Disparities in preventive procedures: comparisons of self-report and Medicare claims data

Biomarkers in Cancer Screening: Promises and Challenges in Cancer Early Detection

Cancer continues to be one the leading causes of death worldwide, primarily due to the late detection of the disease. Cancers detected at early stages may enable more effective intervention of the disease. However, most cancers lack well-established screening procedures except for cancers with an established early asymptomatic phase and clinically validated screening tests. There is a critical need to identify and develop assays/tools in conjunction with imaging approaches for precise screening and detection of the aggressive disease at an early stage. New developments in molecular cancer screening and early detection include germline testing, synthetic biomarkers, and liquid biopsy approaches.

Breast cancer screening among Medicare Advantage enrollees with dementia

BACKGROUND

The decision to screen for breast cancer among older adults with dementia is complex and must often be individualized, as these individuals have an elevated risk of harm from over-screening. Medicare beneficiaries with dementia are increasingly enrolling in Medicare Advantage plans, which typically promote receipt of preventive cancer screening among their enrollees. This study examined the utilization of breast cancer screening among Medicare enrollees with dementia, in Medicare Advantage and in fee-for-service Medicare.

METHODS

We conducted a pooled cross-sectional study of women with Alzheimer's disease and related dementias or cognitive impairment who were eligible for mammogram screening. We used Medicare Current Beneficiary Survey data to identify utilization of biennial mammogram screening between 2012 and 2019. Poisson regression models were used to estimate prevalence ratios of mammogram utilization and to calculate adjusted mammogram rates for Medicare Advantage and fee-for-service Medicare enrollees with dementia, and further stratified by rurality and by dual eligibility for Medicare and Medicaid.

RESULTS

Mammogram utilization was 16% higher (Prevalence Ratio [PR] 1.16; 95% CI: 1.05, 1.29) among Medicare Advantage enrollees with dementia, compared to their counterparts in fee-for-service Medicare. Rural enrollees experienced no significant difference (PR 0.99; 95% CI: 0.72, 1.37) in mammogram use between Medicare Advantage and fee-for-service Medicare enrollees. Among urban enrollees, Medicare Advantage enrollment was associated with a 21% higher mammogram rate (PR 1.21; 95% CI: 1.09, 1.35). Dual-eligible Medicare Advantage enrollees had a 34% higher mammogram rate (PR 1.34; 95% CI: 1.10, 1.63) than dual-eligible fee-for-service Medicare enrollees. Among non-dual-eligible enrollees, adjusted mammogram rates were not significantly different (PR 1.11; 95% CI: 0.99, 1.24) between Medicare Advantage and fee-for-service Medicare enrollees.

CONCLUSIONS

Medicare beneficiaries age 65-74 with Alzheimer's disease and related dementias or cognitive impairment had a higher mammogram use rate when they were enrolled in Medicare Advantage plans compared to fee-for-service Medicare, especially when they were dual-eligible or lived in urban areas. However, some Medicare Advantage enrollees with Alzheimer's disease and related dementias or cognitive impairment may have experienced over-screening for breast cancer.

Latent pathway-based Bayesian models to identify intervenable factors of racial disparities in breast cancer stage at diagnosis

PURPOSE

We built Bayesian Network (BN) models to explain roles of different patient-specific factors affecting racial differences in breast cancer stage at diagnosis, and to identify healthcare related factors that can be intervened to reduce racial health disparities.

METHODS

We studied women age 67-74 with initial diagnosis of breast cancer during 2006-2014 in the National Cancer Institute's SEER-Medicare dataset. Our models included four measured variables (tumor grade, hormone receptor status, screening utilization and biopsy delay) expressed through two latent pathways-a tumor biology path, and health-care access/utilization path. We used various Bayesian model assessment tools to evaluate these two latent pathways as well as each of the four measured variables in explaining racial disparities in stage-at-diagnosis.

RESULTS

Among 3,010 Black non-Hispanic (NH) and 30,310 White NH breast cancer patients, respectively 70.2% vs 76.9% were initially diagnosed at local stage, 25.3% vs 20.3% with regional stage, and 4.56% vs 2.80% with distant stage-at-diagnosis. Overall, BN performed approximately 4.7 times better than Classification And Regression Tree (CART) (Breiman L, Friedman JH, Stone CJ, Olshen RA. Classification and regression trees. CRC press; 1984) in predicting stage-at-diagnosis. The utilization of screening mammography is the most prominent contributor to the accuracy of the BN model. Hormone receptor (HR) status and tumor grade are useful for explaining racial disparity in stage-at diagnosis, while log-delay in biopsy impeded good prediction.

CONCLUSIONS

Mammography utilization had a significant effect on racial differences in breast cancer stage-at-diagnosis, while tumor biology factors had less impact. Biopsy delay also aided in predicting local and regional stages-at-diagnosis for Black NH women but not for white NH women.

Inequities in routine preventive care utilization among persons with overweight/obesity in the United States: An analysis of nativity, racial and ethnic identity, and socioeconomic status

Extant literature documented various health disparities among immigrants and racial and ethnically marginalized individuals in the United States. However, health disparities in the intersection of nativity and race are generally less visited. This cross-sectional study assessed utilization of routine preventive care among adults with overweight/obesity at the junction of their nativity, racial/ethnic identity, and socioeconomic status (i.e., income and education). Pooling data on 120,184 adults with overweight/obesity from the 2013-2018 waves of the National Health Interview Survey (NHIS), we estimated modified Poisson regressions with robust standard errors to obtain adjusted prevalence rates of preventive care visit, receiving flu shot, and having blood pressure, cholesterol and blood glucose screened. We found that immigrant adults with overweight/obesity had lower rates of utilization of all five preventive care services. However, these patterns varied by racial and ethnic sub-populations. While White immigrants had comparable rates of cholesterol and blood glucose screening, they had 2.7%, 2.9%, and 14.5% lower rates of preventive care visit, blood pressure screening, and getting a flu shot respectively, compared to native-born Whites. These patterns were similar for Asian immigrants as well. Black immigrants, on the other hand, had comparable rates of getting a flu shot and blood glucose screening, and had 5.2%, 4.9%, and 4.9% lower rates of preventive care visit, blood pressure screening, and cholesterol screening respectively. Lastly, the rates of utilization among Hispanic immigrants were significantly lower (ranging from 9.2% to 20%) than those of their native-born counterparts for all five preventive care services. These rates further varied by education, income, and length of stay in the US, within the racial and ethnic subgroups. Our findings thus suggest a complex relationship between nativity and racial/ethnic identity in relation to preventive care utilization among adults with overweight/obesity.

Influenza Vaccination Coverage Among Medicare Fee-for-Service Beneficiaries

INTRODUCTION

Influenza vaccination is the best prevention strategy to protect against influenza infection. Determining accurate influenza vaccination coverage is critical. This study assesses the concordance between self-reported and claimed-based influenza vaccination coverage and examines vaccination disparities in the U.S.

METHODS

Data from the 2016-2019 Medicare Current Beneficiary Survey linked to survey participants' influenza vaccination claims were analyzed in 2022. The study population included survey participants aged ≥65 years and enrolled in a Medicare fee-for-service plan. Sensitivity, specificity, kappa statistics, and net bias (the difference between the estimated vaccination coverage based on survey and claims data) were reported. Associations between receipt of influenza vaccine and beneficiaries' characteristics and sex, racial and ethnic, and urban‒rural disparities in influenza vaccination were examined using logistic regressions.

