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Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Mammography remains the only validated screening tool for breast cancer, however, there are limitations to mammography. One of the limitations of mammography is the variable sensitivity based on breast density. Supplemental screening may be considered based on the patient’s risk level and breast density. For average-risk women with nondense breasts, the sensitivity of digital breast tomosynthesis (DBT) screening is high; additional supplemental screening is not warranted in this population. For average-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhanced mammography, screening ultrasound (US), breast MRI, or abbreviated breast MRI. In intermediate-risk women, there is emerging evidence suggesting that women in this population may benefit from breast MRI or abbreviated breast MRI. In intermediate-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhancedmammography or screening US. There is strong evidence supporting screening high-risk women with breast MRI regardless of breast density. Contrast-enhanced mammography, whole breast screening US, or abbreviated breast MRI may be also considered. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This study surveyed the use of systematic strategies to address social determinants of health in the primary care clinical training environment.We designed a 51-item questionnaire targeting medical educators from internal medicine, pediatrics, and family practice to assess strategies to identify and mitigate social needs, the role of trainees in this process, and barriers/facilitators to systematic approaches.The survey was completed by 104 medical educators from 77 institutions. Of the 104 respondents, 28% were not familiar with any standardized tools used for screening for social needs, 27% use geospatial (GIS) or geographic information system (GIG) data, and 35% reported that trainees were not involved in any part of assisting.Nearly one third of medical educators lack familiarity with standardized screening tools for social needs. More than one third reported that trainees are not involved with mitigating social needs. Geospatial and GIS data are not utilized frequently.

Most residency programs do not provide trainees with health equity data for their clinic patients.Equity report cards were developed for internal and family medicine residents in a large health system. After considering which equity indictors were available, how to attribute patients to residents, and what level of granularity was feasible, equity reports were created for five ambulatory quality measures. Chi-square tests were used to test the significance of differences in quality measure satisfaction between groups.Attributing patients to the physician who had seen them for the greatest proportion of encounters performed best. Creating equity reports for individual resident panels was not possible due to insufficient numbers. Most measures had sufficient patients when combining all residents' patients. Inequities were identified for four of five examined measures.Creating aggregate equity reports for all primary care residents across multiple equity indicators was feasible, documenting disparities in health care quality.

Background Up to 60% of preventable mortality is attributable to social determinants of health (SDOH), yet training on SDOH competencies is not widely implemented in residency. The objective of this study was to assess internal and family medicine residents’ competence at identifying and addressing SDOH. Methods Residents’ perceived competence at identifying, discussing, and addressing SDOH in outpatient settings was assessed using a single questionnaire administered in March 2017. In this cross-sectional analysis, bivariate associations of resident characteristics with the following outcomes were examined: identifying, discussing, and addressing patients’ challenges related to SDOH through referrals. Results The survey was completed by 129 (84%) residents. Twenty residents (16%) reported an annual income of less than $50,000 during childhood. Overall, 108 residents (84%) reported previous SDOH training. Two-thirds had outpatient practices in Veterans Affairs or safety-net clinics. Thirty-nine (30%) intended to pursue a career in primary care. The following numbers of residents reported high levels of competence for performing these outcomes: identifying patients’ challenges related to SDOH: 37 (29%); discussing them with patients: 18 (14%); and addressing these challenges through referrals to internal and external resources: 13 (10%) and 11 (9%), respectively. Factors associated with higher competence included older age, lower childhood household income, prior education about SDOH, primary practice site and intention to practice primary care. Conclusions Most residents had previous SDOH training, yet only a small proportion of residents reported being highly competent at identifying or addressing SDOH. Providing opportunities for practical training may be a key component in preparing medical residents to identify and address SDOH effectively in outpatient practice.

