Racial, ethnic, socioeconomic, and access disparities in the use of preventive services among women

Effect of GP visits in the compliance of preventive services: a cross-sectional study in Europe

BACKGROUND

Performing cardiovascular and cancer screenings in target populations can reduce mortality. Visiting a General Practitioner (GP) once a year is related to an increased likelihood of preventive care. The aim of this study was to analyse the influence of visiting a GP in the last year on the delivery of preventive services based on sex and household income.

METHODS

Cross-sectional study using data collected from the European Health Interview Survey 2013-2015 of individuals aged 40-74 years from 29 European countries. The variables included: sociodemographic factors (age, sex, and household income (HHI) quintiles [HHI 1: lowest income, HHI 5: more affluent]), lifestyle factors, comorbidities, and preventive care services (cardiometabolic, influenza vaccination, and cancer screening). Descriptive statistics, bivariate analyses and multilevel models (level 1: citizen, level 2: country) were performed.

RESULTS

242,212 subjects were included, 53.7% were female. The proportion of subjects who received any cardiometabolic screening (92.4%) was greater than cancer screening (colorectal cancer: 44.1%, gynaecologic cancer: 40.0%) and influenza vaccination. Individuals who visited a GP in the last year were more prone to receive preventive care services (cardiometabolic screening: adjusted OR (aOR): 7.78, 95% CI: 7.43-8.15; colorectal screening aOR: 1.87, 95% CI: 1.80-1.95; mammography aOR: 1.76, 95% CI: 1.69-1.83 and Pap smear test: aOR: 1.89, 95% CI:1.85-1.94). Among those who visited a GP in the last year, the highest ratios of cardiometabolic screening and cancer screening benefited those who were more affluent. Women underwent more blood pressure measurements than men regardless of the HHI. Men were more likely to undergo influenza vaccination than women regardless of the HHI. The highest differences between countries were observed for influenza vaccination, with a median odds ratio (MOR) of 6.36 (under 65 years with comorbidities) and 4.30 (over 65 years with comorbidities), followed by colorectal cancer screening with an MOR of 2.26.

CONCLUSIONS

Greater adherence to preventive services was linked to individuals who had visited a GP at least once in the past year. Disparities were evident among those with lower household incomes who visited a GP. The most significant variability among countries was observed in influenza vaccination and colorectal cancer screening.

Equity and unmet need of non-communicable diseases services in Saudi Arabia using a National Household Survey (2019)

BACKGROUND

Saudi Arabia is implementing a comprehensive health system transformation in health services provision, governance, and financing. Given the high burden of non-communicable diseases (NCD), a key objective of the transformation is to integrate NCD prevention and treatment into primary care. The study objectives were to assess primary care service use for treatment of NCDs, to quantify existing inequities in preventive services utilization, and to identify regional and sociodemographic factors associated with these inequities.

METHODS

Using the 2019 Kingdom of Saudi Arabia World Health Survey, multivariable logistic regression models were conducted to identify predictors of utilization of primary care services for NCD prevention and treatment, unmet need among those with a diagnosis of diabetes, hypertension, or dyslipidemia, and unmet need in breast and cervical cancer screening.

RESULTS

Among those with an NCD diagnosis, living in a high-income household was associated with a lower probability of having an unmet need compared to those in low-income households. Furthermore, rural residents were less likely to have an unmet need compared to urban residents (OR 0.58, p=0.029). Individuals without a perceived need for healthcare within the last 12 months had three times the probability of unmet need in comparison to those with such a perceived need (p<0.001). Women in all regions had a lower probability of ever having a mammogram compared to women in the central regions around Riyadh. Women with an education above a secondary level had five times the odds of undergoing cervical cancer screening and three times the likelihood of ever having a mammogram (P=0.012, p=0.02) than other women. Compared to women in low-income households, those in middle (OR 1.99, P=0.026), upper middle (OR 3.47, p<0.001), or high-income households (OR 2.59, p<0.001) had a higher probability of having had cervical cancer screening.

CONCLUSIONS

Inequities in NCD treatment and prevention services' utilization in Saudi Arabia are strongly associated with region of living, population density, wealth, income, education and perceived need for health care. More research is needed to better understand the extent of unmet primary care needs for NCD and how to address the underlying contributing factors to access inequities.

Inequities in routine preventive care utilization among persons with overweight/obesity in the United States: An analysis of nativity, racial and ethnic identity, and socioeconomic status

Extant literature documented various health disparities among immigrants and racial and ethnically marginalized individuals in the United States. However, health disparities in the intersection of nativity and race are generally less visited. This cross-sectional study assessed utilization of routine preventive care among adults with overweight/obesity at the junction of their nativity, racial/ethnic identity, and socioeconomic status (i.e., income and education). Pooling data on 120,184 adults with overweight/obesity from the 2013-2018 waves of the National Health Interview Survey (NHIS), we estimated modified Poisson regressions with robust standard errors to obtain adjusted prevalence rates of preventive care visit, receiving flu shot, and having blood pressure, cholesterol and blood glucose screened. We found that immigrant adults with overweight/obesity had lower rates of utilization of all five preventive care services. However, these patterns varied by racial and ethnic sub-populations. While White immigrants had comparable rates of cholesterol and blood glucose screening, they had 2.7%, 2.9%, and 14.5% lower rates of preventive care visit, blood pressure screening, and getting a flu shot respectively, compared to native-born Whites. These patterns were similar for Asian immigrants as well. Black immigrants, on the other hand, had comparable rates of getting a flu shot and blood glucose screening, and had 5.2%, 4.9%, and 4.9% lower rates of preventive care visit, blood pressure screening, and cholesterol screening respectively. Lastly, the rates of utilization among Hispanic immigrants were significantly lower (ranging from 9.2% to 20%) than those of their native-born counterparts for all five preventive care services. These rates further varied by education, income, and length of stay in the US, within the racial and ethnic subgroups. Our findings thus suggest a complex relationship between nativity and racial/ethnic identity in relation to preventive care utilization among adults with overweight/obesity.

Educational attainment affects the diagnostic time in type 2 diabetes mellitus and the mortality risk of those enrolled in the diabetes pay-for-performance program

Most patients are diagnosed as having diabetes only after experiencing diabetes complications. Educational attainment might have a positive relationship with diabetes prognosis. The diabetes pay-for-performance (P4P) program-providing comprehensive, continuous medical care-has improved diabetes prognosis in Taiwan. This retrospective cohort study investigated how educational attainment affects the presence of diabetes complications at diabetes diagnosis and mortality risk in patients with diabetes enrolled in the P4P program. From the National Health Insurance Research Database, we identified patients aged >45 years who had received a new diagnosis of type 2 diabetes during 2002-2015; they were followed up until the end of 2017. We next used logistic regression analysis to explore whether the patients with different educational attainments had varied diabetic complication risks at diabetes diagnosis. The Cox proportional hazard model was employed to examine the association of different educational attainments in people with diabetes with mortality risk after their enrollment in the P4P program. The results indicated that as educational attainment increased, the risk of diabetes complications at type 2 diabetes diagnosis decreased gradually. When type 2 diabetes with different educational attainments joined the P4P program, high school education had the highest effect on reducing mortality risk; however, those with ≤ 6th grade education had the lowest impact.

A systematic review of the cost-effectiveness of interventions to increase cervical cancer screening among underserved women in Europe

BACKGROUND

This study aimed to conduct a systematic review of the cost-effectiveness studies of interventions to increase cervical cancer screening uptake rates in underserved women in Europe.

METHODS

A search of Embase, Medline, Global Health, PsychINFO, and NHS Economic Evaluation Database was conducted for studies published between January 2000 and September 2022. Studies were eligible if they analysed the cost-effectiveness of any interventions to improve participation in cervical cancer screening among underserved women of any age eligible to participate in cervical cancer screening in European countries, in any language. Study characteristics and cost-effectiveness results were summarised. Study quality was assessed using the Drummond Checklist, and methodological choices were further compared.

RESULTS

The searches yielded 962 unique studies, with 17 of these (from twelve European countries) meeting the eligibility criteria for data extraction. All studies focused on underscreened women as an overarching group, with no identified studies focusing on specific subgroups of underserved women. Generally, self-HPV testing and reminder interventions were shown to be cost-effective to increase the uptake rates. There was also research showing that addressing access issues and adopting different screening modalities could be economically attractive in some settings, but the current evidence is insufficient due to the limited number of studies.

CONCLUSION

This systematic review has revealed a gap in the literature on the cost-effectiveness of interventions to improve uptake rates of cervical cancer screening through tailored provision for specific groups of underserved women.

Association of culturally competent care with influenza vaccination coverage in the United States

BACKGROUND

Cultural minority groups in the United States have lower vaccination rates or worse influenza-related outcomes. Culturally competent care, which aims to engage the social, cultural, and linguistic needs of all patients, may address some of these disparities.

OBJECTIVE

We investigate how self-reported measures of culturally competent care is associated with influenza vaccination rates in the United States.

