Association of socioeconomic and practical unmet needs with self-reported nonadherence to cancer treatment appointments in low-income Latino and Black cancer patients

Objective. Treatment adherence, with minimal numbers of missed appointments, is an important determinant of survival among cancer patients. This study aims to determine if unmet financial, logistic, and supportive care needs predict self-reported adherence to cancer treatment appointments of chemotherapy and/or radiation among low-income ethnic minority patients.

Design. The sample included 1098 underserved Latino and Black patients recruited from cancer clinics in New York City through the Cancer Portal Project. Participants completed a survey which included sociodemographic, health-related questions and a needs assessment, in their preferred language. Patients’ adherence to chemotherapy and/or radiation treatment appointments was assessed using a self-report.

Results. A sample of 1098 patients (581 Latino and 517 Black cancer patients) was recruited. Forty-two Latino cancer patients (7.4%) and 78 Black cancer patients (15.5%) reported missing treatment appointments. Patients, who experienced four or more unmet needs (odds ratios [OR] = 2.02–3.36), and those with unmet housing needs (OR = 3.10–3.31), were more likely to report missing cancer treatment appointments, regardless of their ethnicity/race. Black patients with unmet supportive care (OR = 2.27) and health insurance needs (OR = 3.80) were more likely to miss appointments. Amongst Latinos, legal health-related issues (OR = 2.51) was a significant predictor of missed appointments.

Conclusions. Among ethnic minority cancer patients, unmet socioeconomic and supportive care needs, housing needs in particular, predicted patient-reported missed radiation, and/or chemotherapy appointments. Future research should focus on exploring the impact of practical and supportive unmet needs on adherence and development of interventions aiming to improve cancer treatment adherence.     

Implementation of Virtual Patients in the Training for Occupational Health in Latin America

Abstract

Health professionals trained in occupational health are essential to reduce the burden of occupational accidents and diseases. However, training resources are limited globally. We aimed to promote occupational health and safety (OHS) using virtual patients (VPs) in Brazil, Chile, and Germany. Virtual patients were created in three Latin-American health centers. So-called “partner VPs” comparing the distinct health care systems were designed. Translation, adaptation to different medical and legal systems, expert review, implementation into under- and postgraduate teaching, and user evaluation were performed. Twelve VPs covering traditional and contemporary OHS issues are available in Spanish, Portuguese, and English. Overall, 2371 students used the VPs. The number of Latin American users who evaluated VP content and relevance for their professional career was statistically significantly higher than the number of German students. VPs are a feasible learning method for OHS in middle-income countries. Partner VPs seem to be useful for teaching global aspects.     

Understanding Why Some Women with a History of Gestational Diabetes Do Not Get Tested for Diabetes

BackgroundThe proportion of women with previous gestational diabetes mellitus (GDM) receiving postpartum diabetes testing is far less than desired. Even in health care systems with high testing rates, some women remain untested. We explored what helps and what hinders women to obtain recommended testing.MethodsIn this mixed methods study, we recruited 139 patients with a history of GDM in their most recent pregnancy (6 months to 4.5 years before study enrollment) from a delivery system that had instituted a quality improvement program to increase postpartum diabetes testing rates. We determined whether they had received a postpartum diabetes test according to American Diabetes Association guidelines. Using survey data, we ran logistic regression models to assess correlates of testing status, and we conducted in-depth interviews with 22 women to provide greater context to their survey responses.ResultsOf the 139 women, 21 women (15%) did not complete recommended diabetes testing. From the survey data, women who visited a primary care provider had 72% (95% CI, 0.09–0.83) lesser odds of not having been tested. From the qualitative interviews, difficulty fitting testing around work and caregiver demands were the most common reasons for not testing. Untested women interpreted providers' reassurances that diabetes would resolve after delivery and lack of reminders to reschedule missed appointments and to complete diabetes testing as indicators that their physicians were not concerned about their diabetes risk.ConclusionsAmong hard-to-reach women, multiple demands on their time were common explanations for not receiving a postpartum diabetes test. Consistent messages regarding long-term diabetes risk during pregnancy, access to postpartum primary care and convenient lab appointments, and systematic reminders to providers and patients are approaches that, in combination, may influence more resistant women to test.     

