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Zhu Z, Wang Y, Han J, Li Y. Associations of Pap test utilisation with comorbidity and functional impairment among middle-aged non-Hispanic black women in the USA: a cross-sectional analysis of the 2018 BRFSS data. BMJ Open 2024; 14:e076247. [PMID: 39053959 DOI: 10.1136/bmjopen-2023-076247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVES Limited evidence exists on the association of Pap test utilisation with comorbidity and functional impairment among middle-aged non-Hispanic black (NHB) women in the USA. We aimed to assess whether middle-aged NHB women with a higher burden of comorbidity and functional impairment have a lower rate of Pap test utilisation. DESIGN Nationwide cross-sectional survey in the USA. SETTING 2018 Behavioral Risk Factor Surveillance System. PARTICIPANTS 6359 middle-aged NHB women. EXPOSURES AND OUTCOME The primary exposures were comorbidity and functional impairment. The outcome of interest was whether a woman reported having a Pap test in the last 3 years. DATA ANALYSIS We fit unadjusted and multivariable logistic regression models to calculate ORs and 95% CI for comorbidity and functional impairment. Sensitivity analysis was restricted to women without a history of hysterectomy or cancer. We added interaction terms between exposures and age, as well as lifestyle indicators. RESULTS Of the 6359 women, 4141 (65.1%) had comorbidity and 2429 (38.2%) had functional impairment. Middle-aged NHB women with comorbidity (≥2 vs 0, aOR=0.72, 95% CI=0.61 to 0.85, p trend<0.01) or functional impairment (≥2 vs 0, aOR=0.69, 95% CI=0.57 to 0.83, p trend<0.01) had a lower rate of Pap test utilisation compared with healthier counterparts, regardless of histories of hysterectomy and prior cancer. The analyses for age and lifestyle indicators subgroup difference indicated no statistically significant effect (p interaction>0.05). However, the magnitude of these associations was stronger among women with adverse lifestyle factors (eg, comorbidity ≥2 v.s. 0, aOR=0.53, 95% CI=0.40, to 0.71; functional impairment ≥2 v.s. 0, aOR=0.35, 95% CI=0.16, to 0.72 among binge drinkers). CONCLUSION Comorbidity or functional impairment could be a potential barrier to Pap test utilisation among middle-aged NHB women in the USA. Our study highlights the importance of implementing targeted intervention programmes and prioritised health resource allocation to promote Pap test utilisation. Cohort studies with clear temporality and indicators reflecting disease severity will be essential for further understanding this association.
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Affiliation(s)
- Zhikai Zhu
- National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yali Wang
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiefei Han
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Li
- Department of General Surgery, the First Medical Center, Chinese PLA General Hospital, Beijing, China
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Lin JC, Scott IU, Greenberg PB. Prevalence and Risk Factors of Self-reported Vision Impairment among Native Hawaiians and Pacific Islanders in the United States. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2023; 82:296-301. [PMID: 38093762 PMCID: PMC10713738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Racial disparities in vision impairment have been reported among Black, Hispanic, and White Americans. However, there is a paucity of research on vision impairment among Native Hawaiians and Pacific Islanders (NHPIs). The objective of this study was to determine the prevalence of, and risk factors for, self-reported visual impairment in NHPI adults in the United States (US). Data from the NHPI and 2014 National Health Interview Surveys were analyzed using sample weights and variance estimates. Prevalence was calculated for vision impairment and blindness for the NHPI and overall US populations. Sociodemographic and clinical risk factors of vision impairment were explored using descriptive statistics, χ2 tests, and simple and multiple logistic regression. In total, 2 586 NHPIs and 36 673 individuals in the US were included. The prevalence of vision impairment was 8.8% among NHPIs and 9.1% for the overall US population, and the prevalence of blindness was 0.72% for NHPIs and 0.35% for the overall population. Independent risk factors associated with vision impairment were having a Charlson Comorbidity Index over 1 [OR: 2.89, 95% CI: (1.42-5.88)] and having a family income below $35 000 [OR: 2.03, 95% CI: (1.06-3.89)]. In summary, the rate of blindness is higher among NHPIs than the overall US population, especially for older and unemployed individuals with more comorbidities. Higher comorbidity burden, lower family income, and recent eye care were risk factors for vision impairment. More research is necessary to develop targeted and culturally sensitive interventions to promote NHPI eye health.
