A Learning Health System Approach to Cancer Survivorship Care Among LGBTQ+ Communities

PURPOSE

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals who receive primary care services at community health centers are often referred to external specialty care centers after cancer diagnosis, upon which primary care services are disrupted and may be discontinued because of gaps in communication between primary and oncologic care providers. This qualitative study evaluated barriers and facilitators to effective care coordination for LGBTQ+ patients with cancer and the utility of a novel cancer care coordination tool to mitigate identified barriers.

MATERIALS AND METHODS

Semistructured interviews with LGBTQ+ cancer survivors, caregivers to LGBTQ+ persons, clinical team members who provide care to LGBTQ+ patients, and members of community-based organizations that work with LGBTQ+ patients were conducted. Interview analysis was a multistage process, wherein a constant comparison approach was used. Transcripts were reviewed and coded using Atlas.ti Cloud.

RESULTS

A total of 26 individuals were interviewed: 10 patients, four caregivers, 10 clinical care team members, and two community organization representatives. Interview analysis yielded insight regarding (1) LGBTQ+ patient experiences engaging with primary and oncologic care at the clinic level and (2) perceptions of patient-provider and provider-provider communication and coordination.

CONCLUSION

Interview findings indicate a need for further development of interventions aimed at improving care coordination, patient experience, and outcomes in the cancer care continuum for LGBTQ+ patients. Learning health systems, like the one studied, show great potential for contributing to the development of such interventions.

Addressing racial disparities in perinatal care for African American/Black individuals in the Chicago community health setting: a qualitative study

BACKGROUND

There are persistent disparities in maternal and infant perinatal outcomes experienced by Black birthing persons compared with non-Hispanic white (NHW) individuals in the US. The differences in outcomes arise from not only socioeconomic factors and individual health behaviors but also structural racism. Recent research is beginning to elucidate the benefits of patient navigation to support underserved minoritized individuals who experience this constellation of barriers to equitable care. Qualitative research that utilizes both the experiences of Black birthing individuals and the expert opinion of healthcare providers working with them can serve to guide a patient navigation intervention to further decrease disparities in perinatal outcomes.

METHODS

We conducted 30 interviews between August and December 2020 with Black birthing individuals in the Chicago metropolitan area and healthcare providers who care for this population both in Chicago and across the nation to explore their experiences, perceptions of barriers to care and ways to decrease inequities.

RESULTS

Clinical care team members acknowledged the presence of health disparities experienced by Black pregnant individuals compared with their NHW counterparts stemming from racism, discrimination, and lack of resources. Patients similarly reported personal experiences with these disparities and barriers to care. The successful methods used by clinical care teams to help decrease these differences in the past included patient education on important topics such as breastfeeding and the use of patient advocates. Effectively screening for social determinants of health by someone the patient trusts was also cited as important. Regarding perinatal care practices, clinical care team members described the importance of patient education needs and care team cultural competency. Patients' reported positive and negative experiences corroborated these findings, emphasizing the importance of trust, listening, education, access to care, support, and patient advocacy. Finally, the care team members and patients agreed that active trust-building can help the provider/patient relationship and ultimately improve outcomes.

CONCLUSIONS

These qualitative research findings improve the understanding of barriers to care and will help guide development of an intervention to reduce the health disparities experienced by Black pregnant persons.

Abstract LB169: Assessing the facilitators and barriers of a novel cancer care delivery model adapted for the care coordination of LGBTQ+ cancer survivors

Background: Lesbian, gay, bisexual, transgender and queer (LGBTQ) individuals experience health disparities at disproportionate rates that drive reduced cancer screenings and late-stage cancer diagnoses. Community health centers play critical roles in providing primary care services to LGBTQ+ patients with cancer. Patients diagnosed with cancer and referred to specialty care outside health centers, however, often experience disruptions to their primary care services due to gaps in communication between primary and oncology care providers. The © 4R Oncology Model (Right Information and Right Care for the Right Patient at the Right Time) is a novel, patient-centric care coordination tool developed to facilitate cancer planning and serves as a longitudinal primary care checklist for use by patients and their care team. Our project aims to assess the facilitators and barriers of 4R as a component of primary and specialized care delivered to LGBTQ+ cancer survivors.

Methods: We conducted semi-structured interviews with patients and their caregivers (n =12) and stakeholders (n=12) to assess facilitators and barriers to 4R implementation as a component of care delivered to LGBTQ+ cancer survivors. Research team members deductively identified initial themes from interview transcripts. Preliminary coding schemes were compared among three team members and refined by inductive coding to produce a higher-level study codebook. With this codebook, team members ultimately utilized ATLAS.ti, a qualitative data analysis software, to independently analyze interview transcripts, with discrepancies in coding resolved through team-wide discussions.

