Age-eligible Patients Research Articles

Beyond childhood: exploring the state of transitional care in pediatric pilocytic astrocytoma.

Pediatric pilocytic astrocytoma (PPA) requires prolonged follow-up after initial resection. The landscape of transitional care for PPA patients is not well characterized. The authors sought to examine the clinical course and transition to adult care for these patients to better characterize opportunities for improvement in long-term care. Pediatric patients (younger than 18 years at diagnosis) who underwent biopsy or resection for PPA between May 2000 and November 2022 at the authors' large academic center were retrospectively reviewed. Patient demographics, tumor characteristics, recurrence, adjuvant therapies, and follow-up data were extracted from the electronic medical record via chart review. Charts of patients who were 18 years or older as of January 1, 2024, were reviewed for adult follow-up notes. The authors identified 315 patients who underwent biopsy or resection for PPA between May 2000 and November 2022. The most common tumor location was posterior fossa (59.7%), and gross-total resection (GTR) was achieved in 187 patients (59.4%). In patients with GTR, progression/recurrence occurred less frequently (8.6% vs 41.4%, p < 0.01) compared to patients with non-GTR. Among 177 patients found to be age-eligible for transition to adult care, the authors found that 31 (17.5%) successfully transitioned. The average age at transition from pediatric to adult care was 21.7 years, and the average age at last known adult follow-up was 25.0 years. The authors found that patients who transitioned to adult care were followed longer (12.5 vs 7.0 years, p < 0.01) and were diagnosed at an older age (12.1 vs 9.6 years, p < 0.01) than their untransitioned counterparts. The authors found that there was a low rate of successful transition from pediatric to adult care for PPA; 17.5% of age-eligible patients are now cared for by adult providers, whereas an additional 18.6% completed appropriate follow-up during childhood and did not require transition to adult care. These findings underscore opportunities for improvement in the pediatric-to-adult transition process for patients with PPA, particularly for those with non-GTR who were not followed for at least 10 years, during which the risk of disease progression is thought to be highest.

Going (Anti)Viral: Improving HIV and HCV Screening and HPV Vaccination in Primary Care

Human immunodeficiency virus (HIV) and hepatitis C (HCV) screening and human papillomavirus (HPV) vaccine uptake remain suboptimal. To improve HIV and HCV screening and HPV vaccination, the authors implemented a quality improvement project in three southwestern Pennsylvania family medicine residency practices. From June 1 to November 30, 2021, participating practices used universal screening and vaccination guidelines and chose from multiple strategies at the office (for example, standing orders), provider (for example, multiple forms of provider reminders), and patient (for example, incentives) levels derived from published literature and tailored to local context. Age-eligible patients for each recommendation with at least one in-person office visit during the intervention period were included. To assess the interventions' effect, the authors obtained testing and vaccination data from the electronic health record for the intervention period, contrasted it with identical data from June 1 to November 30, 2020, and used logistic regression controlling for patient age, sex, and race to determine differences in screening and vaccination between intervention and baseline periods. A total of 14,920 and 15,523 patients were eligible in the baseline and intervention periods, respectively. Following the intervention, HIV lifetime screening but not first-time screening for patients 13-64 years old was significantly higher (78.9% vs. 76.1%, p = 0.004, and 39.6% vs. 36.6%, p = 0.152, respectively, adjusted odds ratio [aOR] 1.21, 95% confidence interval [CI] 1.06-1.38). HCV lifetime screening for patients 18-79 years old was significantly higher postintervention (62.5% vs. 53.5%, p < 0.001, aOR 1.51, 95% CI 1.4-1.64). For patients 9-26 years old, no change in HPV initiation was observed, but the percentage of patients who completed their HPV vaccinations in the observed period was significantly higher postintervention (7.0% vs 4.6%, p = 0.006, aOR 1.58, 95% CI 1.14-2.2). During the postintervention period, the researchers identified 0 new HIV diagnoses and 48 HCV diagnoses (19 eligible for treatment). Family medicine residency office-based multistrategy efforts appear to successfully increase patient uptake of HIV and HCV screenings and maintain HPV vaccination rates.

Costs and Projected Effect of a Federally Qualified Health Center-Based Mailed Colorectal Cancer Screening Program in Texas.

