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Choi Y, Lee HJ. Do Regular Cholesterol Screenings Lead to Lower Cholesterol Levels and Better Health Behaviors for All? Spotlight on Middle-Aged and Older Adults in the United States. J Aging Health 2017; 29:389-414. [PMID: 26921271 DOI: 10.1177/0898264316635588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study investigates how the causal effects of cholesterol screening differ by likelihood of using this preventive care service in terms of accessibility gaps and effects on health-related outcomes across groups with advantaged and disadvantaged backgrounds. METHOD We use propensity score matching to analyze a nationally representative sample using data from 2008, 2010, and 2012 waves of the Health and Retirement Study ( N = 3,907). RESULTS We find that respondents who are least likely to get their cholesterol tested benefit most from the use of cholesterol screening when they do use it, while its effects are smallest for those who are most likely to use this service. DISCUSSION Understanding the heterogeneous effects of preventive health service has important policy implications, particularly in terms of how to maximize the public health benefits of preventive care.
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Affiliation(s)
- Yool Choi
- 1 University of California, Los Angeles, USA
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2
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Marton J, Yelowitz A, Shores M, Talbert JC. Does Medicaid Managed Care Help Equalize Racial and Ethnic Disparities in Utilization? Health Serv Res 2016; 51:872-91. [PMID: 26456766 PMCID: PMC4874821 DOI: 10.1111/1475-6773.12396] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To estimate the impact of different forms of Medicaid managed care (MMC) delivery on racial and ethnic disparities in utilization. DATA SOURCE Longitudinal, administrative data on 101,649 children in Kentucky continuously enrolled in Medicaid between January 1997 and June 1999. Outcomes considered are monthly professional, outpatient, and inpatient utilization. STUDY DESIGN We apply an intent-to-treat, instrumental variables analysis using the staggered geographic implementation of MMC to create treatment and control groups of children. PRINCIPAL FINDINGS The implementation of MMC reduced monthly professional visits by a smaller degree for non-whites than whites (3.8 percentage points vs. 6.2 percentage points), thereby helping to equalize the initial racial/ethnic disparity in utilization. The Passport MMC program in the Louisville-centered region statistically significantly reduced disparities for professional visits (closing the gap by 8.0 percentage points), while the Kentucky Health Select MMC program in the Lexington-centered region did not. No substantive impact on disparities was found for either outpatient or inpatient utilization in either program. CONCLUSIONS We find evidence that MMC has the possibility to reduce racial/ethnic disparities in professional utilization. More work is needed to determine which managed care program characteristics drive this result.
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Affiliation(s)
- James Marton
- Department of Economics and Georgia Health Policy CenterAndrew Young School of Policy StudiesGeorgia State UniversityAtlantaGA
| | - Aaron Yelowitz
- Department of EconomicsGatton School of Business and EconomicsUniversity of KentuckyLexingtonKY
| | - Meredith Shores
- Department of EconomicsGatton School of Business and EconomicsUniversity of KentuckyLexingtonKY
| | - Jeffery C. Talbert
- Department of Pharmacy Practice and ScienceUK College of PharmacyLexingtonKY
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Mobley LR, Kuo TM, Traczynski J, Udalova V, Frech HE. Macro-level factors impacting geographic disparities in cancer screening. HEALTH ECONOMICS REVIEW 2014; 4:13. [PMID: 26054402 PMCID: PMC4883991 DOI: 10.1186/s13561-014-0013-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 06/26/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Examine how differences in state regulatory environments predict geographic disparities in the utilization of cancer screening. DATA SOURCES/SETTING 100% Medicare fee-for-service population data from 2001-2005 was developed as multi-year breast (BC) and colorectal cancer (CRC) screening utilization rates in each county in the US. STUDY DESIGN A comprehensive set of supply and demand predictors are used in a multilevel model of county-level cancer screening utilization in the context of state regulatory markets. States dictate insurance mandates/regulations and whether alternative providers (nurse practitioners) can provide preventive care services supplied by MDs. Controlling statistically for the supply of both types of providers, we study the joint effects of two private insurance regulations: one mandating that insureds with serious or chronic health conditions may receive continuity of care from their established physician(s) after changing health insurance plans, and another mandating that external grievance review is an option for all health plan coverage/denial decisions. These private insurance plan regulations are expected to affect the degree of beneficial spillovers from managed care practices, which may have increased area-wide cancer screening rates. PRINCIPAL FINDINGS The two private insurance regulations under study were significant predictors impacted by local market conditions. Managed care spillovers in local markets were significantly associated with higher BC screening rates, but only in states lacking the two forms of regulation under study. Spillovers were significantly associated with higher CRC cancer screening rates everywhere, but much higher in the unregulated states. Area poverty dampened screening rates, but less so for CRC screening in the states with these regulations. CONCLUSIONS Two state insurance regulations that empowered consumers with more autonomy to make informed utilization decisions varied across states, and exhibited significant associations with screening rates, which varied with the degree of managed care penetration or poverty in the state's counties. Beneficial spillover effects from managed care practices and negative influences from area poverty are not uniform across the United States. Both variables had stronger associations with CRC than BC screening utilization, as did state regulatory variables. CRC screening by endoscopy was more subject to market and regulatory factors than BC screening.
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Affiliation(s)
- Lee R Mobley
- />School of Public Health and Andrew Young School of Policy Studies, Georgia State University, Atlanta, GA USA
| | - Tzy-Mey Kuo
- />Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Jeffrey Traczynski
- />Department of Economics, University of Hawaii at Manoa, Honolulu, HI 96822 USA
| | - Victoria Udalova
- />Department of Economics, University of Wisconsin-Madison, Madison, WI 53706 USA
| | - HE Frech
- />Department of Economics, University of California, Santa Barbara, CA USA
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Virk-Baker MK, Martin MY, Levine RS, Wang X, Nagy TR, Pisu M. Mammography utilization among Black and White Medicare beneficiaries in high breast cancer mortality US counties. Cancer Causes Control 2014; 24:2187-96. [PMID: 24077760 DOI: 10.1007/s10552-013-0295-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 09/17/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Disparities in US breast cancer mortality between older Black and White women have increased in the last 20 years. Regular mammography use is important for early detection and treatment: its utilization among older Blacks especially in counties with high Black mortality is of interest, but its extent and determinants are unknown. METHODS We used Medicare claims for Black and White women 65–74 years old in 203 counties with the highest Black breast cancer mortality. Outcomes over 6 years were as follows: ever mammogram, i.e., C 1 screening mammogram, and regular mammogram, i.e., C 3 mammograms. With logistic regressions, we examined the independent effect of race on screening controlling for individual- and county-level factors. RESULTS Of 406,602 beneficiaries, 17 % were Black. Ever and regular mammogram was significantly lower among Blacks (51.6 vs. 56.9 %; 32.9 vs. 43.1 %, respectively). Controlling for covariates, including use of cervical cancer screening, flu shots, or lipids tests, Black women were more likely to have ever mammogram (OR 1.23, CI 1.20–1.25), but not regular mammogram (OR 0.95, CI 0.93–0.97) than White women. County-level managed care penetration was negatively associated with ever and regular mammograms. CONCLUSIONS In Medicare enrollees from these counties, breast cancer screening was low. Black women had same or better odds of screening than White women. Some health care factors, e.g., managed care, were negatively associated with screening. Further studies on the determinants of mammography utilization in older women from these counties are warranted.
