Marcy Winget is the Director of the Evaluation Sciences Unit in the Division of Primary Care and Population Health, Stanford School of Medicine. She has a PhD in epidemiology and an MHS in biostatistics, both from Johns Hopkins Bloomberg School of Public Health. She has 25+ years’ experience in healthcare-related research. Her passion is conducting research aimed at improving the quality of the health care delivery system. Marcy joined Stanford in 2014 where she has led many projects evaluating a wide-range of healthcare delivery improvement efforts, both within and external to Stanford Health Care applying Implementation Science methods.

Current Role at Stanford

Director, Evaluation Sciences Unit

Education & Certifications

  • PhD, Johns Hopkins Bloomberg School of Public Health, Epidemiology (1996)
  • MHS, Johns Hopkins Bloomberg School of Public Health, Biostatistics (1992)
  • BS, University of California, Davis, Genetics (1985)


  • Evaluation of the Cancer Care Transformation Intitative, Stanford School of Medicine


    Stanford CA

All Publications

  • Trauma-Informed Healthcare Leadership? Evidence and opportunities from interviews with leaders during COVID-19. BMC health services research Harris, S. R., Amano, A., Winget, M., Skeff, K. M., Brown-Johnson, C. G. 2024; 24 (1): 515


    COVID-19 impacted the mental health of healthcare workers, who endured pressures as they provided care during a prolonged crisis. We aimed to explore whether and how a Trauma-Informed Care (TIC) approach was reflected in qualitative perspectives from healthcare leaders of their experience during COVID-19 (2020-2021).Semi-structured interviews with healthcare leaders from four institutions were conducted. Data analysis consisted of four stages informed by interpretative phenomenological analysis: 1) deductive coding using TIC assumptions, 2) inductive thematic analysis of coded excerpts, 3) keyword-in-context coding of full transcripts for 6 TIC principles with integration into prior inductive themes, and 4) interpretation of themes through 6 TIC principles (safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and awareness of cultural, historical, and gender issues).The actions of leaders (n = 28) that were reported as successful and supportive responses to the COVID-19 pandemic or else missed opportunities reflected core principles of Trauma-Informed Care. To promote safety, leaders reported affirmative efforts to protect staff by providing appropriate physical protection, and enhanced psychological safety by providing channels for communication about emotional well-being. To promote trustworthiness and transparency, leaders listened to their staff, shared current COVID-19 information, and increased frequency of meetings to disseminate accurate information. To promote mutual support, strategies included wellness check-ins, sharing uplifting stories, affirming common goals, articulating fears, and leading by example. Examples of empowerment included: making time and adjusting modalities for flexible communication; naming challenges outside of the hospital; and functioning as a channel for complaints. Reported missed opportunities included needing more dedicated time and space for healthcare employees to process emotions, failures in leadership managing their own anxiety, and needing better support for middle managers. Awareness of the TIC principle of cultural, historical, and gender issues was largely absent. Results informed the nascent Trauma-Informed Healthcare Leadership (TIHL) framework.We propose the Trauma-Informed Healthcare Leadership framework as a useful schema for action and analysis. This approach yields recommendations for healthcare leaders including creating designated spaces for emotional processing, and establishing consistent check-ins that reference personal and professional well-being.

    View details for DOI 10.1186/s12913-024-10946-9

    View details for PubMedID 38659009

    View details for PubMedCentralID 7946321

  • Evaluation of video visit appropriateness for common symptoms seen in primary care: A retrospective cohort study. Journal of telemedicine and telecare Chen, D., Gonzales, E., Winget, M., Shaw, J., Artandi, M., Tsai, S. A., Nelligan, I. 2024: 1357633X231224094


    INTRODUCTION: Little is known about which conditions seen in primary care are appropriate for video visits. This study evaluated video visits compared to office visits for six conditions: abdominal pain, joint pain, back pain, headache, chest pain, and dizziness.METHODS: Six hundred charts of adult patients from our institution's same-day outpatient clinic were reviewed in this study. Charts for video visits evaluating the aforementioned chief complaints that occurred between August and October 2020 were reviewed and compared with charts for office visits that occurred from August to September 2019. Frequencies of 3-week follow-up visits, Emergency Room visits, imaging, and referrals for office and video visits were measured. Reasons for in-person evaluation for patients seen by video were determined by review of clinician notes.RESULTS: Three-week in-person follow-up was more frequent for patients presenting with chest pain (52% vs 18%, p=0.0007) and joint pain (24% vs 8%, p=0.05) after video evaluation, relative to an office evaluation. Three-week in-person follow-up was also more frequent for patients presenting with dizziness (38% vs 28%) and low back pain (24% vs 14%); however, this difference was not statistically significant. Patients presenting with headache and abdominal pain did not have a higher rate of follow-up.DISCUSSION: Based on the frequency of in-person follow-up, this study suggests that video visits are generally adequate for evaluating headache and abdominal pain. Patients with dizziness and chest pain have the highest frequency of in-person and Emergency Room follow-up within 3 weeks when first seen by video compared to other conditions evaluated and may be less suitable for an initial video visit. Institutions can consider these findings when scheduling and providing guidance to patients on what type of visit is most appropriate for their symptoms.

    View details for DOI 10.1177/1357633X231224094

    View details for PubMedID 38254267

  • Medicine plus mindset: A mixed-methods evaluation of a novel mindset-focused training for primary care teams. Patient education and counseling Leibowitz, K. A., Howe, L. C., Winget, M., Brown-Johnson, C., Safaeinili, N., Shaw, J. G., Thakor, D., Kwan, L., Mahoney, M., Crum, A. J. 2024; 122: 108130


    Patient mindsets influence health outcomes; yet trainings focused on care teams' understanding, recognizing, and shaping patient mindsets do not exist. This paper aims to describe and evaluate initial reception of the "Medicine Plus Mindset" training program.Clinicians and staff at five primary care clinics (N = 186) in the San Francisco Bay Area received the Medicine Plus Mindset Training. The Medicine Plus Mindset training consists of a two-hour training program plus a one-hour follow-up session including: (a) evidence to help care teams understand patients' mindsets' influence on treatment; (b) a framework to support care teams in identifying specific patient mindsets; and (c) strategies to shape patient mindsets.We used a common model (Kirkpatrick) to evaluate the training based on participants' reaction, learnings, and behavior. Reaction: Participants rated the training as highly useful and enjoyable. Learnings: The training increased the perceived importance of mindsets in healthcare and improved self-reported efficacy of using mindsets in practice. Behavior: The training increased reported frequency of shaping patient mindsets.Development of this training and the study's results introduce a promising and feasible approach for integrating mindset into clinical practice. Practice Implications Mindset training can add a valuable dimension to clinical care and should be integrated into training and clinical practice.

    View details for DOI 10.1016/j.pec.2023.108130

    View details for PubMedID 38242012

  • A Nurse-Led Care Delivery App and Telehealth System for Patients Requiring Wound Care: Mixed Methods Implementation and Evaluation Study. JMIR formative research Brown-Johnson, C. G., Lessios, A. S., Thomas, S., Kim, M., Fukaya, E., Wu, S., Kling, S. M., Brown, G., Winget, M. 2023; 7: e43258


    Innovative solutions to nursing care are needed to address nurse, health system, patient, and caregiver concerns related to nursing wellness, work flexibility and control, workforce retention and pipeline, and access to patient care. One innovative approach includes a novel health care delivery model enabling nurse-led, off-hours wound care (PocketRN) to triage emergent concerns and provide additional patient health education via telehealth.This pilot study aimed to evaluate the implementation of PocketRN from the perspective of nurses and patients.Patients and part-time or per-diem, wound care-certified and generalist nurses were recruited through the Stanford Medicine Advanced Wound Care Center in 2021 and 2022. Qualitative data included semistructured interviews with nurses and patients and clinical documentation review. Quantitative data included app use and brief end-of-interaction in-app satisfaction surveys.This pilot study suggests that an app-based nursing care delivery model is acceptable, clinically appropriate, and feasible. Low technology literacy had a modest effect on initial patient adoption; this barrier was addressed with built-in outreach and by simplifying the patient experience (eg, via phone instead of video calls). This approach was acceptable for users, despite total patient enrollment and use numbers being lower than anticipated (N=49; 17/49, 35% of patients used the app at least once beyond the orientation call). We interviewed 10 patients: 7 who had used the app were satisfied with it and reported that real-time advice after hours reduced anxiety, and 3 who had not used the app after enrollment reported having other resources for health care advice and noted their perception that this tool was meant for urgent issues, which did not occur for them. Interviewed nurses (n=10) appreciated working from home, and they reported comfort with the scope of practice and added quality of care facilitated by video capabilities; there was interest in additional wound care-specific training for nonspecialized nurses. Nurses were able to provide direct patient care over the web, including the few participating nurses who were unable to perform in-person care (n=2).This evaluation provides insights into the integration of technology into standard health care services, such as in-clinic wound care. Using in-system nurses with access to electronic medical records and specialized knowledge facilitated app integration and continuity of care. This care delivery model satisfied nurse desires for flexible and remote work and reduced patient anxiety, potentially reducing postoperative wound care complications. Feasibility was negatively impacted by patients' technology literacy and few language options; additional patient training, education, and language support are needed to support equitable access. Adoption was impacted by a lack of perceived need for additional care; lower-touch or higher-acuity settings with a longer wait between visits could be a better fit for this type of nurse-led care.

    View details for DOI 10.2196/43258

    View details for PubMedID 37610798

  • Caregiver Experiences Participating in a Home-Based Primary Care Program: A Pragmatic Evaluation Including Qualitative Interviews and Quantitative Surveys. Journal of applied gerontology : the official journal of the Southern Gerontological Society Kling, S. M., Lessios, A. S., Holdsworth, L. M., Yefimova, M., Wu, S., Martin, M., Sheffrin, M., Winget, M. 2023: 7334648231176380


    The aim of this evaluation was to assess caregiver experience and burden during their first year in a geriatric home-based primary care (HBPC) program with qualitative interviews and surveys. HBPC included in-home visits for homebound, older adult patients. Seventeen caregivers, with varied amount of experience with HBPC, participated in semi-structured interviews. Change in caregiver burden from baseline was captured for 44 caregivers at 3months post-enrollment, 27 caregivers at 6months, and 22 caregivers at 12months. Satisfaction survey was administered at these timepoints, but the last response of 48 caregivers was analyzed. Caregiver interviews revealed three themes: caregiving stressors, reliance on HBPC in relation to other medical care, and healthcare in the home. Surveyed caregivers were highly satisfied, but burden did not change substantially over the 1year intervention. Caregivers appreciated HBPC reduced patient transportation and provided satisfactory primary care, but additional research is needed to tailor this care to reduce caregiver burden.

    View details for DOI 10.1177/07334648231176380

    View details for PubMedID 37269325

  • Evolution of a Project to Improve Inpatient-to-Outpatient Dermatology Care Transitions: Mixed Methods Evaluation. JMIR dermatology Kling, S. M., Aleshin, M. A., Saliba-Gustafsson, E. A., Garvert, D. W., Brown-Johnson, C. G., Amano, A., Kwong, B. Y., Calugar, A., Shaw, J. G., Ko, J. M., Winget, M. 2023; 6: e43389


    BACKGROUND: In-hospital dermatological care has shifted from dedicated dermatology wards to consultation services, and some consulted patients may require postdischarge follow-up in outpatient dermatology. Safe and timely care transitions from inpatient-to-outpatient specialty care are critical for patient health, but communication around these transitions can be disjointed, and workflows can be complex.OBJECTIVE: In this 3-phase quality improvement effort, we developed and evaluated an intervention that leveraged an electronic health record (EHR) feature, known as SmartPhrase, to enable a new workflow to improve transitions from inpatient care to outpatient dermatology.METHODS: Phase 1 (February-March 2021) included interviews with patients and process mapping with key stakeholders to identify gaps and inform an intervention: a SmartPhrase table and associated workflow to promote collection of patient information needed for scheduling follow-up and closed-loop communication between dermatology and scheduling teams. In phase 2 (April-May 2021), semistructured interviews-with dermatologists (n=5), dermatology residents (n=5), and schedulers (n=6)-identified pain points and refinements. In phase 3, the intervention was evaluated by triangulating data from these interviews with measured changes in scheduling efficiency, visit completion, and messaging volume preimplementation (January-February 2021) and postimplementation (April-May 2021).RESULTS: Preintervention pain points included unclear workflow for care transitions, limited patient input in follow-up planning, multiple messaging channels (eg, EHR based, email, and phone messages), and time-inefficient patient tracking. The intervention addressed most pain points; interviewees reported the intervention was easy to adopt and improved scheduling efficiency, workload, and patient involvement. More visits were completed within the desired timeframe of 14 days after discharge during the postimplementation period (21/47, 45%) than the preimplementation period (28/41, 68%; P=.03). The messaging workload also decreased from 88 scheduling-related messages sent for 25 patients before implementation to 30 messages for 8 patients after implementation.CONCLUSIONS: Inpatient-to-outpatient specialty care transitions are complex and involve multiple stakeholders, thus requiring multifaceted solutions. With deliberate evaluation, broad stakeholder input, and iteration, we designed and implemented a successful solution using a standard EHR feature, SmartPhrase, integrated into a standardized workflow to improve the timeliness of posthospital specialty care and reduce workload.

    View details for DOI 10.2196/43389

    View details for PubMedID 37632927

  • Perspectives on the Intersection of Electronic Health Records and Health Care Team Communication, Function, and Well-being. JAMA network open Amano, A., Brown-Johnson, C. G., Winget, M., Sinha, A., Shah, S., Sinsky, C. A., Sharp, C., Shanafelt, T., Skeff, K. 2023; 6 (5): e2313178


    Understanding of the interplay between the electronic health record (EHR), health care team relations, and physician well-being is currently lacking. Approaches to cultivate interpersonal interactions may be necessary to complement advancements in health information technology with high-quality team function.To examine ways in which the EHR, health care team functioning, and physician well-being intersect and interact.Secondary qualitative analysis of semistructured interview data from 2 studies used keyword-in-context approaches to identify excerpts related to teams. Thematic analysis was conducted using pattern coding, then organized using the relationship-centered organization model. Two health care organizations in California from March 16 to October 13, 2017, and February 28 to April 21, 2022, participated, with respondents including attending and resident physicians.Across data sets, themes centered around the interactions between the EHR, health care team functioning, and physician well-being. The first study data focused on EHR-related distressing events and their role in attending physician and resident physician emotions and actions. The second study focused on EHR use and daily EHR irritants.The 73 respondents included attending physicians (53 [73%]) and resident physicians (20 [27%]). Demographic data were not collected. Participants worked in ambulatory specialties (33 [45%]), hospital medicine (10 [14%]), and surgery (10 [14%]). The EHR was reported to be the dominant communication modality among all teams. Interviewees indicated that the EHR facilitates task-related communication and is well suited to completing simple, uncomplicated tasks. However, EHR-based communication limited the rich communication and social connection required for building relationships and navigating conflict. The EHR was found to negatively impact team function by promoting disagreement and introducing areas of conflict into team relationships related to medical-legal pressures, role confusion, and undefined norms around EHR-related communication. In addition, interviewees expressed that physician EHR-related distress affects interactions within the team, eroding team well-being.In this study, the EHR supported task-oriented and efficient communication among team members to get work done and care for patients; however, participants felt that the technology shifts attention away from the human needs of the care team that are necessary for developing relationships, building trust, and resolving conflicts. Interventions to cultivate interpersonal interactions and team function are necessary to complement the efficiency benefits of health information technology.

    View details for DOI 10.1001/jamanetworkopen.2023.13178

    View details for PubMedID 37171816

  • Evaluating the Implementation of Patient-Reported Outcomes in Heart Failure Clinic: A Qualitative Assessment. Circulation. Cardiovascular quality and outcomes Brown-Johnson, C., Calma, J., Amano, A., Winget, M., Harris, S. R., Vilendrer, S., Asch, S. M., Heidenreich, P., Sandhu, A. T., Kalwani, N. M. 2023: e009677


    Patient-reported outcomes (PROs) may improve care for patients with heart failure. The Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) is a patient survey that captures symptom frequency, symptom burden, physical limitations, social limitations, and quality of life. Despite the utility of PROs and the KCCQ-12, the implementation and routine use of these measures can be difficult. We conducted an evaluation of clinician perceptions of the KCCQ-12 to identify barriers and facilitators to implementation into clinical practice.We conducted interviews with cardiologists from 4 institutions across the United States and Canada (n=16) and observed clinic visits at 1 institution in Northern California (n=5). Qualitative analysis was conducted in 2 rounds: (1) rapid analysis constructed around major themes related to the aims of the study and (2) content analysis with codes derived from the rapid analysis and implementation science.Most heart failure physicians and advanced practice clinicians reported that the KCCQ-12 was acceptable, appropriate, and useful in clinical care. Clinician engagement efforts, trialability, and the straightforward design of the KCCQ-12 facilitated its use in clinical care. Further opportunities identified to facilitate implementation include more streamlined integration into the electronic health record and comprehensive staff education on PROs. Participants highlighted that the KCCQ-12 was useful in clinic visits to improve the consistency of patient history taking, focus patient-clinician conversations, collect a more accurate account of patient quality of life, track trends in patient well-being over time, and refine clinical decision-making.In this qualitative study, clinicians reported that the KCCQ-12 enhanced several aspects of heart failure patient care. Use of the KCCQ-12 was facilitated by a robust clinician engagement campaign and the design of the KCCQ-12 itself. Future implementation of PROs in heart failure clinic should focus on streamlining electronic health record integration and providing additional staff education on the value of PROs.URL:; Unique identifier: NCT04164004.

    View details for DOI 10.1161/CIRCOUTCOMES.122.009677

    View details for PubMedID 37114990

  • Home-Based Primary Care for Older Adults: Matched Case-Control Evaluation of Program's Impact on Healthcare Utilization HOME HEALTH CARE MANAGEMENT AND PRACTICE Kling, S. R., Garvert, D. W., Lessios, A., Yefimova, M., Martin, M., Sheffrin, M., Winget, M. 2023
  • Factors Associated with the Breast Cancer Diagnostic Interval across Five Canadian Provinces: A CanIMPACT Retrospective Cohort Study. Cancers Ruco, A., Groome, P. A., McBride, M. L., Decker, K. M., Grunfeld, E., Jiang, L., Kendell, C., Lofters, A., Urquhart, R., Vu, K., Winget, M. 2023; 15 (2)


    The cancer diagnostic process can be protracted, and it is a time of great anxiety for patients. The objective of this study was to examine inter- and intra-provincial variation in diagnostic intervals and explore factors related to the variation. This was a multi-province retrospective cohort study using linked administrative health databases. All females with a diagnosis of histologically confirmed invasive breast cancer in British Columbia (2007-2010), Manitoba (2007-2011), Ontario (2007-2010), Nova Scotia (2007-2012), and Alberta (2004-2010) were included. The start of the diagnostic interval was determined using algorithms specific to whether the patient's cancer was detected through screening. We used multivariable quantile regression analyses to assess the association between demographic, clinical and healthcare utilization factors with the diagnostic interval outcome. We found significant inter- and intra-provincial variation in the breast cancer diagnostic interval and by screen-detection status; patients who presented symptomatically had longer intervals than screen-detected patients. Interprovincial diagnostic interval variation was 17 and 16 days for screen- and symptom-detected patients, respectively, at the median, and 14 and 41 days, respectively, at the 90th percentile. There was an association of longer diagnostic intervals with increasing comorbid disease in all provinces in non-screen-detected patients but not screen-detected. Longer intervals were observed across most provinces in screen-detected patients living in rural areas. Having a regular primary care provider was not associated with a shorter diagnostic interval. Our results highlight important findings regarding the length of the breast cancer diagnostic interval, its variation within and across provinces, and its association with comorbid disease and rurality. We conclude that diagnostic processes can be context specific, and more attention should be paid to developing tailored processes so that equitable access to a timely diagnosis can be achieved.

