RESUMEN
As a result of their military experience, veterans with mental health problems may have unique motivations for seeking help from clergy. Patterns and correlates of seeking pastoral care were examined using a nationwide representative survey that was conducted among veterans of post-9/11 conflicts (adjusted N = 1,068; 56% response rate). Separate multivariate logistic regression models were used to examine veteran characteristics associated with seeking pastoral care and seeking mental health services. Among post-9/11 veterans with a probable mental disorder (n = 461)-defined as a positive screen for posttraumatic stress disorder, major depressive disorder, or alcohol misuse-20.2% reported talking to a "pastoral counselor" in the preceding year, 44.7% reported talking to a mental health professional, and 46.6% reported talking to neither. In a multivariate analysis for veterans with a probable mental disorder, seeing a pastoral counselor was associated with an increased likelihood of seeing a mental health professional in the past year (OR: 2.16; 95% CI: [1.28, 3.65]). In a separate bivariate analysis, pastoral counselors were more likely to be seen by veterans who indicated concerns about stigma or distrust of mental health care. These results suggest that pastoral and mental health care services may complement one another and underscore the importance of enhancing understanding and collaboration between these disciplines so as to meet the needs of the veterans they serve.
Asunto(s)
Trastornos Relacionados con Alcohol/psicología , Trastorno Depresivo Mayor/psicología , Servicios de Salud Mental/estadística & datos numéricos , Cuidado Pastoral , Estigma Social , Trastornos por Estrés Postraumático/psicología , Veteranos/psicología , Adulto , Trastornos Relacionados con Alcohol/diagnóstico , Trastorno Depresivo Mayor/diagnóstico , Femenino , Humanos , Guerra de Irak 2003-2011 , Masculino , Salud Mental , Persona de Mediana Edad , Motivación , Aceptación de la Atención de Salud , Trastornos por Estrés Postraumático/diagnósticoRESUMEN
Existing evidence suggests that preoperative breast magnetic resonance imaging (MRI) might not improve surgical outcomes in the general breast cancer population. To determine if patients differentially benefit from breast MRI, we examined surgical outcomes-initial mastectomy, reoperation, and final mastectomy rates-among patients grouped by histologic type. We identified women diagnosed with early-stage breast cancer from 2004 to 2007 in the SEER-Medicare dataset. We classified patients as having invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), mixed ductal/lobular carcinoma (IDLC) or other histologic type. Medicare claims were used to identify breast MRI and definitive surgeries during the initial surgical treatment episode. We used propensity score methods to account for the differential likelihood of exposure to MRI. Of the 20,332 patients who met our inclusion criteria for this study, 12.2 % had a preoperative breast MRI. Patients with ILC as compared to other histologic groups were most likely to receive MRI [OR 2.32; 95 % CI (2.02-2.67)]. In the propensity score-adjusted analyses, breast MRI was associated with an increased likelihood of an initial mastectomy for all patients and among all histologic subgroups. Among patients with ILC, having a breast MRI was associated with lower odds of a reoperation [OR 0.59; 95 % CI (0.40-0.86)], and an equal likelihood of a final mastectomy compared to similar patients without a breast MRI. Overall and among patients with IDC and IDLC, breast MRI was not significantly associated with a likelihood of a reoperation but was associated with greater odds of a final mastectomy. Our study provides evidence in support of the targeted use of preoperative breast MRI among patients with ILC to improve surgical planning; it does not provide evidence for the routine use of breast MRI among all newly diagnosed breast cancer patients or among patients with IDC.
Asunto(s)
Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama , Carcinoma Lobular , Imagen por Resonancia Magnética , Factores de Edad , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/epidemiología , Femenino , Humanos , Mastectomía , Clasificación del Tumor , Estadificación de Neoplasias , Oportunidad Relativa , Cuidados Preoperatorios , Retratamiento , Estudios Retrospectivos , Factores de Riesgo , Programa de VERF , Resultado del TratamientoRESUMEN
INTRODUCTION: The National Cancer Institute's (NCI) Community Clinical Oncology Program (CCOP) contributes one third of NCI treatment trial enrollment ("accrual") and most cancer prevention and control (CP/C) trial enrollment. Prior research indicated that the local clinical environment influenced CCOP accrual performance during the 1990s. As the NCI seeks to improve the operations of the clinical trials system following critical reports by the Institute of Medicine and the NCI Operational Efficiency Working Group, the current relevance of the local environmental context on accrual performance is unknown. MATERIALS AND METHODS: This longitudinal quasi-experimental study used panel data on 45 CCOPs nationally for years 2000-2007. Multivariable models examine organizational, research network, and environmental factors associated with accrual to treatment trials, CP/C trials, and trials overall. RESULTS: For total trial accrual and treatment trial accrual, the number of active CCOP physicians and the number of trials were associated with CCOP performance. Factors differ for CP/C trials. CCOPs in areas with fewer medical school-affiliated hospitals had greater treatment trial accrual. CONCLUSIONS: Findings suggest a shift in the relevance of the clinical environment since the 1990s, as well as changes in CCOP structure associated with accrual performance. Rather than a limited number of physicians being responsible for the preponderance of trial accrual, there is a trend toward accrual among a larger number of physicians each accruing relatively fewer patients to trial. Understanding this dynamic in the context of CCOP efficiency may inform and strengthen CCOP organization and physician practice.
