Time and distance barriers to mammography facilities in the Atlanta metropolitan area

Factors Influencing Compliance to Follow-up Visits in Orthopaedic Surgery

BACKGROUND

Orthopaedic procedures require postoperative follow-up to maximize recovery. Missed appointments and noncompliance can result in complications and increased healthcare costs. This study investigates the relationship between patient postoperative visit attendance and the distance traveled to receive care.

MATERIALS AND METHODS

A retrospective review of all surgeries performed by a single orthopaedic surgeon in 2019 at level 1 trauma center in a midsized city serving a largely rural population was completed. We excluded patients who underwent another subsequent procedure. Distance to care and time traveled were determined by the patient's address and the clinic address using Google Maps Application Programming Interface. Other variables that may affect attendance at follow-up visits were also collected. Univariate and multivariate logistic regression was done with purposeful selection.

RESULTS

We identified 518 patients of whom 32 (6%) did not attend their first scheduled follow-up appointment. An additional 47 (10%) did not attend their second follow-up. In total, 79 patients (15%) did not attend one of their appointments. Younger age, male sex, Black or African American race, self-pay, Medicaid insurance, accident insurance, and increased distance were individual predictors of missing an appointment. In the final multivariate logistic regression model, male sex (OR 1.74), Black or African American race (OR 2.78), self-pay (OR 3.12), Medicaid (OR 3.05), and traveling more than 70 miles to clinic (OR 2.02) markedly predicted missing an appointment, while workers' compensation (OR 0.23) predicted attendance.

DISCUSSION

Several nonmodifiable patient factors predict patient noncompliance in attending orthopaedic postoperative visits. When patients are considered at high risk of being lost to follow-up, there may be an opportunity to implement interventions to improve follow-up rate and patient outcomes, minimize patient costs, and maximize profitability for the hospital.

Travel Burden to Cancer Screening and Treatment Facilities Among Washington Women: Data From an Integrated Healthcare Delivery System

PURPOSE

To characterize distance traveled for breast cancer screening and to sites of service for breast cancer treatment, among rural and urban women served by a Washington State healthcare network.

METHODS

Data for this study came from one of the largest not-for-profit integrated healthcare delivery systems in Washington State. Generalized linear mixed models with gamma log link function were used to examine the associations between travel distance and sociodemographic and contextual characteristics of patients.

RESULTS

Median travel distance for breast cancer screening facilities, hematologist/oncologists, radiation oncologists, or surgeons was 11, 19, 23, or 11 miles, respectively. Travel distance to breast cancer screening or referral facilities was longer in non-core metropolitan ZIP codes compared to metropolitan ZIP codes. AI/AN and Hispanic women travelled longer distances to reach referral facilities compared to other racial and ethnic groups.

CONCLUSION

Disparities exist in travel distance to breast cancer screening and treatment. Further research is needed to describe sociodemographic and system level characteristics that contribute to such disparities and to discover novel approaches to alleviate this burden.

Racial differences in the association of undetectable HIV viral load and transportation to an HIV provider among men who have sex with men in Atlanta, Georgia: a health equity perspective

There are inequities in HIV outcomes among Black gay, bisexual, and other sexual minority men who have sex with men (GBMSM) compared to GBMSM overall, including access to transportation to HIV care. It is unclear if the relationship between transportation and clinical outcomes extends to viral load. We assessed the relationship between transportation dependence to an HIV provider and undetectable viral load among Black and White GBMSM in Atlanta. We collected transportation and viral load information from GBMSM with HIV from 2016-2017 (n = 345). More Black than White GBMSM had a detectable viral load (25% vs. 15%) and took dependent (e.g. public) transportation (37% vs. 18%). Independent (e.g. car) transportation was associated with undetectable viral load for White GBMSM (cOR 3.61, 95% CI 1.45, 8.97) but was attenuated by income (aOR. 2.29, 95% CI 0.78, 6.71), and not associated for Black GBMSM (cOR 1.18, 95% CI 0.58, 2.24). One possible explanation for no association for Black GBMSM is that there are more competing barriers to HIV care for Black GBMSM than White GBMSM. Further investigation is needed to confirm whether 1) transportation is unimportant for Black GBMSM or 2) transportation interacts with additional factors not considered in this analysis.

Impact of High Neighborhood Socioeconomic Deprivation on Access to Accredited Breast Imaging Screening and Diagnostic Facilities

PURPOSE

The aim of this study was to evaluate the presence or absence of accredited breast imaging facilities in ZIP codes with high or low neighborhood socioeconomic deprivation.

METHODS

A retrospective ecological study design was used. Neighborhood socioeconomic disadvantage rankings at the ZIP code level were defined by the University of Wisconsin Neighborhood Atlas Area Deprivation Index. Outcomes included the presence or absence of FDA- or ACR-accredited mammographic facilities, accredited stereotactic biopsy or breast ultrasound facilities, and ACR Breast Imaging Centers of Excellence. US Department of Agriculture rural-urban commuting area codes were used to define urban and rural status. Access to breast imaging facilities in high-disadvantage (≥97th percentile) and low-disadvantage (≤3rd percentile) ZIP codes was compared using χ2 tests, stratified by urban or rural status.

RESULTS

Among 41,683 ZIP codes, 2,796 were classified as high disadvantage (1,160 rural, 1,636 urban) and 1,028 as low disadvantage (39 rural, 989 urban). High-disadvantage ZIP codes were more likely rural (P < .001) and less likely to have FDA-certified mammographic facilities (28% versus 35%, P < .001), ACR-accredited stereotactic biopsy (7% versus 15%, P < .001), breast ultrasound (9% versus 23%, P < .001), or Breast Imaging Centers of Excellence (7% versus 16%, P < .001). Among urban areas, high-disadvantage ZIP codes were less likely to have FDA-certified mammographic facilities (30% versus 36%, P = .002), ACR-accredited stereotactic biopsy (10% versus 16%, P < .001), breast ultrasound (13% versus 23%, P < .001), and Breast Imaging Centers of Excellence (10% versus 16%, P < .001).

CONCLUSIONS

People living in ZIP codes with high socioeconomic disadvantage are less likely to have accredited breast imaging facilities within their ZIP codes, which may contribute to disparities in access to breast cancer care experienced by underserved groups living in these areas.

Availability Versus Accessibility: Identifying COVID-19 Testing Deserts Across Massachusetts

Throughout the COVID-19 pandemic, communities of color have faced significantly higher rates of COVID-19 infection, as well as poor clinical outcomes. These differences are driven by long-standing structural inequities that prevent effective social distancing efforts and are further exacerbated by disparities in COVID-19 testing. Our study applied the concept of "COVID-19 testing deserts" to systematically identify gaps in testing resource allocation across Massachusetts in May 2020 and March 2021. Testing deserts were identified at the census tract level, using criteria developed by the Department of Agriculture for food deserts. Testing deserts occurred more frequently in segregated Hispanic, segregated Black, mixed minority, and integrated communities, as well as in neighborhoods with low vehicle access and in federally designated Medically Underserved Areas. Segregated communities were those in which more than 50 percent of the population self-identified as non-Hispanic White, Hispanic, non-Hispanic Black, or non-Hispanic Asian, respectively. Testing deserts were overrepresented in counties with high COVID-19 incidence rates, suggesting that testing accessibility is essential for prompt COVID-19 diagnosis and self-isolation.

Food security status and breast cancer screening among women in the United States: Evidence from the Health and Retirement Study and Health Care and Nutrition Study

PURPOSE

To assess the impact of food insecurity on biennial breast cancer screenings (i.e., mammography or breast X-ray) among older women in the United States (US).

METHODS

Data from the 2014 and 2016 waves of the Health and Retirement Study and the 2013 Health Care and Nutrition Study were used. The analyses were limited to a nationally representative sample of 2,861 women between 50 and 74 years of age, residing in the US. We employed a propensity score weighting method to balance observed confounders between food-secure and food-insecure women and fit a binary logistic regression to investigate population-level estimates for the association between food security and breast cancer screening.

RESULTS

Food insecurity was significantly associated with failure to obtain a mammogram or breast X-ray within the past two years. Food-insecure women had 54% lower odds of reporting breast cancer screening in the past 2 years (adjusted OR = 0.46; 95% CI 0.30-0.70, p-value < 0.001) as compared to food-secure women. Additional factors associated with a higher likelihood of receiving breast cancer screenings included greater educational attainment, higher household income, regular access to health care/advice, not smoking, and not being physically disabled or experiencing depressive symptoms.

