Care Delivery Research Articles

Optometrist-delivered selective laser trabeculoplasty in the HES - a training protocol and early service evaluation.

Over the last decade, the delivery of glaucoma care in the UK has changed dramatically, with more non-medical ophthalmic practitioners involved in the care of glaucoma patients. Optometrists and other non-medical professionals are now involved in the delivery of laser treatments in the Hospital Eye Service (HES), but there is currently no standardised national training framework for non-medical clinicians. Moorfields Eye Hospital and UCL's Institute of Ophthalmology have developed and delivered an education and training programme for the delivery of lasers, including Selective Laser Trabeculoplasty (SLT) by non-medical ophthalmic practitioners. The training programme is based on medical education principles, is informed by previous qualitative research into the role of ophthalmic practitioners in the delivery of laser treatments and is expected to have multidisciplinary benefits for ophthalmic healthcare. Clinical audit data indicate that optometrists can deliver safe SLT treatments, adhering to local protocols.

РЕЗУЛЬТАТЫ ЛЕЧЕНИЯ ОЖОГОВОЙ ТРАВМЫ ПО МАТЕРИАЛАМ РАБОТЫ АСТРАХАНСКОГО ОЖОГОВОГО ЦЕНТРА

The relevance of burn traumatism on the territory of the Russian Federation is shown up on the example of the performed analysis of the burn department work of the State Budgetary Healthcare Institution of Alexandr-Mariinskiy Regional Clinical Hospital of the Astrakhan region. With the aid of such data, it is feasible to contemplate the accessibility of high-tech medical care delivery in this direction, as well as to devise additional initiatives for the advancement of the department.

Use of UK faith Centre as a COVID-19 community vaccination clinic: exploring a potential model for community-based health care delivery.

Effective and safe vaccines against COVID-19 are essential to achieve global control of the coronavirus (SARS-CoV-2). Using faith centres may offer a promising route for promoting higher vaccine uptake from certain minority ethnic groups known to be more likely to be vaccine hesitant. This cross-sectional study explored attendees' perceptions, experiences of being offered, and receiving COVID-19 vaccination in a local mosque in Woking, Surrey, UK. About 199 attendees completed a brief questionnaire on experiences, views, motivations about attending the mosque and vaccination on site. The most common ethnic groups reported were White British (39.2%) and Pakistani (22.6%); 36.2% identified as Christian, 23.6% as Muslim, 5.5% as Hindu, and 17.1% had no religion. Genders was relatively equal with 90 men (45.2%) and 98 women (49.2%), and 35-44-year-olds represented the most common age group (28.1%). Views and experiences around receiving vaccinations at the mosque were predominantly positive. Primary reasons for getting vaccinated at the mosque included convenience, accessibility, positive aspects of the venue's intercultural relations, and intentions to protect oneself against COVID-19, regardless of venue type. Negative views and experiences in regards to receiving the vaccination at the mosque were less common (7% expressed no intention of recommending the centre to others), and disliked aspects mostly referred to the travel distance and long waiting times. Offering COVID-19 vaccination in faith centres appears acceptable for different faith groups, ensuring convenient access for communities from all religions and ethnic backgrounds.

Virtual Patient and Family Engagement Strategies in Critical Care: A Scoping Review.

Background: Family engagement in care is increasingly recognized as an essential component of optimal critical care delivery. However, family engagement strategies have traditionally involved in-person family participation. Virtual approaches to family engagement may overcome barriers to family participation in care. The objective of this study was to perform a scoping review of virtual family engagement strategies in the intensive care unit (ICU). Methods: Studies were included if they involved a virtual engagement strategy with family members of an ICU patient and reported either (1) outcomes, (2) user perspectives, and/or (3) barriers or facilitators to virtual engagement in the ICU. Study types included primary research studies and review articles. Study selection followed the Joanna Briggs Institute Methodology for Scoping Reviews guidelines without any cultural, ethnic, gender, or specific language restrictions. The source of evidence included Ovid MEDLINE, PubMed, CINAHL, and Cochrane Library databases from inception to November 17, 2023. Google scholar was searched on December 1, 2023. Data were extracted on virtual engagement strategy used, outcomes (patient-centered, family-centered, and clinical), perspectives (patient, family, and health care professional [HCP]), and reported barriers or facilitators to virtual engagement in the ICU. Results were categorized into adult or pediatric/neonatal ICU setting. Results: Virtual engagement strategies identified were virtual visitation, virtual rounding, and virtual meetings. Family and HCPs were generally supportive of virtual visitation and rounding strategies. Overall, virtual strategies were associated with improved patient, family, and HCP outcomes. There were a few randomized interventional studies evaluating the effectiveness of virtual engagement strategies. Family, HCP, technological, and institutional barriers to the implementation and conduct of virtual engagement strategies were reported. Conclusions: Virtual family engagement strategies are associated with improved outcomes for patients, family, and HCPs. Identified barriers to virtual family engagement should be addressed. Future studies are needed to evaluate the effectiveness of virtual family engagement strategies in a more rigorous manner.

