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PURPOSE: Multidisciplinary lung cancer care is assumed to improve care delivery by increasing transparency, objectivity, and shared decision making; however, there is a lack of high-level evidence demonstrating its benefits, especially in community-based health care systems. We used implementation and team science principles to establish a colocated multidisciplinary lung cancer clinic in a large community-based health care system and evaluated patient experience and outcomes within and outside this clinic. METHODS: We conducted a prospective frequency-matched comparative effectiveness study (ClinicalTrials.gov identifier: NCT02123797 ) evaluating the thoroughness of lung cancer staging, receipt of stage-appropriate treatment, and survival between patients receiving care in the multidisciplinary clinic and those receiving usual serial care. Target enrollment was 150 patients on the multidisciplinary arm and 300 on the serial care arm. We frequency-matched patients by clinical stage, performance status, insurance type, race, and age. RESULTS: A total of 526 patients were enrolled: 178 on the multidisciplinary arm and 348 on the serial care arm. After adjusting for other factors, multidisciplinary patients had significantly higher odds (odds ratio [OR]: 2.3 [95% CI, 1.5 to 3.4]) of trimodality staging compared with serial care. Patients on the multidisciplinary arm also had higher odds of receiving invasive stage confirmation (OR: 2.0 [95% CI, 1.4 to 3.1]) and mediastinal stage confirmation (OR: 1.9 [95% CI, 1.3 to 2.8]). Additionally, patients receiving multidisciplinary care were significantly more likely to receive stage-appropriate treatment (OR: 1.8 [95% CI, 1.1 to 3.0]). We found no significant difference in overall or progression-free survival between study arms. CONCLUSION: The multidisciplinary clinic delivered significant improvements in evidence-based quality care on multiple levels. Even in the absence of a demonstrable survival benefit, these findings provide a strong rationale for recommending this model of care.

BACKGROUND Hydroxyurea is an evidence-based disease-modifying therapy for sickle cell disease (SCD) but is underutilized. The Integration of Mobile Health (mHealth) into Sickle Cell Disease Care to Increase Hydroxyurea Utilization (meSH) multi-center study leveraged mHealth to deliver targeted interventions to patients and providers to foster hydroxyurea utilization. SCD studies often under enroll, and unanticipated events can negatively impact enrollment, making it important to study strategies that ensure adequate study accrual. OBJECTIVE This paper describes the challenges and adaptive strategies used to secure participant enrollment in the meSH study. Adaptive strategies were crucial to alleviate enrollment disruptions due to the COVID-19 pandemic. METHODS Recruitment was anticipated to last 2 months for providers and 6 months for patients. The recruitment strategies used with patients and providers, new recruitment strategies, and recruitment rates were captured and compared. To document recruitment adaptations and their reasons, study staff responsible for recruitment completed an open-ended 9-item questionnaire eliciting challenges to recruitment and strategies used. Themes were extrapolated using thematic content analysis. RESULTS In total, 89 providers and 293 patients enrolled across seven sites. Recruitment duration ranged from 2 to 7 for providers and 7 to 10 months for patients across sites. The study acceptance rate was 86% for both patients and providers. Patients mostly declined participation due to a lack of time and interest in research. Providers declined because of self-perceived high levels of SCD expertise, believing they did not need the intervention. Initially, recruitment involved an in-person invitation to participate during clinic visits (patients and providers), staff meetings (providers), or within the office (providers). Recruitment challenge themes included: 1) lack of interest in research, 2) lack of human resources (e.g., shortage of study staff due to layoffs or resignations during the COVID-19 pandemic), 3) unavailable physical space for recruitment activities due to in-person activity restrictions, and 4) lack of documentation to verify eligibility. Because recruitment was slower than projected, strategies were adapted to include remote approaching and consenting (e.g., telehealth, email and telephone) for patients and providers. Additionally, for patients, recruitment was enriched by simplification of enrollment procedures (e.g., directly approaching patients without a referral from the provider) and a multi-touch method (i.e., warm introductions with flyers, text and patient portal messages). For patients, recruitment rates were similar between the in-person and adapted (virtual with multi-touch) approaches (83.5% and 88.1%, respectively, P=0.23). For providers, however, recruitment rate was higher for in-person versus remote recruitment (96.0% and 70.7%, respectively, P CONCLUSIONS The adapted recruitment strategies, implemented in response to the COVID-19 pandemic, secured a high recruitment rate, which was maintained among patients with SCD using an assortment of enriched remote recruitment strategies. For provider participants, e-mail-alone recruitment methods may not be sufficient to secure study enrollment. INTERNATIONAL REGISTERED REPORT RR2-10.2196/16319

Background There is substantial heterogeneity in symptom management provided to pediatric patients with cancer. The primary objective was to describe the adaptation process and specific adaptation decisions related to symptom management care pathways based on clinical practice guidelines. The secondary objective evaluated if institutional factors were associated with adaptation decisions. Methods Fourteen previously developed symptom management care pathway templates were reviewed by an institutional adaptation team composed of two clinicians at each of 10 institutions. They worked through each statement for all care pathway templates sequentially. The institutional adaptation team made the decision to adopt, adapt or reject each statement, resulting in institution-specific symptom management care pathway drafts. Institutional adaption teams distributed the 14 care pathway drafts to their respective teams; their feedback led to care pathway modifications. Results Initial care pathway adaptation decision making was completed over a median of 4.2 (interquartile range 2.0-5.3) weeks per institution. Across all institutions and among 1350 statements, 551 (40.8%) were adopted, 657 (48.7%) were adapted, 86 (6.4%) were rejected and 56 (4.1%) were no longer applicable because of a previous decision. Most commonly, the reason for rejection was not agreeing with the statement (70/86, 81.4%). Institutional-level factors were not significantly associated with statement rejection. Conclusions Acceptability of the 14 care pathways was evident by most statements being adopted or adapted. The adaptation process was accomplished over a relatively short timeframe. Future work should focus on evaluation of care pathway compliance and determination of the impact of care pathway-consistent care on patient outcomes. Trial registration clinicaltrials.gov, NCT04614662. Registered 04/11/2020, https://clinicaltrials.gov/ct2/show/NCT04614662?term=NCT04614662&draw=2&rank=1.

BackgroundThis study seeks to understand how and for whom COVID-19 disrupted cancer care to understand the potential for cancer health disparities across the cancer prevention and control continuum.MethodsIn this cross-sectional study, participants age 30+ residing in an 82-county region in Missouri and Illinois completed an online survey from June-August 2020. Descriptive statistics were calculated for all variables separately and by care disruption status. Logistic regression modeling was conducted to determine the correlates of care disruption.ResultsParticipants (N=680) reported 21% to 57% of cancer screening or treatment appointments were canceled from March 2020 through the end of 2020. Approximately 34% of residents stated they would need to know if their doctor’s office is taking the appropriate COVID-related safety precautions to return to care. Higher education (OR=1.26, 95%CI:1.11-1.43), identifying as female (OR=1.60, 95%CI:1.12-2.30), experiencing more discrimination in healthcare settings (OR= 1.40, 95%CI:1.13-1.72), and having scheduled a telehealth appointment (OR=1.51, 95%CI:1.07-2.15) were associated with higher odds of care disruption. Factors associated with care disruption were not consistent across races. Higher odds of care disruption for White residents were associated with higher education, female identity, older age, and having scheduled a telehealth appointment, while higher odds of care disruption for Black residents were associated only with higher education.Conclusion(s)This study provides an understanding of the factors associated with cancer care disruption and what patients need to return to care. Results may inform outreach and engagement strategies to reduce delayed cancer screenings and encourage returning to cancer care.Funding SupportThis study was supported by the National Cancer Institute’s Administrative Supplements for P30 Cancer Center Support Grants (P30CA091842-18S2 and P30CA091842-19S4). Kia L. Davis, Lisa Klesges, and Bettina Drake were supported by the National Cancer Institute’s P50CA244431 and Kia L. Davis was also supported by the Breast Cancer Research Foundation. Callie Walsh-Bailey was supported by NIMHD T37 MD014218. The content does not necessarily represent the official view of these funding agencies and is solely the responsibility of the authors.Availability of data and materialThe dataset generated for the study is not publicly available but is available by request. Interested individuals should contact the corresponding author with a brief description of how the data will be used and proof of IRB approval or exemption. Then a de-identified dataset will be shared.

