Multilevel small area estimation for county-level prevalence of colorectal cancer screening test use in the United States using 2018 data

PURPOSE-

National screening estimates mask county-level variations. We aimed to generate county-level colorectal cancer (CRC) screening prevalence estimates for 2018 among adults aged 50-75 years and identify counties with low screening prevalence.

METHODS-

We combined individual-level county data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 204,947) with the 2018 American Community Survey county poverty data as a covariate, and the 2018 U.S. Census county population count data to generate county-level prevalence estimates for being current with any CRC screening test, colonoscopy, and home stool blood test. Because BRFSS is a state-based survey, and because some counties did not have samples for analysis, we used correlation coefficients to test internal consistency between model-based and BRFSS state estimates.

RESULTS-

Correlation coefficients tests were ≥0.97. Model-based national prevalence for any test was 69.9% (95% CI, 69.5% -70.4%) suggesting 30% are not current with screening test use. State mean estimates ranged from 62.1% in Alaska and Wyoming to 76.6% in Maine and Massachusetts. County mean estimates ranged from 42.2% in Alaska to 80.0% in Florida and Rhode Island. Most tests were performed with colonoscopy.

CONCLUSIONS-

Estimates across all U.S. counties showed large variations. Estimates may be informative for planning by states and local screening programs.

Is computed tomographic pulmonary angiography justified in all patients with suspected pulmonary embolism – tertiary multidisciplinary hospital perspective

Background

According to 2019 ESC guidelines for management in patients with the pulmonary embolism (PE), the computed tomographic pulmonary angiography (CTPA) is the diagnostic method of choice in suspected high-risk PE defined as patients with hemodynamic instability. In stable cases, it is recommended to assess the pre-test probability of the PE. However, CTPA with its great accuracy and wide availability in most medical centers is used as often to confirm as to exclude the diagnosis in PE suspected patients, despite the fact that it is linked with the risk of radiation and iodine-containing contrast exposure.

Purpose

The aim of the study was to assess the validity of CTPA use in patients with suspected PE form the perspective of multidisciplinary clinical center.

Methods

We retrospectively analyzed the data of from 52,474 hospitalized patients between 01.2018 and 12.2019. A total of 261 (0.5%) consecutive patients with suspected PE (in the emergency department or during hospitalization) were included into the study. Due to suspicion of PE all patients underwent the CTPA. In this group, we analyzed all available clinical data, results of laboratory and diagnostic tests (before and after CTPA) including estimated glomerular filtration rate (eGFR), creatinine level, transthoracic echocardiography (TTE) and planar ventilation/perfusion (lung scintigraphy) scan (V/Q SPECT) if performed.

Results

The CTPA confirmed PE in 28.9% of patients. The most common final diagnoses, established in the group with negative CTPA result, include heart failure (33.9%), pneumonia (14.4%) exacerbation of chronic obstructive pulmonary disease or asthma (9.3%) and acute coronary syndrome (5.9%). Acute PE was the cause of in-hospital death in 2.4% of patients and the rate of all cause in-hospital death was 11.4%.

In 54.2% of patients we observed the eGFR decline and creatinine level increase, meeting the criteria of the acute contrast-induced nephropathy in 33 of them of them (19.8%). In the group with excluded PE, mean eGFR before CTPA was 70.9ml/min/1.73m2 with the decline to mean 60.4ml/min/1.73m2 during the hospitalization (p<0.01). In patients with negative CTPA result and the worsening of the renal function mean eGFR decline was 17.8ml/min/1.73m2 (p<0.01) and mean creatinine level increase was 38.6μmol/l (p<0.01).

CONSLUSIONS

The initial data collected show the overuse of CTPA in suspected PE, as the diagnosis was confirmed in less than one-third of them. Although CTPA allows to exclude or confirm PE unambiguously, its use is associated with risk of acute contrast-induced nephropathy. Additionally, in patients with exacerbation of heart failure established as final diagnosis after excluding PE, intensive diuretic treatment is crucial and may cause further accompanying renal function worsening.

Therefore, optimizing the diagnostic pathway in patients with suspected PE into less aggravating procedures such as TTE or V/Q SPECT is justifiable.

