The effect of limited english proficiency on prostate-specific antigen screening in American men.

PURPOSE: To evaluate how limited English proficiency (LEP) impacts the prevalence of prostate-specific antigen (PSA) screening in a contemporary, nationally representative cohort of men in the USA. METHODS: The Medical Expenditure Panel Survey was utilized to identify the prevalence of PSA screening between 2013 and 2016 among men ≥ 55. Men who speak a language other than English at home were stratified by self-reported levels of English proficiency (men who speak English very well, well, not well, or not at all). Survey weights were applied, and groups were compared using the adjusted Wald test. A multivariable logistic regression model was used to identify predictors of PSA screening adjusting for patient-level covariates. RESULTS: The cohort included 2,889 men, corresponding to a weighted estimate of 4,765,682 men. 79.6% of men who speak English very well reported receiving at least one lifetime PSA test versus 58.4% of men who do not speak English at all (p < 0.001). Men who reported not speaking English at all had significantly lower prevalence of PSA screening (aOR 0.56; 95% CI 0.35-0.91; p = 0.019). Other significant predictors of PSA screening included older age, income > 400% of the federal poverty level, insurance coverage, and healthcare utilization. CONCLUSIONS: Limited English proficiency is associated with significantly lower prevalence of PSA screening among men in the USA. Interventions to mitigate disparities in prostate cancer outcomes should account for limited English proficiency among the barriers to guideline-concordant care.

Excision of recurrent penile schwannoma with neurovascular bundle sparing: A novel surgical approach.

Penile schwannomas are rare, often painless lesions usually growing on the dorsum of the penis. A young and otherwise healthy male with recurrent painful penile schwannomas and decreased libido was successfully treated with surgical excision. Through fine dissection of the nerve fascicles leading to the primary schwannoma, the lesion was successfully removed without compromising erectile or ejaculatory function. This novel approach allowed for significant symptomatic relief and improved quality of life.

Predictors of Financial Toxicity Among United States Prostate Cancer Survivors: Results From a National Survey.

INTRODUCTION: Despite increasing attention to financial toxicity associated with prostate cancer, national rates of subjective and objective financial toxicity have not been well characterized, and it remains unknown which prostate cancer survivors are at highest risk for undue financial burden. METHODS: Men with a history of prostate cancer were identified from the Medical Expenditure Panel Survey. The proportion of men reporting catastrophic health care expenditures (out-of-pocket spending >10% of income) and other measures of financial toxicity were assessed. Multivariable logistic regression was used to identify independent predictors of financial toxicity. RESULTS: Of a weighted estimate of 2,349,532 men with a history of prostate cancer, 13.5% reported catastrophic health care expenditures, 16% reported subjective worry about ability to pay medical bills, and 15% reported work changes due to their cancer diagnosis. Significant predictors of catastrophic expenditures included private insurance (OR 4.62, 95% CI 1.29-16.49) and medical comorbidities (OR 1.38, 95% CI 1.05-1.82), while high income was protective (>400% vs <100% federal poverty level, OR 0.06, 95% CI 0.02-0.19). Each year of older age was associated with decreased odds of subjective worry about medical bills. Only 12% of men reported their doctor discussed the costs of care in detail. CONCLUSIONS: Nearly 1 in 7 prostate cancer survivors experience catastrophic health care expenditures, and a larger proportion report subjective manifestations of financial toxicity. Many men report their physicians did not address the financial side effects of treatment. These results highlight the patient characteristics associated with this important side effect of prostate cancer care.

Assessing Patient-Reported Financial Hardship in Patients With Cancer in Routine Clinical Care.

PURPOSE: Financial hardship (FH) in cancer care is a growing challenge for patients, their caregivers, and health care providers with impact on morbidity and mortality. In this study, we report on a standardized approach to describe the prevalence and predictors for FH as part of routine clinical workflow. We also report on the association of FH with survival in our cancer patient population. METHODS: This study includes patients who completed a FH screen at least once between 2018 and 2020. Demographics, disease state, and mortality data were extracted from the medical records. Multivariable logistic regression models were used to examine association of sociodemographic and disease variables with FH. By using propensity score weighting to account for differences in demographic and clinical factors between patients with and without FH, we then fit Cox proportional hazards models to examine the relationship between FH and survival. RESULTS: The study cohort included 31,154 patients. FH was reported by 14% (n = 4,250) of the patients. A significantly higher likelihood of having FH (P < .001 for all) was reported by racial/ethnic minority patients; those who were unemployed/disabled, single, or divorced; patients from disadvantaged neighborhoods; and those who were self-pay or had government insurance. Older age, being retired, and living farther from the cancer center were associated with significantly less likelihood of endorsing FH. Patients who endorsed FH had a lower survival (hazard ratio for mortality 1.46). CONCLUSION: Our study identified key groups more likely to report FH in a relatively affluent population at a large cancer center and showed an adverse association between FH and survival. Further research is needed to develop clinical care pathways for patients at high risk for worse financial and clinical outcomes.