Purpose Medical training has traditionally focused on the proximate determinants of disease, with little focus on how social conditions influence health. The authors conducted a scoping review of existing curricula to understand the current programs designed to teach primary care residents about the social determinants of health (SDH). Method In January and March 2017, the authors searched seven databases. Eligible articles focused on primary care residents, described a curriculum related to SDH, were published between January 2007 and January 2017, and were based in the United States. Results Of the initial 5,523 articles identified, 43 met study eligibility criteria. Most programs (29; 67%) were in internal medicine. Sixteen studies (37%) described the curriculum development process. Overall, 20 programs (47%) were short or one-time sessions, and 15 (35%) were longitudinal programs lasting at least 6 months. Thirty-two programs (74%) reported teaching SDH content using didactics, 22 (51%) incorporated experiential learning, and many programs (n = 38; 88%) employed both. Most studies reported satisfaction and/or self-perceived changes in knowledge or attitudes. Conclusions The authors identified wide variation in curriculum development, implementation, and evaluation. They highlight curricula that considered community and resident needs, used conceptual frameworks or engaged multiple stakeholders to select content, used multiple delivery methods, and focused evaluation on changes in skills or behaviors. This review highlights the need not only for systematic, standardized approaches to developing and delivering SDH curricula but also for developing rigorous evaluation of the curricula, particularly effects on resident behavior.

OBJECTIVE: Cognitive impairment (CI) is highly prevalent in breast cancer survivors (BCS), and can be a barrier to health-promoting behaviours. However, the ways in which CI may affect self-regulation or motivation to perform such behaviours have not been explored. We assessed if BCS with CI report greater extrinsic self-regulation compared to those without CI and if this relationship persists after controlling for depression. METHODS: We recruited BCS with diabetes and assessed cognition and motivation to perform healthy diabetes management behaviours (e.g., diet and exercise). Participants completed a cognitive battery evaluating attention, working memory, executive functioning (EF), processing speed (PS), language and memory. The Treatment Self-Regulation Questionnaire (TSRQ) assessed intrinsic versus extrinsic motivation. Depression was determined by a score ≥16 on the Center for Epidemiological Studies Depression Scale. Wilcoxon rank-sum test compared associations between CI and TSRQ scores. RESULTS: Participants were 118 older adults (mean age 65 years). Participants with CI in the following domains had higher extrinsic self-regulation scores compared to those without CI: attention (p < 0.01), PS (p = 0.01), EF (p < 0.01), language (p = 0.02; p = 0.04) and memory (p = 0.04; p = 0.03). After adjusting for depression, the relationship between CI and higher extrinsic self‐regulation scores remained significant. CONCLUSIONS: BCS with CI appear to rely more on external sources of motivation to perform health behaviours, regardless of depression. Future studies and interventions to improve health behaviours should consider screening for CI and involving caregivers for those with CI to improve outcomes.

Introduction: Cancer and diabetes mellitus (DM) are leading causes of death in the United States. Each year, over 245,000 women are diagnosed with breast cancer, and approximately 18% of patients diagnosed have preexisting DM. The presence of a comorbidity, such as DM increases women’s mortality risk by 40%. While studies have shown decreased adherence to hypoglycemic medications after cancer diagnosis, the effect of cancer related beliefs on DM medication adherence has not been fully explored. In this study, we evaluated the association between cancer related beliefs and DM medication adherence in survivors of breast cancer. Hypothesis: Patients with greater positive beliefs about cancer (including personal control, treatment control and understanding) would exhibit greater adherence to DM medication. Methodology: We enrolled women >55 years with Stage 0-IIIA breast cancer diagnosed in the past 10 years, who had completed chemotherapy and/or were prescribed hormonal therapy and had pre-existing type 2 DM treated with at least 1 oral DM medication. Cancer related beliefs were assessed using the Illness Perception Questionnaire (IPQ). Medication adherence was evaluated using the Medication Adherence Rating Scale (MARS). Adherence was dichotomized at a mean MARS score of ≥4.5. Wilcoxon rank-sum tests were used to examine the relationship between patients’ cancer related beliefs and DM medication adherence. Results: Thus far, 108 women have completed baseline surveys. Of these participants, 37% were black, 31% white, 14% Hispanic, 6.5% Asian, and 8.3% other. The mean age was 65 years. Cancer survivors who were adherent to DM medication had a greater sense of personal control over their cancer (median score 22.0 vs. 19.0, p Conclusion: Among breast cancer survivors with comorbid DM, having a greater sense of control over and understanding of cancer was associated with DM medication adherence. Working with breast cancer survivors to increase their perceived control over and understanding of their cancer may help improve adherence to DM medication.

