Ebbert, Jon O.

11135 Background: Cancer screening programs can improve outcomes and may reduce treatment cost and utilization by shifting cancers to earlier, more curable stages at diagnosis (Dx). Few studies have evaluated the impact of screening on outcomes prior to diagnosis. Such information is needed to better understand the potential impact of newer blood-based multicancer early detection technologies. Methods: We conducted a retrospective cohort study using SEER cancer registry data linked with Medicare claims. Patients with a breast cancer (BC) or colorectal cancer (CRC) Dx between 2010-2019 were included if they were 65-74 years old at Dx, continuously enrolled in Medicare Parts A&B, had a Charlson Comorbidity Index of ≤2, and no cancer for ≥12 months prior to Dx. Those enrolled in an HMO or with high genetic risk for BC (in BC cohort) were excluded. Patients were assigned to screening groups prior to Dx; screening was defined as ≥1 screening procedure in the 6 months prior to Dx using CPT/HCPCS codes. Screening included FIT/FOBT, sigmoidoscopy, colonoscopy, CT colonography, mt-sDNA (CRC), and mammography (BC). Screened and not screened groups were compared for statistical significance using chi-squared for categorical variables, Wilcoxon rank-sum test for continuous variables. Results: Screening procedures were more prevalent in the BC cohort (68%) than the CRC cohort (44%) (table). Both screened subgroups (vs non-screened subgroups) had significantly lower proportions of patients diagnosed at stage 4 (2% vs 10% BC, 16% vs 27% CRC) and shorter times from first screening or imaging procedure to confirmed diagnosis (BC: 33 vs 227 days, CRC: 14 vs 29 days). Screened patients in both cancer cohorts had a similar number of average procedures prior to treatment initiation as non-screened (BC: 4.8 vs 4.2, CRC: 3.3 vs 3.3 respectively, including screening procedures). Conclusions: Individuals diagnosed with BC and CRC through screening exhibit earlier stage diagnoses and shorter intervals to diagnosis. Novel screening technologies such as MCED tests can potentially improve peri-diagnostic outcomes in cancers lacking existing or widely adopted screening methods. [Table: see text]

Objective: To determine if the implementation of smoke-free workplace laws reduced the incidence of the acute coronary events including myocardial infarction (MI) and sudden cardiac death (SCD). Background: Nonsmokers chronically exposed to second-hand smoke (SHS) are at increased risk of death from heart disease. However, a nonlinear dose relationship exists between SHS exposure and coronary heart disease (CHD) such that the relative risk of CHD is 1.31 for nonsmokers and 1.78 for smokers. Reductions in admissions for MI in locales where smoke-free workplace laws have been implemented have been observed, but none have assessed SCD. On January 1, 2002, a smoke-free restaurant law (Ordinance #1) was implemented in Olmsted County, Minnesota, and on October 1, 2007, all workplaces became smoke-free (Ordinance #2). Methods: Under the auspices of the Rochester Epidemiology Project, we measured the incidence of MI and SCD during the 18-month calendar period before and after implementation of each smoke-free ordinance. All MI were validated using biomarkers, cardiac pain, and Minnesota coding of the ECG. SCD was defined as out-of-hospital deaths assigned to CHD (ICD-9 codes 410 through 414). Results: For the overall study period of the 18 months before the implementation of the smoke-free restaurant ordinance and 18 months after the implementation of the smoke-free workplace ordinance, we observed a 45% decline in the incidence for MI (p <0.01) and a 50% decline in the incidence for SCD (p <0.01). See Table. During this same period, the prevalence of hypertension, diabetes, hypercholesterolemia, and obesity either remained constant or increased while the prevalence of smoking among adults declined by 23% (22% to 17%). Conclusion: In the Olmsted County population, substantial declines in the incidence of MI and SCD were observed after smoke-free laws were implemented. Smoke-free workplace laws may not only be associated with a decrease in MI but SCD as well.

