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Buchalter RB, Mohan S, Schold JD. Geospatial Modeling Methods in Epidemiological Kidney Research: An Overview and Practical Example. Kidney Int Rep 2024; 9:807-816. [PMID: 38765574 PMCID: PMC11101776 DOI: 10.1016/j.ekir.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/19/2023] [Accepted: 01/08/2024] [Indexed: 05/22/2024] Open
Abstract
Geospatial modeling methods in population-level kidney research have not been used to full potential because few studies have completed associative spatial analyses between risk factors and exposures and kidney conditions and outcomes. Spatial modeling has several advantages over traditional modeling, including improved estimation of statistical variation and more accurate and unbiased estimation of coefficient effect direction or magnitudes by accounting for spatial data structure. Because most population-level kidney research data are geographically referenced, there is a need for better understanding of geospatial modeling for evaluating associations of individual geolocation with processes of care and clinical outcomes. In this review, we describe common spatial models, provide details to execute these analyses, and perform a case-study to display how results differ when integrating geographic structure. In our case-study, we used U.S. nationwide 2019 chronic kidney disease (CKD) data from Centers for Disease Control and Prevention's Kidney Disease Surveillance System and 2006 to 2010 U.S. Environmental Protection Agency environmental quality index (EQI) data and fit a nonspatial count model along with global spatial models (spatially lagged model [SLM]/pseudo-spatial error model [PSEM]) and a local spatial model (geographically weighted quasi-Poisson regression [GWQPR]). We found the SLM, PSEM, and GWQPR improved model fit in comparison to the nonspatial regression, and the PSEM model decreased the positive relationship between EQI and CKD prevalence. The GWQPR also revealed spatial heterogeneity in the EQI-CKD relationship. To summarize, spatial modeling has promise as a clinical and public health translational tool, and our case-study example is an exhibition of how these analyses may be performed to improve the accuracy and utility of findings.
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Affiliation(s)
- R. Blake Buchalter
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
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Agunwamba AA, Zhu X, Sauver JS, Thompson G, Helmueller L, Finney Rutten LJ. Barriers and facilitators of colorectal cancer screening using the 5As framework: A systematic review of US studies. Prev Med Rep 2023; 35:102353. [PMID: 37576848 PMCID: PMC10415795 DOI: 10.1016/j.pmedr.2023.102353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/20/2023] [Accepted: 07/28/2023] [Indexed: 08/15/2023] Open
Abstract
Despite clear evidence that regular screening reduces colorectal cancer (CRC) mortality and the availability of multiple effective screening options, CRC screening continues to be underutilized in the US. A systematic literature search of four databases - Ovid, Medline, EBSCHOhost, and Web of Science - was conducted to identify US studies published after 2017 that reported on barriers and facilitators to CRC screening adherence. Articles were extracted to categorize relevant CRC screening barriers or facilitators that were assessed against CRC screening outcomes using the 5As dimensions: Access, Affordability, Acceptance, Awareness, Activation. Sixty-one studies were included. Fifty determinants of screening within the 5As framework and two additional dimensions including Sociodemographics and Health Status were identified. The Sociodemographics, Access, and Affordability dimensions had the greatest number of studies included. The most common factor in the Access dimension was contact with healthcare systems, within the Affordability dimension was insurance, within the Awareness dimension was knowledge CRC screening, within the Acceptance dimension was health beliefs, within the Activation dimension was prompts and reminders, within the Sociodemographics dimension was race/ethnicity, and among the Health Status dimension was chronic disease history. Among all studies, contact with healthcare systems, insurance, race/ethnicity, age, and education were the most common factors identified. CRC screening barriers and facilitators were identified across individual, clinical, and sociocontextual levels. Interventions that consider multilevel strategies will most effectively increase CRC screening adherence.
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Affiliation(s)
- Amenah A. Agunwamba
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Xuan Zhu
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Jenny St. Sauver
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | - Lila J. Finney Rutten
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
- Exact Sciences Corporation, Madison WI, USA
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Cartwright K, Leekity S, Sheche J, Kanda D, Kosich M, Rodman J, Gonya M, Kelly K, Edwardson N, Pankratz VS, Mishra SI. Health Literacy, Health Numeracy, and Cancer Screening Patterns in the Zuni Pueblo: Insights from and Limitations of "Standard" Questions. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2023; 38:1023-1033. [PMID: 36334245 PMCID: PMC9638364 DOI: 10.1007/s13187-022-02227-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/09/2022] [Indexed: 05/31/2023]
Abstract
American Indians experience disparities in cancer screening, stage at disease diagnoses, and 5-year cancer survival. This study investigates how health literacy and health numeracy may be linked to cancer screening behaviors of Zuni Pueblo members using a survey exploring screening behaviors related to breast, cervical, and colorectal cancers. As part of a larger community-based cancer prevention and control project, Zuni Health Initiative staff conducted surveys from October 2020 through April 2021 of 281 participants (men ages 50-75 and women ages 21-75) from the Zuni Pueblo. Bivariate and multivariable analyses investigated associations between health literacy/numeracy measures and cancer screening behaviors. Bivariate analyses showed some associations between distinct measures of health literacy/numeracy and colorectal cancer (CRC) screening, including both colonoscopy (health literacy) and fecal occult blood testing (FOBT) (health numeracy), as well as cervical cancer screening (health literacy). There were no statistically significant associations between health literacy/numeracy measures and mammogram screening for breast cancer. In multivariable analyses, there were no consistent patterns between health literacy/numeracy and screening for any cancer. There are some individual findings worth noting, such as statistically significant findings for health numeracy and FOBT (those reporting lower health numeracy were less likely to report FOBT). An important finding of this study is that questions used to assess health literacy/numeracy did not identify associations aligned with previous research. We reflect on the ways the "standard" questions may not be sufficiently tailored to the Zuni experience and may contribute to health equity barriers.
