordination: a Systematic Review and Meta-Analysis of Over 30 Years of Empirical Studies.

BACKGROUND: According to a landmark study by the Institute of Medicine, patients with cancer often receive poorly coordinated care in multiple settings from many providers. Lack of coordination is associated with poor symptom control, medical errors, and higher costs. PURPOSE: The aims of this systematic review and meta-analysis were to (1) synthesize the findings of studies addressing cancer care coordination, (2) describe study outcomes across the cancer continuum, and (3) obtain a quantitative estimate of the effect of interventions in cancer care coordination on service system processes and patient health outcomes. METHODS: Of 1241 abstracts identified through MEDLINE, EMBASE, CINAHL, and the Cochrane Library, 52 studies met the inclusion criteria. Each study had US or Canadian participants, comparison or control groups, measures, times, samples, and/or interventions. Two researchers independently applied a standardized search strategy, coding scheme, and online coding program to each study. Eleven studies met the additional criteria for the meta-analysis; a random effects estimation model was used for data analysis. RESULTS: Cancer care coordination approaches led to improvements in 81 % of outcomes, including screening, measures of patient experience with care, and quality of end-of-life care. Across the continuum of cancer care, patient navigation was the most frequent care coordination intervention, followed by home telehealth; nurse case management was third in frequency. The meta-analysis of a subset of the reviewed studies showed that the odds of appropriate health care utilization in cancer care coordination interventions were almost twice (OR = 1.9, 95 % CI = 1.5-3.5) that of comparison interventions. CONCLUSIONS: This review offers promising findings on the impact of cancer care coordination on increasing value and reducing healthcare costs in the USA.