Heterogeneity in mammography use across the nation: separating evidence of disparities from the disproportionate effects of geography

Associations between perceived racial discrimination, racial residential segregation, and cancer screening adherence among low-income African Americans: a multilevel, cross-sectional analysis

OBJECTIVES

African Americans suffer disproportionately from cancer compared to their White counterparts. Racism may be an important determinant, but the literature on its association with cancer screening is limited. We examine associations between racism and cancer screening among a sample of African Americans.

DESIGN

Guided by the Public Health Critical Race Praxis and the Behavioral Model of Health Services Use, we conducted a multilevel, cross-sectional study using cancer risk assessment data collected from 405 callers to the 2-1-1 Texas helpline. We merged these data with contextual data from the U.S. Census Bureau. We assessed perceived racial discrimination using the Experiences of Discrimination Scale and racial residential segregation using the Location Quotient for Racial Residential Segregation. We used multilevel regression models to test hypothesized associations between each indicator of racism and four cancer screening adherence outcomes (Pap test, mammography, colorectal cancer screening [CRCS], and any cancer screening).

RESULTS

Participants were 18-83 years old (mean = 45 years). Most (81%) were non-adherent to at least one recommended screening. Approximately 42% reported experiencing discrimination and 73% lived in a segregated neighborhood. Discrimination was non-significantly related to lower odds of mammography (aOR = 0.68; 95%CI: 0.38-1.22), CRCS (aOR = 0.79; 95%CI: 0.41-1.52), and any cancer screening adherence (aOR = 0.88; 95%CI: 0.59-1.32). Segregation was related to greater odds of mammography (non-significant; aOR = 1.43; 95%CI: 0.76-2.68) and CRCS (significant; aOR = 2.80; 95%CI: 1.21-6.46) but not associated with any cancer screening. Neither indicator of racism was associated with Pap test screening adherence.

CONCLUSIONS

Racism has a nuanced association with cancer screening among low-income, medically underserved African Americans. Specifically, discrimination appears to be associated with lower odds of screening, while segregation may be associated with higher odds of screening in certain situations. Future research is needed to better explicate relations between indicators of racism and cancer screening among African Americans.

Association of racial residential segregation with all-cause and cancer-specific mortality in the reasons for geographic and racial differences in stroke (REGARDS) cohort study

•Increased racial residential segregation increased the risk of all-cause mortality among White participants.•Higher interaction lowered the risk of all-cause mortality among White participants.•Higher isolation lowered the risk of cancer mortality among Black participants.

Association of Residential Racial and Economic Segregation With Cancer Mortality in the US

Importance

Residential segregation is a structural risk factor for poor cancer outcomes. Previous research examining the association of residential segregation with cancer outcomes was limited by older data, restricted geographic areas, and few cancer sites. To guide targeted interventions, a comprehensive evaluation of the association between segregation and cancer outcomes is needed.

Objective

To examine the association of residential racial and economic segregation with cancer mortality at the US county level for all cancers combined and for the 13 cancer types that represent the top 10 causes of cancer deaths in males or females.

Design, Setting, and Participants

This ecological study used county-level sociodemographic data from the 2015-2019 American Community Survey linked with 2015-2019 county-level mortality data. Data analysis was performed from September 2021 to April 2022.

Exposures

Residential racial and economic segregation measured by the Index of Concentration at the Extremes (ICE) and categorized into quintiles 1 (most deprived) through 5 (most privileged).

Main Outcomes and Measures

Age-adjusted cancer mortality was the outcome. Multilevel linear mixed modeling was used to calculate the adjusted mortality rate ratio (aRR).

Results

A total of 3110 counties were included. The age-adjusted mortality rates of all cancers combined were 179.8, 177.3, 167.6, 159.6, and 146.1 per 100 000 population (P < .001 for trend) for the 5 ICE categories (most deprived to least deprived), respectively. Compared with the least deprived counties, aRRs for all cancers combined were 1.22 (95% CI, 1.20-1.24) for the most deprived counties, followed by 1.17 (95% CI, 1.15-1.19), 1.10 (95% CI, 1.09-1.12), and 1.06 (95% CI, 1.04-1.08) for the other 3 quintiles, respectively (P < .001 for trend). Segregation was associated with increased mortality from 12 of 13 selected cancer sites, in which aRRs ranged from 1.06 (95% CI, 1.02-1.09) for brain and other nervous system cancer to 1.49 (95% CI, 1.43-1.54) for lung and bronchus cancer.

Conclusions and Relevance

The findings of this ecological study suggest that residential racial and economic segregation is associated with higher cancer mortality at the county level, highlighting opportunities for geographically targeted cancer prevention and control efforts.

Racism and Cancer Screening among Low-Income, African American Women: A Multilevel, Longitudinal Analysis of 2-1-1 Texas Callers

Although racism is increasingly being studied as an important contributor to racial health disparities, its relation to cancer-related outcomes among African Americans remains unclear. The purpose of this study was to help clarify the relation between two indicators of racism-perceived racial discrimination and racial residential segregation-and cancer screening. We conducted a multilevel, longitudinal study among a medically underserved population of African Americans in Texas. We assessed discrimination using the Experiences of Discrimination Scale and segregation using the Location Quotient for Racial Residential Segregation. The outcome examined was "any cancer screening completion" (Pap test, mammography, and/or colorectal cancer screening) at follow-up (3-10 months post-baseline). We tested hypothesized relations using multilevel logistic regression. We also conducted interaction and stratified analyses to explore whether discrimination modified the relation between segregation and screening completion. We found a significant positive relation between discrimination and screening and a non-significant negative relation between segregation and screening. Preliminary evidence suggests that discrimination modifies the relation between segregation and screening. Racism has a nuanced association with cancer screening among African Americans. Perceived racial discrimination and racial residential segregation should be considered jointly, rather than independently, to better understand their influence on cancer screening behavior.

Impact of Diffuse Large B-Cell Lymphoma on Mammography and Bone Density Testing in Women

Women with diffuse large B-cell lymphoma (DLBCL) are at an increased risk of mortality from breast cancer and osteoporosis. However, the impact of DLBCL on rates of mammography and bone density testing (BDT) is unknown. We compared female DLBCL and non-cancer patients utilizing the Surveillance, Epidemiology, and End Results-Medicare dataset to analyze the predictors of mammography and BDT. Guided by the Social Ecological Model (SEM), we used multivariable logistic regressions with inverse probability treatment weighting to examine the association of intrapersonal, interpersonal, healthcare system, and community factors with mammography and BDT. The rates of mammography (59.8%) and BDT (18.5%) in women with DLBCL were similar to those without cancer (60.2% and 19.6%, respectively). After adjusting for the SEM factors, DLBCL patients were less likely to get mammography and BDT than non-cancer patients. The treatments of radiotherapy and stem cell transplant were not associated with either mammography or BDT. DLBCL diagnosis was associated with lower rates of mammography and BDT rates among women with DLBCL, as compared to non-cancer patients. To reduce the morbidity and mortality from breast cancer and fractures in women with DLBCL, providers should increase their recommendations for mammography in those receiving radiotherapy and BDT in stem cell transplant patients.

