A smoking cessation intervention for rural veterans tailored to individual risk factors: A multicenter randomized clinical trial.

INTRODUCTION: Rates of cigarette use remain elevated among those living in rural areas. Depressive symptoms, risky alcohol use, and weight concerns frequently accompany cigarette smoking and may adversely affect quitting. Whether treatment for tobacco use that simultaneously addresses these issues affects cessation outcomes is uncertain. METHODS: The study was a multicenter, two-group, randomized controlled trial involving mostly rural veterans who smoke (N = 358) receiving treatment at one of five Veterans Affairs Medical Centers. The study randomly assigned participants to a tailored telephone counseling intervention or referral to their state tobacco quitline. Both groups received guideline-recommended smoking cessation pharmacotherapy, selected using a shared decision-making approach. The primary outcome was self-reported seven-day point prevalence abstinence (PPA) at three and six months. The study used salivary cotinine to verify self-reported quitting at six months. RESULTS: Self-reported PPA was significantly greater in participants assigned to Tailored Counseling at three (OR = 1.66; 95 % CI: 1.07-2.58) but not six (OR = 1.35; 95 % CI: 0.85-2.15) months. Post hoc subgroup analyses examining treatment group differences based on whether participants had a positive screen for elevated depressive symptoms, risky alcohol use, and/or concerns about weight gain indicated that the cessation benefit of Tailored Counseling at three months was limited to those with ≥1 accompanying concern (OR = 2.02, 95 % CI: 1.20-3.42). Biochemical verification suggested low rates of misreporting. CONCLUSIONS: A tailored smoking cessation intervention addressing concomitant risk factors enhanced short-term abstinence but did not significantly improve long-term quitting. Extending the duration of treatment may be necessary to sustain treatment effects.

Telemedicine-based inspiratory muscle training and walking promotion with lung cancer survivors following curative intent therapy: a parallel-group pilot randomized trial.

PURPOSE: Following curative-intent therapy of lung cancer, many survivors experience dyspnea and physical inactivity. We investigated the feasibility, acceptability, safety, and potential efficacy of inspiratory muscle training (IMT) and walking promotion to disrupt a postulated "dyspnea-inactivity" spiral. METHODS: Between January and December 2022, we recruited lung cancer survivors from Kaiser Permanente Colorado who completed curative-intent therapy within 1-6 months into a phase-IIb, parallel-group, pilot randomized trial (1:1 allocation). The 12-week intervention, delivered via telemedicine, consisted of exercise training (IMT + walking), education, and behavior change support. Control participants received educational materials on general exercise. We determined feasibility a priori: enrollment of ≥ 20% eligible patients, ≥ 75% retention, study measure completion, and adherence. We assessed acceptability using the Telemedicine-Satisfaction-and-Usefulness-Questionnaire and safety events that included emergency department visits or hospitalizations. Patient-centered outcome measures (PCOMs) included dyspnea (University-of-California-San-Diego-Shortness-of-Breath-Questionnaire), physical activity (activPAL™ steps/day), functional exercise capacity (mobile-based-six-minute-walk-test), and health-related quality of life (HRQL, St.-George's-Respiratory-Questionnaire). We used linear mixed-effects models to assess potential efficacy. RESULTS: We screened 751 patients, identified 124 eligible, and consented 31 (25%) participants. Among 28 participants randomized (14/group), 22 (11/group) completed the study (79% retention). Intervention participants returned > 90% of self-reported activity logs, completed > 90% of PCOMs, and attended > 90% of tele-visits; 75% of participants performed IMT at the recommended dose. Participants had high satisfaction with tele-visits and found the intervention useful. There was no statistically significant difference in safety events between groups. Compared to control participants from baseline to follow-up, intervention participants had statistically significant and clinically meaningful improved HRQL (SGRQ total, symptom, and impact scores) (standardized effect size: -1.03 to -1.30). CONCLUSIONS: Among lung cancer survivors following curative-intent therapy, telemedicine-based IMT + walking was feasible, acceptable, safe, and had potential to disrupt the "dyspnea-inactivity" spiral. Future efficacy/effectiveness trials are warranted and should incorporate IMT and walking promotion to improve HRQL. TRIAL REGISTRATION: ClinicalTrials.gov NCT05059132.