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Affiliation(s)
- John C. Lin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (JCL)
- Division of Ophthalmology, Alpert Medical School, Brown University, Providence, RI (JCL, PBG)
| | - Ingrid U. Scott
- Departments of Ophthalmology and Public Health Sciences, Penn State College of Medicine, Hershey, PA (IUS)
| | - Paul B. Greenberg
- Division of Ophthalmology, Alpert Medical School, Brown University, Providence, RI (JCL, PBG)
- Section of Ophthalmology, VA Providence Healthcare System, Providence, RI (PBG)
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Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA. J Gen Intern Med 2022; 37:2475-2481. [PMID: 34379279 PMCID: PMC9360208 DOI: 10.1007/s11606-021-07072-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND After a certain age, cancer screening may expose older adults to unnecessary harms with limited benefits and represent inefficient use of health care resources. OBJECTIVE To estimate the frequency of cervical, breast, and colorectal cancer screening among adults older than US Preventive Services Task Force (USPSTF) age thresholds at which screening is no longer considered routine and to identify physician and patient factors associated with low-value cancer screening. DESIGN Observational study using pooled cross-sectional data (2011-2016) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. PARTICIPANTS Analyses for cervical and breast cancer screening were limited to visits by women over age 65 (N=37,818) and ages 75 and over (N=19,451), respectively. Analyses for colorectal cancer screening were limited to visits by patients over age 75 (N=31,543). MAIN MEASURES Cancer screening procedures were coded as low value using USPSTF age thresholds. KEY RESULTS Between 2011 and 2016, an estimated 509, 507, and 273 thousand potentially low-value Pap smears, mammograms, and colonoscopies/sigmoidoscopies, respectively, were ordered annually. Low-valuecervical cancer screening was less likely to occur for visits with older (vs. younger) patients. Compared to visits by non-HispanicWhite women, low-valuecervical and breast cancer screening was less likely to occur for visits by women whose race/ethnicitywas something other than non-HispanicWhite, non-HispanicBlack, or Hispanic. Obstetrician/gynecologistswere more likely to order low-valuePap smears and mammograms compared to family/generalpractice physicians. CONCLUSIONS Thousands of cervical, breast, and colorectal cancer screenings at ages beyond routine guideline thresholds occur each year in the USA. Further research is needed to understand whether this pattern represents clinical inertia and resistance to de-adoption of previous screening practices, or whether physicians and/or patients perceive a higher value in these tests than that endorsed by experts writing evidence-based guidelines.
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Reducing overuse of cervical cancer screening: A systematic review. Prev Med 2018; 116:51-59. [PMID: 30149037 DOI: 10.1016/j.ypmed.2018.08.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 08/08/2018] [Accepted: 08/21/2018] [Indexed: 12/18/2022]
Abstract
Overuse of clinical preventive services increases healthcare costs and may deprive underserved patients of necessary care. Up to 45% of cervical cancer screening is overuse. We conducted a systematic review of correlates of overuse of cervical cancer screening and interventions to reduce overuse. The search identified 25 studies (20 observational; 5 intervention). Correlates varied by the type of overuse measured (i.e., too frequent, before/after recommended age to start or stop screening, after hysterectomy), the most common correlates of overuse related to patient age (n = 7), OBGYN practice or provider (n = 5), location (n = 4), and marital status (n = 4). Six observational studies reported a decrease in overuse over time. Screening overuse decreased in all intervention studies, which used before-after designs with no control or comparison groups. Observational studies suggest potential targets for de-escalating overuse. Randomized clinical trials are needed to establish best practices for reducing overuse.
