Intensity, Characteristics, and Factors Associated With Receipt of Care Coordination Among High-Risk Veterans in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VHA) has initiatives underway to enhance the provision of care coordination (CC), particularly among high-risk Veterans. Yet, evidence detailing the characteristics of and who receives VHA CC is limited. OBJECTIVES: We examined intensity, timing, setting, and factors associated with VHA CC among high-risk Veterans. RESEARCH DESIGN: We conducted a retrospective observational cohort study, following Veterans for 1 year after being identified as high-risk for hospitalization or mortality, to characterize their CC. Demographic and clinical factors predictive of CC were identified via multivariate logistic regression. SUBJECTS: A total of 1,843,272 VHA-enrolled high-risk Veterans in fiscal years 2019-2021. MEASURES: We measured 5 CC variables during the year after Veterans were identified as high risk: (1) receipt of any service, (2) number of services received, (3) number of days to first service, (4) number of days between services, and (5) type of visit during which services were received. RESULTS: Overall, 31% of high-risk Veterans in the sample received CC during one-year follow-up. Among Veterans who received ≥1 service, a median of 2 [IQR (1, 6)] services were received. Among Veterans who received ≥2 services, there was a median of 26 [IQR (10, 57)] days between services. Most services were received during outpatient psychiatry (46%) or medicine (16%) visits. Veterans' sociodemographic and clinical characteristics were associated with receipt of CC. CONCLUSIONS: A minority of Veterans received CC in the year after being identified as high-risk, and there was variation in intensity, timing, and setting of CC. Research is needed to examine the fit between Veterans' CC needs and preferences and VHA CC delivery.

Typology of solutions addressing diagnostic disparities: gaps and opportunities.

OBJECTIVES: Diagnostic disparities are preventable differences in diagnostic errors or opportunities to achieve diagnostic excellence. There is a need to summarize solutions with explicit considerations for addressing diagnostic disparities. We aimed to describe potential solutions to diagnostic disparities, organize them into an action-oriented typology with illustrative examples, and characterize these solutions to identify gaps for their further development. METHODS: During four human-centered design workshops composed of diverse expertise, participants ideated and clarified potential solutions to diagnostic disparities and were supported by environmental literature scan inputs. Nineteen individual semi-structured interviews with workshop participants validated identified solution examples and solution type characterizations, refining the typology. RESULTS: Our typology organizes 21 various types of potential diagnostic disparities solutions into four primary expertise categories needed for implementation: healthcare systems' internal expertise, educator-, multidisciplinary patient safety researcher-, and health IT-expertise. We provide descriptions of potential solution types ideated as focused on disparities and compare those to existing examples. Six types were characterized as having diagnostic-disparity-focused examples, five as having diagnostic-focused examples, and 10 as only having general healthcare examples. Only three solution types had widespread implementation. Twelve had implementation on limited scope, and six were mostly hypothetical. We describe gaps that inform the progress needed for each of the suggested solution types to specifically address diagnostic disparities and be suitable for the implementation in routine practice. CONCLUSIONS: Numerous opportunities exist to tailor existing solutions and promote their implementation. Likely enablers include new perspectives, more evidence, multidisciplinary collaborations, system redesign, meaningful patient engagement, and action-oriented coalitions.

Patient-reported outcome and experience domains for diagnostic excellence: a scoping review to inform future measure development.