We recruited women (primarily non-Hispanic White) from 14 rural, segregated counties in a Northeastern US state for an explanatory sequential study: 100 women (ages 50–65 years) completed a survey, and 16 women participated in focus groups. We sought to identify personal (e.g., healthcare mistrust) and environmental (e.g., travel time to healthcare providers) factors related to colorectal and cervical cancer screening. Quantitatively, 89% of participants were up-to-date for cervical screening, and 65% for colorectal screening. Factors interacted such that compounding barriers were associated with lower odds of screening (e.g., insurance status and healthcare mistrust: interaction p = .02 for cervical; interaction p = .05 for colorectal). Qualitatively, three themes emerged regarding barriers to screening: privacy concerns, logistical barriers, and lack of trust in adequacy of healthcare services. While cancer screening was common in rural, segregated counties, women who reported both environmental and personal barriers to screening had lower uptake. Future interventions to promote screening can target these barriers. Supplementary Information The online version contains supplementary material available at 10.1007/s13187-021-02069-0.

Background There is a growing body of research and evidence for the efficacy of Internet-based eating disorder (ED) prevention interventions for adults. However, much less is known about the reach, adoption, implementation and maintenance of these interventions. The RE-AIM (reach, efficacy/effectiveness, adoption, implementation, maintenance) model provides a framework to systematically assess this information. Methods A literature search was conducted in PubMed, Web of Science and PsycINFO for articles published between 2000 and 2019. Additionally, reference lists of the studies included and existing reviews published until the end of 2020 were searched. Sixty original articles describing 54 individual studies fulfilled inclusion criteria. Data were extracted for a total of 43 RE-AIM indicators for each study. Fostering and hindering factors for reach, adoption, implementation and maintenance were assessed qualitatively. Results Overall reporting rates were best for the RE-AIM dimensions reach (62.6%), implementation (57.0%) and effectiveness (54.2%), while adoption (24.2%) and maintenance (21.5%) had comparatively low overall reporting rates. Reporting on indicators of internal validity, such as sample size, effects or description of interventions was better than indicators relevant for dissemination and implementation in real-world settings, e.g. characteristics of non-participants, characteristics and representativeness of settings, and data to estimate cost. Conclusions Because most Internet-based ED prevention interventions are provided in a research-funded context, little is known about their public health impact. Better reporting of factors determining external validity is needed to inform dissemination and implementation of these interventions.

Background Online interventions to prevent mental health problems have proven to be effective. However, knowledge about their implementation in real-world practice as well as for dissemination to the target groups in different settings is scarce. The goal of the ‘ICare’ network is to establish a comprehensive model of eMental-health service delivery in and across different European countries. Since implementation and dissemination are influenced by many contextual factors, in the first phase of ICare a stakeholder survey was conducted. The survey aim was to explore stakeholders’ experiences, needs and attitudes regarding Internet-based prevention of mental health problems and hindering and fostering factors for implementation and dissemination. This article is part of a supplement and describes the design of the stakeholder survey. Survey results are published in separate articles in the same supplement. Methods Based on a literature review and the individual characteristics of the ICare interventions, stakeholder groups were identified in different settings across six European countries. The RE-AIM framework guided the development of the research questions and survey instruments. A concurrent mixed methods design was applied comprising focus groups with the intended target groups of ICare interventions, an online questionnaire with potential facilitators/delivery staff and semi-structured interviews with policy makers. Conclusion The challenge was to develop a design that allowed flexibility but at the same did not jeopardize the validity of the study. Implications drawn from this survey are not restricted to specific preventive interventions but will provide general information on how online mental illness prevention can be best implemented in various settings.

The aim of the study was to better address sociodemographic-related health disparities. This study examined which sociodemographic variables most strongly correlate with self-reported health in patients with chronic musculoskeletal pain.This single-center, cross-sectional study examined adult patients, followed by a physiatrist for chronic (≥4 yrs) musculoskeletal pain. Sociodemographic variables considered were race, sex, and disparate social disadvantage (measured as residential address in the worst vs. best Area Deprivation Index national quartile). The primary comparison was the adjusted effect size of each variable on physical and behavioral health (measured by Patient-Reported Outcomes Measurement Information System [PROMIS]).In 1193 patients (age = 56.3 ± 13.0 yrs), disparate social disadvantage was associated with worse health in all domains assessed (PROMIS Physical Function Β = -2.4 points [95% confidence interval = -3.8 to -1.0], Pain Interference = 3.3 [2.0 to 4.6], Anxiety = 4.0 [1.8 to 6.2], and Depression = 3.7 [1.7 to 5.6]). Black race was associated with greater anxiety than white race (3.2 [1.1 to 5.3]), and female sex was associated with worse physical function than male sex (-2.5 [-3.5 to -1.5]).Compared with race and sex, social disadvantage is more consistently associated with worse physical and behavioral health in patients with chronic musculoskeletal pain. Investment to ameliorate disadvantage in geographically defined communities may improve health in sociodemographically at-risk populations.

During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation.

UNSTRUCTURED During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation.

Cancer in the United States accounts for $600 billion in health care costs, lost work time and productivity, reduced quality of life, and premature mortality. The future of oncology delivery must mend disconnects to equitably improve patient outcomes while constraining costs and burden on patients, caregivers, and care teams. Embedding learning health systems into oncology can connect care, engaging patients and providers in fully interoperable data systems that remotely monitor patients; generate predictive and prescriptive analytics to facilitate appropriate, timely referrals; and extend the reach of clinicians beyond clinic walls. Incorporating functional learning systems into the future of oncology and follow-up care requires coordinated national attention to 4 synergistic strategies: (1) galvanize and shape public discourse to develop and adopt these systems, (2) demonstrate their value, (3) test and evaluate their use, and (4) reform policy to incentivize and regulate their use.

Background In 2019–2020, with National Cancer Institute funding, seven implementation laboratory (I-Lab) partnerships between scientists and stakeholders in ‘real-world’ settings working to implement evidence-based interventions were developed within the Implementation Science Centers in Cancer Control (ISC3) consortium. This paper describes and compares approaches to the initial development of seven I-Labs in order to gain an understanding of the development of research partnerships representing various implementation science designs. Methods In April-June 2021, members of the ISC3 Implementation Laboratories workgroup interviewed research teams involved in I-Lab development in each center. This cross-sectional study used semi-structured interviews and case-study-based methods to collect and analyze data about I-Lab designs and activities. Interview notes were analyzed to identify a set of comparable domains across sites. These domains served as the framework for seven case descriptions summarizing design decisions and partnership elements across sites. Results Domains identified from interviews as comparable across sites included engagement of community and clinical I-Lab members in research activities, data sources, engagement methods, dissemination strategies, and health equity. The I-Labs use a variety of research partnership designs to support engagement including participatory research, community-engaged research, and learning health systems of embedded research. Regarding data, I-Labs in which members use common electronic health records (EHRs) leverage these both as a data source and a digital implementation strategy. I-Labs without a shared EHR among partners also leverage other sources for research or surveillance, most commonly qualitative data, surveys, and public health data systems. All seven I-Labs use advisory boards or partnership meetings to engage with members; six use stakeholder interviews and regular communications. Most (70%) tools or methods used to engage I-Lab members such as advisory groups, coalitions, or regular communications, were pre-existing. Think tanks, which two I-Labs developed, represented novel engagement approaches. To disseminate research results, all centers developed web-based products, and most (n = 6) use publications, learning collaboratives, and community forums. Important variations emerged in approaches to health equity, ranging from partnering with members serving historically marginalized populations to the development of novel methods. Conclusions The development of the ISC3 implementation laboratories, which represented a variety of research partnership designs, offers the opportunity to advance understanding of how researchers developed and built partnerships to effectively engage stakeholders throughout the cancer control research lifecycle. In future years, we will be able to share lessons learned for the development and sustainment of implementation laboratories.