Results: Patients, their caregivers, and stakeholders agree that the 4R model shows potential for use as a first-step intervention to address primary care gaps caused by inadequate care coordination. Suggested improvements to the model include a reduction of textual information and an increased emphasis on mental and emotional support resources on the model’s sequence of care form.

Conclusions: Interim findings indicate that a lack of adequate research on solutions to the disruption of primary care services caused by the initiation of cancer care for LGBTQ+ cancer survivors is a significant barrier for this patient population. The 4R Oncology Model thus shows promise as a solution for initiating and sustaining more continuous communication between primary care and cancer care delivery for LGBTQ+ cancer survivors. Continued analysis of study interviews will further elucidate facilitators and barriers to cancer care coordination for LGBTQ+ individuals, while further informing iterations to the 4R model for the development of a national protocol aimed at improving access to care and outcomes for LGBTQ+ individuals and other underserved groups.

Citation Format: Nihmotallahi Adebayo, Will Dunne, Sankirtana Danner, Juan A. Rivera, Elena Molina, Abbey Ekong, Elizabeth Adetoro, Cori Blum, Cassandra Osei, Julia Trosman, Christine Weldon, Melissa Simon. Assessing the facilitators and barriers of a novel cancer care delivery model adapted for the care coordination of LGBTQ+ cancer survivors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB169.

Abstract PO-021: LGBTQ cancer care: Assessing the benefits and limitations of a novel cancer care coordination tool

Background: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience health disparities at disproportionate rates which drive reduced cancer screenings and late-stage cancer diagnoses. These disparities are the result of barriers to care including a lack of LGBTQ-competent providers, lack of health insurance, unstable housing, and avoidance of care due to medical trauma and concerns about abuse and mistreatment. Community health centers are critical for providing primary care to LGBTQ+ patients with cancer. Unfortunately, once a patient is diagnosed with cancer and referred to specialty care outside the health center, primary care services are often disrupted or even discontinued as a result of gaps in communication between primary and oncological care providers. The © 4R Oncology Model (Right Information and Right Care for the Right Patient at the Right Time) is a novel, patient-centric care coordination tool developed to facilitate cancer planning and serve as a longitudinal primary care checklist for patients and their care team. Our project aims to assess the benefits and limitations of the 4R as a component of care delivered to LGBTQ cancer survivors. Methods: In collaboration with Howard Brown Health, we conducted semi-structured interviews with clinical care team members (N=10) to assess the benefits and limitations of the 4R implementation as a component of care delivered to LGBTQ cancer survivors. A Rapid analysis process, a method used when a quick analysis is required to adopt changes to ongoing processes, will be utilized. Results: Clinical care team members indicate that a lack of adequate research on solutions to the disruption of primary care services caused by cancer care for LGBTQ cancer patients is a significant barrier for this patient population. Team members agree that the 4R is a necessary intervention for addressing primary care gaps caused by inadequate care coordination. Conclusions: The 4R shows promise as a solution for initiating and sustaining more continuous communication between primary care and cancer care delivery for LGBTQ cancer survivors. Future interviews with patients, caregivers, and community organization members will further elucidate the barriers and facilitators to cancer care coordination for this population and how iterations of the 4R can improve access to care and outcomes.

Citation Format: Nihmotallahi Adebayo, Will Dunne, Toni Madorsky, Sankirtana Danner, Juan Rivera, Elena Molina, Abbey Ekong, Elizabeth Adetoro, Cassandra Osei, Julia Trosman, Christine Weldon, Melissa Simon. LGBTQ cancer care: Assessing the benefits and limitations of a novel cancer care coordination tool [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-021.

Abstract PO-046: Building the country's first gynecologic cancer disparity SPORE: A labor of love