METHODS

The National Health Interview Survey (NHIS) 2017 was queried for respondents asked a set of questions which assessed respondents' access to culturally competent care in the past year. The outcome of interest was self-reported receipt of the annual influenza vaccine. Sample-weighted multivariable logistic regressions estimated the adjusted odds ratios and 95 % confidence intervals (95 %CI) of influenza vaccination with response to the cultural competency survey questions as the dependent variable of interest. Subsequent marginal modeling predicted the adjusted vaccination rates among cultural minorities (racial/ethnic minorities, LGBTQ + adults, foreign-born individuals, and non-English speakers) and respondents with high-risk comorbidities for worse influenza outcomes. Models were adjusted for other known determinants of vaccination coverage.

RESULTS

20,303 sample adults were included in the analyses. There were significantly higher odds of influenza vaccination among respondents who were "always" or "most of the time" treated with respect by their providers (aOR 1.53, 95 %CI [1.23-1.90], P < 0.001), given easy-to-understand information (aOR 1.37, 95 %CI [1.19-1.58], P < 0.001), asked about their opinions or beliefs about their care (aOR 1.29, 95 %CI [1.19-1.39], P < 0.001), and seen by providers who shared or understood their culture (aOR 1.15 95 %CI [1.01-1.30], P = 0.03), compared to their counterparts who responded with "some" or "none of the time" to the same survey questions. Higher adjusted influenza vaccination rates were seen among multiple racial/ethnic groups, LGBTQ + adults, foreign-born individuals, non-English speakers, and individuals with high-risk comorbidities who reported positive responses to the cultural competency survey questions.

CONCLUSIONS

We demonstrate a positive association between self-reported frequency of access to culturally competent care and receipt of the annual influenza vaccine. These findings support future efforts to evaluate vaccination outcomes among patients who receive components of culturally competent care, such as linguistically appropriate services, race-concordant healthcare workforce, and community engagement.

Racial and Ethnic Inequities in Use of Preventive Services Among Privately Insured Adults With a Pediatric-Onset Disability

PURPOSE

Cerebral palsy (CP) and spina bifida (SB) are pediatric-onset disabilities. Adults living with CP/SB are in a greater need of preventive care than the general population due to their increased risk for chronic diseases. Our objective was to compare White/Black and White/Hispanic inequities in the use of preventive services.

METHODS

Using 2007-2017 private claims data, we identified a total of 11,635 adults with CP/BS. Of these, 8,935 were White, 1,457 Black, and 1,243 Hispanic. We matched health-related variables (age, sex, comorbid conditions) between White adults and those in each minority subpopulation. Generalized estimating equations were used and all models were adjusted for age, sex, comorbidities, income, education, and US Census divisions. Outcomes of interest were: (1) any office visit; (2) any physical/occupational therapy; (3) wellness visit; (4) bone density screening; (5) cholesterol screening; and (6) diabetes screening.

RESULTS

The rate of recommended services for all subpopulations of adults with CP/SB was low. Compared with White adults, Hispanic adults had lower odds of wellness visits (odds ratio [OR] = 0.71, 95% CI, 0.53-0.96) but higher odds of diabetes screening (OR = 1.48, 95% CI, 1.13-1.93). Compared with White adults, Black adults had lower odds of wellness visits (OR = 0.50, 95% CI, 0.24-1.00) and bone density screening (OR = 0.54, 95% CI, 0.31-0.95).

CONCLUSIONS

Preventive service use among adults with CP/SB was low. Large White-minority disparities in wellness visits were observed. Interventions to address physical accessibility, adoption of telehealth, and increased clinician education may mitigate these disparities, particularly if initiatives target minority populations.

Postpartum Visit Attendance in the United States: A Systematic Review

INTRODUCTION

Adequate postpartum care, including the comprehensive postpartum visit, is critical for long-term maternal health and the reduction of maternal mortality, particularly for people who may lose insurance coverage postpartum. However, variation in previous estimates of postpartum visit attendance in the United States makes it difficult to assess rates of attendance and associated characteristics.

METHODS

We conducted a systematic review of estimates of postpartum visit attendance. We searched PubMed, CINAHL, PsycInfo, and Web of Science for articles published in English from 1995 to 2020 using search terms to capture postpartum visit attendance and use in the United States.

RESULTS

Eighty-eight studies were included in this analysis. Postpartum visit attendance rates varied substantially, from 24.9% to 96.5%, with a mean of 72.1%. Postpartum visit attendance rates were higher in studies using patient self-report than those using administrative data. The number of articles including an estimate of postpartum visit attendance increased considerably over the study period; the majority were published in 2015 or later.

CONCLUSIONS

Our findings suggest that increased systematic data collection efforts aligned with postpartum care guidelines and attention to postpartum visit attendance rates may help to target policies to improve maternal wellbeing. Most estimates indicate that a substantial proportion of women do not attend at least one postpartum visit, potentially contributing to maternal morbidity as well as preventing a smooth transition to future well-woman care. Estimates of current postpartum visit attendance are important for informing efforts that seek to increase postpartum visit attendance rates and to improve the quality of care.

The association of health insurance with the survival of cancer patients with brain metastases at diagnosis

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Patients with brain metastases at diagnosis have limited life expectancy.

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A patient’s insurance is associated with different overall survivals.

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Those with private insurance were most likely to receive all treatments modalities.

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Black patients are disproportionally represented in Medicaid or uninsured groups.

Background

Synchronous brain metastases (SBMs) are a presentation of stage IV cancers with limited treatment options. This study examines the association between health insurance status and overall survival (OS) of patients with SBMs using the National Cancer Database (NCBD).

Methods

We queried the NCDB for patients with SBMs from 2010 to 2015. Included cases were from seven primary cancers. Patients were grouped based on their insurance status. We assessed the association of insurance with OS using a Cox proportional hazards model adjusted for age at diagnosis, sex, race, education level, income level, residential area, treatment facility type, Charlson-Deyo comorbidity status, year of diagnosis, primary tumor type, and receipt of chemotherapy, radiation therapy (RT), immunotherapy, and primary site surgery.

Results

Of 97,659 patients included, those who had Medicaid, Medicare, or without health insurance were less likely to receive brain RT, chemotherapy, and/or surgery of the primary cancer site compared to privately insured patients. In multivariable COX analysis, patients with Medicare (HR = 1.11, 95% CI: 1.09–1.14, P < 0.001), Medicaid (HR = 1.11, 95% CI: 1.09–1.13, P < 0.001), or no insurance (HR = 1.18, 95% CI: 1.14–1.22, P < 0.001) were associated with decreased OS compared to private insurance.

Conclusion

After retrospective analysis, Medicaid, Medicare, and no insurance were all associated with worse OS compared to private insurance. Future studies can focus on determining the factors associated with insurance status and factors contributing to improved OS stratified by insurance status.

Trends in Differences Across Subgroups of Adults in Preventive Services Utilization

BACKGROUND

There were large differences across subgroups of adults in preventive services utilization before 2010. The Affordable Care Act had numerous provisions aimed at increasing utilization as well as at reducing disparities.

OBJECTIVE

This study examines whether preventive services utilization changed over time, across subgroups of adults defined by race/ethnicity, insurance coverage, poverty status, Census region, and urbanicity.

METHODS

Data from the Medical Expenditure Panel Survey Household Component are used to examine service utilization before the passage of the Affordable Care Act (2008/2009), after the implementation of the preventive services mandate and the dependent coverage provision (2012/2013), and after Medicaid expansions (2015/2016). Four preventive services are examined for adults aged 19-64-general checkups, blood cholesterol screening, mammograms, and colorectal cancer screening. Multivariate logistic regression models are used to predict preventive services utilization of adult subgroups in each time period, and to examine how differences across subgroups changed between 2008/2009 and 2015/2016.

RESULTS

There were modest increases in utilization between 2008/2009 and 2015/2016 for blood cholesterol and colorectal cancer screenings. For 3 of 4 preventive services, differences between the Northeast and the Midwest regions narrowed. However, large gaps in utilization across income groups and between those with and without coverage persisted. Disparities across racial/ethnic groups in general checkups persisted over time as well.

CONCLUSION

While some differences have narrowed, large gaps in preventive service utilization across population subgroups remain.

Income disparity and utilization of cardiovascular preventive care services among U.S. adults

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Low income individuals are less likely to receive smoking cessation counseling.

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Low income individuals are less likely to have their blood pressure checked.

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Low income individuals are less likely to be receive exercise counseling.

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Low income individuals are less likely to receive dietary counseling.

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Low income individuals are less likely to have their cholesterol levels checked.

Objective

: Associations between income disparity and utilization of cardiovascular disease (CVD) preventive care services, such as receipt of lifestyle advice and screening for CVD risk factors in populations with and without CVD, are not well understood. The purpose of this study was to evaluate associations between income and utilization of CVD-preventive services among U.S. adults.

Methods

: We included adults ≥18 years with and without CVD from the 2006 to 2015 Medical Expenditure Panel Survey. We categorized participants as high-income (>400% of federal poverty level [FPL]), middle income (200–400% of FPL), low-income (125–200% of FPL) and very low (VL)-income (<125% of FPL). We used logistic regression to compare the likelihood of receiving CVD-preventive services by income strata, adjusting for sociodemographic factors and comorbidities.