Prior cancer research is limited by inconsistencies in defining rurality. The purpose of this study was to describe the prevalence of cancer risk factors and cancer screening behaviors across various county-based rural classification codes, including measures reflecting a continuum, to inform our understanding of cancer disparities according to the extent of rurality.Using an ecological cross-sectional design, we examined differences in cancer risk factors and cancer screening behaviors from the Behavioral Risk Factor Surveillance System and National Health Interview Survey (2008-2013) across rural counties and between rural and urban counties using four rural-urban classification codes for counties and county-equivalents in 2013: U.S. Office of Management and Budget, National Center for Health Statistics, USDA Economic Research Service's rural-urban continuum codes, and Urban Influence Codes.Although a rural-to-urban gradient was not consistently evident across all classification codes, the prevalence of smoking, obesity, physical inactivity, and binge alcohol use increased (all pRural cancer disparities persist across multiple rural-urban classification codes, with marked variation in cancer risk factors and screening evident within rural regions. Focusing only on a rural-urban dichotomy may not sufficiently capture subpopulations of rural residents at greater risk for cancer and cancer-related mortality.

ObjectivesSickle cell disease (SCD) leads to chronic and acute complications that require specialised care to manage symptoms and optimise clinical results. The National Heart Lung and Blood Institute (NHLBI) evidence-based guidelines assist providers in caring for individuals with SCD, but adoption of these guidelines by providers has not been optimal. The objective of this study was to identify barriers to treating individuals with SCD.MethodsThe SCD Implementation Consortium aimed to investigate the perception and level of comfort of providers regarding evidence-based care by surveying providers in the regions of six clinical centres across the USA, focusing on non-emergency care from the providers’ perspective.ResultsRespondents included 105 providers delivering clinical care for individuals with SCD. Areas of practice were most frequently paediatrics (24%) or haematology/SCD specialist (24%). The majority (77%) reported that they were comfortable managing acute pain episodes while 63% expressed comfort with managing chronic pain. Haematologists and SCD specialists showed higher comfort levels prescribing opioids (100% vs 67%, p=0.004) and managing care with hydroxyurea (90% vs 51%, p=0.005) compared with non-haematology providers. Approximately 33% of providers were unaware of the 2014 NHLBI guidelines. Nearly 63% of providers felt patients’ medical needs were addressed while only 22% felt their mental health needs were met.ConclusionsA substantial number of providers did not know about NHLBI’s SCD care guidelines. Barriers to providing care for patients with SCD were influenced by providers’ specialty, training and practice setting. Increasing provider knowledge could improve hydroxyurea utilisation, pain management and mental health support.

During transition from pediatrics to adult health care, young adults with sickle cell disease (SCD) face increased risk of severe morbidities and premature mortality.1 Sickle cell disease complications can be mitigated with hydroxyurea use.2 However, successful alleviation and prevention of SCD morbidities is contingent on initiation of and continued adherence to hydroxyurea therapy.3,4 With higher frequency of SCD-related complications among young adults, we examined the prevalence of hydroxyurea prescription among patients aged 18 to 25 years using statewide claims data. Understanding the patterns of hydroxyurea use in this patient population is key to potentially preventing the high burden of the disease accumulating among young adults.

Background Objectives were to describe barriers to pediatric cancer symptom management care pathway implementation and the impact of the COVID-19 pandemic on clinical research evaluating their implementation. Methods We included 25 pediatric oncology hospitals in the United States that supported a grant submission to perform a cluster randomized trial in which the intervention encompassed care pathways for symptom management. A survey was distributed to site principal investigators prior to randomization to measure contextual elements related to care pathway implementation. Questions included the inner setting measures of the Consolidated Framework for Implementation Research (CFIR), study-specific potential barriers and the impact of the COVID-19 pandemic on clinical research. The Wilcoxon rank sum test was used to compare characteristics of institutions that agreed that their department supported the implementation of symptom management care pathways vs. institutions that did not agree. Results Of the 25 sites, one withdrew because of resource constraints and one did not respond, leaving 23 institutions. Among the seven CFIR constructs, the least supported was implementation climate; 57% agreed there was support, 39% agreed there was recognition and 39% agreed there was prioritization for symptom management care pathway implementation at their institution. Most common barriers were lack of person-time to create care pathways and champion their use (35%), lack of interest from physicians (30%) and lack of information technology resources (26%). Most sites reported no negative impact of the COVID-19 pandemic across research activities. Sites with fewer pediatric cancer patients were more likely to agree that staff are supported to implement symptom management care pathways (P = 0.003). Conclusions The most commonly reported barriers to implementation were lack of support, recognition and prioritization. The COVID-19 pandemic may not be a major barrier to clinical research activities in pediatric oncology.

BACKGROUND Historically, marginalized patients were prescribed less opioid medication than affluent, white patients. However, because of persistent differential access to nonopioid pain treatments, this direction of disparity in opioid prescribing may have reversed. OBJECTIVE To compare social disadvantage and health in patients with chronic pain who were managed with versus without chronic opioid therapy. It was hypothesized that patients routinely prescribed opioids would be more likely to live in socially disadvantaged communities and report worse health. DESIGN Cross-sectional analysis of a retrospective cohort defined from medical records from 2000 to 2019. SETTING Single tertiary safety net medical center. PATIENTS Adult patients with chronic musculoskeletal pain who were managed longitudinally by a physiatric group practice from at least 2011 to 2015 (n = 1173), subgrouped by chronic (≥4 years) adherent opioid usage (n = 356) versus no chronic opioid usage (n = 817). INTERVENTION Not applicable. MAIN OUTCOME MEASURES The primary outcome was the unadjusted between-group difference in social disadvantage, defined by living in the worst national quartile of the Area Deprivation Index (ADI). An adjusted effect size was also calculated using logistic regression, with age, sex, race, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Physical Function scores as covariates. Secondary outcomes included adjusted differences in health by chronic opioid use (measured by PROMIS). RESULTS Patients managed with chronic opioid therapy were more likely to live in a zip code within the most socially disadvantaged national quartile (34.9%; 95% confidence interval [CI] 29.9-39.9%; vs. 24.9%; 95% CI 21.9-28.0%; P

Background Individuals living with sickle cell disease often require aggressive treatment of pain associated with vaso-occlusive episodes in the emergency department. Frequently, pain relief is poor. The 2014 National Heart, Lung, and Blood Institute evidence-based guidelines recommended an individualized treatment and monitoring protocol to improve pain management of vaso-occlusive episodes. Objective This study will implement an electronic health record–embedded individualized pain plan with provider and patient access in the emergency departments of 8 US academic centers to improve pain treatment for adult patients with sickle cell disease. This study will assess the overall effects of electronic health record–embedded individualized pain plans on improving patient and provider outcomes associated with pain treatment in the emergency department setting and explore barriers and facilitators to the implementation process. Methods A preimplementation and postimplementation study is being conducted by all 8 sites that are members of the National Heart, Lung, and Blood Institute–funded Sickle Cell Disease Implementation Consortium. Adults with sickle cell disease aged 18 to 45 years who had a visit to a participating emergency department for vaso-occlusive episodes within 90 days prior to enrollment will be eligible for inclusion. Patients will be enrolled in the clinic or remotely. The target analytical sample size of this study is 160 patient participants (20 per site) who have had an emergency department visit for vaso-occlusive episode treatment at participating emergency departments during the study period. Each site is expected to enroll approximately 40 participants to reach the analytical sample size. The electronic health record–embedded individualized pain plans will be written by the patient’s sickle cell disease provider, and sites will work with the local informatics team to identify the best method to build the electronic health record–embedded individualized pain plan with patient and provider access. Each site will adopt required patient and provider implementation strategies and can choose to adopt optional strategies to improve the uptake and sustainability of the intervention. The study is informed by the Technology Acceptance Model 2 and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Provider and patient baseline survey, follow-up survey within 96 hours of an emergency department vaso-occlusive episode visit, and selected qualitative interviews within 2 weeks of an emergency department visit will be performed to assess the primary outcome, patient-perceived quality of emergency department pain treatment, and additional implementation and intervention outcomes. Electronic health record data will be used to analyze individualized pain plan adherence and additional secondary outcomes, such as hospital admission and readmission rates. Results The study is currently enrolling study participants. The active implementation period is 18 months. Conclusions This study proposes a structured, framework-informed approach to implement electronic health record–embedded individualized pain plans with both patient and provider access in routine emergency department practice. The results of the study will inform the implementation of electronic health record–embedded individualized pain plans at a larger scale outside of Sickle Cell Disease Implementation Consortium centers. Trial Registration ClinicalTrials.gov NCT04584528; https://clinicaltrials.gov/ct2/show/NCT04584528. International Registered Report Identifier (IRRID) DERR1-10.2196/24818

