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Objective: To determine the effects of physician gender on rates of Pap testing, mammography, and cholesterol testing when identifying and adjusting for demographic, psychosocial, and other patient variables known to influence screening rates.Design: A prospective design with baseline and six-month follow-up assessments of patients' screening status.Setting: Twelve community-based group family practice medicine offices in North Carolina.Participants: 1,850 adult patients, aged 18-75 years (six-month response rate, 83%), each of whom identified one of 37 physicians as being his or her regular care provider.Main Results: Where screening was indicated at baseline, the patients of the women physicians were 47% more likely to get a Pap test [odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.05, 2.04] and 56% more likely to get a cholesterol test (OR = 1.56, 95% CI = 1.08, 2.24) during the study period than were the patients of the men physicians. For mammography, the younger patients (aged 35-39 years) of the women physicians were screened at a much higher rate than were the younger patients of the men physicians (OR = 2.69, 95% CI = 0.98, 7.34); however, at older ages, the patients of the women and the men physicians had similar rates of screening.Conclusions: In general, the patients of the women physicians were screened at a higher rate than were the patients of the men physicians, even after adjusting for important patient variables. These findings were not limited to gender-specific screening activities (e.g., Pap testing), as in some previous studies. However, the patients of the women physicians were aggressively screened for breast cancer at the youngest ages, where there is little evidence of benefit from mammography. Larger studies are needed to determine whether this pattern of effects reflects a broader phenomenon in primary care. [ABSTRACT FROM AUTHOR]

The article discusses a study conducted to assess the extent to which shared decision making is used for Prostate Specific Antigen (PSA) screening among patients and physicians. Topics discussed include details of study procedure and its findings, strengths and limitations of the study and risks, benefits and uncertainties of PSA screening in contemporary patient-physician encounters.

Differences among clinical care units in social dynamics and social organization are associated with differences in the clinical course of patients with a range of chronic illness. These differences are also associated with well-being of staff members. Recent attention has focused on understanding these differences among units with an eye towards correcting deficiencies and enhancing strengths of clinical care units. The current study sought to delineate the effect of social and organizational dynamics unique to each unit on staff perceptions of the security of their relationships with other staff and their perceived work pressure. The unit as a major source of differences among staff subjects was compared with the impact of ethnic identity, of work in the morning shift vs other shifts, and of professional role. Results confirmed that unit membership was, by far, the most important correlate of staff perceptions of the unit, particularly those concerning security of relationships with others and perceived work pressure. Moreover, the results suggested that unit differences in perceived security were due to differences among units in long standing turmoil within the unit or long standing problematic ties between the unit and the larger institution which controls it. However, perceived work pressure seems more transient and may reflect the challenge of shorter-temm fluctuations in the demands of patient care. [ABSTRACT FROM AUTHOR]

Background: The purpose of the Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) Program, a Cancer Moonshot℠ Initiative, is to support research to build the evidence base on multilevel interventions that increase rates of colorectal cancer screening, follow-up, and referral to care to address disparities in colorectal cancer screening. The National Cancer Institute funded eight Research Projects to implement multilevel interventions to improve colorectal cancer screening among communities who traditionally have been medically underserved. To analyze the impact of ACCSIS across Research Projects, the consortium developed a set of common data elements. The purpose of this paper is to describe the process of developing the common data elements to facilitate analysis of ACCSIS data as well as support and inform implementation science research studies., Methods: The ACCSIS Data, Design, and Analysis Work Group was tasked with designing common data elements through a review of existing data collection instruments, examination of data elements proposed by the ACCSIS Research Projects, and deliberations on the data required to compare across the Research Projects. ACCSIS Consortium members drafted, revised, and finalized a common data elements document consisting of variables to collect and surveys to administer to evaluate ACCSIS implementation activities and outcomes in a standardized manner across the Research Projects., Results: The ACCSIS Consortium decided to collect the following categories of common data elements: characteristics across multiple levels of the multicomponent interventions, implementation climate, and determinants; interventions and strategies; implementation outcome constructs and definitions; colorectal cancer screening episodes (screening, diagnostic testing follow-up, cancer detection, and cancer treatment); and cost measures. To assess implementation climate, the consortium prioritized constructs from five domains of the Consolidated Framework for Implementation Research., Conclusions: The ACCSIS common data elements offer a set of harmonization data for future implementation efforts. The consortium is conducting a systematic assessment using both quantitative and qualitative approaches to assess data quality and approaches to improve and sustain data collection. Lessons learned from these ongoing activities will offer additional insights to tailor the ACCSIS common data elements and support efforts to increase colorectal cancer screening for populations experiencing disparities., (© 2024. The Author(s).)

