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Dibble KE, Deng Z, Jin M, Connor AE. Associations between race/ethnicity and SEER-CAHPS patient care experiences among female Medicare beneficiaries with breast cancer. J Geriatr Oncol 2023; 14:101633. [PMID: 37741036 PMCID: PMC10843501 DOI: 10.1016/j.jgo.2023.101633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/31/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION We aimed to determine if racial/ethnic disparities exist in survivorship care patient experiences among older breast cancer survivors. MATERIALS AND METHODS Nineteen thousand seventeen female breast cancer survivors aged ≥65 at post-diagnosis survey contributed data via the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) and Centers for Medicare and Medicaid Services Consumer Assessment of Healthcare Providers & Systems (CAHPS) data linkage (2000-2019). Multivariable linear regression models were used to estimate adjusted beta (β) coefficients and standard error (SE) estimates for associations between race/ethnicity and survivorship care patient experiences. RESULTS Most women were non-Hispanic (NH)-White (78.1%; NH-Black [8.1%], NH-Asian [6.5%], Hispanic [6.2%]). On average, women reported 76.3 years (standard deviation [SD] = 7.14) at CAHPS survey and 6.10 years since primary diagnosis (SD = 3.51). Compared with NH-White survivors, NH-Black survivors reported lower mean scores for Getting Care Quickly (β = -5.17, SE = 0.69, p ≤0.001), Getting Needed Care (β = -1.72, SE = 0.63, p = 0.006), and Overall Care Ratings (β = -2.72, SE = 0.48, p ≤0.001), mirroring the results for NH-Asian survivors (Getting Care Quickly [β = -7.06, SE = 0.77, p ≤0.001], Getting Needed Care [β = -4.43, SE = 0.70, p ≤0.001], Physician Communication [β = -1.15, SE = 0.54, p = 0.03], Overall Care Rating [β = -2.32, SE = 0.53, p ≤0.001]). Findings among Hispanic survivors varied, where mean scores were lower for Getting Care Quickly (β = -2.83, SE = 0.79, p ≤0.001), Getting Needed Care (β = -2.43, SE = 0.70, p = 0.001), and Getting Needed Prescription Drug(s) (β = -1.47, SE = 0.64, p = 0.02), but were higher for Health Plan Rating (β = 2.66, SE = 0.55, p ≤0.001). Education, Medicare plan, and multimorbidity significantly modified various associations among NH-Black survivors, and education was a significant modifier among NH-Asian and Hispanic survivors. DISCUSSION We observed racial/ethnic disparities in the associations with survivorship care patient experience among NH-Black, Hispanic, and NH-Asian breast cancer survivors. Future research should examine the impact of education, Medicare plans, and multimorbidity on these associations.
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Affiliation(s)
- Kate E Dibble
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA.
| | - Zhengyi Deng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
| | - Mu Jin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
| | - Avonne E Connor
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA; Department of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21205, USA
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Chmiel C, Reich O, Signorell A, Neuner-Jehle S, Rosemann T, Senn O. Effects of managed care on the proportion of inappropriate elective diagnostic coronary angiographies in non-emergency patients in Switzerland: a retrospective cross-sectional analysis. BMJ Open 2018; 8:e020388. [PMID: 30478102 PMCID: PMC6254409 DOI: 10.1136/bmjopen-2017-020388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Guidelines recommend non-invasive ischaemia testing (NIIT) for the majority of patients with suspected ischaemic heart disease in a non-emergency setting. A substantial number of these patients undergo diagnostic coronary angiography (CA) without therapeutic intervention inappropriately due to lacking preceding NIIT. The aim of this study was to evaluate the effect of voluntary healthcare models with limited access on the proportion of patients without NIIT prior to elective purely diagnostic CA. DESIGN Retrospective cross-sectional analysis of insurance claims data from 2012 to 2015. Data included claims of basic and voluntary healthcare models from approximately 1.2 million patients enrolled with the Helsana Insurance Group. Voluntary healthcare models with limited health access are divided into gate keeping (GK) and managed care (MC) capitation models. INCLUSION CRITERIA patients undergoing CA. EXCLUSION CRITERIA Patients<18 years, incomplete health insurance data coverage, acute cardiac ischaemia and emergency procedures, therapeutic CA (coronary angioplasty/stenting or coronary artery bypass grafting). The effect of voluntary healthcare models on the proportion of NIIT undertaken within 2 months before diagnostic CA was assessed by means of multiple logistic regression analysis, controlled for influencing factors. RESULTS 9173 patients matched inclusion criteria. 33.2% (3044) did not receive NIIT before CA. Compared with basic healthcare models, MC was independently associated with a higher proportion of NIIT (p<0.001, OR 1.17, CI 1.045 to 1.312), when additionally controlled for demographics, insurance coverage, inpatient treatment, cardiovascular medication, chronic comorbidities, high-risk status (patients with therapeutic cardiac intervention 1 month after or 18 months prior to diagnostic CA). GK models showed no significant association with the rate of NIIT (p=0.07, OR 1.11, CI 0.991 to 1.253). CONCLUSIONS In a non-GK healthcare system, voluntary MC healthcare models with capitation were associated with a reduced inappropriate use of diagnostic CA compared with GK or basic models.
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Affiliation(s)
- Corinne Chmiel
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Reich
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | | | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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Miles RC, Onega T, Lee CI. Addressing Potential Health Disparities in the Adoption of Advanced Breast Imaging Technologies. Acad Radiol 2018; 25:547-551. [PMID: 29729855 DOI: 10.1016/j.acra.2017.05.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 05/31/2017] [Indexed: 11/16/2022]
Abstract
With the advent of new screening technologies, including digital breast tomosynthesis, screening ultrasound, and breast magnetic resonance imaging, there is growing concern that existing disparities among traditionally underserved populations will worsen. These newer screening modalities purport improved cancer detection over mammography alone but are not offered at all screening facilities and often require a larger co-pay or out-of-pocket expense. Thus, the potential for worsening disparities with regard to access and appropriate utilization of supplemental screening technologies exists. Currently, there is a dearth of literature on the topic of health disparities related to access and the use of supplemental breast cancer screening and their impact on outcomes. Identifying and addressing explanatory factors for persistent and potentially worsening disparities remain a central focus of efforts to improve equity in breast cancer care. Therefore, this paper provides an overview of factors that may contribute to present and future disparities in breast cancer screening and outcomes, and explores specific relevant topics requiring greater research efforts as more personalized, multimodality breast cancer screening approaches are adopted into clinical practice.