Challenges with Delivering Gender-Specific and Comprehensive Primary Care to Women Veterans

BackgroundThe growing presence of women veterans in Veterans Administration (VA) settings has prompted the need for greater attention to clinical proficiency related to women's health (WH) primary care needs. Instead of making appointments for multiple visits or referring patients to a WH clinic or alternate site for gender-specific care, a comprehensive primary care model now allows for women veteran patients be seen by primary care providers (PCPs) who have WH training/experience and can see patients for both primary and WH care in the context of a single visit. However, little is currently known about the barriers and facilitators WH-PCPs face in using this approach to incorporate gender-specific services into women veterans' primary care services.MethodsWe conducted qualitative in-depth interviews with 22 WH-PCPs at one Midwestern VA Medical Center. All participants were members of one of four outpatient primary care clinics within the main medical center, one off-site satellite clinic, or two off-site community-based outpatient clinics.ResultsInductive thematic analysis identified six themes: 1) Time constraints, 2) importance of staff support, 3) necessity of sufficient space and equipment/supplies, 4) perceptions of discomfort among patients with trauma histories, 5) lack of education/training, and 6) challenges with scheduling/logistics.ConclusionAlthough adequate staff was a key facilitator, the findings suggest that there may be barriers that undermine the ability of VA WH-PCPs to provide high-quality, comprehensive primary and gender-specific care. The nature of these barriers is multifactorial and multilevel in nature, and may therefore require special policy and practice action.     

Patient satisfaction among spanish-speaking patients in a public health setting

Despite the growing literature on health care quality, few patient satisfaction studies have focused upon the public health setting; where many Hispanic patients receive care. The purpose of this study was to examine the differences in satisfaction between English and Spanish-speaking patients in a local health department clinical setting. We conducted a paper-based satisfaction survey of patients that visited any of the seven Jefferson County Department of Health primary care centers from March 19 to April 19, 2008. Using Chi-squared analyses we found 25% of the Spanish-speaking patients reported regularly having problems getting an appointment compared to 16.8% among English-speakers (p < .001). Results of logistic regression analyses indicated that, despite the availability of interpreters at all JCDH primary care centers, differences in satisfaction existed between Spanish and English speaking patients controlling for center location, purpose of visit, and time spent waiting. Specifically, Spanish speaking patients were more likely to report problems getting an appointment and less likely to report having their medical problems resolved when leaving their visit as compared to those who spoke English. Findings presented herein may provide insight regarding the quality of care received, specifically regarding patient satisfaction in the public health setting.     

“Which Clinic? Pre-Covid or Post-Covid?”: Immigration Policy Uncertainty,Immigrant Serving Organization,and the Response to COVID-19

Background

This article examines how immigration policy uncertainty during the Trump presidency shaped how immigrant serving organizations (ISOs) responded to the needs of immigrant community members in the first six months of the COVID-19 pandemic.

Methods

We draw on semi-structured interviews conducted over the summer of 2020 with 31 directors and program coordinators of ISOs and health clinics in three southern states (KY, NC, SC).

Results

Responding to anti-immigrant policies laid the groundwork for organizations to respond quickly and nimbly to COVID-19 related upheavals. However, organizational flexibility may signal organizational precarity, especially given the long-term impacts of both Trump administration immigration policies and the COVID-19 pandemic.

Discussion

Our findings underline how ISOs facilitate access to health and social services for immigrant families. Our findings suggest that this organizational adaptability may signal a relationship between organizational precarity and immigration policy uncertainty that could have an impact well beyond the pandemic.

     

Modelos para el análisis de políticas públicas en salud reportados en publicaciones científicas

ObjectiveTo summarize public health policy models reported in studies published between 2002-2017.MethodUsing MesH vocabulary, we systematically searched articles in English, Spanish and Portuguese in the PubMed, Scielo, Jstor, ProQuest and Google Scholar data-bases. The quality of the articles was assessed using the tool for understanding a qualitative study by CASPe.ResultsA higher proportion of scientific studies were conducted in the African continent. The policies relating to health care were most frequently investigated. Walt and Gilson's model and Kingdon's multiple streams framework were more frequently reported.ConclusionsThe articles set out the public policy analysis model, but not the approach to guide it. A more robust theoretical body needs to be built to enable discussion about the approaches and models for the analysis of public policies. Its distinction is relevant, since it can order methodological proposals for the study of policies.     