Lung cancer survivors' views on telerehabilitation following curative intent therapy: a formative qualitative study.

OBJECTIVES: To inform personalised home-based rehabilitation interventions, we sought to gain in-depth understanding of lung cancer survivors' (1) attitudes and perceived self-efficacy towards telemedicine; (2) knowledge of the benefits of rehabilitation and exercise training; (3) perceived facilitators and preferences for telerehabilitation; and (4) health goals following curative intent therapy. DESIGN: We conducted semi-structured interviews guided by Bandura's Social Cognitive Theory and used directed content analysis to identify salient themes. SETTING: One USA Veterans Affairs Medical Center. PARTICIPANTS: We enrolled 20 stage I-IIIA lung cancer survivors who completed curative intent therapy in the prior 1-6 months. Eighty-five percent of participants had prior experience with telemedicine, but none with telerehabilitation or rehabilitation for lung cancer. RESULTS: Participants viewed telemedicine as convenient, however impersonal and technologically challenging, with most reporting low self-efficacy in their ability to use technology. Most reported little to no knowledge of the potential benefits of specific exercise training regimens, including those directed towards reducing dyspnoea, fatigue or falls. If they were to design their own telerehabilitation programme, participants had a predominant preference for live and one-on-one interaction with a therapist, to enhance therapeutic relationship and ensure correct learning of the training techniques. Most participants had trouble stating their explicit health goals, with many having questions or concerns about their lung cancer status. Some wanted better control of symptoms and functional challenges or engage in healthful behaviours. CONCLUSIONS: Features of telerehabilitation interventions for lung cancer survivors following curative intent therapy may need to include strategies to improve self-efficacy and skills with telemedicine. Education to improve knowledge of the benefits of rehabilitation and exercise training, with alignment to patient-formulated goals, may increase uptake. Exercise training with live and one-on-one therapist interaction may enhance learning, adherence, and completion. Future work should determine how to incorporate these features into telerehabilitation.

Modifiable factors associated with health-related quality of life among lung cancer survivors following curative intent therapy.

OBJECTIVE: The number of lung cancer survivors is increasing along with advances in screening, diagnosis, and treatment. Following curative intent therapy, many lung cancer survivors experience significant health-related quality of life (HRQL) impairments. We sought to identify potentially modifiable factors that contribute to the HRQL of these patients. MATERIALS AND METHODS: In this cross-sectional observational study of disease-free, stage I-IIIA lung cancer survivors following curative intent therapy, we used a conceptual model to examine factors that included behavioral, objective functional and physiologic, self-rated function and symptom burden, specific comorbidities, and non-modifiable demographic and clinical lung cancer-related characteristics. We assessed HRQL using the valid and prognostic European Organization for Research and Treatment of Cancer Quality of Life (QoL) Core 30 global health/QoL subscale. We used univariable and multivariable linear regression modeling with backward elimination of potentially modifiable and non-modifiable factors, and interpreted clinically and statistically significant, consistent, and independent modifiable factors as meaningful. RESULTS: Among 75 participants at a median of 12 months since treatment completion, the mean (standard deviation) C30 global health/QoL score was 62.7 (23.3) points (0-100 scale range). In multivariable analysis, with and without non-modifiable factors, we identified three clinically and statistically significant, consistent, and independent factors (unstandardized ß range) associated with global health/QoL: 1) abnormal exercise-induced dyspnea (-9.23 to -10.0 points); 2) impaired self-rated role function (or inability to perform work or daily activities and pursuing leisure-time activities) (-12.6 to -16.4 points); and 3) abnormal insomnia (or trouble sleeping) (-12.6 to -16.4 points). CONCLUSION: We identified meaningful modifiable factors associated with the HRQL of disease-free, stage I-IIIA lung cancer survivors following curative intent therapy. Interventions to improve the HRQL of these patients should aim to reduce exercise-induced dyspnea, improve role function - the ability to perform work and other daily including leisure-time activities, and control insomnia.

