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Cost and activity analysis for a citywide patient navigation intervention to engage underserved patients in breast cancer treatment: Findings from the Translating Research Into Practice study
Get PDFBackground: Patient navigation is an evidence-based intervention for reducing delays in cancer care for underserved populations. There are limited economic evaluations of patient navigation in the US health care system and few have considered costs at various phases along the implementation spectrum. Having economic data, including costs and cost savings, can support sustainability of patient navigation programs. This study presents findings from a cost and activity analysis of a citywide hospital-based patient navigation program to engage women in timely breast cancer treatment post-diagnosis.
Methods: This study was conducted as part of Translating Research Into Practice (TRIP), a citywide patient navigation hybrid effectiveness-implementation research study conducted at five cancer care hospitals in Boston, Massachusetts. The authors surveyed participating patient navigators and supervisors about their tasks and level of effort over consecutive 10-day periods from 2019 to 2021. Patient navigators documented the time spent on activities in accordance with an 11-step protocol across five sites. Cost data were collected from annual fiscal year end expenditure hospital administrative databases at concurrent time frames. Descriptive analyses were used to calculate average time on tasks, cost per activity and cost per outcome. Cost savings were estimated by calculating the additional persons engaged in timely entry to treatment compared to a matched control group with respect to hospitalization and emergency room costs averted.
Results: Average time spent per day on TRIP-specific navigation activities was approximately 3 hours (range, 0-8 hours) and the average time per patient per day was 25 minutes (n = 7 navigators). Total costs for clinical site interventions were 392,407 for maintenance costs over the study period. A total of 223 patients were served during the intervention period with an average cost per patient of 1759 for maintenance. Potential costs savings with the TRIP navigation program from averted hospitalization and emergency room visits for 63 additional patients who received timely treatment is estimated at 30,429 and 5692 per patient, respectively, compared to treatment as usual.
Conclusions: The economic evaluation in this study provides insight into startup and implementation costs for uptake and scalability of navigation programs across a citywide system. The information may be useful for payors in reimbursing navigation activities and health systems in planning for high quality navigation programs to ensure patient-centered and timely treatment for women diagnosed with breast cancer.No embarg
Machine Learning-Enhanced Surveillance for Surgical Site Infections in Patients Undergoing Colon Surgery: Model Development and Evaluation Study
Get PDFBackground: Surgical site infections (SSIs) are one of the most common health care-associated infections, accounting for nearly 20% of all health care-associated infections in hospitalized patients. SSIs are associated with longer hospital stays, increased readmission rates, higher health care costs, and a mortality rate twice that of patients without infections.
Objective: This study aimed to develop and evaluate machine learning (ML) models for augmenting SSI surveillance after colon surgery with the goal of improving the efficiency of infection control practices by prioritizing patients at high risk.
Methods: We conducted a retrospective study using data from 1508 patients undergoing colon surgery treated between 2018 and 2023 at a single academic medical center. Of these 1508 patients, 66 (4.4%) developed SSIs as adjudicated by infection control practitioners following Centers for Disease Control and Prevention National Healthcare Safety Network criteria. Data included 78 structured variables (eg, demographics, comorbidities, vital signs, laboratory tests, medications, and operative details) and 2 features derived from unstructured clinical notes using natural language processing. ML models-logistic regression, random forest, and Extreme Gradient Boosting (XGBoost)-were trained using stratified 80/20 train-test splits. Class imbalance was addressed using cost-sensitive learning and the synthetic minority oversampling technique. Model performance was evaluated using precision, recall, F1-score, area under the receiver operating characteristic curve, and Brier scores for calibration.
Results: Of the 1508 patients, those who developed SSIs had longer hospital stays (mean 8.1, SD 6.8 days vs mean 6.3, SD 10.5 days; P<.001), higher rates of an American Society of Anesthesiologists score of 3 (52/66, 79% vs 653/1442, 45.3%; P<.001), and elevated white blood cell counts (51/66, 77% vs 734/1442, 50.9%; P<.001). XGBoost achieved the best overall performance with an area under the receiver operating characteristic curve of 0.788, precision of 50%, recall of 38%, and Brier score of 0.035. Random forest yielded perfect precision (100%) but lower recall (23%), with a Brier score of 0.034. Logistic regression showed the highest recall (46%) but the lowest precision (10%), with a Brier score of 0.139. Feature importance analysis using Shapley additive explanations (SHAP) values revealed that the top predictors included recovery duration (SHAP=1.18), SSI keyword frequency (SHAP=1.12), patient age (SHAP=1.12), and American Society of Anesthesiologists score (SHAP=0.94), with natural language processing-derived features ranking among the top 10.
