Emergency Department Use in Adolescent and Young Adult Cancer Early Survivors from 2006 to 2020.

Purpose: Understanding emergency department (ED) use in adolescent and young adult (AYA) survivors could identify gaps in AYA survivorship. Methods: We conducted a cohort study of 7925 AYA survivors (aged 15-39 years at diagnosis) who were 2-5 years from diagnosis in 2006-2020 at Kaiser Permanente Southern California. We calculated ED utilization rates overall and by indication of the encounter (headache, cardiac issues, and suicide attempts). We estimated rate changes by survivorship year and patient factors associated with ED visit using a Poisson model. Results: Cohort was 65.4% women, 45.8% Hispanic, with mean age at diagnosis at 31.3 years. Overall, 38% of AYA survivors had ≥1 ED visit (95th percentile: 5 ED visits). Unadjusted ED rates declined from 374.2/1000 person-years (PY) in Y2 to 327.2 in Y5 (p change < 0.001). Unadjusted rates declined for headache, cardiac issues, and suicide attempts. Factors associated with increased ED use included: age 20-24 at diagnosis [relative risk (RR) = 1.30, 95% CI 1.09-1.56 vs. 35-39 years]; female (RR = 1.27, 95% CI 1.11-1.47 vs. male); non-Hispanic Black race/ethnicity (RR 1.64, 95% CI 1.38-1.95 vs. non-Hispanic white); comorbidity (RR = 1.34, 95% CI 1.16-1.55 for 1 and RR 1.80, 95% CI 1.40-2.30 for 2+ vs. none); and public insurance (RR = 1.99, 95% CI 1.70-2.32 vs. private). Compared with thyroid cancer, cancers associated with increased ED use were breast (RR = 1.45, 95% CI 1.24-1.70), cervical (RR = 2.18, 95% CI 1.76-2.71), colorectal (RR = 2.34, 95% CI 1.94-2.81), and sarcoma (RR = 1.39, 95% CI 1.03-1.88). Conclusion: ED utilization declined as time from diagnosis elapsed, but higher utilization was associated with social determinants of health and cancer types.

Contemporary care patterns in the management of small renal masses.

OBJECTIVES: Incidental small renal masses (SRMs) now account for the majority of new diagnoses of renal cancers. Although there are established management guidelines, referral and management patterns can vary. We aimed to explore identification, practice patterns, and management of identified SRMs in an integrated health system. STUDY DESIGN: Retrospective analysis. METHODS: We identified patients with a newly diagnosed SRM measuring 3 cm or less from January 1, 2013, to December 31, 2017, at Kaiser Permanente Southern California. These patients were flagged at the time of radiographic identification to ensure adequate notification of findings. Diagnostic modality, referral, and treatment patterns were analyzed. RESULTS: Of 519 patients with SRMs, 65% were found on abdominal CT and 22% on renal/abdominal ultrasounds. Within 6 months, 70% of patients consulted with a urologist. Initial management patterns were as follows: active surveillance (60%), partial/radical nephrectomy (18%), and ablation (4%). Among 312 patients on surveillance, 14% eventually received treatment. The majority of patients (69.4%) did not receive guideline-recommended chest imaging for initial staging. Urologist visit within 6 months of SRM diagnosis was associated with increased adherence to staging (P = .003) and subsequent surveillance imaging (P < .001). CONCLUSIONS: In this contemporary analysis of an integrated health system's experience, referral to a urologist was associated with guideline-concordant staging and surveillance imaging. Frequent utilization of active surveillance with a low rate of progression to active treatment was noted in both groups. These findings shed light on care patterns upstream of urologic evaluation and support the need for clinical pathways to be implemented at the time of radiologic diagnosis.

The Probability of Lung Cancer in Patients With Incidentally Detected Pulmonary Nodules: Clinical Characteristics and Accuracy of Prediction Models.

