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Green T, Bosworth HB, Coronado GD, DeBar L, Green BB, Huang SS, Jarvik JG, Mor V, Zatzick D, Weinfurt KP, Check DK. Factors Affecting Post-trial Sustainment or De-implementation of Study Interventions: A Narrative Review. J Gen Intern Med 2024; 39:1029-1036. [PMID: 38216853 DOI: 10.1007/s11606-023-08593-7] [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: 07/14/2023] [Accepted: 12/28/2023] [Indexed: 01/14/2024]
Abstract
In contrast to traditional randomized controlled trials, embedded pragmatic clinical trials (ePCTs) are conducted within healthcare settings with real-world patient populations. ePCTs are intentionally designed to align with health system priorities leveraging existing healthcare system infrastructure and resources to ease intervention implementation and increase the likelihood that effective interventions translate into routine practice following the trial. The NIH Pragmatic Trials Collaboratory, funded by the National Institutes of Health (NIH), supports the conduct of large-scale ePCT Demonstration Projects that address major public health issues within healthcare systems. The Collaboratory has a unique opportunity to draw on the Demonstration Project experiences to generate lessons learned related to ePCTs and the dissemination and implementation of interventions tested in ePCTs. In this article, we use case studies from six completed Demonstration Projects to summarize the Collaboratory's experience with post-trial interpretation of results, and implications for sustainment (or de-implementation) of tested interventions. We highlight three key lessons learned. First, ineffective interventions (i.e., ePCT is null for the primary outcome) may be sustained if they have other measured benefits (e.g., secondary outcome or subgroup) or even perceived benefits (e.g., staff like the intervention). Second, effective interventions-even those solicited by the health system and/or designed with significant health system partner buy-in-may not be sustained if they require significant resources. Third, alignment with policy incentives is essential for achieving sustainment and scale-up of effective interventions. Our experiences point to several recommendations to aid in considering post-trial sustainment or de-implementation of interventions tested in ePCTs: (1) include secondary outcome measures that are salient to health system partners; (2) collect all appropriate data to allow for post hoc analysis of subgroups; (3) collect experience data from clinicians and staff; (4) engage policy-makers before starting the trial.
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Affiliation(s)
- Terren Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA
- Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | | | - Lynn DeBar
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Susan S Huang
- Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Jeffrey G Jarvik
- Department of Radiology, University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - Kevin P Weinfurt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA.
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Kale SS, Tosto GD, Rush LJ, Kullgren J, Russell D, Fried M, Igboeli B, Teater J, Jones KF, Check DK, Merlin J, McAlearney AS. Creating a Palliative Care Clinic for Patients with Cancer Pain and Substance Use Disorder. J Pain Symptom Manage 2024:S0885-3924(24)00720-6. [PMID: 38670295 DOI: 10.1016/j.jpainsymman.2024.04.011] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/04/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Opioids are a first-line treatment for severe cancer pain. However, clinicians may be reluctant to prescribe opioids for patients with concurrent substance use disorders (SUD) or clinical concerns about non-prescribed substance use. MEASURES Patient volume, 60-day retention rate, and use of sublingual buprenorphine to treat opioid use disorder. INTERVENTION We created the Palliative Harm Reduction and Resiliency Clinic, a palliative care clinic founded on harm reduction principles and including formal collaboration with addiction psychiatry. OUTCOMES During the first 18 months, patient volume increased steadily; 70% of patients had at least one subsequent visit within 60 days of the initial appointment; and buprenorphine was prescribed for 55% of patients with opioid use disorder. CONCLUSIONS/LESSONS LEARNED The formal collaboration with addiction psychiatry and the integration of harm reduction principles and practices into ambulatory palliative care improved our ability to provide treatment to a previously underserved patient population with high symptom burden.
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Affiliation(s)
- Sachin S Kale
- Division of Palliative Medicine(S.S.K., J.K., D.R.), The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
| | - Gennaro Di Tosto
- Center for the Advancement of Team Science(G.D.T., L.J.R., A.S.M.), Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Laura J Rush
- Center for the Advancement of Team Science(G.D.T., L.J.R., A.S.M.), Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Justin Kullgren
- Division of Palliative Medicine(S.S.K., J.K., D.R.), The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Deborah Russell
- Division of Palliative Medicine(S.S.K., J.K., D.R.), The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Martin Fried
- Division of General Internal Medicine(M.F.), The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Blessing Igboeli
- Department of Psychiatry and Behavioral Health(B.I., J.T.), The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie Teater
- Department of Psychiatry and Behavioral Health(B.I., J.T.), The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Katie Fitzgerald Jones
- New England Geriatrics Research(K.F.J.), Education, and Clinical Center (GRECC), VA Boston Healthcare System, Jamaica Plain, Massachussetts, USA
| | - Devon K Check
- Department of Population Health Sciences(D.K.C.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Jessica Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) clinical research center(J.M.), Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ann Scheck McAlearney
- Center for the Advancement of Team Science(G.D.T., L.J.R., A.S.M.), Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA; Department of Family and Community Medicine(A.S.M.), College of Medicine, The Ohio State University, Columbus, Ohio, USA
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Jones KF, Osazuwa-Peters OL, Des Marais A, Merlin JS, Check DK. Substance Use Disorders Among US Adult Cancer Survivors. JAMA Oncol 2024; 10:384-389. [PMID: 38206609 PMCID: PMC10784996 DOI: 10.1001/jamaoncol.2023.5785] [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] [Received: 06/05/2023] [Accepted: 09/29/2023] [Indexed: 01/12/2024]
Abstract
Importance Some individuals are predisposed to cancer based on their substance use history, and others may use substances to manage cancer-related symptoms. Yet the intersection of substance use disorder (SUD) and cancer is understudied. Because SUD may affect and be affected by cancer care, it is important to identify cancer populations with a high prevalence of SUD, with the goal of guiding attention and resources toward groups and settings where interventions may be needed. Objective To describe the cancer type-specific prevalence of SUD among adult cancer survivors. Design, Setting, and Participants This cross-sectional study used data from the annually administered National Survey on Drug Use and Health (NSDUH) for 2015 through 2020 to identify adults with a history of solid tumor cancer. Substance use disorder was defined as meeting at least 1 of 4 Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for abuse or at least 3 of 6 criteria for dependence. Main Outcomes and Measures Per NSDUH guidelines, we made adjustments to analysis weights by dividing weights provided in the pooled NSDUH data sets by the number of years of combined data (eg, 6 for 2015-2020). The weighted prevalence and corresponding SEs (both expressed as percentages) of active SUD (ie, within the past 12 months) were calculated for respondents with any lifetime history of cancer and, in secondary analyses, respondents diagnosed with cancer within 12 months prior to taking the survey. Data were analyzed from July 2022 to June 2023. Results This study included data from 6101 adult cancer survivors (56.91% were aged 65 years or older and 61.63% were female). Among lifetime cancer survivors, the prevalence of active SUD was 3.83% (SE, 0.32%). Substance use disorder was most prevalent in survivors of head and neck cancer (including mouth, tongue, lip, throat, and pharyngeal cancers; 9.36% [SE, 2.47%]), esophageal and gastric cancer (9.42% [SE, 5.51%]), cervical cancer (6.24% [SE, 1.41%]), and melanoma (6.20% [SE, 1.34%]). Alcohol use disorder was the most common SUD (2.78% [SE, 0.26%]) overall and in survivors of head and neck cancer, cervical cancer, and melanoma. In survivors of esophageal and gastric cancers, cannabis use disorder was the most prevalent SUD (9.42% [SE, 5.51%]). Among respondents diagnosed with cancer in the past 12 months, the overall prevalence of active SUD was similar to that in the lifetime cancer survivor cohort (3.81% [SE, 0.74%]). However, active SUD prevalence was higher in head and neck (18.73% [SE, 10.56%]) and cervical cancer survivors (15.70% [SE, 5.35%]). The distribution of specific SUDs was different compared with that in the lifetime cancer survivor cohort. For example, in recently diagnosed head and neck cancer survivors, sedative use disorder was the most common SUD (9.81% [SE, 9.17%]). Conclusions and Relevance Findings of this study suggest that SUD prevalence is higher among survivors of certain types of cancer; this information could be used to identify cancer survivors who may benefit from integrated cancer and SUD care. Future efforts to understand and address the needs of adult cancer survivors with comorbid SUD should prioritize cancer populations in which SUD prevalence is high.
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Affiliation(s)
- Katie F. Jones
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
| | | | - Andrea Des Marais
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Jessica S. Merlin
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Devon K. Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Zullig LL, Drake C, Check DK, Brunkert T, Deschodt M, Olson MS, De Geest S. Embedding implementation science in the research pipeline. Transl Behav Med 2024; 14:73-79. [PMID: 37688798 DOI: 10.1093/tbm/ibad050] [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] [Indexed: 09/11/2023] Open
Abstract
Clinical and health services researchers seek to discover effective programs, practices, and interventions to improve people's health. The current paradigm for evidence generation is incremental and misaligned to translate evidence-based discoveries into real-world settings. This persistent challenge are "valleys of death" that represent missed opportunities and preventable missteps to actually use scientific advancements in real-world clinical settings where they can improve health and well-being (De Geest S, Zúñiga F, Brunkert T et al. Powering Swiss health care for the future: implementation science to bridge "the valley of death". 2020;150:w20323). Only one in seven of evidence-based interventions is ever implemented. It is after an average of 17 years. We propose embedding the principles of implementation science throughout the research pipeline, from discovery to adoption, to efficiently translate discoveries into real-world contexts (Balas EA, Boren SA. Managing clinical knowledge for health care improvement. 2000;9:65-70). We outline implications for capacity building, including composition of the research team, study design, and competencies that could bolster the value proposition of implementation science. We describe a research paradigm that recognizes scientists' responsibility to ensure their discoveries be translated into real-world settings.
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Affiliation(s)
- Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Thekla Brunkert
- Institute of Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
- University Department of Geriatric Medicine, Basel, Switzerland
| | - Mieke Deschodt
- Gerontology and Geriatrics, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Competence Center of Nursing, University Hospitals Leuven, Leuven, Belgium
| | - Melvin Skip Olson
- Evidence Generation, Medical Affairs, Novartis Pharma AG, Basel, Switzerland
| | - Sabina De Geest
- Institute of Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Meernik C, Raveendran Y, Kolarova M, Rahman F, Olunuga E, Hammond E, Shivaramakrishnan A, Hendren S, Bosworth HB, Check DK, Green M, Strickler JH, Akinyemiju T. Racial and ethnic disparities in genomic testing among lung cancer patients: a systematic review. J Natl Cancer Inst 2024:djae026. [PMID: 38321254 DOI: 10.1093/jnci/djae026] [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: 08/20/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/08/2024] Open
Abstract
INTRODUCTION Racial and ethnic disparities in genomic testing could exacerbate disparities in access to precision cancer therapies and survival-particularly in the context of lung cancer, where genomic testing has been recommended for the past decade. However, prior studies assessing disparities in genomic testing have yielded mixed results. METHODS We conducted a systemic review to examine racial and ethnic disparities in the use of genomic testing among lung cancer patients in the U.S. Two comprehensive searches in PubMed, Embase, and Scopus were conducted (September 2022, May 2023). Original studies that assessed rates of genomic testing by race or ethnicity were included. Findings were narratively synthesized by outcome. RESULTS The search yielded 2,739 unique records, resulting in 18 included studies. All but one study was limited to patients diagnosed with non-small cell lung cancer. Diagnosis years ranged from 2007-2022. Eleven of 18 studies found statistically significant differences in the likelihood of genomic testing by race or ethnicity; in seven of these studies, testing was lower among Black patients compared to White or Asian patients. However, many studies lacked adjustment for key covariates and included patients with unclear eligibility for testing. CONCLUSIONS A majority of studies, though not all, observed racial and ethnic disparities in the use of genomic testing among patients with lung cancer. Heterogeneity of study results throughout a period of changing clinical guidelines suggests that minoritized populations-Black patients in particular-have faced additional barriers to genomic testing, even if not universally observed at all institutions.