Mailed stool testing for colorectal cancer (CRC) may improve screening uptake and reduce the incidence and mortality of CRC, especially among patients at federally qualified health centers (FQHCs). To expand screening programs it is important to identify cost-effective approaches. We developed a decision-analytic model to estimate the cost, effects on screening and patient outcomes (CRCs detected, CRCs prevented, CRC deaths prevented), and cost-effectiveness of implementing a state-wide mailed stool testing program over 5 years among unscreened, age-eligible (aged 50-75 y) patients at FQHCs in Texas. We compared various outreach strategies and organizational structures (centralized, regional, or a hybrid). We used data from our existing regional mailed stool testing program and recent systematic reviews to set parameters for the model. Costs included start-up and ongoing activities and were estimated in 2022 US dollars from the perspective of a hypothetical third-party payer. Cost-effectiveness was assessed by using both incremental and average cost-effectiveness ratios. Using either a statewide centralized or hybrid organizational configuration to mail stool tests to newly eligible FQHC patients and patients who have responded at least once since program inception is likely to result in the best use of resources over 5 years, enabling more than 110,000 additional screens, detecting an incremental 181 to 194 CRCs, preventing 91 to 98 CRCs, and averting 46 to 50 CRC deaths, at a cost of $10 million to $11 million compared with no program. A statewide mailed stool testing program for FQHC patients can be implemented at reasonable cost with considerable effects on CRC screening outcomes, especially when its structure maximizes program efficiency while maintaining effectiveness.

Sickle Cell Disease Electronic Health Record Population Management Approach to Support Delivery of High-Quality Care: Leaving Paper Lists behind

Children and young adults with sickle cell disease (SCD) require complex health care services to screen for early signs of disease-related complications and to initiate and monitor disease-modifying therapies. Care coordination is challenging as it involves multiple team members across multiple subspecialties. Evidence-based clinical protocols and quality metrics are essential for SCD programs to deliver high-quality care. Systems to track this care delivery are crucial to ensure equitable, accessible care is consistently provided. In 2016, the Comprehensive Sickle Cell Center (CSCC) and the Population Health Innovation Team at Children's Hospital of Philadelphia (CHOP) developed and implemented an electronic health record (EHR)-based system, the SCD patient registry and proactive care outreach tools, to facilitate processes needed to ensure patient service delivery in a timely fashion. We selected Transcranial Doppler (TCD) ultrasounds, hydroxyurea therapy initiation, and annual clinic visits to monitor stroke risk screening, disease-modification therapy, and general chronic illness care. Between January 2015 and June 2023, approximately 1400 patients with SCD were tracked across two CHOP outpatient clinics, the CHOP Philadelphia and CHOP Voorhees campuses. We tracked TCD completion, hydroxyurea prescriptions, and clinic visits per year for age-eligible patients with SS and SB0thal. Prior to implementation of the EHR-based tools and new workflows in October 2016, for age-eligible patients, on average 75% of patients had received annual TCD screening, 55% of patients had received hydroxyurea prescriptions within the prior 6 months, and 85% had attended outpatient hematology clinic at least twice within the year. As of June 2023, on average, completed TCD visits had increased to 91%, patients prescribed hydroxyurea had increased to 78%, and patients attending 2 clinic visits within a year had increased to 89%. These metrics remained consistent and improvement was sustained despite the COVID-19 pandemic. Table 1 describes the drivers influencing these improvements, which included various interventions involving social work, nursing, community health workers, registrars, care coordinators, and physicians. Figure 1 illustrates the changes achieved over time in rates of TCD completion, hydroxyurea prescriptions, and clinic visit attendance. This implementation of an SCD EHR-based population health tool and new care team workflows facilitated more efficient processes for various care team members and improved our ability to consistently provide timely services to children and young adults with SCD. This resulted in sustained improvement in all metrics and high-quality care for our patients.

Increasing COVID-19 Immunization Rates through a Vaccination Program for Hospitalized Children.

Inpatient coronavirus disease 2019 (COVID-19) vaccination initiatives offer a novel strategy to eliminate barriers to care, provide access to interprofessional teams, and decrease COVID-19 morbidity and mortality. Our inpatient vaccination initiative aimed to triple the baseline rate of eligible hospitalized children vaccinated against COVID-19 from 0.95% to 2.85% from December 2021 to June 2022. We implemented a COVID-19 vaccination program for pediatric inpatients eligible to receive a dose based on age, current guidelines, and prior doses received. Key drivers included immunization counseling training, identification of eligible patients, and a streamlined workflow. The outcome measure was the percentage of eligible patients who received a vaccine dose during hospitalization. The process measures included the percentage of age-eligible patients who were appropriately screened for prior doses on admission. We designed a clinical decision support system to enhance eligibility identification. The team performed a health equity analysis which stratified patients by social vulnerability index. During the study period, the average percentage of eligible hospitalized patients vaccinated increased from 0.9% to 3.5%, representing special cause variation and a centerline shift. The average percentage of age-eligible patients screened for prior vaccine doses on admission increased from 66.5% to 81.5%. Patients were more likely to be vaccinated if their clinician was exposed to the clinical decision support system (P < 0.01). The social vulnerability index analysis showed no significant differences. This COVID-19 vaccination initiative highlights how an interprofessional approach can increase vaccination rates in hospitalized children; however, overall inpatient COVID-19 vaccination rates in this setting remained low.