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Affiliation(s)
- Kate Cartwright
- School of Public Administration, University of New Mexico, Albuquerque, NM USA
| | - Samantha Leekity
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM USA
| | - Judith Sheche
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM USA
| | - Deborah Kanda
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM USA
| | - Mikaela Kosich
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM USA
| | - Joseph Rodman
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM USA
| | - Madison Gonya
- School of Public Administration, University of New Mexico, Albuquerque, NM USA
| | - Keith Kelly
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM USA
| | - Nicholas Edwardson
- School of Public Administration, University of New Mexico, Albuquerque, NM USA
| | - V. Shane Pankratz
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM USA
- Department of Internal Medicine, University of New Mexico, Albuquerque, USA
| | - Shiraz I. Mishra
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM USA
- Departments of Pediatrics and Family and Community Medicine, University of New Mexico, Albuquerque, NM USA
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Zahnd WE, Josey MJ, Schootman M, Eberth JM. Spatial accessibility to colonoscopy and its role in predicting late-stage colorectal cancer. Health Serv Res 2021; 56:73-83. [PMID: 32954527 PMCID: PMC7839638 DOI: 10.1111/1475-6773.13562] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To better determine the relationship between spatial access to colonoscopy and colorectal cancer (CRC) outcomes, our objective was to examine the agreement of the classic, enhanced, and variable two-step floating catchment area (2SFCA) methods in evaluating spatial access to colonoscopy and to compare the predictive validity of each method related to late-stage CRC. 2SFCA methods simultaneously consider supply/demand of services and impedance (ie, travel time). DATA SOURCES Colonoscopy provider locations were obtained from the South Carolina Ambulatory Surgery Database. ZIP code tabulation area (ZCTA) level population estimates and area-level poverty level were obtained from the American Community Survey. Rurality was determined by the United States Department of Agriculture's Rural-Urban Commuting Area codes. Individual-level CRC data were obtained from the South Carolina Central Cancer Registry. STUDY DESIGN Using the classic, enhanced, and variable 2SFCA methods, we calculated ZCTA-level spatial access to colonoscopy. We assessed agreement between the three methods by calculating Spearman's rank coefficients and weighted Kappas (Κ). Global and Local Moran's I were used to assess spatial clustering of accessibility scores across 2SFCA methods. We performed multilevel logistic regression analyses to examine the association between spatial accessibility to colonoscopy, area- and individual-level factors, and late-stage CRC. PRINCIPAL FINDINGS We found strong agreement (Weighted Κ = 0.82; 95% CI = 0.79-0.86) and identified similar clustering patterns with the classic and enhanced 2SFCA methods. There was negligible agreement among the classic/enhanced 2SFCA and the variable 2SFCA. Across all 2SFCA methods, regression models showed that spatial access to colonoscopy, rurality, and poverty level were not associated with greater odds of late-stage CRC, though Black race was associated with late-stage CRC across all models. CONCLUSIONS None of the 2SFCA methods showed an association with late-stage CRC. Future studies should explore which elements (spatial or nonspatial) of access to care have the greatest impact on CRC outcomes.
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Affiliation(s)
- Whitney E. Zahnd
- Rural & Minority Health Research CenterArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Big Data Health Science CenterArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
| | - Michele J. Josey
- Department of Epidemiology and BiostatisticsArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
| | - Mario Schootman
- SSM HealthDepartment of Clinical AnalyticsCenter for Clinical ExcellenceSt. LouisMissouriUSA
| | - Jan M. Eberth
- Rural & Minority Health Research CenterArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Big Data Health Science CenterArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Department of Epidemiology and BiostatisticsArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
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5
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Impact of organized colorectal cancer screening programs on screening uptake and screening inequalities: A study of systematic- and patient-reliant programs in Canada. J Cancer Policy 2020. [DOI: 10.1016/j.jcpo.2020.100229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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An Examination of Multilevel Factors Influencing Colorectal Cancer Screening in Primary Care Accountable Care Organization Settings: A Mixed-Methods Study. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2019; 25:562-570. [PMID: 30180112 DOI: 10.1097/phh.0000000000000837] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify patient, provider, and delivery system-level factors associated with colorectal cancer (CRC) screening and validate findings across multiple data sets. DESIGN A concurrent mixed-methods design using electronic health records, provider survey, and provider interview. SETTING Eight primary care accountable care organization clinics in Nebraska. MEASURES Patients' demographic/social characteristics, health utilization behaviors, and perceptions toward CRC screening; provider demographics and practice patterns; and clinics' delivery systems (eg, reminder system). ANALYSIS Quantitative (frequencies, logistic regression, and t tests) and qualitative analyses (thematic coding). RESULTS At the patient level, being 65 years of age and older (odds ratio [OR] = 1.34, P < .001), being non-Hispanic white (OR = 1.93, P < .001), having insurance (OR = 1.90, P = .01), having an annual physical examination (OR = 2.36, P < .001), and having chronic conditions (OR = 1.65 for 1-2 conditions, P < .001) were associated positively with screening, compared with their counterparts. The top 5 patient-level barriers included discomfort/pain of the procedure (60.3%), finance/cost (57.4%), other priority health issues (39.7%), lack of awareness (36.8%), and health literacy (26.5%). At the provider level, being female (OR = 1.88, P < .001), having medical doctor credentials (OR = 3.05, P < .001), and having a daily patient load less than 15 (OR = 1.50, P = .01) were positively related to CRC screening. None of the delivery system factors were significant except the reminder system. Interview data provided in-depth information on how these factors help or hinder CRC screening. Discrepancies in findings were observed in chronic condition, colonoscopy performed by primary doctors, and the clinic-level system factors. CONCLUSIONS This study informs practitioners and policy makers on the effective multilevel strategies to promote CRC screening in primary care accountable care organization or equivalent settings. Some inconsistent findings between data sources require additional prospective cohort studies to validate those identified factors in question. The strategies may include (1) developing programs targeting relatively younger age groups or racial/ethnic minorities, (2) adapting multilevel/multicomponent interventions to address low demands and access of local population, (3) promoting annual physical examination as a cost-effective strategy, and (4) supporting organizational capacity and infrastructure (eg, IT system) to facilitate implementation of evidence-based interventions.
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Blair A, Gauvin L, Ouédraogo S, Datta GD. Area-level income disparities in colorectal screening in Canada: evidence to inform future surveillance. ACTA ACUST UNITED AC 2019; 26:e128-e137. [PMID: 31043818 DOI: 10.3747/co.26.4279] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Participation in colorectal screening remains low even in countries with universal health coverage. Area-level determinants of low screening participation in Canada remain poorly understood. Methods We assessed the association between area-level income and two indicators of colorectal screening (having never been screened, having not been screened recently) by linking census-derived local area-level income data with self-reported screening data from urban-dwelling respondents to the Canadian Community Health Survey (50-75 years of age, cycles 2005 and 2007, n = 18,362) who reported no known risk factors for colorectal cancer. Generalized estimating equation Poisson models estimated the prevalence ratios and differences for having never been screened and having not been screened recently, adjusting for individual-level income, education, marital status, having a regular physician, age, and sex. Results About 53% of the study population had never been screened. Among individuals who had ever been screened, 35% had been screened recently. Adjusting for covariates, lower area-level income was associated with having never been screened [covariate-adjusted prevalence ratios: 1.24 for quartile 1; 95% confidence limits (cl): 1.16, 1.34; 1.25 for quartile 2; 95% cl: 1.15, 1.33; 1.15 for quartile 3; 95% cl: 1.08, 1.23]. Among individuals who had been screened in their lifetime, area-level income was not associated with having not been screened recently. Conclusions Lower area-level income is associated with having never been screened for colorectal cancer even after adjusting for individual socioeconomic factors. Those findings highlight the potential importance of socioeconomic contexts for colorectal screening initiation and merit attention in both future research and surveillance efforts.