    View details for DOI 10.3390/cancers15020404

    View details for PubMedID 36672357

  • Targeting Repetitive Laboratory Testing with Electronic Health Records-Embedded Predictive Decision Support: A Pre-Implementation Study. Clinical biochemistry Rabbani, N., Ma, S. P., Li, R. C., Winget, M., Weber, S., Boosi, S., Pham, T. D., Svec, D., Shieh, L., Chen, J. H. 2023


    INTRODUCTION: Unnecessary laboratory testing contributes to patient morbidity and healthcare waste. Despite prior attempts at curbing such overutilization, there remains opportunity for improvement using novel data-driven approaches. This study presents the development and early evaluation of a clinical decision support tool that uses a predictive model to help providers reduce low-yield, repetitive laboratory testing in hospitalized patients.METHODS: We developed an EHR-embedded SMART on FHIR application that utilizes a laboratory test result prediction model based on historical laboratory data. A combination of semi-structured physician interviews, usability testing, and quantitative analysis on retrospective laboratory data were used to inform the tool's development and evaluate its acceptability and potential clinical impact.KEY RESULTS: Physicians identified culture and lack of awareness of repeat orders as key drivers for overuse of inpatient blood testing. Users expressed an openness to a lab prediction model and 13/15 physicians believed the tool would alter their ordering practices. The application received a median System Usability Scale score of 75, corresponding to the 75th percentile of software tools. On average, physicians desired a prediction certainty of 85% before discontinuing a routine recurring laboratory order and a higher certainty of 90% before being alerted. Simulation on historical lab data indicates that filtering based on accepted thresholds could have reduced 22% of repeat chemistry panels.CONCLUSIONS: The use of a predictive algorithm as a means to calculate the utility of a diagnostic test is a promising paradigm for curbing laboratory test overutilization. An EHR-embedded clinical decision support tool employing such a model is a novel and acceptable intervention with the potential to reduce low-yield, repetitive laboratory testing.

    View details for DOI 10.1016/j.clinbiochem.2023.01.002

    View details for PubMedID 36623759

  • "Never waste a good crisis": A qualitative study of the impact of COVID-19 on palliative care in seven hospitals using the Dynamic Sustainability Framework. Palliative medicine Holdsworth, L. M., Mui, H. Z., Winget, M., Lorenz, K. A. 2022: 2692163221123966


    BACKGROUND: The COVID-19 pandemic led to rapid adaptations among palliative care services, but it is unclear how these adaptations vary in relation to their unique organizational contexts.AIM: Understand how the pandemic impacted the implementation of new and existing palliative care programs in diverse hospital systems using the Dynamic Sustainability Framework.DESIGN: Twelve in-depth interviews with 15 key informants representing palliative care programs from seven hospital systems between April and June 2020.SETTING: Public, not-for-profit private, community, and academic teaching hospitals in the San Francisco Bay Area with existing palliative care programs that were expanding services to new clinical areas (e.g. new outpatient clinic or community-based care).RESULTS: Six themes characterized how palliative care programs were impacted and adapted during the early stages of the COVID-19 pandemic: palliative care involvement in preparing for surge, increased emphasis on advance care planning, advocating for visitors for dying patients, providing emotional support to clinicians, adopting virtual approaches to care, and gaps in chaplaincy support. There was variation in how new and existing programs were able to adapt to early pandemic stresses; systems with new outpatient programs struggled to utilize their programs effectively during the crisis onset.CONCLUSIONS: The fit between palliative care programs and practice setting was critical to program resiliency during the early stages of the pandemic. Reconceptualizing the Dynamic Sustainability Framework to reflect a bidirectional relationship between ecological system, practice setting, and intervention levels might better guide implementers and researchers in understanding how ecological/macro changes can influence interventions on the ground.

    View details for DOI 10.1177/02692163221123966

    View details for PubMedID 36305617

  • The Patient-Reported Outcome Measurement in Heart Failure Clinic Trial: Rationale and Methods of The PRO-HF Trial. American heart journal Kalwani, N. M., Calma, J., Varghese, G. M., Gupta, A., Zheng, J., Brown-Johnson, C., Amano, A., Vilendrer, S., Winget, M., Asch, S. M., Heidenreich, P., Sandhu, A. 2022


    BACKGROUND: Among patients with heart failure (HF), patient-reported health status provides information beyond standard clinician assessment. Although HF management guidelines recommend collecting patient-reported health status as part of routine care, there is minimal data on the impact of this intervention.STUDY DESIGN: The Patient-Reported Outcomes in Heart Failure Clinic (PRO-HF) trial is a pragmatic, randomized, implementation-effectiveness trial testing the hypothesis that routine health status assessment via the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) leads to an improvement in patient-reported health status among patients treated in a tertiary health system HF clinic. PRO-HF has completed randomization of 1,248 participants to routine KCCQ-12 assessment or usual care. Patients randomized to the KCCQ-12 arm complete KCCQ-12 assessments before each HF clinic visit with the results shared with their treating clinician. Clinicians received education regarding the interpretation and potential utility of the KCCQ-12. The primary endpoint is the change in KCCQ-12 over 1 year. Secondary outcomes are HF therapy patterns and healthcare utilization, including clinic visits, testing, hospitalizations, and emergency department (ED) visits. As a sub-study, PRO-HF also evaluated the impact of routine KCCQ-12 assessment on patient experience and the accuracy of clinician-assessed health status. In addition, clinicians completed semi-structured interviews to capture their perceptions on the trial's implementation of routine KCCQ-12 assessment in clinical practice.CONCLUSIONS: PRO-HF is a pragmatic, randomized trial based in a real-world HF clinic to determine the feasibility of routinely assessing patient-reported health status and the impact of this intervention on health status, care delivery, patient experience, and the accuracy of clinician health status assessment.

    View details for DOI 10.1016/j.ahj.2022.10.081

    View details for PubMedID 36309127

  • Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine. Learning health systems Vilendrer, S., Saliba-Gustafsson, E. A., Asch, S. M., Brown-Johnson, C. G., Kling, S. M., Shaw, J. G., Winget, M., Larson, D. B. 2022; 6 (4): e10335


    Many healthcare delivery systems have developed clinician-led quality improvement (QI) initiatives but fewer have also developed in-house evaluation units. Engagement between the two entities creates unique opportunities. Stanford Medicine funded a collaboration between their Improvement Capability Development Program (ICDP), which coordinates and incentivizes clinician-led QI efforts, and the Evaluation Sciences Unit (ESU), a multidisciplinary group of embedded researchers with expertise in implementation and evaluation sciences.To describe the ICDP-ESU partnership and report key learnings from the first 2 y of operation September 2019 to August 2021.Department-level physician and operational QI leaders were offered an ESU consultation to workshop design, methods, and overall scope of their annual QI projects. A steering committee of high-level stakeholders from operational, clinical, and research perspectives subsequently selected three projects for in-depth partnered evaluation with the ESU based on evaluability, importance to the health system, and broader relevance. Selected project teams met regularly with the ESU to develop mixed methods evaluations informed by relevant implementation science frameworks, while aligning the evaluation approach with the clinical teams' QI goals.Sixty and 62 ICDP projects were initiated during the 2 cycles, respectively, across 18 departments, of which ESU consulted with 15 (83%). Within each annual cycle, evaluators made actionable, summative findings rapidly available to partners to inform ongoing improvement. Other reported benefits of the partnership included rapid adaptation to COVID-19 needs, expanded clinician evaluation skills, external knowledge dissemination through scholarship, and health system-wide knowledge exchange. Ongoing considerations for improving the collaboration included the need for multi-year support to enable nimble response to dynamic health system needs and timely data access.Presence of embedded evaluation partners in the enterprise-wide QI program supported identification of analogous endeavors (eg, telemedicine adoption) and cross-cutting lessons across QI efforts, clinician capacity building, and knowledge dissemination through scholarship.

    View details for DOI 10.1002/lrh2.10335

    View details for PubMedID 36263267

    View details for PubMedCentralID PMC9576232

  • Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine LEARNING HEALTH SYSTEMS Vilendrer, S., Saliba-Gustafsson, E. A., Asch, S. M., Brown-Johnson, C. G., Kling, S. R., Shaw, J. G., Winget, M., Larson, D. B. 2022

    View details for DOI 10.1002/lrh2.10335

    View details for Web of Science ID 000843397900001

  • Professional Behavior and Value Erosion: A Qualitative Study of Physicians and the Electronic Health Record. Journal of healthcare management / American College of Healthcare Executives Skeff, K. M., Brown-Johnson, C. G., Asch, S. M., Zionts, D. L., Winget, M., Kerem, Y. 2022


    GOAL: Occurrences of physician burnout have reached epidemic numbers, and the electronic health record (EHR) is a commonly cited cause of the distress. To enhance current understanding of the relationship between burnout and the EHR, we explored the connections between physicians' distress and the EHR.METHODS: In this qualitative study, physicians and graduate medical trainees from two healthcare organizations in California were interviewed about EHR-related distressing events and the impact on their emotions and actions. We analyzed physician responses to identify themes regarding the negative impact of the EHR on physician experience and actions. EHR "distressing events" were categorized using the Accreditation Council for Graduate Medical Education (ACGME) Physician Professional Competencies.PRINCIPAL FINDINGS: Every participating physician reported EHR-related distress affecting professional activities. Five main themes emerged from our analysis: system blocks to patient care; poor implementation, design, and functionality of the EHR; billing priorities conflicting with ideal workflow and best-practice care; lack of efficiency; and poor teamwork function. When mapped to the ACGME competencies, physician distress frequently stemmed from situations where physicians prioritized systems-based practice above other desired professional actions and behaviors. Physicians also reported a climate of silence in which physicians would not share problems due to fear of retribution or lack of confidence that the problems would be addressed.PRACTICAL APPLICATIONS: Physicians and administrators need to address the hierarchy of values that prioritizes system requirements such as those required by the EHR above physicians' other desired professional actions and behaviors. Balancing the importance of competing competencies may help to address rising burnout. We also recommend that administrators consider qualitative anonymous interviews as an effective method to uncover and understand physician distress in light of physicians' reported climate of silence.

    View details for DOI 10.1097/JHM-D-21-00070

    View details for PubMedID 35984408

  • Teledermatology to Facilitate Patient Care Transitions From Inpatient to Outpatient Dermatology: Mixed Methods Evaluation. Journal of medical Internet research Kling, S. M., Saliba-Gustafsson, E. A., Winget, M., Aleshin, M. A., Garvert, D. W., Amano, A., Brown-Johnson, C. G., Kwong, B. Y., Calugar, A., El-Banna, G., Shaw, J. G., Asch, S. M., Ko, J. M. 2022; 24 (8): e38792


    BACKGROUND: Both clinicians and patients have increasingly turned to telemedicine to improve care access, even in physical examination-dependent specialties such as dermatology. However, little is known about whether teledermatology supports effective and timely transitions from inpatient to outpatient care, which is a common care coordination gap.OBJECTIVE: Using mixed methods, this study sought to retrospectively evaluate how teledermatology affected clinic capacity, scheduling efficiency, and timeliness of follow-up care for patients transitioning from inpatient to outpatient dermatology care.METHODS: Patient-level encounter scheduling data were used to compare the number and proportion of patients who were scheduled and received in-clinic or video dermatology follow-ups within 14 and 90 days after discharge across 3 phases: June to September 2019 (before teledermatology), June to September 2020 (early teledermatology), and February to May 2021 (sustained teledermatology). The time from discharge to scheduling and completion of patient follow-up visits for each care modality was also compared. Dermatology clinicians and schedulers were also interviewed between April and May 2021 to assess their perceptions of teledermatology for postdischarge patients.RESULTS: More patients completed follow-up within 90 days after discharge during early (n=101) and sustained (n=100) teledermatology use than at baseline (n=74). Thus, the clinic's capacity to provide follow-up to patients transitioning from inpatient increased from baseline by 36% in the early (101 from 74) and sustained (100 from 74) teledermatology periods. During early teledermatology use, 61.4% (62/101) of the follow-ups were conducted via video. This decreased significantly to 47% (47/100) in the following year, when COVID-19-related restrictions started to lift (P=.04), indicating more targeted but still substantial use. The proportion of patients who were followed up within the recommended 14 days after discharge did not differ significantly between video and in-clinic visits during the early (33/62, 53% vs 15/39, 38%; P=.15) or sustained (26/53, 60% vs 28/47, 49%; P=.29) teledermatology periods. Interviewees agreed that teledermatology would continue to be offered. Most considered postdischarge follow-up patients to be ideal candidates for teledermatology as they had undergone a recent in-person assessment and might have difficulty attending in-clinic visits because of competing health priorities. Some reported patients needing technological support. Ultimately, most agreed that the choice of follow-up care modality should be the patient's own.CONCLUSIONS: Teledermatology could be an important tool for maintaining accessible, flexible, and convenient care for recently discharged patients needing follow-up care. Teledermatology increased clinic capacity, even during the pandemic, although the timeliness of care transitions did not improve. Ultimately, the care modality should be determined through communication with patients to incorporate their and their caregivers' preferences.

    View details for DOI 10.2196/38792

    View details for PubMedID 35921146

  • A 360 degree mixed-methods evaluation of a specialized COVID-19 outpatient clinic and remote patient monitoring program. BMC primary care Vilendrer, S., Lestoquoy, A., Artandi, M., Barman, L., Cannon, K., Garvert, D. W., Halket, D., Holdsworth, L. M., Singer, S., Vaughan, L., Winget, M. 2022; 23 (1): 151


    BACKGROUND: Our goals are to quantify the impact on acute care utilization of a specialized COVID-19 clinic with an integrated remote patient monitoring program in an academic medical center and further examine these data with stakeholder perceptions of clinic effectiveness and acceptability.METHODS: A retrospective cohort was drawn from enrolled and unenrolled ambulatory patients who tested positive in May through September 2020 matched on age, presence of comorbidities and other factors. Qualitative semi-structured interviews with patients, frontline clinician, and administrators were analyzed in an inductive-deductive approach to identify key themes.RESULTS: Enrolled patients were more likely to be hospitalized than unenrolled patients (N=11/137 in enrolled vs 2/126 unenrolled, p=.02), reflecting a higher admittance rate following emergency department (ED) events among the enrolled vs unenrolled, though this was not a significant difference (46% vs 25%, respectively, p=.32). Thirty-eight qualitative interviews conducted June to October 2020 revealed broad stakeholder belief in the clinic's support of appropriate care escalation. Contrary to beliefs the clinic reduced inappropriate care utilization, no difference was seen between enrolled and unenrolled patients who presented to the ED and were not admitted (N=10/137 in enrolled vs 8/126 unenrolled, p=.76). Administrators and providers described the clinic's integral role in allowing health services to resume in other areas of the health system following an initial lockdown.CONCLUSIONS: Acute care utilization and multi-stakeholder interviews suggest heightened outpatient observation through a specialized COVID-19 clinic and remote patient monitoring program may have contributed to an increase in appropriate acute care utilization. The clinic's role securing safe reopening of health services systemwide was endorsed as a primary, if unmeasured, benefit.

    View details for DOI 10.1186/s12875-022-01734-7

    View details for PubMedID 35698064

  • Patient and Health Professional Perceptions of Telemonitoring for Hypertension Management: Qualitative Study. JMIR formative research Baratta, J., Brown-Johnson, C., Safaeinili, N., Goldman Rosas, L., Palaniappan, L., Winget, M., Mahoney, M. 2022; 6 (6): e32874


    BACKGROUND: Hypertension is the most prevalent and important risk factor for cardiovascular disease, affecting nearly 50% of the US adult population; however, only 30% of these patients achieve controlled blood pressure (BP). Incorporating strategies into primary care that take into consideration individual patient needs, such as remote BP monitoring, may improve hypertension management.OBJECTIVE: From March 2018 to December 2018, Stanford implemented a precision health pilot called Humanwide, which aimed to leverage high-technology and high-touch medicine to tailor individualized care for conditions such as hypertension. We examined multi-stakeholder perceptions of hypertension management in Humanwide to evaluate the program's acceptability, appropriateness, feasibility, and sustainability.METHODS: We conducted semistructured interviews with 16 patients and 15 health professionals to assess their experiences with hypertension management in Humanwide. We transcribed and analyzed the interviews using a hybrid approach of inductive and deductive analysis to identify common themes around hypertension management and consensus methods to ensure reliability and validity.RESULTS: A total of 63% (10/16) of the patients and 40% (6/15) of the health professionals mentioned hypertension in the context of Humanwide. These participants reported that remote BP monitoring improved motivation, BP control, and overall clinic efficiency. The health professionals discussed feasibility challenges, including the time needed to analyze BP data and provide individualized feedback, integration of BP data, technological difficulties with the BP cuff, and decreased patient use of remote BP monitoring over time.CONCLUSIONS: Remote BP monitoring for hypertension management in Humanwide was acceptable to patients and health professionals and appropriate for care. Important challenges need to be addressed to improve the feasibility and sustainability of this approach by leveraging team-based care, engaging patients to sustain remote BP monitoring, standardizing electronic medical record integration of BP measurements, and finding more user-friendly BP cuffs.

    View details for DOI 10.2196/32874

    View details for PubMedID 35687380

  • Gearing Up for a Vaccine Requirement: A Mixed Methods Study of COVID-19 Vaccine Confidence Among Workers at an Academic Medical Center. Journal of healthcare management / American College of Healthcare Executives Mahoney, M., Winget, M., Brown-Johnson, C., de Borba, L., Veruttipong, D., Luu, J., Jones, D., Bohman, B., Vilendrer, S. 2022; 67 (3): 206-220


    Assessing barriers to vaccination among healthcare workers may be particularly important given their roles in their respective communities. We conducted a mixed methods study to explore healthcare worker perspectives on receiving COVID-19 vaccines at a large multisite academic medical center.A total of 5,917 employees completed the COVID-19 vaccine confidence survey (20% response rate). Most participants were vaccinated (93%). Compared to vaccinated participants, unvaccinated participants were younger (60% < 44 years), more likely to be from a non-Asian minority group (48%), and more likely to be nonclinical employees (57% vs. 46%). Among the unvaccinated respondents, 53% indicated they would be influenced by their healthcare provider, while 19% reported that nothing would influence them to get vaccinated. Key perceived barriers to vaccination from the qualitative analysis included the need for more long-term safety and efficacy data, a belief in the right to make an individual choice, mistrust, a desire for greater public health information, personal health concerns, circumstances such as prior COVID-19 infection, and access issues.Strategies endorsed by some participants to address their concerns about safety and access included a communication campaign, personalized medicine approaches (e.g., individual appointments to discuss how the vaccine might interact with personal health conditions), and days off to recover. Mistrust and a belief in the right to make an individual choice may be harder barriers to overcome; further dialogue is needed.These findings reflect potential strategies for vaccine requirements that healthcare organizations can implement to enhance vaccine confidence. In addition, organizations can ask respected health professionals to serve as spokespeople, which may help shift the perspectives of unvaccinated healthcare workers.

    View details for DOI 10.1097/JHM-D-21-00226

    View details for PubMedID 35576446

  • Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits. Neurology. Clinical practice Kling, S. M., Falco-Walter, J. J., Saliba-Gustafsson, E. A., Garvert, D. W., Brown-Johnson, C. G., Miller-Kuhlmann, R., Shaw, J. G., Asch, S. M., Yang, L., Gold, C. A., Winget, M. 1800; 11 (6): 472-483


    Background and Objectives: To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties.Methods: Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return).Results: Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination.Discussion: Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

    View details for DOI 10.1212/CPJ.0000000000001065

    View details for PubMedID 34992955

  • Characterizing patient flow after an academic hospital merger and acquisition. The American journal of managed care Sun, R., Bozkurt, S., Winget, M., Cullen, M. R., Seto, T., Hernandez-Boussard, T. 2021; 27 (10): e343-e348


    OBJECTIVES: Hospital mergers and acquisitions are increasingly used as a strategy to facilitate value-based care. However, no studies have assessed health care utilization (HCU) and patient flow across merged institutions. We aim to evaluate patient population distribution, HCU, and patient flow across a recent hospital merger of an academic medical center (AMC), a primary and specialty care alliance (PSC), and a community-based medical center (CMC).STUDY DESIGN: This was a retrospective observational study.METHODS: The study used 2018 adult demographic and encounter data from electronic health records. Patients' parent health care institution was determined by the most frequently visited site of face-to-face visits. Differences in patient demographics and HCU (ie, emergency department [ED] visits, hospitalizations, primary care visits) were compared. Independent factors associated with utilization were identified using adjusted logistic regression models.RESULTS: A total of 406,303 adult patients were identified in the cohort. The PSC setting, compared with the AMC and the CMC, had significantly more female (62.7% vs 54.4% and 58.5%, respectively), older (mean [SD] age, 52.0 [18.1] vs 51.1 [17.8] and 49.2 [17.8] years), and privately insured (63.6% vs 51.3% and 56.0%) patients. A higher proportion of patients at the CMC (27.5%) visited the ED compared with patients at the AMC (10.8%). Approximately 1645 primary care patients (7%) at the CMC setting went to the AMC for specialized care such as oncology, surgery, and neurology.CONCLUSIONS: Hospital mergers are increasing across the United States, allowing AMCs to expand their reach. These findings suggest that patients mainly sought care at their parent health care institution, yet appropriately received specialized care at the AMC. These results provide insights for future mergers and guide resource allocation and opportunities for improving care delivery.

