Telemedicine Reduces Missed Appointments but Disparities Persist

INTRODUCTION

Missed appointments also known as no-shows adversely affect clinical outcomes, clinic efficiency, and quality of care and have been attributed to barriers such as work schedule conflicts and lack of transportation. The widespread telemedicine implementation and adoption that has occurred as a consequence of the COVID-19 pandemic has the potential to address these barriers and improve missed appointment rates. This study aims to analyze the relationship between telemedicine and missed appointments.

METHODS

This retrospective cohort study used electronic health records data from a safety-net academic health center with federally qualified clinics (March 2020-December 2022). Bivariate and multivariable generalized estimating equations were used to analyze the relationship between no-show and appointment type (in-person versus telemedicine appointment). Stratified adjusted regression analyses were used to calculate the average change in the marginal effect of telemedicine appointments on no-shows across covariates. The data were analyzed from September 2023 to October 2023.

RESULTS

Hispanic patients accounted for 60% of the 474,212 appointments, followed by non-Hispanic White (22.5%), non-Hispanic Black (13.3%), Asian (2.7%), Native American (1%), and other race/ethnicity patients (0.6%). The no-show rate for telemedicine appointments was 12% compared with 25% for in-person appointments. Multivariable analysis showed that telemedicine appointment was associated with a decreased likelihood of no-show compared with in-person appointments (OR=0.40, 95% CI=0.40, 0.41). The average change in the marginal effect of telemedicine appointments on the reduction of no-shows across race/ethnicity was greatest for Native American and non-Hispanic Black patients.

CONCLUSIONS

Telemedicine appointments were associated with a decreased likelihood of no-shows, and the protective effect of telemedicine appointments on missed appointments was greatest for underserved groups. Strategies to increase telemedicine uptake, especially for underserved groups, are critical.

Racial and ethnic differences in predictors of participation in an intergenerational social connectedness intervention for older adults

BACKGROUND

Social connectedness is a key determinant of health and interventions have been developed to prevent social isolation in older adults. However, these interventions have historically had a low participation rate amongst minority populations. Given the sustained isolation caused by the COVID-19 pandemic, it is even more important to understand what factors are associated with an individual's decision to participate in a social intervention. To achieve this, we used machine learning techniques to model the racial and ethnic differences in participation in social connectedness interventions.

METHODS

Data were obtained from a social connectedness intervention that paired college students with Houston-area community-dwelling older adults (> 65 yo) enrolled in Medicare Advantage plans. Eligible participants were contacted telephonically and asked to complete the 3-item UCLA Loneliness Scale. We used the following machine-learning methods to identify significant predictors of participation in the program: k-nearest neighbors, logistic regression, decision tree, gradient-boosted decision tree, and random forest.

RESULTS

The gradient-boosted decision tree models yielded the best parameters for all race/ethnicity groups (96.1% test accuracy, 0.739 AUROC). Among non-Hispanic White older adults, key features of the predictive model included Functional Comorbidity Index (FCI) score, Medicare prescription risk score, Medicare risk score, and depression and anxiety indicators within the FCI. Among non-Hispanic Black older adults, key features included disability, Medicare prescription risk score, FCI and Medicare risk scores. Among Hispanic older adults, key features included depression, FCI and Medicare risk scores.

CONCLUSIONS

These findings offer a substantial opportunity for the design of interventions that maximize engagement among minority groups at greater risk for adverse health outcomes.

Food insecurity is inversely associated with positive childhood experiences among a nationally representative sample of children aged 0-17 years in the USA

OBJECTIVE

We examined the association between food insecurity and positive childhood experiences (PCE).

DESIGN

Outcome measure was number of PCE and seven PCE constructs. Food insecurity was assessed with a three-category measure that ascertained whether the respondent could afford and choose to eat nutritious food. We then used bivariate and multivariable Poisson and logistic regressions to analyse the relationship between food insecurity and the outcome measures. The analyses were further stratified by age (≤ 5, 6-11 and 12-17 years).

SETTING

The National Survey of Children's Health (NSCH) from 2017 to 2020, a nationally representative sample of children and adolescents in the USA.

PARTICIPANTS

Parents/caregivers who reported on their children's experiences of PCE and food insecurity from the 2017-2020 NSCH (n 114 709).

