Variation in Reporting of Incidental Findings on Initial Lung Cancer Screening and Associations With Clinician Assessment

PURPOSE

The aim of this study was to quantify the distribution, frequency, and clinical significance of incidental findings (IFs) on initial lung cancer screening (LCS) and the association of report characteristics with subsequent assessment.

METHODS

Health records of patients undergoing initial LCS from 2015 to 2018 in the Minneapolis VA Health Care System were retrospectively reviewed for demographics, Lung CT Screening Reporting & Data System coding, IFs, and subsequent clinical assessment. IFs were considered potentially significant if they were likely to require any follow-up. High-risk significant IFs (SIFs) were potentially malignant. The primary outcome was the SIF being addressed. Outcomes were analyzed using a mixed-effects model.

RESULTS

Patients (n = 901) were primarily male (94.1%) smokers (62.1%) with a mean age of 65.2 years. IFs were extremely common (93.9%), with an average of 2.6 IFs per scan (n = 2,296). Seven hundred eighty-six IFs (34.2%) were deemed likely SIFs, of which 58 (7.4%) were high risk. Two hundred twenty-two (28.2%) were addressed by clinicians, of which 104 (13.2%) underwent testing. Reporting of SIFs varied among radiologists, with at least one SIF in the impression in 24% to 78% of low-dose CT studies with the S modifier, used to indicate the presence of a SIF, applied to 0% to 51% of reports. In the mutually adjusted model, radiologist recommendation (adjusted odds ratio [OR], 4.67; 95% confidence interval [CI], 2.23-9.76), high-risk finding (adjusted OR, 4.35; 95% CI, 1.81-10.45), and reporting in the impression (adjusted OR, 2.58; 95% CI, 1.28-5.18) were associated with increased odds of the SIF's being addressed.

CONCLUSIONS

Radiologists vary in their reporting of IFs on LCS. Further standardization of reporting of SIFs may improve this process, with the simultaneous goals of generating appropriate testing when needed and minimizing low-value care.

The Association Between Racialized Discrimination in Health Care and Pain Among Black Patients With Mental Health Diagnoses

Chronic pain is a costly and debilitating problem in the United States, and its burdens are exacerbated among socially disadvantaged and stigmatized groups. In a cross-sectional study of Black Veterans with chronic pain at the Atlanta VA Health Care System (N = 380), we used path analysis to explore the roles of racialized discrimination in health care settings, pain self-efficacy, and pain-related fear avoidance beliefs as potential mediators of pain outcomes among Black Veterans with and without an electronic health record-documented mental health diagnosis. In unadjusted bivariate analyses, Black Veterans with a mental health diagnosis (n = 175) reported marginally higher levels of pain-related disability and significantly higher levels of pain interference compared to those without a mental health diagnosis (n = 205). Path analyses revealed that pain-related disability, pain intensity, and pain interference were mediated by higher levels of racialized discrimination in health care and lower pain self-efficacy among Black Veterans with a mental health diagnosis. Pain-related fear avoidance beliefs did not mediate pain outcomes. These findings highlight the need to improve the quality and effectiveness of health care for Black patients with chronic pain through the implementation of antiracism interventions within health care systems. Results further suggest that Black patients with chronic pain who have a mental health diagnosis may benefit from targeted pain management strategies that focus on building self-efficacy for managing pain. PERSPECTIVE: Racialized health care discrimination and pain self-efficacy mediated differences in pain-related disability, pain intensity, and pain interference among Black Veterans with and without a mental health diagnosis. Findings highlight the need for antiracism interventions within health care systems in order to improve the quality of care for Black patients with chronic pain. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01983228.

[Effect of PCSK9 inhibitors on early neurological deterioration in patients with branch atheromatous disease]

Objective: To investigate the effect of Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors on the incidence of early neurological deterioration during the treatment of branch atheromatous disease (BAD). Methods: A retrospective analysis of 297 BAD patients admitted to the Department of Neurology in Zhengzhou People's Hospital from January 2020 to April 2023 was made. According to whether to use PCSK9 inhibitor treatment, they were divided into PCSK9 inhibitor group (81 cases) and control group (216 cases). Propensity score matching (PSM) method was used to eliminate the general situation difference between PCSK9 inhibitor group and control group. Seventy-two cases were successfully matched in each group. The early neurological deterioration (END) and low-density lipoprotein cholesterol (LDL-C) were compared. END was defined as the National Institutes of Health Stroke Scale (NIHSS) score increase≥2 points within 72 hours after stroke. Suspicious influencing factors leading to END were screened for multivariate logistic regression model analysis. Results: After PSM matching, among the 144 patients, 90 were male and 54 were female, aged (61.2±9.6) years. After matching, The hospital stay[M(Q1, Q3)] [9(7, 11)d vs 10(8, 13)d] in PCSK9 and NIHSS score at discharge [2(1, 3) vs 3(1, 4) points] were significantly different from those in the control group (all P<0.05). In addition, the incidence of END was reduced in the PCSK9 inhibitor group [12.5%(9/72) vs 31.9%(23/72),P<0.05]. Multivariate logistic regression analysis found that C-reactive protein (CRP)(OR=1.119,95%CI: 1.010-1.240, P<0.05) and PCSK9 inhibitor (OR=0.298, 95%CI: 0.117-0.755, P<0.05) were factors associated with the development of END. Conclusion: The use of PCSK9 inhibitors in the treatment of patients with BAD can reduce the incidence of END.

Connecting Vietnamese-Speaking Immigrants who Smoke to the Asian Smokers Quitline: A Feasibility Pilot of Proactive Outreach Interventions

INTRODUCTION

Cigarette smoking is highly prevalent among Asian American immigrant subgroups. Previously, Asian-language telephone Quitline services were only available in California. In 2012, the Centers for Disease Control and Prevention (CDC) funded the national Asian Smokers' Quitline (ASQ) to expand Asian-language Quitline services nationally. However, there are relatively few calls to the ASQ from outside California.

AIMS AND METHODS

This pilot study assessed the feasibility of two proactive outreach interventions to connect Vietnamese-speaking participants who smoke to the ASQ. Both interventions, (1) proactive telephone outreach with a counselor trained in motivational interviewing (PRO-MI) and (2) proactive telephone outreach with interactive voice response (PRO-IVR), were adapted to be culturally and linguistically appropriate for Vietnamese-speaking participants. Participants were randomly assigned 2:1 to PRO-IVR versus PRO-MI. Assessments were conducted at baseline and 3 months post-enrollment. Feasibility indicators were the recruitment rate and initiation of ASQ treatment.

RESULTS

Using the HealthPartners electronic health record, a large health system in Minnesota, we identified approximately 343 potentially eligible Vietnamese participants who were mailed invitation letters and baseline surveys with telephone follow-up. We enrolled 86 eligible participants (25% recruitment rate). In the PRO-IVR group 7/58 participants were directly transferred to the ASQ (12% initiation rate) and in the PRO-MI group 8/28 participants were warm transferred to the ASQ (29% initiation rate).

CONCLUSIONS

This pilot study demonstrates the feasibility of our recruitment methods and of implementing proactive outreach interventions to promote the initiation of smoking cessation treatment with the ASQ.

IMPLICATIONS

This pilot study contributes novel data on the uptake of Asian Smokers' Quitline (ASQ) services among Vietnamese-speaking people who smoke (PWS) with two proactive outreach interventions: (1) proactive telephone outreach with a counselor trained in motivational interviewing (PRO-MI) and (2) proactive telephone outreach with interactive voice response (PRO-IVR). We found that it is feasible to implement these proactive outreach interventions to promote the initiation of ASQ cessation treatment among Vietnamese-language speaking PWS. Future large trials are needed to rigorously compare PRO-MI and PRO-IVR and conduct budget impact analyses to understand the most efficient strategies for incorporation into health system settings.

Optimizing Longitudinal Tobacco Cessation Treatment in Lung Cancer Screening: A Sequential, Multiple Assignment, Randomized Trial

Importance

Nearly half of the 14.8 million US adults eligible for lung cancer screening (LCS) smoke cigarettes. The optimal smoking cessation program components for the LCS setting are unclear.

Objective

To assess the effect of adding a referral to prescription medication therapy management (MTM) to the tobacco longitudinal care (TLC) program among patients eligible for LCS who smoke and do not respond to early tobacco treatment and to assess the effect of decreasing the intensity of TLC among participants who do respond to early treatment.

Design, Setting, and Participants

This randomized clinical trial included patients who currently smoked cigarettes daily and were eligible for LCS. Recruitment took place at primary care centers and LCS programs at 3 large health systems in the US and began in October 2016, and 18-month follow-up was completed April 2021.

Interventions

(1) TLC comprising intensive telephone coaching and combination nicotine replacement therapy for 1 year with at least monthly contact; (2) TLC with MTM, MTM offered pharmacist-referral for prescription medications; and (3) Quarterly TLC, intensity of TLC was decreased to quarterly contact. Intervention assignments were based on early response to tobacco treatment (abstinence) that was assessed either 4 weeks or 8 weeks after treatment initiation.

Main outcomes and Measures

Self-reported, 6-month prolonged abstinence at 18-month.