Conclusions: ML models can augment traditional SSI surveillance by improving early identification of patients at high risk. The XGBoost model offered the best trade-off between discrimination and calibration, suggesting its utility in clinical workflows. Incorporating structured and unstructured electronic health record data enhances model accuracy and clinical relevance, supporting scalable and efficient infection control practices.No embarg
Risk Factors for Underutilization of Bone Mineral Density Screening in Patients with Inflammatory Bowel Disease Meeting Age and Comorbidity Criteria
No full textIntroduction
The complex interplay of chronic inflammation, malnutrition, and corticosteroid exposure places patients with inflammatory bowel disease (IBD) at higher risk for low bone mineral density (BMD) compared to the general population. As part of evidence-based health maintenance, BMD screening via dual-energy X-ray absorptiometry (DXA) is recommended for older adults and should be considered for individuals with high-risk comorbidities including chronic obstructive pulmonary disease (COPD), heart failure, atrial fibrillation, diabetes, and obesity. Despite these guidelines, studies have consistently demonstrated underutilization of DXA screening within the higher risk IBD populations. This study aims to quantify DXA screening rates among these patients and identify risk factors contributing to screening underutilization.
Methods
In this single-center retrospective cohort study, electronic medical record (EMR) data were used to identify IBD patients aged ≥50 years or with ≥1 chronic comorbidity via International Classification of Diseases-10 (ICD-10) codes K50 (Crohn’s) and K51 (ulcerative colitis) from gastroenterology visits between 1/1/2018 and 12/31/2024. The primary outcomes were DXA scans ordered but not completed (DXA ordered) or completed during the study (DXR resulted). Logistic regression analysis was carried out to examine possible differences in groups with DXA ordered and DXA resulted, while controlling for demographics, comorbidities, and disease duration.
Results
A total of 1,161 patients met the age or comorbidity criteria (mean age 58.1 years, range 20–95; 48.7% male; 88.6% non-Hispanic white; 52.7% Crohn’s disease, 47.3% ulcerative colitis; 44.2% current/former smokers; 37.2% Medicare; 12.5% Medicaid/other). Comorbidities included autoimmune (19.7%), cardiopulmonary (17.3%), and metabolic disorders (57.7%). Among those with available data from EMR reports (n=257), the average disease duration was 22.8 years. Overall DXA order and completion rates were 31.2% and 27.2%, respectively. Regression analyses showed decreased odds of DXA orders in younger age groups (≤49 and 50–59 years) and males, with an increased odds of DXA orders in patients on Medicare and in those with metabolic disorders. Similar patterns were observed for completed DXA scans. In a sub-study (n=250) of those with disease-time available, a higher disease time-to-age ratio was linked to increased odds of DXA resulted.
Conclusion
DXA screening was lower in younger age groups, men, and among those with Medicaid insurance, while higher in Medicare patients and patients with metabolic comorbidities. These findings highlight important considerations for groups at greater risk for underutilization of DXA screening.Master of Science in Clinical InvestigationNo embarg
Adapting an Anxiety Sensitivity Intervention for Perinatal Mental Health: Development of a Digital Intervention
No full textIntroduction: The goal of this study was to adapt an anxiety sensitivity intervention for mobile health delivery to perinatal populations experiencing economic marginalization.
Methods: A community-engaged and user-centered design approach informed the prototype of Reaching Calm. We conducted "think-aloud" interviews with perinatal individuals (n=15) experiencing elevated anxiety and economic stressors. Acceptability and usability were assessed with the Treatment Evaluation Inventory Short Form (TEI-SF) and System Usability Scale (SUS), respectively. We used rapid qualitative analysis to analyze interviews and the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to characterize adaptations.
Results: Mean TEI-SF and SUS scores were 4.3 and 88.0, respectively. Participants reported the content was helpful, values consistent, addressed cultural norms, and elicited feelings of reassurance. Recommendations included additions to content and options for customization. Adaptations included modifications to context and content.