PURPOSE: "Diagnostic excellence," as a relatively new construct centered on the diagnostic process and its health-related outcomes, can be refined by patient reporting and its measurement. We aimed to explore the scope of patient-reported outcome (PRO) and patient-reported experience (PRE) domains that are diagnostically relevant, regardless of the future diagnosed condition, and to review the state of measurement of these patient-reported domains. METHODS: We conducted an exploratory analysis to identify these domains by employing a scoping review supplemented with internal expert consultations, 24-member international expert convening, additional environmental scans, and the validation of the domains' diagnostic relevance via mapping these onto patient diagnostic journeys. We created a narrative bibliography of the domains illustrating them with existing measurement examples. RESULTS: We identified 41 diagnostically relevant PRO and PRE domains. We classified 10 domains as PRO, 28 as PRE, and three as mixed PRO/PRE. Among these domains, 19 were captured in existing instruments, and 20 were captured only in qualitative studies. Two domains were conceptualized during this exploratory analysis with no examples identified of capturing these domains. For 27 domains, patients and care partners report on a specific encounter; for 14 domains, reporting relates to an entire diagnostic journey over time, which presents particular measurement opportunities and challenges. CONCLUSION: The multitude of PRO and PRE domains, if measured rigorously, would allow the diagnostic excellence construct to evolve further and in a manner that is patient-centered, prospectively focused, and concentrates on effectiveness and efficiency of diagnostic care on patients' well-being.

Betrayal-Based Moral Injury and Mental Health Problems Among Healthcare and Hospital Workers Serving COVID-19 Patients.

One factor potentially driving healthcare and hospital worker (HHW)'s declining mental health during the COVID-19 pandemic is feeling betrayed by institutional leaders, coworkers, and/or others' pandemic-related responses and behaviors. We investigated whether HHWs' betrayal-based moral injury was associated with greater mental distress and post-traumatic stress disorder (PTSD) symptoms related to COVID-19. We also examined if these associations varied between clinical and non-clinical staff. From July 2020 to January 2021, cross-sectional online survey data were collected from 1,066 HHWs serving COVID-19 patients in a large urban US healthcare system. We measured betrayal-based moral injury in three groups: institutional leaders, coworkers/colleagues, and people outside of healthcare. Multivariate logistic regression analyses were performed to investigate whether betrayal-based moral injury was associated with mental distress and PTSD symptoms. Approximately one-third of HHWs reported feeling betrayed by institutional leaders, and/or people outside healthcare. Clinical staff were more likely to report feelings of betrayal than non-clinical staff. For all respondents, 49.5% reported mental distress and 38.2% reported PTSD symptoms. Having any feelings of betrayal increased the odds of mental distress and PTSD symptoms by 2.9 and 3.3 times, respectively. These associations were not significantly different between clinical and non-clinical staff. As health systems seek to enhance support of HHWs, they need to carefully examine institutional structures, accountability, communication, and decision-making patterns that can result in staff feelings of betrayal. Building trust and repairing ruptures with HHWs could prevent potential mental health problems, increase retention, and reduce burnout, while likely improving patient care.

Patient Reasoning: Patients' and Care Partners' Perceptions of Diagnostic Accuracy in Emergency Care.

OBJECTIVES: In the context of validating a measure of patient report specific to diagnostic accuracy in emergency department or urgent care, this study investigates patients' and care partners' perceptions of diagnoses as accurate and explores variations in how they reason while they assess accuracy. METHODS: In February 2022, we surveyed a national panel of adults who had an emergency department or urgent care visit in the past month to test a patient-reported measure. As part of the survey validation, we asked for free-text responses about why the respondents indicated their (dis)agreement with 2 statements comprising patient-reported diagnostic accuracy: 1) the explanation they received of the health problem was true and 2) the explanation described what to expect of the health problem. Those paired free-text responses were qualitatively analyzed according to themes created inductively. RESULTS: A total of 1,116 patients and care partners provided 982 responses coded into 10 themes, which were further grouped into 3 reasoning types. Almost one-third (32%) of respondents used only corroborative reasoning in assessing the accuracy of the health problem explanation (alignment of the explanation with either test results, patients' subsequent health trajectory, their medical knowledge, symptoms, or another doctor's opinion), 26% used only perception-based reasoning (perceptions of diagnostic process, uncertainty around the explanation received, or clinical team's attitudes), and 27% used both types of reasoning. The remaining 15% used general beliefs or nonexplicated logic (used only about accurate diagnoses) and combinations of general reasoning with perception-based and corroborative. CONCLUSIONS: Patients and care partners used multifaceted reasoning in their assessment of diagnostic accuracy. IMPLICATIONS: As health care shifts toward meaningful diagnostic co-production and shared decision making, in-depth understanding of variations in patient reasoning and mental models informs use in clinical practice. HIGHLIGHTS: An analysis of 982 responses examined how patients and care partners reason about the accuracy of diagnoses they received in emergency or urgent care.In reasoning, people used their perception of the process and whether the diagnosis matched other factual information they have.We introduce "patient reasoning" in the diagnostic measurement context as an area of further research to inform diagnostic shared decision making and co-production of health.