The NCI P20 SPORE aims to support the feasibility, development and planning activities to build cancer research programs with a dedicated translational focus. The Northwestern University Cancer Health Equity Research SPORE (NU-CHERS) is entering its second year of collaboration with the Lurie Cancer Center and John H. Stroger, Jr. Hospital of Cook County (SHCC). NU-CHERS is dedicated to conducting translational research on gynecologic cancer disparities experienced by women of color in Chicago. This presentation will report the challenges and successes of establishing the nation's first gynecologic cancer disparity SPORE, focused on understanding the clinical disparities experienced by women in Chicago, to improve health outcomes and build trusting reciprocal relationships with the community. Success of NU-CHERS hinges on local partnerships to achieve the elimination of gynecologic cancer disparities. The Lurie Cancer Center has thirty years of experience in developing and implementing cancer research programs and infrastructure. SHCC is a publicly funded hospital that provides access to healthcare to patients, including the uninsured, through a sliding scale based on income or inability to afford insurance deductibles. SHCC also serves a diverse patient population, making it an ideal community partner to facilitate a deeper understanding of gynecologic cancer disparities in the region and develop a richly diverse specimen biobank. NU-CHERS leverages these partnerships to advance research specific to underrepresented groups most impacted by gynecologic cancer disparities that will ultimately establish equitable access to precision medicine oncologic treatments. Through partnerships and infrastructure development, our team has identified lessons learned, opportunities for improvement and challenges requiring even more courage to achieve mandated milestones. For example, for the crucial step of building a robust biobank of annotated specimens, NU-CHERS supported SHCC in adapting protocols to meet local site constraints, as well as aligning data collection capabilities within clinical constraints versus research interests. Other important program achievements fall under the categories of fostering collaborations with communities through partnership with trusted healthcare organizations to facilitate education and reciprocity; best practices for establishing a multi-site research initiative with a Single Institutional Review Board (sIRB); and advancing the work of research projects during a pandemic. Sharing these findings advances the work of eliminating cancer disparities by providing a blueprint for researchers to improve upon for their collaborative cancer disparities programs. NU-CHERS is committed to establishing strong local partnerships and infrastructure in the community and thus legitimizing translational research to leverage basic science discoveries into clinical practice improvements through all the tools afforded by basic and population science researchers.

Citation Format: Denisha R. Brown, Laura Tom, Magdalena Nava, Catherine A. O'Brian, Ivy Leung, Rabih Dahdouh, Edgardo Ramirez, Araceli Estrada, Sankirtana Danner, Cassandra Osei, Will Dunne, Sharon Post, Nihmot Adebayo, Ann Yau, Terri Fraterrigo, Melissa A Simon. Building the country's first gynecologic cancer disparity SPORE: A labor of love [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-046.

Abstract 2552: Adapting a novel cancer care delivery model: identifying barriers unique to care coordination for LGBTQ cancer survivors

Background: Members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community experience health disparities stemming from factors that include barriers to access, such as lack of LGBTQ-competent providers, discrimination, avoidance of care due to concerns about mistreatment, low income, unstable housing and lack of insurance. LGBTQ individuals have reduced rates of cancer screening which may lead to delayed diagnosis, have disproportionately higher rates of certain cancers, and are at elevated risk for many comorbidities, including mental health conditions, substance abuse, smoking-related diseases, cardiovascular disease and HIV. Community health clinics serve a critical role in the health of LGBTQ patients with cancer, however referral to institutionally-disconnected cancer specialists often disrupts care received at their primary care medical home, leaving a large gap in integrated primary care services. Thus, upon cancer diagnosis, LGBTQ patients become vulnerable to disruptions in support systems and fragmentation of cancer and primary care. The 4R model (Right information and Right Care for the Right Patient at the Right Time) is a novel approach our team developed to facilitate cancer planning, as a vehicle for patient enablement and team-based care delivery across the oncology and primary care continuum. The goal of our project is to identify barriers and facilitators to implementation of the 4R model as a component of care delivered to LGBTQ cancer survivors and later develop a protocol tailored to optimally meet the needs and preferences of LGBTQ cancer survivors, including overcoming barriers to optimal care that are presented by fragmentation of multi-level care at sites nationwide.

Methods: In collaboration with one of the largest healthcare organizations caring primarily for an LGBTQ population, semi-structured interviews are being conducted with clinical care team members (N=10), patients (N=25), family/caregivers (N=10), and community organizations (N=5) in order to identify barriers and facilitators to implementation of the 4R model as a component of care delivered to LGBTQ cancer survivors. A Rapid Analysis Process, which is a qualitative analysis method recommended for circumstances in which a quick analysis is required to adopt changes to an ongoing process, will be utilized.

Results: Interviews with clinical team members and stakeholder feedback with our FQHC partner site indicate a lack of research in and need to providing appropriate and effective cancer care coordination for the LGBTQ population. Interviews conducted with various stakeholder groups will reveal important considerations in (1) initiating cancer care, (2) providing appropriate supports and resources, (3) addressing comorbid conditions, and (4) providing follow up cancer monitoring, specifically for LGBTQ individuals.