CONCLUSION

Results demonstrate a socioeconomic gradient existing in regard to the utilization of regular breast cancer screenings among women. Those who tend to have lower education, lower income, and lack of reliable healthcare access are more likely to be food insecure. Thus, more likely to face the financial, logistical, or environmental barriers in obtaining screening services that accompany food insecurity.

Addressing Disparities Related to Access of Multimodality Breast Imaging Services Before and During the COVID-19 Pandemic

Despite technological advancements focused on reducing breast cancer mortality through early detection, there have been reported disparities in the access to these imaging services with underserved patient populations (including racial minority groups and patients of low socioeconomic status) showing underutilization compared to other patient groups. These underserved populations tend to have more advanced breast cancer presentations, in part due to delays in diagnosis resulting in later stage of disease presentation. To make matters worse, the COVID-19 pandemic declared in March 2020 has resulted in significant healthcare disruptions leading to extensive delays in breast imaging services which are expected to negatively impact breast cancer mortality long-term. Given the worsening disparity in breast cancer mortality among racial/ethnic minorities and financially disadvantaged groups, it is vital to address these disparity gaps with the goal of reducing the barriers to timely breast cancer diagnosis and addressing breast cancer mortality differences among breast cancer patients. Therefore, this review aims to provide a discussion highlighting the disparities related to breast imaging access, the effects of the COVID-19 pandemic on these disparities, current targeted interventions implemented in breast imaging practices to reduce these disparities, and future directions on the journey to reducing disparity gaps for breast imaging patients. Tackling the root cause factors of the persistent breast cancer-related disparities is critical to meeting the needs of patients who are disadvantaged and can lead to continued improvement in the quality of individualized care for patients who have higher breast cancer morbidity and mortality risks.

The impact of patient travel time on disparities in treatment for early stage lung cancer in California

BACKGROUND

Travel time to treatment facilities may impede the receipt of guideline-concordant treatment (GCT) among patients diagnosed with early-stage non-small cell lung cancer (ES-NSCLC). We investigated the relative contribution of travel time in the receipt of GCT among ES-NSCLC patients.

METHODS

We included 22,821 ES-NSCLC patients diagnosed in California from 2006-2015. GCT was defined using the 2016 National Comprehensive Cancer Network guidelines, and delayed treatment was defined as treatment initiation >6 versus ≤6 weeks after diagnosis. Mean-centered driving and public transit times were calculated from patients' residential block group centroid to the treatment facilities. We used logistic regression to estimate risk ratios and 95% confidence intervals (CIs) for the associations between patients' travel time and receipt of GCT and timely treatment, overall and by race/ethnicity and neighborhood socioeconomic status (nSES).

RESULTS

Overall, a 15-minute increase in travel time was associated with a decreased risk of undertreatment and delayed treatment. Compared to Whites, among Blacks, a 15-minute increase in driving time was associated with a 24% (95%CI = 8%-42%) increased risk of undertreatment, and among Filipinos, a 15-minute increase in public transit time was associated with a 27% (95%CI = 13%-42%) increased risk of delayed treatment. Compared to the highest nSES, among the lowest nSES, 15-minute increases in driving and public transit times were associated with 33% (95%CI = 16%-52%) and 27% (95%CI = 16%-39%) increases in the risk of undertreatment and delayed treatment, respectively.

CONCLUSION

The benefit of GCT observed with increased travel times may be a 'Travel Time Paradox,' and may vary across racial/ethnic and socioeconomic groups.

Value of Geographical Information Systems in Analyzing Geographic Accessibility to Inform Radiotherapy Planning: A Systematic Review

PURPOSE

Vulnerable populations face geographical barriers in accessing radiotherapy (RT) facilities, resulting in heterogeneity of care received and cancer burden faced. We aimed to explore the current use of Geographical Information Systems (GIS) in access to RT and use these findings to create sustainable solutions against barriers for access in low- and middle-income countries.

MATERIALS AND METHODS

A systematic review using the PRISMA search strategy was done for studies using GIS to explore outcomes among patients with cancer. Included studies were reviewed and classified into three umbrella categories of how GIS has been used in studying access to RT.

RESULTS

Forty articles were included in the final review. Thirty-eight articles were set in high-income countries and two in upper-middle-income countries. Included studies were published from 2000 to 2020, and were comprised of patients with all-cancers combined, breast, colon, skin, lung, prostate, ovarian, and rectal carcinoma patients. Studies were categorized under three groups on the basis of how they used GIS in their analyses: to describe geographic access to RT, to associate geographic access to RT with outcomes, and for RT planning. Most studies fell under multiple categories.

CONCLUSION

Although this field is relative nascent, there is a wide array of functions possible through GIS for RT planning, including identifying high-risk populations, improving access in high-need areas, and providing valuable information for future resource allocation. GIS should be incorporated in future studies, especially set in low- and middle-income countries, which evaluate access to RT.

Insurance-based disparities and risk of financial toxicity among patients undergoing gynecologic cancer operations

OBJECTIVE

To evaluate the risk of financial toxicity (FT) among inpatients undergoing gynecologic cancer resections and the association of insurance status with clinical and financial outcomes.

METHODS

Using the 2008-2019 National Inpatient Sample, we identified adult hospitalizations for hysterectomy or oophorectomy with a diagnosis of cancer. Hospitalization costs, length of stay (LOS), mortality, and complications were assessed by insurance status. Risk of FT was defined as health expenditure exceeding 40% of post-subsistence income. Multivariable regressions were used to analyze costs and factors associated with FT risk.

RESULTS

Of 462,529 patients, 49.4% had government-funded insurance, 44.3% private, and 3.2% were uninsured. Compared to insured, uninsured patients were more commonly Black and Hispanic, admitted emergently, and underwent open operations. Uninsured patients experienced similar mortality but greater rates of complications, LOS, and costs. Overall, ovarian cancer resections had the highest median costs of $17,258 (interquartile range: 12,187-25,491) compared to cervical and uterine. Approximately 52.8% of uninsured and 15.4% of insured patients were at risk of FT. As costs increased across both cohorts over the 12-year study period, the disparity in FT risk by payer status broadened. After risk adjustment, perioperative complications were associated with nearly 2-fold increased risk of FT among uninsured (adjusted odds ratio 1.75, 95% confidence interval 1.46-2.09, p < 0.001). Among the insured, Black and Hispanic race, public insurance, and open operative approach exhibited greater odds of FT.

CONCLUSION

Patients undergoing gynecologic cancer operations are at substantial risk of FT, particularly those uninsured. Targeted cost-mitigation strategies are warranted to minimize financial burden.

Geographic access to lung cancer screening among eligible adults living in rural and urban environments in the United States

BACKGROUND

Although recommended lung cancer screening with low-dose computed tomography scanning (LDCT) reduces mortality among high-risk adults, annual screening rates remain low. This study complements a previous nationwide assessment of access to lung cancer screening within 40 miles by evaluating differences in accessibility across rural and urban settings for the population aged 50 to 80 years and a subset eligible population based on the 2021 US Preventive Services Task Force LDCT lung screening recommendations.

METHODS

Distances from population centers to screening facilities (American College of Radiology Lung Cancer Screening Registry) were calculated, and the number of individuals who had access within graduating distances, including 10, 20, 40, 50, and 100 miles, were estimated. Census tract results were aggregated to counties, and both geographies were classified with rural-urban schemas.

RESULTS

Approximately 5% of the eligible population did not have access to lung cancer screening facilities within 40 miles; however, different patterns of accessibility were observed at different distances, between regions, and across rural-urban environments. Across all distances and geographies, there was a larger percentage of the population in rural geographies with no access. Although the rural population represented approximately 8% of the eligible population, the larger percentage of the rural population with no access was noteworthy and translated into a larger number of individuals with no access at longer distance thresholds (≥40 miles).

CONCLUSIONS

Disparities in access should be examined as both percentages of the population and numbers of individuals with no access in order to tailor interventions to communities and increase access. Geospatial analysis at the census tract level is recommended to help to identify optimal focus areas and reach the most people.

LAY SUMMARY

As annual lung cancer screening rates remain low, this study examines access to lung cancer screening nationwide and across rural and urban settings. A geographic information system network analysis of census tract-level populations is used to estimate access at different distances, including 10, 20, 40, 50, and 100 miles, and the results are aggregated to counties. Approximately 5% of the eligible population does not have access to screening facilities within 40 miles; however, different patterns of accessibility are observed at different distances, between regions, and across rural-urban environments. Across all distances and geographies, there is a larger percentage of the population in rural geographies with no access.

