Leah Tuzzio

Disparities in Indigenous Health: A Cross-Country Comparison Between New Zealand and the United States

OBJECTIVES We compared the health statuses of the indigenous populations of New Zealand and the United States with those of the numerically dominant populations of these countries. METHODS Health indicators compared included health outcome measures, preventive care measures, modifiable risk factor prevalence, and treatment measures. RESULTS In the case of nearly every health status indicator assessed, disparities (both absolute and relative) were more pronounced for Maoris than for American Indians/Alaska Natives. Both indigenous populations suffered from disparities across a range of health indicators. However, no disparities were observed for American Indians/Alaska Natives in regard to immunization coverage. CONCLUSIONS Ethnic health disparities appear to be more pronounced in New Zealand than in the United States. These disparities are not necessarily intractable. Although differences in national health sector responses exist, New Zealand may be well placed in the future to evaluate the effectiveness of new strategies to reduce these disparities given the extent and quality of Maori-specific health information available.

Understanding high-quality cancer care: a summary of expert perspectives.

The Institute of Medicine (IOM) report Crossing the Quality Chasm proposed 6 aims for high‐quality healthcare: effective, safe, timely, efficient, equitable, and patient‐centered, and emphasized care coordination. Through interviews with nationally recognized experts in healthcare quality, perspectives on barriers and facilitators to achieving these aims for cancer patients were elicited.

How do Urban African Americans and Latinos View the Influence of Diet on Hypertension

Uncontrolled hypertension and its complications continue to be major health problems that disproportionately affect poor minority communities. Although dietary modification is an effective treatment for hypertension, it is not clear how hypertensive minority patients view diet as part of their treatment, and what barriers affect their abilities to eat healthy diets. We conducted nine focus groups with 88 African American and Latino patients treated for hypertension to assess their knowledge, attitudes, behaviors, and beliefs concerning hypertension. Participants generally agreed that certain foods and food additives play an important role in the cause and treatment of hypertension. However, they found clinician-recommended diets difficult to follow in the context of their family lives, social situations, and cultures. These diets were often considered expensive, an unwelcome departure from traditional and preferred diets, socially isolating, and not effective enough to obviate the need for medications. These findings suggest the importance of culturally sensitive approaches to dietary improvements.

Providing Care for Cancer Survivors in Integrated Health Care Delivery Systems: Practices, Challenges, and Research Opportunities

PURPOSE Optimal approaches to cancer survivorship care are needed. This study sought to identify practices, barriers, and research opportunities in meeting the care needs of cancer survivors in integrated health care delivery systems. METHODS This study was conducted at 10 sites within the Cancer Research Network, a National Cancer Institute-funded consortium of integrated health care delivery systems providing care for nearly 11 million enrollees. We identified 48 clinical leaders, administrators, and providers in oncology, primary care, nursing administration, and specialty care. Forty (83%) completed semi-structured, audio-recorded, transcribed telephone interviews, which we analyzed using an immersion-crystallization approach. RESULTS Respondents were aware of the needs of cancer survivors and the difficulties they face in transitioning from treatment to follow-up care. Respondents from all sites reported that oncology and primary care are jointly responsible for the care of cancer survivors, often through the use of electronic medical records. Many respondents were not familiar with standardized survivorship care plans. Only two sites had formal cancer survivorship programs in place, and two were developing such programs. Respondents at sites with and without programs acknowledged existing gaps in evidence on the effectiveness of formal survivorship care and expressed a desire for additional research. CONCLUSION Our exploratory study suggests an awareness of cancer survivorship care in integrated health care delivery systems, although approaches to providing such care vary across systems. These settings may offer a unique opportunity to develop, test, and implement innovative models of care, which can be systematically evaluated to inform and enhance cancer survivorship care in diverse health care settings.

Patient-Reported Care Coordination: Associations With Primary Care Continuity and Specialty Care Use

PURPOSE Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use. METHODS We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use. RESULTS Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77). CONCLUSIONS High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.

Predictors of 1‐Year Change in Patient Activation in Older Adults with Diabetes Mellitus and Heart Disease

To identify patterns and predictors of 1‐year change in patient activation in chronically ill older adults.