Care coordination in primary care: mapping the territory.

OBJECTIVE: To document the current approaches to care coordination among different types of care systems in Minnesota. STUDY DESIGN: Observational survey of leaders of most of the care systems in Minnesota that have implemented care coordination. METHODS: Survey questions about organizational structure, size, and approach to care coordination were sent to the leaders of 42 care systems with a total of 327 primary care clinics. RESULTS: Surveys were completed by leaders at every care system participating in this study (100% response rate); 16 small care systems (each with 1-2 clinics) had a total of 26 primary care clinics, 15 medium care systems (3-9 clinics) had 57 clinics, and 11 large care systems (> 9 clinics) had 244 clinics. The large care systems had larger clinics (clinicians per clinic, 8.6 in large vs 4.3 in small and 5.2 in medium; P = .03) and more clinicians per care coordinator (5.7 vs 3.3 and 4.0; P = .04). They also more frequently included a social worker in their care coordination team: 82% vs 25% of small and 40% of medium care systems (P = .01). However, the services provided and complexity tools used were similar. Nearly all reported addressing both medical and social needs for their complex patients with multiple chronic conditions. CONCLUSIONS: Although there are large differences in resources and capabilities between large and small care systems, they were not associated with much difference in the approach taken to care coordination. This map of the care coordination territory in Minnesota has the potential to be valuable to researchers and care system leaders for understanding current implementation trends and directing further evaluations.

Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study.

Background: For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients' needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients' full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs. Methods: In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey. Discussion: Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs.

"A slap in the face": Institutional betrayal, burnout, and career choice regret among frontline health care workers serving COVID-19 patients.

The COVID-19 pandemic has exacted a physical and mental health toll on health care and hospital workers (HHWs). To provide COVID-19 care, HHWs expected health care institutions to support equipment and resources, ensure safety for patients and providers, and advocate for employees' needs. Failure to do these acts has been defined as institutional betrayal. Using a mixed-methods approach, this study aimed to explore the experience of institutional betrayal in HHWs serving COVID-19 patients and the associations between self-reported institutional betrayal and both burnout and career choice regret. Between July 2020 and January 2021, HHWs working in an urban U.S. health care system participated in an online survey (n = 1,189) and semistructured interview (n = 67). Among 1,075 quantitative participants, 57.8% endorsed institutional betrayal. Qualitative participants described frustration when the institution did not prioritize their safety while reporting they perceived receiving inadequate compensation from the system and felt that leadership did not sufficiently respond to their needs. Participants who endorsed prolonged breaches of trust reported more burnout and stronger intent to quit their job. Quantitatively, institutional betrayal endorsement was associated with 3-fold higher odds of burnout, aOR = 2.94, 95% CI [2.22, 3.89], and 4-fold higher odds of career choice regret, aOR = 4.31, 95% CI [3.15, 5.89], compared to no endorsement. Developing strategies to prevent, address, and repair institutional betrayal in HHWs may be critical to prevent and reduce burnout and increase motivation to work during and after public health emergencies.

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals.

BACKGROUND: There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations. PURPOSE: To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients' lives and elicit solutions. METHODS: Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis. RESULTS: Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health. CONCLUSIONS: Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients' gender identity, sexual orientation, race, age, economic status and system-level changes.

Structural and metabolic correlates of neuropsychological profiles in multiple system atrophy and Parkinson's disease.