Results

: The study included 185,081 participants (representing 194.6 million U.S. adults) without CVD, and 32,862 participants (representing 37 million U.S. adults) with CVD. VL-income adults without CVD were less likely than high-income adults to have blood pressure measured within past 2 years [odds ratio [OR] 0.41 (95% confidence interval [CI] 0.37–0.45)] or cholesterol levels checked within past 5 years [0.36 (0.33–0.38)] or receive counseling about diet modifications [0.77 (0.74–0.81)], exercise [0.81 (0.77–0.85)], or smoking cessation [0.71 (0.63–0.79)] within past year. VL-income adults with CVD were also less likely to have blood pressure [0.32 (0.22–0.46)] or cholesterol [0.33 (0.26–0.42)] checked and receive counseling about exercise [0.84 (0.76–0.93)] or smoking cessation [0.78 (0.61–0.99)]. Additional subgroup analyses restricted to participants who had seen a healthcare provider within the preceding 12 months, as well as secondary analyses stratified by sex, race and ethnicity, showed similar disparities between high-income and VL-income participants.

Conclusions

: VL-income adults were less likely to be screened for CVD risk factors or receive CVD-prevention counseling than high-income adults, regardless of CVD status. More work must be done to reduce disparities in access to and utilization of CVD-preventive services among adults in different income groups.

Health preferences and preventive care utilisation: How EQ-5D-5L health preferences may affect uptake

Despite the economic and health benefits of preventive care being well established, the uptake of many cost-effective preventive services remains lower than desired in many cases, especially among specific sub-populations. The value an individual places on health can influence their uptake of preventive care. One way to capture the value an individual places on health and future health status is to examine their health preferences. This study used a novel use of EQ-5D-5L health preferences to determine if health preferences are associated with the uptake of a range of preventive care services, including a cancer screening, blood pressure check, cholesterol check, blood test and urine test. We collected EQ-5D-5L composite time trade-off data in 2018/2019 on 242 respondents residing in Ireland. We estimated an initial tobit model to predict an individual’s health preference to capture health preferences as a regressor. We then estimated a bivariate probit model to examine the uptake of each preventive service and GP use. Each model controlled for health preferences, education, sex, type of health coverage, self-reported health, employment status, age and marital status. Health preferences are a significant determinant of all five preventive services while controlling for other covariates. The results shows that the higher an individual values good health, the more likely they are to avail of preventive care. Health preferences can be noted as a potential determinant of preventive care use that could guide policy responses seeking to increase demand-side factors for preventive care uptake.

Sinonasal adenocarcinoma: Population-based analysis of demographic and socioeconomic disparities

BACKGROUND

Sinonasal adenocarcinoma (SNAC) is a rare tumor. The impact of health disparities on survival, stage at presentation, and utilization of surgery is not well understood in patients with SNAC.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for cases of SNAC from 1973 to 2015. Cases were analyzed to assess for disparities in presentation, treatment, and survival.

RESULTS

SNAC was identified in 630 patients. In a multivariate model of overall survival, an age increase of 10 years (Hazard Ratio (HR) = 1.37, p < 0.001), male sex (HR = 1.26, p = 0.045), and more recent decade of diagnosis (HR = 0.74, p < 0.001) were significantly related to time-to-death. There is a higher rate of SNAC-related death in counties with more rural populations (p = 0.027).

CONCLUSION

Future interventions targeting rural and less well-educated populations may improve care with the goal of increasing the span of healthy life and reducing survival disparities related to SNAC.

Implementation of the polycystic ovary syndrome guidelines: A mixed method study to inform the design and delivery of a lifestyle management program for women with polycystic ovary syndrome

AIM

The 2018 evidence-based polycystic ovary syndrome (PCOS) guidelines recommend lifestyle management as first-line treatment. This study aims to understand the preferred intervention characteristics of a PCOS lifestyle program from the perspectives of women with PCOS to inform the translation of the guidelines into practice.

METHODS

Women with self-reported PCOS residing in Australia took part in semi-structured interviews (n = 20) and an online survey (n = 286). The survey and interview schedule were developed using the template for intervention description and replication checklist.

RESULTS

Women want to take part in a lifestyle program (94.6%) and use government-subsidised sessions to attend (83%). Sessions of 45 to 60 minutes (75%) costing less than AUD$50 are preferred (60%). Topics of most interest related to sustainable daily physical activity (58%), overcoming non-hungry eating (54%), PCOS-specific diets (51%) and how to overcome barriers to behaviour change (45%). A delivery mode that combines online and in-person support is preferred (53%). Women are in need of long-term professional lifestyle support (6-12 months) that provides evidence-based, PCOS-specific, personalised prescription. Multidisciplinary support from a range of PCOS-trained professions is also preferred to address women's physical, psychological and emotional needs.

CONCLUSION

Women with PCOS are willing to take part in lifestyle programs that are low cost, long term, evidence based, PCOS-specific and provide practical strategies for nutrition and physical activity changes. Future online and in-person PCOS programs are strongly recommended to incorporate these findings to improve program engagement and patient satisfaction.

Recommending encounters according to the sociodemographic characteristics of patient strata can reduce risks from type 2 diabetes

Objectives

Physician encounters with patients with type 2 diabetes act as motivation for self-management and lifestyle adjustments that are indispensable for diabetes treatment. We elucidate the sociodemographic sources of variation in encounter usage and the impact of encounter usage on glucose control, which can be used to recommend encounter usage for different sociodemographic strata of patients to reduce risks from Type 2 diabetes.

Data and methods

We analyzed data from a multi-facility clinic in the Midwestern United States on 2124 patients with type 2 diabetes, from 95 ZIP codes. A zero-inflated Poisson model was used to estimate the effects of various ZIP-code level sociodemographic variables on the encounter usage. A multinomial logistic regression model was built to estimate the effects of physical and telephonic encounters on patients’ glucose level transitions. Results from the two models were combined in marginal effect analyses.

Results and conclusions

Conditional on patients’ clinical status, demographics, and insurance status, significant inequality in patient encounters exists across ZIP codes with varying sociodemographic characteristics. One additional physical encounter in a six-month period marginally increases the probability of transition from a diabetic state to a pre-diabetic state by 4.3% and from pre-diabetic to the non-diabetic state by 3.2%. Combined marginal effect analyses illustrate that a ZIP code in the lower quartile of high school graduate percentage among all ZIP codes has 1 fewer physical encounter per six months marginally compared to a ZIP code at the upper quartile, which gives 5.4% average increase in the probability of transitioning from pre-diabetic to diabetic. Our results suggest that policymakers can target particular patient groups who may have inadequate encounters to engage in diabetes care, based on their immediate environmental sociodemographic characteristics, and design programs to increase their encounters to achieve better care outcomes.

Social inequalities in breast cancer screening: evaluating written communications with immigrant Haitian women in Montreal

Background

The province of Quebec (Canada) has implemented a breast cancer screening program to diagnose this cancer at an early stage. The strategy is to refer women 50 to 69 years old for a mammogram every two years by sending an invitation letter that acts as a prescription. Ninety per cent (90%) of deaths due to breast cancer occur in women aged 50 and over. Numerous studies have shown social inequalities in health for most diseases. With breast cancer, a significant paradox arises: its incidence is lower among disadvantaged women and yet, more of them die from this disease. The health care system might play a role in this inequality. The scientific literature documents the potential for creating such inequalities when prevention does not consider equity among social groups. Immigrant women are often disadvantaged. They die of breast cancer more than non-immigrants. Studies attribute this to late-stage diagnosis due to poor adherence to mammography screening programs.

Purpose of the study

The main objective of our research is to assess how Haitian immigrant women in Montreal are reached by the Quebec Breast Cancer Screening Program, and specifically how they perceive the mammogram referral letter sent by the program.

Methods

The study uses a two-step qualitative method: i) In-depth interviews with influential community workers to identify the most relevant issues; ii) Focus groups with disadvantaged women from Montreal’s Haitian community.

Results

A mammogram referral letter from the Breast Cancer Screening Program may be a barrier to compliance with mammography by underprivileged Haitian women in Montreal. This might be attributable to a low level of literacy, poor knowledge of the disease, and lack of financial resources.

Conclusion

Barriers may be underestimated in underprivileged immigrant and non-immigrant communities. A preventive strategy must be adapted to different sub-groups and must also take into account lower literacy levels. To increase mammography uptake, it is crucial that the benefits of prevention be clearly identified and described in understandable terms. Finally, economic access to follow-up measures should be considered.

Outcomes by Race Among Women Referred to an Academic Colposcopy Clinic with a Patient Navigation Program

Background: Although minority women are at higher risk of cervical cancer in the United States, little is known about differences in rates of colposcopy and loop electrosurgical excision procedure (LEEP) by race once patients present for care. Materials and Methods: A prospective registry of patients presenting to an academic colposcopy clinic was queried from 2008 to 2018. Women with missing race or cytology results, prior hysterectomy, or prior history of cervical, vulvar, or vaginal cancer were excluded. Poisson and logistic regression models were performed to evaluate the associations between race and colposcopy, LEEP, and cancer rates, adjusting for referral Papanicolaou (Pap), human papillomavirus (HPV) result, year of visit, age, insurance, pregnancy, number of sexual partners, and smoking status. Results: A total of 4506 women were included (56.1% white and 43.9% non-white). Referral for high-grade cytology was more likely among white compared to non-white women (22.5% vs. 17.5%, p < 0.001), as well as positive HPV testing (white 7.8% vs. non-white 6.0%, p < 0.001). The colposcopy rate was slightly higher among black (incidence rate ratio [IRR]_adjusted 1.11, 95% confidence interval [CI] 1.03-1.19, p = 0.006) and Hispanic women (IRR_adjusted 1.13, 95% CI 1.06-1.21, p = 0.0003) compared to white women. Hispanic women were significantly more likely to undergo LEEP (odds ratio_adjusted 1.26, 95% CI 1.01-1.58, p = 0.04). However, no significant difference in cancer, adenocarcinoma in situ, or high-grade histology was noted by race. Conclusions: Black and Hispanic women referred for abnormal Pap or HPV results underwent a greater number of colposcopies compared to white women, and Hispanic women underwent a greater number of LEEPs. Although cancer is rare in our cohort, there was no statistical difference in rate of cancer by race.

