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Neslund-Dudas C, Tang A, Alleman E, Zarins KR, Li P, Simoff MJ, Lafata JE, Rendle KA, Hartman ANB, Honda SA, Oshiro C, Olaiya O, Greenlee RT, Vachani A, Ritzwoller DP. Uptake of Lung Cancer Screening CT After a Provider Order for Screening in the PROSPR-Lung Consortium. J Gen Intern Med 2024; 39:186-194. [PMID: 37783984 PMCID: PMC10853157 DOI: 10.1007/s11606-023-08408-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/31/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Uptake of lung cancer screening (LCS) has been slow with less than 20% of eligible people who currently or formerly smoked reported to have undergone a screening CT. OBJECTIVE To determine individual-, health system-, and neighborhood-level factors associated with LCS uptake after a provider order for screening. DESIGN AND SUBJECTS We conducted an observational cohort study of screening-eligible patients within the Population-based Research to Optimize the Screening Process (PROSPR)-Lung Consortium who received a radiology referral/order for a baseline low-dose screening CT (LDCT) from a healthcare provider between January 1, 2015, and June 30, 2019. MAIN MEASURES The primary outcome is screening uptake, defined as LCS-LDCT completion within 90 days of the screening order date. KEY RESULTS During the study period, 18,294 patients received their first order for LCS-LDCT. Orders more than doubled from the beginning to the end of the study period. Overall, 60% of patients completed screening after receiving their first LCS-LDCT order. Across health systems, uptake varied from 41 to 87%. In both univariate and multivariable analyses, older age, male sex, former smoking status, COPD, and receiving care in a centralized LCS program were positively associated with completing LCS-LDCT. Unknown insurance status, other or unknown race, and lower neighborhood socioeconomic status, as measured by the Yost Index, were negatively associated with screening uptake. CONCLUSIONS Overall, 40% of patients referred for LCS did not complete a LDCT within 90 days, highlighting a substantial gap in the lung screening care pathway, particularly in decentralized screening programs.
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Affiliation(s)
- Christine Neslund-Dudas
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, MI, USA.
- Department of Public Health Sciences, Henry Ford Health System, One Ford Place, Suite 3E, Detroit, MI, 48202, USA.
| | - Amy Tang
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, MI, USA
| | - Elizabeth Alleman
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, MI, USA
| | - Katie R Zarins
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, MI, USA
| | - Pin Li
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, MI, USA
| | - Michael J Simoff
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, MI, USA
| | - Jennifer Elston Lafata
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, MI, USA
- UNC Eshelman School of Pharmacy and Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Stacey A Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
- Hawaii Permanente Medical Group, Honolulu, HI, USA
| | - Caryn Oshiro
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | | | | | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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Hahn EE, Ritzwoller DP, Munoz-Plaza CE, Gander J, Kushi LH, McMullen C, Oshiro C, Roblin DW, Wernli KJ, Staab J. Incidence and Survival for Patients Diagnosed With Breast, Colorectal, and Lung Cancer in an Integrated System. Perm J 2023; 27:129-135. [PMID: 37724894 PMCID: PMC10723094 DOI: 10.7812/tpp/23.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Documenting trends in cancer incidence and survival is a national priority. This study estimated age- and sex-adjusted incidence and 5-year relative survival among patients with cancer diagnosed within Kaiser Permanente compared to Surveillance, Epidemiology, and End Results (SEER) estimates. METHODS The cohort included Kaiser Permanente health plan members diagnosed with breast (BC), colorectal (CRC), or lung cancer (LC) between January 1, 1999 and December 31, 2018. Incidence was computed as age-adjusted rates per 100,000 member-years. SEER*Stat was used to compute 5-year relative survival. RESULTS Kaiser Permanente BC incidence rates were persistently higher than SEER from 2004 (126.5 [95% confidence interval (CI) = 123.2-129.9] vs 122.6 [95% CI = 121.3-123.2]) through 2013 (132.06 [95% CI = 129.5-135.7] vs 126.7 [95% CI = 125.9-127.5]). Kaiser Permanente CRC and LC incidence rates were lower than SEER for all years except 2008, showing a spike in CRC incidence (51.5 [95% CI = 49.9-53.0] vs 46.1 [95% CI = 45.7-46.4]). Kaiser Permanente BC, CRC, and LC survival estimates for all stages were higher than SEER. CONCLUSIONS Incidence rates for all-stage and localized-stage BC were consistently higher for Kaiser Permanente than for SEER. CRC and LC rates were lower. Kaiser Permanente survival rates were consistently higher than for SEER. The strengths of these findings are associated with the ability to capture "gold-standard" cancer registry data on defined Kaiser Permanente populations. However, findings should be interpreted cautiously given differences in the underlying populations and secular and regional differences between Kaiser Permanente and SEER. The Kaiser Permanente population is younger and more racially diverse than SEER aggregate populations, and Kaiser Permanente members are insured with access to preventive care (eg, smoking cessation programs, cancer screening).
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Affiliation(s)
- Erin E Hahn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Corrine E Munoz-Plaza
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jennifer Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Carmit McMullen
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Caryn Oshiro
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Douglas W Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Jenny Staab
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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Wain K, Carroll NM, Honda S, Oshiro C, Ritzwoller DP. Individuals Eligible for Lung Cancer Screening Less Likely to Receive Screening When Enrolled in Health Plans With Deductibles. Med Care 2023; 61:665-673. [PMID: 37582296 PMCID: PMC10840830 DOI: 10.1097/mlr.0000000000001903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND In 2015, the Centers for Medicare & Medicaid Services and commercial insurance plans began covering lung cancer screening (LCS) without patient cost-sharing for all plans. We explore the impact of enrolling into a deductible plan on the utilization of LCS services despite having no out-of-pocket cost requirement. METHODS This retrospective study analyzed data from the Population-based Research to Optimize the Screening Process Lung Consortium. Our cohort included non-Medicare LCS-eligible individuals enrolled in managed care organizations between February 5, 2015, and February 28, 2019. We estimate a series of sequential logistic regression models examining utilization across the sequence of events required for baseline LCS. We report the marginal effects of enrollment into deductible plans compared with enrollment in no-deductible plans. RESULTS The total effect of deductible plan enrollment was a 1.8 percentage-point (PP) decrease in baseline LCS. Sequential logistic regression results that explore each transition separately indicate deductible plan enrollment was associated with a 4.3 PP decrease in receipt of clinician visit, a 1.7 PP decrease in receipt of LCS order, and a 7.0 PP decrease in receipt of baseline LCS. Reductions persisted across all observable races and ethnicities. CONCLUSIONS These findings suggest individuals enrolled in deductible plans are more likely to forgo preventive LCS services despite requiring no out-of-pocket costs. This result may indicate that increased cost-sharing is associated with suboptimal choices to forgo recommended LCS. Alternatively, this effect may indicate individuals enrolling into deductible plans prefer less health care utilization. Patient outreach interventions at the health plan level may improve LCS.
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Affiliation(s)
- Kris Wain
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Nikki M. Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Stacey Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI
- Hawaii Permanente Medical Group, Honolulu, HI
| | - Caryn Oshiro
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI
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Burnett-Hartman AN, Powers JD, Hixon BP, Carroll NM, Frankland TB, Honda SA, Saia C, Rendle KA, Greenlee RT, Neslund-Dudas C, Zheng Y, Vachani A, Ritzwoller DP. Development of an Electronic Health Record-Based Algorithm for Predicting Lung Cancer Screening Eligibility in the Population-Based Research to Optimize the Screening Process Lung Research Consortium. JCO Clin Cancer Inform 2023; 7:e2300063. [PMID: 37910824 PMCID: PMC10642899 DOI: 10.1200/cci.23.00063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/21/2023] [Accepted: 09/14/2023] [Indexed: 11/03/2023] Open
Abstract
PURPOSE Lung cancer screening (LCS) guidelines in the United States recommend LCS for those age 50-80 years with at least 20 pack-years smoking history who currently smoke or quit within the last 15 years. We tested the performance of simple smoking-related criteria derived from electronic health record (EHR) data and developed and tested the performance of a multivariable model in predicting LCS eligibility. METHODS Analyses were completed within the Population-based Research to Optimize the Screening Process Lung Consortium (PROSPR-Lung). In our primary validity analyses, the reference standard LCS eligibility was based on self-reported smoking data collected via survey. Within one PROSPR-Lung health system, we used a training data set and penalized multivariable logistic regression using the Least Absolute Shrinkage and Selection Operator to select EHR-based variables into the prediction model including demographics, smoking history, diagnoses, and prescription medications. A separate test data set assessed model performance. We also conducted external validation analysis in a separate health system and reported AUC, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy metrics associated with the Youden Index. RESULTS There were 14,214 individuals with survey data to assess LCS eligibility in primary analyses. The overall performance for assigning LCS eligibility status as measured by the AUC values at the two health systems was 0.940 and 0.938. At the Youden Index cutoff value, performance metrics were as follows: accuracy, 0.855 and 0.895; sensitivity, 0.886 and 0.920; specificity, 0.896 and 0.850; PPV, 0.357 and 0.444; and NPV, 0.988 and 0.992. CONCLUSION Our results suggest that health systems can use an EHR-derived multivariable prediction model to aid in the identification of those who may be eligible for LCS.
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Affiliation(s)
| | - J. David Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Brian P. Hixon
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Nikki M. Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | | | - Stacey A. Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Oahu, HI
- Hawaii Permanente Medical Group, Oahu, HI
| | - Chelsea Saia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Yingye Zheng
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA
| | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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5
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Carroll NM, Burnett-Hartman AN, Rendle KA, Neslund-Dudas CM, Greenlee RT, Honda SA, Vachani A, Ritzwoller DP. Smoking status and the association between patient-level factors and survival among lung cancer patients. J Natl Cancer Inst 2023; 115:937-948. [PMID: 37228018 PMCID: PMC10407692 DOI: 10.1093/jnci/djad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Declines in the prevalence of cigarette smoking, advances in targeted therapies, and implementation of lung cancer screening have changed the clinical landscape for lung cancer. The proportion of lung cancer deaths is increasing in those who have never smoked cigarettes. To better understand contemporary patterns in survival among patients with lung cancer, a comprehensive evaluation of factors associated with survival, including differential associations by smoking status, is needed. METHODS Patients diagnosed with lung cancer between January 1, 2010, and September 30, 2019, were identified. We estimated all-cause and lung cancer-specific median, 5-year, and multivariable restricted mean survival time (RMST) to identify demographic, socioeconomic, and clinical factors associated with survival, overall and stratified by smoking status (never, former, and current). RESULTS Analyses included 6813 patients with lung cancer: 13.9% never smoked, 54.2% formerly smoked, and 31.9% currently smoked. All-cause RMST through 5 years for those who never, formerly, and currently smoked was 32.1, 25.9, and 23.3 months, respectively. Lung cancer-specific RMST was 36.3 months, 30.3 months, and 26.0 months, respectively. Across most models, female sex, younger age, higher socioeconomic measures, first-course surgery, histology, and body mass index were positively associated, and higher stage was inversely associated with survival. Relative to White patients, Black patients had increased survival among those who formerly smoked. CONCLUSIONS We identify actionable factors associated with survival between those who never, formerly, and currently smoked cigarettes. These findings illuminate opportunities to address underlying mechanisms driving lung cancer progression, including use of first-course treatment, and enhanced implementation of tailored smoking cessation interventions for individuals diagnosed with cancer.
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Affiliation(s)
- Nikki M Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Andrea N Burnett-Hartman
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Stacey A Honda
- Hawaii Permanente Medical Group, Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
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6
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Hiatt RA, Clayton MF, Collins KK, Gold HT, Laiyemo AO, Truesdale KP, Ritzwoller DP. The Pathways to Prevention program: nutrition as prevention for improved cancer outcomes. J Natl Cancer Inst 2023; 115:886-895. [PMID: 37212639 PMCID: PMC10407697 DOI: 10.1093/jnci/djad079] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/14/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023] Open
Abstract
Adequate nutrition is central to well-being and health and can enhance recovery during illness. Although it is well known that malnutrition, both undernutrition and overnutrition, poses an added challenge for patients with cancer diagnoses, it remains unclear when and how to intervene and if such nutritional interventions improve clinical outcomes. In July 2022, the National Institutes of Health convened a workshop to examine key questions, identify related knowledge gaps, and provide recommendations to advance understanding about the effects of nutritional interventions. Evidence presented at the workshop found substantial heterogeneity among published randomized clinical trials, with a majority rated as low quality and yielding mostly inconsistent results. Other research cited trials in limited populations that showed potential for nutritional interventions to reduce the adverse effects associated with malnutrition in people with cancer. After review of the relevant literature and expert presentations, an independent expert panel recommends baseline screening for malnutrition risk using a validated instrument following cancer diagnosis and repeated screening during and after treatment to monitor nutritional well-being. Those at risk of malnutrition should be referred to registered dietitians for more in-depth nutritional assessment and intervention. The panel emphasizes the need for further rigorous, well-defined nutritional intervention studies to evaluate the effects on symptoms and cancer-specific outcomes as well as effects of intentional weight loss before or during treatment in people with overweight or obesity. Finally, although data on intervention effectiveness are needed first, robust data collection during trials is recommended to assess cost-effectiveness and inform coverage and implementation decisions.