BACKGROUND: The frequency of cancer and accuracy of prediction models have not been studied in large, population-based samples of patients with incidental pulmonary nodules measuring > 8 mm in diameter. RESEARCH QUESTIONS: How does the frequency of cancer vary by size and smoking history among patients with incidental nodules? How accurate are two widely used models for identifying cancer in these patients? STUDY DESIGN AND METHODS: We assembled a retrospective cohort of individuals with incidental nodules measuring > 8 mm in diameter identified by chest CT imaging between 2006 and 2016. We used a validated natural language processing algorithm to identify nodules and their characteristics by scanning the text of dictated radiology reports. We reported patient and nodule characteristics stratified by the presence or absence of a lung cancer diagnosis within 27 months of nodule identification and estimated the area under the receiver operating characteristic curve (AUC) to compare the accuracy of the Mayo Clinic and Brock models for identifying cancer. RESULTS: The sample included 23,780 individuals with a nodule measuring > 8 mm, including 2,356 patients (9.9%) with a lung cancer diagnosis within 27 months of nodule identification. Cancer was diagnosed in 5.4% of never smokers, 12.2% of former smokers, and 17.7% of current smokers. Cancer was diagnosed in 5.7% of patients with nodules measuring 9 to 15 mm, 12.1% of patients with nodules > 15 to 20 mm, and 18.4% of patients with nodules > 20 to 30 mm. In the full sample, the Mayo Clinic model (AUC, 0.747; 95% CI, 0.737-0.757) was more accurate than the Brock model (AUC, 0.713; 95% CI, 0.702-0.724; P < .0001). When restricted to ever smokers, the Mayo Clinic model was still more accurate. Both models overestimated the probability of cancer. INTERPRETATION: Almost 10% of patients with an incidental pulmonary nodule measuring > 8 mm in diameter will receive a lung cancer diagnosis. Existing prediction models have only fair accuracy and overestimate the probability of cancer.

Defining Complex Patient Populations: Implications for Population Size, Composition, Utilization, and Costs.

BACKGROUND: Interventions to support patients with complex needs have proliferated in recent years, but the question of how to identify patients with complex needs has received relatively little attention. There are innumerable ways to structure inclusion and exclusion criteria for complex care interventions, and little is known about the implications of choices made in designing patient selection criteria. OBJECTIVE: To provide insights into the design of patient selection criteria for interventions, by implementing criteria sets within a large health plan member population and comparing the characteristics of the resulting complex patient cohorts. DESIGN: Retrospective observational descriptive study. SUBJECTS: Patients identified as having complex needs, within the membership population of Kaiser Permanente Southern California, a large, population-based health plan with more than 4 million members. We characterize five commonly used archetypes of complex needs: high-cost patients, patients with multiple chronic conditions, frail elders, emergency department high-utilizers, and inpatient high-utilizers. MEASURES: We selected an initial set of criteria for identifying patients in each of the archetypical complex populations, based on available administrative data. We then tested multiple variants of each definition. We compared the resulting patient cohorts using univariate and bivariate descriptive statistics. KEY RESULTS: Overall, 32.7% of the 3,112,797 adults in our population-based sample were selected by at least one of the 25 definitions of complexity we tested. Across definitions the total number of patients identified as complex ranged from 622,560 to 1583 and complex patient cohorts varied widely in demographic characteristics, chronic conditions, healthcare utilization, spending, and survival. CONCLUSIONS: Choice of patient population is critical to the design of complex care programs. Exploratory analyses of population criteria can provide useful information for program planning in the setting of limited resources for interventions. Data such as these should be generated as a key step in program design.

Identifying Populations with Complex Needs: Variation in Approaches Used to Select Complex Patient Populations.

