Recommended care and care adherence following a diagnosis of Lynch syndrome: a mixed-methods study

Abstract Background Lynch syndrome (LS) is the most common hereditary colorectal cancer (CRC) syndrome. This study assesses trends in diagnosis of LS and adherence to recommended LS-related care in a large integrated healthcare organization (~ 575,000 members). Methods Electronic medical record (EMR) data (1999–2015) were examined to identify patients with a diagnosis of LS. We examined their LS-associated care recommendations and adherence to these recommendations. Qualitative patient and provider interviews were conducted with the aim of identifying opportunities for improved care delivery. Results We identified 74 patients with a diagnosis of LS; 64% were diagnosed with a LS-related malignancy prior to their diagnosis of LS. The time to LS diagnosis following development of a LS-related cancer decreased over time: before 2009 11% of individuals received a diagnosis of LS within 1 year of developing a LS-related cancer compared to 83% after 2009 (p < 0.0001). Colonoscopy recommendations were documented in the EMR for almost all patients with LS (96%). Documentation of other recommendations for cancer surveillance was less commonly found. Overall, patient adherence to colonoscopy was high (M = 81.5%; SD = 32.7%), and adherence to other recommendations varied. To improve care coordination, patients and providers suggested providing automated reminder prompts for LS-related surveillance, adding a LS-specific diagnosis code, and providing guidelines for LS-related surveillance in the EMR. Conclusions We identified fewer than expected patients with LS in our large care system, indicating that there is still a diagnostic care gap. However, patients with LS were likely to receive and follow CRC surveillance recommendations. Recommendations for and adherence to extracolonic surveillance were variable. Improved care coordination and clearer documentation of the LS diagnosis is needed.

Download Full-text

Processes of care and outcomes for homeless patients hospitalised for cardiovascular conditions at safety-net versus non-safety-net hospitals: cross-sectional study

BMJ Open ◽

10.1136/bmjopen-2020-046959 ◽

2021 ◽

Vol 11 (4) ◽

pp. e046959

Author(s):

Atsushi Miyawaki ◽

Dhruv Khullar ◽

Yusuke Tsugawa

Keyword(s):

Hospital Mortality ◽

Health Outcomes ◽

Care Delivery ◽

Bypass Graft ◽

Safety Net ◽

Cross Sectional Study ◽

Sectional Study ◽

Cross Sectional ◽

Homeless Adults ◽

To Receive

ObjectivesEvidence suggests that homeless patients experience worse quality of care and poorer health outcomes across a range of medical conditions. It remains unclear, however, whether differences in care delivery at safety-net versus non-safety-net hospitals explain these disparities. We aimed to investigate whether homeless versus non-homeless adults hospitalised for cardiovascular conditions (acute myocardial infarction (AMI) and stroke) experience differences in care delivery and health outcomes at safety-net versus non-safety-net hospitals.DesignCross-sectional study.SettingData including all hospital admissions in four states (Florida, Massachusetts, Maryland, and New York) in 2014.ParticipantsWe analysed 167 105 adults aged 18 years or older hospitalised for cardiovascular conditions (age mean=64.5 years; 75 361 (45.1%) women; 2123 (1.3%) homeless hospitalisations) discharged from 348 hospitals.Outcome measuresRisk-adjusted diagnostic and therapeutic procedure and in-hospital mortality, after adjusting for patient characteristics and state and quarter fixed effects.ResultsAt safety-net hospitals, homeless adults hospitalised for AMI were less likely to receive coronary angiogram (adjusted OR (aOR), 0.42; 95% CI, 0.36 to 0.50; p<0.001), percutaneous coronary intervention (aOR, 0.52; 95% CI, 0.44 to 0.62; p<0.001) and coronary artery bypass graft (aOR, 0.43; 95% CI, 0.26 to 0.71; p<0.01) compared with non-homeless adults. Homeless patients treated for strokes at safety-net hospitals were less likely to receive cerebral arteriography (aOR, 0.23; 95% CI, 0.16 to 0.34; p<0.001), but were as likely to receive thrombolysis therapy. At non-safety-net hospitals, we found no evidence that the probability of receiving these procedures differed between homeless and non-homeless adults hospitalised for AMI or stroke. Finally, there were no differences in in-hospital mortality rates for homeless versus non-homeless patients at either safety-net or non-safety-net hospitals.ConclusionDisparities in receipt of diagnostic and therapeutic procedures for homeless patients with cardiovascular conditions were observed only at safety-net hospitals. However, we found no evidence that these differences influenced in-hospital mortality markedly.