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Affiliation(s)
- Clare Meernik
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, U.S
| | | | - Michaela Kolarova
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, U.S
| | - Fariha Rahman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, U.S
| | | | - Emmery Hammond
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, U.S
| | | | - Steph Hendren
- Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, U.S
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, U.S
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, U.S
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, U.S
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, U.S
- Duke University School of Nursing, Duke University School of Medicine, Durham, NC, U.S
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, U.S
| | - Michelle Green
- Duke Pathology, Duke University School of Medicine, Durham, NC, U.S
| | - John H Strickler
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, U.S
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, U.S
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, U.S
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Check DK, Jackson BE, Reeder-Hayes KE, Dinan MA, Faherty E, Kwong J, Mehta S, Spees L, Wheeler SB, Wilson LE, Lam C. Characteristics, healthcare utilization, and outcomes of patients with HER2-low breast cancer. Breast Cancer Res Treat 2024; 203:329-338. [PMID: 37875669 DOI: 10.1007/s10549-023-07142-4] [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] [Received: 02/28/2023] [Accepted: 09/25/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE Treatment for HER2-low [defined as ImmunoHistoChemistry (IHC) 1 + or 2 + and negative/normal in Situ Hybridization (ISH)] breast cancer patients is rapidly evolving, yet we lack critical information about the HER2-low population. METHODS We conducted a retrospective cohort study of women aged 18 years or older diagnosed with breast cancer between 2010 and 2016 in North Carolina. Analyses were conducted for the overall cohort and a stage IV sub-cohort. We examined demographic and clinical characteristics, and characterized prevalence of HER2-low disease and healthcare utilization. We estimated adjusted rate ratios for the association between HER2 classifications and utilization outcomes, and hazard ratios for 3-year all cause mortality (stage IV only). RESULTS The overall and stage IV cohorts included 12,965 and 635 patients, respectively. HER2-low patients represented more than half of both cohorts (59% overall, 53% stage IV). HER2-low patients were more likely than IHC 0 patients to have hormone receptor (HR)-positive disease. In the stage IV cohort, HER2-low patients were more likely to be Black (26% vs. 16% IHC 0, p = 0.0159). In both cohorts, rates of hospitalizations were slightly higher among HER2-low patients. There were no survival differences between HER2-low and IHC 0 among stage IV patients. CONCLUSION New treatment options for HER2-low breast cancer may have potential for significant impact at the population level particularly for patients with stage IV disease. In light of racial differences between HER2-low and IHC 0 patients observed in our cohort, research- and practice-based efforts to ensure equitable adoption of new treatment guidelines for patients with HER2-low metastatic breast cancer will be essential.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA.
| | | | | | | | | | | | | | - Lisa Spees
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA
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Fisher HM, Check DK, Somers TJ, Kelleher SA, Majestic C, Yu JA, Reed SD, Li Y, Olsen MK, Lerebours R, Keefe FJ, Steinhauser KE, Breitbart WS, Winger JG. Meaning-centered pain coping skills training for patients with metastatic cancer: Protocol for a randomized controlled efficacy trial. Contemp Clin Trials 2023; 135:107363. [PMID: 37884120 PMCID: PMC10842087 DOI: 10.1016/j.cct.2023.107363] [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: 08/15/2023] [Revised: 10/05/2023] [Accepted: 10/23/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Many patients with advanced cancer describe pain as a debilitating symptom that greatly interferes with daily activities and enjoyment of life. Psychosocial interventions can improve cancer-related pain but rarely address spiritual concerns (e.g., loss of meaning, peace), which can influence the pain experience for those facing life-threatening illness. To address these needs, we systematically developed and pilot tested a novel psychosocial intervention called Meaning-Centered Pain Coping Skills Training (MCPC). In this randomized controlled trial, we aim to determine MCPC's efficacy for reducing pain interference (primary outcome) and improving secondary outcomes. We will also estimate MCPC's cost-effectiveness. METHOD/DESIGN Patients (target N = 210) with advanced solid tumor malignancies (Stage IV) and clinically-elevated pain interference will be enrolled and block randomized with equal allocation to MCPC + enhanced usual care or enhanced usual care alone. MCPC's four, videoconferenced, 45-60 min weekly sessions will be individually delivered by trained study therapists. Primary (pain interference) and secondary (pain severity, anxiety and depressive symptoms, pain self-efficacy, social support, spiritual well-being) patient-reported outcomes will be assessed at baseline, and 8-weeks (primary endpoint) and 12-weeks after baseline. CONCLUSION Our MCPC intervention is the first to systematically address the biopsychosocial-spiritual aspects of pain in patients with advanced cancer. If MCPC demonstrates efficacy, next steps will involve hybrid efficacy-effectiveness and implementation work to broaden access to this brief, manualized, remotely-delivered intervention, with the goal of reducing suffering in patients with life-threatening illness.
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Affiliation(s)
- Hannah M Fisher
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Duke Cancer Institute, Duke University Health System, Durham, NC, USA
| | - Devon K Check
- Duke Cancer Institute, Duke University Health System, Durham, NC, USA; Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Tamara J Somers
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Duke Cancer Institute, Duke University Health System, Durham, NC, USA
| | - Sarah A Kelleher
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Duke Cancer Institute, Duke University Health System, Durham, NC, USA
| | - Catherine Majestic
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Duke Cancer Institute, Duke University Health System, Durham, NC, USA
| | - Justin A Yu
- Division of Pediatric Palliative and Supportive Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shelby D Reed
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Yanhong Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Maren K Olsen
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Reginald Lerebours
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Francis J Keefe
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Duke Cancer Institute, Duke University Health System, Durham, NC, USA
| | - Karen E Steinhauser
- Duke Cancer Institute, Duke University Health System, Durham, NC, USA; Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, 27705, USA
| | - William S Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph G Winger
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Duke Cancer Institute, Duke University Health System, Durham, NC, USA.
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Schlichte L, Setji N, Walter J, Acker Y, Casarett D, Pollak KI, Steinhauser K, Check DK, Lakis K, Schmid L, Ma JE. The Use of Templates for Documenting Advance Care Planning Conversations: A Descriptive Analysis. J Pain Symptom Manage 2023; 66:123-136. [PMID: 37080478 DOI: 10.1016/j.jpainsymman.2023.04.015] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/09/2023] [Accepted: 04/12/2023] [Indexed: 04/22/2023]
Abstract
CONTEXT While professional societies and expert panels have recommended quality indicators related to advance care planning (ACP) documentation, including using structured documentation templates, it is unclear how clinicians document these conversations. OBJECTIVE To explore how clinicians document ACP, specifically, which components of these conversations are documented. METHODS A codebook was developed based on existing frameworks for ACP conversations and documentation. ACP documentation from a hospital medicine quality improvement project conducted from November 2019 to April 2021 were included and assessed. Documentation was examined for the presence or absence of each component within the coding schema. Clinician documented ACP using three different note types: template (only template prompts were used), template plus (authors added additional text to the template), and free text only. ACP note components were analyzed by note type and author department. RESULTS A total of 182 ACP notes were identified and reviewed. The most common note type was template plus (58%), followed by free text (28%) and template (14%). The most frequent components across all note types were: important relationships to patient (92%), and discussion of life-sustaining treatment preferences (87%). There was considerable heterogeneity in the components across note types. The presence of components focused on treatment decisions and legal paperwork differed significantly between note types (P < 0.05). Components on preference for medical information, emotional state, or spiritual support were rarely included across all note types. CONCLUSION This study provides a preliminary exploration of ACP documentation and found that templates may influence what information is documented after an ACP conversation.
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Affiliation(s)
- Lindsay Schlichte
- Duke University School of Medicine (L.S.), Durham, North Carolina, USA
| | - Noppon Setji
- Division of General Internal Medicine, Department of Medicine (N.S., J.W., D.C., K.S., J.M.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Jonathan Walter
- Division of General Internal Medicine, Department of Medicine (N.S., J.W., D.C., K.S., J.M.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Yvonne Acker
- Patient Safety and Quality, Duke University Health System (Y.A.), Durham, North Carolina, USA
| | - David Casarett
- Division of General Internal Medicine, Department of Medicine (N.S., J.W., D.C., K.S., J.M.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Kathryn I Pollak
- Department of Population Health Sciences (K.I.P., K.S., D.K.C.), Duke University, Durham, North Carolina, USA; Cancer Prevention and Control (K.I.P., K.S.), Duke Cancer Institute, Durham, North Carolina, USA; Department of Family Medicine and Community Health (K.I.P.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Karen Steinhauser
- Division of General Internal Medicine, Department of Medicine (N.S., J.W., D.C., K.S., J.M.), Duke University School of Medicine, Durham, North Carolina, USA; Department of Population Health Sciences (K.I.P., K.S., D.K.C.), Duke University, Durham, North Carolina, USA; Cancer Prevention and Control (K.I.P., K.S.), Duke Cancer Institute, Durham, North Carolina, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) (K.S.), Durham VA Health Care System, Durham, North Carolina, USA
| | - Devon K Check
- Department of Population Health Sciences (K.I.P., K.S., D.K.C.), Duke University, Durham, North Carolina, USA
| | - Kristen Lakis
- Office of Culture and Wellbeing Hub (K.L.), Duke University Health System, Durham North Carolina, USA
| | - Lorrie Schmid
- Social Sciences Research Institute (L.S.), Duke University, Durham, North Carolina, USA
| | - Jessica E Ma
- Division of General Internal Medicine, Department of Medicine (N.S., J.W., D.C., K.S., J.M.), Duke University School of Medicine, Durham, North Carolina, USA; Geriatric Research Education and Clinical Center (J.M.), Durham VA Health System, Duke University School of Medicine, Durham, North Carolina, USA.
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Jones KF, Fu MR, Wood Magee L, Merlin J, Check DK, McTernan M, Bernacki R, Bulls HW. "It Is So Easy For Them to Dismiss": A Phenomenological Study of Cancer Survivors With Chronic Cancer-Related Pain. J Palliat Med 2023; 26:1090-1099. [PMID: 36944115 PMCID: PMC10440651 DOI: 10.1089/jpm.2022.0538] [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] [Accepted: 02/13/2023] [Indexed: 03/23/2023] Open
Abstract
Background: For many cancer survivors post-cure, chronic pain is a devastating complication of cancer treatment. The prevalence of chronic pain among cancer survivors is double that of the general population. However, little is known about the pain experience of cancer survivors who may have a different perspective than people with advanced cancer or people with noncancer pain. Objective: To understand the lived experience of chronic cancer-related pain in cancer survivors. Methods: We used a qualitative design with a descriptive phenomenological method to conduct in-depth interviews of 13 cancer survivors residing in the United States who completed curative cancer therapy, were at least three months from treatment, and experienced pain attributable to cancer. Data collection was focused on the lived experience and management of chronic cancer-related pain and a deep understanding of how the experience of chronic cancer-related pain shapes pain management choices. Results: The participants had a variety of primary cancer types and cancer pain syndromes. Three essential themes epitomized the experience of living with chronic cancer-related pain: invisible suffering at the cost of survival, an opioid paradox, and a lack of answers on what to expect and what might help. Conclusion and Implications: The results highlight an opportunity for pain self-management, education, and psychosocial interventions to optimize pain in cancer. Participants' experiences identify several opportunities to improve chronic cancer-related pain. Future efforts should prioritize access to multimodal pain treatments, high-quality communication, and expand clinicians' knowledge and skills to manage chronic pain.
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Affiliation(s)
| | - Mei R. Fu
- School of Nursing–Camden, Rutgers University, Camden, New Jersey, USA
| | - Lisa Wood Magee
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA
| | - Jessica Merlin
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Devon K. Check
- Population Health Sciences, Duke Cancer Institute, Durham, North Carolina, USA
| | - Melissa McTernan
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA
| | - Rachelle Bernacki
- Division of Psychosocial Oncology and Palliative Care, Dana Faber-Cancer Institute, Boston, Massachusetts, USA
| | - Hailey Waddell Bulls
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Osazuwa-Peters OL, Wilson LE, Check DK, Roberts MC, Srinivasan S, Clark AG, Crawford J, Chrischilles E, Carnahan RM, Campbell WS, Cowell LG, Greenlee R, Abbott AM, Mosa ASM, Mandhadi V, Stoddard A, Dinan MA. Factors Associated With Receipt of Molecular Testing and its Impact on Time to Initial Systemic Therapy in Metastatic Non-Small Cell Lung Cancer. Clin Lung Cancer 2023; 24:305-312. [PMID: 37055337 DOI: 10.1016/j.cllc.2023.03.001] [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: 10/21/2022] [Revised: 02/13/2023] [Accepted: 03/10/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Despite recommendations for molecular testing irrespective of patient characteristics, differences exist in receipt of molecular testing for oncogenic drivers amongst metastatic non-small cell lung cancer (mNSCLC) patients. Exploration into these differences and their effects on treatment is needed to identify opportunities for improvement. PATIENTS AND METHODS We conducted a retrospective cohort study of adult patients diagnosed with mNSCLC between 2011 and 2018 using PCORnet's Rapid Cycle Research Project dataset (n = 3600). Log-binomial, Cox proportional hazards (PH), and time-varying Cox regression models were used to ascertain whether molecular testing was received, and time from diagnosis to molecular testing and/or initial systemic treatment in the context of patient age, sex, race/ethnicity, and multiple comorbidities status. RESULTS The majority of patients in this cohort were ≤ 65 years of age (median [25th, 75th]: 64 [57, 71]), male (54.3%), non-Hispanic white individuals (81.6%), with > 2 comorbidities in addition to mNSCLC (54.1%). About half the cohort received molecular testing (49.9%). Patients who received molecular testing had a 59% higher probability of initial systemic treatment than patients who were yet to receive testing. Multiple comorbidity status was positively associated with receipt of molecular testing (RR, 1.27; 95% CI 1.08, 1.49). CONCLUSION Receipt of molecular testing in academic centers was associated with earlier initiation of systemic treatment. This finding underscores the need to increase molecular testing rates amongst mNSCLC patients during a clinically relevant period. Further studies to validate these findings in community centers are warranted.
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Affiliation(s)
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Megan C Roberts
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Swetha Srinivasan
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Amy G Clark
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Jeffrey Crawford
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | - Ryan M Carnahan
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA
| | - W Scott Campbell
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE
| | - Lindsay G Cowell
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Robert Greenlee
- Center for Clinical Epidemiology & Population Health, Marshfield Clinical Research Institute, Marshfield, WI
| | - Andrea M Abbott
- Department of Surgery, Medical University of South Carolina, Clinical Sciences, Charleston, SC
| | - Abu S M Mosa
- Department of Health Management and Informatics, University of Missouri School of Medicine, Columbia, MO
| | - Vasanthi Mandhadi
- Department of Health Management and Informatics, University of Missouri School of Medicine, Columbia, MO
| | - Alexander Stoddard
- Biomedical Informatics, Clinical and Translational Science Institute, Medical College of Wisconsin, Milwaukee, WI
| | - Michaela A Dinan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT.
