Racial differences in the treatment of early-stage lung cancer

Accounting for apparent "reverse" racial disparities in Department of Veterans Affairs (VA)-based medical care: influence of out-of-VA care

Conclusions regarding racial differences in care following a newly elevated prostate-specific antigen (PSA) test at the Department of Veterans Affairs (VA) may differ depending on whether follow-up care outside the VA is considered. Consecutive Philadelphia, Pa, VA patients with newly elevated PSA tests (n = 183) were interviewed 1 year after baseline. Among exclusive VA users, Blacks had higher rates of urology referrals and prostate biopsies compared with Whites. However, these racial differences were attenuated when care obtained outside the VA also was considered.

Risk acceptance and risk aversion: patients' perspectives on lung surgery

Patients express risk aversion toward surgery, particularly if surgery can lead to lifelong debility and loss of independence. When faced with a guarantee of progressive lung cancer and no alternatives for cure, however, patients are willing to take extremely high risks of postoperative complications and surgery-related death. This result occurs because risk aversion toward unrelenting cancer death supersedes patients' risk attitudes toward almost all other health states. By adding conditions such as misunderstanding of prognosis, diagnostic uncertainty, a patient's denial of diagnosis, an actual alternative cure such as radiation therapy, or a perceived alternative cure such as prayer, decisions can be shifted so that risk aversion to surgery can predominate. In practical terms, the following statements can be made: 1. For patients who surely have operable stage I or stage II non small cell lung cancer, if patient risk preferences are taken seriously, the pulmonary function level and comorbidities that are acceptable for the offer of surgical care probably need to be liberalized. Patients with short life expectancies because of advanced age or comorbid illness and patients with severe preoperative functional debility (eg, bed-to-chair limitation as defined earlier) should not be candidates, however. 2. The diagnosis of cancer needs to be confirmed absolutely as often as possible before lung resection surgery. 3. Physicians or a staff member must communicate prognosis to a patient as precisely and numerically as possible and ensure the patient's understanding of the data presented. 4. This communicator also must explore a patient's trust in the diagnosis and probe for beliefs in alternative solutions. Important areas for future study include the search for methods that most accurately communicate risk information to patients, especially patients with low numeracy skills. Part of this communication effort should involve the exploration and discussion of patients' alternative beliefs and ways of using these belief systems to help them make the best possible decisions for their long-term health and quality of life. Also, clinicians must identify pulmonary and other predictors of mortality rates and the debility states that patients' cite as most important according to their risk preferences and give up the predictors of transient postoperative complications that patients find acceptable.

Treatment and referral patterns for colorectal cancer

BACKGROUND

National guidelines recommend adjuvant chemotherapy for colorectal cancer stages III, and IV; however, it has been shown that only 45-55% of these patients receive chemotherapy.

OBJECTIVES

We sought to describe treatment patterns for patients diagnosed with colorectal cancer and to examine the reasons why patients do not receive chemotherapy.

RESEARCH DESIGN

This was a retrospective cohort study.

SETTING AND PATIENTS

Patients included newly diagnosed cases of colorectal cancer at a health maintenance organization in central Massachusetts between January 1, 1997, and June 30, 1999.

MAIN OUTCOME MEASURE

The main outcome measure was a referral or visit to an oncologist.

RESULTS

Sixty-six percent (n=143) of the 217 colorectal cancer cases had a referral/visit to an oncologist or evidence of chemotherapy within 4 months of the index date. The referral rates by stage were: stage I, 47.7%; stage II, 59.5%; stage III, 87.1%; and stage IV, 66.7%. Of patients not referred with stage III disease, 4/8 were not referred because the treating physician did not recommend an oncology referral; patient refusal accounted for 3/8 (37.5%). The most commonly cited reason for lack of referral for stage IV patients was existing comorbidities or death. Younger age (<70 years) and stage III at diagnosis were significant predictors of oncology referral/visit.

CONCLUSIONS

A substantial proportion of colorectal cancer patients are receiving appropriate referral for chemotherapy. This study is the first to elucidate reasons why patients do not receive chemotherapy and highlights both patient and physician factors.

The last mile of the way: understanding caregiving in African American families at the end-of-life

This research is based on in-depth ethnographic interviews and focus groups with 88 African American family caregivers from various regions of the United States during a stressful time in their family development--caregiving at the end-of-life--and the grieving during the aftermath. The study employed a stratified purposeful sampling strategy. Subjects were African Americans from the Northern, Southern, and Midwestern United States. Formal care is complicated by the distrust that many African Americans hold toward the health care system, which has resulted from years of exclusion, racism and discrimination. The findings highlight the importance of hearing from African American families to gain an understanding of what services, including family therapy and other psychotherapy, they will need during this process.

Why ethnic minority groups are under-represented in clinical trials: a review of the literature

Randomised controlled trials (RCTs) are considered to be the gold standard in evaluating medical interventions; however, people from ethnic minorities are frequently under-represented in such studies. The present paper addresses a previously neglected debate about the tensions which inform clinical trial participation amongst people from ethnic minorities, in particular, South Asians, the largest ethnic minority group in the UK. In a narrative review of the available literature, based mainly on US studies, the present authors aim to make sense of the issues around under-representation by providing a theoretical reconciliation. In addition, they identify a number of potential barriers to ethnic minority participation in clinical trials. In so doing, the authors recognise that the recent history of eugenic racism, and more general views on clinical trials as a form of experimentation, means that clinical trial participation among people from ethnic minorities becomes more problematic. Lack of participation and the importance of representational sampling are also considered, and the authors argue that health professionals need to be better informed about the issues. The paper concludes by offering a number of strategies for improving ethnic minority accrual rates in clinical trials, together with priorities for future research.

Population Variations in the Initial Treatment of Non–Small-Cell Lung Cancer

Purpose

Dissemination of recommended therapies for non–small-cell lung cancer (NSCLC) have not been described comprehensively. We report the patterns of initial therapy focusing on the investigation of differences in receipt of recommended therapies according to multiple clinical and nonclinical patient characteristics.

Methods

A population-based random sample of newly diagnosed NSCLC patients diagnosed in 10 separate geographic areas was collected in 1996 (n = 898). Data were obtained from medical records. Multiple logistic regression was used to assess the use of recommended therapies.

