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Purpose Long-term consequences of prematurity are a public health concern. A pattern of slow initial weight gain followed by a period of rapid weight gain has been associated with poor cardiometabolic health outcomes. The purpose of this study was to examine the relationships between infant feeding practices and weight gain in a sample of 18-to-24-month olds corrected age born very preterm. Design and Methods A cross-sectional design was used to examine the relationships between infant feeding practices and weight gain. Estimates of effect sizes and model fit estimates were the primary parameters of interest. Results Most of the participants received human milk after birth, but most had transitioned to formula before three months. Slightly less than half received complementary foods prior to four months corrected age. Gains in weight and head circumference were rapid after discharge from the neonatal intensive care unit, while gains in length lagged behind. Infant feeding practices did not have a clinically meaningful effect on weight gain. Conclusions While the initiation of human milk feedings was encouraging, the duration fell short of recommendations. Practices such as the early introduction of complementary feedings and the addition of rice cereal to the bottle are troubling. Additionally, the rapid increase in weight gain may have a negative impact on future cardiometabolic health. Practice Implications. Clinical recommendations include ensuring support for the use of human milk before and after hospital discharge, close monitoring of physical growth, and ensuring adherence to the guidelines for the introduction of complementary foods.

Elevated brachial blood pressure (BP) in childhood tracks into adulthood. Central BP and measures of arterial stiffness, such as aortic augmentation index (AIx) and pulse wave velocity (PWV), have been associated with future cardiovascular disease. This pilot study assessed the feasibility of noninvasively measuring these parameters in preschool children and explored factors that may be associated with elevated BP in this age group. Brachial BP was measured using an electronic oscillometric unit (Dinamap PRO 100) and defined as elevated when systolic BP (SBP) and/or diastolic BP (DBP) was ≥ the 90th percentile for age, gender, and height. Central BP, AIx, and PWV were measured using applanation tonometry (SphygmoCor). C-reactive protein (CRP) was measured in serum samples. Sixteen African-American preschool children were recruited (4.4 ± 0.8 years, 69% males), 6 (38%) of whom had an elevated brachial BP (110 ± 10/69 ± 4 vs. 96 ± 8/55 ± 6 mm Hg, Cohen's d = 2.2). Children with elevated brachial BP had higher central SBP (d = 1.6) and DBP (d = 1.96) (97 ± 6/68 ± 4 vs. 85 ± 8/57 ± 6 mm Hg), AIx (d = 0.88) (31 ± 8 vs. 18 ± 16%, standardized to heart rate), and CRP (3.1 [2.3–6.3] vs. 0.1 [0.1–0.3] mg/dL, d = 2). There was no significant difference in PWV between groups (d = 0.26). CRP and SBP (Spearman r = 0.70), DBP (r = 0.68), central SBP (r = 0.58), and central DBP (r = 0.71) were positively correlated. Wide confidence intervals for the estimated effect sizes indicated a large degree of uncertainty about all estimates due to the small sample size. Noninvasive assessment of central BP and arterial stiffness is feasible in preschool children. Vascular inflammation may be an important factor that influences BP at an early age. Further studies in preschool children are needed to elucidate mechanisms of early onset hypertension.

Background We translated and tested ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heart care for Patients and Caregivers), an early heart failure (HF) palliative care (PC) telehealth intervention, to determine implementation and access challenges in medically-underserved/rural HF patient and caregiver dyads Methods ENABLE CHF-PC was piloted in North- and Southeast U.S. sites (4/1/14-8/31/15). Eligibility criteria included: Class III/IV or Stage C/D HF and age ≥50 years. Intervention components were in-person PC consultation, nurse coach phone sessions (patients: 6 sessions; caregivers: 4 sessions), monthly phone check-ins. Measures included quality of life (QOL), physical/mental health, symptom, and burden outcomes at baseline, 12, and 24 weeks. Feasibility determined by intervention and measurement completion. Conclusion Lessons learned from pilot-testing ENABLE CHF-PC facilitated refinement of strategies to recruit and retain literacy-challenged advanced HF dyads, which have been incorporated in an ongoing efficacy trial of ENABLE CHF-PC. Result Patients (n = 61; NE = 32; SE = 29) and caregivers (n = 48; NE =29; SE =19) were enrolled. HF patients were 70.6 years, NYHA Class IIIa/b (70.5%), mostly male (50.8%), and white (80.3%); caregivers were 64.9 years, mostly female (81.3%), and white (83.3%). Intervention sessions averaged 50 minutes per patient and 46 minutes per caregiver. There were between-site differences in completing pc consultation (NE = 44% vs. SE = 20%), patient sessions (NE = 94% vs. SE = 41%) and measurements (NE = 72% vs. SE = 38%, P = .008). Additional challenges in the SE were recruitment/retention, participants' comprehension of non-hospice palliative care, keeping appointments for data and intervention calls, and completion of health literacy measures. Longitudinal site differences in health reported outcomes relative to the NE, the SE site had lower symptom, mental health, and activation scores but higher QOL, perceived social support, and use of denial and religious coping strategies and SE caregivers had lower burden. Both sites demonstrated small to moderate effect-size improvements for healthcare resource use (hospital and ICU days/month; ED visits/month).

96 Background: Though uninsurance rates declined after the Affordable Care Act, the number of underinsured, or individuals who spend > 10% of their income on out-of-pocket (OOP) medical costs, continues to rise. In patients with metastatic breast cancer (MBC), underinsurance may lead to financial toxicity (FT), or patient-level financial burden and distress, since diagnosis and treatment is extremely costly. This study explores health insurance literacy and the association between FT and health insurance status in women receiving treatment for MBC. Methods: This cross-sectional study utilized survey data collected from 2017-2019 in women age ≥18 receiving treatment for MBC at two academic medical centers in Alabama. FT was measured by the Comprehensive Score for Financial Toxicity (COST) tool (11-item scale from 0-44, with lower scores indicating worse FT). Health insurance status and OOP costs were self-reported. Effect sizes were calculated using Cohen’s d or Cramer’s V. Mixed and generalized linear models clustered by site and treating medical oncologist estimated the association between FT and health insurance status. Results: In 81 women with MBC, median COST score was 24 (interquartile range [IQR] 17-30), 44% had private insurance, 40% Medicare, and 16% Medicaid. Though 25% and 33% of surveyed patients did not know their health insurance premium or deductible cost, respectively, privately insured patients more often knew the cost of their premiums (97%; V = 0.58) and deductibles (81%; V = 0.33) compared to publicly insured patients. In adjusted models, FT levels did not differ significantly based on health insurance type (private insurance COST 21, 95% confidence interval [CI] 18-25; Medicaid COST 23, 95% CI 17-29; Medicare COST 24, 95% CI 20-27). However, risk of severe FT (COST ≤13) was 147% higher for privately insured patients versus Medicare beneficiaries (risk ratio 2.47, 95% CI 1.44-4.21). Conclusions: Despite higher levels of health insurance literacy, privately insured patients receiving treatment for MBC may be at increased risk of severe FT. Further research is needed to understand causes of underinsurance in patients with MBC, which could lead to cancer-related FT.

316 Background: Optimal treatment sequencing (i.e., the order in which drugs are given) for metastatic breast cancer (MBC) is unknown. We aimed to develop an approach to visualize treatment patterns and survival in MBC. Methods: This retrospective study utilized ASCO’s CancerLinQ Discovery® database generated from electronic health records. Subjects included 3,312 women aged ≥18 years who were diagnosed with and received treatment for MBC after 1980. Hormone receptor (HR) status was determined by concordant diagnosis and treatment records. Human epidermal growth factor (HER2) status was determined by delivery of HER2-targeted therapy. Ordered and administered treatments were included. We created spatiotemporal plots of treatment patterns for HR+/HER2-, HER2+, and triple negative (TN) MBC. Individuals were represented on the Y-axis, and time on the X-axis with development of MBC aligned at time 0. Treatment classes were identified by colors: hormone therapies in shades of red, chemotherapies in shades of blue, HER2-targeted therapies in shades of green, and novel therapies in shades of orange. Concurrent treatments were represented by split bars. An overlaid Kaplan-Meier curve allowed for observations about the relationship between survival and treatment. Results: We developed a novel visualization approach to simultaneously display heterogeneous, longitudinal treatments and survival. Median survival after first documentation of MBC was 3.1 (IQR 1.4-7.2), 1.3 (IQR 0.6-2.8), and 2.6 (IQR 1.0-5.2) years for HR+/HER2-, TN, and HER2+ MBC, respectively. Patients with longer survival often had long duration of initial therapy, suggesting a more indolent or responsive disease. Substantial heterogeneity in treatment sequencing was observed for HR+HER2- and TN cohorts. In the HER2+ cohort, HER2-targeted therapy was commonly administered for the duration of treatment with more homogeneous sequencing. Conclusions: This novel visualization approach allows for observing the relationship between treatment patterns and survival, which is challenging to demonstrate with traditional quantitative methods. This approach can generate hypotheses regarding impact of treatment patterns on survival.