In this manuscript, we summarize the goals, content, and impact of the Gender and Health: Impacts of Structural Sexism, Gender Norms, Relational Power Dynamics, and Gender Inequities workshop held by the National Institutes of Health (NIH) Office of Research on Women's Health (ORWH) in collaboration with 10 NIH Institutes, Centers, and Offices. Specifically, we outline the key points emerging from the workshop presentations, which are the focus of the collection of articles in this supplement. The overarching goals of the workshop were to convene NIH staff, the external scientific community, and the public to discuss methods, measurement, modifiable factors, interventions, and best practices in health research on gender as a social and cultural variable and to identify opportunities to advance research and foster collaborations on these key topics. Themes emerging from the workshop include the need for intersectional measures in research on gender and health, the role of multilevel interventions and analyses, and the importance of considering gender as a social and structural determinant of health. Careful, nuanced, and rigorous integration of gender in health research can contribute to knowledge about and interventions to change the social and structural forces that lead to disparate health outcomes and perpetuate inequities., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: To determine safety and effectiveness of percutaneous interventions performed by interventional radiologists at a single institution over 2 decades in patients with dialysis access steal syndrome (DASS)., Materials and Methods: A retrospective review of fistulograms from 2001 to 2021 (N = 11,658) was performed. In total, 286 fistulograms in 212 patients with surgically created dialysis accesses met inclusion criterion of fistulography for suspected DASS. Chart review collected data regarding patient demographics, comorbidities, access characteristics, fistulography findings, intervention(s) performed, and outcomes. Procedures with and without DASS intervention were compared. Odds ratios (ORs), adjusted for age, sex, comorbidities, access characteristics, and multiple within-patient events, were calculated using logistic regression to determine associations between steal intervention status and outcome variables: (a) major adverse events, (b) access preservation, and (c) follow-up surgery. A percutaneously treatable cause of DASS was present in 128 cases (45%). Treatment of DASS lesions was performed in 118 cases. Fifteen embolizations were also performed in patients without DASS lesions., Results: Technical success of DASS interventions, defined by the Society of Interventional Radiology (SIR) reporting standards, was 94%; 54% of interventions resulted in DASS symptom improvement at a median follow-up of 15 days. Patients with steal intervention had 60% lower odds of follow-up surgery (OR, 0.4; P = .007). There was no difference in major adverse events (P = .98) or access preservation (P = .13) between groups., Conclusions: In this retrospective cohort study, approximately half of DASS fistulograms revealed a percutaneously treatable cause of steal. Over half of DASS interventions resulted in symptomatic relief. Percutaneous intervention was associated with lower odds of follow-up surgery without compromising access preservation., (Copyright © 2024 SIR. Published by Elsevier Inc. All rights reserved.)

Introduction: Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase participation in colorectal cancer (CRC) screening. The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated., Methods: We characterized self-sampling and mail strategies used for implementing CRC screening across a consortium of 8 National Cancer Institute Cancer Moonshot Initiative Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) research projects. These projects serve diverse rural, urban, and tribal populations in the US., Results: All 8 ACCSIS projects leveraged self-sampling and mail to promote screening. Strategies included organized mailed FIT outreach with mailed invitations, including FIT kits, reminders, and mailed return (n = 7); organized FIT-DNA outreach with mailed kit return (n = 1); organized on-demand FIT outreach with mailed offers to request a kit for mailed return (n = 1); and opportunistic FIT-DNA with in-clinic offers to be mailed a test for mailed return (n = 2). We found differences in patient identification strategies, outreach delivery approaches, and test return options. We also observed consistent use of Centers for Disease Control and Prevention Summit consensus best practice recommendations by the 7 projects that used mailed FIT outreach., Conclusion: In research projects reaching diverse populations in the US, we observed multiple strategies that leverage self-sampling and mail to promote CRC screening. Mail and self-sampling, including mailed FIT outreach, could be more broadly leveraged to optimize cancer screening.