Results

Overall, 52% of NSCLC patients received recommended therapy. Approximately 69%, 48%, and 41% of patients with stages I and II, III, or IV NSCLC received recommended therapy, respectively. For all stages combined, the use of recommended therapy was significantly inversely associated with age and stage at diagnosis. Recommended therapy also was more common in white versus black patients, and in married versus single patients. Stage-specific analyses revealed a significant decline in the use of recommended surgery with increasing age at diagnosis for early-stage NSCLC only, and a significantly lower use of recommended therapy (primarily chemoradiotherapy) for stage III black and Hispanic patients compared with white patients.

Conclusion

The overall use of recommended therapies for NSCLC is low. Large variations exist in the use of such therapies according to age, race or ethnicity, and marital status. Research combining medical record reviews with other sources of data is needed to better understand the contributions of both patient preferences and physician judgment to these treatment variations.

Primary care physicians who treat blacks and whites

BACKGROUND

In the United States, black patients generally receive lower-quality health care than white patients. Black patients may receive their care from a subgroup of physicians whose qualifications or resources are inferior to those of the physicians who treat white patients.

METHODS

We performed a cross-sectional analysis of 150,391 visits by black Medicare beneficiaries and white Medicare beneficiaries 65 years of age or older for medical "evaluation and management" who were seen by 4355 primary care physicians who participated in a biannual telephone survey, the 2000-2001 Community Tracking Study Physician Survey.

RESULTS

Most visits by black patients were with a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent, P=0.02) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs. 19.3 percent, P=0.005). The physicians treating black patients also reported facing greater difficulties in obtaining access for their patients to high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admission to the hospital.

CONCLUSIONS

Black patients and white patients are to a large extent treated by different physicians. The physicians treating black patients may be less well trained clinically and may have less access to important clinical resources than physicians treating white patients. Further research should be conducted to address the extent to which these differences may be responsible for disparities in health care.

Annual report to the nation on the status of cancer, 1975-2001, with a special feature regarding survival

BACKGROUND

The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updated information regarding cancer occurrence and trends in the U.S. This year's report features a special section on cancer survival.

METHODS

Information concerning cancer cases was obtained from the NCI, CDC, and NAACCR and information concerning recorded cancer deaths was obtained from the CDC. The authors evaluated trends in age-adjusted cancer incidence and death rates by regression models and described and compared survival rates over time and across racial/ethnic populations.

RESULTS

Incidence rates for all cancers combined decreased from 1991 through 2001, but stabilized from 1995 through 2001 when adjusted for delay in reporting. The incidence rates for female lung cancer decreased (although not statistically significant for delay adjusted) and mortality leveled off for the first time after increasing for many decades. Colorectal cancer incidence rates also decreased. Death rates decreased for all cancers combined (1.1% per year since 1993) and for many of the top 15 cancers occurring in men and women. The 5-year relative survival rates improved for all cancers combined and for most, but not all, cancers over 2 diagnostic periods (1975-1979 and 1995-2000). However, cancer-specific survival rates were lower and the risk of dying from cancer, once diagnosed, was higher in most minority populations compared with the white population. The relative risk of death from all cancers combined in each racial and ethnic population compared with non-Hispanic white men and women ranged from 1.16 in Hispanic white men to 1.69 in American Indian/Alaska Native men, with the exception of Asian/Pacific Islander women, whose risk of 1.01 was similar to that of non-Hispanic white women.

CONCLUSIONS

The continued measurable declines for overall cancer death rates and for many of the top 15 cancers, along with improved survival rates, reflect progress in the prevention, early detection, and treatment of cancer. However, racial and ethnic disparities in survival and the risk of death from cancer, and geographic variation in stage distributions suggest that not all segments of the U.S. population have benefited equally from such advances.

Benefits and Costs of Interventions to Improve Breast Cancer Outcomes in African American Women

Purpose

Historically, African American women have experienced higher breast cancer mortality than white women, despite lower incidence. Our objective was to evaluate whether costs of increasing rates of screening or application of intensive treatment will be off-set by survival benefits for African American women.

Methods

We use a stochastic simulation model of the natural history of breast cancer to evaluate the incremental societal costs and benefits of status quo versus targeted biennial screening or treatment improvements among African Americans 40 years of age and older. Main outcome measures were number of mammograms, stage, all-cause mortality, and discounted costs per life year saved (LYS).

Results

At the current screening rate of 76%, there is little incremental benefit associated with further increasing screening, and the costs are high: $124,053 and $124,217 per LYS for lay health worker and patient reminder interventions, respectively, compared with the status quo. Using reminders would cost $51,537 per LYS if targeted to virtually unscreened women or $78,130 per LYS if targeted to women with a two-fold increase in baseline risk. If all patients received the most intensive treatment recommended, costs increase but deaths decrease, for a cost of $52,678 per LYS. Investments of up to $6,000 per breast cancer patient could be used to enhance treatment and still yield cost-effectiveness ratios of less than $75,000 per LYS.

Conclusion

Except in pockets of unscreened or high-risk women, further investments in interventions to increase screening are unlikely to be an efficient use of resources. Ensuring that African American women receive intensive treatment seems to be the most cost-effective approach to decreasing the disproportionate mortality experienced by this population.

Disparity in use of orthotopic liver transplantation among blacks and whites

Orthotopic liver transplantation (OLT) is the best treatment for end-stage liver disease. Limited data exist on the access of minorities to OLT. The aim of this study was to determine whether disparities exist among black and white OLT patients. Data were collected from the United Network for Organ Sharing on black and white 18-70 year-old OLT waiting list registrants (n = 29,013) and OLT recipients (n = 15,805) between 1994 and 1998. Standardized transplant ratios were generated by comparing the racial distribution of OLT patients with the US population. Demographic and clinical characteristics of OLT registrants were compared by race. Multivariate analyses were performed to identify predictors of time to OLT and the likelihood of dying or receiving OLT within 4 years, controlling for severity of illness and other factors. The standardized transplant ratio for black OLT recipients (0.65) was significantly lower than the standardized transplant ratio for white OLT recipients (1.05). Blacks were younger and sicker than whites. After adjustment for severity and other factors, time to OLT among recipients did not differ by race (P >.05). Blacks were more likely to die or become too ill for OLT while waiting (P <.001). Blacks were less likely to receive OLT within 4 years (P <.001). In conclusion, adult blacks were underrepresented among OLT patients. Although waiting times were similar once listed, black race affected outcomes while awaiting OLT. The process of referral and evaluation for OLT should be investigated further.