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Tranvåg EJ, Norheim OF, Ottersen T. Clinical decision making in cancer care: a review of current and future roles of patient age. BMC Cancer 2018; 18:546. [PMID: 29743048 PMCID: PMC5944161 DOI: 10.1186/s12885-018-4456-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 04/30/2018] [Indexed: 01/01/2023] Open
Abstract
Background Patient age is among the most controversial patient characteristics in clinical decision making. In personalized cancer medicine it is important to understand how individual characteristics do affect practice and how to appropriately incorporate such factors into decision making. Some argue that using age in decision making is unethical, and how patient age should guide cancer care is unsettled. This article provides an overview of the use of age in clinical decision making and discusses how age can be relevant in the context of personalized medicine. Methods We conducted a scoping review, searching Pubmed for English references published between 1985 and May 2017. References concerning cancer, with patients above the age of 18 and that discussed age in relation to diagnostic or treatment decisions were included. References that were non-medical or concerning patients below the age of 18, and references that were case reports, ongoing studies or opinion pieces were excluded. Additional references were collected through snowballing and from selected reports, guidelines and articles. Results Three hundred and forty-seven relevant references were identified. Patient age can have many and diverse roles in clinical decision making: Contextual roles linked to access (age influences how fast patients are referred to specialized care) and incidence (association between increasing age and increasing incidence rates for cancer); patient-relevant roles linked to physiology (age-related changes in drug metabolism) and comorbidity (association between increasing age and increasing number of comorbidities); and roles related to interventions, such as treatment (older patients receive substandard care) and outcome (survival varies by age). Conclusions Patient age is integrated into cancer care decision making in a range of ways that makes it difficult to claim age-neutrality. Acknowledging this and being more transparent about the use of age in decision making are likely to promote better clinical decisions, irrespective of one’s normative viewpoint. This overview also provides a starting point for future discussions on the appropriate role of age in cancer care decision making, which we see as crucial for harnessing the full potential of personalized medicine. Electronic supplementary material The online version of this article (10.1186/s12885-018-4456-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eirik Joakim Tranvåg
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway. .,Centre for Cancer Biomarkers CCBIO, Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Ole Frithjof Norheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Centre for Cancer Biomarkers CCBIO, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Trygve Ottersen
- Oslo Group on Global Health Policy, Department of Community Medicine and Global Health and Centre for Global Health, University of Oslo, Oslo, Norway.,Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
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Diaz A, Kang J, Moore SP, Baade P, Langbecker D, Condon JR, Valery PC. Association between comorbidity and participation in breast and cervical cancer screening: A systematic review and meta-analysis. Cancer Epidemiol 2017; 47:7-19. [DOI: 10.1016/j.canep.2016.12.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 12/11/2016] [Accepted: 12/22/2016] [Indexed: 01/08/2023]
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Gandhi PK, Gentry WM, Kibert JL, Lee EY, Jordan W, Bottorff MB, Huang IC. The relationship between four health-related quality-of-life indicators and use of mammography and Pap test screening in US women. Qual Life Res 2015; 24:2113-28. [PMID: 25804316 PMCID: PMC4531104 DOI: 10.1007/s11136-015-0968-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE Limited evidence is available to explain the role of four components of health-related quality of life (HRQoL) on breast and cervical cancer screening. The objective of this study was to determine the relationship between four HRQoL aspects and use of mammography and Pap test screening in US women. METHODS Data were obtained from the 2012 Behavioral Risk Factor Surveillance System (BRFSS). The outcome variables were receiving mammogram <2 versus ≥2 years in women aged 50-74 years, and receiving Pap test <3 versus ≥3 years in women aged 18-64 years. Eight logistic regression models were conducted to test the role of four HRQoL aspects (general health status, physical HRQoL, mental HRQoL, and activity limitation) on the two screening variables, after adjusting for covariates. Statistical analysis accounted for the complex sampling design of the BRFSS, and the a priori alpha error was set at p ≤ 0.05. RESULTS Among respondents, approximately 74 and 78 % of the women received mammography and Pap test, respectively. Three HRQoL aspects (general health status, physical HRQoL, and activity limitation) were significantly associated with mammography use (all p values < 0.05), whereas two HRQoL aspects (general health status and physical HRQoL) were significantly associated with Pap test (p values ≤ 0.05). All significant relationships demonstrated higher cancer screening rates among individuals with better HRQoL. CONCLUSIONS HRQoL is an important factor associated with use of mammography and Pap test. Future studies should explore the mechanisms associated with an individual's HRQoL and use HRQoL assessment as an avenue to influence adherence to use of mammography and Pap tests.