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Affiliation(s)
- Randy C Miles
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114.
| | - Tracy Onega
- Departments of Medicine and Community & Family Medicine, Dartmouth Institute for Health Policy & Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine, Lebanon, New Hampshire
| | - Christoph I Lee
- Department of Radiology, University of Washington School of Medicine, Department of Health Services, University of Washington School of Public Health, Hutchinson Institute for Cancer Outcomes Research, Seattle, Washington
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4
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The Use of Prostate Specific Antigen Screening in Purchased versus Direct Care Settings: Data from the TRICARE® Military Database. J Urol 2017; 198:1295-1300. [DOI: 10.1016/j.juro.2017.07.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 11/18/2022]
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Kobetz E, Seay J, Amofah A, Pierre L, Bispo JB, Trevil D, Gonzalez M, Poitevien M, Koru-Sengul T, Carrasquillo O. Mailed HPV self-sampling for cervical cancer screening among underserved minority women: study protocol for a randomized controlled trial. Trials 2017; 18:19. [PMID: 28086983 PMCID: PMC5237204 DOI: 10.1186/s13063-016-1721-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 11/23/2016] [Indexed: 11/10/2022] Open
Abstract
Background Underserved ethnic minority women experience significant disparities in cervical cancer incidence and mortality, mainly due to lack of cervical cancer screening. Barriers to Pap smear screening include lack of knowledge, lack of health insurance and access, and cultural beliefs regarding disease prevention. In our previous SUCCESS trial, we demonstrated that HPV self-sampling delivered by a community health worker (CHW) is efficacious in circumventing these barriers. This approach increased screening uptake relative to navigation to Pap smear screening. SUCCESS trial participants, as well as our community partners, provided feedback that women may prefer the HPV self-sampler to be delivered through the mail, such that they would not need to schedule an appointment with the CHW. Thus, our current trial aims to elucidate the efficacy of the HPV self-sampling method when delivered via mail. Design We are conducting a randomized controlled trial among 600 Haitian, Hispanic, and African-American women from the South Florida communities of Little Haiti, Hialeah, and South Dade. Women between the ages of 30 and 65 years who have not had a Pap smear within the past 3 years are eligible for the study. Women are recruited by CHWs and complete a structured interview to assess multilevel determinants of cervical cancer risk. Women are then randomized to receive HPV self-sampling delivered by either the CHW (group 1) or via mail (group 2). The primary outcome is completion of HPV self-sampling within 6 months post enrollment. Discussion Our trial is among the first to examine the efficacy of the mailed HPV self-sampling approach. If found to be efficacious, this approach may represent a cost-effective strategy for cervical cancer screening within underserved and underscreened minority groups. Trial registration ClinicalTrials.gov, NCT02202109. Registered on 9 July 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1721-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Erin Kobetz
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Clinical Research Building, 1120 NW 14th Street, Room 610B, Miami, FL, 33136, USA. .,Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA. .,Health Choice Network, 9064 NW 13th Terrace, Miami, FL, 33172, USA.
| | - Julia Seay
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Clinical Research Building, 1120 NW 14th Street, Room 610B, Miami, FL, 33136, USA.,Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Anthony Amofah
- Health Choice Network, 9064 NW 13th Terrace, Miami, FL, 33172, USA
| | - Larry Pierre
- Center for Haitian Studies, 8260 NE 2nd Avenue, Miami, FL, 33138, USA
| | - Jordan Baeker Bispo
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Dinah Trevil
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Clinical Research Building, 1120 NW 14th Street, Room 610B, Miami, FL, 33136, USA
| | - Martha Gonzalez
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Clinical Research Building, 1120 NW 14th Street, Room 610B, Miami, FL, 33136, USA
| | - Martine Poitevien
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Clinical Research Building, 1120 NW 14th Street, Room 610B, Miami, FL, 33136, USA
| | - Tulay Koru-Sengul
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Olveen Carrasquillo
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Clinical Research Building, 1120 NW 14th Street, Room 610B, Miami, FL, 33136, USA.,Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
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Halpern MT, Urato MP, Kent EE. The health care experience of patients with cancer during the last year of life: Analysis of the SEER-CAHPS data set. Cancer 2016; 123:336-344. [PMID: 27654842 DOI: 10.1002/cncr.30319] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 07/02/2016] [Accepted: 08/05/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Providing high-quality medical care for individuals with cancer during their last year of life involves a range of challenges. An important component of high-quality care during this critical period is ensuring optimal patient satisfaction. The objective of the current study was to assess factors influencing health care ratings among individuals with cancer within 1 year before death. METHODS The current study used the Surveillance, Epidemiology, and End Results (SEER)-Consumer Assessment of Healthcare Providers and Systems (CAHPS) data set, a new data resource linking patient-reported information from the CAHPS Medicare Survey with clinical information from the National Cancer Institute's SEER program. The study included 5102 Medicare beneficiaries diagnosed with cancer who completed CAHPS between 1998 and 2011 within 1 year before their death. Multivariable logistic regression analyses examined associations between patient demographic and insurance characteristics with 9 measures of health care experience. RESULTS Patients with higher general or mental health status were significantly more likely to indicate excellent experience with nearly all measures examined. Sex, race/ethnicity, and education also were found to be significant predictors for certain ratings. Greater time before death predicted an increased likelihood of higher ratings for health plan and specialist physician. Clinical characteristics were found to have few significant associations with experience of care. Individuals in fee-for-service Medicare plans (vs Medicare Advantage) had a greater likelihood of excellent experience with health plans, getting care quickly, and getting needed care. CONCLUSIONS Among patients with cancer within 1 year before death, experience with health plans, physicians, and medical care were found to be associated with sociodemographic, insurance, and clinical characteristics. These findings provide guidance for the development of programs to improve the experience of care among individuals with cancer. Cancer 2017;123:336-344. © 2016 American Cancer Society.