317 Background: Electronic health record (EHR) databases are a promising platform for clinical research using real-world data. However, information on potential limitations of these data sources is lacking. We sought to understand how data visualization might be used to identify data inconsistencies and the applicability of previously validated claims-based algorithms used to identify patients with metastatic breast cancer (MBC). Methods: This retrospective study utilized ASCO’s CancerLinQ Discovery database derived from EHR data. Subjects included women ≥18 years treated for MBC diagnosed ≥1980. Subjects with MBC were identified using two billing codes for metastasis on separate dates following primary breast cancer diagnosis. Treatment course sequences were visualized. Patients were represented by a horizontal bar on the Y-axis. Treatments were displayed using colored bars (blue: chemotherapy, red: endocrine therapy, green: HER2 targeted, orange: novel therapy) with time of treatment on the X-axis. Visualizations were qualitatively evaluated, and treatment patterns inconsistent with clinical practice were identified. Results: We identified 4,760 women treated for MBC using billing codes for primary breast cancer diagnosis and distant metastasis. Most patients (96%) had a primary breast cancer diagnosed in 2000 later. Treatment patterns inconsistent with clinical practice identified using the visualization technique included: 1% of patients received adjuvant chemotherapy continuously for ≥1.5 years, suggesting missed coding for metastatic disease; 5% of patients did not receive any treatment in the year following metastasis, suggesting the billing code may have been used in workup and not for confirmed metastatic disease. Among patients with MBC, 50% identified as HR+ across all records had not received hormone therapy, while 39% identified as HR- across all records received hormone therapy. Conclusions: Because previously validated algorithms may not translate well to EHR databases, quality auditing should always be performed. The proposed data visualization can be used for improving algorithms, qualitatively identifying errors, and avoiding biased or inaccurate results.

97 Background: Shared decision-making (SDM), a process where patients partner with their physician to incorporate personal preferences into treatment decisions, is a tenet of high-value healthcare. It is unknown if high-value care associated with SDM manifests in the form of decreased out-of-pocket costs. Therefore, this study analyzes the relationship between patient preference for SDM and financial toxicity in metastatic breast cancer (MBC). Methods: This cross-sectional study utilized surveys of women age ≥ 18 with MBC who received care at two academic hospitals in Alabama between 2017 and 2019. SDM preference and financial toxicity were measured using the Control Preferences Scale and the Comprehensive Score for Financial Toxicity (COST) tool (11-item scale from 0-44, with lower scores indicating worse FT), respectively. Patient demographic and clinical data were abstracted from the electronic medical record. Effect sizes were calculated using Cohen’s d or Cramer’s V. Differences in financial toxicity by SDM preference were estimated using mixed models clustered by site and treating medical oncologist. Results: In 79 women with MBC, 41% preferred SDM, 33% preferred provider-driven decision making, and 22% preferred patient-driven decision making. Patients preferring SDM were more often college educated (48% vs. 40%; V = .15), higher income (52% vs. 44%; V = .09), and privately insured (47% vs. 41%; V = .11). Overall median COST score was 23 (interquartile range 16-30), which varied modestly by SDM preference. After adjusting for patient demographic and clinical characteristics, similar financial toxicity levels were found in patients who preferred SDM (COST 22, 95% confidence interval [CI] 19-25), patient-driven decision making (COST 22, 95% CI 18-26), and provider-driven decision making (COST 24, 95% CI 20-27). Conclusions: Similar levels of financial toxicity were found in patients with differing decision–making preferences regarding their MBC treatment, which may be secondary to lack of discussions about cost. Further research is needed to determine if and how financial toxicity is being identified or included within decision-making.

Category/Date Research Poster presented at Posters on The Move, at NAPNAP's 40th National Conference on Pediatric Health Care, March 7, 2019, New Orleans, LA. Purpose To test the hypothesis that parental self-efficacy (PSE) is associated with infant feeding practices in a group of low-income, African-American (AA) mother-infant dyads. Background/Significance Infant feeding practices of low-income, AA infants do not align with recommendations. These infants are fed formula more often than breastmilk, if breastfed, only for a short duration, and given complementary foods (CFs) early. Understanding factors that contribute to this trend are needed, early feeding practices have implications for dietary practices and weight status later in life. Parental self-efficacy (PSE) has been found to be associated with infant feeding practices, however, this association has not been examined in a sample at risk for unhealthy feeding practices. Research questions 1) Is PSE associated with milk feeding type? 2) Is PSE associated with the duration of any breastfeeding? 3) Is PSE associated with age at introduction of CFs? 4) Is PSE associated with the introduction of inappropriate foods during infancy? Methods This correlation study was a secondary data analysis of the Infant Care, Feeding, and Risk of Obesity study (Infant Care). The study was deemed exempt by the IRB at the University of Alabama at Birmingham. The Infant Care study enrolled first-time AA mothers and their healthy, full-term infants (N = 217) between birth and 3 months of age. In home study visits were conducted at infant age of 3, 6, 9, and 12 months. At each visit, mothers completed the Parenting Sense of Competence Scale, which provided a measure of PSE; infant dietary history and three dietary recalls were also gathered. Dietary data was organized into four variables: 1) ever breastfed; 2) if breastfed, how long; 3) age of first CFs; and 4) if foods considered inappropriate for an infant were provided. Using generalized estimating equations and generalized linear mixed models, crude and covariate-adjusted relationships between PSE and each feeding practice were examined. Covariates included: infant sex, infant birthweight, maternal age, maternal body mass index, maternal education level, maternal marital status, and maternal depression score. Results The feeding practices of this sample were consistent with previous research, low breastfeeding rates and early introduction of CFs were seen. Additionally, PSE was high (M=38.7, range 8-48). No significant associations were seen between PSE and each infant feeding practice, even after adjusting for covariates. Married mothers and those with a college education level were more likely to breastfeed (p Conclusion Prior research has suggested that PSE is associated with infant feeding practices, however, this association was not supported in the current sample. Cultural and sociodemographic differences of this sample compared to prior samples should be explored further to understand if these differences contributed to the contradictory findings. Future research should consider inclusion of a tool that measures cultural beliefs regarding infant feeding. Additionally, the high sense of PSE reported by this sample was unexpected. Understanding predictors to PSE in low-income, AA mother may be needed in future research. Support for the Infant Care study was provided by NIH R01 HD042219-02 (PI: Bentley) Support for this study was provided by the National Association of Pediatric Nurse Practitioners (NAPNAP) 2017 Foundation Research Grant

6560 Background: Closures of hospitals and clinics may have unintended consequences, including increasing patient travel time. Increased patient travel time to healthcare facilities has the potential to adversely impact patient outcomes. Limited data exist on the impact of travel time on healthcare costs and resource utilization. Methods: This retrospective cohort study from 2012-2015 evaluated drive time to cancer care site for Medicare beneficiaries age ≥ 65 in the Southeastern US. The primary outcome was Medicare spending by phase of care (initial, survivorship, end of life [EOL]). Secondary outcomes included resource utilization measured by hospitalization rates, hospitalization sites, intensive care unit (ICU) admissions, and chemotherapy-related hospitalization rates. Hierarchical linear models with patients clustered within cancer care site and adjusted for pertinent covariates were used to determine the effects of drive time on average monthly phase-specific Medicare spending. Results: Median drive time was 32 minutes (IQR 18-59) for the 23,382 included Medicare beneficiaries, with 24% of patients driving > 1 hour to their cancer care site. During the initial phase of care, Medicare spending was 14% higher for patients traveling > 1 hour than those traveling ≤ 30 minutes.Hospitalizationrates were 4-13% higher for patients traveling > 1 hour vs. ≤ 30 minutes in the initial (61 vs. 54), survivorship (27 vs. 26), and EOL (310 vs. 86) phases of care (all p < .05). The majority of patients traveling > 1 hour were hospitalized at a local hospital rather than at their cancer care site, whereas the converse was true for patients traveling ≤ 30 minutes. Conclusions: As healthcare locations close, patients living farther from treatment sites may experience more limited access to care, and healthcare spending could increase for Medicare.

