6500 Background: Low-income and minority populations have less activation in their cancer care, lower health-related quality of life, greater acute care use and total costs of care than affluent and white populations. Community-based interventions are needed to improve patient experiences and quality of cancer care equitably among these populations. We used community-based participatory methods to refine a previously tested intervention for use in urban communities. The intervention, LEAPS, uses community health workers trained to activate patients in discussions with their cancer clinicians regarding advance care planning and symptom-burden and to connect patients with community-based resources to overcome social determinants of health. We conducted a randomized controlled trial of LEAPS in collaboration with an employer-union health plan in Atlantic City, NJ and Chicago, IL. Members of the employer-union health plan with newly diagnosed with hematologic and solid tumor cancers were randomized to the 6-month LEAPS intervention. The objective of the study was to determine whether LEAPS improved quality of life (primary). Secondarily, we evaluated the effect of LEAPS on patient activation, acute care use, and total costs of care. Methods: We used generalized linear regression models to evaluate differences in quality of life and patient activation scores between groups from baseline to 4- and 12-months post-enrollment and regression models offset for length of follow-up to compare emergency department use, hospitalizations, and total costs of care. Results: A total of 160 patients were consented and randomized into the study (80 intervention; 80 control). There were no differences in demographic or clinical factors across groups. The majority were non-White (74%), female (53%), mean age 57 years with breast (31%) or lung cancer (21%) and Stage 3 or 4 (63%) disease. At 4- and 12-months follow-up, the intervention group had greater improvements in quality of life overtime as compared to the control group (difference in difference: 11.5 p < 0.001) and greater change in patient activation overtime (difference in difference: 11.9 (p < 0.001)). At 12-months follow-up there were no differences in emergency department use (0.44 (0.71) versus 0.73 (0.22) p = 0.22) however intervention group participants had fewer hospitalizations (1.55 (0.86) vs. 2.29 (1.31), p = 0.002) and lower median total costs of care ($72,585 vs. $153,980, p = 0.04). Conclusions: Integrating community-based interventions into clinical cancer care delivery for low-income and minority populations can significantly improve patient activation, reduce hospitalizations and total costs of care. These interventions may represent a sustainable resource to facilitate equitable, value-based cancer care. Clinical trial information: NCT03699748.
In a number of recent controversies, from sports teams' use of Indian mascots to the federal government's desecration of sacred sites, American
No abstract
Criminal jurisdiction in Indian country is defined by a central, ironic paradox. Recent federal laws expanding tribal criminal jurisdiction are, in many respects, enormous victories for Indian country, as they acknowledge and reify a more robust notion of tribal sovereignty, one capable of accommodating increased tribal control over safety and security on Indian reservations. At the same time, the laws make clear that sovereignty comes at a price, potentially working to effectuate further assimilation of tribal courts and Indian people. As a result, at the same time that tribal sovereignty gains ground in ways critical to autonomy and self-governance, it is simultaneously threatened by exogenous forces that have the potential to homogenize tribal justice systems legally, politically, and—in particular—culturally.This Article offers the first comprehensive assessment of the Tribal Law and Order Act and the reauthorization of the Violence Against Women Act, respectively, to show how they relate to one another on the ground and the implications for tribal sovereignty and self-determination. Ultimately, based on data compiled for the first time as well as extensive secondary sources, I argue that expanded criminal jurisdiction and punishment authority have, perhaps paradoxically, enhanced the ability of tribes to develop and enforce policies, laws, and procedures that are consistent with tribal custom and tradition. This presents a unique opportunity worthy of further exploration. In other words, rather than sovereignty and assimilation expanding in tension with one another, I find that the application of the laws has been experienced in tribal communities, as least anecdotally and preliminarily, as greatly enhancing—not threatening or destroying—tribal sovereignty and Indian cultural survival.Published: Angela R. Riley, "Crime and Governance in Indian Country," 63 UCLA Law Review 1564 (2016).
Author Stephenie Meyer forever altered the cultural existence of Quileute Indians when she wrote them into her Twilight novels. Now a veritable global phenomenon complete with books, movies, and affiliated merchandise, the Twilight series depicts young, male members of the tribe as vampire-fighting werewolves who ferociously defend a peace and territorial treaty made with local bloodsuckers. In reality, the Quileute Tribe consists of approximately 700 Indians, many of whom live on a remote reservation in the pacific Northwest, a tiny parcel of the once vast Quileute territory. Since Twilight's unprecedented international success, the Quileute have been overwhelmed with fans and entrepreneurs, all grasping, quite literally in some cases, for their own piece of the Quileute.
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