Mapping mammography in Arkansas: Locating areas with poor spatial access to breast cancer screening using optimization models and geographic information systems

Introduction:

Arkansans have some of the worst breast cancer mortality to incidence ratios in the United States (5th for Blacks, 4th for Whites, 7th overall). Screening mammography allows for early detection and significant reductions in mortality, yet not all women have access to these life-saving services. Utilization in Arkansas is well below the national average, and the number of FDA-approved screening facilities has decreased by 38% since 2001. Spatial accessibility plays an important role in whether women receive screenings.

Methods:

We use constrained optimization models within a geographic information system (GIS) to probabilistically allocate women to nearby screening facilities, accounting for facility capacity and patient travel time. We examine accessibility results by rurality derived from rural–urban commuting area (RUCA) codes.

Results:

Under most models, screening capacity is insufficient to meet theoretical demand given travel constraints. Approximately 80% of Arkansan women live within 30 minutes of a screening facility, most of which are located in urban and suburban areas. The majority of unallocated demand was in Small towns and Rural areas.

Conclusions:

Geographic disparities in screening mammography accessibility exist across Arkansas, but women living in Rural areas have particularly poor spatial access. Mobile mammography clinics can remove patient travel time constraints to help meet rural demand. More broadly, optimization models and GIS can be applied to many studies of healthcare accessibility in rural populations.

Assessing and Explaining Geographic Variations in Mammography Screening Participation and Breast Cancer Incidence

Investigating geographic variations in mammography screening participation and breast cancer incidence help improve prevention strategies to reduce the burden of breast cancer. This study examined the suitability of health insurance claims data for assessing and explaining geographic variations in mammography screening participation and breast cancer incidence at the district level. Based on screening unit data (1,181,212 mammography screening events), cancer registry data (13,241 incident breast cancer cases) and claims data (147,325 mammography screening events; 1,778 incident breast cancer cases), screening unit and claims-based standardized participation ratios (SPR) of mammography screening as well as cancer registry and claims-based standardized incidence ratios (SIR) of breast cancer between 2011 and 2014 were estimated for the 46 districts of the German federal state of Lower Saxony. Bland-Altman analyses were performed to benchmark claims-based SPR and SIR against screening unit and cancer registry data. Determinants of district-level variations were investigated at the individual and contextual level using claims-based multilevel logistic regression analysis. In claims and benchmark data, SPR showed considerable variations and SIR hardly any. Claims-based estimates were between 0.13 below and 0.14 above (SPR), and between 0.36 below and 0.36 above (SIR) the benchmark. Given the limited suitability of health insurance claims data for assessing geographic variations in breast cancer incidence, only mammography screening participation was investigated in the multilevel analysis. At the individual level, 10 of 31 Elixhauser comorbidities were negatively and 11 positively associated with mammography screening participation. Age and comorbidities did not contribute to the explanation of geographic variations. At the contextual level, unemployment rate was negatively and the proportion of employees with an academic degree positively associated with mammography screening participation. Unemployment, income, education, foreign population and type of district explained 58.5% of geographic variations. Future studies should combine health insurance claims data with individual data on socioeconomic characteristics, lifestyle factors, psychological factors, quality of life and health literacy as well as contextual data on socioeconomic characteristics and accessibility of mammography screening. This would allow a comprehensive investigation of geographic variations in mammography screening participation and help to further improve prevention strategies for reducing the burden of breast cancer.

Temporal trends of geographic variation in mortality following cancer diagnosis: a population-based study

Background

Inequalities among the western population, combined with the introduction of new treatment options for cancer, have challenged endeavors to provide equal care to patients with cancer. Israel’s highly developed healthcare system and mandatory National Health Insurance afforded an opportunity to study geographic variation over time in mortality following cancer diagnosis.

Methods

This historical prospective cohort study included a nationally representative cohort that was assessed by the Israeli Central Bureau of Statistics 1995 census and followed until 2011. The cancer incidence (1995–2009) was ascertained by the Israel National Cancer Registry. We analyzed the effect on patient outcome of living in a given district, according to the Israeli Central Bureau of Statistics classification. Patients were stratified by the year of diagnosis (1995–1997, 1998–2000, etc.), and associations were adjusted for age, ethnicity, and districts. We excluded patients with malignancies associated with screening program (breast, prostate, colon, and cervical cancers).

Results

This study included 26,173 patients living in 13 residential districts. During the last years (2007–2009) of the study, the hazard ratio (HR) for risk of death was high in 8/13 districts (61.5%), compared to 4/13 (30.7%) during 2004–2006, and 0/13 (0%) during 2001–2003. Districts that were less likely to be associated with increased risk of death were located in the center of Israel and in metropolitan areas, compared to the peripheral regions. Furthermore, HRs were substantially higher in the last years of the study (2007–2009, HRs rose to 1.69, 95%CI: 1.38–2.08) compared to the earlier years (2004–2006, HRs rose to 1.35, 95%CI: 1.13–1.62).

Conclusion

Our findings suggested that geographic variation for mortality following cancer diagnosis have increased over time. Our results provide policy makers with vital information regarding the need for targeted interventions, mainly in peripheral regions.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6353-1) contains supplementary material, which is available to authorized users.

Factors associated with high-risk human papillomavirus test utilization and infection: a population-based study of uninsured and underinsured women

Background

Current cervical cancer screening guidelines recommend a Pap test every 3 years for women age 21–65 years, or for women 30–65 years who want to lengthen the screening interval, a combination of Pap test and high-risk human papilloma virus testing (co-testing) every 5 years. Little population-based data are available on human papilloma virus test utilization and human papilloma virus infection rates. The objective of this study was to examine the patient-level, cervical cancer screening, and area-level factors associated with human papilloma virus testing and infection among a diverse sample of uninsured and underinsured women enrolled in the New Jersey Cancer Early Education and Detection (NJCEED) Program.

Methods

We used data for a sample of 50,510 uninsured/underinsured women, age ≥ 29 years, who screened for cervical cancer through NJCEED between January 1, 2009 and December 31, 2015. Multivariable logistic regression models were used to estimate associations between ever having a human papilloma virus test or a positive test result, and individual- (age, race/ethnicity, birthplace) and area-level covariates (% below federal poverty level, % minority, % uninsured), and number of screening visits.

Results

Only 26.6% (13,440) of the sample had at least one human papilloma virus test. Among women who underwent testing, 13.3% (1792) tested positive for human papilloma virus. Most women who were positive for human papilloma virus (99.4%) had their first test as a co-test. Human papilloma virus test utilization and infection were significantly associated with age, race/ethnicity, birthplace (country), and residential area-level poverty. Rates of human papilloma virus testing and infection also differed significantly across counties in the state of New Jersey.

