Introduction Homeless people have a high burden of cancer risk factors and suboptimal rates of cancer screening, but the epidemiology of cancer has not been well described in this population. We ...assessed cancer incidence, stage, and mortality in homeless adults relative to general population standards. Methods We cross-linked a cohort of 28,033 adults seen at Boston Health Care for the Homeless Program in 2003–2008 to Massachusetts cancer registry and vital registry records. We calculated age-standardized cancer incidence and mortality ratios (SIRs and SMRs). We examined tobacco use among incident cases and estimated smoking-attributable fractions. Trend tests were used to compare cancer stage distributions with those in Massachusetts adults. Analyses were conducted in 2012–2015. Results During 90,450 person-years of observation, there were 361 incident cancers (SIR=1.13, 95% CI=1.02, 1.25) and 168 cancer deaths (SMR=1.88, 95% CI=1.61, 2.19) among men, and 98 incident cancers (SIR=0.93, 95% CI=0.76, 1.14) and 38 cancer deaths (SMR=1.61, 95% CI=1.14, 2.20) among women. For both sexes, bronchus and lung cancer was the leading type of incident cancer and cancer death, exceeding Massachusetts estimates more than twofold. Oropharyngeal and liver cancer cases and deaths occurred in excess among men, whereas cervical cancer cases and deaths occurred in excess among women. About one third of incident cancers were smoking-attributable. Colorectal, female breast, and oropharyngeal cancers were diagnosed at more-advanced stages than in Massachusetts adults. Conclusions Efforts to reduce cancer disparities in homeless people should include addressing tobacco use and enhancing participation in evidence-based screening.
Abstract Purpose Best-worst scaling (BWS) is a survey method for assessing individuals' priorities. It identifies the extremes—best and worst items, most and least important factors, biggest and ...smallest influences—among sets. In this article, we demonstrate an application of BWS in a primary care setting to illustrate its use in identifying patient priorities for services. Methods We conducted a BWS survey in 2014 in Boston, Massachusetts, to assess the relative importance of 10 previously identified attributes of Papanicolaou (Pap) testing services among women experiencing homelessness. Women were asked to evaluate 11 sets of 5 attributes of Pap services, and identify which attribute among each set would have the biggest and smallest influence on promoting uptake. We show how frequency analysis can be used to analyze results. Results In all, 165 women participated, a response rate of 72%. We identified the most and least salient influences on encouraging Pap screening based on their frequency of report among our sample, with possible standardized scores ranging from + 1.0 (biggest influence) to —1.0 (smallest influence). Most important was the availability of support for issues beyond health (+0.39), while least important was the availability of accommodations for personal hygiene (—0.27). Conclusions BWS quantifies patient priorities in a manner that is transparent and accessible. It is easily comprehendible by patients and relatively easy to administer. Our application illustrates its use in a vulnerable population, showing that factors beyond those typically provided in health care settings are highly important to women in seeking Pap screening. This approach can be applied to other health care services where prioritization is helpful to guide decisions.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Homelessness is poorly captured in most administrative data sets making it difficult to understand how, when, and where this population can be better served. This study sought to develop and validate ...a classification model of homelessness. Our sample included 5,050,639 individuals aged 11 years and older who were included in a linked dataset of administrative records from multiple state-maintained databases in Massachusetts for the period from 2011-2015. We used logistic regression to develop a classification model with 94 predictors and subsequently tested its performance. The model had high specificity (95.4%), moderate sensitivity (77.8%) for predicting known cases of homelessness, and excellent classification properties (area under the receiver operating curve 0.94; balanced accuracy 86.4%). To demonstrate the potential opportunity that exists for using such a modeling approach to target interventions to mitigate the risk of an adverse health outcome, we also estimated the association between model predicted homeless status and fatal opioid overdoses, finding that model predicted homeless status was associated with a nearly 23-fold increase in the risk of fatal opioid overdose. This study provides a novel approach for identifying homelessness using integrated administrative data. The strong performance of our model underscores the potential value of linking data from multiple service systems to improve the identification of housing instability and to assist government in developing programs that seek to improve health and other outcomes for homeless individuals.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract A clinician-randomized trial was conducted using the chronic care model for disease management for alcohol use problems among n = 82 women served in a health care for the homeless clinic. ...Women with problem alcohol use received either usual care or an intervention consisting of a primary care provider (PCP) brief intervention, referral to addiction services, and on-going support from a care manager (CM) for 6 months. Both groups significantly reduced their alcohol consumption, with a small effect size favoring intervention at 3 months, but there were no significant differences between groups in reductions in drinking or in housing stability, or mental or physical health. However, intervention women had significantly more frequent participation in substance use treatment services. Baseline differences and small sample size limit generalizability, although substantial reductions in drinking for both groups suggest that screening and PCP brief treatment are promising interventions for homeless women with alcohol use problems.
According to the Centers for Disease Control and Prevention, 115 US residents on average die every day from opioid overdose.1 Combating the OUD epidemic will require coordinated efforts on the part ...of health care professionals, policymakers, community members, scientists, regulators, and government agencies. ...they found that OUD prevalence increased from 2.72% to 4.60% between 2011 and 2015 and that opioid-related deaths increased even more rapidly during this period, by 273%. OUD is a chronic medical disease-not simply a social issue or personal failing- and requires us to provide evidence-based interventions based on precision public health that can identify individuals with (and at risk for) OUD, the numbers of such individuals, and the best means of locating them.
Individuals experiencing homelessness carry a high burden of medical and behavioral health illness.1-3 They often struggle with balancing the daily needs of shelter, food, and safety with management ...of health and health care needs.4 They also frequently lack health insurance or access to continuity of care. This mix of factors often leads to a high usage pattern of the emergency department (ED) system. Multiple studies have documented high usage patterns among homeless individuals and the resultant high costs.1,5,6 Few studies, however, have attempted to evaluate the quality of care compared with individuals without experiences of homelessness.
Methadone clinics serve the needs of some patients well, but for others, the need to obtain medication daily at one fixed site can be too burdensome. Increasing the availability of methadone in ...primary care could extend the benefits of a proven, effective medication.
OBJECTIVE:To estimate fatal and nonfatal opioid overdose events in pregnant and postpartum women in Massachusetts, comparing rates in individuals receiving and not receiving pharmacotherapy for ...opioid use disorder (OUD).
METHODS:We conducted a population-based retrospective cohort study using linked administrative and vital statistics databases in Massachusetts to identify women with evidence of OUD who delivered a liveborn neonate in 2012–2014. We described maternal sociodemographic, medical, and substance use characteristics, computed rates of opioid overdose events in the year before and after delivery, and compared overdose rates by receipt of pharmacotherapy with methadone or buprenorphine in the prenatal and postpartum periods.
RESULTS:Among 177,876 unique deliveries, 4,154 (2.3%) were to women with evidence of OUD in the year before delivery, who experienced 242 total opioid-related overdose events (231 nonfatal, 11 fatal) in the year before or after delivery. The overall overdose rate was 8.0 per 100,000 person-days. Overdoses were lowest in the third trimester (3.3/100,000 person-days in the third trimester) and then increased in the postpartum period with the highest overdose rate 7–12 months after delivery (12.3/100,000 person-days). Overall, 64.3% of women with evidence of OUD in the year before delivery received any pharmacotherapy in the year before delivery. Women receiving pharmacotherapy had reduced overdose rates in the early postpartum period.
CONCLUSION:Pregnant women in Massachusetts have high rates of OUD. The year after delivery is a vulnerable period for women with OUD. Additional longitudinal supports and interventions tailored to women in the first year postpartum are needed to prevent and reduce overdose events.
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