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Elston Lafata Lab

Welcome to our website! The Elston Lafata Team is a diverse group of health care researchers, quality improvement leaders and analysts, students, and postdoctoral trainees. As a team, we work to understand how patient-provider communication and decision making affect the quality of healthcare delivered to and received by diverse populations of patients. We often work in partnership with health care delivery organizations and engage patients to develop, implement, and evaluate practice-integrated decision support innovations focused on improving cancer screening and treatment. Our current research and quality improvement work is focused on understanding adherence to and counseling for oral anti-neoplastic therapy, testing patient-targeted decision support for cancer screening, and developing practitioner-targeted decision support for population management in the context of cancer care.

Medication Counseling and Adherence to Oral Chemotherapy

The Elston Lafata Team is committed to improving oral medication adherence and management in cancer care. Oral antineoplastic therapy, also known as oral chemotherapy, is unique in its frequent use of repeated treatment-rest cycles, concerns regarding toxicity, evidence of overuse, and need for ongoing symptom monitoring at home. With the use of oral antineoplastic therapy expanding, it is important to understand how best to support patients’ adherence to these oral agents. To date, we have launched a total of 3 projects to explore this complex issue.

Patient-Oncologist Communication regarding Oral Chemotherapy during Routine Office Visits

We recently completed a qualitative study to understand how oncologists discuss oral capecitabine with their patients with colorectal cancer. We were particularly interested in the medication counseling patients received and how the patient’s adherence to the prescribed regimen was discussed. Using medical office visit audio recordings/transcripts collected for the Verilogue™ database, we coded and analyzed transcript data and classified the content of patient-provider conversations about oral anticancer medications. A manuscript presenting findings from this study will be published in the Journal of Oncology Practice in early 2020.

Patient-provider Communication and Oral Chemotherapy Adherence (ongoing)

We are conducting a scoping review to identify key patient-provider communication strategies that support patients’ adherence to oral chemotherapy. Results from this review, are identifying multiple communication gaps in current practice as well as intervention opportunities to improve cancer care quality.

Understanding Provider-initiated Counseling and Adherence to Oral Antineoplastic Therapy (ongoing)

We are also conducting an observational, mixed methods pilot study to characterize current medication adherence and counseling practices across time among cancer patients prescribed oral chemotherapy. The pilot is being conducted in partnership with UNC Health Care and will also identify how adherence determinants vary with time and determine provider-initiated counseling strategies that best support adherence and improved outcomes among patients initiating new oral antineoplastic therapy.


Patient-Targeted Colorectal Cancer Screening Decision Support

Colorectal cancer is the second leading cause of cancer death in the United States. While several effective screening methods exist, screening remains underutilized. Prior research has shown that more than 90% of primary care patients receive a physician recommendation for screening when they are due, but just over half of those who receive such recommendations go on to be screened in the next year. Since 2015, our team has worked in partnership with health care delivery organizations to close the gap between physician recommendation for screening and screening uptake among primary care populations. Our overarching goal is to develop effective practice-integrated decision support programs that are accessible and acceptable to broad segments of the population.

Leveraging the EHR and Patient Portal Infrastructure

With funding from the National Cancer Institute (R01 CA197205 Elston Lafata), we are working in partnership with the Henry Ford Health System to develop and test a patient-targeted, colorectal cancer screening decision-support program. The program, called e-assist: Colon Health is designed to facilitate the uptake of physician-recommended colorectal cancer screening by educating patients about their screening options and addressing individual barriers to screening.

The e-assist: Colon Health program is housed within Henry Ford Health System’s online patient portal. The program consists of educational information, video vignettes, and care options tailored to each patient’s decision stage and information preferences. The program was developed in close partnership with care teams at Henry Ford Health System to ensure its fit with existing clinic workflows and practices. Patients were engaged to help develop and refine program content. Early results of this work have highlighted:

  • Challenges in leveraging patient portals to reach diverse patient populations
  • Multi-stakeholder engagement as a means to facilitate program implementation and practice integration and to enhance program utility

Text Messaging to Enhance Decision Support among Diverse Populations 2019-2021

With developmental funding from the UNC Lineberger Comprehensive Cancer Center, we are working to examine the feasibility of text messaging to reach socio-demographically diverse patients at the time of a colorectal cancer screening decision and support them in making a decision to screen. Our text-messaging project consists of three phases. In the first phase, we are employing an online cohort to evaluate candidate text messages for their relevance, salience, usability, and impact on participant’s intentions to use text-based decision support. In Phase II, we will further develop and refine the text message program using input from primary care patients at UNC Health Care. In the final phase, we will pilot the program in partnership with the UNC Health Care System.