Conclusions

These findings suggest that despite access to no-cost cervical cancer screening for eligible women, human papilloma virus test utilization was relatively low among diverse, uninsured and underinsured women in New Jersey, and test utilization and infection were associated with individual-level and area-level factors.

What Happened to Disparities in CRC Screening Among FFS Medicare Enrollees Following Medicare Modernization?

The Medicare Modernization Act of 2003, implemented in 2006, increased managed care options for seniors. It introduced insurance plans for prescription drug coverage for all Medicare beneficiaries, whether they were enrolled in FFS or managed care (Medicare Advantage) plans. The availability of drug coverage beginning in 2006 served to free up budgets for FFS Medicare enrollees that could be used to make copayments for colorectal cancer (CRC) screening using endoscopy (colonoscopy or sigmoidoscopy). In 2007, Medicare eliminated the copayments required by seniors for CRC screening by endoscopy. Later in 2008, CRC screening by colonoscopy became part of the gold standard for CRC screening. This legitimized its use and offered even further encouragement to seniors, who may have been reluctant to undergo the procedure because of the non-pecuniary risks associated with it. In addition, 37 CRC screening interventions occurred during this timeframe to enhance compliance with screening standards. Using multilevel analysis of individuals' endoscopy utilization, derived from 100% FFS Medicare claims, along with county-level market and contextual factors, we compare the periods before and after the MMA (2001-2005 to 2006-2009) to determine whether disparities in the utilization of endoscopic CRC screening occurred or changed over the decade. We examined Blacks, Asians, and Hispanics relative to Whites, and Females relative to Males (with race or ethnicity combined). We examined each state separately for evidence of disparities within states, to avoid confounding by geographic disparities. We expected that the net effect of the policy changes and the targeted interventions over the decade would be to increase CRC screening by endoscopy, reducing disparities. We saw improvements over time (reduced disparities relative to Whites) for Blacks and Hispanics residing in several states, and improvements over time for Females relative to Males in many states. For the vast majority of states, however, disparities persisted with Whites and Males exhibiting greater rates of utilization than other groups. States that undertook the interventions were more likely to have had improvements in disparities or positive disparities for women and minorities. While some gains were made over this time period, the gains were unevenly distributed across the USA and more work needs to be done to reduce remaining disparities.

Racial and ethnic disparities among state Medicaid programs for breast cancer screening

Breast cancer screening by mammography has been shown to reduce breast cancer morbidity and mortality. The use of mammography screening though varies by race, ethnicity, and, sociodemographic characteristics. Medicaid is an important source of insurance in the US for low-income beneficiaries, who are disproportionately members of racial or ethnic minorities, and who are less likely to be screened than women with higher socioeconomic statuses. We used 2006-2008 data from Medicaid claims and enrollment files to assess racial or ethnic and geographic disparities in the use of breast cancer screening among Medicaid-insured women at the state level. There were disparities in the use of mammography among racial or ethnic groups relative to white women, and the use of mammography varied across the 44 states studied. African American and American Indian women were significantly less likely than white women to use mammography in 30% and 39% of the 44 states analyzed, respectively, whereas Hispanic and Asian American women were the minority groups most likely to receive screening compared with white women. There are racial or ethnic disparities in breast cancer screening at the state level, which indicates that analyses conducted by only using national data not stratified by insurance coverage are insufficient to identify vulnerable populations for interventions to increase the use of mammography, as recommended.

Modeling Geospatial Patterns of Late-Stage Diagnosis of Breast Cancer in the US

In the US, about one-third of new breast cancers (BCs) are diagnosed at a late stage, where morbidity and mortality burdens are higher. Health outcomes research has focused on the contribution of measures of social support, particularly the residential isolation or segregation index, on propensity to utilize mammography and rates of late-stage diagnoses. Although inconsistent, studies have used various approaches and shown that residential segregation may play an important role in cancer morbidities and mortality. Some have focused on any individuals living in residentially segregated places (place-centered), while others have focused on persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity (person-centered). This paper compares and contrasts these two approaches in the study of predictors of late-stage BC diagnoses in a cross-national study. We use 100% of U.S. Cancer Statistics (USCS) Registry data pooled together from 40 states to identify late-stage diagnoses among ~1 million new BC cases diagnosed during 2004–2009. We estimate a multilevel model with person-, county-, and state-level predictors and a random intercept specification to help ensure robust effect estimates. Person-level variables in both models suggest that non-White races or ethnicities have higher odds of late-stage diagnosis, and the odds of late-stage diagnosis decline with age, being highest among the <age 50 group. After controlling statistically for all other factors, we examine place-centered isolation and find for anyone living in an isolated Asian community there is a large beneficial association (suggesting lower odds of late-stage diagnosis) while for anyone living in an isolated White community there is a large detrimental association (suggesting greater odds of late-stage diagnosis). By contrast, living in neighborhoods among others of one’s own race or ethnicity (person-centered isolation) is associated with greater odds of late-stage diagnosis, as this measure is dominated by Whites (the majority). At the state level, living in a state that allows unfettered access to a specialist is associated with a somewhat lower likelihood of being diagnosed at a late stage of BC. Geographic factors help explain the likelihood of late-stage BC diagnosis, which varies considerably across the U.S. as heterogeneous compositional and contextual factors portray very different places and potential for improving information and outcomes. The USCS database is expanding to cover more states and is expected to be a valuable resource for ongoing and future place-based cancer outcomes research.

Demographic Disparities in Late-Stage Diagnosis of Breast and Colorectal Cancers Across the USA

BACKGROUND

We determined whether there were disparities in the likelihood of being diagnosed at a late stage for breast cancer (BC) or colorectal cancer (CRC) in each of 40 states, using the recently available US Cancer Statistics (USCS) database.

METHODS

We extracted 981,457 BC cases and 558,568 CRC cases diagnosed in 2004-2009. Separate multilevel regressions were run for each state and each cancer type. Models included person and area-level covariates and were identically specified across states. The disparities foci were race or ethnicity (white, African-American, Hispanic, Asian, all other), gender, and age (<40, 40-49, 50-64, 65-74, and 75+). Using whites, males, and the oldest age group as reference groups, we noted the statistically significant disparities coefficients (p value ≤0.05) and translated the findings via a set of maps of states in the USA.

RESULTS

National disparity estimates were not consistent with disparities identified in the states. Some states had estimates consistent with the national average, while others did not. Patterns of disparities across states were different for each covariate and mapped separately.