Abstract PO5-09-05: Characteristics of newly diagnosed breast cancer patients at a large safety-net system: Implications for health equity and care delivery

Abstract Introduction: Despite the increased awareness and advocacy for health equity, racial and socioeconomic disparities remain prevalent among breast cancer patients. Since lack of access to care is a major barrier, safety-net systems that provide services for the uninsured/underinsured play a significant role in promoting health equity and eliminating disparities. Understanding the patient population treated within these systems, which are often resource-limited, can help develop strategies to improve care delivery and outcomes. Here, we describe characteristics of breast cancer patients treated at a large safety-net system. Methods: Parkland Health (PH) is the safety-net system for Dallas County, and is affiliated with the University of Texas Southwestern Harold C. Simmons Comprehensive Cancer Center (NCI-CCC). Electronic medical records of patients with a new invasive breast cancer diagnosis between 2018 to 2020 at PH were reviewed and data on demographics and clinical presentation were collected. Categorical data was summarized with counts and percentages and continuous data was summarized with median and interquartile range. Statistical comparisons used Chi-square test for categorical data and rank sum test for continuous data with a significance level of 0.05. Data from the National Cancer Database (NCDB) for the same period was used for comparison. Results: A total of 657 patients at PH were included in the analysis (50.2% Hispanic; 32.3% Black). Median age at diagnosis was 53 years (range 46-61), with 39.1% of patients < 50 (12.3% < 40). The majority of patients were uninsured at the time of diagnosis (67.0%). Hispanic patients were younger than others (median age 49 years (range 43-57) vs 57 (range 48-63), p < 0.01), with 51.2% < 50. Late-stage diagnosis was observed in 30.6% of patients (stage III 16.4%, stage IV 14.2%), and triple negative breast cancer (TNBC) accounted for 22.8% of cases. While the stage distribution was not statistically different between racial and ethnic subgroups (p=0.66), black patients were diagnosed with TNBC at a significantly higher rate compared to others (30.2% vs 19.3%, p < 0.01). Although a trend towards higher rate of HER2(+) disease was noted among Hispanics, this difference did not reach the level of statistical significance (22.7% vs 16.5%, p=0.06). One hundred eighty-nine patients (28.8%) were diagnosed outside PH. Compared to Black patients, Hispanic patients were more often diagnosed in the community (22.2% vs 32.4%, p=0.01). Of the 564 patients with stage I-III, 340 (60.3%) had T2-4 and 203 (36.0%) had node positive disease at diagnosis. Median time to treatment initiation (TTI) was 51 days (range 35-76) and was significantly longer in patients who were diagnosed in the community compared to those diagnosed at PH, median 63 days (range 44-96) vs 48 (range 34-70), p < 0.01. Compared to the NCDB, PH patients were younger (39.1% vs 18.4% < 50 years, p < 0.01), presented at a higher rate with late-stage disease (30.6% vs 13.2%, p < 0.01) and TNBC (22.8% vs 10.7%, p < 0.01), and had a longer median time from diagnosis to treatment initiation - 51 days (range 35-76) vs 33 (range 21-49), p < 0.01. Conclusion: Breast cancer patients at PH were significantly different from the national average, with over a third below the USPSTF recommended breast cancer screening age. The rate of late-stage diagnosis at PH was more than two-fold the national average. Lowering the screening age to 40, expansion of outreach mammography programs, improving patient navigation, and simplifying access to indigent care programs are among strategies to promote health equity. Considering the high disease burden among safety-net patients, a systematic effort to increase resources at safety-net health systems is warranted. Citation Format: Sarah Kashanian, Shifa Kanjwal, L. Steven Brown, Andrea Semlow, Mary Hodges, Robyn Cobb, Brad Walsh, Umber Dickerson, Navid Sadeghi. Characteristics of newly diagnosed breast cancer patients at a large safety-net system: Implications for health equity and care delivery [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-09-05.

Abstract PO4-27-02: Pandemic Shifts: How did elective breast cancer care change?

