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Riviere P, Morgan KM, Deshler LN, Demb J, Mehtsun WT, Martinez ME, Gupta S, Banegas M, Murphy JD, Rose BS. Racial disparities in colorectal cancer outcomes and access to care: a multi-cohort analysis. Front Public Health 2024; 12:1414361. [PMID: 38962767 PMCID: PMC11220245 DOI: 10.3389/fpubh.2024.1414361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 06/03/2024] [Indexed: 07/05/2024] Open
Abstract
Introduction Non-Hispanic Black (NHB) Americans have a higher incidence of colorectal cancer (CRC) and worse survival than non-Hispanic white (NHW) Americans, but the relative contributions of biological versus access to care remain poorly characterized. This study used two nationwide cohorts in different healthcare contexts to study health system effects on this disparity. Methods We used data from the Surveillance, Epidemiology, and End Results (SEER) registry as well as the United States Veterans Health Administration (VA) to identify adults diagnosed with colorectal cancer between 2010 and 2020 who identified as non-Hispanic Black (NHB) or non-Hispanic white (NHW). Stratified survival analyses were performed using a primary endpoint of overall survival, and sensitivity analyses were performed using cancer-specific survival. Results We identified 263,893 CRC patients in the SEER registry (36,662 (14%) NHB; 226,271 (86%) NHW) and 24,375 VA patients (4,860 (20%) NHB; 19,515 (80%) NHW). In the SEER registry, NHB patients had worse OS than NHW patients: median OS of 57 months (95% confidence interval (CI) 55-58) versus 72 months (95% CI 71-73) (hazard ratio (HR) 1.14, 95% CI 1.12-1.15, p = 0.001). In contrast, VA NHB median OS was 65 months (95% CI 62-69) versus NHW 69 months (95% CI 97-71) (HR 1.02, 95% CI 0.98-1.07, p = 0.375). There was significant interaction in the SEER registry between race and Medicare age eligibility (p < 0.001); NHB race had more effect in patients <65 years old (HR 1.44, 95% CI 1.39-1.49, p < 0.001) than in those ≥65 (HR 1.13, 95% CI 1.11-1.15, p < 0.001). In the VA, age stratification was not significant (p = 0.21). Discussion Racial disparities in CRC survival in the general US population are significantly attenuated in Medicare-aged patients. This pattern is not present in the VA, suggesting that access to care may be an important component of racial disparities in this disease.
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Affiliation(s)
- Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States
- Center for Health Equity Education & Research (CHEER), University of California, San Diego, La Jolla, CA, United States
- Veterans Affairs San Diego, La Jolla, CA, United States
| | - Kylie M. Morgan
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States
- Center for Health Equity Education & Research (CHEER), University of California, San Diego, La Jolla, CA, United States
- Veterans Affairs San Diego, La Jolla, CA, United States
| | - Leah N. Deshler
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States
- Center for Health Equity Education & Research (CHEER), University of California, San Diego, La Jolla, CA, United States
- Veterans Affairs San Diego, La Jolla, CA, United States
| | - Joshua Demb
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Winta T. Mehtsun
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Maria Elena Martinez
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States
| | - Samir Gupta
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Matthew Banegas
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States
- Center for Health Equity Education & Research (CHEER), University of California, San Diego, La Jolla, CA, United States
| | - James D. Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States
- Center for Health Equity Education & Research (CHEER), University of California, San Diego, La Jolla, CA, United States
- Veterans Affairs San Diego, La Jolla, CA, United States
| | - Brent S. Rose
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States
- Center for Health Equity Education & Research (CHEER), University of California, San Diego, La Jolla, CA, United States
- Veterans Affairs San Diego, La Jolla, CA, United States
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Hellwig LD, Banaag A, Olsen C, Turner C, Haigney M, Koehlmoos T. A health systems assessment of genetic counseling in cardiovascular care in a large health system: Adherence to genetics recommendations in the Military Health System. J Genet Couns 2023. [PMID: 37766662 DOI: 10.1002/jgc4.1791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023]
Abstract
Genetic counseling and genetic testing are important tools for diagnosis, screening, and employment of effective medical management strategies for hereditary cardiovascular diseases. Despite widespread recognition of the benefits of genetic counseling and testing in cardiovascular care, little is published regarding their use in large healthcare systems. We conducted a retrospective cross-sectional study using administrative claims data in the US Military Health System to assess the state of recommended genomic counseling in clinical cardiovascular care. Logistic regression models were used to examine associations of genetic counseling among beneficiaries with hereditary cardiovascular conditions. Approximately 0.44% of beneficiaries in fiscal year 2018 had a diagnosis of a hereditary cardiovascular condition. Among the 23,364 patients with a diagnosis of hereditary cardiovascular disease, only 175 (0.75%) had documented genetic counseling and 196 (0.84%) had documented genetic testing. Genetic counseling did not differ by race, sex, service, or diagnosis. Age group, Active Duty status, rank as a proxy for socioeconomic status, and geographic location contributed significantly to the likelihood of receiving genetic counseling. These findings suggest that genetic counseling is underutilized in clinical cardiovascular care in the Military Health System and may be more broadly, despite expert consensus recommendations for its use and potential life-saving benefits. Unlike previous studies in the US civilian health sector, there did not appear to be disparities in genetic counseling by race or sex in the Military Health System. Strategies to improve care for cardiovascular disease should address the underutilization of recommended genetics evaluations for heritable diagnoses and the challenges of assessing use in large health systems studies.