OBJECTIVES/SPECIFIC AIMS: Our primary objective was to understand the relationship between incident or recent stressful events and adherence to HIV care in the context of other person, environment, and HIV-specific stressors in a sample of Black women living with HIV (WLWH). METHODS/STUDY POPULATION: Thirty in-depth interviews were conducted with Black women living with HIV who receive care at an academic HIV primary care clinic in the Southern region of the United States to elicit stressful events influencing adherence to HIV care. Semi-structured interview guides were used to facilitate discussion regarding stressful events and adherence to HIV care. Interviews were audiotaped and transcribed verbatim. Transcripts were independently coded using a theme-based approach by two experienced coders, findings were compared, and discrepancies were resolved by discussion. RESULTS/ANTICIPATED RESULTS: Participants described frequently experiencing incident stressful events including death or serious illness of a close friend or family member, and relationship, financial, and employment difficulties. Furthermore, participants reported experiencing traumatic events such as sexual and physical abuse during childhood and adolescents. While experiencing traumatic events such as sexual and physical abuse during childhood and adolescence may be distressing, these events did not influence adherence to HIV care. However, incident stressful events as defined above did influence adherence to HIV care for some participants, but not for others. For participants who reported that stressful events did not influence adherence to HIV care, factors such as personal motivation, access to social support, and adaptive coping strategies facilitated their engagement in care. DISCUSSION/SIGNIFICANCE OF IMPACT: Experiencing stressful events, incident or traumatic, is common among Black WLWH and have the potential to negatively influence adherence to HIV care. Thus, Interventions aimed at identifying and addressing stress, social support, and coping are essential to improve adherence to HIV care behaviors.

Attrition can jeopardize both internal and external validity. The goal of this secondary analysis was to examine predictors of attrition using baseline data of 432 participants in the Rural Breast Cancer Survivors study. Attrition predictors were conceptualized based on demographic, social, cancer treatment, physical health, and mental health characteristics. Baseline measures were selected using this conceptualization. Bivariate tests of association, discrete-time Cox regression models and recursive partitioning techniques were used in analysis. Results showed that 100 participants (23%) dropped out by Month 12. Non-linear tree analyses showed that poor mental health and lack of health insurance were significant predictors of attrition. Findings contribute to future research efforts to reduce research attrition among rural underserved populations.

Background Medical devices are incorporating information technology into complex user interfaces, increasing the need for training and testing. However, the actual devices are costly to purchase and maintain. Method Participants in this study programmed a simulated and actual smart medication infusion pump and completed a user satisfaction survey. The number of features accessed successfully and the number of errors made during interface programming with the simulator and pump were compared. Results Differences between the pump and simulator show where the simulator needs to be refined to increase fidelity. Conclusions Simulating devices provides a low-cost platform for nursing education and for device and interface development.

114 Background: Despite national guidelines recommending early palliative care (EPC) for individuals newly-diagnosed with metastatic cancer, it is rarely available in rural community cancer centers serving underserved populations. We conducted the first implementation trial of EPC in rural cancer centers using the evidence-based ENABLE (Educate, Nurture, Advise, Before Life Ends) model of early, concurrent oncology palliative care. Methods: Mixed methods case study of a 4-year American Cancer Society-funded 4-site, implementation trial using a virtual learning collaborative in AL and SC. Guided by the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework, we gathered qualitative and quantitative data via monthly reports and yearly in-person site visits using: 1) a RE-AIM Self-Assessment Tool completed by site staff to measure reach, adoption, implementation, and maintenance; 2) EPC General Organizational Index (GOI) to measure capacity for EPC services and implementation progress; and 3) field notes from site interviews and final reports. Results: Across the 4 sites, 62 patients (range: 4–31; mean: 15) and 46 caregivers (range: 2–22; mean: 12) participated. Baseline patient characteristics included: mean age of 58, 70% female, 17% Black or minority, 57% some college or college, 49% rural dwelling, and 57% non-gynecologic cancer. Sites enrolled at least 58% of the patients they planned to enroll (range: 58%–100%; average: 84%), of which 44% received 100% of ENABLE content and nearly 60% received two-thirds. Reasons for not completing all six sessions included death, unrecorded contacts, or lost to follow up. Longitudinal GOI scores indicated a trend of improved capacity for EPC services at three of the four sites. Qualitative data from site lead interviews revealed administrative (presence or lack of palliative ‘champions’), clinical (having adequate training), and economic (reimbursement) implementation barriers and facilitators. Conclusions: This pilot implementation study demonstrated feasibility and areas to enhance implementation in a larger comparative effectiveness trial to enhance scaling and spreading EPC in community practices.

Objective Research has demonstrated that treating cancer patients' psychological and physical health leads to improved overall health. This may be especially true for palliative care patients facing serious illness. This study examines the proportion and determinants of psychology service utilization in an outpatient palliative care population. Methods Data from an existing clinical database in an outpatient palliative clinic utilizing a collaborative care model to deliver psychology services were explored. This study was framed by Andersen's Behavioral Model of Health Service Use, which incorporates three main components: predisposing, enabling, and need factors to model health service utilization. The sample (N = 149) was majority middle aged, female, and White with a primary diagnosis of cancer. Cross-tabulations were conducted to determine how many patients who met screening criteria for depression or anxiety sought psychology services. Logistic regression analyses were conducted to assess for predisposing, enabling, and need factor determinants of psychology service utilization. Results Among patients who met criteria for moderate depression or anxiety, 50% did not access readily available psychology services. Enabling factors were the strongest determinant of psychology utilization. Factors associated with need for psychology services (i.e., emotional distress and psychological symptom burden) did not reach significance in determining psychology service use. Conclusions This study extends current knowledge about psychology utilization to palliative care outpatients receiving care within a collaborative care model. Directions for future research include further investigation of care models that optimize enabling strategies to enhance access to these services, and examination of patient-reported barriers to receiving this care. Copyright © 2013 John Wiley & Sons, Ltd.

The importance of quality of life (QOL) measurement among breast cancer survivors (BCS) is well-recognized by researchers and clinicians. With data from 427 rural BCS, the authors used a combination of clinical expertise and statistical analysis to revise a 48-item measure of QOL specific to BCS. The revised 15-item measure showed adequate psychometric properties and provides the basis for a brief yet comprehensive multidimensional measure of QOL applicable to most BCS. Future work includes fine-tuning the measurement model and examining its generalizability among non-rural BCS.

Background: The prevalence of depression among breast cancer patients is estimated to be twice that in the general population, is linked to diminished quality of life and impaired adherence to therapy. Depression is frequently underdiagnosed or misdiagnosed in this population. Efficient screening for depression is central to patient-centered care and enhanced clinical outcomes for breast cancer patients. Purpose: To evaluate the use of a commonly utilized symptom assessment instrument as a screen to enhance identification of breast cancer patients experiencing depression. Methods: Data from a longitudinal surveillance database in outpatient supportive and palliative care were utilized, 174 breast cancer patient contacts were evaluated. Patients completed both the MD Anderson Symptom Inventory (MDASI) and the 9-item Patient Health Questionnaire (PHQ-9) as components of a routinely collected patient-reported outcomes battery. Performance of the MDASI (using the 1–10 Depression question) in identifying cases of depression (defined as a score ≥ 15 on the PHQ-9) was determined using receiver operating characteristic (ROC) analysis. Results: Data were available on 174 patient contacts. When scored as a continuous measure, the MDASI performed well with an area under the ROC curve of 0.87 (95% confidence interval [CI], 0.81–0.94). An MDASI cutoff score of >= 6 provided a sensitivity of 73% (95% CI, 58%–88%), a specificity of 80% (95% CI, 74%–87%), a positive predictive value (PPV) of 46%, and a negative predictive value (NPV) of 93%. Conclusion: The “depression” component of the MDASI as a screening instrument for depression in breast cancer patients yields suboptimal sensitivity and specificity for use as a screening tool. Further efforts to evaluate subsequent iterations of the MDASI and combinations of elements in the MDASI that may enhance performance are indicated. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-12-14.