RESULTS

The analysis included 20,854 beneficiaries. Claimed-based vaccination coverage was 60.0%, and survey-based coverage was 76.3%. The net bias was 16.3 percentage points, and kappa statistic indicated moderate data agreement. The sensitivity of self-reported influenza vaccination was 98.7%, and the specificity was 57.4%. Net bias was high among male, non-Hispanic Black and Hispanic beneficiaries, and rural residents. Sex, racial and ethnic, and urban‒rural disparities in influenza vaccination were noticeably smaller according to the survey than claims data.

CONCLUSIONS

The level of data agreement differed by beneficiaries' characteristics and was low among males, racial and ethnic minority groups, and rural residents.

Trends in cervical cancer screening research in sub-Saharan Africa: A bibliometric analysis of publications from 2001 to 2020

Sub-Saharan Africa has the highest incidence of cervical cancer globally. However, compared to developed countries, the region has lower uptake of cervical cancer screening. Research contribution and progress in the field of cervical cancer in the region has not been well investigated. This bibliometric review aimed to address this information gap by examining changes in research volume and type over a 20 year time frame. Medline, Embase, PsycINFO, CINAHL, and Cochrane Library were searched to identify peer-reviewed publications about cervical cancer screening in sub-Saharan Africa. Changes (from 2001 to 2020) in the (i) total publications, (ii) number and proportion of data-based publications relative to non-data-based publications, and descriptive relative to intervention publications, and (iii) the number and proportion of publications meeting the EPOC design criteria relative to those not meeting the EPOC design criteria were assessed using a generalised linear Poisson model, a generalised binomial model and the Pearson Chi-squared test respectively. A two-year increase in time was associated with an estimated 32 % increase in the total number of publications. While no measurement studies were recorded, the bulk of data-based publications (89 %) were descriptive studies. Relative to descriptive publications, a 1 % increase in the proportion of intervention publications was observed over time. Only a small proportion (28 %) of intervention studies met the EPOC design criteria. Our findings suggest that researchers and funders in the region should invest more effort and money in measurement and rigorous intervention research to inform outcome measures and cervical cancer screening policy and practice, respectively.

Change in colorectal cancer (CRC) testing rates associated with the introduction of the first organized screening program in canton Uri, Switzerland: Evidence from insurance claims data analyses from 2010 to 2018

•

First colorectal cancer (CRC) screening program in Switzerland launched in one canton in 2013.

•

Launched in the context of high prevalent opportunistic CRC testing.

•

Led to an increase in fecal occult blood testing and not colonoscopy.

•

Claims data analyses enable estimating the net effect of programs in general population.

The first canton in Switzerland to implement an organized colorectal cancer screening program (OSP) was Uri. Starting in 2013, it offered 50–69-year-olds free testing with colonoscopy every 10 years or fecal occult blood test (FOBT) every 2 years. We tested the association between the OSP and testing rates over time.

We analyzed claims data of 50–69-year-olds from Uri and neighboring cantons (NB) provided by a large health insurance and complemented it with data from the OSP. We fitted multivariate adjusted logistic regression models to compare overall testing rates and by method (colonoscopy or FOBT/both) We computed the 2018 rate of the population up-to-date with testing (colonoscopy within 9 years/FOBT within 2 years).

Yearly overall testing rates in Uri increased from 8.7% in 2010 to 10.8% in 2018 and from 6.5% to 7.9% in NB. In Uri, the proportion tested with FOBT/both increased from 4.7% to 6.0% but decreased from 2.8% to 1.1% in NB. Testing by FOBT/both increased more between 2015 and 2018 than 2010–2012 in Uri than in NB (OR:2.1[95%CI:1.8–2.4]), it increased less for colonoscopy (OR:0.60[95%CI:0.51–0.70]), with no change in overall CRC testing (OR:0.91[95%CI:0.81–1.02]). In 2018 in Uri, 42.5% were up-to-date with testing (FOBT/both:9.2%, colonoscopy:35.7%); in NBs, 40.7% (FOBT/both:2.7%, colonoscopy:39%).

Yearly FOBT rates in Uri were always higher than in NB. Though the OSP in Uri was not associated with a greater increase in overall testing rates, the OSP was associated with increased FOBT.

Effects of Child Protective Custody Status and Health Risk Behaviors on Health Care Use Among Adolescents

OBJECTIVE

To determine whether current protective custody status (ie, youth currently in the temporary or permanent custody of child protective services, eg, foster and kinship care) contributes to increased health care utilization compared to youth never in protective custody. Health characteristics (eg, mental health diagnoses) and behaviors (eg, substance use) were expected to account for differences in health care use among the two groups.

METHODS

Retrospective child welfare administrative data and linked electronic health records data were collected from a county's child welfare system and affiliated freestanding children's hospital between 2012 and 2017. Youth currently in protective custody (n = 2787) were identified and demographically matched to peers never in custody (n = 2787) who received health care from the same children's hospital. Health care use, health risk behaviors, and social, demographic, and diagnostic data were extracted and compared for both cohorts.

RESULTS

In baseline models, health care use was higher for youth in protective custody compared to peers. In adjusted models that included health risk behaviors and patient characteristics, protective custody status was associated with decreased primary and missed care, and no longer a significant predictor of other types of health care use.

CONCLUSIONS

Youth had significantly higher utilization while in protective custody than their demographically similar peers; however, health risk behaviors appear to account for most group differences. Identification of current custody status in pediatric settings and addressing health risk behaviors in this population may be important for health care systems interested in altering health care use and/or cost for this population.

Racial and Ethnic Disparities in Adult Vaccination: A Review of the State of Evidence

Background

Adult vaccination coverage remains low in the United States, particularly among racial and ethnic minority populations.

Objective

To conduct a comprehensive literature review of research studies assessing racial and ethnic disparities in adult vaccination.

Search Methods

We conducted a search of PubMed, Cochrane Library, ClinicalTrials.gov, and reference lists of relevant articles.

Selection Criteria

Research studies were eligible for inclusion if they met the following criteria: (1) study based in the United States, (2) evaluated receipt of routine immunizations in adult populations, (3) used within-study comparison of race/ethnic groups, and (4) eligible for at least one author-defined PICO (patient, intervention, comparison, and outcome) question.

Data Collection and Analysis

Preliminary abstract review was conducted by two authors. Following complete abstraction of articles using a standardized template, abstraction notes and determinations were reviewed by all authors; disagreements regarding article inclusion/exclusion were resolved by majority rule. The Social Ecological Model framework was used to complete a narrative review of observational studies to summarize factors associated with disparities; a systematic review was used to evaluate eligible intervention studies.

Results

Ninety-five studies were included in the final analysis and summarized qualitatively within two main topic areas: (1) factors associated with documented racial-ethnic disparities in adult vaccination and (2) interventions aimed to reduce disparities or to improve vaccination coverage among racial-ethnic minority groups. Of the 12 included intervention studies, only 3 studies provided direct evidence and were of Level II, fair quality; the remaining 9 studies met the criteria for indirect evidence (Level I or II, fair or poor quality).

Conclusions

A considerable amount of observational research evaluating factors associated with racial and ethnic disparities in adult vaccination is available. However, intervention studies aimed at reducing these disparities are limited, are of poor quality, and insufficiently address known reasons for low vaccination uptake among racial and ethnic minority adults.

Social Stability and Unmet Health Care Needs in a Community-Based Sample of Women Who Use Drugs

Objective

To examine the relationship between social stability and access to healthcare services among a community-based sample of adult female drug users.