Identified mental disorders in older adults in primary care: A cross-sectional database study

Introduction: Identifying and managing mental disorders among older adults is an important challenge for primary care in Europe. Electronic medical records (EMRs) offer considerable potential in this regard, although there is a paucity of data on their use for this purpose.

Objectives: To examine the prevalence/treatment of identified mental disorders among older adults (over 55 years) by using data derived from EMRs in general practice.

Methods: We utilized data from a cross-sectional study of mental disorders in primary care, which identified patients with mental disorders based on diagnostic coding and prescribed medicines. We collected anonymized data from 35 practices nationally from June 2014 to March 2015, and secondary analysis of this dataset examined the prevalence of mental disorders in adults aged over 55 years.

Results: 74,261 patients aged over 55 years were identified, of whom 14,143 had a mental health disorder (prevalence rate of 19.1%). There was considerable variation between practices (range: 3.7–38.9%), with a median prevalence of 23.1%. Prevalence increased with age, from 14.8% at 55–59 years to 28.9% at 80–84 years. Most common disorders were depression (17.1%), panic/anxiety (11.3%), cognitive (5.6%), alcohol (3.8%) and substance use (3.8%).

Conclusions: Examining mental disorders among older adults using data derived from EMRs is feasible. Mental disorders are common among older adults attending primary care and this study demonstrates the utility of electronic medical records in epidemiological studies of large populations in primary care.     

Language and use of cancer screening services among border and non-border Hispanic Texas women

Objectives. Compared to other groups, Mexican American women screen less frequently for cervical and breast cancer. The most significant barriers reported by previous researchers include not having a usual source of care, lacking health insurance and English-language difficulties. In this paper we document and examine the factors associated with disparities in cancer screening between border and non-border residents by language of interview (Spanish or English) among Texas Hispanic women. We hypothesize that, controlling for socioeconomic and demographic characteristics, border residents are more likely to utilize screening services than non-border residents because of the greater presence of bilingual services in border counties.

Design. We follow the framework of the Behavioral Model for Vulnerable Populations proposed by Gelberg et al. (Health Services Research, vol. 34, no. 6, pp. 1273–1302, 2000). This model conceptualizes use of health care as an outcome of the interplay of predisposing, enabling and need factors and recognizes that vulnerable groups face additional barriers to health care utilization. Data come from the 2000, 2002 and 2004 Texas Behavioral Risk Factor Surveillance surveys.

Results. Group differences in cancer screenings are explained largely by socioeconomic characteristics and structural barriers to access. The significance of language of interview and of border residence disappear after controlling for factors such as health insurance, income and a usual source of care.

Conclusion. Women who selected to be interviewed in Spanish were less likely to report age-appropriate cancer examinations, health insurance and a regular health care provider than those who selected to be interviewed in English. Disparities in cancer screenings among vulnerable Hispanic populations could be reduced by promoting the establishment of a regular health care provider.     

Patient education in chronic heart failure in primary care (ETIC) and its impact on patient quality of life: design of a cluster randomised trial

Background

Fatigue is a common yet difficult to treat condition in primary care. The objective of this study is to evaluate the cost-effectiveness of a brief cognitive behavioral therapy (CBT) based fatigue self-management (FSM) intervention as compared to usual care among patients with chronic fatigue in primary care.

Methods

An economic evaluation alongside of a parallel randomized controlled study design was used. Computer-generated variable-sized block randomization plan was used to assign patients into treatment groups and data collection staff were blinded to group assignments. Patients aged between 18 and 65 years with at least six months of persistent fatigue and no medical or psychiatric exclusions were enrolled from a large primary care practice in Stony Brook, New York. The FSM group (n = 37) received two sessions of a nurse-delivered, fatigue self-management protocol and a self-help book and the usual care group (n = 36) received regular medical care. The effectiveness measure was the Fatigue Severity Scale and the cost measure was total health care expenditures derived from monthly health services use diaries during follow-up. A societal perspective was adopted and bootstrapped incremental cost-effectiveness ratios (ICERs) and net monetary benefit (NMB) were calculated as measures of cost-effectiveness.