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Jacobs EA, Rathouz PJ, Karavolos K, Everson-Rose SA, Janssen I, Kravitz HM, Lewis TT, Powell LH. Perceived discrimination is associated with reduced breast and cervical cancer screening: the Study of Women's Health Across the Nation (SWAN). J Womens Health (Larchmt) 2013; 23:138-45. [PMID: 24261647 DOI: 10.1089/jwh.2013.4328] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Racial disparities in breast and cervical cancer screening have been documented in African American, Hispanic, and Asian populations. Perceived discrimination may contribute to this disparity. The aim of this study was to understand the relationship between perceived everyday racial/ethnic and other discrimination and receipt of breast and cervical cancer screening in a multiethnic population of women. METHODS We analyzed data from 3,258 women participating in the Study of Women's Health Across the Nation (SWAN), a multiethnic/racial, longitudinal cohort study of the natural history of the menopausal transition conducted at seven U.S. sites. Participants completed a validated measure of perceived discrimination and reasons for believing that they were treated differently, along with Pap smears, clinical breast exams (CBE), and mammography at each follow-up period. We used multiple logistic regression for the binary outcomes of having a Pap smear, CBE, or mammogram in each of the two follow-up years, using self-reported "race discrimination" and "other discrimination" at baseline as the main predictors. RESULTS African American women reported the highest percentage of racial discrimination (35%), followed by Chinese (20%), Hispanic (12%), Japanese (11%), and non-Hispanic white women (3%). Non-Hispanic white women reported the highest percentage of "other" discrimination (40%), followed by Chinese (33%), African American (24%), Japanese (23%), and Hispanic women (16%). Perceived racial discrimination was not associated with reduced receipt of preventive screening, except in one fully adjusted model. Reported discrimination owing to "other" reasons, such as age or gender, was associated with reduced receipt of Pap smear (odds ratio [OR] 0.85; 95% confidence interval [CI] 0.74-0.99), CBE (OR 0.78; 95% CI 0.67-0.91), and mammography (OR 0.80; 95% CI 0.69-0.92) regardless of patient race. CONCLUSIONS Perceived discrimination is an important issue across racial/ethnic groups and is negatively associated with receipt of breast and cervical cancer screening. This is an important issue that needs to be further explored and addressed in efforts to improve the delivery of healthcare to all groups.
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Affiliation(s)
- Elizabeth A Jacobs
- 1 Departments of Medicine and Population Health Sciences, University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin
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6
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Bellinger JD, Brandt HM, Hardin JW, Bynum S, Sharpe PA, Jackson D. The role of family history of cancer on cervical cancer screening behavior in a population-based survey of women in the Southeastern United States. Womens Health Issues 2013; 23:e197-204. [PMID: 23722075 PMCID: PMC3700594 DOI: 10.1016/j.whi.2013.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 03/05/2013] [Accepted: 03/29/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Our objective was to determine the association of self-reported family history of cancer (FHC) on cervical cancer screening to inform a potential link with cancer preventive behaviors in a region with persistent cancer disparities. METHODS Self-reported FHC, Pap test behavior, and access to care were measured in a statewide population-based survey of human papillomavirus and cervical cancer (n = 918). Random-digit dial, computer-assisted telephone interviews were used to contact eligible respondents (adult [ages 18-70] women in South Carolina with landline telephones]. Logistic regression models were estimated using STATA 12. FINDINGS Although FHC+ was not predictive (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.55-2.51), private health insurance (OR, 2.35; 95% confidence interval [CI], 1.15-4.81) and younger age (18-30 years: OR, 7.76; 95% CI, 1.91, 3.16) were associated with recent Pap test behavior. FHC and cervical cancer screening associations were not detected in the sample. CONCLUSIONS Findings suggest targeting older women with screening recommendations and providing available screening resources for underserved women.
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Affiliation(s)
- Jessica D. Bellinger
- Department of Health Services Policy and Management, South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Drive, Suite 204, Columbia, SC 29210, Tel: (803) 251-6317, Fax: (803) 251-6399
| | - Heather M. Brandt
- Department of Health Promotion Education & Behavior, Arnold School of Public Health, University of South Carolina, 800 Sumter Street HESC 312A, Columbia, SC 29208; Tel: (803) 777-4561, Fax: (803) 777-6290
- Cancer Prevention and Control Program, University of South Carolina, 915 Greene Street, Room 230, Columbia, SC 29208
| | - James W. Hardin
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, Biostatistics Collaborative Unit, University of South Carolina, 1600 Hampton Street, Suite 507, Columbia, SC 28208; Tel: (803) 777-0379, Fax: (803) 777-0391
| | - Shalanda Bynum
- Department of Preventive Medicine & Biometrics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, Tel: (301) 295-1585; Fax: (301) 295-1933
| | - Patricia A. Sharpe
- Prevention Research Center, Arnold School of Public Health, University of South Carolina, 921 Assembly Street, Columbia, SC 29208; Tel: (803) 777-4253, Fax: (803) 777-9007
| | - Dawnyéa Jackson
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 800 Sumter Street HESC, Columbia, SC 29208
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Singal AK, Lin YL, Kuo YF, Riall T, Goodwin JS. Primary care physicians and disparities in colorectal cancer screening in the elderly. Health Serv Res 2013; 48:95-113. [PMID: 22716124 PMCID: PMC3480966 DOI: 10.1111/j.1475-6773.2012.01433.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To examine whether having a primary care physician (PCP) is associated with reduced ethnic disparities for colorectal cancer (CRC) screening and whether clustering of minorities within PCPs contributes to the disparities. DATA SOURCES/STUDY SETTING Retrospective cohort study of Medicare beneficiaries age 66-75 in 2009 in Texas. STUDY DESIGN The percentage of beneficiaries up to date in CRC screening in 2009 was stratified by race/ethnicity. Multilevel models were used to study the effect of having a PCP and PCP characteristics on the racial and ethnic disparities on CRC screening. DATA COLLECTION/EXTRACTION METHODS Medicare data from 2000 to 2009 were used to assess prior CRC screening. PRINCIPAL FINDINGS Odds of undergoing CRC screening were more than twice as high in patients with a PCP (OR = 2.05, 95 percent CI 2.03-2.07). After accounting for clustering and PCP characteristics, the black-white disparity in CRC screening rates almost disappears and the Hispanic-white disparity decreases substantially. CONCLUSIONS Ethnic disparities in CRC screening in the elderly are mostly explained by decreased access to PCPs and by clustering of minorities within PCPs less likely to screen any of their patients.
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Affiliation(s)
- Ashwani K Singal
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555-0177, USA
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8
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Paek MS, Lim JW. Factors associated with health care access and outcome. SOCIAL WORK IN HEALTH CARE 2012; 51:506-530. [PMID: 22780701 DOI: 10.1080/00981389.2012.671244] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This study aims to (1) assess ethnic differences in health care access and health outcome between Asian Americans and whites and between Asian American subgroups, (2) examine effects of cultural factors, and (3) investigate moderating effects of health risk behaviors between cultural characteristics and health care access and outcome. Data were derived from the 2007 California Health Interview Survey. Asian Americans (n = 4,462) and whites (n = 4,470) were included. There were significant ethnic differences in health care access and health perception between Asian Americans and Whites and across Asian American subgroups. Health risk behaviors moderated relationships between cultural factors and health care access and outcome. Findings reveal that ethnicity affects an individual's health care access and health perception, and their health behaviors are an important factor that may improve or worsen outcomes. This study may increase our knowledge base of research and interventions to enhance ethnic minority populations' health care accessibility and perceptions.