Background: To describe barriers to pediatric cancer symptom management care pathway implementation and the impact of the COVID-19 pandemic on clinical research evaluating their implementation. Methods: We included 25 pediatric oncology hospitals in the United States that supported a grant submission to perform a cluster randomized trial in which the intervention encompassed care pathways for symptom management. A survey was distributed to site principal investigators to measure contextual elements related to care pathway implementation. Questions included the inner setting measures of the Consolidated Framework for Implementation Research (CFIR), study-specific potential barriers and the impact of the COVID-19 pandemic on clinical research. The Wilcoxon rank sum test was used to compare characteristics of institutions that agreed that their department supported the implementation of symptom management care pathways vs. institutions that did not agree.Results: Of the 25 sites, one withdrew because of resource constraints and one did not respond, leaving 23 institutions. Among the seven CFIR constructs, the least supported was implementation climate; 57% agreed there was support, 39% agreed there was recognition and 39% agreed there was prioritization for symptom management care pathway implementation at their institution. Most common barriers were lack of person-time to create care pathways and champion their use (35%), lack of interest from physicians (30%) and lack of information technology resources (26%). Most sites reported no negative impact of the COVID-19 pandemic across research activities. Sites with fewer pediatric cancer patients were more likely to agree that staff are supported to implement symptom management care pathways (P=0.003). Conclusions: The most commonly reported barriers to implementation were lack of support, recognition and prioritization. The COVID-19 pandemic was not a major barrier to clinical research activities in pediatric oncology.Clinical Trial Registration: NCT04614662

Background Hydroxyurea prevents disease complications among patients with sickle cell disease (SCD). Although its efficacy has been endorsed by the National Health Lung and Blood Institute evidence-based guidelines, its adoption is low, both by patients with SCD and providers. Mobile health (mHealth) apps provide benefits in improving medication adherence and self-efficacy among patients with chronic diseases and have facilitated prescription among medical providers. However, mHealth has not been systematically tested as a tool to increase hydroxyurea adherence nor has the combination of mHealth been assessed at both patient and provider levels to increase hydroxyurea utilization. Objective This study aims to increase hydroxyurea utilization through a combined two-level mHealth intervention for both patients with SCD and their providers with the goals of increasing adherence to hydroxyurea among patients and improve hydroxyurea prescribing behavior among providers. Methods We will test the efficacy of 2 mHealth interventions to increase both patient and provider utilization and knowledge of hydroxyurea in 8 clinical sites of the NHLBI-funded Sickle Cell Disease Implementation Consortium (SCDIC). The patient mHealth intervention, InCharge Health, includes multiple components that address memory, motivation, and knowledge barriers to hydroxyurea use. The provider mHealth intervention, Hydroxyurea Toolbox (HU Toolbox), addresses the clinical knowledge barriers in prescribing and monitoring hydroxyurea. The primary hypothesis is that among adolescents and adults with SCD, adherence to hydroxyurea, as measured by the proportion of days covered (the ratio of the number of days the patient is covered by the medication to the number of days in the treatment period), will increase by at least 20% after 24 weeks of receiving the InCharge Health app, compared with their adherence at baseline. As secondary objectives, we will (1) examine the change in health-related quality of life, acute disease complications, perceived health literacy, and perceived self-efficacy in taking hydroxyurea among patients who use InCharge Health and (2) examine potential increases in the awareness of hydroxyurea benefits and risks, appropriate prescribing, and perceived self-efficacy to correctly administer hydroxyurea therapy among SCD providers between baseline and 9 months of using the HU Toolbox app. We will measure the reach, adoption, implementation, and maintenance of both the InCharge Health and the HU Toolbox apps using the reach, effectiveness, adoption, implementation, and maintenance framework and qualitatively evaluate the implementation of both mHealth interventions. Results The study is currently enrolling study participants. Recruitment is anticipated to be completed by mid-2021. Conclusions If this two-level intervention, that is, the combined use of InCharge Health and HU Toolbox apps, demonstrates efficacy in increasing adherence to hydroxyurea and prescribing behavior in patients with SCD and their providers, respectively, both apps will be offered to other institutions outside the SCDIC through a future large-scale implementation-effectiveness study. Trial Registration ClinicalTrials.gov NCT04080167; https://clinicaltrials.gov/ct2/show/NCT04080167 International Registered Report Identifier (IRRID) DERR1-10.2196/16319

Behavior change research to promote health and prevent disease increasingly relies on a complex set of interacting characteristics across levels of influence such as biological, psychological, behavioral, interpersonal, and environmental. How to best develop health-related interventions that incorporate the individual, the macro-environment, and their interactions remains a challenge. This article considers a set of key dimensions that constitute what we refer to as the ecology of research across a broad context of multilevel research (MLR), spanning fundamental multilevel research (FMLR), multilevel intervention research (MLIR), and multilevel implementation science (MIS). With the goal of promoting improvements in MLIR, we describe the inherent interdependencies among aspects of research and consider how the growth and development of evidence and resources influence the cross-talk among researchers from different perspectives (e.g., disciplines and domains). We propose a framework that highlights opportunities to reduce barriers and address gaps in areas critical to generating an evidence base through MLR, MLIR, and MIS. Overall, we aim to support strategic decisions that can accelerate our understanding of ML health outcomes and interactions among factors within and across levels, with the goal of strengthening the effectiveness of ML interventions across health-related outcomes.

Background: Responsible for 25% of all US cancer deaths, lung cancer presents complex care-delivery challenges. Adoption of the highly recommended multidisciplinary care model suffers from a dearth of good quality evidence. Leading up to a prospective comparative-effectiveness study of multidisciplinary vs. serial care, we studied the implementation of a rigorously benchmarked multidisciplinary lung cancer clinic. Methods: We used a mixed-methods approach to conduct a patient-centered, combined implementation and effectiveness study of a multidisciplinary model of lung cancer care. We established a co-located multidisciplinary clinic to study the implementation of this care-delivery model. We identified and engaged key stakeholders from the onset, used their input to develop the program structure, processes, performance benchmarks, and study endpoints (outcome-related process measures, patient- and caregiver-reported outcomes, survival). In this report, we describe the study design, process of implementation, comparative populations, and how they contrast with patients within the local and regional healthcare system. Trial Registration: ClinicalTrials.gov Identifier: NCT02123797. Results: Implementation: The multidisciplinary clinic obtained an overall treatment concordance rate of 90% (target >85%). Satisfaction scores were high, with >95% of patients and caregivers rating themselves as being “very satisfied” with all aspects of care from the multidisciplinary team (patient/caregiver response rate >90%). The Reach of the multidisciplinary clinic included a higher proportion of minority patients, more women, and younger patients than the regional population. Comparative effectiveness: The comparative effectiveness trial conducted in the last phase of the study met the planned enrollment per statistical design, with 178 patients in the multidisciplinary arm and 348 in the serial care arm. The multidisciplinary cohort had older age and a higher percentage of racial minorities, with a higher proportion of stage IV patients in the serial care arm. Conclusions: This study demonstrates a comprehensive implementation of a multidisciplinary model of lung cancer care, which will advance the science behind implementing this much-advocated clinical care model.