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Affiliation(s)
- Lydia D Hellwig
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Center for Military Precision Health (CMPH), Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Amanda Banaag
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Center for Health Services Research (CHSR), Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Cara Olsen
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Clesson Turner
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Mark Haigney
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Military Cardiovascular Outcomes Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Tracey Koehlmoos
- Center for Health Services Research (CHSR), Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Fuller S, Kuenstler M, Snipes M, Miller M, Lutgendorf MA. Obstetrical health care inequities in a universally insured health care system. AJOG GLOBAL REPORTS 2023; 3:100256. [PMID: 37638226 PMCID: PMC10458343 DOI: 10.1016/j.xagr.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in health care exist and are rooted in long-standing systemic inequities. These disparities result in significant excess health care expenditures and are due to complex interactions between patients, health care providers and systems, and social and environmental factors. In perinatal care, these inequities also exist, with Black patients being 3 to 4 times more likely to die of childbirth compared with White patients. Similar health care inequities may also exist in the Military Health System despite universal health care coverage, stable employment, and social programs that benefit military families. OBJECTIVE This study aimed to evaluate racial disparities in obstetrical outcomes in the Military Health System. STUDY DESIGN This is a retrospective cohort study of deliveries from 2019 to 2021 in the Military Health System, which provides obstetrical care for approximately 35,000 annual deliveries. The study was conducted using National Perinatal Information Center data on cesarean delivery, postpartum hemorrhage, and severe maternal morbidity by race and ethnicity from direct-care military hospitals representing tertiary care medical centers and community hospitals in the United States and abroad. Chi-square analyses and binary logistic regression were used to compare groups. RESULTS The cohort included 68,918 deliveries. Of these, 32,358 (47%) were White, 9594 (13.9%) Black, 3120 (4.5%) Asian Pacific Islander, 456 (0.7%) American Indian/Alaska Native, 19,543 (28.4%) other, 3976 (5.8%) unknown, 7096 (10.3%) Hispanic, 58,009 (84.2%) non-Hispanic, and 4399 (6.4%) other ethnicity. Rates of cesarean delivery were significantly higher for Black (30%; odds ratio, 1.44; 95% confidence interval, 1.37-1.52), Asian Pacific Islander (27%; odds ratio, 1.24; 95% confidence interval, 1.14-1.35), and other (26%; odds ratio, 1.20; 95% confidence interval, 1.15-1.25) compared with White race (23%) (P<.001). Postpartum hemorrhage rates were higher for Black (5.9%; odds ratio, 1.11; 95% confidence interval, 1.00-1.24) and Asian Pacific Islander (7.7%; odds ratio, 1.49; 95% confidence interval, 1.29-1.72) compared with White race (5.3%) (P<.001). Severe maternal morbidity was higher for Black (2.9%; odds ratio, 1.44; 95% confidence interval, 1.24-1.67), Asian Pacific Islander (2.9%; odds ratio, 1.45; 95% confidence interval, 1.15-1.82), and other (2.8%; odds ratio, 1.36; 95% confidence interval, 1.21-1.54) compared with White race (2.1%) (P<.001). For severe maternal morbidity excluding blood transfusions, rates were also significantly higher for Black (1%; odds ratio, 1.68; 95% confidence interval, 1.30-2.17) than for White race (0.6%) (P<.002). Hispanic ethnicity was associated with a lower rate of severe maternal morbidity excluding transfusions (0.5%; odds ratio, 0.68; 95% confidence interval, 0.48-0.98) compared with non-Hispanic ethnicity (0.7%) (P=.04). CONCLUSION Racial disparities in obstetrical outcomes exist in the Military Health System despite universal health care coverage, with significantly higher rates of cesarean delivery and severe maternal morbidity in Black, Asian Pacific Islander, and other races compared with White race. These findings suggest that these disparities are likely related to other factors or social determinants of health rather than availability of health care and insurance coverage. Further work should include investigation into such social determinants of health to address their causes, including systemic and structural barriers.