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Affiliation(s)
- A Blair
- Department of Social and Preventive Medicine, École de Santé Publique de l'Université de Montréal Montreal, QC.,Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC
| | - L Gauvin
- Department of Social and Preventive Medicine, École de Santé Publique de l'Université de Montréal Montreal, QC.,Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC
| | - S Ouédraogo
- Department of Social and Preventive Medicine, École de Santé Publique de l'Université de Montréal Montreal, QC.,Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC
| | - G D Datta
- Department of Social and Preventive Medicine, École de Santé Publique de l'Université de Montréal Montreal, QC.,Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC
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8
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Wheeler SB, Leeman J, Hassmiller Lich K, Tangka FKL, Davis MM, Richardson LC. Data-Powered Participatory Decision Making: Leveraging Systems Thinking and Simulation to Guide Selection and Implementation of Evidence-Based Colorectal Cancer Screening Interventions. Cancer J 2019; 24:136-143. [PMID: 29794539 PMCID: PMC6047526 DOI: 10.1097/ppo.0000000000000317] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
A robust evidence base supports the effectiveness of timely colorectal cancer (CRC) screening, follow-up of abnormal results, and referral to care in reducing CRC morbidity and mortality. However, only two-thirds of the US population is current with recommended screening, and rates are much lower for those who are vulnerable because of their race/ethnicity, insurance status, or rural location. Multiple, multilevel factors contribute to observed disparities, and these factors vary across different populations and contexts. As highlighted by the Cancer Moonshot Blue Ribbon Panel working groups focused on Prevention and Early Detection and Implementation Science inadequate CRC screening and follow-up represent an enormous missed opportunity in cancer prevention and control. To measurably reduce CRC morbidity and mortality, the evidence base must be strengthened to guide the identification of (1) multilevel factors that influence screening across different populations and contexts, (2) multilevel interventions and implementation strategies that will be most effective at targeting those factors, and (3) combinations of strategies that interact synergistically to improve outcomes. Systems thinking and simulation modeling (systems science) provide a set of approaches and techniques to aid decision makers in using the best available data and research evidence to guide implementation planning in the context of such complexity. This commentary summarizes current challenges in CRC prevention and control, discusses the status of the evidence base to guide the selection and implementation of multilevel CRC screening interventions, and describes a multi-institution project to showcase how systems science can be leveraged to optimize selection and implementation of CRC screening interventions in diverse populations and contexts.
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Affiliation(s)
| | | | | | - Florence K L Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, Department of Family Medicine, and OHSU-PSU School of Public Health, Oregon Health and Sciences University, Portland, OR
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
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Kaur Khakh A, Fast V, Shahid R. Spatial Accessibility to Primary Healthcare Services by Multimodal Means of Travel: Synthesis and Case Study in the City of Calgary. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E170. [PMID: 30634454 PMCID: PMC6351935 DOI: 10.3390/ijerph16020170] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/25/2018] [Accepted: 01/03/2019] [Indexed: 11/16/2022]
Abstract
Universal access to primary healthcare facilities is a driving goal of healthcare organizations. Despite Canada's universal access to primary healthcare status, spatial accessibility to healthcare facilities is still an issue of concern due to the non-uniform distribution of primary healthcare facilities and population over space-leading to spatial inequity in the healthcare sector. Spatial inequity is further magnified when health-related accessibility studies are analyzed on the assumption of universal car access. To overcome car-centric studies of healthcare access, this study compares different travel modes-driving, public transit, and walking-to simulate the multi-modal access to primary healthcare services in the City of Calgary, Canada. Improving on floating catchment area methods, spatial accessibility was calculated based on the Spatial Access Ratio method, which takes into consideration the provider-to-population status of the region. The analysis revealed that, in the City of Calgary, spatial accessibility to the primary healthcare services is the highest for the people with an access to a car, and is significantly lower with multimodal (bus transit and train) means despite being a large urban centre. The social inequity issue raised from this analysis can be resolved by improving the city's pedestrian infrastructure, public transportation, and construction of new clinics in regions of low accessibility.
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Affiliation(s)
- Amritpal Kaur Khakh
- Department of Geography, University of Calgary, Calgary, AB T2N 1N4, Canada.
| | - Victoria Fast
- Department of Geography, University of Calgary, Calgary, AB T2N 1N4, Canada.
| | - Rizwan Shahid
- Primary Health Care, Alberta Health Services, Calgary, AB T2W 3N2, Canada.
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10
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Hughes AE, Tiro JA, Balasubramanian BA, Skinner CS, Pruitt SL. Social Disadvantage, Healthcare Utilization, and Colorectal Cancer Screening: Leveraging Longitudinal Patient Address and Health Records Data. Cancer Epidemiol Biomarkers Prev 2018; 27:1424-1432. [PMID: 30135072 PMCID: PMC6279539 DOI: 10.1158/1055-9965.epi-18-0446] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/11/2018] [Accepted: 08/17/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Social disadvantage predicts colorectal cancer outcomes across the cancer care continuum for many populations and places. For medically underserved populations, social disadvantage is likely intersectional-affecting individuals at multiple levels and through membership in multiple disadvantaged groups. However, most measures of social disadvantage are cross-sectional and limited to race, ethnicity, and income. Linkages between electronic health records (EHR) and external datasets offer rich, multilevel measures that may be more informative. METHODS We identified urban safety-net patients eligible and due for colorectal cancer screening from the Parkland-UT Southwestern PROSPR cohort. We assessed one-time screening receipt (via colonoscopy or fecal immunochemical test) in the 18 months following cohort entry via the EHR. We linked EHR data to housing and Census data to generate measures of social disadvantage at the parcel- and block-group level. We evaluated the association of these measures with screening using multilevel logistic regression models controlling for sociodemographics, comorbidity, and healthcare utilization. RESULTS Among 32,965 patients, 45.1% received screening. In adjusted models, residential mobility, residence type, and neighborhood majority race were associated with colorectal cancer screening. Nearly all measures of patient-level social disadvantage and healthcare utilization were significant. CONCLUSIONS Address-based linkage of EHRs to external datasets may have the potential to expand meaningful measurement of multilevel social disadvantage. Researchers should strive to use granular, specific data in investigations of social disadvantage. IMPACT Generating multilevel measures of social disadvantage through address-based linkages efficiently uses existing EHR data for applied, population-level research.
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Affiliation(s)
- Amy E Hughes
- Department of Clinical Sciences, The University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Jasmin A Tiro
- Department of Clinical Sciences, The University of Texas Southwestern Medical Center, Dallas, Texas
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Bijal A Balasubramanian
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Epidemiology, Human Genetics, and Environmental Sciences UTHealth in Dallas, Dallas, Texas
| | - Celette Sugg Skinner
- Department of Clinical Sciences, The University of Texas Southwestern Medical Center, Dallas, Texas
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Sandi L Pruitt
- Department of Clinical Sciences, The University of Texas Southwestern Medical Center, Dallas, Texas
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
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11
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Prokopakis EP, Kaprana A, Karatzanis A, Velegrakis GA, Melissas J, Chalkiadakis G. Association between the increase in incidence of papillary thyroid carcinoma in Crete and exposure to radioactive agents. ACTA OTORHINOLARYNGOLOGICA ITALICA 2018; 38:310-315. [PMID: 29498716 PMCID: PMC6146575 DOI: 10.14639/0392-100x-1642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 07/20/2017] [Indexed: 11/23/2022]
Abstract
The mean gamma-ray distribution in Crete during the years after the nuclear accident at Chernobyl and its correlation with the Papillary Thyroid Cancer (PTC) distribution was identified. A total of 4285 patients underwent total thyroidectomy in our centre between 1990 and 2012. Data of gamma-ray (nSv/h) distribution were selected from the Greek Statistical Authorisation. A geo-spatial statistical model was used to estimate the expected number of patients with PTC and Kriging interpolation prediction model to estimate their distribution. Geographical weighted regression was performed to estimate the risk of PTC in relation to gamma ray distribution. All factors that were examined were found to be statistically significant for PTC distribution in Crete. Gamma-ray was determined as a significant risk factor (OR = 2.89; 95% CI = 1.682-4.989; p value = 0.03). There is a significant correlation between gamma-ray exposure and the increased prevalence of the PTC suggesting that the former may have been a significant risk factor.