Results

Of 636 participants, 228 (35.9%) were female, 564 (89.4%) were White individuals, and the median (IQR) age was 64.3 (59.6-68.8) years. Four weeks or 8 weeks after treatment initiation, 510 participants (80.2%) continued to smoke (ie, early treatment nonresponders) and 126 participants (19.8%) had quit (ie, early treatment responders). The 18 month follow-up survey response rate was 83.2% (529 of 636). Across TLC groups at 18 months follow-up, the overall 6-month prolonged abstinence rate was 24.4% (129 of 529). Among the 416 early treatment nonresponders, 6-month prolonged abstinence for TLC with MTM vs TLC was 17.8% vs 16.4% (adjusted odds ratio [aOR] 1.13; 95% CI, 0.67-1.89). In TLC with MTM, 98 of 254 participants (39%) completed at least 1 MTM visit. Among 113 early treatment responders, 6-month prolonged abstinence for Quarterly TLC vs TLC was 24 of 55 (43.6%) vs 34 of 58 (58.6%) (aOR, 0.54; 95% CI, 0.25-1.17).

Conclusions and Relevance

In this randomized clinical trial, adding referral to MTM with TLC for participants who did not respond to early treatment did not improve smoking abstinence. Stepping down to Quarterly TLC among early treatment responders is not recommended. Integrating longitudinal tobacco cessation care with LCS is feasible and associated with clinically meaningful quit rates.

Trial Registration

ClinicalTrials.gov Identifier: NCT02597491.

[Efficacy of intravenous thrombolysis with tenecteplase in treating the branch atheromatous disease]

Objective: To explore the efficacy of intravenous thrombolysis with tenecteplase (TNK) in the treatment of branch atheromatous disease (BAD). Methods: A total of 148 BAD patients hospitalized in the stroke center of Zhengzhou People's Hospital from January 2020 to March 2023 were retrospectively included. According to whether TNK was used for treatment, the patients were divided into the TNK group (52 cases) and the control group (96 cases). The propensity score matching (PSM) method was used to eliminate baseline differences between the two groups, and 46 pairs were successfully matched. Early neurological deterioration (END) was defined as an increase in the national Institutes of Health Stroke Scale (NIHSS) scores within 7 days of stroke≥2. The 90-day modified Rankin Scale (mRS) was used to compare the long-term efficacy between the two groups. A binary logistic regression model was used to analyze the influencing factors of clinical outcomes in patients with BAD. Results: Among the 92 patients, 62 were males and 30 were females, with an average age of (61.0±9.5) years. After PSM, there were statistically significant differences in NIHSS score at discharge [2 (0, 4) vs 4 (3, 8)] and length of hospital stay [9 (6, 13) d vs 11 (9, 14) d] (both P<0.05) between the two groups. The proportion of mRS 0-2 in TNK group was higher than that in the control group [82.6%(38/46) vs 60.8%(28/46)], while the proportion of END and mRS≥4 was lower than that in the control group [10.8%(5/46) vs 30.4%(14/46); 8.7%(4/46) vs 26.0%(12/46)], with statistically significant differences (P<0.05). The 90-day mortality in the control group was 2.2% (1/46), while no death was detected in the TNK group. Conclusion: Intravenous thrombolysis therapy with TNK can not only increase the proportion of 90-day mRS 0-2 in BAD patients, but also reduce the incidence of END.

Asian American adolescent e-cigarette use and associated protective factors: Heterogeneity in a statewide sample

OBJECTIVES

This study characterized variation in e-cigarette use patterns and related protective factors by ethnicity among Asian American adolescents.

METHODS

Multivariable logistic regressions modelled associations between ethnic group, 6 protective factors (college aspirations, internal developmental assets, positive teacher engagement, family caring, and peer and parent anti-smoking norms), and past 30-day e-cigarette use, adjusting for covariates among 10,482 8th, 9th, and 11th grade Asian American respondents to the 2019 Minnesota Student Survey. Interaction terms (protective factor × ethnic group) were used in 6 subsequent regression models to examine whether the association between each protective factor and e-cigarette use differed as a function of ethnic group.

RESULTS

Respondents included 9.0% Indian, 0.3% Burmese, 7.9% Chinese, 2.5% Filipino, 25.0% Hmong, 3.2% Karen, 4.6% Korean, 2.7% Laotian, 8.2% Vietnamese, 7.5% other, 7.5% multi-ethnic, and 21.6% multi-racial adolescents. E-cigarettes were the predominant form of tobacco use. Laotian and multi-racial groups reported the highest e-cigarette use (16.6% and 16.3%), whereas Chinese and Asian Indians reported the lowest (4.7% and 5.0%). Strong peer anti-smoking norms, higher internal developmental assets scores, and positive teacher engagement were associated with lower odds of e-cigarette use across groups, with significant interactions for internal developmental assets by ethnicity.

CONCLUSIONS

E-cigarettes are the most prevalent tobacco product used by Asian adolescents in Minnesota, with notable heterogeneity by ethnicity. While most established protective factors appeared to function similarly for Asian adolescents, others differed, underscoring the importance of disaggregating data by ethnicity to inform the tailoring of prevention and control strategies for these ethnic groups.

Taking ACTION to Reduce Pain: a Randomized Clinical Trial of a Walking-Focused, Proactive Coaching Intervention for Black Patients with Chronic Musculoskeletal Pain

BACKGROUND

Black patients in the USA are disproportionately affected by chronic pain, yet there are few interventions that address these disparities.

OBJECTIVE

To determine whether a walking-focused, proactive coaching intervention aimed at addressing contributors to racial disparities in pain would improve chronic pain outcomes among Black patients compared to usual care.

DESIGN

Randomized controlled trial with masked outcome assessment ( Clinicaltrials.gov : NCT01983228).

PARTICIPANTS

Three hundred eighty Black patients at the Atlanta VA Health Care System with moderate to severe chronic back, hip, or knee pain.

INTERVENTION

Six telephone coaching sessions over 8-14 weeks, proactively delivered, using action planning and motivational interviewing to increase walking, or usual care.

MAIN MEASURES

Primary outcome was a 30% improvement in pain-related physical functioning (Roland Morris Disability Questionnaire [RMDQ]) over 6 months among Black patients, using intention-to-treat. Secondary outcomes were improvements in pain intensity and interference, depression, anxiety, global impression of change in pain, and average daily steps.

KEY RESULTS

The intervention did not produce statistically significant effects on the primary outcome (at 6 months, 32.4% of intervention participants had 30% improvement on the RMDQ vs. 24.7% of patients in usual care; aOR=1.61, 95% CI, 0.94 to 2.77), nor on other secondary outcomes assessed at 6 months, with the exception that intervention participants reported more favorable changes in pain relative to usual care (mean difference=-0.54, 95% CI, -0.85 to -0.23). Intervention participants also experienced a significant reduction in pain intensity and pain interference over 3 months (mean difference=-0.55, 95% CI, -0.88 to -0.22).

CONCLUSIONS

A novel intervention to improve chronic pain among Black patients did not produce statistically significant improvements on the primary outcome relative to usual care. More intensive efforts are likely required among this population, many of whom were economically disadvantaged and had mental health comorbidities and physical limitations.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01983228.

Latent constructs identified in older individuals who smoke cigarettes and are eligible for lung cancer screening: Factor analysis of baseline data from the PLUTO smoking cessation trial

Introduction

Lung cancer screening (LCS) combined with smoking cessation intervention is currently recommended for older individuals with a history of heavy smoking. Tailoring tobacco treatment for this patient population of older, people who smoke (PWS) may improve cessation rates while efficiently using limited smoking cessation resources. Although some older people who smoke will need more intensive treatment to achieve sustained abstinence, others may be successful with less intensive treatment. A framework to identify them a priori would be helpful to distribute smoking cessation resources accordingly.

Methods

Baseline demographic, smoking, and health data are reported from a randomized clinical trial of longitudinal smoking cessation interventions delivered in the setting of LCS. Candidate variables were factor analyzed to identify latent factors, or constructs, to identify subgroups of older participants among the heterogenous population of older people who smoke.

Results

We identified three factor-derived constructs: self-reported health status, heaviness of smoking, and nicotine dependence. Nicotine dependence was moderately correlated with both of the other two factors.

Conclusions

This factor analysis of baseline participant characteristics identified a set of latent constructs – based on a few practical clinical variables -- that can be used to classify the heterogenous population of older people who smoke to identify. We propose this framework to identify subgroups of people who smoke who might successfully quit with less intense treatment at the time of lung cancer screening.