Objective To evaluate the clinical outcomes of a remote mental health program for managing anxiety and depression, primarily using asynchronous digital communication. Methods This retrospective cohort study examined U.S. adults seeking remote care for anxiety and depression from January 2021 to May 2022. The program involves clinician-led assessment, patient education, medication management, and ongoing monitoring, primarily via text. Anxiety and depression were measured using Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) scores. Outcomes examined were changes in scores, 50% score improvement rate, and remission rate (score <5) at 1, 3, and 6 months. Results During the period evaluated, 11,844 program participants met the inclusion criteria. Most were female (n = 8328, 70.3%); their age ranged from 18–82 years (median 31 years). At baseline, median PHQ-9 and GAD-7 scores were 13 (IQR 9–17); 67% and 69% met score criteria for depression and anxiety, respectively. Most participants (80%) were prescribed a selective serotonin reuptake inhibitor (SSRI). By one month, average PHQ-9 and GAD-7 scores decreased significantly by 9.2 and 9.1 points (both p < .01). At 1-month follow-up, the 50% score improvement rate was 66% for PHQ-9 and 69% GAD-7 ( p < .01). Scores continued to decrease with follow-up. At 3 months, over half achieved remission (percent [95% CI]: 52% [51–54] for anxiety, 53% [52–55] for depression). Similar improvement was observed at 6 months and in sensitivity analyses accounting for loss to follow-up. Conclusions Use of a remote mental health program with digital tools was associated with significant clinical improvement in anxiety and depression. Challenges remain in maintaining patient engagement and ensuring appropriate care quality monitoring in digital mental health programs. Additional research comparing remote digital care to traditional in-person models is warranted. Studies should examine long-term outcomes, optimal care protocols, and the challenges to integrating these programs into existing healthcare systems and ensuring equitable access.

Background Digital and mobile (mHealth) solutions are online or application-based services intended to support individuals with health needs. Despite evidence supporting the use of mHealth for patients with chronic pain, and the increasing desire of these types of solutions by both patients and providers, adoption of mHealth solutions remains limited. Implementation mapping can serve as a practical method to facilitate implementation and adoption of mHealth solutions within healthcare settings. Methods Implementation mapping was used to develop implementation strategies based on contextual determinants organized within the Consolidated Framework for Implementation Research (CFIR) for mHealth eLearning solutions across an integrated, multi-site healthcare system. We describe our experience identifying stakeholders, delineating implementation facilitators and barriers, defining implementation outcomes using RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, outlining initial implementation strategies, and iterating on implementation strategies. Results A total of 30 implementation strategies were identified and implemented. Over the first year, primary and specialty care providers across all the clinical sites ( n = 70) placed 2559 orders for the mHealth solution. Most patients reported receiving the mHealth eLearning module (74%), and most patients felt that the tool improved their knowledge regarding their condition (82%) and their ability to provide self-care related to the condition (73%). Conclusion Practical applications of implementation science methods can help enable change within healthcare settings. Implementation mapping is an exercise that can engage stakeholders to facilitate the incorporation of new methods of care delivery, including mHealth solutions.

Abstract Introduction We sought to determine what type of treatment reengagement after smoking relapse would increase long-term cessation. Aims and Methods Participants were military personnel, retirees, and family members (TRICARE beneficiaries) recruited across the United States from August 2015 through June 2020. At baseline, consented participants (n = 614) received a validated, four-session, telephonic tobacco-cessation intervention with free nicotine replacement therapy. At the 3-month follow-up, 264 participants who failed to quit or relapsed were offered the opportunity to reengage in cessation. Of these, 134 were randomized into three reengagement conditions: (1) repeat initial intervention (“recycle”), (2) Smoking reduction with eventual cessation goal (“rate reduction”), or (3) Choose #1 or #2 (“choice”). Prolonged abstinence and 7-day point prevalence abstinence were measured at 12 months. Results Despite being in a clinical trial advertised as having the opportunity for reengagement, only 51% (134 of the 264) of participants who still smoked at 3-month follow-up were willing to reengage. Overall, participants randomized to recycle had higher prolonged cessation rates at 12 months than rate reduction conditions (OR = 16.43, 95% CI: 2.52 to 107.09, Bonferroni adjusted p = .011). When participants who randomly received recycle or rate reduction were pooled, respectively, with participants who chose recycle or rate reduction in the Choice group, recycle had higher prolonged cessation rates at 12 months than rate reduction (OR = 6.50, 95% CI: 1.49 to 28.42, p = .013). Conclusions Our findings suggest service members and their family members who fail to quit smoking but are willing to reengage in a cessation program are more likely to benefit from repeating the same treatment. Implications Finding methods that are both successful and acceptable to reengage people who smoke who want to quit can have a significant impact on improving the health of the public by reducing the portion of the population who smoke. This study suggests that repeating established cessation programs will result in more people ready to quit successfully achieving their goal.