Funding Acknowledgement

Type of funding source: None

Multilevel Small-Area Estimation of Colorectal Cancer Screening in the United States

Background: The U.S. Preventive Services Task Force recommends routine screening for colorectal cancer for adults ages 50 to 75 years. We generated small-area estimates for being current with colorectal cancer screening to examine sociogeographic differences among states and counties. To our knowledge, nationwide county-level estimates for colorectal cancer screening are rarely presented.Methods: We used county data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS; n = 251,360 adults), linked it to the American Community Survey poverty data, and fitted multilevel logistic regression models. We post-stratified the data with the U.S. Census population data to run Monte Carlo simulations. We generated county-level screening prevalence estimates nationally and by race/ethnicity, mapped the estimates, and aggregated them into state and national estimates. We evaluated internal consistency of our modeled state-specific estimates with BRFSS direct state estimates using Spearman correlation coefficients.Results: Correlation coefficients were ≥0.95, indicating high internal consistency. We observed substantial variations in current colorectal cancer screening estimates among the states and counties within states. State mean estimates ranged from 58.92% in Wyoming to 75.03% in Massachusetts. County mean estimates ranged from 40.11% in Alaska to 79.76% in Florida. Larger county variations were observed in various race/ethnicity groups.Conclusions: State estimates mask county variations. However, both state and county estimates indicate that the country is far behind the "80% by 2018" target.Impact: County-modeled estimates help identify variation in colorectal cancer screening prevalence in the United States and guide education and enhanced screening efforts in areas of need, including areas without BRFSS direct-estimates. Cancer Epidemiol Biomarkers Prev; 27(3); 245-53. ©2018 AACR.

Recommendations From the International Colorectal Cancer Screening Network on the Evaluation of the Cost of Screening Programs

Worldwide, colorectal cancer is the fourth leading cause of death from cancer and the incidence is projected to increase. Many countries are exploring the introduction of organized screening programs, but there is limited information on the resources required and guidance for cost-effective implementation. To facilitate the generating of the economics evidence base for program implementation, we collected and analyzed detailed program cost data from 5 European members of the International Colorectal Cancer Screening Network. The cost per person screened estimates, often used to compare across programs as an overall measure, varied significantly across the programs. In addition, there were substantial differences in the programmatic and clinical cost incurred, even when the same type of screening test was used. Based on these findings, several recommendations are provided to enhance the underlying methodology and validity of the comparative economic assessments. The recommendations include the need for detailed activity-based cost information, the use of a comprehensive set of effectiveness measures to adequately capture differences between programs, and the incorporation of data from multiple programs in cost-effectiveness models to increase generalizability. Economic evaluation of real-world colorectal cancer-screening programs is essential to derive valuable insights to improve program operations and ensure optimal use of available resources.

European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

Abstract A97: Quality assessment of colonoscopy reporting: Results from a statewide cancer screening program

Objectives: Appropriate documentation of the colonoscopy procedure is an important component of patient care and one measure of quality. However, direct evaluation of colonoscopy reporting has been minimal. The aim of this study was to assess the quality of colonoscopy reporting.

Methods: We retrospectively collected data from 110 colonoscopy reports, where at least one polyp was noted. These reports were completed by 110 endoscopists from 2005-2006 through a statewide colorectal cancer screening program in Maryland, representing a variety of reporting formats from endoscopists throughout the state. We evaluated 25 key data elements recommended by the Standardized Colonoscopy Reporting and Data System (CO-RADS), including procedure indications, risk and comorbidity assessments, procedure technical descriptions, colonoscopy findings, and specimen retrieval and submission for pathology.

Results: All 110 reports stated an indication for the endoscopy, 36% included patient's medical comorbidities, 73% documented the bowel preparation quality, and 82% documented specific cecal landmarks. For the 177 individual polyps identified, information on size and morphology was documented for 87% and 53%, respectively. For these key data elements, ambiguous descriptors were sometimes used.

Conclusions: There was considerable variation among these colonoscopy reports. The absence of key data elements may impact the ability to make recommendations for recall intervals for colorectal cancer screening. Measurement of quality indicators in colonoscopy practice can identify areas for quality improvement.

Citation Information: Cancer Prev Res 2010;3(12 Suppl):A97.

Assessment of the quality of colonoscopy reports: results from a multicenter consortium

BACKGROUND

To improve colonoscopy quality, reports must include key quality indicators that can be monitored.

OBJECTIVE

To determine the quality of colonoscopy reports in diverse practice settings.