Implementing Chronic Care Model Treatments for Cigarette Dependence in Community Mental Health Clinics

Objective: Tobacco use is rarely addressed in community mental healthcare settings, despite its high prevalence among people with serious mental illness. The aim of the current study was to gather stakeholder feedback regarding the feasibility of chronic care management strategies for tobacco dependence in community mental health centers (CMHCs). Chronic care strategies evaluated included the 5 As (Ask about tobacco use, Advise users of tobacco to quit, Assess interest in cessation, Assist with cessation, and Arrange for follow-up) and proactive telephone outreach (reaching out to all users of tobacco to offer connection to tobacco cessation treatment). Methods: Using a semi-structured interview guide informed by the Practical Robust Implementation and Sustainability Model, we conducted individual semi-structured interviews with providers, leaders, and clients across two CMHCs. Our objectives were to capture their attitudes toward smoking cessation treatment, two chronic care model interventions (i.e., proactive outreach, the 5 As), and to determine the infrastructure needed to implement such interventions in their CMHCs. Thematic analysis was conducted by two independent coders to uncover pertinent themes. Results: Participants (n = 20) included nine providers, six leaders, and five clients. Thematic analysis revealed three major themes: (1) characteristics of recipients, (2) characteristics of the intervention, and (3) infrastructure needed for implementation and sustainability. Providers, leaders, and clients all reported that tobacco cessation treatment was rarely provided in CMHCs and expressed an interest in such treatments becoming more available. The 5 As and proactive outreach were viewed as feasible and acceptable to deliver and receive. Providers, leaders, and clients wanted support to connect clients with smoking cessation treatment. Providers and leaders requested a range of implementation supports, including didactic trainings, decision aids, performance feedback, and coaching on evidence-based tobacco cessation treatments for people with serious mental illness. Clients requested tobacco cessation resources, such as a cessation counseling provided at the CMHC and prescriptions for cessation medication. Conclusions: CMHC providers, leaders, and clients are interested in making tobacco cessation services more widely accessible and available. The feedback gathered in this study can be used to inform the delivery and implementation of guideline-adherent tobacco dependence care in CMHCs.

A novel opt-in vs opt-out approach to referral-based treatment of tobacco use in Veterans Affairs (VA) primary care clinics: A provider-level randomized controlled trial protocol

To determine whether an opt-out approach is effective for referral to treatment for tobacco use, we designed a clinical reminder for nurses in a primary care setting that provides a referral for patients who smoke cigarettes. We will use a two-arm, cluster-randomized design to assign nurses at the VA New York Harbor Healthcare System to test which mode of referral (opt-in vs opt-out) is more effective. All patients will be referred to evidence-based treatment for tobacco cessation including counseling from the New York State Quitline, and VetsQuit, a text messaging-based system for tobacco cessation counseling. We will measure patient engagement with the referral both in the short and long term to determine if referral modality had an impact on tobacco cessation treatment. We will also measure nurse engagement with the referral before, during, and after the implementation of the reminder to determine whether an opt-out approach is cost effective at the health system level. At the conclusion of this project, we expect to have developed and tested an opt-out system for increasing tobacco cessation treatment for Veterans in VA primary care and to have a thorough understanding of factors associated with implementation. Trial Registration:Clinicaltrials.govIdentifierNCT03477435.

The Association Between Smoking Abstinence and Pain Trajectory Among Veterans Engaged in U.S. Department of Veterans Affairs Mental Health Care

OBJECTIVE

To prospectively examine associations between smoking and nicotine abstinence and pain trajectory over 12 months among smokers with low, moderate, and severe pain and to assess whether these associations differ over time.

DESIGN

A secondary analysis of the "Proactive Outreach for Smokers in VA Mental Health" study, a randomized controlled trial of proactive outreach for veteran smokers engaged in U.S. Department of Veterans Affairs (VA) mental health care.

METHODS

Participants were categorized into "low" (n = 616), "moderate" (n = 479), and "severe" pain (n = 656) groups according to baseline pain score. Associations between self-reported abstinence from smoking and nicotine at 6 and 12 months and pain trajectory, measured via the PEG scale (Pain intensity, Enjoyment of life, General activity) composite score, were assessed through the use of general linear mixed models. Interaction tests assessed whether these associations differed at 6 and 12 months. Analyses were conducted within the overall sample and within the separate pain groups.

RESULTS

There were significant interactions in the overall sample and the low and moderate pain groups, such that 7-day point prevalence smoking abstinence was associated with lower pain scores at 6 but not 12 months. In the severe pain group, 7-day abstinence from both smoking and nicotine was associated with lower pain scores across both time points. Six-month prolonged abstinence was not associated with pain scores.

CONCLUSIONS

In this prospective analysis conducted among veteran smokers engaged in mental health services, 7-day abstinence from smoking and nicotine was associated with significantly lower levels of pain. Education efforts could help better inform smokers on the relationship between smoking and pain.

Self-reported exercise capacity among current smokers eligible for lung cancer screening: Distribution and association with key comorbidities

ONE CONCERN: as lung cancer screening (LCS) is implemented is that patients will be screened who are too ill to benefit. Poor exercise capacity (EC) predicts adverse outcomes following lung resection.

OBJECTIVE

Describe the distribution of EC among smokers eligible for LCS and examine associations with comorbidities.

METHODS

Cross-sectional analysis of baseline data from a randomized controlled trial of tobacco treatment in the context of LCS. Participants responded regarding limitations in moderate activities, ability to climb stairs, and frequency of dyspnea on a scale from never/almost never to all or most of the time. Responses were assigned a numeric score and summed to categorize exercise limitation. Associations between poor EC and key comorbidities were examined using adjusted logistic regression.

RESULTS

660 participants completed a survey with the following characteristics: 64.4% male, 89.5% white, mean age 64.5. Overall EC categories were: good 39.0%, intermediate 41.6%, and poor 19.4%.  Prevalence of poor EC was higher among patients with COPD (OR 4.62 95%CI 3.05-7.02), heart failure (OR 3.07 95%CI 1.62-5.82) and cardiovascular disease (OR 2.24, 95%CI 1.45-3.47), and was highest among patients with multimorbidity. Among patients with COPD and heart failure, 57% had poor and 0% had good EC. In adjusted logistic regression, only COPD and Charlson comorbidity index remained significantly associated with poor EC.

CONCLUSIONS

Many patients eligible for LCS reported poor EC, with increased odds of poor EC among patients with comorbidities. More research is needed to determine how to best integrate EC and comorbidity into eligibility and shared decision-making conversations.

Proactive tobacco treatment for veterans with posttraumatic stress disorder

OBJECTIVE

Individuals with posttraumatic stress disorder (PTSD) smoke at higher rates compared to the general population and experience significant barriers to initiating cessation treatment. Proactive outreach addresses these barriers by directly engaging with smokers and facilitating access to treatment. The objective of the present study was to evaluate a proactive outreach intervention for increasing rates of treatment utilization and abstinence among veteran smokers with and without PTSD.

METHOD

This is a secondary analysis of a randomized controlled trial conducted from 2013 to 2017 that demonstrated the effectiveness of proactive outreach among veterans using Veterans Affairs mental health care services. Electronic medical record data were used to identify participants with (n = 355) and without (n = 1,583) a diagnosis of PTSD. Logistic regressions modeled cessation treatment utilization (counseling, nicotine replacement therapy [NRT], and combination treatment) and abstinence (7-day point prevalence and 6-month prolonged at 6- and 12-month follow-ups) among participants randomized to proactive outreach versus usual care in the PTSD and non-PTSD subgroups, respectively.

RESULTS

Compared to usual care, proactive outreach increased combined counseling and NRT utilization among participants with PTSD (odds ratio [OR] = 26.25, 95% confidence interval [3.43, 201.17]) and without PTSD (OR = 10.20, [5.21, 19.98]). Proactive outreach also increased 7-day point prevalence abstinence at 12 months among participants with PTSD (OR = 2.62, [1.16, 5.91]) and without PTSD (OR = 1.61, [1.11, 2.34]).

CONCLUSIONS

Proactive outreach increased treatment utilization and abstinence among smokers with and without PTSD. Smokers with PTSD may need additional facilitation to initiate cessation treatment but are receptive when it is offered proactively. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Proactive outreach tobacco treatment for socioeconomically disadvantaged smokers with serious mental illness

Smokers with serious mental illness (SMI) face individual, interpersonal, and healthcare provider barriers to cessation treatment utilization and smoking abstinence. Proactive outreach strategies are designed to address these barriers by promoting heightened contact with smokers and facilitating access to evidence-based treatments. The present study examined the effect of proactive outreach among smokers with SMI (n = 939) who were enrolled in the publicly subsidized Minnesota Health Care Programs (MHCP) and compared this effect to that observed among MHCP smokers without SMI (n = 1382). Relative to usual care, the intervention increased treatment utilization among those with SMI (52.1% vs 40.0%, p = 0.002) and without SMI (39.3% vs 25.4%, p < 0.001). The intervention also increased prolonged smoking abstinence among those with SMI (14.9% vs 9.4%, p = 0.010) and without SMI (17.7% vs 13.6%, p = 0.09). Findings suggest that implementation of proactive outreach within publicly subsidized healthcare systems may alleviate the burden of smoking in this vulnerable population. Trial Registration ClinicalTrials.gov identifier: NCT01123967.

Serious Mental Illness and Smoking Cessation Treatment Utilization: the Role of Healthcare Providers

Healthcare provider barriers to cessation resources may be undercutting quit rates for smokers with serious mental illness (SMI). The study aim was to examine how providers influence cessation treatment utilization among smokers with SMI. Data were taken from a trial conducted among smokers in Minnesota Health Care Programs. The sample was split into groups of participants with SMI (n = 939) and without SMI (n = 1382). Analyses assessed whether the association between SMI and treatment utilization was mediated by healthcare provider-delivered treatment advice and healthcare provider bias. Results revealed higher rates of treatment utilization among smokers with SMI than those without SMI (45.9% vs 31.7%, p < 0.001); treatment advice and provider bias did not mediate this association. Subsequent individual regression analyses revealed positive associations between treatment advice and treatment utilization (β 0.21-0.25, p < 0.05), independent of SMI status. Strategies to increase low-income smokers' contacts with providers may reduce treatment utilization barriers among these smokers.

