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We examined cross-sectional associations of living alone with social isolation among community-dwelling older adults in Worcester County, Massachusetts, USA. Four hundred participants 65 years old and older were recruited in community group settings or by direct mail. Participants were queried for living status, social support, frequency of social activity, sociodemographic and lifestyle factors, and health conditions. Social isolation was assessed by lack of social support and decreased frequency of social activity. Physical activity (PA) was measured via an accelerometer and global positioning system (GPS), which was worn by the participant, for at least 7 consecutive days. Participants living alone (N = 110) had less social support than those living with others (N = 290) (p < 0.001) but did not differ significantly in the frequency of their social activities. Group-setting recruitment was strongly associated with greater social activity (p < 0.001). Less social support was independently associated with a less-than-high-school education (p = 0.001), higher CES-D depression score (p < 0.001) and lower PA (p = 0.003). Less social activity was independently associated with a less-than-high-school education (p = 0.007) and annual income less than $50,000 (p = 0.01). Older adults who are socioeconomically disadvantaged, have less social support, and who live alone are more likely to be socially isolated and may benefit from continuation of low-cost social activities and increased social support inside the home. Identifying correlates of social isolation may inform future interventions.

Introduction Stanford Medicine is working to better coordinate care across the Stanford healthcare system, as well as improve patient and provider experiences in seeking and receiving care. This study aimed to explore the complexities of moving from a fragmented to an integrated academic healthcare system and to identify and explain factors (e.g., facilitators and barriers) of the implementation of three interventions meant to improve patient experience, reduce staff burden, and integrate health care systems across faculty and community settings. Methods We conducted qualitative semi‐structured interviews via Zoom with faculty and community physicians. Interviews were audio‐recorded, professionally transcribed, and analyzed using the Consolidated Framework for Implementation Research (CFIR) and open coding. Using consensus coding approaches, researchers met regularly to discuss themes and adaptations to CFIR. Results We analyzed transcripts from interviews with physicians (n = 26). Factors impacting integration included the following: (1) physicians supported the interventions, promoting mission alignment; (2) physicians were motivated for change, reporting the existing system was intolerable; (3) physicians reported different priorities between clinics: faculty versus community and primary care versus specialty; (4) physicians prioritized interpersonal versus system solutions; (5) specialists were wary of unintended consequences of integration, specifically inappropriate bookings or patients being redirected to other clinics. Broadly speaking, facilitator factors 1–2 focused on the openness to, and tension for, change; and barrier factors 3–5 promoted or sustained variation across specialties and faculty/community clinics. Conclusions Our results illustrate the challenges and opportunities of moving from a fragmented to an integrated healthcare system and emphasize the importance of building shared culture, collaboration, and coordinated actions across and within an integrated healthcare network.

Purpose Visitor restriction policies to prevent the spread of COVID-19 among patients and clinicians were widespread during the pandemic, resulting in the exclusion of caregivers at key points of cancer care and treatment decision-making. The aim of this study was to explore how visitor restrictions impacted cancer treatment decision-making and care from patient and physician perspectives. Methods Sixty-seven interviews, including 48 cancer patients and 19 cancer and palliative care physicians from four academic cancer centers in the USA between August 2020 and July 2021. Results Visitor restrictions that prevented caregivers from participating in clinic appointments and perioperative hospital care created challenges in cancer care that spanned three domains: practical, social, and informational. We identified eight themes that characterized challenges within the three domains across all three groups, and that these challenges had negative emotional and psychological consequences for both groups. Physicians perceived that patients’ negative experiences due to lack of support through the physical presence of caregivers may have worsened patient outcomes. Conclusions Our data demonstrate the tripartite structure of the therapeutic relationship in cancer care with caregivers providing critical support in the decision-making and care process to both patients and physicians. Caregiver absences led to practical, psychosocial, and informational burdens on both groups, and likely increased the risk of burnout among physicians. Our findings suggest that the quality of cancer care can be enhanced by engaging caregivers and promoting their physical presence during clinical encounters.

Introduction Tracking adaptations during implementation can help assess and interpret outcomes. The framework for reporting adaptations and modifications‐expanded (FRAME) provides a structured approach to characterize adaptations. We applied the FRAME across multiple health services projects, and developed an analytic approach to assess the impact of adaptations. Methods Mixed methods analysis of research diaries from seven quality improvement (QI) and research projects during the early stages of the COVID‐19 pandemic. Using the FRAME as a codebook, discrete adaptations were described and categorized. We then conducted a three‐step analysis plan: (1) calculated the frequency of adaptations by FRAME categories across projects; (2) qualitatively assessed the impact of adaptations on project goals; and (3) qualitatively assessed relationships between adaptations within projects to thematically consolidate adaptations to generate more explanatory value on how adaptations influenced intervention progress and outcomes. Results Between March and July 2020, 42 adaptations were identified across seven health services projects. The majority of adaptations related to training or evaluation (52.4%) with the goal of maintaining the feasibility (66.7%) of executing projects during the pandemic. Five FRAME constructs offered the most explanatory benefit to assess the impact of adaptations on program and evaluation goals, providing the basis for creating an analytic approach dubbed the “A‐FRAME,” analysis of FRAME data. Using the A‐FRAME, the 42 adaptations were consolidated into 17 succinct adaptations. Two QI projects discontinued altogether. Intervention adaptations related to staffing, training, or delivery, while evaluation adaptations included design, recruitment, and data collection adjustments. Conclusions By sifting qualitative data about adaptations into the A‐FRAME, implementers and researchers can succinctly describe how adaptations affect interventions and their evaluations. The simple and concise presentation of information using the A‐FRAME matrix can help implementers and evaluators account for the influence of adaptations on program outcomes.