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Affiliation(s)
- Shara Fuller
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center San Diego, San Diego, CA (Drs Fuller and Miller)
| | - Molly Kuenstler
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD (Dr Kuenstler and Dr Lutgendorf)
| | - Marie Snipes
- Department of Mathematics and Statistics, Kenyon College, Gambier, OH (Dr Snipes)
| | - Michael Miller
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center San Diego, San Diego, CA (Drs Fuller and Miller)
| | - Monica A. Lutgendorf
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD (Dr Kuenstler and Dr Lutgendorf)
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Rutter CM, May FP, Coronado GD, Pujol TA, Thomas EG, Cabreros I. Racism Is a Modifiable Risk Factor: Relationships Among Race, Ethnicity, and Colorectal Cancer Outcomes. Gastroenterology 2022; 162:1053-1055. [PMID: 34942173 DOI: 10.1053/j.gastro.2021.12.251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Folasade P May
- David Geffen School of Medicine and UCLA Kaiser Permanente Center for Health Equity, University of California, Los Angeles, California
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Data Resources for Evaluating the Economic and Financial Consequences of Surgical Care in the United States. J Trauma Acute Care Surg 2022; 93:e17-e29. [PMID: 35358106 DOI: 10.1097/ta.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
LEVEL OF EVIDENCE V.
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Racial and Socioeconomic Disparities in CKD in the Context of Universal Health Care Provided by the Military Health System. Kidney Med 2022; 4:100381. [PMID: 35072045 PMCID: PMC8767122 DOI: 10.1016/j.xkme.2021.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Rationale & Objective Health-impeding social determinants of health—including reduced access to care—contribute to racial and socioeconomic disparities in chronic kidney disease (CKD). The Military Health System (MHS) provides an opportunity to assess a large, diverse population for CKD disparities in the context of universal health care. Study Design Cross-sectional study. Setting & Participants MHS beneficiaries aged 18 to 64 years receiving care between October 1, 2015, and September 30, 2018. Predictors Race, sponsor’s rank (a proxy for socioeconomic status and social class), median household income by sponsor’s zip code, and marital status. Outcome CKD prevalence, defined by International Classification of Diseases, Tenth Revision codes and/or a validated, laboratory value-based electronic phenotype. Analytical Approach Multivariable logistic regression compared CKD prevalence by predictors, controlling separately for confounders (age, sex, active-duty status, sponsor’s service branch, and depression) and mediators (hypertension, diabetes, HIV, and body mass index). Results Of 3,330,893 beneficiaries, 105,504 (3.2%) had CKD. In confounder-adjusted models, the CKD prevalence was higher in Black versus White beneficiaries (OR, 1.67; 95% CI, 1.64-1.70), but lower in single versus married beneficiaries (OR, 0.77; 95% CI, 0.76-0.79). The prevalence of CKD was increased among those with a lower military rank and among those with a lower median household income in a nearly dose-response fashion (P < 0.0001). Associations were attenuated when further adjusting for suspected mediators. Limitations The cross-sectional design prevents causal inferences. We may have underestimated the CKD prevalence, given a lack of data for laboratory tests conducted outside the MHS and the use of a specific CKD definition. The transient nature of the MHS population may limit the accuracy of zip code–level median household income data. Conclusions Racial and socioeconomic CKD disparities exist in the MHS despite universal health care coverage. The existence of CKD disparities by rank and median household income suggests that social risks may contribute to both racial and socioeconomic disparities despite access to universal health care coverage.