BACKGROUND: Despite increased recognition of cognitive impairment in Multiple System Atrophy (MSA), its neuroanatomical correlates are not well defined. We aimed to explore cognitive profiles in MSA with predominant parkinsonism (MSA-P) and Parkinson's disease (PD) and their relationship to frontostriatal structural and metabolic changes. METHODS: Detailed clinical and neuropsychological evaluation was performed together with diffusion tensor imaging (DTI) and [18F]-fluoro-deoxyglucose positron emission tomography ([18F]-FDG-PET) in patients with MSA-P (n = 11) and PD (n = 11). We compared clinical and neuropsychological data to healthy controls (n = 9) and correlated neuropsychological data with imaging findings in MSA-P and PD. RESULTS: Patients with MSA-P showed deficits in executive function (Trail Making Test B-A) and scored higher in measures of depression and anxiety compared to those with PD and healthy controls. Widespread frontostriatal white matter tract reduction in fractional anisotropy was seen in MSA-P and PD compared to an imaging control group. Stroop Test interference performance correlated with [18F]-FDG uptake in the bilateral dorsolateral prefrontal cortex (DLPFC) and with white matter integrity between the striatum and left inferior frontal gyrus (IFG) in PD. Trail Making Test performance correlated with corticostriatal white matter integrity along tracts from the bilateral IFG in MSA-P and from the right DLPFC in both groups. CONCLUSION: Executive dysfunction was more prominent in patients with MSA-P compared to PD. DLPFC metabolism and frontostriatal white matter integrity seem to be a driver of executive function in PD, whereas alterations in corticostriatal white matter integrity may contribute more to executive dysfunction in MSA-P.

Patient and care partner assessments of diagnostic excellence in the emergency department: A cognitive interview study.

Background: Diagnostic excellence encompasses both receiving an accurate and timely explanation of a health problem that was communicated well, and the process it took to get to the correct diagnosis. Directly eliciting patients' perceptions of their diagnostic experience and outcomes after emergency visits is a promising method of assessing diagnostic excellence. However, little is known about how patients interpret and respond to questions about their diagnostic experiences and outcomes. Objective: To analyze patient and care partners' interpretation of questions capturing patient-reported diagnostic excellence in emergency settings. Design: Cognitive interviews using think-aloud and probing methods. Settings: Interviews were conducted virtually and via phone calls. Participants were patients or care partners of patients recently discharged from three emergency departments within a single academic health system in the Mid-Atlantic region of the US. Participants: 15 patients and care partners, 18 years or older, with recent emergency department experiences. Methods: Qualitative analysis using a deductive approach was used to code transcripts and analyze participant responses to Patient-Report to Improve Diagnostic Excellence in Emergency Department (PRIME-ED) questionnaire items. Themes of patient and care partners' questionnaire interpretations are presented descriptively. Results: 80% of participants were female, 47% were between the ages of 18-24 years, 47% of participants were White, and 7% were Hispanic/Latino. Participants shared their interpretations of diagnostic excellence following PRIME-ED domains: diagnostic accuracy and care team skills, their comprehension of the diagnosis, provider communication of uncertainty, and quality of diagnostic communication, including whether they felt the care team communicated well, adapted communication to their needs, listened and took concerns seriously, treated them as an equal, and provided clear, sufficient, and functional communication about follow-up steps. Responses indicated that patients and care partners can identify diagnostic errors, rationalize why their diagnosis was inaccurate, and assess whether diagnostic excellence was achieved. Respondents identified factors that contributed to their assessments of diagnostic accuracy and the quality of diagnostic communication. The quality of diagnostic communication contributed to patient perception of diagnostic accuracy and understanding of the diagnosis. Conclusions: Patient report is a useful tool for assessing diagnostic excellence in emergency settings. Our patient and care partners describe how they assess diagnostic excellence in the emergency department.Registration: N/A.Tweetable abstract: Patients and care partners provide accessible and useful information to assess diagnostic practices and diagnostic excellence in emergency departments.

Human centered design workshops as a meta-solution to diagnostic disparities.