AbstractBackgroundIrritable bowel syndrome (IBS) is characterized as a central sensitization syndrome (CSS), a group of conditions including fibromyalgia, chronic fatigue, and restless leg syndrome (RLS) among others with frequent comorbidities of anxiety, depression, and chemical sensitivity. The prevalence of comorbid conditions and their impact on IBS symptom severity and quality of life in rural community populations has not been described.MethodsWe administered a cross‐sectional survey to patients with a documented CSS diagnosis in rural primary care practices to evaluate the relationship between CSS diagnoses, quality of life, symptom severity, and interactions with healthcare providers utilizing validated questionnaires. Subgroup analysis was performed on the IBS cohort. Mayo Clinic IRB approved the study.Key ResultsSeven hundred seventy‐five individuals out of 5000 completed the survey (15.5% response rate) with 264 (34%) reporting IBS. Only 3% (n = 8) of IBS patients reported IBS alone without comorbid CSS condition. Most respondents reported overlapping migraine (196, 74%), depression (183, 69%), anxiety (171, 64%), and fibromyalgia (139, 52%). IBS patients with more than two comorbid CS condition showed significantly higher symptom severity with linear increase. Quality of life was lower in IBS with comorbid conditions, particularly in patients with IBS and RLS (mean EQ5‐D 0.36 vs. 0.8 in IBS only, p < 0.01). Quality of life declined as number of comorbid conditions increased.Conclusions & InferencesPatients with IBS often have multiple CS disorders which increases symptom severity and lowers quality of life. Understanding the impact of multiple CSS diagnoses and treating these as a global condition may improve patient experience.

Background Chronic pain in cancer survivors negatively impacts quality of life. This study sought to investigate the relationship between high-impact chronic pain (HICP) -- defined as chronic pain that limits life or work activities on most days or every day in the past 3 months -- and cannabis in cancer survivors. Methods An electronic survey was developed in conjunction with the National Cancer Institute Comprehensive Cancer Centers in the United States. This survey was distributed to cancer survivors within a multi-site, single institution setting. Results The survey response rate was 23.0% (2304/10,000); 72.7% of these patients (1676/2304) did in fact have a confirmed cancer diagnosis. Among these cancer survivors, 16.5% (unweighted 278/1676) had HICP, and 12.4% (208/1676) reported cannabis use since their cancer diagnosis. The prevalence of past 30-day cannabis use was 12.3% (206/1676). Compared to cancer survivors without pain, those with HICP were more likely to believe in the benefits of cannabis (unweighted 92.1% vs. 74.7%; age-adjusted odds ratio [OR] = 3.1; 95% CI: 1.9-5.1) and less likely to believe in its risks (unweighted 48.2% vs. 58.4%; age-adjusted OR = 0.6; 95% CI: 0.4-0.7). Conclusions Cancer survivors with HICP have a higher prevalence of cannabis use compared to those patients without pain. More research is needed to advance pain and symptom management among cancer survivors and to identify clinical scenarios in which benefit is greater than potential harm.

Background: Despite efforts to improve access to Medications for Opioid Use Disorder (MOUD), such as buprenorphine, the number of opioid overdoses in the United States continues to rise. In April 2021, the Department of Health and Human Services removed the mandatory training requirement to obtain a buprenorphine waiver; the goal was to encourage more providers to prescribe buprenorphine, thus improving access. Little is known about the attitudes on buprenorphine prescribing after this policy change. Objective: The primary objective was to assess attitudes among primary care providers toward the removal of the buprenorphine waiver training requirement. A secondary objective was to identify other barriers to prescribing buprenorphine. Methods: We conducted a survey between September 15 and October 13, 2021 to assess the overall beliefs on the effectiveness of MOUD and attitudes toward the removal of the waiver training, current knowledge of buprenorphine, current practice styles related to screening for and treating OUD, and attitudes toward prescribing buprenorphine in the future. This survey was sent to 890 Mayo Clinic primary care providers in 5 US states. Results: One hundred twenty-three respondents (13.8%) completed the survey; 35.8% respondents agreed that the removal of the waiver training was a positive step. These respondents expressed a greater familiarity with the different formulations, pharmacology, and titration of buprenorphine. This group was also more likely to prescribe (or continue to prescribe) buprenorphine in the future. Approximately one-third (34.4%) of respondents reported perceived institutional support in prescribing buprenorphine. This group expressed greater confidence in diagnosing OUD, had greater familiarity with the different formulations, pharmacology, and titration of buprenorphine, and was more likely to prescribe (or continue to prescribe) buprenorphine in the future. Respondents who have been in practice for 11 to 20 years since completion of training were most likely to refer all OUD patients to specialists. Conclusions: Results of our survey suggests that simply removing the mandatory waiver training requirement is insufficient in positively changing attitudes toward buprenorphine prescribing. A key barrier is the perceived lack of institutional support. Future studies investigating effective ways to provide such support may help improve providers’ willingness to prescribe buprenorphine.