Results

The ICER for FSM was -$2358, indicating that FSM dominates UC and it may generate societal cost savings as compared to usual care. Complete case analysis yielded smaller ICER (-$1199) with greater uncertainties. Net monetary benefit analysis showed that FSM has a probability of 0.833 (95% CI: 0.819, 0.847) to achieve positive NMB and the favorable results were not sensitive to assumptions about informal care or treatment costs.

Conclusion

This economic evaluation found initial evidence that a two-session brief CBT-based FSM may be cost-effective as compared to usual care over 12 months. The FSM intervention is potentially a promising intervention for chronic fatigue patients in primary care. Additional research is needed to examine the reproducibility and generalizability of these findings.

Trial registration

ClinicalTrials.gov (NCT00997451, March 28, 2009).

     

Nutrition and Swallowing Therapy in Head and Neck Cancer: Utilization of Care and Preventative Efficacy

Purpose: To examine the impact of ethnicity, Spanish language preference, socioeconomic status, and treatment setting on utilization of supportive services before radiotherapy (RT) among head and neck cancer patients and to determine whether a lack of these services is associated with an increased rate of adverse events.

Methods and Materials: Demographic, staging, and treatment details were retrospectively collected for patients treated at a safety-net hospital (n?=?56) or adjacent private academic hospital (n?=?183) from January 1, 2014, to June 30, 2016. Supportive care services evaluated were limited to speech/swallowing therapy and nutrition therapy. Adverse events and performance measures examined included weight loss during RT, gastric tube placement, emergency department visits, hospital admissions, and missed RT days.

Results: On multivariable analysis, patients receiving treatment at the safety-net hospital were less likely to receive speech/swallowing services. Receiving speech/swallowing therapy before treatment was associated with less weight loss during treatment, and in conjunction with nutrition therapy, was associated with fewer missed RT days.

Conclusion: Safety-net hospital treatment was associated with a lack of utilization of pre-RT speech/swallowing therapy which in turn was associated with increased weight loss. Interventions aimed at improving utilization of these services would improve treatment tolerance and patient outcomes.     

Immigrants and the Affordable Care Act: Changes in Coverage and Access to Care by Documentation Status

Little is known about the effects of the ACA’s coverage expansion among immigrant groups of differing immigration status. Using data from the California Health Interview Survey (2003–2016), we compare changes in health coverage and access to care among immigrants in California before and after implementation of the ACA. We find that the ACA has led to major gains in coverage for lawful permanent residents in California, similar in scope to changes among citizens. However, unauthorized immigrants have experienced only modest increases in coverage, with the result disparity in uninsured rates for this group relative to citizens and permanent residents widening considerably since 2014. Findings indicate a significant increase in having a usual source of care across all groups, but without a significant change in disparities for this outcome. Our results have important implications for the intersection of health policy, immigration, and health equity.

     

Birthing Experiences of Spanish Speakers During the COVID-19 Pandemic in NYC

Patient-provider language discordance is known to negatively affect patient experiences. This study describes the birth experience during COVID-19 among monolingual Spanish and bilingual Spanish/English speakers. Qualitative videoconference interviews with 15 monolingual Spanish and 15 bilingual Spanish/English patients that gave birth during the COVID-19 pandemic at a NYC tertiary-care hospital. 93% of participants had a positive birthing experience. Common themes were quality of care, birth outcome, and supportive staff. 80% of patients lacked a support person postpartum. 27% of Spanish-only speakers felt that an interpreter should have been provided but was not, and 47% felt the experience would have been different if they spoke English. The patient birth experience is tied to birth outcomes and quality of care and remained positive during the beginning of the COVID-19 pandemic. Restrictions on support people during the intra- or postpartum impacted the birthing experience more than provider language discordance.

     

Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study

BackgroundWidespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team‐based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care.ObjectiveThe main study objective was to understand patients’ perspectives on the quality of care that they received for anxiety and depression in primary care teams.MethodsThis was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data.ResultsForty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs.ConclusionGreater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.     