Governmental Investments in Hospital Infrastructure Among Regions and Its Efficiency in China: An Assessment of Building Construction

Hospital infrastructure has been addressed as the prerequisite of healthcare delivery which intensively affects medical quality. Over the past decade, China has proposed a series of investment plans for hospital infrastructure in order to promote healthcare development in underdeveloped regions. Focusing on the construction of hospital buildings as the key component of hospital infrastructure, this study aims to examine whether the investment efficiency is lower where a government prioritizes equity and to explore what kind of geographical predispositions should be embedded in governmental investment plans for hospital infrastructures from the perspectives of both investment equity and efficiency. Relevant data from 330 governmental-invested hospital building construction projects in Sichuan province, China, from 2009 to 2018 were collected. Concentration index was used to evaluate the equity in the distribution of the investments. Tobit model was employed to explore the relationship between regional economic development and investment efficiency measured by an integrated approach of principal component analysis and data envelopment analysis. The results demonstrated a slight concentration of governmental investments in economically developed regions, while a negative association with regional economic development was identified with investment efficiency. Our study illustrated the investment efficiency was higher where a government prioritized equity and provided empirical evidences on switching governmental investment predisposition in the aspect of healthcare infrastructure construction toward less developed regions in China from the perspectives of both investment allocation equity and efficiency, which would further assist in the formulation of region-specific policies and strategies for underdeveloped regions.

Examination of the Association Between Access to Care and Lung Cancer Screening Among High-Risk Smokers

Objective: The purpose of this study was to examine the influence of access to care on the uptake of low-dose computed tomography (LDCT) lung cancer screening among a diverse sample of screening-eligible patients. Methods: We utilized a cross-sectional study design. Our sample included patients evaluated for lung cancer screening at a large academic medical center (AMC) between 2015 and 2017 who met 2013 USPSTF guidelines for LDCT screening eligibility. The completion of LDCT screening (yes, no) was the primary dependent variable. The independent variable was access to care (insurance type, living within the AMC service area). We utilized binary logistic regression analyses to examine the influence of access to care on screening completion after adjusting for demographic factors (age, sex, race) and smoking history (current smoking status, smoking pack-year history). Results: A total of 1,355 individuals met LDCT eligibility criteria, and of those, 29.8% (n = 404) completed screening. Regression analysis results showed individuals with Medicaid insurance (OR, 1.51; 95% CI, 1.03-2.22), individuals living within the AMC service area (OR, 1.71; 95% CI, 1.21-2.40), and those aged 65-74 years (OR, 1.49; 95% CI, 1.12-1.98) had higher odds of receiving LDCT lung cancer screening. Lower odds of screening were associated with having Medicare insurance (OR, 0.30; 95% CI, 0.22-0.41) and out-of-pocket (OR, 0.27; 95% CI, 0.15-0.47). Conclusion: Access to care was independently associated with lowered screening rates. Study results are consistent with prior research identifying the importance of access factors on uptake of cancer early detection screening behaviors.

Feasibility of Rapid Development and Deployment of a Telemedicine Program in a Foot and Ankle Orthopedic Practice

BACKGROUND

A lack of access to care is predictably associated with negative outcomes in foot and ankle surgery. Despite recent advances in telecommunication technologies, the field of orthopedics has been slow to adopt these resources in offsetting barriers to care. The COVID-19 pandemic has forced departments to change their clinical approach, lending unprecedented opportunity to better understand how telehealth may bridge this care gap in foot and ankle practices. The purpose of this study was to assess patient-reported outcomes of telemedicine encounters, including comfort and patient satisfaction. Our hypothesis was that patients would be significantly less satisfied with telemedicine when compared with in-office appointments for all nonemergency visit types.

METHODS

Telemedicine satisfaction was assessed via phone survey with a modified 1 to 5 Likert scale. Patients who had completed a telemedicine visit between April 13, 2020, and June 19, 2020, were eligible to participate. Patient demographics were recorded, and data were analyzed using paired and independent t tests for parametric continuous data and Fisher's exact and chi-square tests for noncontinuous data. A total of 216 patients completed the telemedicine questionnaire.

RESULTS

The overall mean satisfaction for telemedicine visits (4.7) was significantly lower than that for in-office visits (4.9) (P < .001). However, the majority (90.3%) of patients reported they would use telemedicine again in the future. When compared, patients seeking fracture care had significantly higher telemedicine satisfaction (4.9, n = 38) than those receiving nonfracture care (4.6, n = 178) (P = .001), and those greater than 50 miles from the clinic had higher satisfaction (5.0, n = 14) than patients living within 50 miles of the clinic (4.7, n = 202) (P < .001).

CONCLUSION

Patients were more satisfied with their in-office clinic visit than telemedicine, although the vast majority of patients endorsed a willingness to utilize telemedicine in the future. Patients with trauma and greater barriers to foot and ankle care were more satisfied with their telemedicine visits.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Do patient outcomes and follow-up completion rates after shoulder arthroplasty differ based on insurance payor?

BACKGROUND

Disparities associated with socioeconomic status (SES) and insurance coverage have been shown to affect outcomes in different medical conditions and surgical procedures. We hypothesized that patients insured by Medicaid will be associated with lower follow-up rates and inferior outcomes relative to those with Medicare or private insurance.

METHODS

Patients undergoing shoulder arthroplasty, including anatomic total shoulder arthroplasty, reverse arthroplasty, and hemiarthroplasty, were enrolled preoperatively in an institutional database. Preoperative demographics, payor (Medicaid, Medicare, or private insurance), and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores were recorded. Postoperatively, patients completed ASES scores at multiple time points. Follow-up completion rate was calculated as the number of follow-up visits completed relative to possible visits. Continuous variables were compared between groups with 1-way analyses of variance, and chi-squared tests were used for categorical variables. Significance was defined as P < .05.

RESULTS

There were 491 shoulder replacements performed for 438 patients from 2012-2017. The mean follow-up completed percentage was significantly lower (P < .001) for Medicaid patients (62.6% ± 33.7%) relative to Medicare patients (80.2% ± 26.7%; P < .001) and private insurance patients (77.8% ± 22.1%; P = .001). The ASES Composite score increased significantly for all patients from baseline to final follow-up. At each time point, including before surgery and each postoperative time point, patients with Medicaid insurance had significantly lower ASES Composite scores. The final ASES Composite score was significantly lower in the Medicaid patients (66.1 ± 28.7) relative to private insurance patients (78.3 ± 20.8; P = .023). Medicaid patients had significantly lower preoperative (P < .001) and postoperative (P = .018) ASES Pain subscores. In multivariate regression analysis, Medicaid insurance was associated with both inferior preoperative and postoperative ASES scores relative to patients with Medicare or private insurance.

CONCLUSIONS

We observed that all patients, regardless of insurance payor, improved by similar magnitudes after shoulder arthroplasty, though patients with Medicaid insurance had significantly lower preoperative and postoperative ASES scores, primarily because of the ASES Pain subscore. Patients with Medicaid insurance also have lower follow-up rates than other payors.

Going the Extra Mile? How Provider Network Design Increases Consumer Travel Distance, Particularly for Rural Consumers

CONTEXT

The practical accessibility to medical care facilitated by health insurance plans depends not just on the number of providers within their networks but also on distances consumers must travel to reach the providers. Long travel distances inconvenience almost all consumers and may substantially reduce choice and access to providers for some.

METHODS

The authors assess mean and median travel distances to cardiac surgeons and pediatricians for participants in (1) plans offered through Covered California, (2) comparable commercial plans, and (3) unrestricted open-network plans. The authors repeat the analysis for higher-quality providers.

FINDINGS

The authors find that in all areas, but especially in rural areas, Covered California plan subscribers must travel longer than subscribers in the comparable commercial plan; subscribers to either plan must travel substantially longer than consumers in open networks. Analysis of access to higher-quality providers show somewhat larger travel distances. Differences between ACA and commercial plans are generally substantively small.

CONCLUSIONS

While network design adds travel distance for all consumers, this may be particularly challenging for transportation-disadvantaged populations. As distance is relevant to both health outcomes and the cost of obtaining care, this analysis provides the basis for more appropriate measures of network adequacy than those currently in use.