    View details for DOI 10.37765/ajmc.2021.88764

    View details for PubMedID 34668676

  • Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support. Annals of family medicine Shaw, J. G., Winget, M., Brown-Johnson, C., Seay-Morrison, T., Garvert, D. W., Levine, M., Safaeinili, N., Mahoney, M. R. 2021; 19 (5): 411-418


    PURPOSE: Assess effectiveness of Primary Care 2.0: a team-based model that incorporates increased medical assistant (MA) to primary care physician (PCP) ratio, integration of advanced practice clinicians, expanded MA roles, and extended the interprofessional team.METHODS: Prospective, quasi-experimental evaluation of staff/clinician team development and wellness survey data, comparing Primary Care 2.0 to conventional clinics within our academic health care system. We surveyed before the model launch and every 6-9 months up to 24 months post implementation. Secondary outcomes (cost, quality metrics, patient satisfaction) were assessed via routinely collected operational data.RESULTS: Team development significantly increased in the Primary Care 2.0 clinic, sustained across all 3 post implementation time points (+12.2, +8.5, + 10.1 respectively, vs baseline, on the 100-point Team Development Measure) relative to the comparison clinics. Among wellness domains, only "control of work" approached significant gains (+0.5 on a 5-point Likert scale, P = .05), but was not sustained. Burnout did not have statistically significant relative changes; the Primary Care 2.0 site showed a temporal trend of improvement at 9 and 15 months. Reversal of this trend at 2 years corresponded to contextual changes, specifically, reduced MA to PCP staffing ratio. Adjusted models confirmed an inverse relationship between team development and burnout (P <.0001). Secondary outcomes generally remained stable between intervention and comparison clinics with suggestion of labor cost savings.CONCLUSIONS: The Primary Care 2.0 model of enhanced team-based primary care demonstrates team development is a plausible key to protect against burnout, but is not sufficient alone. The results reinforce that transformation to team-based care cannot be a 1-time effort and institutional commitment is integral.

    View details for DOI 10.1370/afm.2714

    View details for PubMedID 34546947

  • Predicting and Responding to Clinical Deterioration in Hospitalized Patients by Using Artificial Intelligence: Protocol for a Mixed Methods, Stepped Wedge Study. JMIR research protocols Holdsworth, L. M., Kling, S. M., Smith, M., Safaeinili, N., Shieh, L., Vilendrer, S., Garvert, D. W., Winget, M., Asch, S. M., Li, R. C. 2021; 10 (7): e27532


    BACKGROUND: The early identification of clinical deterioration in patients in hospital units can decrease mortality rates and improve other patient outcomes; yet, this remains a challenge in busy hospital settings. Artificial intelligence (AI), in the form of predictive models, is increasingly being explored for its potential to assist clinicians in predicting clinical deterioration.OBJECTIVE: Using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, this study aims to assess whether an AI-enabled work system improves clinical outcomes, describe how the clinical deterioration index (CDI) predictive model and associated work processes are implemented, and define the emergent properties of the AI-enabled work system that mediate the observed clinical outcomes.METHODS: This study will use a mixed methods approach that is informed by the SEIPS 2.0 model to assess both processes and outcomes and focus on how physician-nurse clinical teams are affected by the presence of AI. The intervention will be implemented in hospital medicine units based on a modified stepped wedge design featuring three stages over 11 months-stage 0 represents a baseline period 10 months before the implementation of the intervention; stage 1 introduces the CDI predictions to physicians only and triggers a physician-driven workflow; and stage 2 introduces the CDI predictions to the multidisciplinary team, which includes physicians and nurses, and triggers a nurse-driven workflow. Quantitative data will be collected from the electronic health record for the clinical processes and outcomes. Interviews will be conducted with members of the multidisciplinary team to understand how the intervention changes the existing work system and processes. The SEIPS 2.0 model will provide an analytic framework for a mixed methods analysis.RESULTS: A pilot period for the study began in December 2020, and the results are expected in mid-2022.CONCLUSIONS: This protocol paper proposes an approach to evaluation that recognizes the importance of assessing both processes and outcomes to understand how a multifaceted AI-enabled intervention affects the complex team-based work of identifying and managing clinical deterioration.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/27532.

    View details for DOI 10.2196/27532

    View details for PubMedID 34255728

  • Implementation outcomes of Humanwide: integrated precision health in team-based family practice primary care. BMC family practice Brown-Johnson, C. G., Safaeinili, N., Baratta, J., Palaniappan, L., Mahoney, M., Rosas, L. G., Winget, M. 2021; 22 (1): 28


    BACKGROUND: Humanwide was precision health embedded in primary care aiming to leverage high-tech and high-touch medicine to promote wellness, predict and prevent illness, and tailor treatment to individual medical and psychosocial needs.METHODS: We conducted a study assessing implementation outcomes to inform spread and scale, using mixed methods of semi-structured interviews with diverse stakeholders and chart reviews. Humanwide included: 1) health coaching; 2) four digital health tools for blood-pressure, weight, glucose, and activity; 3) pharmacogenomic testing; and 4) genetic screening/testing. We examined implementation science constructs: reach/penetration, acceptability, feasibility, and sustainability. Chart reviews captured preliminary clinical outcomes.RESULTS: Fifty of 69 patients (72%) invited by primary care providers participated in the Humanwide pilot. We performed chart reviews for the 50 participating patients. Participants were diverse overall (50% non-white, 66% female). Over half of the participants were obese and 58% had one or more major cardiovascular risk factor: dyslipidemia, hypertension, diabetes. Reach/penetration of Humanwide components varied: pharmacogenomics testing 94%, health coaching 80%, genetic testing 72%, and digital health 64%. Interview participants (n=27) included patients (n=16), providers (n=9), and the 2 staff who were allocated dedicated time for Humanwide patient intake and orientation. Patients and providers reported Humanwide was acceptable; it engaged patients holistically, supported faster medication titration, and strengthened patient-provider relationships. All patients benefited clinically from at least one Humanwide component. Feasibility challenges included: low provider self-efficacy for interpreting genetics and pharmacogenomics; difficulties with data integration; patient technology challenges; and additional staffing needs. Patient financial burden concerns surfaced with respect to sustainability.CONCLUSION: This is the first report of implementation of a multi-component precision health model embedded in team-based primary care. We found acceptance from both patients and providers; however, feasibility barriers must be overcome to enable broad spread and sustainability. We found that barriers to implementation of precision health in a team-based primary care clinic are mundane and straightforward, though not necessarily easy to overcome. Future implementation endeavors should invest in basics: education, workflow, and reflection/evaluation. Strengthening fundamentals will enable healthcare systems to more nimbly accept the responsibility of meeting patients at the crossroads of innovative science and routinized clinical systems.

    View details for DOI 10.1186/s12875-021-01373-4

    View details for PubMedID 33530939

  • Relationship of socio-demographics, comorbidities, symptoms and healthcare access with early COVID-19 presentation and disease severity. BMC infectious diseases Vaughan, L. n., Veruttipong, D. n., Shaw, J. G., Levy, N. n., Edwards, L. n., Winget, M. n. 2021; 21 (1): 40


    COVID-19 studies are primarily from the inpatient setting, skewing towards severe disease. Race and comorbidities predict hospitalization, however, ambulatory presentation of milder COVID-19 disease and characteristics associated with progression to severe disease is not well-understood.We conducted a retrospective chart review including all COVID-19 positive cases from Stanford Health Care (SHC) in March 2020 to assess demographics, comorbidities and symptoms in relationship to: 1) their access point of testing (outpatient, inpatient, and emergency room (ER)) and 2) development of severe disease.Two hundred fifty-seven patients tested positive: 127 (49%), 96 (37%), and 34 (13%) at outpatient, ER and inpatient, respectively. Overall, 61% were age < 55; age > 75 was rarer in outpatient setting (11%) than ER (14%) or inpatient (24%). Most patients presented with cough (86%), fever/chills (76%), or fatigue (63%). 65% of inpatients reported shortness of breath compared to 30-32% of outpatients and ER patients. Ethnic/minority patients had a significantly higher risk of developing severe disease (Asian OR = 4.8 [1.6-14.2], Hispanic OR = 3.6 [1.1-11.9]). Medicare-insured patients were marginally more likely (OR = 4.0 [0.9-17.8]). Other factors associated with developing severe disease included kidney disease (OR = 6.1 [1.0-38.1]), cardiovascular disease (OR = 4.7 [1.0-22.1], shortness of breath (OR = 5.4 [2.3-12.6]) and GI symptoms (OR = 3.3 [1.4-7.7]; hypertension without concomitant CVD or kidney disease was marginally significant (OR = 2.3 [0.8-6.5]).Early widespread symptomatic testing for COVID-19 in Silicon Valley included many less severely ill patients. Thorough manual review of symptomatology reconfirms the heterogeneity of COVID-19 symptoms, and challenges in using clinical characteristics to predict decline. We re-demonstrate that socio-demographics are consistently associated with severity.

    View details for DOI 10.1186/s12879-021-05764-x

    View details for PubMedID 33421991

  • CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system. Learning health systems Safaeinili, N., Brown-Johnson, C., Shaw, J. G., Mahoney, M., Winget, M. 2020; 4 (1): e10201


    The Consolidated Framework for Implementation Research (CFIR) is a commonly used implementation science framework to facilitate design, evaluation, and implementation of evidence-based interventions. Its comprehensiveness is an asset for considering facilitators and barriers to implementation and also makes the framework cumbersome to use. We describe adaptations we made to CFIR to simplify its pragmatic application, for use in a learning health system context, in the evaluation of a complex patient-centered care transformation.We conducted a qualitative study and structured our evaluation questions, data collection methods, analysis, and reporting around CFIR. We collected qualitative data via semi-structured interviews and observations with key stakeholders throughout. We identified and documented adaptations to CFIR throughout the evaluation process.We analyzed semi-structured interviews with key stakeholders (n = 23) from clinical observations (n = 5). We made three key adaptations to CFIR: (a) promoted "patient needs and resources," a subconstruct of the outer setting, to its own domain within CFIR during data analysis; (b) divided the "inner setting" domain into three layers that account for the hierarchy of health care systems (i. pilot clinic, ii. peer clinics, and iii. overarching health care system); and (c) tailored several construct definitions to fit a patient-centered, primary care setting. Analysis yielded qualitative findings concentrated in the CFIR domains "intervention characteristics" and "outer setting," with a robust number of findings in the new domain "patient needs and resources."To make CFIR more accessible and relevant for wider use in the context of patient-centered care transformations within a learning health system, a few adaptations are key. Specifically, we found success by teasing apart interactions across the inner layers of a health system, tailoring construct definitions, and placing additional focus on patient needs.

    View details for DOI 10.1002/lrh2.10201

    View details for PubMedID 31989028

    View details for PubMedCentralID PMC6971122

  • Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience. Neurology Yang, L., Brown-Johnson, C. G., Miller-Kuhlmann, R., Kling, S. M., Saliba-Gustafsson, E. A., Shaw, J. G., Gold, C. A., Winget, M. 2020


    The COVID-19 pandemic has rapidly moved telemedicine from discretionary to necessary. Here we describe how the Stanford Neurology Department: 1) rapidly adapted to the COVID-19 pandemic, resulting in over 1000 video visits within four weeks and 2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to: equipment/software, provider engagement, workflow/triage, and training. Upon reflection, the key drivers of our success were provider engagement and a supportive physician champion. The physician champion played a critical role understanding stakeholder needs, including staff and physicians' needs, and creating workflows to coordinate both stakeholder groups. Prior to COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated post-pandemic era.

    View details for DOI 10.1212/WNL.0000000000010015

    View details for PubMedID 32611634

  • The Stanford Lightning Report Method: A comparison of rapid qualitative synthesis results across four implementation evaluations. Learning health systems Brown-Johnson, C., Safaeinili, N., Zionts, D., Holdsworth, L. M., Shaw, J. G., Asch, S. M., Mahoney, M., Winget, M. 2020; 4 (2): e10210


    Current evaluation methods are mismatched with the speed of health care innovation and needs of health care delivery partners. We introduce a qualitative approach called the lightning report method and its specific product-the "Lightning Report." We compare implementation evaluation results across four projects to explore report sensitivity and the potential depth and breadth of lightning report method findings.The lightning report method was refined over 2.5 years across four projects: team-based primary care, cancer center transformation, precision health in primary care, and a national life-sustaining decisions initiative. The novelty of the lightning report method is the application of Plus/Delta/Insight debriefing to dynamic implementation evaluation. This analytic structure captures Plus ("what works"), Delta ("what needs to be changed"), and Insights (participant or evaluator insights, ideas, and recommendations). We used structured coding based on implementation science barriers and facilitators outlined in the Consolidated Framework for Implementation Research (CFIR) applied to 17 Lightning Reports from four projects.Health care partners reported that Lighting Reports were valuable, easy to understand, and they implied reports supported "corrective action" for implementations. Comparative analysis revealed cross-project emphasis on the domains of Inner Setting and Intervention Characteristics, with themes of communication, resources/staffing, feedback/reflection, alignment with simultaneous interventions and traditional care, and team cohesion. In three of the four assessed projects, the largest proportion of coding was to the clinic-level domain of Inner Setting-ranging from 39% for the cancer center project to a high of 56% for the life-sustaining decisions project.The lightning report method can fill a gap in rapid qualitative approaches and is generalizable with consistent but flexible core methods. Comparative analysis suggests it is a sensitive tool, capable of uncovering differences and insights in implementation across projects. The Lightning Report facilitates partnered evaluation and communication with stakeholders by providing real-time, actionable insights in dynamic health care implementations.

    View details for DOI 10.1002/lrh2.10210

    View details for PubMedID 32313836

    View details for PubMedCentralID PMC7156867

  • Inter- and intra-provincial variation in screen-detected breast cancer across five Canadian provinces: a CanIMPACT study. Canadian journal of public health = Revue canadienne de sante publique Winget, M., Yuan, Y., McBride, M. L., Kendell, C., Decker, K. M., Grunfeld, E., Groome, P. A., Canadian Team to Improve Community-Based Cancer Care Along the Continuum (CanIMPACT), Biswanger, N., Li, D., Lofters, A., Matthias, S., Mittmann, N., Moineddin, R., Porter, G., Powell, D., Turner, D., Urquhart, R., Vick, B. 2020


    OBJECTIVE: Breast cancer screening aims to identify cancers in early stages when prognosis is better and treatments less invasive. We describe inter- and intra-provincial variation in the percentage of screen-detected cases under publicly funded healthcare systems and factors related to having screen- vs non-screen-detected breast cancer across five Canadian provinces.METHODS: Women aged 40+ diagnosed with incident breast cancer from 2007 to 2012 in five Canadian provinces were identified from their respective provincial cancer registries. Standardized provincial datasets were created linking screening, health administrative, and claims data. Province-specific logistic regression models were used to evaluate the association of demographic and healthcare utilization factors in each province with the odds of screen-detected cancer.RESULTS: There was significant inter- and intra-provincial variation by age. Screen detection ranged from 42% to 52% in ages 50-69 but women aged 50-59 had approximately 4-8% lower screen detection than those aged 60-69 in all provinces. Screening associations with income quintile and rurality varied across provinces. Those least likely to be screen-detected within a province were consistently in the lowest income quintile; OR ranged from 0.62-0.89 relative to highest income quintile/urban patients aged 50-69. Lack of visits to primary care 30months prior to diagnosis was also consistently associated with lower odds of screen detection (OR range, 0.37-0.76).CONCLUSION: Breast cancer screen detection rates in the Canadian provinces examined are relatively high. Associations with income-rurality indicate a need for greater attention and/or targeted outreach to specific communities and/or provincial regions to improve access to breast cancer screening services intra-provincially.

    View details for DOI 10.17269/s41997-019-00282-5

    View details for PubMedID 32020541

  • "Along for the Ride": A Qualitative Study Exploring Patient and Caregiver Perceptions of Decision Making in Cancer Care. MDM policy & practice Holdsworth, L. M., Zionts, D. n., Asch, S. M., Winget, M. n. 2020; 5 (1): 2381468320933576


    Background. Shared decision making is a cornerstone of an informed consent process for cancer treatment, yet there are often many physician and patient-related barriers to participation in the process. Decisions in cancer care are often perceived as relating to a discrete, treatment decision event, yet there is evidence that decisions are longitudinal in nature and reflect a multifactorial experience. Objective. To explore patient and caregiver perceptions of the choices and decision-making opportunities within cancer care. Design. Qualitative in-depth interviews with 37 cancer patients and 7 caregivers carried out as part of an evaluation of a cancer center's effort to improve patient experience. Results. Participants described decision making related to four distinct phases in complex cancer care, with physicians leading, and often limiting, decisions related to disease assessment and treatment options and access, and patients leading decisions related to physician selection. Though physicians led many decisions, patients had a moderating influence on treatment, such that if patients did not like options presented, they would reconsider their options and sometimes switch physicians. Patients had various strategies for dealing with uncertainty when faced with decisions, such as seeking additional information to make an informed choice or making a conscious choice to defer decision making to the physician. Limitations. Patients were sampled from one academic cancer center that serves a predominantly Caucasian, Asian, and Hispanic/Latino population and received complex treatment. Conclusion. Because of the complexity of cancer treatment, many patients felt as though they were a "passenger" in decision making about care and did not lead many of the decisions, though many patients trusted their doctors to make the best decisions and were comforted by their expertise.

    View details for DOI 10.1177/2381468320933576

    View details for PubMedID 32587894

    View details for PubMedCentralID PMC7294494

  • Impact of Mind-Body Medicine Professional Skills Training on Healthcare Professional Burnout. Global advances in health and medicine Weinlander, E. E., Gaza, E. J., Winget, M. 2020; 9: 2164956120906396


    Background: Healthcare professional burnout has reached epidemic proportions, with downstream effects on personal and patient health and on our institutions. Solutions lie in the domains of work culture, operational efforts, and personal strategies.Objectives: To evaluate the impact of a 5-day mind-body medicine professional training program on burnout and quality of life.Methods: We conducted pre- and postevaluation of a mind-body medicine skills training for healthcare professionals on 6 wellness domains using 2 validated instruments: the Maslach Burnout Inventory and the Professional Quality of Life Survey.Results: There was a statistically significant improvement in changes in emotional exhaustion, depersonalization, personal accomplishment, compassion satisfaction, burnout, and secondary traumatic stress which was sustained at 12months. Largest relative improvements occurred in emotional exhaustion and depersonalization, 22% and 21%, respectively.Conclusion: In addition to providing an important patient care skill set, mind-body medicine training may be an effective way to mitigate burnout and improve healthcare professional well-being.

    View details for DOI 10.1177/2164956120906396

    View details for PubMedID 32082951

  • Importance of quality in breast cancer screening practice - a natural experiment in Alberta, Canada. BMJ open Yuan, Y. n., Vu, K. n., Shen, Y. n., Dickinson, J. n., Winget, M. n. 2020; 10 (1): e028766


    Regular breast cancer screening is a widely used cancer prevention strategy. Important quality indicators of screening include cancer detection rate, false positive rate, benign biopsy rate and post-screen invasive cancer rate. We compared quality indicators of community radiology clinics to those of 'Screen Test', which feature centralised batch reading and quality control processes. Both types of providers operated under a single provincial Breast Cancer Screening Programme.Community radiology clinics are operated by independent fee-for-service radiologists serving large and small communities throughout the Canadian province of Alberta. Launched by the provincial cancer agency, the Screen Test operates two physical clinics serving metropolises and mobile units serving remote regions. Eligible women may self-refer to any provider for screening mammography.Women aged 50 to 69 years who had at least one screening mammogram between July 2006 and June 2010 in Alberta were included. Women with missing health region information or prior breast cancer diagnosis were excluded.A total of 389 788 screening mammograms were analysed, of which 12.7% were performed by Screen Test. Compared with Screen Test during 2006 to 2008, community radiology clinics had a lower cancer detection rate (3.6 vs 4.6 per 1000 screens, risk ratio (RR): 0.81, 95% CI: 0.67 to 0.98) and a much higher false positive rate (9.4% vs 3.4%, RR: 2.72, 95% CI: 2.55 to 2.90). Most other performance indicators were also better in Screen Test overall and across all health regions. These performance indicators were similar during 2008 to 2010, showing no improvement with time.Screen Test has a quality assurance process in place and performed significantly better. This provides empirical evidence of the effectiveness of a quality assurance process and may explain some of the large differences in breast cancer screening indicators between provinces and countries with formal programmes and those without.