CONCLUSION

National disparity estimates may mask what is true at the more local, state level because national estimates can confound the effects of race with place. Cancer control efforts are local and require locally relevant information to assess needs. Findings from the period 2004-2009 establish valuable benchmarks against which to assess changes following national health reform implemented in 2010. The USCS database is a valuable new resource that will facilitate future disparities research.

Residential Segregation and Racial Cancer Disparities: A Systematic Review

BACKGROUND

This paper provides the first review of empirical studies of segregation and black-white cancer disparities.

METHODS

We searched all years of PubMed (through May 2016) using these terms: racial segregation, residential segregation, neighborhood racial composition (first terms) and (second terms) cancer incidence, mortality, survival, stage at diagnosis, screening. The 17 (of 668) articles that measured both segregation and a cancer outcome were retained.

RESULTS

Segregation contributed significantly to cancer and to racial cancer disparities in 70% of analyses, even after controlling for socioeconomic status and health insurance. Residing in segregated African-American areas was associated with higher odds of later-stage diagnosis of breast and lung cancers, higher mortality rates and lower survival rates from breast and lung cancers, and higher cumulative cancer risks associated with exposure to ambient air toxics. There were no studies of many types of cancer (e.g., cervical). Studies differed in their measure of segregation, and 40% used an invalid measure. Possible mediators of the segregation effect usually were not tested.

CONCLUSIONS

Empirical analysis of segregation and racial cancer disparities is a recent area of research. The literature is limited to 17 studies that focused primarily on breast cancer. Studies differed in their measure of segregation, yet segregation nonetheless contributed to cancer and to racial cancer disparities in 70% of analyses. This suggests the need for further research that uses valid measures of segregation, examines a variety of types of cancers, and explores the variables that may mediate the segregation effect.

Hispanic and Immigrant Paradoxes in U.S. Breast Cancer Mortality: Impact of Neighborhood Poverty and Hispanic Density

To test the Hispanic and Immigrant Paradoxes-i.e., survival advantages despite a worse risk factor profile-and the modifying role of neighborhood context, we examined associations between patient ethnicity, birthplace, neighborhood Hispanic density and neighborhood poverty among 166,254 female breast cancer patients diagnosed 1995-2009 in Texas, U.S. Of all, 79.9% were non-Hispanic White, 15.8% Hispanic U.S.-born, and 4.2% Hispanic foreign-born. We imputed birthplace for the 60.7% of Hispanics missing birthplace data using multiple imputation. Shared frailty Cox proportional hazard models (patients nested within census tracts) adjusted for age, diagnosis year, stage, grade, histology, urban/rural residence, and local mammography capacity. Whites (vs. U.S.-born Hispanics) had increased all-cause and breast cancer mortality. Foreign-born (vs. U.S.-born) Hispanics had increased all-cause and breast cancer mortality. Living in higher Hispanic density neighborhoods was generally associated with increased mortality, although associations differed slightly in magnitude and significance by ethnicity, birthplace, and neighborhood poverty. We found no evidence of an Immigrant Paradox and some evidence of a Hispanic Paradox where protective effects were limited to U.S.-born Hispanics. Contrary to prior studies, foreign birthplace and residence in higher Hispanic density neighborhoods were associated with increased mortality. More research on intersections between ethnicity, birthplace and neighborhood context are needed.

Using residential segregation to predict colorectal cancer stage at diagnosis: two different approaches

PURPOSE

Studies have found a variety of evidence regarding the association between residential segregation measures and health outcomes in the United States. Some have focused on any individuals living in residentially segregated places, whereas others have examined whether persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity have differential outcomes. This article compares and contrasts these two approaches in the study of predictors of late-stage colorectal cancer (CRC) diagnoses in a cross-national study. We argue that it is very important when interpreting results from studies like this to carefully consider the geographic scope of the analysis, which can significantly change the context and meaning of the results.

METHODS

We use US Cancer Statistics Registry data from 40 states to identify late-stage diagnoses among over 500,000 CRC cases diagnosed during 2004-2009. We pool data over the states and estimate a multilevel model with person, county, and state levels and a random intercepts specification to ensure robust effect estimates. The isolation index of residential segregation is defined for racial and ethnic groups at the county level using Census 2000 data. The association between isolation indices and late-stage CRC diagnosis was measured by (1) anyone living in minority-segregated areas (place-centered approach) and by (2) individuals living in areas segregated by one's own racial or ethnic peers (person-centered approach).

RESULTS

Findings from the place-centered approach suggest that living in a highly segregated African American community is associated with lower likelihood of late-stage CRC diagnosis, whereas the opposite is true for people living in highly segregated Asian communities, and living in highly segregated Hispanic communities has no significant association. Using the person-centered approach, we find that living in places segregated by one's racial or ethnic peers is associated with lower likelihood of late-stage CRC diagnosis.

CONCLUSIONS

In a model that covers a large geographic area across the nation, the place-centered approach is most likely picking up geographic disparities that may be deepened by targeted interventions in minority communities. By contrast, the person-centered approach provides a national average estimate suggesting that residential isolation may confer community cohesion or support that is associated with better CRC prevention.

Inequalities in socioeconomic status and race and the odds of undergoing a mammogram in Brazil

Background

Access to mammograms, in common with other diagnostic procedures, is strongly conditioned by socioeconomic disparities. Which aspects of inequality affect the odds of undergoing a mammogram, and whether they are the same in different localities, are relevant issues related to the success of health policies.

Methods

This study analyzed data from the 2008 PNAD - Brazilian National Household Sample Survey (11.607 million women 40 years of age or older), on having had at least one mammogram over life for women 40 years of age or older in each of Brazil’s nine Metropolitan Regions (MR), according to socioeconomic position. The effects of income, schooling, health insurance and race in the different regions were investigated using multivariate logistical regression for each region individually, and for all MRs combined. The age-adjusted odds of a woman having had a mammogram according to race and stratified by two income strata (and two schooling strata) were also analyzed.

Results

Having a higher income increases four to seven times a woman’s odds of having had at least one mammogram in all MRs except Curitiba. For schooling, the gradient, though less steep, is favorable to women with more years of study. Having health insurance increases two to three times the odds in all MRs. Multivariate analysis did not show differences due to race (except for the Fortaleza MR), but the stratified analysis by income and schooling shows effects of race in most MRs, with greater differences for women with higher socioeconomic status.

Conclusions

This study confirms that income and schooling, as well as having health insurance, are still important determinants of inequality in health service use in Brazil. Additionally, race also contributes to the odds of having had a mammogram. The point is not to isolate the effect of each factor, but to evaluate how their interrelations may exacerbate differences, generating patterns of cumulative adversity, a theme that is still little explored in Brazil. This is much more important when we consider that race has only recently started be included in analyses of health outcomes in Brazil.

How Does Managed Care Improve the Quality of Breast Cancer Care Among Medicare-Insured Minority Women?