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Koehlmoos TP, Korona-Bailey J, Janvrin ML, Madsen C. Racial Disparities in the Military Health System: A Framework Synthesis. Mil Med 2021; 187:e1114-e1121. [PMID: 34910808 DOI: 10.1093/milmed/usab506] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/25/2021] [Accepted: 12/11/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Racial disparities in health care are a well-documented phenomenon in the USA. Universal insurance has been suggested as a solution to mitigate these disparities. We examined race-based disparities in the Military Health System (MHS) by constructing and analyzing a framework of existing studies that measured disparities between direct care (care provided by military treatment facilities) and private sector care (care provided by civilian health care facilities). MATERIALS AND METHODS We conducted a framework synthesis on 77 manuscripts published in partnership with the Comparative Effectiveness and Provider-Induced Demand Collaboration Project that use MHS electronic health record data to present an overview of racial disparities assessed for multiple treatment interventions in a nationally representative, universally insured population. RESULTS We identified 32 studies assessing racial disparities in areas of surgery, trauma, opioid prescription and usage, women's health, and others. Racial disparities were mitigated in postoperative complications, trauma care, and cancer screenings but persisted in diabetes readmissions, opioid usage, and minimally invasive women's health procedures. CONCLUSION Universal coverage mitigates many, but not all, racial disparities in health care. An examination of a broader range of interventions, a closer look at variation in care provided by civilian facilities, and a look at the quality of care by race provide further opportunities for research.
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Affiliation(s)
- Tracey Pérez Koehlmoos
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jessica Korona-Bailey
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Miranda Lynn Janvrin
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Cathaleen Madsen
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
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McEvoy CS, Shah NG, Roberts SE, Carroll AM, Platz TA, Oxner CR, Butler RE, Ricca RL. Universal Healthcare Coverage Does Not Ensure Adherence to Initial Colorectal Cancer Screening Guidelines. Mil Med 2021; 186:e1071-e1076. [PMID: 33211098 DOI: 10.1093/milmed/usaa319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/17/2020] [Accepted: 11/13/2020] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Colorectal cancer is the second leading cause of cancer deaths in the USA, and screening tests are underutilized. The aim of this study was to determine the proportion of individuals at average risk who utilized a recommended initial screening test in a universal healthcare coverage system. MATERIALS AND METHODS This is a retrospective cohort study of active duty and retired military members as well as civilian beneficiaries of the Military Health System. Individuals born from 1960 to 1962 and eligible for full benefits on their 50th birthday were evaluated. Military rank or rank of benefits sponsor was used to determine socioeconomic status. Adherence to the U.S. Preventive Services Task Force guidelines for initial colorectal cancer screening was determined using "Current Procedural Terminology" and "Healthcare Common Procedure Coding System" codes for colonoscopy, sigmoidoscopy, fecal occult blood test, and fecal immunohistochemistry test. Average risk individuals who obtained early screening ages 47 to 49 were also identified. RESULTS This study identified 275,665 individuals at average risk. Of these, 105,957 (38.4%) adhered to screening guidelines. An additional 19,806 (7.2%) individuals were screened early. Colonoscopy (82.7%) was the most common screening procedure. Highest odds of screening were associated with being active duty military (odds ratio [OR] 3.63, 95% confidence interval [CI] 3.43 to 3.85), having highest socioeconomic status (OR 2.37, 95% CI 2.31 to 2.44), and having managed care insurance (OR 4.36, 95% CI 4.28 to 4.44). CONCLUSIONS Universal healthcare coverage does not ensure initial colorectal cancer screening utilization consistent with guidelines no does it eliminate disparities.