Little is known about the impact of family caregiving for adults with poor prognosis cancer on caregivers' own individual self-care practices. We explored differences in caregivers' discrete self-care practices associated with varying levels of caregiver well-being, preparedness, and decision-making self-efficacy.Cross-sectional survey within eight community-based southeastern U.S. cancer centers was conducted. Family caregivers of Medicare beneficiaries ≥65 years with pancreatic, lung, brain, ovarian, head and neck, hematologic, or stage IV cancer completed measures of individual self-care practices (health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, stress management, and sleep), well-being (anxiety, depression, and health-related quality of life [HRQoL]), preparedness, and decision-making self-efficacy.Caregivers (n = 294) averaged 66 years, were mostly female (72.8%), white (91.2%), Protestant (76.2%), retired (54.4%), and patients' spouse/partner (60.2%). Approximately, half were rural-dwellers (46.9%) with incomes$50,000 (53.8%). Most provided support 6-7 days/week (71%) for1 year (68%). Nearly a quarter (23%) reported high depression and 34% reported borderline or high anxiety. Low engagement in all self-care practices was associated with worse caregiver anxiety, depression, and mental HRQoL (all p values .05). Caregivers with lower health responsibility, spiritual growth, interpersonal relation, and stress management scores had lower preparedness and decision-making self-efficacy.A significant proportion of caregivers simultaneously report low engagement in all forms of self-care practices, high depression and anxiety, and low HRQoL mental health scores. Caregiver well-being, preparedness, and decision-making self-efficacy might be optimized through interventions targeted at enhancing health responsibility, stress management, interpersonal relationships, and spiritual growth self-care practices.

Context Little is known about whether early palliative care (EPC) support for family caregivers (CGs) impacts depressive symptoms and grief after care recipients die. Objectives To assess after-death CG depressive symptom and grief scores for early compared to delayed group CGs. Methods We conducted a randomized controlled trial (10/2010–9/2013) of an EPC telehealth intervention for CGs (n = 123) initiated at the time of care recipients' advanced cancer diagnosis (early group) or 12 weeks later (delayed group) in a rural comprehensive cancer center, affiliated clinics, and a Veterans Administration medical center. The ENABLE [Educate, Nurture, Advise, Before Life Ends] CG intervention consisted of three weekly sessions, monthly follow-up, and a bereavement call. CGs completed the Center for Epidemiological Study–Depression (CES-D) scale and the Prigerson Inventory of Complicated Grief-Short Form (PG13) 8–12 weeks after care recipients' deaths. Crude and covariate-adjusted between-group differences were estimated and tested using general linear models. Results For care recipients who died (n = 70), 44 CGs (early: n = 19; delayed: n = 25) completed after-death questionnaires. Mean depressive symptom scores (CES-D) for the early group was 14.6 (SD = 10.7) and for the delayed group was 17.6 (SD = 11.8). Mean complicated grief scores (PG13) for the early group was 22.7 (SD = 4.9) and for the delayed group was 24.9 (SD = 6.9). Adjusted between-group differences were not statistically significant (CES-D: d = 0.07, P = 0.88; PG13: d = −0.21, P = 0.51). Conclusion CGs' depressive symptom and complicated grief scores 8–12 weeks after care recipients' deaths were not statistically different based on the timing of EPC support. The impact of timing of CG EPC interventions on CGs bereavement outcomes requires further investigation.

Purpose: This study aimed to test the construct validity of an instrument to measure student professional behaviors in entry-level occupational therapy (OT) students in the academic setting. Methods: A total of 718 students from 37 OT programs across the United States answered a self-assessment survey of professional behavior that we developed. The survey consisted of ranking 28 attributes, each on a 5-point Likert scale. A split-sample approach was used for exploratory and then confirmatory factor analysis. Results: A three-factor solution with nine items was extracted using exploratory factor analysis [EFA] (n=430, 60%). The factors were ‘Commitment to Learning’ (2 items), ‘Skills for Learning’ (4 items), and ‘Cultural Competence’ (3 items). Confirmatory factor analysis (CFA) on the validation split (n=288, 40%) indicated fair fit for this three-factor model (fit indices: CFI=0.96, RMSEA=0.06, and SRMR=0.05). Internal consistency reliability estimates of each factor and the instrument ranged from 0.63 to 0.79. Conclusion: Results of the CFA in a separate validation dataset provided robust measures of goodness-of-fit for the three-factor solution developed in the EFA, and indicated that the three-factor model fitted the data well enough. Therefore, we can conclude that this student professional behavior evaluation instrument is a structurally validated tool to measure professional behaviors reported by entry-level OT students. The internal consistency reliability of each individual factor and the whole instrument was considered to be adequate to good.

There is a paucity of research examining the relationships between dietary patterns and risk of developing precancerous lesions as well as biomarkers associated with such dietary patterns. The purpose of the current study was to identify dietary patterns that are associated with higher grades of cervical intraepithelial neoplasia (CIN 2+) and to determine whether these dietary patterns are associated with the degree of DNA methylation in the long interspersed nucleotide elements (L1s) of peripheral blood mononuclear cells (PBMCs), a biomarker associated with risk of developing CIN 2+. Study population consisted of 319 child-bearing age women. Dietary patterns were derived by factor analysis. The degree of PBMC L1 methylation was assessed by pyrosequencing. Logistic regression models were used to evaluate the associations between dietary patterns and CIN 2+. Similar models were used to evaluate the associations between dietary patterns and degree of PBMC L1 methylation in women free of CIN 2+. Women with the unhealthiest dietary pattern were 3.5 times more likely to be diagnosed with CIN 2+ than women with the healthiest dietary pattern [OR = 3.5; 95% confidence interval (CI), 1.2–10.1; P = 0.02]. Women at risk for developing CIN 2+ with the healthiest dietary pattern were 3.3 times more likely to have higher PBMC L1 methylation than women with the unhealthiest dietary pattern (OR = 3.3; 95% CI, 1.0–10.6; P = 0.04). Our findings suggest that human papilloma virus associated risk of developing CIN 2+ may be reduced by improving dietary patterns. The degree of PBMC L1 methylation may serve as a biomarker for monitoring the effectiveness of dietary modifications needed for reducing the risk of CIN 2+. Cancer Prev Res; 5(3); 385–92. ©2012 AACR.

The use of driving simulators is increasing in clinical settings that provide driving evaluation and rehabilitation. To identify the driving simulator scenarios desired by certified driver rehabilitation specialists (CDRSs), we developed a questionnaire consisting of 22 driving scenario situations. A total of 164 CDRSs rated each situation in terms of its importance for inclusion in simulator-based driving. The four situations they identified as most critical were turning left across oncoming traffic, navigating four-way intersections with traffic lights or signs, driving in multiple lanes with traffic on both sides, and reacting to unexpected events that require emergency braking or aggressive maneuvers to prevent an accident. We conducted exploratory and confirmatory factor analyses to group the 22 driving scenario situations. The model with the best fit included 11 situations forming three factors: (1) Intersections, (2) Roadway and Traffic Conditions, and (3) Environmental Conditions. Future studies should include these factors in driving simulator scenarios and evaluate their clinical efficacy in driving evaluation and rehabilitation.