Developing a Social Marketing–Based Colorectal Cancer Screening Campaign Centered on Stool-Based Testing for Patients Utilizing Services at a Federally Qualified Healthcare Center

Background More than 50% of colorectal cancer (CRC)–related deaths could be prevented with early detection and treatment. Federally Qualified Healthcare Centers (FQHCs)—safety-net facilities that provide primary care services to uninsured, underinsured and minority patients—report some of the lowest CRC screening rates. Effective CRC screening interventions within FQHCs may help to promote CRC screening utilization among patients from diverse backgrounds. Focus of Article This study was designed to explore average-risk, patient perceptions of facilitators and impediments of using the Fecal Immunochemical Test (FIT) kit for CRC screening within the social marketing framework of the 4 “P’s”—product, price, place, and promotion. Research Aim To conduct formative research with priority populations (i.e., diverse, FQHC patients), assess acceptability of the FIT kit, and identify ways to better meet preferences and needs. Program Design/Approach Qualitative, Focus Groups. Importance to the Social Marketing Field Findings from this study would aid in the future development of a community-based prevention marketing intervention to promote CRC screening within FQHCs that serve diverse patient populations. Methods Focus groups were conducted in English and Spanish with CRC screening age-eligible patients from a South Florida FQHC System. Interview guides were designed to better understand FQHC patient perceptions of CRC Screening via the FIT kit (product) by up-to-date and not up-to-date participants. Additional topics included likes/dislikes (price), preferred location for completing CRC screening and receiving CRC prevention education (place), and strategies for persuasive communication to increase CRC screening among patients who visit FQHCs (promotion). Data were analyzed to identify FIT screening facilitators and impediments using thematic coding in MaxQDA. Results Five focus groups, involving 36 participants aged 50 and older, were conducted. Over half of participants self-identified as Hispanic (36%) or non-Hispanic Black (28%). Key facilitators were the convenience and simplicity of at-home testing (product), presumed affordability of it compared to colonoscopy (price), and ability to return by mail (place). Participants also shared numerous strategies for promotion, including direct referral from Primary Care Providers, mass media campaigns, mailed or electronic reminders from the clinic, and peer advocacy events in churches. Recommendations for Research or Practice Social marketing provides an adequate approach for developing a patient-centered campaign to promote CRC screening uptake at FQHCs. Future CRC screening promotional campaigns at FQHCs should build on the motivation that patients must prioritize their health by emphasizing the convenience of completing CRC screening at home with the capability of mailing it back. Clinics should also work to reduce patient responsibility by developing automated clinic system reminders to openly communicate with patients about CRC screening.

Abstract 1930: Community outreach and engagement to increase colorectal cancer screening in ethnic minority communities

Abstract PURPOSE: Colorectal cancer (CRC) is preventable with screening, yet remains the second leading cause of cancer deaths in the U.S. Nationally, CRC screening substantially declined during the COVID-19 pandemic and is underutilized by ethnic minorities and in safety-net systems. Therefore, City of Hope partnered with Federally Qualified Health Centers (FQHCs) and community and faith-based organizations to improve CRC screening among medically underserved communities. METHODS: Between October 2020 and October 2022, we implemented a multi-component intervention that included community outreach and education (a multi-ethnic multimedia campaign and community training adapted from the NCI Screen2Save (S2S) program) and clinic-based interventions (provider/staff training and patient education). Intervention reach and training participant surveys were assessed. Within our four FQHC sites, we also compared clinic-level CRC screening rates among age-eligible patients before (June 2021) and after implementation of the clinic-based intervention (June 2022). RESULTS: Our reach assessment showed that our multi-ethnic multimedia campaign reached 35.4 million impressions, our S2S education training reached 300 diverse community members, and our provider/staff training reached 150 medical providers. Among the 100 providers surveyed, &amp;gt;80% felt confident they could get their patients to complete their CRC screening test and follow-up care. For the clinic-based intervention component, our baseline sample included 11,259 age-eligible patients across the four FQHC sites. Overall CRC screening rates increased from 45% to 52% before vs. after the intervention implementation period. The site with the highest CRC screening rate (&amp;gt;62%) maintained steady rates over the observation period, whereas three sites with lower baseline rates showed greater pre-post improvements (average 15 percentage-point increase). CONCLUSIONS: An overall increase in CRC screening rates was achieved across FQHCs, despite clinic staffing challenges during the COVID-19 pandemic. Intervention implementation is ongoing with attempts to document individual, clinic improvements by race/ethnicity. Keyword 1: Cancer risk Keyword 2: Cancer detection Citation Format: Kimlin Ashing, Marisela Garcia, Trilokesh Kidambi, Gregory Idos, Sophia Yeung, Charleen Mikail, Magaret Martinez, Scott Kim, Kim Tran, Paul Gregerson, Paul Round, Cherry Lee, Pei-Chi Wu, Nancy Chen, Stephen Denq, Narissa Nonzee. Community outreach and engagement to increase colorectal cancer screening in ethnic minority communities [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1930.