The success of recruiting minorities, women, and elderly into a randomized controlled effectiveness trial

BACKGROUND Heart failure, a leading cause of hospitalization among elderly people, disproportionately afflicts African-American and other non-White populations. Studies of health care interventions often do not include these groups in proportion to numbers in the patient population. Our objective was to assess whether a randomized controlled effectiveness trial enrolled patients by ethnicity/race, gender, and age in proportion to those eligible. METHODS We conducted a randomized controlled trial comparing nurse management and usual care among ambulatory heart failure patients at the four hospitals in East and Central Harlem, New York. We incorporated culturally sensitive and age-appropriate strategies to enroll a demographically representative group into the trial. Recruitment proceeded in several steps: identifying patients with billing code and visit criteria, documenting systolic dysfunction, obtaining clinician permission and correct addresses, contacting patients, and enrolling eligible patients. We assessed differences by ethnicity/race and gender at successive steps in the recruitment process, and differences between enrollees and refusals regarding overall health, evaluation of medical care, and difficulty receiving care. RESULTS We enrolled 406 ambulatory patients by ethnicity/race and gender in proportion to the numbers eligible to be contacted (46% African-American/Black, 33% Hispanic, and 47% female). Among patients contacted, however, those 18 through 74 years were 2.0 to 3.3 times more likely than those > or = 75 years to enroll (p < 0.001). CONCLUSIONS The recruitment strategy successfully enrolled patients by ethnicity/race, gender, and age through 74 years, but not those > or = 75 years. Registries of patients who refuse to enroll in trials could provide guidance for clinical and public policy.

Accuracy and complexities of using automated clinical data for capturing chemotherapy administrations: implications for future research.

Background:Chemotherapy data are important to almost any study on cancer prognosis and outcomes. However, chemotherapy data obtained from tumor registries may be incomplete, and abstracting chemotherapy directly from medical records can be expensive and time consuming. Methods:We evaluated the accuracy of using automated clinical data to capture chemotherapy administrations in a cohort of 757 ovarian cancer patients enrolled in 7 health plans in the HMO Cancer Research Network. We calculated sensitivity and specificity with 95% confidence intervals of chemotherapy administrations extracted from 3 automated clinical data sources (Health Care Procedure Coding System, National Drug Codes, and International Classification of Diseases) compared with tumor registry data and medical chart data. Results:Sensitivity of all 3 data sources varied across health plans from 79.4% to 95.2% when compared with tumor registries, and 75.0% to 100.0% when compared with medical charts. The sensitivities using a combination of 3 data sources were 88.6% (95% confidence intervals: 85.7–91.1) compared with tumor registries and 89.5% (78.5–96.0) compared with medical records; specificities were 91.5% (86.4–95.2) and 90.0% (55.5–99.7), respectively. There was no difference in accuracy between women aged <65 and ≥65 years. Using one set of codes alone (eg, Health Care Procedure Coding System alone) was insufficient for capturing chemotherapy data at most health plans. Conclusions:While automated data systems are not without limitations, clinical codes used in combination are useful in capturing chemotherapy more comprehensively than tumor registry and without the need for costly medical record abstraction.

Patient and oncologist discussions about cancer care costs

PurposePatient out-of-pocket costs are higher for cancer care than for any other health-care sector. Oncologist–patient discussions of costs are not well understood. We conducted an exploratory interview study to examine the frequency, patterns, attitudes, and preferences of both patients and providers on discussion of treatment costs.MethodsWe conducted semi-structured telephone interviews with oncology clinicians and people receiving chemotherapy at a large nonprofit health system. Multiple investigators conducted thematic analysis using modified content analysis, grounded theory, and interaction analysis methods.ResultsPatient themes included the relevance of cost to their experience, preference for the doctor to be the starting point of cost discussions, but relative infrequency of discussions with doctors or other care team member. Provider themes were an emphasis on clinical benefit above costs, conviction that cost-related decisions should rest with patients, and lack of access to treatment costs. Interest in discussing costs and barriers accessing cost information were common themes from both patients and providers.ConclusionsDoctors and patients want to discuss treatment costs but lack access to them. These data support growing evidence for a provider role in discussions of cost during cancer treatment planning.

Cancer research network: using integrated healthcare delivery systems as platforms for cancer survivorship research

IntroductionMuch progress has been made in cancer survivorship research, but there are still many unanswered questions that can and need to be addressed by collaborative research consortia.MethodsSince 1999, the National Cancer Institute-funded HMO Cancer Research Network (CRN) has engaged in a wide variety of research focusing on cancer survivorship. With a focus on thematic topics in cancer survivorship, we describe how the CRN has contributed to research in cancer survivorship and the resources it offers for future collaborations.ResultsWe identified the following areas of cancer survivorship research: surveillance for and predictors of recurrences, health care delivery and care coordination, health care utilization and costs, psychosocial outcomes, cancer communication and decision making, late effects of cancer and its treatment, use of and adherence to adjuvant therapies, and lifestyle and behavioral interventions following cancer treatment.ConclusionsWith over a decade of experience using cancer data in community-based settings, the CRN investigators and their collaborators are poised to generate evidence in cancer survivorship research.Implications for Cancer SurvivorsCollaborative research within these settings can improve the quality of care for cancer survivors within and beyond integrated health care delivery systems.