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Affiliation(s)
- Robert A Hiatt
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Heather T Gold
- New York University (NYU) Langone Health/NYU Grossman School of Medicine, New York, NY, USA
| | | | | | - Debra P Ritzwoller
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA
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7
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Carroll NM, Eisenstein J, Burnett-Hartman AN, Greenlee RT, Honda SA, Neslund-Dudas CM, Rendle KA, Vachani A, Ritzwoller DP. Uptake of novel systemic therapy: Real world patterns among adults with advanced non-small cell lung cancer. Cancer Treat Res Commun 2023; 36:100730. [PMID: 37352588 PMCID: PMC10528526 DOI: 10.1016/j.ctarc.2023.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
INTRODUCTION/BACKGROUND Systemic treatment for advanced non-small cell lung cancer (NSCLC) is shifting from platinum-based chemotherapy to immunotherapy and targeted therapies associated with improved survival in clinical trials. As new therapies are approved for use, examining variations in use for treating patients in community practice can generate additional evidence as to the magnitude of their benefit. PATIENTS AND METHODS We identified 1,442 patients diagnosed with de novo stage IV NSCLC between 3/1/2012 and 12/31/2020. Patient characteristics and treatment patterns are described overall and by type of first- and second-line systemic therapy received. Prevalence ratios estimate the association of patient and tumor characteristics with receipt of first-line therapy. RESULTS Within 180 days of diagnosis, 949 (66%) patients received first-line systemic therapy, increasing from 53% in 2012 to 71% in 2020 (p = 0.0004). The proportion of patients receiving first-line immunotherapy+/-chemotherapy (IMO) increased from 14%-66% (p<0.0001). Overall, 380 (26%) patients received both first- and second-line treatment, varying by year between 16%-36% (p = 0.18). The proportion of patients receiving second-line IMO increased from 13%-37% (p<0.0001). Older age and current smoking status were inversely associated with receipt of first-line therapy. Higher BMI, receipt of radiation, and diagnosis year were positively associated with receipt of first-line therapy. No association was found for race, ethnicity, or socioeconomic status. CONCLUSION The proportion of advanced NSCLC patients receiving first- and second-line treatment increased over time, particularly for IMO treatments. Additional research is needed to better understand the impact of these therapies on patient outcomes, including short-term, long-term, and financial toxicities. MICROABSTRACT Systemic treatment for non-small cell lung cancer (NSCLC) is shifting from platinum-based therapies to immunotherapy and targeted therapies. Using de novo stage IV NSCLC patients identified from 4 healthcare systems, we examine trends in systemic therapy. We saw an increase in the portion of patients receiving any systemic therapy and a sharp increase in the proportion of patients receiving immunotherapy.
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Affiliation(s)
- Nikki M Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.
| | - Jennifer Eisenstein
- Colorado Permanente Medical Group, Kaiser Permanente Colorado, Denver, CO, USA
| | - Andrea N Burnett-Hartman
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | | | - Stacey A Honda
- Hawaii Permanente Medical Group and Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | | | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
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8
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Steiner JS, Blum-Barnett E, Rolland B, Kraus CR, Wainwright JV, Bedoy R, Martinez YT, Alleman ER, Eibergen R, Pieper LE, Carroll NM, Hixon B, Sterrett A, Rendle KA, Saia C, Vachani A, Ritzwoller DP, Burnett-Hartman A. Application of team science best practices to the project management of a large, multi-site lung cancer screening research consortium. J Clin Transl Sci 2023; 7:e145. [PMID: 37456270 PMCID: PMC10346083 DOI: 10.1017/cts.2023.566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/25/2023] [Accepted: 05/22/2023] [Indexed: 07/18/2023] Open
Abstract
Research is increasingly conducted through multi-institutional consortia, and best practices for establishing multi-site research collaborations must be employed to ensure efficient, effective, and productive translational research teams. In this manuscript, we describe how the Population-based Research to Optimize the Screening Process Lung Research Center (PROSPR-Lung) utilized evidence-based Science of Team Science (SciTS) best practices to establish the consortium's infrastructure and processes to promote translational research in lung cancer screening. We provide specific, actionable examples of how we: (1) developed and reinforced a shared mission, vision, and goals; (2) maintained a transparent and representative leadership structure; (3) employed strong research support systems; (4) provided efficient and effective data management; (5) promoted interdisciplinary conversations; and (6) built a culture of trust. We offer guidance for managing a multi-site research center and data repository that may be applied to a variety of settings. Finally, we detail specific project management tools and processes used to drive collaboration, efficiency, and scientific productivity.
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Affiliation(s)
- Julie S. Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Erica Blum-Barnett
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Betsy Rolland
- Carbone Cancer Center and Institute for Clinical and Translational Research, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Courtney R. Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | | | - Ruth Bedoy
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | | | | | - Roxy Eibergen
- Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Lisa E. Pieper
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Nikki M. Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Brian Hixon
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Andrew Sterrett
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Katharine A. Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chelsea Saia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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9
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McCracken CE, Gander JC, McDonald B, Goodrich GK, Tavel HM, Basra S, Weinfield NS, Ritzwoller DP, Roblin DW, Davis TL. Impact of COVID-19 on Trends in Outpatient Clinic Utilization: A Tale of 2 Departments. Med Care 2023; 61:S4-S11. [PMID: 36893413 PMCID: PMC9994570 DOI: 10.1097/mlr.0000000000001812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND The COVID-19 pandemic forced many US health care organizations to shift from mostly in-person care to a hybrid of virtual visits (VV) and in-person visits (IPV). While there was an expected and immediate shift to virtual care (VC) early in the pandemic, little is known about trends in VC use after restrictions eased. METHODS This is a retrospective study using data from 3 health care systems. All completed visits from adult primary care (APC) and behavioral health (BH) were extracted from the electronic health record of adults aged 19 years and older from January 1, 2019 to June 30, 2021. Standardized weekly visit rates were calculated by department and site and analyzed using time series analysis. RESULTS There was an immediate decrease in APC visits following the onset of the pandemic. IPV were quickly replaced by VV such that VV accounted for most APC visits early in the pandemic. By 2021, VV rates declined, and VC visits accounted for <50% of all APC visits. By Spring 2021, all 3 health care systems saw a resumption of APC visits as rates neared or returned to prepandemic levels. In contrast, BH visit rates remained constant or slightly increased. By April 2020, almost all BH visits were being delivered virtually at each of the 3 sites and continue to do so without changes to utilization. CONCLUSIONS VC use peaked during the early pandemic period. While rates of VC are higher than prepandemic levels, IPV are the predominant visit type in APC. In contrast, VC use has sustained in BH, even after restrictions eased.
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Affiliation(s)
| | | | - Bennett McDonald
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | - Glenn K. Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Heather M. Tavel
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Sundeep Basra
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Nancy S. Weinfield
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | | | - Douglas W. Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Teaniese L. Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
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10
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Gander JC, Goodrich G, McDonald B, McCracken CE, Tavel HM, Davis TL, Weinfield NS, Ritzwoller DP, Roblin DW. Virtual Care and Urinary Tract Infection Management: Comparing Ancillary Service Orders and Patient Order Fulfillments Between Virtual and In-person Encounters During the COVID-19 Pandemic in the United States. Med Care 2023; 61:S21-S29. [PMID: 36893415 PMCID: PMC9994568 DOI: 10.1097/mlr.0000000000001805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, more health care issues were being managed remotely. Urinary tract infections (UTIs) are being managed more often using telehealth although few reports compare the rate of UTI ancillary service orders placed and fulfilled during these visits. OBJECTIVES We aimed to evaluate and compare the rate of ancillary service orders and order fulfillments in incident UTI diagnoses between virtual and in-person encounters. RESEARCH DESIGN The retrospective cohort study involved 3 integrated health care systems: Kaiser Permanente (KP) Colorado, KP Georgia, and KP Mid-Atlantic States. SUBJECTS We included incident UTI encounters from adult primary care data from January 2019 to June 2021. MEASURES Data were categorized as: prepandemic (January 2019-March 2020), COVID-19 Era 1 (April 2020-June 2020), and COVID-19 Era 2 (July 2020-June 2021). UTI-specific ancillary services included medication, laboratory, and imaging. Orders and order fulfillments were dichotomized for analyses. Weighted percentages for orders and fulfillments were calculated using inverse probability treatment weighting from logistic regression and compared between virtual and in-person encounters using χ2 tests. RESULTS We identified 123,907 incident encounters. Virtual encounters increased from 13.4% prepandemic to 39.1% in COVID-19 Era 2. Ancillary service orders from virtual encounters were not placed as often as in-person encounters. However, the weighted percentage for ancillary service order fulfillment across all services remained above 65.3% across sites and eras, with many fulfillment percentages above 90%. CONCLUSIONS Our study reported a high rate of order fulfillment for both virtual and in-person encounters. Health care systems should encourage providers to place ancillary service orders for uncomplicated diagnoses, such as UTI, to provide enhanced access to patient-centered care.
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Affiliation(s)
- Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | - Glenn Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Bennet McDonald
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | | | - Heather M. Tavel
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Teaniese L. Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | - Nancy S. Weinfield
- Kaiser Permanente Mid-Atlantic Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | | | - Douglas W. Roblin
- Kaiser Permanente Mid-Atlantic Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
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11
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Roblin DW, Goodrich GK, Davis TL, Gander JC, McCracken CE, Weinfield NS, Ritzwoller DP. Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period? Med Care 2023; 61:S39-S46. [PMID: 36893417 PMCID: PMC9994577 DOI: 10.1097/mlr.0000000000001832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND/OBJECTIVE In recent years, 2 circumstances changed provider-patient interactions in primary care: the substitution of virtual (eg, video) for in-person visits and the COVID-19 pandemic. We studied whether access to care might affect patient fulfillment of ancillary services orders for ambulatory diagnosis and management of incident neck or back pain (NBP) and incident urinary tract infection (UTI) for virtual versus in-person visits. METHODS Data were extracted from the electronic health records of 3 Kaiser Permanente Regions to identify incident NBP and UTI visits from January 2016 through June 2021. Visit modes were classified as virtual (Internet-mediated synchronous chats, telephone visits, or video visits) or in-person. Periods were classified as prepandemic [before the beginning of the national emergency (April 2020)] or recovery (after June 2020). Percentages of patient fulfillment of ancillary services orders were measured for 5 service classes each for NBP and UTI. Differences in percentages of fulfillments were compared between modes within periods and between periods within the mode to assess the possible impact of 3 moderators: distance from residence to primary care clinic, high deductible health plan (HDHP) enrollment, and prior use of a mail-order pharmacy program. RESULTS For diagnostic radiology, laboratory, and pharmacy services, percentages of fulfilled orders were generally >70-80%. Given an incident NBP or UTI visit, longer distance to the clinic and higher cost-sharing due to HDHP enrollment did not significantly suppress patients' fulfillment of ancillary services orders. Prior use of mail-order prescriptions significantly promoted medication order fulfillments on virtual NBP visits compared with in-person NBP visits in the prepandemic period (5.9% vs. 2.0%, P=0.01) and in the recovery period (5.2% vs. 1.6%, P=0.02). CONCLUSIONS Distance to the clinic or HDHP enrollment had minimal impact on the fulfillment of diagnostic or prescribed medication services associated with incident NBP or UTI visits delivered virtually or in-person; however, prior use of mail-order pharmacy option promoted fulfillment of prescribed medication orders associated with NBP visits.
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Affiliation(s)
- Douglas W. Roblin
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | | | | | | | | | - Nancy S. Weinfield
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
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12
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Ritzwoller DP, Goodrich GW, Tavel HM, Odelberg MR, Davis TL, Gander JC, McCracken CE, Weinfield NS, Roblin DW. Patient Factors Associated With Use of Adult Primary Care and Virtual Visits During the COVID-19 Pandemic. Med Care 2023; 61:S12-S20. [PMID: 36893414 PMCID: PMC9994567 DOI: 10.1097/mlr.0000000000001792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND The delivery of adult primary care (APC) shifted from predominately in-person to modes of virtual care during the COVID-19 pandemic. It is unclear how these shifts impacted the likelihood of APC use during the pandemic, or how patient characteristics may be associated with the use of virtual care. METHODS A retrospective cohort study using person-month level datasets from 3 geographically disparate integrated health care systems was conducted for the observation period of January 1, 2020, through June 30, 2021. We estimated a 2-stage model, first adjusting for patient-level sociodemographic, clinical, and cost-sharing factors, using generalized estimating equations with a logit distribution, along with a second-stage multinomial generalized estimating equations model that included an inverse propensity score treatment weight to adjust for the likelihood of APC use. Factors associated with APC use and virtual care use were separately assessed for the 3 sites. RESULTS Included in the first-stage models were datasets with total person-months of 7,055,549, 11,014,430, and 4,176,934, respectively. Older age, female sex, greater comorbidity, and Black race and Hispanic ethnicity were associated with higher likelihood of any APC use in any month; measures of greater patient cost-sharing were associated with a lower likelihood. Conditional on APC use, older age, and adults identifying as Black, Asian, or Hispanic were less likely to use virtual care. CONCLUSIONS As the transition in health care continues to evolve, our findings suggest that to ensure vulnerable patient groups receive high quality health care, outreach interventions to reduce barriers to virtual care use may be warranted.
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Affiliation(s)
| | - Glenn W. Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Heather M. Tavel
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | | | - Teaniese L. Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | - Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | | | - Nancy S. Weinfield
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Douglas W. Roblin
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD
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13
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Weinfield NS, Tavel HM, Goodrich G, McCracken CE, Basra S, Gander JC, Davis TL, Ritzwoller DP, Roblin DW. Health-care-Related Practices in Virtual Behavioral Health Treatment for Major Depression Before and During the COVID-19 Pandemic. Med Care 2023; 61:S47-S53. [PMID: 36893418 PMCID: PMC9994573 DOI: 10.1097/mlr.0000000000001815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND The abrupt shift to virtual care at the onset of the COVID-19 pandemic had the potential to disrupt care practices in virtual behavioral health encounters. We examined changes over time in virtual behavioral health-care-related practices for patient encounters with diagnoses of major depression. METHODS This retrospective cohort study utilized electronic health record data from 3 integrated health care systems. Inverse probability of treatment weighting was used to adjust for covariates across 3 time periods, prepandemic (January 2019-March 2020), peak-pandemic shift to virtual care (April 2020-June 2020), and recovery of health care operations (July 2020-June 2021). First virtual follow-up behavioral health department encounters after an incident diagnostic encounter were examined for differences across the time periods in rates of antidepressant medication orders and fulfillments, and completion of patient-reported symptoms screeners in service of measurement-based care. RESULTS Antidepressant medication orders declined modestly but significantly in 2 of the 3 systems during the peak-pandemic period but rebounded during the recovery period. There were no significant changes in patient fulfillment of ordered antidepressant medications. Completion of symptom screeners increased significantly in all 3 systems during the peak-pandemic period and continued to increase significantly in the subsequent period. CONCLUSIONS A rapid shift to virtual behavioral health care was possible without compromising health-care-related practices. The transition and subsequent adjustment period have instead been marked by improved adherence to measurement-based care practices in virtual visits, signaling a potential new capacity for virtual health care delivery.