Methods

We developed a measure of social stability and examined its relationship to health care access. Data came from a cross-sectional sample of female drug users (N = 538) in Oakland, CA who were interviewed between September 2014 and August 2015. We categorized women as having low (1-5), medium (6-10), or high (11-16) social stability based on the tertile of the index sample distribution. We then used ordered logistic regression to examine the relationship between social stability and self-reported access to mental health services and medical care.

Results

Compared with women in the low stability group, those with high stability experienced a 58% decline in the odds of needed but unmet mental health services [AOR: 0.42; 95% C.I.: 0.26, 0.69] and a 68% decline in the odds of unmet medical care [AOR: 0.32; 95% C.I.: 0.19, 0.54] after adjusting for confounders. The coefficients we observed reduced in size at higher levels of the stability index suggesting a positive association between social experiences and access to healthcare services.

Conclusion

Women who use drugs are at increased risk of adverse health outcomes and often experience high levels of unmet healthcare needs. Our study highlights the importance of addressing social determinants of health and suggests that improving social factors such as housing stability and personal safety may support access to healthcare among female drug users.

Naïve Bayesian network-based contribution analysis of tumor biology and healthcare factors to racial disparity in breast cancer stage-at-diagnosis

Background

Variation in breast cancer stage at initial diagnosis (including racial disparities) is driven both by tumor biology and healthcare factors.

Methods

We studied women age 67-74 with initial diagnosis of breast cancer from 2006 through 2014 in the SEER-Medicare database. We extracted variables related to tumor biology (histologic grade and hormone receptor status) and healthcare factors (screening mammography [SM] utilization and time delay from mammography to diagnostic biopsy). We used naïve Bayesian networks (NBNs) to illustrate the relationships among patient-specific factors and stage-at-diagnosis for African American (AA) and white patients separately. After identifying and controlling confounders, we conducted counterfactual inference through the NBN, resulting in an unbiased evaluation of the causal effects of individual factors on the expected utility of stage-at-diagnosis. An NBN-based decomposition mechanism was developed to evaluate the contributions of each patient-specific factor to an actual racial disparity in stage-at-diagnosis. 2000 bootstrap samples from our training patients were used to compute the 95% confidence intervals (CIs) of these contributions.

Results

Using a causal-effect contribution analysis, the relative contributions of each patient-specific factor to the actual racial disparity in stage-at-diagnosis were as follows: tumor grade, 45.1% (95% CI: 44.5%, 45.8%); hormone receptor status, 5.0% (4.5%, 5.4%); mammography utilization, 23.1% (22.4%, 24.0%); and biopsy delay 26.8% (26.1%, 27.3%).

Conclusion

The modifiable mechanisms of mammography utilization and biopsy delay drive about 49.9% of racial difference in stage-at-diagnosis, potentially guiding more targeted interventions to eliminate cancer outcome disparities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13755-021-00165-5.

Asthma Care Quality, Language, and Ethnicity in a Multi-State Network of Low-Income Children

INTRODUCTION

Prior research has documented disparities in asthma outcomes between Latino children and non-Hispanic whites, but little research directly examines the care provided to Latino children over time in clinical settings.

METHODS

We utilized an electronic health record-based dataset to study basic asthma care utilization (timely diagnosis documentation and medication prescription) between Latino (Spanish preferring and English preferring) and Non-Hispanic white children over a 13-year study period.

RESULTS

In our study population (n = 37,614), Latino children were more likely to have Medicaid, be low income, and be obese than non-Hispanic white children. Latinos (Spanish preferring and English preferring) had lower odds than non-Hispanic whites of having their asthma recorded on their problem list on the first day the diagnosis was noted (odds ratio [OR] = 0.83; 95% CI, 0.77 to 0.89 Spanish preferring; OR = 0.93; 95% CI, 0.87 to 0.99 English preferring). Spanish-preferring Latinos had higher odds of ever receiving a prescription for albuterol (OR = 1.96; 95% CI, 1.52 to 2.52), inhaled corticosteroids (OR = 1.45; 95% CI, 1.01 to 2.09), or oral steroids (OR = 1.48; 95% CI, 1.07 to 2.04) than non-Hispanic whites. Among those with any prescription, Spanish-preferring Latinos had higher rates of albuterol prescriptions compared with non-Hispanic whites (adjusted rate ratio [aRR] = 1.0; 95% CI, 1.01 to 1.13).

CONCLUSIONS

In a multi-state network of clinics, Latino children were less likely to have their asthma entered on their problem list the first day it was noted than non-Hispanic white children, but otherwise did not receive inferior care to non-Hispanic white children in other measures. Further research can examine other parts of the asthma care continuum to better understand asthma disparities.

Cancer screening utilization by residence and sexual orientation

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.

Lack of validity of self-reported mammography data

This qualitative literature review aimed to describe the totality of peer-reviewed scientific evidence from 1990 to 2017 concerning validity of self-reported mammography. This review included articles about mammography containing the words accuracy, validity, specificity, sensitivity, reliability or reproducibility; titles containing self-report, recall or patient reports, and breast or 'mammo'; and references of identified citations focusing on evaluation of 2-year self-reports. Of 45 publications meeting the eligibility criteria, 2 conducted in 1993 and 1995 at health maintenance organisations in Western USA which primarily served highly educated whites provided support for self-reports of mammography over 2 years. Methodological concerns about validity of self-reports included (1) telescoping, (2) biased overestimates particularly among black women, (3) failure to distinguish screening and diagnostic mammography, and (4) failure to address episodic versus consistent mammography use. The current totality of evidence supports the need for research to reconsider the validity of self-reported mammography data as well as the feasibility of alternative surveillance data sources to achieve the goals of the Healthy People Initiative.

Low use of routine medical care among African Americans with high CKD risk: the Jackson Heart Study

Background

Use of routine medical care (RMC) is advocated to address ethnic/racial disparities in chronic kidney disease (CKD) risks, but use is less frequent among African Americans. Factors associated with low RMC use among African Americans at risk of renal outcomes have not been well studied.

Methods

We examined sociodemographic, comorbidity, healthcare access, and psychosocial (discrimination, anger, stress, trust) factors associated with low RMC use in a cross-sectional study. Low RMC use was defined as lack of a physical exam within one year among participants with CKD (estimated glomerular filtration rate < 60 mL/min/1.73m² or urine albumin-to-creatinine ratio > 30 mg/g) or CKD risk factors (diabetes or hypertension). We used multivariable logistic regression to estimate the odds of low RMC use at baseline (2000–2004) for several risk factors.

Results

Among 3191 participants with CKD, diabetes, or hypertension, 2024 (63.4%) were ≥ 55 years of age, and 700 (21.9%) reported low RMC use. After multivariable adjustment, age < 55 years (OR 1.61 95% CI 1.31–1.98), male sex (OR 1.71; 1.41–2.07), <high school diploma (OR 1.31; 1.07–1.62), absence of hypertension (OR 1.74; 1.27–2.39) or diabetes (OR 1.34; 1.09–1.65), and tobacco use (OR 1.43; 1.18–1.72) were associated with low RMC use. Low trust in providers (OR 2.16; 1.42–3.27), high stress (OR 1.41; 1.09–1.82), high daily discrimination (OR 1.30; 1.01–1.67) and low burden of lifetime discrimination (OR 1.52; 1.18–1.94), were also associated with low RMC use.

Conclusions

High-risk African Americans who were younger, male, less-educated, and with low trust in providers were more likely to report low RMC use. Efforts to improve RMC use by targeting these populations could mitigate African Americans’ disparities in CKD risks.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1190-0) contains supplementary material, which is available to authorized users.