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Affiliation(s)
- Michael T Halpern
- RTI International, Research Triangle Park, North Carolina.,Department of Health Services Administration and Policy, Temple University College of Public Health, Philadelphia, Pennsylvania
| | | | - Erin E Kent
- Outcomes Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
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Reduction in health risks and disparities with participation in an employer-sponsored health promotion program. J Occup Environ Med 2014; 55:873-8. [PMID: 23924828 DOI: 10.1097/jom.0b013e31829b2a91] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
There is an increasing awareness among employers and health care providers that health care needs to be tailored to address the diversity of the workforce. Population-based data have shown significant differences in health behaviors and health risks among different racial/ethnic groups in the United States. The purpose of this study was to examine health risks and changes in health risks over time in an employed population at a financial services corporation. This large financial services corporation is naturally concerned about any disparities in health among employees. The study population consists of employees who participated in the organization's medical plan and also the annual health risk appraisal questionnaire in both 2009 and 2010. Significant demographic differences exist among the four ethnic groups studied: whites, African Americans, Hispanics, and Asians. At baseline, African American employees had a significantly higher average number of health risks measured by the health risk appraisal, but they also experienced the greatest improvement in health risks by time 2. There were differences in the health risk profiles of the ethnic groups, with certain risk factors being more prevalent among some ethnicities than among others. The health care costs were not significantly different among the groups studied here. It is likely that other large employers may also find health risk differences among employees belonging to various ethnicities. Future research in this field should seek to understand the reasons behind differences in health among ethnic groups and how best to address them so that all employees can achieve a high level of health and wellness.
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Abstract
BACKGROUND Planned health insurance reform promises and has started to cut reimbursement to Medicare managed care (MMC) plans. If such plans provide better care, adjusting for possible better health of their enrollees, then such reimbursement changes may have unforeseen quality consequences. OBJECTIVES To examine whether long-term follow-up outcomes of patients who receive intensive interventional care for coronary artery disease differed by Medicare plan type. RESEARCH DESIGN Patient-level postdischarge outcomes were multivariate adjusted logistic functions of a patient's insurance type at time of index admission. Data were retrospective secondary percutaneous coronary intervention data from Pennsylvania with 35,417 index admissions in 2004 to 2005 and in-state follow-up hospitalizations within 12 months and in-state death within 3 years of discharge. RESULTS MMC insured patients had a consistently estimated 3-year survival benefit (relative risk of death 0.91; P value 0.003) compared with traditional Medicare traditional fee for service patients. Results were robust to propensity score stratification, subset analyses, and rich controls for observed confounders. Implausibly large associations (between an unmeasured confounder and both insurance status and outcomes) would have to be hypothesized to fully explain the observed survival benefit. CONCLUSIONS Among a large number of Pennsylvanian elderly patients, receiving a very common therapeutic procedure for highly prevalent disease, being insured with MMC was associated with a clinically meaningful long-term survival benefit. Impending health insurance reform that changes the relative attractiveness of MMC plans may have unintended consequences on outcome quality.
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Evans K, Coresh J, Bash LD, Gary-Webb T, Köttgen A, Carson K, Boulware LE. Race differences in access to health care and disparities in incident chronic kidney disease in the US. Nephrol Dial Transplant 2011; 26:899-908. [PMID: 20688771 PMCID: PMC3108345 DOI: 10.1093/ndt/gfq473] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 06/10/2010] [Accepted: 07/12/2010] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The contribution of race differences in access to health care to disparities in chronic kidney disease (CKD) incidence in the United States is unknown. METHODS We examined race differences in usual source of health care, health insurance and CKD incidence among 3883 Whites and 1607 Blacks with hypertension or diabetes enrolled in the Atherosclerosis Risk in Communities Study. In multivariable analyses, we explored the incremental contribution of access to health care in explaining Blacks' excess CKD incidence above and beyond other socioeconomic, lifestyle and clinical factors. RESULTS Compared with Whites, Blacks had poorer access to health care (3 vs 0.3% with no usual source of health care or health insurance, P < 0.001) and experienced greater CKD incidence (14.7 vs 12.0 cases per 1000 person-years, P < 0.001). Blacks' excess risk of CKD persisted after adjusting for demographic, socioeconomic, lifestyle and clinical factors [hazard ratio (HR) (95% confidence interval (95% CI)) = 1.21 (1.01-1.47)]. Adjustment for these factors explained 64% of the excess risk among Blacks. The increased risk for CKD among Blacks was attenuated after additional adjustment for race differences in access to health care [HR (95% CI) = 1.19 (0.99-1.45)], which explained an additional 10% of the disparity. Conclusions. In this population at risk for developing CKD, we found that poorer access to health care among Blacks explained some of Blacks' excess risk of CKD, beyond the excess risk explained by demographic, socioeconomic, lifestyle and clinical factors. Improved access to health care for high-risk individuals could narrow disparities in CKD incidence.
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Affiliation(s)
- Kira Evans
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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10
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Kirsner RS, Ma F, Fleming LE, Federman DG, Trapido E, Duncan R, Rouhani P, Wilkinson JD. Earlier stage at diagnosis and improved survival among Medicare HMO patients with breast cancer. J Womens Health (Larchmt) 2010; 19:1619-24. [PMID: 20815756 DOI: 10.1089/jwh.2009.1768] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE We sought to evaluate differences in the stage at diagnosis and the survival of breast cancer patients enrolled in two different Medicare healthcare delivery systems: fee for service (FFS) and health maintenance organizations (HMO). METHODS We used a linkage of two national databases, the Medicare database from the Centers for Medicare and Medicaid Services (CMS), and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program database, to evaluate differences in demographic data, stage at diagnosis, and survival in patients with breast cancers over the period 1985-2001. RESULTS Medicare patients enrolled in HMOs were diagnosed at an earlier stage of diagnosis than FFS patients. HMO patients diagnosed with breast cancer had improved survival, and these differences remained even after controlling for potential confounders. Specifically, breast cancer patients enrolled in HMOs had 9% increased probability of survival (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.88-0.93) than their counterparts enrolled in FFS. These findings persisted even when patients had a cancer diagnosis before their breast cancer. CONCLUSIONS Improved survival among breast cancer patients in HMOs compared with FFS is likely due to a combination of factors, including but not limited to earlier stage at the time of diagnosis.