Proactive Tobacco Treatment in a Behavioral Health Home

Tobacco use is rarely addressed in community mental healthcare despite high patient smoking prevalence. Community mental health centers have systems in place that could be used to comprehensively address tobacco use. This study tested feasibility of, satisfaction with, and safety of proactive tobacco treatment (tobacco outreach to offer connection to tobacco cessation treatment). Behavioral health home patients who smoke were randomly assigned to usual care (UC; N = 11) or proactive care (PC; N = 9). All participants were called 3-months post-randomization for follow-up. PC patients reported high satisfaction with the program and experienced no adverse events or mental health symptom exacerbation during treatment. PC patients reported greater reductions in cigarettes per day, more quit attempts, and more cessation medication utilization than UC patients. Proactive outreach for tobacco cessation is feasible in a behavioral health home, acceptable to patients, and may reduce smoking heaviness and promote quit attempts.

Population Smoking Characteristics and Cessation Behaviors in a Nationally Representative Cohort of Hispanic Veterans and Hispanic Non-Veterans

INTRODUCTION

The proportion of Hispanics in the U.S. Veteran population is expected to increase rapidly in the next several decades. Although Veterans have a heightened smoking risk relative to the civilian population, few studies have examined whether this risk extends to Hispanic Veterans. The aims of the present study were to examine differences in the smoking and cessation characteristics of Hispanic Veterans and Hispanic non-Veterans, and to determine whether these differences persist after controlling for demographics and markers of acculturation.

MATERIALS AND METHODS

This was a secondary analysis of the 2014-2015 Tobacco Use Supplement of the Current Population Survey administered by the U.S. Census Bureau. The main analysis included Hispanics aged 18 or older (N = 27,341). Additional analyses were restricted to participants who had smoked at least 100 cigarettes in their lifetime (N = 4,951), and current smokers (N = 2,345). Regressions modeled the associations between Veteran status and demographics, markers of acculturation, smoking characteristics, and cessation behaviors. Additional regressions modeled the associations between Veteran status and the smoking and cessation outcomes while adjusting for demographics and the acculturation variables of U.S. nativity, U.S. citizenship, and English interview language. Probability weights produced nationally representative findings.

RESULTS

Hispanic Veterans were older, more likely to be male, and more acculturated than Hispanic non-Veterans. Unadjusted analyses revealed that Hispanic Veterans were more likely to be current daily smokers (8.6% vs. 5.7%, p = 0.015) and much less likely to be never smokers (59.3% vs. 81.0%, p < 0.001) compared to Hispanic non-Veterans. These differences were reduced after adjusting for the demographic and acculturation characteristics of the two groups. However, Hispanic Veterans were still less likely to be never smokers compared to non-Veterans after this adjustment (74.3% vs 80.7%, p < 0.001). In unadjusted analyses, Veterans were less likely to have stopped smoking for one day or longer as part of a quit attempt than non-Veterans (33.2% vs 45.4%, p = 0.056), although this was not a significant difference. Use of telephone quit line was very low for both Hispanic Veterans and Hispanic non-Veterans (4.3%). After adjustment, the difference in the likelihood of stopping smoking for one day or longer as part of a quit attempt was increased, becoming statistically significant (31.4% vs 45.8%, p = 0.030).

CONCLUSION

Demographic and acculturation differences account for much, but not all, of the differences in the smoking characteristics and cessation behaviors of Hispanic Veterans and Hispanic non-Veterans. These findings suggest that Hispanic Veterans, and Veterans more broadly, should be a focal point for cessation efforts. These efforts should include facilitating access to under-utilized cessation treatments, and providing coordinated cessation care for Veterans being treated for comorbid health conditions.

Cost-effectiveness of population-level proactive tobacco cessation outreach among socio-economically disadvantaged smokers: evaluation of a randomized control trial

AIMS

To estimate the cost-effectiveness at population-level of the OPT-IN proactive tobacco cessation outreach program for adult smokers enrolled in publicly funded health insurance plans for low-income persons (e.g. Medicaid).

DESIGN

Cost-effectiveness analysis using a state transition model based on data from the Offering Proactive Treatment Intervention (OPT-IN) randomized control trial.

SETTING

The trial was conducted in Minnesota, USA, and the economic analysis was conducted from the Medicaid program perspective.

PARTICIPANTS

Data were used from 2406 smokers who were randomized into the intervention or comparator groups.

INTERVENTION AND COMPARATOR

The intervention was comprised of proactive outreach (mailed invitation and telephone calls) and free cessation treatment (nicotine replacement therapy and intensive telephone counseling). The comparator was usual care, which comprised access to a primary care physician, insurance coverage of Food and Drug Administration (FDA)-approved smoking cessation medications and the state's telephone quitline.

MEASUREMENTS

Smoking status, quality of life and health-care use at varying times, including at baseline and 1 year.

FINDINGS

The OPT-IN program cost an average of $84 per participant greater than the comparator. One year after randomization, the population-level, 6-month prolonged smoking abstinence rate was 16.5% in the proactive outreach intervention group and 12.1% in the usual care group (P < 0.05). The model projected that the proactive outreach intervention added $78 in life-time cost and generated 0.005 additional quality-adjusted life-years (QALYs), with an expected incremental cost-effectiveness ratio of $4231 per QALY. Probabilistic sensitivity analysis found that the proactive outreach intervention would be cost-effective against a willingness-to-pay threshold of $50 000/QALY approximately 68% of the time.

CONCLUSIONS

Population-level proactive tobacco treatment with personal telephone outreach was effective in achieving higher population-level quit rates and was cost-effective at various willingness-to-pay thresholds, compared with usual care (i.e. reactive treatment). Taken together with prior research, population-level proactive tobacco cessation outreach programs are judged to be highly cost-effective over the long term.

A Proactive Smoking Cessation Intervention for Socioeconomically Disadvantaged Smokers: The Role of Smoking-Related Stigma

Introduction

Smoking denormalization has been paralleled by reduced smoking prevalence, but smoking rates among socioeconomically disadvantaged populations remain high. The social unacceptability of smoking has also led to increased perceptions of smoking-related stigma. By examining how smoking stigma influences cessation intervention effectiveness, we can better tailor interventions to socioeconomically disadvantaged smokers.

Aims and Methods

Data are from a randomized controlled trial evaluating the effectiveness of a proactive cessation intervention on abstinence. Current smokers enrolled in Minnesota Health Care Programs were randomized to proactive outreach (n = 1200) or usual care (n = 1206). The intervention included mailings, telephone outreach, counseling, and access to free cessation treatments. Using baseline measurements, groups with lower (n = 1227) and higher (n = 1093) perceived stigma were formed. Intervention, stigma, and their interaction term were added to a logistic regression modeling abstinence at 12 months.

Results

Lower perceived smoking-related stigma was associated with less support for quitting, lower rates of physician quitting advice, and less motivation for quitting. A logistic regression modeling abstinence found a significant intervention × stigma interaction. The proactive intervention was more effective among smokers with lower perceived smoking-related stigma (odds ratio 1.94, 95% confidence interval, 1.29 to 2.92) than those with higher perceived smoking-related stigma (odds ratio 1.04, 95% confidence interval, 0.70 to 1.55).

Discussion

Smokers with lower perceived smoking-related stigma had social environments that were conducive to smoking, received less physician advice to quit, and were less motivated to quit than higher stigma smokers. Despite these barriers, the intervention was more effective for lower stigma smokers, suggesting that proactive outreach is an efficient treatment for these hard-to-reach smokers.

Implications

Smoking denormalization has led to increased perceptions of smoking-related stigma among many smokers; however, little is known about how this stigma influences the cessation process. In the present study, smokers with lower levels of perceived smoking-related stigma lived in social environments that were more conducive to smoking and were less motivated to quit than higher stigma smokers. Despite these barriers, our proactive outreach cessation intervention was more effective for lower stigma smokers, suggesting that interventions which utilize proactive outreach to stimulate interest in quitting and offer facilitated access to free cessation treatments are an effective treatment approach for these hard-to-reach smokers. These strategies may be particularly effective for motivating smokers enrolled in government-subsidized health insurance programs to take advantage of cessation resources.

Lung Cancer Screening and Smoking Cessation Clinical Trials. SCALE (Smoking Cessation within the Context of Lung Cancer Screening) Collaboration

National recommendations for lung cancer screening for former and current smokers aged 55-80 years with a 30-pack-year smoking history create demand to implement efficient and effective systems to offer smoking cessation on a large scale. These older, high-risk smokers differ from participants in past clinical trials of behavioral and pharmacologic interventions for tobacco dependence. There is a gap in knowledge about how best to design systems to extend reach and treatments to maximize smoking cessation in the context of lung cancer screening. Eight clinical trials, seven funded by the National Cancer Institute and one by the Veterans Health Administration, address this gap and form the SCALE (Smoking Cessation within the Context of Lung Cancer Screening) collaboration. This paper describes methodological issues related to the design of these clinical trials: clinical workflow, participant eligibility criteria, screening indication (baseline or annual repeat screen), assessment content, interest in stopping smoking, and treatment delivery method and dose, all of which will affect tobacco treatment outcomes. Tobacco interventions consider the "teachable moment" offered by lung cancer screening, how to incorporate positive and negative screening results, and coordination of smoking cessation treatment with clinical events associated with lung cancer screening. Unique data elements, such as perceived risk of lung cancer and costs of tobacco treatment, are of interest. Lung cancer screening presents a new and promising opportunity to reduce morbidity and mortality resulting from lung cancer that can be amplified by effective smoking cessation treatment. SCALE teamwork and collaboration promise to maximize knowledge gained from the clinical trials.