Abstract Introduction: As the COVID-19 pandemic began, concerns arose that timely utilization of elective breast cancer care would decrease due to state moratoriums, travel restrictions, or fear, resulting in poorer long-term outcomes. Advances in telemedicine provided a new avenue for care; however, rapid implementation brought concerns about variable uptake and disparities. To support longitudinal clinical and epidemiological studies, this analysis described elective breast cancer care utilization during the first year of the pandemic, including patient, hospital, and geographic barriers and facilitators. Methods: The Multidisciplinary Breast Reconstruction Research Program team reviewed all breast cancer surgeries and procedures at The University of Texas MD Anderson Cancer Center during the pre-pandemic (March 1, 2019 to February 29, 2020) and pandemic (March 1, 2020 to February 28, 2021) periods. The team identified procedures that were deemed elective or preference-sensitive, and summarized the timeline of pandemic milestones and changes, including the implementation of telemedicine appointments. A data analyst summarized the distributions of completed, canceled, rescheduled, and never completed procedures. T tests and analyses of variance tested differences between the pre-pandemic and pandemic year. Generalized linear models assessed patient, hospital, and geographic factors that correlated with successful access to, and completion of, procedures. Two focus groups reviewed data and informed the interpretation of results. Results: During the first pandemic year, 30 breast care procedures were identified that were postponed during March-April, July-August, and December-January. Surprisingly, no decrease in overall utilization of elective care procedures was observed; in fact, 19% more elective breast cancer care surgeries and procedures were scheduled (4752 pre-pandemic vs 4003 pandemic) in 13% more episodes of care (2723 pre-pandemic vs 2415 pandemic). As expected, rescheduling of procedures increased 98% (from 14% pre-pandemic to 27% pandemic); however, the majority of procedures were able to be completed by the end of the year (72% pre-pandemic, 73% pandemic). Telemedicine did not significantly mediate successful completion, as the majority of procedures were prophylactic or reconstructive surgeries. However, extended hours (p = 0.03) and proximity to the hospital facilitated access and successful completion of care (p< 0.01). The most common procedures that were not able to be performed within the first year of the pandemic were autologous breast reconstruction, revision, and mastopexy. Notably, patients reported slightly improved rates of anxiety and depression during the initial pandemic year (11% vs 14%, p = 0.04), possibly due to relative privation or comparison bias. Clinicians and patients/survivors noted several “lessons learned” that may inform access and preference-sensitive care delivery. Conclusions: Despite three periods of state-mandated discontinuation of elective care procedures, the majority of patients were able to access and successfully complete elective breast cancer care during the first year of the COVID-19 pandemic. Future studies and initiatives may use this information to explore innovations in care delivery and short- and long-term effects on health outcomes. Citation Format: Haoqi Wang, Greg Reece, Mary Catherine Bordes, Mia Markey, Aubri Hoffman. Pandemic Shifts: How did elective breast cancer care change? [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-27-02.

Abstract PO5-09-06: Outcomes of breast cancer in a minority-enriched population treated at a large safety-net system: Is site of care a predictor of poor outcomes?

Abstract Background: Breast cancer outcomes in the United States continue to improve, but sociodemographic disparities remain prevalent and impact care delivery and outcomes in vulnerable populations. Safety-net health systems are intended to address inequities by providing access to care for the uninsured/underinsured. Care delivery in a safety-net setting is often inherently complicated by limited resources at these institutions. Here, we present the overall survival (OS) data of breast cancer patients treated at a large safety-net system, compared to the national average. Methods: Parkland Health (PH) is the safety-net system for Dallas County and is affiliated with the University of Texas Southwestern Harold C. Simmons Comprehensive Cancer Center (NCI-CCC). Electronic medical records of patients diagnosed with invasive breast cancer between 2018 to 2020 at PH were reviewed and data on demographics, treatment, and outcomes were collected. Categorical data was summarized with counts and percentages and continuous data was summarized with median and interquartile range. Statistical comparisons used Chi-square test for categorical data and rank sum test for continuous data with a significance level of 0.05. Survival data was analyzed using Cox proportional hazard model. Data from the National Cancer Database (NCDB) for the same period was used for comparison. Results: Of the 657 patients included in the study, the majority (82.5%) belonged to racial and ethnic minorities (Hispanic 50.2%; Black 32.3%). Compared to the NCDB, PH patients were more often uninsured (67% vs 1.6%) or enrolled on Medicaid (14.5% vs 6.9%), and less often on Medicare (8.5% v. 43%) (p< 0.01). Triple negative breast cancer (TNBC) phenotype and late-stage diagnosis (stage III/IV) rates were higher at PH compared to NCDB (TNBC 22.8% vs 10.7%, p< 0.01; late stage 30.6% vs 13.2%, p< 0.01). At a median follow up of 33 (range 24-43) months in PH and 28 (range 21-36) months in NCDB, the unadjusted OS for the PH population was 86.3% vs 92.6% for the NCDB population (p < 0.01). Within the PH population, Black race, higher stage, and TNBC were associated with decreased OS. There was a significant interaction between Black race and TNBC. When combining all patients (PH+NCDB), site of care (PH) was associated with a higher risk of death from breast cancer (HR 1.467, 95% CI 1.192-1.805, p< 0.0005), however, multivariate analysis did not show a significant difference based on site of care. Factors associated with a significantly increased risk of death in this multivariate analysis (corrected for interaction between Black race and TNBC phenotype) included age, late-stage diagnosis, TNBC, Black race, and uninsured status (Table 1). Conclusions: Breast cancer patients treated at PH were more likely to have adverse disease characteristics compared to the NCDB population. When accounting for these risk factors in multivariate analysis, patients treated at PH had similar outcomes compared to the national average. Our findings reinforce the critical role of safety-net systems in promoting health equity and eliminating disparities. Table 1 Citation Format: Sarah Kashanian, Shifa Kanjwal, L. Steven Brown, Andrea Semlow, Mary Hodges, Robyn Cobb, Brad Walsh, Umber Dickerson, Navid Sadeghi. Outcomes of breast cancer in a minority-enriched population treated at a large safety-net system: Is site of care a predictor of poor outcomes? [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-09-06.