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Affiliation(s)
- E P Prokopakis
- Department of Otorhinolaryngology, University Hospital of Crete, Heraklion, Crete, Greece
| | - A Kaprana
- Department of Otorhinolaryngology, University Hospital of Crete, Heraklion, Crete, Greece
| | - A Karatzanis
- Department of Otorhinolaryngology, University Hospital of Crete, Heraklion, Crete, Greece
| | - G A Velegrakis
- Department of Otorhinolaryngology, University Hospital of Crete, Heraklion, Crete, Greece
| | - J Melissas
- Department of Surgical Oncology, University Hospital of Crete, Heraklion, Crete, Greece
| | - G Chalkiadakis
- Department of General Surgery, University Hospital of Crete, Heraklion, Crete, Greece
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12
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Davis MM, Renfro S, Pham R, Hassmiller Lich K, Shannon J, Coronado GD, Wheeler SB. Geographic and population-level disparities in colorectal cancer testing: A multilevel analysis of Medicaid and commercial claims data. Prev Med 2017; 101:44-52. [PMID: 28506715 PMCID: PMC6067672 DOI: 10.1016/j.ypmed.2017.05.001] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 04/25/2017] [Accepted: 05/07/2017] [Indexed: 12/12/2022]
Abstract
Morbidity and mortality from colorectal cancer (CRC) can be attenuated through guideline concordant screening and intervention. This study used Medicaid and commercial claims data to examine individual and geographic factors associated with CRC testing rates in one state (Oregon). A total of 64,711 beneficiaries (4516 Medicaid; 60,195 Commercial) became newly age-eligible for CRC screening and met inclusion criteria (e.g., continuously enrolled, no prior history) during the study period (January 2010-December 2013). We estimated multilevel models to examine predictors for CRC testing, including individual (e.g., gender, insurance, rurality, access to care, distance to endoscopy facility) and geographic factors at the county level (e.g., poverty, uninsurance). Despite insurance coverage, only two out of five (42%) beneficiaries had evidence of CRC testing during the four year study window. CRC testing varied from 22.4% to 46.8% across Oregon's 36 counties; counties with higher levels of socioeconomic deprivation had lower levels of testing. After controlling for age, beneficiaries had greater odds of receiving CRC testing if they were female (OR 1.04, 95% CI 1.01-1.08), commercially insured, or urban residents (OR 1.14, 95% CI 1.07-1.21). Accessing primary care (OR 2.47, 95% CI 2.37-2.57), but not distance to endoscopy (OR 0.98, 95% CI 0.92-1.03) was associated with testing. CRC testing in newly age-eligible Medicaid and commercial members remains markedly low. Disparities exist by gender, geographic residence, insurance coverage, and access to primary care. Work remains to increase CRC testing to acceptable levels, and to select and implement interventions targeting the counties and populations in greatest need.
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Affiliation(s)
- Melinda M Davis
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States; Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, United States; OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, United States.
| | - Stephanie Renfro
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States.
| | - Robyn Pham
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, United States.
| | - Kristen Hassmiller Lich
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
| | - Jackilen Shannon
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, United States.
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente, Portland, OR, United States.
| | - Stephanie B Wheeler
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Center for Health Promotion & Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
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Wheeler DC, Czarnota J, Jones RM. Estimating an area-level socioeconomic status index and its association with colonoscopy screening adherence. PLoS One 2017; 12:e0179272. [PMID: 28594927 PMCID: PMC5464664 DOI: 10.1371/journal.pone.0179272] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 05/27/2017] [Indexed: 01/28/2023] Open
Abstract
Socioeconomic status (SES) is often considered a risk factor for health outcomes. SES is typically measured using individual variables of educational attainment, income, housing, and employment variables or a composite of these variables. Approaches to building the composite variable include using equal weights for each variable or estimating the weights with principal components analysis or factor analysis. However, these methods do not consider the relationship between the outcome and the SES variables when constructing the index. In this project, we used weighted quantile sum (WQS) regression to estimate an area-level SES index and its effect in a model of colonoscopy screening adherence in the Minnesota–Wisconsin Metropolitan Statistical Area. We considered several specifications of the SES index including using different spatial scales (e.g., census block group-level, tract-level) for the SES variables. We found a significant positive association (odds ratio = 1.17, 95% CI: 1.15–1.19) between the SES index and colonoscopy adherence in the best fitting model. The model with the best goodness-of-fit included a multi-scale SES index with 10 variables at the block group-level and one at the tract-level, with home ownership, race, and income among the most important variables. Contrary to previous index construction, our results were not consistent with an assumption of equal importance of variables in the SES index when explaining colonoscopy screening adherence. Our approach is applicable in any study where an SES index is considered as a variable in a regression model and the weights for the SES variables are not known in advance.
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Affiliation(s)
- David C. Wheeler
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, United States of America
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia, United States of America
- * E-mail:
| | - Jenna Czarnota
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Resa M. Jones
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia, United States of America
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, United States of America
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14
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Wang C. The impact of car ownership and public transport usage on cancer screening coverage: Empirical evidence using a spatial analysis in England. JOURNAL OF TRANSPORT GEOGRAPHY 2016; 56:15-22. [PMID: 27829709 PMCID: PMC5091749 DOI: 10.1016/j.jtrangeo.2016.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 07/27/2016] [Accepted: 08/14/2016] [Indexed: 05/19/2023]
Abstract
A spatial analysis has been conducted in England, with the aim to examine the impact of car ownership and public transport usage on breast and cervical cancer screening coverage. District-level cancer screening coverage data (in proportions) and UK census data have been collected and linked. Their effects on cancer screening coverage were modelled by using both non-spatial and spatial models to control for spatial correlation. Significant spatial correlation has been observed and thus spatial model is preferred. It is found that increased car ownership is significantly associated with improved breast and cervical cancer screening coverage. Public transport usage is inversely associated with breast cancer screening coverage; but positively associated with cervical cancer screening. An area with higher median age is associated with higher screening coverage. The effects of other socio-economic factors such as deprivation and economic activity have also been explored with expected results. Some regional differences have been observed, possibly due to unobserved factors. Relevant transport and public health policies are thus required for improved coverage. While restricting access to cars may lead to various benefits in public health, it may also result in worse cancer screening uptake. It is thus recommended that careful consideration should be taken before implementing policy interventions.