RESULTS

Descriptively, 22·13 % of respondents reported mild food insecurity, while 3·45 % of respondents reported moderate to severe food insecurity. On multivariable Poisson regression analyses, there was a lower rate of PCE among children who experienced mild (incidence rate ratio (IRR) = 0·93; 95 % CI 0·92, 0·94) or moderate/severe food insecurity (IRR = 0·84; 95 % CI 0·83, 0·86) compared with those who were food secure. We found an inverse relationship between food insecurity and rate of PCE across all age categories.

CONCLUSIONS

Our study finding lends evidence to support that interventions, public health programmes, as well as public health policies that reduce food insecurity among children and adolescents may be associated with an increase in PCE. Longitudinal and intervention research are needed to examine the mechanistic relationship between food insecurity and PCE across the life course.

SNAP Participation and Medication Adherence Among Older Black Medicaid-Insured Individuals Living With Hypertension

BACKGROUND

Black people are more likely to be diagnosed with hypertension and to experience food insecurity and antihypertensive medication non-adherence compared to White people in the U.S. The Supplemental Nutrition Assistance Program (SNAP)-a means-tested program that targets food insecurity has been shown to affect health outcomes. This study analyzed the relationship between SNAP participation and antihypertensive medication adherence among older Black Medicaid-insured individuals.

METHODS

This is a retrospective cohort study using linked 2006-2014 state of Missouri Medicaid and SNAP administrative claims data. Analyses were restricted to older (≥60 years) Black individuals who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60 years with at least one pharmacy claim (n = 10,693). Our outcome measure is a dichotomous measure of antihypertensive medication adherence defined using the Proportion of Days Covered (≥80% PDC = 1). The exposure variables are four measures of SNAP participation.

RESULTS

A higher proportion of SNAP participants were adherent to their antihypertensive medications compared to non-SNAP participants (43.5% vs. 32.0%). On multivariable analyses, compared to non-SNAP participants there was an increased likelihood of antihypertensive medication adherence among SNAP participants (prevalence ratio [PR] = 1.25; 95% confidence interval [CI] = 1.16-1.35). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of antihypertensive medication adherence among those who were enrolled for 10-12 months (PR = 1.41; 95% CI = 1.08-1.85).

CONCLUSIONS

Medicaid-insured older Black adults who were SNAP participants had a higher likelihood of antihypertensive medication adherence compared to non-SNAP participants.

Supplemental Nutrition Assistance Program Participation and Medication Adherence Among Medicaid-Insured Older Adults Living with Hypertension

BACKGROUND

Food insecurity has been associated with medication non-adherence among individuals living with chronic diseases like hypertension. The relationship between Supplemental Nutrition Assistance Program (SNAP)-a public program that addresses food insecurity-and Medication adherence among older Medicaid-insured adults living with hypertension is not clear.

OBJECTIVE

To analyze the association between patterns of SNAP participation and adherence to antihypertensive medications among older Medicaid-insured individuals.

DESIGN

Retrospective study using linked 2006-2014 state of Missouri's Medicaid claims and Supplemental Nutrition Assistance Program data.

PARTICIPANTS

Older adults (≥ 60 years) who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60.

MAIN MEASURES

The outcome measure was medication adherence assessed using the proportion of days covered (PDC). The exposure measures were as follows: (1) receipt of SNAP benefits (no [0], yes [1]); (2) SNAP benefits receipt during the 12-month Medicaid continuous enrollment (no [0], yes [1]); (3) duration of SNAP participation during the 12-month continuous Medicaid enrollment; and (4) SNAP participation pattern.

KEY RESULTS

On multivariable analyses, there was a statistically significant association between ever participating in SNAP and medication adherence (β = 0.32; S.E. = 0.011). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of medication adherence among those who were enrolled for 10-12 months (β = 0.44, S.E. = 0.041).

CONCLUSIONS

Medicaid-insured older adults who are SNAP participants or enrolled in SNAP for 10-12 months of a 12-month Medicaid continuous enrollment period are more likely to be adherent to antihypertensive medication compared to non-SNAP participants or those enrolled for 1-3 months, respectively.

Churn in the older adult SNAP population

Using administrative records from Missouri, we investigate the characteristics of Supplemental Nutrition Assistance Program (SNAP) participants aged 60 and older who experience administrative churn. Among these adults, 1 in 4 experienced administrative churn, and 1 in 5 experienced more than one spell of churn. Risk of churn, frequency, duration of churn spells, and the value of foregone SNAP benefits varied with individual, household, and geographic characteristics, and was more common among non-whites, members of larger households, and those living in urban areas. Our findings suggest that a significant portion of older adults experience gaps in SNAP benefit receipt.