Cancer Care Quality Improvement

The overarching goal of the UNC Cancer Care Quality Initiative (CCQI) is to support the North Carolina Cancer Hospital’s ability to deliver value-based oncology care. In partnership with UNC Health Care practitioners, we are developing an informatics infrastructure to support oncology population management. We use data analytics to monitor the care quality delivered to UNC Health Care patients and to identify opportunities for improvement. CCQI strives to ensure the development of reliable and valid clinical performance metrics and other analytical capabilities to support care standards and the informatics infrastructure needed by practitioner teams to take appropriate actions and achieve measurable, desired outcomes. We strive to allow real time identification of patients throughout the cancer care continuum enabling:

  • Identification of gaps in evidence-based care
  • Patient risk stratification for targeted service delivery
  • Decision support for patients and clinicians
  • Continual performance monitoring and tracking of outcomes

Our current activities include:

  • Developing a system-wide Cancer Care Quality Dashboard that will be used as platform for real time communication of quality data
  • Developing the infrastructure to identify and attribute patients receiving cancer treatment at one UNC Health Care’s six locations across the state
  • Collaborating with clinical and other cancer care leaders to ensure our reporting meets the needs of clinical teams and adequately supports care quality efforts
  • Collaborating with physicians at UNC Health Care to characterize the prevalence of abnormal chest CTs locally and the type and timing of follow-up care patients with a lung nodule receive. To do so, we are using data from electronic health records, and patient and provider interviews. Findings will identify gaps in care quality and opportunities for interventions to improve the follow-up care offered to this patient population.


Other Current Research

Implicit bias, communication behaviors and care outcomes among black patients with type 2 diabetes

Although we know that medication non-adherence is prevalent among African Americans with diabetes, and that patient-clinician communication contributes to patients’ medication adherence, we know little about how physician implicit bias may present during office visits. In this grant, we are collaborating with researchers at Virginia Commonwealth University and the University of Michigan (R01 DK112009 Hagiwara) to identify clinician communication behaviors associated with implicit bias and, in turn, studying the association between these communication behaviors and the outcomes of black patients with Type 2 diabetes, including patients’ medication adherence and diabetes self-management behaviors.

Understanding the lung cancer screening process

Numerous organizations, including the United States Preventive Services Task Force, recommend annual lung cancer screening with low-dose computed tomography (LDCT) for high-risk adults who meet specific criteria. Despite these recommendations, lung cancer screening remains underused in the United States. We are currently participating in two NCI-funded studies pertaining to lung cancer screening. Both of these projects while relying heavily on data from the electronic health record to understand opportunities to improve the quality of lung cancer screening delivered to diverse patients, also have a focus on the decision making process currently being used by patients and clinicians.

In the first (UMI-CA221939 Pearson-Ritzwoller and Vachani), we are collaborating with researchers in NCI’s Population-based Research to Optimize the Screening PRocess (PROSPR) consortium. As a member of the Lung PROSPR Research Consortium, we are working with five diverse healthcare systems in Colorado, Hawaii, Michigan, Pennsylvania, and Wisconsin to examine lung cancer screening use and outcomes across diverse populations. As part of this effort, we are assessing how variations in the implementation of LCS programs, including how shared decision making has been implemented, effect outcomes across the screening process.

In the second (R01 CA2220990 Carter-Harris), we are using a mixed methods study to understand the “active ingredients” in lung cancer shared decision making and examine the predictors of positive decisional and behavioral outcomes to enable the development of lung cancer screening decision support interventions.. This grant is in collaboration with researchers at Memorial Sloan Kettering and Kaiser Permanente Washington.

Recent Publications

Chou YT, Farley JF, Stinchcombe TE, Proctor AE, Lafata JE, Duestzina SB. The Association Between Medicare Low-Income Subsidy and Anticancer Treatment Update in Advanced Lung Cancer. J Natl Cancer Inst. 2020 Jun 1; 112 (6): 637-646. PMID: 7301149.

Woolf SH, Krist AH, Lafata JE, Jones RM, Lehman RR, Hochheimer CJ, Sabo RT, Frosch DL, Zikmund-Fisher BJ, Longo DR. Engaging Patients in Decisions about Cancer Screening: Exploring the Decision Journey through the Use of a Patient Portal. Am J Prev Med 2018. 54(2):237-247. PMID: 29241715.

Shin Y, Lafata JE, and Cao Y. Statistical Power in Two-Level Hierarchical Linear Models with Arbitrary Number of Factor Levels, Journal of Statistical Planning and Inference. 2018 Mar;194:106-121. PMID 29358843.