COVID-19 Cases and Hospitalizations Among Medicare Beneficiaries With and Without Disabilities - United States, January 1, 2020-November 20, 2021.

Approximately 27% of adults in the United States live with a disability,* some of whom qualify for Medicare benefits. Persons with disabilities are at increased risk for severe COVID-19-associated outcomes compared with the general population (1); however, existing studies have limited generalizability† or only pertain to a specific disability (e.g., intellectual) (2). Older age is also associated with COVID-19-associated hospitalization and death, but the extent to which age might contribute to increased risk for severe COVID-19-associated outcomes among persons with disabilities is unknown (3). To describe the impact of COVID-19 on persons with disabilities and whether and how age contributes to disease rates, CDC assessed COVID-19 cases and hospitalizations during January 2020-November 2021, among Centers for Medicare & Medicaid Services (CMS) Medicare beneficiaries aged ≥18 years who were either eligible because of a disability (disability-eligible§) or only eligible because of age ≥65 years (age-eligible). COVID-19 incidence and hospitalization rates were higher in the disability-eligible group (10,978 and 3,148 per 100,000 population, respectively) throughout the study period compared with the age-eligible group (8,102 and 2,129 per 100,000 population, respectively). Both COVID-19 incidence and hospitalization rates increased with age in both disability- and age-eligible beneficiaries. American Indian or Alaska Native (AI/AN) persons had the highest disability-eligible (4,962 per 100,000) and age-eligible (5,024 per 100,000) hospitalization rates. Among all other racial and ethnic groups, hospitalization rates were higher among disability-eligible than among age-eligible patients. COVID-19 incidence and hospitalization rates among disability-eligible Medicare beneficiaries were disproportionally higher than rates among age-eligible beneficiaries. Collection of disability status as a core demographic variable in public health surveillance data and identification, as well as the addition of disability questions in other existing data sources can guide research and development of interventions for persons with disabilities. Efforts to increase access to and use of COVID-19 prevention and treatment strategies, including activities that support equitable vaccine access regardless of the substantial challenges that older adults and persons with disability face, are critical to reducing severe COVID-19-associated outcomes among these groups.

Shingles vaccination uptake in Massachusetts adults aged 50 years and older

BackgroundShingles (herpes zoster), a medical condition caused by reactivation of latent varicella zoster virus and characterized by painful rash, will affect almost one third of Americans during their lifetime. A licensed vaccine (zoster vaccine live [ZVL]) was recommended for individuals ≥ 60 years old in 2008 to reduce shingles incidence. The Healthy People (HP) 2020 target for shingles vaccination in ≥ 60 year-olds was 30%; in 2014, it stood at 31.8% and in 2017 at 34.9%. While the national coverage target is met, variability remains across age, gender and ethnicity. Understanding factors influencing patient acceptance of the shingles vaccination is needed to help guide program activities and improve vaccination coverage in the adult population. PurposeTo understand Massachusetts consumers’ knowledge, attitudes, behaviors, and barriers to obtaining a shingles vaccination. MethodsWe performed a telephone survey using a stratified sample of Massachusetts residents ≥ 50 years-old who i) responded to the 2012 Massachusetts Behavioral Risk Factor Surveillance System (n = 10,822), ii) agreed to a follow-up survey (n = 6,873), and iii) reported awareness of the shingles vaccination (n = 1,000; n = 529 vaccinated respondents (VR) and n = 471 non-vaccinated respondents (NVR)). Multivariable logistic regression identified factors independently associated with receiving shingles vaccination. ResultsAcross both groups, most respondents (n = 989, 99%) were aware of shingles, perceived shingles as painful, and knew ofothers who had hadshingles. Multivariable logistic regression indicated an association between shingles vaccination and physician recommendation, influenza vaccination, and perception of shingles risk. ConclusionsMore than half of the sub-sample reported not knowing about shingles vaccine, therefore, opportunities to increase awareness should be prioritized. Since provider recommendation and flu vaccination receipt had the greatest odds of increasing shingles vaccination, standard practice should include adding shingles to flu vaccine recommendations for age-eligible patients.

Spatial Insights for Understanding Colorectal Cancer Screening in Disproportionately Affected Populations, Central Texas, 2019.

