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Ganz EM, Brown B, Smith H, Wellisch L, Gupta M, Wagner SM. The association between affordable care act implementation and the prevalence of women having ever received a Pap smear. J OBSTET GYNAECOL 2024; 44:2393359. [PMID: 39176454 DOI: 10.1080/01443615.2024.2393359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 08/12/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND To assess if implementation of the 2010 Patient Protection and Affordable Care Act (ACA) was associated with changes in the prevalence of women having ever received a pap smear. METHODS This study utilised the publicly available Centre for Disease Control National Survey of Family Growth (NSFG) data set. This was a serial cross-sectional study. The comparison groups were defined as women who received cancer screening and prevention interventions prior to full implementation of the ACA (2011-2013) and post full implementation (2017-2019). The primary outcome was self-reporting receipt of a Papanicolaou (Pap) smear. Secondary outcomes included HPV vaccination and mammogram rates. Anonymized patient information was collected from the nationally representative dataset, and analyses were performed utilising STATA 18. RESULTS The two study cohorts obtained from the NSFG included women who responded in 2011-2013 (n = 5601), deemed to be 'Pre-ACA implementation' (Pre ACA), and those who responded in 2017-2019 (n = 6141) 'Post-ACA implementation' (Post ACA). The proportion of women who were 21 years and older and ever had a Pap smear in the Pre ACA group (96.0%) was higher than that of the Post ACA group (94.1%) (OR 0.66 (0.49-0.91)). In contrast, HPV vaccination rates rose, and mammogram rates remained stable in the Post ACA period. CONCLUSION A decrease in proportion of women ever having had a Pap smear despite implementation of health policies to increase access to preventive measures suggests further interventions to improve access to cervical cancer screening are warranted.
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Affiliation(s)
- Eric M Ganz
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Benjamin Brown
- Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Heather Smith
- Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Lawren Wellisch
- Brown University School of Public Health, Providence, RI, USA
| | - Megha Gupta
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Stephen M Wagner
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA
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Akinyemi OA, Awolumate O, Fasokun ME, Odusanya E, Lasisi O, Ugwendum D, Weldeslase TA, Babalola OO, Belie FM, Micheal M. Impact of the Implementation of the Affordability Care Act on Gastric Cancer Survival Rates. Cureus 2024; 16:e64139. [PMID: 39119406 PMCID: PMC11309743 DOI: 10.7759/cureus.64139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction Gastric cancer, a significant public health concern, remains one of the most challenging malignancies to treat effectively. In the United States, survival rates for gastric cancer have historically been low, partly due to late-stage diagnosis and disparities in access to care. The Affordable Care Act (ACA) sought to address such disparities by expanding healthcare coverage and improving access to preventive and early treatment services. Objective This study aims to determine the causal effects of the ACA's implementation on gastric cancer survival rates, focusing on a comparative analysis between two distinct U.S. states: New Jersey, which fully embraced ACA provisions, and Georgia, which has not adopted the policy, as of 2023. Methods In this retrospective analysis, we utilized data from the Surveillance, Epidemiology, and End Results Program (SEER) registry to assess the impact of the ACA on cancer-specific survival (CSS) among gastric cancer patients. The study spanned the period from 2000 to 2020, divided into pre-ACA (2000-2013) and post-ACA (2016-2020) periods, with a two-year washout (2013-2015). We compared Georgia (a non-expansion state) to New Jersey (an expansion state since 2014) using a Difference-in-Differences (DiD) approach. We adjusted for patient demographics, income, metropolitan status, disease stage, and treatment modalities. Results Among 25,061 patients, 58.7% were in New Jersey (14,711), while 41.3% were in Georgia (10,350). The pre-ACA period included 18,878 patients (40.0% in Georgia and 60.0% in New Jersey), and 6,183 patients were in the post-ACA period (45.2% in Georgia and 54.8% in New Jersey). The post-ACA period was associated with a 20% reduction in mortality hazard among gastric cancer patients, irrespective of the state of residence (HR = 0.80, 95% CI: 0.73-0.88). Patients who were residents of New Jersey experienced a 12% reduction in mortality hazard compared to those who resided in Georgia in the post-ACA period (HR = 0.88, 95% CI: 0.78-0.99). Other factors linked to improved survival outcomes included surgery (OR = 0.30, 95% CI: 0.28-0.34) and female gender (OR=0.83, 95% CI: 0.76-0.91). Conclusion The study underscores the ACA's potential positive impact on CSS among gastric cancer patients, emphasizing the importance of healthcare policy interventions in improving patient outcomes.
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Affiliation(s)
- Oluwasegun A Akinyemi
- Health Policy and Management, University of Maryland School of Public Health, College Park, USA
- Surgery, Howard University College of Medicine, Washington, D.C., USA
| | - Oluwatayo Awolumate
- Internal Medicine, Howard University College of Medicine, Washington, D.C., USA
| | - Mojisola E Fasokun
- Epidemiology and Public Health, University of Alabama at Birmingham, Birmingham, USA
| | - Eunice Odusanya
- Obstetrics and Gynecology, Howard University College of Medicine, Washington, D.C., USA
| | - Oluwatobi Lasisi
- Family Medicine, Howard University College of Medicine, Washington, D.C., USA
| | - Derek Ugwendum
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | | | | | - Funmilola M Belie
- Public Health, Southern Connecticut State University, New Haven, USA
| | - Miriam Micheal
- Internal Medicine, Howard University College of Medicine, Washington, D.C., USA
- Internal Medicine, University of Maryland School of Medicine, Baltimore, USA
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Smani S, Novosel M, Sutherland R, Jeong F, Jalfon M, Marks V, Rajwa P, Nolazco JI, Washington SL, Renzulli JF, Sprenkle P, Kim IY, Leapman MS. Association between sociodemographic factors and diagnosis of lethal prostate cancer in early life. Urol Oncol 2024; 42:28.e9-28.e20. [PMID: 38161105 DOI: 10.1016/j.urolonc.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/22/2023] [Accepted: 10/16/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE A subset of patients are diagnosed with lethal prostate cancer (CaP) early in life before prostate-specific antigen (PSA) screening is typically initiated. To identify opportunities for improved detection, we evaluated patient sociodemographic factors associated with advanced vs. localized (CaP) diagnosis across the age spectrum. METHODS We conducted a retrospective cohort study using the National Cancer Database, identifying patients diagnosed with CaP from 2004 to 2020. We compared characteristics of patients diagnosed at the advanced (cN1 or M1) versus localized (cT1-4N0M0) stage. Using multivariable logistic regression, we evaluated the associations among patient clinical and sociodemographic factors and advanced diagnosis, stratifying patients by age as ≤55 (before screening is recommended for most patients), 56 to 65, 66 to 75, and ≥76 years. RESULTS We identified 977,722 patients who met the inclusion criteria. The mean age at diagnosis was 65.3 years and 50,663 (5.1%) had advanced disease. Overall, uninsured (OR = 3.20, 95% CI 3.03-3.78) and Medicaid-insured (OR 2.58, 95% CI 2.48-2.69) vs. privately insured status was associated with higher odds of diagnosis with advanced disease and this effect was more pronounced for younger patients. Among patients ≤55 years, uninsured (OR 4.14, 95% CI 3.69-4.65) and Medicaid-insured (OR 3.39, 95% CI 3.10-3.72) vs. privately insured patients were associated with higher odds of advanced cancer at diagnosis. Similarly, residence in the lowest vs. highest income quartile was associated with increased odds of advanced CaP in patients ≤55 years (OR 1.15, 95% CI 1.02-1.30). Black vs. White race was associated with increased odds of advanced CaP at diagnosis later in life (OR 1.17, 95% CI 1.09-1.25); however, race was not significantly associated with advanced stage CaP in those ≤55 years (P = 0.635). CONCLUSIONS Sociodemographic disparities in diagnosis at advanced stages of CaP were more pronounced in younger patients, particularly with respect to insurance status. These findings may support greater attention to differential use of early CaP screening based on patient health insurance.
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Affiliation(s)
| | | | | | | | - Michael Jalfon
- Department of Urology, Yale School of Medicine, New Haven, CT
| | | | - Paweł Rajwa
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - José Ignacio Nolazco
- Division of Urological Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA; Servicio de Urología, Hospital Universitario Austral, Universidad Austral, Pilar, Argentina
| | | | | | | | - Isaac Y Kim
- Department of Urology, Yale School of Medicine, New Haven, CT
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Howard DH, Tangka FK, Miller J, Sabatino SA. Variation in State-Level Mammography Use, 2012 and 2020. Public Health Rep 2024; 139:59-65. [PMID: 36927203 PMCID: PMC10905756 DOI: 10.1177/00333549231155876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES Mammography is a screening tool for early detection of breast cancer. Uptake in screening use in states can be influenced by Medicaid coverage and eligibility policies, public health outreach efforts, and the Centers for Disease Control and Prevention-funded National Breast and Cervical Cancer Early Detection Program. We described state-specific mammography use in 2020 and changes as compared with 2012. METHODS We estimated the proportion of women aged ≥40 years who reported receiving a mammogram in the past 2 years, by age group, state, and demographic and socioeconomic characteristics, using 2020 Behavioral Risk Factor Surveillance System data. We also compared 2020 state estimates with 2012 estimates. RESULTS The proportion of women aged 50-74 years who received a mammogram in the past 2 years was 78.1% (95% CI, 77.4%-78.8%) in 2020. Across measures of socioeconomic status, mammography use was generally lower among women who did not have health insurance (52.0%; 95% CI, 48.3%-55.6%) than among those who did (79.9%; 95% CI, 79.3%-80.6%) and among those who had a usual source of care (49.4%; 95% CI, 46.1%-52.7%) than among those who did not (81.0%; 95% CI, 80.4%-81.7%). Among women aged 50-74 years, mammography use varied across states, from a low of 65.2% (95% CI, 61.4%-69.0%) in Wyoming to a high of 86.1% (95% CI, 83.8%-88.3%) in Massachusetts. Four states had significant increases in mammography use from 2012 to 2020, and 8 states had significant declines. CONCLUSION Mammography use varied widely among states. Use of evidence-based interventions tailored to the needs of local populations and communities may help close gaps in the use of mammography.
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Affiliation(s)
- David H. Howard
- Department of Health Policy and Management, Winship Cancer Center, Emory University, Atlanta, GA, USA
| | - Florence K.L. Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jacqueline Miller
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Susan A. Sabatino
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Hall JM, Mkuu RS, Cho HD, Woodard JN, Kaye FJ, Bian J, Shenkman EA, Guo Y. Disparities Contributing to Late-Stage Diagnosis of Lung, Colorectal, Breast, and Cervical Cancers: Rural and Urban Poverty in Florida. Cancers (Basel) 2023; 15:5226. [PMID: 37958400 PMCID: PMC10647213 DOI: 10.3390/cancers15215226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Despite advances in cancer screening, late-stage cancer diagnosis is still a major cause of morbidity and mortality in the United States. In this study, we aim to understand demographic and geographic factors associated with receiving a late-stage diagnosis (LSD) of lung, colorectal, breast, or cervical cancer. (1) Methods: We analyzed data of patients with a cancer diagnosis between 2016 and 2020 from the Florida Cancer Data System (FCDS), a statewide population-based registry. To investigate correlates of LSD, we estimated multi-variable logistic regression models for each cancer while controlling for age, sex, race, insurance, and census tract rurality and poverty. (2) Results: Patients from high-poverty rural areas had higher odds for LSD of lung (OR = 1.23, 95% CI (1.10, 1.37)) and breast cancer (OR = 1.31, 95% CI (1.17,1.47)) than patients from low-poverty urban areas. Patients in high-poverty urban areas saw higher odds of LSD for lung (OR = 1.05 95% CI (1.00, 1.09)), breast (OR = 1.10, 95% CI (1.06, 1.14)), and cervical cancer (OR = 1.19, 95% CI (1.03, 1.37)). (3) Conclusions: Financial barriers contributing to decreased access to care likely drive LSD for cancer in rural and urban communities of Florida.