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Affiliation(s)
- Nancy S. Weinfield
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Heather M. Tavel
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Glenn Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | | | - Sundeep Basra
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | - Teaniese L. Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | | | - Douglas W. Roblin
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD
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14
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Roblin DW, Rubenstein KB, Tavel HM, Goodrich GK, Ritzwoller DP, Certa JM, Basra SS, Weinfield NS, Cromwell LA, McDonald B, Davis TL, Gander JC, McCracken CE. Development of a Common Data Model for a Multisite and Multiyear Study of Virtual Visit Implementation: A Case Study. Med Care 2023; 61:S54-S61. [PMID: 36893419 PMCID: PMC9994571 DOI: 10.1097/mlr.0000000000001834] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND/OBJECTIVE In multisite studies, a common data model (CDM) standardizes dataset organization, variable definitions, and variable code structures and can support distributed data processing. We describe the development of a CDM for a study of virtual visit implementation in 3 Kaiser Permanente (KP) regions. METHODS We conducted several scoping reviews to inform our study's CDM design: (1) virtual visit mode, implementation timing, and scope (targeted clinical conditions and departments); and (2) extant sources of electronic health record data to specify study measures. Our study covered the period from 2017 through June 2021. Integrity of the CDM was assessed by a chart review of random samples of virtual and in-person visits, overall and by specific conditions of interest (neck or back pain, urinary tract infection, major depression). RESULTS The scoping reviews identified a need to address differences in virtual visit programs across the 3 KP regionsto harmonize measurement specifications for our research analyses. The final CDM contained patient-level, provider-level, and system-level measures on 7,476,604 person-years for KP members aged 19 years and above. Utilization included 2,966,112 virtual visits (synchronous chats, telephone visits, video visits) and 10,004,195 in-person visits. Chart review indicated the CDM correctly identified visit mode on>96% (n=444) of visits, and presenting diagnosis on >91% (n=482) of visits. CONCLUSIONS Upfront design and implementation of CDMs may be resource intensive. Once implemented, CDMs, like the one we developed for our study, provide downstream programming and analytic efficiencies by harmonizing, in a consistent framework, otherwise idiosyncratic temporal and study site differences in source data.
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Affiliation(s)
- Douglas W. Roblin
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Kevin B. Rubenstein
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | | | | | | | - Julia M. Certa
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Sundeep S. Basra
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Nancy S. Weinfield
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Lee A. Cromwell
- Kaiser Permanente, Center for Research and Evaluation, Atlanta, GA
| | - Bennett McDonald
- Kaiser Permanente, Center for Research and Evaluation, Atlanta, GA
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15
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Roblin DW, Goodrich GK, Davis TL, Gander JC, McCracken CE, Weinfield NS, Ritzwoller DP. Management of Neck or Back Pain in Ambulatory Care: Did Visit Mode or the COVID-19 Pandemic Affect Provider Practice or Patient Adherence? Med Care 2023; 61:S30-S38. [PMID: 36893416 PMCID: PMC9994575 DOI: 10.1097/mlr.0000000000001833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND/OBJECTIVE In recent years, 2 circumstances have changed provider-patient interactions in ambulatory care: (1) the replacement of virtual for in-person visits and (2) the COVID-19 pandemic. We studied the potential impact of each event on provider practice and patient adherence by comparing the frequency of the association of provider orders, and patient fulfillment of those orders, by visit mode and pandemic period, for incident neck or back pain (NBP) visits in ambulatory care. METHODS Data were extracted from the electronic health records of 3 Kaiser Permanente regions (Colorado, Georgia, and Mid-Atlantic States) from January 2017 to June 2021. Incident NBP visits were defined from ICD-10 coded as primary or first listed diagnoses on adult, family medicine, or urgent care visits separated by at least 180 days. Visit modes were classified as virtual or in-person. Periods were classified as prepandemic (before April 2020 or the beginning of the national emergency) or recovery (after June 2020). Percentages of provider orders for, and patient fulfillment of orders, were measured for 5 service classes and compared on: virtual versus in-person visits, and prepandemic versus recovery periods. Comparisons were balanced on patient case-mix using inverse probability of treatment weighting. RESULTS Ancillary services in all 5 categories at each of the 3 Kaiser Permanente regions were substantially ordered less frequently on virtual compared with in-person visits in both the prepandemic and recovery periods (both P ≤ 0.001). Conditional on an order, patient fulfillment within 30 days was high (typically ≥70%) and not likely meaningfully different between visit modes or pandemic periods. CONCLUSIONS Ancillary services for incident NBP visits were ordered less frequently during virtual than in-person visits in both prepandemic and recovery periods. Patient fulfillment of orders was high, and not significantly different by mode or period.
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Affiliation(s)
- Douglas W. Roblin
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | | | | | | | | | - Nancy S. Weinfield
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
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16
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Kim RY, Rendle KA, Mitra N, Saia CA, Neslund-Dudas C, Greenlee RT, Burnett-Hartman AN, Honda SA, Simoff MJ, Schapira MM, Croswell JM, Meza R, Ritzwoller DP, Vachani A. Socioeconomic Status as a Mediator of Racial Disparity in Annual Lung Cancer Screening Adherence. Am J Respir Crit Care Med 2023; 207:777-780. [PMID: 36306485 PMCID: PMC10037473 DOI: 10.1164/rccm.202208-1590le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Roger Y. Kim
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Stacey A. Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Oahu, Hawaii
- Hawaii Permanente Medical Group, Oahu, Hawaii
| | - Michael J. Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Marilyn M. Schapira
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
| | - Jennifer M. Croswell
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, Maryland
| | - Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | | | - Anil Vachani
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
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17
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Selby K, Sedki M, Levine E, Kamineni A, Green BB, Vachani A, Haas JS, Ritzwoller DP, Croswell JM, Ohikere K, Doria-Rose VP, Rendle KA, Chubak J, Lafata JE, Inadomi J, Corley DA. Test performance metrics for breast, cervical, colon and lung cancer screening: a systematic review. J Natl Cancer Inst 2023; 115:375-384. [PMID: 36752508 PMCID: PMC10086636 DOI: 10.1093/jnci/djad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/19/2022] [Accepted: 01/28/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Multiple quality metrics have been recommended to ensure consistent, high-quality execution of screening tests for breast, cervical, colorectal and lung cancers. However, minimal data exist evaluating the evidence base supporting these recommendations and the consistency of definitions and concepts included within and between cancer types. METHODS We performed a systematic review for each cancer type using MEDLINE, Embase and CINAHL from 2010 to April 2020, to identify guidelines from screening programs or professional organizations containing quality metrics for tests used in breast, cervical, colorectal and lung cancer screening. We abstracted metrics' definitions, target performance levels, and related supporting evidence for test completeness, adequacy (sufficient visualization or collection), accuracy, and safety. RESULTS We identified 11 relevant guidelines with 20 suggested quality metrics for breast cancer, 5 guidelines with 9 metrics for cervical cancer, 13 guidelines with 18 metrics for colorectal cancer, and 3 guidelines with 7 metrics for lung cancer. These included 54 metrics related to adequacy (6), test completeness (3), accuracy (33), and safety (12). Target performance levels were defined for 30 metrics (56%). Ten (19%) were supported by evidence, all from breast and colorectal cancer, with no evidence cited to support metrics from cervical and lung cancer screening. CONCLUSIONS Considerably more guideline-recommended test performance metrics exist for breast and colorectal cancer screening than cervical or lung cancer. The domains covered are inconsistent among cancers and few targets are supported by evidence. Clearer evidence-based domains and targets are needed for test performance metrics. REGISTRATION PROSPERO 2020 CRD42020179139.
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Affiliation(s)
- Kevin Selby
- Center for primary care and public health (Unisanté), Lausanne, Switzerland
| | - Mai Sedki
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Emma Levine
- University of California at San Francisco, San Francisco, CA, USA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, USA
| | - Anil Vachani
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Debra P Ritzwoller
- Institute for Research, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Jennifer M Croswell
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Kabiru Ohikere
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Katharine A Rendle
- Department of Family Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, USA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Jennifer Elston Lafata
- Eshelman School of Pharmacy and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, USA, USA
| | - John Inadomi
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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18
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Burnett-Hartman AN, Carroll NM, Croswell JM, Greenlee RT, Honda SA, Neslund-Dudas CM, Kim RY, Rendle KA, Vachani A, Ritzwoller DP. Percentage Up to Date With Chest Computed Tomography Among Those Eligible for Lung Cancer Screening. Am J Prev Med 2023:S0749-3797(23)00004-1. [PMID: 36707314 DOI: 10.1016/j.amepre.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Authors aimed to calculate the percentage up-to-date with testing in the context of lung cancer screening across 5 healthcare systems and evaluate differences according to patient and health system characteristics. METHODS Lung cancer screening‒eligible individuals receiving care within the 5 systems in the Population-based Research to Optimize the Screening Process Lung consortium from October 1, 2018 to September 30, 2019 were included in analyses. Data collection was completed on June 15, 2021; final analyses were completed on April 1, 2022. Chest computed tomography scans and patient characteristics were obtained through electronic health records and used to calculate the percentage completing a chest computed tomography scan in the previous 12 months (considered up-to-date). The association of patient and healthcare system factors with being up-to-date was evaluated with adjusted prevalence ratios and 95% CIs using log-binomial regression models. RESULTS There were 29,417 individuals eligible for lung cancer screening as of September 30, 2019; 8,333 (28.3%) were up-to-date with testing. Those aged 65-74 years (prevalence ratio=1.19; CI=1.15, 1.24, versus ages 55-64), those with chronic obstructive pulmonary disease (prevalence ratio=2.05; CI=1.98, 2.13), and those in higher SES census tracts (prevalence ratio=1.22; CI=1.16, 1.30, highest quintile versus lowest) were more likely to be up-to-date. Currently smoking (prevalence ratio=0.91; CI=0.88, 0.95), having a BMI ≥30 kg/m2 (prevalence ratio=0.83; CI=0.77, 0.88), identifying as Native Hawaiian or other Pacific Islander (prevalence ratio=0.79; CI=0.68, 0.92), and having a decentralized lung cancer screening program (prevalence ratio=0.77; CI=0.74, 0.80) were inversely associated with being up-to-date. CONCLUSIONS The percentage up-to-date with testing among those eligible for lung cancer screening is well below up-to-date estimates for other types of cancer screening, and disparities in lung cancer screening participation remain.
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Affiliation(s)
| | - Nikki M Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Jennifer M Croswell
- Division of Cancer Control and Population Sciences, National Cancer Institute, NIH, Bethesda, Maryland
| | | | - Stacey A Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Oahu, Hawaii; Hawaii Permanente Medical Group, Oahu, Hawaii
| | | | - Roger Y Kim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
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19
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Vachani A, Carroll NM, Simoff MJ, Neslund-Dudas C, Honda S, Greenlee RT, Rendle KA, Burnett-Hartman A, Ritzwoller DP. Stage Migration and Lung Cancer Incidence After Initiation of Low-Dose Computed Tomography Screening. J Thorac Oncol 2022; 17:1355-1364. [PMID: 36087860 PMCID: PMC9703625 DOI: 10.1016/j.jtho.2022.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Despite evidence from clinical trials of favorable shifts in cancer stage and improvements in lung cancer-specific mortality, the effectiveness of lung cancer screening (LCS) in clinical practice has not been clearly revealed. METHODS We performed a multicenter cohort study of patients diagnosed with a primary lung cancer between January 1, 2014, and September 30, 2019, at one of four U.S. health care systems. The primary outcome variables were cancer stage distribution and annual age-adjusted lung cancer incidence. The primary exposure variable was receipt of at least one low-dose computed tomography for LCS before cancer diagnosis. RESULTS A total of 3678 individuals were diagnosed with an incident lung cancer during the study period; 404 (11%) of these patients were diagnosed after initiation of LCS. As screening volume increased, the proportion of patients diagnosed with lung cancer after LCS initiation also rose from 0% in the first quartile of 2014 to 20% in the third quartile of 2019. LCS did not result in a significant change in the overall incidence of lung cancer (average annual percentage change [AAPC]: -0.8 [95% confidence interval (CI): -4.7 to 3.2]) between 2014 and 2018. Stage-specific incidence rates increased for stage I cancer (AAPC = 8.0 [95% CI: 0.8-15.7]) and declined for stage IV disease (AAPC = -6.0 [95% CI: -11.2 to -0.5]). CONCLUSIONS Implementation of LCS at four diverse health care systems has resulted in a favorable shift to a higher incidence of stage I cancer with an associated decline in stage IV disease. Overall lung cancer incidence did not increase, suggesting a limited impact of overdiagnosis.
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Affiliation(s)
- Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Nikki M Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Michael J Simoff
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, Michigan
| | | | - Stacey Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Oahu, Hawaii
| | | | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
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20
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Hoskins K, Linn KA, Ahmedani BK, Boggs JM, Johnson C, Heintz J, Marcus SC, Kaminer I, Zabel C, Wright L, Quintana LM, Buttenheim AM, Daley MF, Elias ME, Jager-Hyman S, Lieberman A, Lyons J, Maye M, McArdle B, Ritzwoller DP, Small DS, Westphal J, Wolk CB, Zhang S, Shelton RC, Beidas RS. Equitable implementation of S.A.F.E. Firearm: A multi-method pilot study. Prev Med 2022; 165:107281. [PMID: 36191653 PMCID: PMC10013361 DOI: 10.1016/j.ypmed.2022.107281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 02/08/2023]
Abstract
Attention to health equity is critical in the implementation of firearm safety efforts. We present our operationalization of equity-oriented recommendations in preparation for launch of a hybrid effectiveness-implementation trial focused on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. In Step 1 of our process, pre-trial engagement with clinican partners and literature review alerted us that delivery of a firearm safety program may vary by patients' medical complexity, race, and ethnicity. In Step 2, we selected the Health Equity Implementation Framework to inform our understanding of contextual determinants (i.e., barriers and facilitators). In Step 3, we leveraged an implementation pilot across 5 pediatric primary care clinics in 2 health system sites to study signals of inequities. Eligible well-child visits for 694 patients and 47 clinicians were included. Our results suggested that medical complexity was not associated with program delivery. We did see potential signals of inequities by race and ethnicity but must interpret with caution. Though we did not initially plan to examine differences by sex assigned at birth, we discovered that clinicians may be more likely to deliver the program to parents of male than female patients. Seven qualitative interviews with clinicians provided additional context. In Step 4, we interrogated equity considerations (e.g., why and how do these inequities exist). In Step 5, we will develop a plan to probe potential inequities related to race, ethnicity, and sex in the fully powered trial. Our process highlights that prospective, rigorous, exploratory work is vital for equity-informed implementation trials.
