Implementation of an educational intervention to improve medical student cost awareness: a prospective cohort study

BACKGROUND

In the context of rising healthcare costs, formal education on treatment-related financial hardship is lacking in many medical schools, leaving future physicians undereducated and unprepared to engage in high-value care.

METHOD

We performed a prospective cohort study to characterize medical student knowledge regarding treatment-related financial hardship from 2019 to 2020 and 2020-2021, with the latter cohort receiving a targeted educational intervention to increase cost awareness. Using Kirkpatrick's four-level training evaluation model, survey data was analyzed to characterize the acceptability of the intervention and the impact of the intervention on student knowledge, attitudes, and self-reported preparedness to engage in cost-conscious care.

RESULTS

Overall, N = 142 medical students completed the study survey; 61 (47.3%) in the non-intervention arm and 81 (66.4%) in the intervention arm. Of the 81 who completed the baseline survey in the intervention arm, 65 (80.2%) completed the immediate post-intervention survey and 39 (48.1%) completed the two-month post-intervention survey. Following the educational intervention, students reported a significantly increased understanding of common financial terms, access to cost-related resources, and level of comfort and preparedness in engaging in discussions around cost compared to their pre-intervention responses. The majority of participants (97.4%) reported that they would recommend the intervention to future students. A greater proportion of financially stressed students reported considering patient costs when making treatment decisions compared to their non-financially stressed peers.

CONCLUSIONS

Targeted educational interventions to increase cost awareness have the potential to improve both medical student knowledge and preparedness to engage in cost-conscious care. Student financial stress may impact high-value care practices. Robust curricula on high-value care, including treatment-related financial hardship, should be formalized and universal within medical school training.

Association of Smartphone Ownership and Internet Use With Markers of Health Literacy and Access: Cross-sectional Survey Study of Perspectives From Project PLACE (Population Level Approaches to Cancer Elimination)

Background

Telehealth is an increasingly important component of health care delivery in response to the COVID-19 pandemic. However, well-documented disparities persist in the use of digital technologies.

Objective

This study aims to describe smartphone and internet use within a diverse sample, to assess the association of smartphone and internet use with markers of health literacy and health access, and to identify the mediating factors in these relationships.

Methods

Surveys were distributed to a targeted sample designed to oversample historically underserved communities from April 2017 to December 2017. Multivariate logistic regression was used to estimate the association of internet and smartphone use with outcomes describing health care access and markers of health literacy for the total cohort and after stratifying by personal history of cancer. Health care access was captured using multiple variables, including the ability to obtain medical care when needed. Markers of health literacy included self-reported confidence in obtaining health information.

Results

Of the 2149 participants, 1319 (61.38%) were women, 655 (30.48%) were non-Hispanic White, and 666 (30.99%) were non-Hispanic Black. The median age was 51 years (IQR 38-65). Most respondents reported using the internet (1921/2149, 89.39%) and owning a smartphone (1800/2149, 83.76%). Compared with the respondents with smartphone or internet access, those without smartphone or internet access were more likely to report that a doctor was their most recent source of health information (344/1800, 19.11% vs 116/349, 33.2% for smartphone and 380/1921, 19.78% vs 80/228, 35.1% for internet, respectively; both P<.001). Internet use was associated with having looked for information on health topics from any source (odds ratio [OR] 3.81, 95% CI 2.53-5.75) and confidence in obtaining health information when needed (OR 1.83, 95% CI 1.00-3.34) compared with noninternet users. Smartphone owners had lower odds of being unable to obtain needed medical care (OR 0.62, 95% CI 0.40-0.95) than nonsmartphone owners. Among participants with a prior history of cancer, smartphone ownership was significantly associated with higher odds of confidence in ability to obtain needed health information (OR 5.63, 95% CI 1.05-30.23) and lower odds of inability to obtain needed medical care (OR 0.17, 95% CI 0.06-0.47), although these associations were not significant among participants without a prior history of cancer.

Conclusions

We describe widespread use of digital technologies in a community-based cohort, although disparities persist. In this cohort, smartphone ownership was significantly associated with ability to obtain needed medical care, suggesting that the use of smartphone technology may play a role in increasing health care access. Similarly, major illnesses such as cancer have the potential to amplify health engagement. Finally, special emphasis must be placed on reaching patient populations with limited digital access, so these patients are not further disadvantaged in the new age of telehealth.