IntroductionColorectal cancer (CRC) screening can reduce morbidity and mortality; however, important disparities exist in CRC uptake. Our study examines the associations of distance to care and frequency of using primary care and screening.MethodsTo examine the distribution of screening geographically and according to several demographic features, we used individual patient-level data, dated September 30, 2018, from a large urban safety-net health system in Central Texas. We used spatial cluster analysis and logistic regression adjusted for age, race, sex, socioeconomic status, and health insurance status.ResultsWe obtained screening status data for 13,079 age-eligible patients from the health system’s electronic medical records. Of those eligible, 55.1% were female, and 55.9% identified as Hispanic. Mean age was 58.1 years. Patients residing more than 20 miles from one of the system’s primary care clinics was associated with lower screening rates (odds ratio [OR], 0.63; 95% CI, 0.43−0.93). Patients with higher screening rates included those who had a greater number of primary care–related (nonspecialty) visits within 1 year (OR, 6.90; 95% CI, 6.04−7.88) and those who were part of the county-level medical assistance program (OR, 1.61; 95% CI, 1.40−1.84). Spatial analysis identified an area where the level of CRC screening was particularly low.ConclusionDistance to primary care and use of primary care were associated with screening. Priorities in targeted interventions should include identifying and inviting patients with limited care engagements.

Colonoscopy Quality and Adherence to Postpolypectomy Surveillance Guidelines in an Underinsured Clinic System.

Background Delivery of high-quality colonoscopy and adherence to evidence-based surveillance guidelines is essential to a high-quality screening program, especially in safety net systems with limited resources. We sought to assess colonoscopy quality and ensure appropriate surveillance in a network of safety net practices. Methods We identified age-eligible patients ages 50-75 within a Federally Qualified Health Center (FQHC) clinic system with evidence of colonoscopy in preceding 10 years. We performed chart reviews to assess key aspects of colonoscopy quality: bowel preparation quality, evidence of cecal intubation, cecal withdrawal time, and the adenoma detection rate. We then utilized established guidelines to assess and revise surveillance colonoscopy intervals, determine whether appropriate surveillance had taken place, and schedule overdue patients as appropriate. Results Of 26,394 age-eligible patients, a total of 3,970 patients had evidence of prior colonoscopy and 1,709 charts were selected and reviewed. Mean age was 57, 54% identified as women and 51% identified as Hispanic. Of 1709 colonoscopies reviewed, 77% had data on bowel preparation, and of those, 85% had adequate preparation quality. Cecal intubation was documented in 89% of procedures. Adequate cecal withdrawal time was documented in 59% of those with documented cecal intubation. Overall adenoma detection rate was 42%. Initial surveillance interval was clearly stated in 72% (n = 1238) of procedures. Of these, initial recommended intervals were too short in 24.5% (n = 304) and too long in 3.6% (n = 45). A total of 132 patients (10.7%) were overdue for appropriate surveillance and were referred for follow-up colonoscopy. Conclusions Overall, the quality of screening colonoscopy was high, but reporting was incomplete. We found fair adherence to evidence-based surveillance guidelines, with significant opportunities to extend surveillance intervals and improve adherence to best practices.

Human Papillomavirus Vaccine: An American Dental Association Clinical Evaluators Panel survey

BackgroundHuman papillomavirus (HPV) is a sexually transmitted oncovirus associated with several malignancies, including oropharyngeal squamous cell carcinoma. The 9-valent HPV vaccine can help protect against the high-risk HPV strains most commonly associated with HPV-related cancers. MethodsThe authors used an electronic survey to assess the roles of dentists and their team members in discussing the HPV vaccine, as well as administering the vaccine in a dental setting. On December 6, 2019, the authors e-mailed a survey link to the American Dental Association Clinical Evaluators (ACE) Panel (n = 813), a sample of American Dental Association member dentists. After 1 e-mail reminder, the survey closed on December 19, 2019, and the authors conducted exploratory and descriptive data analyses using SAS Version 9.4 (SAS). ResultsA total of 329 dentists responded to the survey, and 83 (25%) of them reported that they or their team members discuss the implications of the HPV vaccine with age-eligible patients or their parents or guardians. Dentists lead two-thirds (n = 218) of the discussions, and the clinical examination is the most frequent moment during the patient visit in which HPV-related topics are discussed. Some of the top reasons respondents mentioned for not discussing the vaccine in their practice were the perception that these discussions are best left to other health care professionals and not knowing how to address the topic with patients. If the scope of dental practice is expanded to include administering the vaccine, 125 (38%) of respondents would feel uncomfortable administering the vaccine. The most common potential barriers to administering the vaccine in a dental setting include obtaining reimbursement and vaccine management and preservation. ConclusionsThe survey results suggest that dentists’ comfort levels and perceived roles in discussing and administering the HPV vaccine vary. Practical ImplicationsThere is a need to further define the role of dentists and their team members in the promotion and administration of the HPV vaccine. Resources for dentists and dental team members may be helpful to support professional education and communication about the HPV vaccine.

