Disparities in colorectal cancer (CRC) screening prevalence across United States neighborhoods may reflect social inequities that create barriers to accessing and completing preventive health ...services. Our objective was to identify whether neighborhood social vulnerability was associated with a change in CRC screening prevalence in Boston neighborhoods during the COVID-19 pandemic.
Adults ages 50-74 years due for CRC screening who received primary care at one of 35 primary care practices affiliated with Massachusetts General Hospital or Brigham and Women's Hospital (Boston, MA), 3/1/2020 to 3/1/2022. The Social Vulnerability Index (SVI) is an aggregate measure of neighborhood social factors often used by public health authorities to examine neighborhood susceptibility to many health outcomes.
In 2020, 74.9 % of eligible individuals were up to date with CRC screening and this fell to 67.4 % in 2022 (p < 0.001). In 2020, 36.2 % of eligible patients lived in a neighborhood above the 80th percentile of SVI, consistent with high social vulnerability, while the same value was 35.1 % in 2022. There was no association between the change in screening prevalence and SVI: a decrease of 5.5 % screened in neighborhoods with SVI ≤ 80 compared to a decrease of 3.6 % in neighborhoods with SVI > 80 (p = 0.79).
The COVID-19 pandemic equalized the prevalence of CRC screening across Boston-area neighborhoods despite pre-existing geographic disparities in screening prevalence and SVI. Strategies to ensure equitable participation in CRC screening to promote health equity should be considered to promote equitable pandemic recovery.
Background
Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers.
Objective
To characterize women’s ...primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening.
Design, Setting, Participants
In 2014, we distributed a confidential web and mail survey to 668 women’s health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %).
Main Measures
We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations.
Key Results
The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40–74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21–64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider’s screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %).
Conclusions
Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential.
Nonadherence to prescription drugs results in poorer control of chronic health conditions. Because of significant racial/ethnic disparities in the control of many chronic diseases, differences in the ...rates of and reasons for medication nonadherence should be studied.
1) To determine whether rates of and reasons for medication nonadherence vary by race/ethnicity among seniors; and 2) to evaluate whether any association between race/ethnicity and nonadherence is moderated by prescription coverage and income.
Cross-sectional national survey, 2003.
Medicare beneficiaries > or = 65 years of age, who reported their race/ethnicity as white, black, or Hispanic, and who reported taking at least 1 medication (n = 14,829).
Self-reported nonadherence (caused by cost, self-assessed need, or experiences/side effects) during the last 12 months.
Blacks and Hispanics were more likely than whites to report cost-related nonadherence (35.1%, 36.5%, and 26.7%, respectively, p < .001). There were no racial/ethnic differences in nonadherence caused by experiences or self-assessed need. In analyses controlling for age, gender, number of chronic conditions and medications, education, and presence and type of prescription drug coverage, blacks (odds ratio OR 1.38; 95% confidence interval CI 1.08-1.78) and Hispanics (1.35; 1.02-1.78) remained more likely to report cost-related nonadherence compared to whites. When income was added to the model, the relationship between cost-related nonadherence and race/ethnicity was no longer statistically significant (p = .12).
Racial/ethnic disparities in medication nonadherence exist among seniors, and are related to cost concerns, and not to differences in experiences or self-assessed need. Considering the importance of medication adherence in controlling chronic diseases, affordability of prescriptions should be explicitly addressed to reduce racial/ethnic disparities.
Corley et al examine the differences in the funding, quality, and reporting standards for breast, colorectal, and cervical cancer screening. Standard of care for cancer screening: the term implies ...certainty and consensus. Physicians, patients, and organizations have created guidelines, policies, and regulations regarding how, when, and for whom screening should be used or reimbursed; cumulatively, these statements become the standards of care. However, these standards vary markedly across organ type, often without rationale or evidence.