Role of Race/Ethnicity, Language, and Insurance in Use of Cervical Cancer Prevention Services Among Low-Income Hispanic Women, 2009-2013

Introduction

Hispanic women in the United States have an elevated risk of cervical cancer, but the existing literature does not reveal why this disparity persists.

Methods

We performed a retrospective cohort analysis of 17,828 low-income women aged 21 to 64 years seeking care at Oregon community health centers served by a hosted, linked electronic health record during 2009 through 2013. We assessed the odds of having had Papanicolaou (Pap) tests and receiving human papillomavirus (HPV) vaccine, by race/ethnicity, insurance status, and language.

Results

Hispanic women, regardless of pregnancy status or insurance, had greater odds of having had Pap tests than non-Hispanic white women during the study period. English-preferring Hispanic women had higher odds of having had Pap tests than Spanish-preferring Hispanic women (OR, 2.08; 95% confidence interval [CI], 1.63–2.66) but lower odds of having received HPV vaccination (OR, 0.21; 95% CI, 0.12–0.38). Uninsured patients, regardless of race/ethnicity, had lower odds of HPV vaccine initiation than insured patients did. Once a single dose was received, there were no significant racial/ethnic differences in vaccine series completion.

Conclusion

In this sample of low-income women seeking care at Oregon community health centers, we found minimal racial/ethnic disparities in the receipt of cervical cancer prevention services. Inequities by insurance status, especially in the receipt of HPV vaccine, persist. Community health center–based care may be a useful model to address racial/ethnic disparities in prevention, but this model would need further population-wide study.

Medicaid Expansions and Cervical Cancer Screening for Low-Income Women

OBJECTIVE

Medicaid coverage for low-income women may play an important role in ensuring access to preventive care. This study examines how Medicaid eligibility expansions to nonelderly adults impact cervical cancer screening among low-income women.

DATA SOURCES

We use data from the Behavioral Risk Factor Surveillance System from 2000 to 2010. The primary outcome of interest is whether women in the relevant guideline consistent age range reported having a Pap test in the previous year.

STUDY DESIGN

We use a difference-in-differences approach with matched treatment and comparison states and a simulated eligibility approach based on a continuous measure of Medicaid generosity.

PRINCIPAL FINDINGS

Our results indicate that cervical cancer screening increased among low-income women in expansion states relative to comparison states. Increases in screening rates are largest among low-income Hispanic women.

CONCLUSIONS

Medicaid expansions during the period from 2000 to 2010 were associated with improved cervical cancer screening rates, which is critical for early cervical cancer detection and prevention of cancer morbidity and mortality in women. The results suggest that more widespread Medicaid expansions may have positive effects on preventive health care for women.

Mammography rates after the 2009 revision to the United States Preventive Services Task Force breast cancer screening recommendation

BACKGROUND

In 2009, the United States Preventive Services Task Force (USPSTF) recommended against routine mammography screening for women aged 40-49 years. This revised recommendation was widely criticized and has sparked off intense debate. The objectives of this study are to examine the impact of the revised recommendation on the proportion of women receiving mammograms and how the effect varied by age.

METHODS

We identified women who had continuous health insurance coverage and who did not have breast cancer between 2008 and 2011 in the Truven Health MarketScan Commercial Claims Databases using mammogram procedure codes. Using women aged 50-59 years as a control group, we used a differences-in-differences approach to estimate the impact of the revised recommendation on the proportion of women ages 40-49 years who received at least one mammogram. We also compared the age-specific changes in the proportion of women ages 35-59 years who were screened before and after the release of the revised recommendation.

RESULTS

The proportion of women screened among the 40-49 and 50-59 age groups were 58.5 and 62.5%, respectively, between 2008 and 2009, and 56.9 and 62.0%, respectively, between 2010 and 2011. After 2009, the proportion of women screened declined by 1.2 percentage point among women aged 40-49 years (P < 0.01). The proportion of women screened decreased for all ages, and decreases were larger among women closer to the 40-year threshold.

CONCLUSIONS

The 2009 USPSTF breast cancer recommendation was followed by a small reduction in the proportion of insured women aged 40-49 years who were screened. Reductions were larger among women at the younger end of the age range, who presumably had less prior experience with mammography than women nearing 50.

The Patient-Centered Medical Home: How Is It Related to Quality and Equity Among the General Adult Population?

This study investigates whether patient-reported characteristics of the medical home are associated with improved quality and equity of preventive care, advice on health habits, and emergency department use. We used adjusted risk ratios to examine the association between medical home characteristics and care measures based on the 2010 Medical Expenditure Panel Survey. Medical home characteristics are associated with 6 of the 11 outcome measures, including flu shots, smoking advice, exercise advice, nutrition advice, all advice, and emergency department visits. Educational and income groups benefit relatively equally from medical home characteristics. However, compared with insurance and access to a provider, medical home characteristics have little influence on overall disparities in care. In sum, our findings support that medical home characteristics can improve quality and reduce emergency visits but we find no evidence that medical home characteristics alleviate disparities in care.

The Effect of the 2009 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations on Mammography Rates

OBJECTIVE

To examine the effect of a change in U.S. Preventive Services Task Force (USPSTF) screening guidelines on mammography rates in the United States.

PRINCIPAL FINDINGS

In 2010, the year following the change in guidelines, 12-month mammography prevalence among women aged 40-49 years fell by 2.09 percentage points (95 percent confidence interval [CI]: -2.87 to -1.31) from 54.63 percent in 2008. For women aged 50-74 years, and aged 75 years and older, 12-month screening rates were 2.21 (95 percent CI: -2.65 to -1.77) and 3.60 (95 percent CI: -4.48 to -2.70) percentage points lower than those in 2008. In 2012, for women aged 40-49 years, 12-month prevalence fell to 52.51 percent, a decline of 2.12 percentage points (95 percent CI: -2.79 to -1.32) relative to screening rates prior the USPSTF announcement. For women aged 50-74 years and aged 75 years and older screening rates were 2.45 (95 percent CI: -2.96 to -2.07) and 5.71 (95 percent CI: -6.61 to -4.81) percentage points lower, respectively, in 2012 than in 2008.

CONCLUSION

This study demonstrates an immediate and lasting reduction in the rates of breast cancer screening among women of all age groups after the 2009 revision of screening guidelines by the USPSTF.

Predicting Incongruence between Self-reported and Documented Colorectal Cancer Screening in a Sample of African American Medicare Recipients

Assessments of colorectal cancer (CRC) screening rates typically rely on self-reported screening data, which are often incongruent with medical records. We used multilevel models to examine health-related, socio-demographic and psychological predictors of incongruent self-reports for CRC screening among Medicare-insured African Americans (N = 3,740). Results indicated that living alone decreased, and income increased, the odds of congruently self-reporting endoscopic CRC screening. Being male and having greater number of comorbidities decreased, and having less than a high school education increased, the odds of congruently self-reported fecal occult blood tests. Living alone, age and income had the most robust effects across classifications into one of four mutually exclusive categories defined by screening status (screened/unscreened) and congruence of self-reports. The results underscore the clinical importance of gathering socio-demographic data via patient interviews, and the relevance of these data for judging the veracity of self-reported CRC screenings behaviors.