    View details for DOI 10.1136/bmjopen-2018-028766

    View details for PubMedID 31911508

  • "Racial Bias…I'm Not Sure if It Has Affected My Practice": a Qualitative Exploration of Racial Bias in Team-Based Primary Care. Journal of general internal medicine Brown-Johnson, C. n., Shankar, M. n., Taylor, N. K., Safaeinili, N. n., Shaw, J. G., Winget, M. n., Mahoney, M. n. 2020

    View details for DOI 10.1007/s11606-020-06219-w

    View details for PubMedID 32935312

  • Rapid implementation of video visits in neurology during COVID-19: a mixed methods evaluation. Journal of medical Internet research Saliba-Gustafsson, E. A., Miller-Kuhlmann, R. n., Kling, S. M., Garvert, D. W., Brown-Johnson, C. G., Lestoquoy, A. S., Verano, M. R., Yang, L. n., Falco-Walter, J. n., Shaw, J. G., Asch, S. M., Gold, C. A., Winget, M. n. 2020


    Telemedicine has been used for decades; yet, despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. The SARS-CoV-2 (COVID-19) pandemic however, prompted healthcare systems worldwide to reconsider traditional healthcare delivery. To safeguard healthcare workers and patients many healthcare systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess the adoption, acceptability, appropriateness, and perceptions of potential sustainability.Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semi-structured interviews with providers (n=30) completed between March and May 2020.Video visits were adopted rapidly; 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted satisfaction. Video visits were reported to be more convenient for patients, families, and/or caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

    View details for DOI 10.2196/24328

    View details for PubMedID 33245699

  • Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU. Implementation science : IS Holdsworth, L. M., Safaeinili, N. n., Winget, M. n., Lorenz, K. A., Lough, M. n., Asch, S. n., Malcolm, E. n. 2020; 15 (1): 12


    Innovations to improve quality and safety in healthcare are increasingly complex, targeting multiple disciplines and organizational levels, and often requiring significant behavior change by those delivering care. Learning health systems must tackle the crucial task of understanding the implementation and effectiveness of complex interventions, but may be hampered in their efforts by limitations in study design imposed by business-cycle timelines and implementation into fast-paced clinical environments. Rapid assessment procedures are a pragmatic option for producing timely, contextually rich evaluative information about complex interventions implemented into dynamic clinical settings.We describe our adaptation of rapid assessment procedures and introduce a rapid team-based analysis process using an example of an evaluation of an intensive care unit (ICU) redesign initiative aimed at improving patient safety in four academic medical centers across the USA. Steps in our approach included (1) iteratively working with stakeholders to develop evaluation questions; (2) integration of implementation science frameworks into field guides and analytic tools; (3) selecting and training a multidisciplinary site visit team; (4) preparation and trust building for 2-day site visits; (5) engaging sites in a participatory approach to data collection; (6) rapid team analysis and triangulation of data sources and methods using a priori charts derived from implementation frameworks; and (7) validation of findings with sites.We used the rapid assessment approach at each of the four ICU sites to evaluate the implementation of the sites' innovations. Though the ICU projects all included three common components, they were individually developed to suit the local context and had mixed implementation outcomes. We generated in-depth case summaries describing the overall implementation process for each site; implementation barriers and facilitators for all four sites are presented. One of the site case summaries is presented as an example of findings generated using the method.A rapid team-based approach to qualitative analysis using charts and team discussion using validation techniques, such as member-checking, can be included as part of rapid assessment procedures. Our work demonstrates the value of including rapid assessment procedures for implementation research when time and resources are limited.

    View details for DOI 10.1186/s13012-020-0972-5

    View details for PubMedID 32087724

  • The Stanford Lightning Report Method: A comparison of rapid qualitative synthesis results across four implementation evaluations LEARNING HEALTH SYSTEMS Brown-Johnson, C., Safaeinili, N., Zionts, D., Holdsworth, L. M., Shaw, J. G., Asch, S. M., Mahoney, M., Winget, M. 2019

    View details for DOI 10.1002/lrh2.10210

    View details for Web of Science ID 000503760600001

  • Negotiating Lay and Clinical Issues: Implementing a Lay Navigation Program in Cancer Care. Journal of oncology practice Holdsworth, L. M., Zionts, D., Wang, S., Veruttipong, D., Brown-Johnson, C., Asch, S. M., Rosenthal, E. L., Winget, M. 2019: JOP1900339


    PURPOSE: Patients with cancer face daunting coordination problems at a vulnerable time. Lay navigation programs offer 1 approach to address these problems, but how to best implement these programs presents challenges. We sought to describe those implementation challenges at 1 academic cancer center to inform future efforts.METHODS: We performed a mixed methods study using standard implementation outcomes 1 year after program initiation. Quantitative data from the electronic medical record and qualitative data from in-depth interviews, focus groups, and ethnographic observations were included in analyses. The study took place at a National Cancer Institute-designated comprehensive cancer center across 12 tumor-specific clinics.RESULTS: Supportive care concerns, scheduling, and clinical-related issues were the most frequent issues navigators encountered. Effective navigation required continuous, time-consuming, invisible work, including building and maintaining a broad knowledge base of resources and health system processes, as well as cultivating relationships with diverse and changing clinical teams. The acceptability and appropriateness of lay navigator activities were mixed among clinic and social work staff, related to negotiating lines between clinical and nonclinical care.CONCLUSION: After 1 year of implementation, lay navigators still found it difficult to interpret and prioritize complex patient needs in a way that all clinical staff found appropriate. Negotiating these issues has made it difficult to develop the strong relationships with clinical teams that are needed for an integrated approach to patient care. To successfully coordinate patient care, it seems that lay navigation programs should be integrated with clinical teams to provide more seamless patient care.

    View details for DOI 10.1200/JOP.19.00339

    View details for PubMedID 31693450

  • CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system LEARNING HEALTH SYSTEMS Safaeinili, N., Brown-Johnson, C., Shaw, J. G., Mahoney, M., Winget, M. 2019

    View details for DOI 10.1002/lrh2.10201

    View details for Web of Science ID 000487784900001

  • Role definition is key-Rapid qualitative ethnography findings from a team-based primary care transformation. Learning health systems Brown-Johnson, C., Shaw, J. G., Safaeinili, N., Chan, G. K., Mahoney, M., Asch, S., Winget, M. 2019; 3 (3): e10188


    Purpose: Implementing team-based care into existing primary care is challenging; understanding facilitators and barriers to implementation is critical. We assessed adoption and acceptability of new roles in the first 6months of launching a team-based care model focused on preventive care, population health, and psychosocial support.Methods: We conducted qualitative rapid ethnography at a community-based test clinic, including 74hours of observations and 28 semi-structured interviews. We identified implementation themes related to team-based care and specifically the integration of three roles purposively designed to enhance coordination for better patient outcomes, including preventive screening and mental health: (1) medical assistants as care coordinators; (2) extended care team specialists, including clinical pharmacist and behavioral health professional; and (3) advanced practice providers (APPs)-ie, nurse practitioners and physician assistants.Results: All stakeholders (ie, patients, providers, and staff) reported positive perceptions of care coordinators and extended care specialists; these roles were well defined and quickly implemented. Care coordinators effectively managed care between visits and established strong patient relationships. Specialist colocation facilitated patient access and well-supported diabetes services and mental health care. We also observed unanticipated value: Care coordinators relayed encounter-relevant chart information to providers while scribing; extended care specialists supported informal continuing medical education. In contrast, we observed uncertain definition and expectations of the APP role across stakeholders; accordingly, adoption and acceptability of the role varied.Conclusions: Practice redesign can redistribute responsibility and patient connection throughout a team but should emphasize well-defined roles. Ethnography, conducted early in implementation with multistakeholder perspectives, can provide rapid and actionable insights about where roles may need refinement or redefinition to support ultimate physical and mental health outcomes for patients.

    View details for DOI 10.1002/lrh2.10188

    View details for PubMedID 31317071

  • Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim AMERICAN JOURNAL OF MEDICAL QUALITY Brown-Johnson, C. G., Chan, G. K., Winget, M., Shaw, J. G., Patton, K., Hussain, R., Olayiwola, J., Chang, S., Mahoney, M. 2019; 34 (4): 339–47
  • Beyond Satisfaction Scores: Exploring Emotionally Adverse Patient Experiences AMERICAN JOURNAL OF MANAGED CARE Holdsworth, L. M., Zionts, D. L., De Sola-Smith, K., Valentine, M., Winget, M. D., Asch, S. M. 2019; 25 (5): E145–E152
  • Disparities in breast cancer diagnosis for immigrant women in Ontario and BC: results from the CanIMPACT study BMC CANCER Lofters, A. K., McBride, M. L., Li, D., Whitehead, M., Moineddin, R., Jiang, L., Grunfeld, E., Groome, P. A., Biswanger, N., Decker, K., Kendell, C., Krzyzanowska, M., Matthias, S., Mittmann, N., Porter, G., Powell, D., Turner, D., Urquhart, R., Vick, B., Winget, M., Yuan, Y., CanIMPACT Team 2019; 19: 42


    In Canada, clinical practice guidelines recommend breast cancer screening, but there are gaps in adherence to recommendations for screening, particularly among certain hard-to-reach populations, that may differ by province. We compared stage of diagnosis, proportion of screen-detected breast cancers, and length of diagnostic interval for immigrant women versus long-term residents of BC and Ontario.We conducted a retrospective cohort study using linked administrative databases in BC and Ontario. We identified all women residing in either province who were diagnosed with incident invasive breast cancer between 2007 and 2011, and determined who was foreign-born using the Immigration Refugee and Citizenship Canada database. We used descriptive statistics and bivariate analyses to describe the sample and study outcomes. We conducted multivariate analyses (modified Poisson regression and quantile regression) to control for potential confounders.There were 14,198 BC women and 46,952 Ontario women included in the study population, of which 11.8 and 11.7% were foreign-born respectively. In both provinces, immigrants and long-term residents had similar primary care access. In both provinces, immigrant women were significantly less likely to have a screen-detected breast cancer (adjusted relative risk 0.88 [0.79-0.96] in BC, 0.88 [0.84-0.93] in Ontario) and had a significantly longer median diagnostic interval (2 [0.2-3.8] days in BC, 5.5 [4.4-6.6] days in Ontario) than long-term residents. Women from East Asia and the Pacific were less likely to have a screen-detected cancer and had a longer diagnostic interval, but were diagnosed at an earlier stage than long-term residents. In Ontario, women from Latin America and the Caribbean and from South Asia were less likely to have a screen-detected cancer, had a longer median diagnostic interval, and were diagnosed at a later stage than long-term residents. These findings were not explained by access to primary care.There are inequalities in breast cancer diagnosis for Canadian immigrant women. We have identified particular immigrant groups (women from Latin America and the Caribbean and from South Asia) that appear to be subject to disparities in the diagnostic process that need to be addressed in order to effectively reduce gaps in care.

    View details for DOI 10.1186/s12885-018-5201-0

    View details for Web of Science ID 000455336800002

    View details for PubMedID 30626375

    View details for PubMedCentralID PMC6327524

  • Effectiveness of a Lay Navigation Program in an Academic Cancer Center. Journal of oncology practice Winget, M. n., Holdsworth, L. n., Wang, S. n., Veruttipong, D. n., Zionts, D. n., Rosenthal, E. L., Asch, S. M. 2019: JOP1900337


    A navigation program with lay navigators that targets patients with cancer who are receiving multiple treatment modalities was launched with the goal of improving care coordination.Pseudo-randomization and mixed methods were used to evaluate the program: patients with even-numbered medical records were assigned to navigation help, and patients with odd-numbered medical records made up the control group. Eligible patients were those scheduled to receive at least two treatment modalities. Intent-to-treat, as-treated, and high-user cohorts with propensity matched controls were used to assess the outcomes: patient experience, emergency room (ER) use, and unplanned hospitalizations. In-depth patient interviews explored how and why patients interacted with the navigator program and overall patient experience.Marginally lower incidence rate ratios (IRRs) for both ER visits (IRR, 1.17; 95% CI, 1.00 to 1.36) and unplanned hospitalizations (IRR, 1.18; 95% CI, 0.97 to 1.43) occurred in as-treated patients who used navigation help and who lived within 50 miles of Stanford Hospital compared with their matched controls; other cohort analyses had similar results. Survey scores for patients who received help with navigation did not differ significantly from those for corresponding controls in any of the analytic cohorts. Patient interviews suggested that the navigation program had low visibility among patients and that lay navigators drove use of the program. Patient-reported positive experiences included getting help with complex scheduling, alleviating anxiousness through access to information and educational resources, and getting help with activities outside traditional health care; negative experiences stemmed from having expectations that were not met.Marginally lower rates of ER visits and unplanned hospitalizations for a small subset of patients, low penetration of the navigation program, and mixed comments from patient interviews suggest that a navigation program with a broad scope that targets a large population is not effective. Modifying the program to have a narrower scope of practice may help better target anxious or high-risk patients.

    View details for DOI 10.1200/JOP.19.00337

    View details for PubMedID 31647691

  • Beyond satisfaction scores: exploring emotionally adverse patient experiences. The American journal of managed care Holdsworth, L. M., Zionts, D. L., De Sola-Smith, K. M., Valentine, M. n., Winget, M. D., Asch, S. M. 2019; 25 (5): e145–e152


    Although improving the average patient experience is at the center of recent efforts to make cancer care more patient centered, extreme experiences may be more informative for quality improvement. Little is known about the most deeply dissatisfying experiences that predispose disengagement and negatively influence patient outcomes. We sought to establish a framework for emotionally adverse patient experiences and identify the range of common causes.Qualitative study including in-depth interviews and free-text survey comments.Thematic analysis of 20 open-ended patient interviews and 2389 free-text survey comments collected in a medical center's cancer clinics.Emotionally adverse experiences were rarely reported in survey comments (96; 4.0%) but more frequently discussed in interviews (12 interview participants). Such experiences were identified through explicit statements of negative emotion, language, syntax, and tone. Among these rare comments, hostility as an indicator was easiest to identify, whereas passive expressions of fear or hopelessness were less reliably identified. We identified 3 mutually inclusive high-level domains of triggers of negative emotion-system issues, technical processes, and interpersonal processes-and 10 themes within those domains. There was wide variation in the causes of emotionally adverse experiences and evidence of a complex interplay of patient expectations and preconditions that influenced the perception of negative experiences.This study presents a taxonomy for classifying emotionally adverse patient experiences expressed in free-text format. Further research should test how perceptions of adverse experiences correspond to recorded ratings of patient satisfaction and subsequent enrollment or utilization.

    View details for PubMedID 31120711

  • Lessons Learned: It Takes a Village to Understand Inter-Sectoral Care Using Administrative Data across Jurisdictions. International journal of population data science Groome, P. A., McBride, M. L., Jiang, L., Kendell, C., Decker, K. M., Grunfeld, E., Krzyzanowska, M. K., Winget, M. 2018; 3 (3): 440


    Cancer care is complex and exists within the broader healthcare system. The CanIMPACT team sought to enhance primary cancer care capacity and improve integration between primary and cancer specialist care, focusing on breast cancer. In Canada, all medically-necessary healthcare is publicly funded but overseen at the provincial/territorial level. The CanIMPACT Administrative Health Data Group's (AHDG) role was to describe inter-sectoral care across five Canadian provinces: British Columbia, Alberta, Manitoba, Ontario and Nova Scotia. This paper describes the process used and challenges faced in creating four parallel administrative health datasets. We present the content of those datasets and population characteristics. We provide guidance for future research based on 'lessons learned'. The AHDG conducted population-based comparisons of care for breast cancer patients diagnosed from 2007-2011. We created parallel provincial datasets using knowledge from data inventories, our previous work, and ongoing bi-weekly conference calls. Common dataset creation plans (DCPs) ensured data comparability and documentation of data differences. In general, the process had to be flexible and iterative as our understanding of the data and needs of the broader team evolved. Inter-sectoral data inconsistencies that we had to address occurred due to differences in: 1) healthcare systems, 2) data sources, 3) data elements and 4) variable definitions. Our parallel provincial datasets describe the breast cancer diagnostic, treatment and survivorship phases and address ten research objectives. Breast cancer patient demographics reflect inter-provincial general population differences. Across provinces, disease characteristics are similar but underlying health status and use of healthcare services differ. Describing healthcare across Canadian jurisdictions assesses whether our provincial healthcare systems are delivering similar high quality, timely, accessible care to all of our citizens. We have provided a description of our experience in trying to achieve this goal and, for future use, we include a list of 'lessons learned' and a list of recommended steps for conducting this kind of work.The conduct of inter-sectoral research using linked administrative health data requires a committed team that is adequately resourced and has a set of clear, feasible objectives at the start.Guiding principles include: maximization of sectoral participation by including single-jurisdiction expertise and making the most inclusive data decisions; use of living documents that track all data decisions and careful consideration about data quality and availability differences.Inter-sectoral research requires a good understanding of the local healthcare system and other contextual issues for appropriate interpretation of observed differences.

    View details for DOI 10.23889/ijpds.v3i3.440

    View details for PubMedID 32935017

    View details for PubMedCentralID PMC7299469

  • Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim. American journal of medical quality : the official journal of the American College of Medical Quality Brown-Johnson, C. G., Chan, G. K., Winget, M., Shaw, J. G., Patton, K., Hussain, R., Olayiwola, J. N., Chang, S., Mahoney, M. 2018: 1062860618802365


    A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.

    View details for PubMedID 30409021

  • Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service JOURNAL OF HOSPITAL MEDICINE Kane, M., Rohatgi, N., Heidenreich, P. A., Thakur, A., Winget, M., Shum, K., Hereford, J., Shieh, L., Lew, T., Hom, J., Chi, J., Weinacker, A., Seay-Morrison, T., Ahuja, N. 2018; 13 (7): 482–85

    View details for DOI 10.12788/jhm.2908

    View details for Web of Science ID 000437294500006

  • Re-excision and survival following breast conserving surgery in early stage breast cancer patients: a population-based study BMC HEALTH SERVICES RESEARCH Fisher, S., Yasui, Y., Dabbs, K., Winget, M. 2018; 18: 94


    Increasing population-based evidence suggests that patients who receive breast conserving surgery (BCS) plus radiotherapy have superior survival than those who receive mastectomy. It is unclear, however, how BCS followed by re-excision is associated with all-cause and breast cancer-specific mortality, and whether the BCS survival advantage is maintained if re-excision is needed. The aim of this study was to investigate the clinical, patient, provider and geographic variation associated with receipt of re-excision surgery, and to examine the relationship between re-excision and all-cause and breast cancer-specific mortality.All women diagnosed with stage I-III breast cancer in Alberta, Canada from 2002 to 2009 were identified from the Alberta Cancer Registry, of which 11,626 were eligible for study inclusion. Type of first breast cancer surgery after diagnosis, subsequent re-excisions within 1 year, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate the adjusted odds ratios of re-excision by the factors of interest. Poisson regression models were fitted to compare all-cause and breast cancer-specific mortality by surgical pattern.Re-excision surgery was received by 19% (N = 5659) of patients who initially received BCS. The adjusted odds of re-excision varied significantly by geography of surgery, and by individual surgeon among stage I and II patients beyond the variation explained by the factors investigated (Stage I OR standard deviation (SD) = 0.43; stage II OR SD = 0.39). Patients who were treated with BCS plus re-excision surgery with either mastectomy or further BCS had similar all-cause and breast cancer-specific mortality as those treated with BCS without re-excision.These results suggest that breast cancer patients who are treated with BCS plus re-excision surgery by either mastectomy or further BCS have similar survival as those treated with BCS without re-excision. The significant variation in the likelihood of re-excision by geography and by individual surgeon is concerning, especially given the costs to the patient associated with additional surgery and the financial costs to the health system.