Racial disparity in pregnancy-related mortality following a live birth outcome

PURPOSE

African-American women have a 2- to 4-fold increased risk of pregnancy-related death compared with Caucasian women. We conducted this study to determine if differences in a combination of socioeconomic and medical risk factors may explain this racial disparity in pregnancy-related death.

METHODS

Pregnancy-related deaths of African-American (N=60) and Caucasian (N=47) women were identified from review of pregnancy-associated deaths (N=400) ascertained through cause of death on death certificates, electronic linkage of birth and death files, and review of the hospital discharge database for the State of North Carolina, during the period between 1992 and 1998. Controls (N=3404) were randomly selected from all live births for the same 7-year period. Logistic regression was used to model the association between race and pregnancy-related death.

RESULTS

The unadjusted odds ratio (OR) for pregnancy-related death for African-Americans compared with Caucasians was 3.07 (95% confidence interval [CI], 2.08, 4.54). After controlling for gestational age at delivery, maternal age, income, hypertension, and receipt of prenatal care, African-American race remained a significant predictor variable (OR 2.65 [95% CI 1.73, 4.07]).

CONCLUSIONS

Our analysis confirms that there is a strong association between race and pregnancy-related death, even after adjusting for potential predictors and confounders.

In lung cancer patients, age, race-ethnicity, gender and smoking predict adverse comorbidity, which in turn predicts treatment and survival

OBJECTIVE

This study evaluates the relationship between sociodemographic/exposure factors and comorbidity, and their impact on lung cancer treatment and survival. STUDY AND DESIGN SETTING: Data for 1,155 patients were abstracted from the Josephine Ford Cancer Center Tumor Registry and medical records. Associations were analyzed by linear, logistic, and Cox regression.

RESULTS

Approximately 88% of patients had > or = 1 of 56 comorbidities assessed. In multivariate analysis, comorbidity count was associated with older age, pack-years smoked, heavy alcohol use, lower socioeconomic status (SES), and female gender. Approximately 63% of patients had > or = 1 of 18 adverse prognostic comorbidities (AC), and significant independent predictors of AC were age, pack-years, African-American race/ethnicity, and gender. In multivariate analysis, comorbidity count and AC predicted nonreceipt of surgery in localized disease (OR(> or = 1 vs. 0 AC)=0.38, 95% 0.18, 0.81) and chemotherapy in advanced disease (OR > or = 1 vs. 0 AC)=0.72, 95% 0.51, 1.00). In adjusted analysis, comorbidity predicted survival in localized (hazard ratio (HR)(> or = 2 vs. 0 AC)=2.99, 95% CI 1.75, 5.10) and advanced lung cancer (HR(> or = 2 vs. 0 AC)=1.56, 95% CI 1.25, 1.94).

CONCLUSION

Comorbidity has important deleterious effects on lung cancer outcomes and significant predictors of comorbidity included age, smoking, race/ethnicity, SES, alcohol, and gender.

Racial and ethnic differences in patients' preferences for initial care by specialists

PURPOSE

To examine racial and ethnic differences in patients' preferences for initial care by specialists, and to determine whether trust in the physician and health beliefs account for these differences.

METHODS

We conducted a cross-sectional study of 646 patients in the waiting room of three academic-based internal medicine outpatient practices. We asked subjects about their preference to see their primary care provider or a specialist first regarding the actual health problem that had brought them to see their physician as well as regarding three hypothetical scenarios (2 weeks of new-onset exertional chest pain, 2 months of knee pain, and rash for 4 weeks). We examined the relation among patients' preference for initial care by a specialist and their demographic characteristics, global ratings of their primary care physician and health plan, trust in their primary care physician, and other health beliefs and attitudes.

RESULTS

Averaged for the three scenarios and actual health problem, 13% of patients preferred to see a specialist first. Adjusting for all other covariates, blacks (risk ratio [RR] = 0.55; 95% confidence interval [CI]: 0.20 to 0.92) and Asians (RR = 0.46; 95% CI: 0.19 to 0.75) were much less likely to prefer a specialist than were whites. Patients with less confidence in their primary care physician and greater certainty about needed tests and treatments were more likely to prefer a specialist. These variables, however, did not explain the difference in preference for specialist care among blacks, Asians, and whites.

CONCLUSION

Blacks and Asians are less likely than whites to prefer initial care by a specialist. Future studies should examine whether differences in preference for care lead minorities to underutilize appropriate specialty care or lead whites to overuse specialty care.

A culturally competent approach to cancer news and education in an inner city community: focus group findings

Ethnic minorities who live in socioeconomically disenfranchised communities suffer disproportionately from many health problems including cancer. In an effort to reduce these disparities, many health-care practitioners and scholars have promoted "culturally competent" health education efforts. One component of culturally competent education is a grounded knowledge base. To obtain knowledge about the cancer-related ideas of members of one African American community, researchers conducted focus groups with public housing residents and used the findings to develop a five-part television news series about breast, prostate, and cervix cancers. We found that participants gathered information from the folk, popular, and professional health sectors and constructed their cancer-related ideas from this information. Furthermore, experiences of racism, sexism, and classism colored their beliefs and behaviors regarding the prevention, detection, and treatment of common cancers. For this community "cancer" represents a giant screen upon which individual fears and societal ethnic, political, and economic tensions are projected.

Internet Education of African American Consumers on Quality of Care

This article describes a study using the Internet to teach African American consumers about quality of health care. By reading information on quality of care, consumers can learn ways to assess the care they are receiving, develop strategies needed to participate effectively in communicating with their health care providers, and make informed decisions in their own best interests. We developed an educational intervention using 5 Internet documents on quality of care and evaluated its effectiveness on learning, value of the information, and satisfaction with the instruction between consumers who read the information alone and those who read the information and interacted with a nurse. Participants indicated they learned a great deal from the information at the Web sites and reported that it would be helpful in assessing their own health care. They more frequently described quality care in terms of health outcomes, self care behaviors, and patient education after the Internet instruction, reflecting important concepts contained in the documents.