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Rust G, Zhang S, Yu Z, Caplan L, Jain S, Ayer T, McRoy L, Levine RS. Counties eliminating racial disparities in colorectal cancer mortality. Cancer 2016; 122:1735-48. [PMID: 26969874 DOI: 10.1002/cncr.29958] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/31/2015] [Accepted: 01/25/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Although colorectal cancer (CRC) mortality rates are declining, racial-ethnic disparities in CRC mortality nationally are widening. Herein, the authors attempted to identify county-level variations in this pattern, and to characterize counties with improving disparity trends. METHODS The authors examined 20-year trends in US county-level black-white disparities in CRC age-adjusted mortality rates during the study period between 1989 and 2010. Using a mixed linear model, counties were grouped into mutually exclusive patterns of black-white racial disparity trends in age-adjusted CRC mortality across 20 three-year rolling average data points. County-level characteristics from census data and from the Area Health Resources File were normalized and entered into a principal component analysis. Multinomial logistic regression models were used to test the relation between these factors (clusters of related contextual variables) and the disparity trend pattern group for each county. RESULTS Counties were grouped into 4 disparity trend pattern groups: 1) persistent disparity (parallel black and white trend lines); 2) diverging (widening disparity); 3) sustained equality; and 4) converging (moving from disparate outcomes toward equality). The initial principal component analysis clustered the 82 independent variables into a smaller number of components, 6 of which explained 47% of the county-level variation in disparity trend patterns. CONCLUSIONS County-level variation in social determinants, health care workforce, and health systems all were found to contribute to variations in cancer mortality disparity trend patterns from 1990 through 2010. Counties sustaining equality over time or moving from disparities to equality in cancer mortality suggest that disparities are not inevitable, and provide hope that more communities can achieve optimal and equitable cancer outcomes for all. Cancer 2016;122:1735-48. © 2016 American Cancer Society.
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Affiliation(s)
- George Rust
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL.,Department of Community Health And Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Shun Zhang
- Statistics and Methodology Department, NORC at the University of Chicago, Chicago, Illinois
| | - Zhongyuan Yu
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, New Jersey
| | - Lee Caplan
- Deparment of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Sanjay Jain
- Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Turgay Ayer
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Luceta McRoy
- School of Business and Management, Southern Adventist University, Collegedale, Tennessee
| | - Robert S Levine
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
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16
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Porter NR, Eberth JM, Samson ME, Garcia-Dominic O, Lengerich EJ, Schootman M. Diabetes Status and Being Up-to-Date on Colorectal Cancer Screening, 2012 Behavioral Risk Factor Surveillance System. Prev Chronic Dis 2016; 13:E19. [PMID: 26851338 PMCID: PMC4747441 DOI: 10.5888/pcd13.150391] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction Although screening rates for colorectal cancer are increasing, 22 million Americans are not up-to-date with recommendations. People with diabetes are an important and rapidly growing group at increased risk for colorectal cancer. Screening status and predictors of being up-to-date on screening are largely unknown in this population. Methods This study used logistic regression modeling and data from the 2012 Behavioral Risk Factor Surveillance System to examine the association between diabetes and colorectal cancer screening predictors with being up-to-date on colorectal cancer screening according to criteria of the US Preventive Services Task Force for adults aged 50 or older. State prevalence rates of up-to-date colorectal cancer screening were also calculated and mapped. Results The prevalence of being up-to-date with colorectal cancer screening for all respondents aged 50 or older was 65.6%; for respondents with diabetes, the rate was 69.2%. Respondents with diabetes were 22% more likely to be up-to-date on colorectal cancer screening than those without diabetes. Among those with diabetes, having a routine checkup within the previous year significantly increased the odds of being up-to-date on colorectal cancer screening (odds ratio, 1.90). Other factors such as age, income, education, race/ethnicity, insurance status, and history of cancer were also associated with up-to-date status. Conclusion Regardless of diabetes status, people who had a routine checkup within the past year were more likely to be up-to-date than people who had not. Among people with diabetes, the duration between routine checkups may be of greater importance than the frequency of diabetes-related doctor visits. Continued efforts should be made to ensure that routine care visits occur regularly to address the preventive health needs of patients with and patients without diabetes.
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Affiliation(s)
- Nancy R Porter
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Jan M Eberth
- Assistant Professor of Epidemiology, Department of Epidemiology and Biostatistics, University of South Carolina, Arnold School of Public Health, Columbia, South Carolina.
| | - Marsha E Samson
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Oralia Garcia-Dominic
- Highmark Blue Shield, Camp Hill, Pennsylvania; College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; Penn State Hershey Cancer Institute, Hershey, Pennsylvania; College of Health and Human Development, and The Pennsylvania State University, University Park, Pennsylvani
| | - Eugene J Lengerich
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; Penn State Hershey Cancer Institute, Hershey, Pennsylvania; College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania
| | - Mario Schootman
- Saint Louis University, Saint Louis, Missouri, and Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, Saint Louis, Missouri
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Perceptions of One's Neighborhood and Mammogram Use among a Sample of Low-Income Women at Risk for Human Immunodeficiency Virus and Sexually Transmitted Infections. Womens Health Issues 2015; 26:196-200. [PMID: 26391228 DOI: 10.1016/j.whi.2015.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 08/11/2015] [Accepted: 08/13/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Neighborhood disorder, signs of physical and social disorganization, has been related to a range of poor mental and physical health outcomes. Although individual factors have been widely associated with getting a mammogram, little is known about the impact of the neighborhood environment on a woman's decision to get a mammogram. METHODS In a sample of women at risk for human immunodeficiency virus and sexually transmitted infections, we explored the role of perceptions of one's neighborhood on getting a mammogram. The study included two samples: women 40 to 49 years (n = 233) and women 50 years and older (n = 83). Data were collected from May 2006 through June 2008. RESULTS Women age 50 years and older who lived in a neighborhood with disorder were 72% less likely to get a mammogram compared with women who lived in neighborhoods without disorder. There was no relationship for women age 40 to 49 years. CONCLUSIONS Interventions are needed to increase awareness and encourage women living in neighborhoods with disorder to get a mammogram. In addition to interventions to increase mammography, programs are needed to decrease neighborhood disorder. Increasing neighborhood cohesion, social control, and empowerment could integrate health promotion programs to both reduce disorder and increase health behaviors.
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Sentell T, Braun KL, Davis J, Davis T. Health literacy and meeting breast and cervical cancer screening guidelines among Asians and whites in California. SPRINGERPLUS 2015; 4:432. [PMID: 26306294 PMCID: PMC4540711 DOI: 10.1186/s40064-015-1225-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/07/2015] [Indexed: 02/06/2023]
Abstract
Objectives Empirical evidence regarding cancer screening and health literacy is mixed. Cancer is the leading cause of death in Asian Americans, yet screening rates are notably low. Using a population-based sample, we determined if health literacy: (1) was associated with breast and cervical cancer screening, and (2) helped to explain Asian cancer screening disparities. Methods We analyzed the 2007 California Health Interview Survey for Asian (Japanese, Chinese, Filipino, Korean, Vietnamese, other Asian) and white women within age groups relevant to US Preventive Services Task Force (USPSTF) screening guidelines: cervical: ages 21–65 (n = 15,210) and breast: ages 50–74 (n = 11,163). Multilevel logistic regression models predicted meeting USPSTF screening guidelines both with and without self-reported health literacy controlling for individual-level and contextual-level factors. Results Low health literacy significantly (p < 0.05) predicted lower cancer screening in final models for both cancer types. In unadjusted models, Asians were significantly less likely than whites to receive both screening types and significantly more likely to report low health literacy. However, in multivariable models, the addition of the low health literacy variable did not diminish Asian vs. white cancer screening disparities. Conclusions Self-reported health literacy predicted cervical and breast cancer screening, but was not able to explain Asian cancer screening disparities. We provide new evidence to support a relationship between health literacy and cancer screening. Health literacy is likely a useful focus for interventions to improve cancer screening and ultimately reduce the burden of cancer. To specifically reduce Asian cancer disparities, additional areas of focus should be considered.
