Development of a Conceptual Model of the Patient Experience in Small Cell Lung Cancer: A Qualitative Interview Study

INTRODUCTION

Small cell lung cancer (SCLC) is a subtype of lung cancer, the second most common cancer diagnosis worldwide. Currently, there is little published qualitative research that provides insight into the disease-related symptoms and impacts that are relevant to patients living with SCLC as directly reported by patients themselves.

METHODS

This qualitative, cross-sectional, noninterventional, descriptive study included concept elicitation interviews with participants diagnosed with SCLC and the development of a conceptual model of clinical treatment benefit.

RESULTS

Concept elicitation interview data from 26 participants with SCLC were used to develop a conceptual model of clinical treatment benefit that organized 28 patient-reported concepts into two domains: disease-related symptoms (organ-specific and systemic) and impacts. Organ-specific symptoms included cough, chest pain, and difficulty breathing. Systemic symptoms included pain, fatigue, appetite loss, and dizziness. Impacts included physical functioning, role functioning, reduced movement, impact on sleep, and weight loss.

CONCLUSION

As evidenced by this study, people with SCLC experience considerable and significant symptoms and impacts, including physical and role functioning challenges, that affect their quality of life. This conceptual model will inform the design of a patient-reported outcome (PRO) questionnaire for a future SCLC clinical trial, helping to establish the content validity of the items and questionnaires used in the trial and ensuring that the questionnaires and items selected are appropriately targeted to the population. This conceptual model could also be used to inform future SCLC clinical trials.

De-implementation and substitution of clinical care processes: stakeholder perspectives on the transition to primary human papillomavirus (HPV) testing for cervical cancer screening

Background

New cervical cancer screening guidelines recommend primary human papillomavirus (HPV) testing for women age 30–65 years. Healthcare organizations are preparing to de-implement the previous recommended strategies of Pap testing or co-testing (Pap plus HPV test) and substitute primary HPV testing. However, there may be significant challenges to the replacement of this entrenched clinical practice, even with an evidence-based substitution. We sought to identify stakeholder-perceived barriers and facilitators to this substitution within a large healthcare system, Kaiser Permanente Southern California.

Methods

We conducted semi-structured qualitative interviews with clinician, administrative, and patient stakeholders regarding (a) acceptability and feasibility of the planned substitution; (b) perceptions of barriers and facilitators, with an emphasis on those related to the de-implementation/implementation cycle of substitution; and (c) perceived readiness to change. Our interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). Using a team coding approach, we developed an initial coding structure refined during iterative analysis; the data were subsequently organized thematically into domains, key themes, and sub-themes using thematic analysis, followed by framework analysis informed by CFIR.

Results

We conducted 23 interviews: 5 patient and 18 clinical/administrative. Clinicians perceived that patients feel more tests equals better care, and clinicians and patients expressed fear of missed cancers (“…it’ll be more challenging convincing the patient that only one test is…good enough to detect cancer.”). Patients perceived practice changes resulting in “less care” are driven by the desire to cut costs. In contrast, clinicians/administrators viewed changing from two tests to one as acceptable and a workflow efficiency (“…It’s very easy and half the work.”). Stakeholder-recommended strategies included focusing on the increased efficacy of primary HPV testing and developing clinician talking points incorporating national guidelines to assuage “cost-cutting” fears.

Conclusions

Substitution to replace an entrenched clinical practice is complex. Leveraging available facilitators is key to ease the process for clinical and administrative stakeholders—e.g., emphasizing the efficiency of going from two tests to one. Identifying and addressing clinician and patient fears regarding cost-cutting and perceived poorer quality of care is critical for substitution. Multicomponent and multilevel strategies for engagement and education will be required.

Trial registration

ClinicalTrials.gov, #NCT04371887

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00211-z.

Impact of Physician-Patient Language Concordance on Patient Outcomes and Adherence to Clinical Chest Pain Recommendations

OBJECTIVES

The objective was to evaluate if there is an association between patient-physician language concordance and adverse patient outcomes or physician adherence to clinical recommendations for emergency department (ED) patients with chest pain.