Population models of cancer reflect the overall US population by drawing on numerous existing data resources for parameter inputs and calibration targets. Models require data inputs that are appropriately representative, collected in a harmonized manner, have minimal missing or inaccurate values, and reflect adequate sample sizes. Data resource priorities for population modeling to support cancer health equity include increasing the availability of data that 1) arise from uninsured and underinsured individuals and those traditionally not included in health-care delivery studies, 2) reflect relevant exposures for groups historically and intentionally excluded across the full cancer control continuum, 3) disaggregate categories (race, ethnicity, socioeconomic status, gender, sexual orientation, etc.) and their intersections that conceal important variation in health outcomes, 4) identify specific populations of interest in clinical databases whose health outcomes have been understudied, 5) enhance health records through expanded data elements and linkage with other data types (eg, patient surveys, provider and/or facility level information, neighborhood data), 6) decrease missing and misclassified data from historically underrecognized populations, and 7) capture potential measures or effects of systemic racism and corresponding intervenable targets for change., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Frequently changing cervical cancer screening guidelines over the past two decades have been inconsistently adopted in the United States. Current guidelines set the recommended screening interval to three years for average-risk women aged 21-29 years. Few studies have evaluated how patient and provider factors are associated with implementation of cervical cancer screening intervals among younger women. This study evaluated multilevel factors associated with screening interval length among 69,939 women aged 21-29 years with an initial negative Pap screen between 2010 and 2015 across three large health systems in the U.S. Shorter-interval screening was defined as a second screening Pap within 2.5 years of an initial negative Pap. Mixed-effects logistic regression was performed for each site to identify provider and patient characteristics associated with shorter-interval screening. The odds of shorter-interval screening decreased over the study period across all sites, though the proportion of patients screened within 2.5 years remained between 7.5% and 20.7% across sites in 2014-2015. Patient factors including insurance, race/ethnicity, and pregnancy were associated with shorter-interval screening, though the patterns differed across sites. At one site, the variation in shorter-interval screening explained by the provider was 10.6%, whereas at the other two sites, the provider accounted for < 2% of the variation in shorter-interval screening. Our results highlight the heterogeneity in factors driving cervical cancer screening interval across health systems and point to the need for tailored approaches targeted to both providers and patients to improve guideline-concordant screening., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Background: Although patient navigation has shown promise for increasing participation in colorectal cancer screening and follow-up, little evidence is available to guide implementation of patient navigation in clinical practice. We characterize 8 patient navigation programs being implemented as part of multi-component interventions of the National Cancer Institute's Cancer Moonshot Accelerating Colorectal Cancer Screening and Follow-Up Through Implementation Science (ACCSIS) initiative., Methods: We developed a data collection template organized by ACCSIS framework domains. The template was populated by a representative from each of the 8 ACCSIS research projects. We report standardized descriptions of 1) the socio-ecological context in which the navigation program was being conducted, 2) navigation program characteristics, 3) activities undertaken to facilitate program implementation (eg, training), and 4) outcomes used in program evaluation., Results: ACCSIS patient navigation programs varied broadly in their socio-ecological context and settings, the populations they served, and how they were implemented in practice. Six research projects adapted and implemented evidence-based patient navigation programs; the remaining projects developed new programs. Five projects began navigation when patients were due for initial colorectal cancer screening; 3 projects began navigation later in the screening process, when patients were due for follow-up colonoscopy after an abnormal stool-test result. Seven projects relied on existing clinical staff to deliver the navigation; 1 hired a centralized research navigator. All project researchers plan to evaluate the effectiveness and implementation of their programs., Conclusions: Our detailed program descriptions may facilitate cross-project comparisons and guide future implementation and evaluation of patient navigation programs in clinical practice., (© The Author(s) 2023. Published by Oxford University Press.)