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Affiliation(s)
- Jaclyn M. Hall
- Department of Health Outcomes and Biomedical Informatics, University of Florida, 2199 Mowry Road, Gainesville, FL 32611, USA; (R.S.M.); (H.D.C.); (J.N.W.); (J.B.); (E.A.S.); (Y.G.)
- Cancer Informatics Shared Resource, University of Florida Health Cancer Center, 2033 Mowry Road, Gainesville, FL 32610, USA
| | - Rahma S. Mkuu
- Department of Health Outcomes and Biomedical Informatics, University of Florida, 2199 Mowry Road, Gainesville, FL 32611, USA; (R.S.M.); (H.D.C.); (J.N.W.); (J.B.); (E.A.S.); (Y.G.)
| | - Hee Deok Cho
- Department of Health Outcomes and Biomedical Informatics, University of Florida, 2199 Mowry Road, Gainesville, FL 32611, USA; (R.S.M.); (H.D.C.); (J.N.W.); (J.B.); (E.A.S.); (Y.G.)
- Cancer Informatics Shared Resource, University of Florida Health Cancer Center, 2033 Mowry Road, Gainesville, FL 32610, USA
| | - Jennifer N. Woodard
- Department of Health Outcomes and Biomedical Informatics, University of Florida, 2199 Mowry Road, Gainesville, FL 32611, USA; (R.S.M.); (H.D.C.); (J.N.W.); (J.B.); (E.A.S.); (Y.G.)
- Community Outreach and Engagement, University of Florida Health Cancer Center, 2033 Mowry Road, Gainesville, FL 32610, USA
| | - Frederic J. Kaye
- Division of Hematology and Oncology, Department of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA;
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, University of Florida, 2199 Mowry Road, Gainesville, FL 32611, USA; (R.S.M.); (H.D.C.); (J.N.W.); (J.B.); (E.A.S.); (Y.G.)
- Cancer Informatics Shared Resource, University of Florida Health Cancer Center, 2033 Mowry Road, Gainesville, FL 32610, USA
| | - Elizabeth A. Shenkman
- Department of Health Outcomes and Biomedical Informatics, University of Florida, 2199 Mowry Road, Gainesville, FL 32611, USA; (R.S.M.); (H.D.C.); (J.N.W.); (J.B.); (E.A.S.); (Y.G.)
| | - Yi Guo
- Department of Health Outcomes and Biomedical Informatics, University of Florida, 2199 Mowry Road, Gainesville, FL 32611, USA; (R.S.M.); (H.D.C.); (J.N.W.); (J.B.); (E.A.S.); (Y.G.)
- Cancer Informatics Shared Resource, University of Florida Health Cancer Center, 2033 Mowry Road, Gainesville, FL 32610, USA
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6
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Li M, Vega EA, Mellado S, Salehi O, Kozyreva O, Conrad C. Colorectal cancer in young patients below screening age - Demographic and socioeconomic factors associated with incidence and survival. Surg Oncol 2023; 46:101906. [PMID: 36738697 DOI: 10.1016/j.suronc.2023.101906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/23/2022] [Accepted: 01/22/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND While early onset colorectal cancer (EOCRC) has previously been defined as CRC in patients younger than age 50, recent screening guidelines have been lowered to 45. With more younger patients aged 45-50 are now being screened, incidence trend and outcomes of very early EOCRC (20-44) remains unclear. METHOD Surveillance, Epidemiology, and End Results database was analyzed between 2006 and 2016 using Joinpoint tool to evaluate annual percentage change (APC) in incident rates, focusing on race/ethnicity and socioeconomic status (SES). Cancer specific survival (CSS) was assessed using univariate and multivariate analysis. RESULTS 41,815 EOCRC patients met inclusion criteria. Incidence has increased significantly in both age groups (APC in age group 20-44 = 1.21 and 45-49 = 1.06). Increase incidence of very early EOCRC was observed in White and Hispanic racial/ethnic groups (ACP 1.68 and 2.63), as well as population from counties with high poverty, unemployment, language barrier, foreign born resident, and high school dropout rates (ACP 2.07, 1.87, 1.21, 1.28 and 2.02 respectively). Further, the 5-year CSS was worse in Black patients, and patients from counties with high poverty, unemployment and high school dropouts rates (Age group 20-44, 63.11%, 66.39%, 67.48% and 66.95% respectively). On multivariate analysis, living in high poverty counties was an independent risk factor for poorer CSS for very early EOCRC (HR 1.20, 95% CI 1.07-1.34, p = 0.002). Multivariate analysis was adjusted by sex, pathology type, site of disease, disease extension and surgical treatment history. CONCLUSION Very early EOCRC incidence increases in White, Hispanic and poor patients, and outcomes are worse for minority and low-income patients. Further study on very early EOCRC is needed among those patients.
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Affiliation(s)
- Mu Li
- Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | | | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Wu J, Moss H. Financial Toxicity in the Post-Health Reform Era. J Am Coll Radiol 2023; 20:10-17. [PMID: 36509218 DOI: 10.1016/j.jacr.2022.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/21/2022] [Accepted: 09/27/2022] [Indexed: 12/13/2022]
Abstract
The Patient Protection and Affordable Care Act (ACA), enacted in March 2010, was comprehensive health care reform legislation aimed to improve health care access and quality of care and curb health care-related costs. This review focuses on key provisions of the ACA and their impact on financial toxicity. We will focus our review on cancer care, because this is the most commonly studied disease process in respect to financial toxicity. Patients with cancer face rising expenditures and financial burden, which in turn impact quality of life, compliance to treatment, and survival outcomes. Health insurance expansion include dependent-coverage expansion, Medicaid expansion, and establishment of the Marketplace. Coverage reform focused on reducing financial barriers by limiting cost sharing. Payment reforms included new innovative payment and delivery systems to focus on improving outcomes and reducing costs. Challenges remain as efforts to reduce costs have led to the expansion of insurance plans, such as high-deductible health plans, that may ultimately worsen financial toxicity in cancer and high out-of-pocket costs for further diagnostic testing and procedures. Further research is necessary to evaluate the long-term impacts of the ACA provisions-and threats to the ACA-on outcomes and the costs accrued by patients.
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Affiliation(s)
- Jenny Wu
- Resident, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.
| | - Haley Moss
- Assistant Professor, Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
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Shafer PR, Dusetzina SB, Sabik LM, Platts-Mills TF, Stearns SC, Trogdon JG. High Deductible Health Plans and Use of Free Preventive Services Under the Affordable Care Act. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231182512. [PMID: 37329296 DOI: 10.1177/00469580231182512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
The Affordable Care Act aimed to increase use of preventive services by eliminating cost-sharing to consumers. However, patients may be unaware of this benefit or they may not seek preventive services if they anticipate that the cost of potential diagnostic or treatment services will be too high, both more likely among those in high deductible health plans. We used nationally representative private health insurance claims (100% sample of IBM® MarketScan®) for the United States from 2006 to 2018, restricting the data to enrollment and claims for non-elderly adults who were enrolled for the full plan year. The cross-sectional sample (185 million person-years) is used to describe trends in preventive service use and costs from 2008 through 2016. The cohort sample (9 million people) focuses on the elimination of cost-sharing for certain high-value preventive services in late 2010, requiring continuous enrollment across 2010 and 2011. We examine whether HDHP enrollment is associated with use of eligible preventive services using semi-parametric difference-in-differences to account for endogenous plan selection. Our preferred model implies that HDHP enrollment was associated with a reduction of the post-ACA change in any use of eligible preventive services by 0.2 percentage points or 12.5%. Cancer screenings were unaffected but HDHP enrollment was associated with smaller increases in wellness visits, immunizations, and screening for chronic conditions and sexually transmitted infections. We also find that the policy was ineffective at reducing out-of-pocket costs for the eligible preventive services, likely due to implementation issues.
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Affiliation(s)
- Paul R Shafer
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, MA, USA
| | | | - Lindsay M Sabik
- School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Sally C Stearns
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Liu Y, Pan IWE, Tak HJ, Vlahos I, Volk R, Shih YCT. Assessment of Uptake Appropriateness of Computed Tomography for Lung Cancer Screening According to Patients Meeting Eligibility Criteria of the US Preventive Services Task Force. JAMA Netw Open 2022; 5:e2243163. [PMID: 36409492 PMCID: PMC9679877 DOI: 10.1001/jamanetworkopen.2022.43163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022] Open
Abstract
Importance Currently, computed tomography (CT) is used for lung cancer screening (LCS) among populations with various levels of compliance to the eligibility criteria from the US Preventive Services Task Force (USPSTF) recommendations and may represent suboptimal allocation of health care resources. Objective To evaluate the appropriateness of CT LCS according to the USPSTF eligibility criteria. Design, Setting, and Participants This cross-sectional study used the 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey. Participants included individuals who responded to the LCS module administered in 20 states and had valid answers to questions regarding screening and smoking history. Data were analyzed between October 2021 and August 2022. Exposures Screening eligibility groups were categorized according to the USPSTF 2013 recommendations, and subgroups of individuals who underwent LCS were analyzed. Main Outcomes and Measures Main outcomes included LCS among the screening-eligible population and the proportions of the screened populations according to compliance categories established from the USPSTF 2013 and 2021 recommendations. In addition, the association between respondents' characteristics and LCS was evaluated for the subgroup who were screened despite not meeting any of the 3 USPSTF screening criteria: age, pack-year, and years since quitting smoking. Results A total of 96 097 respondents were identified for the full study cohort, and 2 subgroups were constructed: (1) 3374 respondents who reported having a CT or computerized axial tomography to check for lung cancer and (2) 33 809 respondents who did not meet any screening eligibility criteria. The proportion of participants who were under 50 years old was 53.1%; between 50 and 54, 9.1%; between 55 and 79, 33.8%; and over 80, 4.0%. A total of 51 536 (50.9%) of the participants were female. According to the USPSTF 2013 recommendation, 807 (12.8%) of the screening-eligible population underwent LCS. Among those who were screened, only 807 (20.9%) met all 3 screening eligibility criteria, whereas 538 (20.1%) failed to meet any criteria. Among respondents in subgroup 2, being of older age and having a history of stroke, chronic obstructive pulmonary disease, kidney disease, or diabetes were associated with higher likelihood of LCS. Conclusions and Relevance In this cross-sectional study of the BRFSS 2019 survey, the low uptake rate among screening-eligible patients undermined the goal of LCS of early detection. Suboptimal screening patterns could increase health system costs and add financial stress, psychological burden, and physical harms to low-risk patients, while failing to provide high-quality preventive services to individuals at high risk of lung cancer.
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Affiliation(s)
- Yu Liu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - I-Wen Elaine Pan
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Hyo Jung Tak
- Department of Health Services Research and Administration, University of Nebraska Medical Center, Omaha
| | - Ioannis Vlahos
- Thoracic Imaging Department, The University of Texas MD Anderson Cancer Center, Houston
| | - Robert Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
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10
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Friedman AS, Thomas S, Suttiratana SC. Differences in Cancer Screening Responses to State Medicaid Expansions by Race and Ethnicity, 2011‒2019. Am J Public Health 2022; 112:1630-1639. [PMID: 36223588 PMCID: PMC9558180 DOI: 10.2105/ajph.2022.307027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To estimate whether state Medicaid expansions' relationships to breast, cervical, and colorectal cancer screening differ by race/ethnicity. Methods. Analyses conducted in 2021 used 2011-2016 and 2018-2019 Behavioral Risk Factor Surveillance System data on adults aged 40 to 64 years with household incomes below 400% of the federal poverty guideline (FPG; n = 537 250). Triple-difference analyses compared cancer screening in Medicaid expansion versus nonexpansion states, before versus after expansion, among people with incomes above versus below the eligibility cutoff (138% FPG). Race/ethnicity and ethnicity-by-language interaction terms tested for effect modification. Results. Associations between Medicaid expansions and cancer screening were significant for past-2-year mammograms and past-5-year colorectal screening. Effect modification analyses showed elevated mammography among non-Hispanic Asian women (+9.0 percentage points; 95% confidence interval [CI] = 3.2, 14.8) and Hispanic women (+6.0 percentage points; 95% CI = 2.0, 10.1), and Papanicolaou tests among Hispanic women (+4.2 percentage points; 95% CI = 0.1, 8.2). Findings were not limited to English- or Spanish-speaking respondents and were robust to insurance status controls. Conclusions. Medicaid expansions yielded statistically significant increases in income-eligible Asian and Hispanic women's mammography and Hispanic women's Pap testing relative to non-Hispanic White women. Neither language proficiency nor insurance status explained these findings. (Am J Public Health. 2022;112(11):1630-1639. https://doi.org/10.2105/AJPH.2022.307027).