METHODS

We conducted a retrospective observational study of adult ED chest pain encounters with a troponin order from May 2016 to September 2017 across 15 community EDs. Outcomes were 30-day acute myocardial infarction or all-cause mortality, hospital admission/observation, or noninvasive cardiac testing. To assess patient outcomes, we used the overall cohort. To assess adherence to clinical recommendations, we used a subgroup of patients with a low-risk HEART score. A mixed-effects logistic regression model was used to compare the odds of the outcomes between language concordant and discordant patient-physician pairs, controlling for patient characteristics.

RESULTS

Overall, 52,014 ED encounters were included (10,791 low-risk HEART encounters). Of those 6,452 (12.4%) encounters were language discordant and 1.7% in each group had an adverse outcome. Adjusted models demonstrated no increased risk for language discordant ED encounters when comparing adverse outcomes (odds ratio [OR] = 0.96, 95% confidence interval [CI] = 0.6 to 1.5) for all patients or recommended care (OR = 1.02, 95% CI = 0.87 to 1.2) for low-risk patients.

CONCLUSIONS

No associations were found between patient-physician language concordance and outcomes or physician adherence to clinical recommendations for ED patients with chest pain. Accessible and effective interpretation services, combined with a decision support tool with standard clinical recommendations, may have contributed to equitable care.

Americans' views on the use and regulation of dietary supplements

This article presents the views of Americans on what the government's future role should be in regulating or overseeing the growing sales of dietary supplements for health purposes. Based on results of multiple national opinion surveys, including the views of both users and nonusers of supplements, we found that a substantial percentage of Americans surveyed reported that they regularly take dietary supplements as a part of their routine health regimen. However, they reported that they do not discuss the use of dietary supplements with their physicians because they believe that the physicians know little or nothing about these products and may be biased against them. Many users felt so strongly about the potential health benefits of some of these products that they reported that they would continue to take them even if they were shown to be ineffective in scientifically conducted clinical studies. However, there also was broad public support for increased government regulation of these products. We found that a majority of Americans surveyed supported the following: to require that the Food and Drug Administration review the safety of new dietary supplements prior to their sale; to provide increased authority to remove from sale those products shown to be unsafe; and to increase government regulation to ensure that advertising claims about the health benefits of dietary supplements are true.

Health information, the Internet, and the digital divide

Through an analysis of recent data on adults' and children's computer use and experiences, this DataWatch shows that use of computers and the Internet is widespread and that significant percentages of the public are already using the Internet to get health information. The surveys also show that the Internet is already a useful vehicle for reaching large numbers of lower-income, less-educated, and minority Americans. However, a substantial digital divide continues to characterize computer and Internet use, with lower-income blacks especially affected. Implications for the future of health communication on the Internet also are explored.

Health care in the upcoming 2000 election

Health care will be one of the top issues in the year 2000 election, but voters' interest in health care is not as great as it was in 1992. There is no single unifying theme to the health care issue. Rather, there are multiple concerns: making Medicare financially sound, providing coverage for prescription medicines for seniors, covering the uninsured, and addressing patients' rights. Voters favor an incremental approach to expanding health insurance coverage rather than a major program. They express about equal levels of support for plans similar in concept to those proposed by presidential candidates Al Gore and George W. Bush.

Understanding the managed care backlash

This paper examines the depth and breadth of the public backlash against managed care and the reasons for it. We conclude that the backlash is real and influenced by at least two principal factors: (1) A significant proportion of Americans report problems with managed care plans; and (2) the public perceives threatening and dramatic events in managed care that have been experienced by just a few. In addition, public concern is driven by fear that regardless of how well their plans perform today, care might not be available or paid for when they are very sick.

Media coverage of managed care: is there a negative bias?

We conducted content analysis of media coverage (both print and broadcast) of managed care over the period 1 January 1990 to 30 June 1997, examining in detail more than 2,100 randomly selected stories. Coverage changed noticeably over the seven and a half-year period, with early years focused on managed care as a business story, and later years focused more on patient care and concerns about backlash. Coverage differed substantially depending on media source. The large majority of all media coverage of managed care was neutral in tone. However, the tone of coverage has become more critical over time and differs dramatically by source of media. The most visible media sources--television and newspaper special series--conveyed negative stories in more than half of their coverage and most often used anecdotes in telling their stories.

The public and the welfare reform debate

OBJECTIVES

To identify the core beliefs and policy preferences of the American public toward changing the welfare system and providing support for low-income families.