PURPOSE

The aim of this study is to investigate if evidence-based clinical guidelines are implemented equitability among ethnic minority breast cancer patients using Medicare Advantage and investigate if presumed advantages of managed care over fee-for-service are greater for minorities than for Whites.

METHODS

Data from the Surveillance, Epidemiology, and End Results and Medicare were used to examine 70,755 women over age 65 diagnosed with early stage breast cancer between 2005 and 2009. Implementation of two clinical guidelines was assessed: receipt of radiation therapy after breast conserving surgery and estrogen receptor status documentation. Multilevel logistic regression and inverse propensity weighting controlled for confounding.

RESULTS

African Americans are still less likely than Whites to receive radiation therapy after breast-conserving surgery, whether they use Medicare fee-for-service (OR 95 % CI) = 0.90 (0.83, 0.98) or managed care (OR 95 % CI) = 0.87 (0.76, 1.00). Differences between receipt of radiation therapy by insurance plan type was nonexistent. Relative to FFS, the use of managed care improved the odds of having estrogen receptor status documented by 44 % in African Americans, (OR 95 % CI) = 1.44 (1.15, 1.83) and by 42 % in Latina patients (OR 95 % CI) = 1.42 (1.17, 1.78).

CONCLUSIONS

Compared to Medicare fee-for-service, ethnic and racial disparities among Medicare Advantage users were reduced. We observed fewer disparities, but not an elimination of disparities, among Medicare Advantage enrollees receiving breast cancer care with an organizational and patient component of care. This suggests managed care may still need to focus on minority patient empowerment and involvement in care.

Breast Cancer Screening Among Women with Medicaid, 2006-2008: a Multilevel Analysis

INTRODUCTION

Nationally, about one third of women with breast cancer (BC) are diagnosed at late stage, which might be reduced with greater utilization of BC screening. The purpose of this paper is to examine the predictors of BC mammography use among women with Medicaid, and differences among Medicaid beneficiaries in their propensity to use mammography.

METHODS

The sample included 2,450,527 women drawn from both fee-for-service and managed care Medicaid claims from 25 states, during 2006-2008. The authors used multilevel modeling of predictors at person, county, and state levels of influence and examined traditional factors affecting access and the expanded scope of practice allowed for the nurse practitioner (NP) in some states to provide primary care independent of physician oversight.

RESULTS

Black [OR = 0.87; 95 % CI (0.87-0.88)] and American Indian women [OR = 0.74; 95 % CI (0.71-0.76)] had lower odds ratio of mammography use than white women, while Hispanic [OR = 1.06; 95 % CI (1.05-1.07)] had higher odds ratio of mammography use than white women. Living in counties with higher Hispanic residential segregation [OR = 1.16; 95 % CI (1.10-1.23)] was associated with a higher odds ratio of mammography use compared to areas with low Hispanic residential segregation, whereas living among more segregated black [OR = 0.78; 95 % CI (0.75-0.81)] or Asian [OR = 0.19; 95 % CI (0.17-0.21)] communities had lower odds ratio compared to areas with low segregation. Holding constant statistically the perceived shortage of MDs, which was associated with significantly lower mammography use, the NP regulatory variable [OR = 1.03; 95 % CI (1.01-1.07)] enhanced the odds ratio of mammography use among women in the six states with expanded scope of practice, compared with women residing in 19 more restrictive states.

CONCLUSIONS

Racial and ethnic disparities exist in the use of mammography among Medicaid-insured women. More expansive NP practice privileges in states are associated with higher utilization, and may help reduce rural disparities.

Socioecological determinants of mammography screening in Mexican rural areas

Purpose

– The purpose of this paper is to determine which socioecological factors encourage rural women to participate in mammographies rather than avoiding taking the test.

Design/methodology/approach

– The study mainly uses data from the 2007 Rural Households Evaluation Survey (ENCEL-2007). These crossover data are analyzed using the framework proposed in the Spatial-Interaction Model of Mammography Use (SIMMU), through a three-level logistic regression model to examine the likelihood that a woman will choose to participate in a mammography.

Findings

– At the woman-household level, the completion of the Pap smear and the asset index is the strongest determinant of mammography participation. Obtaining preventive medicine services or being enrolled in the Popular Insurance System prevent women from undergoing screening. At the interpersonal level, the probability of screening use decreases with lower social coverage. At the intermediate level, availability of health centers is negatively related to the use of screening.

Research limitations/implications

– The study fails to take into account the fact that women’s propensity to have a mammography may vary over time relatively to life changes. Moreover, findings were restricted to women ages from 40 to 49 and limited due to the lack of published data or data quality issues.

Practical implications

– The results of this research can give health planners, policymakers and social marketers a platform for how to approach social change and promote the cancer screening health behavior through the marketing mix (price, place, promotion and product) in the design of their programs.

Originality/value

– In addition to be informative and persuasive with people to change their behavior, this paper also seeks to provide a direction for using commercial marketing tools through social marketing to “sell” the health behavior. Due to target population variation, this paper addresses the health behavior change strategy by audience segmentation, regarded as essential to successful health communication campaigns.

Association between individual and geographic factors and nonadherence to mammography screening guidelines

BACKGROUND

This study investigates factors that are associated with nonadherence to mammography screening guidelines in Utah, a state where mammography screening rates have remained consistently lower than national averages.

METHODS

We examined data on reported mammography use among women aged 40-74 years from the 2008 and 2010 Utah Behavioral Risk Factor Surveillance System (n=5,197, weighted n=417,064). Logistic regression models were used to estimate the effects of individual-level and geographic (travel time to nearest mammography facility, geographic accessibility, and rural/urban residence) factors on the odds of a woman not reporting receiving a mammogram in the last 2 years.

RESULTS

In 2008 and 2010, a disproportionate number of women aged 40-49 (43.1%, 95% confidence interval [CI] 39.9%-46.3%) reported not receiving a mammogram within the last 2 years compared to women 50-74 (26.8%, 95% CI 24.9%-28.7%). None of the geographic factors were significant predictors of screening adherence. Based on covariate adjusted models, statistically significant (p<0.05) factors associated with increased odds of not receiving mammogram within the last 2 years included not having a regular physician, no health insurance, being aged 40-49, income less than $25,000, and the presence of three or more children in the home.

CONCLUSION

Mammography screening efforts in Utah should focus on improving access to insurance or a regular source of health care. Future research should also consider how best to address extreme time demands and competing priorities that present potential barriers for women with large families, resulting in lower screening levels among these women.