Disparities in Cervical Cancer (CC) mortality outcomes between African American (AA) and White women have been studied for decades. However, conclusions about the effect of race on CC survival differ across studies. This study assessed differences in CC survival between AA and White women diagnosed between 1985 and 2010 and treated at two major hospitals in the southeastern US. The study sample included 925 AA and 1192 White women diagnosed with cervical adenocarcinoma, adenosquamous cell carcinoma, or squamous cell carcinoma. Propensity score adjustment and matching were employed to compare 5‐year survival between the two racial groups. Crude comparisons suggested relevant racial differences in survival. However, the racial differences became of small magnitude after propensity‐score adjustment and in matched analyses. Nonlinear models identified age at diagnosis, cancer stage, mode of treatment, and histological subtype as the most salient characteristics predicting 5‐year survival of CC, yet these characteristics were also associated with race. Crude racial differences in survival might be partly explained by underlying differences in the characteristics of racial groups, such as age at diagnosis, histological subtype, cancer stage, and the mode of treatment. The study results highlight the need to improve access to early screening and treatment opportunities for AA women to improve posttreatment survival from CC.

The purpose of this mixed methods study was to evaluate the effect of participation in the "Seasoned Arts At the Samford for You" (SAASY) programme, which included a 6-week acting class and four public performances, on the psychological well-being and health-related quality of life of older adults. Twelve older adults with chronic conditions from a low-income senior apartment and a senior living community participated in the programme. The acting class, led by two professional artists, met for a 2-hour class weekly for six weeks. Participants completed the General Well-being Schedule (GWBS) and the 36-Item Short-Form Health Survey (SF-36) both at the beginning of the programme and one month after the programme ended. In addition, participants were individually interviewed to explore the perceived impact of the theatre programme on their well-being. Participants reported a significantly higher score in the GWBS and on the physical but not on the mental component summary of the SF-36 at post-SAASY programme. Content analysis of the interview transcripts revealed that participants attained an improved sense of self-worth and self-advocacy and overcame self-imposed limitations. Results showed improvement in psychological well-being and health-related quality of life, most notably in the physical health component of SF-36 after participating in the programme. Practice implications for occupational therapists using drama as a creative leisure occupation to promote health among older adults with chronic conditions may involve analysis of participants' occupational profile, identification of deficit areas and adaptation of the acting programme content to meet specific needs and goals. The present study used a pretest and post test one group design that has numerous inherent limitations that affect the ability to make valid inferences from study findings. A more rigorous research design with a wait-listed control group and collection of outcome measures immediately after the acting class as well as at three months follow-up is essential in validating the present findings. Outcome measures used in future studies to evaluate the health benefits of a theatre programme should focus on ameliorating the effects of disease on disability (such as functional mobility, everyday cognitive function and activities of daily living) in addition to prevention.

Background Little has been reported about what happens during an outpatient palliative care consultation (OPCC) for persons with advanced heart failure (HF). Methods Qualitative content analysis of provider notes documented during OPCCs of NYHA Class III/IV patients performed per protocol as part of a parent pilot trial of an early concurrent HF palliative care intervention (ENABLE CHF-PC: Educate, Nurture, Advise, Before Life Ends; [4/1/14–8/31/15]) conducted at two sites located in the North- and Southeast. T-tests used to evaluate site-differences. Conclusion OPCCs for HF primarily focused on evaluating symptoms (i.e., mood, dyspnea), advance directive/code status, caregiver/family support, functional status, and on recommending care coordination and referrals. There were considerable regional differences in OPCC assessment and recommendation practices. Results may be biased by disparate OPCC documentation templates at each site. Additional measures, such as uniform charting templates, are needed to ensure that OPCCs for HF patients are comprehensive and standardized. Result Of 61 ENABLE CHF-PC participants, 39 (64%) had an OPCC (Northeast site, n=27; Southeast site, n=12), averaging 60 minutes in duration. Areas most frequently assessed were history of close relationships (n=35, 90%), advance directive/code status (n=33, 85%), family support (n=33, 85%), and functional status (n=30, 77%). Symptoms most frequently evaluated were mood (n= 35, 90%), breathlessness (n=28, 72%), and chest pain (n=24, 62%). Treatment recommendations focused on care coordination (n=13, 33%) and specialty referrals (n=12, 31%). Between-site OPCC differences included assessment of family support (Northeast vs. Southeast site: 100% vs. 50%), code status (96% vs. 58%), goals of care discussions (89% vs. 41.7%), and prognosis understanding (85% vs. 33%). Treatment recommendation differences were most pronounced for care coordination (40.7% vs. 17%).

93 Background: Time-driven activity-based costing (TDABC) can be used by health systems to identify inefficiencies and improve the patient experience in clinical encounters. This quality improvement project utilized a Plan, Do, Study, Act (PDSA) cycle to evaluate routine clinic-based care for women with metastatic breast cancer (MBC). Methods: A project plan was developed to directly observe the time spent by MBC patients in clinic (Plan). Patient clinical encounters could include a physician visit along with scans, infusion, and/or labs. We then created process maps of typical patient clinical experiences (Do). Next, we tabulated times (mean, standard deviation [SD]) that patients spent in waiting areas and with each clinical team member (physician, fellow, nurse practitioner, registered nurse, medical assistant, chaplain, social worker, pharmacist, navigator) to identify care inefficiencies (Study). Lastly, we discussed results with providers and identified and implemented strategies for improving efficiency (Act). Results: We directly observed clinic visits (n = 33) for MBC patients from November 2016 to June 2017. On average, patients spent 219 minutes (SD 108) at clinic visits including 71 minutes (SD 45) spent with clinical team members and 85 minutes (SD 43) spent in waiting areas. We identified several opportunities for efficiency improvement, including the delay prior to rooming by medical assistants (n = 31; mean 22, SD 20 minutes), delays with port lab draws in infusion (n = 5; mean 22, SD 13 minutes), and delays awaiting drug from pharmacy (n = 22; mean 15, SD 29 minutes). To improve efficiency, we implemented strategies including having a dedicated infusion nurse assigned to draw labs from patient ports and modifications to medical assistants’ workflow. Conclusions: In this PDSA cycle, we found that patients spend a substantial amount of time at clinic visits, and the majority of this time is spent in waiting areas. Our use of process mapping and evaluation of time spent receiving care identified important opportunities for improving care delivery and efficiency for patients with MBC.

The purpose of this article is to: (1) describe out of pocket (OOP) costs among minority and Caucasian participants in the BCEI, the Breast Cancer Education Intervention, a randomized clinical trial of psychoeducational quality of life interventions for breast cancer survivors (BCS); and (2) examine the OOP burden, as measured by the proportion of income spent OOP, between the two racial/ethnic groups. We examined baseline OOP costs reported by 261 early-stage I and II breast cancer survivors who participated in the BCEI trial. Data were collected using the Breast Cancer Finances Survey and the Breast Cancer Sociodemographic and Treatment Tool. OOP costs averaged $316 per month since diagnosis. Direct medical costs were $281, and direct non-medical were $66. There were no significant differences in total OOP costs or direct medical and non-medical OOP costs between minority and Caucasian BCS. Minority BCS with incomes of $40,000 or less spent a greater proportion of income in total OOP and direct medical OOP costs (31.4 and 27% for BCS with incomes ≤ $20,000; 19.5 and 18.8% for BCS with incomes $20,001-40,0000) compared to their Caucasian counterparts (12.6 and 9.2% for BCS with incomes ≤ $20,000; 8.7 and 8.2% for BCS with incomes $20,001-40,0000). OOP costs can be a considerable burden for breast cancer survivors representing as much as 31% of monthly income depending on BCS' income levels. Future studies can investigate how this burden affects the quality of life of breast cancer survivors, especially minorities.