The impact of devaluing Women of Color: stress, reproduction, and justice.

This commentary is in response to the Call for Papers put forth by the Critical Midwifery Studies Collective (June 2022). We argue that due to a long and ongoing history of gendered racism, Women of Color are devalued in U.S. society. Devaluing Women of Color leads maternal healthcare practitioners to miss and even dismiss distress in Women of Color. Theresult is systematic underdiagnosis, undertreatment, and the delivery of poorer care to Women of Color, which negatively affects reproductive outcomes generally and birth outcomes specifically. These compounding effects exacerbate distress in Women of Color leading to greater distress. Stress physiology is ancient and intricately interwoven with healthy pregnancy physiology, and this relationship is a highly conserved reproductive strategy. Thus, where there is disproportionate or excess stress (distress), unsurprisingly, there are disproportionate and excess rates of poorer reproductive outcomes. Stress physiology and reproductive physiology collide with social injustices (i.e., racism, discrimination, and anti-Blackness), resulting in pernicious racialized maternal health disparities. Accordingly, the interplay between stress and reproduction is a key social justice issue and an important site for theoretical inquiry and birth equity efforts. Fortunately, both stress physiology and pregnancy physiology are highly plastic-responsive to the benefits of increased social support and respectful maternity care. Justice means valuing Women of Color and valuing their right to have a healthy, respected, and safe life.

Bridging the mismatch: observing the introduction of new anesthesia technology for a low-resource environment.

The objective of this study was to examine the impact of the introduction of the Universal Anaesthesia Machine (UAM), a device designed for use in clinical environments with limited clinical perioperative resources, on the choice of general anesthesia technique and safe anesthesia practice in a tertiary-care hospital in Sierra Leone. We introduced an anesthesia machine (UAM) into Connaught Hospital, Freetown, Sierra Leone. We conducted a prospective observational study of anesthesia practice and an examination of perioperative clinical parameters among surgical patients at the hospital to determine the usability of the device, its impact on anesthesia capacity, and changes in general anesthesia technique. We observed a shift from the use of ketamine total intravenous anesthesia to inhalational anesthesia. This shift was most demonstrable in anesthesia care for appendectomies and surgical wound management. In 10 of 17 power outages that occurred during inhalational general anesthesia, anesthesia delivery was uninterrupted because inhalational anesthesia was being delivered with the UAM. Anesthesia technologies tailored to overcome austere environmental conditions can support the delivery of safe anesthesia care while maintaining fidelity to recommended international anesthesia practice standards.

General practice nurse perceptions of barriers and facilitators to implementation of best-practice dementia care recommendations—a qualitative interview study

IntroductionWith an aging population and a growing prevalence of people living with dementia, the demand for best-practice dementia care in general practice increases. There is an opportunity to better utilise the nurse role within the primary care team to meet this increasing demand in the provision of care for people living with dementia. However, general practice nurses have limited knowledge in the provision of best-practice care for people living with dementia and their carer(s). A number of best-practice dementia care recommendations contained in the Australian Clinical Practice Guidelines and Principles of Care for People with Dementia have been identified as highly relevant to the role of the general practice nurse.AimsTo explore general practice nurses’ perspectives on published best-practice dementia care recommendations relevant to their role and identify barriers and facilitators to their implementation into clinical practice.MethodsThirteen Australian general practice nurses took part in this qualitative interview study. The research questions for this study were addressed within a paradigmatic framework of social constructionism. Data were transcribed verbatim and thematically analysed.ResultsThere was a high level of agreement between general practice nurses that the recommendations were important, reflected best-practice dementia care and were relevant to their role. However the recommendations were perceived as limited in their usefulness to nurses’ clinical practice due to being too vague and lacking direction. Four main themes were identified describing barriers and facilitators to operationalising best-practice dementia care.: creating a comfortable environment; changing approach to care; optimising the general practice nurse role and working collaboratively. Nine sub-themes were described: physical environment; social environment; complexity of care; care planning for the family; professional role and identity, funding better dementia care, education, networking and resources; different roles, one team; and interagency communication.ConclusionThis study identified several factors that need addressing to support general practice nurses to integrate best-practice dementia care recommendations into daily clinical practice. The development of interventions needs to include strategies to mitigate potential barriers and enhance facilitators that they perceive impact on their delivery of best-practice care for people living with dementia and their carer(s). The knowledge gained in this study could be used to develop multi-faceted interventions informed by theoretical implementation change models to enable the general practice nurse to operationalise best-practice dementia care recommendations.