The contribution of social and environmental factors to race differences in dental services use

Dental services use is a public health issue that varies by race. African Americans are less likely than whites to make use of these services. While several explanations exist, little is known about the role of segregation in understanding this race difference. Most research does not account for the confounding of race, socioeconomic status, and segregation. Using cross-sectional data from the Exploring Health Disparities in Integrated Communities Study, we examined the relationship between race and dental services use. Our primary outcome of interest was dental services use within 2 years. Our main independent variable was self-identified race. Of the 1408 study participants, 59.3% were African American. More African Americans used dental services within 2 years than whites. After adjusting for age, gender, marital status, income, education, insurance, self-rated health, and number of comorbidities, African Americans had greater odds of having used services (odds ratio = 1.48, 95% confidence interval 1.16, 1.89) within 2 years. Within this low-income racially integrated sample, African Americans participated in dental services more than whites. Place of living is an important factor to consider when seeking to understand race differences in dental service use.

National patterns in diabetes screening: data from the National Health and Nutrition Examination Survey (NHANES) 2005-2012

BACKGROUND

There are few current population-based estimates of the patterns of diabetes screening in the United States. The American Diabetes Association (ADA) recommends universal screening of adults ≥ 45 years, and high-risk adults < 45 years, but there is no current assessment of ADA guideline performance in detecting diabetes and prediabetes. Furthermore, data on racial/ethnic patterns of screening are limited.

OBJECTIVE

Our aim was to estimate diabetes screening prevalence for the US adult population and specifically for those who meet ADA criteria; to report the prevalence of prediabetes and diabetes among these groups; and to determine if high-risk race/ethnicity was associated with reported screening.

DESIGN

This was a Cross-sectional survey.

PARTICIPANTS

Non-pregnant adults (≥ 21 years) without diabetes or prediabetes who participated in the National Health and Nutrition Examination Survey (NHANES) in 2005-2012 (n = 17,572) were included in the study. "Screening-recommended" participants, classified by ADA criteria, included (1) adults ≥ 45 years and (2) "high-risk" adults < 45 years. "Screening-not-recommended" participants were adults < 45 years who did not meet criteria.

MAIN MEASURES

Diabetes screening status was obtained by self-report. We used calibrated HbA1c and/or fasting glucose levels to define undiagnosed diabetes and prediabetes.

KEY RESULTS

Seventy-six percent of the study population (approximately 136 million US adults) met ADA criteria. Among them, less than half (46.2%) reported screening; undiagnosed diabetes affected 3.7% (5 million individuals), and undiagnosed prediabetes affected 36.3% (49 million people.) African Americans were more likely to report screening, both among adults ≥ 45 years and among "high risk" younger adults (OR 1.27 and 1.36, respectively.) Hispanic participants were also more likely to report screening (OR 1.31 for older adults, 1.42 for younger adults.) The screening rate among "screening-not-recommended" adults was 29.6%; the prevalence of diabetes and prediabetes were 0.4 and 10.2%, respectively.

CONCLUSIONS

In a nationally representative sample, 76% of adults met ADA screening criteria, of whom fewer than half reported screening. Limitations include cross-sectional design and screening self-report.

Review of the evidence: prevalence of medical conditions in the United States population with serious mental illness

OBJECTIVE

Persons with serious mental illness (SMI) have high rates of premature mortality from preventable medical conditions, but this group is underrepresented in epidemiologic surveys and we lack national estimates of the prevalence of conditions such as obesity and diabetes in this group. We performed a comprehensive review to synthesize estimates of the prevalence of 15 medical conditions among the population with SMI.

METHOD

We reviewed studies published in the peer-reviewed literature from January 2000 to August 2012. Studies were included if they assessed prevalence in a sample of 100 or more United States (US) adults with schizophrenia or bipolar disorder.

RESULTS

A total of 57 studies were included in the review. For most medical conditions, the prevalence estimates varied considerably. For example, estimates of obesity prevalence ranged from 26% to 55%. This variation appeared to be due to differences in measurement (e.g., self-report versus clinical measures) and underlying differences in study populations. Few studies assessed prevalence in representative, community samples of persons with SMI.

CONCLUSIONS

In many studies, the prevalence of medical conditions among the population with SMI was higher than among the overall US population. Screening for and monitoring of these conditions should be common practice in clinical settings serving persons with SMI.

Recent trends in adherence to continuous screening for breast cancer among Medicare beneficiaries

OBJECTIVE

The aim of this study is to examine recent trends in adherence to continuous screening, especially the rate of subsequent screening mammography following an initial screening before and after the U.S. Preventive Services Task Force (USPSTF) revised its guidelines on breast cancer in November 2009.

METHODS

We retrospectively analyzed Medicare fee-for-service claims data to: 1) compare rate of subsequent screening mammography over 27 month periods for 317,150 women screened in either 2004 or 2009; and 2) examine patterns of subsequent screening by age and race.

RESULTS

When adjusted for age, race, state of residence, county-level covariates, and clustered on ordering provider, the rate of subsequent screening decreased in 2009 relative to 2004 (OR=0.75; 95% CI: 0.74-0.76). Adjusted odds ratios are similar for alternative follow-up windows (15 months, 0.71; 24 months, 0.70; 30 months 0.75). The decline was mostly attributable to women 75 and older who are now less likely to return for a subsequent screening. Although USPSTF guidelines call for 24 months, approximately half of women continue screening at 12-month intervals in both cohorts.

CONCLUSIONS

The rate of subsequent screening mammography has declined after 2009. Older women seem to follow the revised USPSTF guideline, but confusion by physicians and patients about competing guidelines may be contributing to these findings.

Medicare claims versus beneficiary self-report for influenza vaccination surveillance

BACKGROUND

Although self-reported influenza vaccination status is routinely used in surveillance to estimate influenza vaccine coverage, Medicare data are becoming a promising resource for influenza surveillance to inform vaccination program management and planning.

PURPOSE

To evaluate the concordance between self-reported influenza vaccination and influenza vaccination claims among Medicare beneficiaries.

METHODS

This study compared influenza vaccination based upon Medicare claims and self-report among a sample of Medicare beneficiaries (N=9,378) from the 2011 Medicare Current Beneficiary Survey, which was the most recent year of data at the time of analysis (summer 2013). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using self-reported data as the referent standard. Logistic regression was used to compute the marginal mean proportions for whether a Medicare influenza vaccination claim was present among beneficiaries who reported receiving the vaccination.

RESULTS

Influenza vaccination was higher for self-report (69.4%) than Medicare claims (48.3%). For Medicare claims, sensitivity=67.5%, specificity=96.3%, positive predictive value=97.6%, and negative predictive value=56.7%. Among beneficiaries reporting receiving an influenza vaccination, the percentage of beneficiaries with a vaccination claim was lower for beneficiaries who were aged <65 years, male, non-Hispanic black or Hispanic, and had less than a college education.

CONCLUSIONS

The classification of influenza vaccination status for Medicare beneficiaries can differ based upon survey and claims. To improve Medicare claims-based surveillance studies, further research is needed to determine the sources of discordance in self-reported and Medicare claims data, specifically for sensitivity and negative predictive value.

The validity of self-reported cancer screening history and the role of social disadvantage in Ontario, Canada

BACKGROUND

Self-report may not be an accurate method of determining cervical, breast and colorectal cancer screening rates due to recall, acquiescence and social desirability biases, particularly for certain sociodemographic groups. Therefore, the aims of this study were to determine the validity of self-report of cancer screening in Ontario, Canada, both for people in the general population and for socially disadvantaged groups based on immigrant status, ethnicity, education, income, language ability, self-rated health, employment status, age category (for cervical cancer screening), and gender (for fecal occult blood testing).

METHODS

We linked multiple data sources for this study, including the Canadian Community Health Survey and provincial-level health databases. Using administrative data as our gold standard, we calculated validity measures for self-report (i.e. sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values), calculated report-to-record ratios, and conducted a multivariable regression analysis to determine which characteristics were independently associated with over-reporting of screening.