Interventions to support patients with complex needs are proliferating. However, little attention has been paid to methods for identifying complex patients. This study aims to summarize approaches used to define populations with complex needs in practice, by cataloging specific population criteria and organizing them into a taxonomy. The authors conducted a pragmatic review of literature published January 2000-December 2018 using PubMed. Search results were limited to English-language studies of adults that specified a set of objective criteria to identify a population with complex needs. The authors abstracted data from each article on population parameters, and conducted thematic analysis guided by deductive coding. The review identified 70 studies reflecting 90 unique complex population definitions. Complex populations criteria reflected 3 approaches: stratification, segmentation, and targeting. Six domains of population criteria were found within, including age-based criteria (59 populations); income (12); health care costs (45); health care utilization (39); health conditions (35); and subjective criteria (15). Criteria from multiple domains were frequently used in combination, and exact specifications were highly variable within each domain. Overall, 83% of the 90 population definitions included at least 1 cost- or utilization-based criterion. Nearly every study in the review presented a unique approach to identifying patients with complex needs but a limited number of "schools of thought" were found. Variability in definitions and inconsistent terminology are potential sources of ambiguity between stakeholders. Greater specificity and transparency in complex population definition would be a substantial contribution to the emerging field of complex care.

Methods to identify and prioritize research projects and perform embedded research in learning healthcare systems.

BACKGROUND: The Embedded Healthcare Research Conference aimed to promote and enhance research-operations partnerships in diverse health care settings. Within this conference, the Priorities and Methods Workgroup set out to define a vision of embedded research that leverages diverse methods to address clearly articulated research questions of importance to health systems. METHODS: The Workgroup session involved a combination of small and large group discussions around three broadly focused topics: the integration of embedded research within the existing quality improvement (QI) ecosystem; the identification, prioritization and formulation of embedded research questions; the creation of an embedded research "tool kit." RESULTS: Workgroup participants envisioned a future for embedded research that is characterized by authentic engagement between researchers and health system leaders; seamless integration between research, QI and clinical operations; clear and explicit articulation of research questions; an appropriate balance between rigor and relevance in applied methodology; alignment between study design, available resources and the importance of the knowledge to be gained; efficient processes; and bi-directional communication. Important barriers to achieving this vision include limited access to executive leaders, silos that discourage integration of research and QI, generally low tolerance for disruption in high-risk clinical settings, limited access to data, and limited availability of researchers with requisite skills and training. CONCLUSIONS: Embedded research holds potential to enhance the relevance, value and use of research, while also creating generalizable knowledge. Key recommendations include building authentic relationships, discouraging silos, encouraging innovation and experimentation, and expanding opportunities for funding research in delivery systems.

Clinician Perspectives on Implementing Video Visits in Home-Based Palliative Care.

Background: Despite the increasing use and acceptance of technology in health care, there is limited evidence on the usefulness and appropriate use of telehealth in home-based palliative care (HBPC). As part of the process evaluation of a pragmatic trial of video visits in HBPC, we assessed clinician experience with video visit implementation. Methods: We assessed clinicians' experiences with and perception of the usefulness and appropriateness of video visits using anonymous surveys and brief qualitative interviews with a subset of survey participants. Qualitative analyses were guided by sociotechnical frameworks that emphasize technology's "value proposition" for its end users as being key to adoption. Results: Clinicians (36 physicians and 48 registered nurses) generally had favorable attitudes toward video visits and telehealth. Respondents felt confident in the skills needed to make their role in video visits successful. Clinicians were neutral on whether video visits were useful for their practice or enhanced the patient-caregiver experience. Clinicians found video visits to be most appropriate for follow-up care (as opposed to start of care). The interviews yielded two themes that complemented the survey findings: (1) factors enhancing the value proposition (positive responses from patients and families and convenience) and (2) factors diminishing the value proposition (issues related to the technology and scheduling). Discussion: Our findings provide insights into clinicians' experiences with implementing remote video physician consultations, facilitated by a nurse in the patient's home in the pre-COVID-19 era. Clinician views about video visits may have shifted with the pandemic, which occurred after our data collection was complete. Clinical Trials Registration No. NCT#03694431.

The Influence of Health Education Teacher Characteristics on Students' Health-Related Knowledge Gains.