SETTING

The consortium of the Clinical Outcomes Research Initiative, which includes 73 U.S. gastroenterology practice sites that use a structured computerized endoscopy report generator, which includes fields for specific quality indicators.

DESIGN

Prospective data collection from 2004 to 2006.

MAIN OUTCOMES MEASUREMENTS

Reports were queried to determine if specific quality indicators were recorded. Specific end points, including quality of bowel preparation, cecal intubation rate, and detection of polyp(s) >9 mm in screening examinations were compared for 53 practices with more than 100 colonoscopy procedures per year.

RESULTS

Of the 438,521 reports received during the study period, 13.9% did not include bowel-preparation quality and 10.1% did not include comorbidity classification. The overall cecal intubation rate was 96.3%, but cecal landmarks were not recorded in 14% of the reports. Missing polyp descriptors included polyp size (4.9%) and morphology (14.7%). Reporting interventions for adverse events during the procedure varied from 0% to 6.5%. Among average-risk patients who received screening examinations, the detection rate of polyps >9 mm, adjusted for age, sex, and race, was between 4% and 10% in 81% of practices.

LIMITATION

Bias toward high rates of reporting because of the standard use of a computerized report generator.

CONCLUSIONS

There is significant variation in the quality of colonoscopy reports across diverse practices, despite the use of a computerized report generator. Measurement of quality indicators in clinical practice can identify areas for quality improvement.

Development of a federally funded demonstration colorectal cancer screening program

Colorectal cancer is the second leading cause of cancer-related mortality among U.S. adults. In 2004, treatment costs for colorectal cancer were $8.4 billion. There is substantial evidence that colorectal cancer incidence and mortality are reduced with regular screening. The natural history of this disease is also well described: most colorectal cancers develop slowly from preexisting polyps. This slow development provides an opportunity to intervene with screening tests, which can either prevent colorectal cancer through the removal of polyps or detect it at an early stage. However, much less is known about how best to implement an effective colorectal cancer screening program. Screening rates are low, and uninsured persons, low-income persons, and persons who have not visited a physician within a year are least likely to be screened. Although the Centers for Disease Control and Prevention (CDC) has 15 years of experience supporting the National Breast and Cervical Cancer Early Detection Program for the underserved population, a similar national program for colorectal cancer is not in place. To explore the feasibility of implementing a national program for the underserved U.S. population and to learn which settings and which program models are most viable and cost-effective, CDC began a 3-year colorectal cancer screening demonstration program in 2005. This article describes briefly this demonstration program and the process CDC used to design it and to select program sites. The multiple-methods evaluation now under way to assess the program's feasibility and describe key outcomes is also detailed. Evaluation results will be used to inform future activities related to organized screening for colorectal cancer.

Cost of starting colorectal cancer screening programs: results from five federally funded demonstration programs

INTRODUCTION

In 2005, the Centers for Disease Control and Prevention (CDC) started a 3-year colorectal cancer screening demonstration project and funded five programs to explore the feasibility of a colorectal cancer program for the underserved U.S. population. CDC is evaluating the five programs to estimate implementation cost, identify best practices, and determine the most cost-effective approach. The objectives are to calculate start-up costs and estimate funding requirements for widespread implementation of colorectal cancer screening programs.

METHODS

An instrument was developed to collect data on resource use and related costs. Costs were estimated for start-up activities, including program management, database development, creation of partnerships, public education and outreach, quality assurance and professional development, and patient support. Monetary value of in-kind contributions to start-up programs was also estimated.

RESULTS

Start-up time ranged from 9 to 11 months for the five programs; costs ranged from $60,602 to $337,715. CDC funding and in-kind contributions were key resources for the program start-up activities. The budget category with the largest expenditure was labor, which on average accounted for 67% of start-up costs. The largest cost categories by activities were management (28%), database development (17%), administrative (17%), and quality assurance (12%). Other significant expenditures included public education and outreach (9%) and patient support (8%).

CONCLUSION

To our knowledge, no previous reports detail the costs to begin a colorectal cancer screening program for the underserved population. Start-up costs were significant, an important consideration in planning and budgeting. In-kind contributions were also critical in overall program funding. Start-up costs varied by the infrastructure available and the unique design of programs. These findings can inform development of organized colorectal cancer programs.

Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable

BACKGROUND

Standardized reporting systems for diagnostic and screening tests facilitate quality improvement programs and clear communication among health care providers. Although colonoscopy is commonly used for screening, diagnosis, and therapy, no standardized reporting system for this procedure currently exists. The Quality Assurance Task Group of the National Colorectal Cancer Roundtable developed a reporting and data system for colonoscopy based on continuous quality improvement indicators.

DESIGN

The Task Group systematically reviewed quality indicators recommended by the Multi-Society Task Force on Colorectal Cancer and developed consensus-based terminology for reporting and data systems to capture these data elements. The Task Group included experts in several disciplines: gastroenterology, primary care, diagnostic imaging, and health care delivery.

RESULTS AND CONCLUSIONS

The standardized colonoscopy reporting and data system provides a tool that can be used for efforts in continuous quality improvement within and across practices that use colonoscopy.

Associations of subsite-specific colorectal cancer incidence rates and stage of disease at diagnosis with county-level poverty, by race and sex

BACKGROUND

This study examined associations of subsite-specific colorectal cancer incidence rates and stage of the disease with county-level poverty.

METHODS

The 1998-2001 colorectal cancer incidence data, covering 75% of the United States population, were from 38 states and metropolitan areas. The county-level poverty data were categorized into 3 groups according to the percentage of the population below the poverty level in 1999: <10% (low-poverty), 10%-19% (middle-poverty), and >or=20% (high-poverty). Age-adjusted subsite-specific incidence rates (for all ages) and stage-specific incidence rates (for ages >or=50) were examined by race (whites and blacks), sex, and the county's poverty level. The differences in the incidence rates were examined using the 2-tailed z-statistic.

RESULTS

The incidence rates of proximal colon cancer were higher among white males (11% higher) and white females (15% higher) in the low-poverty than in the high-poverty counties. No differences across county poverty levels were observed among whites for distal colon and rectal cancers or among blacks for all the subsites. The late-to-early stage incidence rate ratios were higher in the high-poverty than in the low-poverty counties among white and black males for distal colon and rectal cancers, among white females for distal colon cancer, and among black females for rectal cancer. For proximal colon cancer, however, the late-to-early stage rate ratios were similar across all county poverty levels.

CONCLUSIONS

Higher incidence rates of proximal cancer were observed among white males and females in the low-poverty counties relative to the high-poverty counties. The higher late-to-early stage rate ratios in high-poverty than in low-poverty counties is observed for distal colon and rectal cancers, but not for proximal colon cancer.

Socioeconomic differences in cancer screening participation: comparing cognitive and psychosocial explanations

This paper compares psychosocial and cognitive models of socioeconomic variation in participation in screening for colorectal cancer. The psychosocial model suggests that factors such as higher stress and lower social support explain, in part, why people from lower socioeconomic status (SES) environments are less likely to participate in screening. The cognitive model suggests that beliefs about cancer risk and screening will play an important part in differential participation. In practice both sets of factors may contribute to explaining socioeconomic differentials. The data for these analyses are drawn from a randomised controlled trial of colorectal cancer screening (the UK Flexible Sigmoidoscopy Trial). The participants are from the Scottish centre, where recruitment was stratified to generate a socioeconomically diverse sample. The dependent variable was interest in attending screening. A questionnaire covering demographic status, psychosocial and cognitive factors as well as interest in screening was sent to 10,650 adults. The results showed the predicted SES gradient in interest. There were also SES differences in both psychosocial and cognitive variables. A series of logistic regression models were used to test potential mediators of the association between SES and interest in attending screening by successively including psychosocial factors, cognitive factors, and then both, in the equation. Only the inclusion of the cognitive variables significantly reduced the variation associated with SES, providing better support for the cognitive than the psychosocial model.

Testing for prostate and colorectal cancer: comparison of self-report and medical record audit

BACKGROUND

Self-reported data are often used to determine cancer screening test utilization, but self-report may be inaccurate.

METHODS

We interviewed members of three health maintenance organizations and reviewed their medical records for information on digital rectal exam (DRE), prostate-specific antigen (PSA) test, fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy (response rate 65%). We calculated the sensitivity, specificity, concordance, and kappa statistic to compare the two sources for black men (n = 363), white and other men (n = 847), and women (n = 920) by study location.