RESULTS

Specificity was less than 70% overall and for all subgroups for cervical and breast cancer screening, and sensitivity was lower than 80% overall and for all subgroups for fecal occult blood testing FOBT. Report-to-record ratios were persistently significantly greater than 1 across all cancer screening types, highest for the FOBT group: 1.246 [1.189-1.306]. Regression analyses showed no consistent patterns, but sociodemographic characteristics were associated with over-reporting for each screening type.

CONCLUSIONS

We have found that in Ontario, as in other jurisdictions, there is a pervasive tendency for people to over-report their cancer screening histories. Sociodemographic status also appears to influence over-reporting. Public health practitioners and policymakers need to be aware of the limitations of self-report and adjust their methods and interpretations accordingly.

Policy dilemmas in Latino health care and implementation of the Affordable Care Act

The changing Latino demographic in the United States presents a number of challenges to health care policy makers, clinicians, organizations, and other stakeholders. Studies have demonstrated that Latinos tend to have worse patterns of access to, and utilization of, health care than other ethnic and racial groups. The implementation of the Affordable Care Act (ACA) of 2010 may ameliorate some of these disparities. However, even with the ACA, it is expected that Latinos will continue to have problems accessing and using high-quality health care, especially in states that are not expanding Medicaid eligibility as provided by the ACA. We identify four current policy dilemmas relevant to Latinos' health and ACA implementation: (a) the need to extend coverage to the undocumented; (b) the growth of Latino populations in states with limited insurance expansion;

State Medicaid expansion decisions and disparities in women's cancer screening

BACKGROUND

There are substantial disparities in breast and cervical cancer screening that stem from lack of health insurance. Although the Affordable Care Act (ACA) expands insurance coverage to many Americans, there are differences in availability of Medicaid coverage across states.

PURPOSE

To understand the potential impact of Medicaid expansions on disparities in preventive care for low-income women by assessing pre-ACA breast and cervical cancer screening across states currently expanding and not expanding Medicaid to low-income adults.

METHODS

Data from the 2012 Behavioral Risk Factor Surveillance System (analyzed in 2014) were used to consider differences in demographics among women for whom screening is recommended, including income and race/ethnicity, across expansion and nonexpansion states. Self-reported screening was compared by state expansion status overall, for the uninsured, and for low-income women. Logistic regressions were estimated to assess differences in self-reported screening across expansion and nonexpansion states controlling for demographics.

RESULTS

Women in states that are not expanding Medicaid had significantly lower odds of receiving recommended mammograms (OR=0.87, 95% CI=0.79, 0.95) or Pap tests (OR=0.87, 95% CI=0.79, 0.95). The difference was larger among the uninsured (OR=0.72, 95% CI=0.56, 0.91 for mammography; OR=0.78, 95% CI=0.65, 0.94 for Pap tests).

CONCLUSIONS

As women in nonexpansion states remain uninsured and others gain coverage, existing disparities in cancer screening by race and socioeconomic status are likely to widen. Health risks and associated costs to underserved populations must be taken into account in ongoing debates over expansion.

Comparison of self-report influenza vaccination coverage with data from a population based computerized vaccination registry and factors associated with discordance

OBJECTIVES

We aim to compare influenza vaccination coverages obtained using two different methods; a population based computerized vaccination registry and self-reported influenza vaccination status as captured by a population survey.

METHODS

The study was conducted in the Autonomous Community of Madrid (ACM), Spain, and refers to the 2011/12 influenza vaccination campaign. Information on influenza vaccination status according to a computerized registry was extracted from the SISPAL database and crossed with the electronic clinical records in primary care (ECRPC). Self-reported vaccine uptake was obtained from subjects living in the ACM included in the 2011-12 Spanish National Health Survey (SNHS). Independent study variables included: age, sex, immigrant status and the presence of high risk chronic conditions. Vaccination coverages were calculated according to study variables. Crude and adjusted prevalence ratios were computed to assess concordance.

RESULTS

The study population included 5,245,238 adults living in the ACM in year 2011 with an individual ECRPC and 1449 adult living the ACM and interviewed in the SNHS from October 2011 to June 2012. The weighted vaccination coverage for the study population according to self-reported data was 19.77% and 15.04% from computerized registries resulting in a crude prevalence ratio (cPR) of 1.31 (95% CI 1.20-1.44) so self-reported data significantly overestimated 31% the registry coverage. Self-reported coverages are always higher than registry based coverages when the study population is stratified by the study variables. Self-reported overestimation was higher among men than women, younger age groups, immigrants and those without chronic conditions. Both methods provide the most concordant estimations for the target population of the influenza vaccine.

CONCLUSIONS

Self-report influenza vaccination uptake overestimates vaccination registries coverages. The validity of self-report seems to be negatively affected by socio-demographic variables and the absence of chronic conditions. Possible strategies must be considered and implemented to improve both coverage estimation methods.

Agreement between self-reported and registered colorectal cancer screening: a meta-analysis

This random-effects meta-analysis investigates the accuracy of self-reported colorectal cancer screening history as a function of screening mode (colonoscopy, flexible sigmoidoscopy, faecal occult blood testing - FOBT, double-contrast barium enema - DCBE) and survey mode (written, telephone, face-to-face). Summary estimates of sensitivity, specificity, positive predictive value (PPV) and area under the receiver operating characteristic curve (AUC) were calculated. Medical record data were used as reference. We included 23 studies comprising 11,592 subjects. Colonoscopy yielded higher AUC [0.948, 95% confidence interval (CI) = 0.918, 0.968] than flexible sigmoidoscopy (0.883, 95% CI = 0.849, 0.911) and FOBT (0.869, 95% CI = 0.833, 0.898). Colonoscopy showed the highest sensitivity (0.888, 95% CI = 0.835, 0.931), whereas specificity was comparable between screening modes (ranging from 0.802 for FOBT to 0.904 for DCBE). AUC was not significantly different between survey modes. Prevalence of screening history correlated positively with sensitivity and negatively with specificity, possibly because of errors in the medical records. In conclusion, the accuracy of self-reported cancer screening is generally moderate, and higher for colonoscopy than for sigmoidoscopy and FOBT.

Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care

BACKGROUND

Prior studies have shown racial/ethnic disparities in colorectal cancer (CRC) screening but have not provided a full national picture of disparities across all major racial/ethnic groups.

PURPOSE

To provide a more complete, up-to-date picture of racial/ethnic disparities in CRC screening and contributing socioeconomic and access barriers.

METHODS

Behavioral Risk Factor Surveillance System data from 2010 were analyzed in 2013. Hispanic/Latino participants were stratified by preferred language (Hispanic-English versus Hispanic-Spanish). Non-Hispanics were categorized as White, Black, Asian, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native. Sequential regression models estimated adjusted relative risks (RRs) and the degree to which SES and access to care explained disparities.

RESULTS

Overall, 59.6% reported being up-to-date on CRC screening. Self-reported CRC screening was highest in the White (62.0%) racial/ethnic group; followed by Black (59.0%); Native Hawaiian/Pacific Islander (54.6%); Hispanic-English (52.5%); American Indian/Alaska Native (49.5%); Asian (47.2%); and Hispanic-Spanish (30.6%) groups. Adjustment for SES and access partially explained disparities between Whites and Hispanic-Spanish (final relative risk [RR]=0.76, 95% CI=0.69, 0.83); Hispanic-English (RR=0.94, 95% CI=0.91, 0.98); and American Indian/Alaska Native (RR=0.91, 95% CI=0.85, 0.97) groups. The RR of screening among Asians was unchanged after adjustment for SES and access (0.78, p<0.001). After full adjustment, screening rates were not significantly different among Whites, Blacks, or Native Hawaiian/Pacific Islanders.

