Jennifer Livaudais-Toman

A Randomized, Controlled Trial to Increase Discussion of Breast Cancer in Primary Care

Background: Assessment and discussion of individual risk for breast cancer within the primary care setting are crucial to discussion of risk reduction and timely referral. Methods: We conducted a randomized controlled trial of a multiethnic, multilingual sample of women ages 40 to 74 years from two primary care practices (one academic, one safety net) to test a breast cancer risk assessment and education intervention. Patients were randomly assigned to control or intervention group. All patients completed a baseline telephone survey and risk assessment (via telephone for controls, via tablet computer in clinic waiting room before visit for intervention). Intervention (BreastCARE) patients and their physicians received an individualized risk report to discuss during the visit. One-week follow-up telephone surveys with all patients assessed patient–physician discussion of family cancer history, personal breast cancer risk, high-risk clinics, and genetic counseling/testing. Results: A total of 655 control and 580 intervention women completed the risk assessment and follow-up interview; 25% were high-risk by family history, Gail, or Breast Cancer Surveillance Consortium risk models. BreastCARE increased discussions of family cancer history [OR, 1.54; 95% confidence interval (CI), 1.25–1.91], personal breast cancer risk (OR, 4.15; 95% CI, 3.02–5.70), high-risk clinics (OR, 3.84; 95% CI, 2.13–6.95), and genetic counseling/testing (OR, 2.22; 95% CI, 1.34–3.68). Among high-risk women, all intervention effects were stronger. Conclusions: An intervention combining an easy-to-use, quick risk assessment tool with patient-centered risk reports at the point of care can successfully promote discussion of breast cancer risk reduction between patients and primary care physicians, particularly for high-risk women. Impact: Next steps include scaling and dissemination of BreastCARE with integration into electronic medical record systems. Cancer Epidemiol Biomarkers Prev; 23(7); 1245–53. ©2014 AACR.

Perceived versus objective breast cancer risk in diverse women.

BACKGROUND Prior research suggests that women do not accurately estimate their risk for breast cancer. Estimating and informing women of their risk is essential for tailoring appropriate screening and risk reduction strategies. METHODS Data were collected for BreastCARE, a randomized controlled trial designed to evaluate a PC-tablet based intervention providing multiethnic women and their primary care physicians with tailored information about breast cancer risk. We included women ages 40-74 visiting general internal medicine primary care clinics at one academic practice and one safety net practice who spoke English, Spanish, or Cantonese, and had no personal history of breast cancer. We collected baseline information regarding risk perception and concern. Women were categorized as high risk (vs. average risk) if their family history met criteria for referral to genetic counseling or if they were in the top 5% of risk for their age based on the Gail or Breast Cancer Surveillance Consortium Model (BCSC) breast cancer risk model. RESULTS Of 1,261 participants, 25% (N=314) were classified as high risk. More average risk than high risk women had correct risk perception (72% vs. 18%); 25% of both average and high risk women reported being very concerned about breast cancer. Average risk women with correct risk perception were less likely to be concerned about breast cancer (odds ratio [OR]=0.3; 95% confidence interval [CI]=0.2-0.4) while high risk women with correct risk perception were more likely to be concerned about breast cancer (OR=5.1; 95%CI=2.7-9.6). CONCLUSIONS Many women did not accurately perceive their risk for breast cancer. Women with accurate risk perception had an appropriate level of concern about breast cancer. Improved methods of assessing and informing women of their breast cancer risk could motivate high risk women to apply appropriate prevention strategies and allay unnecessary concern among average risk women.

Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English Proficiency

BackgroundLanguage barriers disrupt communication and impede informed consent for patients with limited English proficiency (LEP) undergoing healthcare procedures. Effective interventions for this disparity remain unclear.ObjectiveAssess the impact of a bedside interpreter phone system intervention on informed consent for patients with LEP and compare outcomes to those of English speakers.DesignProspective, pre-post intervention implementation study using propensity analysis.SubjectsHospitalized patients undergoing invasive procedures on the cardiovascular, general surgery or orthopedic surgery floors.InterventionInstallation of dual-handset interpreter phones at every bedside enabling 24-h immediate access to professional interpreters.Main MeasuresPrimary predictor: pre- vs. post-implementation group; secondary predictor: post-implementation patients with LEP vs. English speakers. Primary outcomes: three central informed consent elements, patient-reported understanding of the (1) reasons for and (2) risks of the procedure and (3) having had all questions answered. We considered consent adequately informed when all three elements were met.Key ResultsWe enrolled 152 Chinese- and Spanish-speaking patients with LEP (84 pre- and 68 post-implementation) and 86 English speakers. Post-implementation (vs. pre-implementation) patients with LEP were more likely to meet criteria for adequately informed consent (54% vs. 29%, p = 0.001) and, after propensity score adjustment, had significantly higher odds of adequately informed consent (AOR 2.56; 95% CI, 1.15–5.72) as well as of each consent element individually. However, compared to post-implementation English speakers, post-implementation patients with LEP had significantly lower adjusted odds of adequately informed consent (AOR, 0.38; 95% CI, 0.16–0.91).ConclusionsA bedside interpreter phone system intervention to increase rapid access to professional interpreters was associated with improvements in patient-reported informed consent and should be considered by hospitals seeking to improve care for patients with LEP; however, these improvements did not eliminate the language-based disparity. Additional clinician educational interventions and more language-concordant care may be necessary for informed consent to equal that for English speakers.

Hospital discharge preparedness for patients with limited English proficiency: A mixed methods study of bedside interpreter-phones

OBJECTIVE Assess effects of a bedside interpreter-phone intervention on hospital discharge preparedness among patients with limited English proficiency (LEP). METHODS Mixed-methods study compared patient-reported discharge preparedness and knowledge of medications and follow-up appointments among 189 Chinese- and Spanish-speakers before (n=94) and after (n=95) bedside interpreter-phone implementation, and examined nurse and resident-physician interpreter-phone utilization through focus groups. RESULTS Pre-post discharge preparedness (Care Transitions Measure mean 77.2 vs. 78.5; p=0.62) and patient-reported knowledge of follow-up appointments, discharge medication administration and side effects did not differ significantly. Pre-post knowledge of medication purpose increased in bivariate (88% vs. 97%, p=0.02) and propensity score adjusted analyses [aOR (adjusted odds ratio), 4.49; 95% CI, 1.09-18.4]. Nurses and physicians reported using interpreter-phones infrequently for discharge communication, preferring in-person interpreters for complex discharges and direct communication with family for routine discharges. Post-implementation patients reported continued use of ad-hoc family interpreters (43%) or no interpretation at all (22%). CONCLUSION Implementation of a bedside interpreter-phone systems intervention did not consistently improve patient-reported measures of discharge preparedness, possibly due to limited uptake during discharges. PRACTICE IMPLICATIONS Hospital systems must better understand clinician preferences for discharge communication to successfully increase professional interpretation and shift culture away from using family members as interpreters.

Effectiveness of an Intervention to Teach Physicians How to Assist Patients to Quit Smoking in Argentina

INTRODUCTION We evaluated an intervention to teach physicians how to help their smoking patients quit compared to usual care in Argentina. METHODS Physicians were recruited from six clinical systems and randomized to intervention (didactic curriculum in two 3-hour sessions) or usual care. Smoking patients who saw participating physicians within 30 days of the intervention (index clinical visit) were randomly sampled and interviewed by telephone with follow-up surveys at months 6 and 12 after the index clinical visit. Outcomes were tobacco abstinence (main), quit attempt in the past month, use of medications to quit smoking, and cigarettes per day. Repeated measures on the same participants were accommodated via generalized linear mixed models. RESULTS Two hundred fifty-four physicians were randomized; average age 44.5 years, 53% women and 12% smoked. Of 1378 smoking patients surveyed, 81% were women and 45% had more than 12 years of education. At 1 month, most patients (77%) reported daily smoking, 20% smoked some days and 3% had quit. Mean cigarettes smoked per day was 12.9 (SD = 8.8) and 49% were ready to quit within the year. Intention-to-treat analyses did not show significant group differences in quit rates at 12 months when assuming outcome response was missing at random (23% vs. 24.1%, P = .435). Using missing=smoking imputation rule, quit rates were not different at 12 months (15.6% vs. 16.4% P = .729). Motivated smokers were more likely to quit at 6 months (17.7% vs. 9.6%, P = .03). CONCLUSIONS Training in tobacco cessation for physicians did not improve abstinence among their unselected smoking patients.