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Affiliation(s)
- Abigail S Friedman
- Abigail S. Friedman and Sakinah C. Suttiratana are with the Yale School of Public Health, New Haven, CT. Sasha Thomas is with Yale College, New Haven
| | - Sasha Thomas
- Abigail S. Friedman and Sakinah C. Suttiratana are with the Yale School of Public Health, New Haven, CT. Sasha Thomas is with Yale College, New Haven
| | - Sakinah C Suttiratana
- Abigail S. Friedman and Sakinah C. Suttiratana are with the Yale School of Public Health, New Haven, CT. Sasha Thomas is with Yale College, New Haven
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11
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Koroukian SM, Dong W, Albert JM, Kim U, Eom KY, Rose J, Owusu C, Zanotti KM, Cooper GS, Tsui J. Post-Affordable Care Act Improvements in Cancer Stage Among Ohio Medicaid Beneficiaries Resulted From an Increase in Stable Coverage. Med Care 2022; 60:821-830. [PMID: 36098269 DOI: 10.1097/mlr.0000000000001779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The mechanisms underlying improvements in early-stage cancer at diagnosis following Medicaid expansion remain unknown. We hypothesized that Medicaid expansion allowed for low-income adults to enroll in Medicaid before cancer diagnosis, thus increasing the number of stably-enrolled relative to those who enroll in Medicaid only after diagnosis (emergently-enrolled). METHODS Using data from the 2011-2017 Ohio Cancer Incidence Surveillance System and Medicaid enrollment files, we identified individuals diagnosed with incident invasive breast (n=4850), cervical (n=1023), and colorectal (n=3363) cancer. We conducted causal mediation analysis to estimate the direct effect of pre- (vs. post-) expansion on being diagnosed with early-stage (-vs. regional-stage and distant-stage) disease, and indirect (mediation) effect through being in the stably- (vs. emergently-) enrolled group, controlling for individual-level and area-level characteristics. RESULTS The percentage of stably-enrolled patients increased from 63.3% to 73.9% post-expansion, while that of the emergently-enrolled decreased from 36.7% to 26.1%. The percentage of patients with early-stage diagnosis remained 1.3-2.9 times higher among the stably-than the emergently-enrolled group, both pre-expansion and post-expansion. Results from the causal mediation analysis showed that there was an indirect effect of Medicaid expansion through being in the stably- (vs. emergently-) enrolled group [risk ratios with 95% confidence interval: 1.018 (1.010-1.027) for breast cancer, 1.115 (1.064-1.167) for cervical cancer, and 1.090 (1.062-1.118) for colorectal cancer. CONCLUSION We provide the first evidence that post-expansion improvements in cancer stage were caused by an increased reliance on Medicaid as a source of stable insurance coverage.
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Affiliation(s)
- Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University
- Case Comprehensive Cancer Center, Case Western Reserve University
- Center for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Weichuan Dong
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University
| | - Jeffrey M Albert
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University
| | - Uriel Kim
- Kellogg School of Management, Northwestern University, Evanston, IL
| | - Kirsten Y Eom
- Public Health Research Institute, The MetroHealth System and Case Western Reserve University
| | - Johnie Rose
- Case Comprehensive Cancer Center, Case Western Reserve University
- Center for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Cynthia Owusu
- Case Comprehensive Cancer Center, Case Western Reserve University
- Department of Internal Medicine, University Hospitals of Cleveland, School of Medicine, Case Western Reserve University
| | - Kristine M Zanotti
- Case Comprehensive Cancer Center, Case Western Reserve University
- Department of Obstetrics and Gynecology, Gynecologic Oncology, University Hospitals of Cleveland, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Gregory S Cooper
- Case Comprehensive Cancer Center, Case Western Reserve University
- Department of Internal Medicine, University Hospitals of Cleveland, School of Medicine, Case Western Reserve University
| | - Jennifer Tsui
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
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12
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Huepenbecker SP, Fu S, Sun CC, Zhao H, Primm KM, Giordano SH, Meyer LA. Medicaid expansion and 2-year survival in women with gynecologic cancer: a difference-in-difference analysis. Am J Obstet Gynecol 2022; 227:482.e1-482.e15. [PMID: 35500609 PMCID: PMC9420833 DOI: 10.1016/j.ajog.2022.04.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/15/2022] [Accepted: 04/23/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Affordable Care Act implemented optional Medicaid expansion starting in 2014, but the association between Medicaid expansion and gynecologic cancer survival is unknown. OBJECTIVE To evaluate the impact of Medicaid expansion by comparing 2-year survival among gynecologic cancers before and after 2014 in states that did and did not expand Medicaid using a difference-in-difference analysis. STUDY DESIGN We searched the National Cancer Database for women aged 40 to 64 years, diagnosed with a primary gynecologic malignancy (endometrial, ovarian, cervical, vulvar, and vaginal) between 2010 and 2016. We used a quasiexperimental difference-in-difference multivariable Cox regression analysis to compare 2-year survival between states that expanded Medicaid in January 2014 and states that did not expand Medicaid as of 2016. We performed univariable subgroup difference-in-difference Cox regression analyses on the basis of stage, income, race, ethnicity, and geographic location. Adjusted linear difference-in-difference regressions evaluated the proportion of uninsured patients on the basis of expansion status after 2014. We evaluated adjusted Kaplan-Meier curves to examine differences on the basis of study period and expansion status. RESULTS Our sample included 169,731 women, including 78,669 (46.3%) in expansion states and 91,062 (53.7%) in nonexpansion states. There was improved 2-year survival on adjusted difference-in-difference Cox regressions for women with ovarian cancer in expansion than in nonexpansion states after 2014 (hazard ratio, 0.88; 95% confidence interval, 0.82-0.94; P<.001) with no differences in endometrial, cervical, vaginal, vulvar, or combined gynecologic cancer sites on the basis of expansion status. On univariable subgroup difference-in-difference Cox analyses, women with ovarian cancer with stage III-IV disease (P=.008), non-Hispanic ethnicity (P=.042), those in the South (P=.016), and women with vulvar cancer in the Northeast (P=.022), had improved 2-year survival in expansion than in nonexpansion states after 2014. In contrast, women with cervical cancer in the South (P=.018) had worse 2-year survival in expansion than in nonexpansion states after 2014. All cancer sites had lower proportions of uninsured patients in expansion than in nonexpansion states after 2014. CONCLUSION There was a significant association between Medicaid expansion and improved 2-year survival for women with ovarian cancer in states that expanded Medicaid after 2014. Despite improved insurance coverage, racial, ethnic, and regional survival differences exist between expansion and nonexpansion states.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Shuangshuang Fu
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Hui Zhao
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Kristin M Primm
- Department of Epidemiology, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Sharon H Giordano
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX.
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13
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Millar MM, Edwards SL, Herget KA, Orleans B, Ofori‐Atta BS, Kirchhoff AC, Carter ME, Nagata M, Sweeney C. Adherence to Guideline-Recommended cancer screening among Utah cancer survivors. Cancer Med 2022; 12:3543-3554. [PMID: 36029153 PMCID: PMC9939153 DOI: 10.1002/cam4.5168] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/04/2022] [Accepted: 08/08/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Adherence to cancer screening is important for cancer survivors because they are at high risk of subsequent cancer diagnoses or recurrence. We assessed adherence to breast, cervical, and colorectal cancer-(CRC)-screening guidelines and evaluated demographic disparities among a population-based sample of survivors. METHODS A representative sample of Utah survivors diagnosed from 2012-2018 with any reportable invasive cancer was selected from central cancer registry records for a survey about survivorship needs. We estimated the proportion of eligible survivors adhering to U.S. Preventive Services Task Force screening guidelines and calculated risk ratios and 95% confidence intervals. Analyses were age-adjusted and weighted to account for sample design and nonresponse. RESULTS And 1421 survivors completed the survey (57.2% response rate). Screening adherence was 74.4% for breast, 69.4% for cervical, and 79.7% for CRC. Rural residents were more likely to adhere to breast cancer screening than urban residents (86.1% vs. 72.7%; adjusted RR = 1.19, CI = 1.05, 1.36). Higher educational attainment was associated with increased adherence to cervical and colorectal cancer screening. Younger age was associated with greater adherence to cervical cancer screening (p = 0.006) but lower adherence to CRC screening (p = 0.003). CRC screening adherence was lower among the uninsured and those without a primary care provider (45.6%) compared to those with a regular provider (83.0%; adjusted RR = 0.57, CI = 0.42, 0.79). CONCLUSIONS Surveys based on samples from central cancer registries can provide population estimates to inform cancer control. Findings demonstrate work is needed to ensure all Utah cancer survivors obtain recommended cancer screenings. Efforts should focus particularly on increasing uptake of breast and cervical cancer screening and reducing demographic disparities in CRC screening. PRECIS Despite high risk for subsequent cancer diagnosis, Utah cancer survivors are not all obtaining recommended breast, cervical, and colorectal cancer screenings. This presents a significant healthcare gap.
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Affiliation(s)
- Morgan M. Millar
- Utah Cancer RegistryUniversity of UtahSalt Lake CityUtahUSA,Division of EpidemiologyUniversity of UtahSalt Lake CityUtahUSA,Huntsman Cancer InstituteUniversity of UtahSalt Lake CityUtahUSA
| | | | | | - Brian Orleans
- Huntsman Cancer InstituteUniversity of UtahSalt Lake CityUtahUSA
| | | | - Anne C. Kirchhoff
- Huntsman Cancer InstituteUniversity of UtahSalt Lake CityUtahUSA,Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | | | - Marie Nagata
- Breast and Cervical Cancer Early Detection Program, Utah Department of Health and Human ServicesSalt Lake CityUtahUSA
| | - Carol Sweeney
- Utah Cancer RegistryUniversity of UtahSalt Lake CityUtahUSA,Division of EpidemiologyUniversity of UtahSalt Lake CityUtahUSA,Huntsman Cancer InstituteUniversity of UtahSalt Lake CityUtahUSA
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Martinez ME, Gomez SL, Canchola AJ, Oh DL, Murphy JD, Mehtsun W, Yabroff KR, Banegas MP. Changes in Cancer Mortality by Race and Ethnicity Following the Implementation of the Affordable Care Act in California. Front Oncol 2022; 12:916167. [PMID: 35912225 PMCID: PMC9327742 DOI: 10.3389/fonc.2022.916167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
Although Affordable Care Act (ACA) implementation has improved cancer outcomes, less is known about how much the improvement applies to different racial and ethnic populations. We examined changes in health insurance coverage and cancer-specific mortality rates by race/ethnicity pre- and post-ACA. We identified newly diagnosed breast (n = 117,738), colorectal (n = 38,334), and cervical cancer (n = 11,109) patients < 65 years in California 2007-2017. Hazard rate ratios (HRR) and 95% confidence intervals (CI) were calculated using multivariable Cox regression to estimate risk of cancer-specific death pre- (2007-2010) and post-ACA (2014-2017) and by race/ethnicity [American Indian/Alaska Natives (AIAN); Asian American; Hispanic; Native Hawaiian or Pacific Islander (NHPI); non-Hispanic Black (NHB); non-Hispanic white (NHW)]. Cancer-specific mortality from colorectal cancer was lower post-ACA among Hispanic (HRR = 0.82, 95% CI = 0.74 to 0.92), NHB (HRR = 0.69, 95% CI = 0.58 to 0.82), and NHW (HRR = 0.90; 95% CI = 0.84 to 0.97) but not Asian American (HRR = 0.95, 95% CI = 0.82 to 1.10) patients. We observed a lower risk of death from cervical cancer post-ACA among NHB women (HRR = 0.68, 95% CI = 0.47 to 0.99). No statistically significant differences in breast cancer-specific mortality were observed for any racial or ethnic group. Cancer-specific mortality decreased following ACA implementation for colorectal and cervical cancers for some racial and ethnic groups in California, suggesting Medicaid expansion is associated with reductions in health inequity.