Measuring the quality of diabetes care using administrative data: is there bias?

OBJECTIVES

Health care organizations often measure processes of care using only administrative data. We assessed whether measuring processes of diabetes care using administrative data without medical record data is likely to underdetect compliance with accepted standards for certain groups of patients.

DATA SOURCES/STUDY SETTING

Assessment of quality indicators during 1998 using administrative and medical records data for a cohort of 1,335 diabetic patients enrolled in three Minnesota health plans.

STUDY DESIGN

Cross-sectional retrospective study assessing hemoglobin A1c testing, LDL cholesterol testing, and retinopathy screening from the two data sources. Analyses examined whether patient or clinic characteristics were associated with underdetection of quality indicators when administrative data were not supplemented with medical record data.

DATA COLLECTION/EXTRACTION METHODS

The health plans provided administrative data, and trained abstractors collected medical records data.

PRINCIPAL FINDINGS

Quality indicators that would be identified if administrative data were supplemented with medical records data are often not identified using administrative data alone. In adjusted analyses, older patients were more likely to have hemoglobin A1c testing underdetected in administrative data (compared to patients <45 years, OR 2.95, 95 percent CI 1.09 to 7.96 for patients 65 to 74 years, and OR 4.20, 95 percent CI 1.81 to 9.77 for patients 75 years and older). Black patients were more likely than white patients to have retinopathy screening underdetected using administrative data (2.57, 95 percent CI 1.16 to 5.70). Patients in different health plans also differed in the likelihood of having quality indicators underdetected.

CONCLUSIONS

Diabetes quality indicators may be underdetected more frequently for elderly and black patients and the physicians, clinics, and plans who care for such patients when quality measurement is based on administrative data alone. This suggests that providers who care for such patients may be disproportionately affected by public release of such data or by its use in determining the magnitude of financial incentives.

The Group-Based Medical Mistrust Scale: psychometric properties and association with breast cancer screening

BACKGROUND

There is little research on medical mistrust as a barrier to breast cancer screening. This study investigated the psychometric properties of a new scale, the Group-Based Medical Mistrust Scale (GBMMS), and its association with cancer screening attitudes and breast cancer screening practices among African American and Latina women.

METHODS

Participants were 168 African American and Latina urban women who completed the GBMMS and measures of sociodemographics, cancer screening pros and cons, acculturation, breast cancer screening practices and physician recommendation of such screening.

RESULTS

A principal components analysis of GBMMS items revealed three factors that were analyzed as subscales: (1) suspicion, (2) group disparities in health care, and (3) lack of support from health care providers. Convergent validity of the GBMMS was supported by its negative association with perceived benefits of cancer screening and acculturation and positive association with perceived disadvantages of cancer screening. Results further showed that women who reported no previous mammogram or a long-term lapse in mammography participation (>5 years) had significantly higher total GBMMS scores (P < 0.04) compared to women who were either adherent to mammography guidelines or nonadherent but reported a mammogram within the past 5 years. This analysis controlled for physician recommendation.

CONCLUSIONS

Results support the validity of the GBMMS and its association with breast cancer screening adherence. The GBMMS may be used to further investigate medical mistrust as a barrier to screening for cancers for which ethnic group disparities have been observed.

Differences in Medicare expenditures during the last 3 years of life

OBJECTIVE

To examine age, gender, race, and area income differences in Medicare expenditures in the 3 years before death.

DESIGN

Cross-sectional study.

PARTICIPANTS

A random sample of aged Medicare beneficiaries who died 1996 to 1999, N = 241,047.

MEASURES

We estimate differences in mean Medicare expenditures by year before death and by age, gender, race, and area income, adjusting for comorbidities and Medicaid enrollment.

RESULTS

Expenditures for blacks are lower in the second and third years before death and are not significantly different from whites in the last year of life (LYOL) (y3 = 70%, P <.0001; y2 = 82%, P <.0001; LYOL = 119%, P =.098). Differences in expenditures between decedents with area incomes over $35,000 compared to under $20,000 attenuate by the LYOL (y3 = 116%, P <.0001; y2 = 107%, P <.0001; LYOL = 96%, P <.0001). Expenditure patterns for women versus men vary by age. Among the younger cohorts (68 to 74 and 75 to 79), expenditures are higher for women in all 3 years before death. This difference attenuates among older cohorts; in the oldest cohort (90+), expenditures for men exceed those for women by 11% in the LYOL (P <.0001). Older beneficiaries have higher expenditures in the second and third years before death but lower expenditures in the LYOL. On average, the youngest cohort expended $8,017 more in the LYOL relative to the oldest cohort, whereas in the third year before death, the oldest cohort's expenditures were $5,270 more than those for the youngest cohort (P <.0001).

CONCLUSIONS

Age-associated differences in aggregate Medicare payments for end-of-life care are more substantial than other differences. The fact that other differences attenuate in the LYOL may reflect having overcome barriers to health care, or reflect an effective ceiling on the opportunities to provide services for persons with overwhelming illness.

The uncharted waters of emotion: ethnicity, trait emotion and emotion expression in older adults

Emotions are central to contemporary theories of health, and a growing body of psychological research has shown emotion and emotion regulatory styles to be predictive of health outcomes. Yet despite these clear links and the fact that patterns of emotion and expression are partially a product of culture, there is a meager literature on the emotional characteristics of different ethnic groups. Even where ethnicity has been investigated in emotions research, it has typically been operationalized in such a way that within-group differences are obscured with most individuals assigned to broad ethnic categories, such as non-Hispanic White, or Black. In the present study we draw on data from a multi-ethnic sample of 755 community-dwelling older adults to parse a picture of the emotional characteristics of three of the largest and most culturally distinct ethnic groups in the Northeastern United States: African Americans, West Indians (Jamaicans), and Eastern Slavs (Russians and Ukrainians) from the former Soviet Republic, as well as a comparison group of US-born European Americans. As predicted, there were striking differences in nine of 10 trait emotions as well as in levels of emotion expressed during conflict. The findings are discussed in terms of emotion socialization and implications for prediction and intervention in psychosocial models of emotions, emotion regulation, and health in older ethnic populations.

Racial/ethnic differences in influenza vaccination coverage in high-risk adults

OBJECTIVES

This study identified racial/ethnic disparities in influenza vaccination in high-risk adults.