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Affiliation(s)
- Pranav K Gandhi
- Department of Pharmacy Practice, South College School of Pharmacy, 400 Goodys Lane, Knoxville, TN, 37922, USA,
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Amante DJ, Hogan TP, Pagoto SL, English TM, Lapane KL. Access to care and use of the Internet to search for health information: results from the US National Health Interview Survey. J Med Internet Res 2015; 17:e106. [PMID: 25925943 PMCID: PMC4430679 DOI: 10.2196/jmir.4126] [Citation(s) in RCA: 205] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 02/18/2015] [Indexed: 11/25/2022] Open
Abstract
Background The insurance mandate of the Affordable Care Act has increased the number of people with health coverage in the United States. There is speculation that this increase in the number of insured could make accessing health care services more difficult. Those who are unable to access care in a timely manner may use the Internet to search for information needed to answer their health questions. Objective The aim was to determine whether difficulty accessing health care services for reasons unrelated to insurance coverage is associated with increased use of the Internet to obtain health information. Methods Survey data from 32,139 adults in the 2011 National Health Interview Study (NHIS) were used in this study. The exposure for this analysis was reporting difficulty accessing health care services or delaying getting care for a reason unrelated to insurance status. To define this exposure, we examined 8 questions that asked whether different access problems occurred during the previous 12 months. The outcome for this analysis, health information technology (HIT) use, was captured by examining 2 questions that asked survey respondents if they used an online health chat room or searched the Internet to obtain health information in the previous 12 months. Several multinomial logistic regressions estimating the odds of using HIT for each reported access difficulty were conducted to accomplish the study objective. Results Of a survey population of 32,139 adults, more than 15.90% (n=5109) reported experiencing at least one access to care barrier, whereas 3.63% (1168/32,139) reported using online health chat rooms and 43.55% (13,997/32,139) reported searching the Internet for health information. Adults who reported difficulty accessing health care services for reasons unrelated to their health insurance coverage had greater odds of using the Internet to obtain health information. Those who reported delaying getting care because they could not get an appointment soon enough (OR 2.2, 95% CI 1.9-2.5), were told the doctor would not accept them as a new patient or accept their insurance (OR 2.1, 95% CI 1.7-2.5 and OR 2.1, 95% CI 1.7-2.5, respectively), or because the doctor’s office was not open when they could go (OR 2.2, 95% CI 1.9-2.7) had more than twice the odds of using the Internet to obtain health information compared to those who did not report such access difficulties. Conclusions People experiencing trouble accessing health care services for reasons unrelated to their insurance status are more likely to report using the Internet to obtain health information. Improving the accuracy and reliability of health information resources that are publicly available online could help those who are searching for information due to trouble accessing health care services.
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Affiliation(s)
- Daniel J Amante
- Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.
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Hamilton JG, Breen N, Klabunde CN, Moser RP, Leyva B, Breslau ES, Kobrin SC. Opportunities and challenges for the use of large-scale surveys in public health research: a comparison of the assessment of cancer screening behaviors. Cancer Epidemiol Biomarkers Prev 2015; 24:3-14. [PMID: 25300474 PMCID: PMC4294943 DOI: 10.1158/1055-9965.epi-14-0568] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Large-scale surveys that assess cancer prevention and control behaviors are a readily available, rich resource for public health researchers. Although these data are used by a subset of researchers who are familiar with them, their potential is not fully realized by the research community for reasons including lack of awareness of the data and limited understanding of their content, methodology, and utility. Until now, no comprehensive resource existed to describe and facilitate use of these data. To address this gap and maximize use of these data, we catalogued the characteristics and content of four surveys that assessed cancer screening behaviors in 2005, the most recent year with concurrent periods of data collection: the National Health Interview Survey, Health Information National Trends Survey, Behavioral Risk Factor Surveillance System, and California Health Interview Survey. We documented each survey's characteristics, measures of cancer screening, and relevant correlates; examined how published studies (n = 78) have used the surveys' cancer screening data; and reviewed new cancer screening constructs measured in recent years. This information can guide researchers in deciding how to capitalize on the opportunities presented by these data resources.