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Affiliation(s)
- Maria Elena Martinez
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA, United States
- Moores Cancer Center, University of California, San Diego, La Jolla, CA, United States
| | - Scarlett L. Gomez
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, United States
| | - Alison J. Canchola
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Debora L. Oh
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - James D. Murphy
- Moores Cancer Center, University of California, San Diego, La Jolla, CA, United States
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego School of Medicine, La Jolla, CA, United States
| | - Winta Mehtsun
- Moores Cancer Center, University of California, San Diego, La Jolla, CA, United States
- Department of Surgery, University of California, San Diego School of Medicine, La Jolla, CA, United States
| | - K. Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Kennesaw, GA, United States
| | - Matthew P. Banegas
- Moores Cancer Center, University of California, San Diego, La Jolla, CA, United States
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego School of Medicine, La Jolla, CA, United States
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15
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Shih YCT, Sabik LM, Stout NK, Halpern MT, Lipscomb J, Ramsey S, Ritzwoller DP. Health Economics Research in Cancer Screening: Research Opportunities, Challenges, and Future Directions. J Natl Cancer Inst Monogr 2022; 2022:42-50. [PMID: 35788368 PMCID: PMC9255920 DOI: 10.1093/jncimonographs/lgac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/03/2022] [Indexed: 01/26/2023] Open
Abstract
Cancer screening has long been considered a worthy public health investment. Health economics offers the theoretical foundation and research methodology to understand the demand- and supply-side factors associated with screening and evaluate screening-related policies and interventions. This article provides an overview of health economic theories and methods related to cancer screening and discusses opportunities for future research. We review 2 academic disciplines most relevant to health economics research in cancer screening: applied microeconomics and decision science. We consider 3 emerging topics: cancer screening policies in national as well as local contexts, "choosing wisely" screening practices, and targeted screening efforts for vulnerable subpopulations. We also discuss the strengths and weaknesses of available data sources and opportunities for methodological research and training. Recommendations to strengthen research infrastructure include developing novel data linkage strategies, increasing access to electronic health records, establishing curriculum and training programs, promoting multidisciplinary collaborations, and enhancing research funding opportunities.
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Affiliation(s)
- Ya-Chen Tina Shih
- Section of Cancer Economics and Policy, Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Michael T Halpern
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, and the Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Scott Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Institute, Seattle, WA, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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16
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Wallace NJ, Devaiah AK. Pituitary Carcinoma Diagnosis and Survival Improvement, with Affordable Care Act Correlation: A SEER Database Study. Skull Base Surg 2022; 83:305-311. [DOI: 10.1055/s-0040-1722747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Introduction Pituitary carcinomas are challenging tumors to diagnose and treat due to their rarity and limited data surrounding their etiology. Traditionally, these patients have exhibited poor survival. Over the last several decades, our understanding of pituitary carcinomas has dramatically increased, and there have been recent initiatives to improve patient access to health care, including the Affordable Care Act (ACA). This study investigates whether there were any changes in incidence and treatment outcomes of pituitary carcinoma that correlated with these advances.
Methods A retrospective case review was conducted utilizing the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute. Those with primary site pituitary tumors with noncontiguous metastases were identified from 1975 to 2016. Demographic data, overall, and cause-specific outcomes were obtained. The data were analyzed using SPSS to generate 5-year Kaplan–Meier curves.
Results The incidence of pituitary carcinoma pre- and post-ACA was 0.31 and 2.14 diagnoses/year, respectively. This represents a significant increase (Chi-square, p < 0.00002). In addition, 1-, 2-, and 5-year overall survival of these patients was determined to be 88.2, 74.0, and 66.6% which was significantly improved compared with prior studies. Cause-specific survival of these patients follow similar trends exhibiting 94.1, 79.0, 71.1% after 1, 2, and 5 years, respectively.
Conclusion The survival for pituitary carcinoma has improved significantly which signals a change in how practitioners should counsel their patients. There is a significant surge in the number of cases in the post-ACA timeline, which suggests that improving patient access has played a part in wider recognition and treatment initiation for this disease.
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Affiliation(s)
- Nathan J. Wallace
- Department of Otolaryngology, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Anand K. Devaiah
- Departments of Otolaryngology, Neurological Surgery, and Ophthalmology, Boston University School of Medicine, Boston, Massachusetts, United States
- Division of Biomedical & Health Technology Development & Transfer Domain, Boston University Institute for Health System Innovation & Policy, Boston, Massachusetts, United States
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17
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Hao S, Parikh AA, Snyder RA. Racial Disparities in the Management of Locoregional Colorectal Cancer. Surg Oncol Clin N Am 2021; 31:65-79. [PMID: 34776065 DOI: 10.1016/j.soc.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.
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Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA.
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Khosla S, Hershow RC, Freels S, Jefferson GD, Davis FG, Peterson CE. Head and neck squamous cell carcinomas among males of the three largest Asian diasporas in the US, 2004-2013. Cancer Epidemiol 2021; 74:102011. [PMID: 34416546 DOI: 10.1016/j.canep.2021.102011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 07/31/2021] [Accepted: 08/07/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Head and neck squamous cell carcinomas (HNSCC) have not been fully examined in the Asian diasporas in the US, despite certain Asian countries having the highest incidence of specific HNSCCs. METHODS National Cancer Database was used to compare 1046 Chinese, 887 South Asian (Indian/Pakistani), and 499 Filipino males to 156,927 Non-Hispanic White (NHW) males diagnosed with HNSCC between 2004-2013. Multinomial logistic regression was used to assess the association of race/ethnicity with two outcomes - site group and late-stage diagnosis. Temporal trends were explored for site groups and subsites. RESULTS South Asians had a greater proportion of oral cavity cancer [OCC] compared to NHWs (59 % vs. 25 %; ORadj =7.3 (95 % CI: 5.9-9.0)). In contrast, Chinese (64 % vs. 9%; ORadj =34.0 (95 % CI: 26.5-43.6)) and Filipinos (47 % vs. 9%; ORadj =10.0 (95 % CI: 7.8-12.9)) had a greater proportion of non-oropharyngeal cancer compared to NHWs. All three Asian subgroups had a higher likelihood of being diagnosed by age 40 (14 % Chinese, 10 % South Asian and 8% Filipino compared to 3% in NHW; p < 0.001). Chinese males had lower odds of late-stage diagnosis, compared to NHWs. South Asian cases doubled from 2004 to 2013 largely due to an increase in OCC cases (34 cases in 2004 to 86 in 2013). CONCLUSION Asian diasporas are at a higher likelihood of specific HNSCCs. Risk factors, screening and survival need to be studied further, and policy changes are needed to promote screening and to discourage high-risk habits in these Asian subgroups.
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Affiliation(s)
- Shaveta Khosla
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor St., Chicago, IL, 60612, USA; Department of Emergency Medicine, College of Medicine, University of Illinois at Chicago, 808 S. Wood St., Chicago, IL, 60612, USA.
| | - Ronald C Hershow
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor St., Chicago, IL, 60612, USA
| | - Sally Freels
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor St., Chicago, IL, 60612, USA
| | - Gina D Jefferson
- Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS, 39216, USA
| | - Faith G Davis
- School of Public Health, University of Alberta, 3-083 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, AB, T6G 1C9, Canada
| | - Caryn E Peterson
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor St., Chicago, IL, 60612, USA
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Utilization of High-Volume Hospitals for High-Risk Cancer Surgery in California Following Medicaid Expansion. J Gastrointest Surg 2021; 25:1875-1884. [PMID: 32705616 DOI: 10.1007/s11605-020-04747-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/15/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION A primary goal of the recent state and federal health reform is to increase access to care through expanded insurance coverage. We sought to evaluate the effect of Medicaid expansion (ME) on four high-risk cancer operations in California. METHODS The California Office of Statewide Health Planning database was used to identify patients who underwent either lung, esophageal, pancreas, or rectal resection for cancer between 2012 and 2016. To include only patients eligible for Medicaid and not Medicare, patients > 65 years were excluded. Trends in insurance coverage rates and utilization of high-volume hospitals were evaluated relative to the pre-policy (2012-2013) versus the post-policy (2014-2016) period. RESULTS Overall 10,569 individuals (esophageal: 5.6%; lung: 38%; pancreas: 14.1%; rectal: 42.3%) underwent a cancer operation. Following ME, Medicaid coverage increased from 12.4 to 20.2% (p < 0.001). There were no differences in age, sex, and race of Medicare beneficiaries pre- versus post-policy implementation (all p > 0.05). Of note, following ME, there was an increase in probability of utilization of high-volume hospitals for lung (47.6% vs. 56.3%), rectal (74.0% vs. 77.7%), and pancreas (60.2% vs. 68.5%) (p < 0.05 for all) cancer operations. Overall probability of surgery at a high-volume center after expansion increased by 5.8% among Medicaid beneficiaries versus other patients in the same time period. ME was not associated, however, with improvement in clinical outcomes such as complications, in-hospital mortality, or readmission (all p > 0.05). CONCLUSION ME was associated with an increase in Medicaid coverage, which resulted in more beneficiaries undergoing cancer operations at high-volume hospitals. While ME was associated with increased access to care, peri-operative outcomes were comparable pre- versus post-ME implementation.
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Alcalá HE, Keim-Malpass J, Mitchell EM. Sexual Assault and Cancer Screening Among Men and Women. JOURNAL OF INTERPERSONAL VIOLENCE 2021; 36:NP6243-NP6259. [PMID: 30477387 DOI: 10.1177/0886260518812797] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Emerging research has shown that experiences of sexual violence are associated with cancer screening behaviors. However, to date, little attention has been given to the impact of sexual assault on cancer screening behaviors, particularly among men. To address this, we used data from the 2014 Kansas Behavioral Risk Factor Surveillance System. This survey is conducted annually via telephone. Logistic regressions were used to calculate odds of ever engaging (i.e., lifetime) in specific screening behaviors (clinical breast exam [CBE], mammogram, Pap test, colonoscopy/sigmoidoscopy, fecal occult blood test and prostate-specific antigen [PSA] test) and current compliance with cancer screening recommendations (CBE, mammogram, Pap test, colorectal cancer screening, and PSA test), with lifetime sexual assault as the independent variables. Colorectal cancer screening models were stratified by gender. All models adjusted for confounders. Sexual assault was associated with lower odds of ever receiving a PSA test and, for women, higher odds of ever receiving a colonoscopy or sigmoidoscopy. Sexual assault was associated with lower odds of current compliance with CBE, mammogram, Pap test, and PSA test screening recommendations. A history of sexual assault was associated with lower odds of current compliance with cancer screening procedures, with the notable exception of colorectal cancer screening. Less consistent patterns were seen for lifetime screenings. Results suggest that alternatives to currently recommended procedures (like self-collection of HPV [human papilloma virus] DNA) or modified screening procedures may be a promising route to increase current compliance with cancer screening among a population that may avoid these procedures due to pain or fear of retraumatization.