Conclusions: Findings suggest high acceptability and usability. Community-engaged, user-centered design may enhance digital intervention acceptability for perinatal individuals.No embarg
A Competency-Based Ultrasound-Guided Breast Biopsy Training Program for Radiologists From Low-and-Middle-Income Countries that Leverages Mobile Health Technology (NCT04501419): A Study Protocol
Get PDFIntroductionWhile ultrasound-guided breast biopsy (UGBB) performed by a radiologist is the standard of care in high-income countries for diagnosing breast cancer, blind or surgical biopsy has been the norm in low-and middle-income countries (LMIC) in part because LMIC radiologists lack the skill to perform UGBB. We present the study protocol of a competency-based UGBB training program for LMIC Nigerian radiologists that leverages mobile health technology.MethodsThis institutional review board-approved prospective multi-institutional single-arm clinical trial (ClinicalTrials.gov identifier: NCT04501419) involves 13 Nigerian radiologists from eight tertiary hospitals in South West and South East Nigeria. Our training program is unique because it uses a competency-based curriculum developed specifically for LMIC radiologists. The competency-based curriculum incorporates blended learning (e-learning and trainer-led), simulation (supervised and unsupervised), and patient biopsy (supervised and unsupervised) components. The study time frame is two years: 1 year for the trainees to complete active training and patient recruitment and another 1 year for patient follow-up. Primary outcome measures include trainees' competency (measured using the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE)), the radiology-pathology concordance rate, and the complication rate. Secondary outcome measures include the diagnostic interval and the positive predictive value of UGBB.ConclusionBuilding capacity for UGBB in Nigeria and other LMIC can potentially improve breast cancer outcomes through early diagnosis. This training program is part of an implementation multi-component strategy package in Nigeria to improve breast cancer outcomes. This training program can also be adapted for other image-guided procedures that could impact global cancer control through diagnosis, therapeutic intervention, and/or palliation.No embarg
Health-related quality of life in racial and ethnic minority adults with type 2 diabetes: validity and responsiveness of the EQ-5D-3L
Get PDFPurpose
Health-related quality of life (HRQL) assessment provides insights into the lived experiences of diverse populations. This study evaluated the convergent validity and responsiveness of the EQ-5D-3L in racial/ethnic minority populations with type 2 diabetes and elevated hemoglobin A1c (HbA1c).
Methods
Secondary data from a clinical trial of a diabetes adherence support intervention for African-American and Latinx patients with type 2 diabetes (NCT02990299) were analyzed. Clinical (HbA1c, systolic blood pressure [SBP], body mass index [BMI]), psychological (brief 4-item diabetes distress scale [DDS4] for diabetes-related distress, 9-item patient health questionnaire [PHQ-9] for depressive symptoms), and HRQL (EQ-5D-3L) data were collected at baseline and every 6 months for 2 years. Convergent validity was assessed by examining the strength of associations between clinical/psychological measures and EQ-5D scores. A responder analysis using generalized estimating equation models was used to evaluate the EQ-5D's sensitivity to changes in clinical/psychological factors over time.
Results
Among 221 individuals analyzed, HbA1c and SBP levels did not differ across those reporting varying levels of problems in any EQ-5D dimension. Individuals with higher BMI were more likely to report problems with mobility, usual activities, pain/discomfort, and anxiety/depression. DDS4 scores were moderately correlated with EQ-5D anxiety/depression dimension and index score, while PHQ-9 scores were strongly correlated with both. EQ-5D index score was insensitive to improvements in clinical measures but sensitive to improvements in psychological measures over time.
Conclusion
The EQ-5D-3L captured variations in BMI and psychological measures but not in HbA1c and SBP. This study provides HRQL estimates that can be compared with other populations or studies.No embarg
Impact of lifting school mask mandates on community SARS-CoV-2 cases, hospitalizations, and deaths: a retrospective observational study
Get PDFBackground: School masking mandates were widely adopted as a pandemic control measure, however, limited data are available regarding their effectiveness as a strategy for reducing burden of disease in the surrounding community.
Objective: To evaluate the impact of school masking policy de-adoption (mask-lifting) on SARS-CoV-2 incidence rates, hospitalizations, and deaths in the surrounding community.
Methods: Design: Retrospective observational study with an event study design, a difference-in-difference method; a target trial emulation (TTE) framework was applied as a secondary analysis. Cohort creation: Data collected from 9/2021 to 6/2022 on SARS-CoV-2 cases, hospitalizations, deaths and vaccination rates were combined with district-level masking policy data. Analysis: In the event study, the impact of masking policy de-adoption on SARS-CoV-2 cases per 100,000 county residents stratified by age during the 8-week period following the policy change was estimated. Effects on hospitalization and deaths per 1,000,000 residents were secondarily estimated. In a secondary analysis, a target trial emulation framework was applied to estimate average treatment effects.