The Society for Behavioral Medicine (SBM) recommends expanding access to high-speed, high-definition internet and increasing broadband width for rural communities in the USA to increase telehealth opportunities for populations facing geographic barriers to accessing quality healthcare. High-speed telehealth will allow healthcare providers to care for patients in “real time” and will expand access to specialty providers thereby increasing timely follow-up, improving health outcomes, and reducing rural health disparities. Moreover, SBM recommends that the current National Broadband Plan legislation be protected and enhanced to ensure high-quality, but also affordable, internet services in rural areas. Several legislative bills have been put forth but are not fully funded or enacted by individual states. In addition, further mechanisms and supplemental funding are needed to address the continued lack of resources to enhance rural broadband including infrastructure, research, and regulatory reform.

Background: Sickle cell disease (SCD) is a chronic blood disorder, which disproportionately impacts Black individuals. Hydroxyurea therapy prevents SCD-related complications; yet it is underutilized, which contributes to further health inequities. Mobile health (mHealth) apps for patients and providers have the potential to improve hydroxyurea adherence. Our objective was to use the RE-AIM framework to evaluate the impact of the COVID-19 pandemic on implementation and effectiveness of patient and provider hydroxyurea (HU) mHealth apps (InCharge Health app and HU Toolbox app, respectively) in two large academic medical centers. Methods: Patient-level data (n=46) were collected between 11/2019-7/2020. Adherence was measured by calculating Percentage of Days Covered (PDC) from prescription records over 24 weeks before implementing the mHealth apps and during 12 and 24 weeks of implementation. As a response to the COVID-19 pandemic and to reduce virus spread, both sites temporarily suspended non-emergent clinical activities. During implementation, Site A clinics shut down for approximately 2 months (3/2020-5/2020) and Site B clinics for 7 months (3/2020-10/2020). To better understand contextual factors associated with mHealth implementation, we purposively sampled participants according to app use level (high vs low) and conducted semi-structured interviews with adult SCD patients, providers (physicians, nurse practitioners, and physician assistants), administrators, and research staff between 6/2020 and 3/2021. Results: A total of 46 patients participated and contributed to the PDC hydroxyurea adherence data. Mean change in PDC, adjusted for baseline PDC, was greater at Site A than at Site B (12-weeks: difference = 16.59%, p=.01, Figure 1A; 24-weeks: difference = 15.08%, p=.01, Figure 1B). Eleven patients (mean age 26.2 years old, 64% males, 100% Black, 73% HbSS, 45% low app users) and 11 providers (mean age 36.7 years old, 73% females, 36% Black, 54.5% physicians, average 8 years in practice, 36% low app users) completed the semi-structured interviews across the 2 sites. Site B was more affected during the COVID-19 pandemic where patients had difficulty obtaining hydroxyurea and other challenges related to reaching their providers and clinic setting for non-urgent or emergent reasons. In addition, participants with lower baseline hydroxyurea adherence level, as measured by PDC, had a more remarkable improvement in their PDC values at 12 weeks (Figure 1C) and 24 weeks (Figure 1D) Additional qualitative data focused on the implementation process were collected from 3 administrators, and 4 research staff. Among patients, both high and low app users reported the pandemic was a barrier to getting needed care (e.g., difficulty getting to hospital/clinic) and obtaining hydroxyurea; this was particularly a concern among low app users at Site B. Among providers, all but 2 high app users reported the pandemic did not impact app use, but nearly all low users perceived the pandemic to be a barrier to using the provider app because fewer patients came to clinic for maintenance SCD visits during the COVID-19 pandemic. Low users also reported the pandemic would negatively impact continued use of the app. Administrators and research staff also said reduced in-person clinic visits were a barrier to app implementation. Conclusions: mHealth apps are promising tools for improving hydroxyurea adherence among adolescents and adults with SCD. Contextual data show that some patients who experienced challenges accessing healthcare during COVID-19 pandemic have also experienced challenges navigating mHealth implementation. A focus on removing barriers to mobile apps use during care disruptions will likely improve patient and provider mHealth apps implementation, and ultimately, reduce health inequities for this vulnerable population. Our findings suggest that strategies such as including an mHealth facilitator has the potential to help addressing some of these implementation challenges. Note: Sherif Badawy and Lisa DiMartino are co-first authors with equal contribution Figure 1 Figure 1. Disclosures Badawy: Sanofi Genzyme: Consultancy; Bluebird Bio Inc: Consultancy; Vertex Pharmaceuticals Inc: Consultancy. Shah: Alexion: Speakers Bureau; Bluebird Bio: Consultancy; CSL Behring: Consultancy; Emmaus: Consultancy; GBT: Consultancy, Research Funding, Speakers Bureau; GLG: Consultancy; Guidepoint Global: Consultancy; Novartis: Research Funding, Speakers Bureau. Hankins: Bluebird Bio: Consultancy; UpToDate: Consultancy; Vindico Medical Education: Consultancy; Global Blood Therapeutics: Consultancy.

Introduction Human papilloma virus (HPV) infection can cause cervical, anal, penile, vaginal, and oropharyngeal cancer. The CDC recommends HPV vaccination as a 2 or 3-dose series at Methods Retrospective data was collected using the Sickle Cell Clinical Research and Intervention Program (SCCRIP) study database (Hankins JS, et al. Pediatr Blood Cancer 2018). Patients aged 12-18 years between October 1, 2018 and December 31, 2019 with any SCD genotype and who were enrolled on the SCCRIP study were included in analysis. The following variables were extracted: age, sex, race, ethnicity, age, economic hardship index (EHI), parental education level, household income, genotype, SCD-specific knowledge, and distance to healthcare facility. The prevalence of completed HPV series, defined as 2 doses ages Results In total, 373 patients met inclusion criteria. Their median age was 15.2 (range 12-19), 50% were female, 225 (60.3%) had HbSS/Sβ 0-thalassemia, and 114 (29.7%) had HbC/Sβ +-thalassemia. The mean SES index was 70% (±27%) and the mean QoL score 73 (±14.6). HPV vaccine completion rates increased from 31% to 56.2% after the bundle implementation (Figure 1, p Discussion Prevention of communicable diseases such as HPV is imperative in the general population. However, baseline vaccination rates in adolescents with SCD is low. A QI intervention that includes provider education and incentives, active verification of HPV vaccination status, and promotes coordinated communication between the nurse, providers, and patients effectively increased completion of the HPV vaccine series among adolescents with SCD. Continued strategies are needed to further increase the rates of vaccine completion. Figure 1 Figure 1. Disclosures Hankins: Vindico Medical Education: Consultancy; Global Blood Therapeutics: Consultancy; UpToDate: Consultancy; Bluebird Bio: Consultancy.

BACKGROUND Past research has yielded promising results on the effectiveness of Internet-based interventions to prevent eating disorders (EDs) in adolescents, but further information is needed to evaluate the public health impact of their large-scale dissemination. This article used an established framework to systematically review the extent to which indicators of the reach, effectiveness, adoption, implementation and maintenance [cf. Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM)-framework] of universal and targeted online ED prevention programmes are reported in the literature, in order to estimate their future dissemination potential. METHODS The literature search was conducted on PubMed, Web of Science and PsycINFO, and complemented by searching existing reviews and the reference lists of the studies included. Twenty-two studies published between 2000 and April 2019 met the inclusion criteria. We extracted data on a total of 43 indicators, within RE-AIM dimensions for each article, including qualitative coding of fostering and hindering factors. RESULTS Reach (55.0%) and implementation (54.0%) were the dimensions reported on most frequently, followed by effectiveness (46.8%), adoption (34.7%) and maintenance (18.2%). While internal validity indicators were frequently reported (e.g. sample size, effects and intervention intensity), most studies failed to report on elements of external validity, such as representativeness of participants and settings, adoption rates, implementation costs and programme sustainability. CONCLUSIONS Evidence indicates that Internet-based ED prevention programmes can reach a large number of adolescents and can be feasibly implemented in school settings. However, given the paucity of large-scale dissemination studies available for review, the degree to which schools are willing to adopt preventive interventions, as well as the transferability of programmes to different settings and geographical regions remains unclear.