Driving Status and Transportation Disadvantage Among Medicare Beneficiaries

Transportation disadvantage may have important implications for the health, well-being, and quality of life of older adults. This study used the 2015 National Health Aging Trends Study, a nationally representative study of Medicare beneficiaries aged 65 and over (N = 7,498), to generate national estimates of transportation modalities and transportation disadvantage among community-dwelling older adults in the United States. An estimated 10.8 million community-dwelling older adults in the United States rarely or never drive. Among nondrivers, 25% were classified as transportation disadvantaged, representing 2.3 million individuals. Individuals with more chronic medical conditions and those reliant on assistive devices were more likely to report having a transportation disadvantage (p < .05). Being married resulted in a 50% decreased odds of having a transportation disadvantage (p < .01). Some individuals may be at higher risk for transportation-related barriers to engaging in valued activities and accessing care, calling for tailored interventions such as ride-share services combined with care coordination strategies.

Mapping mammography in Arkansas: Locating areas with poor spatial access to breast cancer screening using optimization models and geographic information systems

Introduction:

Arkansans have some of the worst breast cancer mortality to incidence ratios in the United States (5th for Blacks, 4th for Whites, 7th overall). Screening mammography allows for early detection and significant reductions in mortality, yet not all women have access to these life-saving services. Utilization in Arkansas is well below the national average, and the number of FDA-approved screening facilities has decreased by 38% since 2001. Spatial accessibility plays an important role in whether women receive screenings.

Methods:

We use constrained optimization models within a geographic information system (GIS) to probabilistically allocate women to nearby screening facilities, accounting for facility capacity and patient travel time. We examine accessibility results by rurality derived from rural–urban commuting area (RUCA) codes.

Results:

Under most models, screening capacity is insufficient to meet theoretical demand given travel constraints. Approximately 80% of Arkansan women live within 30 minutes of a screening facility, most of which are located in urban and suburban areas. The majority of unallocated demand was in Small towns and Rural areas.

Conclusions:

Geographic disparities in screening mammography accessibility exist across Arkansas, but women living in Rural areas have particularly poor spatial access. Mobile mammography clinics can remove patient travel time constraints to help meet rural demand. More broadly, optimization models and GIS can be applied to many studies of healthcare accessibility in rural populations.

Sociodemographic disparities in access to ovarian cancer treatment

Background

Ovarian cancer is the fifth most common cause of cancer death among women in the United States. Failure to receive optimal treatment and poorer survival rates have been reported for older women, African-American women, women with low income, and women with public health insurance coverage or no coverage. Additionally, regional differences in geographic access influence the type of treatment women may seek. This paper explores geographic accessibility and sociodemographic vulnerability in Georgia, which influence receipt of optimal ovarian cancer treatment.

Methods

An enhanced two-step floating catchment area (E2SFCA), defining physical access, was created for each census tract and gynecologic oncologist clinic. Secondly, sociodemographic variables reflecting potential social vulnerability were selected from U.S. Census and American Community Survey data at the tract level. These two measures were combined to create a measure of Geosocial Vulnerability. This framework was tested using Georgia ovarian cancer mortality records.

Results

Geospatial access was higher in urban areas with less accessibility in suburban and rural areas. Sociodemographic vulnerability varied geospatially, with higher vulnerability in urban citers and rural areas. Sociodemographic measures were combined with geospatial access to create a Geosocial Vulnerability Indicator, which showed a significant positive association with ovarian cancer mortality.

Conclusions

Spatial and sociodemographic measures pinpointed areas of healthcare access vulnerability not revealed by either spatial analysis or sociodemographic assessment alone. Whereas lower healthcare accessibility in rural areas has been well described, our analysis shows considerable heterogeneity in access to care in urban areas where the disadvantaged census tracts can be easily identified.

Inequality in geographical distribution of hospitals and hospital beds in densely populated metropolitan cities of Iran

Background

This study aims to assess geographical distribution of hospitals and extent of inequalities in hospital beds against socioeconomic status (SES) of residents of five metropolitan cities in Iran.

Methods

A cross-sectional analysis was conducted to measure geographical inequality in hospital and hospital bed distributions of 68 districts in five metropolitan cities during 2016 using geographic information system (GIS), and Gini and Concentration indices. Correlation analysis was performed to show the relationship between the SES and inequality in hospital beds densities.

Results

The study uncovered marked inequalities in hospitals and hospital beds distributions. The Gini indices for hospital beds were greater than 0.55. The aggregated concentration indices for public and private hospital beds were 0.33 and 0.49, respectively. The GIS revealed that 216 (70.6%) hospitals were located in two highest socioeconomic status classes in the cities. Only 29 (9.5%) hospitals were located in the lowest class. The public, private, and the cumulative hospitals beds distributions in Tehran and Esfahan showed significant (p < 0.05) positive correlation with SES of the residents.

Conclusions

The high inequalities in hospital and hospital beds distributions in our study imply an overlooked but growing concern for geographical access to healthcare in rapidly urbanizing metropolitan cities in Iran. Thus, regardless of ownership, decision-makers should emphasize the disadvantaged areas in metropolitan cities when need arises for the establishment of new healthcare facilities in order to ensure fairness in healthcare. The metropolitan cities and rapid urbanization settings in other countries could learn lessons to reduce or prevent similar issues which might have hampered access to healthcare.

GIScience and cancer: State of the art and trends for cancer surveillance and epidemiology

Maps are well recognized as an effective means of presenting and communicating health data, such as cancer incidence and mortality rates. These data can be linked to geographic features like counties or census tracts and their associated attributes for mapping and analysis. Such visualization and analysis provide insights regarding the geographic distribution of cancer and can be important for advancing effective cancer prevention and control programs. Applying a spatial approach allows users to identify location-based patterns and trends related to risk factors, health outcomes, and population health. Geographic information science (GIScience) is the discipline that applies Geographic Information Systems (GIS) and other spatial concepts and methods in research. This review explores the current state and evolution of GIScience in cancer research by addressing fundamental topics and issues regarding spatial data and analysis that need to be considered. GIScience, along with its health-specific application in the spatial epidemiology of cancer, incorporates multiple geographic perspectives pertaining to the individual, the health care infrastructure, and the environment. Challenges addressing these perspectives and the synergies among them can be explored through GIScience methods and associated technologies as integral parts of epidemiologic research, analysis efforts, and solutions. The authors suggest GIScience is a powerful tool for cancer research, bringing additional context to cancer data analysis and potentially informing decision-making and policy, ultimately aimed at reducing the burden of cancer.

Cost-effectiveness of patient navigation for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program

OBJECTIVES

Patient navigation (PN) services have been shown to improve cancer screening in disparate populations. This study estimates the cost-effectiveness of implementing PN services within the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

We adapted a breast cancer simulation model to estimate a population cohort of women aged 40-64 years from the NBCCEDP through their lifetime. We incorporated their screening frequency and screening and diagnostic costs.

RESULTS

Within the NBCCEDP, Program with PN (vs. No PN) resulted in a greater number of mammograms per woman (4.23 vs. 4.14), lower lifetime mortality from breast cancer (3.53% vs. 3.61%), and fewer missed diagnostic resolution per woman (0.017 vs. 0.025). The estimated incremental cost-effectiveness ratios for a Program with PN was $32,531 per quality-adjusted life-years relative to Program with No PN.

CONCLUSIONS

Incorporating PN services within the NBCCEDP may be a cost-effective way of improving adherence to screening and diagnostic resolution for women who have abnormal results from screening mammography. Our study highlights the value of supportive services such as PN in improving the quality of care offered within the NBCCEDP.

Spatial Accessibility to Mammography Services in the Lower Mississippi Delta Region States

PURPOSE

To characterize spatial access to mammography services across 8 Lower Mississippi Delta Region (LMDR) states. These states include the Delta Region, a federally designated, largely rural, and impoverished region with a high proportion of black residents and low mammography utilization rates.

METHODS

Using the enhanced 2-step floating catchment area method, we calculated spatial accessibility scores for mammography services across LMDR census tracts. We compared accessibility scores between the Delta and non-Delta Regions of the LMDR. We also performed hotspot analysis and constructed spatial lag models to detect clusters of low spatial access and to identify sociodemographic factors associated with access, respectively. We obtained mammography facility locations data from the Food and Drug Administration and sociodemographic variables from the American Community Survey and the US Department of Agriculture.