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Affiliation(s)
- Robert S Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Department of Dermatology, Miami, Florida 33136, USA.
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11
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Differences in melanoma outcomes among Hispanic Medicare enrollees. J Am Acad Dermatol 2010; 62:768-76. [DOI: 10.1016/j.jaad.2009.11.594] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 11/14/2009] [Accepted: 11/17/2009] [Indexed: 11/23/2022]
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12
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Are health-care relationships important for mammography adherence in Latinas? J Gen Intern Med 2008; 23:2024-30. [PMID: 18839258 PMCID: PMC2596511 DOI: 10.1007/s11606-008-0815-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 04/18/2008] [Accepted: 09/12/2008] [Indexed: 01/15/2023]
Abstract
BACKGROUND Latinas are the fastest growing racial ethnic group in the United States and have an incidence of breast cancer that is rising three times faster than that of non-Latino white women, yet their mammography use is lower than that of non-Latino women. OBJECTIVES We explored factors that predict satisfaction with health-care relationships and examined the effect of satisfaction with health-care relationships on mammography adherence in Latinas. DESIGN AND SETTING We conducted a cross-sectional survey of 166 Latinas who were >or=40 years old. Women were recruited from Latino-serving clinics and a Latino health radio program. MEASUREMENTS Mammography adherence was based on self-reported receipt of a mammogram within the past 2 years. The main independent variable was overall satisfaction with one's health-care relationship. Other variables included: self report of patient-provider communication, level of trust in providers, primary language, country of origin, discrimination experiences, and perceptions of racism. RESULTS Forty-three percent of women reported very high satisfaction in their health-care relationships. Women with high trust in providers and those who did not experience discrimination were more satisfied with their health-care relationships compared to women with lower trust and who experienced discrimination (p < .01). Satisfaction with the health-care relationship was, in turn, significantly associated with mammography adherence (OR: 3.34, 95% CI: 1.47-7.58), controlling for other factors. CONCLUSIONS Understanding the factors that impact Latinas' mammography adherence may inform intervention strategies. Efforts to improve Latina's satisfaction with physicians by building trust may lead to increased use of necessary mammography.
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Schueler KM, Chu PW, Smith-Bindman R. Factors Associated with Mammography Utilization: A Systematic Quantitative Review of the Literature. J Womens Health (Larchmt) 2008; 17:1477-98. [DOI: 10.1089/jwh.2007.0603] [Citation(s) in RCA: 273] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristin M. Schueler
- Department of Radiology, Santa Clara Valley Medical Center; San Jose, California
| | - Philip W. Chu
- Department of Radiology, University of California, San Francisco, California
| | - Rebecca Smith-Bindman
- Department of Radiology, Santa Clara Valley Medical Center; San Jose, California
- Department of Radiology, University of California, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
- Department of Obstetrics, Gynecology and Reproductive Medicine, University of California, San Francisco, California
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Franks P, Fiscella K. Reducing disparities downstream: prospects and challenges. J Gen Intern Med 2008; 23:672-7. [PMID: 18214626 PMCID: PMC2324139 DOI: 10.1007/s11606-008-0509-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 12/04/2007] [Accepted: 01/04/2008] [Indexed: 10/22/2022]
Abstract
Addressing upstream or fundamental causes (such as poverty, limited education, and compromised healthcare access) is essential to reduce healthcare disparities. But such approaches are not sufficient, and downstream interventions, addressing the consequences of those fundamental causes within the context of any existing health system, are also necessary. We present a definition of healthcare disparities and two key principles (that healthcare is a social good and disparities in outcomes are a quality problem) that together provide a framework for addressing disparities downstream. Adapting the chronic care model, we examine a hierarchy of three domains for interventions (health system, provider-patient interactions, and clinical decision making) to reduce disparities downstream and discuss challenges to implementing the necessary changes.
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Affiliation(s)
- Peter Franks
- Center for Healthcare Policy and Research, Department of Family and Community Medicine, University of California at Davis, Sacramento, CA USA
| | - Kevin Fiscella
- Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY USA
- Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY USA
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Seligman HK, Chattopadhyay A, Vittinghoff E, Bindman AB. Racial and ethnic differences in receipt of primary care services between medicaid fee-for-service and managed care plans. J Ambul Care Manage 2007; 30:264-73. [PMID: 17581438 DOI: 10.1097/01.jac.0000278986.18428.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We used a cross-sectional, population-based sample of Medicaid beneficiaries aged 18-64 to determine whether managed care enrollment was associated with reduced racial/ethnic disparities in self-reported access to primary care services compared with fee-for-service. Managed care beneficiaries reported greater access in each racial/ethnic category and for each outcome than did fee-for-service beneficiaries, although associations were not always statistically significant. Racial/ethnic minorities enrolled in managed care plans reported as much benefit from managed care enrollment as did whites. Within Medicaid, interventions aimed at the health insurance delivery model can facilitate increased access to primary care services without enhancing racial/ethnic disparities.
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Affiliation(s)
- Hilary K Seligman
- San Francisco General Hospital, University of California San Francisco, San Francisco, CA 94143, USA.
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Balsa AI, Cao Z, McGuire TG. Does managed health care reduce health care disparities between minorities and Whites? JOURNAL OF HEALTH ECONOMICS 2007; 26:101-21. [PMID: 16893581 DOI: 10.1016/j.jhealeco.2006.06.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Revised: 06/12/2006] [Accepted: 06/12/2006] [Indexed: 05/11/2023]
Abstract
This paper investigates whether managed care ameliorates or aggravates ethnic and racial health care disparities in Medicare. First, we analyze the choice of type of insurance made by Medicare enrollees to see if minorities are more likely to choose the managed care alternative. Second, we study the differential effect of managed care on disparities using several measures of access, use and cost of services. Both analyses are conducted on two independent data sets, the Medicare Current Beneficiary Survey and the National Health Interview Survey. We conclude that relative to Whites, minorities are at least as well off -- in terms of benefits and costs -- in Medicare managed care as in Medicare traditional indemnity plans.
