Faculty Bibliography

Background: To our knowledge, no systematic review of empirical papers describing cancer care coordination interventions has yet been conducted. The aim of this presentation is to describe the methods and findings from a systematic review and meta-analysis of all empirical papers describing cancer care coordination published between 1990-2012. Methods: Of 1241 abstracts collected from a search of PubMed and EMBASE, 108 studies were retrieved and reviewed; 49 were included in the systematic review. Each study had US or Canadian adult or child participants; each paper had comparison or control groups, measures, samples, and/or interventions. Two researchers independently applied a standardized search strategy, coding scheme, and on-line coding program to each study. Eight RCT's met additional criteria for meta-analysis; a random effects estimation model was used for data analysis. Results: Among the 49 articles included in our systematic review, those that included implicit or explicit definitions of cancer care coordination described four components: (1) roles and models for communication and transfer of care between primary care physicians and oncologists during active treatment and survivorship; (2) care navigation through designated personnel or telecommunication processes among care team members; (3) treatment summaries and survivorship care plans; and (4) multidisciplinary communication accompanying patient and practice management within the framework of the Chronic Care Model (N=14). We found a medium-sized effect of cancer care coordination on care usage outcomes among the randomized clinical trials (e.g., reduced Emergency Department visits; g = 0.37 [95% CI = 0.29 - 0.44], I2= .000. Fail-safe N = 86). Conclusions: The findings from this current systematic review and meta-analysis will contribute to the evidence base on strategies that can improve the coordination of cancer care, particularly for patients with multiple chronic conditions, and thereby advance the goals of health care refo!

Background: Epigenetic regulatory pathways are intensely studied for their involvement in breast tumorigenesis, however little is currently known about the genetic variation in epigenome components contributing to the risk and/or prognosis of breast cancer. In this study we have tested how the novel germline genetic signatures identified in epigenetic regulatory genes (ERGs) may potentially contribute to clinical prediction of breast cancer risk. Methods: We have genotyped 711 SNPs tagging 87 ERGs in 1985 breast cancer cases and 1609 controls, using Sequenom i-Plex. The samples were of white European origin with the fraction of Ashkenazi Jewish (AJ) ancestry (n=1642). The association of SNPs with breast cancer risk was assessed using logistic regression, adjusted by age, AJ status and estrogen-receptor (ER) status. The predictive ability of SNP signatures was tested by ROC curves using logistic regression fitting the SNP/clinical covariate models, and the area under the curve (AUC) was used to assess their utility in the classification of breast cancer risk. Results: We have identified the signature of 20 SNPs tagging 13 ERGs, significantly associated with breast cancer risk. The strongest association has been observed for RUNX1 (rs7280097, OR=0.83, CI 95%: 0.71-0.94, p=0.006) and PRDM16 (rs12135987, OR=1.22, CI 95%: 1.06-1.42, p=0.007). The inclusion of predictor variables (age, AJ status, ER status) and 20 associated SNPs in logistic regression ROC curve analysis yielded in best fitting model involving 10 SNPs tagging 8 ERGs with AUC of 0.723, compared to 0.660 with predictor variables alone (p=0.003). Conclusions: We have identified a signature of 20 SNPs in epigenetic regulatory genes (20-SNP-ERG) significantly associated with breast cancer risk. In addition, the incorporation of 10 SNPs from 20-SNP-ERG into risk prediction model increases the ability to classify breast cancer risk in addition to other clinical and demographic covariates. The results suggest the promising clinical potential!

Parent training has great potential to alter the developmental trajectories of young Latino children with or at risk for behavior problems. However, traditional parent training programs may seem culturally irrelevant or inappropriate to Latino parents as they promote practices that are based on white, middle class standards. The current study of treatment acceptability used focus group and key informant interviewing methodology to investigate Latina mothers' views on the causes of young children's misbehavior and the acceptability of evidence-based parenting strategies. The sample consisted of Spanish- and English-speaking Latina mothers of 3- to 6-year-olds recruited from day-care centers and preschools in New York City. Focus groups were conducted with 34 mothers, and key informant interviews with 5 mothers whose children had behavior problems. Results showed that the most commonly viewed causes of child misbehavior were child temperament, fighting in the home, and negative peer influence. Mothers found some evidence-based parenting strategies acceptable (e.g., the use of praise, social rewards) and others objectionable (e.g., selective ignoring in pubic situations, the elimination of spanking). For some strategies, there was little consensus on its acceptability (e.g., time-out). Taken together, results highlight the critical need for aligning parent and clinician goals at the outset of treatment, and of including a strong psychoeducational component in parent training programs because not all of its components are consistent with Latino cultural norms and beliefs. 2012

ABSTRACT. Background: Because obesity has become a major public health problem, attention to a range of its predictors is needed. This study examined the association of physical factors, personal characteristics, and substance use with obesity in a sample (N = 815) of African American and Puerto Rican young adults with a mean age of 32. Methods: Body mass index (BMI) was calculated to assess obesity. Bivariate and multivariate logistic regression analyses were conducted. Results: Bivariate analyses showed that protective factors such as physical activity (adjusted odds ratio [AOR] = .82, 95% confidence interval [CI] = .74-.91), healthy diet (AOR = .96, 95% CI = .93-.99), self-control (AOR = .93, 95% CI = .87-.98), and life satisfaction (AOR = .97, 95% CI = .95-.99) were associated with a reduced probability of being obese. Marijuana use was also associated with a decreased probability of obesity (AOR = .89, 95% CI = .80-.99), but was not considered a protective factor. Risk factors such as short sleep duration (AOR = 1.70, 95% CI = 1.24-2.33) and depressive mood (AOR = 1.05, 95% CI = 1.01-1.09) were associated with an increased probability of being obese. Conclusions: For African Americans and Puerto Ricans, programs to treat obesity should focus on increasing sleep, physical activity, and life satisfaction.