Primary care provider perspectives on screening mammography in older women: A qualitative study

Objective

Guidelines informing screening mammography for older women are lacking. This study sought to characterize PCP perspectives on screening mammography for patients aged 75 and older.

Methods

This was an exploratory, qualitative study based on semi-structured, one-on-one interviews with PCPs from six clinics affiliated with a tertiary medical center. Two independent coders analyzed interview transcripts and identified themes, subthemes, and representative quotes using inductive analysis methodology.

Results

Ten providers completed interviews. The majority (90%) of providers reported insufficient evidence to suggest a best practice for screening in this population. Providers relied on shared decision-making with patients, a process facilitated by strong provider-patient relationships. Providers took into consideration factors such as functional status, personal risk of breast cancer, and patient preference. Time constraints disincentivized providers to engage in discussions.

Conclusions

PCPs make decisions about screening mammography for older patients on an individualized basis, taking into account patient overall health status and desire for aggressive intervention. They often rely on shared decision-making given unclear clinical guidelines.

Practice implications

These findings suggest that fostering strong provider-patient relationships, addressing patient knowledge gaps, and compensating providers for time spent on counseling may facilitate cost-efficient and patient-centered utilization of screening mammography.

Characterizing participants in the North Carolina Breast and Cervical Cancer Control Program: A retrospective review of 90,000 women

BACKGROUND

The North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) provides breast cancer screening services to underserved women to mitigate disparities in access to care. The authors sought to characterize this understudied population.

METHODS

Women 21 years old or older who underwent their first breast cancer screen through NC BCCCP from 2008 to 2018 were included. Demographic factors associated with the timeline of care and odds of a breast cancer diagnosis were identified with negative binomial and logistic regression, respectively.

RESULTS

Of the 88,893 women identified, 45.5% were non-Hispanic (NH) White, 30.9% were NH Black, 19.6% were Hispanic, 1.7% were American Indian, and 1.1% were Asian. Breast cancer was diagnosed in 2.5% of the women (n = 2255). Hispanic women were the least likely to be diagnosed with breast cancer (odds ratio vs NH White women, 0.40; 95% confidence interval [CI], 0.34-0.47). Among patients with breast pathology, the median time to diagnosis was 19 days (interquartile range [IQR], 10-33 days), and the time to treatment was 33 days (IQR, 19-54 days). After adjustments, a longer time to diagnosis was significantly associated with age (incidence rate ratio [IRR], 1.01; 95% CI, 1.01-1.02) and being NH Black (vs NH White; IRR, 1.17; 95% CI, 1.06-1.29). A longer time to treatment was significantly associated with age (IRR, 1.01; 95% CI, 1.01-1.01), being NH Black (vs NH White; IRR, 1.20; 95% CI, 1.10-1.31), and being Hispanic (vs NH White; IRR, 1.22; 95% CI, 1.05-1.41).

CONCLUSIONS

NC BCCCP participants with breast cancer received treatment within approximately 1 month of presentation, and this finding aligns with quality care benchmarks. Nevertheless, racial/ethnic disparities in timeliness of care persist, and this suggests opportunities for improvement.

LAY SUMMARY

This review of approximately 90,000 participants in a breast cancer screening program for uninsured and underinsured women highlights the importance of safety net programs in providing timely care to underserved patients. The authors found that the North Carolina Breast and Cervical Cancer Control Program met timeliness benchmarks from the Centers for Disease Control and Prevention across all racial/ethnic groups. However, non-Hispanic Black women experienced relative delays in the time to diagnosis, and both non-Hispanic Black women and Hispanic women experienced relative delays in the time to treatment. These findings demonstrate how racial/ethnic disparities in the timeliness of care can persist even within a program intended to reduce barriers to access.

Patient Perspectives on the Financial Costs and Burdens of Breast Cancer Surgery

PURPOSE

Although financial toxicity is a well-documented aspect of cancer care, little is known about how patients narratively characterize financial experiences related to breast cancer treatment. We sought to examine these patient experiences through mixed methods analysis.

METHODS

Women (≥ 18 years old) with a history of breast cancer were recruited from the Love Research Army and Sisters Network to complete an 88-item electronic survey including an open-ended response. Quantitative data were used to sort and stratify responses to the open-ended question, which comprised the qualitative data evaluated here. Descriptive statistics and qualitative content analysis were used to evaluate the financial costs and other burdens resulting from breast cancer surgery.