Association of Leisure-Time Physical Activity With Health-Related Quality of Life Among US Lung Cancer Survivors.

Background: Physical activity and exercise improve function, symptom control, and health-related quality of life (QoL) for many cancer survivors; however, the evidence is limited and inconsistent in lung cancer. We examined the relationship between leisure-time physical activity (LTPA) and health-related QoL in a national sample of US lung cancer survivors. Methods: We conducted a cross-sectional study using the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. We defined LTPA as a self-report of engaging in any physical activity or exercise such as running, calisthenics, golf, gardening, or walking for exercise in the past 30 days, health-related QoL as the number of days of having poor physical or mental health in the past 30 days, and general health status. We analyzed using multivariable logistic regressions with 95% confidence intervals (CIs). Results: Among 614 lung cancer survivors, 316 (51.5%) reported engaging in LTPA. The counts (and proportions) of participants who engaged in LTPA vs no LTPA were, respectively, 135 (42.7%) vs 63 (21.1%) for 0 days of poor physical health, 222 (70.3%) vs 174 (58.4%) for 0 days of poor mental health, and 158 (50.0%) vs 77 (25.8%) for good to excellent general health. In multivariable analyses, participating in LTPA was associated with odds ratios of 2.64 (95% CI = 1.76 to 3.96) and 1.43 (95% CI = 0.97 to 2.10) for 0 days of poor physical and mental health, respectively, and 2.61 (95% CI = 1.74 to 3.91) for good to excellent general health. Conclusions: Participating in LTPA was associated with improved health-related QoL. Interventions to promote LTPA and/or exercise-based rehabilitation may improve QoL among lung cancer survivors.

Predictors of Receipt of Clinical Preventive Services in Adolescents and Adults with Down Syndrome Accessing Medicaid.

BACKGROUND: Persons with Down syndrome (DS) require preventive care that addresses their age-/gender- and syndrome-specific needs. Yet, adolescents and adults with DS do not receive these preventive care services as recommended. OBJECTIVE/HYPOTHESIS: To identify factors that predict receipt of age-/gender- and syndrome-specific preventive healthcare among adolescents and adults with DS. We hypothesized that more healthcare encounters and greater medical complexity would increase receipt of preventive care due to more opportunities to complete these activities. METHODS: Using Medicaid claims (2006-2010) for California, Colorado, Michigan, and Pennsylvania, we conducted a retrospective cohort study of adolescents and adults with DS (≥12 years old). We modeled receipt of both ≥1 wellness examination and ≥1 thyroid function test (TFT) in 2009-2010 as a function of receipt of those same healthcare activities in 2006-08, adjusting for demographics, key comorbidities, and medical complexity using multivariable logistic regression. RESULTS: In this cohort of 3487 adolescents and adults with DS accessing Medicaid, 17% received both ≥1 wellness examination and ≥1 TFT in 2006-2008, 15% in 2009-2010, and only 7% during both time periods. Despite medical complexity and frequent healthcare interactions, the best predictor of future receipt of these activities was past receipt. State of residence variably impacted receipt of these preventive activities. CONCLUSIONS: Although past receipt of wellness examination and TFT was the best predictor of future receipt of these activities, overall rates were quite low in this cohort of adolescents and adults with DS. Further work is needed to improve preventive healthcare delivery to this vulnerable population.

Low Rates of Preventive Healthcare Service Utilization Among Adolescents and Adults With Down Syndrome.