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Affiliation(s)
- Katelin Hoskins
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Kristin A Linn
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Jennifer M Boggs
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Christina Johnson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jonathan Heintz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven C Marcus
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Isabelle Kaminer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Celeste Zabel
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Leslie Wright
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - LeeAnn M Quintana
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | | | - Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Marisa E Elias
- Department of Pediatrics, Henry Ford Health, Detroit, MI, USA
| | - Shari Jager-Hyman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adina Lieberman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Lyons
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Melissa Maye
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Bridget McArdle
- Department of Pediatrics, Henry Ford Health, Detroit, MI, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Dylan S Small
- Wharton School of Business, University of Pennsylvania, Philadelphia, PA, USA
| | - Joslyn Westphal
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, MI, USA
| | | | - Shiling Zhang
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Rachel C Shelton
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rinad S Beidas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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21
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Kamineni A, Doria-Rose VP, Chubak J, Inadomi JM, Corley DA, Haas JS, Kobrin SC, Winer RL, Elston Lafata J, Beaber EF, Yudkin JS, Zheng Y, Skinner CS, Schottinger JE, Ritzwoller DP, Croswell JM, Burnett-Hartman AN. Evaluation of Harms Reporting in U.S. Cancer Screening Guidelines. Ann Intern Med 2022; 175:1582-1590. [PMID: 36162112 PMCID: PMC9903969 DOI: 10.7326/m22-1139] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Cancer screening should be recommended only when the balance between benefits and harms is favorable. This review evaluated how U.S. cancer screening guidelines reported harms, within and across organ-specific processes to screen for cancer. OBJECTIVE To describe current reporting practices and identify opportunities for improvement. DESIGN Review of guidelines. SETTING United States. PATIENTS Patients eligible for screening for breast, cervical, colorectal, lung, or prostate cancer according to U.S. guidelines. MEASUREMENTS Information was abstracted on reporting of patient-level harms associated with screening, diagnostic follow-up, and treatment. The authors classified harms reporting as not mentioned, conceptual, qualitative, or quantitative and noted whether literature was cited when harms were described. Frequency of harms reporting was summarized by organ type. RESULTS Harms reporting was inconsistent across organ types and at each step of the cancer screening process. Guidelines did not report all harms for any specific organ type or for any category of harm across organ types. The most complete harms reporting was for prostate cancer screening guidelines and the least complete for colorectal cancer screening guidelines. Conceptualization of harms and use of quantitative evidence also differed by organ type. LIMITATIONS This review considers only patient-level harms. The authors did not verify accuracy of harms information presented in the guidelines. CONCLUSION The review identified opportunities for improving conceptualization, assessment, and reporting of screening process-related harms in guidelines. Future work should consider nuances associated with each organ-specific process to screen for cancer, including which harms are most salient and where evidence gaps exist, and explicitly explore how to optimally weigh available evidence in determining net screening benefit. Improved harms reporting could aid informed decision making, ultimately improving cancer screening delivery. PRIMARY FUNDING SOURCE National Cancer Institute.
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Affiliation(s)
- Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (A.K., J.C.)
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (V.P.D., S.C.K., J.M.C.)
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (A.K., J.C.)
| | - John M Inadomi
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah (J.M.I.)
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California (D.A.C.)
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.S.H.)
| | - Sarah C Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (V.P.D., S.C.K., J.M.C.)
| | - Rachel L Winer
- Department of Epidemiology, University of Washington, Seattle, Washington (R.L.W.)
| | - Jennifer Elston Lafata
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, and Henry Ford Health System, Detroit, Michigan (J.E.L.)
| | - Elisabeth F Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (E.F.B., Y.Z.)
| | - Joshua S Yudkin
- University of Texas Health Science Center at Houston, Houston, Texas (J.S.Y.)
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (E.F.B., Y.Z.)
| | - Celette Sugg Skinner
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, and Simmons Comprehensive Cancer Center, Dallas, Texas (C.S.S.)
| | - Joanne E Schottinger
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California (J.E.S.)
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado (D.P.R., A.N.B.)
| | - Jennifer M Croswell
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (V.P.D., S.C.K., J.M.C.)
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22
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Kim RY, Rendle KA, Mitra N, Saia CA, Neslund-Dudas C, Greenlee RT, Burnett-Hartman AN, Honda SA, Simoff MJ, Schapira MM, Croswell JM, Meza R, Ritzwoller DP, Vachani A. Racial Disparities in Adherence to Annual Lung Cancer Screening and Recommended Follow-Up Care: A Multicenter Cohort Study. Ann Am Thorac Soc 2022; 19:1561-1569. [PMID: 35167781 PMCID: PMC9447384 DOI: 10.1513/annalsats.202111-1253oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/14/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: Black patients receive recommended lung cancer screening (LCS) follow-up care less frequently than White patients, but it is unknown if this racial disparity persists across both decentralized and centralized LCS programs. Objectives: To determine adherence to American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS) recommendations among individuals undergoing LCS at either decentralized or centralized programs and to evaluate the association of race with LCS adherence. Methods: We performed a multicenter retrospective cohort study of patients receiving LCS at five heterogeneous U.S. healthcare systems. We calculated adherence to annual LCS among patients with a negative baseline screen (Lung-RADS 1 or 2) and recommended follow-up care among those with a positive baseline screen (Lung-RADS 3, 4A, 4B, or 4X) stratified by type of LCS program and evaluated the association between race and adherence using multivariable modified Poisson regression. Results: Of the 6,134 total individuals receiving LCS, 5,142 (83.8%) had negative baseline screens, and 992 (16.2%) had positive baseline screens. Adherence to both annual LCS (34.8% vs. 76.1%; P < 0.001) and recommended follow-up care (63.9% vs. 74.6%; P < 0.001) was lower at decentralized compared with centralized programs. Among individuals with negative baseline screens, a racial disparity in adherence was observed only at decentralized screening programs (interaction term, P < 0.001). At decentralized programs, Black race was associated with 27% reduced adherence to annual LCS (adjusted relative risk [aRR], 0.73; 95% confidence interval [CI], 0.63-0.84), whereas at centralized programs, no effect by race was observed (aRR, 0.98; 95% CI, 0.91-1.05). In contrast, among those with positive baseline screens, there was no significant difference by race for adherence to recommended follow-up care by type of LCS program (decentralized aRR, 0.95; 95% CI, 0.81-1.11; centralized aRR, 0.81; 95% CI, 0.71-0.93; interaction term, P = 0.176). Conclusions: In this large multicenter study of individuals screened for lung cancer, adherence to both annual LCS and recommended follow-up care was greater at centralized screening programs. Black patients were less likely to receive annual LCS than White patients at decentralized compared with centralized LCS programs. Our results highlight the need for further study of healthcare system-level mechanisms to optimize longitudinal LCS care.
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Affiliation(s)
- Roger Y. Kim
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health
- Department of Biostatistics, Epidemiology, and Informatics, and
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, and
| | | | | | | | | | - Stacey A. Honda
- Center for Health Research, Kaiser Permanente Hawaii, Oahu, Hawaii
| | - Michael J. Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Marilyn M. Schapira
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer M. Croswell
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, Maryland; and
| | - Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | | | - Anil Vachani
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
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23
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Beaber EF, Kamineni A, Burnett-Hartman AN, Hixon B, Kobrin SC, Li CI, Oliver M, Rendle KA, Skinner CS, Todd K, Zheng Y, Ziebell RA, Breslau ES, Chubak J, Corley DA, Greenlee RT, Haas JS, Halm EA, Honda S, Neslund-Dudas C, Ritzwoller DP, Schottinger JE, Tiro JA, Vachani A, Doria-Rose VP. Evaluating and Improving Cancer Screening Process Quality in a Multilevel Context: The PROSPR II Consortium Design and Research Agenda. Cancer Epidemiol Biomarkers Prev 2022; 31:1521-1531. [PMID: 35916603 PMCID: PMC9350927 DOI: 10.1158/1055-9965.epi-22-0100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/08/2022] [Accepted: 05/06/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Cancer screening is a complex process involving multiple steps and levels of influence (e.g., patient, provider, facility, health care system, community, or neighborhood). We describe the design, methods, and research agenda of the Population-based Research to Optimize the Screening Process (PROSPR II) consortium. PROSPR II Research Centers (PRC), and the Coordinating Center aim to identify opportunities to improve screening processes and reduce disparities through investigation of factors affecting cervical, colorectal, and lung cancer screening in U.S. community health care settings. METHODS We collected multilevel, longitudinal cervical, colorectal, and lung cancer screening process data from clinical and administrative sources on >9 million racially and ethnically diverse individuals across 10 heterogeneous health care systems with cohorts beginning January 1, 2010. To facilitate comparisons across organ types and highlight data breadth, we calculated frequencies of multilevel characteristics and volumes of screening and diagnostic tests/procedures and abnormalities. RESULTS Variations in patient, provider, and facility characteristics reflected the PROSPR II health care systems and differing target populations. PRCs identified incident diagnoses of invasive cancers, in situ cancers, and precancers (invasive: 372 cervical, 24,131 colorectal, 11,205 lung; in situ: 911 colorectal, 32 lung; precancers: 13,838 cervical, 554,499 colorectal). CONCLUSIONS PROSPR II's research agenda aims to advance: (i) conceptualization and measurement of the cancer screening process, its multilevel factors, and quality; (ii) knowledge of cancer disparities; and (iii) evaluation of the COVID-19 pandemic's initial impacts on cancer screening. We invite researchers to collaborate with PROSPR II investigators. IMPACT PROSPR II is a valuable data resource for cancer screening researchers.
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Affiliation(s)
- Elisabeth F. Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | - Brian Hixon
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Sarah C. Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Christopher I. Li
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Malia Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Katharine A. Rendle
- Departments of Family Medicine and Community Health and of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Celette Sugg Skinner
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Kaitlin Todd
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Erica S. Breslau
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Robert T. Greenlee
- Center for Clinical Epidemiology & Population Health, Marshfield Clinic Research Institute, Marshfield, WI
| | - Jennifer S. Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Ethan A. Halm
- Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Stacey Honda
- Hawaii Permanente Medical Group, Kaiser Permanente Center for Integrated Health Care Research, Honolulu, HI
| | | | | | | | - Jasmin A. Tiro
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Anil Vachani
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - V. Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
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24
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Nicholas LH, Davidoff AJ, Howard DH, Keating NL, Ritzwoller DP, Robin Yabroff K, Bradley CJ. Cancer Survivorship and Supportive Care Economics Research: Current Challenges and Next Steps. J Natl Cancer Inst Monogr 2022; 2022:57-63. [PMID: 35788375 DOI: 10.1093/jncimonographs/lgac004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Rapid growth in the number of cancer survivors raises numerous questions about health and economic outcomes among survivors along with their families, caregivers, and employers. Health economics theory and methods can contribute to many open questions to improve survivorship. METHODS In this paper, we review key areas where more research is needed and describe strategies for improving data infrastructure, research funding, and capacity building to strengthen survivorship health economics research. CONCLUSIONS Health economics has broadened an understanding of key supply- and demand-side factors that promote cancer survivorship. To ensure necessary research in survivorship health economics moving forward, we recommend dedicated funding, inclusion of health economics outcomes in primary data collection, and investments in secondary data sets.
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Affiliation(s)
- Lauren Hersch Nicholas
- Department of Health Systems, Management & Policy, Colorado School of Public Health & University of Colorado Cancer Center, Aurora, CO, USA
| | | | - David H Howard
- Department of Health Policy & Management, Emory University, Atlanta, Georgia
| | - Nancy L Keating
- Departments of Health Care Policy and Medicine, Harvard Medical School, Cambridge, MA, USA
| | | | | | - Cathy J Bradley
- Department of Health Systems, Management & Policy, Colorado School of Public Health & University of Colorado Cancer Center, Aurora, CO, USA
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25
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Shih YCT, Sabik LM, Stout NK, Halpern MT, Lipscomb J, Ramsey S, Ritzwoller DP. Health Economics Research in Cancer Screening: Research Opportunities, Challenges, and Future Directions. J Natl Cancer Inst Monogr 2022; 2022:42-50. [PMID: 35788368 PMCID: PMC9255920 DOI: 10.1093/jncimonographs/lgac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/03/2022] [Indexed: 01/26/2023] Open
Abstract
Cancer screening has long been considered a worthy public health investment. Health economics offers the theoretical foundation and research methodology to understand the demand- and supply-side factors associated with screening and evaluate screening-related policies and interventions. This article provides an overview of health economic theories and methods related to cancer screening and discusses opportunities for future research. We review 2 academic disciplines most relevant to health economics research in cancer screening: applied microeconomics and decision science. We consider 3 emerging topics: cancer screening policies in national as well as local contexts, "choosing wisely" screening practices, and targeted screening efforts for vulnerable subpopulations. We also discuss the strengths and weaknesses of available data sources and opportunities for methodological research and training. Recommendations to strengthen research infrastructure include developing novel data linkage strategies, increasing access to electronic health records, establishing curriculum and training programs, promoting multidisciplinary collaborations, and enhancing research funding opportunities.
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Affiliation(s)
- Ya-Chen Tina Shih
- Correspondence to: Ya-Chen Tina Shih, PhD, Department of Health Services Research, Unit 1444, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030-4009, USA.
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Michael T Halpern
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, and the Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Scott Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Institute, Seattle, WA, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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26
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Cvietusa PJ, Goodrich GK, Steiner JF, Shoup JA, King DK, Ritzwoller DP, Shetterly SM, Bender BG. Transition to Virtual Asthma Care During the COVID-19 Pandemic: An Observational Study. J Allergy Clin Immunol Pract 2022; 10:1569-1576. [PMID: 35263682 PMCID: PMC8898589 DOI: 10.1016/j.jaip.2022.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The COVID-19 pandemic increased reliance on virtual care for patients with persistent asthma. OBJECTIVE This retrospective cohort study assessed changes from in-person to virtual care during the pandemic. In patients with persistent asthma, compared with the same period before the pandemic. METHODS Kaiser Permanente Colorado members aged 18 to 99 years with persistent asthma were evaluated during two periods (March to October 2019 and March to October 2020). Comparison of asthma exacerbations (hospitalizations, emergency department visits, and courses of oral prednisone) and asthma medication metrics were evaluated between the two periods and by type of care received during the pandemic (no care, virtual care only, in-person care only, or a mix of virtual and in-person care). Population characteristics by type of care received during the pandemic were also evaluated. RESULTS Among 7,805 adults with persistent asthma, those who used more virtual care or sought no care during the pandemic were younger and had fewer comorbidities, mental health diagnoses, or financial barriers. Exacerbations decreased (0.264 to 0.214; P <.001) as did courses of prednisone (0.213 to 0.169). Asthma medication adherence (0.53 to 0.54; P <.001) and the asthma medication ratio, a quality-of-care metric (0.755 to 0.762; P = .019), increased slightly. Patients receiving a mix of in-person and virtual care had the highest rate of exacerbations (0.83) and a lower asthma medication ratio (0.74) despite having the highest adherence (.57). CONCLUSIONS Despite an increase in virtual care, asthma exacerbations decreased except among individuals who received both in-person and virtual care, likely because they had more severe disease.