Resting-State Functional Connectivity Differences in College Students with and without Food Insecurity

We used functional magnetic resonance imaging (fMRI) to investigate cross-sectional differences in functional connectivity across cognitive networks at rest among age and sex matched college students with very low food security [food insecurity (FI); n = 20] and with high food security (n = 20). The participants completed the Behavior Rating Inventory of Executive Function-2 (BRIEF-2) and Adverse Childhood Experiences (ACEs) questionnaires. Seven-minute resting-state fMRI scans were collected. Independent Component Analysis assessed group connectivity differences in three large-scale networks: the default-mode network (DMN), the frontoparietal network (FPN), and the salience network (SN). FI was associated with poorer Global BRIEF scores (adjusted β = 8.36; 95% CI: 2.32, 14.40) and five BRIEF subscales: Inhibit, Initiate, Working Memory, Plan, and Organize (p-values < 0.05). The students with FI had greater functional connectivity between the FPN and left middle temporal gyrus (cluster size p-FWE = 0.029), the SN and precuneus (cluster size p-FWE < 0.001), and the SN and right middle frontal gyrus (cluster size p-FWE = 0.016) compared to the students with high food security. Exploratory correlations revealed that greater connectivity between the SN and right middle frontal gyrus was associated with poorer BRIEF Inhibit scores (p = 0.038), and greater connectivity between the FPN and left middle temporal gyrus was associated with poorer BRIEF Organize scores (p = 0.024) for the students with FI. Greater functional connectivity between the FPN, DMN, and SN at rest may contribute to executive function difficulties for college students with FI.

Utilization Gaps During the COVID-19 Pandemic: Racial and Ethnic Disparities in Telemedicine Uptake in Federally Qualified Health Center Clinics

BACKGROUND

The Coronavirus Aid, Relief, and Economic Security (CARES) Act led to the rapid implementation of telemedicine across healthcare office settings. This innovation has the potential to improve healthcare use and ensure continuity of care. However, this delivery model could have an unintended consequence of worsening racial/ethnic disparities in healthcare utilization if adoption varies across sub-populations.

OBJECTIVE

To examine associations between telemedicine use and race/ethnicity between 3/1/2020 and 11/30/2020, and the influence of other individual- and geographical-level factors on this relationship.

DESIGN

Cohort study PARTICIPANTS: EMR data from 55 clinics in a FQHC network MAIN MEASURES: The dependent variable was visit type (in-person vs. telemedicine). Predictors of interest were patient race and ethnicity. To account for repeated visits within each patient nested within clinic, a three-level, mixed-effects, multivariable, logistic regression model was used. Subgroup analyses examined correlates of telemedicine use in African American and Hispanic cohorts, separately.

KEY RESULTS

The analytic sample included 233,302 visits for 67,733 unique patients. African Americans (OR = 0.65, 95% CI: 0.61, 0.69), Asians (OR = 0.58, 95% CI: 0.52, 0.65), and American Indians / Alaska Natives and other Pacific Islanders (OR = 0.82, 95% CI: 0.70, 0.98) were significantly less likely to use telemedicine compared to Whites. Hispanics were also less likely to have a telemedicine visit (OR = 0.49, 95% CI: 0.47, 0.51) compared to non-Hispanics. Nonacute visits were more likely to be conducted via telemedicine. Distance to clinic exhibited a dose-response relationship such that patients who lived farthest from the clinics were most likely to have telemedicine visits. In the subgroup analyses to examine predictors of telemedicine use, the dose-response relationship between distance from clinic and telemedicine use persisted, with increasing distance associated with increasing likelihood of telemedicine use, in both African American and Hispanic cohorts. Nonacute visits were associated with telemedicine use in the Hispanic cohort, but not in the Black / African American cohort.

CONCLUSION

Racial/ethnic disparities in telemedicine use persisted among this cohort. However, telemedicine improved utilization for African Americans and Hispanics living farther away from the clinic.