Download Full-text

Feasibility of Screening for Lynch Syndrome Among Patients With Colorectal Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2008.17.5950 ◽

2008 ◽

Vol 26 (35) ◽

pp. 5783-5788 ◽

Cited By ~ 512

Author(s):

Heather Hampel ◽

Wendy L. Frankel ◽

Edward Martin ◽

Mark Arnold ◽

Karamjit Khanduja ◽

...

Keyword(s):

Colorectal Cancer ◽

Lynch Syndrome ◽

Mismatch Repair ◽

Cancer Surveillance ◽

Study Cohort ◽

Entire Study ◽

Gene Testing ◽

Revised Bethesda Guidelines ◽

Repair Genes ◽

Entire Study Cohort

Purpose Identifying individuals with Lynch syndrome (LS) is highly beneficial. However, it is unclear whether microsatellite instability (MSI) or immunohistochemistry (IHC) should be used as the screening test and whether screening should target all patients with colorectal cancer (CRC) or those in high-risk subgroups. Patients and Methods MSI testing and IHC for the four mismatch repair proteins was performed on 500 tumors from unselected patients with CRC. If either MSI or IHC was abnormal, complete mutation analysis for the mismatch repair genes was performed. Results Among the 500 patients, 18 patients (3.6%) had LS. All 18 patients detected with LS (100%) had MSI-high tumors; 17 (94%) of 18 patients with LS were correctly predicted by IHC. Of the 18 probands, only eight patients (44%) were diagnosed at age younger than 50 years, and only 13 patients (72%) met the revised Bethesda guidelines. When these results were added to data on 1,066 previously studied patients, the entire study cohort (N = 1,566) showed an overall prevalence of 44 of 1,566 patients (2.8%; 95% CI, 2.1% to 3.8%) for LS. For each proband, on average, three additional family members carried MMR mutations. Conclusion One of every 35 patients with CRC has LS, and each has at least three relatives with LS; all of whom can benefit from increased cancer surveillance. For screening, IHC is almost equally sensitive as MSI, but IHC is more readily available and helps to direct gene testing. Limiting tumor analysis to patients who fulfill Bethesda criteria would fail to identify 28% (or one in four) cases of LS.

Download Full-text

Abstract 2552: Adapting a novel cancer care delivery model: identifying barriers unique to care coordination for LGBTQ cancer survivors

10.1158/1538-7445.am2021-2552 ◽

2021 ◽

Author(s):

Nicolas Francone ◽

Jonathan Alhalel ◽

Will Dunne ◽

Sankirtana Danner ◽

Nihmotallahi Adebayo ◽

...

Keyword(s):

Cancer Survivors ◽

Care Coordination ◽

Cancer Care ◽

Care Delivery ◽

Delivery Model ◽

Care Delivery Model

Download Full-text

Impact of a hospital specialty pharmacy in partnership with a free-standing care coordination organization on time to delivery and receipt of oral anticancer drugs.

Journal of Clinical Oncology ◽

10.1200/jco.2020.39.28_suppl.43 ◽

2021 ◽

Vol 39 (28_suppl) ◽

pp. 43-43

Author(s):

Melissa Parsons Beauchemin ◽

Morgan RL Lichtenstein ◽

Rohit R. Raghunathan ◽

Sahil D Doshi ◽

Cynthia Law ◽

...