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Affiliation(s)
- Christian S McEvoy
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.,Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, USA
| | - Nina G Shah
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, USA
| | - Sarah E Roberts
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, USA
| | - Anna M Carroll
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, USA
| | - Timothy A Platz
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Christopher R Oxner
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Ralph E Butler
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Robert L Ricca
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
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Núñez ER, Caverly TJ, Zhang S, Glickman ME, Qian SX, Boudreau JH, Slatore CG, Miller DR, Wiener RS. Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019. JAMA Netw Open 2021; 4:e2116233. [PMID: 34236409 PMCID: PMC8267608 DOI: 10.1001/jamanetworkopen.2021.16233] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in real-world practice, with data limited to case series from selected LCS programs. OBJECTIVE To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020. MAIN OUTCOMES AND MEASURES Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims. RESULTS Of 28 294 veterans (26 835 [94.8%] men; 21 969 individuals [77.6%] were White; mean [SD] age, 65.2 [5.5] years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio [OR], 1.19 [95% CI, 1.10-1.29]), veterans with posttraumatic stress disorder (OR, 1.13 [95% CI, 1.03-1.23]), veterans with substance use disorders (OR, 1.11 [95% CI, 1.01-1.22]), veterans with lower income (OR, 0.88 [95% CI, 0.79-0.98]), and those living at a greater distance from a VHA facility (OR, 1.06 [95% CI, 1.02-1.10]) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 [95% CI, 0.28-0.43]) and those screened in high LCS volume facilities (OR, 0.38 [95% CI, 0.21-0.67]) or academic facilities (OR, 0.86 [95% CI, 0.80-0.92]) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions. CONCLUSIONS AND RELEVANCE In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.
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Affiliation(s)
- Eduardo R. Núñez
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Tanner J. Caverly
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan School of Medicine, Ann Arbor
| | - Sanqian Zhang
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Mark E. Glickman
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Shirley X. Qian
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Jacqueline H. Boudreau
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Donald R. Miller
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
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Norton JM, Grunwald L, Banaag A, Olsen C, Narva AS, Marks E, Koehlmoos TP. CKD Prevalence in the Military Health System: Coded Versus Uncoded CKD. Kidney Med 2021; 3:586-595.e1. [PMID: 34401726 PMCID: PMC8350811 DOI: 10.1016/j.xkme.2021.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Rationale & Objective Chronic kidney disease (CKD) is common but often goes unrecorded. Study Design Cross-sectional. Setting & Participants Military Health System (MHS) beneficiaries aged 18 to 64 years who received care during fiscal years 2016 to 2018. Predictors Age, sex, active duty status, race, diabetes, hypertension, and numbers of kidney test results. Outcomes We defined CKD by International Classification of Diseases, Tenth Revision (ICD-10) code and/or a positive result on a validated electronic phenotype that uses estimated glomerular filtration rate and measures of proteinuria with evidence of chronicity. We defined coded CKD by the presence of an ICD-10 code. We defined uncoded CKD by a positive e-phenotype result without an ICD-10 code. Analytical Approach We compared coded and uncoded populations using 2-tailed t tests (continuous variables) and Pearson χ2 test for independence (categorical variables). Results The MHS population included 3,330,893 beneficiaries. Prevalence of CKD was 3.2%, based on ICD code and/or positive e-phenotype result. Of those identified with CKD, 63% were uncoded. Compared with beneficiaries with coded CKD, those with uncoded CKD were younger (aged 45 ± 13 vs 52 ± 11 years), more often women (54.4% vs 37.6%) and active duty (20.2% vs 12.5%), and less often of Black race (18.5% vs 31.5%) or with diabetes (23.5% vs 43.5%) or hypertension (46.6% vs 77.1%; P < 0.001). Beneficiaries with coded (vs uncoded) CKD had greater numbers of kidney test results (P < 0.001). Limitations Use of cross-sectional administrative data prevents inferences about causality. The CKD e-phenotype may fail to capture CKD in individuals without laboratory data and may underestimate CKD. Conclusions The prevalence of CKD in the MHS is ~3.2%. Beneficiaries with well-known CKD risk factors, such as older age, male sex, Black race, diabetes, and hypertension, were more likely to be coded, suggesting that clinicians may be missing CKD in groups traditionally considered lower risk, potentially resulting in suboptimal care.