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Affiliation(s)
- Peter J. Cvietusa
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colo,Department of Asthma, Allergy, and Immunology, Permanente Medical Group, Denver, Colo,Corresponding author: Peter J. Cvietusa, MD, Department of Asthma, Allergy, and Immunology, Colorado Permanente Medical Group, Kaiser Permanente Colorado, 10400 East Alameda Ave, Denver, Colo 80247
| | - Glenn K. Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colo
| | - John F. Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colo
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colo
| | - Diane K. King
- Center for Behavioral Health Research and Services, Institute of Social and Economic Research, University of Alaska Anchorage, Anchorage, Alaska
| | | | | | - Bruce G. Bender
- Division of Pediatric Behavioral Health, National Jewish Health, Denver, Colo
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27
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Ritzwoller DP. A Feasible Path to Reductions in Racial and Ethnic Disparities in Lung Cancer Screening? JNCI Cancer Spectr 2022; 6:pkac034. [PMID: 35642318 PMCID: PMC9156841 DOI: 10.1093/jncics/pkac034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 01/21/2023] Open
Affiliation(s)
- Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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28
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Saldana L, Ritzwoller DP, Campbell M, Block EP. Using economic evaluations in implementation science to increase transparency in costs and outcomes for organizational decision-makers. Implement Sci Commun 2022; 3:40. [PMID: 35410434 PMCID: PMC9004101 DOI: 10.1186/s43058-022-00295-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/29/2022] [Indexed: 11/26/2022] Open
Abstract
Background Economic evaluations frequently are utilized to compare the value of different interventions in medicine and health in concrete terms. Implementation science also would benefit from the incorporation of economic evaluations, but such studies are rare in the literature. The National Cancer Institute has supported a special collection of articles focusing on economic evaluations in implementation science. Even when interventions are supported by substantial evidence, they are implemented infrequently in the field. Implementation costs are important determinants for whether organizational decision-makers choose to adopt an intervention and whether the implementation process is successful. Economic evaluations, such as cost-effectiveness analyses, can help organizational decision-makers choose between implementation approaches for evidence-based interventions by accounting for costs and succinctly presenting cost/benefit tradeoffs. Main text This manuscript presents a discussion of important considerations for incorporating economic evaluations into implementation science. First, the distinction between intervention and implementation costs is presented, along with an explanation of why the comprehensive representation of implementation costs is elusive. Then, the manuscript describes how economic evaluations in implementation science may differ from those in medicine and health intervention studies, especially in terms of determining the perspectives and outcomes of interest. Finally, referencing a scale-up trial of an evidence-based behavioral health intervention, concrete case examples of how cost data can be collected and used in economic evaluations targeting implementation, rather than clinical outcomes, are described. Conclusions By gaining a greater understanding of the costs and economic impact associated with different implementation approaches, organizational decision-makers will have better transparency for future replication and scale-up. The use of economic evaluations can help to advance this understanding and provide researchers, purveyors or third-party intermediaries, and organizational decision-makers with essential information to facilitate implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00295-1.
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Abstract
IMPORTANCE Patient factors help explain disparities in breast cancer treatments and outcomes. OBJECTIVE To determine the extent to which geospatial variation in initial breast cancer care can be attributed to region vs patient factors with the aim of guiding quality improvement efforts. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective population-based cohort study from January 1, 2007, through December 31, 2016, using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database that included 31 571 patients diagnosed with stage I to III breast cancer from 2007 through 2013. Five metrics of care delivery were defined: stage I at diagnosis, chemotherapy receipt, radiation therapy receipt, endocrine therapy (ET) initiation (year 1), and ET continuation (years 3-5). Data analysis was performed from January to June 2021. EXPOSURES Stage I diagnosis and treatment with chemotherapy, radiation therapy, or ET. MAIN OUTCOMES AND MEASURES For each metric, total variance was attributed proportionally to 4 domains-random, patient factors (eg, age, race and ethnicity, socioeconomic status), region (health service area [HSA]), and unexplained-using hierarchical multivariable modeling. RESULTS Of 31 571 total patients (median [IQR] age, 71 [68-75] years), 19 391 (61.4%) had stage I disease at diagnosis. Among eligible patients, 17 297 of 21 190 (81.6%) received radiation therapy, 7204 of 9903 (72.8%) received chemotherapy, 13 115 of 26 855 (48.8%) initiated ET, and 13 944 of 26 855 (52.1%) continued ET. Geospatial density (ie, heat) maps highlight regional performance patterns. For all 5 metrics, region/HSA explained more observed variation (24%-48%) than patient factors (1%-4%); the largest share of variation was unexplained (35%-54%). The metrics with the largest proportion of total variance attributed to region/HSA were ET initiation and continuation (28% and 39%, respectively). CONCLUSIONS AND RELEVANCE In this cohort study, there was substantial unexplained geospatial variation in initial breast cancer care. The variance attributed to region/HSA was multifold larger than that explained by patient factors. The importance of patient factors such as race and ethnicity notwithstanding, future quality improvement efforts should focus on reducing unwarranted geospatial variation, especially including optimizing the delivery of ET in low-performing regions.
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Affiliation(s)
- Michael J. Hassett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Angela C. Tramontano
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Harvard Medical School, Boston, Massachusetts,Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Rinaa S. Punglia
- Harvard Medical School, Boston, Massachusetts,Department of Radiation Oncology, Brigham & Women’s Hospital, Boston, Massachusetts
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Abstract
OBJECTIVE Mindful Mood Balance (MMB) is an effective Web-based program for residual depressive symptoms that prevents relapse among patients with partial recovery from major depressive episodes. This cost-effectiveness analysis was conducted from the health plan perspective alongside a pragmatic randomized controlled trial of MMB. METHODS Adults were recruited from behavioral health and primary care settings in a large integrated health system and randomly assigned to MMB plus usual depression care (MMB+UDC) or UDC. Patients had at least one prior major depressive episode; a current score of 5-9 on the Patient Health Questionnaire-9, indicating residual depressive symptoms; and Internet access. Program costs included recruitment, coaching, and MMB licensing. Center for Medicare and Medicaid fee schedules were applied to electronic health record utilization data for psychotropic medications and psychiatric and psychotherapy visits. Effectiveness was measured as depression-free days (DFDs), converted from PHQ-9 scores collected monthly for 1 year. Incremental cost-effectiveness ratios were calculated with various sets of cost inputs. RESULTS A total of 389 patients (UDC, N=210; MMB+UDC, N=179) had adequate follow-up PHQ-9 measures for inclusion. MMB+UDC patients had 29 more DFDs during follow-up. Overall, the incremental cost of MMB+UDC was $431.54 over 12 months. Incremental costs per DFD gained ranged from $9.63 for program costs only to $15.04 when psychiatric visits, psychotherapy visits, and psychotropic medications were included. CONCLUSIONS MMB offers a cost-effective Web-based program for reducing residual depressive symptoms and preventing relapse. Health systems should consider adopting MMB as adjunctive to traditional mental health care services.
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Affiliation(s)
- Jennifer M Boggs
- Institute for Health Research, Kaiser Permanente Colorado, Aurora (Boggs, Ritzwoller, Beck); Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder (Dimidjian); Graduate Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Segal)
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora (Boggs, Ritzwoller, Beck); Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder (Dimidjian); Graduate Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Segal)
| | - Arne Beck
- Institute for Health Research, Kaiser Permanente Colorado, Aurora (Boggs, Ritzwoller, Beck); Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder (Dimidjian); Graduate Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Segal)
| | - Sona Dimidjian
- Institute for Health Research, Kaiser Permanente Colorado, Aurora (Boggs, Ritzwoller, Beck); Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder (Dimidjian); Graduate Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Segal)
| | - Zindel V Segal
- Institute for Health Research, Kaiser Permanente Colorado, Aurora (Boggs, Ritzwoller, Beck); Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder (Dimidjian); Graduate Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Segal)
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Banegas MP, Hassett MJ, Keast EM, Carroll NM, O'Keeffe-Rosetti M, Fishman PA, Uno H, Hornbrook MC, Ritzwoller DP. Patterns of Medical Care Cost by Service Type for Patients With Recurrent and De Novo Advanced Cancer. Value Health 2022; 25:69-76. [PMID: 35031101 DOI: 10.1016/j.jval.2021.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/11/2021] [Accepted: 06/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES There is limited knowledge about the cost patterns of patients who receive a diagnosis of de novo and recurrent advanced cancers in the United States. METHODS Data on patients who received a diagnosis of de novo stage IV or recurrent breast, colorectal, or lung cancer between 2000 and 2012 from 3 integrated health systems were used to estimate average annual costs for total, ambulatory, inpatient, medication, and other services during (1) 12 months preceding de novo or recurrent diagnosis (preindex) and (2) diagnosis month through 11 months after (postindex), from the payer perspective. Generalized linear regression models estimated costs adjusting for patient and clinical factors. RESULTS Patients who developed a recurrence <1 year after their initial cancer diagnosis had significantly higher total costs in the preindex period than those with recurrence ≥1 year after initial diagnosis and those with de novo stage IV disease across all cancers (all P < .05). Patients with de novo stage IV breast and colorectal cancer had significantly higher total costs in the postindex period than patients with cancer recurrent in <1 year and ≥1 year (all P < .05), respectively. Patients in de novo stage IV and those with recurrence in ≥1 year experienced significantly higher postindex costs than the preindex period (all P < .001). CONCLUSIONS Our findings reveal distinct cost patterns between patients with de novo stage IV, recurrent <1-year, and recurrent ≥1-year cancer, suggesting unique care trajectories that may influence resource use and planning. Future cost studies among patients with advanced cancer should account for de novo versus recurrent diagnoses and timing of recurrence to obtain estimates that accurately reflect these care pattern complexities.
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Affiliation(s)
- Matthew P Banegas
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA; University of California San Diego, La Jolla, CA, USA.
| | | | - Erin M Keast
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Nikki M Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | | | - Paul A Fishman
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | - Hajime Uno
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Mark C Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
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Croswell JM, Corley DA, Lafata JE, Haas JS, Inadomi JM, Kamineni A, Ritzwoller DP, Vachani A, Zheng Y. Cancer screening in the U.S. through the COVID-19 pandemic, recovery, and beyond. Prev Med 2021; 151:106595. [PMID: 34217414 PMCID: PMC8722181 DOI: 10.1016/j.ypmed.2021.106595] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 01/08/2023]
Abstract
COVID-19 has proved enormously disruptive to the provision of cancer screening, which does not just represent an initial test but an entire process, including risk detection, diagnostic follow-up, and treatment. Successful delivery of services at all points in the process has been negatively affected by the pandemic. There is a void in empirical high-quality evidence to support a specific strategy for administering cancer screening during a pandemic and its resolution phase, but several pragmatic considerations can help guide prioritization efforts. Targeting guideline-eligible people who have never been screened, or those who are significantly out of date with screening, has the potential to maximize benefits now and into the future. Disruptions to care due to the pandemic could represent an unparalleled opportunity to reassess early detection programs towards an explicit, thoughtful, and just prioritization of populations historically experiencing cancer disparities. By focusing screening services on populations that have the most to gain, and by careful and deliberate planning for the period following the pandemic, we can positively affect cancer outcomes for all.
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Affiliation(s)
- Jennifer M Croswell
- Division of Cancer Control and Population Sciences, National Cancer Institute, USA.
| | - Douglas A Corley
- The Permanente Medical Group, Kaiser Permanente, Northern California, USA
| | - Jennifer Elston Lafata
- University of North Carolina Lineberger Comprehensive Cancer Center and Eshelman School of Pharmacy, USA
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, USA
| | - John M Inadomi
- Department of Internal Medicine, University of Utah School of Medicine, USA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, USA
| | | | - Anil Vachani
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, USA
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, USA
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Ritzwoller DP, Meza R, Carroll NM, Blum-Barnett E, Burnett-Hartman AN, Greenlee RT, Honda SA, Neslund-Dudas C, Rendle KA, Vachani A. Evaluation of Population-Level Changes Associated With the 2021 US Preventive Services Task Force Lung Cancer Screening Recommendations in Community-Based Health Care Systems. JAMA Netw Open 2021; 4:e2128176. [PMID: 34636916 PMCID: PMC8511972 DOI: 10.1001/jamanetworkopen.2021.28176] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The US Preventive Services Task Force (USPSTF) released updated lung cancer screening recommendations in 2021, lowering the screening age from 55 to 50 years and smoking history from 30 to 20 pack-years. These changes are expected to expand screening access to women and racial and ethnic minority groups. OBJECTIVE To estimate the population-level changes associated with the 2021 USPSTF expansion of lung cancer screening eligibility by sex, race and ethnicity, sociodemographic factors, and comorbidities in 5 community-based health care systems. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed data of patients who received care from any of 5 community-based health care systems (which are members of the Population-based Research to Optimize the Screening Process Lung Consortium, a collaboration that conducts research to better understand how to improve the cancer screening processes in community health care settings) from January 1, 2010, through September 30, 2019. Individuals who had complete smoking history and were engaged with the health care system for 12 or more continuous months were included. Those who had never smoked or who had unknown smoking history were excluded. EXPOSURES Electronic health record-derived age, sex, race and ethnicity, socioeconomic status (SES), comorbidities, and smoking history. MAIN OUTCOMES AND MEASURES Differences in the proportion of the newly eligible population by age, sex, race and ethnicity, Charlson Comorbidity Index, chronic obstructive pulmonary disease diagnosis, and SES as well as lung cancer diagnoses under the 2013 recommendations vs the expected cases under the 2021 recommendations were evaluated using χ2 tests. RESULTS As of September 2019, there were 341 163 individuals aged 50 to 80 years who currently or previously smoked. Among these, 34 528 had electronic health record data that captured pack-year and quit-date information and were eligible for lung cancer screening according to the 2013 USPSTF recommendations. The 2021 USPSTF recommendations expanded screening eligibility to 18 533 individuals, representing a 53.7% increase. Compared with the 2013 cohort, the newly eligible 2021 population included 5833 individuals (31.5%) aged 50 to 54 years, a larger proportion of women (52.0% [n = 9631]), and more racial or ethnic minority groups. The relative increases in the proportion of newly eligible individuals were 60.6% for Asian, Native Hawaiian, or Pacific Islander; 67.4% for Hispanic; 69.7% for non-Hispanic Black; and 49.0% for non-Hispanic White groups. The relative increase for women was 13.8% higher than for men (61.2% vs 47.4%), and those with a lower comorbidity burden and lower SES had higher relative increases (eg, 68.7% for a Charlson Comorbidity Index score of 0; 61.1% for lowest SES). The 2021 recommendations were associated with an estimated 30% increase in incident lung cancer diagnoses compared with the 2013 recommendations. CONCLUSIONS AND RELEVANCE This cohort study suggests that, in diverse health care systems, adopting the 2021 USPSTF recommendations will increase the number of women, racial and ethnic minority groups, and individuals with lower SES who are eligible for lung cancer screening, thus helping to minimize the barriers to screening access for individuals with high risk for lung cancer.