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Affiliation(s)
- Ana I Balsa
- Health Economics Research Group, University of Miami, Miami, FL, USA.
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Kee C, Overstreet KM. Disparities in depression care in managed care settings. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2007; 27 Suppl 1:S26-S32. [PMID: 18085582 DOI: 10.1002/chp.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The implementation of managed health care two decades ago produced sweeping changes in the delivery of health care. A large number of patients who have depression are cared for in managed care settings. Despite the fact that managed health care programs have offered the advantage of affordable and effective treatment of depression to many patients, racial and ethnic minorities remain underdiagnosed and undertreated. Diagnosis of depression, prescribing of antidepressant therapy, and referral for psychotherapy occur significantly less often in minority patients compared with whites. In the managed care setting, a number of issues at the physician level may negatively affect the quality of depression care, including attitudes toward psychiatry and mental health services, unfamiliarity with best practice guidelines for depression, and lack of cultural competency. On the other hand, a number of innovative approaches (eg, collaborative care) have demonstrated effectiveness in managed care settings. In some cases, physician education can be integrated with these approaches to assist health care providers in managed care organizations to provide the best possible depression care. This article focuses on issues relevant to depression care of minorities in the managed care sector, cites strategies for improving quality of depression care, and discusses implications for CME.
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Affiliation(s)
- Chandra Kee
- Delaware Physicians Care, Inc., 252 Chapman Road, Suite 250, Newark, DE 19702, USA.
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Kirsner RS, Ma F, Fleming L, Federman DG, Trapido E, Duncan R, Wilkinson JD. The effect of medicare health care delivery systems on survival for patients with breast and colorectal cancer. Cancer Epidemiol Biomarkers Prev 2006; 15:769-73. [PMID: 16614122 DOI: 10.1158/1055-9965.epi-05-0838] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Two of the most common types of health care delivery systems in the U.S. are fee-for-service (FFS) and managed care systems such as health maintenance organizations (HMO). Differences may exist in patient outcomes depending on the health care delivery system in which they are enrolled. We evaluated differences in the survival of patients with breast and colorectal cancer at diagnosis between the two Medicare health care delivery systems (FFS and HMO). METHODS We used a linkage of two national databases, the Medicare database from the Centers for Medicare and Medicaid Services, and the National Cancer Institute's Surveillance, Epidemiology, and End Results program database, to evaluate differences in demographic data, stage at diagnosis, and survival between breast and colorectal cancer over the period 1985 to 2001. RESULTS Medicare patients enrolled in HMOs were diagnosed at an earlier stage of diagnosis than FFS patients. HMO patients diagnosed with breast and colorectal cancer had improved survival, and these differences remained even after controlling for potential confounders (such as stage at diagnosis, age, race, socioeconomic status, and marital status). Specifically, patients enrolled in HMOs had 9% greater survival in hazards ratio if they had breast cancer, and 6% if they had colorectal cancer. CONCLUSIONS Differences exist in survival among patients in HMOs compared with FFS. This is likely due to a combination of factors, including but not limited to, earlier stage at the time of diagnoses.
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Abstract
Cardiovascular diseases (CVD) are the leading causes of death among Mexican American adults living in the United States. Using data from a modified Behavioral Risk Factor Surveillance Survey and guided by the Anderson Model, this study examined the effect of nativity on CVD screening practices among 423 Mexican American adults living in Chicago. Dependent variables included having had a blood pressure and cholesterol screening and a routine check up in the past 2 years. Multivariate analyses were used to control for sociodemographic factors, while accounting for complex sampling design. Compared to those born in Mexico, US-born Mexican Americans had significantly greater odds of obtaining blood pressure (OR=5.61), and cholesterol screenings (OR=1.60) and having a routine checkup (OR=2.69) in the past 2 years. Health professionals with an agenda to increase screenings for CVD risk factors among Mexican Americans living in northern cities should understand the impact of nativity on screening practices.
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Affiliation(s)
- Janine M Jurkowski
- Department of Health Policy, Management & Behavior, School of Public Health, University at Albany (SUNY), One University Place, Rensselaer, New York 12144, USA.
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Ark PD, Hull PC, Husaini BA, Craun C. Religiosity, religious coping styles, and health service use: racial differences among elderly women. J Gerontol Nurs 2006; 32:20-9; quiz 30-1. [PMID: 16915743 DOI: 10.3928/00989134-20060801-05] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study explored racial differences in the effects of religiosity and religious coping styles on health service use. The sample (N = 274) consisted of a cross-section of women ages 55 and older living in publicly subsidized high-rise dwellings in Nashville, Tennessee (1999 to 2000) and included 159 White and 115 African American women. The results suggested the effects of religiosity on health service use are generally negative for both groups. However, the effects of religious coping styles on health service use differed by race. The self-directing coping style was associated with higher levels of use for White women, but with lower levels of use for African American women. The deferring coping style was associated with greater physician visits and inpatient days among White women, but with fewer inpatient days among African American women. The collaborative coping style was associated with higher inpatient days among African American women, but had no significant effect on use patterns for White women. Conducting assessments of religiosity and religious coping styles would enhance holistic nursing practice.