Primary care providers (PCPs) typically manage breast cancer screening, breast cancer prevention, the evaluation of breast complaints and abnormalities, and the referral of appropriate patients to breast oncologists. PCPs also provide survivorship care for their patients. Most cancer patients also see their PCPs while undergoing diagnostic testing and treatment for cancer and often rely on their advice and support. PCPs who are able to engage in breast cancer-related discussions regarding advanced diagnostic testing, treatment regimens, treatment-related adverse effects, and end-of-life care can help their patients with important decision-making. This chapter aims to prepare PCPs to engage their patients and oncology colleagues in discussions about the spectrum of care for breast cancer: diagnostic testing, staging, treatment, adverse effects, prognosis and survivorship, and end-of-life care.

The population of adult cancer survivors is increasing over time and they are at risk of developing recurrent and secondary cancers, even years after completion of treatment. Post-treatment care of survivors is increasingly the responsibility of primary care providers. Surveillance for recurrence and screening for secondary malignancies related to treatment depend largely on the primary malignancy, treatment regimen, and presence of a hereditary cancer syndrome, such as a BRCA mutation. This article presents surveillance strategies for the most common malignancies.

Assess the impact of a 5min video on screening mammogram referrals and completion.We recruited women ages 40 years or older without a current mammogram at a federally qualified community health center (FQHC). Women were assigned to the intervention or usual care. Immediately prior to their appointments, women in the intervention group viewed a brief video that included a demonstration of how patients may request a mammogram referral. All women completed a pre- and post-visit telephone survey about knowledge of breast cancer screening and patient activation.Mean age was 52 years, 50% had less than a high school education and 75% preferred Spanish. The proportion of mammogram referrals in the intervention group was significantly higher than the control group, 37% vs. 15%, respectively (p0.01). Similarly, the intervention group had a higher proportion of completed mammograms, 33% vs. 13% (p0.02). There were no differences in breast cancer knowledge or patient activation between the intervention and control groups.A brief, pre-visit video significantly increased screening mammography referrals and completion in this mostly Spanish-speaking FQHC population.Our intervention demonstrates the effectiveness of a brief-video intervention in a population with low education and low English language proficiency.

e24053 Background: Cancer and diabetes mellitus (DM) are leading causes of death in the US and survivors with comorbid DM have a significantly higher mortality. Furthermore, posttraumatic stress disorder (PTSD) can be triggered by life-threatening illnesses such as cancer; however, little is known about the impact of cancer-related PTSD (Ca-PTSD) on illness beliefs and glycemic control. We undertook this study to assess factors associated with DM management in breast cancer survivors with DM. Methods: We recruited women with Stage 0-IIIA breast cancer diagnosed in the past 10 years, who had completed chemotherapy and/or hormonal therapy and had pre-existing DM on ≥1 oral DM medication. The Impact of Event Scale-Revised (IES-R) was used to assess distress caused by cancer. A total IES-R score of ≥33 identified those with probable Ca-PTSD. Cancer and DM related beliefs were assessed using the Illness Perception Questionnaire. Objective adherence to DM medication was assessed using electronic caps that record bottle openings. Wilcoxon rank-sum tests were used to examine the relationship between Ca-PTSD and illness beliefs. Pearson correlation tests were used to assess the relationship between cancer related stress, DM medication adherence, and glycemic control. Results: Of 111 women recruited to date, mean age was 65.4 years and 37% were black, 31% white, 14% Hispanic, 6% Asian, and 8% other. Of these, 15% had probable Ca-PTSD. Survivors with Ca-PTSD were more likely to believe the consequences of cancer and DM were more severe (median score 23.5 vs. 19.0 [p < 0.001] and 24.0 vs. 16.0 [p < 0.001], respectively), that cancer and DM were more cyclical or recurrent (15.0 vs. 9.0 [p = 0.002] and 13.0 vs. 8.5 [p = 0.002], respectively), and there was greater emotional impact due to cancer and DM (24.0 vs. 16.5 [p < 0.001] and 23.0 vs. 14.0 [p < 0.001], respectively). Additionally, those with Ca-PTSD were less likely to understand their cancer (14.0 vs. 20.0, p = 0.004). Furthermore, as cancer-related stress scores increased, glycemic control worsened (r = 0.23, p = 0.03) and DM medication adherence decreased (r = -0.23, p = 0.04). Conclusions: Breast cancer survivors with comorbid DM who have Ca-PTSD are more likely to have negative beliefs about both cancer and DM. Cancer-related stress is also associated with poorer glycemic control and DM medication adherence. Providers should be aware of the impact of cancer related stress on beliefs about comorbid illnesses and increase interventions that support cancer survivors to better manage their comorbidities.