Banegas MP, Yabroff KR, O’Keeffe-Rosetti M, Ritzwoller DP, Fishman PA, Salloum RG, Lafata JE, Hornbrook MC. Medical Care Costs Associated with Cancer in Integrated Delivery Systems. Journal of the National Comprehensive Cancer Network,2018 April16(4):402-410. PMID 29632060.

Elston Lafata, J, CG Miller, DA Shires, KE Dyer, S Ratliff and M Schreiber. Patients’ adoption of and feature access within electronic patient portals. American Journal of Managed Care, 2018 Nov 1;24(11):e352-e357. PMID 30452203.

Shires DA, Tabriz AA, Miller CG, Lafata JE. Team Culture and Care Quality in Patient-Centered Medical Homes, The American Journal of Accountable Care, September 2018, in press.

Hagiwari N, Mezuk B, Elston Lafata J, Vrana SR, and Fetters M. A Study Protocol for Investigating Physician Communication Behaviors that Link Physician Implicit Racial Bias and Patient Clinical Outcomes in Black Patients with Type 2 Diabetes Using an Exploratory Sequential Mixed Methods Design, BMJ Open. 2018 Oct 18:8(10):e022623. PMID 30341127.

Brenner AT, Malo TL, Margolis M, Elston Lafata J, James S, Vu MB, Reuland DS. Evaluating Shared Decision Making for Lung Cancer Screening. JAMA Intern Med. 2018 Oct 1;178(10):1311-1316. PMID:30105393

Dyer KE, Shires DA, Flocke SA, Hawley ST, Jones RM, Resnicow K, Shin Y, Lafata JE. Patient-Reported Needs Following a Referral for Colorectal Cancer Screening, Am J Prev Med 2018 Dec 13 PMID 30554975.

Lafata JE, Shin Y, Flocke S, Hawley ST, Jones, RM, Resnicow K, Schreiber M, Shires DA, Tu SP. Randomized trial to evaluate the effectiveness and impact of offering post-office visit decision support and assistance in obtaining physician-recommended colorectal cancer screening: the e-assist: Colon Health Study-a Protocol Study, BMJ Open. 2019 Jan 7;9(1):e023986.

Park J, Kotzias D, Kuo P, Logan Iv RL, Merced K, Singh S, Tanana M, Karra Taniskidou E, Lafata JE, Atkins DC, Tai-Seale M, Imel ZE, Smyth P. Detecting conversation topics in primary care office visits from transcripts of patient-provider interactions. J Am Med Inform Assoc. 2019 Dec 1;26(12):1493-1504. PMID: 31532490.

Tabriz AA, Fleming PJ, Shin Y, Resnicow K, Jones RM, Flocke SA, Shires DA, Hawley ST, Willens D, Lafata JE. Challenges and opportunities using online portals to recruit diverse patients to behavioral trials. J Am Med Inform Assoc. 2019 Dec 1;26(12):1637-1644. PMID: 31532482.

Hagiwara N, Lafata JE, Mezuk B, Vrana S, Fetters M. Detecting implicit racial bias in provider communication behaviors to reduce disparities: Challenges, solutions and future directions for novel coding systems. Patient Education and Counseling. 2019 Apr 19; 102(9):1738-1743. PMID: 31036330.

Fang G, Annis IE, Elston Lafata J, Cykert, S. Applying Machine Learning to Predict Real-World Individual Treatment Effects – Insights from a Virtual Patient Cohort. Journal of the American Medical Informatics Association. 2019 Oct 1; 26(10):977-988. PMID: 31220274.

Chou Y, Farley JF, Stinchcombe TE, Proctor AE, Elston Lafata J, Dusetzina. Delays in Orally-administered Anticancer Treatment Initiation for Medicare Beneficiaries, in press.

Johnson Shen M, Elston Lafata, J, Bylund C. Lower Adherence: A Description of Colorectal Cancer Screening Barrier Talk. Journal of Health Communication. 2019 Dec. 4; 25(1): 43-53. PMID: 31795843.

Tabriz AA, Flocke SA, Shires DA, Dyer KF, Schreiber M, Lafata JE. A Logic Model Framework for Considering the Inputs, Processes and Outcomes of a Health Care Organization – Research Partnership. BMJ Quality and Safety. 2019 Dec 11. PMID: 31826921.

Cole A, Wood W, Muluneh B, Lund J, Elston Lafata J, Dusetzina S. Comparative safety and healthcare expenditures among chronic myeloid leukemia patients initiating first-line imatinib, dasatinib, or nilotinib, in press.

Nguyen B, Wu B, Sanoff H, Lafata JE. Patient-Oncologist Communication regarding Oral Chemotherapy during Routine Office Visits. Journal of Oncology Practice, accepted.