RESULTS

For DRE, FOBT, sigmoidoscopy, and colonoscopy, testing rates determined by self-report were higher than those in medical records. Kappa statistics showed fair to good agreement (0.40-0.80) for PSA, sigmoidoscopy, and colonoscopy among most subgroups. For DRE and FOBT, the agreement was poor except among participants from one HMO. Sensitivity was > or = 80% for sigmoidoscopy among most subgroups, and > or = 85% for endoscopy (sigmoidoscopy and colonoscopy), >75% for DRE, and > or = 63% for PSA among all subgroups. Specificity exceeded 80% for FOBT and colonoscopy among all subgroups. Agreement was lower among older age groups. For all tests, agreement was poor between the reasons for testing.

CONCLUSION

Overreporting for some cancer tests should be considered when using self-reported data to evaluate progress towards reaching national goals for prevention behaviors.

Acceptance of flexible sigmoidoscopy screening for colorectal cancer

This study was conducted in the Kaiser Permanente Medical Care Program of Northern California to identify patient characteristics that explain interest in flexible sigmoidoscopy (FS) screening. A mailed screening invitation to 6837 age-eligible patients elicited responses from 49%. Efforts to reach and interview both eligible respondents and non-respondents resulted in 2728 computer-assisted telephone interviews (CATI), with 60% indicating interest in FS screening. Five components of the Integrated Behavioral Model were measured with respect to FS screening: attitude, affect, social influence, facilitators/barriers, and perceived risk of colorectal cancer. All five model components were significantly and independently associated with interest in FS, with patient attitude being the strongest predictor. Of the 32 items comprising the model components, nine items having the highest correlations with FS interest were identified as potentially important issues to address by efforts to increase interest in screening. Six of these were attitudinal beliefs. The findings from this theory-driven study provide specific targets for the design of interventions to increase FS interest and screening rates.

Socioeconomic variation in participation in colorectal cancer screening

OBJECTIVES

To investigate socioeconomic variation in participation in flexible sigmoidoscopy (FS) screening for colorectal cancer.

DESIGN

A prospective study nested within a multicentre randomised controlled trial of the efficacy of FS screening for the prevention and early detection of colorectal cancer (the UK flexible sigmoidoscopy trial).

SETTING

Glasgow, Scotland.

PARTICIPANTS

55-64 year old adults, registered with general practitioners participating in the FS trial.

MAIN OUTCOME MEASURES

Screening participation measured at three levels: questionnaire return; interest in screening; attendance at screening.

RESULTS

Socioeconomic deprivation was a strong predictor of participation. Return of the screening questionnaire, expression of interest in screening, and attendance at the test, were all lower in more deprived groups.

CONCLUSIONS

These results highlight the need to consider ways to reduce inequalities in screening uptake, in parallel with the introduction of any new screening programmes, to avoid exacerbating social gradients in cancer mortality.

A national survey of primary care physicians' colorectal cancer screening recommendations and practices

BACKGROUND

National data on providers' colorectal cancer (CRC) screening knowledge, attitudes, and practices are sparse. This study assessed primary care physicians' (PCPs') beliefs about the effectiveness of CRC screening, their recommendations for screening, their perceptions of the influence of published guidelines on their CRC screening recommendations, and how they conduct CRC screening in their clinical practices.

METHODS

A questionnaire was administered to a nationally representative sample of practicing PCPs. Of 1718 eligible physicians, 1235 (72%) responded.

RESULTS

Only 2% of PCPs said they did not recommend CRC screening. Over 80% indicated that they most often recommend CRC screening with fecal occult blood testing and/or flexible sigmoidoscopy, although colonoscopy was perceived as the more effective screening modality. Nearly two-thirds of obstetrician/gynecologists and one-fourth of other practitioners reported conducting fecal occult blood testing exclusively by digital rectal exam. Only 29% of PCPs said they perform sigmoidoscopy. Estimated volumes of ordering, performing, or referring for CRC screening were low, and <20% reported that three-fourths or more of their older patients were up to date with CRC screening as recommended by the physician. Many PCPs reported recommending CRC screening at nonstandard starting ages or too-frequent intervals.

CONCLUSIONS

Awareness of CRC screening among PCPs in the United States is high. However, knowledge gaps about the timing and frequency of screening and suboptimal screening delivery were evident.