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Affiliation(s)
- Pamela D Ark
- University of Central Florida, School of Nursing, Orlando 32816-2210, USA
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Howard DH, Sentell T, Gazmararian JA. Impact of health literacy on socioeconomic and racial differences in health in an elderly population. J Gen Intern Med 2006; 21:857-61. [PMID: 16881947 PMCID: PMC1831584 DOI: 10.1111/j.1525-1497.2006.00530.x] [Citation(s) in RCA: 189] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Differences in health literacy levels by race and education are widely hypothesized to contribute to health disparities, but there is little direct evidence. OBJECTIVE To examine the extent to which low health literacy exacerbates differences between racial and socioeconomic groups in terms of health status and receipt of vaccinations. DESIGN Retrospective cohort study. PARTICIPANTS (OR PATIENTS OR SUBJECTS): Three thousand two hundred and sixty noninstitutionalized elderly persons enrolling in a Medicare managed care plan in 1997 in Cleveland, OH; Houston, TX; South Florida; and Tampa, FL. MEASUREMENTS Dependent variables were physical health SF-12 score, mental health SF-12 score, self-reported health status, receipt of influenza vaccine, and receipt of pneumococcal vaccine. Independent variables included health literacy, educational attainment, race, income, age, sex, chronic health conditions, and smoking status. RESULTS After adjusting for demographic and health-related variables, individuals without a high school education had worse physical and mental health and worse self-reported health status than those with a high school degree. Accounting for health literacy reduced these differences by 22% to 41%. Black individuals had worse self-reported health status and lower influenza and pneumococcal vaccination rates. Accounting for health literacy reduced the observed difference in self-reported health by 25% but did not affect differences in vaccination rates. CONCLUSIONS We found that health literacy explained a small to moderate fraction of the differences in health status and, to a lesser degree, receipt of vaccinations that would normally be attributed to educational attainment and/or race if literacy was not considered.
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Affiliation(s)
- David H Howard
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
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Call KT, McAlpine DD, Johnson PJ, Beebe TJ, McRae JA, Song Y. Barriers to care among American Indians in public health care programs. Med Care 2006; 44:595-600. [PMID: 16708009 DOI: 10.1097/01.mlr.0000215901.37144.94] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to examine the extent to which reported barriers to health care services differ between American Indians (AIs) and non-Hispanic Whites (Whites). METHODS A statewide stratified random sample of Minnesota health care program enrollees was surveyed. Responses from AI and White adult enrollees (n=1281) and parents of child enrollees (n=572) were analyzed using logistic regression models that account for the complex sample design. Barriers examined include: financial, access, and cultural barriers, confidence/trust in providers, and discrimination. RESULTS Both AIs and Whites report barriers to health care access. However, a greater proportion of AIs report barriers in most categories. Among adults, AIs are more likely to report racial discrimination, cultural misunderstandings, family/work responsibilities, and transportation difficulties, whereas Whites are more likely to report being unable to see their preferred doctor. A higher proportion of adult enrollees compared with parents of child enrollees report barriers in most categories; however, differences between parents of AIs and White children are more substantial. In addition to racial discrimination and cultural misunderstandings, parents of AI children are more likely than parents of White enrollees to report limited clinic hours, lack of respect for religious beliefs, and mistrust of their child's provider as barriers. CONCLUSIONS Although individuals have enrolled in health care programs and have access to care, barriers to using these services remain. Significant differences between AIs and Whites involve issues of trust, respect, and discrimination. Providers must address barriers experienced by AIs to improve accessibility, acceptability, and quality of care for AI health care consumers.
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Affiliation(s)
- Kathleen Thiede Call
- School of Public Health, University of Minnesota, Minneapolis 55455, and Mayo Clinic, Rochester, USA.
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Viera AJ, Thorpe JM, Garrett JM. Effects of sex, age, and visits on receipt of preventive healthcare services: a secondary analysis of national data. BMC Health Serv Res 2006; 6:15. [PMID: 16504097 PMCID: PMC1402283 DOI: 10.1186/1472-6963-6-15] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Accepted: 02/23/2006] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Sex and age may exert a combined influence on receipt of preventive services with differences due to number of ambulatory care visits. METHODS We used nationally representative data to determine weighted percentages and adjusted odds ratios of men and women stratified by age group who received selected preventive services. The presence of interaction between sex and age group was tested using adjusted models and retested after adding number of visits. RESULTS Men were less likely than women to have received blood pressure screening (aOR 0.44;0.40-0.50), cholesterol screening (aOR 0.72;0.65-0.79), tobacco cessation counseling (aOR 0.66;0.55-0.78), and checkups (aOR 0.53;0.49-0.57). In younger age groups, men were particularly less likely than women to have received these services. In adjusted models, this observed interaction between sex and age group persisted only for blood pressure measurement (p = .016) and routine checkups (p < .001). When adjusting for number of visits, the interaction of age on receipt of blood pressure checks was mitigated but men were still overall less likely to receive the service. CONCLUSION Men are significantly less likely than women to receive certain preventive services, and younger men even more so. Some of this discrepancy is secondary to a difference in number of ambulatory care visits.
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Affiliation(s)
- Anthony J Viera
- Robert Wood Johnson Clinical Scholars Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Joanne M Garrett
- Robert Wood Johnson Clinical Scholars Program and Department of Obstetrics/Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Walsh JME, Salazar R, Terdiman JP, Gildengorin G, Pérez-Stable EJ. Promoting use of colorectal cancer screening tests. Can we change physician behavior? J Gen Intern Med 2005; 20:1097-101. [PMID: 16423097 PMCID: PMC1490293 DOI: 10.1111/j.1525-1497.2005.0245.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Revised: 07/27/2005] [Accepted: 07/27/2005] [Indexed: 12/31/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) screening is underutilized despite evidence that screening reduces mortality. OBJECTIVE To assess the effect of an intervention targeting physicians and their patients on rates of CRC screening. DESIGN A randomized clinical trial of community physicians and their patients. PARTICIPANTS Ninety-four community primary care physicians randomly assigned to an intervention consisting of academic detailing and direct mailings to patients or a control group. Patients aged 50 to 79 years in the intervention group physicians received a letter from their physician, a brochure on CRC screening, and a packet of fecal occult blood test (FOBT) cards. MEASUREMENTS After 1 year we measured receipt of the following: (1) FOBT in the past 2 years, (2) flexible sigmoidoscopy (SIG) or colonoscopy (COL) in the previous 5 years, and (3) any CRC screening. We report the percent change from baseline in both groups. RESULTS 9,652 patients were enrolled for 2 years, and 3,732 patients were enrolled for 5 years. There was no increase in any CRC screening that occurred in the intervention group for patients enrolled for 2 years (12.7 increase vs 12.5%, P=.51). Similar results were seen for any CRC screening among patients enrolled for 5 years (9.7% increase vs 8.6%, P=.45). The only outcome on which the intervention had an effect was on patient rates of screening SIG (7.4% increase vs 4.4%, P<.01). CONCLUSION With the exception of an increase in rates of SIG in the intervention group, the intervention had no effect on rates of CRC screening. Future interventions should assess innovative approaches to increase rates of CRC screening.
