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Purpose: Understanding emergency department (ED) use in adolescent and young adult (AYA) survivors could identify gaps in AYA survivorship. Methods: We conducted a cohort study of 7925 AYA survivors (aged 15–39 years at diagnosis) who were 2–5 years from diagnosis in 2006–2020 at Kaiser Permanente Southern California. We calculated ED utilization rates overall and by indication of the encounter (headache, cardiac issues, and suicide attempts). We estimated rate changes by survivorship year and patient factors associated with ED visit using a Poisson model. Results: Cohort was 65.4% women, 45.8% Hispanic, with mean age at diagnosis at 31.3 years. Overall, 38% of AYA survivors had ≥1 ED visit (95th percentile: 5 ED visits). Unadjusted ED rates declined from 374.2/1000 person-years (PY) in Y2 to 327.2 in Y5 (p change < 0.001). Unadjusted rates declined for headache, cardiac issues, and suicide attempts. Factors associated with increased ED use included: age 20–24 at diagnosis [relative risk (RR) = 1.30, 95% CI 1.09–1.56 vs. 35–39 years]; female (RR = 1.27, 95% CI 1.11–1.47 vs. male); non-Hispanic Black race/ethnicity (RR 1.64, 95% CI 1.38–1.95 vs. non-Hispanic white); comorbidity (RR = 1.34, 95% CI 1.16–1.55 for 1 and RR 1.80, 95% CI 1.40–2.30 for 2+ vs. none); and public insurance (RR = 1.99, 95% CI 1.70–2.32 vs. private). Compared with thyroid cancer, cancers associated with increased ED use were breast (RR = 1.45, 95% CI 1.24–1.70), cervical (RR = 2.18, 95% CI 1.76–2.71), colorectal (RR = 2.34, 95% CI 1.94–2.81), and sarcoma (RR = 1.39, 95% CI 1.03–1.88). Conclusion: ED utilization declined as time from diagnosis elapsed, but higher utilization was associated with social determinants of health and cancer types. [ABSTRACT FROM AUTHOR]

Background: Studies have examined relationships between teacher characteristics and student achievement in courses such as math and science. This study is among the first to examine effects of teacher characteristics on student knowledge in a health course. Methods: Student (N = 6143) pretest and posttest data were linked to teacher (N = 67) data. Changes in student knowledge scores from pre- to postcourse were explored using mixed-effects linear models. Teacher characteristics included professional development (PD) attendance, having a dedicated classroom, certification type, educational background, years' experience, and athletic coaching status. Results: Teacher characteristics associated with greater student knowledge gains included: being certified to teach health versus not certified (p < 0.001), having a dedicated classroom versus no classroom (p = 0.017), and for middle school teachers, having attended =3 PD sessions versus =2 (p = 0.023). Less knowledge gain was associated with teachers that coached versus noncoaches (p = 0.040) and having a health degree versus no health degree (p = 0.049). "Post hoc" analyses revealed the negative effect of health degree was only significant among coaches (p = 0.026). Conclusions: Findings suggest opportunities for maximizing student knowledge gains through tailored selection of health teachers and provision of appropriate teaching support.

Background: Little is known about racial/ethnic differences in symptom severity among patients receiving home-based palliative care (HomePal). Objectives: To determine whether symptom severity differs between White patients and patients of color receiving HomePal and whether gender moderates the difference. Design: This is a cross-sectional exploratory study. Setting/Subjects: Baseline data were from 2090 patients receiving HomePal in Kaiser Permanente Southern California. Measurements: Multivariable median regression analyses were carried out across race/ethnicity groups and stratified by gender to assess differences in Edmonton Symptom Assessment System (ESAS) scores at HomePal admission. Results: Asian/Pacific Islander men and Black men had lower ESAS scores compared than White men (−5 [−7.8, −2.2], p = 0.0005 and −5.4 [−8.7, −2.1], p = 0.001, respectively); there were marginal ESAS differences across race/ethnic groups for women. Conclusion: Patients of color reported lower symptom severity than White patients. More research is needed to understand how the intersection of culture and gender affects symptom experience and reporting in patients living with serious illness. Trial Registration: ClinicalTrials.gov: NCT#03694431. [ABSTRACT FROM AUTHOR]

Physical activity is an important factor in chronic disease control and prevention. Yet women and rural residents consistently report lower rates of physical activity than their male and urban/suburban counterparts. The objective of this study was to assess the relationship between personal, social, and environmental barriers and meeting moderate physical activity recommendations in a sample of rural women. Data were obtained from a telephone survey of 2,510 residents of rural southeastern Missouri, Tennessee, and Arkansas. After adjusting for age and income, women who identified personal barriers, such as lack of time, no motivation, disinterest in exercise, and having no one to exercise with were less likely to meet physical activity recommendations. There was evidence of a dose-response relationship between the number of barriers identified and meeting moderate physical activity recommendations among women with higher incomes and women with lower incomes; however, this relationship was most striking among women with annual household incomes of $25,000 or more. These findings may be used to tailor physical activity interventions to women in rural communities. KEYWORDS. Physical activity, women, rural populations, barriers to physical activity