    View details for PubMedID 29422097

  • Development of a Tailored Survey to Evaluate a Patient-Centered Initiative AMERICAN JOURNAL OF MANAGED CARE Winget, M., Haji-Sheikhi, F., Asch, S. M. 2018; 24 (2): E37–E44


    Patient-centered care initiatives have proliferated, but assessing their effectiveness requires measures tailored to their likely effects. In this article, we describe the development and pilot testing of patient surveys used to assess change in patients' cancer care experiences over time in response to a patient-centered care initiative.Prospective case series.Domains of patient-centered care were informed by the goals of the initiative and a review of existing tools. Items were selected and modified from 6 domains of validated or semivalidated instruments. Items were piloted with patients with cancer in waiting room settings to further assess the relevance and clarity of items, whether important concepts were missing, and acceptability regarding place and timing of the surveys and to estimate baseline top box scores (percentage of patients scoring an item the highest quality level) to minimize likely ceiling effects. The instrument was then administered to a consecutive sample of Stanford Cancer Center patients. Baseline item responses, Cronbach's alpha, and response bias were estimated.Items were modified based on patient feedback, top box scores, and reassessment of the domains. Over 6 months, 11,273 patients were surveyed, with a 49.7% response rate. Baseline top box scores ranged from 41.7% to 75.0% for any given item. Reliability and internal consistency were high for all domains (Cronbach's alpha ≥0.80) except for the access domain.We developed reliable instruments to evaluate the essential elements of a patient-centered care initiative at an academic medical center, which minimized patient burden and maximized the response rate.

    View details for PubMedID 29461850

  • Factors Associated With Delayed Discharge on General Medicine Service at an Academic Medical Center. Journal for healthcare quality : official publication of the National Association for Healthcare Quality Rohatgi, N. n., Kane, M. n., Winget, M. n., Haji-Sheikhi, F. n., Ahuja, N. n. 2018


    Lack of collaboration between care teams and patients/families has been associated with delayed discharge from the hospital. In this study, we determine whether patients' awareness of the estimated date of discharge (EDD) was associated with a decrease in delayed discharge, and determine the factors associated with a delayed discharge. A total of 221 patients admitted to the General Medicine service between July and September 2014 were included in the study. Estimated date of discharge was identified within 36 hours of admission. The bedside nurse communicated this EDD to the patient/family. Patients were interviewed to identify whether they were aware of their EDD. Bedside nurses were interviewed to identify barriers to discharge. In our study, 49.8% of the patients had a delayed discharge. Patients who were aware of their EDD were less likely to have a delayed discharge (odds ratio [OR], 0.3 [95% confidence interval (CI), 0.1-0.6], p < .001). Patients who were discharged on Saturday or Sunday (OR, 4.8 [95% CI, 1.7-14.6], p < .001) and patients who were waiting for physicians' consult (OR, 4.5 [95% CI, 1.6-14.4], p = .007) were more likely to have a delayed discharge. Early identification of the EDD and communicating it with the care team and the patient/family, mobilizing resources for safe weekend discharges, and creating efficient process for consultations might decrease delayed discharges.

    View details for DOI 10.1097/JHQ.0000000000000126

    View details for PubMedID 29315151

  • Use of physician services during the survivorship phase: a multi-province study of women diagnosed with breast cancer. Current oncology KENDELL, C., Decker, K. M., Groome, P. A., McBride, M. L., Jiang, L., Krzyzanowska, M. K., Porter, G., Turner, D., Urquhart, R., Winget, M., Grunfeld, E. 2017; 24 (2): 81-89


    Oncologists have traditionally been responsible for providing routine follow-up care for cancer survivors; in recent years, however, primary care providers (pcps) are taking a greater role in care during the follow-up period. In the present study, we used a longitudinal multi-province retrospective cohort study to examine how primary care and specialist care intersect in the delivery of breast cancer follow-up care.Various databases (registry, clinical, and administrative) were linked in each of four provinces: British Columbia, Manitoba, Ontario, and Nova Scotia. Population-based cohorts of breast cancer survivors were identified in each province. Physician visits were identified using billings or claims data and were classified as visits to primary care (total, breast cancer-specific, and other), oncology (medical oncology, radiation oncology, and surgery), and other specialties. The mean numbers of visits by physician type and specialty, or by combinations thereof, were examined. The mean numbers of visits for each follow-up year were also examined by physician type.The results showed that many women (>64%) in each province received care from both primary care and oncology providers during the follow-up period. The mean number of breast cancer-specific visits to primary care and visits to oncology declined with each follow-up year. Interprovincial variations were observed, with greater surgeon follow-up in Nova Scotia and greater primary care follow-up in British Columbia. Provincial differences could reflect variations in policies and recommendations, relevant initiatives, and resources or infrastructure to support pcp-led follow-up care.Optimizing the role of pcps in breast cancer follow-up care might require strategies to change attitudes about pcp-led follow-up and to better support pcps in providing survivorship care.

    View details for DOI 10.3747/co.24.3454

    View details for PubMedID 28490921

  • Factors associated with mode of colorectal cancer detection and time to diagnosis: a population level study BMC HEALTH SERVICES RESEARCH Sikdar, K. C., Dickinson, J., Winget, M. 2017; 17


    Although it is well-known that early detection of colorectal cancer (CRC) is important for optimal patient survival, the relationship of patient and health system factors with delayed diagnosis are unclear. The purpose of this study was to identify the demographic, clinical and healthcare factors related to mode of CRC detection and length of the diagnostic interval.All residents of Alberta, Canada diagnosed with first-ever incident CRC in years 2004-2010 were identified from the Alberta Cancer Registry. Population-based administrative health datasets, including hospital discharge abstract, ambulatory care classification system and physician billing data, were used to identify healthcare services related to CRC diagnosis. The time to diagnosis was defined as the time from the first CRC-related healthcare visit to the date of CRC diagnosis. Mode of CRC detection was classified into three groups: urgent, screen-detected and symptomatic. Quantile regression was performed to assess factors associated with time to diagnosis.9626 patients were included in the study; 25% of patients presented as urgent, 32% were screen-detected and 43% were symptomatic. The median time to diagnosis for urgent, screen-detected and symptomatic patients were 6 days (interquartile range (IQR) 2-14 days), 74 days (IQR 36-183 days), 84 days (IQR 39-223 days), respectively. Time to diagnosis was greater than 6 months for 27% of non-urgent patients. Healthcare factors had the largest impact on time to diagnosis: 3 or more visits to a GP increased the median by 140 days whereas 2 or more visits to a GI-specialist increased it by 108 days compared to 0-1 visits to a GP or GI-specialist, respectively.A large proportion of CRC patients required urgent work-up or had to wait more than 6 months for diagnosis. Actions are needed to reduce the frequency of urgent presentation as well as improve the timeliness of diagnosis. Findings suggest a need to improve coordination of care across multiple providers.

    View details for DOI 10.1186/s12913-016-1944-y

    View details for Web of Science ID 000391888300001

    View details for PubMedID 28056946

    View details for PubMedCentralID PMC5376684

  • Waiting Time Intervals for Non-small Cell Lung Cancer Diagnosis and Treatment in Alberta: Quantification of Intervals and Identification of Risk Factors Associated with Delays. Clinical oncology Kim, J. O., Davis, F., Butts, C., Winget, M. 2016; 28 (12): 750-759


    Very little is known regarding the time required to diagnose and treat patients with non-small cell lung cancer (NSCLC) in Canada. We sought to quantify diagnostic and treatment intervals for NSCLC care in Alberta and identify risk factors for delays.The Alberta Cancer Registry identified all cases of stage I-III NSCLC diagnosed and treated in Alberta, Canada from 2004 to 2011. Diagnostic data were obtained from physician billing, inpatient/outpatient hospital data and electronic medical records to quantify the duration of diagnostic and treatment intervals and their sum (system interval). Multivariable logistic regression was carried out to identify factors associated with delays.Of the 3009 eligible patients included, the median and 90th percentile system interval was 78 (95% confidence interval 76-80) and 185 days (95% confidence interval 178-195), respectively. The treatment interval was longer than the diagnostic interval, with medians of 51 (95% confidence interval 49-53) and 38 (95% confidence interval 36-40) days, respectively. After adjustment, age > 60 years and treatment by modalities other than supportive care (especially surgery) were associated with delays. Factors associated with prompt care included high acuity presentations and stage III disease.The majority of Albertans with potentially curable NSCLC exceeded guidelines for the timeliness of their care.

    View details for DOI 10.1016/j.clon.2016.06.010

    View details for PubMedID 27357099

  • Primary care physician use across the breast cancer care continuum: CanIMPACT study using Canadian administrative data. Canadian family physician Medecin de famille canadien Jiang, L., Lofters, A., Moineddin, R., Decker, K., Groome, P., Kendell, C., Krzyzanowska, M., Li, D., McBride, M. L., Mittmann, N., Porter, G., Turner, D., Urquhart, R., Winget, M., Zhang, Y., Grunfeld, E. 2016; 62 (10): e589-e598


    To describe primary care physician (PCP) use and continuity of PCP care across the breast cancer care continuum.Population-based, retrospective cohort study using provincial cancer registries linked to health administrative databases.British Columbia, Manitoba, and Ontario.All women with incident invasive breast cancer from 2007 to 2012 in Manitoba and Ontario and from 2007 to 2011 in British Columbia.The number and proportions of visits to PCPs were determined. Continuity of care was measured using the Usual Provider of Care index calculated as the proportion of visits to the most-often-visited PCP in the 6 to 30 months before a breast cancer diagnosis (baseline) and from 1 to 3 years following a breast cancer diagnosis (survivorship).More than three-quarters of patients visited their PCPs 2 or more times during the breast cancer diagnostic period, and more than 80% of patients had at least 1 PCP visit during breast cancer adjuvant treatment. Contact with the PCP decreased over time during breast cancer survivorship. Of the 3 phases, women appeared to be most likely to not have PCP contact during adjuvant treatment, with 10.7% (Ontario) to 18.7% (British Columbia) of women having no PCP visits during this phase. However, a sizable minority of women had at least monthly visits during the treatment phase, particularly in Manitoba and Ontario, where approximately a quarter of women saw a PCP at least monthly. We observed higher continuity of care with PCPs in survivorship (compared with baseline) in all provinces.Primary care physicians were generally involved throughout the breast cancer care continuum, but the level of involvement varied across care phases and by province. Future interventions will aim to further integrate primary and oncology care.

    View details for PubMedID 27737994

  • Electronic Release of Pathology and Radiology Results to Patients: Opinions and Experiences of Oncologists. Journal of oncology practice / American Society of Clinical Oncology Winget, M., Haji-Sheikhi, F., Brown-Johnson, C., Rosenthal, E. L., Sharp, C., Buyyounouski, M. K., Asch, S. M. 2016; 12 (8): e792-9


    There is an emerging standard to provide patients rapid electronic access to elements of their medical records. Although surveys of patients generally support it, this practice is controversial among oncologists, because few empiric data are available for scenarios of potentially life-threatening conditions like cancer. We report the views of oncologists about patient electronic access to radiology and pathology results that could potentially indicate disease progression.Four months before oncologists were surveyed, final results of radiology/pathology reports were routinely made available to patients online through a secure portal after a 7-day, hold to provide clinicians time to review and communicate results with the patients. Mixed methods were used to assess physician attitudes and experiences toward this change.One hundred twenty-nine oncologists were surveyed, and 82 (64%) responded. A small majority (54%) responded that the release of reports was somewhat or very beneficial for patients who received normal radiology/pathology results before discussion with a physician, but 87% said it was somewhat or very harmful for patients to receive abnormal results before discussion. Forty-nine percent reported that release of reports had a somewhat or very negative impact on communication with their patients.Almost half of oncologists reported that sharing digital radiology and pathology records had a negative impact on their communication with patients. Patient surveys in similar cancer populations would complement the physician perspective. Efforts are needed to improve consensus among oncologists and patients on how to best communicate such results in a timely fashion.

    View details for DOI 10.1200/JOP.2016.011098

    View details for PubMedID 27382001

  • Using Multilevel Models to Explain Variation in Clinical Practice: Surgeon Volume and the Surgical Treatment of Breast Cancer ANNALS OF SURGICAL ONCOLOGY Fisher, S., Yasui, Y., Dabbs, K., Winget, M. 2016; 23 (6): 1845-1851


    To investigate the relationship between surgeon caseload and surgery type, and variation in the surgical treatment of early stage breast cancer patients in Alberta, Canada.All women diagnosed with stage I to III breast cancer in Alberta from 2002 to 2010 were identified from the Alberta Cancer Registry. Type of surgery, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate adjusted odds ratios (OR) of receiving mastectomy by surgeon volume. Empirical Bayes estimation was used to estimate adjusted OR for individual surgeons and hospitals.Mastectomy was found to be inversely related to surgeon volume among stage I and II patients. Patients whose surgery was conducted by a low-volume surgeon had twice the odds of receiving mastectomy as those that had surgery performed by a very high-volume surgeon (stage I OR 2.36, 95 % confidence interval 1.40, 3.97; stage II OR 1.96, 95 % confidence interval 1.13, 3.42). OR of mastectomy varied widely by individual surgeon beyond the variation explained by the factors investigated.Surgeon characteristics, including surgeon volume, are associated with surgery type received by breast cancer patients in Alberta. Significant variation in the likelihood of breast-conserving surgery (BCS) by surgeon is concerning given the potential benefits of BCS for those who are eligible.

    View details for DOI 10.1245/s10434-016-5118-2

    View details for Web of Science ID 000375613500011

    View details for PubMedID 26842490

  • Factors related to breast cancer detection mode and time to diagnosis in Alberta, Canada: a population-based retrospective cohort study BMC HEALTH SERVICES RESEARCH Yuan, Y., Li, M., Yang, J., Elliot, T., Dabbs, K., Dickinson, J. A., Fisher, S., Winget, M. 2016; 16


    Understanding the factors affecting the mode and timeliness of breast cancer diagnosis is important to optimizing patient experiences and outcomes. The purposes of the study were to identify factors related to the length of the diagnostic interval and assess how they vary by mode of diagnosis: screen or symptom detection.All female residents of Alberta diagnosed with first primary breast cancer in years 2004-2010 were identified from the Alberta Cancer Registry. Data were linked to Physician Claims and screening program databases. Screen-detected patients were identified as having a screening mammogram within 6-months prior to diagnosis; remaining patients were considered symptom-detected. Separate quantile regression was conducted for each detection mode to assess the relationship between demographic/clinical and healthcare factors.Overall, 38 % of the 12,373 breast cancer cases were screen-detected compared to 47 % of the screen-eligible population. Health region of residence was strongly associated with cancer detection mode. The median diagnostic interval for screen and symptom-detected cancers was 19 and 21 days, respectively. The variation by health region, however, was large ranging from an estimated median of 4 to 37 days for screen-detected patients and from 17 to 33 days for symptom-detected patients. Cancer stage was inversely associated with the diagnostic interval for symptom-detected cancers, but not for screen-detected cancers.Significant variation by health region in both the percentage of women with screen-detected cancer and the length of the diagnostic interval for screen and symptom-detected breast cancers suggests there could be important differences in local breast cancer diagnostic care coordination.

    View details for DOI 10.1186/s12913-016-1303-z

    View details for Web of Science ID 000370405000001

    View details for PubMedID 26892589

    View details for PubMedCentralID PMC4759735

  • Survival in stage I-III breast cancer patients by surgical treatment in a publicly funded health care system ANNALS OF ONCOLOGY Fisher, S., Gao, H., Yasui, Y., Dabbs, K., Winget, M. 2015; 26 (6): 1161-1169


    Recent investigations of breast cancer survival in the United States suggest that patients who receive mastectomy have poorer survival than those who receive breast-conserving surgery (BCS) plus radiotherapy, despite clinically established equivalence. This study investigates breast cancer survival in the publicly funded health care system present in Alberta, Canada.Surgically treated stage I-III breast cancer cases diagnosed in Alberta from 2002 to 2010 were included. Demographic, treatment and mortality information were collected from the Alberta Cancer Registry. Unadjusted overall and breast cancer-specific mortality was assessed using Kaplan-Meier and cumulative incidence curves, respectively. Cox proportional hazards models were used to calculate stage-specific mortality hazard estimates associated with surgical treatment received.A total of 14 939 cases of breast cancer (14 633 patients) were included in this study. The unadjusted 5-year all-cause survival probabilities for patients treated with BCS plus radiotherapy, mastectomy, and BCS alone were 94% (95% CI 93% to 95%), 83% (95% CI 82% to 84%) and 74% (95% CI 70% to 78%), respectively. Stage II and III patients who received mastectomy had a higher all-cause (stage II HR = 1.36, 95% CI 1.13-1.48; stage III HR = 1.74, 95% CI 1.24-2.45) and breast cancer-specific (stage II HR = 1.39, 95% CI 1.09-1.76; stage III HR = 1.79, 95% CI 1.21-2.65) mortality hazard compared with those who received BCS plus radiotherapy, adjusting for patient and clinical characteristics. BCS alone was consistently associated with poor survival.Stage II and III breast cancer patients diagnosed in Alberta, Canada, who received mastectomy had a significantly higher all-cause and breast cancer-specific mortality hazard compared with those who received BCS plus radiotherapy. We suggest greater efforts toward educating and encouraging patients to receive BCS plus radiotherapy rather than mastectomy when it is medically feasible and appropriate.

    View details for DOI 10.1093/annonc/mdv107

    View details for Web of Science ID 000357997500018

    View details for PubMedID 25712459

  • Using administrative data to estimate time to breast cancer diagnosis and percent of screen-detected breast cancers - a validation study in Alberta, Canada EUROPEAN JOURNAL OF CANCER CARE Yuan, Y., Li, M., Yang, J., Winget, M. 2015; 24 (3): 367-375


    Appropriate use of administrative data enables the assessment of care quality at the population level. Our objective was to develop/validate methods for assessing quality of breast cancer diagnostic care using administrative data, specifically by identifying relevant medical tests to estimate the percentage screen/symptom-detected cancers and time to diagnosis. Two databases were created for all women diagnosed with a first-ever breast cancer in years 2007-2010 in Alberta, Canada, with dates of medical tests received in years 2006-2010. One purchased database had test results and was used to determine the 'true' first relevant test of a cancer diagnosis. The other free administrative database had test types but no test results. Receiver operating characteristic curves and concordance rates were used to assess estimates of percent screen/symptom-detected breast cancers; Log-rank test was used to assess time to diagnosis obtained from the two databases. Using a look-back period of 4-6 months from cancer diagnosis to identify relevant tests resulted in over 94% concordance, sensitivity and specificity for classifying patients into screen/symptom-detected group; good agreement between the distributions of time to diagnosis was also achieved. Our findings support the use of administrative data to accurately identify relevant tests for assessing the quality of breast cancer diagnostic care.

    View details for DOI 10.1111/ecc.12277

    View details for Web of Science ID 000353660500009

    View details for PubMedID 25521706

  • Treatment variation in patients diagnosed with early stage breast cancer in Alberta from 2002 to 2010: a population-based study BMC HEALTH SERVICES RESEARCH Fisher, S., Gao, H., Yasui, Y., Dabbs, K., Winget, M. 2015; 15


    Breast-conserving surgery (BCS) followed by radiotherapy is generally the preferred treatment for women diagnosed with early stage breast cancer. This study aimed to investigate the proportion of patients who receive BCS versus mastectomy and post-BCS radiotherapy, and explore factors associated with receipt of these treatments in Alberta, Canada.A retrospective population-based study was conducted that including all patients surgically treated with stage I-III breast cancer diagnosed in Alberta from 2002-2010. Clinical characteristics, treatment information and patient age at diagnosis were collected from the Alberta Cancer Registry. Log binomial multiple regression was used to calculate stage-specific relative risk estimates of receiving BCS and post-BCS radiotherapy.Of the 14 646 patients included in the study, 44% received BCS, and of those, 88% received post-BCS radiotherapy. The adjusted relative risk of BCS was highest in Calgary and lowest in Central Alberta for all disease stages. Relative to surgeries performed in Calgary, those performed in Central Alberta were significantly less likely to be BCS for stage I (RR = 0.65; 95% 0.57, 0.72), II (RR = 0.58; 95% 0.49, 0.68), and III (RR = 0.62; 95% CI: 0.37, 0.95) disease, respectively, adjusting for patient age at diagnosis, clinical and treatment characteristics. No significant variation of post-BCS radiotherapy was found.Factors such as region of surgical treatment should not be related to the receipt of standard care within a publicly-funded health care system. Further investigation is needed to understand the significant geographic variation present within the province in order to identify appropriate interventions.