In 2012, United States consensus guidelines were modified to recommend that cervical cancer screening not begin before age 21 and, since 2014, the Health Effectiveness Data and Information Set (HEDIS), a health plan quality measurement too, has included a measure for non-recommended cervical cancer screening among females ages 16-20. Our goal was to describe prevalence over time of cervical cancer screening before age 21 following the 2012 guideline change, and provide information to help understand how rapidly new guidelines may be disseminated and implemented into clinical practice. We used longitudinal clinical and administrative data from three diverse healthcare systems in the Population-based Research to Optimize the Screening Process (PROSPR II) consortium to examine annual trends in screening before age 21. We identified 55,316 average-risk, screening-eligible females ages 18-20 between 2011 and 2017. For each calendar year, we estimated the proportion of females who received a Papanicolaou (Pap) test. We observed a steady decline in the proportion of females under age 21 who received a Pap test, from an average of 8.3% in 2011 to <1% in 2017 across the sites. The observed steady decline suggests growing adherence to the 2012 consensus guidelines. This trend was consistent across diverse geographic regions, healthcare systems, and patient populations, strengthening the generalizability of the results; however, since we only had 1-2 years of study data prior to the consensus guidelines, we cannot discern whether screening under age 21 was already in decline. Nonetheless, these results provide data to compare with other guideline changes to de-implement non-recommended screening practices., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Despite decades of ethical, empirical, and policy support, shared decision-making (SDM) has failed to become standard practice in US cancer care. Organizational and health system characteristics appear to contribute to the difficulties in implementing SDM in routine care. However, little is known about the relevance of the different characteristics in specific healthcare settings. The aim of the study was to explore how organizational and health system characteristics affect SDM implementation in US cancer care., Methods: We conducted semi-structured interviews with diverse cancer care stakeholders in the USA. Of the 36 invited, 30 (83%) participants consented to interview. We used conventional content analysis to analyze transcript content., Results: The dominant theme in the data obtained was that concerns regarding a lack of revenue generation, or indeed, the likely loss of revenue, were a major barrier preventing implementation of SDM. Many other factors were prominent as well, but the view that SDM might impair organizational or individual profit margins and reduce the income of some health professionals was widespread. On the organizational level, having leadership support for SDM and multidisciplinary teams were viewed as critical to implementation. On the health system level, views diverged on whether embedding tools into electronic health records (EHRs), making SDM a criterion for accreditation and certification, and enacting legislation could promote SDM implementation., Conclusion: Cancer care in the USA has currently limited room for SDM and is prone to paying lip service to the idea. Implementation efforts in US cancer care need to go further than interventions that target only the clinician-patient level. On a policy level, SDM could be included in alternative payment models. However, its implementation would need to be thoroughly assessed in order to prevent further misdirected incentivization through box ticking.

Background: Cancer screening is a complex process encompassing risk assessment, the initial screening examination, diagnostic evaluation, and treatment of cancer precursors or early cancers. Metrics that enable comparisons across different screening targets are needed. We present population-based screening metrics for breast, cervical, and colorectal cancers for nine sites participating in the Population-based Research Optimizing Screening through Personalized Regimens consortium., Methods: We describe how selected metrics map to a trans-organ conceptual model of the screening process. For each cancer type, we calculated calendar year 2013 metrics for the screen-eligible target population (breast: ages 40-74 years; cervical: ages 21-64 years; colorectal: ages 50-75 years). Metrics for screening participation, timely diagnostic evaluation, and diagnosed cancers in the screened and total populations are presented for the total eligible population and stratified by age group and cancer type., Results: The overall screening-eligible populations in 2013 were 305 568 participants for breast, 3 160 128 for cervical, and 2 363 922 for colorectal cancer screening. Being up-to-date for testing was common for all three cancer types: breast (63.5%), cervical (84.6%), and colorectal (77.5%). The percentage of abnormal screens ranged from 10.7% for breast, 4.4% for cervical, and 4.5% for colorectal cancer screening. Abnormal breast screens were followed up diagnostically in almost all (96.8%) cases, and cervical and colorectal were similar (76.2% and 76.3%, respectively). Cancer rates per 1000 screens were 5.66, 0.17, and 1.46 for breast, cervical, and colorectal cancer, respectively., Conclusions: Comprehensive assessment of metrics by the Population-based Research Optimizing Screening through Personalized Regimens consortium enabled systematic identification of screening process steps in need of improvement. We encourage widespread use of common metrics to allow interventions to be tested across cancer types and health-care settings., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The human papillomavirus (HPV) vaccine is a powerful tool in cancer prevention. In combination with cervical cancer screening programs, this vaccine has the potential to nearly eliminate death from cervical cancer. However, this remarkable public health success can only be realized if vaccines reach those most at risk-unscreened women. Vaccinating only those already well-screened would have little impact on cervical cancer mortality, exacerbate disparities, and be a striking public health failure. We use data from the Behavioral Risk Factor Surveillance System optional Adult HPV Vaccination module between 2013 and 2016 to assess the association between HPV vaccine status and cervical cancer screening behavior. Only 27% of eligible women had received any HPV vaccination. Uninsured women were less likely to be vaccinated (aOR: 0.48, 95% CI:0.30-0.76) and less likely to be screened (aOR: 0.41, 95% CI:0.28-0.60) than insured women. Vaccinated women were more than twice as likely to be up to date on screening than unvaccinated women (aOR: 2.14, 95% CI:1.46-3.12). Younger women were 49% less likely to be up to date on screening (aOR: 0.51, 95% CI:0.37-0.71), but over 4 times more likely to be vaccinated (aOR: 4.44, 95% CI:3.20-6.17) than older women. Unvaccinated, unscreened women are at continued risk for cervical cancer. Uninsured women were most likely to be in this group. Concerted efforts should be focused on increasing vaccination and screening in this population. Cancer prevention innovations, like the HPV vaccine, must reach at-risk populations to avoid further protecting the protected and failing to reduce existing health disparities., (Copyright © 2019. Published by Elsevier Inc.)