RESULTS

Overall, there were no differences in spatial accessibility scores between the Delta and non-Delta Regions, though there was some state-to-state variation. Clusters of low spatial access were found in parts of the Arkansas, Mississippi, and Tennessee Delta. Spatial lag models found that poverty was associated with greater spatial access to mammography.

CONCLUSIONS

The lack of identified differences in spatial access to mammography in the Delta and non-Delta Regions suggests that psychosocial or financial barriers play a larger role in lower mammography utilization rates. Identifying clusters of low spatial access to mammography services can help inform resource allocation. Further, our study underscores the value of using coverage-based methods rather than travel time or container measures to evaluate spatial access to care.

Factors Associated with Adherence to Preventive Breast Cancer Screenings among Middle-aged African American Women

Medical and other health professionals recommend biyearly screening for breast cancer for women 40-74 years of age. However, the breast cancer screening rate of African American women aged 45 and up is lower than that of other ethnicities. The present study intended to identify factors impacting African American women's participation in breast cancer screening. This study is a longitudinal secondary data analysis of 3,911 African American participants of the Study of Women's Health Across the Nation. By using Systems Model of Clinical Preventive Care, multinomial logistic regression was applied to explore the likelihood of having breast cancer screenings (breast exam and/or mammogram) associating with predisposing factors, enabling factors, referencing factors, and situational factors. Participants with older age, with higher education, having a healthcare provider for female health, in far distance, and with a cancer(s) were significantly more likely to adhere to the recommendations of breast cancer screenings. However, participants who did not have time to visit doctors, did not trust the physicians, and who smoked regularly were significantly less likely to adhere to the recommendations of breast cancer screenings. Implications for policy and practice are discussed.

Geographic Access to Cancer Care and Mortality Among Adolescents

PURPOSE

Adolescents with cancer have had less improvement in survival than other populations in the United States. This may be due, in part, to adolescents not receiving treatment at Children's Oncology Group (COG) institutions, which have been shown to increase survival for some cancers. The objective of this ecologic study was to examine geographic distance to COG institutions and adolescent cancer mortality.

METHODS

We calculated cancer mortality among adolescents and sociodemographic and healthcare access factors in four geographic zones at selected distances surrounding COG facilities: Zone A (area within 10 miles of any COG institution), Zones B and C (concentric rings with distances from a COG institution of >10-25 miles and >25-50 miles, respectively), and Zone D (area outside of 50 miles).

RESULTS

The adolescent cancer death rate was highest in Zone A at 3.21 deaths/100,000, followed by Zone B at 3.05 deaths/100,000, Zone C at 2.94 deaths/100,000, and Zone D at 2.88 deaths/100,000. The United States-wide death rate for whites without Hispanic ethnicity, blacks without Hispanic ethnicity, and persons with Hispanic ethnicity was 2.96 deaths/100,000, 3.10 deaths/100,000, and 3.26 deaths/100,000, respectively. Zone A had high levels of poverty (15%), no health insurance coverage (16%), and no vehicle access (16%).

CONCLUSIONS

Geographic access to COG institutions, as measured by distance alone, played no evident role in death rate differences across zones. Among adolescents, socioeconomic factors, such as poverty and health insurance coverage, may have a greater impact on cancer mortality than geographic distance to COG institution.

Insurance status affects postoperative morbidity and complication rate after shoulder arthroplasty

BACKGROUND

Shoulder arthroplasty is an effective procedure for managing patients with shoulder pain secondary to end-stage arthritis. Insurance status has been shown to be a predictor of patient morbidity and mortality. The current study evaluated the effect of patient insurance status on perioperative outcomes after shoulder replacement surgery.

METHODS

Data between 2004 and 2011 were obtained from the Nationwide Inpatient Sample. Analysis included patients undergoing shoulder arthroplasty (partial, total, and reverse) procedures determined by International Classification of Disease, 9th Revision procedure codes. The primary outcome was medical and surgical complications occurring during the same hospitalization, with secondary analyses of mortality and hospital charges. Additional analyses using the coarsened exact matching algorithm were performed to assess the influence of insurance type in predicting outcomes.

RESULTS

A data inquiry identified 103,290 shoulder replacement patients (68,578 Medicare, 27,159 private insurance, 3544 Medicaid/uninsured, 4009 other). The overall complication rate was 17.2% (n = 17,810) and the mortality rate was 0.20% (n = 208). Medicare and Medicaid/uninsured patients had a significantly higher rate of medical, surgical, and overall complications compared with private insurance using the controlled match data. Multivariate regression analysis found that having private insurance was associated with fewer overall medical complications.

CONCLUSION

Private insurance payer status is associated with a lower risk of perioperative medical and surgical complications compared with an age- and sex-matched Medicare and Medicaid/uninsured payer status. Mortality was not statistically associated with payer status. Primary insurance payer status should be considered as an independent risk factor during preoperative risk stratification for shoulder arthroplasty procedures.

Availability of Healthcare Resources and Colorectal Cancer Outcomes Among Non-Hispanic White and Non-Hispanic Black Adults

This study aims to examine if access to healthcare, measured through the availability of medical resources at the neighborhood level, influences colorectal cancer (CRC) stage, treatment and survival using the Surveillance Epidemiology and Ends Result (SEER) dataset (November 2012), linked with the 2004 Area Resource File. A cross-sectional study was conducted to determine the association between availability of healthcare resources and CRC outcomes among non-Hispanic Black (n = 9162) and non-Hispanic White patients (n = 97,264). CRC patients were identified using the SEER*Stat program, and individual socio-demographic, clinical, and county-level healthcare access variables were obtained for each patient. Among NH-W patients, residence in counties with lower number of oncology hospitals was associated with increased odds of late stage diagnosis (OR 1.09, 95 % CI 1.04-1.14), reduced odds of receiving surgery (OR 0.83, 95 % CI 0.74-0.92) and higher hazard rates (HR 1.09, 95 % CI 1.06-1.12). There were no significant associations among NH-B patients. Increased availability of healthcare resources improves CRC outcomes among NH-W patients. However, future studies are required to better understand healthcare utilization patterns in NH-B neighborhoods, and identify other important dimensions of healthcare access such as affordability, acceptability and accommodation.

'Pharmacy deserts' are prevalent in Chicago's predominantly minority communities, raising medication access concerns

Attempts to explain and address disparities in the use of prescription medications have focused almost exclusively on their affordability. However, the segregation of residential neighborhoods by race or ethnicity also may influence access to the pharmacies that, in turn, provide access to prescription medications within a community. We examined whether trends in the availability of pharmacies varied across communities in Chicago with different racial or ethnic compositions. We also examined the geographic accessibility of pharmacies to determine whether "pharmacy deserts," or low-access neighborhoods, were more common in segregated black and Hispanic communities than elsewhere. We found that throughout the period 2000-2012 the number of pharmacies was lower in segregated minority communities than in segregated white communities and integrated communities. In 2012 there were disproportionately more pharmacy deserts in segregated black communities, as well as in low-income communities and federally designated Medically Underserved Areas. Our findings suggest that public policies aimed at improving access to prescription medications may need to address factors beyond insurance coverage and medication affordability. Such policies could include financial incentives to locate pharmacies in pharmacy deserts or the incorporation of pharmacies into community health centers in Medically Underserved Areas.

Health research needs more comprehensive accessibility measures: integrating time and transport modes from open data

Background

In this paper, we demonstrate why and how both temporality and multimodality should be integrated in health related studies that include accessibility perspective, in this case healthy food accessibility. We provide evidence regarding the importance of using multimodal spatio-temporal accessibility measures when conducting research in urban contexts and propose a methodological approach for integrating different travel modes and temporality to spatial accessibility analyses. We use the Helsinki metropolitan area (Finland) as our case study region to demonstrate the effects of temporality and modality on the results.

Methods

Spatial analyses were carried out on 250 m statistical grid squares. We measured travel times between the home location of inhabitants and open grocery stores providing healthy food at 5 p.m., 10 p.m., and 1 a.m. using public transportation and private cars. We applied the so-called door-to-door approach for the travel time measurements to obtain more realistic and comparable results between travel modes. The analyses are based on open access data and publicly available open-source tools, thus similar analyses can be conducted in urban regions worldwide.