Keyword(s):

Care Coordination ◽

Multivariable Analysis ◽

Cancer Center ◽

Free Standing ◽

Delivery Date ◽

Anti Cancer ◽

Before And After ◽

Specialty Pharmacy ◽

Insurance Data ◽

To Receive

43 Background: Most oral anti-cancer drugs (OACD) prescriptions require extensive coordination between providers and payers, which can delay drug receipt. Specialty pharmacies are intended to facilitate communication between multiple entities to deliver OACDs with increased efficiency. In 2018, our cancer center partnered with Shields Health Solutions (SHS), a freestanding organization providing care coordination to implement a hospital-based specialty pharmacy. We evaluated the rate of failed drug receipt (FR) and time to drug receipt (TTR) before and after specialty pharmacy implementation. Methods: We prospectively collected data on all new OACD prescriptions for adult oncology patients at a large, urban cancer center from 1/1/2018 to 12/31/2019. In fall 2018, a specialty pharmacy was opened to facilitate drug procurement for patients. We collected patient demographic, clinical, and insurance data, OACD name, date prescribed, delivery date, and interactions with payers and financial assistance groups. For prescriptions received, TTR was the number of days from OACD prescription to patient receipt of the drug. FR was defined as failure to receive a prescribed OACD. We excluded OACD prescriptions for a washout period of two months during pharmacy initiation. We used multivariable logistic regression to examine factors associated with TTR > 7 days and FR before and after specialty pharmacy implementation. Results: In total, 883 patients were prescribed 1145 new OACDs. The majority of prescribed drugs were targeted treatment (56%, N = 646) and 72% (N = 819) required prior authorization (PA). Of all prescriptions, 86% (N = 999) were successfully received with an overall median TTR of 7 days. Adjusted analyses showed that patients were more likely to receive their drugs in less than 7 days after specialty pharmacy implementation (OR: 1.4 95% CI 1.04 – 1.81), p = 0.03). In an unadjusted analysis, patients were more likely to receive their initial medications after specialty pharmacy implementation, compared to before specialty pharmacy implementation (89% vs. 84%, p = 0.04). Multivariable analysis showed a trend toward more patients receiving drugs after specialty pharmacy implementation (OR: 1.42, 95% CI 0.98 – 2.03, p = 0.06). Conclusions: The implementation of a hospital-based specialty pharmacy in partnership with SHS decreased TTR. This difference is in part attributable to improved care coordination and communication. A centralized approach may improve overall efficiency due to fewer clinical practice disruptions.

Download Full-text

Securing the wireless emergency alerts system

Communications of the ACM ◽

10.1145/3481042 ◽

2021 ◽

Vol 64 (10) ◽

pp. 85-93

Author(s):

Jihoon Lee ◽

Gyuhong Lee ◽

Jinsung Lee ◽

Youngbin Im ◽

Max Hollingsworth ◽

...

Keyword(s):

Open Source ◽

Open Source Software ◽

Software Defined Radio ◽

Severe Weather ◽

Base Stations ◽

The Public ◽

Software Libraries ◽

Amber Alerts ◽

Almost All ◽

To Receive

Modern cell phones are required to receive and display alerts via the Wireless Emergency Alert (WEA) program, under the mandate of the Warning, Alert, and Response Act of 2006. These alerts include AMBER alerts, severe weather alerts, and (unblockable) Presidential Alerts, intended to inform the public of imminent threats. Recently, a test Presidential Alert was sent to all capable phones in the U.S., prompting concerns about how the underlying WEA protocol could be misused or attacked. In this paper, we investigate the details of this system and develop and demonstrate the first practical spoofing attack on Presidential Alerts, using commercially available hardware and modified open source software. Our attack can be performed using a commercially available software-defined radio, and our modifications to the open source software libraries. We find that with only four malicious portable base stations of a single Watt of transmit power each, almost all of a 50,000-seat stadium can be attacked with a 90% success rate. The real impact of such an attack would, of course, depend on the density of cellphones in range; fake alerts in crowded cities or stadiums could potentially result in cascades of panic. Fixing this problem will require a large collaborative effort between carriers, government stakeholders, and cellphone manufacturers. To seed this effort, we also propose three mitigation solutions to address this threat.