RESULTS

In total, 511 respondents completed the survey in its entirety and wrote an open-ended response. Participants reported significant financial burden in different categories including direct payments for medical care and indirect costs such as lost wages and travel expenses. Treatment-related costs burdened participants for years after diagnosis, forming a financial arc for many participants. Discrepancies existed between the degree of financial burden reported on multiple-choice questions and participants' corresponding open-ended descriptions of financial burden. Participants described a lack of communication surrounding costs with their providers and difficulty negotiating payments with insurance.

CONCLUSION

Breast cancer care can result in ongoing financial burden years after diagnosis among all patients, even those with adequate insurance patient populations.

Electronic Health Record Use by Sex Among Physicians in an Academic Health Care System

This cohort study examines the association of sex with electronic health record use among physicians and patient satisfaction.

Characterizing participants in the North Carolina Breast and Cervical Cancer Control Program (NC BCCCP): A review of 90,000 women

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Background: Overall breast cancer mortality in the US has declined since 1990, but racial/ethnic disparities have worsened. Since 1992, NC BCCCP has provided free/low-cost breast cancer screening to underserved women as part of a national effort by the Centers for Disease Control and Prevention (CDC) to mitigate these disparities. We sought to characterize and evaluate benchmarks for this previously unstudied, state-level cohort. Methods: We identified women ≥18y who underwent their first breast cancer screening via NC BCCCP from 2009-2018. Univariate analysis was used to compare differences in timeline of care and rates of breast pathology (i.e., cancer or atypia) by race/ethnicity and age. Logistic and negative binomial regression were used to identify factors associated with cancer diagnosis and time from enrollment to diagnosis (TTD) and treatment (TTT), respectively. Results: 88,893 women with complete records were identified (median age 50y, IQR 44-56): 45.5% were Non-Hispanic (NH) white, 30.9% NH black, 19.5% Hispanic, 1.7% American Indian (AI), and 1.1% Asian. Overall participation peaked in 2012 but steadily increased among Hispanic women over time (p < 0.001). Breast pathology was diagnosed in 2,016 (2.3%) women, with rates ranging from 1% in Hispanic women to 2.7% in NH whites. After adjustment, Hispanic women were least likely (vs NH white women: OR 0.40; 95% CI 0.34-0.47) to be diagnosed with breast cancer. Median TTD was 19d and TTT was 33d, both within the CDC’s 60d standard. In univariate analyses, women < 50 had shorter TTD (median 18d vs 21d) and TTT (median 30d vs 35d) vs women ≥50 (both p < 0.01), and there were no significant differences by race/ethnicity or between women with atypia vs cancer. In multivariate models, however, older age and NH black race were associated with longer TTD and TTT. Conclusions: NC BCCCP meets national quality benchmarks for TTD and TTT. These data also highlight broader opportunities to achieve racial/ethnic parity and improve equity for breast cancer prevention. [Table: see text]

Inadequate Utilization of Diagnostic Colonoscopy Following Abnormal FIT Results in an Integrated Safety-Net System

OBJECTIVES

The effectiveness of stool-based colorectal cancer (CRC) screening is contingent on colonoscopy completion in patients with an abnormal fecal immunochemical test (FIT). Understanding system and patient factors affecting follow-up of abnormal screening tests is essential to optimize care for high-risk cohorts.

METHODS

This retrospective cohort study was conducted in an integrated safety-net system comprised of 11 primary-care clinics and one Gastroenterology referral unit and included patients 50-75 years, with a positive FIT between April 2012 and February 2015.

RESULTS

Of the 2,238 patients identified, 1,245 (55.6%) completed their colonoscopy within 1-year of the positive FIT. The median time from positive FIT to colonoscopy was 184 days (interquartile range 140-232). Of the 13% of FIT positive patients not referred to gastroenterology, 49% lacked documentation addressing their abnormal result or counseling on the increased risk of CRC. Of the patients referred but who missed their appointments, 62% lacked documentation following up on the abnormal result in the absence of a completed colonoscopy. FIT positive patients never referred to gastroenterology or who missed their appointment after referrals were more likely to have comorbid conditions and documented illicit substance use compared with patients who completed a colonoscopy.

CONCLUSIONS

Despite access to colonoscopy and a shared electronic health record system, colonoscopy completion after an abnormal FIT is inadequate within this safety-net system. Inadequate follow-up is in part explained by inappropriate screening, but there is an absence of clear documentation and systematic workflow within both primary care and GI specialty care addressing abnormal FIT results.