Results: N = 3,970 districts composed of 53,453 schools were included in the cohort. In the event study, no consistent trends for COVID-19 case rates were identified for the whole cohort or for any age group. For the whole cohort, there was a statistically significant increase found 6-8 weeks following the policy change (maximum increase, 1.91 hospitalizations per 1,000,000 county residents); increases in hospitalizations were also found in the stratified analysis for all age groups, although absolute impacts were small. An increase in deaths was found during the period from 4 to 7 weeks following the policy change (maximum increase 0.62 deaths per 1,000,000 residents). In the stratified analysis, small increases in death rates were seen in 50-69 year olds (range, 0.088-1.49) and >70 year olds (range, 0.23-2.58) but not in younger groups. In the TTE framework, cases, hospitalizations, and deaths were similar in control and intervention counties.
Conclusion: This study evaluating the impact of lifting of mask mandates in schools, analyzed in two ways, was consistent results ranging from no impact to a small but statistically significant impact of the policy change on SARS-CoV-2 case and severe outcomes rates in the surrounding community. Findings can be used to inform future pandemic policy responses for elementary and secondary schoolsNo embarg
Multicenter comparative analysis of FRED-X, pipeline shield, and surpass evolve in treating intracranial aneurysms
No full textBackground
In recent years, newer flow diverters have been developed with surface modification and varying wire densities. Our study evaluated outcomes among three newer generation flow diverter devices, FRED-X, PED Shield and Surpass Evolve.
Methods
This was a retrospective study of patients from five participating institutions across the United States. Patients who underwent flow diversion of intracranial aneurysms using the FRED-X, PED Shield or Surpass Evolve between February 2022 and September 2024 were included. Outcomes of interest were technical success, angiographic occlusion and in-stent stenosis (ISS).
Results
Among 447 patients with 452 aneurysms, adjunct device use was highest with Surpass Evolve (36.4%) versus PED Shield (15.7%) and FRED-X (6.4%) (p < .001). Good wall apposition after angioplasty/stenting was most frequent with Surpass Evolve (32.3%) versus PED Shield (13.7%) and FRED-X (4.5%) (p < .001). At six months, complete occlusion was achieved in 69.3% (PED Shield), 63.6% (FRED-X), and 58% (Surpass Evolve) (p = .254). ISS rates were comparable at six months (p = .826). At 12 months, complete occlusion was observed in 78.9% of PED Shield, 68.4% of FRED-X, and 64.5% of Surpass Evolve aneurysms. Most ISS cases at 12 months were mild. Kaplan-Meier analysis showed no significant difference in occlusion rates (p = .914).
Conclusions
Flow diversion using FRED-X, PED Shield and Surpass Evolve resulted in comparable rates of angiographic occlusion and ISS. However, adjunctive devices were more commonly needed with Surpass Evolve.No embarg
Promotion of COVID-19 vaccination for youth and families in Worcester, Massachusetts: a Diffusion of Innovations approach
Get PDFIntroduction: Diffusion of innovations (DOI) theory can explain adoption of new technologies, like COVID-19 vaccines. We used an adapted version of DOI theory to guide efforts to adapt and implement evidence-based interventions to support COVID-19 vaccination for youth and families.
Methods: Guided by community partner input, we triangulated data on infection and vaccination rates with qualitative focus group and interview data, and a synthesis of literature on evidence-based interventions for vaccine promotion to adapt interventions.
Results: Implemented in three phases, we relied on trusted messengers to share vaccine narratives and tailored the degree of interaction between trusted messengers and adopters. We began broadly in the form of a community-wide communications campaign and progressively narrowed in focus towards direct engagement with trusted messengers.
Discussion: DOI framework can be used to plan for and implement interventions as demonstrated by our two-year project to respond to the ever-evolving context of the COVID-19 pandemic.No embarg
Deep learning-based aberration compensation improves contrast and resolution in fluorescence microscopy
Get PDFOptical aberrations hinder fluorescence microscopy of thick samples, reducing image signal, contrast, and resolution. Here we introduce a deep learning-based strategy for aberration compensation, improving image quality without slowing image acquisition, applying additional dose, or introducing more optics. Our method (i) introduces synthetic aberrations to images acquired on the shallow side of image stacks, making them resemble those acquired deeper into the volume and (ii) trains neural networks to reverse the effect of these aberrations. We use simulations and experiments to show that applying the trained 'de-aberration' networks outperforms alternative methods, providing restoration on par with adaptive optics techniques; and subsequently apply the networks to diverse datasets captured with confocal, light-sheet, multi-photon, and super-resolution microscopy. In all cases, the improved quality of the restored data facilitates qualitative image inspection and improves downstream image quantitation, including orientational analysis of blood vessels in mouse tissue and improved membrane and nuclear segmentation in C. elegans embryos.No embarg