INTRODUCTION: People with Down syndrome have health risks that require specific lifelong preventive health care. With increasing life expectancy, people with Down syndrome also face health conditions typical of their unaffected peers and thus need coordinated health care. The purpose of this study is to describe rates of age/sex- and Down syndrome-specific preventive healthcare activities among adolescents and adults with Down syndrome. METHODS: Using Medicaid claims (2006-2010) in California, Colorado, Michigan, and Pennsylvania, the cohort was defined as people with Down syndrome aged ≥12 years seen by primary care providers and enrolled in Medicaid for ≥45 of 60 months without dual Medicare enrollment (n=3,501). Age focus-consistent primary care providers were defined as having a focus concordant with a patient's age: 12-17 years, child or mixed-focus; ≥26 years, adult or mixed-focus; 18-25 years, any focus. Differences in healthcare activities were evaluated using Pearson's chi-square, Fisher's exact, and Kruskal-Wallis tests. Analyses were performed in 2015-2017. RESULTS: Of the cohort, 79% had an age focus-consistent primary care provider. However, 40% of adults aged ≥26 years received care from a child-focused primary care provider. Only 43% with an age focus-consistent provider had ≥1 well examination (age focus-inconsistent primary care provider: 35%, p<0.001). Most preventive activities had poor rates (<50%) regardless of age focus consistency between provider and patient age or whether they were age/sex- or Down syndrome-specific (well examinations; vaccinations; sleep apnea; hearing; and breast, cervical, and colon cancer screenings). Lipids, vision, and thyroid screenings reached moderate levels (50% to <80%). CONCLUSIONS: Rates of age/sex- and Down syndrome-specific preventive recommendations were low among adolescents and adults with Down syndrome, regardless of the age focus consistency of their primary care provider. This represents a significant opportunity to improve primary care in this vulnerable population.

Systematic Review of Preoperative Risk Discussion in Practice.

BACKGROUND: Informed consent is an ethical imperative of surgical practice. This requires effective communication of procedural risks to patients and is learned during residency. No systematic review has yet examined current risk disclosure. This systematic review aims to use existing published information to assess preoperative provision of risk information by surgeons. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a guide, a standardized search in Ovid MEDLINE, Embase, CINHAL, and PubMed was performed. Three reviewers performed the study screening, with 2-reviewer consensus required at each stage. Studies containing objective information concerning preoperative risk provision in adult surgical patients were selected for inclusion. Studies exclusively addressing interventions for pediatric patients or trauma were excluded, as were studies addressing risks of anesthesia. RESULTS: The initial search returned 12,988 papers after deduplication, 33 of which met inclusion criteria. These studies primarily evaluated consent through surveys of providers, record reviews and consent recordings. The most ubiquitous finding of all study types was high levels of intra-surgeon variation in what risk information is provided to patients preoperatively. Studies recording consents found the lowest rates of risk disclosure. Studies using multiple forms of investigation corroborated this, finding disparity between verbally provided information vs chart documentation. CONCLUSIONS: The wide variance in what information is provided to patients preoperatively inhibits the realization of the ethical and practical components of informed consent. The findings of this review indicate that significant opportunities exist for practice improvement. Future development of surgical communication tools and techniques should emphasize standardizing what risks are shared with patients.

Factors Impacting Perceived Access to Early Prenatal Care among Pregnant Veterans Enrolled in the Department of Veterans Affairs.

BACKGROUND: Despite the relatively recent Department of Veterans Affairs (VA) policy advances in providing care for veterans and their infants during the perinatal period, little information exists regarding access to prenatal care for women veterans. Currently, VA medical centers do not provide onsite pregnancy care for veterans, but pay for care from community obstetricians through the Veterans Choice Program (VCP) and related non-VA care programs. The VCP is subcontracted to two large contractors, Health Net and TriWest, to assist the VA in administering the VCP. To date, no studies have evaluated women's perceived access to prenatal care under the VCP. OBJECTIVE: The purpose of this study was to understand pregnant veterans' perceived access to community prenatal care through the VCP. DESIGN: The Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study is a longitudinal, prospective multisite observational cohort study of pregnant and postpartum veterans at 15 VA facilities nationwide. Telephone surveys were conducted with women veterans at 20 weeks of pregnancy. We used multivariable logistic regression to examine the odds of receiving care early enough adjusted for these key factors. Measures included perceived access to early prenatal care by race, age, marital status, history of mental health conditions, urban/rural residence, and the VCP contractor (Health Net vs. TriWest). RESULTS: Overall, 519 women veterans completed the baseline pregnancy survey. A sizeable proportion of participants reported a history of mental health conditions, including depression (56.7%), anxiety disorder (45.5%), and posttraumatic stress disorder (40.5%). White veterans were more likely to report perceived timely access to prenatal care than minority veterans (66% vs. 52%; p = .0038). Veterans receiving care at Health Net facilities were more likely to report receiving prenatal care as early as desired in comparison to veterans at TriWest facilities (adjusted odds ratio, 0.48; 95% CI, 0.32-0.73), whereas veterans with a history of depression were 1.7 times more likely to report perceived delays in desired prenatal care compared with veterans without a history of depression (adjusted odds ratio, 1.65; 95% CI, 1.08-2.53). CONCLUSIONS: We found that nearly one-third of women reported problems receiving early prenatal care as soon as they would have liked. Women with histories of depression and racial minorities may require additional maternity care coordination services to ensure they receive timely prenatal care. Community-based provider networks under the VCP should continue to be expanded so that pregnant veterans are able to access high-quality prenatal care in a timely manner.

Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial.

PURPOSE: To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers. DESIGN: Pre-post quasi-experimental trial. SETTING: General medical units of four US Department of Veterans Affairs hospitals. SUBJECTS: 898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively). INTERVENTION: The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback. MEASURES: The primary outcome was self-reported 7-day point prevalence abstinence at six months. ANALYSIS: Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression. RESULTS: Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI95)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI95=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001). CONCLUSIONS: Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.

Attending rounds: What do the all-star teachers do?

AIM: To examine differences in the types of teaching activities performed during rounds between the most effective and least effective inpatient teaching attendings. METHODS: Participants included 56 attending physicians supervising 279 trainees. Trained observers accompanied teams during rounds and recorded the frequencies of educational activities that occurred. Students and residents then rated their satisfaction with the teaching on rounds. RESULTS: Attending physicians with the highest learner satisfaction scores performed significantly more teaching activities per patient than attending physicians who were rated as average or less-effective (2.1 vs. 1.4 vs. 1.5; p = .03). There were significant differences in the frequencies of 3 out of the 9 specific teaching activities observed, including answering specific patient-care related questions (77% vs. 66% vs. 47%; p = .003), teaching on learner chosen topics (8% vs. 2% vs. 2%; p = .02), and providing feedback (31% vs. 10% vs. 0.1%; p = .001). CONCLUSIONS: Specific categories of teaching activities-patient-specific teaching, teaching on learner-identified topics, and providing real-time feedback-are performed more frequently by the highest-rated attending physicians, which can guide faculty development.

Grant Success for Early-Career Faculty in Patient-Oriented Research: Difference-in-Differences Evaluation of an Interdisciplinary Mentored Research Training Program.

PURPOSE: Since 2004, the Clinical Faculty Scholars Program (CFSP) at the University of Colorado Anschutz Medical Campus has provided intensive interdisciplinary mentoring and structured training for early-career clinical faculty from multiple disciplines conducting patient-oriented clinical and outcomes research. This study evaluated the two-year program's effects by comparing grant outcomes for CFSP participants and a matched comparison cohort of other junior faculty. METHOD: Using 2000-2011 institutional grant and employment data, a cohort of 25 scholars was matched to a cohort of 125 comparison faculty (using time in rank and pre-period grant dollars awarded). A quasi-experimental difference-in-differences design was used to identify the CFSP effect on grant outcomes. Grant outcomes were measured by counts and dollars of grant proposals and awards as principal investigator. Outcomes were compared within cohorts over time (pre- vs. post-period) and across cohorts. RESULTS: From pre- to post-period, mean annual counts and dollars of grant awards increased significantly for both cohorts, but mean annual dollars increased significantly more for the CFSP than for the comparison cohort (delta $83,427 vs. $27,343, P < .01). Mean annual counts of grant proposals also increased significantly more for the CFSP than for the comparison cohort: 0.42 to 2.34 (delta 1.91) versus 0.77 to 1.07 (delta 0.30), P < .01. CONCLUSIONS: Institutional investment in mentored research training for junior faculty provided significant grant award gains that began after one year of CFSP participation and persisted over time. The CFSP is a financially sustainable program with effects that are predictable, significant, and enduring.