Incidence and mortality of many preventable cancers are higher in rural compared to urban U.S. regions. However, prior research is limited by methodological inconsistencies in defining rurality, and has largely focused on a rural-urban dichotomy which ignores potential variability of cancer risk factors and outcomes within rural and urban settings. These limitations hamper data interpretation and may lead to inequitable distribution of resources to address disparities. In this study, we describe cancer risk factors and screening across various U.S. rural-urban classification codes to inform our understanding of cancer disparities across the rural to urban continuum. We examined the prevalence and trends in cancer risk factors and screening across the following rural-urban classification codes for counties and county-equivalents in 2013; U.S. Office of Management and Budget (OMB), National Center for Health Statistics (NCHS), U.S. Department of Agriculture, Economic Research Service’s rural-urban continuum codes (RUCC), and Urban Influence Codes (UIC). County-level data on demographics (age, race, education, income, poverty level, insurance status), and cancer risk factors (obesity, physical inactivity, alcohol consumption), including cancer screening (colorectal, cervical and breast) were obtained from the U.S. Census Bureau, Behavioral Risk Factor Surveillance System, and National Health Interview Survey from 2008-2013. Overall, rural counties’ populations were more likely to be older, white, and uninsured with lower educational attainment and household income than urban counties (all ptrend Citation Format: Kelly A. Hirko, Huiwen Xu, Laura Q. Rogers, Michelle Y. Martin, Siddhartha Roy, Kimberly M. Kelly, Shannon M. Christy, Kimlin T. Ashing, Jean C. Yi, Marquita W. Lewis-Thames, Cathy D. Meade, Qian Lu, Clement K. Gwede, Julianna Nemeth, Rachel M. Ceballos, Usha Menon, Katie Cueva, Karen Yeary, Lisa Klesges, Monica L. Baskin, Kassandra I. Alcaraz, Sabrina Ford. Cancer risk factors and screening across various U.S. rural classification codes: Cancer disparities in the context of rurality [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-258.

Background Past research has yielded promising results on the effectiveness of Internet-based interventions to prevent eating disorders (EDs) in adolescents, but further information is needed to evaluate the public health impact of their large-scale dissemination. This article used an established framework to systematically review the extent to which indicators of the reach, effectiveness, adoption, implementation and maintenance [cf. Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM)-framework] of universal and targeted online ED prevention programmes are reported in the literature, in order to estimate their future dissemination potential. Methods The literature search was conducted on PubMed, Web of Science and PsycINFO, and complemented by searching existing reviews and the reference lists of the studies included. Twenty-two studies published between 2000 and April 2019 met the inclusion criteria. We extracted data on a total of 43 indicators, within RE-AIM dimensions for each article, including qualitative coding of fostering and hindering factors. Results Reach (55.0%) and implementation (54.0%) were the dimensions reported on most frequently, followed by effectiveness (46.8%), adoption (34.7%) and maintenance (18.2%). While internal validity indicators were frequently reported (e.g. sample size, effects and intervention intensity), most studies failed to report on elements of external validity, such as representativeness of participants and settings, adoption rates, implementation costs and programme sustainability. Conclusions Evidence indicates that Internet-based ED prevention programmes can reach a large number of adolescents and can be feasibly implemented in school settings. However, given the paucity of large-scale dissemination studies available for review, the degree to which schools are willing to adopt preventive interventions, as well as the transferability of programmes to different settings and geographical regions remains unclear.

In this chapter, four case studies offer practical examples of implementation approaches that can accelerate evidence-based cancer prevention. The applied knowledge from the cases adds to the understanding that culture, context, politics, and partnership are key elements in driving health improvement, and although not always well understood or easily measured, they are a reminder that cancer prevention and care delivery exist within a complex system. In considering transformations in health care, moving from a linear and deconstructed model of delivery to consider complex adaptive models that could drive better outcomes was key to improved outcomes. Similarly, understanding context and complexity is a key consideration for implementing cancer prevention and control interventions into existing multisector social systems, be they health care, community, or statewide systems.

Background Child obesity is a major public health challenge, increasing the risk of chronic medical conditions such as type 2 diabetes, metabolic syndrome, and hypertension. Among U.S. states, Tennessee has one of the highest rates of child obesity. Emerging communication technologies can help to deliver highly disseminable population-level interventions to improve health behavior. The aim of this paper is to report the implementation and the evaluation of the reach of Memphis FitKids, a web-based application, intended to promote healthy behaviors for families and children. Methods A community-level demonstration project, Memphis FitKids, was developed and implemented in Tennessee’s Greater Memphis Area. This application (www.memphisfitkids.org) was designed for parents to assess their children’s obesity risk through determinants such as weight, diet, physical activity, screen time, and sleep adequacy. A built-in “FitCheck” tool used this collected information to create a report with tailored recommendations on how to make healthy changes. A Geographic Information Systems component was implemented to suggest low-cost neighborhood resources that support a healthy lifestyle. A social marketing framework was used to develop and implement FitKids, and a Community Advisory Board with representatives from community partners (e.g., the YMCA of Memphis, the Pink Palace Family of Museums, and the Memphis Public Library) supported the implementation of the project. Five kiosks distributed in the community served as public access points to provide a broad reach across socioeconomic strata. Presentations at community events and the use of Facebook facilitated the promotion of FitKids. Website traffic and Facebook usage were evaluated with Google Analytics and Facebook Insights, respectively. Results In Tennessee, 33,505 users completed 38,429 FitCheck sessions between July 2014 and December 2016. Among these, 6763 sessions were completed at the five kiosks in the community. FitKids was presented at 112 community events and the social media posts reached 23,767 unique Facebook users. Conclusions The Memphis FitKids demonstration project showed that web-based health tools may be a viable strategy to increase access to information about healthy weight and lifestyle options for families. Mobile-friendly web-based applications like Memphis FitKids may also serve health professionals in their efforts to support their clients in adopting healthy behaviors. Electronic supplementary material The online version of this article (10.1186/s12889-018-5968-6) contains supplementary material, which is available to authorized users.

U.S. Preventive Services Task Force (USPSTF) clinical guidelines at present rarely assign the highest grade recommendation to behavioral counseling interventions for chronic disease prevention or risk reduction because of concerns about the certainty and quality of the evidence base. As a result, the broad integration of behavioral counseling interventions in primary care remains elusive. Thus, there is an urgent need for novel perspectives on how to generate the highest-quality and -certainty evidence for primary care-focused behavioral counseling interventions. As members of the Society of Behavioral Medicine (SBM)--a multidisciplinary scientific organization committed to improving population health through behavior change--we review the USPSTF mandate and current recommendations for behavioral counseling interventions and provide a perspective for the future that calls for concerted and coordinated efforts among SBM, USPSTF, and other organizations invested in the rapid and wider uptake of beneficial, feasible, and referable primary care-focused behavioral counseling interventions. This perspective highlights five areas for further development, including (1) behavioral counseling-focused practice-based research networks; (2) promotion of USPSTF evidence standards and the increased use of pragmatic RCT design; (3) quality control and improvement procedures for behavioral counseling training; (4) systematic research on effective primary care-based collaborative care models; and (5) methodologic innovations that capitalize on disruptive technologies and healthcare transformation. Collective efforts to improve the health of all Americans in the 21st century and beyond must ensure that effective, feasible, and referable behavioral counseling interventions are embedded in modern primary care practice.