Results

Our results show that both time and mode of transport have a prominent impact on the outcome of the analyses; thus, understanding the realities of accessibility in a city may be very different according to the setting of the analysis used. In terms of travel time, there is clear variation in the results at different times of the day. In terms of travel mode, our results show that when analyzed in a comparable manner, public transport can be an even faster mode than a private car to access healthy food, especially in central areas of the city where the service network is dense and public transportation system is effective.

Conclusions

This study demonstrates that time and transport modes are essential components when modeling health-related accessibility in urban environments. Neglecting them from spatial analyses may lead to overly simplified or even erroneous images of the realities of accessibility. Hence, there is a risk that health related planning and decisions based on simplistic accessibility measures might cause unwanted outcomes in terms of inequality among different groups of people.

Health related lifestyle and preventive medical care of rural Spanish women compared to their urban counterparts

The objective of this work is to study the differences in health related behavior, habits and preventive health care attendance between women living in rural areas and their metropolitan counterparts in Spain. We analyzed health related behavior (such as leisure time physical activity, smoking, alcohol use and other health related dietary patterns) and preventive medical attendance (gynecological attendance, mammography frequency, flu vaccinations, cholesterol and blood pressure checks) in a total of 17,833 women older than 16 from the Spanish National Health Survey 2006. A multinomial logistic regression model was employed to compare groups (adjusted for age and social class). The main findings of this study is that the likelihood of receiving and attending to preventive public health care services was significantly lower for women in medium-sized urban or rural and remote locations than those living in metropolitan areas, as well as differences in health-related lifestyle behaviours.

Neighborhood Predictors of Mammography Barriers Among US-Based Latinas

BACKGROUND

Little is known about how neighborhood factors are associated with Latinas' barriers to cancer screening, including mammography. To address this gap, we examined barriers to mammography by neighborhood racial/ethnic composition and socioeconomic status among a federally qualified health center (FQHC)-based sample of non-adherent Latinas in Western Washington State.

METHODS

Baseline data were drawn from a larger intervention study (n = 536 Latinas). Women indicated why they had not obtained a mammogram in the past 2 years (no reason, knowledge, psychocultural, economic). American Community Survey (2007-2011) data were used to calculate four neighborhood measures that were categorized in tertiles (T): socioeconomic-based concentration, socioeconomic-based segregation, Latino-based concentration, and Latino-based segregation.

RESULTS

The proportion of women reporting knowledge-, psychocultural-, and economic-based reasons for not obtaining mammograms in the past 2 years was, respectively, 0.35, 0.19, and 0.31. Approximately 14 % indicated no particular reason. Relative to women residing in areas with greater Latino-based segregation, women in areas with less Latino-based segregation were less likely to report knowledge-based and economic-based reasons for not obtaining a mammogram (p ≤ 0.05). Relative to women residing in areas with greater concentration of Latinos, women in areas with the lowest concentrations were less likely to report knowledge-based reasons for not obtaining a mammogram (p ≤ 0.05).

CONCLUSIONS

Our findings provide important information about the role of neighborhood characteristics and mammography use among Latinas obtaining care from FQHCs. Future research might examine the mediating role of neighborhood characteristics in the efficacy of mammography screening interventions.

Travel Burden to Breast MRI and Utilization: Are Risk and Sociodemographics Related?

PURPOSE

Mammography, unlike MRI, is relatively geographically accessible. Additional travel time is often required to access breast MRI. However, the amount of additional travel time and whether it varies on the basis of sociodemographic or breast cancer risk factors is unknown.

METHODS

The investigators examined screening mammography and MRI between 2005 and 2012 in the Breast Cancer Surveillance Consortium by (1) travel time to the closest and actual mammography facility used and the difference between the two, (2) women's breast cancer risk factors, and (3) sociodemographic characteristics. Logistic regression was used to examine the odds of traveling farther than the closest facility in relation to women's characteristics.

RESULTS

Among 821,683 screening mammographic examinations, 76.6% occurred at the closest facility, compared with 51.9% of screening MRI studies (n = 3,687). The median differential travel time among women not using the closest facility for mammography was 14 min (interquartile range, 8-25 min) versus 20 min (interquartile range, 11-40 min) for breast MRI. Differential travel time for both imaging modalities did not vary notably by breast cancer risk factors but was significantly longer for nonurban residents. For non-Hispanic black compared with non-Hispanic white women, the adjusted odds of traveling farther than the closest facility were 9% lower for mammography (odds ratio, 0.91; 95% confidence interval, 0.87-0.95) but more than two times higher for MRI (odds ratio, 2.64; 95% confidence interval, 1.36-5.13).

CONCLUSIONS

Breast cancer risk factors were not related to excess travel time for screening MRI, but sociodemographic factors were, suggesting the possibility that geographic distribution of advanced imaging may exacerbated disparities for some vulnerable populations.

Is the closest facility the one actually used? An assessment of travel time estimation based on mammography facilities

Background

Characterizing geographic access depends on a broad range of methods available to researchers and the healthcare context to which the method is applied. Globally, travel time is one frequently used measure of geographic access with known limitations associated with data availability. Specifically, due to lack of available utilization data, many travel time studies assume that patients use the closest facility. To examine this assumption, an example using mammography screening data, which is considered a geographically abundant health care service in the United States, is explored. This work makes an important methodological contribution to measuring access—which is a critical component of health care planning and equity almost everywhere.

Method

We analyzed one mammogram from each of 646,553 women participating in the US based Breast Cancer Surveillance Consortium for years 2005–2012. We geocoded each record to street level address data in order to calculate travel time to the closest and to the actually used mammography facility. Travel time between the closest and the actual facility used was explored by woman-level and facility characteristics.

Results

Only 35 % of women in the study population used their closest facility, but nearly three-quarters of women not using their closest facility used a facility within 5 min of the closest facility. Individuals that by-passed the closest facility tended to live in an urban core, within higher income neighborhoods, or in areas where the average travel times to work was longer. Those living in small towns or isolated rural areas had longer closer and actual median drive times.

Conclusion

Since the majority of US women accessed a facility within a few minutes of their closest facility this suggests that distance to the closest facility may serve as an adequate proxy for utilization studies of geographically abundant services like mammography in areas where the transportation networks are well established.

The National Mammography Database: Preliminary Data

OBJECTIVE

The purposes of our study were to analyze screening mammography data submitted to the National Mammography Database (NMD) since its inception to confirm data collection feasibility, to draw parallels to data from the Breast Cancer Surveillance Consortium (BCSC), and to examine trends over time. We also retrospectively evaluated practice-level variation in terms of practice type, practice setting, census region, and annual volume.

MATERIALS AND METHODS

Data from 90 mammography facilities in the NMD registry were analyzed. The registry receives mammography data collected as part of standard clinical practice, including self-reported demographic information, clinical findings, screening mammography interpretation, and biopsy results. Outcome metrics calculated were cancer detection rate, recall rate, and positive predictive values for biopsy recommended (PPV2) and biopsy performed (PPV3).

RESULTS

The NMD successfully collected and analyzed data for 3,181,437 screening mammograms performed between January 2008 and December 2012. Mean values for outcomes were cancer detection rate of 3.43 per 1000 (95% CI, 3.2-3.7), recall rate of 10% (95% CI, 9.3-10.7%), PPV2 of 18.5% (95% CI, 16.7-20.2%), and PPV3 of 29.2% (95% CI, 26.2-32.3%). No statistically significant difference was seen in performance measurements on the basis of practice type, practice setting, census region, or annual volume. NMD performance measurements parallel those reported by the BCSC.

CONCLUSION

The NMD has become the fastest growing mammography registry in the United States, providing nationwide performance metrics and permitting comparison with published benchmarks. Our study shows the feasibility of using the NMD to audit mammography facilities and to provide current, ongoing benchmark data.

Primary care characteristics and their association with health screening in a low-socioeconomic status public rental-flat population in Singapore- a mixed methods study

Background

In Singapore, subsidized primary care is provided by centralized polyclinics; since 2000, policies have allowed lower-income Singaporeans to utilize subsidies at private general-practitioner (GP) clinics. We sought to determine whether proximity to primary care, subsidised primary care, or having regular primary care associated with health screening participation in a low socioeconomic-status public rental-flat community in Singapore.

Methods

From 2009–2014, residents in five public rental-flat enclaves (N = 936) and neighboring owner-occupied precincts (N = 1060) were assessed for participation in cardiovascular and cancer screening. We then evaluated whether proximity to primary care, subsidised primary care, or having regular primary care associated with improved adherence to health screening. We also investigated attitudes to health screening using qualitative methodology.