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Affiliation(s)
- Jada G Hamilton
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Nancy Breen
- Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, NCI, NIH, Rockville, Maryland
| | - Carrie N Klabunde
- Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, NCI, NIH, Rockville, Maryland
| | - Richard P Moser
- Science of Research and Technology Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, NCI, NIH, Rockville, Maryland
| | - Bryan Leyva
- Process of Care Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, NCI, NIH, Rockville, Maryland
| | - Erica S Breslau
- Process of Care Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, NCI, NIH, Rockville, Maryland
| | - Sarah C Kobrin
- Process of Care Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, NCI, NIH, Rockville, Maryland
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Kepka D, Breen N, King JB, Meissner HI, Roland KB, Benard VB, Saraiya M. Demographic factors associated with overuse of Pap testing. Am J Prev Med 2014; 47:629-33. [PMID: 25175763 DOI: 10.1016/j.amepre.2014.07.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 05/23/2014] [Accepted: 07/16/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Since 2003, U.S. Preventive Services Task Force guidelines recommend against Pap testing for women without a cervix following a hysterectomy and those aged >65 years. Few population-based studies have investigated factors associated with overuse of Pap testing in the U.S. PURPOSE To evaluate patient characteristics associated with overuse of Pap testing. METHODS A cross-sectional study was conducted using data from the 2010 National Health Interview Survey (NHIS) for women aged ≥30 years. NHIS is a nationally representative survey that employs a random, stratified, multi-stage cluster sampling design. In 2010, the NHIS administered a Cancer Control Supplement with questions on cervical cancer screening and hysterectomy status. Conducted in 2011-2013, all analyses account for the stratification and clustering of data within the complex NHIS survey design. Multivariate logistic regression models were used in all analyses. RESULTS Among women who have undergone a hysterectomy, younger age, Hispanic and black race/ethnicity, exceeding 400% of poverty level, and private health insurance coverage were significantly associated with receipt of a recent Pap test since hysterectomy. Among women aged >65 years, non-Hispanic white ethnicity, higher education level, exceeding 400% of poverty level, and no hysterectomy were significantly associated with receipt of a recent Pap test. CONCLUSIONS Targeted efforts to reduce unnecessary testing among older women and women with a hysterectomy in compliance with clinical recommendations for cervical cancer prevention are needed. Specific attention should be paid to privately insured women with incomes above 400% of the federal poverty level.
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Affiliation(s)
- Deanna Kepka
- Huntsman Cancer Institute, Cancer Control and Population Sciences, University of Utah, College of Nursing, Salt Lake City, Utah; NIH, National Cancer Institute, Health Services and Economics Branch, Rockville.