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Affiliation(s)
- Min-So Paek
- Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, Ohio 44106, USA.
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9
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Casillas J, Castellino SM, Hudson MM, Mertens AC, Lima ISF, Liu Q, Zeltzer LK, Yasui Y, Robison LL, Oeffinger KC. Impact of insurance type on survivor-focused and general preventive health care utilization in adult survivors of childhood cancer: the Childhood Cancer Survivor Study (CCSS). Cancer 2010; 117:1966-75. [PMID: 21509774 DOI: 10.1002/cncr.25688] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 07/26/2010] [Accepted: 09/02/2010] [Indexed: 11/09/2022]
Abstract
BACKGROUND Lack of health insurance is a key barrier to accessing care for chronic conditions and cancer screening. The influence of insurance type (private, public, none) on survivor-focused and general preventive health care in adult survivors of childhood cancer was examined. METHODS The Childhood Cancer Survivor Study is a retrospective cohort study of childhood cancer survivors diagnosed between 1970 and 1986. Among 8425 adult survivors, the relative risk (RR) and 95% confidence interval (CI) of receiving survivor-focused and general preventive health care were estimated for uninsured (n = 1390) and publicly insured (n = 640), compared with for the privately insured (n = 6395) RESULTS Uninsured survivors were less likely than those privately insured to report a cancer-related visit (adjusted RR, 0.83; 95% CI, 0.75-0.91) or a cancer center visit (adjusted RR, 0.83; 95% CI, 0.71-0.98). Uninsured survivors had lower levels of utilization in all measures of care in comparison with privately insured. In contrast, publicly insured survivors were more likely to report a cancer-related visit (adjusted RR, 1.22; 95% CI, 1.11-1.35) or a cancer center visit (adjusted RR, 1.41; 95% CI, 1.18-1.70) than were privately insured survivors. Although publicly insured survivors had similar utilization of general health examinations, they were less likely to report a Papanicolaou test or a dental examinations CONCLUSIONS Among this large, socioeconomically diverse cohort, publicly insured survivors utilize survivor-focused health care at rates at least as high as survivors with private insurance. Uninsured survivors have lower utilization of both survivor-focused and general preventive health care.
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Affiliation(s)
- Jacqueline Casillas
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California 90095, USA.
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10
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Cancer screening practices among racially and ethnically diverse breast cancer survivors: results from the 2001 and 2003 California Health Interview Survey. J Cancer Surviv 2009; 4:1-14. [DOI: 10.1007/s11764-009-0102-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 10/21/2009] [Indexed: 11/26/2022]
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Mobley LR, Kuo TM(M, Clayton LJ, Evans WD. Mammography facilities are accessible, so why is utilization so low? Cancer Causes Control 2009; 20:1017-28. [PMID: 19205911 PMCID: PMC2694850 DOI: 10.1007/s10552-009-9295-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 01/08/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study examines new socio-ecological variables reflecting community context as predictors of mammography use. METHODS The conceptual model is a hybrid of traditional health-behavioral and socio-ecological constructs with an emphasis on spatial interaction among women and their environments, differentiating between several levels of influence for community context. Multilevel probability models of mammography use are estimated. The study sample includes 70,129 women with traditional Medicare fee-for-service coverage for inpatient and outpatient services, drawn from the SEER-Medicare linked data. The study population lives in heterogeneous California, where mammography facilities are dense but utilization rates are low. RESULTS Several contextual effects have large significant impacts on the probability of mammography use. Women living in areas with higher proportions of elderly in poverty are 33% less likely to use mammography. However, dually eligible women living in these poor areas are 2% more likely to use mammography than those without extra assistance living in these areas. Living in areas with higher commuter intensity, higher violent crime rates, greater land use mix (urbanicity), or more segregated Hispanic communities exhibit -14%, -1%, -6%, and -3% (lower) probability of use, respectively. Women living in segregated American Indian communities or in communities where more elderly women live alone exhibit 16% and 12% (higher) probability of use, respectively. Minority women living in more segregated communities by their minority are more likely to use mammography, suggesting social support, but this is significant for Native Americans only. Women with disability as their original reason for entitlement are found 40% more likely to use mammography when they reside in communities with high commuter intensity, suggesting greater ease of transportation for them in these environments. CONCLUSIONS Socio-ecological variables reflecting community context are important predictors of mammography use in insured elderly populations, often with larger magnitudes of effect than personal characteristics such as race or ethnicity (-3% to -7%), age (-2%), recent address change (-7%), disability (-5%) or dual eligibility status (-1%). Better understanding of community factors can enhance cancer control efforts.
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Affiliation(s)
- Lee R. Mobley
- Public Health and Environment Division, RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA, e-mail:
| | - Tzy-Mey (May) Kuo
- Public Health and Environment Division, RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA, e-mail:
| | - Laurel J. Clayton
- Public Health and Environment Division, RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA, e-mail:
| | - W. Douglas Evans
- Department of Prevention and Community Health, George Washington University, School of Public Health and Health Services, 2121 I Street, N.W., Washington, DC 20052, USA
- Department of Global Health, George Washington University, School of Public Health and Health Services, 2121 I Street, N.W., Washington, DC 20052, USA
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Teno JM, Mitchell SL, Skinner J, Kuo S, Fisher E, Intrator O, Rhodes R, Mor V. Churning: the association between health care transitions and feeding tube insertion for nursing home residents with advanced cognitive impairment. J Palliat Med 2009; 12:359-62. [PMID: 19327073 DOI: 10.1089/jpm.2008.0168] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is a tenfold variation across U.S. states in the prevalence of feeding tube use among elderly nursing home residents (NHR) with advanced cognitive impairment. The goal of this study was to examine whether regions with higher rates of health care transitions at the end of life are more likely to use feeding tubes in patients with severe cognitive impairment. METHODS A retrospective cohort study of U.S. nursing home residents with advanced cognitive impairment. The incidence of feeding tube insertion was determined by Medicare Part A and B billing data. A count of the number of health care transition in the last 6 months of life was determined for nursing home residents. A multivariate model examined the association of residing in a geographic region with a higher rates of health care transition and the insertion of a feeding tube in nusing home resident with advance cognitive impairment. RESULTS Hospital Referral Region (HRR) health care transitions varied from 192 (Salem, Oregon) to 509 per 100 decedents (Monroe, Louisiana) within the last 6 months of life. HRRs with higher transition rates had a higher incidence of feeding tube insertion (Spearman correlation = 0.58). Subjects residing in regions with the highest quintile of transitions rates were 2.5 times (95% confidence interval [CI] 1.9-3.2) more likely to have a feeding tube inserted compared to those that resided in the lowest quintile. CONCLUSIONS Regions with higher rates of care transitions among nursing home residents are also much more likely to have higher rates of feeding tube placement for patients with severe cognitive impairment, a population in whom benefit is unlikely.
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Affiliation(s)
- Joan M Teno
- Center for Gerontology and Health Care Research, Department of Community Health, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.