Hypertension, Diabetes and Medication Adherence among the Older Supplemental Nutritional Assistance Program Population

The burdens of chronic diseases such as hypertension and diabetes for older Americans are profound. Yet, data on the population-level prevalence of hypertension and diabetes among the older adult Supplemental Nutritional Assistance Program (SNAP) population and the associated level of medication adherence is lacking despite evidence of the "treat or eat" trade-off in the general population. We used linked administrative data from SNAP and Medicaid between 2006 and 2014 in the state of Missouri to document rates of hypertension or diabetes diagnoses and medication adherence. About 69% of the study sample were found to be diagnosed with a hypertension and 40% with diabetes. Approximately 1 in 4 of those living with hypertension and 1 and 3 of those living with diabetes were nonadherent to antihypertensive or antidiabetic medications each year, on average. Furthermore, medication non-adherence increases with age and is more common among non-White and urban residents.

Black-White racial disparities in health care utilization and self-reported health among cancer survivors: The role of food insecurity

BACKGROUND

Non-Hispanic Blacks continue to have worse cancer outcomes than non-Hispanic Whites. Suboptimal health care utilization and poor self-reported health among non-Hispanic Blacks contribute to these disparities. The relationship between race, food security status (FSS), and health care utilization or self-reported health among cancer survivors is not clear. This study aims to fill this gap in the science.

METHODS

The 2011-2018 National Health Interview Survey data were used. Bivariate and multivariable logistic regression analyses were used to examine the relationship between race (non-Hispanic Whites or non-Hispanic Blacks), FSS (high, marginal, low, or very low), health care utilization, and self-reported health among cancer survivors. Analyzed health care utilization measures included cost-related medication underuse (CRMU), cost-related delayed care, cost-related forgone care, seeing/talking to a medical specialist, seeing/talking to a general doctor, and overnight hospital stay.

RESULTS

A higher proportion of Blacks reported very low food security in comparison with Whites (10.58% vs 4.24%; P ≤ .0001). Blacks were significantly less likely to report a medical specialist visit and more likely to report fair/poor health in the past 12 months even after adjustments for FSS. There was a dose-response relationship between FSS and CRMU, cost-related delayed care, cost-related forgone care, overnight hospital stay, and self-reported health status for both Whites and Blacks.

CONCLUSIONS

Significant disparities in health care utilization and self-reported health across race and FSS persist among cancer survivors. Interventions that target food insecurity have the potential to reduce suboptimal health care utilization and self-reported health among cancer survivors.

Food Insecurity is Related to Disordered Eating Behaviors Among College Students

OBJECTIVE

To determine the association between food insecurity and disordered eating behaviors (DEBs) in undergraduate college students.

METHODS

Cross-sectional data of college students (n = 533) were collected from February to April 2020. Food security was measured with the US Department of Agriculture's Adult Food Security Survey Module. Disordered eating behaviors were measured with the Eating Disorder Examination Questionnaire. Associations were examined statistically with Pearson chi-square tests of independence and general linear regression models.

RESULTS

Across all food security ranges, linear trends detailed significant associations between food insecurity and global DEBs (β = 0.17; P < 0.001), eating concern (β = 0.27; P < 0.001), shape concern (β = 0.17; P = 0.001), and weight concern (β = 0.21; P < 0.001), but not restraint (β = 0.10; P = 0.08).

CONCLUSIONS AND IMPLICATIONS

Food insecurity was consistently related to DEBs. Future research may consider longitudinally examining this relationship, as food insecurity and DEBs may be associated with worse health outcomes among vulnerable college students.

Is There a Relationship between County-Level Food Insecurity Rates and Breast Cancer Stage at Diagnosis?

The relationship between county food insecurity (FI) rate and breast cancer stage at diagnosis is not clear. Using 2010-2016 Surveillance Epidemiology and End Results (SEER) and Feeding America data we analyzed the association between county FI rate in quartiles (low, medium, high, very high) and breast cancer stage at diagnosis among adult females (≥18 years). We also analyzed the effect of insurance status and county poverty level on this relationship, and whether this relationship varies among non-elderly (<65 years) and elderly (≥ 65 years) individuals. Bivariate and multivariable multilevel logistic regression were used for analyses. Bivariate analysis showed increased likelihood of late-stage breast cancer with increasing county FI rate. This relationship persisted after adjusting for insurance status but was no longer significant after adjusting for county-level poverty rate. There was a statistically significant association between counties with very high food insecurity rates and late-stage breast cancer diagnosis (OR = 1.07; 95% CI = 1.00, 1.14) among the elderly population. Very high county food insecurity rate was associated with late-stage breast cancer among elderly women. Population-level interventions focused on counties with very high food insecurity rates could reduce disparities in stage at breast cancer diagnosis among elderly women.