| | - Nancy Breen
- NIH, National Cancer Institute, Health Services and Economics Branch, Rockville
| | | | - Helen I Meissner
- NIH, Tobacco Regulatory Science Program, Office of Disease Prevention, Bethesda, Maryland
| | - Katherine B Roland
- CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Epidemiology and Applied Research Branch, Atlanta, Georgia
| | - Vicki B Benard
- CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Epidemiology and Applied Research Branch, Atlanta, Georgia
| | - Mona Saraiya
- CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Epidemiology and Applied Research Branch, Atlanta, Georgia
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Partin MR, Powell AA, Bangerter A, Halek K, Burgess JF, Fisher DA, Nelson DB. Levels and variation in overuse of fecal occult blood testing in the Veterans Health Administration. J Gen Intern Med 2012; 27:1618-25. [PMID: 22810358 PMCID: PMC3509310 DOI: 10.1007/s11606-012-2163-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 06/14/2012] [Accepted: 06/21/2012] [Indexed: 12/24/2022]
Abstract
BACKGROUND Policy-makers have called for efforts to reduce overuse of cancer screening tests, including colorectal cancer screening (CRCS). Overuse of CRCS tests other than colonoscopy has not been well documented. OBJECTIVE To estimate levels and correlates of fecal occult blood test (FOBT) overuse in a national Veterans Health Administration (VHA) sample. DESIGN Observational PARTICIPANTS Participants included 1,844 CRCS-eligible patients who responded to a 2007 CRCS survey conducted in 24 VHA facilities and had one or more FOBTs between 2003 and 2009. MAIN MEASURES We combined survey data on race, education, and income with administrative data on region, age, gender, CRCS procedures, and outpatient visits to estimate overuse levels and variation. We coded FOBTs as overused if they were conducted <10 months after prior FOBT, <9.5 years after prior colonoscopy, or <4.5 years after prior barium enema. We used multinomial logistic regression models to examine variation in overuse by reason (sooner than recommended after prior FOBT; sooner than recommended after colonoscopy, barium enema, or a combination of procedures), adjusting for clustering of procedures within patients, and patients within facilities. KEY RESULTS Of 4,236 FOBTs received by participants, 885 (21 %) met overuse criteria, with 323 (8 %) sooner than recommended after FOBT, and 562 (13 %) sooner than recommended after other procedures. FOBT overuse varied across facilities (9-32 %, p<0.0001) and region (12-23 %, p< .0012). FOBT overuse after prior FOBT declined between 2003 and 2009 (8 %-5 %, p= .0492), but overuse after other procedures increased (11-19 %, p= .0002). FOBT overuse of both types increased with number of outpatient visits (OR 1.15, p<0.001), but did not vary by patient demographics. More than 11 % of overused FOBTs were followed by colonoscopy within 12 months. CONCLUSIONS Many FOBTs are performed sooner than recommended in the VHA. Variation in overuse by facility, region, and outpatient visits suggests addressing FOBT overuse will require system-level solutions.
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Affiliation(s)
- Melissa R Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 55417, USA.
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12
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Habbema D, De Kok IMCM, Brown ML. Cervical cancer screening in the United States and the Netherlands: a tale of two countries. Milbank Q 2012; 90:5-37. [PMID: 22428690 DOI: 10.1111/j.1468-0009.2011.00652.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
CONTEXT This article compares cervical cancer screening intensity and cervical cancer mortality trends in the United States and the Netherlands to illustrate the potential of cross-national comparative studies. We discuss the lessons that can be learned from the comparison as well as the challenges in each country to effective and efficient screening. METHODS We used nationally representative data sources in the United States and the Netherlands to estimate the number of Pap smears and the cervical cancer mortality rate since 1950. The following questions are addressed: How do differences in intensity of Pap smear use between the countries translate into differences in mortality trends? Can population coverage rates (the proportion of eligible women who had a Pap smear within a specified period) explain the mortality trends better than the total intensity of Pap smear use? FINDINGS Even though three to four times more Pap smears per woman were conducted in the United States than in the Netherlands over a period of three decades, the two countries' mortality trends were quite similar. The five-year coverage rates for women aged thirty to sixty-four were quite comparable at 80 to 90 percent. Because screening in the Netherlands was limited to ages thirty to sixty, screening rates for women under thirty and over sixty were much higher in the United States. These differences had consequences for age-specific mortality trends. The relatively good coverage rate in the Netherlands can be traced back to a nationwide invitation system based on municipal population registries. While both countries followed a "policy cycle" involving evidence review, surveillance of screening practices and outcomes, clinical guidelines, and reimbursement policies, the components of this cycle were more systematically linked and implemented nationwide in the Netherlands than in the United States. To a large extent, this was facilitated by a public health model of screening in the Netherlands, rather than a medical services model. CONCLUSIONS Cross-country studies like ours are natural experiments that can produce insights not easily obtained from other types of study. The cervical cancer screening system in the Netherlands seems to have been as effective as the U.S. system but used much less screening. Adequate coverage of the female population at risk seems to be of central importance.