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13
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Schenck AP, Peacock SC, Klabunde CN, Lapin P, Coan JF, Brown ML. Trends in colorectal cancer test use in the medicare population, 1998-2005. Am J Prev Med 2009; 37:1-7. [PMID: 19423273 DOI: 10.1016/j.amepre.2009.03.009] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 12/22/2008] [Accepted: 03/10/2009] [Indexed: 12/24/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) screening has been covered under the Medicare program since 1998. No prior study has addressed the question of the completeness of CRC screening in the entire Medicare cohort. METHODS In 2008, CRC test-use rates were analyzed for the national fee-for-service Medicare population using Medicare enrollment and claims data from 1998 through 2005. Annual test-use rates were calculated for fecal occult blood testing, sigmoidoscopy, barium enema, and colonoscopy for each year by the demographic characteristics of enrollees. A current-in-Medicare rate was calculated to assess the percentage of enrollees with CRC testing according to recommended intervals. RESULTS Colonoscopy rates have increased every year since the introduction of CRC screening coverage. Test-use rates for all other test modalities have steadily decreased. The percentage of Medicare enrollees receiving appropriate tests has slowly increased. In 2005, 47% of enrollees aged >or=65 years and 33% of enrollees aged 50-64 years had claims indicating that they had been tested according to recommended intervals. CONCLUSIONS CRC test-use rates in the Medicare population are low. Disparities are apparent by age, race/ethnicity, gender, disability, income, and geographic residence. Much work remains to be done to increase testing to acceptable levels.
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Affiliation(s)
- Anna P Schenck
- The Carolinas Center for Medical Excellence, Cary, North Carolina 27518-8598, USA.
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14
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Baron-Epel O, Friedman N, Lernau O. Reducing disparities in mammography-use in a multicultural population in Israel. Int J Equity Health 2009; 8:19. [PMID: 19454004 PMCID: PMC2689238 DOI: 10.1186/1475-9276-8-19] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 05/19/2009] [Indexed: 11/25/2022] Open
Abstract
Background In the past mammography-use has been reported to be low in Israel compared to other western countries. The objectives of this study were (1) to assess the increase in mammography-use during the years 2002 to 2007 in four population groups in Maccabi Healthcare Services (MHS), Israel: non-immigrant non-ultraorthodox, ultraorthodox, and immigrant Jewish women and Arab women; (2) to assess ethnic and socioeconomic disparities in mammography-use. Methods A random telephone survey of 1,550 women receiving healthcare services from MHS was performed during May-June 2007. Information from MHS claims-records database regarding mammography-use was obtained for each woman for the period 2002 to 2007. Since mammography-use serves as a quality assurance measure for primary care, MHS sent mail and telephone invitations for mammography to all women since the end of 2004. Results At the beginning of the follow-up period (2002) mammography-use among Jewish non-immigrant non-ultraorthodox and ultraorthodox women was higher than among Arab and Jewish immigrant women. During the 5 year follow-up these disparities decreased significantly. In 2007, mammography-use by Arab women was only slightly lower compared to all groups of Jewish women. In 2007, after adjustment for socioeconomic factors there was only a borderline significant difference between Jewish and Arab women. The socioeconomic variables were not associated with mammography-use in 2002 and 2007 in any of the groups except for marital status in immigrant women in 2002. Conclusion The interventions implemented by MHS may have increased mammography-use in all population groups, decreasing disparities between the groups, however the differences between Jewish and Arab women have not been completely eliminated and indicate a need for further targeted interventions. No significant socioeconomic disparities in mammography-use were observed.
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Affiliation(s)
- Orna Baron-Epel
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.
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Cangelosi JD, Ranelli E, Markham FS. Who is making lifestyle changes due to preventive health care information? A demographic analysis. Health Mark Q 2009; 26:69-86. [PMID: 19408177 DOI: 10.1080/07359680802619776] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
This paper sought to describe from a set of demographic and lifestyle characteristics, the person who is significantly and positively impacted by preventive health care (PHC) information. Based on past research, six two-part hypotheses (PHC information and lifestyle) were developed, with a total examination of 12 possible relationships. Five of the six hypotheses were at least partially accepted, as were eight out of the 12 possible relationships. In addition, there was at least one significant relationship with a demographic variable in 12 of the 13 lifestyle change variables. It can be said with confidence that persons who are seeking and are positively impacted by PHC information are better educated, have higher incomes, are female, usually older, and married. The most important lifestyle changes emanating from PHC information are "changes in eating habits," "having periodic physician checkups," "utilizing nutritional labeling," and "joining a health club or wellness center." "Changes in social life," "sleeping habits," "getting regular exercise," and "attendance at health fairs and seminars" were also associated with the utilization of PHC information, but to a lesser extent.
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Affiliation(s)
- Joseph D Cangelosi
- College of Business, University of Central Arkansas, Conway, Arkansas 72035, USA.
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Wells KJ, Battaglia TA, Dudley DJ, Garcia R, Greene A, Calhoun E, Mandelblatt JS, Paskett ED, Raich PC. Patient navigation: state of the art or is it science? Cancer 2008; 113:1999-2010. [PMID: 18780320 DOI: 10.1002/cncr.23815] [Citation(s) in RCA: 418] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
First implemented in 1990, patient navigation interventions are emerging today as an approach to reduce cancer disparities. However, there is lack of consensus about how patient navigation is defined, what patient navigators do, and what their qualifications should be. Little is known about the efficacy and cost-effectiveness of patient navigation. For this review, the authors conducted a qualitative synthesis of published literature on cancer patient navigation. By using the keywords 'navigator' or 'navigation' and 'cancer,' 45 articles were identified in the PubMed database and from reference searches that were published or in press through October 2007. Sixteen studies provided data on the efficacy of navigation in improving timeliness and receipt of cancer screening, diagnostic follow-up care, and treatment. Patient navigation services were defined and differentiated from other outreach services. Overall, there was evidence of some degree of efficacy for patient navigation in increasing participation in cancer screening and adherence to diagnostic follow-up care after the detection of an abnormality. The reported increases in screening ranged from 10.8% to 17.1%, and increases in adherence to diagnostic follow-up care ranged from 21% to 29.2% compared with control patients. There was less evidence regarding the efficacy of patient navigation in reducing either late-stage cancer diagnosis or delays in the initiation of cancer treatment or improving outcomes during cancer survivorship. There were methodological limitations in most studies, such as a lack of control groups, small sample sizes, and contamination with other interventions. Although cancer-related patient navigation interventions are being adopted increasingly across the United States and Canada, further research will be necessary to evaluate their efficacy and cost-effectiveness in improving cancer care.
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Affiliation(s)
- Kristen J Wells
- Department of Health Outcomes and Behavior, Division of Cancer Prevention and Control, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 33612, USA.