Association of Health Insurance Literacy With Financial Hardship in Patients With Cancer.

Importance: Patient-reported financial hardship is an increasing challenge in cancer care delivery. Health insurance literacy and its association with financial hardship in patients with cancer, especially after controlling for financial literacy, have not been well examined. Objective: To examine the prevalence of and factors in the association between health insurance literacy and financial literacy as well as the overall and individual domains of financial hardship and their association with health insurance literacy, both independently and when adjusted for financial literacy, in patients with cancer. Design, Setting, and Participants: This cross-sectional survey study recruited and enrolled patients from 2 separate ambulatory infusion centers at Mayo Clinic Arizona in Phoenix, Arizona, and the University of Mississippi Medical Center in Jackson, Mississippi. Adult patients aged 18 years or older were enrolled from December 2019 to February 2020 and from August to October 2020 at Mayo Clinic Arizona (n = 299) and from September 2020 through January 2021 at the University of Mississippi Medical Center (n = 105). Survey respondents received a $5 gift card. Exposures: Surveys included questions about sociodemographic characteristics, health insurance literacy and financial literacy, financial knowledge, and financial hardship and its domains (material hardship, psychological hardship, and behavioral hardship). Main Outcomes and Measures: Financial hardship was assessed using the COST-FACIT (Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy) measure and National Health Interview Survey questions to capture information about the domains of financial hardship. The Health Insurance Literacy Measure is a validated 21-item measure of a consumer's ability to select and use health insurance. Five questions from the National Financial Capability Study assessed financial literacy. Results: A total of 404 participants were enrolled in the study. Median (IQR) age of the respondents was 63 (54-71) years, and 219 were women (54%), 307 were non-Hispanic White individuals (76%), 153 (38%) had private insurance, and 289 (72%) had solid tumors. Overall financial hardship (denoted by median COST-FACIT score <27 points) was reported by 49% (95% CI, 44%-53%) of the cohort. Prevalence of financial hardship was higher using the National Health Interview Survey questions, with 68% (95% CI, 63%-72%) of respondents reporting at least 1 hardship domain (n = 276). Sixty-six percent (95% CI, 60%-69%) of respondents (n = 265) had a high level of financial literacy. The mean (SD) Health Insurance Literacy Measure score was 64.9 (13.3) points. In multivariable analyses, each 10-point increase in the Health Insurance Literacy Measure score was associated with lower odds of financial hardship (odds ratio, 0.82; 95% CI, 0.68-0.99; P = .04). However, this association was no longer significant after adjusting for financial literacy. Conclusions and Relevance: Results of this study showed that, despite a high level of health insurance literacy and financial literacy, the prevalence of financial hardship was high. Although there were lower odds of financial hardship with increased health insurance literacy, the association was no longer significant when financial literacy was added to the model, suggesting that a high level of financial literacy may help mitigate the adverse outcome of lower health insurance literacy levels in patients with cancer.

Salvage versus primary holmium laser enucleation of the prostate: trends, outcomes and safety analysis.

PURPOSE: To study the safety, efficacy and trends in index procedures leading to salvage holmium laser enucleation of the prostate (S-HoLEP). METHODS: This was a single-institution retrospective review of HoLEPs performed between 2006 and 2020. Patients who underwent S-HoLEP were compared to those undergoing primary holmium laser enucleation of the prostate (P-HoLEP). The endpoint of primary interest were functional outcomes. Changes in index procedures over the study period were analyzed. RESULTS: A total of 633 HoLEPs were performed during the study, with 217 being S-HoLEP. The S-HoLEP cohort was older than P-HoLEP cohort, 71.2 years vs 68.8 years (p = 0.03). All other factors were well matched. The most common index procedures prior to S-HoLEP included transurethral resection of the prostate (TURP) (87, 40.1%), transurethral microwave thermotherapy (TUMT) (44, 20.3%), photoselective vaporization of the prostate (PVP) (24, 11.1%) and prostatic urethral lift (PUL) (24, 11.1%). Preoperative prostate volume, IPSS and Qmax were similar between groups. Intra-operatively, S-HoLEP had longer procedure and morcellation times (p = 0.01 and 0.007). Postoperatively, the S-HoLEP cohort had longer catheter duration and hospitalization (both p < 0.001). Postoperative Qmax, IPSS and 90-day complication rates were similar. On temporal analysis, minimally invasive surgical therapies (MIST) have become more prevalent as index procedures. CONCLUSION: S-HoLEP is safe and efficacious for patients requiring additional BPH surgical intervention. S-HoLEP patients had longer operative times and hospital stays but equivalent postoperative functional outcomes compared to P-HoLEP. As MIST mature and gain traction, it is expected that rates of S-HoLEP will continue to rise.