Results

In the rental flat population, for cardiovascular screening, regular primary care was independently associated with regular diabetes screening (adjusted odds ratio, aOR = 1.59, CI = 1.12–2.26, p = 0.009) and hyperlipidemia screening (aOR = 1.82, CI = 1.10–3.04, p = 0.023). In the owner-occupied flats, regular primary care was independently associated with regular hypertension screening (aOR = 9.34 (1.82–47.85, p = 0.007), while subsidized primary care was associated with regular diabetes screening (aOR = 2.94, CI = 1.04–8.31, p = 0.042). For cancer screening, in the rental flat population, proximity to primary care was associated with less participation in regular colorectal cancer screening (aOR = 0.42, CI = 0.17–0.99, p = 0.049) and breast cancer screening (aOR = 0.29, CI = 0.10–0.84, p = 0.023). In the owner-occupied flat population, for gynecological cancer screening, usage of subsidized primary care and proximity to primary care was associated with higher rates of breast cancer and cervical cancer screening; however, being on regular primary care followup was associated with lower rates of mammography (aOR = 0.10, CI = 0.01–0.75, p = 0.025). On qualitative analysis, patients were discouraged from screening by distrust in the doctor-patient relationship; for cancer screening in particular, patients were discouraged by potential embarrassment.

Conclusions

Regular primary care was independently associated with regular participation in cardiovascular screening in both low-SES and higher-SES communities. However, for cancer screening, in the low-SES community, proximity to primary care was associated with less participation in regular screening, while in the higher-SES community, regular primary care was associated with lower screening participation; possibly due to embarrassment regarding screening modalities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0411-5) contains supplementary material, which is available to authorized users.

Travel by public transit to mammography facilities in 6 US urban areas

We examined lack of private vehicle access and 30 minutes or longer public transportation travel time to mammography facilities for women 40 years of age or older in the urban areas of Boston, Philadelphia, San Antonio, San Diego, Denver, and Seattle to identify transit marginalized populations - women for whom these travel characteristics may jointly present a barrier to clinic access. This ecological study used sex and race/ethnicity data from the 2010 US Census and household vehicle availability data from the American Community Survey 2008-2012, all at Census tract level. Using the public transportation option on Google Trip Planner we obtained the travel time from the centroid of each census tract to all local mammography facilities to determine the nearest mammography facility in each urban area. Median travel times by public transportation to the nearest facility for women with no household access to a private vehicle were obtained by ranking travel time by population group across all U.S. census tracts in each urban area and across the entire study area. The overall median travel times for each urban area for women without household access to a private vehicle ranged from a low of 15 minutes in Boston and Philadelphia to 27 minutes in San Diego. The numbers and percentages of transit marginalized women were then calculated for all urban areas by population group. While black women were less likely to have private vehicle access, and both Hispanic and black women were more likely to be transit marginalized, this outcome varied by urban area. White women constituted the largest number of transit marginalized. Our results indicate that mammography facilities are favorably located for the large majority of women, although there are still substantial numbers for whom travel may likely present a barrier to mammography facility access.

Small-area spatio-temporal analyses of participation rates in the mammography screening program in the city of Dortmund (NW Germany)

Background

The population-based mammography screening program (MSP) was implemented by the end of 2005 in Germany, and all women between 50 and 69 years are actively invited to a free biennial screening examination. However, despite the expected benefits, the overall participation rates range only between 50 and 55 %. There is also increasing evidence that belonging to a vulnerable population, such as ethnic minorities or low income groups, is associated with a decreased likelihood of participating in screening programs. This study aimed to analyze in more detail the intra-urban variation of MSP uptake at the neighborhood level (i.e. statistical districts) for the city of Dortmund in northwest Germany and to identify demographic and socioeconomic risk factors that contribute to non-response to screening invitations.

Methods

The numbers of participants by statistical district were aggregated over the three periods 2007/2008, 2009/2010, and 2011/2012. Participation rates were calculated as numbers of participants per female resident population averaged over each 2-year period. Bayesian hierarchical spatial models extended with a temporal and spatio-temporal interaction effect were used to analyze the participation rates applying integrated nested Laplace approximations (INLA). The model included explanatory covariates taken from the atlas of social structure of Dortmund.

Results

Generally, participation rates rose for all districts over the time periods. However, participation was persistently lowest in the inner city of Dortmund. Multivariable regression analysis showed that migrant status and long-term unemployment were associated with significant increases of non-attendance in the MSP.

Conclusion

Low income groups and immigrant populations are clustered in the inner city of Dortmund and the observed spatial pattern of persistently low participation in the city center is likely linked to the underlying socioeconomic gradient. This corresponds with the findings of the ecological regression analysis manifesting socioeconomically deprived neighborhoods as risk factors for low attendance in the MSP. Spatio-temporal surveillance of participation in cancer screening programs may be used to identify spatial inequalities in screening uptake and plan spatially focused interventions.

Perceptions of One's Neighborhood and Mammogram Use among a Sample of Low-Income Women at Risk for Human Immunodeficiency Virus and Sexually Transmitted Infections

BACKGROUND

Neighborhood disorder, signs of physical and social disorganization, has been related to a range of poor mental and physical health outcomes. Although individual factors have been widely associated with getting a mammogram, little is known about the impact of the neighborhood environment on a woman's decision to get a mammogram.

METHODS

In a sample of women at risk for human immunodeficiency virus and sexually transmitted infections, we explored the role of perceptions of one's neighborhood on getting a mammogram. The study included two samples: women 40 to 49 years (n = 233) and women 50 years and older (n = 83). Data were collected from May 2006 through June 2008.

RESULTS

Women age 50 years and older who lived in a neighborhood with disorder were 72% less likely to get a mammogram compared with women who lived in neighborhoods without disorder. There was no relationship for women age 40 to 49 years.

CONCLUSIONS

Interventions are needed to increase awareness and encourage women living in neighborhoods with disorder to get a mammogram. In addition to interventions to increase mammography, programs are needed to decrease neighborhood disorder. Increasing neighborhood cohesion, social control, and empowerment could integrate health promotion programs to both reduce disorder and increase health behaviors.

What factors influence follow-up in orthopedic trauma surgery?

BACKGROUND

Among surgical patients, follow-up visits are essential for monitoring post-operative recovery and determining ongoing treatment plans. Non-adherence to clinic follow-up appointments has been associated with poorer outcomes in many different patient populations. We sought to identify factors associated with non-attendance at follow-up appointments for orthopedic trauma patients.

MATERIALS AND METHODS

A retrospective chart review at a level I trauma center identified 2,165 patients who underwent orthopedic trauma surgery from 2008 to 2009. Demographic data including age, sex, race, tobacco use, American Society of Anesthesiologist (ASA) score, insurance status, distance from the hospital, and follow-up time were collected. Injury characteristics including fracture type, anatomic location of the operation, length of hospital stay, living situation and employment status were recorded. Attendance at the first scheduled follow-up visit was recorded. Multivariable log-binomial regression analyses were used with statistical significance maintained at p < 0.05.

RESULTS

Of the 2,165 patients included in the analysis, 1,449 (66.9 %) attended their first scheduled post-operative clinic visit. 33.1 % (717) were not compliant with keeping their first clinic appointment after surgery. Patients who used tobacco, lived more than 100 miles from the clinic site, did not have private insurance, had an ASA score >2, or had a fracture of the hip or pelvis were significantly less likely to follow-up. Age, sex, and race were not significantly associated with failure to follow-up.

DISCUSSION

Follow-up appointments are essential for preventing complications among orthopedic trauma patients. By identifying patients at risk of failure to follow-up, orthopedic surgeons can appropriately design and implement long-term treatment plans specifically targeted for high-risk patients.

Cost of services provided by the National Breast and Cervical Cancer Early Detection Program

BACKGROUND

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) is the largest cancer screening program for low-income women in the United States. This study updates previous estimates of the costs of delivering preventive cancer screening services in the NBCCEDP.

METHODS

We developed a standardized web-based cost-assessment tool to collect annual activity-based cost data on screening for breast and cervical cancer in the NBCCEDP. Data were collected from 63 of the 66 programs that received funding from the Centers for Disease Control and Prevention during the 2006/2007 fiscal year. We used these data to calculate costs of delivering preventive public health services in the program.