Purpose: Cancer treatment can precipitate functional limitations that restrict survivors' ability to work. Yet, it is unclear whether healthcare providers discuss the potential for employment limitations with their patients. We assessed the frequency of patient-provider communication about employment, from the perspectives of survivors, and examined whether receiving a treatment summary was associated with employment communication., Methods: Cancer survivors who were working at diagnosis were identified from the Health Information National Trends Survey-4, conducted in 2014 (n = 290). Separate multivariable regression analyses examined the associations between survivor characteristics and employment communication and receipt of a treatment summary and employment communication., Results: Among cancer survivors who were working at diagnosis, 62.69% (95% CI 54.42-70.95) reported discussing employment with any healthcare provider at any time since diagnosis. Younger cancer survivors and those more recently treated were more likely to ever have employment discussions. Survivors who received a treatment summary were also more likely to ever discuss employment with any healthcare provider than survivors who did not receive a treatment summary (OR = 3.47, 95% CI 1.02-11.84)., Conclusions: Approximately two thirds of cancer survivors who were working at diagnosis ever discussed employment with a healthcare provider. Thus, for a sizable portion of cancer survivors, the potential impact of cancer on employment is never discussed with any healthcare provider., Implications for Cancer Survivors: Efforts are needed to proactively screen patients for cancer-related work limitations, empower patients to discuss employment concerns with their healthcare providers, and develop interventions that support survivors' goals for working throughout treatment and recovery.

Purposes: Despite recommendations against prostate cancer screening with prostate-specific antigen (PSA) tests, about one-fourth of men age ≥40 years received PSA tests in 2015. This study aimed to answer 3 questions for men who had a PSA test in the past year: (1) What percentage of these men received the test first suggested by physicians? (2) What factors were associated with physician-initiated PSA testing (PIPT) versus patient/someone else-initiated testing? (3) What percentage of patients ever had shared decision-making when tests were initiated by physicians?, Methods: We analyzed the 2000 and 2015 National Health Interview Survey data. We calculated age-standardized prevalence of PIPT for both years. For 2015, we used logistic regression to calculate adjusted prevalence ratios for PIPT. We also calculated the prevalence of ever discussing both advantages and disadvantages., Results: The age-standardized prevalence of PIPT was significantly higher in 2015 (84.9%) than in 2000 (72.3%). In 2015, nearly 90% of PSA screenings for men aged ≥70 years were suggested by physicians. PIPT was positively associated with 2 or more comorbid conditions and number of patient visits to the doctor. Less than one-third of men reported they had ever participated in a discussion of advantages and disadvantages of PSA testing., Conclusions: The majority of men who had PSA testing in the past year reported that their physicians were the first to suggest testing, including men aged ≥70 years. Our study also points to the challenges and needs in conducting shared decision-making before PSA testing in clinical practice., Competing Interests: Conflict of interest: none declared., (© Copyright 2018 by the American Board of Family Medicine.)