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Affiliation(s)
| | - Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor
| | - Nikki M. Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | | | | | - Stacey A. Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Oahu
| | | | | | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Beidas RS, Ahmedani BK, Linn KA, Marcus SC, Johnson C, Maye M, Westphal J, Wright L, Beck AL, Buttenheim AM, Daley MF, Davis M, Elias ME, Jager-Hyman S, Hoskins K, Lieberman A, McArdle B, Ritzwoller DP, Small DS, Wolk CB, Williams NJ, Boggs JM. Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care. Implement Sci 2021; 16:89. [PMID: 34551811 PMCID: PMC8456701 DOI: 10.1186/s13012-021-01154-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/24/2021] [Indexed: 01/23/2023] Open
Abstract
Background Insights from behavioral economics, or how individuals’ decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., “Nudge”) powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers? Methods The Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians’ use of an evidence-based firearm safety practice, S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receive S.A.F.E. Firearm materials, including training and cable locks. Half of the practices (k = 16) will be randomized to receive Nudge; the other half (k = 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to the S.A.F.E Firearm program. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning. Discussion The ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care. Trial registration ClinicalTrials.gov, NCT04844021. Registered 14 April 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01154-8.
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Affiliation(s)
- Rinad S Beidas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Kristin A Linn
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven C Marcus
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Johnson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa Maye
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Joslyn Westphal
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Leslie Wright
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Arne L Beck
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | | | - Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Molly Davis
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marisa E Elias
- Department of Pediatrics, Henry Ford Health System, Detroit, MI, USA
| | - Shari Jager-Hyman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katelin Hoskins
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adina Lieberman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Bridget McArdle
- Department of Pediatrics, Henry Ford Health System, Detroit, MI, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Dylan S Small
- Wharton School of Business, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Jennifer M Boggs
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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Ritzwoller DP, Hassett MJ, Uno H. Regarding the Utility of Unstructured Data and Natural Language Processing for Identification of Breast Cancer Recurrence. JCO Clin Cancer Inform 2021; 5:1024-1025. [PMID: 34637320 PMCID: PMC9848577 DOI: 10.1200/cci.21.00091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/20/2021] [Indexed: 01/23/2023] Open
Affiliation(s)
- Debra P. Ritzwoller
- Debra P. Ritzwoller, PhD, Institute for Health Research, Kaiser
Permanente Colorado, Aurora, CO; Michael J. Hassett, MD, MPH, Department of
Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, Harvard Medical
School, Boston, MA; and Hajime Uno, PhD, Harvard Medical School, Boston,
MA
| | - Michael J. Hassett
- Debra P. Ritzwoller, PhD, Institute for Health Research, Kaiser
Permanente Colorado, Aurora, CO; Michael J. Hassett, MD, MPH, Department of
Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, Harvard Medical
School, Boston, MA; and Hajime Uno, PhD, Harvard Medical School, Boston,
MA
| | - Hajime Uno
- Debra P. Ritzwoller, PhD, Institute for Health Research, Kaiser
Permanente Colorado, Aurora, CO; Michael J. Hassett, MD, MPH, Department of
Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, Harvard Medical
School, Boston, MA; and Hajime Uno, PhD, Harvard Medical School, Boston,
MA
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36
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Varga A, Gruß I, Ritzwoller DP, Bradley CJ, Sterrett AT, Banegas MP. Characterizing employment of colorectal cancer survivors using electronic health records. JAMIA Open 2021; 4:ooab061. [PMID: 34345806 PMCID: PMC8327368 DOI: 10.1093/jamiaopen/ooab061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/11/2021] [Accepted: 07/07/2021] [Indexed: 11/12/2022] Open
Abstract
Objective Although the value of collecting occupational data is well-established, these data are not systematically collected in clinical practice. We assessed the availability of electronic health record (EHR)-based occupation data within a large integrated health care system to determine the feasibility of its use in research. Materials and Methods We used a mixed-methods approach to extract EHR data and define employment status, employer, and employment industry of 1107 colorectal cancer survivors. This was a secondary analysis of a subset of the Patient Outcomes Research to Advance Learning (PORTAL) colorectal cancer cohort. Results We categorized the employment industry for 46% of the cohort. Employment status was available for 58% of the cohort. The employer was missing for over 95% of the cohort. Conclusion By combining data from structured and free-text EHR fields, we identified employment status and industry for approximately half of our sample. Findings demonstrate limitations of EHR data and underscore the need for systematic collection of occupation data in clinical practice.
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Affiliation(s)
- Alexandra Varga
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Inga Gruß
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Cathy J Bradley
- University of Colorado Denver, Colorado School of Public Health, Aurora, Colorado, USA
| | - Andrew T Sterrett
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
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Wagner NM, Ritzwoller DP, Raebel MA, Goodrich GK, Cvietusa PJ, King DK, Shoup JA, Bender BG. Can digital communication technology reduce health system personnel time? An evaluation of personnel requirements and costs in a randomized controlled trial. Transl Behav Med 2021; 11:863-869. [PMID: 33449120 DOI: 10.1093/tbm/ibaa130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Use of digital communication technologies (DCT) shows promise for enhancing outcomes and efficiencies in asthma care management. However, little is known about the impact of DCT interventions on healthcare personnel requirements and costs, thus making it difficult for providers and health systems to understand the value of these interventions. This study evaluated the differences in healthcare personnel requirements and costs between usual asthma care (UC) and a DCT intervention (Breathewell) aimed at maintaining guidelines-based asthma care while reducing health care staffing requirements. We used data from a pragmatic, randomized controlled trial conducted in a large integrated health system involving 14,978 patients diagnosed with asthma. To evaluate differences in staffing requirements and cost between Breathewell and UC needed to deliver guideline-based care we used electronic health record (EHR) events, provider time tracking surveys, and invoicing. Differences in cost were reported at the patient and health system level. The Breathewell intervention significantly reduced personnel requirements with a larger percentage of participants requiring no personnel time (45% vs. 5%, p < .001) and smaller percentage of participants requiring follow-up outreach (44% vs. 68%, p < .001). Extrapolated to the total health system, cost for the Breathewell intervention was $16,278 less than usual care. The intervention became cost savings at a sample size of at least 957 patients diagnosed with asthma. At the population level, using DCT to compliment current asthma care practice presents an opportunity to reduce healthcare personnel requirements while maintaining population-based asthma control measures.
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Affiliation(s)
- Nicole M Wagner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,Adult and Child Consortium for Outcomes Research and Dissemination Science, University of Colorado Denver, Denver, CO, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Marsha A Raebel
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Glenn K Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Peter J Cvietusa
- Department of Asthma, Allergy and Immunology, Kaiser Permanente Colorado, Denver, CO, USA
| | - Diane K King
- Center for Behavioral Health Research and Services, Institute of Social and Economic Research, University of Alaska Anchorage, Anchorage, AK, USA
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Bruce G Bender
- Division of Pediatric Behavioral Health, National Jewish Health, Denver, CO, USA
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Neslund-Dudas C, Tang A, Alleman E, Lafata JE, Honda SA, Oshiro C, Rendle KA, Vachani A, Olaiya O, Greenlee RT, Simoff MJ, Ritzwoller DP. Completion of lung cancer screening after a baseline order for LDCT at five diverse health systems. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10506 Background: In 2014 and 2015, the Affordable Care Act required coverage of, and CMS began reimbursing for lung cancer screening (LCS). Previous studies have shown that when new screening tests or treatments become available, disparities in disease outcomes often increase due to those with fewer resources having less access and greater barriers to care. African American men have historically had higher incidence of and death due to lung cancer than white males in the U.S., raising concerns regarding access to LCS and the potential for increases in disparities in lung cancer. We aimed to determine whether individual or neighborhood level factors were associated with completion of a baseline screening after an order for LCS low dose CT (LDCT) was placed. Methods: In a retrospective study conducted within the five health systems of the Lung Population-based Research to Optimize the Screening Process (PROSPR) Consortium, we determined adherence to baseline LDCT after a health care provider placed an order for LCS (January 2014 through June 2019). Follow-up was available through September 2019. Patients of interest for this analysis were current or former smokers, age 55 to 80 with a 30+ pack-year smoking history. Smoking history and other individual level variables were determined through electronic medical records. Neighborhood factors were derived from the 2010 Census and multivariable logistic regression was used. Results: Of the 13,920 patients that had at least one order for a baseline LCS exam, 14.1% were non-Hispanic Black, 70.3% were non-Hispanic White, and 15.7% were of other or unknown race. Overall, 61.2% of patients completed a LDCT within 90 days and 71.9% completed a scan by the end of follow-up. Completion of a baseline scan differed by health system (LDCT at 90-days, range 51% - 84%, p<0.0001) and increased in general across scan year (range 49.1%-66.0%, p <0.001). In multivariate logistic regression models, males (aOR=1.15, 95% CI 1.07-1.23, p=<0.0001), former smokers (aOR=1.31, 95% CI 1.21-1.40, p <0.0001), and those with a prior history of any cancer (aOR=1.16, 95% CI 1.02-1.32, p=0.03) were more likely to complete LDCT. Blacks were marginally less likely to have completed a baseline LDCT (aOR=0.90, 95% CI 0.81-1.00, p=0.06) within 90 days of an order. Sex modified the associations of race on completion of orders (p=0.08) (Black men aOR=0.81, 95% CI 0.70-0.94, p=0.006 ; Black women aOR=0.99, 95% CI 0.86-1.14, p=0.89). Conclusions: This multisite study indicates Black men in particular may have a lower likelihood of completing a baseline LCS after an order for screening is placed. As lung cancer screening programs move forward, attention should be given to factors associated with reduced uptake and adherence of screening to ensure disparities in lung cancer outcomes do not persist and increase. Provider and health system factors that may impact LCS uptake should be explored in future studies.