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Affiliation(s)
- Tetine Sentell
- Office of Public Health Studies, University of Hawai'i, 1960 East-West Road, Biomed, D-104, Honolulu, HI 96822 USA
| | - Kathryn L Braun
- Office of Public Health Studies, University of Hawai'i, 1960 East-West Road, Biomed, D-104, Honolulu, HI 96822 USA ; 'Imi Hale Native Hawaiian Cancer Network (U54CA153459), Papa Ola Lōkahi, 894 Queen Street, Honolulu, HI 96813 USA
| | - James Davis
- Biostatistics Core, John A. Burns School of Medicine, Medical Education Building, Suite 401, 651 Ilalo Street, Honolulu, HI 96813 USA
| | - Terry Davis
- Section of General Medicine, School of Medicine, Shreveport, Louisiana State University Health Sciences Center, 1501 Kings Highway, P.O. Box 33932, Shreveport, LA 71130-3932 USA
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Lee J, Carvallo M. Socioecological perspectives on cervical cancer and cervical cancer screening among Asian American women. J Community Health 2015; 39:863-71. [PMID: 24863746 DOI: 10.1007/s10900-014-9887-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Although cervical cancer is one of the most commonly diagnosed cancers among Vietnamese American women (VAW) and Korean American women (KAW), both groups consistently report much lower rates of cervical cancer screening compared with other Asian ethnic subgroups and non-Hispanic Whites. This study aimed to explore multilevel factors that may underlie low screening rates among VAW and KAW living in a city where their ethnic communities are relatively small. The socioecological model was used as a conceptual framework. Thirty participants were conveniently recruited from ethnic beauty salons run by VA and KA cosmetologists in Albuquerque, New Mexico. The participants' average age was 44.6 years (SD = .50; range = 21-60). Most participants were married (80 %) and employed (73.3 %), and had health insurance (83.3 %). A qualitative interview was conducted in Vietnamese or Korean and transcribed verbatim. A thematic content analysis was used to identify major codes, categories, and patterns across the transcripts. The study identified several factors at the individual (e.g., pregnancy, poverty, personality), interpersonal (e.g., family responsibility, mother as influential referent), and community (e.g., lack of availability, community size) levels. The study sheds light on four major areas that must be taken into consideration in the development of culturally appropriate, community-based interventions aimed to reduce disparities in cervical cancer screening among ethnic minority women in the United States: (1) ethnic community size and geographic location; (2) cross-cultural similarities and dissimilarities; (3) targeting of not only unmarried young women, but also close referents; and (4) utilization of trusted resources within social networks.
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Affiliation(s)
- Jongwon Lee
- College of Nursing, University of New Mexico, MSC 09 5350, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA,
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Pruitt SL, Davidson NO, Gupta S, Yan Y, Schootman M. Missed opportunities: racial and neighborhood socioeconomic disparities in emergency colorectal cancer diagnosis and surgery. BMC Cancer 2014; 14:927. [PMID: 25491412 PMCID: PMC4364088 DOI: 10.1186/1471-2407-14-927] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 11/26/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Disparities by race and neighborhood socioeconomic status exist for many colorectal cancer (CRC) outcomes, including screening use and mortality. We used population-based data to determine if disparities also exist for emergency CRC diagnosis and surgery. METHODS We examined two emergency CRC outcomes using 1992-2005 population-based U.S. SEER-Medicare data. Among CRC patients aged ≥66 years, we examined racial (African American vs. white) and neighborhood poverty disparities in two emergency outcomes defined as: 1) newly diagnosed CRC or 2) CRC surgery associated with: obstruction, perforation, or emergency inpatient admission. Multilevel logistic regression (patients nested in census tracts) analyses adjusted for sociodemographic, tumor, and clinical covariates. RESULTS Of 83,330 CRC patients, 29.1% were diagnosed emergently. Of 55,046 undergoing surgery, 26.0% had emergency surgery. For both outcomes, race and neighborhood poverty disparities were evident. A significant race by poverty interaction (p < .001) was noted: poverty rate was associated with both outcomes among African Americans, but not whites. Compared to whites in low poverty (<10%) neighborhoods, African Americans in high poverty (≥20%) neighborhoods had increased odds of emergency diagnosis (AOR: 1.50, 95% CI: 1.38-1.63) and surgery (AOR: 1.63, 95% CI: 1.47-1.81). CONCLUSIONS Emergency CRC outcomes are associated with high poverty residence among African Americans in this population-based study, potentially contributing to observed disparities in CRC morbidity and mortality. Targeted efforts to increase CRC screening among African Americans living in high poverty neighborhoods could reduce preventable disparities.
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Affiliation(s)
- Sandi L Pruitt
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd E1, 410D Dallas, TX, USA.
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Mobley LR, Kuo TM, Traczynski J, Udalova V, Frech HE. Macro-level factors impacting geographic disparities in cancer screening. HEALTH ECONOMICS REVIEW 2014; 4:13. [PMID: 26054402 PMCID: PMC4883991 DOI: 10.1186/s13561-014-0013-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 06/26/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Examine how differences in state regulatory environments predict geographic disparities in the utilization of cancer screening. DATA SOURCES/SETTING 100% Medicare fee-for-service population data from 2001-2005 was developed as multi-year breast (BC) and colorectal cancer (CRC) screening utilization rates in each county in the US. STUDY DESIGN A comprehensive set of supply and demand predictors are used in a multilevel model of county-level cancer screening utilization in the context of state regulatory markets. States dictate insurance mandates/regulations and whether alternative providers (nurse practitioners) can provide preventive care services supplied by MDs. Controlling statistically for the supply of both types of providers, we study the joint effects of two private insurance regulations: one mandating that insureds with serious or chronic health conditions may receive continuity of care from their established physician(s) after changing health insurance plans, and another mandating that external grievance review is an option for all health plan coverage/denial decisions. These private insurance plan regulations are expected to affect the degree of beneficial spillovers from managed care practices, which may have increased area-wide cancer screening rates. PRINCIPAL FINDINGS The two private insurance regulations under study were significant predictors impacted by local market conditions. Managed care spillovers in local markets were significantly associated with higher BC screening rates, but only in states lacking the two forms of regulation under study. Spillovers were significantly associated with higher CRC cancer screening rates everywhere, but much higher in the unregulated states. Area poverty dampened screening rates, but less so for CRC screening in the states with these regulations. CONCLUSIONS Two state insurance regulations that empowered consumers with more autonomy to make informed utilization decisions varied across states, and exhibited significant associations with screening rates, which varied with the degree of managed care penetration or poverty in the state's counties. Beneficial spillover effects from managed care practices and negative influences from area poverty are not uniform across the United States. Both variables had stronger associations with CRC than BC screening utilization, as did state regulatory variables. CRC screening by endoscopy was more subject to market and regulatory factors than BC screening.