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Affiliation(s)
- Jenna M Norton
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Lindsay Grunwald
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Amanda Banaag
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Cara Olsen
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Andrew S Narva
- College of Agriculture, Urban Sustainability & Environmental Sciences, University of the District of Columbia, Washington, DC
| | - Eric Marks
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD.,Division of Nephrology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
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11
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Pope J, Banaag A, Madsen C, Hanson T, Khan M, Koehlmoos TP. The Mitigation of Racial Disparities in Cervical Cancer Screening Among U.S. Active Duty Service Women. Mil Med 2021; 186:e373-e378. [PMID: 33175967 DOI: 10.1093/milmed/usaa427] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/02/2020] [Accepted: 10/07/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The U.S. Preventive Services Task Force recommends regular cervical cancer screening for women aged 21-65 years. Such screening is key to reducing mortality and morbidity. Despite improvement in the screening rate, cervical cancer still disproportionately affects women of minority groups because of access to quality health care. The Military Health System (MHS) mitigates this barrier through universal healthcare coverage for all active duty service members and their families. However, such racial/ethnic disparities, seen in civilian population, have not been studied in the MHS. MATERIALS AND METHODS This is a retrospective cross-sectional study utilizing fiscal years 2011-2016 claims data obtained from the MHS Data Repository for 112,572 active duty service women aged 21-64 years. Study analyses included descriptive statistics on patient demographics, calculations of the proportion of patients who received cervical cancer screenings as well as the proportion of patients in compliance with USPSTF guidelines, and unadjusted odds ratios for the likelihood of compliance by race and military service. RESULTS Of the study population, 50.0% of active duty women were screened for cervical cancer. When compared to White women, Black (1.05 OR, 1.03-1.08 CI), Native American/Alaskan Native (1.26 OR, 1.15-1.39 CI), and Other (1.12 OR, 1.06-1.18 CI) women were significantly more likely to receive cervical cancer screenings. The proportions of 3-year compliance were relatively equal within each race category (ranging from 43% to 45%), with no significant findings for the odds of compliance in any race when compared to White active duty women; however, proportions of 3-year compliance by service ranged from 11.7% in the Marines to 84.4% in the Navy, and active duty women in the Navy were six times more likely to be in compliance with guidelines than women in the Army. When looking at 5-year compliance in active duty women aged 30-64 years, women in the Navy were more likely than women in the Army to meet compliance guidelines (1.24 OR, 1.14-1.36 CI), while women in the Air Force were slightly less likely (0.90 OR, 0.82-0.98 CI). CONCLUSIONS The women in our population demonstrated similar or lower compliance than other studies conducted in the U.S. general population, and racial disparities for cervical cancer screening were partially mitigated in active duty service women. While our research demonstrates that universal insurance can help provide equal access and care, investigation into the factors that encourage greater usage among members of different military branches may help to understand and develop policies to improve health care systems.
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Affiliation(s)
- Jessica Pope
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Amanda Banaag
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Cathaleen Madsen
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Tranessia Hanson
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Munziba Khan
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Tracey Perez Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
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12
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Deerin JF, Clifton R, Elmi A, Lewis PE, Kuo I. Hepatitis B birth dose vaccination patterns in the military health System, 2014-2018. Vaccine 2021; 39:2094-2102. [PMID: 33741189 DOI: 10.1016/j.vaccine.2021.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Since 2005, the universal hepatitis B (HepB) birth dose has been recommended for all medically stable infants weighing ≥2,000 g at birth. The timing of the birth dose provides a critical safeguard and prevents infection among infants born to HBsAg-positive mothers not identified prenatally. We assess infant HepB vaccination in the U.S. Department of Defense's Military Health System (MHS) to identify trends in vaccination coverage and sociodemographic factors associated with non-receipt of the birth dose, receiving the first HepB vaccine >3 days of life, and not receiving any HepB vaccine in the first 18 months of life utilizing parental refusal codes. To our knowledge, this is one of the first studies assessing trends in parental refusal of the HepB birth dose utilizing administrative claims parental refusal codes. METHODS We conducted a retrospective cohort analysis of MHS live births from January 1, 2014 through December 31, 2018 utilizing administrative claims data. Data were included from 44 hospitals in 24 unique states, territories, or countries. We analyzed diagnosis codes for vaccine refusal and vaccination and current procedural terminology (CPT) codes to identify vaccination patterns. Generalized linear mixed effects models with a logit link were used to assess factors associated with vaccination patterns. RESULTS HepB birth dose vaccination coverage increased from 79.6% in 2014 to 88.1% in 2018 (p < .0001). Refusal rates also increased from 3.7% in 2014 to 4.5% in 2018 (p < .0001). The percentage of patients with missing diagnosis codes for vaccine refusal or vaccination decreased from 16.7% in 2014 to 7.4% in 2018. Factors associated with non-receipt of the birth dose included earlier year of birth, white maternal race, higher maternal age, higher birth order, and longer infant length of stay in hospital. CONCLUSION Vaccination coverage for HepB birth dose is high in the MHS and increased over time; concurrently, refusal rates also increased over time. Utilizing administrative claims data has the benefit of differentiating reasons for non-receipt of the birth dose over time.