The relationship between smoking cessation and binge drinking, depression, and anxiety symptoms among smokers with serious mental illness

INTRODUCTION

Concerns about the adverse effects of smoking cessation on alcohol use and mental health are a barrier to cessation for smokers with serious mental illness (SMI). The purpose of this study is to examine how incident smoking cessation affects binge drinking and symptoms of depression and anxiety among smokers with SMI.

METHODS

The present study is a secondary analysis of the OPTIN trial, which demonstrated the effectiveness of proactive outreach for smoking cessation among Minnesota Health Care Programs enrollees. Participants with ICD-9 codes indicating schizophrenia spectrum disorders, psychotic disorders, bipolar disorders, or severe/recurrent major depressive disorder were categorized as having SMI (n = 939); remaining smokers were categorized as non-SMI (n = 1382). Multivariable regressions modeled the association between incident smoking cessation and binge drinking, PHQ-2 depression scores, and PROMIS anxiety scores in the two groups.

RESULTS

Quitting smoking was not associated with binge drinking among those with SMI, but was associated with less binge drinking among those without SMI (p = 0.033). Quitting smoking was not associated with PHQ-2 depression scores among those with or without SMI. However, quitting smoking was associated with lower mean PROMIS anxiety scores for those with SMI (p = 0.031), but not those without SMI.

CONCLUSION

Quitting smoking was not associated with heightened binge drinking or symptoms of depression and anxiety among smokers with SMI. These findings suggest that quitting smoking is not detrimental for these patients, and provide evidential support for facilitating access to cessation resources for patients with serious mental illness who smoke.

The Equity Impact of Proactive Outreach to Smokers: Analysis of a Randomized Trial

INTRODUCTION

Population-based smoking-cessation services tend to preferentially benefit high-SES smokers, potentially exacerbating disparities. Interventions that include proactive outreach, telephone counseling, and free or low-cost cessation medications may be more likely to help low-SES smokers quit. This analysis evaluated the role of SES in smokers' response to a population-based proactive smoking-cessation intervention.

METHODS

This study, conducted in 2016 and 2017, was a secondary analysis of the Veterans Victory Over Tobacco Study, a multicenter pragmatic RCT of a proactive smoking-cessation intervention conducted from 2009 to 2011. Logistic regression modeling was used to test the effect of income or education level on 6-month prolonged abstinence at 1-year follow-up.

RESULTS

Of the 5,123 eligible, randomized participants, 2,565 (50%) reported their education level and 2,430 (47%) reported their income level. The interactions between education (p=0.07) or income (p=0.74) X treatment arm were not statistically significant at the 0.05 level. The largest effect sizes for the intervention were found among smokers in the lowest education category (≤11th grade), with a quit rate of 17.3% as compared with 5.7% in usual care (OR=3.5, 95% CI=1.4, 8.6) and in the lowest income range (<$10,000), with a quit rate of 18.7% as compared with 9.4% in usual care (OR=2.2, 95% CI=1.2, 4.0).

CONCLUSIONS

In a large, multicenter smoking-cessation trial, proactive outreach was associated with higher rates of prolonged abstinence among smokers at all SES levels. Proactive outreach interventions that integrate telephone-based care and facilitated cessation medication access have the potential to reduce socioeconomic disparities in quitting.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT00608426.

[Analysis on the gender-specific risk factors of new-onset cerebral hemorrhage]

Objective: To explore the gender-specific risk factors of new-onset cerebral hemorrhage. Methods: In this prospective cohort study,a total of 98 961 participants((51.1±12.6)years old), who underwent the 2006 to 2007 physical examination and met the inclusion criteria, were enrolled from the Kailuanstudy cohort. There were 78 908 (79.7%) male,and 20 053 (20.3%) female.The incidence of cerebral hemorrhage was observed once per year until December 31, 2016.The difference on the incidence of cerebral hemorrhage between male and female was compared. Multivariate Cox regression analysis was applied to analyze therisk factors of cerebral hemorrhage events among different genders. Results: The participants were followed up for(10.00±0.73) years,and 860 cerebral hemorrhage events were recorded during follow up. The incidence of cerebral hemorrhage in the population was 86.90/10 million person years (standardized incidence rate of 47.85/10 million person years). The incidence of cerebral hemorrhage was significantly higher in male (49.61/10 million person years) than in female (34.07/10 million person years, P<0.05). Multivariate Cox regression analysis showed that 45-59 years old, ≥ 60 years old, diabetes,and waist-hip ratio were more strongly related to new-onset of cerebral hemorrhage events in female than in male, and the hazard ratios(95%CI) were 2.33 (1.23-4.43) ,2.71 (1.30-5.66) ,2.16 (1.24-3.74) and 8.79 (1.42-54.32) in female versus 1.55 (1.21-1.97) ,2.16 (1.68-2.78) ,1.19 (0.93-1.53) and 3.21 (1.09-9.41) in male, respectively. The risk of male cerebral hemorrhage increased by 29% (HR=1.29, 95%CI 1.19-1.40) in male and 24% (HR=1.24, 95%CI 1.20-1.28) in female,when the systolic blood pressure increased 10 mmHg (1 mmHg=0.133 kPa). Conclusions: The incidence of cerebral hemorrhage is higher in male than in female in this cohort.The association between systolic blood pressure and cerebral hemorrhage is stronger in male than that in female.The associations between age, waist-hip ratio, diabetes and cerebral hemorrhage are stronger in female than in male. Trial Registration: Chinese Clinical Trail Registry, ChiCTR-TNC-11001489.

Initial results of a lung cancer screening demonstration project: a local program evaluation

OBJECTIVES

To describe participation rates, results, and lessons learned from a lung cancer screening (LCS) demonstration project.

STUDY DESIGN

Prospective observational study at 1 of 8 centers participating in a national Veterans Health Administration LCS demonstration project.

METHODS

An electronic health record (EHR) algorithm and tobacco pack-year (TPY) information prompt identified patients potentially eligible for LCS. LCS invitation was planned to consist of shared decision-making materials, an invitation letter to call the LCS manager, a reminder letter, and an outreach phone call for nonresponders. The outreach call was subsequently dropped due to time constraints on the LCS manager. Lung nodules and incidental findings on LCS low-dose computed tomography (LDCT) were recorded in templated radiology reports and tracked with EHR notes.

RESULTS

Of 6133 potentially eligible patients, we identified 1388 patients with eligible TPY information: 918 were invited for LCS and 178 (19%) completed LCS. LCS completion was more likely in patients in the mailing-plus-call outreach group (phase I) compared with the mail-only group (phase II) (22% vs 9%; P <.001). Among those completing an LDCT, 61% had lung nodules requiring follow-up: 43% of the nodules were less than 4 mm in diameter, 12 patients required further diagnostic evaluation, and 2 had lung malignancies. There were 179 incidental LDCT findings in 116 patients, and 20% were clinically significant.

CONCLUSIONS

Important considerations in LCS are accurate identification of eligible patients, balancing invitation approaches with resource constraints, and establishing standardized methods for tracking numerous small lung nodules and incidental findings detected by LDCT.

Validating the use of veterans affairs tobacco health factors for assessing change in smoking status: accuracy, availability, and approach

BACKGROUND

Accurate smoking status is key for research purposes, but can be costly and difficult to measure. Within the Veteran's Health Administration (VA), smoking status is recorded as part of routine care as "health factors" (HF)-fields that researchers can query through the electronic health record (EHR). Many researchers are interested in using these fields to track changes in smoking status over time, however the validity of this measure for assessing change is unknown. The primary goal of this project was to examine whether HFs can be used to accurately measure change in tobacco status over time, with secondary goals of assessing the optimum timeframe for assessment and variation in accuracy by site.

METHODS

Secondary analysis of the Veterans VICTORY study, a pragmatic smoking cessation randomized controlled trial conducted from 2009 to 2011. Eligible subjects were identified via the EHR using a past 90-day HF indicating current tobacco use (for example: "CURRENT SMOKER", "CURRENTLY USES TOBACCO"). Participants were surveyed at 1 year to determine prolonged smoking abstinence. We identified HFs for tobacco status within +/- 120 days of the follow-up survey mailing date and recorded the temporally closest HF. Among subjects with both measures, we compared the two for agreement using kappa statistics and concordance.

RESULTS

1713 subjects (33%) had both follow-up survey and HF data, 1594 (31%) had only a survey response, 790 (15%) had only HF and 1026 (20%) had neither. For subjects with both measures, there was 90% concordance and moderate agreement (Kappa 0.48, 95%CI 0.41-0.55, Sensitivity 54.4, 95%CI 41.1-67.7, Specificity 94.3, 95%CI 87.5-100.0).