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Affiliation(s)
- Judith M E Walsh
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, California, USA.
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Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005; 353:692-700. [PMID: 16107622 DOI: 10.1056/nejmsa051207] [Citation(s) in RCA: 283] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Since 1997, all managed-care plans administered by Medicare have reported on quality-of-care measures from the Health Plan Employer Data and Information Set (HEDIS). Studies of early data found that blacks received care that was of lower quality than that received by whites. In this study, we assessed changes over time in the overall quality of care and in the magnitude of racial disparities in nine measures of clinical performance. METHODS In order to compare the quality of care for elderly white and black beneficiaries enrolled in Medicare managed-care plans who were eligible for at least one of nine HEDIS measures, we analyzed 1.8 million individual-level observations from 183 health plans from 1997 to 2003. For each measure, we assessed whether the magnitude of the racial disparity had changed over time with the use of multivariable models that adjusted for the age, sex, health plan, Medicaid eligibility, and socioeconomic position of beneficiaries on the basis of their area of residence. RESULTS During the seven-year study period, clinical performance improved on all measures for both white enrollees and black enrollees (P<0.001). The gap between white beneficiaries and black beneficiaries narrowed for seven HEDIS measures (P<0.01). However, racial disparities did not decrease for glucose control among patients with diabetes (increasing from 4 percent to 7 percent, P<0.001) or for cholesterol control among patients with cardiovascular disorders (increasing from 14 percent to 17 percent; change not significant, P=0.72). CONCLUSIONS The measured quality of care for elderly Medicare beneficiaries in managed-care plans improved substantially from 1997 to 2003. Racial disparities declined for most, but not all, HEDIS measures we studied. Future research should examine factors that contributed to the narrowing of racial disparities on some measures and focus on interventions to eliminate persistent disparities in the quality of care.
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Affiliation(s)
- Amal N Trivedi
- Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, USA
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Kirsner RS, Ma F, Fleming L, Trapido E, Duncan R, Federman DG, Wilkinson JD. The Effect of Medicare Health Care Systems on Women With Breast and Cervical Cancer. Obstet Gynecol 2005; 105:1381-8. [PMID: 15932833 DOI: 10.1097/01.aog.0000161326.15602.fb] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Two common health care delivery systems in the United States are fee-for-service and managed care systems, including health maintenance organizations (HMOs). Differences may exist in patient outcomes depending upon the health care delivery system in which they are enrolled. We evaluated possible differences in the stage at diagnosis for breast and cervical cancer between 2 Medicare health care delivery systems (ie, fee for service and HMO) over the period 1985-2001. METHODS We used a linkage of 2 national databases: the Medicare database from the Centers for Medicare and Medicaid Services and the National Cancer Institute's Surveillance, Epidemiology, and End Results program database to evaluate differences in stage at diagnosis between HMO and fee for service for breast and cervical cancer. RESULTS We studied 130,336 Medicare-aged women with breast cancer (83% Medicare fee for service) and 6,758 women with cervical cancer (87% Medicare fee for service). We found an earlier stage of diagnosis for HMO patients, which remained significant after adjusting for potential confounding variables. Women enrolled in HMOs with breast cancer were 17% more likely and those with cervical cancer 35% more likely to be diagnosed at an in situ stage of diagnosis than fee-for-service patients. It is of note that when women had other cancer diagnoses, no statistically significant differences were seen in stage at diagnosis for either cancer between fee-for-service and HMO patients. CONCLUSION Differences exist in stage at diagnosis between Medicare patients enrolled in HMOs compared with fee for service. This is likely due in part to use of or access to care.
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Affiliation(s)
- Robert S Kirsner
- Department of Dermatology and Cutaneous Surgery, Department of Epidemiology and Public Health, University of Miami School of Medicine, Miami, Florida 33125, USA.
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Koroukian SM, Litaker D, Dor A, Cooper GS. Use of preventive services by Medicare fee-for-service beneficiaries: does spillover from managed care matter? Med Care 2005; 43:445-52. [PMID: 15838408 DOI: 10.1097/01.mlr.0000160376.42562.79] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Health care delivery varies with the level of managed care activity (MCA) in an area, potentially affecting health care for those not participating in managed care programs. However, the extent to which MCA is associated with the use of cancer screening by fee-for-service beneficiaries (FFS) is unclear. OBJECTIVE We sought to study colorectal cancer screening among Medicare FFS beneficiaries in relation to levels of Medicare MCA. RESEARCH DESIGN This study linked 1999 Medicare denominator and Part B claims data with the 1998 Area Resource File. After categorizing MCA as low (<10%), moderate (10-29.99%), or high (> or =30%), we assessed the association between colorectal cancer screening among FFS beneficiaries and MCA, controlling for individual demographic variables and county-level attributes of socioeconomic status and physician resources. SUBJECTS We included Medicare FFS beneficiaries 65 years of age or older with both Part A and Part B coverage for the entire calendar year from large counties in the study. MEASURES We measured the likelihood of undergoing fecal occult blood testing (FOBT), flexible sigmoidoscopy (FLEX), or colonoscopy (COL). RESULTS Compared with Medicare FFS beneficiaries residing in counties with low MCA, those in high MCA counties were significantly more likely to undergo FOBT (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] 1.04-1.16), FLEX (AOR 1.11, 95% CI 1.04-1.18), or colonoscopy, after receiving FOBT/FLEX (AOR 1.07, 95% CI 1.02-1.13). CONCLUSIONS From a public health perspective, an association between higher levels of MCA and colorectal cancer screening among those not enrolled in managed care may translate into modest increases in use of colorectal cancer screening and possibly earlier detection.
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Affiliation(s)
- Siran M Koroukian
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4945, USA.