Promoting early detection tests for colorectal carcinoma and adenomatous polyps: a framework for action: the strategic plan of the National Colorectal Cancer Roundtable

BACKGROUND

The purpose of the current study was to provide health professionals, professional organizations, policy makers, and the general public with a practical blueprint for increasing the practice of screening for colorectal carcinoma (CRC) and adenomatous polyps over the next decade. The National Colorectal Cancer Roundtable (NCCRT) was founded in 1997 by the American Cancer Society and the Centers for Disease Control and Prevention to provide strategic leadership, advocacy, long-range planning, and coordination of interventions targeted at reducing the disease burden of CRC through education, early detection, and prevention. The NCCRT and its three workgroups include CRC survivors; recognized experts in primary care, gastroenterology, radiology, colorectal surgery, nursing, public policy, epidemiology, and behavioral science; patient advocates; and representatives of health plans and insurers, government, and other organizations.

METHODS

The NCCRT performed a literature review of published and unpublished data related to CRC screening guidelines, compliance, and barriers to adherence, as well as test effectiveness and cost-effectiveness. Members of the three NCCRT workgroups developed summary reports regarding professional education, public education and awareness, and health policy. A drafting committee developed the final strategic plan from workgroup reports, which was reviewed by the entire NCCRT membership, amended, and subsequently approved in final form.

RESULTS AND CONCLUSIONS

Although the rationale for population-wide CRC screening is well established, the majority of adults in the U.S. are not currently being screened for CRC. Thus, the nation foregoes an opportunity to reduce CRC-related mortality by an estimated >or= 50%. To increase CRC screening rates, the issues of patient and physician barriers to screening, lack of universal coverage, lack of incentives to motivate adherence, and expanded infrastructure must be addressed.

Achieving quality in flexible sigmoidoscopy screening for colorectal cancer

BACKGROUND

Sigmoidoscopy screening, which can dramatically reduce colorectal cancer mortality, is supported increasingly by physicians and payers, and is likely to be performed more frequently in the future. As more physicians and nonphysician medical personnel learn how to perform this procedure, and with attention to quality standards, the overall impact of sigmoidoscopy screening may improve. This review describes elements that characterize high-quality examinations and identifies resources for in-depth information on performing flexible sigmoidoscopy.

METHODS

The domains of quality were identified from textbooks, articles, and the professional opinions of gastroenterologists and primary care physicians. Information was obtained from MEDLINE, bibliographies in recent articles, medical professional organizations, equipment manufacturers' representatives, and focus groups of primary care physicians.

RESULTS

Nine domains of quality are identified and discussed: training, logistical start-up, patient interaction, bowel preparation, examination technique, lesion recognition, complications, reporting, and processing (equipment cleaning and disinfection).

CONCLUSIONS

Persons learning how to perform and to implement flexible sigmoidoscopy may use this information to help ensure the quality of screening examinations.

Medicare premium buy-in programs: results of SSA demonstration projects

Three programs known collectively as the Medicare buy-in programs are available to pay Medicare Part B premiums and, in some cases, other medical expenses for certain low-income individuals. The Health Care Financing Administration administers those programs, with most functions performed by the states. The Social Security Administration (SSA) plays an indirect role in the buy-in programs: with certain exceptions, people who qualify for Medicare and hence for buy-in are beneficiaries of Social Security retirement or disability programs. SSA is often cited as an agency that might be able to increase enrollment in the buy-in programs through outreach to its beneficiaries and by acting as an intermediary in the enrollment process. The three buy-in programs have different requirements for eligibility. The Qualified Medicare Beneficiary (QMB) program includes individuals who have Part A Medicare benefits and whose income does not exceed 100 percent of federal poverty guidelines. People in the Specified Low-Income Medicare Beneficiary (SLMB) program are individuals who would otherwise be QMBs but whose income is more than 100 percent but less than 120 percent of poverty guidelines. People in the Qualified Individual (QI) program are those who meet the other criteria but whose income is less than 175 percent of poverty guidelines. Various reports and studies by government agencies and advocacy organizations conclude that the buy-in programs are not reaching many of the people who are eligible. Low enrollment appears to be a particular issue for the SLMB and QI programs. States have tried various outreach efforts, but the effectiveness of those efforts has not been adequately assessed. In 1998, Congress mandated that SSA conduct a demonstration project to determine how to increase participation in the buy-in programs. The project tested six different administrative models in which outreach letters were sent to potential beneficiaries asking them to contact SSA and then be screened for eligibility and referred for enrollment. SSA was able to screen about 7.1 percent of letter recipients for buy-in eligibility: 4.2 percent were potentially eligible for the programs based on income and resources, and 3.7 percent enrolled in a buy-in program. An evaluation of the probability that letter recipients would contact SSA to be screened found that: Among the elderly, older individuals were less likely to be screened but more likely to enroll. Among the disabled, older individuals were more likely to be screened but less likely to enroll. The disabled were less likely to be screened but more likely to enroll. Individuals with higher Social Security benefits were more likely to be screened but less likely to enroll. Women were more likely to be screened and to enroll. Being married did not appear to affect screening but negatively affected enrollment. Individuals with a preference for materials in Spanish were much more likely to be screened and enrolled. In some of the demonstration sites, enrollment in a Medicare+Choice plan increased the probability of being both screened and enrolled. SSA conducted a survey of some people who did not respond to the outreach letter. Most of those from whom explanations of the nonresponse were obtained had not responded because they were not eligible on the basis of their income or resources. If SSA were to reproduce the demonstrations in a nationwide outreach effort, a national mailing would include nearly 20 million individuals. If response rates were similar to those seen in the 1999 demonstrations, outreach would produce over 740,000 new buy-in enrollees. That number might be increased modestly by conducting additional outreach efforts in conjunction with the mailing.