CONCLUSIONS

We found high concordance but only moderate agreement by kappa statistics between HFs and survey data. The difference is likely accounted for by the natural history of quit attempts, in which patients cycle in and out of quit attempts. HFs appear to provide an accurate measure of population level quit behavior utilizing data collected in the course of clinical care.

Proactive Tobacco Treatment for Smokers Using Veterans Administration Mental Health Clinics

INTRODUCTION

Veterans with a mental health diagnosis have high rates of tobacco use but encounter low rates of treatment from providers. This study tested whether a proactive tobacco treatment approach increases treatment engagement and abstinence rates in Department of Veterans Affairs mental health patients.

STUDY DESIGN

RCT.

SETTING/PARTICIPANTS

The study was performed from 2013 to 2017 and analyses were conducted in 2017. Investigators used the electronic medical record at four Veterans Administration facilities to identify patients documented as current smokers and who had a mental health clinic visit in the past 12 months.

INTERVENTION

Patients were mailed an introductory letter and baseline survey. Survey respondents were enrolled and randomized to intervention (n=969) or control (n=969). Control participants received a list of usual Veterans Administration smoking services. Intervention participants received a motivational outreach call, multisession telephone counseling, and assistance with obtaining nicotine replacement therapy.

MAIN OUTCOME MEASURES

Participants completed surveys at baseline, 6 months, and 12 months after randomization. The primary outcome was self-reported 7-day abstinence from cigarettes at 12-month follow-up. Secondary outcomes included use of cessation treatment, self-reported 7-day abstinence at 6-month follow-up, and 6-month prolonged abstinence at 12-month follow-up.

RESULTS

At 12 months, intervention participants were more likely to report using telephone counseling (19% vs 3%, OR=7.34, 95% CI=4.59, 11.74), nicotine replacement therapy (47% vs 35%, OR=1.63, 95% CI=1.31, 2.03), or both counseling and nicotine replacement therapy (16% vs 2%, OR=11.93, 95% CI=6.34, 22.47). Intervention participants were more likely to report 7-day abstinence (19% vs 14%, OR=1.50, 95% CI=1.12, 2.01) and prolonged 6-month abstinence (16% vs 9%, OR=1.87, 95% CI=1.34, 2.61). After adjusting for non-ignorable missingness at follow-up, the intervention effects on 7-day and prolonged abstinence remained significant (p<0.05).

CONCLUSIONS

Proactive outreach was more effective than usual Veterans Administration care at increasing treatment engagement and long-term abstinence in mental health patients.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01737281.

Does need for cognitive closure explain individual differences in lung cancer screening? A brief report

The need for cognitive closure describes the extent to which a person, faced with a decision, prefers any answer in lieu of continued uncertainty. This construct may be relevant in lung cancer screening, which can both reduce and increase uncertainty. We examined whether individual differences in need for cognitive closure are associated with Veterans' completion of lung cancer screening using a self-administered survey (N = 361). We also assessed whether need for cognitive closure moderates an association between screening completion and lung cancer risk perception. Contrary to our main hypothesis, high need for cognitive closure Veterans were not more likely to complete lung cancer screening and need for cognitive closure did not have a moderating role.

Proactive tobacco treatment for individuals with and without a mental health diagnosis: Secondary analysis of a pragmatic randomized controlled trial

INTRODUCTION

Individuals with (vs. without) mental illness use tobacco at higher rates and have more difficulty quitting. Treatment models for smokers with mental illness are needed.

METHODS

This secondary analysis of the Victory Over Tobacco study [a pragmatic randomized clinical trial (N=5123) conducted in 2009-2011 of Proactive Care (proactive outreach plus connection to smoking cessation services) vs. Usual Care] tests the effectiveness of treatment assignment in participants with and without a mental health diagnosis on population-level, 6month prolonged abstinence at one year follow-up.

RESULTS

Analyses conducted in 2015-6 found that there was no interaction between treatment group and mental health group on abstinence (F(1,3300=1.12, p=0.29)). Analyses stratified by mental health group showed that those without mental illness, assigned to Proactive Care, had a significantly higher population-level abstinence rate than those assigned to Usual Care (OR=1.40, 95% CI=1.17-1.67); in those with mental illness, assignment to Proactive Care produced a non-significant increase in abstinence compared to Usual Care (OR=1.18, 95% CI=0.98-1.41). Those with mental illness reported more medical visits, cessation advice and treatment (p<0.001), similar levels of abstinence motivation (p>0.05), but lower abstinence self-efficacy (p<0.001).

CONCLUSIONS

Those with a mental health diagnosis benefitted less from proactive outreach regarding tobacco use. VA primary care patients with mental illness may not need additional outreach because they are connected to cessation resources during medical appointments. This group may also require more intensive cessation interventions targeting self-efficacy to improve cessation rates. Clinicaltrials.gov registration # NCT00608426.

Treatment barriers among younger and older socioeconomically disadvantaged smokers

OBJECTIVES

Underutilization of smoking cessation treatments contributes to high rates of smoking in socioeconomically disadvantaged populations. Guided by a conceptual framework, the present study explored how healthcare provider factors, social environment characteristics, and cessation beliefs influence treatment utilization among low-income smokers and whether these associations vary by age.

STUDY DESIGN

Analyses were conducted on baseline data from 2406 participants enrolled in a randomized controlled trial that evaluated the effectiveness of a proactive outreach cessation intervention among a sample of younger (18-34 years) and older (35-64 years) smokers enrolled in public healthcare assistance programs.

METHODS

Multivariable logistic regression models predicted past year cessation treatment utilization (CTU) among younger and older smokers. Independent variables included measures of healthcare provider barriers, social environment characteristics, and cessation beliefs.

RESULTS

Younger smokers were less likely to have CTU than older smokers (27.2% vs 36.2%; P <.001). In both groups, number of cigarettes per day, more problems accessing healthcare, receiving medication-related cessation advice, and readiness to quit were positively associated with CTU (P <.05). Among younger smokers, living with another smoker was associated with lower odds of CTU while receipt of cessation advice was associated (P = .033) with higher odds of CTU.

CONCLUSIONS

In this sample of low-income smokers, interest in quitting was high but treatment utilization was low. Increasing utilization of cessation treatments via interventions that target issues specific to low-income smokers, including healthcare provider access and advice, the home environment, and motivation to quit, is an important step toward reducing smoking rates in this population.

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

PURPOSE

To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers.

DESIGN

Pre-post quasi-experimental trial.

SETTING

General medical units of four US Department of Veterans Affairs hospitals.

SUBJECTS

898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively).

INTERVENTION

The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback.

MEASURES

The primary outcome was self-reported 7-day point prevalence abstinence at six months.

ANALYSIS

Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression.

RESULTS

Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI₉₅)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI₉₅=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001).

CONCLUSIONS

Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.

Taking ACTION to reduce pain: ACTION study rationale, design and protocol of a randomized trial of a proactive telephone-based coaching intervention for chronic musculoskeletal pain among African Americans

Background

Rates of chronic pain are rising sharply in the United States and worldwide. Presently, there is evidence of racial disparities in pain treatment and treatment outcomes in the United States but few interventions designed to address these disparities. There is growing consensus that chronic musculoskeletal pain is best addressed by a biopsychosocial approach that acknowledges the role of psychological and environmental factors, some of which differ by race.

Methods/Design

The primary aim of this randomized controlled trial is to test the effectiveness of a non-pharmacological, self-regulatory intervention, administered proactively by telephone, at improving pain outcomes and increasing walking among African American patients with hip, back and knee pain. Participants assigned to the intervention will receive a telephone counselor delivered pedometer-mediated walking intervention that incorporates action planning and motivational interviewing. The intervention will consist of 6 telephone counseling sessions over an 8–10 week period. Participants randomly assigned to Usual Care will receive an informational brochure and a pedometer. The primary outcome is chronic pain-related physical functioning, assessed at 6 months, by the revised Roland and Morris Disability Questionnaire, a measure recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT). We will also examine whether the intervention improves other IMMPACT-recommended domains (pain intensity, emotional functioning, and ratings of overall improvement). Secondary objectives include examining whether the intervention reduces health care service utilization and use of opioid analgesics and whether key contributors to racial/ethnic disparities targeted by the intervention mediate improvement in chronic pain outcomes Measures will be assessed by mail and phone surveys at baseline, three months, and six months. Data analysis of primary aims will follow intent-to-treat methodology.

Discussion

We will tailor our intervention to address key contributors to racial pain disparities and examine the effects of the intervention on important pain treatment outcomes for African Americans with chronic musculoskeletal pain.

Trial registration

ClinicalTrials.gov: NCT01983228. Registered 6 November 2013.

What factors do patients consider most important in making lung cancer screening decisions? Findings from a demonstration project conducted in the Veterans Health Administration

INTRODUCTION

The National Lung Screening Trial recently reported that annual low-dose computed tomography screening is associated with decreased lung cancer mortality in high-risk smokers. This study sought to identify the factors patients consider important in making lung cancer screening (LCS) decisions, and explore variations by patient characteristics and LCS participation.

MATERIAL AND METHODS

This observational survey study evaluated the Minneapolis VA LCS Clinical Demonstration Project in which LCS-eligible Veterans (N=1388) were randomized to either Direct LCS Invitation (mailed with decision aid, N=926) or Usual Care (provider referral, N=462). We surveyed participants three months post-randomization (response rate 44%) and report the proportion of respondents rating eight decision-making factors (benefits, harms, and neutral factors) as important by condition, patient characteristics, and LCS completion.