A “Sense”-ational HPV Vaccination Quality Improvement Project in a Family Medicine Residency Practice

BackgroundHuman papillomavirus (HPV) vaccination uptake for adolescents and young adults in the United States remains far from national goals. Using a multi-component intervention aligned with community-wide efforts, we implemented a quality improvement project to increase HPV vaccinations among 9-26 year-old male and female patients in an urban, low income, minority population family medicine residency practice. MethodsThe pre-intervention year was November 2, 2014 to October 31, 2015 and the intervention year was November 1, 2015 to October 31, 2016. Based on community input and published literature, the interventions were creative, practice-specific provider-, patient-, and system-level strategies. To compare pre- and post-intervention vaccinations, HPV vaccination data were extracted from an electronic medical record request for age-eligible patients seen in the practice during the intervention year. Chi-square, McNemar’s and 2-tailed, 2-sample Z tests were used to test differences in vaccination initiation (≥1 dose) and completion (3 doses) across groups and over time. ResultsDespite high pre-intervention rates (58% and 75%), HPV vaccine initiation significantly increased 12.8 percentage points (PP) for males and 10.6 PP for females from pre- to post-intervention (P < 0.001). HPV vaccine completion also significantly increased 16 PP for males and 10.9 PP for females (P < 0.001). Young adult patients (18-26 years-old) had significant increases in completion rates (9.9 PP; P < 0.001), not observed among adolescents (20 PP; ns). ConclusionsConsistent and abundant positive HPV vaccination messaging, low-cost sensory rewards, process change, and community, clinician, and nonclinical staff engagement were associated with higher HPV vaccine initiation and completion, especially among young adults.

Financial Incentives to Increase Colorectal Cancer Screening Uptake and Decrease Disparities

IMPORTANCEColorectal cancer screening rates are suboptimal, particularly among sociodemographically disadvantaged groups.OBJECTIVETo examine whether guaranteed money or probabilistic lottery financial incentives conditional on completion of colorectal cancer screening increase screening uptake, particularly among groups with lower screening rates.DESIGN, SETTING, AND PARTICIPANTSThis parallel, 3-arm randomized clinical trial was conducted from March 13, 2017, through April 12, 2018, at 21 medical centers in an integrated health care system in western Washington. A total of 838 age-eligible patients overdue for colorectal cancer screening who completed a questionnaire that confirmed eligibility and included sociodemographic and psychosocial questions were enrolled.INTERVENTIONSInterventions were (1) mail only (n = 284; up to 3 mailings that included information on the importance of colorectal cancer screening and screening test choices, a fecal immunochemical test [FIT], and a reminder letter if necessary), (2) mail and monetary (n = 270; mailings plus guaranteed $10 on screening completion), or (3) mail and lottery (n = 284; mailings plus a 1 in 10 chance of receiving $50 on screening completion).MAIN OUTCOMES AND MEASURESThe primary outcome was completion of any colorectal cancer screening within 6 months of randomization. Secondary outcomes were FIT or colonoscopy completion within 6 months of randomization. Intervention effects were compared across sociodemographic subgroups and self-reported psychosocial measures.RESULTSA total of 838 participants (mean [SD] age, 59.7 [7.2] years; 546 [65.2%] female; 433 [52.2%] white race and 101 [12.1%] Hispanic ethnicity) were included in the study. Completion of any colorectal screening was not significantly higher for the mail and monetary group (207 of 270 [76.7%]) or the mail and lottery group (212 of 284 [74.6%]) than for the mail only group (203 of 284 [71.5%]) (P = .11). For FIT completion, interventions had a statistically significant effect (P = .04), with a net increase of 7.7% (95% CI, 0.3%–15.1%) in the mail and monetary group and 7.1% (95% CI, −0.2% to 14.3%) in the mail and lottery group compared with the mail only group. For patients with Medicaid insurance, the net increase compared with mail only in FIT completion for the mail and monetary or the mail and lottery group was 37.7% (95% CI, 11.0%–64.3%) (34.2% for the mail and monetary group and 40.4% for the mail and lottery group) compared with a net increase of only 5.6% (95% CI, −0.9% to 12.2%) among those not Medicaid insured (test for interaction P = .03).CONCLUSIONS AND RELEVANCEFinancial incentives increased FIT uptake but not overall colorectal cancer screening. Financial incentives may decrease screening disparities among some sociodemographically disadvantaged groups.TRIAL REGISTRATIONClinicalTrials.gov identifier:

Health-Related Quality of Life (HRQL) Trajectories during Treatment for Advanced Stage Pediatric Hodgkin Lymphoma (HL)