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Michel KF, Spaulding A, Jemal A, Yabroff KR, Lee DJ, Han X. Associations of Medicaid Expansion With Insurance Coverage, Stage at Diagnosis, and Treatment Among Patients With Genitourinary Malignant Neoplasms. JAMA Netw Open 2021; 4:e217051. [PMID: 34009349 PMCID: PMC8134994 DOI: 10.1001/jamanetworkopen.2021.7051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Health insurance coverage is associated with improved outcomes in patients with cancer. However, it is unknown whether Medicaid expansion through the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the diagnosis and treatment of patients with genitourinary cancer. OBJECTIVE To assess the association of Medicaid expansion with health insurance status, stage at diagnosis, and receipt of treatment among nonelderly patients with newly diagnosed kidney, bladder, or prostate cancer. DESIGN, SETTING, AND PARTICIPANTS This case-control study included adults aged 18 to 64 years with a new primary diagnosis of kidney, bladder, or prostate cancer, selected from the National Cancer Database from January 1, 2011, to December 31, 2016. Patients in states that expanded Medicaid were the case group, and patients in nonexpansion states were the control group. Data were analyzed from January 2020 to March 2021. EXPOSURES State Medicaid expansion status. MAIN OUTCOMES AND MEASURES Insurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses. RESULTS Among a total of 340 552 patients with newly diagnosed genitourinary cancers, 94 033 (27.6%) had kidney cancer, 25 770 (7.6%) had bladder cancer, and 220 749 (64.8%) had prostate cancer. Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 (95% CI, -1.4 to -0.8) percentage points across all incomes and a net decrease in the low-income population of 4.4 (95% CI, -5.7 to -3.0) percentage points compared with nonexpansion states. Expansion was also associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels (difference-in-difference, 1.4 [95% CI, 0.1 to 2.6] percentage points) and among individuals with low income (difference-in-difference, 4.6 [95% CI, 0.3 to 9.0] percentage points) and in prostate cancer among individuals with low income (difference-in-difference, 3.0 [95% CI, 0.3 to 5.7] percentage points). Additionally, there was a net increase associated with expansion compared with nonexpansion in receipt of active surveillance for low-risk prostate cancer of 4.1 (95% CI, 2.9 to 5.3) percentage points across incomes and 4.5 (95% CI, 0 to 9.0) percentage points among patients in low-income areas. CONCLUSIONS AND RELEVANCE These findings suggest that Medicaid expansion was associated with decreases in uninsured status, increases in the proportion of kidney and prostate cancer diagnosed in an early stage, and higher rates of active surveillance in the appropriate, low-risk prostate cancer population. Associations were concentrated in population residing in low-income areas and reinforce the importance of improving access to care to all patients with cancer.
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Affiliation(s)
- Katharine F. Michel
- University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Aleigha Spaulding
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K. Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Daniel J. Lee
- University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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Rekhter N, Ermasova N. Culture of prevention and early disease detection of cancer in Russia. Soc Sci Med 2021; 277:113905. [PMID: 33845392 DOI: 10.1016/j.socscimed.2021.113905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/20/2020] [Accepted: 04/01/2021] [Indexed: 11/17/2022]
Abstract
This study analyzed the early cancer detection in Russia. Using data from the Russian Ministry of Health from 2005 to 2016, this study aims to evaluate relationships between the number of patients diagnosed with I-II stage of cancer with the number of preventive visits, screening tests, and expedited access to specialists. The results of de-trending time-series model indicate that the number of specialists in outpatient facilities and the number of patients' preventive visits positively affect the number of patients diagnosed with cancer for the first time and the number of patients diagnosed with I-II degree cancer. The Russian Federation's experience suggests that early detection of cancer can be achieved by increasing the number of early cancer screening facilities, providing free screening, and moderating geographical and time constraints that prevent people of different geographic and socio-economic backgrounds from being screened. Another strategy includes dispelling myths associated with cancer screening, fostering outreach and patient education, and assuring availability and timely referrals to specialists and laboratory work.
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Affiliation(s)
- Natalia Rekhter
- Bachelor of Health Administration Program, Governors State University, 1 University Parkway, Building G Office 182, University Park, Il, 60484, United States.
| | - Natalia Ermasova
- Public Finance, Governors State University, 1 University Parkway, University Park, Il, 60484, United States.
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Mohs Surgery for SEER Registry-Captured Melanoma In Situ and Rare Cutaneous Tumors: Comparing National Utilization Patterns Before and After Implementation of the Affordable Care Act (2010) and Appropriate Use Criteria (2012). Dermatol Surg 2021; 46:1021-1029. [PMID: 31929340 DOI: 10.1097/dss.0000000000002316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The Affordable Care Act (ACA) and the appropriate use criteria (AUC) for Mohs micrographic surgery (MMS) had the potential to increase utilization rates of MMS for indicated skin cancers, but it is unknown whether this has occurred. OBJECTIVE To determine whether rates of MMS utilization for head and neck melanoma in situ (MIS) and rare cutaneous tumors (RCTs) increased after the implementation of the ACA and AUC publication. MATERIALS AND METHODS Retrospective review using data from the SEER database. Melanoma in situ and RCT tumor cases from before and after the ACA and AUC publication were compared. RESULTS Twenty-four thousand six hundred seventy-eight cases were analyzed. Mohs micrographic surgery utilization for MIS decreased from 13.9% before the ACA to 12.3% after the ACA (odds ratio 0.87; p = .012). There was no significant change in MMS utilization for MIS after publication of the AUC. There was also no significant change in MMS utilization for treatment of RCT after the ACA or AUC publication. Stratification of patients into age groups younger or older than 65 years did not change utilization rates. CONCLUSION Rates of MMS for treatment of MIS and RCT have not increased since the advent of the ACA or AUC. This finding highlights the need for continued efforts to improve access to MMS and to increase education of its utility in treating skin cancer.
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Hatch B, Hoopes M, Darney BG, Marino M, Templeton AR, Schmidt T, Cottrell E. Impacts of the Affordable Care Act on Receipt of Women's Preventive Services in Community Health Centers in Medicaid Expansion and Nonexpansion States. Womens Health Issues 2021; 31:9-16. [PMID: 33023807 PMCID: PMC9206529 DOI: 10.1016/j.whi.2020.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/21/2020] [Accepted: 08/26/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The Affordable Care Act (ACA) increased health insurance coverage throughout the United States and improved care delivery for some services. We assess whether ACA implementation and Medicaid expansion were followed by greater receipt of recommended preventive services among women and girls in a large network of community health centers. METHODS Using electronic health record data from 354 community health centers in 14 states (10 expansion, 4 nonexpansion), we used generalized estimating equations and difference-in-difference methods to compare receipt of six recommended preventive services (cervical cancer screening, human papilloma virus vaccination, chlamydia screening, influenza vaccination, human immunodeficiency virus screening, and blood pressure screening) among active female patients ages 11 to 65 (N = 711,121) before and after ACA implementation and between states that expanded versus did not expand Medicaid. RESULTS Except for blood pressure screening, receipt of all examined preventive services increased after ACA implementation in both Medicaid expansion and nonexpansion states. Influenza vaccination and blood pressure screening increased more in expansion states (adjusted absolute prevalence difference-in-difference, 1.55; 95% confidence interval, 0.51-2.60; and 1.98; 95% confidence interval, 0.91-3.05, respectively). Chlamydia screening increased more in nonexpansion states (adjusted absolute prevalence difference-in-difference: -4.21; 95% confidence interval, -6.98 to -1.45). Increases in cervical cancer screening, human immunodeficiency virus screening, and human papilloma virus vaccination did not differ significantly between expansion and nonexpansion states. CONCLUSIONS Among female patients at community health centers, receipt of recommended preventive care improved after ACA implementation in both Medicaid expansion and nonexpansion states, although the overall rates remained low. Continued support is needed to overcome barriers to preventive care in this population.
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Affiliation(s)
- Brigit Hatch
- School of Medicine, Family Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Blair G Darney
- School of Medicine, Family Medicine, Oregon Health & Science University, Portland, Oregon; School of Medicine, Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- School of Medicine, Family Medicine, Oregon Health & Science University, Portland, Oregon
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25
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Diaz A, Pawlik TM. Insurance status and high-volume surgical cancer: Access to high-quality cancer care. Cancer 2020; 127:507-509. [PMID: 33084043 DOI: 10.1002/cncr.33234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Adrian Diaz
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio
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Lantz PM, Rosenbaum S. The Potential and Realized Impact of the Affordable Care Act on Health Equity. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2020; 45:831-845. [PMID: 32589207 DOI: 10.1215/03616878-8543298] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The Affordable Care Act (ACA) was designed with multiple goals in mind, including a reduction in social disparities in health care and health status. This was to be accomplished through some novel provisions and a significant infusion of resources into long-standing public programs with an existing track record related to health equity. In this article, we discuss seven ACA provisions with regard to their intended and realized impact on social inequalities in health, focusing primarily on socioeconomic and racial/ethnic disparities. Arriving at its 10th anniversary, there is significant evidence that the ACA has reduced social disparities in key health care outcomes, including insurance coverage, health care access, and the use of primary care. In addition, the ACA has had a significant impact on the volume/range of services offered and the financial security of community health centers, and through section 1557, the ACA broadened the civil rights landscape in which the health care system operates. Less clear is how the ACA has contributed to improved health outcomes and health equity. Extant evidence suggests that the part of the ACA that has had the greatest impact on social disparities in health outcomes-including preterm births and mortality-is the Medicaid expansion.
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Spada NG, Geramita EM, Zamanian M, van Londen GJ, Sun Z, Sabik LM. Changes in Disparities in Stage of Breast Cancer Diagnosis in Pennsylvania After the Affordable Care Act. J Womens Health (Larchmt) 2020; 30:324-331. [PMID: 32986501 DOI: 10.1089/jwh.2020.8478] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: This study sought to determine if increased access to health insurance following the Affordable Care Act (ACA) resulted in an increased proportion of early-stage breast cancer diagnosis among women in Pennsylvania, particularly minorities, rural residents, and those of lower socioeconomic status. Materials and Methods: Data on 35,735 breast cancer cases among women 50-64 and 68-74 years of age in Pennsylvania between 2010 and 2016 were extracted from the Pennsylvania Cancer Registry and analyzed in 2019. Women 50-64 years of age were subdivided by race/ethnicity, area of residence, and socioeconomic status as measured by area deprivation index (ADI). We compared the proportions of early-stage breast cancer diagnosis pre-ACA (2010-2013) and post-ACA (2014-2016) for all women 50-64 years of age to all women 68-74 years of age. This comparison was also made between paired sociodemographic subgroups for women 50-64 years of age. Multivariable logistic regression models were constructed to assess how race, area of residence, ADI, and primary care physician (PCP) density interacted to impact breast cancer diagnosis post-ACA. Results: The proportion of early-stage breast cancer diagnosis increased by 1.71% post-ACA among women 50-64 years of age (p < 0.01), whereas women 68-74 years of age saw no change. Multivariable logistic regression analysis demonstrated that minority women had lower odds of early-stage breast cancer diagnosis pre-ACA, but not post-ACA, when controlling for ADI. Meanwhile, increased area-level socioeconomic advantage was associated with higher odds of being diagnosed with early-stage breast cancer pre- and post-ACA irrespective of controlling for race, area of residence, or PCP density. Conclusions: Enhanced access to health insurance under the ACA was associated with an increased proportion of early-stage breast cancer diagnosis in Pennsylvanian women 50-64 years of age and may have reduced racial, but not socioeconomic, disparities in breast cancer diagnosis.
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Affiliation(s)
- Neal G Spada
- Department of Medicine and University of Pittsburgh, Pennsylvania, USA
| | - Emily M Geramita
- Department of Medicine and University of Pittsburgh, Pennsylvania, USA
| | - Maryam Zamanian
- Department of Medicine and University of Pittsburgh, Pennsylvania, USA
| | - G J van Londen
- Department of Medicine and University of Pittsburgh, Pennsylvania, USA
| | - Zhaojun Sun
- Department of Health Policy and Management, University of Pittsburgh, Pennsylvania, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, Pennsylvania, USA
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McGrew KM, Peck JD, Vesely SK, Janitz AE, Snider CA, Dougherty TM, Campbell JE. Effect Modification of the Association Between Race and Stage at Colorectal Cancer Diagnosis by Socioeconomic Status. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2020; 25 Suppl 5, Tribal Epidemiology Centers: Advancing Public Health in Indian Country for Over 20 Years:S29-S35. [PMID: 31348188 PMCID: PMC7043013 DOI: 10.1097/phh.0000000000000993] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To compare risks of distant-stage colorectal cancer (CRC) diagnosis between whites and American Indian/Alaska Natives (AI/ANs) and to explore effect modification by area-based socioeconomic status (SES). DESIGN Retrospective cohort study using data from the Oklahoma Central Cancer Registry. SETTING Oklahoma. PARTICIPANTS White and AI/AN cases of CRC diagnosed in Oklahoma between 2001 and 2008 (N = 8 438). A subanalysis was performed on the cohort of those aged 50 years and older (N = 7 728). MAIN OUTCOME MEASURE Risk of distant-stage CRC diagnosis stratified by SES score. RESULTS Race and SES were independently associated with distant-stage diagnosis. In SES-stratified analyses, AI/ANs in the 2 lowest SES groups experienced increased risks in the overall cohort and among those aged 50 years and older. In multivariable models, risks remained significant among those aged 50 years and older in the lowest SES groups (Adjusted risk ratio SES score of 2: 1.31, 95% confidence interval: 1.06-1.63 and adjusted risk ratio SES score of 1: 1.21, 95% confidence interval: 1.01-1.44). CONCLUSION Socioeconomic status is an effect modifier in the association between race/ethnicity and stage at CRC diagnosis. Disparities in stage at CRC diagnosis exist between AI/ANs and whites with lower estimated SES. Efforts are needed to increase CRC screening among lower SES AI/ANs.
