Associations between Food Pantry Size and Distribution Method and Healthfulness of Foods Received by Clients in Baltimore City Food Pantries.

This study aimed to evaluate the association of the overall nutritional quality and the weight share of specific types of foods received by food pantry clients with food pantry size and distribution method. Data on healthy food weights using the gross weight share (GWS) of select foods and the validated Food Assortment Score Tool (FAST) were collected from 75 food pantry clients in Baltimore, Maryland. The average FAST score across the study population was 63.0 (SD: 10.4). Overall, no statistically significant differences in average FAST scores by pantry size and distribution method were found. However, among client-choice pantries, clients of small pantries had higher scores (p < 0.05) while among medium pantries, clients of traditional pantries had higher scores (p < 0.01). Subgroup analysis of GWS was stratified by pantry size and distribution methods. Findings suggested multi-level, multi-component interventions combining environmental strategies are needed to enhance the healthfulness of foods received by clients. Our analysis provided data to consider further refinements of pantry interventions and planning of more rigorous research on factors influencing the effectiveness of pantry interventions.

Primary care clinicians' perceptions of colorectal cancer screening tests for older adults.

Colonoscopy is an effective screening test for colorectal cancer but is associated with significant risks and burdens, especially in older adults. Stool tests, which are more convenient, more accessible, and less invasive, can be important tools to improve screening. How clinicians make decisions about colonoscopy versus stool tests in older patients is not well-understood. We conducted semi-structured interviews with primary care clinicians throughout Maryland in 2018-2019 to examine how clinicians considered the use of stool tests for colorectal cancer screening in their older patients. Thirty clinicians from 21 clinics participated. The mean clinician age was 48.2 years. The majority were physicians (24/30) and women (16/30). Four major themes were identified using qualitative content analysis: (1) Stool test equivalency - although many clinicians still considered colonoscopy as the test of choice, some clinicians considered stool tests equivalent options for screening. (2) Reasons for recommending stool tests - clinicians reported preferentially using stool tests in sicker/older patients or patients who declined colonoscopy. (3) Stool test overuse - some clinicians reported recommending stool tests for patients for whom guidelines do not recommend any screening. (4) Barriers to use - perceived barriers to using stool tests included lack of familiarity, un-returned stool test kits, concern for accuracy, and concern about cost. In summary, clinicians reported preferentially using stool tests in sicker and older patients and mentioned examples of potential overuse. Additional studies are needed on how to better individualize the use of different colorectal screening tests in older patients.

Exploring the Reasons for Low Usage and Informing Strategies to Improve Use of a Nonprofit Grocery Store in Baltimore City.

Introducing new grocery stores into low-income communities has been a focus of policy efforts to improve the food environment. Yet, evidence of the impact of this strategy on diet and health outcomes is inconsistent. In Baltimore, a not-for-profit grocery store was opened by the Salvation Army in March 2018 with the goal of improving healthy food access. Unfortunately, the store has so far failed to attract sufficient customers. This study explored the reasons for low usage from the perspective of community members and staff members. A qualitative, formative research study was conducted at the store, which included semi-structured interviews (n = 21), direct observations (n = 8), and sociodemographic surveys (n = 152). Reasons for low store usage included high prices, confusion regarding the nature of the store, and lack of product variety. Reducing prices, increasing community engagement, and using promotional materials were all recommended strategies to increase usage. The Salvation Army is interested in potentially opening other nonprofit grocery stores. The results of this study will be used to help the Salvation Army refine their nonprofit grocery store model and in their future planning.

Primary Care Clinician Decision-Making Around Surveillance Colonoscopies in Older Adults with Prior Adenomas.

INTRODUCTION: While guidelines recommend against routine colorectal cancer screening in adults >75 years and/or those with limited life expectancies, there is no clear guidance on when surveillance colonoscopies following prior adenoma detection should stop. How primary care clinicians weigh the potential risks and benefits of surveillance colonoscopies in older adults with prior adenomas is unknown. METHODS: We conducted semistructured in-person interviews with 30 primary care clinicians from 21 clinics in Maryland. We asked how clinicians decided whether to continue or stop surveillance colonoscopies in older adults (65+ years) with prior adenomas. Interview transcripts were independently coded by 2 investigators using qualitative content analysis. RESULTS: Participants described a range of decision-making approaches. Some deferred to specialists because they did not feel confident making decisions about stopping surveillance in light of the higher cancer risk involved. Some took a more active role and discussed the decision with patients and/or specialists. Other clinicians felt comfortable stopping surveillance colonoscopies and made these decisions based on patient age, comorbidities, or life expectancy. DISCUSSION: We found a range of decision-making approaches among primary care clinicians on whether to continue surveillance colonoscopies in older adults with prior adenomas. Separate bodies of evidence currently exist on how prior adenoma characteristics influence colorectal cancer risk and on how older age and declining health influence the benefit/harm balance of screening. Information is lacking on the benefits and harms of surveillance in older adults with prior adenomas. Developing the evidence to address this knowledge gap is critically needed to inform clinical decision making.