Care delivery concepts such as healthcare quality, safety, equity, and teamwork are crucial in the care of patients. While the importance of these concepts becomes self-evident to many clerkship students, engaging pre-clerkship students has proven challenging. We created a three-session, case-based learning (CBL) curriculum that deliberately integrated care delivery concepts and basic science content. In this format, students demonstrated increased understanding of concept relevance and faculty assessments showed improved knowledge acquisition. CBL is both feasible and acceptable to pre-clerkship students as a method to teach care delivery topics.

Objective To document disparities in registration and use of an online patient portal among older adults. Materials and methods Data from 534 older adults were linked with information from the Northwestern Medicine Electronic Data Warehouse on patient portal registration and use of functions (secure messaging, prescription reauthorizations, checking test results, and monitoring vital statistics). Age, gender, race, education, self-reported chronic conditions, and the Newest Vital Sign health literacy measure were available from cohort data. Results Most patients (93.4%) had a patient portal access code generated for them, and among these 57.5% registered their accounts. In multivariable analyses, White patients (P < .001) and college graduates were more likely to have registered their patient portal (P = .015). Patients with marginal (P = .034) or adequate (P < .001) health literacy were also more likely to have registered their patient portal. Among those registering their accounts, most had messaged their physician (90%), checked a test result (96%), and ordered a reauthorization (55%), but few monitored their vital statistics (11%). Adequate health literacy patients were more likely to have used the messaging function (P = .003) and White patients were more likely to have accessed test results (P = .004). Higher education was consistently associated with prescription reauthorization requests (all P < .05). Discussion Among older American adults, there are stark health literacy, educational, and racial disparities in the registration, and subsequent use of an online patient portal. These population sub-group differences may exacerbate existing health disparities. Conclusions If patient portals are implemented, intervention strategies are needed to monitor and reduce disparities in their use.

To examine the impact of depressive symptoms on asthma outcomes and medication adherence in inner-city elderly patients with asthma.Cohort study of elderly asthmatics receiving primary care at three clinics in New York City and Chicago from 1 January 2010 to 1 January 2012. Depressive symptoms were ascertained with the Patient Health Questionnaire (PHQ-9). Outcomes included asthma control (Asthma Control Questionnaire, ACQ), asthma-related quality of life (Asthma Quality of Life Questionnaire, AQLQ), and acute resource utilization (inpatient and outpatient visits). Asthma medication adherence was evaluated using the Medication Adherence Reporting Scale (MARS).Three hundred and seventeen participants ≥60 years were included in the study (83% women, 30% Hispanic, and 31% Black). In unadjusted analyses, participants with depressive symptoms were more likely to report poor asthma control (p.001), worse AQLQ scores (p.001), and higher rates of inpatient asthma-related visits (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.04-3.99). Those with depressive symptoms also reported lower medication adherence (OR: 0.23, 95%CI: 0.10-0.54). Similar results were obtained in analyses adjusting for age, sex, race/ethnicity, income, asthma medication prescription, years with asthma, intubation history, comorbidities, and health literacy.In this cohort of elderly inner-city participants, depressive symptoms were associated with poorer asthma control and quality of life, as well as with lower rates of adherence to controller medications. Future work exploring possible mediators, including adherence, might elucidate the relationship between depression and poorer asthma outcomes in this population.