    View details for DOI 10.1186/s12913-015-0680-z

    View details for Web of Science ID 000348820000001

    View details for PubMedCentralID PMC4308832

  • Aggressiveness of End-of-Life Care for Patients With Colorectal Cancer in Alberta, Canada: 2006-2009 JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Hu, W., Yasui, Y., White, J., Winget, M. 2014; 47 (2): 231-244


    North American studies have documented practice variations and deficiencies in end-of-life (EOL) cancer care, such as trends toward treating dying patients aggressively and disparities in access to palliative care or hospice services.To assess the frequency of aggressive health care usage at the EOL and identify factors associated with receiving aggressive care among patients who died of colorectal cancer.Data from the Alberta Cancer Registry, in/outpatient hospital records, and cancer electronic medical records were linked. Death in an acute care hospital, chemotherapy use in the last 14 days of life, more than one emergency room (ER) visit, more than one hospital admission, and any intensive care unit (ICU) admission in the last 30 days of life were used as indicators of aggressive care. Logistic regression was used to identify risk factors associated with each indicator.A total of 2074 patients were included: 50.1% died in an acute care hospital; 3.7% received chemotherapy in the last 14 days of life; and 12.5% had multiple ER visits, 9.5% had multiple hospitalizations, and 2.2% had an ICU admission during the last 30 days of life. Age had the strongest association with chemotherapy use. Geographical region of residence had the strongest association with multiple ER visits and hospitalizations and dying in an acute care hospital. Tumor stage and duration of disease were associated with the ICU admission.The percentage of patients who died in an acute care hospital is higher than the 17% U.S. benchmark. Other indicators of receiving aggressive EOL care are consistent with existing care quality benchmarks. The considerable regional variation, however, indicates potential for system improvements.

    View details for DOI 10.1016/j.jpainsymman.2013.03.021

    View details for Web of Science ID 000331150000008

    View details for PubMedID 23870414

  • Timeliness of cancer care from diagnosis to treatment: a comparison between patients with breast, colon, rectal or lung cancer INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Li, X., Scarfe, A., King, K., Fenton, D., Butts, C., Winget, M. 2013; 25 (2): 197-204


    The purpose of this study was to assess the value in measuring specific time intervals across cancer sites to identify potentially important variation in the timeliness of cancer care that may inform needed changes and/or improvements in coordination of care.Retrospective population-level study. Demographic and treatment information were obtained from the Alberta Cancer Registry. Date of oncologist-consult was obtained from cancer medical records.Alberta, Canada.All patients diagnosed in 2005 with breast, colon, rectal or lung cancer who were residents of Alberta, Canada.(i) Number of days from diagnosis to first treatment by treatment modality and cancer site, (ii) number of days from surgery to post-surgery consultation and subsequent treatment and (iii) relationship between clinical and demographic factors and the cancer-specific provincial median time for outcome measures (i) and (ii).Time from diagnosis to surgery, if first treatment, was ∼4 months for lung cancer compared with 1-2 months for breast and colorectal cancers. Factors associated with this time interval for breast and colorectal cancers was stage at diagnosis but was region of residence for lung cancer.Important variation within and across cancer sites identified in the care intervals evaluated in this study provides relevant information to inform local areas for improvement. Comparisons of these intervals across healthcare systems may also provide insights into strengths of different models for coordinating care.

    View details for DOI 10.1093/intqhc/mzt003

    View details for Web of Science ID 000316966800013

    View details for PubMedID 23349426

  • An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation. Journal of evaluation in clinical practice Kling, S. M., Kalwani, N. M., Winget, M., Gupta, K., Saliba-Gustafsson, E. A., Baratta, J., Garvert, D. W., Veruttipong, D., Brown-Johnson, C. G., Vilendrer, S., Gaspar, C., Levin, E., Tsai, S. 2023


    Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics.Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2.Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001).This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.

    View details for DOI 10.1111/jep.13896

    View details for PubMedID 37459156

  • Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool. Surgery Brown-Johnson, C. G., Spargo, T., Kling, S. M., Saliba-Gustafsson, E. A., Lestoquoy, A. S., Garvert, D. W., Vilendrer, S., Winget, M., Asch, S. M., Maggio, P., Nazerali, R. S. 2021


    BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n= 20) and surgeons (n= 10) to explore stakeholder perspectives on video visits.RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

    View details for DOI 10.1016/j.surg.2021.03.029

    View details for PubMedID 33941389

  • "Never Waste A Good Crisis'': A Qualitative Study of Programmatic Challenges, Opportunities, and Gaps Illuminated by the COVID-19 Pandemic in Seven Hospital Systems Holdsworth, L., Mui, H., Winget, M., Lorenz, K. ELSEVIER SCIENCE INC. 2021: 675–76
  • Health after cancer: Early patient experience in a pilot survivorship clinic embedded in primary care. Schapira, L., Winget, M., Wu, S., Kim, J., Brown-Johnson, C. AMER SOC CLINICAL ONCOLOGY. 2018
  • Who are the cancer patients most likely to utilize lay navigation services and what types of issues do they ask for help? Winget, M., Veruttipong, D., Holdsworth, L. M., Zionts, D., Asch, S. M. AMER SOC CLINICAL ONCOLOGY. 2018
  • Is there congruence between the types of triggers that cause delight or disgust in cancer care? Holdsworth, L. M., Zionts, D., Asch, S., Winget, M. AMER SOC CLINICAL ONCOLOGY. 2018
  • Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service. Journal of hospital medicine Kane, M. n., Rohatgi, N. n., Heidenreich, P. n., Thakur, A. n., Winget, M. n., Shum, K. n., Hereford, J. n., Shieh, L. n., Lew, T. n., Horn, J. n., Chi, J. n., Weinacker, A. n., Seay-Morrison, T. n., Ahuja, N. n. 2018


    Multidisciplinary rounds (MDR) facilitate timely communication amongst the care team and with patients. We used Lean techniques to redesign MDR on the teaching general medicine service.To examine if our Lean-based new model of MDR was associated with change in the primary outcome of length of stay (LOS) and secondary outcomes of discharges before noon, documentation of estimated discharge date (EDD), and patient satisfaction.This is a pre-post study. The preperiod (in which the old model of MDR was followed) comprised 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) comprised 2085 patients between October 23, 2014, and April 30, 2015.Lean-based redesign of MDR.LOS, discharges before noon, EDD, and patient satisfaction.There was no change in the mean LOS. Discharges before noon increased from 6.9% to 10.7% (P < .001). Recording of EDD increased from 31.4% to 41.3% (P < .001). There was no change in patient satisfaction.Lean-based redesign of MDR was associated with an increase in discharges before noon and in recording of EDD.

    View details for PubMedID 29394300

  • Patient Perception of Speech Outcomes: The Relationship Between Clinical Measures and Self-Perception of Speech Function Following Surgical Treatment for Oral Cancer. American journal of speech-language pathology Constantinescu, G., Rieger, J., Winget, M., Paulsen, C., Seikaly, H. 2017; 26 (2): 241-247


    Treatment for oral cancer can result in speech impairments that can have varying impacts on patient quality of life. This study explored the relationship between clinical measures of speech impairment and the perception that patients had of this change in the early stage of recovery.This was a quasi-experimental 1-group pre-post study design carried out on 10 patients with surgical intervention for oral cancer. Two clinical measures (word intelligibility and consonant phoneme error) and 2 patient-perception measures (Speech Handicap Index total score and Speech Handicap Index patient criteria score) were collected at preoperative and 1-month postoperative appointments.Qualitative analysis revealed discordance between clinical and patient-perceived measures in 4 of 10 patients. Change in consonant phoneme error and change in word intelligibility were significantly correlated (r = .827). Furthermore, on average, statistically significant relationships were not found between clinical and patient-perceived measures or between the 2 patient-perception measures.Discordance between clinical and patient-perceived measures was observed in almost half of the sample, indicating that clinical tests did not fully explain the extent of impairment perceived by patients. Speech outcomes should focus on both types of measures, and patient perception outcomes should be carefully considered when recommending speech therapy.

    View details for DOI 10.1044/2016_AJSLP-15-0170

    View details for PubMedID 28359083

  • The implementation of a lay care navigation service at the Stanford Cancer Institute. Brown-Johnson, C., Holdsworth, L. J., Rosenthal, E., Asch, S., Winget, M. AMER SOC CLINICAL ONCOLOGY. 2017
  • The impact of false positive breast cancer screening mammograms on screening retention: A retrospective population cohort study in Alberta, Canada CANADIAN JOURNAL OF PUBLIC HEALTH-REVUE CANADIENNE DE SANTE PUBLIQUE Shen, Y., Winget, M., Yuan, Y. 2017; 108 (5-6): E539–E545
  • Improving Care With a Portfolio of Physician-Led Cancer Quality Measures at an Academic Center Improving Care With a Portfolio of Physician-Led Cancer Quality Measures at an Academic Center Porter, J. B. 2017; 13 (8): e673-e682


    Development and implementation of robust reporting processes to systematically provide quality data to care teams in a timely manner is challenging. National cancer quality measures are useful, but the manual data collection required is resource intensive, and reporting is delayed. We designed a largely automated measurement system with our multidisciplinary cancer care programs (CCPs) to identify, measure, and improve quality metrics that were meaningful to the care teams and their patients.Each CCP physician leader collaborated with the cancer quality team to identify metrics, abiding by established guiding principles. Financial incentive was provided to the CCPs if performance at the end of the study period met predetermined targets. Reports were developed and provided to the CCP physician leaders on a monthly or quarterly basis, for dissemination to their CCP teams.A total of 15 distinct quality measures were collected in depth for the first time at this cancer center. Metrics spanned the patient care continuum, from diagnosis through end of life or survivorship care. All metrics improved over the study period, met their targets, and earned a financial incentive for their CCP.Our quality program had three essential elements that led to its success: (1) engaging physicians in choosing the quality measures and prespecifying goals, (2) using automated extraction methods for rapid and timely feedback on improvement and progress toward achieving goals, and (3) offering a financial team-based incentive if prespecified goals were met.

    View details for DOI 10.1200/JOP.2017.021139

    View details for PubMedCentralID PMC5880618

  • PathWell: The Development of a Triage Center and Access Hub for Comprehensive Palliative Care in Oncology Tribett, E., Winget, M., Webster, L., Valmayor, D., Lunger, J., Falconer, P., Chan, S. ELSEVIER SCIENCE INC. 2016: E148
  • PathWell: The development of a triage center and access hub for comprehensive palliative care in oncology Ramchandran, K., Tribett, E., Winget, M., Webster, L., Valmayor, D., Lunger, J. AMER SOC CLINICAL ONCOLOGY. 2016
  • Development and pilot of brief surveys to evaluate the quality of coordinated, patient-centered cancer care. Winget, M., Sheikhi, F., Asch, S. AMER SOC CLINICAL ONCOLOGY. 2016
  • Using Canadian administrative data to evaluate primary and oncology care of breast cancer patients post-treatment: Subset of the CanIMPACT Study. McBride, M. L., Groome, P., Turner, D., Jorgensen, M., Kendell, C., Porter, G., Jiang, L., Krzyzanowska, M., Lofters, A., Moineddin, R., Grunfeld, E., Winget, M. AMER SOC CLINICAL ONCOLOGY. 2016
  • Is screening enough? Implications of a pilot utilizing standard screening criteria for early palliative referral Ramchandran, K., Winget, M., Tribett, E. L., Anderson, B., Morris, A., Blayney, D. W. AMER SOC CLINICAL ONCOLOGY. 2015
  • From PRO screening to improved wellness: A nurse-led intervention Morris, A., Tribett, E. L., Tun, S., Winget, M., Blayney, D. W., Ramchandran, K. AMER SOC CLINICAL ONCOLOGY. 2015
  • Factors related to time to breast cancer diagnosis in screen vs symptom-detected women in Alberta, Canada and implications Winget, M., Yuan, Y., Li, M., Yang, J., Elliot, T., Dabbs, K., Dickinson, J. WILEY-BLACKWELL. 2015: 35–36
  • Treatment variation in patients diagnosed with early stage breast cancer in Alberta from 2002 to 2010: a population-based study. BMC health services research Fisher, S., Gao, H., Yasui, Y., Dabbs, K., Winget, M. 2015; 15: 35


    Breast-conserving surgery (BCS) followed by radiotherapy is generally the preferred treatment for women diagnosed with early stage breast cancer. This study aimed to investigate the proportion of patients who receive BCS versus mastectomy and post-BCS radiotherapy, and explore factors associated with receipt of these treatments in Alberta, Canada.A retrospective population-based study was conducted that including all patients surgically treated with stage I-III breast cancer diagnosed in Alberta from 2002-2010. Clinical characteristics, treatment information and patient age at diagnosis were collected from the Alberta Cancer Registry. Log binomial multiple regression was used to calculate stage-specific relative risk estimates of receiving BCS and post-BCS radiotherapy.Of the 14 646 patients included in the study, 44% received BCS, and of those, 88% received post-BCS radiotherapy. The adjusted relative risk of BCS was highest in Calgary and lowest in Central Alberta for all disease stages. Relative to surgeries performed in Calgary, those performed in Central Alberta were significantly less likely to be BCS for stage I (RR = 0.65; 95% 0.57, 0.72), II (RR = 0.58; 95% 0.49, 0.68), and III (RR = 0.62; 95% CI: 0.37, 0.95) disease, respectively, adjusting for patient age at diagnosis, clinical and treatment characteristics. No significant variation of post-BCS radiotherapy was found.Factors such as region of surgical treatment should not be related to the receipt of standard care within a publicly-funded health care system. Further investigation is needed to understand the significant geographic variation present within the province in order to identify appropriate interventions.

    View details for DOI 10.1186/s12913-015-0680-z

    View details for PubMedID 25609420

    View details for PubMedCentralID PMC4308832

  • The relationship between lingual and hypoglossal nerve function and quality of life in head and neck cancer JOURNAL OF ORAL REHABILITATION Elfring, T., Boliek, C. A., Winget, M., Paulsen, C., Seikaly, H., Rieger, J. M. 2014; 41 (2): 133-140


    Sensorimotor impairment of the tongue has the potential to affect speech and swallowing. The purpose of this study was to critically examine the effects of nerve preservation and reinnervation after reconstruction of the base of tongue on patient-perceived outcomes of quality of life (QoL) related to speech and swallowing through completion of the EORTC QLQ-H&N35 standardised questionnaire. Thirty participants with a diagnosis of base of tongue cancer underwent primary resection and reconstruction with a radial forearm free flap, which may or may not have included nerve repair to the lingual nerve, hypoglossal nerve or both. Eight QoL domains sensitive to changes in motor and sensory nerve function were included in the analysis. Transected lingual and hypoglossal nerves were associated with difficulty in swallowing, social eating, dry mouth and social contact. There were fewer problems reported when these nerves were either repaired or left intact. There were no significant differences between patient nerve status and QoL outcomes for speech, sticky saliva and use of feeding tubes. This study was the first to examine the impact of sensory or motor nerve transection and reconstruction on health-related QoL outcomes.

    View details for DOI 10.1111/joor.12116

    View details for Web of Science ID 000329945800008

    View details for PubMedID 24289234

  • Validation of administrative data sources for endoscopy utilization in colorectal cancer diagnosis BMC HEALTH SERVICES RESEARCH Li, X., Hilsden, R., Hossain, S., Fleming, J., Winget, M. 2012; 12


    Validation of administrative data is important to assess potential sources of bias in outcome evaluation and to prevent dissemination of misleading or inaccurate information. The purpose of the study was to determine the completeness and accuracy of endoscopy data in several administrative data sources in the year prior to colorectal cancer diagnosis as part of a larger project focused on evaluating the quality of pre-diagnostic care.Primary and secondary data sources for endoscopy were collected from the Alberta Cancer Registry, cancer medical charts and three different administrative data sources. 1672 randomly sampled patients diagnosed with invasive colorectal cancer in years 2000-2005 in Alberta, Canada were included. A retrospective validation study of administrative data for endoscopy in the year prior to colorectal cancer diagnosis was conducted. A gold standard dataset was created by combining all the datasets. Number and percent identified, agreement and percent unique to a given data source were calculated and compared across each dataset and to the gold standard with respect to identifying all patients who underwent endoscopy and all endoscopies received by those patients.The combined administrative data and physician billing data identified as high or higher percentage of patients who had one or more endoscopy (84% and 78%, respectively) and total endoscopy procedures (89% and 81%, respectively) than the chart review (78% for both).Endoscopy data has a high level of completeness and accuracy in physician billing data alone. Combined with hospital in/outpatient data it is more complete than chart review alone.

    View details for DOI 10.1186/1472-6963-12-358

    View details for Web of Science ID 000311722800001

    View details for PubMedID 23062117

  • Sarcopenia is associated with postoperative infection and delayed recovery from colorectal cancer resection surgery BRITISH JOURNAL OF CANCER Lieffers, J. R., Bathe, O. F., Fassbender, K., Winget, M., Baracos, V. E. 2012; 107 (6): 931-936


    Skeletal muscle depletion (sarcopenia) predicts morbidity and mortality in the elderly and cancer patients.We tested whether sarcopenia predicts primary colorectal cancer resection outcomes in stage II-IV patients (n=234). Sarcopenia was assessed using preoperative computed tomography images. Administrative hospitalisation data encompassing the index surgical admission, direct transfers for inpatient rehabilitation care and hospital re-admissions within 30 days was searched for International Classification of Disease (ICD)-10 codes for postoperative infections and inpatient rehabilitation care and used to calculate length of stay (LOS).Overall, 38.9% were sarcopenic; 16.7% had an infection and 9.0% had inpatient rehabilitation care. Length of stay was longer for sarcopenic patients overall (15.9 ± 14.2 days vs 12.3 ± 9.8 days, P=0.038) and especially in those ≥ 65 years (20.2 ± 16.9 days vs 13.1 ± 8.3 days, P=0.008). Infection risk was greater for sarcopenic patients overall (23.7% vs 12.5%; P=0.025), and especially those ≥ 65 years (29.6% vs 8.8%, P=0.005). Most (90%) inpatient rehabilitation care was in patients ≥ 65 years. Inpatient rehabilitation was more common in sarcopenic patients overall (14.3% vs 5.6%; P=0.024) and those ≥ 65 years (24.1% vs 10.7%, P=0.06). In a multivariate model in patients ≥ 65 years, sarcopenia was an independent predictor of both infection (odds ratio (OR) 4.6, (95% confidence interval (CI) 1.5, 13.9) P<0.01) and rehabilitation care (OR 3.1 (95% CI 1.04, 9.4) P<0.04).Sarcopenia predicts postoperative infections, inpatient rehabilitation care and consequently a longer LOS.

    View details for DOI 10.1038/bjc.2012.350

    View details for Web of Science ID 000308703400006

    View details for PubMedID 22871883

  • Validation of colorectal cancer surgery data from administrative data sources BMC MEDICAL RESEARCH METHODOLOGY Li, X., King, C., Degara, C., White, J., Winget, M. 2012; 12


    Surgery is the primary treatment for colorectal cancer for both curative and palliative intent. Availability of high quality surgery data is essential for assessing many aspects of the quality of colorectal cancer care. The objective of this study was to determine the quality of different administrative data sources in identifying surgery for colorectal cancer with respect to completeness and accuracy.All residents in Alberta, Canada who were diagnosed with invasive colorectal cancer in years 2000-2005 were identified from the Alberta Cancer Registry and included in the study. Surgery data for these patients were obtained from the Cancer Registry (which collects the date of surgery for which the primary tumor was removed) and compared to surgery data obtained from two different administrative data sources: Physician Billing and Hospital Inpatient data. Sensitivity, specificity, positive predictive value, negative predictive value and observed agreement were calculated compared to the Cancer Registry data.The Physician Billing data alone or combined with Hospital Inpatient data demonstrated equally high sensitivity (97% for both) and observed agreement with the Cancer Registry data (93% for both) for identifying surgeries. The Hospital Inpatient data, however, had the highest specificity (80%). The positive predictive value varied by disease stage and across data sources for stage IV (99% for stages I-III and 83-89% for stage IV), the specificity is better for colon cancer surgeries (72-85%) than for rectal cancer surgeries (60-73%); validation measures did not vary over time.Physician Billing data identify the colorectal cancer surgery more completely than Hospital Inpatient data although both sources have a high level of completeness.

