Using Cognitive Testing to Develop Items for Surveying Asian American Cancer Patients and Their Caregivers as a Pathway to Culturally Competent Care

We report the results from cognitive interviews with Asian American patients and their caregivers. We interviewed seven caregivers and six patients who were all bilingual Asian Americans. The main goal of the cognitive interviews was to test a survey instrument developed for a study about perspectives of Asian American patients with advanced cancer who are facing decisions around end-of-life care. We were particularly interested to see whether items commonly used in White and Black populations are culturally meaningful and equivalent in Asian populations, primarily those of Chinese and Vietnamese ethnicity. Our exploration shows that understanding respondents' language proficiency, degree of acculturation, and cultural context of receiving, processing, and communicating information about medical care can help design questions that are appropriate for Asian American patients and caregivers, and therefore can help researchers obtain quality data about the care Asian American cancer patients receive.

Using qualitative methods to develop a contextually tailored instrument: Lessons learned

OBJECTIVE

To develop a population-specific instrument to inform hepatitis B virus (HBV) and human papilloma virus (HPV) prevention education and intervention based on data and evidence obtained from the targeted population of Khmer mothers reflecting their socio-cultural and health behaviors.

METHODS

The principles of community-based participatory research (CBPR) guided the development of a standardized survey interview. Four stages of development and testing of the survey instrument took place in order to inform the quantitative health survey used to collect data in stage five of the project. This article reports only on Stages 1-4.

RESULTS

This process created a new quantitative measure of HBV and HPV prevention behavior based on the revised Network Episode Model and informed by the targeted population. The CBPR method facilitated the application and translation of abstract theoretical ideas of HBV and HPV prevention behavior into culturally-relevant words and expressions of Cambodian Americans (CAs).

CONCLUSIONS

The design of an instrument development process that accounts for distinctive socio-cultural backgrounds of CA refugee/immigrant women provides a model for use in developing future health surveys that are intended to aid minority-serving health care professionals and researchers as well as targeted minority populations.

Making Cuts to Medicare: The Views of Patients, Physicians, and the Public

Purpose

Cancer-related expenditures are increasing health care costs. Determining how patients with cancer, oncologists, and the general public view Medicare spending and whether they would support cost-containment measures is important to identifying acceptable approaches to reducing health care expenditures.

Methods

Patients with cancer treated at an academic medical center, a random national sample of oncologists, and the general public were surveyed between July 2012 and March 2013 about causes of high health care costs and proposed cost-control measures.

Results

Three hundred twenty-six patients (response rate, 72%), 250 oncologists (response rate, 55%), and 891 members of the general public (response rate, 50%) completed surveys. The majority thought Medicare spending was a moderate or big problem (75.8% of patients; 97.2% of oncologists; 75.3% of the general public) and thought Medicare could spend less without causing harm (65.6% of patients; 74.0% of oncologists; 69.7% of the general public). There was broad consensus that drug and insurance companies' profits added to costs, although physicians, hospitals, and patients were also perceived as sharing responsibility. More than 75% of respondents supported enabling Medicare to refuse reimbursement for more expensive treatment if less costly, equally effective treatment was available. Respondents generally favored means testing Medicare cost sharing but, except for oncologists, resisted the idea of an independent oversight panel. All groups opposed annual ceilings on Medicare spending per patient.

Conclusion

The majority of respondents view Medicare costs as a substantial problem and that all players in the system, including providers, contribute to high costs. Most thought Medicare could spend less without causing harm. Overall, respondents strongly favored not paying for more expensive treatments when cheaper ones are equally effective.

High-risk alcohol use after weight loss surgery

BACKGROUND

Bariatric or weight loss surgery (WLS) may alter alcohol metabolism resulting in a higher prevalence of problem drinking postoperatively. Few studies distinguish those who report improvements in drinking from those who report worsening behavior after surgery. The objective of this study was to characterize high-risk alcohol use before and after WLS and according to surgery type.

METHODS

We interviewed patients before and annually after WLS. High-risk alcohol use as assessed via a modified version of the Alcohol Use Disorders Identification Test-Consumption.