METHODS

We analyzed data on influenza vaccination in 7655 adults with high-risk conditions, using data from the 1999 National Health Interview Survey (NHIS). We stratified data by age and used multiple logistic regression to adjust for gender, education, income, employment, and health care access.

RESULTS

After control for covariates, White patients with diabetes, chronic heart conditions, and cancer had a higher prevalence of influenza vaccination than did Black patients with the same conditions. Similarly, White patients with 2 or more high-risk conditions were more likely to receive the influenza vaccine than Black patients with the same conditions.

CONCLUSIONS

Significant racial/ethnic differences exist in influenza vaccination of high-risk individuals, and missed vaccination opportunities seem to contribute to the less-than-optimal influenza vaccination coverage in the United States.

Diversity matters: Unique populations of women and breast cancer screening

BACKGROUND

Ethnic differences in breast cancer screening behaviors are well established. However, there is a lack of understanding regarding exactly what causes these differences and which characteristics in low-screening populations should be targeted in an effort to modify screening behavior.

METHODS

Stratified cluster sampling was used to recruit 1364 women (ages 50-70 years) from 6 ethnic groups: African-American women; U.S.-born white women; English-speaking Caribbean, Haitian, and Dominican women; and immigrant Eastern-European women. In interviews, respondents provided information concerning demographic and structural variables related to mammogram utilization (age, education, income, marital status, physician recommendation, access, and insurance) and a set of cognitive variables (fatalism, perception of personal risk, health beliefs concerning cancer) and socioemotional variables (stress, cancer worry, embarrassment, and pain).

RESULTS

For data analysis, the authors used a 2-step logistic regression with frequency of mammograms over a 10-year period (< or = 4 mammograms over 10 years or > or = 5 mammograms over 10 years) as a dependent variable. U.S.-born African-American women and Dominican women were screened as frequently as European-American women, but the remaining minority groups were screened with less frequency. With one exception, ethnicity ceased to predict screening frequency once cognitive and emotional variables were controlled.

CONCLUSIONS

Although women from clearly operationalized ethnic groups continue to screen at rates substantially below those of the majority groups, these differences appear to be explained substantially by differences in psychologic variables. This is encouraging because, rather than targeting culture for intervention, variables can be targeted that are amenable to change, such as emotions and beliefs.

Patient satisfaction and referral intention: effect of patient-physician match on ethnic origin and cultural similarity

The study brought a cultural perspective into the mainstream model of health service quality by taking into account minorities' unique experience, patient-physician match on ethnic origin and cultural similarity. Survey data from Asian-American respondents supported a three-dimensional humaneness-professionalism-competence model of physician attributes. Physician humaneness and professionalism, patient-physician match on ethnic origin and cultural similarity predicted patient overall satisfaction and referral intention among Asian-Americans. Interestingly, the 3-dimensional model of physician attributes was also revealed in a Caucasian-American sample. However, Caucasian-Americans differ from Asian-Americans in several ways: physician competence was a significant predictor of overall satisfaction; professionalism was the only determinant of referral intention; and cultural similarity was not a significant factor with regards to either overall satisfaction or referral intention.

Differences in treatment and outcome between African-American and white women with endometrial cancer

PURPOSE

To investigate disparities in treatment and outcomes between African-American and white women with endometrial cancer.

PATIENTS AND METHODS

We analyzed 1992 to 1998 Surveillance, Epidemiology, and End Results data for 21,561 women with epithelial cancers of the endometrium. Sequential Cox proportional hazard models were used to determine the association between tumor characteristics (stage, grade, and histologic type), sociodemographic characteristics (age and marital status), and treatment (surgery and radiation therapy) and the racial difference in mortality.

RESULTS

The unadjusted hazard ratio (HR) for death from endometrial cancer for African-American women compared with white women was 2.57. However, African-American women were significantly more likely to present with advanced-stage disease and have poorly differentiated tumors or tumors with an unfavorable histologic type and were significantly less likely to undergo definitive surgery at all stages of disease. Adjusting for tumor and sociodemographic characteristics lowered the HR for African-American women to 1.80. Further adjustment for the use of surgery reduced the HR to 1.51. The association between surgery and survival was stronger among white women (HR, 0.26) than among African-American women (HR, 0.44).

CONCLUSION

African-American women with endometrial cancer are significantly less likely to undergo primary surgery and have significantly shorter survival than white women with endometrial cancer. Racial differences in treatment are associated with racial differences in survival. The association between use of surgery and survival is weaker among African-American than white women, raising questions about potential racial differences in the effectiveness of surgery.

The persuasiveness of racial arguments as a subtle measure of racism

These studies provide evidence of the reliability and validity of a new indirect measure of racism, the Racial Argument Scale (RAS). On the RAS, participants rate how well arguments support conclusions that are positive or negative toward Blacks rather than their agreement with the arguments and conclusions. These studies show that the RAS has good internal consistency, high levels of test-retest reliability, good convergent validity with other self-report measures of racism, and does not correlate with social desirability or right-wing authoritarianism. Furthermore, these studies show that the RAS predicts behavioral measures of racism and that the RAS is able to predict positivity and negativity toward Blacks that is not measured by other self-report measures of racism. These studies suggest that the RAS is a reliable and valid measure of racial attitudes.

Methods for using Medicare data to compare procedure rates among Asians, blacks, Hispanics, Native Americans, and whites

OBJECTIVE

Small sample sizes in Asian, Hispanic, and Native American groups and misreporting of race/ethnicity across all groups (including blacks and whites) limit the usefulness of racial/ethnic comparisons based on Medicare data. The objective of this paper is to compare procedure rates for these groups using Medicare data, to assess how small sample size and misreporting affect the validity of comparisons, and to compare rates after correcting for misreporting.

DATA

We use 1997 physician claims data for a 5 percent sample of Medicare beneficiaries aged 65 and older to study cardiac procedures and tests.

STUDY DESIGN

We calculate age and sex-adjusted rates and confidence intervals by race/ethnicity. Confidence intervals are compared among the groups. Out-of-sample data on misreporting of race/ethnicity are used to assess potential bias due to misreporting, and to correct for the bias.