Download Full-text

E-Governance in India to Combat COVID-19

International Journal of Research in Advent Technology ◽

10.32622/ijrat.812202001 ◽

2021 ◽

Vol 8 (12) ◽

pp. 1-5

Author(s):

Dr. Mangesh M. Ghonge ◽

Mr. Deepak Pathratkar

Keyword(s):

Private Sector ◽

Mutual Contact ◽

Work From Home ◽

The World ◽

Current Scenario ◽

The Government ◽

Almost All ◽

To Receive

Viral pandemics are a serious threat. COVID-19 is not the first, and it won't be the last. As the whole world is going through the black phase of COVID-19 virus, the scientists are trying to invent a fighting vaccine against the same. Each and every sector in every part of the world is infected by the outburst of the fatal virus. Right from business and trade to sports and entertainment, every aspect of life is suffering a lot. To combat the outbreak of the pandemic, most of the countries have used partial to complete lockdown as the only weapon to stop the spread of the virus. In the current scenario, almost all the private sector companies as well as the government offices have suggested all the employees to work from home to stop the community spread of the disease that may occur if people come in mutual contact. While we think of governing authorities around the world, each and every government provides some e-facilities to their citizens to some what extent. Generally E-Governance can be stated as the facility to receive each and everything electronically i.e. you don’t need to go to outside home to receive any document or order. In this paper, we briefly described the different aspects of e-governance.

Download Full-text

A Mixed-Methods Study of Multi-Level Factors Influencing Mammography Overuse: Implications for De-implementation.

10.21203/rs.3.rs-506568/v2 ◽

2021 ◽

Author(s):

Jessica D. Austin ◽

Parisa Tehranifar ◽

Carmen B. Rodriguez ◽

Laura Brotzman ◽

Mariangela Agovino ◽

...

Keyword(s):

Mixed Methods ◽

Older Women ◽

Survey Data ◽

Mammography Screening ◽

Care Delivery ◽

Interview Data ◽

Mixed Methods Study ◽

Spanish Speaking ◽

Factors Influencing ◽

Multi Level

Abstract Background There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse. Methods This explanatory, sequential, mixed-methods study collected survey data (n = 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥ 70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n = 19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n = 5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process. Results Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not experience overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may be reasons for overuse. Providers identified potential strategies including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may no longer benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop a standard process of care around mammography screening. Conclusions Multi-level factors contributing to mammography overuse are dynamic and reinforced. To ensure equitable de-implementation, there is a need for more refined theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

Download Full-text

Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot?

BMJ Quality & Safety ◽

10.1136/bmjqs-2019-009742 ◽

2019 ◽

Vol 29 (2) ◽

pp. 103-112 ◽

Cited By ~ 1

Author(s):

Ryan J Ellis ◽

Cary Jo R Schlick ◽

Joe Feinglass ◽

Mary F Mulcahy ◽

Al B Benson ◽

...

Keyword(s):