Abstract PS18-08: Bridging Disparities in Survivorship Care: Leveraging Telehealth for Diverse Patients in Safety Net Hospital

Abstract Background There are 3.8 million breast cancer survivors (BCS) in the United States and 67-88% of them report unmet needs in survivorship care. With advancements in breast cancer treatment and improved survival rates, there is a growing need to expand survivorship care to address the long-term physical, psychosocial, and medical needs of cancer survivors. There is a significant disparity in access to high-quality survivorship care, particularly for diverse patient populations in safety net hospitals. BCS in marginalized communities experience worse health-related quality of life (HRQOL) outcomes following cancer treatment in the management of symptoms, complications of treatment, and overall health-related distress. Thus, new models that leverage complex care management principles and novel care delivery systems, such as telehealth, are needed to provide multidisciplinary care and support for self-management. Methods We conducted a single-arm, pilot intervention trial of telehealth group medical visits (tGMV) in a safety net hospital serving low-income and racially and ethnically diverse BCS. The study team included physicians, advanced practitioners, PCPs, clinical psychologists, nurses, dieticians, exercise instructors, Traditional Chinese Medicine practitioners, sexual health counselors, research coordinators, and patient navigators. We enrolled a total of 6 cohorts of 7-10 BCS for the tGMV intervention (2 cohorts each in English, Spanish, and Cantonese). Each cohort had four weekly sessions on the following topics: 1) Reclaiming your health after cancer, 2) Managing emotional health, 3) Sexual health and relationship, and 4) Food is medicine. All participants were trained on the telehealth video conference platform. The curriculum was culturally adapted in the Spanish and Cantonese cohorts. Study staff followed up with participants by phone after each session. We evaluated feasibility and acceptability as primary outcomes with prespecified thresholds for >90 % completion of planned sessions and >70% attendance. Participants’ evaluation of the intervention and self-efficacy were secondary outcomes, which are not reported in this abstract. Results Fifty-three women with stage I-III breast cancer were enrolled in the study. The age was 37 to 75 (median: 58). There were 14 (26%) English-speaking participants, 19 (36%) Spanish-speaking participants, and 20 (38%) Cantonese-speaking participants. Eight (15%) participants identified as White, three (5.7%) Black A/A, 23 (43%) Asians, and 19 (36%) Hispanic; 43 (81%) participants were foreign-born. Twenty-seven (51%) participants reported food insecurity on the screening survey. The overall attendance rate was 98% (English: 97%, Spanish: 97%, and Cantonese: 100%). Of the 53 participants, 41 (77%) found the telehealth format acceptable, 47 (88%) agreed/strongly agreed that it was easy to log in and stay connected, 53 (100%) agreed/strongly agreed that tGMV were a good use of their time, 52 (98%) understood the purpose of the telehealth format, and 50 (94%) felt the information was easy to understand. Conclusions Telehealth-delivered group medical visits are feasible and acceptable in a safety net setting and are a promising intervention that may help in addressing the unmet needs of cancer survivors. We also found that despite the reported low uptake of telehealth in safety net settings, emphasis on training and technical support during sessions can increase the utilization of telehealth. Citation Format: Ivan Leung, Evelin Trejo, Ana Velázquez Mañana, Elizabeth Castillo, Barbara Cicerelli, Robin McBride, Piera Wong, Huiyu Xie, Lily Zhang, Nancy Burke, Niharika Dixit. Bridging Disparities in Survivorship Care: Leveraging Telehealth for Diverse Patients in Safety Net Hospital [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS18-08.

Virtual mental health inpatient wards: from inception to implementation

Shane Kirwan and colleagues describe the virtual mental health inpatient wards implemented in Ireland in response to the COVID-19 pandemic and discuss the continuing development of this model of care delivery.

Abstract PO4-10-09: MBC Community Barriers and Patient Navigation Training Needs

Abstract Background Komen’s mission is to save lives by meeting the most critical needs in our communities and investing in breakthrough research to prevent and cure breast cancer. One method to achieve our mission is through patient navigation. Evidence supports the role of patient navigation in improving breast health outcomes. Patient navigators identify and address barriers to equitable cancer care delivery in a fragmented healthcare system and work to ease the burdens that patients diagnosed with breast cancer experience. As a valued member of a patient’s health care team, patient navigators contribute to improving the quality of cancer care and eliminating barriers throughout the continuum of care. However, not all breast cancer patients experience the same barriers. Metastatic breast cancer (MBC) is the most advanced stage of breast cancer, and there is some evidence that suggests those diagnosed with MBC have unique experiences and needs that often determine and/or contribute to their disease trajectory. Despite this, little in-depth systematic work has been done to understand the unique challenges faced by those diagnosed with MBC or to explore strategies to address those challenges, and there have been no known efforts to equip patient navigators to specifically address the unique barriers of those diagnosed with MBC. Methods Susan G. Komen®’s Center for Applied Research (CfAR) designed the MBC Patient Navigation Training research study to improve the health outcomes of those diagnosed with MBC through patient navigation. The study design includes 4 phases of qualitative methodology with MBC and patient navigator communities to accomplish the following objectives: Examine the needs and barriers of MBC patients (Phase 1) Identify what needs and barriers MBC patients face that can be addressed through patient navigation (Phase 2) Assess the gaps in Komen's Patient Navigation Training Programs' ability to prepare navigators across the United States to address the identified needs/barriers of MBC patients (Phase 3) Design a new module to fill the gaps in Komen's Patient Navigation Training Program to support patient navigators serving MBC communities across the U.S. (Phase 4) Participants were recruited through a grassroots approach to community engagement, with members of the study team, Komen staff, and other breast health advocates contacting individuals and organizations across the U.S. Individuals were invited to attend a virtual introductory call to meet study staff and each other before consenting to participate in the virtual focus groups. Results Participants diagnosed with MBC (n=17) attended one of four virtual focus groups held May 2023 to share their lived experiences. The focus groups were recorded, the recordings were transcribed and checked for accuracy, and study staff analyzed data using a constant comparison approach to qualitative data analysis with NVivo data management software. Those diagnosed with MBC identified challenges of their diagnosis, barriers within the healthcare system, financial toxicity, lack of support, and health inequities as factors limiting their access to care. These participants also identified the role patient navigators could serve to help address these challenges. Next Steps In Phase 2, the study team will examine to what extent patient navigators feel prepared to address the barriers of MBC communities. Based on the findings from this study, the team will identify areas where more training is needed (Phase 3) and design a training module for Komen’s Patient Navigation Training Program (Phase 4) to better prepare patient navigators across the U.S. to meet the needs of MBC communities and improve health outcomes and cancer care delivery. Citation Format: Stephanie McCoy, Kyandra Fox, Kasey Volpe, Toni Lee, Janet Okamoto, Julie McMahon, Kari Wojtanik. MBC Community Barriers and Patient Navigation Training Needs [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-10-09.