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Deshpande AD, McQueen A, Coups EJ. Different effects of multiple health status indicators on breast and colorectal cancer screening in a nationally representative US sample. Cancer Epidemiol 2011; 36:270-5. [PMID: 22079763 DOI: 10.1016/j.canep.2011.10.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 10/03/2011] [Accepted: 10/07/2011] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To examine the independent associations between multiple health status indicators and breast and colorectal cancer screening (CRCS) in a national US sample. STUDY DESIGN AND SETTING Analysis of cross-sectional data from the 2005 National Health Interview Survey (NHIS) involved 5115 men and 7100 women aged 50 years and older. MEASURES Health status indicators included: self-reported perceived health status, number of chronic conditions, and functional limitation due to a chronic condition. Individuals were considered adherent to CRCS guidelines if they reported having a home-based fecal occult blood test in the past year or endoscopy in the past 10 years. Women were adherent to breast cancer screening guidelines if they reported having a mammogram in the previous 2 years. Statistical analyses were conducted using SUDAAN software to account for the complex sampling of the NHIS survey. Logistic regression was used to examine associations between each of the health status indicators and screening adherence for CRCS and mammography and to calculate estimated screening rates. RESULTS The three health status indicators were independently and differentially associated with screening adherence. Poor perceived health was associated with lower mammography among women, whereas a greater number of chronic conditions were consistently associated with greater screening. In adjusted analyses, functional limitation was only significantly associated with greater CRCS among women. CONCLUSIONS Our analyses included three common indicators of health status and provide new evidence of their complex associations with cancer screening. Future studies must examine the mechanisms by which these indicators influence screening recommendations and adherence among older adults over time.
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Affiliation(s)
- Anjali D Deshpande
- Division of Health Behavior Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63108, USA.
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Nguyen LT, Davis RB, Kaptchuk TJ, Phillips RS. Use of complementary and alternative medicine and self-rated health status: results from a national survey. J Gen Intern Med 2011; 26:399-404. [PMID: 21053090 PMCID: PMC3055973 DOI: 10.1007/s11606-010-1542-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 09/27/2010] [Accepted: 10/04/2010] [Indexed: 01/22/2023]
Abstract
BACKGROUND Despite the absence of conclusive evidence of effectiveness, complementary and alternative medicine (CAM) is used by 4 of 10 adults in the US; little is known about the association between CAM use and health status. OBJECTIVE To determine the relation between CAM use and self-reported health status and health improvement over time. DESIGN AND PARTICIPANTS We performed a secondary database analysis using data from the 2007 National Health Interview Survey of non-institutionalized US residents conducted by the National Center of Health Statistics of the Center for Disease Control. We identified CAM users and compared them to non-users. We used multivariable logistic regression to model the health status of respondents. We controlled for confounders including socio-demographic, clinical, and behavioral factors. The models were evaluated for discrimination and calibration. MAIN MEASURES The likelihood of respondents to report 'Excellent' current health and 'Better' health than in the prior year. KEY RESULTS Based on 23,393 respondents, we found 37% of U.S. adults used complementary and alternative medicine and 63% did not use any CAM. Compared to those who did not use CAM, CAM users were more likely to rate their health as 'Excellent' (adjusted-odds ratio (AOR) = 1.14, 95% CI = [1.03,1.26]). Similarly, CAM users were more likely to report their health as 'Better' than in the prior year (AOR = 1.64, 95% CI = [1.49,1.83]). The c-statistics for the two models were 0.755 and 0.616, respectively. CONCLUSION We found a significant association between CAM use and self-rated excellent health and health improvement over the prior year. Prospective trials are required to determine whether CAM use is causally related to excellent health status and better health than in the prior year.