Using a group medical visit model to promote healthy behaviour change with an underserved population

BACKGROUND

Models of care are needed to address physical activity, nutrition promotion and weight loss in primary care settings, especially with underserved populations who are disproportionately affected by chronic illness. Group medical visits (GMVs) are one approach that can help overcome some of the barriers to behaviour change in underserved populations, including the amount of time required to care for these patients due to socio-economic stressors and psychosocial complexities (1). GMVs have been shown to improve care in coronary artery disease and diabetes, but more evidence is needed in underserved settings.

OBJECTIVE

This project sought to evaluate a GMV incorporating a physical activity component in an underserved patient population, measuring biometric and motivation outcome measures.

METHODS

This project used a pre-post intervention study design through patient surveys at baseline and 12 weeks. We included validated motivational measures along with self-reported demographic information. A GMV intervention promoting physical activity and nutrition to promote weight loss was delivered by an interdisciplinary primary care team and community partners in a Federally Qualified Health Center in Rochester, NY. The intervention consisted of six, 2-hour sessions that occurred every other week at the clinic site.

RESULTS

Participants lost a significant amount of weight and maintained the weight loss at 6 months. In addition, there was a significant improvement in motivation measures.

CONCLUSION

This study provides preliminary evidence that our GMV model can improve weight loss and autonomous motivation in an underserved population. This project has potential for scalability and sustainability.

Psychological and neighborhood factors associated with urban women's preventive care use

Women are more likely than men to forego care-including preventive care. Understanding which factors influence women's preventive care use has the potential to improve health. This study focuses on the largely understudied areas of psychological barriers (depression) and neighborhood factors (support and stressors) that may be associated with women's preventive care use through secondary analysis of the Chicago Community Adult Health Study. Across models, 30-40% of the variance in preventive care adherence was explained by the neighborhood. Depressive symptoms were not associated with preventive care use when neighborhood factors were included. However, stratified models showed that associations varied by race/ethnicity. Previous research has tended to focus on individual determinants of care, but this study suggests that barriers to care are far more complex. Efforts aimed at improving care utilization need to be multipronged and interventions need to take an individual's demographics, mental health, and context into account.

Increasing uptake of evidence-based screening services though a community health worker-delivered multimodality program: study protocol for a randomized pragmatic trial

BACKGROUND

Underserved ethnic minority populations experience significant disparities in HIV, hepatitis C virus (HCV), colorectal cancer (CRC), and cervical cancer incidence and mortality. Much of the excess burden of these diseases among underserved communities is due to lack of preventive care, including screening. Barriers to disease screening include low awareness, lack of access to care and health insurance, and cultural beliefs regarding disease prevention. Our current trial aims to examine community health worker (CHW)-delivered, home-based multi-modality screening for HIV, HCV, CRC, and cervical cancer simultaneously.

DESIGN

We are conducting a randomized pragmatic trial among 900 Haitian, Hispanic, and African-American participants from diverse underserved communities in South Florida. People between the ages of 50 and 65 who have not had appropriate HIV, HCV, CRC, and cervical cancer screening per United States Preventive Services Task Force (USPSTF) recommendations are eligible for the study. Participants are recruited by CHWs and complete a structured interview to assess multilevel determinants of disease risk. Participants are then randomized to receive HIV, HCV, CRC, and cervical cancer screening via navigation to care by a CHW (Group 1) or via CHW-delivered home-based screening (Group 2). The primary outcome is completion of screening for each of these diseases within 6 months post-enrollment.

DISCUSSION

Our trial is among the first to examine the effectiveness of a CHW-delivered, multimodality, home-based disease-screening approach. If found to be effective, this approach may represent a cost-effective strategy for disease screening within underserved and underscreened minority groups.

TRIAL REGISTRATION

Clinical Trials.gov # NCT02970136, registered November 21, 2016.

Cancer Screening Among Women Prescribed Opioids: A National Study

PURPOSE

Prior work suggests that there are competing demands between addressing pain and other issues in primary care, potentially lessening delivery of evidence-based cancer screening. We assessed the association between opioid therapy and cancer screening among women in a nationally representative US sample.

METHODS

We conducted an observational analysis of the 2005-2015 Medical Expenditure Panel Surveys. We included all women aged ≥18 years without cancer and with opioid prescription and preventive care services data. Logistic regression analyses examined associations between receipt of opioid prescription (any vs none) and receipt of breast, cervical, and colorectal cancer screenings. Analyses were adjusted for sociodemographic characteristics, health status, health conditions, and usual source of care, as well as health care utilization.

RESULTS

Of 53,982 participants, 15.8% reported ≥1 opioid prescription. Compared with women not prescribed opioids, those prescribed opioids were more likely to visit their doctor (median number of visits per year = 5, vs 1). Without adjustment for number of visits, women prescribed opioids were more likely to receive all 3 cancer screenings; the adjusted odds ratio for breast cancer screening was 1.26 (95% CI, 1.16-1.38), that for cervical cancer screening was 1.22 (95% CI, 1.13-1.33), and that for colorectal cancer screening was 1.22 (95% CI, 1.12-1.33). With adjustment for number of visits, adjusted odds ratios decreased (breast 1.07 [95% CI, 0.98-1.18]; cervical 1.01 [95% CI, 0.93-1.09]; colorectal 1.04 [95% CI, 0.95-1.14]).

CONCLUSIONS

In a nationally representative sample, receipt of opioid prescriptions was not associated with less recommended cancer screenings. Rather, women receiving opioids had greater adjusted odds of receiving breast, cervical, and colorectal cancer screening, although the associations were attenuated by adjusting for their more frequent office visits relative to women not receiving opioids.

Trends in Cancer Survival by Health Insurance Status in California From 1997 to 2014

Importance

There have been substantial improvements in the early detection, treatment, and survival from cancer in the United States, but it is not clear to what extent patients with different types of health insurance have benefitted from these advancements.

Objective

To examine trends in cancer survival by health insurance status from January 1997 to December 2014.

Design, Setting, and Participants

California Cancer Registry (a statewide cancer surveillance system) data were used to estimate population-based survival by health insurance status in 3 calendar periods: January 1997 to December 2002, January 2003 to December 2008, and January 2009 to December 2014 with follow-up through 2014. Overall, 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma in California were included in the study.

Main Outcomes and Measures

Five-year all-cause and cancer-specific survival probabilities by insurance category and calendar period for each cancer site and sex; hazard ratios (HRs) and 95% CIs for each insurance category (none, Medicare, other public) compared with private insurance in each calendar period.

Results

According to data from 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma gathered from the California Cancer Registry, improvements in survival were almost exclusively limited to patients with private or Medicare insurance. For patients with other public or no insurance, survival was largely unchanged or declined. Relative to privately insured patients, cancer-specific mortality was higher in uninsured patients for all cancers except prostate, and disparities were largest from 2009 to 2014 for breast (HR, 1.72; 95% CI, 1.45-2.03), lung (men: HR, 1.18; 95% CI, 1.06-1.31 and women: HR, 1.32; 95% CI, 1.15-1.50), and colorectal cancer (women: HR, 1.30; 95% CI, 1.05-1.62). Mortality was also higher for patients with other public insurance for all cancers except lung, and disparities were largest from 2009 to 2014 for breast (HR, 1.25; 95% CI, 1.17-1.34), prostate (HR, 1.17; 95% CI, 1.04-1.31), and colorectal cancer (men: HR, 1.16; 95% CI, 1.08-1.23 and women: HR, 1.11; 95% CI, 1.03-1.20).

Conclusions and Relevance

After accounting for patient and clinical characteristics, survival disparities for men with prostate cancer and women with lung or colorectal cancer increased significantly over time, reflecting a lack of improvement in survival for patients with other public or no insurance. To mitigate these growing disparities, all patients with cancer need access to health insurance that covers all the necessary elements of health care, from prevention and early detection to timely treatment according to clinical guidelines.

Medicare Annual Wellness Visits: A Scoping Review of Current Practice Models and Opportunities for Pharmacists

Objective:

To explore the existing practice models and practice opportunities surrounding pharmacist-delivered Medicare Annual Wellness Visits (AWVs), with the goal of improving patient access through advanced pharmacy-based health services.

Data Sources:

English-language articles published in peer-reviewed journals from January 2011 to March 2018 were reviewed by searching PubMed and Google Scholar databases using permutations of terms such as “pharmacist/pharmacy,” “Medicare,” “Annual Wellness Visit,” “develop/development,” and “implement/implementation.”