Relationships between allostatic load, unhealthy behaviors, and depressive disorder in U.S. adults, 2005–2012 NHANES

Unhealthy behaviors may modify relationships between chronic stress and depression among diverse older adults. We analyzed nationally representative cross-sectional data from participants aged 40-79 years of the 2005-2012 National Health and Nutrition Examination Survey. Unhealthy behaviors included current smoking, excessive/binge drinking, insufficient physical activity, and fair/poor diet. Allostatic load was defined by 10 biomarkers indicating the cumulative physiologic burden of stress. Depressive disorder was assessed using the Patient Health Questionnaire. Multivariable logistic regression examined whether current smoking, excessive/binge drinking, insufficient physical activitiy, and fair/poor diet modified relationships between allostatic load and depressive disorder. Mean age of 12,272 participants was 55.6 years (standard error = 0.19), 51.9% were women, and most had at least a high school education (81.8%). Latinos (11.3%) and African Americans (10.4%) were more likely than Whites (7.1%; p < 0.001) to meet depressive disorder criteria. Allostatic load was not associated independently with depressive disorder in any racial/ethnic group and this lack of a relationship did not differ by the extent of unhealthy behaviors. Although Latinos and African Americans report higher levels of depression than Whites, physiological markers of stress do not appear to explain these differences.

Coping With Chronic Stress by Unhealthy Behaviors: A Re-Evaluation Among Older Adults by Race/Ethnicity:

Objective: To assess the role of unhealthy behaviors in the relationship between chronic stress and significant depressive symptoms by race/ethnicity among older adults. Method: Participant data from the 2006 to 2008 Health and Retirement Study were analyzed. Unhealthy behaviors included current smoking, excessive/binge drinking, and obesity. Chronic stress was defined by nine previously used factors. The eight-item Center for Epidemiologic Studies Depression (CES-D) Scale measured depressive symptoms, where ≥4 symptoms defined significant. Multivariable logistic regression assessed the effects of chronic stress and unhealthy behaviors in 2006 on depressive symptoms in 2008. Results: A higher chronic stress index score predicted depressive symptoms in 2008 among African Americans, Latinos, and Whites (adjusted odds ratio [aOR] = 1.78, 95% confidence interval [CI] = [1.48, 2.15]; aOR = 1.54, 95% CI = [1.15, 2.05]; and aOR = 1.40, 95% CI = [1.26, 1.56], respectively). Unhealthy behaviors moderated this relationship among Latinos (aOR = 1.54, 95% CI = [1.02, 2.33]). Discussion: Unhealthy behaviors were not effective coping mechanisms for chronic stress in terms of preventing significant depressive symptoms. Instead, they strengthened the relationship between chronic stress and significant depressive symptoms among Latinos.

Effect of appreciation for Indigenous cultures and exposure to racial insults on alcohol and drug use initiation among multiethnic Argentinean youth.