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11
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Winger JG, Kelleher SA, Ramos K, Check DK, Yu JA, Powell VD, Lerebours R, Olsen MK, Keefe FJ, Steinhauser KE, Porter LS, Breitbart WS, Somers TJ. Meaning-centered pain coping skills training for patients with metastatic cancer: Results of a randomized controlled pilot trial. Psychooncology 2023. [PMID: 37173865 DOI: 10.1002/pon.6151] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/07/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE For patients with advanced cancer, pain is a common and debilitating symptom that can negatively impact physical, emotional, and spiritual well-being. This trial examined the feasibility and initial effects of Meaning-Centered Pain Coping Skills Training (MCPC), a cognitive-behavioral pain management intervention with an emphasis on enhancing meaning (i.e., a personal sense of purpose, worth, and significance) and peace. METHODS We enrolled 60 adults with stage IV solid tumor cancers and moderate-severe pain between February 2021 and February 2022. Participants were randomized 1:1 to MCPC + usual care or usual care alone. Meaning-Centered Pain Coping Skills Training consisted of four weekly 60-min individual sessions via videoconference or telephone, delivered by a trained therapist using a manualized protocol. Participants completed validated measures of pain severity, pain interference, pain self-efficacy, spiritual well-being (i.e., meaning, peace, and faith), and psychological distress at baseline and 5-week and 10-week follow-ups. RESULTS All feasibility metrics exceeded prespecified benchmarks. Fifty-eight percent of screened patients were eligible, and 69% of eligible patients consented. Of those assigned to MCPC, 93% completed all sessions and 100% of those who completed follow-ups reported using coping skills weekly. Retention was strong at 5-week (85%) and 10-week (78%) follow-ups. Meaning-Centered Pain Coping Skills Training participants reported better scores than control participants across outcome measures, including moderate-to-large sized differences at 10-week follow-up in pain severity (Cohen's d = -0.75 [95% confidence interval: -1.36, -0.14]), pain interference (d = -0.82 [-1.45, -0.20]), and pain self-efficacy (d = 0.74 [0.13, 1.35]). CONCLUSIONS MCPC is a highly feasible, engaging, and promising approach for improving pain management in advanced cancer. Future efficacy testing is warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04431830, registered 16 June 2020.
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Affiliation(s)
- Joseph G Winger
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina, USA
| | - Sarah A Kelleher
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina, USA
| | - Katherine Ramos
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina, USA
- Geriatric Research, Education, and Clinical Center, (GRECC), Durham VA Health Care System, Durham, North Carolina, USA
- Center for the Study of Human Aging and Development, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Devon K Check
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Justin A Yu
- Division of Pediatric Palliative and Supportive Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Victoria D Powell
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Geriatrics Research, Education, and Clinical Center (GRECC), LTC Charles S. Kettles VA Medical Center, Ann Arbor, Michigan, USA
| | - Reginald Lerebours
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Maren K Olsen
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Francis J Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina, USA
| | - Karen E Steinhauser
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina, USA
- Center for the Study of Human Aging and Development, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Laura S Porter
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina, USA
| | - William S Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Tamara J Somers
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Health System, Durham, North Carolina, USA
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12
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Check DK, Jones KF, Fish LJ, Dinan MA, Dunbar TK, Farley S, Ma J, Merlin JS, O'Regan A, Oeffinger KC. Clinician Perspectives on Managing Chronic Pain After Curative-Intent Cancer Treatment. JCO Oncol Pract 2023; 19:e484-e491. [PMID: 36595729 PMCID: PMC10530392 DOI: 10.1200/op.22.00410] [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: 06/10/2022] [Revised: 08/19/2022] [Accepted: 11/04/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Among cancer survivors who have completed curative-intent treatment, the high prevalence and adverse consequences of chronic pain are well documented. Yet, research on clinicians' experiences with and perspectives on managing chronic pain among cancer survivors is critically lacking. METHODS We conducted semistructured interviews with 17 clinicians (six oncology, three palliative care, and eight primary care) affiliated with an academic medical center. Interview questions addressed clinicians' experiences with and perspectives on managing chronic pain (with or without opioid therapy) during the transition from active treatment to survivorship. A multidisciplinary team conducted content analysis of interview transcripts to identify and refine themes related to current practices and challenges in managing chronic pain in this context. RESULTS Overall, clinicians perceived chronic pain to be relatively uncommon among cancer survivors. Identified challenges included a lack of clarity about which clinician (or clinicians) are best positioned to manage chronic pain among cancer survivors, and (relatedly) complexities introduced by long-term opioid management, with many clinicians describing this practice as outside their skill set. Additionally, although most clinicians recognized chronic pain as a biopsychosocial phenomenon, they described challenges with effectively managing psychosocial stressors, including difficulty accessing mental or behavioral health services for cancer survivors. CONCLUSION Discovered challenges highlight unmet needs related to cancer survivor-clinician communication about chronic pain and the absence of a chronic pain management home for cancer survivors, including those requiring long-term opioid therapy. Research evaluating routine pain monitoring and accessible, tailored models of multimodal pain care in survivorship may help to address these challenges.
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Affiliation(s)
- Devon K. Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Katie F. Jones
- Boston College, William F. Connell School of Nursing, Chestnut Hill, MA
| | - Laura J. Fish
- Duke Cancer Institute, Durham, NC
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC
| | - Michaela A. Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - T. Kayla Dunbar
- Doctor of Osteopathic Medicine Program, Philadelphia College of Osteopathic Medicine, Philadelphia, PA
| | | | - Jessica Ma
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jessica S. Merlin
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Amy O'Regan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Kevin C. Oeffinger
- Duke Cancer Institute, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
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13
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Staman KL, Check DK, Zatzick D, Mor V, Fritz JM, Sluka K, DeBar LL, Jarvik JG, Volandes A, Coronado GD, Chambers DA, Weinfurt KP, George SZ. Intervention delivery for embedded pragmatic clinical trials: Development of a tool to measure complexity. Contemp Clin Trials 2023; 126:107105. [PMID: 36708968 PMCID: PMC10126825 DOI: 10.1016/j.cct.2023.107105] [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: 10/08/2022] [Revised: 01/03/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Conducting an embedded pragmatic clinical trial in the workflow of a healthcare system is a complex endeavor. The complexity of the intervention delivery can have implications for study planning, ability to maintain fidelity to the intervention during the trial, and/or ability to detect meaningful differences in outcomes. METHODS We conducted a literature review, developed a tool, and conducted two rounds of phone calls with NIH Pragmatic Trials Collaboratory Demonstration Project principal investigators to develop the Intervention Delivery Complexity Tool. After refining the tool, we piloted it with Collaboratory demonstration projects and developed an online version of the tool using the R Shiny application (https://duke-som.shinyapps.io/ICT-ePCT/). RESULTS The 6-item tool consists of internal and external factors. Internal factors pertain to the intervention itself and include workflow, training, and the number of intervention components. External factors are related to intervention delivery at the system level including differences in healthcare systems, the dependency on setting for implementation, and the number of steps between the intervention and the outcome. CONCLUSION The Intervention Delivery Complexity Tool was developed as a standard way to overcome communication challenges of intervention delivery within an embedded pragmatic trial. This version of the tool is most likely to be useful to the trial team and its health system partners during trial planning and conduct. We expect further evolution of the tool as more pragmatic trials are conducted and feedback is received on its performance outside of the NIH Pragmatic Trials Collaboratory.
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Affiliation(s)
- Karen L Staman
- Duke Clinical Research Institute, CHB Wordsmith, Inc, Raleigh, NC, USA
| | - Devon K Check
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | | | | | | | - Kevin P Weinfurt
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Durham, NC, USA.
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14
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Check DK, Jackson BE, Spees L, Dinan MA, Kwong J, Mehta S, Wheeler SB, Wilson LE, Faherty E, Reeder-Hayes KE, Lam C. Treatment patterns and health care resource use of patients with metastatic breast cancer with HER2-low expression: A cancer registry-linked insurance claims study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.399] [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] [Indexed: 11/20/2022] Open
Abstract
399 Background: Metastatic breast cancer (mBC) expresses varied levels of HER2 protein. While HER2+ mBC patients are treated with anti-HER2 therapies, those with lower levels of HER2 expression [HER2-low; immunohistochemistry (IHC) 1+, IHC 2+ with In Situ Hybridization (ISH) -] are currently classified as HER2-negative and are not treated with anti-HER2 therapies. This study aims to estimate population-based prevalence of HER2-low expression among mBC patients and assess healthcare resource utilization and breast cancer specific mortality rates, comparing HER2-low and HER2 IHC 0 patients. Methods: This was a retrospective population-based cohort study of women diagnosed with de novo mBC in North Carolina from 2010-2016, using a multi-payer linkage of insurance claims to state cancer registry data. We examined demographic and clinical characteristics, inpatient, emergency department (ED), and outpatient infusion visits over 12 months and lines of systemic therapy over 24 months by HER2 status and hormone receptor (HR) status. We estimated rates of hospitalization, emergency department (ED) and outpatient infusion visits per 1000-person days as well as hazard ratios for 3-year breast cancer specific mortality. Results: The cohort included 635 mBC patients; 53% (n = 337) met HER2-low criteria and 23.1% (n = 147) were HER2 IHC 0. Compared to HER2 IHC 0 patients, more HER2-low patients had hormone receptor (HR)+ disease (82% vs. 71%, p = 0.008) and were Black (26% vs. 16%, p = 0.029). HER2-low patients also had slightly higher rates of hospitalization (21.4 vs. 18.9, p = 0.003) and ED visits (2.4 vs. 1.8, p = 0.015), but similar rates of outpatient infusion visits (15.7 vs. 16.0, p = 0.684) compared to HER2 IHC 0. There were no differences in mortality due to mBC, comparing HER2 IHC 0 and HER2-low patients (HR: 0.90, 95% CI: 0.68-1.20, p = 0.483). Among HER2-low/HR+ patients, the most common regimens in first line (1L) included endocrine monotherapy (46.6%), chemotherapy (combination or monotherapy) (32.9%), and endocrine therapy with CDK4/6 inhibitors (18.8%). Similar patterns were seen in the second line (2L) with endocrine monotherapy (63.5%), chemotherapy (combination or monotherapy) (25.9%), and endocrine therapy with CDK4/6 inhibitors (9.5%). Most HER2-low/HR- patients received chemotherapy in 1L (88.9%) and 2L (90.9%). Conclusions: About 1 in 2 mBC patients met criteria to be classified as HER2-low. Overall, HER2-low patients experienced slightly higher rates of healthcare utilization than HER2 IHC 0 patients but had similar outcomes. Among HER2-low patients, treatment patterns by HR status were consistent with the standard of care for HER2 IHC 0 patients. There may be potential to improve outcomes among HER-low patients with anti-HER2 therapies demonstrating efficacy across levels of HER2 expression.
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Affiliation(s)
| | | | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
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15
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Porter LS, Ramos K, Baucom DH, Steinhauser K, Erkanli A, Strauman TJ, Zafar SY, Check DK, Leo K, Liu E, Keefe FJ. Evaluating a couple communication skills training (CCST) intervention for advanced cancer: study protocol for a randomized controlled trial. Trials 2022; 23:712. [PMID: 36028908 PMCID: PMC9419413 DOI: 10.1186/s13063-022-06656-4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For patients and their intimate partners, advanced cancer poses significant challenges that can negatively impact both individuals and their relationship. Prior studies have found evidence that couple-based communication skills interventions can to be beneficial for patients and partners. However, these studies have been limited by reliance on in-person treatment delivery and have not targeted couples at high risk for poor outcomes. This study tests the efficacy of a Couples Communication Skills Training (CCST) intervention delivered via videoconference for couples reporting high levels of holding back from discussing cancer-related concerns, a variable associated with poorer psychological and relationship functioning. METHODS This RCT is designed to evaluate the efficacy of CCST in improving patient and partner relationship functioning (primary outcome). Secondary outcomes include patient and partner psychological functioning and patient symptoms and health care use. We also examine the role of objective and self-reported communication behaviors as mediators of treatment effects. Two hundred thirty patients with advanced lung, gastrointestinal, genitourinary, and breast cancer and their partners will be randomized to CCST or an education control intervention. Participants in both conditions complete self-reported outcome measures at baseline, mid-treatment, post-treatment, and 3 months post-treatment. Objective measures of communication are derived from video-recorded couple conversations collected at baseline and post-treatment. An implementation-related process evaluation (assessing implementation outcomes and potential barriers to/facilitators of implementation) will be conducted to inform future efforts to implement CCST in real-world settings. DISCUSSION This trial can yield important new knowledge about effective ways to improve patient and partner adjustment to advanced cancer. TRIAL REGISTRATION This study trial is registered at clinicaltrials.gov (Trial # NCT04590885); registration date: October 19, 2020.