Study Selection and Data Extraction:

Original articles reporting resources (inputs), processes, and programmatic outcomes (uptake and delivery, interventions made, financial models, satisfaction) of pharmacist-delivered AWV services were retained.

Data Synthesis:

Eight articles describing 6 unique studies representing current pharmacist-delivered AWV practices were included in the final review. All identified articles used observational study designs and were published in peer-reviewed journals from 2014 to 2017. Five studies utilized staff (in-house) pharmacists working in internal or family medicine clinics via collaborative practice agreements; one study described a model for outsourcing AWV services through a community pharmacy. Pharmacists completed 37 to 300 AWVs and performed both medication- and non-medication-related interventions, with a mean of 3.5 to 5.4 interventions/patient. Quarterly revenue ranged from $3750 to $22 340 (USD), with 40 pharmacist-hours required for initial program development.

Implications for Patient Care and Clinical Practice:

This scoping review will serve as a guide for pharmacists wishing to implement AWV services in their own practices.

Conclusions:

There is opportunity for ambulatory/community pharmacists to expand their practices to include AWV services in states that allow collaborative practice agreements. Interprofessional collaboration between physicians and pharmacists can optimize and aid adoption of pharmacist-delivered AWV services.

Effectiveness of Medicare cost-sharing elimination for Cancer screening on utilization

Background

The Patient Protection and Affordable Care Act (ACA) eliminated the cost-sharing requirement for several preventive cancer screenings. This study examined the cancer screening utilization of mammogram, Pap smear and colonoscopy in Medicare fee-for-service (FFS) under the ACA.

Methods

The primary data were the 2007–2013 Medicare Current Beneficiary Survey linked to FFS claims. The effect of the cost-sharing removal on the probability of receiving a preventive cancer screening test was estimated using a logistic regression, separately for each screening test, adjusting for the complex survey design. The model was also separately estimated for different socioeconomic and race/ethnic groups.

The study sample included beneficiaries with Part B coverage for the entire calendar year, excluding beneficiaries in Medicaid or Medicare Advantage plans. Beneficiaries with a claims-documented or self-reported history of targeted cancers, who were likely to have diagnostic tests or have surveillance screenings were excluded.

The screening measures were constructed separately following Medicare coverage and U.S. Preventive Services Task Force (USPSTF) recommendations. We measured the screening utilization outcome drawing from claims data, as well as using the self-reported survey data.

Results

After the cost-sharing removal policy, we found no statistically significant difference in a beneficiary’s probability of receiving a colonoscopy (transition period: OR = 1.08, 95% CI = 0.90–1.29; post-policy period: OR = 1.08, 95% CI = 0.83–1.42), a mammogram (transition period: OR = 1.03, 95% CI = 0.91–1.17; post-policy period: OR = 1.07, 95% CI = 0.88–1.30), or a biennial Pap smear (transition period: OR = 0.87, 95% CI = 0.69–1.09; post-policy period: OR = 0.72, 95% CI = 0.51–1.03) in claims-based measures following Medicare coverage. Similarly, we found null effects of the policy change on utilization of colonoscopy among enrollees 50–75 years old, biennial mammograms by women 50–74, and triennial Pap smear tests among women 21–65 in claims-based measures according to USPSTF. The findings from survey-based measures were consistent with the estimates from claims-based measures, except that the use of Pap smear declined since 2011. Further, the policy change did not increase utilization in patients with disadvantaged socioeconomic characteristics. Yet the disparate patterns in adjusted screening rates by socioeconomic status and race/ethnicity persisted over time.

Conclusions

Removing out-of-pocket costs for screenings did not provide enough incentives to increase the screening rates among Medicare beneficiaries.

Optimism may moderate screening mammogram frequency in Medicare: A longitudinal study

Higher trait optimism and/or lower cynical hostility are associated with healthier behaviors and lower risk of morbidity and mortality, yet their association with health care utilization has been understudied. Whether these psychological attitudes are associated with breast cancer screening behavior is unknown. To assess the association of optimism and cynical hostility with screening mammography in older women and whether sociodemographic factors acted as mediators of these relationships, we used Women's Health Initiative (WHI) observational cohort survey data linked to Medicare claims. The sample includes WHI participants without history of breast cancer who were enrolled in Medicare Parts A and B for ≥2 years from 2005-2010, and who completed WHI baseline attitudinal questionnaires (n = 48,291). We used survival modeling to examine whether screening frequency varied by psychological attitudes (measured at study baseline) after adjusting for sociodemographic characteristics, health conditions, and healthcare-related variables. Psychological attitudes included trait optimism (Life Orientation Test-Revised) and cynical hostility (Cook Medley subscale), which were self-reported at study baseline. Sociodemographic, health conditions, and healthcare variables were self-reported at baseline and updated through 2005 as available. Contrary to our hypotheses, repeated events survival models showed that women with the lowest optimism scores (i.e., more pessimistic tendencies) received 5% more frequent screenings after complete covariate adjustment (p < .01) compared to the most optimistic group, and showed no association between cynical hostility and frequency of screening mammograms. Sociodemographic factors did not appear to mediate the relationship between optimism and screenings. However, higher levels of education and higher levels of income were associated with more frequent screenings (both p < .01). We also found that results for optimism were primarily driven by women who were aged 75 or older after January 2009, when changes to clinical guidelines lead to uncertainty about risks and benefits of screening in this age group. The study demonstrated that lower optimism, higher education, and higher income were all associated with more frequent screening mammograms in this sample after repeated events survival modeling and covariate adjustment.

Social Inequalities in Prenatal Folic Acid Supplementation: Results from the ELFE Cohort

Most professional and international organizations recommend folic acid supplementation for women planning pregnancy. Various studies have shown high levels of non-compliance with this recommendation. This study aimed to identify sociodemographic characteristics related to this compliance. The analyses were based on 16,809 women from the French nationwide ELFE cohort (Etude Longitudinale Française depuis l’Enfance). Folic acid supplementation was assessed at delivery, and sociodemographic characteristics were collected at two months postpartum. The association between sociodemographic characteristics and compliance with recommendations on folic acid supplementation (no supplementation, periconceptional supplementation, and supplementation only after the periconceptional period) was examined using multivariate multinomial logistic regression. Only 26% of French women received folic acid supplementation during the periconceptional period, 10% of women received supplementation after the periconceptional period, and 64% received no supplementation. Young maternal age, low education level, low family income, multiparity, single parenthood, maternal unemployment, maternal overweight, and smoking during pregnancy were related to lower likelihood of folic acid supplementation during the periconceptional period compared to no supplementation. These associations were not explained by unplanned pregnancy. Immigrant and underweight women were more likely to receive folic acid supplementation after the periconceptional period. Our study confirms great social disparities in France regarding the compliance with the recommendations on folic acid supplementation.

Impact of The Affordable Care Act's Elimination of Cost-Sharing on the Guideline-Concordant Utilization of Cancer Preventive Screenings in the United States Using Medical Expenditure Panel Survey

Currently available evidence regarding the association of the Affordable Care Act’s (ACA) elimination of cost-sharing and the utilization of cancer screenings is mixed. We determined whether the ACA’s zero cost-sharing policy affected the guideline-concordant utilization of cancer screenings, comparing adults (≥21 years) from 2009 with 2011–2014 data from the Medical Expenditure Panel Survey. Study participants were categorized as: 21–64 years with any private insurance, ≥65 years with Medicare only, and 21–64 years uninsured, with a separate sample for each type of screening test. Adjusted weighted prevalence and prevalence ratios (PR (95%CI)) were estimated. In 2014 (vs. 2009), privately-insured women reported 2% (0.98 (0.97–0.99)) and 4% (0.96 (0.93–0.99)) reduction in use of Pap tests and mammography, respectively. Privately-insured non-Hispanic Asian women had 16% (0.84 (0.74–0.97)) reduction in mammography in 2014 (vs. 2009). In 2011 (vs. 2009), privately-insured and Medicare-only men reported 9% (1.09 (1.03–1.16)) and 13% (1.13 (1.02–1.25)) increases in colorectal cancer (CRC) screenings, respectively. Privately-insured women reported a 6–7% rise in 2013–2014 (vs. 2009), and Hispanic Medicare beneficiaries also reported 40–44%, a significant rise in 2011–2014 (vs. 2009), in the utilization of CRC screenings. While the guideline-concordant utilization of Pap tests and mammography declined in the post-ACA period, the elimination of cost-sharing appeared to have positively affected CRC screenings of privately-insured males, females, and Hispanic Medicare-only beneficiaries. Greater awareness about the zero cost-sharing policy may help in increasing the uptake of cancer screenings.

Knowledge, Beliefs and Attitudes of Somali Men in Olmsted County, Minnesota, U.S., on the Human Papillomavirus Vaccine and Cervical Cancer Screening: January 17, 2015

This study explores the general knowledge of Human Papillomavirus vaccine (HPV) and cervical cancer screening (CCS) among Somali men in the U.S., who are major decision-makers in Somali households. HPV infects both men and women, and causes genital warts and cervical cancer (CC). High mortality from CC persists among minorities due to low uptake of preventive tools. Eleven questions assessed general knowledge of HPV and CCS among 30 Somali male respondents. The knowledge of HPV and CCS by education level, age, and years lived in the U.S., was assessed using the health belief model. Most respondents had no knowledge of HPV vaccine and CCS, and low perceived susceptibility to HPV infection. There is need for more research on Somali men's attitude to HPV vaccine and CCS uptake among Somali adolescents and women.