Empirical research and health policies on asthma have focused on children and young adults, even though asthma morbidity and mortality are higher among older asthmatics.To explore the relationship of asthma-related beliefs and self-reported controller medication adherence in older asthmatics.An observational study of asthma beliefs and self-management among older adults.Asthmatics ages ≥ 60 years (N = 324, mean age 67.4 ± 6.8, 28 % white, 32 % black, 30 % Hispanic) were recruited from primary care practices in New York City and Chicago.Self-reported controller medication adherence was assessed using the Medication Adherence Report Scale. Based on the Common Sense Model of Self-Regulation, patients were asked if they believe they only have asthma with symptoms, their physician can cure their asthma, and if their asthma will persist. Beliefs on the benefit, necessity and concerns of treatment use were also assessed. Multivariate logistic regression was used to examine the association of beliefs with self-reported medication adherence.The majority (57.0 %) of patients reported poor adherence. Poor self-reported adherence was more common among those with erroneous beliefs about asthma illness and treatments, including the "no symptoms, no asthma" belief (58.7 % vs. 31.7 %, respectively, p 0.001), "will not always have asthma" belief (34.8 % vs. 12.5 %, p 0.001), and the "MD can cure asthma" belief (21.7 % vs. 9.6 %, p = 0.01). Adjusting for illness beliefs, treatment beliefs and demographics, patients with a "no symptoms, no asthma" belief had lower odds of having good self-reported adherence (odds ratio [OR] 0.45, 95 % confidence interval [CI] 0.23-0.86), as did those with negative beliefs about the benefits (OR 0.73, 95 % CI 0.57-0.94) and necessity (OR 0.89, 95 % CI 0.83-0.96) of treatment.Illness and treatment beliefs have a strong influence on self-reported medication adherence in older asthmatics. Interventions to improve medication adherence in older asthmatics by modifying illness and treatment beliefs warrant study.

Background With emphasis on the meaningful use of electronic health records, patient portals are likely to become increasingly important. Little is known about patient enrollment in, and use of, patient portals after explicit invitation from providers.

In this issue, Kerlikowske and colleagues study the risk for cancer in women with dense breasts to inform strategies for supplemental screening. The editorialists discuss the study and emphasize th...

Background Previous studies of patient portals have found low rates of enrollment and significant disparities in enrollment by race and ethnicity. As the reasons for these findings are unclear, we sought to identify patient reported barriers to enrollment in a patient portal. Methods We conducted a telephone survey of patients in one urban general internal medicine clinic. Patients were eligible if they did not enroll within 30 days of receiving an electronic order inviting participation. Our primary outcomes were: (a) reasons for not enrolling in the patient portal; (b) reasons for not attempting enrollment; and (c) perceived benefits of the portal. Results Participants’ (N¼159) mean age was 51 years, 48% were black, 72% female, and 70% had a college degree or greater. 63% of respondents not enrolling reported never attempting enrollment despite remembering receiving an order. Most of these 63% did not attempt enrollment because of lack of information or motivation. Smaller proportions reported not attempting enrollment because of negative attitudes toward the portal (30%) or computer related obstacles (8%). Overall, respondents favorably viewed most patient portal features, however black respondents were less likely than white respondents to consider features assisting self-management such as getting test results (69% vs 86%; p

Our study goal was to assess the effects of a brief patient video on breast cancer knowledge and attitudes among Latina women at a community health center.We conducted pre- and post-testing of knowledge and attitudes in women aged 40 years or older with active screening referrals (n=91). We compared pre- and post-test knowledge and attitudes overall and by baseline values.Mean knowledge increased from 5.8/10 to 6.9/10 (p0.05), with the greatest increases in those with low baseline knowledge (p.001). There were no changes in mean attitudes, which were high at baseline (3.8/5); however, among the 16 women with negative/neutral attitudes, 50% developed positive attitudes after watching the video (p0.05). Baseline intention to complete screening was high at 98%.Although the overall effects were modest, the greatest improvements were in those with low baseline knowledge scores and negative/neutral baseline attitudes. Future testing should examine the effects in a community-based sample.A brief patient video has promise for influencing patient knowledge and perhaps attitudes while being amenable to integration into clinical flow.