Background HF caregivers often experience caregiving burden, impacting their physical and psychological well-being. Social support and social problem-solving, as coping resources, may influence the effect of caregiving burden on self-care, depressive symptoms, and quality of life. Yet, studies examining these coping resources on HF caregiver outcomes are lacking. Purpose To investigate whether social support and social problem-solving mediate the relationships among caregiving burden, self-care, depressive symptoms, and quality of life in HF caregivers. Methods Using a descriptive, cross-sectional, correlational design, HF caregivers (n=530) completed online surveys, including the Dutch Objective Burden Inventory, the Interpersonal Support Evaluation List-12, the Social Problem-Solving Inventory Revised-Short, the Center for Epidemiological Studies - Depression scale, the Denyes Self-care Practice Instrument, and the Bakas Caregiving Outcomes Scale. Path analytic methods were used to examine a hypothesized mediating role of social support and social problem solving in the relationships between caregiving burden and caregiver self-care, depressive symptoms, and quality of life. The analysis proceeded in two phases: 1) a model-development phase with ∼62% of the sample (n=329) used to make data-based decisions on measurement indicators and structure of the path model; and 2) a confirmatory phase with ∼38% of the sample (n=201) used to provide unbiased inference on the model structure resulting from the initial phase. Results Participants were 41.39 (± 10.38) years old, Caucasian (78.3%), men (50.9%) caring for their spouse with HF (44.9%). Perceived caregiver burden was a predictor of caregiver social support (standardized effect B= -.4), self-care (Total B= -.39), depressive symptoms (Total B= .45), and quality of life (Total B= -.33). Higher level of caregiver burden was associated with less social support, worse self-care, more depression and decreased quality of life. Social support mediated the relationship between caregiving burden and depression (56% of Total effect), but did not appear to relevantly mediate the relationship between caregiving burden and self-care (11% of Total effect) or quality of life (0% of Total effect). When considered simultaneously with social support, social problem-solving was not a relevant mediator between caregiving burden and outcomes. Conclusions Caregiving burden negatively impacts caregiver outcomes. Social support appears more beneficial in mediating the effects of caregiving burden on depression, but has little mediational effect on caregiver self-care or quality of life.

Background While recent evidence demonstrates providing early palliative care (EPC) with routine heart failure (HF) care can improve quality of life (QOL) and reduce symptom burden and healthcare use, there is limited evidence examining EPC in a racially diverse HF population in the Southeastern US. Aims To describe and explore patient (PT) and caregiver (CG) participants’ baseline sociodemographics and outcome measures focusing on racial differences. Methods We compared sociodemographics and baseline PT/CG-reported outcome measures (Kansas City Cardiomyopathy Questionnaire [KCCQ], Hospital Anxiety/Depression Scale [HADS], religious coping style, & CG burden (Montgomery Borgatta Caregiver Burden [MCBC] Scale). We then calculated racial differences in these measures using T-tests adjusted with a False Discovery Rate. Results Of 487 participants, there were 357 PTs (nWhite(W)= 157; nBlack(B)= 200) and 130 CGs (nW= 55; nB= 75). Relative to race, Black PTs were younger (nW= 65.12; nB= 62.72; d= 0.29; p= 0.037), less likely to be married (nW= 90; nB= 78; d=0. 42, p= 0.0024), less likely to have private insurance coverage (nW= 103; nB= 83; d= 0.42, p= 0.0024), less likely to have a rural residence (nw= 55, nB= 39; d=0.35; p= 0.0086). Clinically, Black PTs had a lower ejection fraction (Mw= 44.99, MB= 38.9; d= 0.38, p= 0.0047) and fewer had a DNR order (nW= 37; nB = 22; d= 0.36, p= 0.0101). Black PTs also reported more negative religious coping (Mw= 3.8; MB=3.65; d=0.32, p= 0.473). Relative to race, more Black CGs were Protestant (nw= 48, nB= 74; d= 0.39). Black CGs reported lower HADS-depression scores (Mw= 5.36, MB= 4.15; d= 0.38) and lower CG burden scores (MBCB (Mw= 45.05; MB= 42.59; d= 0.43)). Conclusion There were relevant differences in RCT participants’ demographic and clinical characteristics at baseline. It will be important to consider these differences in analyzing trial outcomes and in intervention impact. Ultimately, if racial differences are identified this presents opportunities for tailoring the cultural aspects of the intervention to improve both access to and acceptability of EPC in all HF populations. ClinicalTrials.gov Identifier: NCT02505425.

The purpose of this study was to explore the relationship between sleep apnea indicators and injury in older farmers from Kentucky and South Carolina. Participants reported at least 1 day of farm work during the preceding year (n = 756) and received income from farming. The primary outcome variable was occurrence of injuries because of farm work in the past year. Main explanatory variables of interest included snoring, gasping, snorting, or cessation of breathing while asleep; trouble sleeping; consumption of sleep medications; trouble staying awake during daytime; and sleep quality. Simple logistic regressions established bivariate associations between explanatory and outcome variables. Explanatory variables significantly associated with the outcome in the bivariate analyses were used to fit a multivariable logistic regression model. The results show that just over 10% of participants experienced a farm injury in the past year. Significant bivariate associations were detected between the occurrence of injuries and number of days of farm work (odds ratio [OR] = 1.003, p = .0002); number of hours of farm work during the last week (OR = 1.017, p = .0047); male gender (OR = 2.48, p = .0007); arthritis or rheumatism conditions (OR = 1.981, p = .004); stopped breathing while sleeping (OR = 2.338, p = .0027); and problems staying awake during the past month (OR = 2.561, p = .001). In the final multivariable model, "stopping breathing while asleep" (p

Introduction: National Comprehensive Cancer Network (NCCN) guideline-based treatment is increasingly recognized as a marker of high quality care. Payers are progressively limiting reimbursement for non-guideline based care as they move towards value-based cancer care. However, the impact of treatment regimen concordance with NCCN guidelines on cost and health care utilization in early stage breast cancer is unclear. Methods: This was a secondary analysis of Medicare administrative claims data from 2012-2015 for all women aged ≥65 with stage I-III breast cancer who received care within the University of Alabama at Birmingham Cancer Community Network. Concordance to NCCN Clinical Practice guidelines was assessed for treatment regimens including hormonal medications, chemotherapy, and/or HER2-targeted therapy. Costs to Medicare (reimbursements to providers for all care received) were averaged monthly from the start of cancer treatment until death or available follow-up. Health care utilization (emergency department [ED] visits and hospitalizations) was identified from the start of cancer treatment until death or available follow-up. Cost and adjusted monthly utilization rates per thousand observations and their corresponding 95% confidence intervals (CI) were estimated using linear mixed effect models and generalized linear models, respectively, using the negative binomial distribution and log link function. Results: Of 1042 patients on treatment for early stage breast cancer, 82% received a guideline concordant treatment, with 79% receiving a “preferred” treatment and 3% receiving an “other” but still on-guideline treatment. Those receiving guideline concordant treatment were more likely to be white, treated at large volume centers, have an earlier stage cancer, ER/PR positive, and HER2 negative (p Conclusions: Despite the majority of early stage breast cancer patients receiving guideline concordant care, almost one in five did not, with an even higher proportion of guideline discordance in those receiving chemotherapy. Guideline concordant treatment was significantly associated with lower costs and lower rates of health care utilization after adjusting for patient and center characteristics. The appropriateness of guideline deviation should be examined from both the patient and payer perspectives. Citation Format: Williams CP, Azuero A, Pisu M, Halilova KI, Adewakun S, Yagnik SK, Goertz H-P, Rocque GB. Impact of guideline concordant treatment on cost and health care utilization in early stage breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD7-01.

Objective: Fertility and childbearing issues are the major quality of life concerns among young breast cancer survivors. Practical approaches are needed to convey reproductive health information. The Fertility and Cancer Project (FCP) is a dedicated research project that provides online reproductive health and fertility education. We report FCP participants' (a) changes in mood and functioning and (b) changes in knowledge of fertility and cancer from baseline to 6-month follow-up. Methods: Participants completed five self-report baseline measures, accessed FCP content and participated in online discussions. At 6 months post FCP study entry, participants were asked to complete follow-up self-reports. Results: One hundred and six breast cancer survivors from 8 countries participated in the FCP. Mean age at diagnosis was 34.3 years; mean time since diagnosis was 22 months. Significant change was detected in improved physical functioning (p=0.019) and social functioning (p=0.02). Significant changes were also noted in improved fertility knowledge (p=0.011). Conclusion: Preliminary evidence shows that young breast cancer survivors derive improved mood and knowledge benefit from FCP participation. Internet-based approach may be a viable format for engaging this population of cancer survivors. Copyright © 2009 John Wiley & Sons, Ltd.