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Affiliation(s)
| | - Amy Tang
- Henry Ford Health System, Detroit, MI
| | | | - Jennifer Elston Lafata
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stacey A. Honda
- Hawaii Permanente Medical Group and Center for Integrated Health Care Research, Kaiser Permanente, Honolulu, HI
| | - Caryn Oshiro
- Kaiser Permanente Center for Integrated Health Care Research, Honolulu, HI
| | | | - Anil Vachani
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Kim R, Rendle KA, Neslund-Dudas C, Greenlee RT, Burnett-Hartman AN, Honda SA, Simoff MJ, Croswell JM, Ritzwoller DP, Vachani A. Community-based lung cancer screening adherence to Lung-RADS recommendations. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10540 Background: In the NLST and NELSON trials, most low-dose CT (LDCT) screen-detected lung cancers were not diagnosed during the first round of screening, suggesting that longitudinal adherence to lung cancer screening (LCS) recommendations is key. Adherence was as high as 95% in clinical trials, but limited data exist regarding LCS adherence in clinical practice. We aimed to determine adherence to Lung-RADS recommendations among community-based patients undergoing LCS. Methods: We performed a multicenter retrospective cohort study of patients screened for lung cancer at healthcare systems within the Lung Population-based Research to Optimize the Screening Process (PROSPR) Consortium. We included 55-80 year-old current or former smokers who received a baseline (T0) LDCT with a Lung-RADS score between January 1, 2015 and September 30, 2017 and excluded patients who were diagnosed with lung cancer prior to the T0 scan. Over a 24-month period, we calculated the proportion of patients adherent to Lung-RADS recommendations and evaluated associations with patient-level (age, sex, race, ethnicity, smoking status, body mass index, Elixhauser comorbidities, year of T0 scan, and Lung-RADS score) and census tract (median family income, level of education) data, using multivariable logistic regression with mixed effects to account for site variability. Results: Of the 6,723 patients in our cohort (median age 65 years [IQR 60-69]; 45.1% female; 73.0% white; 59.0% current smokers), 5,583 (83.0%) had Lung-RADS 1 or 2 T0 scans, 733 (10.9%) Lung-RADS 3, 274 (4.1%) Lung-RADS 4A, and 133 (2.0%) Lung-RADS 4B or 4X. Overall, 55.2% (3,709/6,723) of patients were adherent (Table). In the final multivariable model, Black patients had reduced adherence compared to white patients (adjusted odds ratio [aOR] 0.79, 95% CI 0.66-0.94), while greater adherence was observed in former smokers compared to current smokers (aOR 1.33, 95% 1.19-1.49). Compared to individuals with a negative T0 scan (Lung-RADS 1 or 2), those with Lung-RADS 3 (aOR 1.56, 95% CI 1.31-1.86), 4A (aOR 1.63, 95% CI 1.24-2.15), or 4B/4X (aOR 3.59, 95% CI 2.30-5.60) T0 scans had greater odds of adherence. Conclusions: In the largest study of real-world patients receiving LCS to date, adherence to Lung-RADS recommendations is lower than previously observed in clinical trials. Our results highlight the need for further study of system-level mechanisms to improve longitudinal LCS adherence rates.[Table: see text]
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Affiliation(s)
- Roger Kim
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | - Stacey A. Honda
- Hawaii Permanente Medical Group and Center for Integrated Health Care Research, Kaiser Permanente, Honolulu, HI
| | | | | | | | - Anil Vachani
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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40
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Corley DA, Sedki M, Ritzwoller DP, Greenlee RT, Neslund-Dudas C, Rendle KA, Honda SA, Schottinger JE, Udaltsova N, Vachani A, Kobrin S, Li CI, Haas JS. Cancer Screening During the Coronavirus Disease-2019 Pandemic: A Perspective From the National Cancer Institute's PROSPR Consortium. Gastroenterology 2021; 160:999-1002. [PMID: 33096099 PMCID: PMC7575503 DOI: 10.1053/j.gastro.2020.10.030] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 02/07/2023]
Affiliation(s)
- The National Cancer Institute’s PROSPR ConsortiumCorleyDouglas A.∗SedkiMai∗Division of Research, Kaiser Permanente Northern California,
Oakland, CaliforniaRitzwollerDebra P.Institute for Health Research, Kaiser Permanente Colorado,
Denver, ColoradoGreenleeRobert T.Center for Clinical Epidemiology and Population Health,
Marshfield Clinic Research Institute, Marshfield, WisconsinNeslund-DudasChristineDepartment of Public Health Sciences, Henry Ford Cancer
Institute, Henry Ford Health System, Detroit, MichiganRendleKatharine A.Department of Family Medicine and Community Health, University of
Pennsylvania Perelman School of Medicine, Philadelphia,
PennsylvaniaHondaStacey A.Department of Pathology, Kaiser Permanente Hawaii, Honolulu,
HawaiiSchottingerJoanne E.Department of Hematology and Oncology, Kaiser Permanente Southern
California, Oakland, CaliforniaUdaltsovaNataliaDivision of Research, Kaiser Permanente Northern California,
Oakland, CaliforniaVachaniAnilDivision of Pulmonology, Allergy and Critical Care, University of
Pennsylvania Perelman School of Medicine, Philadelphia,
PennsylvaniaKobrinSarahNational Cancer Institute, Bethesda, MarylandLiChristopher I.Fred Hutchinson Cancer Research Center, Seattle,
WashingtonHaasJennifer S.Division of General Internal Medicine, Massachusetts General
Hospital, Boston, Massachusetts
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Mai Sedki
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Robert T Greenlee
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Christine Neslund-Dudas
- Department of Public Health Sciences, Henry Ford Cancer Institute, Henry Ford Health System, Detroit, Michigan
| | - Katharine A Rendle
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Stacey A Honda
- Department of Pathology, Kaiser Permanente Hawaii, Honolulu, Hawaii
| | - Joanne E Schottinger
- Department of Hematology and Oncology, Kaiser Permanente Southern California, Oakland, California
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Anil Vachani
- Division of Pulmonology, Allergy and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Koff PB, Min SJ, Freitag TJ, Diaz DLP, James SS, Voelkel NF, Linderman DJ, Diaz Del Valle F, Zakrajsek JK, Albert RK, Bull TM, Beck A, Stelzner TJ, Ritzwoller DP, Kveton CM, Carwin S, Ghosh M, Keith RL, Westfall JM, Vandivier RW. Impact of Proactive Integrated Care on Chronic Obstructive Pulmonary Disease. Chronic Obstr Pulm Dis 2021; 8. [PMID: 33238087 DOI: 10.15326/jcopdf.2020.0139] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Up to 50% of chronic obstructive pulmonary disease (COPD) patients do not receive recommended care for COPD. To address this issue, we developed Proactive Integrated Care (Proactive iCare), a health care delivery model that couples integrated care with remote monitoring. Methods We conducted a prospective, quasi-randomized clinical trial in 511 patients with advanced COPD or a recent COPD exacerbation, to test whether Proactive iCare impacts patient-centered outcomes and health care utilization. Patients were allocated to Proactive iCare (n=352) or Usual Care ( =159) and were examined for changes in quality of life using the St George's Respiratory Questionnaire (SGRQ), symptoms, guideline-based care, and health care utilization. Findings Proactive iCare improved total SGRQ by 7-9 units (p < 0.0001), symptom SGRQ by 9 units (p<0.0001), activity SGRQ by 6-7 units (p<0.001) and impact SGRQ by 7-11 units (p<0.0001) at 3, 6 and 9 months compared with Usual Care. Proactive iCare increased the 6-minute walk distance by 40 m (p<0.001), reduced annual COPD-related urgent office visits by 76 visits per 100 participants (p<0.0001), identified unreported exacerbations, and decreased smoking (p=0.01). Proactive iCare also improved symptoms, the body mass index-airway obstruction-dyspnea-exercise tolerance (BODE) index and oxygen titration (p<0.05). Mortality in the Proactive iCare group (1.1%) was not significantly different than mortality in the Usual Care group (3.8%; p=0.08). Interpretation Linking integrated care with remote monitoring improves the lives of people with advanced COPD, findings that may have been made more relevant by the coronavirus 2019 (COVID-19) pandemic.
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Affiliation(s)
- Patricia B Koff
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Sung-Joon Min
- Division of Health Care Policy and Research, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Tammie J Freitag
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Debora L P Diaz
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Shannon S James
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Norbert F Voelkel
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Derek J Linderman
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Fernando Diaz Del Valle
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Jonathan K Zakrajsek
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Richard K Albert
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Todd M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Arne Beck
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Thomas J Stelzner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Christine M Kveton
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Stephanie Carwin
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Moumita Ghosh
- National Jewish Health, Denver, Colorado, United States
| | - Robert L Keith
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States.,Denver Veterans Administration Medical Center, Denver, Colorado, United States
| | - John M Westfall
- Department of Family Medicine, High Plains Research Network, University of Colorado Denver, Anschutz Medical Campus, United States
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
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42
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Banegas MP, Rivera DR, O'Keeffe-Rosetti MC, Carroll NM, Pawloski PA, Tabano DC, Epstein MM, Yeung K, Hornbrook MC, Lu C, Ritzwoller DP. Long-Term Patterns of Oral Anticancer Agent Adoption, Duration, and Switching in Patients With CML. J Natl Compr Canc Netw 2020; 17:1166-1172. [PMID: 31590146 DOI: 10.6004/jnccn.2019.7303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/29/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Oral tyrosine kinase inhibitors (TKIs) have been the standard of care for chronic myeloid leukemia (CML) since 2001. However, few studies have evaluated changes in the treatment landscape of CML over time. This study assessed the long-term treatment patterns of oral anticancer therapies among patients with CML. METHODS This retrospective cohort study included patients newly diagnosed with CML between January 1, 2000, and December 31, 2016, from 10 integrated healthcare systems. The proportion of patients treated with 5 FDA-approved oral TKI agents-bosutinib, dasatinib, imatinib, nilotinib, and ponatinib-in the 12 months after diagnosis were measured, overall and by year, between 2000 and 2017. We assessed the use of each oral agent through the fourth-line setting. Multivariable logistic regression estimated the odds of receiving any oral agent, adjusting for sociodemographic and clinical characteristics. RESULTS Among 853 patients with CML, 81% received an oral agent between 2000 and 2017. Use of non-oral therapies decreased from 100% in 2000 to 5% in 2005, coinciding with imatinib uptake from 65% in 2001 to 98% in 2005. Approximately 28% of patients switched to a second-line agent, 9% switched to a third-line agent, and 2% switched to a fourth-line agent. Adjusted analysis showed that age at diagnosis, year of diagnosis, and comorbidity burden were statistically significantly associated with odds of receiving an oral agent. CONCLUSIONS A dramatic shift was seen in CML treatments away from traditional, nonoral chemotherapy toward use of novel oral TKIs between 2000 and 2017. As the costs of oral anticancer agents reach new highs, studies assessing the long-term health and financial outcomes among patients with CML are warranted.
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Affiliation(s)
- Matthew P Banegas
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Donna R Rivera
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | | | - Nikki M Carroll
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado
| | | | - David C Tabano
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado.,Denver Public Health, Denver, Colorado
| | - Mara M Epstein
- Meyers Primary Care Institute, Worcester, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts
| | - Kai Yeung
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Mark C Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Christine Lu
- Harvard Medical School, Boston, Massachusetts; and.,Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Debra P Ritzwoller
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado
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43
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Carroll NM, Ritzwoller DP, Banegas MP, O'Keeffe-Rosetti M, Cronin AM, Uno H, Hornbrook MC, Hassett MJ. Performance of Cancer Recurrence Algorithms After Coding Scheme Switch From International Classification of Diseases 9th Revision to International Classification of Diseases 10th Revision. JCO Clin Cancer Inform 2020; 3:1-9. [PMID: 30869998 DOI: 10.1200/cci.18.00113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We previously developed and validated informatic algorithms that used International Classification of Diseases 9th revision (ICD9)-based diagnostic and procedure codes to detect the presence and timing of cancer recurrence (the RECUR Algorithms). In 2015, ICD10 replaced ICD9 as the worldwide coding standard. To understand the impact of this transition, we evaluated the performance of the RECUR Algorithms after incorporating ICD10 codes. METHODS Using publicly available translation tables along with clinician and other expertise, we updated the algorithms to include ICD10 codes as additional input variables. We evaluated the performance of the algorithms using gold standard recurrence measures associated with a contemporary cohort of patients with stage I to III breast, colorectal, and lung (excluding IIIB) cancer and derived performance measures, including the area under the receiver operating curve, average absolute prediction error, and correct classification rate. These values were compared with the performance measures derived from the validation of the original algorithms. RESULTS A total of 659 colorectal, 280 lung, and 2,053 breast cancer cases were identified. Area under the receiver operating curve derived from the updated algorithms was 89.0% (95% CI, 82.3% to 95.7%), 88.9% (95% CI, 79.3% to 98.2%), and 80.5% (95% CI, 72.8% to 88.2%) for the colorectal, lung, and breast cancer algorithms, respectively. Average absolute prediction errors for recurrence timing were 2.7 (SE, 11.3%), 2.4 (SE, 10.4%), and 5.6 months (SE, 21.8%), respectively, and timing estimates were within 6 months of actual recurrence for more than 80% of colorectal, more than 90% of lung, and more than 50% of breast cancer cases using the updated algorithm. CONCLUSION Performance measures derived from the updated and original algorithms had overlapping confidence intervals, suggesting that the ICD9 to ICD10 transition did not affect the RECUR Algorithm performance.
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Affiliation(s)
| | | | | | | | | | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | | | - Michael J Hassett
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
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44
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Brooks GA, Uno H, Aiello Bowles EJ, Menter AR, O'Keeffe-Rosetti M, Tosteson ANA, Ritzwoller DP, Schrag D. Hospitalization Risk During Chemotherapy for Advanced Cancer: Development and Validation of Risk Stratification Models Using Real-World Data. JCO Clin Cancer Inform 2020; 3:1-10. [PMID: 30995122 DOI: 10.1200/cci.18.00147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Hospitalizations are a common occurrence during chemotherapy for advanced cancer. Validated risk stratification tools could facilitate proactive approaches for reducing hospitalizations by identifying at-risk patients. PATIENTS AND METHODS We assembled two retrospective cohorts of patients receiving chemotherapy for advanced nonhematologic cancer; cohorts were drawn from three integrated health plans of the Cancer Research Network. We used these cohorts to develop and validate logistic regression models estimating 30-day hospitalization risk after chemotherapy initiation. The development cohort included patients in two health plans from 2005 to 2013. The validation cohort included patients in a third health plan from 2007 to 2016. Candidate predictor variables were derived from clinical data in institutional data warehouses. Models were validated based on the C-statistic, positive predictive value, and negative predictive value. Positive predictive value and negative predictive value were calculated in reference to a prespecified risk threshold (hospitalization risk ≥ 18.0%). RESULTS There were 3,606 patients in the development cohort (median age, 63 years) and 634 evaluable patients in the validation cohort (median age, 64 years). Lung cancer was the most common diagnosis in both cohorts (26% and 31%, respectively). The selected risk stratification model included two variables: albumin and sodium. The model C-statistic in the validation cohort was 0.69 (95% CI, 0.62 to 0.75); 39% of patients were classified as high risk according to the prespecified threshold; 30-day hospitalization risk was 24.2% (95% CI, 19.9% to 32.0%) in the high-risk group and 8.7% (95% CI, 6.1% to 12.0%) in the low-risk group. CONCLUSION A model based on data elements routinely collected during cancer treatment can reliably identify patients at high risk for hospitalization after chemotherapy initiation. Additional research is necessary to determine whether this model can be deployed to prevent chemotherapy-related hospitalizations.
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Affiliation(s)
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA
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Boggs JM, Beck A, Ritzwoller DP, Battaglia C, Anderson HD, Lindrooth RC. A Quasi-Experimental Analysis of Lethal Means Assessment and Risk for Subsequent Suicide Attempts and Deaths. J Gen Intern Med 2020; 35:1709-1714. [PMID: 32040838 PMCID: PMC7280370 DOI: 10.1007/s11606-020-05641-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 01/03/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Counseling on access to lethal means is highly recommended for patients with suicide risk, but there are no formal evaluations of its impact in real-world settings. OBJECTIVE Evaluate whether lethal means assessment reduces the likelihood of suicide attempt and death outcomes. DESIGN Quasi-experimental design using an instrumental variable to overcome confounding due to unmeasured patient characteristics that could influence provider decisions to deliver lethal means assessment. SETTING Kaiser Permanente Colorado, an integrated health system serving over 600,000 members, with comprehensive capture of all electronic health records, medical claims, and death information. PARTICIPANTS Adult patients who endorsed suicide ideation on the Patient Health Questionnaire-9 (PHQ-9) depression screener administered in behavioral health and primary care settings from 2010 to 2016. INTERVENTIONS Provider documentation of lethal means assessment in the text of clinical notes, collected using a validated Natural Language Processing program. MEASUREMENTS Main outcome was ICD-9 or ICD-10 codes for self-inflicted injury or suicide death within 180 days of index PHQ-9 event. RESULTS We found 33% of patients with suicide ideation reported on the PHQ-9 received lethal means assessment in the 30 days following identification. Lethal means assessment reduced the risk of a suicide attempt or death within 180 days from 3.3 to 0.83% (p = .034, 95% CI = .069-.9). LIMITATIONS Unmeasured suicide prevention practices that co-occur with lethal means assessment may contribute to the effects observed. CONCLUSIONS Clinicians should expand the use of counseling on access to lethal means, along with co-occurring suicide prevention practices, to all patients who report suicide ideation.
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Affiliation(s)
- Jennifer M Boggs
- Kaiser Permanente Colorado Institute for Health Research, 2550 S. Parker Rd., Suite 200, Aurora, CO, 80014, USA.