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Affiliation(s)
- Kaitlin M. McGrew
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jennifer D. Peck
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Sara K. Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Amanda E. Janitz
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cuyler A. Snider
- Oklahoma Area Tribal Epidemiology Center, Southern Plains Tribal Health Board, Oklahoma City, OK
| | - Tyler M. Dougherty
- Oklahoma Area Tribal Epidemiology Center, Southern Plains Tribal Health Board, Oklahoma City, OK
| | - Janis E. Campbell
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Eom KY, Jarlenski M, Schoen RE, Robertson L, Sabik LM. Sex differences in the impact of Affordable Care Act Medicaid expansion on colorectal cancer screening. Prev Med 2020; 138:106171. [PMID: 32592796 DOI: 10.1016/j.ypmed.2020.106171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 05/14/2020] [Accepted: 06/14/2020] [Indexed: 12/23/2022]
Abstract
Access to care varies by sex such that interactions with insurance status result in mixed patterns of preventive services utilization. We examined sex-specific effects of ACA Medicaid expansions on receipt of CRC screening. We used Behavioral Risk Factor Surveillance System data (2008-2016) for adults aged 50-64 years with household income ≤138% of federal poverty level to examine self-reported lifetime use of guideline-recommended CRC screening services overall and by screening modality. We employed difference-in-difference models comparing changes in CRC screening in 20 Medicaid expansion states before and after the ACA to changes in 18 states that did not expand Medicaid during our study period. We divided the expansion period into implementation (2014) and post-expansion (2016) periods to account for possible lagged effects. We observed time-varying effects of Medicaid expansion that revealed relative increases in CRC screening occurring during the post-expansion period. Heterogeneous effects by sex and by screening modality were also observed: there was a significant relative increase of 16.2 percentage points (95% CI [2.2, 30.2]; p-value = 0.023) in lifetime colonoscopy use among women in expansion states relative to non-expansion states in the post-expansion period. There were no significant effects of Medicaid expansion among men. Health insurance expansion had a lagged but significant effect on CRC screening among low-income non-elderly women in Medicaid expansion states, but no effect for men. The observed increase in CRC screening among women suggests that barriers to CRC screening may differ by sex, and tailored interventions to increase CRC screening improve outcomes.
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Affiliation(s)
- Kirsten Y Eom
- University of Pittsburgh, Department of Health Policy and Management, Pittsburgh, PA, United States of America.
| | - Marian Jarlenski
- University of Pittsburgh, Department of Health Policy and Management, Pittsburgh, PA, United States of America
| | - Robert E Schoen
- University of Pittsburgh, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh, PA, United States of America
| | - Linda Robertson
- UPMC Hillman Cancer Center, Pittsburgh, PA, United States of America
| | - Lindsay M Sabik
- University of Pittsburgh, Department of Health Policy and Management, Pittsburgh, PA, United States of America
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30
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Lee M, Jenkins WD, Adjei Boakye E. Cancer screening utilization by residence and sexual orientation. Cancer Causes Control 2020; 31:951-964. [PMID: 32833199 DOI: 10.1007/s10552-020-01339-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 08/13/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Although few studies have examined screening uptake among sexual minorities (lesbian, gay, bisexual, queer), almost none have examined it in the specific context of rural populations. Therefore, our objective was to assess how cancer screening utilization varies by residence and sexual orientation. METHODS Publicly available population-level data from the 2014 and 2016 Behavioral Risk Factor Surveillance System were utilized. Study outcomes included recommended recent receipt of breast, cervical, and colorectal cancer screening. Independent variables of interest were residence (rural/urban) and sexual orientation (heterosexual/gay or lesbian/bisexual). Weighted proportions and multivariable logistic regressions were used to assess the association between the independent variables and the outcomes, adjusting for demographic, socioeconomic, and healthcare utilization factors. RESULTS Rates for all three cancer screenings were lowest in rural areas and among sexual minority populations (cervical: rural lesbians at 64.8% vs. urban heterosexual at 84.6%; breast: rural lesbians at 66.8% vs. urban heterosexual at 80.0%; colorectal for males: rural bisexuals at 52.4% vs. urban bisexuals at 81.3%; and colorectal for females: rural heterosexuals at 67.2% vs. rural lesbians at 74.4%). In the multivariate analyses for colorectal screening, compared to urban heterosexual males, both rural gay and rural heterosexual males were less likely to receive screening (aOR = 0.45; 95% = 0.24-0.73 and aOR = 0.79; 95% = 0.72-0.87, respectively) as were rural heterosexual females (aOR = 0.87; 95% = 0.80-0.94) compared to urban heterosexual females. For cervical screening, lesbians were less likely to receive screening (aOR = 0.62; 95% = 0.41-0.94) than heterosexuals, and there were no differences for breast screening. CONCLUSION We found that rural sexual minorities may experience disparities in cancer screening utilization associated with the compounding barriers of rural residence and sexual minority status, after adjusting for demographic, socioeconomic, and healthcare utilization factors. Further work is needed to identify factors influencing these disparities and how they might be addressed.
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Affiliation(s)
- Minjee Lee
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA. .,Simons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL, USA.
| | - Wiley D Jenkins
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Eric Adjei Boakye
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA.,Simons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL, USA
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Hammock JB, Williams CP, Aswani MS, Thomas JW, Rocque GB. Oncologic Services Through Project Access and Other Safety Net Care Coordination Programs. JCO Oncol Pract 2020; 16:e1489-e1498. [PMID: 32735510 DOI: 10.1200/op.20.00127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Little is known about the provision of oncologic services by Project Access safety net care coordination programs. MATERIALS AND METHODS Information on safety net care coordination program locations, health services, and patient eligibility was obtained via program Web sites and calls. For programs not offering oncologic care, program directors were interviewed to identify oncologic care barriers. RESULTS Web sites of 29 safety net care coordination programs in 22 states were identified; 62% (n = 18) offered oncologic services. Programs were in 65% (n = 11) of states that did not expand Medicaid. Of those offering oncologic services, 83% (n = 15) offered free chemotherapy, and 93% (n = 27) of all programs offered oncologic imaging. Program director interviews revealed costs, longitudinal care, and multiple-physician buy-in as barriers limiting oncologic care. CONCLUSION Third-party care coordination centers provide a novel and potentially unrecognized approach to increasing oncology service access. Further research should identify strategies to overcome the relative lack of oncologic care offerings.
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Affiliation(s)
- James B Hammock
- Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham, AL
| | - Courtney P Williams
- Division of Hematology and Oncology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Monica S Aswani
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL
| | - John W Thomas
- Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham, AL
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
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Kirkpatrick D, Dunn M, Tuttle R. Breast Cancer Stage at Presentation in Ohio: The Effect of Medicaid Expansion and the Affordable Care Act. Am Surg 2020. [DOI: 10.1177/000313482008600327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients presenting with localized breast cancer have a five-year survival of 99 per cent, whereas survival falls to 27 per cent in advanced disease. This obviates the importance of early diagnosis and treatment. Our study evaluates the impact of Ohio's Medicaid expansion and the passage of the Affordable Care Act (ACA) on the stage at which Ohioans were diagnosed with breast cancer. Data were collected for 3056 patients presenting with breast cancer between 2006 and 2016 in the Dayton area. Patients were divided into groups based on cancer stage. The percentage of patients presenting with advanced disease (stage 3 or 4) was compared both before and after ACA implementation and Ohio Medicaid expansion. These results were also compared with statewide data maintained by the Ohio Department of Health. Compared with pre-ACA, the number of uninsured patients post-ACA was noted to fall 83 per cent, the number of patients presenting with Medicaid increased by five times, and the proportion of patients younger than 65 years presenting with breast cancer increased by approximately 7 per cent. These changes notwithstanding, no difference was identified in the percentage of patients presenting with advanced breast cancer before and after ACA implementation or Ohio Medicaid expansion ( P = 0.56). Statewide data similarly demonstrated no change ( P = 0.88). Improved insurance access had a smaller-than-anticipated impact on the stage at which Ohioans presented with breast cancer. As significant morbidity and mortality can be avoided by earlier presentation, additional research is appropriate to identify factors affecting patients’ decision to seek breast cancer screening and care.
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Affiliation(s)
- Dan Kirkpatrick
- Department of Surgery, Boonschoft School of Medicine, Wright State University, Dayton, Ohio; and
- General Surgery, 88th Medical Group, Wright Patterson Air Force Base, Dayton, Ohio
| | - Margaret Dunn
- Department of Surgery, Boonschoft School of Medicine, Wright State University, Dayton, Ohio; and
| | - Rebecca Tuttle
- Department of Surgery, Boonschoft School of Medicine, Wright State University, Dayton, Ohio; and
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Yabroff KR, Valdez S, Jacobson M, Han X, Fendrick AM. The Changing Health Insurance Coverage Landscape in the United States. Am Soc Clin Oncol Educ Book 2020; 40:e264-e274. [PMID: 32453633 DOI: 10.1200/edbk_279951] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Changes in the health insurance coverage landscape in the United States during the past decade have important implications for receipt and affordability of cancer care. In this paper, we summarize evidence for the association between health insurance coverage and cancer prevention and treatment. We then discuss ongoing changes in health care coverage, including implementation of provisions of the Affordable Care Act, increasing prevalence of high-deductible health insurance plans, and factors that affect health care delivery, with a focus on vertical integration of hospitals and providers. We summarize the evidence for the effects of the changes in health coverage on care and discuss areas for future research with the goal of informing efforts to improve cancer care delivery and outcomes in the United States.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | - Samuel Valdez
- Department of Economics, University of California, Irvine, CA
| | - Mireille Jacobson
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA
| | - Xuesong Han
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | - A Mark Fendrick
- University of Michigan Center for Value-Based Insurance Design, Ann Arbor, MI
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Abstract
BACKGROUND This study examines the expansion of health insurance coverage in Massachusetts under state health reform as a natural experiment to investigate whether expanded insurance coverage reduced the likelihood of advanced stage colorectal cancer (CRC) and breast cancer (BCA) diagnosis. METHODS Our study populations include CRC or BCA patients aged 50-64 years observed in the Massachusetts Cancer Registry and Surveillance Epidemiology and End Results (SEER) registries for 2001-2013. We use difference-in-differences regression models to estimate changes in the likelihood of advanced stage diagnosis after Massachusetts health reform, relative to comparison states without expanded coverage (Connecticut, New Jersey, Georgia, Kentucky, and Michigan). RESULTS We find some suggestive evidence of a decline in the proportion of advanced stage CRC cases. Approximately half of the CRC patients in Massachusetts and control states were diagnosed at advanced stages pre reform; there was a 2 percentage-point increase in this proportion across control states and slight decline in Massachusetts post reform. Adjusted difference-in-difference estimates suggest a 3.4 percentage-point (P=0.005) or 7% decline, relative to Massachusetts baseline, in the likelihood of advanced stage diagnosis after the reform in Massachusetts, though this result is sensitive to years included in the analysis. We did not find a significant effect of reform on BCA stage at diagnosis. CONCLUSIONS The decline in the likelihood of advanced stage CRC diagnosis after Massachusetts health reform may suggest improvements in access to health care and CRC screening. Similar declines were not observed for BCA, perhaps due to established BCA-specific safety-net programs.