PRINCIPAL FINDINGS

Sample sizes are sufficient to find significant ethnic and racial differences for most procedures studied. Blacks' rates tend to be lower than whites. Asian and Hispanic rates also tend to be lower than whites', and about the same as blacks'. Sample sizes for Native Americans are very small (about .1 percent of the data); nonetheless, some significant differences from whites can still be identified. Biases in rates due to misreporting are small (less than 10 percent) for blacks, Hispanics, and whites. Biases in rates for Asians and Native Americans are greater, and exceed 20 percent for some procedures.

CONCLUSIONS

Sample sizes for Asians, blacks, and Hispanics are generally adequate to permit meaningful comparisons with whites. Implementing a correction for misreporting makes Medicare data useful for all ethnic groups. Misreporting race/ethnicity and small sample sizes do not materially limit the usefulness of Medicare data for comparing rates among racial and ethnic groups.

Racial differences in initial treatment for clinically localized prostate cancer. Results from the prostate cancer outcomes study

OBJECTIVE

We examined whether there were racial differences in initial treatment for clinically localized prostate cancer and investigated whether demographic, socioeconomic, clinical, or tumor characteristics could explain any racial differences.

DESIGN

Prospective cohort study.

SETTING

Population-based tumor registries in Connecticut, Los Angeles, and Atlanta.

PARTICIPANTS

We evaluated 1144 African-American and non-Hispanic white men, aged 50 to 74 years, with clinically localized cancer diagnosed between October 1994 and October 1995.

MEASUREMENTS AND MAIN RESULTS

We obtained demographic, socioeconomic, and clinical data from patient surveys and medical record abstractions. We reported adjusted percentages for receiving treatment derived from multinomial logistic regression. We found an interaction between race and tumor aggressiveness. Among men with more aggressive cancers (PSA > or = 20 ng/mL or Gleason score > or = 8), African Americans were less likely to undergo radical prostatectomy than non-Hispanic whites (35.2% vs 52.0%), but more likely to receive conservative management (38.9% vs 16.3%, P=.003). Among the 71% of subjects with less aggressive cancers, African Americans and non-Hispanic whites were equally likely to receive either radical prostatectomy or radiation therapy (80.0% vs 84.5%, P=.2).

CONCLUSIONS

African Americans with more aggressive cancers were less likely to undergo radical prostatectomy and more likely to be treated conservatively. These treatment differences may reflect African Americans' greater likelihood for presenting with pathologically advanced cancer for which surgery has limited effectiveness. Among men with less aggressive cancers-the majority of cases-there were no racial differences in undergoing radical prostatectomy or radiation therapy.

Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness

PURPOSE

To evaluate the use and effectiveness of cancer-directed therapy in elderly patients with locally advanced pancreatic cancer (LAPC).

METHODS

We used the linked Surveillance, Epidemiology, and End Results Medicare database to perform a retrospective cohort study in 1,696 patients diagnosed with LAPC between 1991 and 1996. We calculated cancer-directed treatment use rates, then used logistic regression to identify patient and health system factors that were associated with receipt of treatment. Effectiveness of treatment was estimated using Cox proportional hazards models and propensity score methods.

RESULTS

In our cohort, 44% of patients received some form of cancer-directed therapy (24% radiation with concurrent chemotherapy, 13% radiation alone, and 7% chemotherapy alone). Older age, lower socioeconomic status, presence of comorbid illness, no care in a teaching hospital, and residence in the western United States were associated with a lower likelihood of receiving treatment (P </=.05). Among those treated, younger age and certain geographic locations were the only predictors of receiving combined-modality therapy. The adjusted hazard ratio for death associated with any treatment in the Cox model was 0.53 (P <.0001). Effectiveness estimates obtained using propensity score methods were similar.

CONCLUSION

This analysis supports the effectiveness of cancer-directed treatment in elderly patients with LAPC, but use is low. Receipt of treatment is strongly correlated with non-disease-related factors, especially sociodemographic characteristics, indicating possible disparities in access to care.

Building the Case for Cultural Competence

Cultural competence in the provision of health care is a very important area of investigation and is receiving recognition at multiple levels. Minority groups constitute a significant and growing percentage of our population. However, there has been no commensurate increase in the number of minority physicians. There is a tremendous need for medical professional schools and health care organizations to implement formal cultural competence training for current and future health professionals. In this article, we present the findings of an extensive literature review that describes how several factors have brought the need for cultural competence to the forefront. These factors include a greater appreciation for the impact of culture on health, changes in U.S. demographics, increased awareness in health care disparities, and modifications in legislative and accreditation mandates.

Racial Disparity in the Dose and Dose Intensity of Breast Cancer Adjuvant Chemotherapy

PURPOSE

The purpose of this study was to investigate the impact of race and obesity on dose and dose intensity of adjuvant chemotherapy.

METHODS

We abstracted data on patient/tumor characteristics, treatment course, physicians' intention to give a first cycle dose reduction, and reasons for dose reductions/delays from oncology records of 489 women treated from 1985 to 1997 in 10 treatment sites in two geographical regions. Administered doses and dose intensity were compared to standard regimens. Multivariate regression models determined the impact of race and body mass index (BMI) on dose proportion (actual:expected doses) and relative dose intensity (RDI) controlling for patient characteristics, comorbidity, chemotherapy regimen, site, and year of treatment. Logistic regressions explored race and BMI versus use of first cycle dose reductions.

RESULTS

African-Americans received lower chemotherapy dose proportion and RDI than whites (0.80 vs. 0.85, p = 0.03 and 0.76 vs. 0.80, p = 0.01). In multivariate analyses, dose proportion was 0.09 lower (p = 0.002), and RDI was 0.10 (p < 0.001) lower in non-overweight African-Americans than whites. Obesity was associated with lower dose proportion (p < 0.01) and RDI (p < 0.03). Race and BMI were independently associated with first cycle dose reductions. Non-overweight African-Americans (p < 0.05) and overweight and obese African-American and white women (p < 0.001) were more likely to have first cycle dose reductions than non-overweight whites.

CONCLUSION

We identified systematic differences in the administration of chemotherapy given to African-Americans and to overweight and obese women. These differences may contribute to documented disparities in outcome.

Charity for the Dying: Who Receives Unreimbursed Hospice Care?