The Well-Woman Project: Listening to Women's Voices

Purpose: The U.S. Affordable Care Act (ACA) of 2010 included the Well-Woman Visit (WWV) as one of the preventive services, which must be covered without cost sharing. Despite concerted efforts to increase access to the WWV, data from the early years of the ACA demonstrated ongoing barriers, including insufficient consumer and provider awareness of the ACA's no cost-sharing provision for preventive services. As such, 2 years after full implementation of the ACA, the Well-Woman Project (WWP) used qualitative methods to learn about women's perceptions of the WWV and barriers that affect their ability to be healthy and seek well-woman care.

Methods: Women's voices were captured by Listening Sessions in eight cities and through stories from women across the United States posted to a WWP Website, or reported over a WWP toll-free phone line. Thematic analysis of Listening Sessions and stories was conducted using Dedoose software.

Results: In 2016, Listening Sessions (17) were held with 156 women; in addition, stories were collected from 102 women across the United States. Women are aware of the importance of preventive care, but report multiple barriers to seeking such care. However, they are able to articulate a variety of system and policy strategies that mitigate the complexity of navigating the health care system; help women prioritize their health and accessing health care; promote positive relationships with providers; empower women to advocate for themselves and others; promote positive mental health as well as access to safe environments, healthy food, and social support systems; decrease barriers related to lack of transportation and childcare; and support the provision of trauma informed care in the health care delivery system.

Conclusion: To improve women's health status and reduce inequities, making the preventive well-care visit available without cost-sharing is necessary, but not a sufficient strategy.

Effects of the ACA on Preventive Care Disparities

BACKGROUND

The Affordable Care Act (ACA) requires non-grandfathered private insurance plans, starting with plan years on or after September 23rd, 2010, to provide certain preventive care services without any cost sharing in the form of deductibles, copayments or co-insurance. This requirement may affect racial and ethnic disparities in preventive care as it provides the largest copay reduction in preventive care.

OBJECTIVES

We ask whether the ACA's free preventive care benefits are associated with a reduction in racial and ethnic disparities in the utilization of four preventive services: cholesterol screenings, colonoscopies, mammograms, and Pap smears.

METHODS

We use a data set of over 6000 individuals from the 2009, 2010, and 2013 Medical Expenditure Panel Surveys (MEPS). We restrict our data set only to individuals who are old enough to be eligible for each preventive service. Our difference-in-differences logistic regression model classifies privately insured Hispanics, African Americans, and Asians as the treatment groups and 2013 as the after-policy year. Our control group consists of non-Hispanic whites on Medicaid as this program already covered preventive care services for free or at a low cost before the ACA.

RESULTS

After controlling for income, education, marital status, preferred interview language, self-reported health status, employment, having a usual source of care, age and gender, we find that the ACA is associated with increases in the probability of the median, privately insured Hispanic person to get a colonoscopy by 3.6% and a mammogram by 3.1%, compared to a non-Hispanic white person on Medicaid. Similarly, we find that the median, privately insured African American person's probability of receiving these two preventive services improved by 2.3 and 2.4% compared to a non-Hispanic white person on Medicaid. We do not find any significant improvements for any racial or ethnic group for cholesterol screenings or Pap smears. Furthermore, our results do not indicate any significant changes for Asians compared to non-Hispanic whites in utilizing the four preventive services. These reductions in racial/ethnic disparities are robust to reconfigurations of time periods, previous diagnosis, and residential status.

CONCLUSIONS

Early effects of the ACA's provision of free preventive care are significant for Hispanics and African Americans. Further research is needed for the later years as more individuals became aware of these benefits.

Eliciting vulnerable patients' preferences regarding colorectal cancer screening: a systematic review

BACKGROUND

Patient preferences are important to consider in the decision-making process for colorectal cancer (CRC) screening. Vulnerable populations, such as racial/ethnic minorities and low-income, veteran, and rural populations, exhibit lower screening uptake. This systematic review summarizes the existing literature on vulnerable patient populations' preferences regarding CRC screening.

METHODS

We searched the CINAHL, PsycINFO, PubMed, Scopus, and Web of Science databases for articles published between January 1, 1996 and December 31, 2017. We screened studies for eligibility and systematically abstracted and compared study designs and outcomes.

RESULTS

A total of 43 articles met the inclusion criteria, out of 2,106 articles found in our search. These 43 articles were organized by the primary sub-population(s) whose preferences were reported: 27 report on preferences among racial/ethnic minorities, eight among low-income groups, six among veterans, and two among rural populations. The majority of studies (n=34) focused on preferences related to test modality. No single test modality was overwhelmingly supported by all sub-populations, although veterans seemed to prefer colonoscopy. Test attributes such as accuracy, sensitivity, cost, and convenience were also noted as important features. Furthermore, a preference for shared decision-making between vulnerable patients and providers was found.

CONCLUSION

The heterogeneity in study design, populations, and outcomes of the selected studies revealed a wide spectrum of CRC screening preferences within vulnerable populations. More decision aids and discrete choice experiments that focus on vulnerable populations are needed to gain a more nuanced understanding of how vulnerable populations weigh particular features of screening methods. Improved CRC screening rates may be achieved through the alignment of vulnerable populations' preferences with screening program design and provider practices. Collaborative decision-making between providers and vulnerable patients in preventive care decisions may also be important.

What Explains Education Disparities in Screening Mammography in the United States? A Comparison with The Netherlands

Background: In the U.S., less educated women are substantially less likely to receive screening mammography. It is not clear whether this is due to differences in access to screening or in perceptions of breast cancer risks and the effectiveness of screening. We weigh the plausibility of these two explanations by examining how the dependence of mammography on education changes after conditioning on indicators of access and perceptions. We also compare estimates for the U.S. with those for the Netherlands where there is universal access to a publicly financed screening program. Method: Cross-sectional and cross-country comparable individual level data from the American Life Panel (n = 646) and the Netherlands Longitudinal Internet Studies for the Social Sciences (n = 1398) were used to estimate and explain education disparities in screening mammograms given to American and Dutch women aged 40+. The education gradient was estimated using logit models. Controls were sequentially added to detect whether disparities were explained by differences in access or perceptions of risks and effectiveness. Results: In the United States, high school graduates were 11.5 percentage points (95% CI: 1–22 percentage points) less likely than college graduates to receive a screening mammogram in the previous two years. This education gradient was largely explained by differences in income, insurance coverage and receipt of medical advice. It was not explained by educational differences in the perceived risk of breast cancer and the effectiveness of mammography. There were no education disparities in receipt of mammography among Dutch women within the 50–75 age range covered by the national screening program. Conclusion: In the absence of a universal screening program in the U.S., determinants of access—income, insurance coverage and receipt of medical advice—appear to drive the education disparities in screening mammography.

Higher Predictive Value Positive for MMA Than ACA MTM Eligibility Criteria Among Racial and Ethnic Minorities: An Observational Study

The objective of this study was to examine positive predictive value (PPV) of medication therapy management (MTM) eligibility criteria under Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial and ethnic groups. The study analyzed Medicare data (2012-2013) for 2 213 594 beneficiaries. Medication utilization issues were determined based on medication utilization measures mostly developed by Pharmacy Quality Alliance. MMA was associated with higher PPV than ACA in identifying individuals with medication utilization issues among non-Hispanic blacks (blacks) and Hispanics than non-Hispanic whites (whites). For example, odds ratio for having medication utilization issues to whites when examining MMA in 2013 and ACA were 1.09 (95% confidence interval [CI] = 1.04-1.15) among blacks, and 1.17 (95% CI = 1.10-1.24) among Hispanics, in the main analysis. Therefore, MMA was associated with 9% and 17% higher PPV than ACA in identifying patients with medication utilization issues among blacks and Hispanics, respectively, than whites.

Food Insecurity and Family Well-Being Outcomes among Households with Young Children

OBJECTIVES

To investigate associations between household food insecurity and multiple family well-being variables in an effort to illuminate previously understudied, policy-amenable mechanisms through which food insecurity threatens healthy development.

STUDY DESIGN

Data are drawn from the nationally representative Early Childhood Longitudinal Study-Birth Cohort. The Early Childhood Longitudinal Study-Birth Cohort contains longitudinal data on household food insecurity and several family well-being factors including maternal physical and mental health, positive parenting practices and disciplinary strategies, and frequency and severity of spousal conflict. We use regression models with lagged dependent variables to estimate associations between food insecurity and family well-being outcomes, on a subsample of low-income families (N ≈ 2100-4700).

RESULTS

Household food insecurity was significantly associated with poorer maternal physical health; increased depressive symptoms and use of harsh discipline strategies; and greater frequency and negativity of conflict between parents. Associations were strongest and most consistent when children were preschool aged. Transitions into food insecurity between toddlerhood and preschool were also associated with significantly worse parental physical and mental health outcomes, and more family conflict, with similar though slightly weaker and less consistent associations for transitioning into food insecurity between infancy and toddlerhood.

CONCLUSIONS

Food insecurity is associated with significant decreases in family health and well-being. Clinicians and other public health officials play a critical role in assessing risk for children and families, and linking families with supportive services. Screening families experiencing or at risk for food insecurity and connecting them with resources is an avenue through which public health practitioners can support family health.