Exploring the role of neighborhood socio-demographic factors on HPV vaccine initiation among low-income, ethnic minority girls

Little is known about whether neighborhood factors are associated with human papillomavirus (HPV) vaccine uptake, especially among disadvantaged groups that can benefit most from the vaccine. We used data collected from immigrant, low-income mothers of adolescent girls and data from the 2005-2009 American Community Survey to investigate the relationship between HPV vaccine initiation and neighborhood characteristics. We compared initiation rates across levels of neighborhood disadvantage and employed multilevel logistic regression models to examine contextual effects on uptake. Overall, 27 % of girls (n = 479) initiated the vaccine. Initiation rates were highest among girls from the most disadvantaged neighborhoods (30 %), however, neighborhood factors were not independently associated with vaccine initiation after adjusting for individual factors. Mother's awareness of HPV, age, and insurance status were strong predictors for initiation. Future interventions should focus on improving awareness among low-income mothers as well as targeting vulnerable families outside the catchment area of public programs.

Breast cancer screening, area deprivation, and later-stage breast cancer in Appalachia: does geography matter?

OBJECTIVE

To model the relationship of an area-based measure of a breast cancer screening and geographic area deprivation on the incidence of later stage breast cancer (LSBC) across a diverse region of Appalachia.

DATA SOURCE

Central cancer registry data (2006-2008) from three Appalachian states were linked to Medicare claims and census data.

STUDY DESIGN

Exploratory spatial analysis preceded the statistical model based on negative binomial regression to model predictors and effect modification by geographic subregions.

PRINCIPAL FINDINGS

Exploratory spatial analysis revealed geographically varying effects of area deprivation and screening on LSBC. In the negative binomial regression model, predictors of LSBC included receipt of screening, area deprivation, supply of mammography centers, and female population aged>75 years. The most deprived counties had a 3.31 times greater rate of LSBC compared to the least deprived. Effect of screening on LSBC was significantly stronger in northern Appalachia than elsewhere in the study region, found mostly for high-population counties.

CONCLUSIONS

Breast cancer screening and area deprivation are strongly associated with disparity in LBSC in Appalachia. The presence of geographically varying predictors of later stage tumors in Appalachia suggests the importance of place-based health care access and risk.

Applying the Fuzzy Delphi Method for determining socio-ecological factors that influence adherence to mammography screening in rural areas of Mexico

In Mexico, regular participation in mammography screening is low, despite higher survival rates. The objective of our research is to highlight healthcare procedures to be optimized and target areas to encourage investment and to raise awareness about the benefits of early diagnosis. Those socio-ecological factors (community, interpersonal and individual) were collected through a review of literature and based on the spatial interaction model of mammography use developed by Mobley et al. The opinion of diverse groups of experts on the importance of those factors was collected by survey. The Fuzzy Delphi Method helped to solve the inherent uncertainty of the survey process. Our findings suggest that population health behaviors, proximity-density to facilities/ physicians and predisposing factors are needed to increase the screening rate. Variations in expert group size could affect the accuracy of the conclusions. However, the application of the enhanced aggregation method provided a group consensus that is less susceptible to misinterpretation and that weighs the opinion of each expert according to their clinical experience in mammography research.

Spatial Sufficiency of 5% Medicare Standard Analytic Files

The 5% Medicare Standard Analytic Files (SAF) are random samples used to analyze national trends in medical treatments, expenditures, and outcomes. Their utility in small-area or multilevel analyses is unknown. To demonstrate possible limitations of the 5% SAF for analysis of health behaviors in small areas. We use descriptive Chi-square goodness-of-fit tests and mapping to explore consistency in the 5% representation of the 100% population in states and counties. We conduct multilevel modeling of individual utilization of mammography or endoscopy services for cancer screening and contrast findings across the 5% and 100% files. Subjects are enrolled in both parts A and B Medicare coverage and ages 65-104, alive and residing in the same state, with no gaps in coverage during the study period. Identically defined groups are drawn from the 5% SAF and 100% population claims and denominator files. The Chi-square tests of homogeneous population subgroups in 5% and 100% files exhibit significant differences in 7 of 8 states. Maps confirm this among states' counties and find that one state is generally under-represented by the 5% SAF, while others show areas with variable representation. Multilevel modeling results are largely consistent across the partitions of the data, but 5% sample models have much lower statistical power. Area-level covariate effect estimates show some differences across the two datasets. Multilevel modeling with contextual variables may be misleading in small area analyses conducted using 5% Medicare SAFs. Provider supply and market characteristics show inconsistent results. Disparities research may benefit from 100% files to provide statistical power needed to detect meaningful differences. This is significant because the Centers for Medicare and Medicaid Services have recently curtailed permissions to use the 100% files. These 100% files are one of few sources of population data available in the U.S. that are representative of small areas in the U.S.. In times of constrained budgets, using population data files is essential so that resources can be targeted to areas robustly identified as having greatest need or gaps in outcomes.

State-of-the-art and future directions in multilevel interventions across the cancer control continuum

We conducted literature searches and analyses to describe the current state of multilevel intervention (MLI) research and to identify opportunities to advance cancer control and prevention. We found single-level studies that considered other contextually important levels, and multilevel health-care systems research and community-wide studies. This literature is characterized by limited reporting of theoretical, contextual, temporal, and implementation factors. Most MLIs focus on prevention and screening, rather than diagnosis, treatment, or survivorship. Opportunities relate to 1) dynamic, adaptive emergent interventions and research designs that evolve over time by attending to contextual factors and interactions across levels; 2) analyses that include simulation modeling, or multimethod approaches that integrate quantitative and qualitative methods; and 3) translation and intervention approaches that locally reinvent MLIs in different contexts. MLIs have great potential to reduce cancer burden by using theory and integrating quantitative, qualitative, participatory, and transdisciplinary methods that continually seek alignment across intervention levels, pay attention to context, and adapt over time.

Significance of increasing poverty levels for determining late-stage breast cancer diagnosis in 1990 and 2000

We examine the association between late-stage breast cancer diagnosis and residential poverty in Detroit, Atlanta, and San Francisco in 1990 and 2000. We tested whether residence in census tracts with increasing levels of poverty were associated with increased odds of a late-stage diagnosis in 1990 and 2000 and found that it was. To test this, we linked breast cancer cases from the Surveillance, Epidemiology, and End Results cancer registries with poverty data from the census. Tracts were grouped into low, moderate, and high poverty based on the percentage of households reporting income below the poverty level. While late-stage breast cancer rates and the number of women living in high and moderate-poverty areas declined absolutely between 1990 and 2000, estimates from our combined three-city model showed that odds of a late-stage diagnosis remained stubbornly elevated in increasingly poor areas in both years. Non-Hispanic black women faced higher odds of a late-stage diagnosis relative to non-Hispanic white women in both years. In separate regressions for each city, the odds ratios affirm that combining data across cities may be misleading. In 1990 and 2000, only women living in moderately poor neighborhoods of San Francisco faced elevated odds, while in Detroit women in both moderate- and high-poverty areas faced increased likelihood of late-stage diagnosis. In Atlanta, none of the poverty measures were significant in 1990 or 2000. In our test of physician supply on stage, an increase in the number of neighborhood primary care doctor's offices was associated with decreased odds of a late-stage diagnosis only for Detroit residents and for non-Hispanic whites in the three-city model.