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Affiliation(s)
- Jessica Fung Deerin
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology, United States.
| | - Rebecca Clifton
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology, United States
| | - Angelo Elmi
- The George Washington University, Milken Institute School of Public Health, Department of Biostatistics and Bioinformatics, United States
| | - Paul E Lewis
- Defense Health Agency, Armed Forces Health Surveillance Branch, United States
| | - Irene Kuo
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology, United States
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13
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Rutter CM, Knudsen AB, Lin JS, Bouskill KE. Black and White Differences in Colorectal Cancer Screening and Screening Outcomes: A Narrative Review. Cancer Epidemiol Biomarkers Prev 2020; 30:3-12. [PMID: 33144285 DOI: 10.1158/1055-9965.epi-19-1537] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 05/06/2020] [Accepted: 10/21/2020] [Indexed: 11/16/2022] Open
Abstract
Racial disparities in colorectal cancer incidence are widely documented. There are two potential mechanisms for these disparities: differences in access to screening, including screening follow-up, and differences in underlying risk of colorectal cancer. We reviewed the literature for evidence of these two mechanisms. We show that higher colorectal cancer incidence in blacks relative to whites emerged only after the dissemination of screening and describe evidence of racial disparities in screening rates. In contrast to the strong evidence for differences in colorectal cancer screening utilization, there is limited evidence for racial differences in adenoma prevalence. In general, black and white patients who are screened have similar adenoma prevalence, though there is some evidence that advanced adenomas and adenomas in the proximal colon are somewhat more likely in black than white patients. We conclude that higher rates of colorectal cancer incidence among black patients are primarily driven by lower rates of colorectal cancer screening. Our findings highlight the need to increase black patients' access to quality screening to reduce colorectal cancer incidence and mortality.
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Affiliation(s)
| | - Amy B Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Lin
- Kaiser Permanente Center for Health Research, Portland, Oregon
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14
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White PM, Itzkowitz SH. Barriers Driving Racial Disparities in Colorectal Cancer Screening in African Americans. Curr Gastroenterol Rep 2020; 22:41. [PMID: 32647903 DOI: 10.1007/s11894-020-00776-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Colorectal cancer screening has been shown to decrease mortality from colorectal cancer. Screening disparities continue to exist among ethnic minorities, particularly for African Americans. We herein review the barriers of colorectal cancer screening in this population. RECENT FINDINGS At its foundation are patient barriers, which are further compounded by physician-related barriers and the idiosyncrasies of the healthcare system. Interventions to address the barriers include patient outreach, provider education, and healthcare legislation addressing financial barriers. Recent research has focused on factors predicting intentions to undergo colorectal cancer screening. Underlying all of the barriers is the systemic racism that affects and influences the healthcare system as much as all other institutions and contributes to inequities in the delivery of effective cancer prevention efforts. Perpetual disparities in CRC screening within the African American community are due to multifactorial barriers from the individual patient to provider and healthcare system and societal influences. An awareness of the behavioral and systemic factors that affect African Americans must underpin efforts to reach full equity in delivering CRC screening to this often medically underserved segment of our society.
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Affiliation(s)
- Pascale M White
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Box 1069, New York, NY, 10029, USA
| | - Steven H Itzkowitz
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Box 1069, New York, NY, 10029, USA.
