A pragmatic randomized trial of mailed fecal immunochemical testing to increase colorectal cancer screening among low-income and minoritized populations.

BACKGROUND: Colorectal cancer (CRC) screening is underused, particularly among low-income and minoritized populations, for whom the coronavirus disease 2019 (COVID-19) pandemic has challenged progress in achieving equity. METHODS: A hub-and-spoke model was used. The hub was a nonacademic organization and the spokes were three community health center (CHC) systems overseeing numerous clinic sites. Via a cluster-randomized trial design, nine clinic sites were randomized to intervention and 16 clinic sites were randomized to usual care. Patient-level interventions included invitation letters, mailed fecal immunochemical tests (FITs), and call/text-based reminders. Year 1 intervention impact, which took place during the COVID-19 pandemic, was assessed as the proportion completing screening among individuals not up to date at baseline, which compared intervention and nonintervention clinics accounting for intraclinic cluster variation; confidence intervals (CIs) around differences not including 0 were interpreted as statistically significant. RESULTS: Among 26,736 patients who met eligibility criteria, approximately 58% were female, 55% were Hispanic individuals, and 44% were Spanish speaking. The proportion completing screening was 11.5 percentage points (ppts) (95% CI, 6.1-16.9 ppts) higher in intervention versus usual care clinics. Variation in differences between intervention and usual care clinics was observed by sex (12.6 ppts [95% CI, 7.2-18.0 ppts] for females; 8.8 ppts [95% CI, 4.7-13.9 ppts] for males) and by racial and ethnic group (13.8 ppts [95% CI, 7.0-20.6 ppts] for Hispanic individuals; 13.0 ppts [95% CI, 3.6-22.4 ppts] for Asian individuals; 11.3 ppts [95% CI, 5.8-16.8 ppts] for non-Hispanic White individuals; 6.1 ppts [95% CI, 0.8-10.4 ppts] for Black individuals). CONCLUSIONS: A regional mailed FIT intervention was effective for increasing CRC screening rates across CHC systems serving diverse, low-income populations.

Hub-and-Spoke centralized intervention to optimize colorectal cancer screening and follow-up: A pragmatic, cluster-randomized controlled trial protocol.

BACKGROUND: Guidelines recommend screening for colorectal cancer (CRC), but participation and abnormal test follow up rates are suboptimal, with disparities by demography. Evidence-based interventions exist to promote screening, but community adoption and implementation are limited. METHODS: The San Diego Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) program is an academic-community partnership testing regional implementation of a Hub-and-Spoke model for increasing CRC screening and follow-up. The "hub" is a non-academic, non-profit organization that includes 17 community health center (CHC) systems, serving over 190 rural and urban clinic sites. The "spokes" are 3 CHC systems that oversee 11-28 clinics each, totaling over 60 clinics. Using a cluster-randomized trial design, 9 clinics were randomized to intervention and 16 to usual care. Within intervention clinics, approximately 5000 eligible patients not up-to-date with CRC screening per year were identified for intervention. Interventions include an invitation primer, a mailed fecal immunochemical test with completion instructions, and phone and text-based reminders (hub) and patient navigation protocol to promote colonoscopy completion after abnormal FIT (spoke). Outcomes include: 1) proportion of patients up-to-date with screening after three years in intervention versus non-intervention clinics; 2) proportion of patients with abnormal FIT completing colonoscopy within six months of the abnormal result. Implementation science measures are collected to assess acceptability, intervention and usual care adaptations, and sustainability of the intervention strategies. CONCLUSION: This large-scale, regional cluster randomized trial among CHCs serving diverse populations is anticipated to accelerate progress in CRC prevention in underserved populations. TRIAL REGISTRATION: NCT04941300.

Care Team Integration in Primary Care Improves One-Year Clinical and Financial Outcomes in Diabetes: A Case for Value-Based Care.

Despite significant treatment advances, diabetes outcomes remain suboptimal and health care costs continue to rise. There are limited data on the feasibility and financial implications of integrating a diabetes-specific care team in the primary care setting (ie, where the majority of diabetes is treated). This pragmatic quality improvement project investigated whether a cardiometabolic care team intervention (CMC-TI) could achieve greater improvements in clinical, behavioral, and cost outcomes compared to usual diabetes care in a large primary care group in Southern California. Over 12 months, n = 236 CMC-TI and n = 239 usual care patients with type 1 or 2 diabetes were identified using the electronic medical record. In the CMC-TI group, a registered nurse (RN)/certified diabetes educator care manager, medical assistant health coach, and RN depression care manager utilized electronic medical record-based risk stratification reports, standardized decision-support tools, live and remote tailored treatments, and coaching to manage care. Results indicated that the CMC-TI group achieved greater improvements in glycemic and lipid control, diabetes self-management behaviors, and emotional distress over 1 year compared with the usual care group (all P < .05). The CMC-TI group also had a significant 12.6% reduction in total health care costs compared to a 51.7% increase in the usual care group during the same period and inclusive of CMC-TI program costs. Patients and providers reported high satisfaction with CMC-TI. These findings highlight that team-based care management interventions that utilize nurses, medical assistant health coaches, and behavioral specialists to support diabetes patients can help primary care practices achieve value-based targets of improved health, cost, and patient experience.