Hyposplenism from Mycobacterium avium complex infection in a patient with AIDS and immune thrombocytopenia

We describe a patient with HIV-related immune thrombocytopenic purpura with known Mycobacterium avium complex (MAC) infection presenting with intracerebral hemorrhage associated with severe thrombocytopenia who failed splenectomy following unsuccessful trials of corticosteroids and intravenous immunoglobulin. His presplenectomy peripheral blood smear showed Howell-Jolly bodies and microscopic examination of his spleen demonstrated multiple granulomas with numerous acid-fast organisms replacing the normal splenic tissue. We postulate that splenic hypofunction secondary to overwhelming MAC infection contributed to the failure of the thrombocytopenia to promptly respond to splenectomy.

Coding mammograms using the classification "probably benign finding--short interval follow-up suggested"

OBJECTIVE

Many benign breast lesions revealed by mammography show features indicating that the lesions have a high, but not complete, likelihood of being benign. The Breast Imaging Reporting and Data System (BI-RADS) allows radiologists to classify these mammograms as "probably benign finding-short interval follow-up suggested" (category 3). We explored whether certain factors are associated with the use of category 3 in a national cancer detection program.

MATERIALS AND METHODS

We analyzed data from the National Breast and Cervical Cancer Early Detection Program, a comprehensive nationwide program that provides cancer screening for low-income and medically underserved women. The study population included all women at least 40 years old who had undergone mammography on or before September 30, 1996 (n = 372,760).

RESULTS

Of the 372,760 mammograms, 7.7% were classified as category 3. The probability of receiving a category 3 classification decreased as patients' ages increased. Women who were symptomatic were nearly twice as likely as women who were asymptomatic to receive a category 3 classification, and women whose clinical breast examinations had abnormal findings were more than twice as likely as women with examinations having normal findings to receive a category 3 classification. The percentage of mammograms classified as category 3 by state or tribal organization ranged from 1.4% to 14.0%.

CONCLUSION

Several patient variables, including patient symptomatology, were associated with the probability of having a mammogram classified as category 3. One of the most important determinants was where the patient underwent mammography, which suggests that variability exists among radiologists themselves in using this BI-RADS code for "probably benign" mammographic lesions.

Sun protection behaviors of the U.S. white population

BACKGROUND

Sun protection behaviors are recommended to prevent skin cancer, which has increased in incidence. This study measured the prevalence of sun protection behaviors and determined personal characteristics associated with them.

METHODS

Data from 10,048 white respondents to the 1992 National Health Interview Survey Cancer Control Supplement were analyzed. Multiple logistic regression models were constructed to relate personal characteristics to specific behaviors.

RESULTS

Fifty-three percent of respondents reported they were "very likely" to use sunscreen, wear protective clothing, or seek shade if they were outside on a sunny day for more than 1 hr. Proportions for the individual behaviors were 32, 28, and 30%, respectively. Compared with people who do not burn, those reporting severe sunburn after 1 hr of sun exposure reported more use of sunscreens (odds ratio [OR] = 2.4, 95% confidence interval [CI] 2.0, 2.9), shade (OR = 1.8, 95% CI 1.5, 2.1), and protective clothing (OR = 2.2, 95% CI 1.9, 2.7). Other factors associated with practicing protection behaviors included a personal history of skin cancer, older age, and female sex.