Can You Do Health Disparities Research with Publicly Available Datasets?

RATIONALE AND OBJECTIVES

Given the growing importance of identifying and reducing health disparities, it is important for radiologist researchers to engage in this space to promote evidence-based imaging disparities policy. However, researchers are often hindered by access to appropriate data to perform quality research.

MATERIALS AND METHODS

This paper reviews existing publicly available data sets that may be useful for performing imaging disparities research.

RESULTS

Multiple data sources are publicly available and have been used by previous researchers to examine imaging disparities.

CONCLUSIONS

This paper provides an overview of publicly available data sources that radiologists can use for imaging disparities research. Appropriate use of these data sources will require researchers to carefully consider the overall research question and level of analysis.

Supporting the Health of Low Socioeconomic Status Employees: Qualitative Perspectives From Employees and Large Companies

OBJECTIVE

The aim of this study was to identify alignments between wellness offerings low socioeconomic status (SES) employees need and those large companies can provide.

METHODS

Focus groups (employees); telephone interviews (large companies). Employees were low-SES, insured through their employers, and employed by large Washington State companies. Focus groups covered perceived barriers to healthy behaviors at work and potential support from companies. Interviews focused on priorities for employee health and challenges reaching low-SES employees.

RESULTS

Seventy-seven employees participated in eight focus groups; 12 companies completed interviews. Employees identified facilitators and barriers to healthier work environments; companies expressed care for employees, concerns about employee obesity, and reluctance to discuss SES.

CONCLUSION

Our findings combine low-SES employee and large company perspectives and indicate three ways workplaces could most effectively support low-SES employee health: create healthier workplace food environments; prioritize onsite physical activity facilities; use clearer health communications.

Health Volunteerism and Improved Cancer Health for Latina and African American Women and Their Social Networks: Potential Mechanisms

Health volunteerism has been associated with positive health outcomes for volunteers and the communities they serve. This work suggests that there may be an added value to providing underserved populations with information and skills to be agents of change. The current study is a first step toward testing this hypothesis. The purpose is to identify how volunteerism may result in improved cancer health among Latina and African American women volunteers. A purposive sample of 40 Latina and African American female adults who had participated in cancer volunteerism in the past 5 years was recruited by community advocates and flyers distributed throughout community venues in San Diego, CA. This qualitative study included semi-structured focus groups. Participants indicated that volunteerism not only improved their health but also the health of their family and friends. Such perceptions aligned with the high rates of self-report lifetime cancer screening rates among age-eligible patients (e.g., 83-93 % breast; 90-93 % cervical; 79-92 % colorectal). Identified mechanisms included exposure to evidence-based information, health-protective social norms and support, and pressure to be a healthy role model. Our findings suggest that train-the-trainer and volunteer-driven interventions may have unintended health-protective effects for participating staff, especially Latina and African American women.

Variations in Progression and Regression of Precancerous Lesions of the Uterine Cervix on Cytology Testing Among Women of Different Races

Background

Although not incorporated into current cervical cancer screening guidelines, racial differences are known to persist in both occurrence of and outcomes related to cervical cancer.

Objective

To compare the differences in progression and regression of precancerous lesions of the uterine cervix on cervical cytologic analysis among women of different races who adhered to cervical cancer screening recommendations and follow-up.

Methods

Retrospective cohort study comparing differences in precancerous lesion diagnoses for patients receiving adequate evaluation according to the American Society for Colposcopy and Cervical Pathology guidelines. The authors fit Markov multistate models to estimate self-reported race-specific expected wait times and hazard ratios for each possible regression and progression and compared a race model with an intercept-only model using a likelihood ratio test.

Results

The sample included 5472 women receiving a Papanicolaou test between January 2006 and September 2016, contributing a total of 24,316 person-years of follow-up. Of 21 hazard ratios tested for significance, the following 4 hazard ratios (95% CIs) were statistically significant: atypical squamous cells of undetermined significance (ASC-US) progression to low-grade squamous intraepithelial lesion (LSIL) for Hispanic patients (0.72; 95% CI, 0.54-0.96); LSIL regression to ASC-US for Hispanic patients (1.55; 95% CI, 1.04-2.31), LSIL regression to ASC-US for Asian patients (1.91; 95% CI, 1.08-3.36), and high-grade squamous intraepithelial lesion regression to LSIL for black patients (0.39; 95% CI, 0.16-0.96). There is an observed trend that all racial groups other than white had a slower rate of progression from ASC-US to LSIL, with Hispanics having demonstrated the slowest rate from ASC-US to LSIL. Hispanics also demonstrated the fastest rate from LSIL to HSIL when compared with all other race categories. In regressions, blacks had the slowest rate of regression from HSIL to LSIL, and Asians had the fastest rate from LSIL to ASC-US. The Hispanic group demonstrated the fastest expected progression (17.6 months; 95% CI, 11.5-25.5), as well as the fastest regression (27.6 months; 95% CI, 21.5-35.6), and the black group has the slowest expected times for both progression (28.1 months; 95% CI, 14.6-47.2) and regression (49 months; 95% CI, 29.1-86.2). The number of visits (1 vs ≥2) in the study was differentially distributed both by race (P=.033) and by last diagnosis (P<.001).

Conclusion

Variations in precancerous lesions of the uterine cervix are not uniform across races.

Access to Employee Wellness Programs and Use of Preventive Care Services Among U.S. Adults

INTRODUCTION

There is little research at the national level on access to employee wellness programs and the use of preventive care services. This study examined the use of seven preventive care services among U.S working adults with access to employee wellness programs.

METHODS

The study population comprised 17,699 working adults aged ≥18 years, obtained from the 2015 National Health Interview Survey. Multivariate logistic regression models examined the relationship between access to employee wellness programs and use of seven preventive care services: influenza vaccination, blood pressure check, diabetes check, cholesterol check, Pap smear test, mammogram, and colon cancer screening. Data analysis began in Fall 2016.

RESULTS

Overall, 46.6% of working adults reported having access to employee wellness programs in 2015. Working adults with access to employee wellness programs had higher odds of receiving influenza vaccination (OR=1.57, 95% CI=1.43, 1.72, p<0.001), blood pressure check (OR=2.46, 95% CI=2.17, 2.78, p<0.001), diabetes check (OR=1.30, 95% CI=1.12, 1.50, p<0.001), cholesterol check (OR=1.48, 95% CI=1.33, 1.67, p<0.001), and mammogram (OR=1.57, 95% CI=1.24, 1.98, p<0.001). However, there was no significant difference between access to employee wellness programs and the use of Pap smear test and colon cancer screening services.

CONCLUSIONS

Using a nationally representative sample of individuals, this study found a positive association between access to employee wellness programs and the use of preventive care services. The results support favorable policies to encourage implementing wellness programs in all worksites, especially those with <50 employees.

Risk Factors for Late Screening Mammography

BACKGROUND

Breast cancer has the highest incidence of cancers in women in the United States. Previous research has shown that screening mammography contributes to reduced breast cancer mortality. This study aimed to clarify why late screening might occur in an at-risk population.

MATERIALS AND METHODS

This study was a prospective cross-sectional study including 758 patients presenting to our radiology department for routine screening mammography who completed a 30-question survey regarding personal characteristics and mammography history. Univariate and multivariate logistic regression were performed to determine whether survey responses correlated with late screening.

RESULTS

Of the 758 patients, 184 (24%) were noncompliant with screening mammography guidelines. Risk factors for late screening included younger age (P = 0.001), white race/ethnicity (P = 0.03), self-reported lack of financial means or health insurance (P = 0.005), lack of satisfaction with a previous mammogram experience (P = 0.001), inadequate mammography education by a physician (P = 0.001), and lack of awareness/comprehension of screening mammography guidelines (P = 0.002).

CONCLUSION

Many factors contribute to late screening mammography. Although some are outside physician control, others can be influenced: patient education regarding screening mammography guidelines, and patient satisfaction with the mammography experience. This study highlights the importance of communication with and education of patients.

Critical Consciousness: A Critique and Critical Analysis of the Literature

The education system has been heralded as a tool of liberation and simultaneously critiqued as a tool of social control to maintain the oppressive status quo. Critical consciousness (CC), developed by the Brazilian educator, Paulo Freire, advanced an educational pedagogy to liberate the masses from systemic inequity maintained and perpetuated by process, practices and outcomes of interdependent systems and institutions. If people are not aware of inequity and do not act to constantly resist oppressive norms and ways of being, then the result is residual inequity in perpetuity. If inequity is likened to a disease or poison, then CC has been deemed the antidote to inequity and the prescription needed to break the cycle. As such, CC is a construct that has important scholarly, practice and policy implications. Scholars, noting the relevance and application of CC to current social problems, have advanced CC theory and practice. However, these innovative advancements have left fissures in the CC theoretical base in need of resolution and consensus to advance a collective and organized body of CC theory. This paper explores the divergent CC scholarship within CC theory and practice articles, provides an in-depth review of the inconsistencies, and suggests ideas to resolve the discrepancies from the literature to support the need for a new, CC-based construct, transformative potential. Without such a review, moving toward conceptual clarity, the lack of a coherent CC knowledgebase will impede the reflection and action needed to transform systems and institutions that maintain and perpetuate systemic inequity that have dehumanizing consequences. If implemented within urban education, theoretical models, grounded in CC theory, could help achieve a system of education that is just, equitable and liberating.