Variation in Hospice Experiences by Care Setting for Patients With Dementia

ObjectivesUse of hospice care among patients with dementia has been steadily increasing. Our objectives were to characterize quality of hospice care experiences among decedents who had a primary diagnosis of dementia and their caregivers and investigate differences across settings of hospice care.DesignWe analyzed Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data from caregiver respondents whose family members received hospice care.Setting and ParticipantsData from 96,845 caregiver respondents whose family members had a primary diagnosis of dementia and died in 2017 or 2018 while receiving hospice care in 2829 hospices.MethodsWe calculated quality measure scores overall and stratified by setting, adjusting for mode of survey administration and differences in case mix, and examined variability in hospice-level scores among decedents with dementia.ResultsMean quality measure scores ranged from 69.0 (Getting Hospice Care Training) to 90.9 (Getting Emotional Support). Measure scores varied significantly across settings, with caregivers of decedents who received care in a nursing home (NH), acute care hospital (ACH), or assisted living facility (ALF) consistently reporting poorer quality of care. Hospice-level scores varied substantially, with a wide range between the 10th and 90th percentiles of hospice performance (eg, 25 points).Conclusions and ImplicationsThere are important opportunities to improve hospice care for patients with dementia and their caregivers, particularly with respect to caregiver training, symptom management, and across all dimensions within the NH, ACH, and ALF settings. Variability in care experiences across hospices, as well as long lengths of stay for those with dementia, highlight the importance of informed and timely hospice referral.     

Complementary or alternative? The use of homeopathic products and antibiotics amongst pre-school children

Background

Colorectal cancer screening rates are low among disadvantaged patients; few studies have explored barriers to screening in community health centers. The purpose of this study was to describe barriers to/facilitators of colorectal cancer screening among diverse patients served by community health centers.

Methods

We identified twenty-three outpatients who were eligible for colorectal cancer screening and their 10 primary care physicians. Using in-depth semi-structured interviews, we asked patients to describe factors influencing their screening decisions. For each unscreened patient, we asked his or her physician to describe barriers to screening. We conducted patient interviews in English (n = 8), Spanish (n = 2), Portuguese (n = 5), Portuguese Creole (n = 1), and Haitian Creole (n = 7). We audiotaped and transcribed the interviews, and then identified major themes in the interviews.

Results

Four themes emerged: 1) Unscreened patients cited lack of trust in doctors as a barrier to screening whereas few physicians identified this barrier; 2) Unscreened patients identified lack of symptoms as the reason they had not been screened; 3) A doctor's recommendation, or lack thereof, significantly influenced patients' decisions to be screened; 4) Patients, but not their physicians, cited fatalistic views about cancer as a barrier. Conversely, physicians identified competing priorities, such as psychosocial stressors or comorbid medical illness, as barriers to screening. In this culturally diverse group of patients seen at community health centers, similar barriers to screening were reported by patients of different backgrounds, but physicians perceived other factors as more important.

Conclusion

Further study of these barriers is warranted.     

Negotiating old and new ways: contextualizing adapted health care-seeking behaviors of Korean immigrants in Hawaii

Objective. Korean immigrants have been identified as one of the most disadvantaged ethnic groups in terms of health insurance coverage and health care access in the USA. Korean immigrants enjoyed access to primary and preventive care services in their home country. This study explores how Korean immigrants' health-seeking behaviors are reconstructed by contextualizing their health care experience and adaptation process in Hawaii.

Design. Face-to-face individual in-depth interviews were conducted with 20 recently arrived Korean immigrant adults in Hawaii, who were selected by a purposive sampling method.

Results. A diminution of seeking professional health care services after immigration was the prominent change in their health care behaviors. They delayed seeking primary care, underused preventive care, extended self-diagnosis and self-treatment, and practiced more treatment- and emergency-oriented care. New immigrants also adopted ethnic enclave health care and transnational health care as alternative strategies to meet their health care needs given the structural and cultural constraints. Sociocultural contexts of both home and host countries shaped the behavioral changes and adoption of alternative health care strategies, interplaying with an individual's characteristics. Lack of health insurance and unfamiliarity with the health care system were the most important factors in the decision whether to and when to seek professional health care, while the lack of English proficiency and cultural concerns were the major determinants of where to get health care.

Conclusions. The study suggested that efforts should be concentrated to minimize structural barriers to health insurance and to improve health care access through policy interventions. Ethnic networks and ethnic media could be used as an effective informational reservoir for introducing various health care resources, disseminating information, and navigating new immigrants to the health system and services. Utilizing ethnic health care facilities and professionals would foster the promotion of immigrant health care without language and cultural challenges.