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Affiliation(s)
- Laura S Porter
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, DUMC 102506, Durham, NC, 27710, USA.
| | - Katherine Ramos
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, DUMC 102506, Durham, NC, 27710, USA
| | - Donald H Baucom
- Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karen Steinhauser
- Population Health Sciences Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | | | - S Yousuf Zafar
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Devon K Check
- Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Karena Leo
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, DUMC 102506, Durham, NC, 27710, USA
| | - Evan Liu
- Trinity College of Arts & Sciences, Duke University, Durham, NC, USA
| | - Francis J Keefe
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, DUMC 102506, Durham, NC, 27710, USA
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16
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Check DK, Avecilla RAV, Mills C, Dinan MA, Kamal AH, Murphy B, Rezk S, Winn A, Oeffinger KC. Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies. J Pain Symptom Manage 2022; 63:e397-e417. [PMID: 34748896 DOI: 10.1016/j.jpainsymman.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/12/2022]
Abstract
CONTEXT Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear. OBJECTIVES To provide an evidence synthesis. METHODS We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods. RESULTS Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14). CONCLUSIONS We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine (D.K.C.), Durham, North Carolina; Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina.
| | - Renee A V Avecilla
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Coleman Mills
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health (M.A.D.), New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center (M.A.D.), New Haven, Connecticut
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University Medical Center (A.H.K.), Durham, North Carolina
| | - Beverly Murphy
- Duke University Medical Center Library & Archives, Duke University School of Medicine (B.M.), Durham, North Carolina
| | - Salma Rezk
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy (S.R.), Chapel Hill, North Carolina
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin (A.W.), Milwaukee, Wisconsin
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University School of Medicine (K.C.O.), Durham, North Carolina
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Gupta A, Nshuti L, Grewal US, Sedhom R, Check DK, Parsons HM, Blaes AH, Virnig BA, Lustberg MB, Subbiah IM, Nipp RD, Dy SM, Dusetzina SB. Financial Burden of Drugs Prescribed for Cancer-Associated Symptoms. JCO Oncol Pract 2022; 18:140-147. [PMID: 34558297 PMCID: PMC9213200 DOI: 10.1200/op.21.00466] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/28/2021] [Accepted: 09/01/2021] [Indexed: 01/09/2023] Open
Abstract
PURPOSE The financial toxicity of anticancer drugs is well-documented, but little is known about the costs of drugs used to manage cancer-associated symptoms. METHODS We reviewed relevant guidelines and compiled drugs used to manage seven cancer-associated symptoms (anorexia and cachexia, chemotherapy-induced peripheral neuropathy, constipation, diarrhea, exocrine pancreatic insufficiency, cancer-associated fatigue, and chemotherapy-induced nausea and vomiting). Using GoodRx website, we identified the retail price (cash price at retail pharmacies) and lowest price (discounted, best-case scenario of out-of-pocket costs) for patients without insurance for each drug or formulation for a typical fill. We describe lowest prices here. RESULTS For anorexia and cachexia, costs ranged from $5 US dollars (USD; generic olanzapine or mirtazapine tablets) to $1,156 USD (brand-name dronabinol solution) and varied widely by formulation of the same drug or dosage: for olanzapine 5 mg, $5 USD (generic tablet) to $239 USD (brand-name orally disintegrating tablet). For chemotherapy-induced peripheral neuropathy, costs of duloxetine varied from $12 USD (generic) to $529 USD (brand-name). For constipation, the cost of sennosides or polyethylene glycol was <$15 USD, whereas newer agents such as methylnaltrexone were expensive ($1,001 USD). For diarrhea, the cost of generic loperamide or diphenoxylate-atropine tablets was <$15 USD. For exocrine pancreatic insufficiency, only brand-name formulations were available, range of cost, $1,072 USD-$1,514 USD. For cancer-associated fatigue, the cost of generic dexamethasone or dexmethylphenidate was <$15 USD, whereas brand-name modafinil was more costly ($1,284 USD). For a 4-drug nausea and vomiting prophylaxis regimen, costs ranged from $181 USD to $1,430 USD. CONCLUSION We highlight the high costs of many symptom control drugs and the wide variation in the costs of these drugs. These findings can guide patient-clinician discussions about cost-effectively managing symptoms, while promoting the use of less expensive formulations when possible.
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Affiliation(s)
- Arjun Gupta
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
| | - Leonce Nshuti
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Udhayvir S. Grewal
- Department of Internal Medicine, Louisiana State University, Shreveport, LA
| | - Ramy Sedhom
- Division of Oncology, University of Pennsylvania, PA
| | - Devon K. Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Helen M. Parsons
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN
| | - Anne H. Blaes
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
| | - Beth A. Virnig
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN
| | | | - Ishwaria M. Subbiah
- Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ryan D. Nipp
- Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Sydney M. Dy
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD
| | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
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18
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Roberts AW, Eiffert S, Wulff-Burchfield EM, Dusetzina SB, Check DK. Opioid Use Disorder and Overdose in Older Adults With Breast, Colorectal, or Prostate Cancer. J Natl Cancer Inst 2021; 113:425-433. [PMID: 32805032 DOI: 10.1093/jnci/djaa122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 08/05/2020] [Accepted: 08/11/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Despite high rates of opioid therapy, evidence about the risk of preventable opioid harms among cancer survivors is underdeveloped. Our objective was to estimate the odds of opioid use disorder (OUD) and overdose following breast, colorectal, or prostate cancer diagnosis among Medicare beneficiaries. METHODS We conducted a retrospective cohort study using 2007-2014 Surveillance, Epidemiology, and End Results-Medicare data for cancer survivors with a first cancer diagnosis of stage 0-III breast, colorectal, or prostate cancer at age 66-89 years between 2008 and 2013. Cancer survivors were matched to up to 2 noncancer controls on age, sex, and Surveillance, Epidemiology, and End Results region. Using Firth logistic regression, we estimated adjusted 1-year odds of OUD or nonfatal opioid overdose associated with a cancer diagnosis. We also estimated adjusted odds of OUD and overdose separately and by cancer stage, prior opioid use, and follow-up time. RESULTS Among 69 889 cancer survivors and 125 007 controls, the unadjusted rates of OUD or nonfatal overdose were 25.2, 27.1, 38.9, and 12.4 events per 10 000 patients in the noncancer, breast, colorectal, and prostate samples, respectively. There was no association between cancer and OUD. Colorectal survivors had 2.3 times higher odds of opioid overdose compared with matched controls (adjusted odds ratio = 2.33, 95% confidence interval = 1.49 to 3.67). Additionally, overdose risk was greater in those with more advanced disease, no prior opioid use, and preexisting mental health conditions. CONCLUSIONS Opioid overdose was a rare, but statistically significant, outcome following stage II-III colorectal cancer diagnosis, particularly among previously opioid-naïve patients. These patients may require heightened screening and intervention to prevent inadvertent adverse opioid harms.
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Affiliation(s)
- Andrew W Roberts
- Department of Population Health, University of Kansas Medical Center (KUMC), University of Kansas Cancer Center, Kansas City, KS, USA.,Department of Anesthesiology, University of Kansas Medical Center (KUMC), University of Kansas Cancer Center, KS, USA
| | - Samantha Eiffert
- Department of Population Health, University of Kansas Medical Center (KUMC), University of Kansas Cancer Center, Kansas City, KS, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Elizabeth M Wulff-Burchfield
- Divisions of Medical Oncology and Palliative Medicine, Department of Internal Medicine, KUMC, Kansas City, KS, USA
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine; Duke Cancer Institute, Durham, NC, USA
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19
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Check DK, Winger JG, Jones KA, Somers TJ. Predictors of Response to an Evidence-Based Behavioral Cancer Pain Management Intervention: An Exploratory Analysis From a Clinical Trial. J Pain Symptom Manage 2021; 62:391-399. [PMID: 33387606 DOI: 10.1016/j.jpainsymman.2020.12.020] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/03/2020] [Accepted: 12/24/2020] [Indexed: 10/22/2022]
Abstract
CONTEXT Interventions that teach patients cognitive and behavioral strategies for managing cancer pain have demonstrated effectiveness. Systematic reviews of such interventions call for research to inform their implementation in practice, including investigations into which patients are most likely to benefit. OBJECTIVES We aimed to identify predictors of response to an evidence-based behavioral intervention for cancer pain, pain coping skills training (PCST). METHODS We conducted an exploratory secondary analysis of a randomized noninferiority trial comparing in-person to videoconference-based PCST. Using modified Poisson regression, we estimated the adjusted associations of patient characteristics with clinically meaningful reductions (≥30%) in pain severity and pain interference. RESULTS Of the 178 patients who were randomized, 135 completed at least one follow-up assessment and were included in this analysis. Proportions of patients experiencing reductions in pain severity and pain interference were 34% and 46%, respectively. In multivariable analysis, education level was associated with a reduction in pain severity (adjusted relative risk, some college or technical school vs. college or higher: 0.49, 95% CI: 0.26-0.93). Patients with colorectal cancer were 61% more likely to experience a reduction in pain interference than patients with breast cancer (95% CI:1.21-2.34). Marital status was also statistically significantly associated with pain interference reduction, with married patients less likely to experience a reduction in pain interference (adjusted relative risk, married vs. not: 0.69, 95% CI: 0.49-0.98). CONCLUSION Our findings elucidate several subgroups of patients who may be especially likely to benefit from PCST, informing both targeted implementation efforts and opportunities to improve delivery for diverse patients.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke Cancer Institute, Durham, North Carolina, USA.
| | - Joseph G Winger
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tamara J Somers
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Duke Cancer Institute, Durham, North Carolina, USA
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20
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Davis MM, Gunn R, Kenzie E, Dickinson C, Conway C, Chau A, Michaels L, Brantley S, Check DK, Elder N. Integration of Improvement and Implementation Science in Practice-Based Research Networks: a Longitudinal, Comparative Case Study. J Gen Intern Med 2021; 36:1503-1513. [PMID: 33852140 PMCID: PMC8175491 DOI: 10.1007/s11606-021-06610-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 08/31/2019] [Accepted: 01/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Implementation science (IS) and quality improvement (QI) inhabit distinct areas of scholarly literature, but are often blended in practice. Because practice-based research networks (PBRNs) draw from both traditions, their experience could inform opportunities for strategic IS-QI alignment. OBJECTIVE To systematically examine IS, QI, and IS/QI projects conducted within a PBRN over time to identify similarities, differences, and synergies. DESIGN Longitudinal, comparative case study of projects conducted in the Oregon Rural Practice-based Research Network (ORPRN) from January 2007 to January 2019. APPROACH We reviewed documents and conducted staff interviews. We classified projects as IS, QI, IS/QI, or other using established criteria. We abstracted project details (e.g., objective, setting, theoretical framework) and used qualitative synthesis to compare projects by classification and to identify the contributions of IS and QI within the same project. KEY RESULTS Almost 30% (26/99) of ORPRN's projects included IS or QI elements; 54% (14/26) were classified as IS/QI. All 26 projects used an evidence-based intervention and shared many similarities in relation to objective and setting. Over half of the IS and IS/QI projects used randomized designs and theoretical frameworks, while no QI projects did. Projects displayed an upward trend in complexity over time. Project used a similar number of practice change strategies; however, projects classified as IS predominantly employed education/training while all IS/QI and most QI projects used practice facilitation. Projects including IS/QI elements demonstrated the following contributions: QI provides the mechanism by which the principles of IS are operationalized in order to support local practice change and IS in turn provides theories to inform implementation and evaluation to produce generalizable knowledge. CONCLUSIONS Our review of projects conducted over a 12-year period in one PBRN demonstrates key synergies for IS and QI. Strategic alignment of IS/QI within projects may help improve care quality and bridge the research-practice gap.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, 97239, USA.
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Rose Gunn
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Erin Kenzie
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Caitlin Dickinson
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Cullen Conway
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Alex Chau
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, 97239, USA
| | - LeAnn Michaels
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Steven Brantley
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Nancy Elder
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, 97239, USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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21
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Check DK, Bagett CD, Kim K, Roberts AW, Roberts MC, Robinson T, Oeffinger KC, Dinan MA. Predictors of Chronic Opioid Use: A Population-level Analysis of North Carolina Cancer Survivors Using Multi-Payer Claims. J Natl Cancer Inst 2021; 113:1581-1589. [PMID: 33881543 PMCID: PMC8562975 DOI: 10.1093/jnci/djab082] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/22/2021] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background No population-based studies have examined chronic opioid use among cancer survivors who are diverse with respect to diagnosis, age group, and insurance status. Methods We conducted a retrospective cohort study using North Carolina cancer registry data linked with claims from public and private insurance (2006-2016). We included adults with nonmetastatic cancer who had no prior chronic opioid use (n = 38 366). We used modified Poisson regression to assess the adjusted relative risk of chronic opioid use in survivorship (>90-day continuous supply of opioids in the 13-24 months following diagnosis) associated with patient characteristics. Results Only 3.0% of cancer survivors in our cohort used opioids chronically in survivorship. Predictors included younger age (adjusted risk ratio [aRR] 50-59 vs 60-69 = 1.23, 95% confidence interval [CI] = 1.05 to 1.43), baseline depression (aRR = 1.22, 95% CI = 1.06 to 1.41) or substance use (aRR = 1.43, 95% CI = 1.15 to 1.78) and Medicaid (aRR vs private = 1.93, 95% CI = 1.56 to 2.40). Survivors who used opioids intermittently (vs not at all) before diagnosis were twice as likely to use opioids chronically in survivorship (aRR = 2.62, 95% CI = 2.28 to 3.02). Those who used opioids chronically (vs intermittently or not at all) during active treatment had a nearly 17-fold increased likelihood of chronic use in survivorship (aRR = 16.65, 95% CI = 14.30 to 19.40). Conclusions Younger and low-income survivors, those with baseline depression or substance use, and those who require chronic opioid therapy during treatment are at increased risk for chronic opioid use in survivorship. Our findings point to opportunities to improve assessment of psychosocial histories and to engage patients in shared decision-making around long-term pain management, when chronic opioid therapy is required during treatment.
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Affiliation(s)
| | | | - KyungSu Kim
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Megan C Roberts
- University of North Carolina at Chapel Hill, Chapel Hill, NC
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22
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Price M, Howell EP, Dalton T, Ramirez L, Howell C, Williamson T, Fecci PE, Anders CK, Check DK, Kamal AH, Goodwin CR. Inpatient palliative care utilization for patients with brain metastases. Neurooncol Pract 2021; 8:441-450. [PMID: 34277022 DOI: 10.1093/nop/npab016] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty palliative care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients. Methods We examined the rates of PC consults in a cohort of 1303 patients with BM admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults. Results We analyzed 1303 patients admitted to the hospital with BM. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs 26.0% in Black/African American patients, P = .0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, P < .0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (P < .0001). Conclusions In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service, and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.