- University of Colorado Anschutz Medical Campus, Aurora, USA.
| | - Arne Beck
- Kaiser Permanente Colorado Institute for Health Research, 2550 S. Parker Rd., Suite 200, Aurora, CO, 80014, USA
- University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Debra P Ritzwoller
- Kaiser Permanente Colorado Institute for Health Research, 2550 S. Parker Rd., Suite 200, Aurora, CO, 80014, USA
- University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Catherine Battaglia
- University of Colorado Anschutz Medical Campus, Aurora, USA
- Department of Veterans Affairs (VA) Eastern Colorado Health Care System, Aurora, CO, USA
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Bender BG, Wagner NM, Shoup JA, Goodrich GK, Shetterly SM, Cvietusa PJ, Anderson CB, Xu S, Ritzwoller DP, Tacinas C, King DK, Raebel MA. Adults With Asthma Experience No Increase in Asthma-related Exacerbations When Digital Communication Technology Tools Are Employed to Offset Provider Workload: A Pragmatic Randomized Trial. Med Care 2020; 58:352-359. [PMID: 32197029 PMCID: PMC10950384 DOI: 10.1097/mlr.0000000000001265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Challenges to health care efficiency are increasingly addressed with the help of digital communication technology tools (DCTs). OBJECTIVE The objective of this study was to test whether DCT, compared with Usual Care, can reduce health care clinician burden without increasing asthma-related exacerbations among patients with asthma in a large integrated health care system. RESEARCH DESIGN The (Breathewell) program was a pragmatic, randomized trial at (Kaiser Permanente Colorado), where asthma nurses screen patients for poor symptom control when beta2-agonist refill requests came within 60 days of previous fill or in the absence of a controller medication fill within 4 months (beta2-agonist overfill). A total of 14,978 adults with asthma were randomized to Usual Care or 1 of 2 DCT intervention groups (Text/Phone call or Email). SUBJECTS Participants included adults 18 and older with an asthma diagnosis at the time of randomization and no history of chronic obstructive pulmonary disease. MEASURES Primary outcome measures included asthma-related health care resource utilization (eg, asthma nurse contacts), medication use, and exacerbations. RESULTS A total of 1933 patients had 4337 events which met beta2-agonist overfill criteria. Of the 2874 events in the intervention arm, 1188 (41%) were resolved by DCT contact and did not require additional clinician contact. Asthma medication use and exacerbations over 12 months did not differ among the 3 groups. CONCLUSIONS DCT tools can successfully contact adult asthma patients to screen for symptoms and facilitate intervention. The absence of differences in medication fills and health care utilization indicates that the strategic replacement of nursing interventions by digital outreach did not reduce treatment adherence or compromise health care outcomes.
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Affiliation(s)
- Bruce G. Bender
- Division of Pediatric Behavioral Health, National Jewish Health, Denver, CO
| | - Nicole M. Wagner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Glenn K. Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | | | - Peter J. Cvietusa
- Department of Asthma, Allergy and Immunology, Kaiser Permanente Colorado, Denver, CO
| | | | - Stan Xu
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | | | - Cathy Tacinas
- Department of Asthma, Allergy and Immunology, Kaiser Permanente Colorado, Denver, CO
| | - Diane K. King
- Center for Behavioral Health Research and Services, Institute of Social and Economic Research, University of Alaska Anchorage, Anchorage, AK
| | - Marsha A. Raebel
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
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47
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Carroll NM, Burnett-Hartman AN, Joyce CA, Kinnard W, Harker EJ, Hall V, Steiner JS, Blum-Barnett E, Ritzwoller DP. Real-world Clinical Implementation of Lung Cancer Screening-Evaluating Processes to Improve Screening Guidelines-Concordance. J Gen Intern Med 2020; 35:1143-1152. [PMID: 31974902 PMCID: PMC7174472 DOI: 10.1007/s11606-019-05539-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 10/18/2019] [Accepted: 10/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Lung cancer screening (LCS) requires complex processes to identify eligible patients, provide appropriate follow-up, and manage findings. It is unclear whether LCS in real-world clinical settings will realize the same benefits as the National Lung Screening Trial (NLST). OBJECTIVE To evaluate the impact of process modifications on compliance with LCS guidelines during LCS program implementation, and to compare patient characteristics and outcomes with those in NLST. DESIGN Retrospective cohort study. SETTING Kaiser Permanente Colorado (KPCO), a non-profit integrated healthcare system. PATIENTS A total of 3375 patients who underwent a baseline lung cancer screening low-dose computed tomography (S-LDCT) scan between May 2014 and June 2017. MEASUREMENTS Among those receiving an S-LDCT, proportion who met guidelines-based LCS eligibility criteria before and after LCS process modifications, differences in patient characteristics and outcomes between KPCO LCS patients and the NLST cohort, and factors associated with a positive screen. RESULTS After modifying LCS eligibility confirmation processes, patients receiving S-LDCT who met guidelines-based LCS eligibility criteria increased from 45.6 to 92.7% (P < 0.001). Prior to changes, patients were older (68 vs. 67 years; P = 0.001), less likely to be current smokers (51.3% vs. 52.5%; P < 0.001), and less likely to have a ≥ 30-pack-year smoking history (50.0% vs. 95.3%; P < 0.001). Compared with NLST participants, KPCO LCS patients were older (67 vs. 60 years; P < 0.001), more likely to currently smoke (52.3% vs. 48.1%; P < 0.001), and more likely to have pulmonary disease. Among those with a positive baseline S-LDCT, the lung cancer detection rate was higher at KPCO (9.4% vs. 3.8%; P < 0.001) and was positively associated with prior pulmonary disease. CONCLUSION Adherence to LCS guidelines requires eligibility confirmation procedures. Among those with a positive baseline S-LDCT, comorbidity burden and lung cancer detection rates were notably higher than in NLST, suggesting that the study of long-term outcomes in patients undergoing LCS in real-world clinical settings is warranted.
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Affiliation(s)
- Nikki M Carroll
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
| | | | - Caroline A Joyce
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - William Kinnard
- Colorado Permanente Medical Group, Kaiser Permanente Colorado, Denver, CO, USA
| | - Eric J Harker
- Colorado Permanente Medical Group, Kaiser Permanente Colorado, Denver, CO, USA
| | - Virginia Hall
- Kaiser Foundation Health Plan, Kaiser Permanente Colorado, Denver, CO, USA
| | - Julie S Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Erica Blum-Barnett
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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King DK, Shoup JA, Raebel MA, Anderson CB, Wagner NM, Ritzwoller DP, Bender BG. Planning for Implementation Success Using RE-AIM and CFIR Frameworks: A Qualitative Study. Front Public Health 2020; 8:59. [PMID: 32195217 PMCID: PMC7063029 DOI: 10.3389/fpubh.2020.00059] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/17/2020] [Indexed: 11/13/2022] Open
Abstract
Background: RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) and CFIR (Consolidated Framework for Implementation Research) dissemination and implementation frameworks define theory-based domains associated with the adoption, implementation and maintenance of evidence-based interventions. Used together, the two frameworks identify metrics for evaluating implementation success, i.e., high reach and effectiveness resulting in sustained practice change (RE-AIM), and modifiable factors that explain and enhance implementation outcomes (CFIR). We applied both frameworks to study the implementation planning process for a technology-delivered asthma care intervention called Breathewell within an integrated care organization. The goal of the Breathewell intervention is to increase the efficiency of delivering resource-intensive asthma care services. Methods: We reviewed historical documents (i.e., meeting agendas; minutes) from 14 months of planning to evaluate alignment of implementation team priorities with RE-AIM domains. Key content was extracted and analyzed on topics, frequency and amount of discussion within each RE-AIM domain. Implementation team members were interviewed using questions adapted from the CFIR Interview Guide Tool to focus their reflection on the process and contextual factors considered during pre-implementation planning. Documents and transcripts were initially coded using RE-AIM domain definitions, and recoded using CFIR constructs, with intent to help explain how team decisions and actions can contribute to adoption, implementation and maintenance outcomes. Results: Qualitative analysis of team documents and interviews demonstrated strong alignment with the RE-AIM domains: Reach, Effectiveness, and Implementation; and with the CFIR constructs: formal inclusion of provider and staff stakeholders in implementation planning, compatibility of the intervention with workflows and systems, and alignment of the intervention with organizational culture. Focus on these factors likely contributed to RE-AIM outcomes of high implementation fidelity. However, team members expressed low confidence that Breathewell would be adopted and maintained post-trial. A potential explanation was weak alignment with several CFIR constructs, including tension for change, relative priority, and leadership engagement that contribute to organizational receptivity and motivation to sustain change. Conclusions: While RE-AIM provides a practical framework for planning and evaluating practice change interventions to assure their external validity, CFIR explains why implementation succeeded or failed, and when used proactively, identifies relevant modifiable factors that can promote or undermine adoption, implementation, and maintenance.
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Affiliation(s)
- Diane K. King
- Center for Behavioral Health Research and Services, University of Alaska Anchorage, Anchorage, AK, United States
| | - Jo Ann Shoup
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, United States
| | - Marsha A. Raebel
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, United States
| | - Courtney B. Anderson
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, United States
| | - Nicole M. Wagner
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, United States
| | - Debra P. Ritzwoller
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, United States
| | - Bruce G. Bender
- Department of Pediatrics, National Jewish Health, Denver, CO, United States
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49
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Rendle KA, Burnett-Hartman AN, Neslund-Dudas C, Greenlee RT, Honda S, Elston Lafata J, Marcus PM, Cooley ME, Vachani A, Meza R, Oshiro C, Simoff MJ, Schnall MD, Beaber EF, Doria-Rose VP, Doubeni CA, Ritzwoller DP. Evaluating Lung Cancer Screening Across Diverse Healthcare Systems: A Process Model from the Lung PROSPR Consortium. Cancer Prev Res (Phila) 2020; 13:129-136. [PMID: 31871221 PMCID: PMC7010351 DOI: 10.1158/1940-6207.capr-19-0378] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/18/2019] [Accepted: 12/18/2019] [Indexed: 02/07/2023]
Abstract
Numerous organizations, including the United States Preventive Services Task Force, recommend annual lung cancer screening (LCS) with low-dose CT for high risk adults who meet specific criteria. Despite recommendations and national coverage for screening eligible adults through the Centers for Medicare and Medicaid Services, LCS uptake in the United States remains low (<4%). In recognition of the need to improve and understand LCS across the population, as part of the larger Population-based Research to Optimize the Screening PRocess (PROSPR) consortium, the NCI (Bethesda, MD) funded the Lung PROSPR Research Consortium consisting of five diverse healthcare systems in Colorado, Hawaii, Michigan, Pennsylvania, and Wisconsin. Using various methods and data sources, the center aims to examine utilization and outcomes of LCS across diverse populations, and assess how variations in the implementation of LCS programs shape outcomes across the screening process. This commentary presents the PROSPR LCS process model, which outlines the interrelated steps needed to complete the screening process from risk assessment to treatment. In addition to guiding planned projects within the Lung PROSPR Research Consortium, this model provides insights on the complex steps needed to implement, evaluate, and improve LCS outcomes in community practice.
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Affiliation(s)
- Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | | | | | | | - Stacey Honda
- Center for Health Research, Hawaii Permanente Medical Group, Kaiser Permanente Hawaii, Oahu, Hawaii
| | - Jennifer Elston Lafata
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, Michigan
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Pamela M Marcus
- Division of Cancer Control and Population Sciences, NCI, Bethesda, Maryland
| | | | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Rafael Meza
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Caryn Oshiro
- Center for Health Research, Hawaii Permanente Medical Group, Kaiser Permanente Hawaii, Oahu, Hawaii
| | - Michael J Simoff
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, Michigan
| | - Mitchell D Schnall
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, NCI, Bethesda, Maryland
| | - Chyke A Doubeni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
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50
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Boggs JM, Lindrooth RC, Battaglia C, Beck A, Ritzwoller DP, Ahmedani BK, Rossom RC, Lynch FL, Lu CY, Waitzfelder BE, Owen-Smith AA, Simon GE, Anderson HD. Association between suicide death and concordance with benzodiazepine treatment guidelines for anxiety and sleep disorders. Gen Hosp Psychiatry 2020; 62:21-27. [PMID: 31765794 PMCID: PMC7001528 DOI: 10.1016/j.genhosppsych.2019.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/04/2019] [Accepted: 11/12/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Guidelines for management of anxiety and sleep disorders emphasize antidepressant medications and/or psychotherapy as first/second-line and benzodiazepines as third-line treatments. We evaluated the association between suicide death and concordance with benzodiazepine guidelines. METHODS Retrospective case-control study of patients with anxiety and/or sleep disorders from health systems across 8 U.S. states within the Mental Health Research Network. Suicide death cases were matched to controls on year and health system. Appropriate benzodiazepine prescribing defined as: no monotherapy, no long duration, and/or age < 65 years. The association between guideline concordance and suicide death was evaluated, adjusting for diagnostic and treatment covariates. RESULTS Sample included 6960 patients with anxiety disorders (2363 filled benzodiazepine) and 6215 with sleep disorders (1237 filled benzodiazepine). Benzodiazepine guideline concordance was associated with reduced odds for suicide in patients with anxiety disorders (OR = 0.611, 95% CI = 0.392-0.953, p = 0.03) and was driven by shorter duration of benzodiazepine use with concomitant psychotherapy or antidepressant medication. The association of benzodiazepine guideline concordance with suicide death did not meet statistical significance in the sleep disorder group (OR = 0.413, 95% CI = 0.154-1.11, p = 0.08). CONCLUSIONS We found reduced odds for suicide in those with anxiety disorders who filled benzodiazepines in short-moderate duration with concomitant psychotherapy or antidepressant treatment.
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Affiliation(s)
- Jennifer M Boggs
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States of America; Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus.
| | - Richard C Lindrooth
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus
| | - Catherine Battaglia
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus; Department of Veterans Affairs (VA) Eastern Colorado Health Care System, Aurora, CO, United States of America
| | - Arne Beck
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States of America; Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States of America; Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, United States of America; Behavioral Health Services, Henry Ford Health System, Detroit, MI, United States of America
| | - Rebecca C Rossom
- HealthPartners Institute, Bloomington, MN, United States of America
| | - Frances L Lynch
- Kaiser Permanente Center for Integrated Health Care Research, Honolulu, HI, United States of America
| | - Christine Y Lu
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, United States of America
| | - Beth E Waitzfelder
- Kaiser Permanente Center for Health Research, Honolulu, HI, United States of America
| | - Ashli A Owen-Smith
- School of Public Health, Georgia State University, Atlanta, GA, United States of America; Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, United States of America
| | - Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Heather D Anderson
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, CO, United States of America
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