ABSTRACT. Background: The objective of this study is to examine trajectories of marijuana use among African Americans and Puerto Ricans from adolescence to adulthood, with attention paid to work commitment, financial stability, drug use, and violence. Methods: Participants (N = 816) completed in-class questionnaires as students in the East Harlem area of New York City at the first wave and provided follow-up data at 4 additional points in time (mean ages = 14, 19, 24, 29, and 32 years). Among 816 participants, there were 60% females, 52% African American, and 48% Puerto Ricans. Results: The chronic marijuana user trajectory group compared with the none or low, increasing, and/or moderate marijuana user trajectory group was associated with negative aspects of work commitment, financial stability, and the social environment. The chronic marijuana user group was similar to the increasing marijuana user group on work commitment and financial stability. Conclusions: These results suggest that treating marijuana use in late adolescence may reduce difficulty in the assumption of adult roles. Because chronic marijuana users experienced the most adverse effects in each of the domains, they require more intense clinical intervention than moderate marijuana users.

Gay, bisexual, and other men who have sex with men (MSM) have been disproportionately affected by HIV and AIDS since the beginning of the epidemic in the United States and in many other parts of the world. The HIV epidemic is inextricably tied to other health problems that disproportionately affect gay, bisexual, and other MSM including psychological comorbidities, substance use, sexual victimization, stigmatization, and multiple forms of discrimination. These interrelated health problems and social issues can be characterized as a syndemic of mutually reinforcing conditions or epidemics. Moreover, the syndemic is directed by biological, behavioral, psychosocial, and structural determinants. Addressing HIV within the context of a larger syndemic will require a more holistic approach to HIV prevention and treatment that recognizes the interplay between biological, behavioral, psychosocial, and structural factors that affect the health and well-being of sexual minority men.

Nurses Improving Care of Healthsystem Elders (NICHE) provides hospitals with tools and resources to implement an initiative to improve health outcomes in older adults and their families. Beginning in 2011, members have engaged in a process of program self-evaluation, designed to evaluate internal progress toward developing, sustaining, and disseminating NICHE. This manuscript describes the NICHE Site Self-evaluation and reports the inaugural self-evaluation data in 180 North American hospitals. NICHE members evaluate their program utilizing the following dimensions of a geriatric acute care program: guiding principles, organizational structures, leadership, geriatric staff competence, interdisciplinary resources and processes, patient- and family-centered approaches, environment of care, and quality metrics. The majority of NICHE sites were at the progressive implementation level (n = 100, 55.6%), having implemented interdisciplinary geriatric education and the geriatric resource nurse (GRN) model on at least one unit; 29% have implemented the GRN model on multiple units, including specialty areas. Bed size, teaching status, and Magnet status were not associated with level of implementation, suggesting that NICHE implementation can be successful in a variety of settings and communities.

OBJECTIVE: Previous studies addressing racial disparities in treatment for early-stage prostate cancer have focused on the etiology of undertreatment of black men. Our objective was to determine whether racial disparities are attributable to undertreatment, overtreatment, or both. METHODS: Using the SEER-Medicare dataset, we identified men 67-84 years-old diagnosed with localized prostate cancer from 1998 to 2007. We stratified men into clinical benefit groups using tumor aggressiveness and life expectancy. Low-benefit was defined as low-risk tumors and life expectancy <10 years; high-benefit as moderate-risk tumors and life expectancy >/=10 years; all others were intermediate-benefit. Logistic regression modeled the association between race and treatment (radical prostatectomy or radiotherapy) across benefit groups. RESULTS: Of 68,817 men (9.8% black and 90.2% white), 56.2% of black and 66.3% of white men received treatment (adjusted odds ratio (OR)=0.65; 95% CI, 0.62-0.69). The percent of low-, intermediate-, and high-benefit men who received treatment was 56.7%, 68.4%, and 79.6%, respectively (P=<0.001). In the low-benefit group, 51.9% of black vs. 57.2% of white patients received treatment (OR=0.74; 95% CI, 0.67-0.81) compared to 57.2% vs. 69.6% in the intermediate-benefit group (OR=0.64; 95% CI, 0.59-0.70). Racial disparity was largest in the high-benefit group (64.2% of black vs. 81.4% of white patients received treatment; OR=0.57; 95% CI, 0.48-0.68). The interaction between race and clinical benefit was significant (P<0.001). CONCLUSION: Racial disparities were largest among men most likely to benefit from treatment. However, a substantial proportion of both black and white men with a low clinical benefit received treatment, indicating a high level of overtreatment.

Medical respite programs provide care to homeless patients who are too sick to be on the streets or in a traditional shelter, but not sick enough to warrant inpatient hospitalization. They are designed to improve the health of homeless patients while also decreasing costly hospital use. Although there is increasing interest in implementing respite programs, there has been no prior systematic review of their effectiveness. We conducted a comprehensive search for studies of medical respite program outcomes in multiple biomedical and sociological databases, and the grey literature. Thirteen articles met inclusion criteria. The articles were heterogeneous in methods, study quality, inclusion of a comparison group, and outcomes examined. Available evidence showed that medical respite programs reduced future hospital admissions, inpatient days, and hospital readmissions. They also resulted in improved housing outcomes. Results for emergency department use and costs were mixed but promising. Future research utilizing adequate comparison groups is needed.