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Affiliation(s)
- Meghan Price
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth P Howell
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Tara Dalton
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ramirez
- Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, North Carolina, USA
| | - Claire Howell
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Theresa Williamson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Carey K Anders
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Devon K Check
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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23
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Shah A, Polascik TJ, George DJ, Anderson J, Hyslop T, Ellis AM, Armstrong AJ, Ferrandino M, Preminger GM, Gupta RT, Lee WR, Barrett NJ, Ragsdale J, Mills C, Check DK, Aminsharifi A, Schulman A, Sze C, Tsivian E, Tay KJ, Patierno S, Oeffinger KC, Shah K. Implementation and Impact of a Risk-Stratified Prostate Cancer Screening Algorithm as a Clinical Decision Support Tool in a Primary Care Network. J Gen Intern Med 2021; 36:92-99. [PMID: 32875501 PMCID: PMC7858708 DOI: 10.1007/s11606-020-06124-2] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/07/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Implementation methods of risk-stratified cancer screening guidance throughout a health care system remains understudied. OBJECTIVE Conduct a preliminary analysis of the implementation of a risk-stratified prostate cancer screening algorithm in a single health care system. DESIGN Comparison of men seen pre-implementation (2/1/2016-2/1/2017) vs. post-implementation (2/2/2017-2/21/2018). PARTICIPANTS Men, aged 40-75 years, without a history of prostate cancer, who were seen by a primary care provider. INTERVENTIONS The algorithm was integrated into two components in the electronic health record (EHR): in Health Maintenance as a personalized screening reminder and in tailored messages to providers that accompanied prostate-specific antigen (PSA) results. MAIN MEASURES Primary outcomes: percent of men who met screening algorithm criteria; percent of men with a PSA result. Logistic repeated measures mixed models were used to test for differences in the proportion of individuals that met screening criteria in the pre- and post-implementation periods with age, race, family history, and PSA level included as covariates. KEY RESULTS During the pre- and post-implementation periods, 49,053 and 49,980 men, respectively, were seen across 26 clinics (20.6% African American). The proportion of men who met screening algorithm criteria increased from 49.3% (pre-implementation) to 68.0% (post-implementation) (p < 0.001); this increase was observed across all races, age groups, and primary care clinics. Importantly, the percent of men who had a PSA did not change: 55.3% pre-implementation, 55.0% post-implementation. The adjusted odds of meeting algorithm-based screening was 6.5-times higher in the post-implementation period than in the pre-implementation period (95% confidence interval, 5.97 to 7.05). CONCLUSIONS In this preliminary analysis, following implementation of an EHR-based algorithm, we observed a rapid change in practice with an increase in screening in higher-risk groups balanced with a decrease in screening in low-risk groups. Future efforts will evaluate costs and downstream outcomes of this strategy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ariel Schulman
- Duke University, Durham, NC, USA.,Maimonides Medical Center, New York, NY, USA
| | - Christina Sze
- Duke University, Durham, NC, USA.,Weill Cornell Medical College, New York, NY, USA
| | | | - Kae Jack Tay
- Duke University, Durham, NC, USA.,SingHealth, Duke-NUS, Singapore, Singapore
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24
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Check DK, Zullig LL, Davis MM, Davies L, Chambers D, Fleisher L, Kaplan SJ, Proctor E, Ramanadhan S, Schroeck FR, Stover AM, Koczwara B. Improvement Science and Implementation Science in Cancer Care: Identifying Areas of Synergy and Opportunities for Further Integration. J Gen Intern Med 2021; 36:186-195. [PMID: 32869193 PMCID: PMC7859137 DOI: 10.1007/s11606-020-06138-w] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 08/11/2020] [Indexed: 12/30/2022]
Abstract
Efforts to improve cancer care primarily come from two fields: improvement science and implementation science. The two fields have developed independently, yet they have potential for synergy. Leveraging that synergy to enhance alignment could both reduce duplication and, more importantly, enhance the potential of both fields to improve care. To better understand potential for alignment, we examined 20 highly cited cancer-related improvement science and implementation science studies published in the past 5 years, characterizing and comparing their objectives, methods, and approaches to practice change. We categorized studies as improvement science or implementation science based on authors' descriptions when possible; otherwise, we categorized studies as improvement science if they evaluated efforts to improve the quality, value, or safety of care, or implementation science if they evaluated efforts to promote the implementation of evidence-based interventions into practice. All implementation studies (10/10) and most improvement science studies (6/10) sought to improve uptake of evidence-based interventions. Improvement science and implementation science studies employed similar approaches to change practice. For example, training was employed in 8/10 implementation science studies and 4/10 improvement science studies. However, improvement science and implementation science studies used different terminology to describe similar concepts and emphasized different methodological aspects in reporting. Only 4/20 studies (2 from each category) described using a formal theory or conceptual framework to guide program development. Most studies were multi-site (10/10 implementation science and 6/10 improvement science) and a minority (2 from each category) used a randomized design. Based on our review, cancer-related improvement science and implementation science studies use different terminology and emphasize different methodological aspects in reporting but share similarities in purpose, scope, and methods, and are at similar levels of scientific development. The fields are well-positioned for alignment. We propose that next steps include harmonizing language and cross-fertilizing methods of program development and evaluation.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences and Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.
| | - Leah L Zullig
- Department of Population Health Sciences and Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Melinda M Davis
- Oregon Rural Practice-based Research Network and Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR, USA
| | - Louise Davies
- The VA Outcomes Group, White River Junction VA Medical Center, Hartford, VT, USA.,The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH, USA.,Department of Surgery - Otolaryngology Head & Neck Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - David Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | | | - Samantha J Kaplan
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, USA
| | - Enola Proctor
- The Brown School at Washington University in St. Louis, St. Louis, MO, USA
| | - Shoba Ramanadhan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Florian R Schroeck
- The VA Outcomes Group, White River Junction VA Medical Center, Hartford, VT, USA.,The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH, USA.,Section of Urology and Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, PA, USA
| | - Angela M Stover
- Department of Health Policy and Management, Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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25
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Check DK, Winn AN, Fergestrom N, Reeder-Hayes KE, Neuner JM, Roberts AW. Response to Strassels and Durham. J Natl Cancer Inst 2020; 112:1280. [DOI: 10.1093/jnci/djaa146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke Cancer Institute, Durham, NC, USA
| | - Aaron N Winn
- Department of Clinical Sciences, School of Pharmacy, Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Nicole Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Katherine E Reeder-Hayes
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill (UNC-CH) School of Medicine, UNC-CH Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Joan M Neuner
- Department of Medicine, Division of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Andrew W Roberts
- Department of Population Health and Department of Anesthesiology, University of Kansas Medical Center (KUMC), Kansas City, KS, USA
- KU Cancer Center, KUMC, Kansas City, KS, USA
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Abstract
IMPORTANCE National efforts to improve safe opioid prescribing focus on preventing misuse, overdose, and opioid use disorder. This approach overlooks opportunities to better prevent other serious opioid-related harms in complex populations, such as older adult survivors of cancer. Little is known about the rates and risk factors for comprehensive opioid-related harms in this population. OBJECTIVE To determine rates of multiple opioid-related adverse drug events among older adults who survived breast cancer and estimate the risk of these events associated with opioid use in the year after completing cancer treatment. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used 2007 to 2016 Surveillance, Epidemiology and End Results-Medicare data from fee-for-service Medicare beneficiaries with first cancer diagnosis of stage 0 to III breast cancer at age 66 to 90 years from January 1, 2008, through December 31, 2015, who completed active breast cancer treatment. Data were analyzed from October 31, 2019, to June 10, 2020. EXPOSURES Repeated daily measure indicating possession of any prescription opioid supply in Medicare Part D prescription claims. MAIN OUTCOMES AND MEASURES Adjusted risk ratios (aRRs), estimated using modified Poisson generalized estimating equation models, for adverse drug events related to substance misuse (ie, diagnosed opioid abuse, dependence, or poisoning), other adverse drug events associated with opioid use (ie, gastrointestinal events, infections, falls and fractures, or cardiovascular events), and all-cause hospitalization associated with opioid supply the prior day, controlling for patient characteristics. RESULTS Among 38 310 women included in the study (mean [SD] age, 74.3 [6.3] years), there were 0.010 (95% CI, 0.008-0.011) adverse drug events related to substance misuse per 1000 person-days, 0.237 (95% CI, 0.229-0.245) other adverse drug events associated with opioid use per 1000 person-days, and 0.675 (95% CI, 0.662-0.689) all-cause hospitalizations per 1000 person-days. Opioid use was associated with increased risk of adverse drug events related to substance misuse (aRR, 14.62; 95% CI, 9.69-22.05; P < .001), other adverse drug events related to opioid use (aRR, 2.50; 95% CI, 2.11-2.96; P < .001), and all-cause hospitalization (aRR, 2.77; 95% CI, 2.55-3.02; P < .001). In a dose-response effect, individuals with high daily opioid doses had consistently higher risks of all study outcomes compared with individuals who had low opioid doses. Compared with days with no opioid exposure, the risk of any adverse drug event related to substance misuse was 3.4-fold higher for individuals with a current opioid supply ≥50 mg morphine equivalent dose per day (aRR, 3.40; 95% CI, 2.47-4.68; P < .001), while the risk was 2.3-fold higher for individuals with 1 to 49 mg morphine equivalent dose per day (aRR, 2.29; 95% CI, 1.89-2.77; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that among older adults who survived breast cancer, continued prescription opioid use in the year after completing active cancer treatment was associated with an immediate increased risk of a broad range of serious adverse drug events related to substance misuse and other adverse drug events associated with opioid use. Clinicians should consider the comprehensive risks of managing cancer pain with long-term opioid therapy.
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Affiliation(s)
- Aaron N. Winn
- School of Pharmacy, Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee
| | - Devon K. Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Amy Farkas
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Nicole M. Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Joan M. Neuner
- Division of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Andrew W. Roberts
- Department of Population Health, University of Kansas Medical Center, Kansas City
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City
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Kamal AH, Check DK, Bull J, Wolf S, Troy J, Samsa G, Nicolla JM, Harker M, Taylor DH. Associations of Patient Characteristics and Care Setting with Complexity of Specialty Palliative Care Visits. J Palliat Med 2020; 24:83-90. [PMID: 32634037 DOI: 10.1089/jpm.2020.0149] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Information routinely collected during a palliative care consultation request may help predict the level of complexity of that patient encounter. Objectives: We examined whether patient and consultation characteristics, as captured in consultation requests, are associated with the number of unmet palliative care needs that emerge during consultation, as an indicator of complexity. Design: We performed a retrospective cohort analysis of palliative care consultations. Setting: We analyzed quality-of-care data from specialty palliative care consultations contained in the Quality Data Collection Tool of the Global Palliative Care Quality Alliance from 2012 to 2017. Measurements: Using 13 point-of-care assessments of quality of life, symptoms, advance care planning, and prognosis, we created a complexity score ranging from 0 (not complex) to 13 (highest complexity). Using multivariable linear regression, we examined the relationships of consultation setting and patient characteristics with complexity score. Results: Patients in our cohort (N = 3121) had an average complexity score of 6.7 (standard deviation = 3.7). Female gender, nonwhite race, and neurological (e.g., dementia) and noncancer primary diagnosis were associated with increased complexity score. The hospital intensive care unit, compared with the general floor, was associated with higher complexity scores. In contrast, outpatient and residence, compared with the general floor, were associated with lower complexity scores. Conclusion: Patient, disease, and care setting factors known at the time of specialty palliative care consultation request are associated with level of complexity, and they may inform teams about the right service provisions, including time and expertise, required to meet patient needs.