OBJECTIVES This study evaluated the effect of factors reflecting appreciation of Indigenous culture and racial insults on alcohol and drug use initiation among multi-ethnic youth in Jujuy, Argentina. METHODS Students were surveyed from 27 secondary schools that were randomly selected to represent the province. A total of 3040 eligible students in 10th grade, age 14 to 18years were surveyed in 2006 and 2660 of these same students completed surveys in 11th grade in 2007. Multivariate logistic regression models assessed the effect of appreciation for Indigenous cultures and reported exposure to racial insults in 10th grade on incident current alcohol drinking in previous 30days, binge drinking (≥5 drinks at one sitting), and lifetime drug use (marijuana, inhalants or cocaine) in 11th grade among students not reporting these behaviors in 2006. RESULTS In 2006, 63% of respondents reported high appreciation for Indigenous cultures and 39% had ever experienced racial insults. In 2007, incident current drinking was 24.4%, binge drinking 14.8%, and any drug use initiation was 4.1%. Exposure to racial insults increased the likelihood of binge drinking (OR=1.6; 95% CI 1.2-2.1) but was not significant for any drug use. Appreciation for Indigenous cultures reduced the risk of any drug use initiation (OR=0.5, 95% CI 0.3-0.7) but had no effect for alcohol drinking outcomes. These effects were independent of Indigenous ethnicity. CONCLUSIONS Enhancing appreciation for Indigenous cultures and decreasing racial insults are achievable goals that can be incorporated into programs to prevent youth substance use.

Racial and Ethnic Differences in Prostate Cancer Survivors’ Perceived Engagement in Treatment Decision-Making

ObjectiveWe examined prostate cancer patients’ perceived engagement in treatment decision-making and associated factors by race/ethnicity in a multiethnic sample.MethodWe identified patients through the California Cancer Registry. Patients completed a cross-sectional telephone interview in English, Spanish, Cantonese, or Mandarin. Multivariable logistic regression models, stratified by race/ethnicity, estimated the associations of patient demographic and health status characteristics on (1) doctor asked patient to help decide treatment plan and (2) patient and doctor worked out a treatment plan together.ResultsWe included 855 prostate cancer patients: African American (19%), Asian American (15%), Latino (24%), and White (42%). Asian American patients were less likely than White patients to report that their doctors asked them to help decide a treatment plan (OR = 0.31; 95% CI = 0.18–0.53) and that they worked out a treatment plan with their doctors (OR = 0.54; 95% CI = 0.33–0.90). Language of interview was a significant contributing factor in stratified analysis for both outcomes.ConclusionAsian American prostate cancer patients reported less engagement in treatment decision-making, with Chinese language being a significant contributing factor. Future research should identify patient-centered strategies that effectively engage underserved patients and support healthcare providers in shared decision-making with multiethnic and multilingual patients.

An Intervention Tool to Increase Patient–Physician Discussion of Lifestyle Risk Factors for Breast Cancer

BACKGROUND Risk assessment and discussion of lifestyle in primary care are crucial elements of breast cancer prevention and risk reduction. Our objective was to evaluate the impact of a breast cancer risk assessment and education tool on patient-physician discussion of behaviors and breast cancer risk. MATERIALS AND METHODS We conducted a randomized controlled trial with an ethnically and linguistically diverse sample of women, ages 40-74, from two primary care practices. Intervention participants completed a tablet computer-based Breast Cancer Risk Assessment and Education (BreastCARE) intervention in the waiting room before a scheduled visit. Both patients and physicians received an individualized risk report to discuss during the visit. Control patients underwent usual care. Telephone surveys assessed patient-physician discussion of weight, exercise, and alcohol use 1 week following the visit. RESULTS Among the 1235 participants, 27.7% (161/580) intervention and 22.3% (146/655) usual-care patients were high risk for breast cancer. Adjusting for clustering by physician, the intervention increased discussions of regular exercise (odds ratios [OR] = 1.94, 1.50-2.51) and weight (OR = 1.56, 1.23-1.96). There was no effect of the intervention on discussion of alcohol. Women with some college education were more likely to discuss their weight than those with high school education or less (OR = 1.75, 1.03-2.96). Similarly, non-English speakers were more likely to discuss their weight compared with English speakers (OR = 2.33, 1.04-5.22). CONCLUSIONS BreastCARE is a feasible risk assessment tool that can successfully promote discussions about modifiable breast cancer risk factors between patients and primary care physicians.