CONCLUSIONS

Large racial/ethnic disparities in CRC screening persist, including substantial differences between English-speaking versus Spanish-speaking Hispanics. Disparities are only partially explained by SES and access to care. Future studies should explore the low rate of screening among Asians and how it varies by racial/ethnic subgroup and language.

Health literacy and cancer screening: a systematic review

OBJECTIVE

To evaluate published evidence about health literacy and cancer screening.

METHODS

Seven databases were searched for English language articles measuring health literacy and cancer screening published in 1990-2011. Articles meeting inclusion criteria were independently reviewed by two investigators using a standardized data abstraction form. Abstracts (n=932) were reviewed and full text retrieved for 83 articles. Ten articles with 14 comparisons of health literacy and cancer screening according to recommended medical guidelines were included in the analysis.

RESULTS

Most articles measured health literacy using the S-TOFHLA instrument and documented cancer screening by self-report. There is a trend for an association of inadequate health literacy and lower cancer screening rates, however, the evidence is mixed and limited by study design and measurement issues.

CONCLUSION

A patient's health literacy may be a contributing factor to being within recommended cancer screening guidelines.

PRACTICE IMPLICATIONS

Future research should: be conducted using validated health literacy instruments; describe the population included in the study; document cancer screening test completion according to recommended guidelines; verify the completion of cancer screening tests by medical record review; adjust for confounding factors; and report effect size of the association of health literacy and cancer screening.

Disparities in multiple chronic conditions within populations

Disadvantaged populations are disproportionately affected by multiple chronic conditions (MCCs), yet few studies examine the prevalence, outcomes, or effectiveness of MCC interventions in minority and socioeconomically deprived individuals and populations. An important first step in understanding MCCs, not only in such diverse population groups, but also in the general population as a whole, is to broaden the definition and scope of MCC measurement, to encompass more than the simple additive effect of clinical conditions, and to include a wide range of health and health-related aspects that interact and make up the full spectrum of multimorbidity. Only with the use of a comprehensive MCC measurement can some of the differences between the disadvantaged populations be adequately detected. Better understanding of the disparities in access to high quality health and healthcare for persons with MCCs can help guide policy and practice aimed at the prevention and amelioration of the effects of MCCs among disadvantaged groups. Indeed, disparity in MCC populations has been identified as a key goal of the U.S. Department of Health and Human Services’ Strategic Framework on MCCs. The aim of the present paper is to describe current knowledge on disparities in the population of persons with MCCs and to guide efforts for the prevention and management of MCCs in disadvantaged populations.

Journal of Comorbidity 2013;3:45–50

Disparities in preventive health services among Somali immigrants and refugees

African immigrants and refugees-almost half of them from Somalia-account for one of the fastest-growing groups in the United States. There is reason to suspect that Somali-Americans may be at risk for low completion of recommended preventive health services. This study's aim was to quantify disparities in preventive health services among Somali patients compared with non-Somali patients in an academic primary care practice in Rochester, Minn. It also examined the effect of medical interpreters, emergency department visits, and primary care visits on the completion of preventive services. Rates of pap smears, vaccinations (influenza, pneumococcus, and tetanus), lipid screening, colorectal cancer screening, and mammography were assessed in Somali and non-Somali patients during the second quarter of 2008. Data were collected regarding the utilization of medical interpreters, emergency services, and primary care services among Somali patients. Results were reported using standard descriptive statistics. Of the 91,557 patients identified in the database, 810 were Somali. Somali patients had significantly lower completion rates of colorectal cancer screening, mammography, pap smears, and influenza vaccination than non-Somali patients. Use of medical interpreters and primary care services were generally associated with higher completion rates of preventive services. There are significant discrepancies in the provision of preventive health services to Somali patients compared with that of non-Somali patients. These findings suggest the need to identify the root causes of these discrepancies so that interventions may be crafted to close the gap.

Association between race, place, and preventive health screenings among men: findings from the exploring health disparities in integrated communities study

African American men consistently report poorer health and have lower participation rates in preventive screening tests than White men. This finding is generally attributed to race differences in access to care, which may be a consequence of the different health care markets in which African American and White men typically live. This proposition is tested by assessing race differences in use of preventive screenings among African American and White men residing within the same health care marketplace. Logistic regression was used to examine the association between race and physical, dental, eye and foot examinations, blood pressure and cholesterol checks, and colon and prostate cancer screenings in men in the Exploring Health Disparities in Integrated Communities in Southwest Baltimore Study. After adjusting for covariates, African American men had greater odds of having had a physical, dental, and eye examination; having had their blood pressure and cholesterol checked; and having been screened for colon and prostate cancer than White men. No race differences in having a foot examination were observed. Contrary to most findings, African American men had a higher participation rate in preventive screenings than White men. This underscores the importance of accounting for social context in public health campaigns targeting preventive screenings in men.

Does social disadvantage affect the validity of self-report for cervical cancer screening?

Objective

The aim was to review the international literature on the validity of self-report of cervical cancer screening, specifically of studies that made direct comparisons among women with and without social disadvantage, based on race/ethnicity, foreign-born status, language ability, income, or education.

Method

The databases of Medline, EBM Reviews, and CINAHL from 1990 to 2011 were searched using relevant search terms. Articles eligible for data extraction documented the prevalence of cervical cancer screening based on both self-report and an objective measure for women both with and without at least one measure of social disadvantage. The report-to-record ratio, the ratio of the proportion of study subjects who report at least one screening test within a particular time frame to the proportion of study subjects who have a record of the same test within that time frame, was calculated for each subgroup.

Results

Five studies met the extraction criteria. Subgroups were based on race/ethnicity, education, and income. In all studies, and across all subgroups, report-to-record ratios were greater than one, indicative of pervasive over-reporting.

Conclusion

The findings suggest that objective measures should be used by policymakers, researchers, and public-health practitioners in place of self-report to accurately determine cervical cancer screening rates.

Mammography rates after the 2009 US Preventive Services Task Force breast cancer screening recommendation

OBJECTIVE

To measure the impact of the 2009 US Preventive Services Task Force (USPSTF) breast cancer screening recommendation, which recommended against routine screening for women aged 40 to 49 and stated that there was "insufficient evidence" to recommend screening for women aged 75 and older, on mammography rates.

METHODS

Self-reported mammography rates were calculated using the 2006-2010 Medical Expenditure Panel Surveys (n=29,857). The paper reports mammography rates by age group (40 to 49, 50 to 74, and 75 and older), adjusted for age, race/ethnicity, socioeconomic status, and region. The study was performed at Emory University in Atlanta, Georgia, USA in 2012.

RESULTS

Differences in mammography rates between 2010 and earlier years were not significant. Among women aged 40-49, biennial mammography rates declined by -0.5 percentage points between 2006 to 2009 and 2010 (95% confidence interval [CI]: -3.0 to 1.9; p=0.67). Among women aged 50-74, rates declined by -0.07 percentage points (95% CI: -1.8 to 1.7; p=0.93). Among women aged 75 years and older, rates declined by -0.1 percentage points (95% CI: -4.2 to 3.9; p=0.94).

CONCLUSION

The revision to the USPSTF breast cancer screening recommendation did not affect screening patterns.