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Affiliation(s)
- Arif H Kamal
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Duke Fuqua School of Business, Durham, North Carolina, USA
| | - Devon K Check
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke School of Medicine, Durham, North Carolina, USA
| | - Janet Bull
- Four Seasons, Hendersonville, North Carolina, USA
| | - Steven Wolf
- Department of Biostatistics, Duke School of Medicine, Durham, North Carolina, USA
| | - Jesse Troy
- Department of Pediatrics, Duke School of Medicine, Durham, North Carolina, USA
| | - Greg Samsa
- Department of Biostatistics, Duke School of Medicine, Durham, North Carolina, USA
| | - Jonathan M Nicolla
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Matthew Harker
- Duke Clinical Research Institute, Duke Margolis Center for Health Policy, Durham, North Carolina, USA
| | - Donald H Taylor
- Duke Clinical Research Institute, Duke Margolis Center for Health Policy, Durham, North Carolina, USA.,Department of Family Medicine and Community Health, Duke Sanford School of Public Policy, Durham, North Carolina, USA
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Check DK, Winn AN, Fergestrom N, Reeder-Hayes KE, Neuner JM, Roberts AW. Concurrent Opioid and Benzodiazepine Prescriptions Among Older Women Diagnosed With Breast Cancer. J Natl Cancer Inst 2020; 112:765-768. [PMID: 31605134 PMCID: PMC7357325 DOI: 10.1093/jnci/djz201] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/18/2019] [Accepted: 10/02/2019] [Indexed: 11/13/2022] Open
Abstract
Guidelines recommend using caution in co-prescribing opioids with benzodiazepines, yet, in practice, the extent of concurrent prescribing is poorly understood. Notably, no population-based studies, to our knowledge, have investigated concurrent prescribing among patients with cancer. We conducted a retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) database linked with Medicare claims (2012-2016) for women diagnosed with breast cancer. We used modified Poisson regression to examine predictors of any concurrent prescriptions in the year post-diagnosis and Poisson regression to examine predictors of the number of overlapping days. We found that 13.0% of the 19 267 women in our sample had concurrent prescriptions. Women who underwent more extensive treatment and those with previous use of opioids or benzodiazepines were at increased risk for concurrent prescriptions (adjusted risk ratio of previous benzodiazepine use vs no previous use = 15.05, 95% confidence interval = 13.19 to 17.19). Among women with concurrent prescriptions, overlap was most pronounced among low-income, rural, and Hispanic women (adjusted incidence rate ratio of Hispanic vs non-Hispanic white = 1.25, 95% confidence interval = 1.20 to 1.30). Our results highlight opportunities to reduce patients' unnecessary exposure to this combination.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke Cancer Institute, Durham, NC
| | - Aaron N Winn
- Department of Clinical Sciences, School of Pharmacy, Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI
| | - Nicole Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI
| | - Katherine E Reeder-Hayes
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill (UNC-CH) School of Medicine, UNC-CH Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Joan M Neuner
- Department of Medicine, Division of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI
| | - Andrew W Roberts
- Department of Population Health and Department of Anesthesiology, University of Kansas Medical Center (KUMC), KU Cancer Center, KUMC, Kansas City, KS
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Check DK, Kaufman BG, Kamal AH, Casarett DJ. Top Ten Tips Palliative Care Clinicians Should Know About Integrating Population Health Principles into Practice. J Palliat Med 2020; 23:568-572. [DOI: 10.1089/jpm.2020.0100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Devon K. Check
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | | | - Arif H. Kamal
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - David J. Casarett
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
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Lee C, Check DK, Manace Brenman L, Kushi LH, Epstein MM, Neslund-Dudas C, Pawloski PA, Achacoso N, Laurent C, Fehrenbacher L, Habel LA. Adjuvant endocrine therapy for breast cancer patients: impact of a health system outreach program to improve adherence. Breast Cancer Res Treat 2020; 180:219-226. [PMID: 31975315 DOI: 10.1007/s10549-020-05539-z] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 01/17/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Reports suggest that up to 50% of women with hormone receptor-positive (HR+) breast cancer (BC) do not complete the recommended 5 years of adjuvant endocrine therapy (AET). We examined the impact of an outreach program at Kaiser Permanente Northern California (KPNC) on adherence and discontinuation of AET among patients who initiated AET. METHODS We assembled a retrospective cohort of all KPNC patients diagnosed with HR+, stage I-III BC initiating AET before (n = 4287) and after (n = 3580) implementation of the outreach program. We compared adherence proportions and discontinuation rates before and after program implementation, both crude and adjusted for age, race/ethnicity, education, income, and stage. We conducted a pooled analysis of data from six Cancer Research Network (CRN) sites that had not implemented programs for improving AET adherence, using identical methods and time periods, to assess possible secular trends. RESULTS In the pre-outreach period, estimated adherence in years 1, 2, and 3 following AET initiation was 75.2%, 71.0%, and 67.3%; following the outreach program, the estimates were 79.4%, 75.6%, and 72.2% (p-values < .0001 for pairwise comparisons). Results were comparable after adjusting for clinical and demographic factors. The estimated cumulative incidence of discontinuation was 0.22 (0.21-0.24) and 0.18 (0.17-0.19) at 3 years for pre- and post-outreach groups (p-value < .0001). We found no evidence of an increase in adherence between the study periods at the CRN sites with no AET adherence program. CONCLUSION Adherence and discontinuation after AET initiation improved modestly following implementation of the outreach program.
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Affiliation(s)
- Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke Cancer Institute, Durham, NC, USA
| | - Leslie Manace Brenman
- Kaiser Permanente Northern California Breast Cancer Tracking System, Oakland, CA, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Mara M Epstein
- Meyers Primary Care Institute and the Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Christine Neslund-Dudas
- Department of Public Health Sciences, Henry Ford Health System and the Henry Ford Cancer Institute, Detroit, MI, USA
| | | | - Ninah Achacoso
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Cecile Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Louis Fehrenbacher
- Kaiser Permanente Northern California Medical Oncology, Oakland, CA, USA
| | - Laurel A Habel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Check DK, Hutcheson KA, Poisson LM, Pocobelli G, Sakoda LC, Zaveri J, Chang SS, Chubak J. Factors associated with employment discontinuation among older and working age survivors of oropharyngeal cancer. Head Neck 2019; 41:3948-3959. [PMID: 31490588 DOI: 10.1002/hed.25943] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 02/22/2019] [Revised: 07/11/2019] [Accepted: 08/15/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Oropharyngeal cancer survivors experience difficulty returning to work after treatment. To better understand specific barriers to returning to work, we investigated factors associated with discontinuing employment among older and working-age survivors. METHODS The sample included 675 oropharyngeal cancer survivors (median: 6 years posttreatment) diagnosed from 2000 to 2013 and employed at diagnosis. Relative risk models were constructed to examine the independent associations of demographic and health factors, and symptom experiences per the MD Anderson Symptom Inventory - Head and Neck Module (MDASI-HN) with posttreatment employment, overall and by age (<60 years vs ≥60 years at survey). RESULTS Symptom interference was not statistically significantly associated with posttreatment employment status among respondents ≥60 years. Among working-age respondents <60 years, symptom interference was strongly associated with posttreatment employment. CONCLUSIONS Efforts to assess and lessen symptom burden in working-age survivors should be evaluated as approaches to support regaining core functions needed for continued employment.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Laila M Poisson
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Gaia Pocobelli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Lori C Sakoda
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Jhankruti Zaveri
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Steven S Chang
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Check DK, Kwan ML, Chawla N, Dusetzina SB, Valice E, Ergas IJ, Roh JM, Kolevska T, Rosenstein DL, Kushi LH. Opportunities to Improve Detection and Treatment of Depression Among Patients With Breast Cancer Treated in an Integrated Delivery System. J Pain Symptom Manage 2019; 57:587-595. [PMID: 30508637 PMCID: PMC6386165 DOI: 10.1016/j.jpainsymman.2018.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/23/2018] [Accepted: 11/26/2018] [Indexed: 01/07/2023]
Abstract
CONTEXT Patients with cancer commonly experience depression. If not addressed, depression can lead to reduced quality of life and survival. OBJECTIVE Given the introduction of national initiatives to improve management of psychiatric symptoms among patients with cancer, we examined patterns of depression detection and treatment over time, and with respect to patient characteristics. METHODS This cross-sectional study linked data from the Pathways Study, a prospective cohort study of women diagnosed with breast cancer at Kaiser Permanente Northern California between 2005 and 2013, with data from Kaiser Permanente Northern California's electronic medical record. Pathways participants eligible for this analysis had no known prior depression but reported depressive symptoms at baseline. We used modified Poisson regression to assess the association of cancer diagnosis year and other patient characteristics with receipt of a documented clinician response to depressive symptoms (depression diagnosis, mental health referral, or antidepressant prescription). RESULTS Of the 725 women in our sample, 34% received a clinician response to depression. We observed no statistically significant association of breast cancer diagnosis year with clinician response. Characteristics associated with clinician response included Asian race (adjusted risk ratio, Asian vs. white: 0.44, 95% CI: 0.29-0.68) and depression severity (adjusted risk ratio, mild-moderate vs. severe depression: 1.45, 95% CI: 1.11-1.88). CONCLUSION Most patients in our sample did not receive a clinician response to their study-reported depression, and rates of response do not appear to have improved over time. Asian women, and those with less severe depression, appeared to be at increased risk of having unmet mental health care needs.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Neetu Chawla
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily Valice
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Isaac J Ergas
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Janise M Roh
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Tatjana Kolevska
- Kaiser Permanente Northern California Vallejo Medical Center, Vallejo, California, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Check DK, Albers KB, Uppal KM, Suga JM, Adams AS, Habel LA, Quesenberry CP, Sakoda LC. Examining the role of access to care: Racial/ethnic differences in receipt of resection for early-stage non-small cell lung cancer among integrated system members and non-members. Lung Cancer 2018; 125:51-56. [PMID: 30429038 PMCID: PMC6242353 DOI: 10.1016/j.lungcan.2018.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 01/25/2018] [Revised: 08/21/2018] [Accepted: 09/09/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To examine the role of uniform access to care in reducing racial/ethnic disparities in receipt of resection for early stage non-small cell lung cancer (NSCLC) by comparing integrated health system member patients to demographically similar non-member patients. MATERIALS AND METHODS Using data from the California Cancer Registry, we conducted a retrospective cohort study of patients from four racial/ethnic groups (White, Black, Hispanic, Asian/Pacific Islander), aged 21-80, with a first primary diagnosis of stage I or II NSCLC between 2004 and 2011, in counties served by Kaiser Permanente Northern California (KPNC) at diagnosis. Our cohort included 1565 KPNC member and 4221 non-member patients. To examine the relationship between race/ethnicity and receipt of surgery stratified by KPNC membership, we used modified Poisson regression to calculate risk ratios (RR) adjusted for patient demographic and tumor characteristics. RESULTS Black patients were least likely to receive surgery regardless of access to integrated care (64-65% in both groups). The magnitude of the black-white difference in the likelihood of surgery receipt was similar for members (RR: 0.82, 95% CI: 0.73-0.93) and non-members (RR: 0.86, 95% CI: 0.80-0.94). Among members, roughly equal proportions of Hispanic and White patients received surgery; however, among non-members, Hispanic patients were less likely to receive surgery (non-members, RR: 0.93, 95% CI: 0.86-1.00; members, RR: 0.98, 95% CI: 0.89-1.08). CONCLUSION Disparities in surgical treatment for NSCLC were not reduced through integrated health system membership, suggesting that factors other than access to care (e.g., patient-provider communication) may underlie disparities. Future research should focus on identifying such modifiable factors.
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Affiliation(s)
- Devon K Check
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Kathleen B Albers
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Kanti M Uppal
- Vacaville Medical Center, Kaiser Permanente Northern California, 1 Quality Drive, Vacaville, CA, 95688, USA.
| | - Jennifer Marie Suga
- Vallejo Medical Center, Kaiser Permanente Northern California, 975 Sereno Drive, Vallejo, CA, 94589, USA.
| | - Alyce S Adams
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Laurel A Habel
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Charles P Quesenberry
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Lori C Sakoda
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
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Check DK, Aaronson DS, Nielsen ME, Lee VS, Ergas IJ, Roh JM, Kushi LH, Tang L, Kwan ML. Perioperative Intravesical Chemotherapy for Patients WithNon-Muscle-invasive Bladder Cancer: Understanding the Extent of and Sources of Variation in Guideline-recommended Use. Urology 2018; 124:107-112. [PMID: 30359712 DOI: 10.1016/j.urology.2018.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 06/02/2018] [Revised: 09/07/2018] [Accepted: 10/04/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine intravesical chemotherapy (IVC) use according to non-muscle-invasive bladder cancer patient disease risk, and the contributions of multilevel factors to variation in proficient use among patients with low-intermediate disease. METHODS This study included 988 patients diagnosed with non-muscle-invasive bladder cancer in an integrated health system in Northern California from 2015-2017. We calculated IVC receipt by disease risk, and among patients with low-intermediate risk disease, assessed the relationship between multilevel factors and IVC receipt using a logistic regression model with random intercepts for provider and service area, and patient-, provider-, and service area-level fixed effects. We further assessed the association of provider- and service area-level factors with IVC use by examining intraclass correlation coefficients. RESULTS Similar proportions of low-intermediate (36%) and high-risk (34%) patients received IVC. In the multivariate analysis, including low-intermediate risk patients, service area volume was strongly and statistically significantly associated with IVC use (adjusted odds ratio, high- vs low-volume: 0.08, 95% Confidence Interval: 0.01-0.58). Provider- and service area-level intraclass correlation coefficients were large, (38%, P = .0009 and 39% P = .03, respectively) indicating that much of the variance in IVC use was explained by factors at these levels. CONCLUSION Our findings highlight opportunities to improve proficient use of IVC. Future research should assess provider- and practice-level barriers to IVC use among low-intermediate risk patients.