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Affiliation(s)
- Lee R Mobley
- />School of Public Health and Andrew Young School of Policy Studies, Georgia State University, Atlanta, GA USA
| | - Tzy-Mey Kuo
- />Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Jeffrey Traczynski
- />Department of Economics, University of Hawaii at Manoa, Honolulu, HI 96822 USA
| | - Victoria Udalova
- />Department of Economics, University of Wisconsin-Madison, Madison, WI 53706 USA
| | - HE Frech
- />Department of Economics, University of California, Santa Barbara, CA USA
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Pruitt SL, Leonard T, Murdoch J, Hughes A, McQueen A, Gupta S. Neighborhood effects in a behavioral randomized controlled trial. Health Place 2014; 30:293-300. [PMID: 25456014 DOI: 10.1016/j.healthplace.2014.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 09/29/2014] [Accepted: 10/02/2014] [Indexed: 10/24/2022]
Abstract
Randomized controlled trials (RCTs) of interventions intended to modify health behaviors may be influenced by neighborhood effects which can impede unbiased estimation of intervention effects. Examining a RCT designed to increase colorectal cancer (CRC) screening (N=5628), we found statistically significant neighborhood effects: average CRC test use among neighboring study participants was significantly and positively associated with individual patient's CRC test use. This potentially important spatially-varying covariate has not previously been considered in a RCT. Our results suggest that future RCTs of health behavior interventions should assess potential social interactions between participants, which may cause intervention arm contamination and may bias effect size estimation.
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Affiliation(s)
- Sandi L Pruitt
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA; Harold C. Simmons Comprehensive Cancer Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9169, USA.
| | - Tammy Leonard
- Economics Department, University of Dallas, 1845 E. Northgate Dr., Irving, TX 75026, United States
| | - James Murdoch
- School of Economic, Political, and Policy Sciences, University of Texas-Dallas, 800W. Campbell Rd, GR31, Richardson, TX 75080, USA
| | - Amy Hughes
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA; School of Economic, Political, and Policy Sciences, University of Texas-Dallas, 800W. Campbell Rd, GR31, Richardson, TX 75080, USA
| | - Amy McQueen
- Division of Health Behavior Research, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue Campus, Box 8005, St. Louis, MO 63110, USA
| | - Samir Gupta
- Division of Gastroenterology, Department of Internal Medicine, Moores Cancer Center, University of California, San Diego, CA, USA; Department of Veterans Affairs, San Diego Healthcare System, 3350 La Jolla Village Dr MC 111D, San Diego, CA 92161, USA
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Wheeler SB, Kuo TM, Goyal RK, Meyer AM, Hassmiller Lich K, Gillen EM, Tyree S, Lewis CL, Crutchfield TM, Martens CE, Tangka F, Richardson LC, Pignone MP. Regional variation in colorectal cancer testing and geographic availability of care in a publicly insured population. Health Place 2014; 29:114-23. [PMID: 25063908 DOI: 10.1016/j.healthplace.2014.07.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 06/25/2014] [Accepted: 07/01/2014] [Indexed: 12/15/2022]
Abstract
Despite its demonstrated effectiveness, colorectal cancer (CRC) testing is suboptimal, particularly in vulnerable populations such as those who are publicly insured. Prior studies provide an incomplete picture of the importance of the intersection of multilevel factors affecting CRC testing across heterogeneous geographic regions where vulnerable populations live. We examined CRC testing across regions of North Carolina by using population-based Medicare and Medicaid claims data from disabled individuals who turned 50 years of age during 2003-2008. We estimated multilevel models to examine predictors of CRC testing, including distance to the nearest endoscopy facility, county-level endoscopy procedural rates, and demographic and community contextual factors. Less than 50% of eligible individuals had evidence of CRC testing; men, African-Americans, Medicaid beneficiaries, and those living furthest away from endoscopy facilities had significantly lower odds of CRC testing, with significant regional variation. These results can help prioritize intervention strategies to improve CRC testing among publicly insured, disabled populations.
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Affiliation(s)
- Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, USA.
| | - Tzy-Mey Kuo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Ravi K Goyal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Anne-Marie Meyer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, USA
| | - Emily M Gillen
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, USA
| | - Seth Tyree
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Carmen L Lewis
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, 5045 Old Clinic Building, CB#7110, Chapel Hill, NC 27599-5039, USA
| | - Trisha M Crutchfield
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, USA
| | - Christa E Martens
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Florence Tangka
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Lisa C Richardson
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Michael P Pignone
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, USA; Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, 5045 Old Clinic Building, CB#7110, Chapel Hill, NC 27599-5039, USA
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Pruitt SL, Leonard T, Zhang S, Schootman M, Halm EA, Gupta S. Physicians, clinics, and neighborhoods: multiple levels of influence on colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2014; 23:1346-55. [PMID: 24732630 DOI: 10.1158/1055-9965.epi-13-1130] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We (i) described variability in colorectal cancer (CRC) test use across multiple levels, including physician, clinic, and neighborhood; and (ii) compared the performance of novel cross-classified models versus traditional hierarchical models. METHODS We examined multilevel variation in CRC test use among patients not up-to-date with screening in a large, urban safety net health system (2011-2012). Outcomes included: (i) fecal occult blood test (FOBT) or (ii) colonoscopy and were ascertained using claims data during a 1-year follow-up. We compared Bayesian (i) cross-classified four-level logistic models nesting patients within separate, nonoverlapping "levels" (physicians, clinics, and census tracts) versus (ii) three hierarchical two-level models using deviance information criterion. Models were adjusted for covariates (patient sociodemographic factors, driving time to clinic, and census tract poverty rate). RESULTS Of 3,195 patients, 157 (4.9%) completed FOBT and 292 (9.1%) completed colonoscopy during the study year. Patients attended 19 clinics, saw 177 physicians, and resided in 332 census tracts. Significant variability was observed across all levels in both hierarchical and cross-classified models that was unexplained by measured covariates. For colonoscopy, variance was similar across all levels. For FOBT, physicians, followed by clinics, demonstrated the largest variability. Model fit using cross-classified models was superior or similar to 2-level hierarchical models. CONCLUSIONS Significant and substantial variability was observed across neighborhood, physician, and clinic levels in CRC test use, suggesting the importance of factors at each of these levels on CRC testing. IMPACT Future multilevel research and intervention should consider the simultaneous influences of multiple levels, including clinic, physician, and neighborhood.