Racial and Ethnic Disparities in Health Information Technology Use and Associated Trends among Individuals Living with Chronic Diseases

Health information technology (HIT) can enhance optimal health care access and utilization among individuals living with chronic diseases. This study aimed to provide population-level information on racial/ethnic disparities in HIT use and associated trends among those living with chronic diseases. The study sample consisted of adult respondents (≥18 years) of the 2011-2018 National Health Interview Survey living with at least 1 chronic condition. Binomial regression was used to analyze the association between race/ethnicity, year, and 4 measures of HIT use for patient-provider interaction. Regression parameter estimates were used to predict the trends in probability of the outcome variables across race/ethnicity. About 73% of the study sample were non-Hispanic Whites, 15% were non-Hispanic Blacks, and 13% were Hispanics. Compared to non-Hispanic Whites, there were decreased adjusted odds of any HIT use among non-Hispanic Blacks (OR = 0.72; 95% CI = 0.67, 0.76) and Hispanics (OR = 0.78; 95% CI = 0.72, 0.84). The likelihood of any HIT use increased with increasing year (OR: 1.16; 95% CI = 1.15, 1.18). Trends in racial/ethnic disparities were wider for email communication with provider and online prescription refill compared to online scheduling of appointment. The COVID-19 pandemic has led to accelerated adoption or expansion of HIT for patient care. Limited HIT use among non-Hispanic Blacks and Hispanics could worsen the disproportionate chronic disease burden, suboptimal clinical outcomes, and preventable health care costs experienced by this subpopulation. In conclusion, there is a need for intentional and strategic population-level interventions to increase HIT adoption and use among non-Hispanic Blacks and Hispanics living with chronic diseases.

County-Level Determinants of COVID-19 Testing and Cases: Are there Racial/Ethnic Disparities in Texas?

Reports suggest that COVID-19 affects people of color disproportionately. Texas ranks second in the count of confirmed US cases. This study examined the relationship between county-level racial/ethnic composition and COVID-19 testing/cases in Texas, adjusting for population-level demographic characteristics, health factors, and health care access measures. County-level testing and case data, obtained from the Texas Department of State Health Services, were combined with the 2020 Robert Wood Johnson Foundation County Health Rankings data. Outcome variables were tests per 100,000 population and cases per 100,000 population. The independent variable of interest was percent of racial and ethnic composition. Multivariable linear regression analyses were used. There was a statistically significant increase in COVID-19 testing/100,000 population with every 1% increase in the proportion of African Americans/Blacks (β = 2065.4; P = 0.009), Asians (β = 2056.2; P = 0.015), and Hispanics (β = 1641.1; P = 764.7). After controlling for county characteristics and cases/100,000 population, these relationships were no longer significant. However, primary care physician rate was significantly associated with testing/100,000 population (β = 64.0; P = 0.027), as was the percent of uninsured (β = -469.9; P = 0.024). An analysis of case data showed that African Americans had the largest number of cases/100,000 (β = 432.2; P = 0.001), followed by Hispanics (β = 422.8; P < 0.001) and Asians (β = 415.4; P = 0.004). As in other parts of the United States, African Americans and Hispanics are most affected by COVID-19 in Texas. Community-based strategies to improve access to testing or reduce community spread outside clinical settings should target counties with low primary care physician rates or a high proportion of uninsured residents.

Factors Associated with COVID-Related Mortality: the Case of Texas

Background

Texas ranks 2nd in the count of COVID cases. Pre-existing disparities in healthcare may be intersecting with COVID-19 outcomes.

Objectives

To explore the relationship between county-level race/ethnic composition and COVID-19 mortality in the state of Texas and determine whether county-level health factors, healthcare access measures, and other demographic characteristics explain this relationship.

Methods

This retrospective study uses county-level case and fatality data obtained from the Texas Department of State Health Services and merged with the 2020 Robert Wood Johnson foundation (RWJF) county health rankings data. The outcome variables were fatalities per 100,000 population. A two-part/hurdle model examined (1) the probability of having a COVID-19 fatality and (2) fatalities per 100,000 population in counties with 1+ fatalities. For both parts of the hurdle model, we examined the impacts of racial and ethnic composition, adjusting for county characteristics and health factors.