RESULTS

Of 541 participants who underwent WLS, 375 (69% retention) completed the 1-year interview and 328 (63% retention) completed the 2-year interview. At 1 year, 13% reported high-risk drinking compared to 17% at baseline, P = .10; at year 2, 13% reported high-risk drinking compared to 15% at baseline, P = .39; 7% and 6% of patients, respectively, reported new high-risk drinking at 1- and 2-year follow-up. At both follow-up time points, more than half of those who reported high-risk drinking at baseline no longer did so. A larger proportion of gastric bypass patients (71%) reported amelioration in high-risk drinking than gastric banding (48%) at year 1, but this difference did not reach statistical significance (P = .07); the difference largely dissipated by year 2 (50% versus 57%) .

CONCLUSION

Although 7% of patients report new high-risk alcohol use 1 year after WLS, more than half who reported high-risk alcohol use before surgery discontinued high-risk drinking.

Sex, race, and consideration of bariatric surgery among primary care patients with moderate to severe obesity

BACKGROUND

Bariatric surgery is one of few obesity treatments to produce substantial weight loss but only a small proportion of medically-eligible patients, especially men and racial minorities, undergo bariatric surgery.

OBJECTIVE

To describe primary care patients' consideration of bariatric surgery, potential variation by sex and race, and factors that underlie any variation.

DESIGN, SETTING, AND PATIENTS

Telephone interview of 337 patients with a body mass index or BMI > 35 kg/m(2) seen at four diverse primary care practices in Greater-Boston.

MEASUREMENTS

Patients' consideration of bariatric surgery.

RESULTS

Of 325 patients who had heard of bariatric surgery, 34 % had seriously considered surgery. Men were less likely than women and African Americans were less likely than Caucasian patients to have considered surgery after adjustment for sociodemographics and BMI. Comorbid conditions did not explain sex and racial differences but racial differences dissipated after adjustment for quality of life (QOL), which tended to be higher among African American than Caucasian patients. Physician recommendation of bariatric surgery was independently associated with serious consideration for surgery [OR 4.95 (95 % CI 2.81-8.70)], but did not explain variation in consideration of surgery across sex and race. However, if recommended by their doctor, men were as willing and African American and Hispanic patients were more willing to consider bariatric surgery than their respective counterparts after adjustment. Nevertheless, only 20 % of patients reported being recommended bariatric surgery by their doctor and African Americans and men were less likely to receive this recommendation; racial differences in being recommended surgery were also largely explained by differences in QOL. High perceived risk to bariatric surgery was the most commonly cited barrier; financial concerns were uncommonly cited.

LIMITATIONS

Single geographic region; examined consideration and not who eventually proceeded with bariatric surgery.

CONCLUSION

African Americans and men were less likely to have considered bariatric surgery and were less likely to have been recommended surgery by their doctors. Differences in how obesity affects QOL appear to account for some of these variations. High perceived risk rather than financial barrier was the major deterrent for patients.

Expectations for weight loss and willingness to accept risk among patients seeking weight loss surgery

IMPORTANCE

Weight loss surgery (WLS) has been shown to produce long-term weight loss but is not risk free or universally effective. The weight loss expectations and willingness to undergo perioperative risk among patients seeking WLS remain unknown.

OBJECTIVES

To examine the expectations and motivations of WLS patients and the mortality risks they are willing to undertake and to explore the demographic characteristics, clinical factors, and patient perceptions associated with high weight loss expectations and willingness to assume high surgical risk.

DESIGN

We interviewed patients seeking WLS and conducted multivariable analyses to examine the characteristics associated with high weight loss expectations and the acceptance of mortality risks of 10% or higher.

SETTING

Two WLS centers in Boston.

PARTICIPANTS

Six hundred fifty-four patients.

MAIN OUTCOME MEASURES

Disappointment with a sustained weight loss of 20% and willingness to accept a mortality risk of 10% or higher with WLS.