Geographic disparities in late-stage cancer diagnosis: multilevel factors and spatial interactions

In 2009 in the United States, breast cancer was the most common cancer in women, and colorectal cancer was the third most common cancer in both men and women. Currently, over 40% of these cancers are diagnosed at an advanced stage, which results in higher morbidity and mortality than would obtain with optimal cancer screening utilization. To provide information that might improve these cancer outcomes we use spatial analysis to answer questions related to both Why and Where disparities in late-stage cancer diagnoses are observed. In examining Why, we include state level characteristics reflecting characteristics of states' cancer control planning, insurance markets and managed care environments to help model the spatial heterogeneity from place to place. To answer questions related to Where disparities are observed, we generate county level predictions of late-stage cancer rates from a random-intercept multilevel model estimated on the population data from 11 pooled SEER Registries. The findings allow for comparisons across states that reveal logical starting points for a national effort to control cancer.

Mammography capacity and appointment wait times: barriers to breast cancer screening

OBJECTIVE

To assess the impact of mammography capacity on appointment wait times.

METHODS

We surveyed by telephone all mammography facilities federally certified in 2008 in California, Connecticut, Georgia, Iowa, New Mexico, and New York using a simulated patient format. County-level mammography capacity, defined as the number of mammography machines per 10,000 women aged 40 and older, was estimated from FDA facility certification records and US Census data.

RESULTS

1,614 (86%) of 1,882 mammography facilities completed the survey. Time until next available screening mammogram appointment was <1 week at 55% of facilities, 1-4 weeks at 34% of facilities, and >1 month at 11% of facilities. Facilities in counties with lower capacity had longer wait times, and a one-unit increase in county capacity was associated with 21% lower odds of a facility reporting a wait time >1 month (p < 0.01). There was no association between wait time and the availability of evening or weekend appointments or digital mammography.

CONCLUSION

Lower mammography capacity is associated with longer wait times for screening mammograms.

IMPACT

Enhancement of mammography resources in areas with limited capacity may reduce wait times for screening mammogram appointments, thereby increasing access to services and rates of breast cancer screening.

Incorporating geospatial capacity within clinical data systems to address social determinants of health

Linking electronic health record (EHR) systems with community information systems (CIS) holds great promise for addressing inequities in social determinants of health (SDH). While EHRs are rich in location-specific data that allow us to uncover geographic inequities in health outcomes, CIS are rich in data that allow us to describe community-level characteristics relating to health. When meaningfully integrated, these data systems enable clinicians, researchers, and public health professionals to actively address the social etiologies of health disparities.This article describes a process for exploring SDH by geocoding and integrating EHR data with a comprehensive CIS covering a large metropolitan area. Because the systems were initially designed for different purposes and had different teams of experts involved in their development, integrating them presents challenges that require multidisciplinary expertise in informatics, geography, public health, and medicine. We identify these challenges and the means of addressing them and discuss the significance of the project as a model for similar projects.

Condicionantes socioeconômicos e geográficos do acesso à mamografia no Brasil, 2003-2008

Este estudo examinou os efeitos de características da população e geográficas na chance de mamografia, no Brasil em 2003 e 2008. A partir do Suplemento Saúde da Pesquisa Nacional por Amostra de Domicílios, foram analisados os padrões de mamografia em mulheres com 25 anos ou mais, por meio de razão de prevalências, e em mulheres com 40 anos ou mais, por meio de regressão logística multivariada, incluindo o local de residência e a distribuição geográfica da oferta. Entre as mulheres com 50-69 anos, 54,6% relataram ter feito mamografia, em 2003, e 71,5%, em 2008. A chance de realização do exame é maior entre as de 50 a 69 anos, aumenta com a renda familiar e escolaridade, dentre as casadas, para as que consultaram médico e têm plano de saúde. Residir em área metropolitana triplica a chance de mamografia. Comparado com a região Norte, residentes das demais regiões têm chances maiores e a distância influencia negativamente a realização do exame. No período, a cobertura aumentou na faixa etária alvo da política nacional, com redução das desigualdades de renda e de escolaridade. A ampliação do acesso parece mais ligada às políticas de aumento de renda e inclusão social, e à ampliação da oferta de exames na rede pública e conveniada, do que ao aumento do número de mamógrafos.

Plasma biomarker profiles differ depending on breast cancer subtype but RANTES is consistently increased

BACKGROUND

Current biomarkers for breast cancer have little potential for detection. We determined whether breast cancer subtypes influence circulating protein biomarkers.

METHODS

A sandwich ELISA microarray platform was used to evaluate 23 candidate biomarkers in plasma samples that were obtained from subjects with either benign breast disease or invasive breast cancer. All plasma samples were collected at the time of biopsy, after a referral due to a suspicious screen (e.g., mammography). Cancer samples were evaluated on the basis of breast cancer subtypes, as defined by the HER2 and estrogen receptor statuses.

RESULTS

Ten proteins were statistically altered in at least one breast cancer subtype, including four epidermal growth factor receptor ligands, two matrix metalloproteases, two cytokines, and two angiogenic factors. Only one cytokine, RANTES, was significantly increased (P < 0.01 for each analysis) in all four subtypes, with areas under the curve (AUC) for receiver operating characteristic values that ranged from 0.76 to 0.82, depending on cancer subtype. The best AUC values were observed for analyses that combined data from multiple biomarkers, with values ranging from 0.70 to 0.99, depending on the cancer subtype. Although the results for RANTES are consistent with previous publications, the multi-assay results need to be validated in independent sample sets.

CONCLUSIONS

Different breast cancer subtypes produce distinct biomarker profiles, and circulating protein biomarkers have potential to differentiate between true- and false-positive screens for breast cancer.

IMPACT

Subtype-specific biomarker panels may be useful for detecting breast cancer or as an adjunct assay to improve the accuracy of current screening methods.

Does context matter for the relationship between deprivation and all-cause mortality? The West vs. the rest of Scotland

Background

A growing body of research emphasizes the importance of contextual factors on health outcomes. Using postcode sector data for Scotland (UK), this study tests the hypothesis of spatial heterogeneity in the relationship between area-level deprivation and mortality to determine if contextual differences in the West vs. the rest of Scotland influence this relationship. Research into health inequalities frequently fails to recognise spatial heterogeneity in the deprivation-health relationship, assuming that global relationships apply uniformly across geographical areas. In this study, exploratory spatial data analysis methods are used to assess local patterns in deprivation and mortality. Spatial regression models are then implemented to examine the relationship between deprivation and mortality more formally.