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Zhao J, Mao Z, Fedewa SA, Nogueira L, Yabroff KR, Jemal A, Han X. The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years. CA Cancer J Clin 2020; 70:165-181. [PMID: 32202312 DOI: 10.3322/caac.21604] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 01/22/2023] Open
Abstract
Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes.
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Affiliation(s)
- Jingxuan Zhao
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Ziling Mao
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stacey A Fedewa
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Leticia Nogueira
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - K Robin Yabroff
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
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Tangka F, Kenny K, Miller J, Howard DH. The eligibility and reach of the national breast and cervical cancer early detection program after implementation of the affordable care act. Cancer Causes Control 2020; 31:473-489. [PMID: 32157463 DOI: 10.1007/s10552-020-01286-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/19/2020] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The uninsured rate declined following passage of the Affordable Care Act in 2010. It is unclear how this decrease affected the size of the population eligible for existing safety net programs. We evaluated trends in the number of women eligible for breast and cervical cancer screening and diagnostic services under the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the reach of the program. METHODS Using the Census Bureau's Small Area Health Insurance Estimates data, we calculated the number of women who met the NBCCEDP eligibility criteria based on age, income, and insurance status. We used these data in conjunction with program to estimate the proportion of eligible women served by the NBCCEDP. RESULTS The number of women eligible for breast cancer screening and diagnostic services under the program declined from 5.4 (90% CI 5.2-5.6) to 2.8 (90% CI 2.6-3.0) million from 2011 to 2017. The number of women eligible for cervical cancer screening and diagnostic services declined from 10.3 (90% CI 10.0-10.6) to 5.3 (90% CI 5.1-5.6) million. The share of eligible women served by the program was 15.0% (90% CI 14.8-15.1%) for breast services in 2016-2017 and 6.8% (90% CI 6.7-6.8%) for cervical services in 2015-2017. CONCLUSION Insurance coverage expansions may have contributed to a decrease in the number of program-eligible women. There are many more women eligible for the program than are served.
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Affiliation(s)
- Florence Tangka
- Division of Cancer Prevention and Control, Winship Cancer Center, Emory University, Atlanta, GA, 30030, USA
| | - Kristy Kenny
- Division of Cancer Prevention and Control, Winship Cancer Center, Emory University, Atlanta, GA, 30030, USA
| | - Jacqueline Miller
- Division of Cancer Prevention and Control, Winship Cancer Center, Emory University, Atlanta, GA, 30030, USA
| | - David H Howard
- Department of Health Policy and Management, Winship Cancer Center, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30030, USA.
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Mbah OM, Kinlaw AC, Trogdon JG, Wheeler SB, Samuel CA. The Affordable Care Act and Ethnic Disparities in Colorectal Cancer Screening. Am J Prev Med 2020; 58:175-181. [PMID: 31959320 PMCID: PMC8285085 DOI: 10.1016/j.amepre.2019.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 09/02/2019] [Accepted: 09/03/2019] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Cost sharing can deter the use of health services and act as a potential contributor to racial/ethnic disparities in cancer. The Affordable Care Act required most health plans to cover, without cost sharing, preventive services, including colorectal cancer screening. Population-based data were used to estimate the impact of the Affordable Care Act's cost-sharing provision (together with other Affordable Care Act provisions targeting preventive care) on ethnic disparities in colorectal cancer screening, comparing Hispanics with non-Hispanics. METHODS An interrupted time series quasi-experimental analysis was used to examine ethnic differences in colorectal cancer screening pre- and post-implementation of the Affordable Care Act (analysis performed in 2018). The study cohort included insured individuals aged 50-64 years who participated in the Medical Expenditure Panel Survey from 2007 through 2015 (n=44,343). RESULTS During the pre-Affordable Care Act period, screening rates decreased annually for non-Hispanics by -0.38 per 100 adults per year (95% CI= -0.55, -0.22) but remained level for Hispanics (annual trend per 100 adults: 0.01, 95% CI= -0.34, 0.35). After cost sharing was eliminated in 2011, colorectal cancer screening rates increased for both Hispanics (by 1.29 per 100 adults, 95% CI=0.69, 1.89) and non-Hispanics (by 0.58 per 100 adults, 95% CI=0.18, 0.99). The difference in trend increases between Hispanics and non-Hispanics was not statistically significant (0.70%, 95% CI= -0.24, 1.64). CONCLUSIONS These findings suggest that Affordable Care Act implementation resulted in increased colorectal cancer screening; however, the effect of the law was not significantly different between Hispanics and non-Hispanics. These results provide indications that more needs to be done to reduce racial/ethnic disparities in colorectal cancer screening.
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Affiliation(s)
- Olive M Mbah
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Alan C Kinlaw
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Cleo A Samuel
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Polek C, Hardie T. Cancer Screening and Prevention in Lesbian, Gay, Bisexual, and Transgendered Community and Asian Lesbian, Gay, Bisexual, and Transgendered Members. Asia Pac J Oncol Nurs 2019; 7:6-11. [PMID: 31879678 PMCID: PMC6927152 DOI: 10.4103/apjon.apjon_46_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/06/2019] [Indexed: 11/17/2022] Open
Abstract
Participation in cancer screening and prevention (cessation of or reduction in modifiable health risk behaviors) are the most effective methods of reducing cancer morbidity and mortality. Some members of the lesbian, gay, bisexual, and transgendered (LGBT) communities have not participated in screening for a variety of reasons which have been explored in the literature. Common and unique behavioral risks are also reviewed. Knowledge about Asian members of the LGBT community participation in cancer screening and prevention is limited. This paper reviews the current literature on participation and barriers to cancer screening and prevention for the LGBT community and provides some insights for the Asian LGBT subcommunity. Potential interventions that have been demonstrated to be effective are presented for potential implementation within nursing practice and practice settings. Suggestions for future research are also provided to enhance the care of the LGBT community.
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Affiliation(s)
- Carolee Polek
- School of Nursing, University of Delaware, Newark, DE, USA
| | - Thomas Hardie
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Valvi N, Vin-Raviv N, Akinyemiju T. Medicaid Expansion and Breast Cancer Screening in Appalachia and Non-Appalachia, United States, BRFSS 2003 to 2015. Cancer Control 2019; 26:1073274819845874. [PMID: 31067985 PMCID: PMC6509986 DOI: 10.1177/1073274819845874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Prior data suggests that breast cancer screening rates are lower among women in the Appalachian region of the United States. This study examined the changes in breast cancer screening before and after the implementation of the Affordable Care Act Medicaid expansion, in Appalachia and non-Appalachia states. Methods: Data from the Behavioral Risk Factor Surveillance System between 2003 and 2015 were analyzed to evaluate changes in breast cancer screening in the past 2 years among US women aged 50-74 years. Multivariable adjusted logistic regression and generalized estimating equation models were utilized, adjusting for sociodemographic, socioeconomic, and health-care characteristics. Data were analyzed for 2 periods: 2003 to 2009 (pre-expansion) and 2011 to 2015 (post-expansion) comparing Appalachia and non-Appalachia states. Results: The prevalence for of self-reported breast cancer screening in Appalachia and non-Appalachia states were 83% and 82% (P < .001), respectively. In Appalachian states, breast cancer screening was marginally higher in non-expanded versus expanded states in both the pre-expansion (relative risk [RR]: 1.002, 95% confidence interval [CI]: 1.002-1.003) and post-expansion period (RR: 1.001, 95% CI: 1.001-1.002). In non-Appalachian states, screening was lower in non-expanded states versus expanded states in both the pre-expansion (RR: 0.98, 95% CI: 0.97-0.98) and post-expansion period (RR: 0.95, 95% CI: 0.95-0.96). There were modest 3% to 4% declines in breast cancer screening rates in the pos-texpansion period regardless of expansion and Appalachia status. Conclusions: Breast cancer screening rates were higher in Appalachia versus non-Appalachia US states and higher in expanded versus nonexpanded non-Appalachia states. There were modest declines in breast cancer screening rates in the post-expansion period regardless of expansion and Appalachia status, suggesting that more work may be needed to reduce administrative, logistical, and structural barriers to breast cancer screening services.
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Affiliation(s)
- Nimish Valvi
- 1 Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Neomi Vin-Raviv
- 2 School of Social Work, College of Health and Human Sciences, Colorado State University, Fort Collins, CO, USA.,3 University of Northern Colorado Cancer Rehabilitation Institute, School of Sport and Exercise Science, University of Northern Colorado, Greeley, CO, USA
| | - Tomi Akinyemiju
- 1 Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA.,4 Markey Cancer Center, University of Kentucky, Lexington, KY, USA
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Steenland M, Sinaiko A, Glynn A, Fitzgerald T, Cohen J. The effect of the Affordable Care Act on patient out-of-pocket cost and use of preventive cancer screenings in Massachusetts. Prev Med Rep 2019; 15:100924. [PMID: 31333996 PMCID: PMC6617340 DOI: 10.1016/j.pmedr.2019.100924] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 05/15/2019] [Accepted: 06/15/2019] [Indexed: 12/11/2022] Open
Abstract
In an effort to increase use of preventive health care, The Patient Protection and Affordable Care Act (ACA) eliminated cost-sharing for preventive cancer screening services for the privately insured. The impact on patient spending and use of these screenings is still poorly understood. We used an interrupted time series analysis with the Massachusetts All-Payer Claims Database (2009-2012) to assess changes in trends in costs and use of breast, cervical and colorectal cancer screenings after the ACA policy. We find that the ACA was associated with a 0.024 (95% CI: -0.031, -0.017, p < 0.001) and 0.424 (95% CI: -0.481, -0.368, p < 0.001) percentage point decrease in the likelihood of a copayment each week for preventive breast and cervical cancer screenings respectively. The likelihood of copayment for colon cancer screening declined throughout the study period, with the rate of decline slowing following the ACA (trend in percent of screenings with copayment -0.130 before vs -0.071 after ACA, p = 0.014). Overall, we find only weak evidence that the ACA policy increased screenings. We find no significant effect on utilization for cervical cancer or colon cancer screening. For breast cancer screening, we find a small immediate increase in the utilization rate in the month after the policy change, with no change in trend after the ACA policy. Policy makers may need to consider other complementary policy options to increase screening rates.
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Affiliation(s)
- Maria Steenland
- Population Studies and Training Center, Brown University, 68 Waterman St, Providence, RI 02912, USA
| | - Anna Sinaiko
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Amy Glynn
- Commonwealth Care Alliance, 30 Winter Street, Boston, MA 02108, USA
| | | | - Jessica Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
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Affordable Care Act and cancer stage at diagnosis in an underserved population. Prev Med 2019; 126:105748. [PMID: 31195020 DOI: 10.1016/j.ypmed.2019.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/06/2019] [Accepted: 06/04/2019] [Indexed: 11/20/2022]
Abstract
The Patient Protection and Affordable Care Act (ACA) has increased insurance coverage among underserved individuals, but the effect of ACA on cancer diagnosis is currently debated, particularly in Medicaid non-expansion states. Therefore, we aimed to assess the effect of ACA implementation on stage at diagnosis among underserved cancer patients in Texas, a Medicaid non-expansion state. We used data from the institutional registry of the JPS Center for Cancer Care, which serves an urban population of underserved cancer patients. Eligible individuals were aged 18 to 64 years and diagnosed with a first primary invasive solid tumor between 2008 and 2015. We used a natural experiment framework and interrupted time-series analysis to assess level (i.e. immediate) and slope (over time) changes in insurance coverage and cancer stage at diagnosis between pre- and post-ACA periods. Our study population comprised 4808 underserved cancer patients, of whom 51% were racial/ethnic minorities. The prevalence of uninsured cancer patients did not immediately change after ACA implementation but modestly decreased over time (PR = 0.94; 95% CL: 0.90, 0.98). The prevalence of early- and advanced-stage diagnosis did not appreciably change overall or when stratified by screen-detectable cancers. Our results suggest that ACA implementation decreased the prevalence of uninsured cancer patients but had little effect on cancer stage at diagnosis in an underserved population. Given that Texas is a Medicaid non-expansion state, Medicaid expansion and alternative approaches may need to be further explored to improve earlier cancer diagnosis among underserved individuals.