OBJECTIVES

Many deaths occur among persons without insurance coverage for hospice care. We examined the patient and agency characteristics associated with receiving unreimbursed hospice care in a national survey.

RESULTS

We examined the receipt of unreimbursed care using the 1998 National Home and Hospice Care Survey (NHHCS) discharge dataset. Overall, only 3% of hospice patients received unreimbursed care. Because 98% of older adults are eligible for Medicare, we stratified multivariate analysis on age greater or less than 65 years. Among persons less than 65 years of age, younger, nonwhite persons were more likely to receive unreimbursed care, as were persons with cancer. Agencies providing unreimbursed care to persons over the age of 65 years were more likely to be not-for-profit and freestanding.

CONCLUSION

Recipients of unreimbursed hospice care are demographically similar to the uninsured, and whether uninsured persons receive unreimbursed hospice care depends on clinical and agency organizational factors related to the motivation to provide unreimbursed care.

Cadaver-donor renal transplantation of children in Israel (1990-2001): racial disparities in health care delivery?

OBJECTIVE

To evaluate the allocation and outcome of cadaver-donor renal transplantation (CDRTx) among Jewish and Arab children in Israel.

METHODS

Data on CDRTxs in patients who had end-stage renal failure (ESRF), were younger than 18 years, and were on dialysis treatment were obtained for the 11-year period of January 1990 to December 2000 from the Israeli Dialysis and Transplant Registry, supplemented by 10 years of follow-up (January 1991-December 2000) from our own center.

RESULTS

The Israeli Dialysis and Transplant Registry data show that 64 of 130 available cadaver-donor kidneys (CDKs) were allocated to Jewish patients (49.2%) and 66 of 130 were allocated to Arab children (50.8%): Moslem, Druze, or Christian. The Jew/Arab patient ratio for a waiting time of <1 year was 0.97 and for 1 to 2 years was 1.45, whereas that ratio was 0.6 for 2 to 4 years and 2.0 for >4 years. The mean renal transplant score (RTx score), reflecting the urgency of the need for RTx of an ESRF patient, was identical for Jew and Arab: 4.93 and 4.96. Our own center data refer to 69 dialysis (47 Arabs and 22 Jews) and 4 predialysis patients younger than 18 years who underwent 78 RTxs. Eighteen Arab and 14 Jewish children from our center received 20 and 15 CDRTxs in Israel, with a mean waiting time of 29.6 and 25.4 months for Jew and Arab, respectively (ratio: 1.16). In our center, the outcome (after 7 years) of graft survival and function was not different between Jewish and Arab RTx recipients.

CONCLUSIONS

Allocation of CDRTxs between young Jewish and Arab ESRF patients on dialysis did not differ and was associated with comparable waiting times, identical RTx scores, and similar long-term outcome. This is a remarkable finding, certainly in the face of the unequal race allocation of RTxs in the United States as well as the long unstable local (Middle East) political situation.

Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care

OBJECTIVES

Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care.

METHODS

The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers.

RESULTS

Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care.

CONCLUSIONS

Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.

Racial disparities in breast carcinoma survival rates: seperating factors that affect diagnosis from factors that affect treatment

BACKGROUND

Black females have lower breast carcinoma survival rates compared with white females. One possible reason is that black females have more advanced-stage breast disease. Another factor may be racial differences in the utilization of cancer treatments.

METHODS

The authors determined racial differences in 6-year stage specific survival rates, adjusting for age and treatments (using estrogen receptor [ER] status), to determine whether there were racial differences in treatment. Racial differences in the stage distributions of breast disease were used to examine the impact of racial factors on breast carcinoma diagnosis.

RESULTS

For all breast carcinoma cases, the stage specific 6-year survival rates, in general, were significantly lower for black females for all stages combined and for Stages I-III in every age group. However, examination by different treatments, as measured by ER status, revealed some different results. Only black women younger than age 50 years with ER-positive tumors and women younger than age 65 years with ER-negative tumors had significantly lower stage-specific survival rates. In addition, the stage distribution analyses showed that black females of every age group had less Stage I breast disease.

CONCLUSIONS

For younger black women (younger than age 50 years), there was evidence of racial differences in treatment for both women with ER-positive tumors and women with ER-negative tumors, as indicated by their lower stage-specific survival rates. In contrast, for black females age 65 years or older with ER-positive or ER-negative tumors, the lack of a significant difference in the stage-specific survival rate suggests that Medicare may help to alleviate racial disparities in cancer treatment. Furthermore, racial differences in the stage distributions indicated the need for earlier diagnosis for black females of every age.

Which psychiatric patients board on the medical service?

OBJECTIVES

Patients who require psychiatric hospitalization may be admitted to a medical service only because there are no available inpatient psychiatric beds. These patients are psychiatric "boarders." The goals of this study were to describe the extent of the boarder problem and to compare the characteristics of patients who are placed successfully into psychiatric facilities from the emergency department (ED) with those who require admission to the medical service as a boarder.

METHODS

A retrospective cohort study of a large pediatric ED was conducted. Included were patients who required inpatient psychiatric admission between July 1, 1999, and June 30, 2000. Patients were excluded when they needed inpatient medical treatment before psychiatric placement. The main outcome measured was placement into a psychiatric facility or boarding on medical service.

RESULTS

Of the 315 patients who presented to the ED and required psychiatric admission, 103 (33%) were boarded on the medical service. Multivariate logistic regression demonstrated an increased odds of boarding for age 10 to 13 years (adjusted odds ratio [AOR]: 3.5; 95% confidence interval [CI]: 1.8-6.6), black race (AOR: 2.3; 95% CI: 1.1-4.8), presenting on a weekend or holiday (AOR: 3.8; 95% CI: 1.6-8.8), and presenting from October to June (October-December 1999 [AOR: 4.7; 95% CI: 1.7-13.4], January-March 2000 [AOR: 14.5; 95% CI: 4.9-42.6], and April-June 2000 [AOR: 10.4; 95% CI: 3.5-30.2]) but a decreased odds for 1 insurance company (AOR: 0.08; 95% CI: 0.02-0.4). There was a linear increase in odds of boarding as severity of homicidal ideation increased from none to mild (AOR: 1.5; 95% CI: 1.2-1.8) to moderate (AOR: 2.3; 95% CI: 2.0-2.6) to severe (AOR: 3.5; 95% CI: 3.2-3.8). Suicidal patients also had increased risk of boarding (AOR: 2.2; 95% CI: 1.2-4.3).