BACKGROUND: As behavioral health risks account for the major causes of preventable morbidity and mortality in the United States, national guidelines recommend that physicians routinely screen patients for risk factors, and counsel as appropriate. OBJECTIVES: To assess the scope of health risk screening and characterize the communication content of counseling for health behavior change in 2 general internal medicine practices. DESIGN AND PARTICIPANTS: We studied videotapes of 125 new patient visits to General Internists affiliated with academic medical centers in Chicago, IL (70%) and Burlington, VT (30%). All videotapes were content analyzed to examine (1) the incidence and outcome of screening for diet, exercise, tobacco, alcohol, drugs, sex, seatbelt use, helmet use, firearms, smoke detectors, and sun exposure; (2) the content of counseling for at-risk behaviors, with a focus on 11 counseling tasks associated with health behavior change. RESULTS: Patient age in these 125 initial visits ranged from 22 to 85 years. Within the 91 visits that included at least 1 screening attempt, there were a total of 361 distinct screening discussions (mean=3.9, SD=2.2, range=1 to 9). Seventy-four (20.5%) of the 361 screening discussions revealed an at-risk behavior. On average, 2.4 of the 11 counseling tasks were accomplished for each of the 74 behavioral health risks (SD=2.2, range 0 to 9); only education about the problem (56.8%) and general advice about the solution (62.2%) were evident in more than half of the counseling attempts. CONCLUSIONS: This observational study reveals that communication tasks associated with successful counseling were relatively infrequent occurrences during initial visits in 2 primary care practices.

Breast-conserving surgery (BCS) has been the recommended treatment for early-stage breast cancer since 1990 yet many women still do not receive this procedure.To examine the relationship between birthplace and use of BCS in Asian-American and Pacific-Islander (AAPI) women, and to determine whether disparities between white and AAPI women persist over time.Retrospective cohort study.Women with newly diagnosed stage I or II breast cancer from 1992 to 2000 in the Surveillance, Epidemiology, and End Results program.Receipt of breast -conserving surgery for initial treatment of stage I or II breast cancer.Overall, AAPI women had lower rates of BCS than white women (47% vs 59%; P.01). Foreign-born AAPI women had lower rates of BCS than U.S.-born AAPI and white women (43% vs 56% vs 59%; P.01). After adjustment for age, marital status, tumor registry, year of diagnosis, stage at diagnosis, tumor size, histology, grade, and hormone receptor status, foreign-born AAPI women (adjusted OR [aOR], 0.49; 95% CI, 0.32 to 0.76) and U.S.-born AAPI women (aOR, 0.77; 95% CI, 0.62 to 0.95) had lower odds of receiving BCS than white women. Use of BCS increased over time for each racial/ethnic group; however, foreign-born AAPI women had persistently lower rates of BCS than non-Hispanic white women.AAPI women, especially those who are foreign born, are less likely to receive BCS than non-Hispanic white women. Of particular concern, differences in BCS use among foreign-born and U.S.-born AAPI women and non-Hispanic white women have persisted over time. These differences may reflect inequities in the treatment of early-stage breast cancer for AAPI women, particularly those born abroad.

ContextThe prevalence of obesity has increased substantially since the 1980s. While immigrants are the fastest growing segment of the US population, little is known about obesity or clinician counseling about diet and exercise in this group.ObjectivesTo estimate the prevalence of obesity among immigrant subgroups and quantify the magnitude of the association with duration of US residence, and to describe reported diet and exercise counseling by birthplace, race, and ethnicity.Design, Setting, and ParticipantsCross-sectional study using data from the 2000 National Health Interview Survey.Main Outcome MeasuresBody mass index (BMI, measured as weight in kilograms divided by the square of height in meters) based on self-reported height and weight measurements, and self-reported rates of diet and exercise counseling.ResultsOf 32 374 respondents, 14% were immigrants. The prevalence of obesity was 16% among immigrants and 22% among US-born individuals. The age- and sex-adjusted prevalence of obesity was 8% among immigrants living in the United States for less than 1 year, but 19% among those living in the United States for at least 15 years. After adjusting for age, sociodemographic, and lifestyle factors, living in the United States for 10 to 15 and at least 15 years was associated with BMI increases of 0.88 and 1.39, respectively. The association for 15 years or more was significant for all immigrant subgroups except foreign-born blacks. Additionally, immigrants were less likely than US-born individuals to report discussing diet and exercise with clinicians (18% vs 24%, P