Background: Shared decision-making (SDM) is poorly implemented in routine care, despite being promoted by health policies. No reviews have solely focused on an in-depth synthesis of the literature around organizational- and system-level characteristics (i.e., characteristics of healthcare organizations and of healthcare systems) that may affect SDM implementation. A synthesis would allow exploration of interventions to address these characteristics. The study aim was to compile a comprehensive overview of organizational- and system-level characteristics that are likely to influence the implementation of SDM, and to describe strategies to address those characteristics described in the literature., Methods: We conducted a scoping review using the Arksey and O'Malley framework. The search strategy included an electronic search and a secondary search including gray literature. We included publications reporting on projects that promoted implementation of SDM or other decision support interventions in routine healthcare. We screened titles and abstracts, and assessed full texts for eligibility. We used qualitative thematic analysis to identify organizational- and system-level characteristics., Results: After screening 7745 records and assessing 354 full texts for eligibility, 48 publications on 32 distinct implementation projects were included. Most projects (N = 22) were conducted in the USA. Several organizational-level characteristics were described as influencing the implementation of SDM, including organizational leadership, culture, resources, and priorities, as well as teams and workflows. Described system-level characteristics included policies, clinical guidelines, incentives, culture, education, and licensing. We identified potential strategies to influence the described characteristics, e.g., examples how to facilitate distribution of decision aids in a healthcare institution., Conclusions: Although infrequently studied, organizational- and system-level characteristics appear to play a role in the failure to implement SDM in routine care. A wide range of characteristics described as supporting and inhibiting implementation were identified. Future studies should assess the impact of these characteristics on SDM implementation more thoroughly, quantify likely interactions, and assess how characteristics might operate across types of systems and areas of healthcare. Organizations that wish to support the adoption of SDM should carefully consider the role of organizational- and system-level characteristics. Implementation and organizational theory could provide useful guidance for how to address facilitators and barriers to change.

Purpose: To describe the implementation of nursing-based venous access team (VAT) and standardized interventional radiology (IR) protocols in accordance with Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines to provide central venous access while preserving peripheral veins in patients with chronic kidney disease (CKD)., Materials and Methods: Review of peripherally inserted central catheter (PICC) and small-bore central catheter (SBCC) referral and placement data from VAT and IR databases was conducted over a 12-year period. SBCC referral was automatic for patients with creatinine levels ≥ 3 mg/dL or a renal transplant regardless of creatinine level unless dialysis was not planned. All SBCC insertions, regardless of referral source, were identified and reviewed, and SBCC placements prompted by K/DOQI PICC contraindication were identified. Catheter types, indications, access sites, technical success, and complications were ascertained., Results: A total of 35,781 requests for PICC placement were made to the VAT; 1,889 (5%) were referred to IR for SBCC placement per institutional policy, and 2,200 SBCCs were attempted or newly placed during this period, 1,879 (85%) based on K/DOQI contraindications. Primary indication for SBCC placement was antibiotic therapy (59%). Access sites included right internal jugular vein (IJV) (70%), left IJV (24%), right external jugular vein (EJV) (3%), left EJV (2%), right common femoral vein (CFV) (0.3%), and left CFV (0.2%). Technical success rate of SBCC insertion was 99%. Six minor (0.3%) and three major (0.1%) complications occurred., Conclusions: Automatic referral for SBCC placement in patients with CKD via VAT and IR protocols may eliminate PICC placement and thereby protect peripheral veins needed for hemodialysis. SBCC placement has high technical success and low complication rates., (Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.)