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15
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Sharp SP, Ata A, Chismark AD, Canete JJ, Valerian BT, Wexner SD, Lee EC. Racial disparities after stoma construction in colorectal surgery. Colorectal Dis 2020; 22:713-722. [PMID: 31876362 DOI: 10.1111/codi.14943] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 11/29/2019] [Indexed: 12/12/2022]
Abstract
AIM Racial disparities are under-recognized among patients undergoing colorectal surgery. The purpose of this study was to determine the complication rates and surgical outcomes stratified by race and ethnicity among patients undergoing colorectal surgery with intestinal stoma creation. METHOD The ACS NSQIP database from 2013 to 2016 was used. Colon, rectum and small bowel cases requiring intestinal stoma creation were selected. Both African-American and other groups of minority patients were compared with Caucasian patients using a complex multivariable analysis model. Primary outcomes of interest were complication rates, mortality and extended hospital length of stay. RESULTS The study included 38 088 admissions. After multivariable analysis, African-American patients still had a prolonged length of hospital stay and higher complication rates. Other minorities also had a prolonged length of hospital stay and higher complication rates. CONCLUSIONS Both African-American and other groups of minority patients requiring an ostomy suffer significantly higher postoperative complication rates and a prolonged hospital length of stay, even after comorbidity adjustment. Access to care, socioeconomic status and comorbid disease management are all important factors for minority patients who undergo colorectal surgery requiring intestinal stoma construction.
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Affiliation(s)
- S P Sharp
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, New York, USA.,Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - A Ata
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, New York, USA
| | - A D Chismark
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, New York, USA
| | - J J Canete
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, New York, USA
| | - B T Valerian
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, New York, USA
| | - S D Wexner
- Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - E C Lee
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, New York, USA
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16
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Cheng Y, Liu J, Liao Q, Hu X, Lv H, Ding P, Nie S, Tan L. Population-Based Incidence, Mortality, And Survival For Gastrointestinal Cancers During 2006-2016 In Wuhan, Central China. Cancer Manag Res 2019; 11:9233-9241. [PMID: 31754312 PMCID: PMC6825471 DOI: 10.2147/cmar.s209925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/28/2019] [Indexed: 11/23/2022] Open
Abstract
Objective Incidence and mortality rates of malignant tumors in China are higher than global averages, especially for gastrointestinal (GI) cancers. To advance understanding of the epidemiology of GI cancers and to seek clues for cancer control, this study compared the incidence, mortality, and survival for GI cancers among residents of Wuhan (central China) and Chinese Americans. Methods A population-based study of cancer epidemiology was carried out on Wuhan residents and Chinese Americans. Data were collected from the Cancer Registry of Jiang’an District in Wuhan and the Surveillance, Epidemiology, and End Results (SEER) program. Joinpoint regression analyses were used to examine trends in the incidence and mortality of GI cancers in Wuhan. Furthermore, we estimated age-specific rates of incidence and mortality and survival rates of GI cancers in both populations. Results Among male GI cancer patients, mortality rates exhibited a significant increasing trend during 2006–2016 in Wuhan, with an annual percentage change (APC) of 7.4% (95% CI 1.7%–13.3%). Among female patients, the incidence of GI cancers showed a declining trend (APC –2.3%, 95% CI –3.4% to –1.3%) during 2006–2013, then escalated with an APC of 6.2% (95% CI 2.3%–10.2%) during 2013–2016. Both male and female patients with esophageal cancer in Wuhan experienced better survival than Chinese Americans. However, survival rates for the other three GI cancers in Wuhan were relatively lower than Chinese Americans. Conclusion Escalating trends were observed in incidence among women and mortality among men with GI cancers. In addition, the survival rates of GI cancer patients in Wuhan were lower than Chinese Americans. As such, additional efforts are needed to control GI cancers in Wuhan, central China.
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Affiliation(s)
- Yao Cheng
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jianhua Liu
- Department of Infectious Diseases Prevention and Control, Yichang Centers for Diseases Prevention and Control, Yichang, People's Republic of China
| | - Qing Liao
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xuejiao Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Hongyan Lv
- Department of Chronic Disease Prevention and Control, Jiang'an District Centers for Disease Preventive and Control, Wuhan, People's Republic of China
| | - Peiyan Ding
- Department of Chronic Disease Prevention and Control, Jiang'an District Centers for Disease Preventive and Control, Wuhan, People's Republic of China
| | - Shaofa Nie
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Li Tan
- Department of Hospital Infection Management, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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