OBJECTIVES: Diagnostic errors - inaccurate or untimely diagnoses or failures to communicate diagnoses - are harmful and costly for patients and health systems. Diagnostic disparities occur when diagnostic errors are experienced at disproportionate rates by certain patient subgroups based, for example, on patients' age, sex/gender, or race/ethnicity. We aimed to develop and test the feasibility of a human centered design workshop series that engages diverse stakeholders to develop solutions for mitigating diagnostic disparities. METHODS: We employed a series of human centered design workshops supplemented by semi-structured interviews and literature evidence scans. Co-creation sessions and rapid prototyping by patient, clinician, and researcher stakeholders were used to generate design challenges, solution concepts, and prototypes. RESULTS: A series of four workshops attended by 25 unique participants was convened in 2019-2021. Workshops generated eight design challenges, envisioned 29 solutions, and formulated principles for developing solutions in an equitable, patient-centered manner. Workshops further resulted in the conceptualization of 37 solutions for addressing diagnostic disparities and prototypes for two of the solutions. Participants agreed that the workshop processes were replicable and could be implemented in other settings to allow stakeholders to generate context-specific solutions. CONCLUSIONS: The incorporation of human centered design through a series of workshops promises to be a productive way of engaging patient-researcher stakeholders to mitigate and prevent further exacerbation of diagnostic disparities. Healthcare stakeholders can apply human centered design principles to guide thinking about improving diagnostic performance and to center diverse patients' needs and experiences when implementing quality and safety improvements.

The Reliability of Graduate Medical Education Quality of Care Clinical Performance Measures.

Background: Graduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied. Objective: To examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care. Methods: From 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated. Results: The highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable. Conclusions: GME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.

Incorporating harms into the weighting of the revised Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator 90).

OBJECTIVE: To reweight the Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator [PSI] 90) from weights based solely on the frequency of component PSIs to those that incorporate excess harm reflecting patients' preferences for outcome-related health states. DATA SOURCES: National administrative and claims data involving hospitalizations in nonfederal, nonrehabilitation, acute care hospitals. STUDY DESIGN: We estimated the average excess aggregate harm associated with the occurrence of each component PSI using a cohort sample for each indicator based on denominator-eligible records. We used propensity scores to account for potential confounding in the risk models for each PSI and weighted observations to estimate the "average treatment effect in the treated" for those with the PSI event. We fit separate regression models for each harm outcome. Final PSI weights reflected both the disutilities and the frequencies of the harms. DATA COLLECTION/EXTRACTION METHODS: We estimated PSI frequencies from the 2012 Healthcare Cost and Utilization Project State Inpatient Databases with present on admission data and excess harms using 2012-2013 Centers for Medicare & Medicaid Services Medicare Fee-for-Service data. PRINCIPAL FINDINGS: Including harms in the weighting scheme changed individual component weights from the original frequency-based weighting. In the reweighted composite, PSIs 11 ("Postoperative Respiratory Failure"), 13 ("Postoperative Sepsis"), and 12 ("Perioperative Pulmonary Embolism or Deep Vein Thrombosis") contributed the greatest harm, with weights of 29.7%, 21.1%, and 20.4%, respectively. Regarding reliability, the overall average hospital signal-to-noise ratio for the reweighted PSI 90 was 0.7015. Regarding discrimination, among hospitals with greater than median volume, 34% had significantly better PSI 90 performance, and 41% had significantly worse performance than benchmark rates (based on percentiles). CONCLUSIONS: Reformulation of PSI 90 with harm-based weights is feasible and results in satisfactory reliability and discrimination, with a more clinically meaningful distribution of component weights.

Crossing Academic Boundaries for Diagnostic Safety: 10 Complex Challenges and Potential Solutions From Clinical Perspectives and High-Reliability Organizing Principles.