In 2012, United States consensus guidelines were modified to recommend that cervical cancer screening not begin before age 21 and, since 2014, the Health Effectiveness Data and Information Set ...(HEDIS), a health plan quality measurement too, has included a measure for non-recommended cervical cancer screening among females ages 16–20. Our goal was to describe prevalence over time of cervical cancer screening before age 21 following the 2012 guideline change, and provide information to help understand how rapidly new guidelines may be disseminated and implemented into clinical practice. We used longitudinal clinical and administrative data from three diverse healthcare systems in the Population-based Research to Optimize the Screening Process (PROSPR II) consortium to examine annual trends in screening before age 21. We identified 55,316 average-risk, screening-eligible females ages 18–20 between 2011 and 2017. For each calendar year, we estimated the proportion of females who received a Papanicolaou (Pap) test. We observed a steady decline in the proportion of females under age 21 who received a Pap test, from an average of 8.3% in 2011 to <1% in 2017 across the sites. The observed steady decline suggests growing adherence to the 2012 consensus guidelines. This trend was consistent across diverse geographic regions, healthcare systems, and patient populations, strengthening the generalizability of the results; however, since we only had 1–2 years of study data prior to the consensus guidelines, we cannot discern whether screening under age 21 was already in decline. Nonetheless, these results provide data to compare with other guideline changes to de-implement non-recommended screening practices.
ABSTRACT
Background
Massachusetts health reform has achieved near-universal insurance coverage, yet little is known about the effects of this legislation on disparities.
Objective
Since racial/ethnic ...minorities and low-income individuals are over-represented among the uninsured, we assessed the effects of health reform on disparities.
Design
Cross-sectional survey data from the Behavioral Risk Factor Surveillance Survey (BRFSS), 2006–2008.
Participants
Adults from Massachusetts (n = 36,505) and other New England states (n = 63,263).
Main Measures
Self-reported health coverage, inability to obtain care due to cost, access to a personal doctor, and health status. To control for trends unrelated to reform, we compared adults in Massachusetts to those in all other New England states using multivariate logistic regression models to calculate adjusted predicted probabilities.
Key Results
Overall, the adjusted predicted probability of health coverage in Massachusetts rose from 94.7% in 2006 to 97.7% in 2008, whereas coverage in New England remained around 92% (p < 0.001 for difference-in-difference). While cost-related barriers were reduced in Massachusetts, there were no improvements in access to a personal doctor or health status. Although there were improvements in coverage and cost-related barriers for some disadvantaged groups relative to trends in New England, there was no narrowing of disparities in large part because of comparable or larger improvements among whites and the non-poor.
Conclusions
Achieving equity in health and health care may require additional focused intervention beyond health reform.
History has shown that we must adapt and learn from crises so that we can improve how we deliver care and conduct research to improve clinical outcomes. The COVID‐19 pandemic has expedited work ...regarding virtual research methods and serves as an opportunity to evaluate how to initiate, implement, and sustain cancer prevention, early detection, and treatment research going forward.
Introduction Timely follow-up of abnormal tests is critical to the effectiveness of cancer screening, but may vary by screening test, healthcare system, and sociodemographic group. Methods Timely ...follow-up of abnormal mammogram and fecal occult blood testing or fecal immunochemical tests (FOBT/FIT) were compared by race/ethnicity using Population-Based Research Optimizing Screening through Personalized Regimens consortium data. Participants were women with an abnormal mammogram (aged 40–75 years) or FOBT/FIT (aged 50–75 years) in 2010–2012. Analyses were performed in 2015. Timely follow-up was defined as colonoscopy ≤3 months following positive FOBT/FIT; additional imaging or biopsy ≤3 months following Breast Imaging Reporting and Data System Category 0, 4, or 5 mammograms; or ≤9 months following Category 3 mammograms. Logistic regression was used to model receipt of timely follow-up adjusting for study site, age, year, insurance, and income. Results Among 166,602 mammograms, 10.7% were abnormal; among 566,781 FOBT/FITs, 4.3% were abnormal. Nearly 96% of patients with abnormal mammograms received timely follow-up versus 68% with abnormal FOBT/FIT. There was greater variability in receipt of follow-up across healthcare systems for positive FOBT/FIT than for abnormal mammograms. For mammography, black women were less likely than whites to receive timely follow-up (91.8% vs 96.0%, OR=0.71, 95% CI=0.51, 0.97). For FOBT/FIT, Hispanics were more likely than whites to receive timely follow-up than whites (70.0% vs 67.6%, OR=1.12, 95% CI=1.04, 1.21). Conclusions Timely follow-up among women was more likely for abnormal mammograms than FOBT/FITs, with small variations in follow-up rates by race/ethnicity and larger variation across healthcare systems.