Although most cancer survivors are at risk for being lost in the transition from treatment to survivorship, rural breast cancer survivors face special challenges that might place them at particular risk. This small-scale preliminary study had 2 specific aims: (aim 1) establish the feasibility of rural breast cancer survivors participation in a longitudinal quality of life (QOL) intervention trial and (aim 2) determine the effects of the Breast Cancer Education Intervention (BCEI) on overall QOL. Fifty-three rural breast cancer survivors were randomized to either an experimental (n = 27) or a wait-control arm (n = 26). Participants in the experimental arm received the BCEI consisting of 3 face-to-face education and support sessions and 2 face-to-face and 3 telephone follow-up sessions, along with supplemental written and audiotape materials over a 6-month period. Breast Cancer Education Intervention modules and interventions are organized within a QOL framework. To address the possible effects of attention, wait-control participants received 3 face-to-face sessions and 3 telephone sessions during the first 6 months of participation in the study, but not the BCEI intervention. Research questions addressing aim 1 were as follows: (a) can rural breast cancer survivors be recruited into a longitudinal intervention trial, and (b) can their participation be retained. Research questions for aim 2 were as follows: (a) do participants who received the BCEI show improvement in overall QOL, and (b) is the QOL improvement sustained over time. Data were analyzed using repeated-measures general linear mixed models. Results demonstrated the ability to recruit and retain 53 rural breast cancer survivors, that the experimental arm showed improvement in overall QOL (P = .013), and that there were significant differences in overall QOL between the experimental and wait-control groups at both months 3 and 6. Thus, it appears that at least some rural breast cancer survivors can and will participate in a larger trial and will maintain their participation and that those that do participate experience significant QOL benefit.

Introduction: It is estimated that 2-3 million children in the US have diagnosed hypertension that can track to adulthood and is a risk factor for cardiovascular disease (CVD). However, the prevalence of instance elevations of blood pressure (BP) in children is estimated to greatly exceed the prevalence of hypertension. There is increasing evidence that risk factors for CVD, including hypertension and instance elevations in BP, begin in childhood. It is unclear when the elevations in BP first appear in children and what factors influence BP. Few studies have examined instance elevations in BP in preschool children and/or what factors influence BP. Hypothesis: The purpose of this study was to determine the prevalence of elevated BP readings in a group of rural and urban preschool children and to determine if there were differences in BP status (normal, prehypertensive, or hypertensive range) based on race, gender, location, prematurity status, or body mass index (BMI) status. Methods: A cross-sectional comparative design was used to address the purpose. A convenience sample of 56 3-5 year old children (27 rural, 29 urban; 37 male, 19 female; 33 Black, 21 White) were recruited from Head Start Centers. Height, weight, and BP were collected according to protocols at the Centers. Results: Based on pediatric percentiles, 30% of the children had elevated BP readings; 14% Pre-Hypertensive readings (6 males; 2 female; 4 Black; 4 White); 16% Hypertensive readings (6 males; 3 females; 5 Black, 4 White). Seventy-six percent of elevated BP readings were systolic BP (SBP); 47% of those with elevated BP readings had diastolic elevations, while 23.5% had elevations in both SBP and DBP. Nine participants were overweight; 5 were obese. Over 65% of the children with BP elevations were normoweight. There were no differences in BP status based on race, gender, location, prematurity or BMI Status. There was a small effect size for the relationship between race, BMI status, prematurity and BP status. Conclusions: Thirty percent of 3-5 year-old children in this sample had elevated BP readings, the majority of which were SBP. BP should be measured in children at each visit to health care providers and elevations in BP readings addressed early to prevent later hypertension and other CVDs.

Symptoms guide disease management, and patients frequently report HIV-related symptoms, but HIV symptom patterns reported by patients have not been described in the era of improved antiretroviral treatment. The objectives of our study were to investigate the prevalence and burden of symptoms in people living with HIV and attending an outpatient clinic. The prevalence, burden, and bothersomeness of symptoms reported by patients in routine clinic visits during 2011 were assessed using the 20-item HIV Symptom Index. Principal component analysis was used to identify symptom clusters and relationships between groups using appropriate statistic techniques. Two main clusters were identified. The most prevalent and bothersome symptoms were muscle aches/joint pain, fatigue, and poor sleep. A third of patients had seven or more symptoms, including the most burdensome symptoms. Even with improved antiretroviral drug side-effect profiles, symptom prevalence and burden, independent of HIV viral load and CD4+ T cell count, are high.

Federal policies have a significant effect on how businesses spend money. The 2009 HITECH (Health Information Technology for Economic and Clinical Health Act) authorized incentive payments through Medicare and Medicaid to clinicians and hospitals when they use certified electronic health records privately and securely to achieve specified improvements in care delivery. Federal incentive payments were offered in 2011 for hospitals that had satisfied "meaningful use" criteria. A longitudinal study of nonfederal hospital information technology (IT) budgets (N = 493) during the years 2009 to 2011 found increases in the percentage of hospital annual operating budgets allocated to IT in the years leading up to these federal incentives. This increase was most pronounced among hospitals receiving high proportions of their reimbursements from Medicaid, followed by hospitals receiving high proportions of their reimbursements from Medicare, possibly indicating a budget shift during this period to more IT spending to achieve meaningful-use policy guidelines.

Purpose To determine the effect of early versus delayed initiation of a palliative care intervention for family caregivers (CGs) of patients with advanced cancer. Patients and Methods Between October 2010 and March 2013, CGs of patients with advanced cancer were randomly assigned to receive three structured weekly telephone coaching sessions, monthly follow-up, and a bereavement call either early after enrollment or 3 months later. CGs of patients with advanced cancer were recruited from a National Cancer Institute cancer center, a Veterans Administration Medical Center, and two community outreach clinics. Outcomes were quality of life (QOL), depression, and burden (objective, stress, and demand). Results A total of 122 CGs (early, n = 61; delayed, n = 61) of 207 patients participated; average age was 60 years, and most were female (78.7%) and white (92.6%). Between-group differences in depression scores from enrollment to 3 months (before delayed group started intervention) favored the early group (mean difference, −3.4; SE, 1.5; d = −.32; P = .02). There were no differences in QOL (mean difference, −2; SE, 2.3; d = −.13; P = .39) or burden (objective: mean difference, 0.3; SE, .7; d = .09; P = .64; stress: mean difference, −.5; SE, .5; d = −.2; P = .29; demand: mean difference, 0; SE, .7; d = −.01; P = .97). In decedents' CGs, a terminal decline analysis indicated between-group differences favoring the early group for depression (mean difference, −3.8; SE, 1.5; d = −.39; P = .02) and stress burden (mean difference, −1.1; SE, .4; d = −.44; P = .01) but not for QOL (mean difference, −4.9; SE, 2.6; d = −.3; P = .07), objective burden (mean difference, −.6; SE, .6; d = −.18; P = .27), or demand burden (mean difference, −.7; SE, .6; d = −.23; P = .22). Conclusion Early-group CGs had lower depression scores at 3 months and lower depression and stress burden in the terminal decline analysis. Palliative care for CGs should be initiated as early as possible to maximize benefits.

The purpose of this article is to report the results of behavioral assessments collected at three time points of a cohort of children adopted from the former Soviet Union with particular emphasis on the impact of the adoptive family on problem behaviors.Families adopting from the former USSR are concerned about the influence of pre-adoptive circumstances on their child's future health.The study utilized data gathered in 1998 when the children's mean age was close to 8 years, in 2001 when the children were entering early adolescence, and in 2006 when the average age of the children was just over 15 years. The authors hypothesized that the negative impact of risk factors decreases over time, and that a family environment that is stable and supportive is inversely related to problem behaviors. The Child Behavior Checklist, the Family Environment Scale, and a parental report form were used for data collection.Significant relationships between family environment and problem behaviors over time were found, with lower levels of conflict and higher levels of cohesion associated to lower problem behaviors. Being female does contribute to problem behavior with the passage of time.Although the magnitude of these effects was small to moderate, a protective family environment may assist in decreasing problem behaviors.