Background: The ethical argument that shared decision-making is "the right" thing to do, however laudable, is unlikely to change how healthcare is organized, just as evidence alone will be an insufficient factor: practice change is governed by factors such as cost, profit margin, quality, and efficiency. It is helpful, therefore, when evaluating new approaches such as shared decision-making to conceptualize potential consequences in a way that is broad, long-term, and as relevant as possible to multiple stakeholders. Yet, so far, evaluation metrics for shared decision-making have been mostly focused on short-term outcomes, such as cognitive or affective consequences in patients. The goal of this article is to hypothesize a wider set of consequences, that apply over an extended time horizon, and include outcomes at interactional, team, organizational and system levels, and to call for future research to study these possible consequences., Main Argument: To date, many more studies have evaluated patient decision aids rather than other approaches to shared decision-making, and the outcomes measured have typically been focused on short-term cognitive and affective outcomes, for example knowledge and decisional conflict. From a clinicians perspective, the shared decision-making process could be viewed as either intrinsically rewarding and protective, or burdensome and impractical, yet studies have not focused on the impact on professionals, either positive or negative. At interactional levels, group, team, and microsystem, the potential long-term consequences could include the development of a culture where deliberation and collaboration are regarded as guiding principles, where patients are coached to assess the value of interventions, to trade-off benefits versus harms, and assess their burdens-in short, to new social norms in the clinical workplace. At organizational levels, consistent shared decision-making might boost patient experience evaluations and lead to fewer complaints and legal challenges. In the long-term, shared decision-making might lead to changes in resource utilization, perhaps to reductions in cost, and to modification of workforce composition. Despite the gradual shift to value-based payment, some organizations, motivated by continued income derived from achieving high volumes of procedures and contacts, will see this as a negative consequence., Conclusion: We suggest that a broader conceptualization and measurement of shared decision-making would provide a more substantive evidence base to guide implementation. We outline a framework which illustrates a hypothesized set of proximal, distal, and distant consequences that might occur if collaboration and deliberation could be achieved routinely, proposing that well-informed preference-based patient decisions might lead to safer, more cost-effective healthcare, which in turn might result in reduced utilization rates and improved health outcomes.

Background: Interventions using theory should change behavior and identify both mechanisms of effect and necessary conditions. To date, inconsistent description of "use of theory" has limited understanding of how theory improves intervention impact., Purpose: The purpose of this study was to describe the use of theory in health behavior intervention development by coding grant proposals., Methods: We developed an abstraction tool to characterize investigators, interventions, and theory use and identified seven core elements describing both how and how much theory was used. We used the tool to review and code NCI's funded cancer screening intervention R01 proposals, 1998-2009., Results: Of 116 proposals, 38 met criteria; all but one described a conceptual model unique to the proposed research. Few proposals included plans to identify mechanisms of effect or conditions necessary for intervention effectiveness., Conclusions: Cancer screening intervention grant proposals rarely use theory in ways that advance behavioral or theoretical sciences. Proposed core elements may classify and synthesize the use of theory in behavioral intervention research.

Background: Transcatheter aortic valve replacement (TAVR) clinical trials in North America excluded patients on dialysis and, consequently, the outcomes of TAVR in dialysis-dependent patients remain unknown., Methods: All Medicare fee-for-service patients undergoing TAVR (n = 5,005) or surgical aortic valve replacement (SAVR) (n = 32,634) between January 1, 2011, and November 30, 2012, were identified using procedural codes collected by the Centers for Medicare & Medicaid Services. Dialysis status and comorbidities were identified using diagnosis codes present on arrival for TAVR hospitalization. Patients supported on dialysis who underwent TAVR (n = 224) were compared with non-dialysis patients who underwent TAVR as well as a propensity-matched group of contemporaneous dialysis patients who underwent SAVR (n = 194 pairs)., Results: The TAVR patients on dialysis were younger than non-dialysis TAVR patients (79.2 years vs 84.1 years; p < 0.01) but had higher prevalence of comorbidities. Dialysis TAVR patients had increased mortality at 30 days (13% vs 6%, p < 0.01) and significantly worse survival by Kaplan-Meier analysis. Multivariable regression found dialysis to be independently associated with worse survival (hazard ratio, 1.73; 95% confidence interval, 1.33% to 2.25%, p < 0.01) in TAVR patients. Propensity-matched dialysis SAVR and dialysis TAVR patients had no significant differences in demographic or risk factors. Matched dialysis TAVR patients had shorter length of stay (6 interquartile range, 4 to 10] vs 10 [IQR 7 to 18] days; p < 0.01) and comparable survival., Conclusions: TAVR in dialysis patients is associated with decreased survival compared with non-dialysis patients; however, it is comparable with SAVR in high risk dialysis patients based on a propensity-matched comparison., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)