Sumedha Chhatre

Purpose: To evaluate the association between patient–physician trust, treatment choice, patient-reported outcomes, and patient-reported experiences among patients with localized prostate cancer. Materials and Methods: We conducted a secondary analysis of data from a multicenter randomized controlled trial among patients with localized prostate cancer. Trust was measured at baseline, prior to treatment, using the Patient Trust–Wake Forest Physician Trust Scale (PTWF). Outcomes were assessed at baseline and at 3, 6, 12, and 24 mo. Treatments were robotic-assisted laparoscopic radical prostatectomy, radiation therapy, and active surveillance. The primary treatment outcome was receipt of active treatment (surgery or radiation therapy) versus active surveillance. Multivariable logistic regression and linear mixed-effects models were adjusted for age, race/ethnicity, marital status, education, employment, insurance, prostate cancer risk group, intervention assignment, and study site. Sensitivity analyses modeling trust as a continuous variable yielded findings that were materially consistent with the primary analyses. Results: The high-trust group had higher odds of receiving active treatment than the low-trust group did (adjusted odds ratio [OR] = 1.80, 95% confidence interval [CI] = 1.14–2.87; P = 0.013). Higher baseline trust was also consistently associated with better physical and mental health-related quality of life and higher satisfaction with care and treatment decision making across follow-up assessments through 24 mo. Sensitivity analyses using trust as a continuous measure produced similar findings. Conclusions: Higher patient–physician trust was independently associated with treatment choice, patient-reported outcomes, and patient-reported experience. These findings underscore the importance of patient–physician trust as a component of patient-centered cancer care and shared decision making. Future studies should evaluate interventions designed to strengthen trust and improve patient-centered outcomes across diverse clinical settings.

Background: In the US, the Veterans Health Administration is the largest single institutional provider of Human Immunodeficiency Virus (HIV) care for veterans. Retention in care can affect treatment adherence and care outcomes. Psychiatric disorders are prevalent in people with HIV and may lead to poorer retention in care and outcomes. Objectives: To examine the association between retention in HIV care, psychiatric comorbidities, and clinical outcomes among veterans with HIV. Research Design: In this retrospective study, veterans aged ≥18, seen with a diagnosis of HIV between 2000 and 2017, were identified from the Corporate Data Warehouse. We identified those with and without psychiatric comorbidities in the HIV cohort. Outcomes (mortality, viral suppression, and inpatient and outpatient visits) were assessed over a five-year follow-up period. Retention in care was measured during the first year of follow-up. We modeled outcomes as a function of retention in care and tested the moderating effects of psychiatric comorbidity and treatment for psychiatric comorbidity. Results: Cohort consisted of 59,649 veterans with a diagnosis of HIV; 66% had psychiatric comorbidity, and 90% received treatment for it. Overall, 49% were retained in HIV care. Retention in care was associated with better survival and viral suppression, regardless of psychiatric comorbidity; however, psychiatric comorbidity influenced healthcare utilization. Conclusions: Our study provides important insights into the relationship between retention in care, psychiatric comorbidity, and outcomes in veterans with HIV. Future research must assess the barriers to care and strategies to integrate mental health and HIV treatments for veterans.

Purpose: The Abdominal Hernia-Q(AHQ) is a validated PRO tool for hernia patients. This study aimed to determine the Minimal Important Change (MIC) for the AHQ, examining changes in AHQ scores and exploring associations with key clinical characteristics. Methods: A retrospective cohort design was used. Patients who underwent hernia repair between January 2017 and January 2022 and completed the AHQ preoperatively and six months postoperatively were included. Anchor (Short Form Health Survey (SF-12) and Hernia-related Quality of Life Survey (HerQLes)) and distribution-based methods were used to compute the MIC. The distribution method used 0.5×standard deviation [SD] and minimal detectable change [MDC; 1.96×SEM], to identify the MIC. Results: A total of 147 patients met the inclusion criteria, with a mean age of 55.69 (SD 12.26), 60% female and a BMI of 30.8 km/m2 (26.9–36.5). A grand mean MIC of 6.8 was derived. One hundred twenty-nine patients met or exceeded the MIC, while 18 did not. Patients meeting the MIC had significantly worse baseline AHQ scores (46 vs. 68, p < 0.001) and higher postoperative AHQ scores (86 vs. 67, p < 0.001). There was no difference in operative characteristics or complications between groups, with the exception that patients not achieving MIC had a higher rate of seroma (28% vs. 9.3%, p = 0.038). Conclusion: The findings suggest that patients with worse preoperative status may still experience clinically significant benefits. Establishing the MIC for the AHQ may enable the identification of patients likely to experience significant improvements in quality of life after hernia repair.