RESULTS

Overall, the most important factor was personal risk of lung cancer and the least important factor was health risks from LCS. The reported importance varied by patient characteristics, including smoking status, health status, and education level. Overall, the potential harms of LCS were reported less important than the benefits or the neutral decision-making factors. Exposure to Direct LCS Invitation (with decision aid) increased Veterans' attention to specific decision-making factors; compared to Usual Care respondents, a larger proportion of Direct LCS Invitation respondents rated the chance of false-positive results, LCS knowledge, LCS convenience, and anxiety as important. Those completing LCS considered screening harms less important, with the exception of incidental findings.

CONCLUSION

Decision tools influence Veterans' perceptions about LCS decision-making factors. As the factors important to LCS decision making vary by patient characteristics, targeted materials for specific subgroups may be warranted. Attention should be paid to how LCS incidental findings are communicated.

Ethnic Disparities in the Use of Nicotine Replacement Therapy for Smoking Cessation in an Equal Access Health Care System

Purpose.

To examine ethnic variations in the use of nicotine replacement therapy (NRT) in an equal access health care system.

Design.

Cross-sectional survey.

Setting.

Eighteen Veterans Affairs medical and ambulatory care centers.

Subjects.

A cohort of male current smokers (n = 1606).

Measures.

Use of NRT (nicotine patch or nicotine gum), ethnicity, sociodemographics, health status, smoking-related history, and facility prescribing policy.

Results.

Overall, only 34% of African-American and 26% of Hispanic smokers have ever used NRT as a cessation aid compared with 50% of white smokers. In the past year, African-American smokers were most likely to have attempted quitting. During a serious past-year quit attempt, however, African-American and Hispanic smokers reported lower rates of NRT use than white smokers (20% vs. 22% vs. 34%, respectively, p = .001). In multivariate analyses, ethnicity was independently associated with NRT use during a past-year quit attempt. Compared with white smokers, African-American (adjusted odds ratio, .53; 95% confidence interval, .34–.83) and Hispanic (adjusted odds ratio, .55; 95% confidence interval, .28–1.08) smokers were less likely to use NRT.

Conclusions.

Assessment of variations in use of NRT demonstrates that African-American and Hispanic smokers are less likely to use NRT during quit attempts. Future research is needed on the relative contributions of patient, physician, and system features to gaps in guideline implementation to provide treatment for ethnic minority smokers.

Evaluation of a Motivational Interviewing Training Program for Tobacco Cessation Counseling in Primary Care

Training sessions that offer feedback and coaching to trainees are effective in helping participants retain motivational interviewing skills for tobacco cessation counseling.

Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for socioeconomically disadvantaged smokers: a randomised clinical trial

Background

Evidenced-based tobacco cessation treatments are underused, especially by socioeconomically disadvantaged smokers. This contributes to widening socioeconomic disparities in tobacco-related morbidity and mortality.

Methods

The Offering Proactive Treatment Intervention trial tested the effects of a proactive outreach tobacco treatment intervention on population-level smoking abstinence and tobacco treatment use among a population-based sample of socioeconomically disadvantaged smokers. Current smokers (n=2406), regardless of interest in quitting, who were enrolled in the Minnesota Health Care Programs, the state's publicly funded healthcare programmes for low-income populations, were randomly assigned to proactive outreach or usual care. The intervention comprised proactive outreach (tailored mailings and telephone calls) and free cessation treatment (nicotine replacement therapy and intensive, telephone counselling). Usual care comprised access to a primary care physician, insurance coverage of Food and Drug Administration-approved smoking cessation medications, and the state's telephone quitline. The primary outcome was self-reported 6-month prolonged smoking abstinence at 1 year and was assessed by follow-up survey.

Findings

The proactive intervention group had a higher prolonged abstinence rate at 1 year than usual care (16.5% vs 12.1%, OR 1.47, 95% CI 1.12 to 1.93). The effect of the proactive intervention on prolonged abstinence persisted in selection models accounting for non-response. In analysis of secondary outcomes, use of evidence-based tobacco cessation treatments were significantly greater among proactive outreach participants compared with usual care, particularly combination counselling and medications (17.4% vs 3.6%, OR 5.69, 95% CI 3.85 to 8.40).

Interpretation

Population-based proactive tobacco treatment increases engagement in evidence-based treatment and is effective in long-term smoking cessation among socioeconomically disadvantaged smokers. Findings suggest that dissemination of population-based proactive treatment approaches is an effective strategy to reduce the prevalence of smoking and socioeconomic disparities in tobacco use.

Trial registration number

NCT01123967.

Longitudinal Care Improves Cessation in Smokers Who Do Not Initially Respond to Treatment by Increasing Cessation Self-Efficacy, Satisfaction, and Readiness to Quit: A Mediated Moderation Analysis

BACKGROUND

The Tobacco Longitudinal Care study was a randomized controlled trial for smoking cessation. It demonstrated that longitudinal care for smoking cessation, in which telephone-based counseling and nicotine replacement therapy were offered for 12 months, was more effective than the standard 8-week treatment.

PURPOSE

This study aims to identify for whom and how longitudinal care increased the likelihood of abstinence.

METHODS

Mediated moderation analyses were utilized across three time points.

RESULTS

There was a trend towards smokers who did not respond to treatment (i.e., were still smoking) by 21 days being more likely to be abstinent at 6 months if they received longitudinal care rather than usual care. Similarly, those who did not respond to treatment by 3 months were more likely to be abstinent at 12 months if they received longitudinal care. At both time points, the likelihood of abstinence did not differ across treatment conditions among participants who responded to treatment (i.e., quit smoking). The effect on 6-month outcomes was mediated by satisfaction and readiness to quit. Cessation self-efficacy, satisfaction, and readiness to quit mediated the effect on 12-month outcomes. The effect of treatment condition on the likelihood of abstinence at 18 months was not moderated by response to treatment at 6 months.

CONCLUSIONS

Smokers who did not respond to initial treatment benefited from longitudinal care. Differential effects of treatment condition were not observed among those who responded to early treatment. Conditional assignment to longitudinal care may be useful. Determining for whom and how interventions work over time will advance theory and practice.

The association of military discharge variables with smoking status among homeless Veterans

OBJECTIVE

There is a dearth of research examining the health correlates of tobacco use within the homeless population, particularly with respect to homeless Veterans. An aim of the present study was to compare homeless Veteran and homeless non-Veteran smokers across a series of socio-demographic and health variables, and to determine whether any of these variables were independently associated with Veteran status. A subsequent aim was to compare the socio-demographic and health profiles of Veteran smokers and Veteran nonsmokers, and to determine whether any of these variables were independently associated with current smoking.

METHODS

Data were obtained from the 2009 Homelessness in Minnesota survey conducted by the Wilder Research Foundation. The final sample included 4750 homeless individuals living throughout Minnesota.

RESULTS

The prevalence of smoking was greater among homeless Veterans (74%) than homeless non-Veterans (70%). The prevalence of physical and mental health problems was higher among homeless Veteran smokers than homeless non-Veteran smokers, although these variables were not independently associated with Veteran status after controlling for socio-demographics. Analyses of the homeless Veteran sample indicated that receipt of Veterans' benefits, type of discharge, and alcohol and/or chemical dependence were independently associated with current smoking.

CONCLUSION

Homeless Veteran smokers exhibit heightened rates of physical and mental health problems compared to homeless non-Veteran smokers. Military service and discharge characteristics may contribute to this high smoking prevalence. Future efforts should focus on increasing Veterans' access to and knowledge of Veterans' health resources, and on developing innovative strategies to boost cessation in this population.

Associations between smoking behaviors and financial stress among low-income smokers

OBJECTIVE

Many American households struggle to bring in sufficient income to meet basic needs related to nutrition, housing, and healthcare. Nicotine addiction and consequent expenditures on cigarettes may impose extra financial strain on low-income households. We examine how cigarette use behaviors relate to self-reported financial stress/strain among low-income smokers.

METHODS

At baseline in 2011/12, OPT-IN recruited adult smokers age 18-64 from the administrative databases of the state-subsidized Minnesota Health Care Programs (N = 2406). We tested whether nicotine dependency, type of cigarettes used, and smoking intensity were associated with self-reported difficulty affording food, healthcare, housing, and living within one's income. All regression models were adjusted for race, education, income, age, and gender.

RESULTS

Difficulty living on one's income (77.4%), paying for healthcare (33.6%), paying for housing (38.4%), and paying for food (40.8%) were common conditions in this population. Time to first cigarette and cigarettes smoked per day predicted financial stress related to affording food, housing, and living within one's income (all p < 0.05). For instance, those whose time to first cigarette was greater than 60 minutes had about half the odds of reporting difficulty paying for housing compared to those who had their first cigarette within five minutes of waking (adjusted odds ratio = 0.55 [95% CI: 0.41, 0.73]). Type of cigarette used was not associated with any type of financial stress/strain.

CONCLUSIONS

Smoking and particularly heavy smoking may contribute in an important way to the struggles that low-income households with smokers face in paying for necessities.