Racial/ethnic disparities in provision of dental procedures to children enrolled in Delta Dental insurance in Milwaukee, Wisconsin

OBJECTIVES

Most studies on the provision of dental procedures have focused on Medicaid enrollees known to have inadequate access to dental care. Little information on private insurance enrollees exists. This study documents the rates of preventive, restorative, endodontic, and surgical dental procedures provided to children enrolled in Delta Dental of Wisconsin (DDWI) in Milwaukee.

METHODS

We analyzed DDWI claims data for Milwaukee children aged 0-18 years between 2002 and 2008. We linked the ZIP codes of enrollees to the 2000 U.S. Census information to derive racial/ethnic estimates in the different ZIP codes. We estimated the rates of preventive, restorative, endodontic, and surgical procedures provided to children in different racial/ethnic groups based on the population estimates derived from the U.S. Census data. Descriptive and multivariable analysis was done using Poisson regression modeling on dental procedures per year.

RESULTS

In 7 years, a total of 266,380 enrollees were covered in 46 ZIP codes in the database. Approximately, 64 percent, 44 percent, and 49 percent of White, African American, and Hispanic children had at least one dental visit during the study period, respectively. The rates of preventive procedures increased up to the age of 9 years and decreased thereafter among children in all three racial groups included in the analysis. African American and Hispanic children received half as many preventive procedures as White children.

CONCLUSION

Our study shows that substantial racial disparities may exist in the types of dental procedures that were received by children.

A comparison of breast and cervical cancer legislation and screening in Georgia, North Carolina, and South Carolina

We identified legislation (1989-2005) relating to breast and cervical cancer in Georgia, North Carolina, and South Carolina and examined its impact on screening rates for these cancers and on Black-White disparities in screening rates. Legislation was identified using the National Cancer Institute's (NCI) State Cancer Legislative Database (SCLD) Program. Screening rates were identified using the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System. Georgia and North Carolina enacted more laws on breast and cervical cancer than did South Carolina. The laws specifically intended to increase breast and cervical cancer screening were mandates requiring that insurance policies cover such screening; Georgia and North Carolina enacted such laws, but South Carolina did not. However, we were unable to demonstrate an effect of these laws on either screening rates or disparities. This may reinforce the importance of evidence-based health promotion programs to increase screening.

Number of first-contact access components required to improve preventive service receipt in primary care homes

BACKGROUND

A fundamental aim of primary care redesign and the patient-centered medical home is improving access to care. Patients who report having a usual site of care and usual provider are more likely to receive preventive services, but less is known about the influence of specific components of first-contact access (e.g., availability of appointments, advice by telephone) on preventive services receipt.

OBJECTIVE

To examine the relationship between number of first-contact access components and receipt of recommended preventive services.

DESIGN

Secondary survey data analysis.

PARTICIPANTS

Five thousand five hundred and seven insured adults who had continuity with a usual primary care physician and participated in the 2003-2006 round of the Wisconsin Longitudinal Survey.

MAIN MEASURES

Using multivariable logistic regression, we calculated adjusted risk ratios, adjusted predicted probabilities and 95% confidence intervals for each preventive service.

KEY RESULTS

Experiencing more first-contact access components was significantly associated with a higher rate of receiving cholesterol tests, flu shots and prostate exams but not mammography. There was variation in the number of components needed (between two and seven) to achieve a significant difference.

CONCLUSIONS

Having an increasing number of first-access components in a primary care office may improve preventive services receipt, and more components may be required for those services requiring greater provider contact (e.g., prostate exam) versus those that require less (e.g., mammography). In primary care redesign, the largest gains in preventive services receipt likely will come with redesign of multiple components simultaneously. While our study is a necessary step towards broadly understanding the relationship between first-contact access and preventive service receipt, other important questions remain. Certain components may drive greater improvements in the receipt of different services, and the effect of some of these components may depend on individual patient characteristics. Further research is critical for understanding redesign strategies that may optimize preventive service delivery.

Patient compliance with telephone triage recommendations: a meta-analytic review

OBJECTIVE

To systematically investigate the extent to which patients comply with triage advice from telenurses and to identify factors that potentially influence compliance.

METHODS

Findings from 13 studies identified through interdisciplinary research databases (1990-2010) were meta-analyzed. Separate pooled analyses compared patients' compliance rates for emergency services and office care (13 outcomes), emergency services and self care (13 outcomes), and self care and office care (12 outcomes).

RESULTS

Overall patient compliance was 62%, but varied by intensity of care recommended with low compliance rates for advice to see a general practitioner. Reasons for noncompliance include patients reporting to have heard a different disposition, patients' intentions and health beliefs.

CONCLUSION

Patient compliance to triage recommendations was influenced by the interactive role of patient perceptions and the quality of provider communication, both of which were mediated by access to health services. Further research is needed to clarify whether noncompliance is attributable to poor communication by the nurse or patient misinterpretation.

PRACTICE IMPLICATIONS

We highlight the need for communication-skills training in a telephone-consultation context that is patient centered, and specifically addresses building active listening and active advising skills and advantages to structuring the call.

Self-reported cancer screening among elderly Medicare beneficiaries: a rural-urban comparison

PURPOSE

We examined the rural-urban disparity of screening for breast cancer and colorectal cancer (CRC) among the elder Medicare beneficiaries and assessed rurality's independent impact on receipt of screening.

METHODS

Using 2005 Medicare Current Beneficiary Survey, we applied weighted logistic regression to estimate the overall rural-urban disparity and rurality's independent impact on cancer screening, controlling for patient, and area factors.

RESULTS

From urban, large rural, small rural, and isolated rural areas, the rates for mammogram last year were 53%, 52%, 45%, and 44%, respectively. They were 56%, 50%, 48%, and 43% for CRC screening, respectively. After controlling for patient and area level characteristics, rurality is significantly associated with CRC screening, but not mammogram.

CONCLUSIONS

We found rural-urban disparities for both mammogram and CRC screenings. Patient and area factors totally eliminated the rural-urban disparity for mammogram but not CRC screening. Health promotions to improve cancer screening should focus more on small and isolated rural areas.

Lipid testing in patients with rheumatoid arthritis and key cardiovascular-related comorbidities: a medicare analysis

OBJECTIVE

For patients with rheumatoid arthritis (RA) and comorbid cardiovascular disease (CVD), diabetes, or hyperlipidemia, annual lipid testing is recommended to reduce morbidity and mortality from comorbidities. Given trends encouraging complex patients to receive care in "medical homes," we examined associations between regularly seeing a primary care provider (PCP) and lipid testing in RA patients with cardiovascular-related comorbidities.

METHODS

We performed a retrospective cohort study examining a 5% random USA Medicare sample (2004-06) of beneficiaries over 65 years old with RA and concomitant CVD, diabetes, or hyperlipidemia (n = 16,893). We examined the relationship between receiving lipid testing in 2006 and having at least 1 PCP visit per year in 2004, 2005, and 2006 using multivariate regression.

RESULTS

Ninety percent of patients had prevalent CVD; 46% had diabetes, and 64% had hyperlipidemia. However, annual lipid testing was only performed in 63% of these RA patients. Thirty percent of patients saw a PCP less than once per year, despite frequent visits (mean >9) with other providers. Patients without at least 1 annual PCP visit were 16% less likely to have lipid testing. Increased age, complexity scores, hospitalization, and large town residence predicted decreased lipid testing.

CONCLUSIONS

Despite comorbid CVD, diabetes, or hyperlipidemia, 30% of Medicare RA patients saw a PCP less than once per year, and 1 in 3 lacked annual lipid testing. Findings support advocating primary care visits at least once per year. Remaining gaps in lipid testing suggest the need for additional strategies to improve lipid testing in at-risk RA patients.