Introduction: Improving gender‐sensitive suicide prevention programming for women veterans is crucial. Veterans Crisis Line (VCL) is a preventive strategy used by the US Department of Veterans Affairs. Public health measures implemented during COVID‐19 pandemic may have affected the nature of VCL calls.Objectives: To assess the gender differences in the VCL contacts made in year 2020 and subsequent suicidal self‐directed violence (SSDV) outcomes in the 12 months follow‐up.Methods: Cohort study.Outcomes: Composite measure of SSDV (dichotomized as nonfatal suicide event and/or suicide) in the 12 months following VCL call.Results: Compared to veterans with low‐risk assessment, those with high/moderate risk had significantly higher odds of SSDV in the follow‐up year (OR = 4.12, 95% CI: 3.82, 4.45). We assessed the association of gender, combination of VCL risk, and suicide attempt (SA) history, on SSDV. The VCL risk and SA history combinations were independently associated with SSDV. However, there was no differential association on SSDV for different gender/VCL risk and SA history combinations (p = 0.6247).Conclusions and Relevance: Our 2020 VCL data outcomes are largely consistent with those from our prior work examining 2018 VCL contacts. Overall, VCL risk assessment was relatively stable across the gender binary during COVID pandemic.

Background: Technical efficiency evaluates a hospital’s economic performance and plays an important role in variations in quality of care and outcomes. The study objective was to examine the association between hospital efficiency and quality of care among fee-for-service Medicare beneficiaries with prostate cancer and to assess if race moderates this association. Design: Retrospective study using Surveillance, Epidemiological, and End Results—Medicare (SEER-Medicare) data from 1998 to 2016 for prostate cancer patients aged ≥ 66. We computed hospital technical efficiency using a data envelopment analysis. Outcomes were emergency room visits, hospitalizations, cost, and mortality (all-cause and prostate cancer-specific). We used competing risk regression for survival, log-link GLM models for cost, and Poisson models for count data. The propensity score approach was used to minimize selection bias. Results: The cohort consisted of 323,325 patients. Compared to higher efficiency hospitals (upper quartile), low hospital efficiency (i.e., lower quartile) was associated with a higher hazard of long-term mortality (Hazard ratio (HR) = 1.06, 95% CI = 1.05, 1.08) and long-term prostate cancer-specific mortality (HR = 1.14, 95% CI = 1.11, 1.17). Compared to higher efficiency levels, lower levels were associated with impaired emergency room visits, hospitalizations, and costs. A one unit increase in the efficiency score was associated with greater benefits for cost and mortality for African American and white patients. The benefit was larger for African American patients compared to white patients. Conclusions: Increasing hospital efficiency may help improve outcomes among Medicare prostate cancer patients. Policies to redirect patients to hospitals with higher efficiency can enhance the quality of care and outcomes.

Background: Disparities in suicide rates by veteran status are particularly striking for women. Veterans Crisis Line (VCL) is a preventive strategy.Objectives: Examine the relationships and gender differences between VCL risk rating, and subsequent suicidal self‐directed violence (SSDV) in the 12‐months following VCL index call.Methods: Cohort study of VCL callers in 2018.Outcomes: Dichotomized composite SSDV (non‐fatal suicide event and/or suicide) in the 12 months following VCL call.Results: Veterans with high/moderate VCL risk had significantly higher odds of SSDV (OR = 4.02, 95% CI: 3.75, 4.30). There were no gender/VCL risk interaction (p = 0.3605). We also examined the association of gender, combination of VCL risk and suicide attempt (SA) history, on SSDV. Differential odds of SSDV for gender and combined VCL risk and SA history combinations were observed (p = 0.0005). Compared to those with lower VCL risk without SA history, those with high/moderate VCL risk with SA history showed higher odds of SSDV. Magnitude was higher for men, than for women veterans.Conclusions and Relevance: Veterans Crisis Line risk assessment performs relatively stable across the gender binary and highlights potential gender differences when factoring in SA history. Combining risk assessment and attempt history may lead to effective suicide prevention strategies.

Background: While psychological difficulties, such as depression, among prostate cancer patients are known, their longitudinal burden remains understudied. We assessed the burden of depression across low-, intermediate- and high-risk prostate cancer groups, and the association between regret and long-term depression. Methods: Secondary analysis of data from a multi-centered randomized controlled study among localized prostate cancer patients was carried out. Assessments were performed at baseline, and at 3-, 6-, 12- and 24-month follow-up. Depression was assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. A CES-D score ≥ 16 indicates high depression. Regret was measured using the regret scale of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). The proportion of patients with high depression was compared over time, for each risk category. Logistic regression was used to assess the association between regret, and long-term depression after adjusting for age, race, insurance, smoking status, marital status, income, education, employment, treatment, number of people in the household and study site. Results: The study had 743 localized prostate cancer patients. Median depression scores at 6, 12 and 24 months were significantly larger than the baseline median score, overall and for the three prostate cancer risk groups. The proportion of participants with high depression increased over time for all risk groups. Higher regret at 24-month follow-up was significantly associated with high depression at 24-month follow-up, after adjusting for covariates. Conclusions: A substantial proportion of localized prostate cancer patients continued to experience long-term depression. Patient-centered survivorship care strategies can help reduce depression and regret, and improve outcomes in prostate cancer care.