DESIGN

Results are presented from 19 telephone and in-person surveys of adults nationwide between 1937 and February 1995.

SETTING

At-home interviews with adults.

PARTICIPANTS

Seventeen surveys; each survey involved 1000 to 2000 adults nationwide.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The results showed that the public supports strong welfare reform measures (eg, time limits and work requirements), but it is reluctant simply to cut off welfare benefits to people and leave them without some means of basic support. The surveys identified five underlying beliefs that shape the public's policy preferences: (1) welfare causes more harm than good because it discourages work and causes families to break up; (2) welfare should be a temporary transition to work, not a long-term subsidy for low-income families; (3) the country spends too much on welfare programs; (4) lack of economic opportunity as well as personal responsibility is the reason people need welfare; and (5) both government and people themselves have a shared responsibility for ensuring that people have a minimum standard of living.

CONCLUSIONS

The outcome of the welfare reform debate will have a substantial impact on the 21% of the nation's children who now live in poverty. The jury is still out on what the public will support in the welfare reform debate. The Medicaid program is caught in the middle of the welfare reform debate, and its ultimate fate may rely on state rather than federal decision making.

How much does the public know about health reform?

With federal action on major health reform set to take place in 1994, a recent survey of 1,200 adults found major gaps in Americans' understanding of what the problems are or how major legislative proposals would address them. While the public is primarily concerned about how health reform will affect them personally, their current lack of knowledge heightens the impact that political advertising, media coverage, and public education campaigns will have.

Fear & loathing: why Californians are concerned about health care

A larger percentage of Californians than Americans overall lack insurance, and a poll of state residents shows a greater level of concern about health care costs and access. Among the reasons: a recognition that the uninsured face serious barriers to care and a fear among middle-class Californians that insurance and medical care costs could make coverage unaffordable.

Health care, the California primary, and the 1992 election

Voters in the June 2 last-in-the-nation California primary indicated that candidates' character, experience, and leadership ability have become more significant than their stands on such issues as health reform. However, among substantive campaign issues, health care ranked second, behind the economy. That is consistent with previous poll results from New Hampshire, the nation's first primary state.

New Hampshire, health care, and the 1992 election

A poll of New Hampshire voters who participated in the February 17 presidential primary shows that the recession and overall concern for the economy was the most important factor in determining the outcome of the election. Health care and national health insurance ranked second, significantly outranking concerns over all other issues. When presented with the leading policy options for health care reform, the majority of voters favored a plan that would guarantee universal coverage by law--either a "play or pay" plan or an all-government plan. However, even though a majority of voters favored universal coverage, they also preferred plans that would make insurance available through private insurers rather than through an all-government plan.

The 1991 Pennsylvania Senate race and national health insurance

Voter interest in reform of the American health care system played a central role in the November 5 come-from-behind reelection victory of Democratic Senator Harris Wofford of Pennsylvania over Republican candidate Richard Thornburgh. In a post-election poll of 1,000 Pennsylvania voters, over 50 percent identified "national health insurance" as one of two issues that mattered most in deciding how to vote. And 21 percent of voters said the issue was the "single most important factor" in their voting decision. The results of the Pennsylvania Senate race suggest that universal health care has arrived as a mainstream political issue and that political candidates who fail to address the issue do so at their peril.

Some considerations in the design of a high power, pulsed n(2) laser

Pulsed, megawatt laser power levels at 3371 A from nitrogen gas require the formation of a high density plasma of high electron temperature in the first few nanoseconds of gaseous breakdown. This has been obtained from a laser tube powered by a pulse forming network in the form of a low impedance, parallel plate transmission line. Another low impedance, parallel plate transmission line, charged to 30 kV is used to pulse charge the pulse forming line by means of a synchronized, multiple spark gap switch. The pulse forming transmission line terminates in a continuous high voltage electrode which runs parallel to the axis of the tube, i.e., in the direction of the light beam. The finite, nonzero time required for the gas in the laser tube to break down, permits (a) pulse charging this line to voltages many times larger than the dc breakdown voltage of the nitrogen in the laser tube, and (b) the placement of the switch in the circuit where its impedance does not limit the rate of rise of current during the laser excitation process. Furthermore, it is shown that decreasing the impedance of the pulse forming line increases the laser output power, when the current in the laser circuit is not limited by circuit inductance.