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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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Is the type of Medicare insurance associated with colorectal cancer screening prevalence and selection of screening strategy? Med Care 2008; 46:S84-90. [PMID: 18725838 DOI: 10.1097/mlr.0b013e31817fdf80] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Medicare managed care (MMC) plans may be better positioned to deliver preventive services than fee-for-service (FFS) insurers. We assessed whether beneficiaries in MMC plans were more likely than those in traditional FFS insurance to receive colorectal cancer (CRC) screening and whether type of insurance was associated with use of specific screening strategies. METHODS We studied 10,173 respondents to the 2000 Medicare Current Beneficiary Survey representing 24,394,204 US Medicare beneficiaries. We identified 4 CRC screening strategies: (1) interval-appropriate screening, (2) fecal occult blood testing (FOBT) within the past 2 years, (3) colonoscopy or sigmoidoscopy within the past 5 years, and (4) primary invasive screening (interval-appropriate colonoscopy or sigmoidoscopy without FOBT). Using a propensity score model to adjust for the nonrandom selection of insurance based on sociodemographic characteristics and other respondent-reported "care-seeking" variables, we compared the adjusted percentage of MMC and FFS beneficiaries screened using each CRC screening strategy. RESULTS In this sample, 21.6% of Medicare beneficiaries were continuously enrolled in MMC, 61.3% had FFS with supplemental insurance, and 17.1% had FFS coverage alone. Just over 51% of beneficiaries received interval-appropriate CRC screening. Interval-appropriate CRC screening was reported by 54.7% in FFS with supplemental insurance, 52.9% in MMC, and 36.3.% in the FFS group without supplemental insurance (P < 0.001). Use of the FOBT strategy was more common in MMC compared with FFS with or without supplemental insurance. Adjustment for sociodemographic characteristics and care-seeking propensity had a sizable impact on differences in screening prevalence, but did not substantially alter the conclusions. CONCLUSIONS In 2000, the type of Medicare insurance was associated with differences in the prevalence of interval-appropriate CRC screening with lower prevalence among FFS beneficiaries who lacked supplemental insurance. Although managed care did not produce more CRC screening than supplemental insurance, managed care plans seem to have encouraged FOBT testing over other strategies.
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Lower adherence to screening mammography guidelines among ethnic minority women in America: a meta-analytic review. Prev Med 2008; 46:479-88. [PMID: 18295872 PMCID: PMC2920292 DOI: 10.1016/j.ypmed.2008.01.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 12/30/2007] [Accepted: 01/08/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study investigates the association between ethnic minority status and receiving a screening mammogram within the past 2 years among American women over 50. METHOD The findings from 33 studies identified from interdisciplinary research databases (1980 to 2006) were synthesized. Separate pooled analyses compared white non-Hispanics to African Americans (28 outcomes), Hispanics (18 outcomes), and Asian/Pacific Islanders (10 outcomes). RESULTS Using the random effects model, results showed that African Americans were screened less than white non-Hispanics at a marginal level (OR 0.87, 95% CI 0.75, 1.00). Larger and significant discrepancies were observed for Hispanics (OR 0.65, 95% CI 0.50, 0.85) and Asian/Pacific Islanders (OR 0.63, 95% CI 0.39, 0.99) compared to white non-Hispanics. However, among studies controlling for socioeconomic status, ethnic differences in mammography screening were no longer significant for African Americans (OR 1.05, 95% CI 0.71, 1.76), Hispanics (OR 1.08, 95% CI 0.64, 1.93), or Asian/Pacific Islanders (OR 1.08, 95% CI 0.64, 1.93). Subgroup analyses further showed that geographical region, sampling method, and data collection strategy significantly impacted results. CONCLUSIONS This study found evidence that ethnic minority-screening mammography differences exist but were impacted by socioeconomic status. Implications for interpreting existing knowledge and future research needs are discussed.
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Affiliation(s)
- Lisa A Newman
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Abstract
OBJECTIVE To evaluate the impact of Medicaid Managed Care (MMC) on racial disparities in access to care consistent with the Institute of Medicine (IOM) definition of racial disparity, which excludes differences stemming from health status but includes socioeconomic status (SES)-mediated differences. DATA SOURCES Secondary data from the Adult Samples of the 1997-2001 National Health Interview Survey, metropolitan statistical area (MSA)-level Medicaid Health Maintenance Organization (MHMO) market share from the 1997 to 2001 InterStudy MSA Trend Dataset, and MSA characteristics from the 1997 to 2001 Area Resource File. STUDY DESIGN I estimate multivariate regression models to compare racial disparities in doctor visits, emergency room (ER) use, and having a usual source of care between enrollees in MMC and Medicaid Fee-for-Service (FFS) plans. To contend with potential selection bias, I use a difference-in-difference analytical strategy and assess the impact of greater MHMO market share at the MSA level on Medicaid enrollees' access measures. To implement the IOM definition of racial disparity, I adjust for health status but not SES factors using a novel method to transform the distribution of health status for minority populations to approximate the white health status distribution. PRINCIPAL FINDINGS MMC enrollment is associated with lowered disparities in having any doctor visit in the last year for blacks, and in having any usual source of care for both blacks and Hispanics. Increasing Medicaid HMO market share lowered disparities in having any doctor visits in the last year for both blacks and Hispanics. Although disparities in most other measures were not much affected, black-white ER use disparities exist among MMC enrollees and in areas of high MHMO market share. CONCLUSIONS MMC programs' reduction of some disparities suggests that recent shifts in Medicaid policy toward managed care plans have benefited minority enrollees. Future research should investigate whether black-white disparities in ER use within MMC groups represent the flexibility of MMC plans to locate primary care in ERs or an inefficient delivery of care.
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Affiliation(s)
- Benjamin Lê Cook
- Mathematica Policy Research, Inc., 955 Massachusetts Ave., Suite 801, Cambridge, MA 02139, 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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Sassi F, Luft HS, Guadagnoli E. Reducing racial/ethnic disparities in female breast cancer: screening rates and stage at diagnosis. Am J Public Health 2006; 96:2165-72. [PMID: 17077392 PMCID: PMC1698161 DOI: 10.2105/ajph.2005.071761] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed whether population rates of mammography screening, and their changes over time, were associated with improvements in breast cancer stage at diagnosis and whether the strength of this association varied by race/ethnicity. METHODS We analyzed state cancer registry data linked to socioeconomic characteristics of patients' areas of residence for 1990-1998 time trends in the likelihood of early stage diagnosis. We appended each cancer registry record with matching subgroup estimates of self-reported mammography screening. RESULTS Trends in screening and stage at diagnosis were consistent within groups, but African American women had a significantly lower proportion of early stage cancers despite an advantage in screening. Population screening rates were significantly associated with early diagnosis, with a weaker association in African American women than White women (odds ratio [OR] = 1.70; P<.0001 vs OR=2.02; P<.0001, respectively). CONCLUSIONS Improvements in screening rates during the 1990s across racial/ethnic groups appear to have contributed significantly to earlier diagnosis within each group, but a smaller effect in African American women should raise concerns. A key health policy challenge is to ensure that screening effectively translates into earlier diagnosis.
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Affiliation(s)
- Franco Sassi
- Department of Social Policy, The London School of Economics and Political Science, London, United Kingdom.
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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: 188] [Impact Index Per Article: 10.4] [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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Blackman DJ, Masi CM. Racial and ethnic disparities in breast cancer mortality: are we doing enough to address the root causes? J Clin Oncol 2006; 24:2170-8. [PMID: 16682736 DOI: 10.1200/jco.2005.05.4734] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Breast cancer is the most common noncutaneous malignancy and the second most lethal form of cancer among women in the United States. Mortality from breast cancer has declined since the late 1980s, but this decline has been steeper among white women compared with black women. As a result, the black:white mortality rate ratio has increased over the last two decades. Other ethnic minorities also suffer from disproportionately high breast cancer mortality rates. This review discusses the causes of racial and ethnic disparities in breast cancer mortality and describes the most common approaches to reducing these disparities. The literature suggests that outcome disparities are related to patient-, provider-, and health system-level factors. Lack of insurance, fear of testing, delay in seeking care, and unfavorable tumor characteristics all contribute to disparities at the patient level. At the provider level, insufficient screening, poor follow-up of abnormal screening tests, and nonadherence to guideline-based treatments add to outcome disparities. High copayment requirements, lack of a usual source of care, fragmentation of care, and uneven distribution of screening and treatment resources exacerbate disparities at the health system level. Although pilot programs have increased breast cancer screening among select populations, persistent disparities in mortality suggest that changes are needed at the policy level to address the root causes of these disparities.