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Affiliation(s)
- Devon K Check
- Kaiser Permanente Northern California Division of Research, Oakland, CA.
| | - David S Aaronson
- Department of Urology, Kaiser Permanente Northern California Oakland Medical Center, Oakland, CA
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Valerie S Lee
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Isaac J Ergas
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Janise M Roh
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Lawrence H Kushi
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Li Tang
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Institute, Buffalo, NY
| | - Marilyn L Kwan
- Kaiser Permanente Northern California Division of Research, Oakland, CA
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Pinheiro LC, Check DK, Rosenstein D, Reeder-Hayes KE, Dusetzina S. Examining potential gaps in supportive medication use for US and foreign-born Hispanic women with breast cancer. Support Care Cancer 2018; 27:1639-1646. [DOI: 10.1007/s00520-018-4406-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 08/03/2018] [Indexed: 02/02/2023]
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Check DK, Chawla N, Kwan ML, Pinheiro L, Roh JM, Ergas IJ, Stewart AL, Kolevska T, Ambrosone C, Kushi LH. Understanding racial/ethnic differences in breast cancer-related physical well-being: the role of patient-provider interactions. Breast Cancer Res Treat 2018; 170:593-603. [PMID: 29623576 PMCID: PMC6528788 DOI: 10.1007/s10549-018-4776-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 03/27/2018] [Accepted: 03/30/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE Racial/ethnic differences in cancer symptom burden are well documented, but limited research has evaluated modifiable factors underlying these differences. Our objective was to examine the role of patient-provider interactions to help explain the relationship between race/ethnicity and cancer-specific physical well-being (PWB) among women with breast cancer. METHODS The Pathways Study is a prospective cohort study of 4505 women diagnosed with breast cancer at Kaiser Permanente Northern California between 2006 and 2013. Our analysis included white, black, Hispanic, and Asian participants who completed baseline assessments of PWB, measured using the Functional Assessment of Cancer Therapy for Breast Cancer, and patient-provider interactions, measured by the Interpersonal Processes of Care Survey (IPC) (N = 4002). Using step-wise linear regression, we examined associations of race/ethnicity with PWB, and changes in associations when IPC domains were added. RESULTS We observed racial/ethnic differences in PWB, with minorities reporting lower scores than whites (beta, black: - 1.79; beta, Hispanic: - 1.92; beta, Asian: - 1.68; p < 0.0001 for all comparisons). With the addition of health and demographic covariates to the model, associations between race/ethnicity and PWB score became attenuated for blacks and Asians (beta: - 0.63, p = 0.06; beta: - 0.68, p = 0.02, respectively) and, to a lesser extent, for Hispanic women (beta: - 1.06, p = 0.0003). Adjusting for IPC domains did not affect Hispanic-white differences (beta: - 1.08, p = 0.0002), and slightly attenuated black-white differences (beta: - 0.51, p = 0.14). Asian-white differences narrowed substantially (beta: - 0.31, p = 0.28). CONCLUSIONS IPC domains, including those capturing perceived discrimination, respect, and clarity of communication, appeared to partly explain PWB differences for black and Asian women. Results highlight opportunities to improve providers' interactions with minority patients, and communication with minority patients about their supportive care needs.
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Affiliation(s)
- Devon K Check
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Neetu Chawla
- Veterans Affairs Greater Los Angeles Healthcare System, 16111 Plummer Street, Building 25, Room B111, North Hills, CA, 91343, USA
| | - Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Laura Pinheiro
- Division of General Internal Medicine, Weill Department of Medicine, 525 East 68th Street, F-2011, New York, NY, 10065, USA
| | - Janise M Roh
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Isaac J Ergas
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Anita L Stewart
- Institute for Health and Aging, University of California San Francisco, 3333 California St. Suite 340, San Francisco, CA, 94118-0646, USA
| | - Tatjana Kolevska
- Vallejo Medical Center, Kaiser Permanente Northern California, 975 Sereno Drive, Vallejo, CA, 94589, USA
| | - Christine Ambrosone
- Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
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Affiliation(s)
- Devon K Check
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Ethan M Basch
- Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill
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Abstract
BACKGROUND Patients with advanced cancer who have dependent children are an important population with a life-limiting illness and high levels of psychological distress. Few studies have addressed the experience of being a parent with advanced cancer and their potential palliative needs. AIM To describe the experience of living with advanced cancer as a parent, including illness experience, parental concerns, and treatment decision making and to explore whether these experiences differ by their functional status. DESIGN We conducted a cross-sectional, qualitative study using in-depth, semi-structured interviews. Data were analyzed using thematic content analysis. SETTING AND PARTICIPANTS A total of 42 participants with metastatic cancer and with at least one child under the age of 18 years were recruited from a comprehensive cancer center. 25 participants were rated as having high functional status (the Eastern Cooperative Oncology Group (ECOG) Performance Status Scale = 0-1) and 17 with low functional status (ECOG=2-4). RESULTS We identified four themes regarding the experience of being a parent with advanced cancer: (1) parental concerns about the impact of their illness and death on their children, (2) "missing out" and losses of parental role and responsibilities, (3) maintaining parental responsibilities despite life-limiting illness, and (4) parental identity influencing decision making about treatment. Parental functional status influenced not only physical responsibilities but also intensified parenting psychological concerns. CONCLUSION Parents with metastatic cancer may have unique palliative care needs as they experience parenting concerns while managing the psychological and physical demands of advanced cancer.
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Affiliation(s)
- Eliza M Park
- 1 Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Devon K Check
- 2 Division of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mi-Kyung Song
- 3 Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Katherine E Reeder-Hayes
- 4 Division of Hematology-Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura C Hanson
- 5 Palliative Care Program, Division of Geriatrics, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin M Yopp
- 1 Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- 1 Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,6 Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Deborah K Mayer
- 7 School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Check DK, Park EM, Reeder-Hayes KE, Mayer DK, Deal AM, Yopp JM, Rosenstein DL, Hanson LC. Concerns underlying treatment preferences of advanced cancer patients with children. Psychooncology 2016; 26:1491-1497. [PMID: 27228327 DOI: 10.1002/pon.4164] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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: 09/01/2015] [Revised: 03/10/2016] [Accepted: 04/27/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Decision-making about advanced cancer treatment is complex and may be influenced by patients' family context, including the presence of children. We explored how parental values and concerns motivate patients' preferences about aggressiveness of advanced cancer treatment as well as preferences for palliative care and hospice services. METHODS We conducted semi-structured interviews with 42 patients with advanced cancer who had at least one child under 18 years. We created and applied thematic codes. Descriptive analyses were used to report the number of participants who mentioned each code. RESULTS The majority of participants (29/42) reported that having children influenced their preferences for advanced cancer care. For most parents, extending life to maximize the time they had left to parent their children was important in guiding treatment preferences. Others prioritized preserving their physical condition and parental functioning and remaining physically close to their children. Many parents discussed life extension and parental functioning preservation as competing priorities. Most of the sample expressed interest in palliative care services and hospice, but responses by several participants reflected concerns about dying at home and lack of clarity about the role of early palliative care. CONCLUSIONS Parents in our sample expressed that maximizing time with their children and preserving parental functioning were important concerns underlying their preferences for advanced cancer care. Future research should assess the palliative and end-of-life care needs and preferences of parents with advanced cancer, which may differ from those of non-parents. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Devon K Check
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, NC, USA
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Katherine E Reeder-Hayes
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Deborah K Mayer
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Allison M Deal
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Justin M Yopp
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA.,Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine and Palliative Care Program, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
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Check DK, Samuel CA, Rosenstein DL, Dusetzina SB. Investigation of Racial Disparities in Early Supportive Medication Use and End-of-Life Care Among Medicare Beneficiaries With Stage IV Breast Cancer. J Clin Oncol 2016; 34:2265-70. [PMID: 27161968 DOI: 10.1200/jco.2015.64.8162] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [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 Early supportive care may improve quality of life and end-of-life care among patients with cancer. We assessed racial disparities in early use of medications for common cancer symptoms (depression, anxiety, insomnia) and whether these potential disparities modify end-of-life care. METHODS We used 2007 to 2012 SEER-Medicare data to evaluate use of supportive medications (opioid pain medications and nonopioid psychotropics, including antidepressants/anxiolytics and sleep aids) in the 90 days postdiagnosis among black and white women with stage IV breast cancer who died between 2007 and 2012. We used modified Poisson regression to assess the relationship between race and supportive treatment use and end-of-life care (hospice, intensive care unit, more than one emergency department visit or hospitalization 30 days before death, in-hospital death). RESULTS The study included 752 white and 131 black women. We observed disparities in nonopioid psychotropic use between black and white women (adjusted risk ratio [aRR], 0.51; 95% CI, 0.35 to 0.74) but not in opioid pain medication use. There were also disparities in hospice use (aRR, 0.86; 95% CI, 0.74 to 0.99), intensive care unit admission or more than one emergency department visit or hospitalization 30 days before death (aRR, 1.28; 95% CI, 1.01 to 1.63), and risk of dying in the hospital (aRR, 1.59; 95% CI, 1.22 to 2.09). Supportive medication use did not attenuate end-of-life care disparities. CONCLUSION We observed racial disparities in early supportive medication use among patients with stage IV breast cancer. Although they did not clearly attenuate end-of-life care disparities, medication use disparities may be of concern if they point to disparities in adequacy of symptom management given the potential implications for quality of life.
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Affiliation(s)
- Devon K Check
- All authors: University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Cleo A Samuel
- All authors: University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Stacie B Dusetzina
- All authors: University of North Carolina at Chapel Hill, Chapel Hill, NC
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Check DK, Rosenstein DL, Dusetzina SB. Early supportive medication use and end-of-life care among Medicare beneficiaries with advanced breast cancer. Support Care Cancer 2016; 24:3463-72. [PMID: 26994634 DOI: 10.1007/s00520-016-3174-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 09/10/2015] [Accepted: 03/11/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE A randomized controlled trial of cancer patients has linked early supportive care with improved hospice use and less-aggressive end-of-life care. In practice, the early use of supportive interventions and potential impact on end-of-life care are poorly understood. We sought to describe early use of medications to treat common breast cancer symptoms (pain, insomnia, anxiety, and depression) and to assess the relationship between early use of these treatments and end-of-life care. METHODS Secondary analysis of 2006-2012 SEER-Medicare data was performed. Women included had stage IV breast cancer and died within the observation period. We used modified Poisson regression to assess the relationship between supportive medication use in the 90 days post-diagnosis and several end-of-life care measures (hospice use, in-hospital death, chemotherapy receipt within 14 days of death, ICU admission, or >1 hospitalization or emergency department/ED visit 30 days before death). RESULTS Among the 947 women included, 68 % of women used at least one supportive medication in the 90 days following their diagnosis: 60.3 % used opioid pain medications and 28.3 % received non-opioid psychotropic medications. Early use of any supportive medications was not associated with end-of-life care. Similarly, we found no differences in end-of-life care between opioid pain medication users and non-users. However, we found that non-opioid psychotropic medication users were less likely to receive chemotherapy in the last 14 days of life (aRR 0.33, 95 % CI 0.12-0.88). CONCLUSIONS Non-opioid psychotropic use was associated with some aspects of end-of-life care. Future research should consider alternative measures of palliative and supportive care use using administrative data sources.
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Affiliation(s)
- Devon K Check
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Lineberger Comprehensive Cancer Center, 101 Manning Dr, Chapel Hill, NC, 27514, USA
| | - Stacie B Dusetzina
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,UNC Lineberger Comprehensive Cancer Center, 101 Manning Dr, Chapel Hill, NC, 27514, USA. .,Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Kerr Hall, Room 2203, Chapel Hill, NC, 27599, USA.
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Check DK, Reeder-Hayes KE, Basch EM, Zullig LL, Weinberger M, Dusetzina SB. Investigating racial disparities in use of NK1 receptor antagonists to prevent chemotherapy-induced nausea and vomiting among women with breast cancer. Breast Cancer Res Treat 2016; 156:351-9. [PMID: 26968396 DOI: 10.1007/s10549-016-3747-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 01/07/2016] [Accepted: 03/04/2016] [Indexed: 10/22/2022]
Abstract
Chemotherapy-induced nausea and vomiting (CINV) is a major concern for cancer patients and, if uncontrolled, can seriously compromise quality of life (QOL) and other treatment outcomes. Because of the expense of antiemetic medications used to prevent CINV (particularly oral medications filled through Medicare Part D), disparities in their use may exist. We used 2006-2012 SEER-Medicare data to evaluate the use of neurokinin-1 receptor antagonists (NK1s), a potent class of antiemetics, among black and white women initiating highly emetogenic chemotherapy for the treatment of early-stage breast cancer. We used modified Poisson regression to assess the relationship between race and (1) any NK1 use, (2) oral NK1 (aprepitant) use, and (3) intravenous NK1 (fosaprepitant) use. We report adjusted risk ratios (aRR) and 95 % confidence intervals (CI). The study included 1130 women. We observed racial disparities in use of any NK1 (aRR: 0.68, 95 % CI 0.51-0.91) and in use of oral aprepitant specifically (aRR: 0.54, 95 % CI 0.35-0.83). We did not observe disparities in intravenous fosaprepitant use. After controlling for variables related to socioeconomic status, disparities in NK1 and aprepitant use were reduced but not eliminated. We found racial disparities in women's use of oral NK1s for the prevention of CINV. These disparities may be partly explained by racial differences in socioeconomic status, which may translate into differential ability to afford the medication.
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Affiliation(s)
- Devon K Check
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, CB#7411, Chapel Hill, NC, 27599, USA.