Miller CA, Lafata JE, Thomson MD. The Effects of Personalizing Colorectal Cancer Risk Communication on Risk Perceptions and Health Behavior Intentions: a Randomized Trial of Average-Risk Adults. J Cancer Educ. 2020 Jan 29. PMID: 31997146.

Tabriz AA, Neslund-Dudas C, Turner K, Rivera MP, Reuland DS, Lafata JE. How Health-Care Organizations Implement Shared Decision-Making When It Is Required for Reimbursement: The Case of Lung Cancer Screening. Chest, 2020.

October 2020

Jennifer Elston Lafata presented research entitled Challenges and Opportunities in Implementing Shared Decision Making in Cancer Screening at the UNC Lineberger Cancer Outcomes Seminar.

January 2020

Patrice Jordan Fleming and Morgan Johnson attended the 2020 North Carolina Public Health Leaders Conference.

Amir Alishahi Tabriz and Patrice Jordan Fleming gave a guest lecture to graduate students in the UNC Eshelman School of Pharmacy’s new Implementation Science course. The lecture focused on measuring program and implementation outcomes for the e-assist: Colon Health program.

December 2019

Jennifer Elston Lafata presented research entitled Operationalizing knowledge co-production in the context of delivery system science: The delivery system science partnership (DSSP) framework at the 12th Annual Conference on the Science of Dissemination and Implementation. Amir Alishahi Tabriz was a co-author on the submitted abstract.

November 2019

Jennifer Elston Lafata presented a grand rounds presentation entitled Using Technology to Extend Office Visit Colorectal Cancer Screening Discussions at the UF Health Cancer Center.

October 2019

Amir Alishahi Tabriz presented research on lung cancer shared decision making at the 2019 International Conference on Communication in Healthcare (ICCH). Jennifer Elston Lafata was a co-author on the submitted abstract.

Jennifer Elston Lafata presented research on patient-provider discussions about BRCA1/2 testing at the 2019 International Conference on Communication in Healthcare (ICCH). Patrice Jordan Fleming was the first author and Morgan Johnson was a co-author on the submitted abstract.

September 2019

Jennifer Elston Lafata presented research entitled Building a Population Management Informatics Infrastructure for Oncology Care at the 2019 ASCO Quality Care Symposium. Stephen Harris II was a co-author on the submitted abstract.

Jennifer Elston Lafata

(919) 966-9480

Jennifer Elston Lafata, Ph.D. is Professor and Executive Vice Chair in the Division of Pharmaceutical Outcomes and Policy at the UNC Eshelman School of Pharmacy at the University of North Carolina at Chapel Hill. She also serves as the co-lead for the UNC Cancer Care Quality Initiative and Associate Director in the UNC Institute for Healthcare Quality Improvement. She conducts practice-integrated research to understand and improve patient-clinician communication and decision making, particularly in the context of cancer prevention and control.

Stephen Harris II, BS BA

Stephen Harris II is a Business Analytics Specialist for Oncology Services at UNC Health Care. He joined the Elston Lafata Team in May 2018. His position provides analytical support for cancer quality improvement initiatives by establishing data sources and methods for data collection, display, and analysis.

Michelle O’Neil, MPA


Michelle O’Neil, MPA is a Quality & Organizational Excellence Leader for Oncology Services at UNC Health Care. Michelle provides on the ground operational improvement coaching support for the cancer hospital’s outpatient clinics as well as project management for the Cancer Care Quality Initiative. She has been with the Elston Lafata Team since October 2019.

Joelle Baxter

Joelle Baxter is a Research Coordinator at Henry Ford Health System in Detroit Michigan. She provides onsite research support for the e-assist: Colon Health study.

Ellen Nixon, MA

Ellen Nixon, MA is a Research Coordinator at Henry Ford Health System in Detroit Michigan. Her training is in applied sociology with a concentration in research and evaluation and health care policy. She currently works as part of the Elston Lafata Team providing onsite coordination for the e-assist: Colon Health Study.

Joshua Brown, MPS

Past Position(s): Graduate Research Assistant, Social/Clinical Research Specialist

Current: Market Finance Professional II | Humana

Daniel Erim, MD, PhD, MS

Past Position(s): Graduate Research Assistant

Current: Senior Consultant, HEOR Modelling & Simulation | Parexel

Audrey Holdren, BA

Past Position(s): Quality & Organizational Excellence Leader for Oncology Services UNC Health Care.

Current: Colon and Rectal Surgery Coordinator | UT Southwestern

Teri Long, BS

Past Position(s): Undergraduate Research Assistant

Current: Director of Critical Care & Cardiology Services| Doylestown Hospital

Bobbie Nguyen, PharmD

Past Position(s): Graduate Research Assistant

Current: Pharmacy Resident | University of Maryland Baltimore Washington Medical Center