Citation Format: Nicolas Francone, Jonathan Alhalel, Will Dunne, Sankirtana Danner, Nihmotallahi Adebayo, Toni Madorsky, Cassandra Osei, Juan Rivera, Julia Trossman, Christine Weldon, Elizabeth Adetoro, Melissa Simon. Adapting a novel cancer care delivery model: identifying barriers unique to care coordination for LGBTQ cancer survivors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2552.

Abstract 719: The emergence of the COVID-19 pandemic and its impact on a novel cancer care delivery model at Federally Qualified Health Centers

Background: The emergence of COVID-19 has particularly disrupted the lives of vulnerable patients needing comprehensive care, including cancer survivors. Moreover, patients receiving immunosuppressive treatment for cancer are at heightened infection risk and when infected, cancer survivors are at higher risk of serious infection. Further complicating matters, surgeries with curative intent have been significantly limited and systemic therapies for patients with cancer have been delayed to minimize patient and staff exposure to SARS-CoV-2. Preexisting gaps in cancer screening, treatment, and follow up as well as in the monitoring of primary care needs for patients at Federally Qualified Health Centers (FQHCs) have become more apparent due to the COVID-19 pandemic. The 4R model (Right information and Right Care for the Right Patient at the Right Time) is a novel approach our team developed to facilitate cancer planning, as a vehicle for patient enablement and team-based care delivery across the oncology and primary care continuum. The innovative cancer care delivery model has been successfully implemented and used in a pre-COVID setting. The COVID-19 pandemic provides an urgent need to study the ways in which preexisting cancer care delivery models have been disrupted and to adapt processes in order to provide quality care.

Methods: Semi-structured interviews are being conducted with clinical care team members (N=10), patients (N=25), family/caregivers (N=10), and community organizations (N=5) in order to identify areas in which care for patients with cancer in a primary care setting have changed and how clinics are adapting to their patients' needs in the setting of the COVID-19 pandemic. A Rapid analysis process, which is a qualitative analysis method recommended for circumstances in which a quick analysis is required to adopt changes to an ongoing process, will be utilized.

Results: Preliminary results from stakeholder feedback and clinical care team interviews have revealed changes in the FQHC's approach to cancer care coordination during the COVID-19 pandemic. In the spring/early summer of 2020, clinical team members were overburdened with clinical operation changes and the need to swiftly re-allocate resources towards COVID-19 testing. Non-emergent appointments transitioned to telehealth and care coordinators, the keystone of the 4R model, were working remotely and were met with significant obstacles in referring cancer survivors to specialty care and community resources. Conducting additional interviews will help elucidate the receptivity of the recently implemented 4R cancer care delivery model and inform how telehealth can be harnessed during this time to meet the complex needs and coordinating care for patients with cancer.

Citation Format: Nicolas Francone, Will Dunne, Jonathan Alhalel, Sankirtana Danner, Nihmotallahi Adebayo, T Madorsky, Cassandra Osei, Juan Rivera, J Trossman, Christine Weldon, Elizabeth Adetoro, Melissa Simon. The emergence of the COVID-19 pandemic and its impact on a novel cancer care delivery model at Federally Qualified Health Centers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 719.

The Complex Interplay of Communication and Trust in Healthcare Delivery

Effective communication in clinician-patient relationships is an essential part of improving health outcomes. Ineffective communication in clinical settings leaves patients feeling undervalued and unheard. Breakdowns in communication can have particularly profound effects on minority or underserved populations, where health disparities already exist. Effective communication is critical for establishing trust, which allows individuals to feel they can share their concerns and questions. Distrust is a particularly important issue in maternal health, where current US rates of maternal mortality and morbidity are 3.1 times higher in Black and African American (AA) pregnant and birthing persons than their non-Hispanic white counterparts. To address the widespread issue of medical distrust and its connection with maternal health outcomes, the OPTIMIZE study is currently implementing an innovative intervention aimed at improving perinatal care for Black/AA pregnant persons. This intervention prompts clinician-patient conversations to enhance communication and repair trust, including a focus on patients' goals, concerns, social determinants of health, and safety. The implications of this intervention are broad, including the potential to improve trust and communication in other clinical specialties.

Successful treatment by lumboperitoneal shunting of a spinal subclavicular fistula following thoracotomy

A 60-year-old woman with a Pancoast tumor developed a spinal subclavicular fistula after thoracotomy. Pseudomonas meningitis was treated with intravenous cefotaxime before lumboperitoneal shunting. A brief review of the neurosurgical literature on direct and indirect approaches to the closure of cerebrospinal fluid fistulas is presented.