RESULTS

On average, patients expected to lose as much as 38% of their weight after WLS and expressed disappointment if they did not lose at least 26%. Most patients (84.8%) accepted some risk of dying to undergo WLS, but only 57.5% were willing to undergo a hypothetical treatment that produced a 20% weight loss. The mean acceptable mortality risk to undergo WLS was 6.7%, but the median risk was only 0.1%; 19.5% of all patients were willing to accept a risk of at least 10%. Women were more likely than men to be disappointed with a 20% weight loss but were less likely to accept high mortality risk. After initial adjustment, white patients appeared more likely than African American patients to have high weight loss expectations and to be willing to accept high risk. Patients with lower quality-of-life scores and those who perceived needing to lose more than 10% and 20% of weight to achieve "any" health benefits were more likely to have unrealistic weight loss expectations. Low quality-of-life scores were also associated with willingness to accept high risk.

CONCLUSIONS AND RELEVANCE

Most patients seeking WLS have high weight loss expectations and believe they need to lose substantial weight to derive any health benefits. Educational efforts may be necessary to align expectations with clinical reality.

Patient, public, and oncologists’ attitudes toward rationing medical care

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Background: Lowering health care costs is critical. Patients with cancer (PT) and oncologists (MD) regularly make decisions regarding interventions with potentially marginal benefit but substantial expense. What are the attitudes of PT, the public (GP), and MD on ways to control costs? Methods: In 2012, surveys were completed by 326 adult PT (Response Rate (RR)=72%), a random sample of 891 U.S. adults (RR=50%) and 245 MD (RR=55%). Results: A majority thought Medicare spending was a big or moderate problem (76% PT; 75% GP; 97% MD) and that Medicare could spend less without causing harm (66% PT; 70% GP; 74% MD). Respondents attributed rising costs to multiple factors including drug companies charging too much (94% PT; 90% GP; 94% MD) and insurance company profits (88% PT; 88% GP; 83% MD). Many also thought physicians and hospitals provided unnecessary tests and treatments (RX) (69% PT; 81% GP; 70% MD). Regarding solutions, most supported refusing to pay for expensive care if an equally effective, less expensive alternative was available or if therapy did not improve survival or quality of life (QOL). Few respondents were willing to refuse payment for RX that extend life by 4 months. Conclusions: The majority of those sampled view Medicare costs as a substantial problem and pharmaceutical and insurance companies as significant contributors. The GP in particular believe physicians and hospitals add considerably to the cost problem. A majority favor not paying for more expensive RX when cheaper ones are equally effective or if RX do not improve survival or QOL. MD were accepting of an independent oversight panel however this was met with resistance by PT and the GP. Currently, Medicare and other payers do not consistently follow such practices. [Table: see text]

The co-occurrence of depression and substance abuse in late adolescence

This article examines the role of adolescent social relationships in fostering the occurrence and co-occurrence of depression and substance abuse, using two waves of data from a community sample of adolescents (N = 900). Multinomial logistic response models were estimated to identify the extent to which risk and protective features of youths' family and peer relations were differentially linked with depressive symptoms, substance abuse, and their co-occurrence. Taking a within-person, configurational approach to adolescent adaptation, contrasts involved four subgroups of adolescents: those high on both depressed mood and substance abuse, those who experience neither problem, those evidencing high levels of depressive symptoms only, and those high on substance abuse only. Risk for depressive symptoms was differentiated by its association with conflict and lack of support in the friendship domain. Substance abuse was associated with negative peer pressure, but these youth were otherwise little different from youths with no problems. Whereas co-occurrence of depression and substance use was associated with more difficulties in both the family and peer environments, the most distinctive risk was that of low family support. Discussion centers on the developmental antecedents of co-occurring problems and family relations during adolescence.

Sampling gay men: Random Digit Dialing versus sources in the Gay Community

OBJECTIVES

To assess the feasibility of obtaining a probability sample of gay/bisexual men using Random Digit Dialing (RDD), assess its validity, and describe differences between such a sample and a sample recruited from sources in the gay community.

METHODS

Two samples, one of men participating in an event at the Gay Community Center (N = 26) and one of randomly selected men (N = 52), were recruited by telephone in targeted New York City neighborhoods. A five-minute questionnaire for identifying gay/bisexual men was administered. Respondents who identified themselves as gay/bisexual were also asked about their gay identity and level of affiliation with the gay community.

RESULTS

The screen questionnaire had excellent sensitivity (.96) in identifying gay/bisexual men. RDD sampling identified a high percent of gay/bisexual-identified men (29%). Gay/bisexual men identified through the RDD technique were qualitatively different from gay/bisexual men contacted through the gay community: they were less affiliated with the gay community, had higher levels of internalized homophobia, and differed in the attitudes they endorsed.