OBJECTIVE: We apply the high-reliability organization (HRO) paradigm to the diagnostic process, outlining challenges to enacting HRO principles in diagnosis and offering solutions for how diagnostic process stakeholders can overcome these barriers. BACKGROUND: Evidence shows that healthcare is starting to organize for higher reliability by employing various principles and practices of HRO. These hold promise for enhancing safer care, but there has been little consideration of the challenges that clinicians and healthcare systems face while enacting HRO principles in the diagnostic process. To effectively deploy the HRO perspective, these barriers must be seriously considered. METHOD: We review key principles of the HRO paradigm, the diagnostic errors and harms that potentially can be prevented by its enactment, the challenges that clinicians and healthcare systems face in executing various principles and practices, and possible solutions that clinicians and organizational leaders can take to overcome these challenges and barriers. RESULTS: Our analyses reveal multiple challenges including the inherent diagnostic uncertainty; the lack of diagnosis-focused performance feedback; the fact that diagnosis is often a solo, rather than team, activity; the tendency to simplify the diagnostic process; and professional and institutional status hierarchies. But these challenges are not insurmountable-there are strategies and solutions available to overcome them. CONCLUSION: The HRO lens offers some important ideas for how the safety of the diagnostic process can be improved. APPLICATION: The ideas proposed here can be enacted by both individual clinicians and healthcare leaders; both are necessary for making systematic progress in enhancing diagnostic performance.

Towards refining World Cancer Research Fund/American Institute for Cancer Research cancer prevention recommendations for red and processed meat intake: insights from Alberta's Tomorrow Project cohort.

Current cancer prevention recommendations advise limiting red meat intake to <500 g/week and avoiding consumption of processed meat, but do not differentiate the source of processed meat. We examined the associations of processed meat derived from red v. non-red meats with cancer risk in a prospective cohort of 26 218 adults who reported dietary intake using the Canadian Diet History Questionnaire. Incidence of cancer was obtained through data linkage with Alberta Cancer Registry with median follow-up of 13·3 (interquartile range (IQR) 5·1) years. Multivariable Cox proportional hazards regression models were adjusted for covariates and stratified by age and sex. The median consumption (g/week) of red meat, processed meat from red meat and processed meat from non-red meat was 267·9 (IQR 269·9), 53·6 (IQR 83·3) and 11·9 (IQR 31·8), respectively. High intakes (4th Quartile) of processed meat from red meat were associated with increased risk of gastrointestinal cancer adjusted hazard ratio (AHR): 1·68 (95 % CI 1·09, 2·57) and colorectal cancers AHR: 1·90 (95 % CI 1·12, 3·22), respectively, in women. No statistically significant associations were observed for intakes of red meat or processed meat from non-red meat. Results suggest that the carcinogenic effect associated with processed meat intake may be limited to processed meat derived from red meats. The findings provide preliminary evidence towards refining cancer prevention recommendations for red and processed meat intake.

Mandatory Public Health Measures for Coronavirus-19 Are Associated With Improved Mortality, Equity and Economic Outcomes.

The impact of public health measures on the coronavirus-2019 pandemic was analyzed by comparing mandatory versus voluntary nonpharmaceutical interventions between 2 comparable European countries and among 3 U.S. states. Using an ecological retrospective cohort study design, we examine differences in mortality, economic impact, and equity. Compared to voluntary policies, mandatory shelter-in-place policies were associated with a 3- to 5-fold lower population-adjusted mortality in the U.S. model and between 11- to 12-fold lower in the European one. Voluntary shelter-in-place measures were associated with overall increased mortality cost, as measured by value of a statistical life; somewhat greater decreases in gross domestic product; and substantial negative impacts on minority communities, who experienced markedly increased mortality rates (the percentage of minority deaths was 2.3 and 4 times greater in the U.S. model and 14.5 times higher in the European one) and mortality cost (2.7- and 4.5-fold higher in the U.S. model and 11.1-fold higher in the European one). We conclude that voluntary policies are less effective than mandatory ones, based on historical precedent and the current analysis. Negative effects on health equity mirrored the increased mortality outcomes of voluntary policies, and there was no apparent economic benefit associated with voluntary measures.