Racial/ethnic groups comprised largely of foreign-born individuals have lower rates of cancer screening than white Americans. Little is known about whether these disparities are related primarily to their race/ethnicity or birthplace.To determine whether foreign birthplace explains some racial/ethnic disparities in cancer screening.Cross-sectional study using 1998 data from the National Health Interview Survey.Completion of cervical, breast, or colorectal cancer screening.Of respondents, 15% were foreign born. In analyses adjusted for sociodemographic characteristics and illness burden, black respondents were as or more likely to report cancer screening than white respondents; however, Hispanic and Asian-American and Pacific Islander (AAPI) respondents were significantly less likely to report screening for most cancers. When race/ethnicity and birthplace were considered together, U.S.-born Hispanic and AAPI respondents were as likely to report cancer screening as U.S.-born whites; however, foreign-born white (adjusted odds ratio [AOR], 0.58; 95% confidence interval [CI], 0.41 to 0.82), Hispanic (AOR, 0.65; 95% CI, 0.53 to 0.79), and AAPI respondents (AOR, 0.28; 95% CI, 0.19 to 0.39) were less likely than U.S.-born whites to report Pap smears. Foreign-born Hispanic and AAPI respondents were also less likely to report fecal occult blood testing (FOBT); AORs, 0.72; 95% CI, 0.53 to 0.98; and 0.61; 95% CI, 0.39 to 0.96, respectively); and sigmoidoscopy (AORs, 0.70; 95% CI, 0.51 to 0.97; and 0.63; 95% CI, 0.40 to 0.99, respectively). Furthermore, foreign-born AAPI respondents were less likely to report mammography (AOR, 0.49; 95% CI, 0.28 to 0.86). Adjusting for access to care partially attenuated disparities among foreign-born respondents.Foreign birthplace may explain some disparities previously attributed to race or ethnicity, and is an important barrier to cancer screening, even after adjustment for other factors. Increasing access to health care may improve disparities among foreign-born persons to some degree, but further study is needed to understand other barriers to screening among the foreign-born.

Introduction Patient portals are the “front door” to telehealth - online scheduling, video visit links, and digital after visit summaries are often conveyed via the patient portal. Patient portal tools often require similar patient skills and attitudes as telehealth adoption. Analyzing patients’ perceptions and beliefs around this digital patient engagement tool may lead to insights regarding telehealth, particularly in historically underrepresented patient populations. Methods Participants from a Federally Qualified Health Center (FQHC) in Chicago, IL were surveyed on general technology use, healthcare-specific technology use, and barriers and facilitators to patient portal use. Results The 149 respondents (81% response rate) represented a unique population base with 96% African American, 74% with educational attainment of some college or less, and 48% with at least one chronic medical condition. Technology access and use were high with 78% computer ownership, 98% mobile phone ownership (with 75% smartphone ownership). In terms of patient portal perception, 75% rated Perceived Usefulness (U) as high. Perceived Ease of Use (E) domains similarly had 70% or higher agreement from patients, and potential barriers and facilitators in the Attitudes Toward Use (A) section included a preference to calling their doctor, and minority of patients viewing the portal as unsafe way to communication, too complicated to use, or taking too much time. Additional stratification analysis by demographic variables (age, gender, educational attainment, and number of chronic conditions) revealed differences in portal perception across the Usefulness, Ease of Use, and Attitudes domains. Discussion Insights from barriers, attitudes, and capacity to use patient portal tools deliver important insight into overall adoption of other digital health modalities, including telehealth. In an urban historically underserved patient population, technology access and use is quite high, and mobile phones access was nearly ubiquitous with a large majority using the internet function on their mobile device. Different age groups, genders, levels of educational attainment, or degree of multi-morbidity have different values and needs. Therefore, each subpopulation needs targeted messaging of different portal benefits. Conclusion Our research provides initial insights into patient-level factors influencing patient portal attitudes, with implications toward telehealth adoption. Demographic differences have a significant impact on attitudes toward technology adoption. Equitable uptake of portal and telehealth services will require tailored messaging, training, and multiple modes of communication, including web-based and mobile.