Socioeconomic disparities in sleep duration among veterans of the US wars in Iraq and Afghanistan

We characterized socioeconomic disparities in short sleep duration, which is linked to multiple adverse health outcomes, in a population-based sample of veterans of the US wars in Iraq and Afghanistan who had interacted with the Minneapolis VA Health Care System. Lower reported household assets, lower food security, greater reported discrimination, and lower subjective social status were significantly (P<.05) related to less sleep, even after adjusting for demographics, health behaviors, and posttraumatic stress disorder diagnosis. Assisting veterans to navigate social and socioeconomic stressors could promote healthful sleep and overall health.

The relation between social support and smoking cessation: revisiting an established measure to improve prediction

BACKGROUND

Although social support is an integral element in smoking cessation, the literature presents mixed findings regarding the type(s) of social support that are most helpful. The Partner Interaction Questionnaire (PIQ) is commonly used to measure social support in this context.

PURPOSE

We explored the possibility that more nuanced distinctions between items on the PIQ than what is customarily used could improve the prediction of cessation.

METHODS

Baseline PIQ responses of smokers enrolled in a cessation program was submitted to an exploratory factor analysis. Emergent factors were used to predict cessation at several time points.

RESULTS

Four factors emerged, which differed from the two subscales that are typically used. The four-factor version predicted cessation; the two-factor version did not.

CONCLUSIONS

Identifying the types of social support that predict smoking cessation depend on our ability to measure social support. More nuanced measures will likely clarify the role of social support in cessation.

Training primary care clinicians in motivational interviewing: a comparison of two models

OBJECTIVES

To evaluate implementing two training models for motivational interviewing (MI) to address tobacco use with primary care clinicians.

METHODS

Clinicians were randomized to moderate or high intensity. Both training modalities included a single ½ day workshop facilitated by MI expert trainers. The high intensity (HI) training provided six booster sessions including telephone interactions with simulated patients and peer coaching by MI champions over 3 months. To assess performance of clinicians to deliver MI, an objective structured clinical evaluation (OSCE) was conducted before and 12 weeks after the workshop training.

RESULTS

Thirty-four clinicians were enrolled; 18 were randomly assigned to HI. Compared to the moderate intensity group, the HI group scored significantly higher during the OSCE for three of six global Motivational Interviewing Treatment Integrity scale scores. There was also significant improvement for three of the four measures of MI counseling knowledge, skills and confidence.

CONCLUSIONS

Using champions and telephone interactions with simulated patients as enhancement strategies for MI training programs is feasible in the primary care setting and results in greater gains in MI proficiency.

PRACTICE IMPLICATIONS

Results confirm and expand evidence for use of booster sessions to improve the proficiency of MI training programs for primary care clinicians.

Proactive outreach for smokers using VHA mental health clinics: protocol for a patient-randomized clinical trial

Background

Persons with a mental health diagnosis have high rates of tobacco use and face numerous barriers to cessation including high levels of nicotine dependence, low rates of tobacco treatment referrals from mental health providers, and limited availability of tobacco treatment targeted to their needs. This manuscript describes the rationale and methods of a clinical trial with the following aims: 1) Compare the reach and efficacy of a proactive telephone-based tobacco cessation program for Veterans Health Administration (VHA) mental health clinic patients to VHA usual care and 2) Model longitudinal associations between baseline patient characteristics and long-term abstinence.

Methods/design

We will use the electronic medical record to identify patients across four VHA healthcare facilities who have a clinical reminder code indicating current tobacco use in the past six months and who have had a mental health clinic visit in the past 12 months. We will send each patient an introductory letter and baseline survey. Survey respondents (N = 3840) will be randomized in a 1:1 fashion to intervention or control. Control participants will receive VHA usual care. Intervention participants will receive proactive motivational telephone outreach to offer tobacco treatment. Intervention participants interested in treatment will receive eight weeks of nicotine replacement therapy plus eight sessions of specialized telephone counseling over two months, followed by monthly maintenance counseling for four months. We will conduct telephone surveys with participants at six and 12 months to assess study outcomes. We will collect a mailed saliva sample from patients reporting 7-day abstinence on the telephone surveys. The primary outcome will be cotinine-validated abstinence at 12-month follow-up.

Discussion

Mental health patients are a high-risk smoking population with significant barriers to cessation. This study will evaluate the efficacy of a program that proactively reaches out to smokers with a mental health treatment history to engage them into telephone cessation counseling targeted to the needs of mental health patients.

Trial registration

Clinicaltrials.gov: NCT01737281 (registered November 5, 2012).

Smoking cessation among African American and white smokers in the Veterans Affairs health care system

OBJECTIVES

We examined whether a proactive care smoking cessation intervention designed to overcome barriers to treatment would be especially effective at increasing cessation among African Americans receiving care in the Veterans Health Administration.

METHODS

We analyzed data from a randomized controlled trial, the Veterans Victory over Tobacco study, involving a population-based electronic registry of current smokers (702 African Americans, 1569 whites) and assessed 6-month prolonged smoking abstinence at 1 year via a follow-up survey of all current smokers. We also examined candidate risk adjustors for the race effect on smoking abstinence.

RESULTS

The interaction between patient race and intervention condition (proactive care vs. usual care) was not significant. Overall, African Americans had higher quit rates than Whites (13% vs. 9%; P < .006) regardless of condition.

CONCLUSIONS

African Americans quit at higher rates than Whites. These findings may be a result of the large number of veterans receiving smoking cessation services and the lack of racial differences in receipt of these services as well as racial differences in smoking history, self-efficacy, and motivation to quit that favor African Americans.

Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial

IMPORTANCE

Current tobacco use treatment approaches require smokers to request treatment or depend on the provider to initiate smoking cessation care and are therefore reactive. Most smokers do not receive evidence-based treatments for tobacco use that include both behavioral counseling and pharmacotherapy.

OBJECTIVE

To assess the effect of a proactive, population-based tobacco cessation care model on use of evidence-based tobacco cessation treatments and on population-level smoking cessation rates (ie, abstinence among all smokers including those who use and do not use treatment) compared with usual care among a diverse population of current smokers.

DESIGN, SETTING, AND PARTICIPANTS

The Veterans Victory Over Tobacco Study, a pragmatic randomized clinical trial involving a population-based registry of current smokers aged 18 to 80 years. A total of 6400 current smokers, identified using the Department of Veterans Affairs (VA) electronic medical record, were randomized prior to contact to evaluate both the reach and effectiveness of the proactive care intervention.

INTERVENTIONS

Current smokers were randomized to usual care or proactive care. Proactive care combined (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or in-person). Proactive outreach included mailed invitations followed by telephone outreach to motivate smokers to seek treatment with choice of services.

MAIN OUTCOMES AND MEASURES

The primary outcome was 6-month prolonged smoking abstinence at 1 year and was assessed by a follow-up survey among all current smokers regardless of interest in quitting or treatment utilization.

RESULTS

A total of 5123 participants were included in the primary analysis. The follow-up survey response rate was 66%. The population-level, 6-month prolonged smoking abstinence rate at 1 year was 13.5% for proactive care compared with 10.9% for usual care (P = .02). Logistic regression mixed model analysis showed a significant effect of the proactive care intervention on 6-month prolonged abstinence (odds ratio [OR], 1.27 [95% CI, 1.03-1.57]). In analyses accounting for nonresponse using likelihood-based not-missing-at-random models, the effect of proactive care on 6-month prolonged abstinence persisted (OR, 1.33 [95% CI, 1.17-1.51]).

CONCLUSIONS AND RELEVANCE

Proactive, population-based tobacco cessation care using proactive outreach to connect smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00608426.

The effect of cognitive load and patient race on physicians' decisions to prescribe opioids for chronic low back pain: a randomized trial

OBJECTIVE

To test the hypothesis that racial biases in opioid prescribing would be more likely under high levels of cognitive load, defined as the amount of mental activity imposed on working memory, which may come from environmental factors such as stressful conditions, chaotic workplace, staffing insufficiency, and competing demands, one's own psychological or physiological state, as well as from demands inherent in the task at hand.

DESIGN

Two (patient race: White vs Black) by two (cognitive load: low vs high) between-subjects factorial design.

SETTING AND PARTICIPANTS

Ninety-eight primary care physicians from the Veterans Affairs Healthcare System.

METHODS

Web-based experimental study. Physicians were randomly assigned to read vignettes about either a Black or White patient, under low vs high cognitive load, and to indicate their likelihood of prescribing opioids. High cognitive load was induced by having physicians perform a concurrent task under time pressure.

RESULTS

There was a three-way interaction between patient race, cognitive load, and physician gender on prescribing decisions (P = 0.034). Hypotheses were partially confirmed. Male physicians were less likely to prescribe opioids for Black than White patients under high cognitive load (12.5% vs 30.0%) and were more likely to prescribe opioids for Black than White patients under low cognitive load (30.8% vs 10.5%). By contrast, female physicians were more likely to prescribe opioids for Black than White patients in both conditions, with greater racial differences under high (39.1% vs 15.8%) vs low cognitive load (28.6% vs 21.7%).

CONCLUSIONS

Physician gender affected the way in which patient race and cognitive load influenced decisions to prescribe opioids for chronic pain. Future research is needed to further explore the potential effects of physician gender on racial biases in pain treatment, and the effects of physician cognitive load on pain treatment.