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Affiliation(s)
- Dionne J Blackman
- Section of General Internal Medicine and the Center for Interdisciplinary Health Disparities Research, The University of Chicago, Chicago, IL 60637, USA.
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Doubeni CA, Field TS, Ulcickas Yood M, Rolnick SJ, Quessenberry CP, Fouayzi H, Gurwitz JH, Wei F. Patterns and predictors of mammography utilization among breast cancer survivors. Cancer 2006; 106:2482-8. [PMID: 16634097 DOI: 10.1002/cncr.21893] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Improvements in cancer detection and treatment have resulted in increasing numbers of breast cancer survivors. Information regarding the use of mammography by breast cancer survivors is limited. METHODS The use of surveillance mammography was examined over a 5-year period in a retrospective cohort of women age>or=55 years who were diagnosed with incident primary breast cancer (1996-1997) while enrolled in 1 of 4 geographically diverse integrated health systems. RESULTS Of the 797 women included in the study, 80% (n=636) underwent mammograms during the first year after treatment for breast cancer. The percentage of women having mammograms during each yearly period decreased significantly over time. In multivariable analyses, older women with comorbid illnesses or those with late-stage disease were less likely to undergo mammograms, whereas those who underwent breast-conserving therapy (adjusted odds ratio [OR] of 1.38 [95% confidence interval (95% CI), 1.09-1.75]) were more likely to have mammograms. Women who had outpatient visits with a gynecologist (adjusted OR of 3.49 [95% CI, 2.55-4.79]), or a primary care physician (adjusted OR of 2.21 [95% CI, 1.73-2.82]) during the year were more likely to undergo mammograms in that year. CONCLUSIONS The use of mammography among breast cancer survivors declines over time. Efforts are needed to increase awareness among healthcare providers and breast cancer survivors of the value of follow-up mammography. The current findings highlight the importance of maintaining ongoing contact with primary care physicians and gynecologists.
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Affiliation(s)
- Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Massachusetts, Worcester, Massachusetts 01655, 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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Ponce NA, Huh S, Bastani R. Do HMO market level factors lead to racial/ethnic disparities in colorectal cancer screening? A comparison between high-risk Asian and Pacific Islander Americans and high-risk whites. Med Care 2005; 43:1101-8. [PMID: 16224303 DOI: 10.1097/01.mlr.0000182487.72429.56] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few studies have explored health care market structure and colorectal cancer (CRC) screening test use, and little is known whether market factors contribute to racial/ethnic screening disparities. OBJECTIVE We investigated whether HMO market level factors, controlling for individual covariates, differentially impact Asian American and Pacific Islander (AAPI) subjects' access to CRC screening compared with white subjects. RESEARCH DESIGN AND METHODS We used random intercept hierarchical models to predict CRC test use. Individual-level survey data was linked to market data by metropolitan statistical areas from InterStudy. SUBJECTS Insured first-degree relatives, ages 40-80, of a random sample of colorectal cancer cases identified from the California Cancer Registry: 515 white subjects and 396 AAPI subjects residing in 36 metropolitan statistical areas (MSAs). MEASURES Dependent variables were receipt of (1) annual fecal occult blood test only; (2) sigmoidoscopy in the past 5 years; (3) colonoscopy in the past 10 years; and (4) any of these tests over the recommended time interval. Market characteristics were HMO penetration, HMO competition, and proportion of staff/group/network HMOs. FINDINGS Market characteristics were as important as individual-level characteristics for AAPI but not for white subjects. Among AAPI subjects, a 10% increase in the percent of group/staff/network model HMO was associated with a reduction in colonoscopy use (28.9% to 20.5%) and in receipt of any of the CRC tests (53.2% to 45.4%). CONCLUSIONS The prevailing organizational structure of a health care market confers a penalty on access to CRC test use among high-risk AAPI subjects but not among high-risk white subjects. Identifying the differential effect of market structure on race/ethnicity can potentially reduce the cancer burden among disadvantaged racial groups.
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Affiliation(s)
- Ninez A Ponce
- Division of Cancer Prevention and Control, Jonsson Comprehensive Cancer Center & UCLA School of Public Health, Los Angeles, CA 90095-1772, USA.
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Jacobs EA, Karavolos K, Rathouz PJ, Ferris TG, Powell LH. Limited English proficiency and breast and cervical cancer screening in a multiethnic population. Am J Public Health 2005; 95:1410-6. [PMID: 16043670 PMCID: PMC1449374 DOI: 10.2105/ajph.2004.041418] [Citation(s) in RCA: 202] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the relationship between ability to speak English and receipt of Papanicolaou tests, clinical breast examinations, and mammography in a multiethnic group of women in the United States. METHODS We used longitudinal data from the Study of Women Across the Nation to examine receipt of breast and cervical cancer screening among Chinese, Japanese, Hispanic, and White women who reported reading and speaking (1) only a language other than English, (2) another language more fluently than English, or (3) only English or another language and English with equal fluency. Logistic regression was used to analyze the data. RESULTS Reading and speaking only a language other than English and reading and speaking another language more fluently than English, were significantly and negatively associated with receipt of breast and cervical cancer screening in unadjusted models. Although these findings were attenuated in adjusted models, not speaking English well or at all remained negatively associated with receipt of cancer screening. CONCLUSIONS These findings suggest that language barriers contribute to health disparities by impeding adequate health communication.
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Affiliation(s)
- Elizabeth A Jacobs
- John H. Stroger Jr Hospital of Cook County and Rush University Medical Center, Chicago, IL 60612, USA.
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32
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McAlearney AS, Reeves KW, Tatum C, Paskett ED. Perceptions of insurance coverage for screening mammography among women in need of screening. Cancer 2005; 103:2473-80. [PMID: 15884097 PMCID: PMC4450347 DOI: 10.1002/cncr.21068] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Breast carcinoma remains a significant health problem in the U.S., especially among underserved populations. Although screening mammography is recommended for early detection, in 2002, approximately 25% of women age > 40 years had not had a mammogram within the past 2 years. The current study examined perceptions of insurance coverage and cost as barriers to screening mammography within an underserved, predominantly low-income population of women in need of a mammogram. METHODS Between 1998 and 2002, face-to-face interviews were conducted with 897 women age > or = 40 years. All women were part of a randomized, controlled study evaluating a health education intervention designed to improve mammography screening. They were asked questions at baseline about cost and insurance coverage as barriers to mammography screening. Women's reports of their level of insurance coverage for mammography were compared with actual coverage by their insurance type to determine the accuracy of their perception of insurance coverage for mammography. The relation between perception of insurance coverage and the barrier of cost was investigated. RESULTS Greater than half of the women who needed a mammogram identified cost as a barrier to mammography; however, 40% of these women had an inappropriate perception of their insurance coverage. Underestimating or not knowing the level of mammography coverage was strongly associated with reporting cost-related difficulty (odds ratio [OR] = 4.57, 95% confidence interval [95% CI], 1.95-10.70 for the underestimate category; OR = 4.42, 95% CI, 1.80-10.88 for the don't know category), regardless of true coverage levels. CONCLUSIONS Providing women with information regarding their actual coverage for mammograms may reduce the impact of cost as a barrier to screening mammography.