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Cardoso R, Niedermaier T, Chen C, Hoffmeister M, Brenner H. Colonoscopy and Sigmoidoscopy Use among the Average-Risk Population for Colorectal Cancer: A Systematic Review and Trend Analysis. Cancer Prev Res (Phila) 2019; 12:617-630. [PMID: 31289028 DOI: 10.1158/1940-6207.capr-19-0202] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/11/2019] [Accepted: 07/03/2019] [Indexed: 12/24/2022]
Abstract
Monitoring population-level colonoscopy and sigmoidoscopy use is crucial to estimate the future burden of colorectal cancer and guide screening efforts. We conducted a systematic literature search on colonoscopy and sigmoidoscopy use, published between November 2016 and December 2018 in the databases PubMed and Web of Science to update previous reviews and analyze time trends for various countries. In addition, we used data from the German and European Health Interview Surveys and the National Health Interview Survey to explore recent time trends for Germany and the US, respectively. The literature search yielded 23 new articles: fourteen from the US and nine from Australia, Canada, England, Germany, Saudi Arabia, and South Korea. Colonoscopy use within 10 years was highest and, apart from the youngest age groups eligible for colorectal cancer screening, kept increasing to levels close to 60% in the US and Germany. A recent steep increase was also observed for South Korea. Limited data were available on sigmoidoscopy use; regional studies from the US suggest that sigmoidoscopy has become rarely used. Despite high uptake and ongoing increase in the US, Germany, and South Korea, use of colonoscopy and sigmoidoscopy has either remained low or essentially unknown for the majority of countries.
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Affiliation(s)
- Rafael Cardoso
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Tobias Niedermaier
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Chen Chen
- Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hermann Brenner
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany. .,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
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Huguet N, Angier H, Rdesinski R, Hoopes M, Marino M, Holderness H, DeVoe JE. Cervical and colorectal cancer screening prevalence before and after Affordable Care Act Medicaid expansion. Prev Med 2019; 124:91-97. [PMID: 31077723 PMCID: PMC6578572 DOI: 10.1016/j.ypmed.2019.05.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/03/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
Abstract
Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an increase in insured visits after the 2014 Affordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs. Electronic health record data on 624,601 non-pregnant patients aged 21-64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using difference-in-difference methodology. Female patients had 19% increased odds of receiving cervical cancer screening post- relative to pre-ACA in expansion states [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.09-1.31] and 23% increased odds in non-expansion states (aOR = 1.23, 95% CI = 1.05-1.46): the greatest increase was among uninsured patients in expansion states (aOR = 1.36, 95% CI = 1.16-1.59) and privately-insured patients in non-expansion states (aOR = 1.43, 95% CI = 1.11-1.84). Colorectal cancer screening prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states. For most outcomes, the observed changes were not significantly different between expansion and non-expansion states. Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.
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Affiliation(s)
- Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States
| | - Rebecca Rdesinski
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States
| | - Megan Hoopes
- OCHIN Inc., 1881 SW Naito Pkwy, Portland, OR, 97201, United States
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States; Division of Biostatistics, School of Public Health, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, United States
| | - Heather Holderness
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States.
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States
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Tak CR, Biltaji E, Kohlmann W, Maese L, Hainaut P, Villani A, Malkin D, Sherwin CM, Brixner DI, Schiffman JD. Cost-effectiveness of early cancer surveillance for patients with Li-Fraumeni syndrome. Pediatr Blood Cancer 2019; 66:e27629. [PMID: 30719841 PMCID: PMC6826253 DOI: 10.1002/pbc.27629] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/10/2018] [Accepted: 12/21/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Patients with germline TP53 pathogenic variants (Li-Fraumeni syndrome [LFS]) are at extremely high lifetime risk of developing cancer. Recent data suggest that tumor surveillance for patients with LFS may improve survival through early cancer detection. The objective of this study was to assess the cost-effectiveness of a cancer surveillance strategy for patients with LFS compared with those whose tumors present clinically. METHODS A Markov decision analytic model was developed from a third-party payer perspective to estimate cost-effectiveness of routine cancer surveillance over a patient's lifetime. The model consisted of four possible health states: no cancer, cancer, post-cancer survivorship, and death. Model outcomes were costs (2015 United States Dollars [USD]), effectiveness (life years [LY] gained), and incremental cost-effectiveness ratio (ICER; change in cost/LY gained). One-way sensitivity analyses and probabilistic sensitivity analyses examined parameter uncertainty. RESULTS The model showed a mean cost of $46 496 and $117 102 and yielded 23 and 27 LY for the nonsurveillance and surveillance strategies, respectively. The ICER for early cancer surveillance versus no surveillance was $17 125 per additional LY gained. At the commonly accepted willingness to pay threshold of $100 000/life-year gained, surveillance had a 98% probability of being the most cost-effective strategy for early cancer detection in this high-risk population. CONCLUSIONS Presymptomatic cancer surveillance is cost-effective for patients with germline pathogenic variants in TP53. Lack of insurance coverage or reimbursement in this population may have significant consequences and leads to undetected cancers presenting in later stages of disease with worse clinical outcomes.
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Affiliation(s)
- Casey R. Tak
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,UNC Health Sciences at MAHEC, Asheville, North Carolina
| | - Eman Biltaji
- Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah,Program in Personalized Health, University of Utah, Salt Lake City, Utah,Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Wendy Kohlmann
- Program in Personalized Health, University of Utah, Salt Lake City, Utah,Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Luke Maese
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah,Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Pierre Hainaut
- Institute for Advanced Biosciences, Inserm U1209 CNRS UMR5309 University Grenoble-Alpes, Grenoble, France
| | - Anita Villani
- Division of Haematology/Oncology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - David Malkin
- Division of Haematology/Oncology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Catherine M.T. Sherwin
- Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah
| | - Diana I Brixner
- Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah,Program in Personalized Health, University of Utah, Salt Lake City, Utah
| | - Joshua D. Schiffman
- Program in Personalized Health, University of Utah, Salt Lake City, Utah,Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah,Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Doria-Rose VP, Greenlee RT, Buist DSM, Miglioretti DL, Corley DA, Brown JS, Clancy HA, Tuzzio L, Moy LM, Hornbrook MC, Brown ML, Ritzwoller DP, Kushi LH, Greene SM. Collaborating on Data, Science, and Infrastructure: The 20-Year Journey of the Cancer Research Network. EGEMS (WASHINGTON, DC) 2019; 7:7. [PMID: 30972356 PMCID: PMC6450242 DOI: 10.5334/egems.273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/16/2018] [Indexed: 12/13/2022]
Abstract
The Cancer Research Network (CRN) is a consortium of 12 research groups, each affiliated with a nonprofit integrated health care delivery system, that was first funded in 1998. The overall goal of the CRN is to support and facilitate collaborative cancer research within its component delivery systems. This paper describes the CRN's 20-year experience and evolution. The network combined its members' scientific capabilities and data resources to create an infrastructure that has ultimately supported over 275 projects. Insights about the strengths and limitations of electronic health data for research, approaches to optimizing multidisciplinary collaboration, and the role of a health services research infrastructure to complement traditional clinical trials and large observational datasets are described, along with recommendations for other research consortia.
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Affiliation(s)
- V. Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, US
| | | | - Diana S. M. Buist
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, US
| | - Diana L. Miglioretti
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, US
- University of California Davis School of Medicine, Davis, CA, US
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, US
| | - Jeffrey S. Brown
- Department of Population Medicine, Harvard Medical School, Boston, MA, US
- Harvard Pilgrim Health Care Institute, Boston, MA, US
| | - Heather A. Clancy
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, US
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, US
| | - Lisa M. Moy
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, US
| | - Mark C. Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, US
- Retired
| | - Martin L. Brown
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, US
- Retired
| | | | - Lawrence H. Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, US
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Impact of The Affordable Care Act's Elimination of Cost-Sharing on the Guideline-Concordant Utilization of Cancer Preventive Screenings in the United States Using Medical Expenditure Panel Survey. Healthcare (Basel) 2019; 7:healthcare7010036. [PMID: 30832276 PMCID: PMC6473889 DOI: 10.3390/healthcare7010036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/30/2019] [Accepted: 02/26/2019] [Indexed: 12/21/2022] Open
Abstract
Currently available evidence regarding the association of the Affordable Care Act’s (ACA) elimination of cost-sharing and the utilization of cancer screenings is mixed. We determined whether the ACA’s zero cost-sharing policy affected the guideline-concordant utilization of cancer screenings, comparing adults (≥21 years) from 2009 with 2011–2014 data from the Medical Expenditure Panel Survey. Study participants were categorized as: 21–64 years with any private insurance, ≥65 years with Medicare only, and 21–64 years uninsured, with a separate sample for each type of screening test. Adjusted weighted prevalence and prevalence ratios (PR (95%CI)) were estimated. In 2014 (vs. 2009), privately-insured women reported 2% (0.98 (0.97–0.99)) and 4% (0.96 (0.93–0.99)) reduction in use of Pap tests and mammography, respectively. Privately-insured non-Hispanic Asian women had 16% (0.84 (0.74–0.97)) reduction in mammography in 2014 (vs. 2009). In 2011 (vs. 2009), privately-insured and Medicare-only men reported 9% (1.09 (1.03–1.16)) and 13% (1.13 (1.02–1.25)) increases in colorectal cancer (CRC) screenings, respectively. Privately-insured women reported a 6–7% rise in 2013–2014 (vs. 2009), and Hispanic Medicare beneficiaries also reported 40–44%, a significant rise in 2011–2014 (vs. 2009), in the utilization of CRC screenings. While the guideline-concordant utilization of Pap tests and mammography declined in the post-ACA period, the elimination of cost-sharing appeared to have positively affected CRC screenings of privately-insured males, females, and Hispanic Medicare-only beneficiaries. Greater awareness about the zero cost-sharing policy may help in increasing the uptake of cancer screenings.
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Disparities in genetic services utilization in a random sample of young breast cancer survivors. Genet Med 2018; 21:1363-1370. [DOI: 10.1038/s41436-018-0349-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 10/17/2018] [Indexed: 11/09/2022] Open
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Chhabra KR, Ellimoottil CS, Dimick JB. Repealing the Affordable Care Act and Implications for Cancer Care. Surg Oncol Clin N Am 2018; 27:615-620. [PMID: 30213406 DOI: 10.1016/j.soc.2018.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Calls to repeal the Affordable Care Act (ACA) have become increasingly frequent. Most attempts to repeal the ACA have targeted specific policies rather than the ACA as a whole. This article describes the specific policies under debate and the ramifications of repealing each of them. Specific attention is given to insurance coverage, individual premiums, and budgetary impact. Based on the literature regarding the ACA's impact to date, the impact of ACA repeal on Surgical oncology care is predicted.
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Affiliation(s)
- Karan R Chhabra
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Chad S Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, MI, USA; Dow Division of Health Services Research, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
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Abstract
The Affordable Care Act (ACA) of 2010 placed a substantial emphasis on public health and prevention. Subsequent research on its effects reveals some notable successes and some missteps and offers important lessons for future legislators. The ACA's Prevention and Public Health Fund, intended to give public health budgetary flexibility, provided crucial funding for public health services during the Great Recession but proved highly vulnerable to subsequent budget cuts. Several programs that aimed to increase strategic thinking and planning around public health at the state level have proven to be more enduring, suggesting that the convening authority of the federal government can be a powerful tool for progress, especially when buttressed by some funding. Most important, by expanding insurance and mandating a minimum level of coverage, the ACA both increased access to clinical preventive services and freed up local public health budgets to engage in population health activities.
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Affiliation(s)
- Nadia Chait
- Robert F. Wagner Graduate School of Public Service, New York University, New York, NY 10012, USA; ,
| | - Sherry Glied
- Robert F. Wagner Graduate School of Public Service, New York University, New York, NY 10012, USA; ,
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