Introduction: The treatment of advanced stage HL typically includes dose-dense chemotherapy with or without involved field radiation. However, little is known about the HRQL of pediatric patients during initial treatment. We describe the HRQL trajectory over time by child and parent-proxy rater and examine baseline patient characteristics associated with the trajectory.Methods: Children and adolescents, ages 5-17.9 years newly diagnosed with advanced stage HL and enrolled in Children's Oncology Group AHOD 1331, and their parents were co-enrolled in an embedded study to assess HRQL (n=310). Children (age ≥11 years) and parent proxies (of children 5-17.9 years) reported on the child's global HRQL using the Child Health Rating Inventories (CHRIs) at four times: (1) baseline, (2) cycle 2, (3) cycle 5, and (4) end of therapy, approximately 6-7 months following initial diagnosis. The 7-item CHRIs-Global yields scores that range from 0-100, with higher scores indicating better HRQL. A repeated measures linear regression model was fit with categorical time (reference, baseline), rater, child race, ethnicity, and continuous age. An interaction of rater and time was tested and predicted means were plotted.Results: 97% of age-eligible patients and parents completed baseline HRQL assessments with 93% completing planned follow-ups. Median child age was 15.5 years (q1=5.4, q3=18.9) and 50.3% were female. Most children were white (76.1%) and non-Hispanic (82.6%). There was no significant interaction between rater and time (Figure), so this was subsequently excluded from the model. Scores improved slightly at time 2 (β=2.5, 95%CI=0.3, 4.6) and 3 (β=2.8, 95%CI=0.3, 5.3) compared to baseline; larger improvements were seen by time 4 (β=10.6, 95%CI=7.9, 13.3) after completion of therapy. Children reported higher HRQL than their parent proxies (β=5.6, 95%CI=3.9, 7.2), males had higher HRQL than females (β=4.6, 95%CI=1.0, 8.3), and older age was associated with lower HRQL (β=-0.8, 95%CI=-1.5, -0.1). There was no significant effect of race or ethnicity.Conclusions: Completion rates of HRQL were high across all time periods and for both raters. HRQL, impaired at baseline, likely from the disease process, improved slightly during treatment, with larger improvements by the end of initial therapy. Future research will examine how clinical and treatment factors impact the HRQL trajectory. [Display omitted] DisclosuresParsons:Seattle Genetics: Research Funding. Rodday:Seattle Genetics: Research Funding. Henderson:Seattle Genetics: Research Funding.

Patient’s knowledge about HIV and willingness toward rapid HIV oral testing in dental settings, Jodhpur, Rajasthan

Background: As various dental procedures can transmit HIV, rapid HIV oral testing facilities in dental settings could play a major role in prevention of HIV infection. Being most popular HIV testing methods worldwide, the rapid HIV oral test is not available in India and its level of acceptance in Indian dental settings is unexplored. This study conducted with the objective to assess patient’s knowledge about HIV and their willingness toward rapid HIV oral testing in dental settings.Methods: This cross-sectional study was conducted in two dental clinics selected from two different largest mixed socioeconomic housing societies of Jodhpur respectively. A semi structured questionnaire consisting of demographics, respondent’s general knowledge towards AIDS/HIV infection, willingness towards HIV rapid oral test was developed for data collection. Standard descriptive statistics were calculated and comparisons between demographic data and willingness to get tested in dental setting, awareness for HIV etc. were analyzed.Results: Total of 473 age-eligible patients were surveyed out of which 214 were males. The difference about the knowledge of HIV/AIDS between two groups of education levels (p&lt;0.05) was statistically significant and almost 82% of these respondents were willing to have HIV oral rapid saliva testing as a part of regular dental appointment.Conclusions: It can be concluded that dental patient generally are willing for HIV rapid oral testing, but additional studies are needed to explore relevant policy implications.

Acceptance of HPV Vaccination in Kidney Transplant Recipients

Background: Human Papilloma virus (HPV) infections are an increasingly concerning etiology for post-transplantation viral-related malignancies. The nonavalent HPV vaccine (Gardasil 9) affords transplant recipients the best opportunity for malignancy prevention, but remains underutilized. Not previously reported for solid organ transplant recipients, we studied influential factors for HPV vaccine non-initiation. Methods: This survey, conducted from May to December 2017, examined influential factors for HPV vaccine non-initiation. HPV-related disease period prevalence was also analyzed in this regional survey. Results: Of the 164 patients approached for the study, 157 participated and 154 completed the survey resulting in a 95% response rate. Twenty-nine percent of patients within the United States Food and Drug Administration (FDA) approved age range had started or completed the HPV vaccine series at survey administration. The most significant reason for HPV vaccine non-initiation among age eligible transplant patients was a reduced physician intention to recommend. Conclusion: HPV vaccination remains underutilized in solid organ transplant patients. Emphasis on physician intention to recommend HPV vaccination will reduce vaccine non-initiation rates.