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Affiliation(s)
- Ann Scheck McAlearney
- Division of Health Services Management and Policy, School of Public Health, The Ohio State University, Columbus, Ohio 43210, USA.
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Bigby J, Holmes MD. Disparities across the breast cancer continuum. Cancer Causes Control 2005; 16:35-44. [PMID: 15750856 DOI: 10.1007/s10552-004-1263-1] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2004] [Accepted: 07/08/2004] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We performed a structured review of the literature to identify areas of greater and lesser knowledge of the nature of disparities across the breast cancer continuum from risk and prevention to treatment and mortality. METHODS We searched OvidMedline and PubMed to identify published studies from January 1990 to March 2004 that address disparities in breast cancer. We read the abstracts of the identified articles and then reviewed the articles if they were in English, were limited to American populations, limited to women, and described quantitative outcomes. We designated the articles as addressing one or more disparities across one or more of the domains of the breast cancer continuum. RESULTS Substantial research exists on racial disparities in breast cancer screening, diagnosis, treatment, and survival. Disparities in screening and treatment exist across other domains of disparities including age, insurance status, and socioeconomic position. Several gaps were identified including how factors interact. CONCLUSION A structured review of breast cancer disparities suggests that research in other domains of social inequality and levels of the cancer continuum may uncover further disparities. A multidisciplinary and multi-pronged approach is needed to translate the knowledge from existing research into interventions to reduce or eliminate disparities.
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Affiliation(s)
- Judyann Bigby
- Department of Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120, 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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Elmore JG, Nakano CY, Linden HM, Reisch LM, Ayanian JZ, Larson EB. Racial Inequities in the Timing of Breast Cancer Detection, Diagnosis, and Initiation of Treatment. Med Care 2005; 43:141-8. [PMID: 15655427 DOI: 10.1097/00005650-200502000-00007] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent studies suggest differences in quality and timeliness of care received may be major contributing sources to the racial disparity in breast cancer detection and related outcomes. METHODS Female patients with breast cancer diagnosed during 1985-1993 (n=400) and followed through June 20, 2001, were included in this retrospective cohort study. Three white patients were selected randomly and matched to each black patient by year of diagnosis. Method and timing of diagnosis and timing of treatment were abstracted from medical records. Initial staging and subsequent breast cancer recurrence and vital status were obtained from the Hospital and Connecticut State Tumor Registry. RESULTS Black women were more likely than white women to be diagnosed after a patient-noted abnormality. Black women were less likely than white women to have completed a diagnostic evaluation within 30 days after a patient-noted abnormality (P <0.01) or after having an abnormality noted on screening mammogram (P=0.0001) and were less likely to have initiated treatment within 30 days of diagnosis (P=0.0001). Women diagnosed after a patient-noted abnormality were more likely to have subsequent breast cancer recurrence and/or death due to breast cancer compared with women diagnosed after a screening mammogram (56% versus 24%, respectively, P <0.05). CONCLUSIONS Racial differences were identified at each step in the evaluation and treatment clinical pathway, including method of detection, timing from first symptoms of cancer to pathologic diagnosis, and timing from diagnosis to initiation of treatment. The findings highlight the need to provide equal opportunity for timely medical care and treatment.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington 98104-2499, 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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Stepanikova I, Cook KS. Insurance Policies and Perceived Quality of Primary Care Among Privately Insured Patients. Med Care 2004; 42:966-74. [PMID: 15377929 DOI: 10.1097/00005650-200410000-00005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Little is known about whether some features of managed care widen disparities in patients' evaluations of primary care. OBJECTIVES We investigated whether the magnitudes of racial and ethnic/language-based differences in patients' evaluations of the quality of primary care vary by capitation and gatekeeping. DESIGN We used a telephone survey of a representative sample of the US noninstitutionalized population, Community Tracking Study Household Survey 1998-1999, and Followback Survey of respondents' insurance administrators. SETTING AND PARTICIPANTS Our sample was privately insured adults who saw a physician at least once during the year preceding the interview and whose last visit was to a primary care physician. MAIN OUTCOME MEASURES We measured patients' evaluations of (1) how well the physician listened, (2) how well the physician explained, and (3) how thorough and careful the physician was during the last visit. RESULTS Significant white-minority differences emerge more often in plans using capitation or gatekeeping than in other plans. The gaps in patients' evaluations of their primary care providers' (PCP) explanations and thoroughness between whites and Hispanics interviewed in English are larger when the PCP is capitated than when the PCP is not capitated. The gap in the evaluations of their PCP's explanations by whites and Hispanics interviewed in English is larger in plans that require referrals for specialist visits than in other plans. The magnitude of racial and ethnic/language-based gaps for Hispanics interviewed in Spanish, blacks, and Native American/Asian/Pacific Islanders do not differ by capitation and gatekeeping. CONCLUSION English-speaking Hispanics' perceptions of the quality of primary care may be more dissimilar from whites' when capitation or gatekeeping are used than when these policies are not used.
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Rao RS, Graubard BI, Breen N, Gastwirth JL. Understanding the factors underlying disparities in cancer screening rates using the Peters-Belson approach: results from the 1998 National Health Interview Survey. Med Care 2004; 42:789-800. [PMID: 15258481 DOI: 10.1097/01.mlr.0000132838.29236.7e] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cancer screening rates vary substantially by race and ethnicity. We applied the Peters-Belson approach, often used in wage discrimination studies, to analyze disparities in cancer screening rates between different groups using the 1998 National Health Interview Survey. METHODS A regression model predicting the probability of getting screened is fit to the majority group and then used to estimate the expected values for minority group members had they been members of the majority group. The average difference between the observed and expected values for a minority group is the part of the disparity that is not explained by the covariates. RESULTS The observed disparities in colorectal cancer screening (5.88%) and digital rectal screening (8.54%) between white and black men were explained fully by the difference in their covariate distributions. Only half of the disparity in the observed screening rates (13.54% for colorectal and 17.47% for digital rectal) between white and Hispanic men was explained by the difference in covariates between the groups. The entire disparity observed in mammography screening rates for black and Hispanic women (2.71% and 6.53%, respectively) compared with white women was explained by the difference in covariate distributions. CONCLUSIONS We found that the covariates that explain the disparity in screening rates between the white and the black population do not explain the disparity between the white and the Hispanic population. Knowing how much of a health disparity is explained by measured covariates can be used to develop more effective interventions and policies to eliminate disparity.
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Affiliation(s)
- R Sowmya Rao
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, Applied Research Program, National Cancer Institute, Department of Health and Human Services, Bethesda, Maryland 20892, USA
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Tye S, Phillips KA, Liang SY, Haas JS. Moving beyond the typologies of managed care: the example of health plan predictors of screening mammography. Health Serv Res 2004; 39:179-206. [PMID: 14965083 PMCID: PMC1361000 DOI: 10.1111/j.1475-6773.2004.00221.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To develop a framework of factors to characterize health plans, to identify how plan characteristics were measured in a national survey, and to apply our findings to an analysis of the predictors of screening mammography. DATA SOURCE The primary data were from the 1996 Medical Expenditure Panel Survey. STUDY DESIGN Women ages 40+, with private insurance, and no history of breast cancer were included in the study (N = 2,909). We used multivariate logistic regression to estimate mammography utilization in the past two years relative to health plan and demographic factors. Health plan measures included whether there is a defined provider network, whether coverage is restricted to a network, use of gatekeepers, level of cost containment, copayment and deductible amounts, coinsurance rate, and breadth of benefit coverage. PRINCIPAL FINDINGS We found no significant difference in reported mammography utilization using a dichotomous comparison of individuals enrolled in managed care versus indemnity plans. However, women in health plans with a defined provider network were more likely to report having received a mammogram in the past two years than those without networks (adjusted OR= 1.21, 95 percent CI = 1.07-1.36), and women in gatekeeper plans were more likely to report receiving mammography than those without gatekeepers (adjusted OR = 1.18, 95 percent CI = 1.03-1.36). Restricted out-of-network coverage, use of cost containment, enrollee cost sharing, and breadth of benefit coverage did not appear to affect mammography use. CONCLUSIONS It is important to examine the effect of individual health plan components on the utilization of health care, rather than use the traditional broader categorizations of managed versus nonmanaged care or simple health plan typologies.