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Haggstrom DA, Phillips KA, Liang SY, Haas JS, Tye S, Kerlikowske K. Variation in screening mammography and Papanicolaou smear by primary care physician specialty and gatekeeper plan (United States). Cancer Causes Control 2004; 15:883-92. [PMID: 15577290 DOI: 10.1007/s10552-004-1138-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess whether the specialty of a patient's primary care physician or being part of a gatekeeper plan influence breast and cervical cancer screening. METHODS Cross-sectional study of women in a national sample. For mammography, we studied women aged 40 and above, and for Papanicolaou (Pap) smear, women aged 18-65 years. Screening mammography or Pap smear within the previous two years was measured by patient self-report. The key independent variables were primary care physician specialty and whether the patient had a gatekeeper. RESULTS Among women seen by a family practice physician, there was a higher probability of being screened if the patient was part of a gatekeeper plan than if the patient was not part of a gatekeeper plan: mammography (OR = 1.35; 95% CI = 1.20-1.52) and Pap smear (OR = 1.60; 95% CI = 1.34-1.91). Among women seen by an internal medicine physician, cancer screening did not vary significantly by gatekeeper status. CONCLUSIONS The impact of gatekeeper plans upon cancer screening varies according to the primary care physician's specialty. Policy interventions designed to increase cancer screening should take into account different responses to gatekeeper requirements among different types of providers.
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Affiliation(s)
- David A Haggstrom
- San Francisco General Hospital, Division of General Internal Medicine, University of California, San Francisco.
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Abstract
Abstract
The U.S. Preventive Services Task Force recommends cervical cancer screening begin with the onset of sexual activity and be repeated at least every 3 years until age 65. Previous studies examining the annual utilization and frequency of Pap screening have relied on patient self-report, found to be less reliable than medical records and administrative data. We estimate the age-specific rate and frequency of Pap screening in a U.S. health plan using 1998–2002 administrative data on 150,052 female enrollees within the Kaiser Permanente Northwest health plan, Portland, OR. We analyze the age-specific rate of cervical and vaginal Pap screening and age-specific proportion of routinely screened women receiving cervical screening at various yearly intervals. Of the enrolled women, 31.2% received a Pap smear in 1998, with utilization highest for ages 25–29 (62.4%). Among routinely screened women, 36% were estimated to receive annual cervical smears, versus 22% biennial, 13% triennial, and 29% less frequent screening. Less frequent screening was observed with increasing age. These are the first age-specific estimates of Pap screening frequency and annual utilization in a general healthcare setting, derived from administrative data, rather than self-report. Overall Pap utilization was lower than found in national surveys based on self-report. Despite limited evidence of benefit from more frequent screening, a substantially higher proportion of women was found to receive annual rather than either biennial or triennial screening. Sporadic screening was also more prevalent than expected based on prior self-reported data. Further opportunities exist for improving screening adherence, even within traditionally less vulnerable populations.
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Affiliation(s)
- Ralph P. Insinga
- 1Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI and
| | - Andrew G. Glass
- 2Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Brenda B. Rush
- 2Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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Abstract
OBJECTIVE This paper describes trends in screening mammography utilization over the past decade and assesses the remaining disparities in mammography use among medically underserved women. We also describe the barriers to mammography and report effective interventions to enhance utilization. DESIGN We reviewed medline and other databases as well as relevant bibliographies. MAIN RESULTS The United States has dramatically improved its use of screening mammography over the past decade, with increased rates observed in every demographic group. Disparities in screening mammography are decreasing among medically underserved populations but still persist among racial/ethnic minorities and low-income women. Additionally, uninsured women and those with no usual care have the lowest rates of reported mammogram use. However, despite apparent increases in mammogram utilization, there is growing evidence that limitations in the national survey databases lead to overestimations of mammogram use, particularly among low-income racial and ethnic minorities. CONCLUSIONS The United States may be farther from its national goals of screening mammography, particularly among underserved women, than current data suggests. We should continue to support those interventions that increase mammography use among the medically underserved by addressing the barriers such as cost, language and acculturation limitations, deficits in knowledge and cultural beliefs, literacy and health system barriers such as insurance and having a source regular of medical care. Addressing disparities in the diagnostic and cancer treatment process should also be a priority in order to affect significant change in health outcomes among the underserved.
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Affiliation(s)
- Monica E Peek
- Division of General Internal Medicine, Ruch Medical College, Rush University Medical Center, Chicago, Ill. 60612, USA.
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Saha S, Arbelaez JJ, Cooper LA. Patient-physician relationships and racial disparities in the quality of health care. Am J Public Health 2003; 93:1713-9. [PMID: 14534227 PMCID: PMC1448039 DOI: 10.2105/ajph.93.10.1713] [Citation(s) in RCA: 378] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2003] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study explored whether racial differences in patient-physician relationships contribute to disparities in the quality of health care. METHODS We analyzed data from The Commonwealth Fund's 2001 Health Care Quality Survey to determine whether racial differences in patients' satisfaction with health care and use of basic health services were explained by differences in quality of patient-physician interactions, physicians' cultural sensitivity, or patient-physician racial concordance. RESULTS Both satisfaction with and use of health services were lower for Hispanics and Asians than for Blacks and Whites. Racial differences in the quality of patient-physician interactions helped explain the observed disparities in satisfaction, but not in the use of health services. CONCLUSIONS Barriers in the patient-physician relationship contribute to racial disparities in the experience of health care.
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Affiliation(s)
- Somnath Saha
- Section of General Internal Medicine, Portland Veterans Affairs Medical Center, Department of Veterans Affairs, Portland, OR 97239, USA.
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Abstract
Unless action is directed to address the multiple influences on coronary heart disease (CHD) risk reduction behaviors, across all population groups, the aims of Healthy People 2010 with regard to CHD will not be realized. Health-promotion and disease-prevention models, including a framework for primordial, primary, and secondary prevention provided by an American Heart Association task force, and a model for interventions to eliminate health disparities are reviewed. The role of culture, ethnicity, race, and socioeconomic status and how these concepts have been studied in recent lifestyle interventions aimed at CHD risk reduction is explored. Finally, these findings are synthesized to provide suggestions for nursing care delivery in primary and tertiary care settings.
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Affiliation(s)
- Deborah A Chyun
- Yale University School of Nursing, New Haven, Conn 06536-0740, USA.
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