CONCLUSIONS

Boarders are a problem in pediatrics, and this study identifies multiple characteristics that were associated with increasing a youth's odds of becoming a boarder at this institution. The suicidal and homicidal symptom results suggest a reverse triage system in which sicker patients are not necessarily given priority by psychiatric facilities. These data highlight mental health practices that need to be reassessed to ensure optimal care for youths with acute mental illness.

A decade of research on disparities in Medicare utilization: lessons for the health and health care of vulnerable men

Medicare research has shown that there are substantial disparities by race and socioeconomic status in use of services. In this article, I review past research and discuss how findings apply specifically to vulnerable men aged 65 years or older. Six lessons from this review are identified and illustrated here. Disparities in certain measures of health are growing; to reverse this trend, substantial efforts are needed, including dissemination of information about disparities as well as testing of hypotheses regarding underlying causes.

Patterns of care for the treatment of bladder cancer

PURPOSE

We examined bladder cancer patterns of care and differences in treatments administered to patients by age, race/ethnicity and gender using a population based sample.

MATERIAL AND METHODS

A random sample of bladder cancer patients diagnosed in 1995 without upper urinary tract involvement in 8 Surveillance, Epidemiology and End Results registries were included. Tumor stage and grade were used to assign patients to risk groups and patterns of care were investigated. Descriptive analyses and logistic regression models examined differences in care based on patient age, race/ethnicity and gender.

RESULTS

Of the 669 patients 485 patients had superficial disease, including 222 at low, 151 at intermediate and 112 at high risk, while 154 had muscle invasive disease. Of the patients with superficial bladder cancer 73.4% underwent transurethral bladder resection only. Those with muscle invasive disease were most commonly treated with transurethral bladder resection only (49.1%) or cystectomy only (31%). Intravesical chemotherapy in patients with superficial tumors and aggressive treatment with cystectomy and/or systemic chemotherapy in those with muscle invasive disease increased in relation to risk classification, as may have been expected. However, multivariate analyses suggested an influence of co-morbidities on intravesical therapy in patients with superficial tumors and an influence of patient age and geographic region on aggressive treatment for muscle invasive disease.

CONCLUSIONS

No differences in treatment were identified based on patient race/ethnicity or gender. Treatment for superficial disease is primarily influenced by risk category and co-morbidities, while treatment for muscle invasive disease is influenced by patient age and geographic region.

Asian-Pacific Islander race independently predicts poor outcome in patients with endometrial cancer

OBJECTIVE

The Department of Defense health care system provides access to care without respect to age, race, or socioeconomic status. We sought to determine the effect of race as a predictor of survival in patients with endometrial cancer treated in the Department of Defense medical system.

METHODS

Information on patients with endometrial carcinoma was extracted from the Department of Defense centralized tumor registry for the period 1988 to 1995. Data included age at diagnosis, military status, race, tumor histology, grade, FIGO surgical stage, adjuvant therapies, and disease-free survival. The chi(2) test was used for analysis of prognostic factors and adjuvant treatments between racial groups. Actuarial survival curves were calculated by using the method of Kaplan and Meier and compared by the log-rank test. Variables found to be significant on univariate analysis (P < 0.05) were entered into a multivariate Cox regression analysis.

RESULTS

Of 1811 patients meeting criteria for the study, racial distribution was 90% Caucasian, 4.4% African-American, and 5.5% Asian-Pacific Islander. African-Americans had more advanced stages of disease compared to Caucasians (P < 0.001). Both African-Americans and Asian-Pacific Islanders had higher grade tumors and less favorable histologic types than Caucasians (P < 0.05). The extent of adjuvant therapies was similar for racial groups. African-Americans and Asian-Pacific Islanders had significantly worse 5-year disease-free survivals than Caucasians (P = 0.007). Additional poor prognostic factors included age >60 years, grade, unfavorable histology, and stage. On multivariate analysis age >60 years, stage, and Asian-Pacific Islander race remained significant prognostic factors.

CONCLUSION

African-Americans and Asian-Pacific Islanders had worse survivals than Caucasians. After controlling for imbalances in clinicopathologic factors, Asian-Pacific Islander race was found to be a newly identified poor prognostic factor.

Adherence to surveillance among patients with superficial bladder cancer

BACKGROUND

Patients diagnosed with superficial bladder cancer who have not undergone total cystectomy are at high risk for recurrence, and bladder surveillance with cystoscopy is recommended for such patients every 3-6 months. We examined the degree to which bladder cancer patients undergo the recommended surveillance procedures and identified patient and primary care provider characteristics associated with nonadherence to these recommendations.

METHODS

We used information obtained from the Surveillance, Epidemiology, and End Results (SEER) Program-Medicare-linked database to identify 6717 patients aged 65 years or older who were diagnosed with superficial bladder cancer from 1992 through 1996 and who survived for at least 3 years after diagnosis but did not have a total cystectomy. We used information obtained from Medicare claims forms to examine the frequency with which these patients had a surveillance examination of the bladder during each of five contiguous 6-month intervals from month 7 to month 36 following diagnosis. We examined characteristics of patients and their physicians that were associated with low-intensity surveillance (defined as having an examination during fewer than two of the five possible follow-up intervals). Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). All statistical tests were two-sided.

RESULTS

Only 40% of the entire cohort had an examination during all five intervals; 1216 patients (18.1%) had low-intensity surveillance. Patient characteristics that were independently associated with low-intensity surveillance were being age 75 years or older (adjusted OR = 1.54, 95% CI = 1.35 to 1.74), nonwhite (adjusted OR = 1.94, 95% CI = 1.57 to 2.40), and having favorable tumor histology (adjusted OR = 0.59, 95% CI = 0.48 to 0.72 for poorly differentiated versus referent well-differentiated tumor grade) and high comorbidity (adjusted OR = 1.72, 95% CI = 1.30 to 2.27). Residence in an urban area or in a census tract with low median income was also associated with low-intensity surveillance.

CONCLUSIONS

The actual practice of surveillance for patients with superficial bladder cancer differs substantially from the standards recommended in clinical guidelines.