A Scoping Review of Published Intimate Partner Violence Curricula for Medical Trainees.

Intimate partner violence (IPV) affects many, and health care has the potential to provide a safe space for individuals experiencing IPV. However, physicians cite lack of time and education as barriers. The aim of this study is to complete a review of published IPV curricula in medical school, residency training, and postresidency training. We performed a scoping review to provide a quantitative assessment and summary review of existing IPV curricula. In May 2020, a librarian conducted a search of Ovid MEDLINE, Ovid EMBASE, and Scopus. We evaluated each article for the following curriculum content and structure items: (1) year introduced; (2) delivery method; (3) curriculum type; (4) curriculum content; (5) curriculum effectiveness; and (6) implementation barriers. Fifty-six articles met criteria, most were for medical school learners (n = 32, 57.1%) and short-term (lasting less than one academic year) (n = 41, 73.2%). For residency, IPV curricula were most frequently taught in family medicine, internal medicine, and emergency medicine. Formal lecture and use of standardized patients were the most popular delivery methods. Most curricula taught risk factors for and identification of individuals who have experienced IPV. The most cited implementation barrier was limited time in standard medical education, followed by inability to measure the effectiveness of the curriculum. There was great variation in the methods of assessing effectiveness of IPV curricula. Published IPV curricula are varied, without consistent validated tools for assessing efficacy. Future initiatives to establish a standard of competency for medical students regarding IPV, including a standard curriculum, may better ensure that physicians are capable of identifying and caring for individuals who have experienced IPV.

COVID-19 Impact on the Doctor-Patient Relationship: Patient Perspectives on Emergency Physician Empathy and Communication.

OBJECTIVE: To investigate in how the current COVID-19 pandemic affects patient's perceptions of emergency physician empathy and communication. METHODS: Patients cared for by Emergency Department physicians with the lowest satisfaction scores were surveyed within one week of discharge via phone. Using questions from the Consultation and Relational Empathy (CARE) survey, patients rated their satisfaction with their Emergency provider's empathy and communication on a scale of 1 to 5 and provided feedback on how the patient-provider interaction could be improved. Demographic data and patient responses to CARE survey questions were compared between pre-COVID-19 and during COVID-19 time. Patient's open-ended responses were analyzed for themes related to the impact of COVID-19 on the patient-provider relationship. RESULTS: Patient median quantitative scores were 5 (4-5) across all five questions of pre-COVID-19 and 5 (4-5) during COVID-19 for all questions except two (showing care and compassion), median 5(5-5). Female patients rated provider empathy and communication lower than mens. There was no differences across age strata. A shift in provider focuses to COVID-19 only care (N=3), and an understanding of the stress on healthcare processes (N=13) from open-ended responses themes emerged of patients who want to minimize interactions within the emergency department (N=3). CONCLUSIONS: The external factor of the current pandemic did not negatively impact patient's satisfaction scores. Many patients express leniency and gratitude for emergency providers during this challenging time. Their responses seem to mirror current societal views of frontline healthcare workers.

Patient Suggestions to Improve Emergency Physician Empathy and Communication.

Emergency physician empathy and communication is increasingly important and influences patient satisfaction. This study investigated if there is a need for improvement in provider empathy and communication in our emergency department and what areas could be targeted for future improvement. Patients cared for by emergency physicians with the lowest satisfaction scores were surveyed within 1 week of discharge. Patients rated their emergency provider's empathy and communication and provided feedback on the patient-provider interaction. Compared to survey responses nationally, our providers fell between the 10th and 25th percentiles for all questions, except question 5 (making a plan of action with [the patient]) which was between the 5th and 10th percentile. Areas most frequently cited for improvement were "wanting to know why" (N = 30), "time is short" (N = 15), and "listen to the patient" (N = 13). Survey percentiles and open-ended suggestions demonstrate a need for providers to give thorough explanations, spend more time with the patient, and demonstrate active listening. These themes can be used to strengthen the provider-patient relationship.