6549 Background: LC is common and lethal; care-delivery is complex, varies in quality and outcomes, stimulating calls for multidisciplinary treatment planning (MTP) involving key specialists. This much-advocated model lacks rigorous evaluation. We conducted a prospective cohort study of MTP v Serial Care (SC) in a community healthcare system. Methods: Newly-diagnosed LC patients with performance status (PS) 0-2, and their caregivers, were enrolled from a LC multispecialty group clinic (MGC) or single-specialty general oncology clinics. A subset of general oncology clinic patients were discussed in a Multidisciplinary Thoracic Oncology Conference (MTOC), others were not (Serial Care [SC]). In this analysis, we compare MGC and MTOC patients (MTP recipients) to SC patients. Primary endpoint was overall survival (OS); secondary endpoints were measures of quality: staging practices, guideline-concordant treatment, timeliness of care, patient and caregiver satisfaction. We adjusted proportional hazards and logistic models for age, sex, histology, stage, PS, insurance, and race. Results: 254 patients received MTP v 272 SC. After a median 30 months’ follow up, there was no difference in OS (adjusted hazard ratio 1.10 [CI 0.87-1.40], p = .43). Stage-confirmatory biopsy was done in 61% MTP v 45% SC patients (adjusted odds ratio [aOR] 2.59, CI 1.74-3.86, p < .0001); 81% MTP v 68% SC patients received guideline-concordant treatment (aOR 2.04, CI 1.31-3.19, p < .002). Although the time from lesion detection to diagnostic biopsy (25 v 15 days, p = .004) or staging biopsy (29 v 20 days, p = .007) was higher with MTP, there was no difference in time to definitive treatment (60 v 57 days, p = .06). MTP patients and their caregivers reported greater satisfaction with the combined quality of care received from all team members (p < .0001) at baseline, 3 and 6 months. Conclusions: MTP for LC significantly improved the quality of care including the thoroughness of staging, use of guideline-concordant care, and patient satisfaction. Contrary to reports from retrospective analyses, timeliness of care was worse with MTP. Patient and caregiver satisfaction was superior with MTP. Despite improved quality, MTP was not associated with improved LC survival. Clinical trial information: NCT02123797.

A1 Introduction to the 8th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health David Chambers1, Lisa Simpson2 1Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD, 20850, USA; 2AcademyHealth, Washington, DC, 20036, USA For the second year in a row, we are pleased to be able to share the proceedings of the Annual Conference on the Science of Dissemination and Implementation in Health, a large meeting reflecting the expanding and evolving research field that seeks to optimize the use of evidence, interventions, and tools from health research within the myriad of settings where people receive health care, make health-related decisions, and increase knowledge of influences on the health of the population. We once again benefitted from a strong partnership, co-led by AcademyHealth and the National Institutes of Health (NIH), with co-sponsorship from the Agency for Healthcare Research and Quality (AHRQ), the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation (RWJF), the US Department of Veterans Affairs (VA), and the WT Grant Foundation. In addition, we benefitted from the collaboration of staff from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). NIH and AcademyHealth again co-led the program planning committee, which focused on the development of the plenary sessions, and convened a scientific advisory panel to suggest speakers and advise on the overall conference development. The planning committee identified four key areas around which to focus the plenary panels and keynote address. Dr. America Bracho, M.D., M.P.H., Executive Director of Latino Health Access in Orange County, California, spoke about the opportunities for implementation science to inform efforts to improve community health and engage underserved populations. The three plenary panels each focused on a significant future direction for dissemination and implementation (D & I) research: the interface between D&I science and population health, emerging opportunities for global implementation science, and the challenges around implementation of precision medicine. The plenary sessions were complemented by facilitated lunchtime discussions on the same three topics, which offered participants an opportunity to identify key research questions for each and brainstorm next steps. Synopses of the lunchtime discussions are included in this supplement. Given the overwhelming success of the 2014 conference and the large number of abstracts received in 2014 (660), the program planning committee identified eight program tracks for abstract submitters to respond to, and through which the concurrent sessions of the conference would be organized. These tracks—Behavioral Health, Big Data and Technology for Dissemination and Implementation Research, Clinical Care Settings, Global Dissemination and Implementation, Promoting Health Equity and Eliminating Disparities, Health Policy Dissemination and Implementation, Prevention and Public Health, and Models, Measures and Methods— were designed to enable conference participants to follow a consistent theme across the multiple sessions of the conference and form the structure of this supplement. The call for abstracts, including individual paper presentations, individual posters and panel presentations, resulted in 515 submissions, spread across the eight thematic tracks. Over one hundred reviewers devoted their time to ensuring a comprehensive and expert review, and reviews were conducted within each track and coordinated by the track leads. For the final program, 64 oral presentations, 12 panels, and 263 posters were presented over the two-day meeting. Slides for the oral presentations and panels (with the agreement of the authors) were posted on the conference website (http://diconference.academyhealth.org/archives/2015archives) and all abstracts were included on the conference webapp (https://academyhealth.confex.com/academyhealth/2015di/meetingapp.cgi). This supplement has compiled the abstracts for presented papers, panel sessions, and lunchtime discussions from the 8th Annual Meeting on the Science of Dissemination and Implementation in Health: Optimizing Personal and Population Health. We are pleased to have the abstracts from the conference together in one volume once again, and look forward to the 9th Annual meeting, scheduled for December in Washington, D.C.

Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

Many grant proposals identify the use of a given evaluation model or framework but offer little about how such models are implemented. The authors discuss what it means to employ a specific model, RE-AIM, and key dimensions from this model for program planning, implementation, evaluation, and reporting. The authors report both conceptual and content specifications for the use of the RE-AIM model and a content review of 42 recent dissemination and implementation grant applications to National Institutes of Health that proposed the use of this model. Outcomes include the extent to which proposals addressed the overall RE-AIM model and specific items within the five dimensions in their methods or evaluation plans. The majority of grants used only some elements of the model (less than 10% contained thorough measures across all RE-AIM dimensions). Few met criteria for “fully developed use” of RE-AIM and the percentage of key issues addressed varied from, on average, 45% to 78% across the RE-AIM dimensions. The results and discussion of key criteria should help investigators in their use of RE-AIM and illuminate the broader issue of comprehensive use of evaluation models.

Context To aid translation of childhood obesity interventions evidence into practice, research studies must report results in a way that better supports pragmatic decision making. The current review evaluated the extent to which information on key external validity dimensions, participants, settings, interventions, outcomes, and maintenance of effects, was included in research studies on behavioral treatments for childhood obesity. Evidence acquisition Peer-reviewed studies of behavioral childhood obesity treatments published between 1980 and 2008 were identified from (1) electronic searches of social science and medical databases; (2) research reviews of childhood obesity interventions; and (3) reference lists cited in these reviews. Included studies reported on a controlled obesity intervention trial, targeted overweight or obese children aged 2–18 years, included a primary or secondary anthropometric outcome, and targeted change in dietary intake or physical activity behaviors. Evidence synthesis 1071 publications were identified and 77 met selection criteria. Studies were coded on established review criteria for external validity elements. All studies lacked full reporting of generalizability elements. Across criteria, the average reporting was 23.9% (range=0%–100%). Infrequently reported were setting-level selection criteria and representativeness, characteristics regarding intervention staff, implementation of the intervention content, costs, and program sustainability. Conclusions Enhanced reporting of relevant and pragmatic information in behavioral investigations of childhood obesity interventions is needed to improve the ability to evaluate the applicability of results to practice implementation. Such evidence would improve translation of research to practice, provide additional explanation for variability in intervention outcomes, and provide insights into successful adaptations of interventions to local conditions.

Objectives The purpose of this study was to examine relationships among body mass index (BMI), selfperceptions, and body image discrepancy in African American (AA) girls. Methods Baseline self-perception and BMI data were collected by trained staff from 303 preadolescent AA girls participating in the girls health enrichment multi-site studies. Correlations and multivariable logistic regression analyses were performed to identify relationships of BMI with self-perception factors. Results Girls with a BMI at or above the 85th percentile were more likely to have greater body image discrepancy and participate in weight control behaviors than girls with a BMI below the 85th percentile. Body image discrepancy was not related to selfesteem, but was positively correlated with physical activity self-concept and self-efficacy, and diet selfefficacy. Conclusion Girls with higher BMI had greater body image discrepancy and were less confident in abilities to be active and eat healthy. Findings may inform the development of obesity interventions for preadolescents.