Recent studies have found that physicians with access to a large language model (LLM) chatbot during clinical reasoning tests may score no better to worse compared to the same chatbot performing alone with an input that included the entire clinical case. This study explores how physicians approach using LLM chatbots during clinical reasoning tasks and whether the amount of clinical case content included in the input affects performance. We conducted semi-structured interviews with U.S. physicians on experiences using an LLM chatbot and developed a typology based on input patterns. We then analyzed physician chat logs from two randomized controlled trials, coding each clinical case to an input approach type. Lastly, we used a linear mixed-effects model to compare the case scores of different input approach types. We identified four input approach types based on patterns of content amount: copy-paster (entire case), selective copy-paster (pieces of a case), summarizer (user-generated case summary), and searcher (short queries). Copy-pasting and searching were utilized most. No single type was associated with scoring higher on clinical cases. Other factors such as different prompting strategies, cognitive engagement, and interpretation of the outputs may have more impact and should be explored in future studies.

Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations. To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers. From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients. Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation. The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed. In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99). To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers. ClinicalTrials.gov Identifier: NCT03611309.

Abstract Non-English Speaking late-life Chinese immigrants are hard to reach. We developed a staged, multi-facet, community-engaged approach to recruiting participants for aging research. We first used a direct mail campaign targeting neighborhoods with high concentrations of racial minorities, and sent mails to households with a possible Chinese family name. Invitational letter, interest survey and flyers are printed in traditional and simplified Chinese using large font. Flyers include a colorful graphic portraying diverse racial background. Prior to the mailing, we presented the study at senior centers, faith-based organizations, community centers and bingos that hosted higher rates of minority older adults. We posted study materials in Chinese language schools and Chinese “WeChat” groups. We also encouraged current participants to “tell a friend”. Chinese-English bilingual staff are trained and certified as recruiters. Within two months, over 50 participants from diverse neighborhoods are recruited. Our community-engaged, linguistically and culturally appropriate approach has been highly effective.

Little is known about the health and health behaviors of non-English Speaking late-life Asian immigrants, which is attributable to language and cultural barriers to participate research. In our Healthy Aging and Neighborhood Study, we collected objective measures of space and time use, location- and time-specific physical activities using accelerometer and Global Positioning System devices, and self-reported sleep quality and health. We obtained 3,915 person-days of accelerometer readings from 511 participants including 43 Asians. Compared to non-Hispanic Whites, Asians had worse self-rated health and poorer vision, more medical conditions and physical limitations as measured by ADL and IADL. Asians had higher daily step counts overall and at home; high proportions of steps on sidewalk or street and senior centers, lower in fee-based outdoor recreational areas, less in restaurant and vehicle. Sleep quality did not differ significantly between Asians and Whites. Risk profiles differed between Asians and Whites, which warrants further investigation.

Abstract Little is known about the health and health care needs of non-English Speaking late-life Asian immigrants. Due to language barriers and memory issues, self-report data are unreliable for investigating activity patterns in this population. In the ongoing NIA-funded Healthy Aging and Neighborhood Study, we developed a novel method to objectively measure space and time use, location- and time-specific physical and social activities using accelerometer (ACC) and Global Positioning System (GPS) devices. The study has recruited over 150 Caucasians and 150 minorities including 50 non-English speaking late-life Asian immigrants. The participants answered surveys in their preferred language (English, Spanish, traditional or simplified Chinese) and wore ACC/GPS devices for 7 to 10 full days. Activity levels and geographic locations are recorded every 30 seconds. Using the combined ACC/GPS data, time- and location-specific activity amounts, time use and mobility patterns are objectively measured. Baseline findings will be reported at the GSA conference.

Abstract Adequate minority participation is critical to health disparity research. Conventional direct mails are less effective in minority recruitment. The Healthy Aging and Neighborhood Study developed a multifaceted, community-engaged, culturally and linguistically appropriate method to recruit community-living older adults (≥65y) in Worcester County, Massachusetts. The research team is bilingual, racially and culturally diverse. A direct mail campaign was conducted in a geographically diverse random sample of residents from neighborhoods with high concentrations of minorities, stratified by rurality. To increase minority participation, the mailings included an invitational letter or a flyer with a graphic that portrays diverse racial/ethnic background. We engaged communities by presenting the study at senior and community centers, and faith-based organizations that are frequented by minorities and by posting study information in minority social media groups (e.g., Chinese resident associations). Participants promoted the study to friends while staff promoted through professional or social networks. To recruit non-English speaking minorities, all materials were printed in age-friendly large fonts in Spanish or Chinese, and interviews were conducted using their preferred language. Within 9 months, we enrolled 326 participants, including 216 Whites, 57 Hispanics, 21 Blacks, 31 Asians, and 1 Native American. An additional 38 Asians are on the waiting list. Blacks were more likely to respond to community presentations. Hispanics were most likely to respond to the colorful flyer. Older minorities (>76y) were more likely to respond to presentations (57%) while the younger (<75y) to the mailings (60%). In summary, this multifaceted recruitment approach is effective in minority recruitment.