The Impact of Alcohol-Related Presentations to Emergency Departments on Days with a Public Holiday or Sporting Event: A Retrospective Cohort Study.

The consumption of alcohol within the Australian community continues to rise, impacting care delivery in already over-burdened emergency departments (EDs). This study aimed to examine the impact of alcohol-related presentations (ARPs) to EDs on days with a public holiday or sporting event. A retrospective cohort study was undertaken using routinely collected health data pertaining to patient presentations diagnosed with an alcohol-related disorder (ICD-10-AM code F10) to two EDs in Queensland, Australia from January 1, 2016 - December 31, 2020. Descriptive and inferential statistics were used to describe and compare ARPs on event days versus non-event days and uncomplicated versus other ARPs on event days only. Of all 5,792 ARPs, nine percent (n = 529) occurred on public holidays or sporting event days. When compared by day type, type of presentation, mode of arrival, and day of week differed between event and non-event days. On event days, uncomplicated ARPs differed to other ARPs, with uncomplicated ARPs being younger, having shorter median length-of-stay (LOS), and less likely to be admitted to hospital. In this multi-site study, public holidays and sporting events had a noteworthy impact on ARPs to EDs. Focused refinement on the clinical management of uncomplicated ARPs is warranted to inform future resource allocation, including on event days.

“Hypertension is such a difficult disease to manage”: federally qualified health center staff- and leadership-perceived readiness to implement a technology-facilitated team-based hypertension model

BackgroundDespite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City.MethodsDuring a dedicated pre-implementation period (3–9 months/site, 2021–2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR).ResultsMost survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0–1), evidence-based practice attitudes (mean = 2.7, range = 0–4), and implementation leadership (mean = 2.5, range = 0–4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares.ConclusionsThis study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success.Trial registrationClinicalTrials.gov NCT03713515, date of registration: October 19, 2018.

Abstract PO5-05-04: Advancing Treatment and Management of Patients with HR+/HER2- Breast Cancer: Findings from a Quality Improvement Initiative

Abstract Background: With the advent of novel oral oncolytics, the cancer care delivery model for HR+/HER2- breast cancer (BC) is evolving, shifting the responsibility for medication adherence and monitoring and managing of side effects to patients and their caregivers. In this quality improvement (QI) initiative, we aimed to uncover and address gaps in patient and provider education, risk reduction, adverse event management, and shared decision-making in order to improve outcomes for HR+/HER2+ patients on oral oncolytics. Methods: From 9/2022 to 12/2022, 54 HCPs who treat breast cancer and 111 HR+/HER2- BC patients from 4 US community oncology clinics completed surveys assessing attitudes, values, and challenges related to practice patterns, education, and therapy adherence in HR+/HER2- BC. HCPs participated in audit-feedback sessions to reflect on survey results and their own practice, and developed action plans to improve care, which were implemented in subsequent collaborative patient-provider learning sessions. Results: Top reported HCP challenges in HR+/HER2- BC care include providing patient-centered supportive care measures (32%), patient adherence/lack of follow up (22%), and individualizing treatment plans (17%). Additionally, 43% of providers reported that improved collaboration across interprofessional teams would most improve care. Top reported patient challenges include worry about and/or difficulty managing side effects from treatment (26%), difficulty scheduling visits with many different HCPs/following up (24%), and difficulty communicating with healthcare teams (16%). In surveys, 28% of patients reported frequently or very frequently missing/skipping doses of oral breast cancer medication. Top reasons for missing/skipping doses included forgetting or not having it nearby (36%), cost (21%), and side effects (20%). To address the top challenges identified in baseline surveys, HCPs developed and implemented action plans, such as improving the identification of patients at high risk of recurrence, establishing patient-provider educational sessions, increasing the use of patient navigators, incorporating oral adherence toolkits, and educating patients and staff about available supportive care resources. After implementation of patient-provider collaborative education sessions at community clinics, patients reporting high levels of knowledge about BC treatment options and communicating side effects/symptoms increased from 27% to 57%, and 37% to 77%, respectively. At 60-day follow-up, 58% of patients reported taking a more active role in treatment decision-making, and 52% reported setting reminders/alarms/using apps to remember to take medication on time. Conclusions: Patient adherence to oral oncolytic medications remains a challenge in BC treatment. This quality improvement initiative uncovered underlying barriers to effective treatment management of HR+/HER2- breast cancer patients on oral oncolytics. Action plans and educational resources were developed and implemented to address identified barriers and optimize treatment management for HR+/HER2- BC. These methods and findings represent key opportunities for improvement that can be implemented in community oncology practices to improve adherence to oral oncolytics and overall HR+/HER2- breast cancer care. Citation Format: Jane Meisel, Chelsie Anderson, Ilona Dewald, Jeffrey Carter, Cherilyn Heggen, Kelly McKinnon. Advancing Treatment and Management of Patients with HR+/HER2- Breast Cancer: Findings from a Quality Improvement Initiative [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-05-04.