Mobile health applications ("apps") have rapidly proliferated, yet their ability to improve outcomes for patients remains unclear. A validated tool that addresses apps' potentially important ...dimensions has not been available to patients and clinicians. The objective of this study was to develop and preliminarily assess a usable, valid, and open-source rating tool to objectively measure the risks and benefits of health apps. We accomplished this by using a Delphi process, where we constructed an app rating tool called THESIS that could promote informed app selection. We used a systematic process to select chronic disease apps with ≥4 stars and <4-stars and then rated them with THESIS to examine the tool's interrater reliability and internal consistency. We rated 211 apps, finding they performed fair overall (3.02 out of 5 95% CI, 2.96-3.09), but especially poorly for privacy/security (2.21 out of 5 95% CI, 2.11-2.32), interoperability (1.75 95% CI, 1.59-1.91), and availability in multiple languages (1.43 out of 5 95% CI, 1.30-1.56). Ratings using THESIS had fair interrater reliability (κ = 0.3-0.6) and excellent scale reliability (ɑ = 0.85). Correlation with traditional star ratings was low (r = 0.24), suggesting THESIS captures issues beyond general user acceptance. Preliminary testing of THESIS suggests apps that serve patients with chronic disease could perform much better, particularly in privacy/security and interoperability. THESIS warrants further testing and may guide software and policymakers to further improve app performance, so apps can more consistently improve patient outcomes.
CONTEXT Homeless persons face numerous barriers to receiving health care and
have high rates of illness and disability. Factors associated with health
care utilization by homeless persons have not ...been explored from a national
perspective. OBJECTIVE To describe factors associated with use of and perceived barriers to
receipt of health care among homeless persons. DESIGN AND SETTING Secondary data analysis of the National Survey of Homeless Assistance
Providers and Clients. SUBJECTS A total of 2974 currently homeless persons interviewed through homeless
assistance programs throughout the United States in October and November 1996. MAIN OUTCOME MEASURES Self-reported use of ambulatory care services, emergency departments,
and inpatient hospital services; inability to receive necessary care; and
inability to comply with prescription medication in the prior year. RESULTS Overall, 62.8% of subjects had 1 or more ambulatory care visits during
the preceding year, 32.2% visited an emergency department, and 23.3% had been
hospitalized. However, 24.6% reported having been unable to receive necessary
medical care. Of the 1201 respondents who reported having been prescribed
medication, 32.1% reported being unable to comply. After adjustment for age,
sex, race/ethnicity, medical illness, mental health problems, substance abuse,
and other covariates, having health insurance was associated with greater
use of ambulatory care (odds ratio OR, 2.54; 95% confidence interval CI,
1.19-5.42), inpatient hospitalization (OR, 2.60; 95% CI, 1.16-5.81), and lower
reporting of barriers to needed care (OR, 0.37; 95% CI, 0.15-0.90) and prescription
medication compliance (OR, 0.35; 95% CI, 0.14-0.85). Insurance was not associated
with emergency department visits (OR, 0.90; 95% CI, 0.47-1.75). CONCLUSIONS In this nationally representative survey, homeless persons reported
high levels of barriers to needed care and used acute hospital-based care
at high rates. Insurance was associated with a greater use of ambulatory care
and fewer reported barriers. Provision of insurance may improve the substantial
morbidity experienced by homeless persons and decrease their reliance on acute
hospital-based care.
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