CONCLUSIONS

A large percentage of white U.S. adults did not protect themselves from sun exposure. Additional education of the general public and persons at higher risk for skin cancer is needed.

Incidence of dysplasia and carcinoma of the uterine cervix in an Appalachian population

BACKGROUND

Cervical cancer mortality rates in the Appalachian population of southeastern Kentucky have been shown to be unusually high. To better understand the high cervical cancer death rate in this area, we developed a population-based cervical disease registry.

PURPOSE

This study describes the incidence of cervical dysplasia, carcinoma in situ, and invasive cervical cancer in 1986 and 1987 among White women in a 36-county area of Appalachian Kentucky based on histologic diagnoses.

METHODS

We compared average annual age-adjusted incidence rates for carcinoma in situ and invasive cervical cancer in the study area with those for women in the Surveillance, Epidemiology, and End Results (SEER) Program.

RESULTS

The incidence rate of invasive cervical cancer for women in the study area (14.9 per 100,000) was nearly twice that for White women in the SEER population (7.8 per 100,000), but it was similar to that for Black women in the SEER population (15.3 per 100,000). The incidence of carcinoma in situ for women in the study population (38.2 per 100,000) was 21% higher than that for White women (31.5 per 100,000) or for Black women (31.2 per 100,000) in the SEER population. The average annual age-adjusted incidence rate for all grades of dysplasia among women in the study population was 194.6 per 100,000. No comparable population-based incidence rates for dysplasia could be identified.

CONCLUSIONS

Cervical cancer incidence rates are higher in Appalachian Kentucky than in the SEER population. Poverty appears to be a factor associated with these rates.

IMPLICATIONS

Low-density populations such as those in rural Appalachia deserve greater attention in cancer control research. The population-based cervical dysplasia rates reported here may be useful for comparisons in future investigations.

Age and Pap smear history as a basis for intervention strategy

As a means of developing effective intervention strategies for promoting Pap smear screening, we analyzed data from a population-based women's health survey (N = 603) in a 36-county area in southeastern Kentucky. The cervical cancer mortality rate for white women in this area is one of the highest in the United States. By using selected sociodemographic, health-care utilization, health knowledge, and health behavior variables in age-specific logistic regression models, we discriminated between women who had had a Pap smear within 3.5 years and those who had not. Several variables predicted Pap screening status regardless of the woman's age. Women of all age groups who had not been recently screened had encounters with the medical-care system. A key variable that affected use of screening services was ever use of birth control pills. The main differences between the three age groups were as follows: the 18-44 age group was less likely to see a private physician and less likely to seek medical care of any type, except for care related to pregnancy; only the 45-59 age group believed that cost of medical care was a problem; and only for the 60 or older age group were socioeconomic variables associated with not having recently had a Pap test.

Recombination between viral and cellular sequences generates transforming sarcoma virus

A series of sarcoma viruses has been obtained from tumors induced by transformation-defective (td) mutants of the Schmidt-Ruppin strain of Rous sarcoma virus, subgroup A (SR-A). The RNA sequences of these "recovered avian sarcoma viruses" (rASVs) were compared with those of td mutants and of SR-A by oligonucleotide fingerprinting. Of six sarcoma-specific oligonucleotides present in SR-A RNA, three to six were missing in the RNAs of the four td mutants examined. All six isolates of rASV examined have regained these six oligonucleotides. In addition, most rASV RNAs have three new oligonucleotides not present in the RNA either of td mutants or of SR-A. The newly obtained oligonucleotides are located between 800 and 2600 nucleotides from the 3' end of rASV RNA, which corresponds to the src region of SR-A RNA mapped previously. Furthermore, viral RNAs of two td mutants isolated from a clone of rASV lack most src-specific oligonucleotides, including the three new ones. No differences were found among RNAs of td, SR-A, and rASV in the regions outside of src. Our results indicate that RNA sequences that rASVs have acquired from cells in the process of conversion from td virus to transforming virus are mapped within the src region and segregate with the transforming function. Some of the sequences are new and some are identical with those in SR-A RNA.