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Affiliation(s)
- Long T Nguyen
- Division for Research and Education in Complementary and Integrative Medical Therapies, Harvard Medical School Osher Research Center, 401 Park Drive, Suite 22-A West, Boston, MA 02215, USA.
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Index to predict 5-year mortality of community-dwelling adults aged 65 and older using data from the National Health Interview Survey. J Gen Intern Med 2009; 24:1115-22. [PMID: 19649678 PMCID: PMC2762505 DOI: 10.1007/s11606-009-1073-y] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Revised: 06/25/2009] [Accepted: 07/06/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Prognostic information is becoming increasingly important for clinical decision-making. OBJECTIVE To develop and validate an index to predict 5-year mortality among community-dwelling older adults. DESIGN AND PARTICIPANTS A total of 24,115 individuals aged >65 who responded to the 1997-2000 National Health Interview Survey (NHIS) with follow-up through 31 December 2002 from the National Death Index; 16,077 were randomly selected for the development cohort and 8,038 for the validation cohort. MEASUREMENTS 39 risk factors (functional measures, illnesses, behaviors, demographics) were included in a multivariable Cox proportional hazards model to determine factors independently associated with mortality. Risk scores were calculated for participants using points derived from the final model's beta coefficients. To evaluate external validity, we compared survival by quintile of risk between the development and validation cohorts. RESULTS Seventeen percent of participants had died by the end of the study. The final model included 11 variables: age (1 point for 70-74 up to 7 points for >85); male: 3 points; BMI <25: 2 points; perceived health (good: 1 point, fair/poor: 2 points); emphysema: 2 points; cancer: 2 points; diabetes: 2 points; dependent in instrumental activities of daily living: 2 points; difficulty walking: 3 points; smoker-former: 1 point, smoker-current: 3 points; past year hospitalizations-one: 1 point, >2: 3 points. We observed close agreement between 5-year mortality in the two cohorts; which ranged from 5% in the lowest risk quintile to 50% in the highest risk quintile in the validation cohort. CONCLUSIONS This validated mortality index can be used to account for participant life expectancy in analyses using NHIS data.
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Massad LS, Einstein M, Myers E, Wheeler CM, Wentzensen N, Solomon D. The impact of human papillomavirus vaccination on cervical cancer prevention efforts. Gynecol Oncol 2009; 114:360-4. [PMID: 19410282 PMCID: PMC2703690 DOI: 10.1016/j.ygyno.2009.04.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 04/06/2009] [Accepted: 04/10/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To review concepts, information, obstacles, and approaches to cervical cancer screening and prevention as vaccination against human papillomavirus (HPV) types 16 and 18 is adopted. METHODS Expert forum, conducted September 12-13, 2008, hosted by the Society of Gynecologic Oncologists, including 56 experts in cervical cancer and titled Future Strategies of Cervical Cancer Prevention: What Do We Need to Do Now to Prepare? RESULTS The current approach to cervical cancer screening in the U.S. is limited by its opportunistic nature. If given to women before exposure, a vaccine against HPV 16,18 can decrease cervical cancer risk by up to 70%. The impact on abnormal cytology and cervical intraepithelial neoplasia (CIN) will be less but still substantial. As the prevalence of high-grade CIN falls, fewer women with positive screening tests will have truly preinvasive disease. To minimize harm from false positive tests in women who are at low risk for cancer because of early vaccination, later initiation of and longer intervals between screenings are ideal. However, the vaccine is less effective when administered after first intercourse, and delivering and documenting HPV vaccination to girls at optimal ages may prove difficult. CONCLUSIONS Until population-based data on the performance of cytology, HPV testing, and alternate screening or triage interventions become available, modifying current screening guidelines is premature. Current recommendations to initiate screening as late as age 21 and to screen less often than annually are appropriate for young women known to have been vaccinated before first intercourse.
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Affiliation(s)
- L Stewart Massad
- Division of Gynecologic Oncology, Washington University School of Medicine, St Louis, MO 63110, USA.
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