Background: Continuity of care is an important element of advanced prostate cancer care due to the availability of multiple treatment options, and associated toxicity. However, the association between continuity of care and outcomes across different racial groups remains unclear.Objective: To assess the association of provider continuity of care with outcomes among Medicare fee‐for‐service beneficiaries with advanced prostate cancer and its variation by race.Design: Retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER)‐Medicare data.Subjects: African American and white Medicare beneficiaries aged 66 or older, and diagnosed with advanced prostate cancer between 2000 and 2011. At least 5 years of follow‐up data for the cohort was used.Measures: Short‐term outcomes were emergency room (ER) visits, hospitalizations, and cost during acute survivorship phase (2‐year post‐diagnosis), and mortality (all‐cause and prostate cancer‐specific) during the follow‐up period. We calculated continuity of care using Continuity of Care Index (COCI) and Usual Provider Care Index (UPCI), for all visits, oncology visits, and primary care visits in acute survivorship phase. We used Poisson models for ER visits and hospitalizations, and log‐link GLM for cost. Cox model and Fine‐Gray competing risk models were used for survival analysis, weighted by propensity score. We performed similar analysis for continuity of care in the 2‐year period following acute survivorship phase.Results: One unit increase in COCI was associated with reduction in short‐term ER visits (incidence rate ratio [IRR] = 0.65, 95% confidence interval [CI] 0.64, 0.67), hospitalizations (IRR = 0.65, 95% CI 0.64, 0.67), and cost (0.64, 95% CI 0.61, 0.66) and lower hazard of long‐term mortality. Magnitude of these associations differed between African American and white patients. We observed comparable results for continuity of care in the follow‐up period.Conclusions: Continuity of care was associated with improved outcomes. The benefits of higher continuity of care were greater for African Americans, compared to white patients. Advanced prostate cancer survivorship care must integrate appropriate strategies to promote continuity of care.

Introduction:Our objective was to assess whether Medicaid expansion is associated with reduced racial disparity in quality of care measured as 30-day mortality, 90-day mortality, and 30-day...

Background: Web-based tools developed to facilitate a shared decision-making (SDM) process may facilitate the implementation of lung cancer screening (LCS), an evidence-based intervention to improve cancer outcomes. Veterans have specific risk factors and shared experiences that affect the benefits and potential harms of LCS and thus may value a veteran-centric LCS decision tool (LCSDecTool). Objective: This study aims to conduct usability testing of an LCSDecTool designed for veterans receiving care at a Veteran Affairs medical center. Methods: Usability testing of the LCSDecTool was conducted in a prototype version (phase 1) and a high-fidelity version (phase 2). A total of 18 veterans and 8 clinicians participated in phase 1, and 43 veterans participated in phase 2. Quantitative outcomes from the users included the System Usability Scale (SUS) and the End User Computing Satisfaction (EUCS) in phase 1 and the SUS, EUCS, and Patient Engagement scale in phase 2. Qualitative data were obtained from observations of user sessions and brief interviews. The results of phase 1 informed the modifications of the prototype for the high-fidelity version. Phase 2 usability testing took place in the context of a pilot hybrid type 1 effectiveness-implementation trial. Results: In the phase 1 prototype usability testing, the mean SUS score (potential range: 0-100) was 81.90 (SD 9.80), corresponding to an excellent level of usability. The mean EUCS score (potential range: 1-5) was 4.30 (SD 0.71). In the phase 2 high-fidelity usability testing, the mean SUS score was 65.76 (SD 15.23), corresponding to a good level of usability. The mean EUCS score was 3.91 (SD 0.95); and the mean Patient Engagement scale score (potential range 1 [low] to 5 [high]) was 4.62 (SD 0.67). The median time to completion in minutes was 13 (IQR 10-16). A thematic analysis of user statements documented during phase 2 high-fidelity usability testing identified the following themes: a low baseline level of awareness and knowledge about LCS increased after use of the LCSDecTool; users sought more detailed descriptions about the LCS process; the LCSDecTool was generally easy to use, but specific navigation challenges remained; some users noted difficulty understanding medical terms used in the LCSDecTool; and use of the tool evoked veterans’ struggles with prior attempts at smoking cessation. Conclusions: Our findings support the development and use of this eHealth technology in the primary care clinical setting as a way to engage veterans, inform them about a new cancer control screening test, and prepare them to participate in an SDM discussion with their provider.