Results

The odds of having a COVID-19 fatality decreased with a unit increase in the rate of primary care physicians in a county (OR = 0.93; 95% CI = 0.89, 0.99). In the second part of the model, there was a statistically significant increase in COVID-19 fatalities/100,000 population with every 1 % increase in the proportion of Hispanics (β = 5.41; p = 0.03) and African Americans (β = 5.08; p value = 0.04).

Conclusion

Counties with higher rates of minorities, specifically Hispanics and African Americans, have a higher COVID-19 fatality burden. Targeted interventions are needed to raise awareness of preventive measures in these communities.

Impact of Medicaid Expansion on Healthcare Access Among Individuals Living With Chronic Diseases

INTRODUCTION

The Affordable Care Act's Medicaid expansion has been found to increase healthcare access among low-income individuals in the general population. Fewer studies have explored the impact of Medicaid expansion on healthcare access among those living with chronic diseases. It is also unclear whether the impact of Medicaid expansion varies across levels of educational attainment or poverty among this subgroup. This study investigates the impact of Medicaid expansion on healthcare access among adults aged 18-64 years living with chronic diseases, as well as its variations across educational attainment and federal poverty levels.

METHODS

The 2011-2017 Behavioral Risk Factor Surveillance System data were used. Difference-in-difference analyses explored the impact of Medicaid expansion on healthcare access (health insurance coverage, routine checkup, having a personal doctor, and cost-related delayed care within the past 1 year) among individuals living with chronic diseases. Analyses were also stratified by levels of educational attainment and quartiles of the federal poverty level. Data were analyzed between February and November 2019.

RESULTS

Medicaid expansion was associated with increased health insurance coverage (β=0.27, 95% CI=0.16, 0.38), increased likelihood of having a routine checkup (β=0.12, 95% CI=0.04, 0.22) within the past 1 year, increased likelihood of having a personal doctor (β=0.08, 95% CI=0.01, 0.12), and decreased likelihood of reporting cost-related delayed care (β=-0.10, 95% CI=-0.19, -0.02). Medicaid expansion was associated with increased health insurance coverage across all levels of educational attainment and federal poverty level quartiles.

CONCLUSIONS

Medicaid expansion increased healthcare access for low-income individuals living with chronic diseases.

Supplemental Nutrition Assistance Program size and timing and hypertension-related emergency department claims among Medicaid enrollees

The Supplemental Nutrition Assistance Program (SNAP) is a public policy program that aims to reduce food insecurity-a social determinant of health that has been associated with suboptimal blood pressure control in the United States. The aim of the article was to explore the association between SNAP benefit timing and size and probability of hypertension-related emergency department (ED) claims. This study used the SNAP data from the Missouri's Department of Social Services for January 2010 to December 2013 linked to Medicaid ED claims data. The dependent variable was probability of hypertension-related and hypertensive emergency ED claims. The independent variables of interest were week of calendar and SNAP benefit months and SNAP benefit amount. Probit regression analyses were conducted. Average marginal effects are reported.In a sample of 6,013,951 Medicaid-insured SNAP beneficiaries, 11,709 hypertension-related claims were submitted for every 100,000 claims. The average marginal effect of SNAP benefit amount on hypertension-related ED claims was -0.0000638 (P < .001); thus, a $100 increase in SNAP benefits will reduce hypertension-related claims by 638 claims per 100,000 claim. The reduction in ED claims was higher for lower SNAP benefit amounts than at higher SNAP benefit amounts. There was no statistically significant association between week of calendar month in which SNAP benefit was received and probability of hypertension-related ED claims. Higher SNAP benefit amount was associated with a decreased probability of hypertension-related ED claims. The impact of an additional dollar of SNAP benefits was larger at lower SNAP benefit amounts.

Determinants of HPV vaccine awareness and healthcare providers' discussion of HPV vaccine among females

Two human papillomavirus (HPV) vaccines are available and can prevent 98% of HPV 16 and 18 infections. This study aimed to explore determinants of 1) HPV vaccine awareness among a cohort of low-income women participating in a cancer prevention program in Central Texas and compare them to United States residents; 2) determinants of healthcare providers' discussion of HPV vaccine among female residents of the United States.

Bivariate and multivariable analysis of HPV vaccine awareness using survey data (n = 359) collected between 2014 and 2016 in Central Texas, and the Health Information and Nutrition Survey (HINTS) data which is a nationally representative dataset (unweighted n = 1214) collected in 2013 were conducted. Bivariate and multivariable regression analyses of healthcare providers' discussion of the HPV vaccine using the HINTS survey data were also conducted.