Results

The initial exploratory spatial data analysis reveals concentrations of high standardized mortality ratios (SMR) and deprivation (hotspots) in the West of Scotland and concentrations of low values (coldspots) for both variables in the rest of the country. The main spatial regression result is that deprivation is the only variable that is highly significantly correlated with all-cause mortality in all models. However, in contrast to the expected spatial heterogeneity in the deprivation-mortality relationship, this relation does not vary between regions in any of the models. This result is robust to a number of specifications, including weighting for population size, controlling for spatial autocorrelation and heteroskedasticity, assuming a non-linear relationship between mortality and socio-economic deprivation, separating the dependent variable into male and female SMRs, and distinguishing between West, North and Southeast regions. The rejection of the hypothesis of spatial heterogeneity in the relationship between socio-economic deprivation and mortality complements prior research on the stability of the deprivation-mortality relationship over time.

Conclusions

The homogeneity we found in the deprivation-mortality relationship across the regions of Scotland and the absence of a contextualized effect of region highlights the importance of taking a broader strategic policy that can combat the toxic impacts of socio-economic deprivation on health. Focusing on a few specific places (e.g. 15% of the poorest areas) to concentrate resources might be a good start but the impact of socio-economic deprivation on mortality is not restricted to a few places. A comprehensive strategy that can be sustained over time might be needed to interrupt the linkages between poverty and mortality.

Use of evidence-based strategies to promote mammography among medically underserved women

BACKGROUND

Several web-based resources recommend effective intervention strategies to promote use of mammography but there is limited information on whether the strategies are used, particularly by organizations that serve medically underserved women.

PURPOSE

In 2010, data collected by the Avon Breast Health Outreach Program (BHOP) were analyzed to examine the diffusion of evidence-based intervention strategies among funded organizations.

METHODS

Data on intervention strategies were obtained from a 2009 survey of Avon BHOP organizations funded during 2006-2009. Self-reported use of mammography was reported from annual intake forms administered to medically underserved women aged ≥40 years, excluding those with a history of breast cancer or initial enrollees not exposed to the strategies. Strategies reflected interventions reviewed in the Guide to Community Preventive Services. Those recommended to increase demand and use of mammography included (1) client reminders; (2) small media; (3) one-to-one education; (4) removal of structural barriers to rescreening; and (5) group education-and one that lacked sufficient evidence to warrant a recommendation (6) client incentives.

RESULTS

Among 86 organizations, 96% used three or more intervention strategies. The most common strategies were group education (91%) and client reminders (83%). The overall crude-percentage of recent mammography use was 84%. This percentage was similar for clinical sites and nonclinical sites, despite the disproportionate enrollment of medically underserved women in nonclinical sites.

CONCLUSIONS

The wide use of evidence-based strategies among Avon BHOP-funded organizations and high percentage of recent mammography use among women exposed to the strategies suggests that medically underserved women are benefiting from effective interventions to increase use of mammography.

Erosion in the Healthcare Safety Net: Impacts on Different Population Groups

Safety net hospitals (SNHs) have played a critical role in the U.S. health system providing access to health care for vulnerable populations, in particular the Medicaid and uninsured populations. However, little research has examined how access for these populations changes when contraction of the safety net occurs. Institutional policies, such as hospital closure or ownership conversion, could affect the supply of minority health care providers, thus exacerbating disparities in outcomes. We use multilevel logistic modeling of person-level hospital discharge data to examine the effects of contractions in the California safety net over the period of 1990-2000 on access to care as measured by changes in ambulatory care sensitive condition (ACSC) admissions, using geographic methods to characterize proximity to a contraction event. We found that presence of a contraction event was associated with a statistically significant increase in the predicted probability of impeded access, with an increase of about 1% for Medicaid-insured populations and about 4-5% for the uninsured. The Medicaid-insured group also maintained the highest rates of ACSC admissions over time, suggesting persistent access problems for this vulnerable group. This research is timely given continued budget problems in many states, where rising unemployment has increased the number of Medicaid enrollees by 6 million and uninsured individuals by 1.5 million, increasing pressure on remaining SNHs.

Presence of medical schools may contribute to reducing breast cancer mortality and disparities

Understanding differences among counties more or less successful in addressing breast cancer (BC) mortality disparities is important. Medical resources may be more available in counties with BC mortality rates (BCMR) low and similar for White and Black women. Based on Black and White BCMR we classified selected counties in four types from failing (high BCMR for both groups of women) to successful (low BCMR for both). Medical resource data were from Area Resource Files. In multivariate analyses, number of physicians or hospitals, HMO penetration, and proportion of hospitals with mammography centers did not predict county type. The proportion of hospitals with medical schools predicted counties being with Black:White disparities vs. with reverse disparities (OR 0.96, CI 0.94-0.99), or being successful vs. failing (OR 1.03, CI 1.00-1.06) or vs. with disparities (OR 1.04, CI 1.01-1.07). Medical resources did not explain county type differences, but type of care available may be important.

An eight-year snapshot of geospatial cancer research (2002-2009): clinico-epidemiological and methodological findings and trends

Geographic information systems (GIS) offer a very rich toolbox of methods and technologies, and powerful research tools that extend far beyond the mere production of maps, making it possible to cross-link and study the complex interaction of disease data and factors originating from a wide range of disparate sources. Despite their potential indispensable role in cancer prevention and control programmes, GIS are underrepresented in specialised oncology literature. The latter has provided an impetus for the current review. The review provides an eight-year snapshot of geospatial cancer research in peer-reviewed literature (2002-2009), presenting the clinico-epidemiological and methodological findings and trends in the covered corpus (93 papers). The authors concluded that understanding the relationship between location and cancer/cancer care services can play a crucial role in disease control and prevention, and in better service planning, and appropriate resource utilisation. Nevertheless, there are still barriers that hinder the wide-scale adoption of GIS and related technologies in everyday oncology practice.

Predictors of endoscopic colorectal cancer screening over time in 11 states

Objectives

We study a cohort of Medicare-insured men and women aged 65+ in the year 2000, who lived in 11 states covered by Surveillance, Epidemiology, and End Results (SEER) cancer registries, to better understand various predictors of endoscopic colorectal cancer (CRC) screening.

Methods

We use multilevel probit regression on two cross-sectional periods (2000–2002, 2003–2005) and include people diagnosed with breast cancer, CRC, or inflammatory bowel disease (IBD) and a reference sample without cancer.

Results

Men are not universally more likely to be screened than women, and African Americans, Native Americans, and Hispanics are not universally less likely to be screened than whites. Disparities decrease over time, suggesting that whites were first to take advantage of an expansion in Medicare benefits to cover endoscopic screening for CRC. Higher-risk persons had much higher utilization, while older persons and beneficiaries receiving financial assistance for Part B coverage had lower utilization and the gap widened over time.

Conclusions

Screening for CRC in our Medicare-insured sample was less than optimal, and reasons varied considerably across states. Negative managed care spillovers were observed, demonstrating that policy interventions to improve screening rates should reflect local market conditions as well as population diversity.