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Hematology/Oncology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ethan M Basch
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, CB#7411, Chapel Hill, NC, 27599, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Hematology/Oncology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Leah L Zullig
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, CB#7411, Chapel Hill, NC, 27599, USA.,Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Stacie B Dusetzina
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, CB#7411, Chapel Hill, NC, 27599, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Park EM, Deal AM, Check DK, Hanson LC, Reeder-Hayes KE, Mayer DK, Yopp JM, Song MK, Muriel AC, Rosenstein DL. Parenting concerns, quality of life, and psychological distress in patients with advanced cancer. Psychooncology 2015; 25:942-8. [PMID: 26282575 DOI: 10.1002/pon.3935] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 05/08/2015] [Accepted: 07/15/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Parents with life-limiting illness anticipate the loss of their parental role and the long-term consequences of their illness on their children. The purpose of this study was to examine relationships between parenting concerns, quality of life (QOL), and symptoms of depression and anxiety in parents with advanced cancer who have dependent children. METHODS Sixty-three parents diagnosed with a Stage IV solid malignancy completed the Hospital Anxiety Depression Scale (HADS), Parenting Concerns Questionnaire (PCQ), and Functional Assessment of Cancer Therapy-General (FACT-G). The Medical Outcomes Study Social Support Survey (social support) and Eastern Cooperative Oncology Group (ECOG) performance status were assessed as potential covariates. We performed descriptive statistics and multivariable linear regression models for depression, anxiety, and QOL measures. RESULTS Mean PCQ score was 2.3 (SD 0.9), reflecting mild to moderate parenting concerns. Average depression and anxiety scores were 6.0 (SD 4.2) and 8.2 (SD 3.9), respectively. PCQ scores were associated with depressive symptoms (r = 0.46, p < 0.001), anxiety symptoms (r = 0.52, p < 0.0001), and QOL scores (r = -0.60, p < 0.001). The relationship of PCQ scores to anxiety symptoms (B = 1.5 p = 0.016) and QOL (B = -5.7, p = 0.02) remained significant after controlling for ECOG status, social support, and treatment status. CONCLUSIONS Parenting concerns are associated with anxiety and depressive symptoms and worse QOL in parents diagnosed with advanced cancer. Further studies that evaluate how parental status affects coping and psychological distress in advanced cancer are needed.Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Eliza M Park
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, United States
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Devon K Check
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, NC, United States
| | - Laura C Hanson
- Division of Geriatric Medicine and Palliative Care Program, Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Katherine E Reeder-Hayes
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Deborah K Mayer
- School of Nursing, University of North Carolina, Chapel Hill, NC, United States
| | - Justin M Yopp
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, United States
| | - Mi-Kyung Song
- School of Nursing, University of North Carolina, Chapel Hill, NC, United States
| | - Anna C Muriel
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, United States.,Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
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Birken SA, Ellis SD, Walker JS, DiMartino LD, Check DK, Gerstel AA, Mayer DK. Guidelines for the use of survivorship care plans: a systematic quality appraisal using the AGREE II instrument. Implement Sci 2015; 10:63. [PMID: 25935752 PMCID: PMC4425878 DOI: 10.1186/s13012-015-0254-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/22/2015] [Indexed: 11/28/2022] Open
Abstract
Background Survivorship care plans (SCPs) are written treatment summaries and follow-up care plans that are intended to facilitate communication and coordination of care among survivors, cancer care providers, and primary care providers. A growing number of guidelines for the use of SCPs exist, yet SCP use in the United States remains limited. Limited use of SCPs may be due to poor quality of these guidelines. The purpose of the study was to evaluate the quality of guidelines for SCP use, tools that are intended to promote evidence-based medicine. Methods We conducted a comprehensive search of the literature using MEDLINE/PubMed, EMBASE (Excerpta Medica Database), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) published through April 2014, in addition to grey literature sources and bibliographic and expert reviews. Guideline quality was assessed using the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation, 2nd edition), a tool developed by an international group of scientists to advance the quality of clinical practice guidelines. To promote consistency with extant studies using the AGREE II instrument and to clearly and unambiguously identify potentially useful guidelines for SCP use, we also summarized AGREE II scores by strongly recommending, recommending, or not recommending the guidelines that we evaluated. Results Of 128 documents screened, we included 16 guidelines for evaluation. We did not strongly recommend any of the 16 guidelines that we evaluated; we recommended 5 and we did not recommend 11. Overall, guidelines scored highest on clarity of presentation (i.e., guideline language, structure, and format): Guidelines were generally unambiguous in their recommendations that SCPs should be used. Guidelines scored lowest on applicability (i.e., barriers and facilitators to implementation, implementation strategies, and resource implications of applying the guideline): Few guidelines discussed facilitators and barriers to guideline application; advice and tools for implementing guidelines were vague; and none explicitly discussed resource implications of implementing the guidelines. Conclusions Guidelines often advocated survivorship care plan use without justification or suggestions for implementation. Improved guideline quality may promote survivorship care plan use. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0254-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, 135 Dauer Drive, Campus Box 7411, Chapel Hill, NC, 27599-7411, USA.
| | - Shellie D Ellis
- Department of Health Policy and Management, University of Kansas School of Medicine, Mail Stop 3044, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
| | - Jennifer S Walker
- Health Sciences Library, The University of North Carolina at Chapel Hill, 335 S. Columbia Street, Chapel Hill, NC, 27599-7585, USA.
| | - Lisa D DiMartino
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, 135 Dauer Drive, Campus Box 7411, Chapel Hill, NC, 27599-7411, USA.
| | - Devon K Check
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, 135 Dauer Drive, Campus Box 7411, Chapel Hill, NC, 27599-7411, USA.
| | - Adrian A Gerstel
- School of Nursing, University of North Carolina at Chapel Hill, 2800 Carrington Hall CB# 7460, Chapel Hill, NC, 27599, USA.
| | - Deborah K Mayer
- School of Nursing, University of North Carolina at Chapel Hill, 2800 Carrington Hall CB# 7460, Chapel Hill, NC, 27599, USA.
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Park EM, Check DK, Yopp JM, Deal AM, Edwards TP, Rosenstein DL. An exploratory study of end-of-life prognostic communication needs as reported by widowed fathers due to cancer. Psychooncology 2015; 24:1471-6. [PMID: 25655038 DOI: 10.1002/pon.3757] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 12/05/2014] [Accepted: 12/18/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Effective physician communication about prognosis is a critical aspect of quality care for families affected by terminal illness. This is particularly important for spousal caregivers of terminally ill parents of dependent children, who may have unique needs for communication about anticipated death. The objective of this study was to explore end-of-life prognostic communication experiences reported by bereaved fathers whose wives died from cancer. METHODS From October 2012 to November 2013 we surveyed widowed fathers whose wives died from cancer through an open-access educational website. The survey included the following open-ended questions regarding prognostic communication: 'What is the most important thing you would like us to know about whether/how your wife's doctors communicated with you about her anticipated death? What do you wish had been different, if anything?' We performed traditional content analysis of responses. Two researchers coded and categorized the data. RESULTS Two hundred forty-four men responded to the survey questions on prognostic communication. Major themes addressed by respondents were the importance of clear and honest communication and physician bedside manner. They also identified unmet information needs, including wanting to know prognosis sooner. Relevant sub-themes included death coming as a surprise, avoidance, and caregiver regret. CONCLUSIONS Surviving spouses due to cancer can provide important insights for health care providers about optimum prognostic communication at the end of life. Increased physician attention to the communication preferences of both patients and their partners may improve bereavement outcomes for family members.
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Affiliation(s)
- Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Devon K Check
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin M Yopp
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Teresa P Edwards
- H. W. Odum Institute for Research in Social Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Mayer DK, Birken SA, Check DK, Chen RC. Summing it up: an integrative review of studies of cancer survivorship care plans (2006-2013). Cancer 2014; 121:978-96. [PMID: 25252164 DOI: 10.1002/cncr.28884] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [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: 03/03/2014] [Revised: 04/14/2014] [Accepted: 04/29/2014] [Indexed: 11/06/2022]
Abstract
In 2006, the Institute of Medicine recommended that cancer survivors who are completing primary treatment receive a survivorship care plan (SCP) based on face validity. The state of scientific knowledge regarding the SCP is unclear. The authors conducted an integrative review of existing evidence regarding SCPs. The MEDLINE/PubMed database, the Excerpta Medica Database (EMBASE), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database were searched for relevant studies published between 2006 and 2013 using a combination of keywords: "survivors," "survivorship," "care plans," "care planning," "treatment summaries," and "cancer." Articles were included if they 1) reported results from an empirical study, 2) included cancer survivors who were diagnosed at age ≥ 18 years, 3) related to SCP, and 4) were published in English. In total, 781 records were retrieved; 77 were identified as duplicates, and 665 were abstracts or presentations that did not relate to SCPs for adults or were not empirical, which left 42 articles for inclusion in this review. Studies regarding SCP fell into 3 categories: 1) content (n=14), 2) dissemination and implementation (n=14), and 3) survivor and provider outcomes (n=14). SCPs have been endorsed and are associated with improved knowledge, but SCP use remains sporadic. Only 4 studies were randomized controlled trials (RCTs) that avoided many biases associated with observational studies. Other limitations included cross-sectional or pre-SCP-post-SCP ("pre-post") designs, limited generalizability caused by a lack of sample diversity, and a lack of systematic testing of data-collection tools. The quantity and quality of SCP research are limited. SCPs have been endorsed, but evidence of improved outcomes associated with SCP is limited. Future research that addresses the methodological concerns of extant studies is needed regarding SCP use, content, and outcomes.
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Affiliation(s)
- Deborah K Mayer
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina; University of North Carolina Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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Abstract
BACKGROUND Certificates of Confidentiality are intended to facilitate participation in critical public health research by protecting against forced disclosure of identifying data in legal proceedings, but little is known about the effect of Certificate descriptions in consent forms. METHODS To gain preliminary insights, we conducted qualitative interviews with 50 HIV-positive individuals in Durham, North Carolina to explore their subjective understanding of Certificate descriptions and whether their reactions differed based on receiving a standard versus simplified description. RESULTS Most interviewees were neither reassured nor alarmed by Certificate information, and most said it would not influence their willingness to participate or provide truthful information. However, compared with those receiving the simplified description, more who read the standard description said it raised new concerns, that their likelihood of participating would be lower, and that they might be less forthcoming. Most interviewees said they found the Certificate description clear, but standard-group participants often found particular words and phrases confusing, while simplified-group participants more often questioned the information's substance. CONCLUSIONS Valid informed consent requires comprehension and voluntariness. Our findings highlight the importance of developing consent descriptions of Certificates and other confidentiality protections that are simple and accurate. These qualitative results provide rich detail to inform a larger, quantitative study that would permit further rigorous comparisons.
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Affiliation(s)
- Laura M. Beskow
- Duke Institute for Genome Sciences & Policy, 240 North Building, Duke University, Campus Box 90141, Durham, NC 27708 USA, Tel: 919-668-2293, FAX: 919-668-0799
| | - Devon K. Check
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Check DK, Wolf LE, Dame LA, Beskow LM. Certificates of confidentiality and informed consent: perspectives of IRB chairs and institutional legal counsel. IRB 2014; 36:1-8. [PMID: 24649737 PMCID: PMC4076050] [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] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Devon K. Check
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Leslie E. Wolf
- Center for Law, Health & Society, Georgia State University College of Law, Atlanta, GA, USA
| | - Lauren A. Dame
- Institute for Genome Sciences and Policy, Duke University, Durham, NC USA
| | - Laura M. Beskow
- Institute for Genome Sciences and Policy, Duke University, Durham, NC USA
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Curtis LH, Mi X, Qualls LG, Check DK, Hammill BG, Hammill SC, Heidenreich PA, Masoudi FA, Setoguchi S, Hernandez AF, Fonarow GC. Transitional adherence and persistence in the use of aldosterone antagonist therapy in patients with heart failure. Am Heart J 2013; 165:979-986.e1. [PMID: 23708170 DOI: 10.1016/j.ahj.2013.03.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 03/14/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aldosterone antagonist therapy is recommended for selected patients with heart failure and reduced ejection fraction. Adherence to therapy in the transition from hospital to home is not well understood. METHODS We identified patients with heart failure and reduced ejection fraction who were ≥65 years old, eligible for aldosterone antagonist therapy, and discharged home from hospitals in the Get With the Guidelines-Heart Failure registry between January 1, 2005, and December 31, 2008. We used Medicare prescription drug event data to measure adherence. Main outcome measures were prescription at discharge, outpatient prescription claim within 90 days, discontinuation, and adherence as measured with the medication possession ratio. We used the cumulative incidence function to estimate rates of initiation and discontinuation. RESULTS Among 2,086 eligible patients, 561 (26.9%) were prescribed an aldosterone antagonist at discharge. Within 90 days, 78.6% of eligible patients with a discharge prescription filled a prescription for the therapy, compared with 13.0% of eligible patients without a discharge prescription (P < .001). The median medication possession ratio was 0.63 over 1 year of follow-up. Among 634 patients who filled a prescription within 90 days of discharge, 7.9% discontinued therapy within 1 year. CONCLUSION Most eligible patients were not prescribed aldosterone antagonist therapy at discharge from a heart failure hospitalization. Eligible patients without a discharge prescription seldom initiated therapy as outpatients. Most patients who were prescribed an aldosterone antagonist at discharge filled the prescription within 90 days and remained on therapy.
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Affiliation(s)
- Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC.
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Check DK, Weinfurt KP, Dombeck CB, Kramer JM, Flynn KE. Use of central institutional review boards for multicenter clinical trials in the United States: a review of the literature. Clin Trials 2013; 10:560-7. [PMID: 23666951 DOI: 10.1177/1740774513484393] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND To improve the efficiency of conducting multicenter clinical trials, the Food and Drug Administration, the Office of Human Research Protections, and the Department of Health and Human Services have expressed support for using a centralized institutional review board (IRB) process. However, research institutions differ in their willingness to defer to central IRBs. PURPOSE We aimed to review and describe peer-reviewed journal articles on the use of central IRBs for multicenter clinical trials in the United States in an effort to inform the policy discussion about central IRBs. METHODS We used a PubMed search and consulted IRB experts and the bibliographies of other reviews to identify relevant commentaries and empirical studies. RESULTS Our search identified 33 articles related to the use of central IRBs for multicenter trials in the United States. Of these, 22 were commentary pieces and 11 were empirical studies. LIMITATIONS Our review was restricted to journal articles about the use of central IRBs for multicenter clinical trials in the United States. CONCLUSIONS There is limited empirical work on the use of central IRBs for multicenter trials in the United States. Most published studies focused on problems in efficiency associated with redundant local reviews of multicenter studies and the potential benefits of a centralized system. Because the absence of studies on the use of central IRBs may be due to their infrequent use, additional work is needed to generate data on the use of central IRBs and to elucidate and address the concerns that research institutions have about deferring ethical review to a central IRB.
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Affiliation(s)
- Devon K Check
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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