174 Background: Patient navigation programs in cancer care have historically focused on assisting persons to overcome barriers to accessing care. Evidence is emerging to support the impact of navigation interventions across the cancer continuum. However, navigation programs have varied designs, resulting in a lack of clarity about the optimal approach to delivering services to patients, and a lack of evidence linking program design to outcomes. Methods: A planned retrospective analysis of Medicare administrative claims for a population of older beneficiaries diagnosed with cancer: The main exposure was the number of contacts in person or over the phone with PCCP navigators in the 6 month period starting from the quarter in which patients enrolled in the PCCP. Repeated measures generalized linear models with normal distribution were used to evaluate trends in total cost over time based on: number of contacts, quarters post-enrollment (TIME), and the interaction between number of contacts and TIME. Intra-correlation was controlled for repeated measures. Results: 4,337 patients were included in this analysis. 17.9% had one contact, 17.7% had two, 22.2% had 3-4, 24.2% had 5-10, and 18.0% had more than 10 contacts. African Americans had a greater number of participants with more than 10 navigator contacts, as stage 4 cancers, and initial or end-of-life phase of care. Patients who received more than 3 contacts had significantly higher levels of baseline cost. Models to evaluate total cost over time demonstrate an effect of navigator contact on cost that is associated with number of contacts. This trend is statistically significant at 3-4 contacts or more, and remains significant at 10 or more contacts. Conclusions: Increased navigator contact is associated with increased slope of decline in utilization and cost indicates that navigation programs should be adequately resourced to deliver care that enables navigators to have contact with patients a minimum of 3-4 contacts over a six month period.

21 Background: Family caregivers of persons with cancer are at high risk for distress and may benefit from formal support services. The purpose of this study was to describe cancer family caregiver’s use of and desire for formal support services. Methods: Cross-sectional mail survey conducted in communities of eight cancer centers in Tennessee, Alabama, and Florida. Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers reported support service use and completed validated measures of depression, anxiety, burden, preparedness, and health. Results: Caregivers(n = 294) were on average age 65.5 years and mostly female (72.8%), white (91.2%), and care recipients’ spouse/partner (60.2%). Patients averaged 75.3 years and were mostly male (54.4%). Formal support services were used by 32.0% (n = 94) of all caregivers; 4.4% used therapy or counseling, 19.7% received education and training; and 11.2% received assistance from local, state, or national organizations. Twenty-eight percent of all caregivers were “mostly or “extremely” interested in receiving support services; of those, 44% had high depressive symptoms, 52.3% had high anxiety symptoms, and 36.4% in the lowest quartile of preparedness. In multivariate analyses, participation in services was significantly associated with lower objective burden, higher preparedness, not working, and not being the patient’s spouse. Being “mostly” or “extremely” interested in support services was significantly associated with being a minority, shorter durations of caregiving, and with higher stress burden. Conclusions: While distressed and underprepared family caregivers reported strong interest in formal support services, only a small proportion accessed these services. Strategies to increase service use may include targeting those caregivers who are still early in their caregiving experience and who report high stress burden.

Background: Persons with dementia usually receive mouth care from nursing assistants. Inadequate mouth care causes poor oral health, a risk for systemic diseases like pneumonia. Nursing assistants struggle with balancing optimal mouth care against triggering care-resistant behaviors.

Background: HIV-associated neurocognitive disorders occur in nearly 50% of adults with HIV. Such disorders can interfere with everyday functioning such as driving and medication adherence. Therefore, cognitive interventions are needed to address such neurocognitive disorders as well as improve everyday functioning, especially as people age with HIV. Objective: This article reports and discusses the overall rationale and development of speed of processing training, a computerized Internet cognitive training program, to improve this specific neurocognitive ability as well as everyday functioning and quality of life in adults aging with HIV. Although this protocol has been shown to improve speed of processing, everyday functioning, and quality of life in healthy, community-dwelling older adults in the advanced cognitive training in vital elderly (ACTIVE) study, its efficacy in adults aging with HIV has not been established. Nevertheless, such a cognitive intervention is particularly germane as 52%-59% of adults with HIV experience HIV-associated neurocognitive disorders (HAND), and both the frequency and severity of such disorders may increase with advancing age. Methods: The description of this longitudinal randomized controlled trial covers the following: (1) rationale for speed of processing training in this clinical population, (2) overview of overall study design, (3) eligibility criteria and HAND, (4) intervention dosage, (5) assessment battery, and (6) examination of biomarkers. Results: The project was funded in April 2016 and enrolment is on-going. The first results are expected to be submitted for publication in 2020. Conclusions: Similar novel cognitive intervention approaches are suggested as they may be of value to those with HAND and may utilize similar features of this current randomized controlled trial (RCT) protocol to examine their therapeutic efficacy. Trial Registration: ClinicalTrials.gov NCT02758093; https://clinicaltrials.gov/ct2/show/NCT02758093 (Archived by Webcite at http://www.webcitation.org/6p8C5fBCX) [JMIR Res Protoc 2017;6(4):e68]

19 Background: The Oncology Care Model (OCM) is a specialty care model developed by the Centers for Medicare & Medicaid (CMS) Innovation Center aimed at providing higher quality, more highly coordinated cancer care and reducing costs for patients undergoing chemotherapy. The OCM calculates costs of care in a novel way by anchoring costs within episodes of care, defined as six-month intervals triggered by initial anti-cancer treatment, as opposed to diagnosis date. The purpose of this study is to assess costs within the OCM episodes of care. Methods: This was a secondary analysis of Medicare administrative claims data for beneficiaries 65 and older with cancer who received anti-cancer drug treatment (chemotherapy, hormone therapy) between 2012-2015 at an institution in the UAB Cancer Community Network (CCN). Total and service-specific costs (Medicare reimbursement to providers) per patient-episode were summed from inpatient, outpatient, chemotherapy, radiation therapy, testing/pathology, evaluation and management (E/M), home health, skilled nursing facility (SNF), and hospice claims. Prescription drug costs were not included. Mean costs for the first three OCM episodes were calculated and compared to (1) diagnosis-based costs (six-month intervals starting at cancer diagnosis) and (2) service type. Results: Average total cost in the first three OCM episodes of care was $24,922 (n=13,902), $18,534 (n=6,618), and $16,548 (n=4,672). Compared to episode-based cost, average total diagnosis-based cost was higher in the first episode of care ($33,244, n=9,615), and lower in the second and third episodes ($17,143, n=9,110; $12,897, n=8,002). Episode-based outpatient, inpatient, and chemotherapy costs were the highest service-specific costs in all three episodes of care (1st: $8,374, $5,493, $2,445; 2nd: $6,188, $3,913, $3,158; 3rd: $5,909, $3,251, $3,399). Conclusions: Costly chemotherapy and inpatient and outpatient visits indicate an opportunity for targeted improvement resulting in higher value care. Knowledge of current costs of care will aid oncology practices in transition to the OCM and in usage of value-based services for better quality cancer care.

Purpose: To determine reliability, diagnostic values, and minimal detectable change scores, 90% confidence (MDC90) of pediatric clinical tests of vestibular function. Methods: Twenty children with severe to profound bilateral sensorineural hearing loss and 23 children with typical development, aged 6 to 12 years, participated. The Head Thrust Test, Emory Clinical Vestibular Chair Test, Bucket Test, Dynamic Visual Acuity, Modified Clinical Test of Sensory Interaction on Balance, and Sensory Organization Test were completed twice for reliability. Reference standard diagnostic tests were rotary chair and vestibular evoked myogenic potential. Reliability, sensitivity,specificity,predictivevalues,likelihoodratios,andMDC90 scoreswerecalculated.Results:Reliability ranged from an intraclass correlation coefficient of 0.73 to 0.95. Sensitivity, specificity, and predictive values, using cutoff scores for each test representing the largest area under the curve, ranged from 63% to 100%. The MDC90 forDynamicVisualAcuityandModifiedClinicalTestofSensoryInteractiononBalancewere8optotypes and 16.75 seconds, respectively. Conclusions: Clinical tests can be used accurately to identify children with vestibular hypofunction. (Pediatr Phys Ther 2014;26:180–190) Key words: child, diagnostic tests/standards, postural balance, reproducibility of results, ROC curves, sensitivity and specificity, sensorineural hearing loss, vestibular function tests