Abstract PO3-11-02: Characterizing Breast Cancer Care Fragmentation Among Young Black Women Diagnosed with Breast Cancer

Abstract Introduction Fragmented cancer care is defined as receiving care across multiple institutions. The National Academy of Medicine has identified cancer care fragmentation as a priority area for cost reduction. However, little is known about the role of fragmented care on receipt of guideline-recommended care patient-reported outcomes, particularly among populations affected by health inequities like Black women. The objective of this study was to characterize breast cancer care fragmentation among a population-based cohort of young Black women with breast cancer. Methods Study participants were a population-based sample of self-identified Black women diagnosed with invasive breast cancer at or below age 50, recruited since 2017 through the Florida and Tennessee state cancer registries. As part of the study, participants completed baseline questionnaires about their cancer care delivery experiences. Participants were eligible if they self-reported the locations where they received their cancer treatment (i.e., diagnosis, surgery, chemotherapy, and radiation). Indicator variables for care fragmentation were created to identify participants who received their diagnosis, surgery, chemotherapy, and radiation within the same health system and those who received their cancer care across multiple health systems. Chi-squared tests were used to assess the relationship between care fragmentation, receipt of guideline-recommended genetic testing, and self-rated health. Self-rated health was dichotomized into Excellent/Very Good/Good and Fair/Poor. Results A total of 183 Black women diagnosed breast cancer ≤ age 50 were included in the analysis. Among the included participants, 11% (n=20) only had surgery, 15% (n=27) had surgery and radiation, 17% (n=31) had surgery and chemotherapy, and 57% (n=105) had surgery, chemotherapy, and radiation. Among the 105 women who had surgery, chemotherapy, and radiation, 17% (n=17) received all cancer treatment within the same health system of diagnosis, 21% (n=21) received all cancer treatment within the same health system but were diagnosed within a different health system, and the remaining 62% of participants received their cancer treatment across different health systems, representing care fragmentation. In chi-squared analyses, fragmented care was not associated with lower receipt of genetic testing(p=0.33) or self-rated health (p=0.28). Conclusion In this population-based study, most participants had fragmented breast cancer care, however fragmentation was not associated with lower self-rated health or receipt of guideline-recommended germline genetic testing. Current approaches for assessing care fragmentation are often too coarse to capture the complexity of breast cancer care delivery and service availability. Patient-centered conceptual models of what drives cancer care fragmentation and the specific aspects of fragmentation that have the potential to drive adverse outcomes are critical. Citation Format: Mya Roberson, Jordyn Brown, Brianna Taffe, Anne Weidner, Lindsay Venton, Sonya Reid, Tuya Pal. Characterizing Breast Cancer Care Fragmentation Among Young Black Women Diagnosed with Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-11-02.

Digitally Mediated Relationships: How social representation in technology influences the therapeutic relationship in primary care.

Relationships, built on trust, knowledge, regard, and loyalty, have been demonstrated to be fundamental to health care delivery. Strong relationships between patients and providers have been linked to more compassionate care delivery, and better patient experience and outcomes, and may be particularly important in primary care models. The rapid adoption of digital technologies since the onset of COVID-19 has led health care systems to seriously consider a “digital-first” primary care delivery model. Questions remain regarding what impact this transformation will have on the therapeutic relationship. Using a rapid ethnographic approach this study explores how patient and provider understandings of therapeutic relationships and digital health technologies may influence relationship-building or maintenance between patients with complex care needs and their care providers. Three team-based primary care sites in Toronto, Ontario, Canada were included in the study. Across the three sites 9 patients with chronic health conditions, 1 caregiver, and 10 healthcare providers (including family physicians, family medicine residents, social workers, and nurse practitioners) participated. Interviews were conducted with all participants and 8 observations of virtual clinical encounters (phone and video visits) were conducted. Using social representation theory as a lens, analysis revealed that participants’ constructions of therapeutic relationships and digital technologies were informed by their identities, experiences, and expectations. For participants to see technologies as enabling to the therapeutic relationship, there needed to be alignment between how participants viewed the role of technology in care and in their lives, and how they recognized (or constructed) a good therapeutic relationship. This exploratory work suggests the need to think about how both patients’ and providers’ views of technology may determine whether digital technologies can be leveraged to meet patient needs while maintaining, or building, strong therapeutic relationships.