    View details for DOI 10.1186/1471-2288-12-97

    View details for Web of Science ID 000306907200001

    View details for PubMedID 22784239

  • Referral Rate to Oncologists and its Variation by Hospital for Colorectal Cancer Patients ANNALS OF SURGICAL ONCOLOGY Kreiter, E., Yasui, Y., de Gara, C., WHITE, J., Winget, M. 2012; 19 (3): 714-721


    Recent population-based studies in Alberta, Canada, found that approximately 50% of patients with stage III colon or stages II/III rectal adenocarcinoma did not receive guideline-recommended treatment (surgery plus chemotherapy or chemoradiation); a primary reason was not having an oncologist consult. We assessed the relationship between the hospital where the surgery was performed and the probability of a patient not having an oncologist consult.All patients diagnosed with stage III colon or stage II/III rectal adenocarcinoma between 2002 and 2005 in Alberta who had surgery were identified from the Alberta Cancer Registry and included in the study. Multivariable logistic regression modeling with hospitals as random effects was used to estimate cancer-type-specific odds ratios of not having an oncologist consult for each hospital, adjusted for age, sex, and comorbidities, relative to the overall nonconsultation rate.Overall, 21% of stage III colon, 25% of stage II rectal, and 13% of stage III rectal adenocarcinoma patients did not have an oncologist consult. Rates varied appreciably across hospitals and between cancer types within hospitals, even after the case-mix adjustment (adjusted odds ratios of nonconsultation ranged from 0.4 to 8.1). Small hospitals that performed 12 or fewer surgeries had nearly 100% consultation rates.The variation in oncologist-consult rates, particularly for stage II rectal cancer patients, is concerning. We are presenting the findings to the surgical community and discussing interventions to improve oncologist-consult rates.

    View details for DOI 10.1245/s10434-011-2063-y

    View details for Web of Science ID 000300313800004

    View details for PubMedID 21922337

  • Adherence to Treatment Guidelines in Stage II/III Rectal Cancer in Alberta, Canada CLINICAL ONCOLOGY Eldin, N. S., Yasui, Y., Scarfe, A., Winget, M. 2012; 24 (1): E9-E17
  • Variation in risk of second primary cancer CANADIAN MEDICAL ASSOCIATION JOURNAL Winget, M., Yasui, Y. 2012; 184 (1): 19-20

    View details for DOI 10.1503/cmaj.111424

    View details for Web of Science ID 000299654100004

    View details for PubMedID 22125335

  • Association Between Receipt and Timing of Adjuvant Chemotherapy and Survival for Patients With Stage III Colon Cancer in Alberta, Canada CANCER Lima, I. S., Yasui, Y., Scarfe, A., Winget, M. 2011; 117 (16): 3833-3840


    Surgery followed by adjuvant chemotherapy has been standard treatment for stage III colon cancer since 1990. However, to date, clinical trials have not been conducted to determine the definitive outer time limit by which adjuvant chemotherapy should be received for optimal survival benefit. The objective of the current study was to assess the association between the receipt/timing of adjuvant chemotherapy and patient survival in clinical practice.Residents of Alberta who were diagnosed with stage III colon adenocarcinoma in years 2000 to 2005 who underwent surgery were included in the study. Patients were identified from the Alberta Cancer Registry and were linked to hospital data and neighborhood-level socioeconomic data from the 2001 Canadian Census. Cox proportional hazards models were used to estimate hazard ratios of death according to the timing of chemotherapy.There were 1053 patients in the study; 648 (61%) initiated adjuvant chemotherapy within 16 weeks of surgery. There was no difference in overall survival or colon cancer-specific survival between those who received adjuvant chemotherapy from 8 to 12 weeks postsurgery compared with those who received it within 8 weeks. However, those who received chemotherapy 12 to 16 weeks after surgery and those who either received it >16 weeks after surgery or received no treatment had a 43% and 107% greater risk of dying, respectively, than those who received chemotherapy within 8 weeks of surgery (hazard ratio, 1.43 [95% confidence interval, 0.96-2.13] and hazard ratio, 2.07 [95% confidence interval, 1.56-2.76], respectively). Analyses were controlled for age, year, and region of residence at diagnosis; sex; neighborhood-level socioeconomic factors; and number of comorbidities.The results from this study were consistent with current guideline recommendations in Alberta that patients with stage III adenocarcinoma should receive chemotherapy within 12 weeks of surgery.

    View details for DOI 10.1002/cncr.25954

    View details for Web of Science ID 000293672700025

    View details for PubMedID 21319156

  • Utilization of oncology services and receipt of treatment: a comparison between patients with breast, colon, rectal, or lung cancer ANNALS OF ONCOLOGY Li, X., Butts, C., Fenton, D., King, K., Scarfe, A., Winget, M. 2011; 22 (8): 1902-1909


    Higher awareness could translate into better care for patients with breast cancer than for those with other cancers. This study examines utilization of two key oncology services across cancer sites: consultation with an oncologist and receipt of treatment.All residents of Alberta, Canada, who were diagnosed in 2005 with breast, colon, rectal, or lung cancer and had a disease stage that should be treated with chemotherapy, radiation therapy, or hormonal therapy were included. Data were obtained from the Alberta Cancer Registry and electronic cancer medical records. Percentages of patients who had a consultation and who received treatment were compared. Multivariable log-binomial regression models were used to identify patient characteristics associated with not having the outcomes.A much higher percentage of patients with breast cancer had consultations and received treatment (92% and 83%, respectively) than those with colon (83% and 59%), rectal (86% and 73%), or lung (77% and 66%) cancer. Age, disease stage, region of residence, and surgery status are related to having a consultation and/or receiving treatment but the relationship varies by cancer site.Efforts are needed to eliminate disparities in utilization of key cancer services across cancer sites.

    View details for DOI 10.1093/annonc/mdq692

    View details for Web of Science ID 000293300700030

    View details for PubMedID 21278218

  • A Comparison of Charlson and Elixhauser Comorbidity Measures to Predict Colorectal Cancer Survival Using Administrative Health Data CANCER Lieffers, J. R., Baracos, V. E., Winget, M., Fassbender, K. 2011; 117 (9): 1957-1965


    Cancer survival is related to features of the primary malignancy and concurrent presence of nonmalignant diseases (comorbidities), including weight-related conditions (obesity, weight loss). The Charlson and Elixhauser methods are 2 well-known methods that take comorbidities into account when explaining survival. They differ in both the number and categorization of comorbidities.Cancer, comorbidity, and survival data were acquired from inpatient administrative hospital records in 574 colorectal cancer patients. Robust Poisson regression was used to analyze 2- and 3-year survival according to cancer features and comorbidities classified by the Charlson and Elixhauser methods. Data for weight-related conditions (body mass index, weight loss) and performance status were acquired upon a new patient visit to the regional cancer center. Discrimination was assessed with the concordance (c) statistic.A base model (age, sex, stage) had excellent discrimination (c-statistic, 0.824 [2-year survival] and 0.827 [3-year survival]). The addition of Charlson comorbidities did not outperform the base model (c-statistic, 0.831 [2-year survival] and 0.833 [3-year survival]). Elixhauser comorbidities added higher discrimination compared with the base model, both in stage and overall (c-statistic, 0.852 [2-year survival] and 0.854 [3-year survival]; P < .01). The greatest increase in the c-statistic contributed by the addition of the Elixhauser comorbidities occurred in stage II patients (increased from 0.683 to 0.838). Overall, the Elixhauser comorbidities outperformed the Charlson comorbidities (P < .05). The use of self-reported weight and performance status data significantly increased discrimination by the Elixhauser method in 2-year but not 3-year survival.The Elixhauser method is a superior comorbidity risk-adjustment model for colorectal cancer survival prediction.

    View details for DOI 10.1002/cncr.25653

    View details for Web of Science ID 000289833100022

    View details for PubMedID 21509773

  • Uptake and tolerance of adjuvant chemotherapy in early stage NSCLC patients in Alberta, Canada LUNG CANCER Winget, M., Fleming, J., Li, X., Gao, Z., Butts, C. 2011; 72 (1): 52-58


    Adjuvant chemotherapy for early stage non-small cell lung cancer was approved for provincial insurance coverage in Alberta, Canada in 2004. The purpose of this study was to measure factors related to uptake of chemotherapy in eligible patients and compare toxicity and survival outcomes in the Alberta population with those found in clinical trials. All Alberta residents diagnosed with stage IB-IIB NSCLC from 2004 to 2006 who had surgery and a consultation with an oncologist to discuss initial treatment were included in the study. Diagnostic, demographic, and vital statistics data were obtained from the Alberta Cancer Registry; chart reviews were conducted to identify details related to treatments discussed, refused, co-morbidities, and toxicity. Analyses were conducted to identify factors associated with discussion and receipt of chemotherapy and toxicity. Toxicity and survival were calculated and compared to clinical trial results. 226 patients were included in the study. Adjuvant chemotherapy was not recommended to 57 patients (25%) and 30 patients (13%) refused chemotherapy. Primary reasons for not recommending chemotherapy were co-morbidities and/or frailty (24 patients). Of the 139 patients who began chemotherapy, 47 (34%) stopped treatment early. Stage II patients who received adjuvant chemotherapy had over a 2-fold decrease in risk of death compared to those who did not receive chemotherapy after adjusting for age and co-morbidities. Efforts to improve uptake of adjuvant chemotherapy in patients with stage II NSCLC should be made as the survival advantage appears to be comparable to that found in clinical trials.

    View details for DOI 10.1016/j.lungcan.2010.07.005

    View details for Web of Science ID 000289130700009

    View details for PubMedID 20708293

  • Characteristics of Patients With Stage III Colon Adenocarcinoma Who Fail to Receive Guideline-Recommended Treatment CANCER Winget, M., Hossain, S., Yasui, Y., Scarfe, A. 2010; 116 (20): 4849-4856


    Many patients with stage III colon adenocarcinoma do not receive adjuvant chemotherapy despite the proven survival advantage it offers. To enhance the provision of optimal cancer care, patient characteristics associated with not receiving guideline-adherent treatment must be identified among patients with operable, stage III colon adenocarcinoma.This was a population-based, retrospective study of all patients who underwent surgery for stage III colon adenocarcinoma diagnosed from 2002 through 2005 in Alberta, Canada. Demographic and treatment information captured in the Alberta Cancer Registry were linked to: 1) hospital discharge data to determine comorbidities, 2) electronic medical records to identify consults with oncologists, and 3) the 2001 Canadian census for neighborhood-level socioeconomic data. Multivariate log-binomial regression models were used to identify patient characteristics that were associated with not having a consultation with a medical oncologist and not receiving adjuvant chemotherapy.Of the 772 patients who underwent surgery for stage III colon adenocarcinoma and met the eligibility criteria, 618 patients (80%) had a consultation with an oncologist. Of those, 388 patients (63%) initiated adjuvant chemotherapy within 84 days of their surgery. Patient characteristics that were associated with not having a consultation with an oncologist were neighborhood income, geography, age, and comorbidities. Of those patients who had a consultation, after adjusting for comorbidities, only older age was related to not receiving adjuvant chemotherapy.The current results indicated that the proportion of patients with stage III colon adenocarcinoma who did not receive treatment according to evidence-based guidelines was appreciable. The authors concluded that the association of this failure with patient age, geography, and income is concerning and that evaluation of referral patterns and interventions are needed.

    View details for DOI 10.1002/cncr.25250

    View details for Web of Science ID 000282910800001

    View details for PubMedID 20578180

  • Comparison of Treatment Received Versus Long-Standing Guidelines for Stage III Colon and Stage II/III Rectal Cancer Patients Diagnosed in Alberta, Saskatchewan, and Manitoba in 2004 CancerCare 2008 Meeting Cree, M., Tonita, J., Turner, D., Nugent, Z., Alvi, R., Barss, R., King, C., Winget, M. CIG MEDIA GROUP, LP. 2009: 141–45


    Guideline-recommended treatment for stage II/III colorectal cancer includes postsurgical chemotherapy and/or radiation as standard of care. This study measures adherence to guidelines across 3 Canadian provinces and evaluates the relationship of patient characteristics with receiving standard care.All surgically treated patients diagnosed in 2004 with stage III colon or stage II/III rectal cancer and residing in Alberta, Saskatchewan, or Manitoba were identified from provincial cancer registries. Sex, age at diagnosis, and area of residence were also obtained from the cancer registry. The primary outcome of interest was receipt of standard care: surgery followed by chemotherapy or radiation therapy (adjuvant therapy). chi2 tests and binary regression with log link assessed the relationship of patient demographic characteristics (age, sex, residence, cancer disease stage) with receipt of standard care.About half of the patients received adjuvant therapy. Patients with stage III rectal cancer were more likely to receive adjuvant treatment than stage II patients in Alberta and Saskatchewan. There was a large decrease in the percentage of patients who received adjuvant treatment with increasing age in all the provinces (P < .001), ranging from about 80% of those aged < 65 years to about 20% of those aged >or= 75 years for colon cancer patients and from about 70% to 30%, respectively, for rectal cancer patients. The decrease of adjuvant treatment with increasing age was most marked in Alberta.The percentage of patients receiving guideline-recommended treatment is low. Reasons for lack of adherence to guidelines need to be addressed.

    View details for DOI 10.3816/CCC.2009.n.023

    View details for Web of Science ID 000268129500003

    View details for PubMedID 19632928

  • Predictors of Surgery and Consult with an Oncologist for Adjuvant Chemotherapy in Early Stage NSCLC Patients in Alberta, Canada JOURNAL OF THORACIC ONCOLOGY Winget, M., Stanger, J., Gao, Z., Butts, C. 2009; 4 (5): 629-634


    In the fall of 2004, adjuvant chemotherapy for early stage non-small cell lung cancer (NSCLC) patients was approved for coverage by the Alberta Cancer Board, the provincial agency responsible for systemic therapy in the province of Alberta. The purpose of this study was to measure the proportion of early stage NSCLC patients diagnosed between 2004 and 2006 that received surgery and subsequently had a consult with an oncologist at a cancer facility, and to identify factors related to receiving surgery and having a consult that could be addressed.A retrospective observational study was conducted. All patients diagnosed with stage IB, IIA, or IIB NSCLC in Alberta from 2004 to 2006 were identified from the Alberta cancer registry. Date of definitive surgery, gender, age at diagnosis, and area of residence were also obtained from the cancer registry and evaluated as predictors for surgery and oncology consult. Date of consult with an oncologist was obtained from the electronic medical record of the Alberta Cancer Board.There were 561 patients diagnosed with stage IB-IIB NSCLC from 2004 to 2006, 352 of whom had surgery and 255 of whom subsequently had a consult with an oncologist. Age and residence at diagnosis were both strongly associated with the likelihood of receiving surgery and the likelihood of attending a consult with an oncologist.Several areas of further research have been identified by this study including age and rural residence on treatment/referral patterns.

    View details for Web of Science ID 000265557700012

    View details for PubMedID 19276835

  • Palliative radiotherapy for women with breast cancer CLINICAL ONCOLOGY Danielson, B., Winget, M., Gao, Z., MURRAY, B., Pearcey, R. 2008; 20 (7): 506-512


    Palliative radiotherapy (PRT) plays an important role in women with metastatic breast cancer. However, not all cancer patients with an indication for PRT receive it. The aim of this study was to measure the use of PRT for women who have died of breast cancer in the Canadian province of Alberta, and to identify factors that might affect this use.All women who died of breast cancer in Alberta between 2000 and 2004 were identified from the Alberta Cancer Registry. PRT, defined as any radiotherapy given with palliative intent, was abstracted from the radiotherapy databases of the treatment facilities of the Alberta Cancer Board (ACB). The variables evaluated were: age at death, regional health authority (RHA), driving distance to nearest radiotherapy facility, receipt of initial treatment at an ACB facility, receipt of radiotherapy as part if initial treatment, residence in a city with an ACB facility, residence in a city with radiotherapy facilities or visiting radiation oncologists, median household income, and municipality population. Backwards stepwise logistic regression was used to determine the final set of predictor variables for the use of PRT.In total, 1906 women were identified as having died of breast cancer between 2000 and 2004, inclusive. Of these, 50.4% received at least one course of PRT. Factors associated with not receiving PRT in the final multiple logistic regression model for women who lived outside of the cities with radiotherapy facilities were: age>75 years, community size>10,000, median income<$47,000, and residence in RHA 4. For women living in cities with radiotherapy facilities, only age was significant.There are many factors that influence the receipt of PRT in Alberta that are unrelated to patient need. The education of physicians and patients, as well as the establishment of more radiotherapy facilities, will help to improve the use of PRT.

    View details for DOI 10.1016/j.clon.2008.04.013

    View details for Web of Science ID 000259748700003

    View details for PubMedID 18524556

  • Across-province standardization and comparative analysis of time-to-care intervals for cancer BMC CANCER Winget, M., Turner, D., Tonita, J., King, C., Nugent, Z., Alvi, R., Barss, R. 2007; 7


    A set of consistent, standardized definitions of intervals and populations on which to report across provinces is needed to inform the Provincial/Territorial Deputy Ministries of Health on progress of the Ten-Year Plan to Strengthen Health Care. The objectives of this project were to: 1) identify a set of criteria and variables needed to create comparable measures of important time-to-cancer-care intervals that could be applied across provinces and 2) use the measures to compare time-to-care across participating provinces for lung and colorectal cancer patients diagnosed in 2004.A broad-based group of stakeholders from each of the three participating cancer agencies was assembled to identify criteria for time-to-care intervals to standardize, evaluate possible intervals and their corresponding start and end time points, and finalize the selection of intervals to pursue. Inclusion/exclusion criteria were identified for the patient population and the selected time points to reduce potential selection bias. The provincial 2004 colorectal and lung cancer data were used to illustrate across-province comparisons for the selected time-to-care intervals.Criteria identified as critical for time-to-care intervals and corresponding start and end points were: 1) relevant to patients, 2) relevant to clinical care, 3) unequivocally defined, and 4) currently captured consistently across cancer agencies. Time from diagnosis to first radiation or chemotherapy treatment and the smaller components, time from diagnosis to first consult with an oncologist and time from first consult to first radiation or chemotherapy treatment, were the only intervals that met all four criteria. Timeliness of care for the intervals evaluated was similar between the provinces for lung cancer patients but significant differences were found for colorectal cancer patients.We identified criteria important for selecting time-to-care intervals and appropriate inclusion criteria that were robust across the agencies that did not result in an overly selective sample of patients to be compared. Comparisons of data across three provinces of the selected time-to-care intervals identified several important differences related to treatment and access that require further attention. Expanding this collaboration across Canada would facilitate improvement of and equitable access to quality cancer care at a national level.

    View details for DOI 10.1186/1471-2407-7-186

    View details for Web of Science ID 000251424400001

    View details for PubMedID 17916257

  • Evaluation of serum protein profiling by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry for the detection of prostate cancer: I. Assessment of platform reproducibility CLINICAL CHEMISTRY Semmes, O. J., Feng, Z., Adam, B. L., Banez, L. L., Bigbee, W. L., Campos, D., Cazares, L. H., Chan, D. W., Grizzle, W. E., IZBICKA, E., Kagan, J., Malik, G., McLerran, D., Moul, J. W., Partin, A., Prasanna, P., Rosenzweig, J., Sokoll, L. J., Srivastava, S., Srivastava, S., Thompson, I., Welsh, M. J., White, N., Winget, M., Yasui, Y., Zhang, Z., Zhu, L. 2005; 51 (1): 102-112


    Protein expression profiling for differences indicative of early cancer has promise for improving diagnostics. This report describes the first stage of a National Cancer Institute/Early Detection Research Network-sponsored multiinstitutional evaluation and validation of this approach for detection of prostate cancer.Two sequential experimental phases were conducted to establish interlaboratory calibration and standardization of the surface-enhanced laser desorption (SELDI) instrumental and assay platform output. We first established whether the output from multiple calibrated Protein Biosystem II SELDI-ionization time-of-flight mass spectrometry (TOF-MS) instruments demonstrated acceptable interlaboratory reproducibility. This was determined by measuring mass accuracy, resolution, signal-to-noise ratio, and normalized intensity of three m/z "peaks" present in a standard pooled serum sample. We next evaluated the ability of the calibrated and standardized instrumentation to accurately differentiate between selected cases of prostate cancer and control by use of an algorithm developed from data derived from a single site 2 years earlier.When the described standard operating procedures were established at all laboratory sites, the across-laboratory measurements revealed a CV for mass accuracy of 0.1%, signal-to-noise ratio of approximately 40%, and normalized intensity of 15-36% for the three pooled serum peaks. This was comparable to the intralaboratory measurements of the same peaks. The instrument systems were then challenged with sera from a selected group of 14 cases and 14 controls. The classification agreement between each site and the established decision algorithm were examined by use of both raw peak intensity boosting and ranked peak intensity boosting. All six sites achieved perfect blinded classification for all samples when boosted alignment of raw intensities was used. Four of six sites achieved perfect blinded classification with ranked intensities, with one site passing the criteria of 26 of 28 correct and one site failing with 19 of 28 correct.These results demonstrate that "between-laboratory" reproducibility of SELDI-TOF-MS serum profiling approaches that of "within-laboratory" reproducibility as determined by measuring discrete m/z peaks over time and across laboratories.