RESULTS

We estimated the total cost of all NBCCEDP services to be $296 (standard deviation [SD], $123) per woman served (including the estimated value of in-kind donations, which constituted approximately 15% of this total estimated cost). The estimated cost of screening and diagnostic services was $145 (SD, $38) per women served, which represented 57.7% of the total cost excluding the value of in-kind donations. Including the value of in-kind donations, the weighted mean cost of screening a woman for breast cancer was $110 with an office visit and $88 without, the weighted mean cost of a diagnostic procedure was $401, and the weighted mean cost per breast cancer detected was $35,480. For cervical cancer, the corresponding cost estimates were $61, $21, $415, and $18,995, respectively.

CONCLUSIONS

These NBCCEDP cost estimates may help policy makers in planning and implementing future costs for various potential changes to the program.

European transnational ecological deprivation index and participation in population-based breast cancer screening programmes in France

BACKGROUND

We investigated factors explaining low breast cancer screening programme (BCSP) attendance taking into account a European transnational ecological Deprivation Index.

PATIENTS AND METHODS

Data of 13,565 women aged 51-74years old invited to attend an organised mammography screening session between 2010 and 2011 in thirteen French departments were randomly selected. Information on the women's participation in BCSP, their individual characteristics and the characteristics of their area of residence were recorded and analysed in a multilevel model.

RESULTS

Between 2010 and 2012, 7121 (52.5%) women of the studied population had their mammography examination after they received the invitation. Women living in the most deprived neighbourhood were less likely than those living in the most affluent neighbourhood to participate in BCSP (OR 95%CI=0.84[0.78-0.92]) as were those living in rural areas compared with those living in urban areas (OR 95%CI=0.87[0.80-0.95]). Being self-employed (p<0.0001) or living more than 15min away from an accredited screening centre (p=0.02) was also a barrier to participation in BCSP.

CONCLUSION

Despite the classless delivery of BCSP, inequalities in uptake remain. To take advantage of prevention and to avoid exacerbating disparities in cancer mortality, BCSP should be adapted to women's personal and contextual characteristics.

Effect of marital status on treatment and survival of extremity soft tissue sarcoma

BACKGROUND

Spousal support has been hypothesized as providing important psychosocial support for patients and as such has been noted to provide a survival advantage in a number of chronic diseases and cancers. However, the specific effect of marital status on survival in soft tissue sarcomas (STSs) of the extremity has not been explored in detail.

PATIENTS AND METHODS

A total of 7384 patients were evaluated for this study using a Surveillance, Epidemiology, and End Results (SEER) registry query for patients over 20 years old with extremity STS diagnosed between 2004 and 2009. Survival outcomes were analyzed using Gray's test after patients were stratified by marital status. The Fine and Gray model, a multivariable regression model, was used to assess whether marital status was an independent predictor of sarcoma specific death. Statistical significance was maintained at P < 0.05.

RESULTS

Analysis of the SEER database showed that single patients were more likely to die of their STS and at a faster rate than married patients. No differences were noted in tumor size and tumor site on presentation between married and single patients. However, single patients presented with higher grade tumors more frequently (P = 0.013), received less radiotherapy (P < 0.001), and had less surgery carried out (P < 0.001), compared with their married peers. Regression analysis showed that after accounting for tumor size, grade, site, histology, use of radiotherapy, age, gender, region where the patients were from, and income, being single continued to serve as an independent predictor of sarcoma-specific death; P < 0.0001.

CONCLUSION

Overall survival is worse for single patients, when compared with married patients, with STS. Single patients do not undergo surgical resection or receive radiation therapy as frequently as their married counterparts. Social support systems and barriers to care should be evaluated at time of diagnosis and addressed in single patients to potentially improve survival outcomes.

Dilated eye examination screening guideline compliance among patients with diabetes without a diabetic retinopathy diagnosis: the role of geographic access

OBJECTIVE

To estimate the prevalence of, and factors associated with, dilated eye examination guideline compliance among patients with diabetes mellitus (DM), but without diabetic retinopathy.

RESEARCH DESIGN AND METHODS

Utilizing the computerized billing records database, we identified patients with International Classification of Diseases (ICD)-9 diagnoses of DM, but without any ocular diagnoses. The available medical records of patients in 2007-2008 were reviewed for demographic and ocular information, including visits through 2010 (n=200). Patients were considered guideline compliant if they returned at least every 15 months for screening. Participant street addresses were assigned latitude and longitude coordinates to assess their neighborhood socioeconomic status (using the 2000 US census data), distance to the screening facility, and public transportation access. Patients not compliant, based on the medical record review, were contacted by phone or mail and asked to complete a follow-up survey to determine if screening took place at other locations.

RESULTS

The overall screening compliance rate was 31%. Patient sociodemographic characteristics, insurance status, and neighborhood socioeconomic measures were not significantly associated with compliance. However, in separate multivariable logistic regression models, those living eight or more miles from the screening facility were significantly less likely to be compliant relative to those living within eight miles (OR=0.36 (95% CI 0.14 to 0.86)), while public transit access quality was positively associated with screening compliance (1.34 (1.07 to 1.68)).

CONCLUSIONS

Less than one-third of patients returned for diabetic retinopathy screening at least every 15 months, with transportation challenges associated with noncompliance. Our results suggest that reducing transportation barriers or utilizing community-based screening strategies may improve compliance.

The National Prevention Strategy and breast cancer screening: scientific evidence for public health action

Mammography screening rates in the United States have remained fairly stable over the past decade, and screening rates remain low for some groups. We examined insights from recent public health research on breast cancer screening to identify promising new approaches to improve screening rates and address persistent health disparities in mammography use. We considered this research in the context of the four strategic directions of the National Prevention Strategy: elimination of health disparities, empowered people, healthy and safe community environments, and clinical and community preventive services. This research points to the value of direct outreach and case management services, interventions to support more patient-centered models of care, and more organized, population-based approaches to identify women who are eligible to be screened, encourage participation, and monitor results.

Racial disparities in travel time to radiotherapy facilities in the Atlanta metropolitan area

Low-income women with breast cancer who rely on public transportation may have difficulty in completing recommended radiation therapy due to inadequate access to radiation facilities. Using a geographic information system (GIS) and network analysis we quantified spatial accessibility to radiation treatment facilities in the Atlanta, Georgia metropolitan area. We built a transportation network model that included all bus and rail routes and stops, system transfers and walk and wait times experienced by public transportation system travelers. We also built a private transportation network to model travel times by automobile. We calculated travel times to radiation therapy facilities via public and private transportation from a population-weighted center of each census tract located within the study area. We broadly grouped the tracts by low, medium and high household access to a private vehicle and by race. Facility service areas were created using the network model to map the extent of areal coverage at specified travel times (30, 45 and 60 min) for both public and private modes of transportation. The median public transportation travel time to the nearest radiotherapy facility was 56 min vs. approximately 8 min by private vehicle. We found that majority black census tracts had longer public transportation travel times than white tracts across all categories of vehicle access and that 39% of women in the study area had longer than 1 h of public transportation travel time to the nearest facility. In addition, service area analyses identified locations where the travel time barriers are the greatest. Spatial inaccessibility, especially for women who must use public transportation, is one of the barriers they face in receiving optimal treatment.

Characteristics of US counties with no mammography capacity

Access to screening mammography may be limited by the availability of facilities and machines, and nationwide mammography capacity has been declining. We assessed nationwide capacity at state and county levels from 2003 to 2009, the most recent year for which complete data were available. Using mammography facility certification and inspection data from the Food and Drug Administration, we geocoded all mammography facilities in the United States and determined the total number of fully accredited mammography machines in each US County. We categorized mammography capacity as counties with zero capacity (i.e., 0 machines) or counties with capacity (i.e.,≥1 machines), and then compared those two categories by sociodemographic, health care, and geographic characteristics. We found that mammography capacity was not distributed equally across counties within states and that more than 27 % of counties had zero capacity. Although the number of mammography facilities and machines decreased slightly from 2003 to 2009, the percentage of counties with zero capacity changed little. In adjusted analyses, having zero mammography capacity was most strongly associated with low population density (OR = 11.0; 95 % CI 7.7-15.9), low primary care physician density (OR = 8.9; 95 % CI 6.8-11.7), and a low percentage of insured residents (OR = 3.3; 95 % CI 2.5-4.3) when compared with counties having at least one mammography machine. Mammography capacity has been and remains a concern for a portion of the US population--a population that is mostly but not entirely rural.