BACKGROUND: Studies have examined relationships between teacher characteristics and student achievement in courses such as math and science. This study is among the first to examine effects of teacher characteristics on student knowledge in a health course. METHODS: Student (N = 6143) pretest and posttest data were linked to teacher (N = 67) data. Changes in student knowledge scores from pre- to postcourse were explored using mixed-effects linear models. Teacher characteristics included professional development (PD) attendance, having a dedicated classroom, certification type, educational background, years' experience, and athletic coaching status. RESULTS: Teacher characteristics associated with greater student knowledge gains included: being certified to teach health versus not certified (p < .001), having a dedicated classroom versus no classroom (p = .017), and for middle school teachers, having attended ≥3 PD sessions versus ≤2 (p = .023). Less knowledge gain was associated with teachers that coached versus noncoaches (p = .040) and having a health degree versus no health degree (p = .049). Post hoc analyses revealed the negative effect of health degree was only significant among coaches (p = .026). CONCLUSIONS: Findings suggest opportunities for maximizing student knowledge gains through tailored selection of health teachers and provision of appropriate teaching support.

Value of a facilitated quality improvement initiative on cardiovascular disease risk: findings from an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL).

RATIONALE, AIMS AND OBJECTIVES: In the United States, cardiovascular disease (CVD) is the leading cause of death. The US Centers for Disease Control and Prevention contracted an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL) programme as part of its effort to identify strategies to address CVD risk factors. METHODS: This study analysed patient-level data from 7527 patients in 43 primary care practices. The researchers assessed average change in control rates for CVD-related measures across practices, and then across patients between baseline and a patient's last visit during the practice's tenure in the programme (referred to as 'end line') using repeated measures analysis of variance and random effects generalized least squares, respectively. RESULTS: Among non-diabetic patients, there were significant increases in control rates for overall blood pressure (74.3% to 78.0%, P = 0.0002), systolic blood pressure (70.3% to 80.6%, P = 0.0099), diastolic blood pressure (90.1% to 92.7%, P = 0.0001) and low-density lipoprotein (LDL; 48.6% to 53.1%, P = 0.0001) between baseline and end line. Among diabetic patients, there was a significant increase in diastolic blood pressure control (59.8% to 61.9%, P = 0.0141). While continuous CVD-related outcomes show an overall trend between baseline and end line, patients with uncontrolled measures at baseline showed a decrease between baseline and end line relative to their counterparts who were controlled at baseline. CONCLUSIONS: Findings from the AT GOAL evaluation support the value of a facilitated quality improvement (QI) initiative on managing CVD risk.

Initiatives to Enhance Primary Care Delivery: Two Examples from the Field.

OBJECTIVES: Increasing demands on primary care providers have created a need for systems-level initiatives to improve primary care delivery. The purpose of this paper is to describe and present outcomes for two such initiatives: the Pennsylvania Academy of Family Physicians' Residency Program Collaborative (RPC) and the St. Johnsbury Vermont Community Health Team (CHT). METHODS: Researchers conducted case studies of the initiatives using mixed methods, including: secondary analysis of program and electronic health record data, systematic document review and interviews. RESULTS: RPC is a learning collaborative that teaches quality improvement and patient-centeredness to primary care providers, residents, clinical support staff, and administrative staff in residency programs. Results show that participation in a higher number of live learning sessions resulted in a significant increase in patient centered medical home recognition attainment and significant improvements in performance in diabetic process measures including eye exams (14.3%, p=0.004), eye referrals (13.82%, p=0.013), foot exams (15.73%, p=0.003), smoking cessation (15.83%, p=0.012), and self-management goals (25.45%, p=0.001). As a community-clinical linkages model, CHT involves primary care practices, community health workers (CHWs), and community partners. Results suggest that CHT members successfully work together to coordinate comprehensive care for the individuals they serve. Further, individuals exposed to CHWs experienced increased stability in access to health insurance (p=0.001) and prescription drugs (p=0.000), and the need for health education counseling (p=0.000). CONCLUSION: Findings from this study indicate that these two system-level strategies have the promise to improve primary care delivery. Additional research can determine the extent to which these strategies can improve other health outcomes.