Cancer Care ◽

Care Delivery ◽

Blind Spot ◽

Sociodemographic Factors ◽

Care Quality ◽

Hospital Level ◽

Lung Cancers ◽

Factors Associated ◽

Hospital Variation ◽

To Receive

BackgroundChemotherapy quality measures consider hospitals compliant when chemotherapy is recommended, even if it is not received. This may mask shortcomings in cancer care delivery. Objectives of this study were to (1) identify patient factors associated with failure to receive recommended chemotherapy without a documented contraindication and (2) assess hospital variation in failure to administer recommended chemotherapy.MethodsPatients from 2005 to 2015 with breast, colon and lung cancers who failed to receive recommended chemotherapy were identified using the National Cancer Database. Hospital-level rates of failure to administer recommended chemotherapy were calculated, and patient and hospital factors associated with failure to receive recommended chemotherapy were identified by multivariable logistic regression.ResultsA total of 183 148 patients at 1281 hospitals were analysed. Overall, 3.5% of patients with breast, 6.6% with colon and 10.7% with lung cancers failed to receive recommended chemotherapy. Patients were less likely to receive recommended chemotherapy in all cancers if uninsured or on Medicaid (p<0.05), as were non-Hispanic black patients with both breast and colon cancer (p<0.001). Significant hospital variation was observed, with hospital-level rates of failure to administer recommended chemotherapy as high as 21.8% in breast, 40.2% in colon and 40.0% in lung cancers.Conclusions and relevanceThough overall rates are low, failure to receive recommended chemotherapy is associated with sociodemographic factors. Hospital variation in failure to administer recommended chemotherapy is masked by current quality measure definitions and may define a significant and unmeasured difference in hospital quality.

Download Full-text

Adult Care in Cystic Fibrosis

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0039-3400289 ◽

2019 ◽

Vol 40 (06) ◽

pp. 857-868 ◽

Cited By ~ 4

Author(s):

J. Stuart Elborn

Keyword(s):

Health Care ◽

Cystic Fibrosis ◽

Care Delivery ◽

Health Care Systems ◽

Well Being ◽

Models Of Care ◽

Adult Care ◽

Care Systems ◽

Expanding Population ◽

Almost All

AbstractCystic fibrosis (CF) is now more common in adults than children in countries with well-developed health care systems. The number of adults continues to increase and will further increase if the new cystic fibrosis transmembrane conductance regulator (CFTR) modulators are disease modifying. Most of the complex morbidity and almost all the mortality of CF occur in adults and will increasingly follow this pattern even with new effective modulator therapies. Maintaining good quality of life including social functioning and maximizing survival for adults are the key priorities. This requires a highly knowledgeable and adaptable multidisciplinary team, which, though focused on maintaining lung health, requires an increasing range of other disciplines and specialties to maximize well-being. Changes in health care systems will require current models of care to adapt to provide care for the large number of adult patients. With increasing survival and age, many are likely to have both CF morbidities and additional diseases of aging. New models are needed for health care delivery for this expanding population with complex medical conditions.

Download Full-text

Assessing Patients’ Perceptions of Cancer Care Coordination in a Community-Based Setting

JCO Oncology Practice ◽

10.1200/jop.19.00509 ◽

2020 ◽

Vol 16 (8) ◽

pp. e726-e733

Author(s):

Izumi Okado ◽

Kevin Cassel ◽

Ian Pagano ◽

Randall F. Holcombe

Keyword(s):

Care Coordination ◽

Family Caregiver ◽

Cancer Care ◽

Care Delivery ◽

Disease Stage ◽

Patient Navigator ◽

Patient Questionnaire ◽

Cancer Disease ◽

Caregiver Support

PURPOSE: Effective care coordination (CC) is a hallmark of a high-quality cancer care. However, efforts to improve cancer care delivery are limited by the lack of a clinically useful tool to assess CC. In this study, we examined patients’ perceptions of cancer CC using a novel tool, the Care Coordination Instrument (CCI), and evaluated the quality of the CCI. METHODS: The CCI is a 29-item patient questionnaire that assesses CC across varied practice settings and patient populations overall and for three critical domains of CC: communication, navigation, and operational. We conducted univariable and multivariable regression analyses to identify patient clinical and practice characteristics associated with optimal versus suboptimal CC. RESULTS: Two hundred patients with cancer completed the CCI questionnaire between October 2018 and January 2019, of whom 189 were used for the analysis. The presence of a family caregiver and a diagnosis of a blood cancer were correlated with overall positive reports of CC ( P < .001 and P < .05, respectively). Poorer perceptions of CC were associated with having a head and neck cancer and the absence of family caregiver support. The effects of cancer disease stage and having access to a patient navigator on CC were not statistically significant. CONCLUSION: Integrating a patient-centered tool to assess cancer CC can be a strategy to optimize cancer care delivery. Understanding factors associated with effective and ineffective CC can help inform efforts to improve overall quality of care and care delivery.

Download Full-text