No Impact of Probiotics to Reduce Clostridium difficile Infection in Hospitalized Patients: A Real-world Experience.

We assessed the effectiveness of a Lactobacillus probiotic on rates of health care facility-onset Clostridium difficile infection (HO-CDI) in patients receiving antibiotics. A total of 1576 patients were evaluated. There was no difference in the HO-CDI incidence between those who received probiotics and those who did not (1.8% vs 0.9%; P = .16).

Outcomes of rapid identification for gram-positive bacteremia in combination with antibiotic stewardship at a community-based hospital system.

BACKGROUND: Rapid diagnostics for bloodstream infections have been shown to improve outcomes. Most studies have focused on rapid diagnostics for a single pathogen and have been conducted in academic medical centers. The Verigene Gram-Positive Blood Culture Test (BC-GP) identifies 12 gram-positive organisms and 3 genetic markers of antibiotic resistance from positive blood culture media in 2.5 hours. This study evaluates implementation of the Verigene BC-GP panel in combination with real-time support from the Antibiotic Stewardship Team (AST) in a community hospital system. METHODS: This multicenter, pre-post, quasi-experimental study was conducted at the five hospitals that compose Scripps Healthcare. Rapid diagnostic testing was performed at a central laboratory from 7 a.m.-7 p.m. Pharmacists notified physicians of results and assisted with antibiotic modifications. The primary outcomes were average time to targeted antibiotic therapy and difference in antibiotic duration for contaminants. Secondary end points included hospital length of stay, mortality, pharmacy costs, and overall hospitalization costs. Adult patients with a gram-positive bacteremia admitted in 2011 (pre-rapid testing) were compared with those admitted in 2014 (post-rapid testing). RESULTS: There were 103 patients in the preintervention group and 64 patients in the intervention group. The optimized identification process, combined with AST intervention, improved mean time to targeted antibiotic therapy (61.1 vs 35.4 hrs, p<0.001) and decreased mean duration of antibiotic therapy for blood culture contaminants (42.3 vs 24.5 hrs, p=0.03). Median length of stay (9.1 vs 7.2 days, p=0.04) and overall median hospitalization costs ($17,530 vs $10,290, p=0.04) were lower in the intervention group. Mortality was similar between groups (9.1% vs 9.2%, p=0.98). CONCLUSION: Rapid identification of gram-positive blood cultures with AST intervention decreased time to targeted antibiotic therapy, length of unnecessary antibiotic therapy for blood culture contaminants, length of stay, and overall hospital costs.

Monetary matched incentives to encourage the purchase of fresh fruits and vegetables at farmers markets in underserved communities.

INTRODUCTION: Farmers market programs may increase access to more healthful foods and reduce the high prevalence of obesity in low-income communities. The objective of this study was to examine outcomes of the Fresh Fund farmers market program serving low-income neighborhoods in San Diego, California. METHODS: Through its Farmers Market Fresh Fund Incentive Program, the County of San Diego Health and Human Services Agency offered monetary incentives to government nutrition assistance recipients to purchase fresh produce at 5 farmers markets. Participants enrolled at participating markets from June 1, 2010, through December 31, 2011; they completed baseline and follow-up surveys of daily consumption and weekly spending on fruits and vegetables. We examined enrollment, participation, participant health perceptions, and vendor revenue. RESULTS: During the study period, 7,298 eligible participants enrolled in Fresh Fund; most (82%) had previously never been to a farmers market. Among 252 participants with matched surveys at baseline and 12-month follow-up, the proportion who reported their diet to be "healthy" or "very healthy" increased from 4% to 63% (P < .001); nearly all (93%) stated that Fresh Fund was "important" or "very important" in their decision to shop at the farmers market. Vendors reported that 48% of all market revenue they received was received through the Fresh Fund program. At 2 markets, revenue from June 1, 2011, through January 31, 2012, increased by 74% and 68% compared with revenue from June 1, 2010, through January 31, 2011. CONCLUSION: Participants in the Fresh Fund program self-reported increases in daily consumption and weekly spending on fruits and vegetables, and vendors at participating farmers markets also increased their revenue.

Calculation of photoelectron spectra of molybdenum and tungsten complexes using Green's functions methods.

Green's functions calculations are presented for several complexes of molybdenum and tungsten, two metals that are similar structurally but display subtle, but significant, differences in electronic structure. Outer valence Green's functions IPs for M(CO)6, M(Me)6, MH6, [MCl4O](-), and [MO4](-) (M = Mo, W) are generally within +/-0.2 eV of available experimental photoelectron spectra. The calculations show that electrons in M-L bonding orbitals are ejected at lower energies for Mo while the detachment energy for electrons in d orbitals varies with metal and complex. For the metal carbonyls, the quasiparticle picture assumed in OVGF breaks down for the inner valence pi CO molecular orbitals due to the coupling of two-hole-one-particle charge transfer states to the one-hole states. Incorporation of the 2h1p states through a Tamm-Dancoff approximation calculation accurately represents the band due to detachment from these molecular orbitals. Though the ordering of IPs for Green's functions methods and DFT Koopmans' theorem IPs is similar for the highest IPs for most compounds considered, the breakdown of the quasiparticle picture for the metal carbonyls suggests that scaling of the latter values may result in a fortuitous or incorrect assignment of experimental VDEs.