Compliance with New York City's beverage regulations and beverage consumption among children in early child care centers.

INTRODUCTION: This article examines the association between the New York City regulations on beverages served in child care centers and beverage consumption among enrolled children. The regulations include requirements related to beverages served to children throughout the day. METHODS: Beverage consumption data were collected on 636 children enrolled in 106 group child care centers in New York City. Data on compliance with the regulations were collected through direct observation, interviews with center staff, and a site inventory. Logistic regression for rare events was used to test associations between compliance with the regulations and beverage consumption. RESULTS: Compliance with the regulations was associated with lower odds of children consuming milk with more than 1% fat content and sugar-sweetened beverages during meals and snacks. There was not a significant relationship between compliance with the regulations and children's consumption of water. CONCLUSION: The findings suggest a strong, direct relationship between what a center serves and what a child consumes, particularly regarding consumption of higher-fat milk and sugar-sweetened beverages. Therefore, policies governing the types of beverages served in child care centers may increase children's consumption of more healthful beverages and reduce the consumption of less healthful ones.

Evaluation design of New York City's regulations on nutrition, physical activity, and screen time in early child care centers.

This article describes the multi-method cross-sectional design used to evaluate New York City Department of Health and Mental Hygiene's regulations of nutrition, physical activity, and screen time for children aged 3 years or older in licensed group child care centers. The Center Evaluation Component collected data from a stratified random sample of 176 licensed group child care centers in New York City. Compliance with the regulations was measured through a review of center records, a facility inventory, and interviews of center directors, lead teachers, and food service staff. The Classroom Evaluation Component included an observational and biometric study of a sample of approximately 1,400 children aged 3 or 4 years attending 110 child care centers and was designed to complement the center component at the classroom and child level. The study methodology detailed in this paper may aid researchers in designing policy evaluation studies that can inform other jurisdictions considering similar policies.

Promoting brain health for African Americans: evaluating the healthy brain initiative, a community-level demonstration project.

INTRODUCTION: African Americans are at significantly greater risk than non-Hispanic Whites or Hispanics for cognitive impairment. This study presents an evaluation of the Alzheimer's Association's Healthy Brain Initiative, a culturally tailored community-level intervention to increase knowledge and awareness of brain health among African American baby boomers. METHODS: The evaluation used a mixed-method design with data collection before, during, and after intervention implementation. RESULTS: The intervention was implemented with fidelity to model design by Alzheimer's Association chapters. Partnerships between chapters and community organizations to increase awareness of brain health among African American baby boomers were facilitated. Community members who participated in intervention workshops demonstrated increased knowledge, awareness, and intentions to engage in recommended health-protective behaviors. CONCLUSION: A community-level intervention can increase knowledge and awareness of brain health among African American baby boomers. In addition, such interventions can motivate participants' intentions to engage in health-protective behaviors to maintain overall health and brain health.

Barriers to physical activity among women in the rural midwest.

Physical activity is an important factor in chronic disease control and prevention. Yet women and rural residents consistently report lower rates of physical activity than their male and urban/suburban counterparts. The objective of this study was to assess the relationship between personal, social, and environmental barriers and meeting moderate physical activity recommendations in a sample of rural women. Data were obtained from a telephone survey of 2,510 residents of rural southeastern Missouri, Tennessee, and Arkansas. After adjusting for age and income, women who identified personal barriers, such as lack of time, no motivation, disinterest in exercise, and having no one to exercise with were less likely to meet physical activity recommendations. There was evidence of a dose-response relationship between the number of barriers identified and meeting moderate physical activity recommendations among women with higher incomes and women with lower incomes; however, this relationship was most striking among women with annual household incomes of 25,000 US Dollar or more. These findings may be used to tailor physical activity interventions to women in rural communities.