Assessment of Clinician Decision-making on Cancer Screening Cessation in Older Adults With Limited Life Expectancy.

Importance: Despite clinical practice guidelines recommending against routine cancer screening in older adults with limited life expectancy, older adults are still frequently screened for breast, colorectal, and prostate cancers. Objective: To examine primary care clinicians' decision-making on stopping breast, colorectal, or prostate cancer screening in older adults with limited life expectancy. Design, Setting, and Participants: In qualitative interviews coupled with medical record-stimulated recall, clinicians from 17 academic and community clinics affiliated with a large health system were asked how they came to specific cancer screening decisions in 2 or 3 of their older patients with less than 10-year of estimated life expectancy, including patients with and without recent screening. Patients were surveyed by telephone. Data collection occurred between October 2018 and May 2019. Main Outcomes and Measures: Clinician interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed with qualitative content analysis to identify major themes. Patient surveys assessed perception of cancer screening decisions, importance of clinician recommendation, and willingness to stop screening. Results: Twenty-five primary care clinicians (mean [SD] age, 47.1 [9.7] years; 14 female [56%]) discussed 53 patients during medical record-stimulated recall, ranging from 2 to 3 patients per clinician; 46 patients and 1 caregiver (mean [SD] age 74.9 [5.4]; 31 female [66%]) participated in the survey. Clinician interviews revealed 5 major themes: (1) cancer screening decisions were not always conscious, deliberate decisions; (2) electronic medical record alerts were connected with less deliberate decision-making; (3) cancer screening was not binary and clinicians often considered other options to scale back screening without actually stopping; (4) in addition to patient characteristics, clinicians were influenced by patient request and anecdotal experiences; and (5) influences outside of the primary care clinician-patient dyad were important, such as from specialists and patients' family or friends. Patient surveys asked approximately 64 cancer screening decisions of 47 patients. Patients did not recall approximately half (31 of 64) of their cancer screening decisions. Among those with recent screening, the mean score for willingness to stop screening was 3.2 (95% CI 2.5-3.9) on a 5-point Likert scale (with 1 indicating "extremely unlikely" and 5 indicating "extremely likely"). In most screening decisions that involved specialists (13 of 16), patients valued specialists' recommendations over those of primary care clinicians. Conclusions and Relevance: Cancer screening decision-making is complex. Study findings suggest that strategies that facilitate more deliberate decision-making may be important in cancer screening of older adults with limited life expectancy.

Clinician Perspectives on Overscreening for Cancer in Older Adults With Limited Life Expectancy.

BACKGROUND/OBJECTIVES: Guidelines recommend against routine screening for breast, colorectal, and prostate cancers in older adults with less than 10 years of life expectancy. However, clinicians often continue to recommend cancer screening for these patients. We examined primary care clinicians' perspectives regarding overscreening, as defined by limited life expectancy. DESIGN: Semistructured, in-depth individual interviews. SETTING: Twenty-one academic and nonacademic primary care clinics in Maryland. PARTICIPANTS: Thirty primary care clinicians from internal medicine, family medicine, medicine/pediatrics, and geriatric medicine. MEASUREMENTS: Interviews explored whether the clinicians believed that overscreening for breast, colorectal, or prostate cancers existed in older adults and their views on using life expectancy to decide on stopping routine screening. Audio recordings of the interviews were transcribed verbatim. Two investigators independently coded all transcripts using qualitative content analysis. RESULTS: Most clinicians were physicians (24/30) and women (16/30). Content analysis generated three major themes. (1) Many, but not all, clinicians perceived overscreening in older adults as a problem. (2) There was controversy around using limited life expectancy to define overscreening due to concerns that the guidelines did not capture potential nonmortality benefits of screening; that population-based screening data could not be easily applied to individuals; that this approach failed to account for patient choice; and that life expectancy predictions were inaccurate. (3) Some clinicians worried that using life expectancy to define overscreening may inadvertently introduce bias and lead to unintended harms. CONCLUSIONS: Several clinicians disagreed with guideline frameworks of using limited life expectancy to guide cancer screening cessation. Some disagreement stems from inadequate knowledge about the benefits and harms of cancer screening and indicates a need for education or decision support. Other reasons for disagreement highlight the need to refine the current recommended cancer screening approaches and identify strategies to avoid unintended consequences, such as introducing bias or exacerbating existing disparities. J Am Geriatr Soc 68:1462-1468, 2020.