Background: The research enterprise has embraced patient centeredness in embedded efficient pragmatic trials, but limited data exist on using patient-reported outcomes (PROs) collected as part of usual clinical care for research. Objectives: We sought to assess the performance of different assessment methods for obtaining PROs in a pragmatic cluster randomized trial (HomePal study) designed to compare two models of home-based palliative care (HBPC). Design: Descriptive analytics, comparative trends, and psychometric performance of PROs collected in the HomePal study; measures included Edmonton Symptom Assessment System (ESAS), PROMIS-10, and others administered at baseline, 1, and 6 months. Setting/Subjects: HomePal was conducted in the Southern California and Northwest Kaiser Permanente regions in the United States; subjects were patients receiving HBPC and their caregivers. Measurements: We specifically compared ESAS obtained by research staff with those obtained by clinical HBPC nurses at the time of HBPC enrollment. We also compared ESAS completed by patients versus if done or assisted by a caregiver (proxy). Results: We enrolled 3533 patients and had 2205 ESAS measurements that met the criteria for analysis at baseline and 1447 at the one-month follow-up assessment. Research staff-obtained ESAS at admission to HBPC was higher overall (indicating more symptoms) than the clinically collected measure whether symptoms were reported by patients (31.7 ± 15.4 vs. 26.0 ± 13.4) or by proxies (36.9 ± 15.6 vs. 26.5 ± 13.5). These differences persisted with follow-up ESAS measures. Conclusions: We identified significant variability in PRO responses between different surveyors and whether proxy interaction was needed suggesting complex issues around PRO measure performance for pragmatic embedded trials. ClinicalTrials.gov Identifier: NCT03694431. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Incidental small renal masses (SRMs) now account for the majority of new diagnoses of renal cancers. Although there are established management guidelines, referral and management patterns can vary. We aimed to explore identification, practice patterns, and management of identified SRMs in an integrated health system. STUDY DESIGN: Retrospective analysis. METHODS: We identified patients with a newly diagnosed SRM measuring 3 cm or less from January 1, 2013, to December 31, 2017, at Kaiser Permanente Southern California. These patients were flagged at the time of radiographic identification to ensure adequate notification of findings. Diagnostic modality, referral, and treatment patterns were analyzed. RESULTS: Of 519 patients with SRMs, 65% were found on abdominal CT and 22% on renal/abdominal ultrasounds. Within 6 months, 70% of patients consulted with a urologist. Initial management patterns were as follows: active surveillance (60%), partial/radical nephrectomy (18%), and ablation (4%). Among 312 patients on surveillance, 14% eventually received treatment. The majority of patients (69.4%) did not receive guideline-recommended chest imaging for initial staging. Urologist visit within 6 months of SRM diagnosis was associated with increased adherence to staging (P = .003) and subsequent surveillance imaging (P < .001). CONCLUSIONS: In this contemporary analysis of an integrated health system's experience, referral to a urologist was associated with guideline-concordant staging and surveillance imaging. Frequent utilization of active surveillance with a low rate of progression to active treatment was noted in both groups. These findings shed light on care patterns upstream of urologic evaluation and support the need for clinical pathways to be implemented at the time of radiologic diagnosis. [ABSTRACT FROM AUTHOR]

Background: Despite the increasing use and acceptance of technology in health care, there is limited evidence on the usefulness and appropriate use of telehealth in home-based palliative care (HBPC). As part of the process evaluation of a pragmatic trial of video visits in HBPC, we assessed clinician experience with video visit implementation. Methods: We assessed clinicians' experiences with and perception of the usefulness and appropriateness of video visits using anonymous surveys and brief qualitative interviews with a subset of survey participants. Qualitative analyses were guided by sociotechnical frameworks that emphasize technology's "value proposition" for its end users as being key to adoption. Results: Clinicians (36 physicians and 48 registered nurses) generally had favorable attitudes toward video visits and telehealth. Respondents felt confident in the skills needed to make their role in video visits successful. Clinicians were neutral on whether video visits were useful for their practice or enhanced the patient-caregiver experience. Clinicians found video visits to be most appropriate for follow-up care (as opposed to start of care). The interviews yielded two themes that complemented the survey findings: (1) factors enhancing the value proposition (positive responses from patients and families and convenience) and (2) factors diminishing the value proposition (issues related to the technology and scheduling). Discussion: Our findings provide insights into clinicians' experiences with implementing remote video physician consultations, facilitated by a nurse in the patient's home in the pre-COVID-19 era. Clinician views about video visits may have shifted with the pandemic, which occurred after our data collection was complete. Clinical Trials Registration No. NCT#03694431., Competing Interests: No competing financial interests exist., (© Thearis A. Osuji et al. 2020; Published by Mary Ann Liebert, Inc.)