Compared to non-Hispanic Whites, there was a decreased likelihood of HPV vaccine awareness among non-Hispanic Blacks (OR = 0.50; 95% CI = 0.28–0.90) and Hispanics (OR = 0.55; 95% CI = 0.30–0.99) in the grant funded program, as well as non-Hispanic Blacks (OR = 0.28; 95% CI = 0.14–0.58) and Hispanics (OR = 0.22; 95% CI = 0.12–0.41) in the HINTS data. There was also a decreased likelihood of healthcare providers discussing the HPV vaccine with respondents who were 35–49 years (OR = 0.50; 95% CI = 0.30–0.84), 50–64 years (OR = 0.26; 95% CI = 0.14–0.49) or ≥ 65 years compared to those who were 18–34 years among the HINTS data respondents.

Interventions to increase HPV awareness among non-Hispanic Blacks and Hispanics, as well as encourage healthcare providers' discussion of the HPV vaccination during patient encounters regardless of the patient's age are needed.

•

African Americans and Hispanics were less likely to be aware of the HPV vaccine.

•

Residence was not associated with HPV vaccine awareness.

•

Age was associated with healthcare providers' discussion of HPV vaccine.

The role of health literacy and communication habits on previous colorectal cancer screening among low-income and uninsured patients

Objective

To determine the association between health literacy, communication habits and colorectal cancer (CRC) screening among low-income patients.

Methods

Survey responses of patients who received financial assistance for colonoscopy between 2011 and 2014 at a family medicine residency clinic were analyzed using multivariate logistic regression (n = 456). There were two dependent variables: (1) previous CRC screening and (2) CRC screening adherence. Our independent variables of interest were health literacy and communication habits.

Results

Over two-thirds (67.13%) of respondents had not been previously screened for CRC. Multivariate analysis showed a decreased likelihood of previous CRC screening among those who had marginal (OR = 0.52; 95% CI = 0.29–0.92) or inadequate health literacy (OR = 0.49; 95% CI = 0.27–0.87) compared to those with adequate health literacy. Controlling for health literacy, the significant association between educational attainment and previous CRC screening was eliminated. Thus, health literacy mediated the relationship between educational attainment and previous CRC screening. There was no significant association between communication habits and previous CRC screening. There was no significant association between screening guideline adherence, and health literacy or communication.

Conclusion

Limited health literacy is a potential barrier to CRC screening. Suboptimal CRC screening rates reported among those with lower educational attainment may be mediated by limited health literacy.

•

Lower educational attainment was associated with no prior colorectal cancer (CRC) screening.

•

Inadequate health literacy was associated with not having a prior CRC screening.

•

Health literacy eliminated the association between education and previous CRC screening.

•

Health literacy level had no association with adhering to CRC screening guidelines.

•

Patients' communication habits had no association with prior colorectal cancer screening.

Predictors of Colorectal Cancer Screening: Does Rurality Play a Role?

PURPOSE

The purpose of this study was to explore the associations between sociodemographic factors such as residence, health care access, and colorectal cancer (CRC) screening among residents of Texas.

METHODS

Using the 2012 Behavioral Risk Factor Surveillance Survey, we performed logistic regression analyses to determine predictors of CRC screening among Texas residents, including rural versus urban differences. Our outcomes of interest were previous (1) CRC screening using any CRC test, (2) fecal occult blood test (FOBT), or (3) endoscopy, as well as up-to-date screening using (4) any CRC test, (5) FOBT, or (6) endoscopy. The independent variable of interest was rural versus urban residence; we controlled for other sociodemographic and health care access variables such as lack of health insurance.

RESULTS

Multivariate analysis showed that individuals who were residents of a rural/non-Metropolitan Statistical Area (MSA) location (OR = 0.70, 95% CI = 0.51-0.97) or a suburban county (OR = 0.61, 95% CI = 0.39-0.95) were less likely to report ever having any CRC screening compared to residents of a center city of an MSA. Residents of a rural/non-MSA location were less likely (OR = 0.49, 95% CI = 0.28-0.87) than residents of a center city of an MSA to be up-to-date using FOBT. There was decreased likelihood of ever being screened for CRC among the uninsured (OR = 0.43, 95% CI = 0.31-0.59).

CONCLUSIONS

Effective development and implementation of strategies to improve screening rates should aim at improving access to health care, taking into account demographic characteristics such as rural versus urban residence.