Workplace microaggressions: results of a survey of the American College of Surgeons members

BackgroundWorkplace microaggressions are a longstanding but understudied problem in the surgical specialties. Microaggressions in healthcare are linked to negative emotional and physical health outcomes and can contribute to burnout and suboptimal delivery of patient care. They also negatively impact recruitment, retention and promotion, which often results in attrition. Further attrition at the time of an impending surgical workforce shortage risks compromising delivery of health care to the diverse US population and may jeopardize the financial stability of health care organizations. To date, studies on microaggressions have consisted of small focus groups comprised of women faculty or trainees at a single institution. There are no large, multi-organizational, gender-inclusive studies on microaggressions experienced by practicing surgeons. Objective(s)To examine the demographic and occupational characteristics of surgeons who do and do not report experiencing workplace microaggressions and whether these experiences would influence a decision to pursue a career in surgery again. Study DesignWe developed and internally validated a web-based survey to assess surgeon experiences with microaggressions and associated sequelae. The survey was distributed through a convenience sample of nine American College of Surgeons (ACS) online Communities from November 2022 to January 2023. All ACS Communities comprised members who had completed residency or fellowship training and had experience in the surgical workforce. The survey contained demographic, occupational, and validated microaggression items. Analyses include descriptive and chi-squared statistics, t-tests, and bivariable and multivariable logistic regression. ResultsThe survey was completed by 377 ACS members with the following characteristics: working as a surgeon (80.9%), non-Hispanic white (71.8%), general surgeons (71.0%), age ≥ 50 years (67.4%), fellowship-trained (61.0%), and women (58.4%). A total of 254 (67.4%) respondents reported experiencing microaggressions. Younger surgeons (p=0.002), women (p<0.001) and fellowship-trained surgeons (p=0.001) were more likely to report experiencing microaggressions than their counterparts. Surgeons working in academic medical centers or healthcare systems with teaching responsibilities were more likely to experience microaggressions than those in private practice (p<0.01). Surgeons currently working as a surgeon or those who are unable to work reported more experience with microaggressions (p=0.003). There was no difference in microaggressions experienced among respondents by surgical specialties, race/ethnicity, or for surgeons with a self-reported disability. In multivariable logistic regression, women had higher odds of experiencing microaggressions than men [aOR 15.9; 95% C.I.: 7.7-32.8] and surgeons in private practice had significantly lower odds of experiencing microaggressions compared to surgeons in academic medicine (aOR 0.3; 95% C.I. 0.1-0.8) or in healthcare systems with teaching responsibilities (aOR 0.2; 95% C.I. 0.1-0.6). Among surgeons responding to an online survey, respondents reporting microaggressions were less likely to say they would choose a career in surgery again (p<0.001). ConclusionsSurgeons reporting experience with microaggressions reflect the diversification of surgical specialties and subspecialties. With continued expansion of surgeon gender and race/ethnicity representation, deliberate efforts to address and eliminate workplace microaggressions could have broad implications for improving recruitment and retention of surgeons.

Rapid Implementation of the Virtual Clinic Concept in an Oncology Department to Minimize the Exposure of Patients with Cancer to COVID-19.

The global pandemic was an emerging challenge that significantly impacted healthcare systems and the delivery of care. Prompt actions and adaptive techniques, such as the virtual clinic, were implemented to ensure the quality and continuity of the care provided. The aim of this quality improvement project was to ensure the smooth implementation and effectiveness of the virtual clinic during the COVID-19 crisis. A specialized team of multidisciplinary healthcare providers was established to systematically ensure the implementation of the virtual clinic within the Department of Oncology. The team used multiple Plan-Do-Study-Act (PDSA) cycles of the quality improvement model to achieve the final goal and facilitate the transition to the virtual clinic. A total of 29 weekly virtual clinic sessions were conducted, covering various oncology services. From March to December 2020, 81% of the scheduled patients (3888) responded to virtual clinic calls. Physicians initiated 234 unplanned virtual clinic calls to follow up on a patient's condition. In addition, 916 medications were shipped to patients as needed. A patient satisfaction survey in May 2020 indicated an overall satisfaction rate of 92% with the virtual clinic process. Staff satisfaction was also high (91%), and 88% of the physicians believed that the virtual clinic would continue beyond the pandemic. Implementing the virtual clinic is achievable through following systematic steps and effectively addressing emerging challenges as required. The concept of the virtual clinic was well accepted by patients and staff.