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Affiliation(s)
- Sandi L Pruitt
- Authors' Affiliations: Department of Clinical Sciences; Harold C. Simmons Comprehensive Cancer Center;
| | - Tammy Leonard
- School of Economic, Political, and Policy Sciences, University of Texas-Dallas, Dallas, Texas
| | - Song Zhang
- Authors' Affiliations: Department of Clinical Sciences
| | - Mario Schootman
- Department of Epidemiology, College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri
| | - Ethan A Halm
- Authors' Affiliations: Department of Clinical Sciences; Department of General Internal Medicine, University of Texas Southwestern Medical Center
| | - Samir Gupta
- Division of Gastroenterology, Department of Internal Medicine, Moores Cancer Center, University of California San Diego; and Department of Veterans Affairs, San Diego Healthcare System, San Diego, California
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Charns MP, Foster MK, Alligood EC, Benzer JK, Burgess JF, Li D, McIntosh NM, Burness A, Partin MR, Clauser SB. Multilevel interventions: measurement and measures. J Natl Cancer Inst Monogr 2012; 2012:67-77. [PMID: 22623598 DOI: 10.1093/jncimonographs/lgs011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Multilevel intervention research holds the promise of more accurately representing real-life situations and, thus, with proper research design and measurement approaches, facilitating effective and efficient resolution of health-care system challenges. However, taking a multilevel approach to cancer care interventions creates both measurement challenges and opportunities. METHODS One-thousand seventy two cancer care articles from 2005 to 2010 were reviewed to examine the state of measurement in the multilevel intervention cancer care literature. Ultimately, 234 multilevel articles, 40 involving cancer care interventions, were identified. Additionally, literature from health services, social psychology, and organizational behavior was reviewed to identify measures that might be useful in multilevel intervention research. RESULTS The vast majority of measures used in multilevel cancer intervention studies were individual level measures. Group-, organization-, and community-level measures were rarely used. Discussion of the independence, validity, and reliability of measures was scant. DISCUSSION Measurement issues may be especially complex when conducting multilevel intervention research. Measurement considerations that are associated with multilevel intervention research include those related to independence, reliability, validity, sample size, and power. Furthermore, multilevel intervention research requires identification of key constructs and measures by level and consideration of interactions within and across levels. Thus, multilevel intervention research benefits from thoughtful theory-driven planning and design, an interdisciplinary approach, and mixed methods measurement and analysis.
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Affiliation(s)
- Martin P Charns
- Center for Organization, Leadership and Management Research, US Department of Veterans Affairs, Boston, MA, USA
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Lamont EB, He Y, Subramanian SV, Zaslavsky AM. Do socially deprived urban areas have lesser supplies of cancer care services? J Clin Oncol 2012; 30:3250-7. [PMID: 22869877 DOI: 10.1200/jco.2011.40.4228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Area social deprivation is associated with unfavorable health outcomes of residents across the full clinical course of cancer from the stage at diagnosis through survival. We sought to determine whether area social factors are associated with the area health care supply. PATIENTS AND METHODS We studied the area supply of health services required for the provision of guideline-recommended care for patients with breast cancer and colorectal cancer (CRC) in each of the following three distinct clinical domains: screening, treatment, and post-treatment surveillance. We characterized area social factors in 3,096 urban zip code tabulation areas by using Census Bureau data and the health care supply in the corresponding 465 hospital service areas by using American Hospital Association, American Medical Association, and US Food and Drug Administration data. In two-level hierarchical models, we assessed associations between social factors and the supply of health services across areas. RESULTS We found no clear associations between area social factors and the supply of health services essential to the provision of guideline recommended breast cancer and CRC care in urban areas. The measures of health service included the supply of physicians who facilitate screening, treatment, and post-treatment care and the supply of facilities required for the same services. CONCLUSION Because we found that the supply of types of health care required for the provision of guideline-recommended cancer care for patients with breast cancer and CRC did not vary with markers of area socioeconomic disadvantage, it is possible that previously reported unfavorable breast cancer and CRC outcomes among individuals living in impoverished areas may have occurred despite an apparent adequate area health care supply.
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Geographic disparities in late-stage cancer diagnosis: multilevel factors and spatial interactions. Health Place 2012; 18:978-90. [PMID: 22789866 DOI: 10.1016/j.healthplace.2012.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 06/06/2012] [Accepted: 06/12/2012] [Indexed: 11/20/2022]
Abstract
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.
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Arcaya M, Brewster M, Zigler CM, Subramanian SV. Area variations in health: a spatial multilevel modeling approach. Health Place 2012; 18:824-31. [PMID: 22522099 DOI: 10.1016/j.healthplace.2012.03.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 03/21/2012] [Accepted: 03/26/2012] [Indexed: 10/28/2022]
Abstract
Both space and membership in geographically-embedded administrative units can produce variations in health, resulting in geographic clusters of good and poor health. Despite important differences between these two types of dependence, one is easily mistaken for the other, and the possibility that both are at work is commonly ignored. We fit a series of hierarchical and spatially-explicit multilevel models to a U.S. county-level life dataset of life expectancy in 1999 to demonstrate approaches for data analysis and interpretation when multiple sources of area-clustering are present. We demonstrate the methods to detect, interpret, and differentiate evidence of spatial and geographic membership effects and discuss key considerations for analyzing data with spatial or/and membership dimensions. We find evidence that life expectancy is driven by both within-state geographic process, and by spatial processes. We argue that considering spatial and membership processes simultaneously yields valuable insights into the patterning of area variations in health.
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Affiliation(s)
- Mariana Arcaya
- Department of Society, Human Development and Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.
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Mobley LR, Kuo TM, Urato M, Subramanian S, Watson L, Anselin L. Spatial Heterogeneity in Cancer Control Planning and Cancer Screening Behavior. ANNALS OF THE ASSOCIATION OF AMERICAN GEOGRAPHERS. ASSOCIATION OF AMERICAN GEOGRAPHERS 2012; 102:1113-1124. [PMID: 24944346 PMCID: PMC4059347 DOI: 10.1080/00045608.2012.657494] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Each state is autonomous in its comprehensive cancer control (CCC) program, and considerable heterogeneity exists in the program plans. However, researchers often focus on the concept of nationally representative data and pool observations across states using regression analysis to come up with average effects when interpreting results. Due to considerable state autonomy and heterogeneity in various dimensions-including culture, politics, historical precedent, regulatory environment, and CCC efforts-it is important to examine states separately and to use geographic analysis to translate findings in place and time. We used 100 percent population data for Medicare-insured persons aged 65 or older and examined predictors of breast cancer (BC) and colorectal cancer (CRC) screening from 2001-2005. Examining BC and CRC screening behavior separately in each state, we performed 100 multilevel regressions. We summarize the state-specific findings of racial disparities in screening for either cancer in a single bivariate map of the 50 states, producing a separate map for African American and for Hispanic disparities in each state relative to whites. The maps serve to spatially translate the voluminous regression findings regarding statistically significant disparities between whites and minorities in cancer screening within states. Qualitative comparisons can be made of the states' disparity environments or for a state against a national benchmark using the bivariate maps. We find that African Americans in Michigan and Hispanics in New Jersey are significantly more likely than whites to utilize CRC screening and that Hispanics in 6 states are significantly and persistently more likely to utilize mammography than whites. We stress the importance of spatial translation research for informing and evaluating CCC activities within states and over time.
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