Lower attendance rates in immigrant versus non-immigrant women in the Norwegian Breast Cancer Screening Programme

Objective

The Norwegian Breast Cancer Screening Programme invites women aged 50–69 to biennial mammographic screening. Although 84% of invited women have attended at least once, attendance rates vary across the country. We investigated attendance rates among various immigrant groups compared with non-immigrants in the programme.

Methods

There were 4,053,691 invitations sent to 885,979 women between 1996 and 2015. Using individual level population-based data from the Cancer Registry and Statistics Norway, we examined percent attendance and calculated incidence rate ratios, comparing immigrants with non-immigrants, using Poisson regression, following women's first invitation to the programme and for ever having attended.

Results

Immigrant women had lower attendance rates than the rest of the population, both following the first invitation (53.1% versus 76.1%) and for ever having attended (66.9% versus 86.4%). Differences in attendance rates between non-immigrant and immigrant women were less pronounced, but still present, when adjusted for sociodemographic factors. We also identified differences in attendance between immigrant groups. Attendance increased with duration of residency in Norway. A subgroup analysis of migrants' daughters showed that 70.0% attended following the first invitation, while 82.3% had ever attended.

Conclusions

Immigrant women had lower breast cancer screening attendance rates. The rationale for immigrant women's non-attendance needs to be explored through further studies targeting women from various birth countries and regions.

Socioeconomic Differences in Use of Low-Value Cancer Screenings and Distributional Effects in Medicare

OBJECTIVE

Consuming low-value health care not only highlights inefficient resource use but also brings an important concern regarding the economics of disparities. We identify the relation of socioeconomic characteristics to the use of low-value cancer screenings in Medicare fee-for-service (FFS) settings, and quantify the amount subsidized from nonusers and taxpayers to users of these screenings.

DATA SOURCES

2007-2013 Medicare Current Beneficiary Survey, Medicare FFS claims, and the Area Health Resource Files.

STUDY DESIGN

Our sample included enrollees in FFS Part B for the entire calendar year. We excluded beneficiaries with a claims-documented or self-reported history of targeted cancers, or those enrolled in Medicaid or Medicare Advantage plans. We identified use of low-value Pap smears, mammograms, and prostate-specific antigen tests based on established algorithms, and estimated a logistic model with year dummies separately for each test.

DATA COLLECTION/EXTRACTION METHODS

Secondary data analyses.

PRINCIPAL FINDINGS

We found a statistically significant positive association between privileged socioeconomic characteristics and use of low-value screenings. Having higher income and supplemental private insurance strongly predicted more net subsidies from Medicare.

CONCLUSIONS

FFS enrollees who are better off in terms of sociodemographic characteristics receive greater subsidies from taxpayers for using low-value cancer screenings.

A decade of improved access to screening is associated with fewer colorectal cancer deaths in African Americans: a single-center retrospective study

Background

Controversy exists as to whether disparities in colorectal cancer (CRC) outcomes in African Americans (AAs) are best resolved by screening at age 45 or by proper use of existing guidelines. In 2004, an aggressive colonoscopy-based CRC screening program was implemented throughout New York City. Our goal was to determine the effect of that program on CRC outcomes in our mostly AA population.

Methods

CRC cases entered into Harlem Hospital’s tumor registry from January 1992 to December 2011 were divided into two cohorts: 1992-2003, the pre-intensive screening era (PSE), and 2004-2011, the intensive screening era (ISE). Each cohort was reviewed for demographics, indication for colonoscopy, tumor location, tumor stage, and mortality. Multivariate analysis was applied to the pooled cohorts to determine factors associated with survival.

Results

Inclusion criteria were met by 379 patients: 207 PSE and 172 ISE. Racial distribution, gender, age at presentation, and tumor location were not different during the two eras. Over 75% of patients were AA. During the ISE, 84% were insured compared to 34% in the PSE (P<0.0001). Fewer patients died during the ISE (21%) than during the PSE (67%) (P<0.0001). The ISE patients were diagnosed with earlier stages of CRC compared to the PSE. Increased survival was associated with being insured (hazard ratio [HR] 1.91, 95% confidence interval [CI] 1.30-2.81), distal tumors (HR 1.43, 95%CI 1.05-1.95), and being female (HR 1.36, 95%CI 1.01-1.850).

Conclusions

A multifaceted program reduced CRC outcome disparities in a poor AA community. Aggressive implementation of current colonoscopy screening guidelines still has unrealized potential to reduce CRC mortality disparities in AAs.

Presentation, Treatment, and Outcomes of Haitian Women With Breast Cancer in Miami and Haiti: Disparities in Breast Cancer-A Retrospective Cohort Study

PURPOSE

We compared a cohort of Haitian immigrants with residents in Haiti with breast cancer (BC) to evaluate the effects of location on presentation, treatment, and outcomes.

PATIENTS AND METHODS

Participants were Haitian women with BC living in Miami who presented to the University of Miami/Jackson Memorial Hospital and women with BC living in Haiti who presented to the Innovating Health International Women's Cancer Center. The primary outcome was the relationship between location, cancer characteristics, and survival. The secondary objective was to compare our results with data extracted from the SEER database. Cox regression was used to compare survival.

RESULTS

One hundred two patients from University of Miami/Jackson Memorial Hospital and 94 patients from Innovating Health International were included. The patients in Haiti, compared with the patients in Miami, were younger (mean age, 50.2 v 53.7 years, respectively; P = .042), presented after a longer duration of symptoms (median, 20 v 3 months, respectively; P < .001), had more advanced stage (44.7% v 25.5% with stage III and 27.6% v 18.6% with stage IV BC, respectively), and had more estrogen receptor (ER) -negative tumors (44.9% v 26.5%, respectively; P = .024). The percentage of women who died was 31.9% in Haiti died compared with 17.6% in Miami. Median survival time was 53.7 months for women in Haiti and was not reached in Miami. The risk of death was higher for women in Haiti versus women in Miami (adjusted hazard ratio, 3.09; P = .0024).

CONCLUSION

Women with BC in Haiti experience a significantly worse outcome than immigrants in Miami, which seems to be related to a more advanced stage and younger age at diagnosis, more ER-negative tumors, and lack of timely effective treatments. The differences in age and ER status are not a result of access to care and are unexplained.

Inequity in Recording of Risk in a Local Population-Based Screening Programme for Cardiovascular Disease

Background

Screening for cardiovascular disease is an important primary preventive measure, yet research has documented that not all population groups receive the same quality of preventive healthcare.

Design

Longitudinal analysis of cardiovascular disease risk factor recording.

Methods

Data were made available from a local population-based screening programme for cardiovascular disease (1989-1999), whereby residents aged 35-60 years were invited for screening every 5 years (n = 84 646). Data were recorded for major risk factors including blood pressure, cholesterol, body mass index, smoking status, and alcohol consumption. Completeness of risk factor recording was compared between groups in the screened population defined by gender, ethnicity (Caucasian/South Asian) and employment status (employed/unemployed).

Results

Recording of risk in the screened population was significantly less complete for women and South Asian participants over the duration of the screening programme, compared with men and Caucasian participants respectively. Conversely, recording of risk was significantly more complete for the unemployed compared with the employed participants.

Conclusions

These findings present evidence of a less systematic screening procedure for women and South Asians, whilst it seems that men, Caucasian participants and the unemployed were appropriately screened. Inequalities at the primary preventive level will likely influence outcome, because equitable identification of risk is important for the provision of successful treatment measures, and to reduce inequalities in morbidity and mortality due to cardiovascular disease.

Socioeconomic, Geospatial, and Geopolitical Disparities in Access to Health Care in the US 2011-2015

Individuals forgoing needed medical care due to barriers associated with cost are at risk of missing needed care that may be necessary for the prevention or maintenance of a chronic condition among other things. Thus, continued monitoring of factors associated with forgone medical care, especially among vulnerable populations, is critical. National survey data (2011–2015) for non-institutionalized adults residing in the USA were utilized to assess forgone medical care, defined as not seeking medical care when the individual thought it was necessary because of cost in the past 12 months. Logistic regression was used to predict forgone medical care vs. sought medical care. Racial/ethnic minority working-age adults, those with lower incomes, those with lower educations, those residing in the South, and those residing in states that failed to participate in Medicaid Expansion in 2014 were more likely (p < 0.01) to forgo medical care due to cost in the past year. Policy makers seeking to reduce barriers to forgone medical care can use this information to tailor their efforts (e.g., mechanisms targeted to bridge gaps in access to care) to those most at-risk and to consider state-level policy decisions that may impact access to care.

Information Poverty and Reproductive Healthcare: Assessing the Reasons for Inequity between Income Groups

It is commonly known that in the United States women who are low income do not access reproductive healthcare services and information with the same reliability and regularity of women who are higher income. A qualitative research approach was undertaken to assess the root cause of this disparity. In-depth semistructured interviews were conducted with 15 women divided among socioeconomic lines. The primary barriers to care for women who are low income are clinical staff attitudes, knowledge of care available and needed, and cost or lack of insurance. This study adds to the current understanding of the barriers to reproductive healthcare for women of different socioeconomic statuses.