    View details for DOI 10.1373/clinchem.2004.038950

    View details for Web of Science ID 000225991100019

    View details for PubMedID 15613711

  • A web-based system for managing and co-ordinating multiple multisite studies CLINICAL TRIALS Winget, M., Kincaid, H., Lin, P., Li, L., Kelly, S., Thornquist, M. 2005; 2 (1): 42-49


    Efficient and secure collection and management of information is essential in any modern biomedical study. Data management and coordination of multisite studies is a complex process. It involves development of systems for data collection, data cleaning with quality assurance checks, and specimen tracking, as well as development of procedures for conducting the study, training clinical sites, and communicating with sites to answer study questions and resolve and track data inquiries and resolutions. We developed a secure web-based system that is designed to automate evaluation of eligibility criteria and data collection, track specimens, serve as a resource for study-specific information, facilitate communication across sites in multisite studies, track data queries and resolutions, and allow administrative management of studies. The system combines a common framework across studies that defines the internal structure for all the web pages, with a study-specific one that defines the content of each page via a relational database. This combination creates a flexible and efficient environment enabling several multisite studies to be simultaneously or consecutively implemented and managed in a timely manner. We describe the development process, the system and its evaluation, current status, lessons learned, and future development plans.

    View details for Web of Science ID 000232622500007

    View details for PubMedID 16279578

  • An automated peak identification/calibration procedure for high-dimensional protein measures from mass spectrometers JOURNAL OF BIOMEDICINE AND BIOTECHNOLOGY Yasui, Y., McLerran, D., Adam, B. L., Winget, M., Thornquist, M., Feng, Z. D. 2003: 242-248
  • A data-analytic strategy for protein biomarker discovery: profiling of high-dimensional proteomic data for cancer detection BIOSTATISTICS Yasui, Y., Pepe, M., Thompson, M. L., Adam, B. L., Wright, G. L., Qu, Y. S., Potter, J. D., Winget, M., Thornquist, M., Feng, Z. D. 2003; 4 (3): 449-463


    With recent advances in mass spectrometry techniques, it is now possible to investigate proteins over a wide range of molecular weights in small biological specimens. This advance has generated data-analytic challenges in proteomics, similar to those created by microarray technologies in genetics, namely, discovery of 'signature' protein profiles specific to each pathologic state (e.g. normal vs. cancer) or differential profiles between experimental conditions (e.g. treated by a drug of interest vs. untreated) from high-dimensional data. We propose a data-analytic strategy for discovering protein biomarkers based on such high-dimensional mass spectrometry data. A real biomarker-discovery project on prostate cancer is taken as a concrete example throughout the paper: the project aims to identify proteins in serum that distinguish cancer, benign hyperplasia, and normal states of prostate using the Surface Enhanced Laser Desorption/Ionization (SELDI) technology, a recently developed mass spectrometry technique. Our data-analytic strategy takes properties of the SELDI mass spectrometer into account: the SELDI output of a specimen contains about 48,000 (x, y) points where x is the protein mass divided by the number of charges introduced by ionization and y is the protein intensity of the corresponding mass per charge value, x, in that specimen. Given high coefficients of variation and other characteristics of protein intensity measures (y values), we reduce the measures of protein intensities to a set of binary variables that indicate peaks in the y-axis direction in the nearest neighborhoods of each mass per charge point in the x-axis direction. We then account for a shifting (measurement error) problem of the x-axis in SELDI output. After this pre-analysis processing of data, we combine the binary predictors to generate classification rules for cancer, benign hyperplasia, and normal states of prostate. Our approach is to apply the boosting algorithm to select binary predictors and construct a summary classifier. We empirically evaluate sensitivity and specificity of the resulting summary classifiers with a test dataset that is independent from the training dataset used to construct the summary classifiers. The proposed method performed nearly perfectly in distinguishing cancer and benign hyperplasia from normal. In the classification of cancer vs. benign hyperplasia, however, an appreciable proportion of the benign specimens were classified incorrectly as cancer. We discuss practical issues associated with our proposed approach to the analysis of SELDI output and its application in cancer biomarker discovery.

    View details for Web of Science ID 000184100800011

    View details for PubMedID 12925511

  • Development of common data elements: the experience of and recommendations from the early detection research network INTERNATIONAL JOURNAL OF MEDICAL INFORMATICS Winget, M. D., Baron, J. A., Spitz, M. R., Brenner, D. E., Warzel, D., Kincaid, H., Thornquist, M., Feng, Z. D. 2003; 70 (1): 41-48


    There have been an increasing number of large research consortia in recent years funded by the National Cancer Institute (NCI) to facilitate multi-disciplinary, multi-institutional cancer research. Some of these consortia have central data collection plans similar to a multi-center clinical trial whereas others plan to store data locally and pool or share the data at a later date. Regardless of the goal of the consortium, there is a need to standardize the way certain data are collected and stored, transferred, or reported across the institutions involved. This communication is a report of the process and current status of the development of common data elements (CDEs) by the Early Detection Research Network (EDRN). The development of the CDEs involved several stages with each stage requiring input from multi-disciplinary experts in oncology, epidemiology, biostatistics, pathology, informatics, and study coordination. An effort was made to be consistent with other consortia developing similar CDEs and to follow data standards when available. Initial focus was on identifying the minimum data that would be necessary to collect on all EDRN study participants and EDRN specimens. There are currently CDEs in the development or pilot phase for eight different organ sites and 13 different types of specimen procurements and plans to develop CDEs for 12 or more additional types of specimens.

    View details for DOI 10.1016/S1386-5056(03)00005-4

    View details for Web of Science ID 000182905900005

    View details for PubMedID 12706181

  • A national virtual specimen database for early cancer detection 16th IEEE Symposium on Computer-Based Medical Systems Kincaid, H., Kelly, S., Crichton, D., Johnsey, D., Winget, M., Srivastava, S. IEEE COMPUTER SOC. 2003: 117–123
  • Phases of biomarker development for early detection of cancer JOURNAL OF THE NATIONAL CANCER INSTITUTE Pepe, M. S., Etzioni, R., Feng, Z. D., Potter, J. D., Thompson, M. L., Thornquist, M., Winget, M., Yasui, Y. 2001; 93 (14): 1054-1061

    View details for Web of Science ID 000169829000009

    View details for PubMedID 11459866

  • Breast cancer risk and "delayed" primary Epstein-Barr virus infection CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Yasui, Y., Potter, J. D., Stanford, J. L., Rossing, M. A., Winget, M. D., Bronner, M., Daling, J. 2001; 10 (1): 9-16


    Parallel to its established causal association with both infectious mononucleosis (IM) and young adulthood Hodgkin disease (YAHD), we propose a hypothesis that "delayed" primary EBV infection (i.e., primary infection occurring during adolescence or adulthood) is associated with elevated breast cancer risk. We evaluated this hypothesis with two investigations, one descriptive and the other analytic. The descriptive study used international/United States cancer registry data to assess the association between incidence rates of breast cancer and those of YAHD. The incidence rates of the seemingly unrelated neoplasms were strongly correlated (correlation coefficients of 0.74 and 0.88 for international and United States data, respectively; these were higher than the correlation coefficients of YAHD with two other cancers that we considered). Populations with higher incidence rates corresponded to those with higher likelihood of delayed primary EBV infection. The analytical study was based on a population-based case-control study of breast cancer in middle-aged women. Age-adjusted odds ratios of breast cancer in women who reported a history of IM, relative to women who did not, increased monotonically from 0.55 [95% confidence interval (CI), 0.05-6.17] for women with 0-9 years of age at IM onset to 2.67 (CI, 1.04-6.89) for women with > or =25 years of age at IM onset (P = 0.016). An older age at tonsillectomy, another surrogate of delayed EBV exposure, was also associated with increased risk of breast cancer: odds ratios, 0.92 (CI, 0.57-1.48) and 1.76 (CI, 1.15-2.69) for women with tonsillectomy at 0-4 years of age and > or =15 years of age, respectively (P = 0.018). Adjusting for additional potential confounders did not modify the associations appreciably. The implications of the findings and a potential biological mechanism are presented.

    View details for Web of Science ID 000166651600003

    View details for PubMedID 11205495

  • An empirical evaluation of various priors in the empirical Bayes estimation of small area disease risks STATISTICS IN MEDICINE Yasui, Y., Liu, H., Benach, J., Winget, M. 2000; 19 (17-18): 2409-2420


    Empirical and fully Bayes estimation of small area disease risks places a prior distribution on area-specific risks. Several forms of priors have been used for this purpose including gamma, log-normal and non-parametric priors. Spatial correlation among area-specific risks can be incorporated in log-normal priors using Gaussian Markov random fields or other models of spatial dependence. However, the criterion for choosing one prior over others has been mostly logical reasoning. In this paper, we evaluate empirically the various priors used in the empirical Bayes estimation of small area disease risks. We utilize a Spanish mortality data set of a 12-year period to give the underlying true risks, and estimate the true risks using only a 3-year portion of the data set. Empirical Bayes estimates are shown to have substantially smaller mean squared errors than Poisson likelihood-based estimates. However, relative performances of various priors differ across a variety of mortality outcomes considered. In general, the non-parametric prior provides good estimates for lower-risk areas, while spatial priors provide good estimates for higher-risk areas. Ad hoc composite estimates averaging the estimates from the non-parametric prior and those from a spatial log-normal prior appear to perform well overall. This suggests that an empirical Bayes prior that strikes a balance between these two priors, if one can construct such a prior, may prove to be useful for the estimation of small area disease risks.

    View details for Web of Science ID 000089275000016

    View details for PubMedID 10960862

  • Antibody to human immunodeficiency virus type 1 (HIV-1) gp160 in mucosal specimens of asymptomatic HIV-1-infected volunteers parenterally immunized with an experimental recombinant HIV-1 IIIB gp160 vaccine CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY Lambert, J. S., Viscidi, R., Walker, M. C., Clayman, B., Winget, M., Wolff, M., Schwartz, D. H. 1997; 4 (3): 302-308


    Twenty-two human immunodeficiency virus type 1 (HIV-1)-infected, asymptomatic volunteers with CD4 cell counts of >600 cells/mm3 who were enrolled in a phase I immunotherapy trial comparing two schedules of immunization of an HIV-1 IIIB-based recombinant gp160 (rgp160) experimental vaccine were evaluated for rgp160-specific antibodies in parotid saliva, genital secretions, and serum. When the study was unblinded, it was determined that five volunteers had received rgp160 on a month 0, 1, 2, 3, 4, and 5 immunization schedule, seven volunteers had received rgp160 on a month 0, 1, 2, and 5 schedule, five had received alum/deoxycholate placebo, and seven had received a licensed hepatitis B virus vaccine. Five volunteers consented to the donation of parotid saliva but not genital secretions. Prior to immunization, parotid saliva specimens were available for 11 of 22 volunteers, seminal plasma (SP) specimens were available for 7 of 22 volunteers, cervicovaginal lavage (CVL) specimens were available for 5 of 22 volunteers, and serum was available for 22 of 22 volunteers. These baseline specimens and specimens collected at 1 and 7 months after the final immunizations were assessed by enzyme-linked immunosorbent assay for immunoglobulin G (IgG) and IgA antibodies specific for HIV-1 LAI rgp160 or HIV-1 MN rgp160. No augmentation in HIV rgp160-specific IgG or IgA antibody production in either parotid saliva or serum specimens of vaccinees compared to that in controls was observed after immunization. There were insufficient numbers of SP or CVL specimens available for statistical comparisons between vaccinees and controls. Overall, anti-LAI rgp160 IgG antibodies were detected in the parotid saliva specimens of 20 of 22 volunteers, the seminal plasma specimens of 11 of 11 volunteers, and the CVL specimens of 6 of 6 volunteers and in 21 of 22 serum specimens. Fewer volunteers expressed anti-LAI rgp160 IgA antibodies in mucosal or serum specimens: 11 of 22 parotid saliva specimens, 3 of 11 SP specimens, 3 of 5 CVL samples, and 12 of 22 sera.

    View details for Web of Science ID A1997WX24900013

    View details for PubMedID 9144368

  • Wood-burning stoves and lower respiratory illnesses in Navajo children PEDIATRIC INFECTIOUS DISEASE JOURNAL Robin, L. F., Lees, P. S., Winget, M., Steinhoff, M., Moulton, L. H., Santosham, M., Correa, A. 1996; 15 (10): 859-865


    Acute lower respiratory illnesses (ALRI) have been associated with exposure to domestic smoke. To examine further this association, a case-control study was conducted among Navajo children seen at the Public Health Service Indian Hospital at Fort Defiance, AZ.Cases, children hospitalized with an ALRI (n = 45), were ascertained from the inpatient logs during October, 1992, through March, 1993. Controls, children who had a health record at the same hospital and had never been hospitalized for ALRI, were matched 1:1 to cases on date of birth and gender. Home interviews of parents of subjects during March and April, 1993, elicited information on heating and cooking fuels and other household characteristics. Indoor air samples were collected for determination of time-weighted average concentrations of respirable particles (i.e. < 10 microns in diameter).Age of cases at the time of admission ranged from 1 to 24 months (median, 7 months); 60% of the cases were male. Matched pair analysis revealed an increased risk of ALRI for children living in households that cooked with any wood (odds ratio (OR), 5.0; 95% confidence interval (CI), 0.6 to 42.8), had indoor air concentrations of respirable particles > or = 65 micrograms/m3 (i.e. 90th percentile) (OR 7.0, 95% CI 0.9 to 56.9), and where the primary caretaker was other than the mother (OR 9, 95% CI 1.1 to 71.4). Individual adjustment for potential confounders resulted in minor change (i.e. < 20%) in these results. Indoor air concentration of respirable particles was positively correlated with cooking and heating with wood (P < 0.02) but not with other sources of combustion emissions.Cooking with wood-burning stoves was associated with higher indoor air concentrations of respirable particles and with an increased risk of ALRI in Navajo children.

    View details for Web of Science ID A1996VL70800004

    View details for PubMedID 8895916

  • Immunoglobulin G subclass responses of children during infection with Onchocerca volvulus CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY Gbakima, A. A., Nutman, T. B., Bradley, J. E., McReynolds, L. A., Winget, M. D., Hong, Y., Scott, A. L. 1996; 3 (1): 98-104


    To characterize the patterns of immunoglobulin G (IgG) subclass and IgE reactivity during the early stages of onchocerciasis, sera were collected from 224 children (age groups, 2 to 5, 6 to 10, and 11 to 15 years) residing in a region of Sierra Leone where Onchocerca volvulus is endemic, and these samples were tested by enzyme-linked immunosorbent assay for their reactivity to adult antigens (OvAg) and against four recombinant proteins (OV11, OV27, OV29, and OV16). Over 88% of the samples contained detectable levels of anti-OvAg IgG. In samples from microfilaria (MF)-positive children, IgG4 responses were significantly elevated and constituted on average 39, 35 and 28% of the total IgG responses for the age groups of 2 to 5, 6 to 10, and 11 to 15 years, respectively. For MF-negative individuals, the mean contributions of IgG4 to the total IgG response were 11% (2 to 5 years), 27% (6 to 10 years), and 56% (11 to 15 years). OvAg-specific IgE was detectable in the sera from both MF-negative and MF-positive individuals. To increase the specificity of the response, recombinant antigens OV11, OV27, and OV29 were tested individually or as a cocktail. Nearly 50% of the MF-negative children and 85% of the MF-positive children had detectable levels of IgG against at least one of the recombinant antigens. Only a small portion of the IgG against the recombinant peptides was IgG4. The prevalence of IgG against OV16 in samples from MF-negative children was 51%, and that for MF-positive children was 75%. The general profile of the humoral immune responses mounted by both MF-positive and a large percentage of the MF-negative children during the initial phases of infection with O. volvulus is similar to the profile reported for adults harboring chronic O. volvulus infections. These results suggest that very quickly after infection, the interactions between parasite and host result in an immunological environment that may contribute to the maintenance of a long-term, chronic infection.

    View details for Web of Science ID A1996TP77700018

    View details for PubMedID 8770512



    The proto-oncogene HER2/neu encodes a protein tyrosine kinase (p185HER2) that is homologous to the human epidermal growth factor receptor. Amplification and/or overexpression of HER2/neu occurs in multiple human malignancies and appears to be integrally involved in progression of some breast and ovarian cancers. Because of this fact, HER2/neu is an intriguing target for specific cancer therapeutic strategies. One such strategy is active specific immunotherapy, in which the immune system is targeted at specific antigens expressed by tumor cells. We have employed a transfected cell line that secretes the extracellular domain of p185HER2 as a source of HER2-derived immunogen in a guinea pig model. The immunized animals developed a cellular immune response, as monitored by delayed-type hypersensitivity, and antisera derived from immunized animals specifically inhibited the in vitro growth of human breast tumor cells overexpressing p185HER2. These data provide support for an immunotherapeutic approach to cancers characterized by overexpression of the HER2/neu proto-oncogene.

    View details for Web of Science ID A1990EB95400001

    View details for PubMedID 1979347



    High levels of expression of either the epidermal growth factor receptor or the receptor-like HER2/neu gene product p185HER2 have been observed in a variety of human malignancies. Because of the association of this high level expression with certain human tumors, we have generated a panel of monoclonal antibodies specific for either the epidermal growth factor receptor or p185HER2 to study their structure, function, and antigenic domains in the normal and neoplastic states. We used the epidermoid carcinoma line A431 to generate five monoclonal antibodies which immunoprecipitate the epidermal growth factor receptor. These monoclonal antibodies bind to the extracellular domain of the epidermal growth factor receptor and demonstrate variable effects on epidermal growth factor binding. We used a stably transfected NIH 3T3 cell line expressing the HER2/neu gene to produce and characterize 10 monoclonal antibodies which immunoprecipitate p185HER2. These monoclonal antibodies bind to the extracellular domain of p185HER2 and do not cross-react with the epidermal growth factor receptor. The characteristics and potential applications of these monoclonal antibodies will be discussed.

    View details for Web of Science ID A1990CQ37700032

    View details for PubMedID 1689212



    Epidermal growth factor (EGF) and transforming growth factor alpha (TGF alpha) compete with each other for binding to the EGF receptor. These two growth factors have similar actions, but there are distinguishable differences in their biological activities. It has never been clear how this one receptor can mediate different responses. A monoclonal antibody to the EGF receptor (13A9) has been identified which has only small effects on the binding of EGF to the EGF receptor, but which has very large effects on the binding of TGF alpha to the EGF receptor; 5 micrograms/mL antibody has been shown to totally block 0.87 microM TGF alpha from binding to purified EGF receptor and to lower both the high- and low-affinity binding constants of TGF alpha binding to EGF receptor on A431 cells by about 10-fold. The 13A9 antibody causes a 2.5-fold stimulation of the tyrosine kinase activity of partially purified EGF receptor, compared to a 4.0-fold stimulation of the tyrosine kinase activity by EGF under the same conditions. The data suggest either that the antibody stabilizes a conformation of the EGF receptor which is not favorable for TGF alpha binding or that it blocks a part of the surface of the receptor which is necessary for TGF alpha binding but not EGF binding.

    View details for Web of Science ID A1989AH82900032

    View details for PubMedID 2790004



    The HER2/c-erbB-2 gene encodes the epidermal growth factor receptorlike human homolog of the rat neu oncogene. Amplification of this gene in primary breast carcinomas has been show to correlate with poor clinical prognosis for certain cancer patients. We show here that a monoclonal antibody directed against the extracellular domain of p185HER2 specifically inhibits the growth of breast tumor-derived cell lines overexpressing the HER2/c-erbB-2 gene product and prevents HER2/c-erbB-2-transformed NIH 3T3 cells from forming colonies in soft agar. Furthermore, resistance to the cytotoxic effect of tumor necrosis factor alpha, which has been shown to be a consequence of HER2/c-erbB-2 overexpression, is significantly reduced in the presence of this antibody.

    View details for Web of Science ID A1989T444300032

    View details for PubMedID 2566907