Abstract C58: Effect of physicians' recommendation on the perceived effectiveness of the HPV vaccine in preventing cervical cancer

Abstract Background: The human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with nearly 80 million people currently infected. It causes virtually all cervical cancers in the United States. There are three prophylactic HPV vaccines approved and recommended in the United States, and they protect against 70-90% of the HPV types that cause cervical cancer. Although the HPV vaccine is safe and effective, vaccination rates remain suboptimal. Physicians' recommendation of the HPV vaccine is known to be the most important predictor of vaccine uptake, and prior research suggests that promoting the HPV vaccine as an anticancer vaccine increases vaccination rates. However, no previous national study has evaluated how physicians' recommendation of the HPV vaccine might influence patients' or parental views of the vaccines' effectiveness. We sought to assess how physicians' recommendation of the HPV vaccine influenced patients' view of the effectiveness of the vaccine in preventing cervical cancer. Methods: Nationally representative data (n=1171) on respondents who were or had immediate family between the ages of 9 and 27 years old were obtained from the 2014 Health Information National Trends Survey 4, Cycle 4. Outcome of interest was an “effective” response to the question: “In your opinion, how successful is the HPV vaccine at preventing cervical cancer?” Main independent variable was physician HPV vaccine recommendation in the last 12 months (yes, no, don't know). Weighted, multivariable logistic regression was used to evaluate the effect of physicians' recommendation of the HPV vaccine on patients' perception on the effectiveness of the vaccine in preventing cervical cancer. Results: Approximately 26% of respondents reported receiving a physician recommendation for the HPV vaccine and 28% perceived the vaccine as effective in preventing cervical cancer. Respondents who did not have a physician's HPV recommendation, or did not know they had one in the last 12 months were 55% (aOR = 0.45, 95% CI, 0.27 - 0.73) and 76% (aOR = 0.24, 95% CI, 0.12 - 0.48) less likely to perceive the HPV vaccine as effective against cervical cancer, respectively. Respondents were less likely to perceive the HPV vaccine as effective in preventing cervical cancer if they were aged 35-49 (aOR = 0.46, 95% CI, 0.25 - 0.82) vs. 18-34 and had a high school diploma (aOR = 0.44, 95% CI, 0.24 - 0.81) or some college education (aOR = 0.39, 95% CI, 0.23 - 0.66) compared with college degree. Conclusions: Only one in four respondents with an immediate family member eligible for the HPV vaccine received a physician recommendation in our study. However, those who received a recommendation were significantly more likely to perceive the HPV vaccine as effective in preventing cervical cancer. Our finding provides added impetus for more physicians to utilize every clinical encounter as an opportunity to recommend the HPV vaccine to age-eligible parents and patients. Citation Format: Eric Adjei Boakye, Nosayaba Osazuwa-Peters, Vy Pham, Betelihem B. Tobo, Matthew C. Simpson, Thomas Burroughs, Paula Buchanan. Effect of physicians' recommendation on the perceived effectiveness of the HPV vaccine in preventing cervical cancer [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C58.

Implementation and process evaluation of three interventions to promote screening mammograms delivered for 4years in a large primary care population.

The optimal form of outreach to promote repeated, on time screening mammograms in primary care has not been established. The purpose of this study is to assess the implementation process and process outcomes for three interventions for promoting biannual screening mammography in a randomized trial. In a large urban primary care practice over a 4-year period, we randomized women aged 40-85 and eligible for mammograms to three interventions: reminder letter only (LO), reminder letter + reminder call (RC), and reminder letter + counseling call (CC). We tracked information system development, staff training, patient and provider recruitment, reach, dose delivered and received, fidelity, and context measures. Ninety-three of 95 providers approved participation by 80% (23,999) of age-eligible patients, of whom only 207 (0.9%) opted not to receive any intervention. Of 9161 initial reminder letters mailed to women coming due or overdue for mammograms, 0.8% were undeliverable. Of women in the RC and CC arms unresponsive to the first reminder letter (n=3982), 71.4% were called and reached, and of those, 49.1% scheduled a mammogram. Only 33.4% of women reached in the CC arm received full counseling, and women in the CC arm were less likely to schedule a mammogram than those in the RC arm. Implementing mail and telephone mammography reminders is feasible and acceptable in a large urban practice and reaches a majority of patients. Many schedule a mammogram when reached. A reminder letter followed by a simple reminder call if needed may be the optimal approach to promoting screening mammograms.

Health Volunteerism and Improved Cancer Health for Latina and African American Women and Their Social Networks: Potential Mechanisms.

Health volunteerism has been associated with positive health outcomes for volunteers and the communities they serve. This work suggests that there may be an added value to providing underserved populations with information and skills to be agents of change. The current study is a first step toward testing this hypothesis. The purpose is to identify how volunteerism may result in improved cancer health among Latina and African American women volunteers. A purposive sample of 40 Latina and African American female adults who had participated in cancer volunteerism in the past 5years was recruited by community advocates and flyers distributed throughout community venues in San Diego, CA. This qualitative study included semi-structured focus groups. Participants indicated that volunteerism not only improved their health but also the health of their family and friends. Such perceptions aligned with the high rates of self-report lifetime cancer screening rates among age-eligible patients (e.g., 83-93% breast; 90-93% cervical; 79-92% colorectal). Identified mechanisms included exposure to evidence-based information, health-protective social norms and support, and pressure to be a healthy role model. Our findings suggest that train-the-trainer and volunteer-driven interventions may have unintended health-protective effects for participating staff, especially Latina and African American women.