Few measurement instruments for children's eating behaviors and beliefs have been specifically validated for African-American children. Validation within this population is important because of potential cultural and ethnic influences. Objectives were to evaluate established and newly developed or adapted dietary psychosocial measures in a sample of 303 preadolescent African-American girls and their caregivers. Acceptable internal consistency (Cronbach's alphaor = 0.70) was found for measures of girls' self-efficacy for healthy eating, outcome expectancies for healthy eating, positive family support for healthy eating and household availability of low-fat food and fruit, juice and vegetables (FJV). Evidence for concurrent validity was found with significant associations between self-efficacy for healthy eating and lower intake of energy (r = -0.17) and fat grams (r = -0.16). Greater FJV availability was associated with greater FJV intake (r = 0.14) and lower body mass index (BMI) in girls (r = -0.12). Positive family support for healthy eating was associated with higher BMI in girls (r = 0.41). These results contribute to the development of scales to evaluate prevention interventions related to dietary intake in African-American children.

Background The translation and dissemination of prevention intervention evidence into practice is needed to address significant public health issues such as childhood obesity. Increased attention to and reporting of external validity information in research publications would allow for better understanding of generalizability issues relevant to successful translation. To demonstrate this potential, recent reports of childhood obesity prevention interventions were evaluated on the extent to which external validity dimensions were reported. Methods Childhood obesity prevention studies that were controlled, long-term research trials published between 1980 and 2004 that reported a behavioral target of physical activity and/or healthy eating along with at least one anthropometric outcome were identified in 2005. Studies were summarized between 2005 and 2006 using review criteria developed by Green and Glasgow in 2006. Results Nineteen publications met selection criteria. In general, all studies lacked full reporting on potential generalizability and dissemination elements. Median reporting over all elements was 34.5%; the mode was 0% with a range of 0% to 100%. Most infrequent were reports of setting level selection criteria and representativeness, characteristics regarding intervention staff, implementation of intervention content, costs, and program sustainability. Conclusions The evidence base for future prevention interventions can be improved by enhancing the reporting of contextual and generalizability elements central to translational research. Such efforts face practical hurdles but could provide additional explanation for variability in intervention outcomes, insights into successful adaptations of interventions, and help guide policy decisions.

Obesity prevalence is increasing in the U.S., especially among children and minority populations. This report describes the design and baseline data of the ongoing Girls health Enrichment Multi-site Studies (GEMS) trial (Memphis site), which is testing the efficacy of a 2-year family-based intervention to reduce excessive increase in body mass index (BMI). This randomized, controlled trial conducted at community centers in Memphis, Tennessee requires major measurements at baseline and at 12 and 24 months post-randomization. The participants are healthy African-American girls and one parent/caregiver of each girl. Participating girls are of ages 8-10 years, with BMI>or=25th percentile of the CDC 2000 growth charts or with one overweight or obese parent/caregiver (BMI>or=25 kg/m(2)). The active intervention is designed to prevent excessive weight gain by promoting healthy eating habits and increasing physical activity. An alternative intervention (comparison group) promotes general self-esteem and social efficacy. The main outcome measure is the difference between the two treatment groups in the change in BMI at 2 years. Three hundred and three girls have been randomly assigned to receive the test intervention (n=153) or the alternative intervention (n=150). The two groups do not differ in baseline characteristics. At the time of enrollment, the mean age was 9 years, the mean BMI was 22 kg/m(2) (mean BMI percentile=77 th), and 41% were overweight (BMI>/=95th percentile using CDC 2000 growth charts). Participants' intake of fruits and vegetables (1.3 serving/day) and fats (36% kcal), and their participation in moderate-to-vigorous physical activity (20 min/day), did not meet national recommendations. The GEMS obesity prevention intervention targets improved diet and increased physical activity to reduce excessive weight gain in healthy African-American girls of ages 8-10.

Objective: The objective of this study was to compare characteristics of smokers who did and did not report use of cessation aids as part of a tobacco control program in a military setting (n = 8994). Design: The study is a longitudinal epidemiological study where the relationship between smoking status at follow-up and use of pharmacologic aids to quit smoking were assessed. Main Outcome Measures: Smoking cessation, post baseline use of cessation aids to quit smoking. Results and Conclusions: Individuals remaining abstinent were 70% less likely to have used NRT/ pharmacological aids compared to those that relapsed. NRT/pharmacological aid users were more likely to report plans to smoke after military training, to have friends who smoke, and to accept a cigarette from a friend. NRT/pharmacological aid users were more likely to believe that using NRT was safer than smoking and to have engaged in harm reduction strategies. Our findings suggest that selection bias related to such characteristics may explain some of the discrepancies between effect sizes reported in efficacy compared to effectiveness studies of NRT and smoking outcomes currently reported in the literature.

BACKGROUND: Whereas children's active travel to school (ATS) has confirmed benefits, only a few large national surveys of ATS exist. METHODS: Using data from the Health Behavior in School-aged Children (HBSC) 2009-2010 US survey, we conducted a logistic regression model to estimate the odds ratios of ATS and a linear regression model to estimate the adjusted mean differences of the percentage of ATS within a school. RESULTS: Overall, 21.4% of children engaged in at least one way of active travel to or from school. ATS was less common for trips to school than from school. Greater distance to school was a major barrier preventing children from ATS. Children living in large cities were more likely to engage in ATS, and schools located in a large city had higher proportions of ATS rate. Children having lower family satisfaction, or engaging in a greater number of physically active days during the past week were all more likely to engage in ATS. CONCLUSIONS: Although ATS is low among US children, significant variation exists. HBSC is a promising data source for an ATS study. As the first study to explore the variation of ATS at school level, this research contributes uniquely to current knowledge.© 2016, American School Health Association. SR2S Language: en

BACKGROUND AND OBJECTIVES Use of health services in rural communities has not been well studied. We explored how black and white children used health services in a rural Mississippi community. METHODS Data were prospectively collected for 396 children attending a private practice to determine if race was associated with the use of health services in this community. RESULTS White children made more sick contacts than black children (P < 0.001). Black children (36%) were more likely to be treated in the emergency room than white children (24%; P = 0.013). There was no black-white difference in the hospitalization rates, although white children were more likely to undergo ear-nose-throat (ENT) surgery for pressure equalizing tube (PET) placement, and/or tonsillectomy and adenoidectomy (T and A; P < 0.001). Even after controlling for various confounders, the frequency of all physician sick contacts was twice as high for white children than for black children (RR = 2.17; 95% C.I. = 1.32-3.58). CONCLUSION Overall, black children used disproportionately fewer health services than their white counterparts, but used significantly higher emergency room services. Private insurance coverage was the single most significant variable that accounted for the black-white differential use of the emergency room.

Current public health and medical evidence rely heavily on efficacy information to make decisions regarding intervention impact. This evidence base could be enhanced by research studies that evaluate and report multiple indicators of internal and external validity such as Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) as well as their combined impact. However, indices that summarize the combined impact of, and complex interactions among, intervention outcome dimensions are not currently available. We propose and discuss a series of composite metrics that combine two or more RE-AIM dimensions, and can be used to estimate overall intervention impact. Although speculative and, at this point, there have been limited empirical data on these metrics, they extend current methods and are offered to yield more integrated composite outcomes relevant to public health. Such approaches offer potential to help identify interventions most likely to meaningfully impact population health.

While childhood obesity has been linked to television (TV) viewing, specific mechanisms are not well understood. Obesity related to TV viewing might plausibly be related to decreased physical activity, increased food intake, reductions in metabolic rate, or combinations of these. The current investigation sought to ascertain the metabolic effects of quiet rest, listening to a story, watching a passive TV program, and watching an active TV show. Counter-balanced conditions were presented to 90 pre-pubertal girls ranging in body mass index from underweight to obese. In addition, effects between resting energy expenditure (REE) and race, body mass index, skinfold measures, physical activity, pubertal stage and average hours spent viewing TV were explored. Results indicated no significant differences in metabolic rate between weight groups nor between activity conditions (story listening and TV viewing) and rest conditions. A significant dose-response relationship was found in which REE decreased as average weekly hours of TV viewing increased, after adjusting for body mass index and puberty stage. Additionally, later stages of pubertal development compared to earlier stages were related to higher levels of REE. Results of this study suggest that metabolic rate alone cannot account for the consistently observed relationship between television viewing and obesity. Future studies should focus on energy intake, physical inactivity, or combinations of these with metabolic rate in seeking specific mechanisms responsible for television viewing related to obesity.