CONCLUSIONS

To reduce bias imported by sampling highly affiliated respondents, RDD sampling techniques should, and can, be used in studies of gay/bisexual men.

Effects of a glucose polymer sports drink on blood glucose, insulin, and performance in subjects with diabetes

Regular exercise has long been recognized as a cornerstone of diabetes management along with diet and medication. The purpose of this study was to determine the effects of a glucose polymer sports drink (GPSD) on blood glucose and electrolyte levels in persons with type I or type II diabetes. Twenty-five subjects controlled with insulin were randomized in a double-blind, two-period, crossover design study. Blood glucose and electrolyte levels were measured at intervals during a 60-minute, submaximal treadmill test and for 60 minutes postexercise. Wide variations in blood glucose levels within and between subjects hindered statistical analysis. However, a significant difference in mean blood glucose levels was determined, with overall blood glucose levels higher in the GPSD group compared with placebo. The use of the GPSD also prevented the onset of postexercise hypoglycemia and did not cause or contribute to hyperglycemia.

Public knowledge, attitudes, and beliefs about homeless people: evidence for compassion fatigue

Media reports suggest that the public is becoming impatient with the homeless--that so-called "compassion fatigue" has gripped the nation. This characterization of public sentiment could have important policy consequences-- restrictive measures can be justified by growing public impatience, and progressive housing policies seem feasible within a hostile climate of opinion. But evidence to support the compassion fatigue notion is anecdotal. We examine the issue by tracking the results of public opinion polls and by reporting detailed evidence from a nationwide random-digit dial telephone survey (N = 1,507) concerning knowledge attitudes and beliefs about homeless people. To be sure, the public sees homelessness as an undesirable social problem and wants something done about it. However, although the homeless are clearly stigmatized, there is little evidence to suggest that the public has lost compassion and is unwilling to support policies to help homeless people.

Depression and the social developmental context of adolescence

This article examines the interrelations of personal and social factors in fostering longitudinal patterns of depressive symptoms, using 3 waves of data from high school students in the Boston area. Previously depressed and nondepressed youths differed markedly in their emotional responsiveness to family and friend relations. Chronically depressed youths were unresponsive to family problems, but were highly reactive to peer relations. Among previously asymptomatic youths, family relations exerted greater effects on depressed mood than relations with peers. Further analyses suggest a process through which chronic family turmoil shapes long-term mental health while also intensifying the distancing from family and investment in peer relationships that typically occurs in adolescence. Findings illustrate the importance of modeling transactions between personal and environmental factors in research on adolescent mental health and development.

Depression and the social developmental context of adolescence

This article examines the interrelations of personal and social factors in fostering longitudinal patterns of depressive symptoms, using 3 waves of data from high school students in the Boston area. Previously depressed and nondepressed youths differed markedly in their emotional responsiveness to family and friend relations. Chronically depressed youths were unresponsive to family problems, but were highly reactive to peer relations. Among previously asymptomatic youths, family relations exerted greater effects on depressed mood than relations with peers. Further analyses suggest a process through which chronic family turmoil shapes long-term mental health while also intensifying the distancing from family and investment in peer relationships that typically occurs in adolescence. Findings illustrate the importance of modeling transactions between personal and environmental factors in research on adolescent mental health and development.

Health problems reported by residents of a neighborhood contaminated by a hazardous waste facility

A symptom prevalence survey was conducted of a neighborhood exposed to airborne hazardous wastes. Residents' responses were compared to those of a nearby control population. The results revealed that the exposed group had more self-reported complaints referable to the respiratory system (wheezing, shortness of breath, chest discomfort, persistent colds, coughs), constitutional complaints (always fatigued, bowel dysfunction), and irregular heart beat. When the effect of a documented irritant source in a small portion of the control population was removed, the exposed group also complained more often of irritation of the eyes and nose. There was a biological gradient for several of these effects. Efforts to eliminate the influence of confounding and recall bias are discussed. The results suggest either that the general population reacts to chemicals at levels much lower than the available occupational literature would indicate or that the effects are more long lasting than previously thought.