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Affiliation(s)
- Sherilyn Tye
- School of Pharmacy, University of California, San Francisco 94143, USA
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Phillips KA, Haas JS, Liang SY, Baker LC, Tye S, Kerlikowske K, Sakowski J, Spetz J. Are gatekeeper requirements associated with cancer screening utilization? Health Serv Res 2004; 39:153-78. [PMID: 14965082 PMCID: PMC1360999 DOI: 10.1111/j.1475-6773.2004.00220.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE There is widespread debate over whether health plans should require enrollees to use "gatekeepers," which are primary care providers that coordinate care and control access to specialists. However, little is known about whether health plan gatekeeper requirements improve or reduce quality-of-care. Our objective was to examine whether gatekeeper requirements are associated with the utilization of cancer screening for breast, cervical, and prostate cancer. DATA SOURCES Three linked sources (N = 13,534): (1) 1996 Medical Expenditure Panel Survey (MEPS) Household Survey, a nationally representative, ongoing survey sponsored by the Agency for Healthcare Research and Quality; (2) 1996 MEPS Health Insurance Plan Abstraction, which codes data from health plan booklets obtained from privately insured respondents, and (3) 1995 National Health Interview Survey. STUDY DESIGN/DATA COLLECTION Cross-sectional, multivariate logistic regression analysis using secondary data. PRINCIPAL FINDINGS We found in multivariate analyses that women in gatekeeper plans were significantly more likely to obtain mammography screening (Odds Ratio [OR] = 1.22, 95 percent Confidence Interval [CI] 1.07-1.40), clinical breast examinations (OR = 1.39, 95 percent CI 1.23-1.57), and Pap smears (OR = 1.33, 95 percent CI 1.16-1.52) than women not in gatekeeper plans. In contrast, gatekeeper requirements were not associated with prostate cancer screening (OR = 1.11, 95 percent CI 0.93-1.33). We found no association between screening utilization and aggregate plan types (HMO, POS, PPO, FFS). CONCLUSIONS Gatekeeper requirements are associated with higher utilization of widely recommended cancer screening procedures, but not with utilization of a less uniformly recommended cancer screening procedure. Researchers should consider the analysis of specific plan characteristics rather than aggregate plan types in conducting future research, and insurers and policymakers should consider the potential benefits of gatekeepers with respect to preventive care when designing health plans and legislation.
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Affiliation(s)
- Kathryn A Phillips
- School of Pharmacy, Institute of Health Policy Studies, UCSF Comprehensive Cancer Center, University of California, San Francisco 94143, USA
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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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Sadler GR, Ryujin L, Nguyen T, Oh G, Paik G, Kustin B. Heterogeneity within the Asian American community. Int J Equity Health 2003; 2:12. [PMID: 14697098 PMCID: PMC328089 DOI: 10.1186/1475-9276-2-12] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2002] [Accepted: 12/29/2003] [Indexed: 12/19/2022] Open
Abstract
Background Educational interventions are grounded on scientific data and assumptions about the community to be served. While the Pan Asian community is composed of multiple, ethnic subgroups, it is often treated as a single group for which one health promotion program will be applicable for all of its cultural subgroups. Compounding this stereotypical view of the Pan Asian community, there is sparse data about the cultural subgroups' similarities and dissimilarities. The Asian Grocery Store based cancer education program evaluation data provided an opportunity to compare data collected under identical circumstances from members of six Asian American cultural groups. Methods A convenience sample of 1,202 Asian American women evaluated the cultural alignment of a cancer education program, completing baseline and follow-up surveys that included questions about their breast cancer knowledge, attitudes, and screening behaviors. Participants took part in a brief education program that facilitated adherence to recommended screening guidelines. Results Unique recruitment methods were needed to attract participants from each ethnic group. Impressions gained from the aggregate data revealed different insights than the disaggregate data. Statistically significant variations existed among the subgroups' breast cancer knowledge, attitudes, and screening behaviors that could contribute to health disparities among the subgroups and within the aggregate Pan Asian community. Conclusion Health promotion efforts of providers, educators, and policy makers can be enhanced if cultural differences are identified and taken into account when developing strategies to reduce health disparities and promote health equity.
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Affiliation(s)
- Georgia Robins Sadler
- Moores University of California San Diego Cancer Center, La Jolla, California 92093-0658, USA
- Department of Surgery, University of California San Diego School of Medicine, La Jolla, California 92093-0658, USA
| | - Lisa Ryujin
- Moores University of California San Diego Cancer Center, La Jolla, California 92093-0658, USA
| | - Tammy Nguyen
- Moores University of California San Diego Cancer Center, La Jolla, California 92093-0658, USA
| | - Gia Oh
- Moores University of California San Diego Cancer Center, La Jolla, California 92093-0658, USA
| | - Grace Paik
- Moores University of California San Diego Cancer Center, La Jolla, California 92093-0658, USA
| | - Brenda Kustin
- Moores University of California San Diego Cancer Center, La Jolla, California 92093-0658, USA
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Sambamoorthi U, McAlpine DD. Racial, ethnic, socioeconomic, and access disparities in the use of preventive services among women. Prev Med 2003; 37:475-84. [PMID: 14572431 DOI: 10.1016/s0091-7435(03)00172-5] [Citation(s) in RCA: 212] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND In this article we estimate the variations in receipt of age-appropriate preventive services among adult women between 21 and 64 years of age, by race and ethnic group, socioeconomic status, and access to health care. We also assess whether differences in access to care and socioeconomic status may explain racial and ethnic differences in the use of preventive services. METHOD Nationally representative data on adult women from the Medical Expenditure Panel Survey were used to estimate the effect of socioeconomic characteristics on the receipt of each preventive service. Receipt of each of four preventive services-cholesterol test, blood pressure reading, and two cancer screening tests (Papanicolaou smear, mammogram)-according to the 1996 recommendations of the U.S. Preventive Services Task Force were examined. RESULTS An overwhelming majority of adult women (93%) had had a blood pressure reading within the last 2 years. Eighty-four percent of women had had their cholesterol checked within the last 5 years. Seventy-five percent of women had received a mammogram and 80% received Pap tests. College education, high income, usual source of care, and health insurance consistently predicted use of preventive services. These factors also explained ethnic disparities in the receipt of preventive services between Latinas and white women. CONCLUSIONS The results from our study are encouraging because only a minority of women do not receive age-appropriate preventive services. However, low socioeconomic status, lack of insurance, and lack of a usual source of care represent significant barriers to preventive care for adult women.
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Affiliation(s)
- Usha Sambamoorthi
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 30 College Avenue, New Brunswick, NJ 08901, USA.
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