Asunto(s)
Servicios de Salud Comunitaria/organización & administración , Oncología Médica/organización & administración , National Cancer Institute (U.S.) , Programas Nacionales de Salud/organización & administración , Neoplasias/prevención & control , Evaluación de Programas y Proyectos de Salud , Proyectos de Investigación , Humanos , Afiliación Organizacional , Estados UnidosRESUMEN
BACKGROUND: Although the informed consent process is supposed to help potential research participants make informed and voluntary decisions about participating in research, little is known about how participants react to language in the informed consent document and whether their reactions are related to their willingness to enroll in clinical trials. We examined the relationship between patients' reactions to standard informed consent language and their willingness to participate in a hypothetical clinical trial. METHODS AND RESULTS: We simulated the consent process for a hypothetical cardiology clinical trial with 470 patients in an outpatient cardiovascular medicine clinic at a large academic medical center. We analyzed the spontaneous comments and questions that participants made during the interviews about each section of the informed consent document. Few participants made positive comments. Participants made the most negative comments about the sections on risks, study purpose or protocol, and payment for injury. Having a negative reaction to any section was associated with a lower likelihood of participating in the clinical trial. Using a multivariable model, we found that negative reactions in the patient rights, financial disclosure, and confidentiality sections predicted willingness to participate (P<0.001). CONCLUSIONS: Recognizing elements of informed consent that elicit questions and concerns from potential research participants may help investigators design clinical research trials and model language in a way that reduces concerns or increases participant understanding, thereby enhancing informed consent for research.
Asunto(s)
Cardiología , Ensayos Clínicos como Asunto , Confidencialidad , Consentimiento Informado , Responsabilidad Legal , Selección de Paciente , Proyectos de Investigación , Sujetos de Investigación/psicología , Centros Médicos Académicos , Anciano , Instituciones de Atención Ambulatoria , Cardiología/economía , Cardiología/ética , Cardiología/legislación & jurisprudencia , Distribución de Chi-Cuadrado , Ensayos Clínicos como Asunto/economía , Ensayos Clínicos como Asunto/ética , Ensayos Clínicos como Asunto/legislación & jurisprudencia , Comprensión , Confidencialidad/ética , Confidencialidad/legislación & jurisprudencia , Conflicto de Intereses , Toma de Decisiones , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Consentimiento Informado/ética , Consentimiento Informado/legislación & jurisprudencia , Entrevistas como Asunto , Lenguaje , Responsabilidad Legal/economía , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Selección de Paciente/ética , Proyectos de Investigación/legislación & jurisprudencia , Sujetos de Investigación/economía , Sujetos de Investigación/legislación & jurisprudenciaRESUMEN
PURPOSE: One goal of the Patient-Reported Outcomes Measurement Information System (PROMIS) is to develop a measure of sexual functioning that broadens the definition of sexual activity and incorporates items that reflect constructs identified as important by patients with cancer. We describe how cognitive interviews improved the quality of the items and discuss remaining challenges to assessing sexual functioning in research with cancer populations. METHODS: We conducted 39 cognitive interviews of patients with cancer and survivors on the topic of sexual experience. Each of the 83 candidate items was seen by 5-24 participants. Participants included both men and women and varied by cancer type, treatment trajectory, race, and literacy level. Significantly revised items were retested in subsequent interviews. RESULTS: Cognitive interviews provided useful feedback about the relevance, sensitivity, appropriateness, and clarity of the items. Participants identified broad terms (e.g., "sex life") to assess sexual experience and exposed the challenges of measuring sexual functioning consistently, considering both adjusted and unadjusted sexual experiences. CONCLUSIONS: Cognitive interviews were critical for item refinement in the development of the PROMIS measure of sexual function. Efforts are underway to validate the measure in larger cancer populations.
Asunto(s)
Cognición , Neoplasias/complicaciones , Satisfacción del Paciente/estadística & datos numéricos , Calidad de Vida , Conducta Sexual , Disfunciones Sexuales Psicológicas/etiología , Estrés Psicológico , Adaptación Psicológica , Adulto , Anciano , Femenino , Grupos Focales , Humanos , Masculino , Persona de Mediana Edad , Modelos Teóricos , Neoplasias/epidemiología , Psicometría , Investigación Cualitativa , Indicadores de Calidad de la Atención de Salud , Disfunciones Sexuales Psicológicas/epidemiología , Encuestas y Cuestionarios , Resultado del Tratamiento , Estados Unidos/epidemiologíaAsunto(s)
Servicios de Salud Comunitaria/organización & administración , Medicaid/economía , Atención Primaria de Salud/organización & administración , Evaluación de Programas y Proyectos de Salud , Servicios de Salud Comunitaria/economía , Humanos , Reembolso de Seguro de Salud , North Carolina , Atención Primaria de Salud/economía , Desarrollo de Programa , Estados UnidosRESUMEN
BACKGROUND: Little is known about the effects of investigators' financial disclosures on potential research participants. METHODS: We conducted a vignette trial in which 470 participants in a telephone survey were randomly assigned to receive a simulated informed consent document that contained 1 of 2 financial disclosures (per capita payments to the research institution or equity ownership by the investigator) or no disclosure. The main outcome measures were trust in medical research and willingness to participate in a hypothetical clinical trial. RESULTS: Participants in the equity group reported less willingness to participate than participants in the per capita payments group (P = .01) and the no disclosure group (P = .03). Trust in the investigator was highest in the per capita payments group and lowest in the equity group (P < .001). Trust among participants who received no disclosure was also greater than trust among participants in the equity group (P = .04) but did not differ significantly from trust among participants in the per capita payments group (P = .15). Participants in the equity group made 3 times as many negative comments as participants in the per capita payments group; and 10 participants in the equity group spontaneously said they would not participate in the hypothetical trial because of the financial interest, compared with only 1 such participant from the other groups. CONCLUSIONS: Although investigators' financial disclosures in research do not substantially affect willingness to participate, potential research participants are more troubled by equity interests than by per capita payments.