Colonoscopist and primary care physician supply and disparities in colorectal cancer screening

Longer travel times to acute hospitals are associated with lower likelihood of cancer screening receipt among rural-dwelling adults in the U.S. South

PURPOSE

Given rural hospitals' role in providing outpatient services, we examined the association between travel burdens and receipt of cancer screening among rural-dwelling adults in the U.S. South region.

METHODS

First, we estimated network travel times and distances to access the nearest and second nearest acute care hospital from each rural census tract in the U.S. South. After appending the Centers for Disease Control's PLACES dataset, we fitted generalized linear mixed models.

RESULTS

Longer distances to the second nearest hospital are negatively associated with breast, colorectal, and cervical cancer screening receipt among eligible rural-dwelling adults. Rural-dwelling women in counties with 1 closure had reduced likelihood of breast cancer screening. Residence in a partial- or whole-county Health Professional Shortage Area (HPSA) was negatively associated with cancer screening receipt. Specialist (OB/GYN and gastroenterologist) supply was positively associated with receipt of cancer screening. Uninsurance was positively associated with cervical and breast cancer screening receipt. Medicaid expansion was associated with increased breast and cervical cancer screening.

CONCLUSIONS

Rural residents in partial-county primary care HPSAs had the lowest rates of breast, cervical, and colorectal cancer screening, compared with whole-county HPSAs and non-shortage areas. These residents also faced the greatest distances to their nearest and second nearest hospital. This is notable because rural residents in the South face greater travel burdens for cancer care compared with residents in other regions. Finally, the positive association between uninsurance and breast and cervical cancer screening may reflect the CDC's National Breast and Cervical Cancer Early Detection Program's effectiveness.

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polyps removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk.

DESIGN AND METHODS

We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-month follow-up, and Life Simple7 (LS7)-a cardiovascular disease (CVD) risk score-at 6 months and 1 year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed-methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors.

DISCUSSION

Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction.

TRIAL REGISTRATION

NCT05174286; clinicaltrials.gov; August 31st, 2023.

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

Background

Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polys removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk.

Design and Methods

We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-months follow up, and Life Simple7 (LS7) - a cardiovascular disease (CVD) risk score - at 6 months and 1-year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed-methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors.

Discussion

Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction.

Trial registration

NCT05174286.

Engaging the community on colorectal cancer screening: Additional factors identified by African Americans as potential barriers during focus groups

OBJECTIVE

African-Americans have the highest rate of colorectal cancer deaths. Adherence to colorectal cancer screening guidelines can improve outcomes. The objective of this study was to evaluate physician trust and barriers to screening utilizing a unique bi-directional learning focus group involving African-American adults and health care learners.

METHODS

A focus group of African-American adults from a community church and university health care learners was conducted to identify colon cancer screening barriers. Health care learners were medical students, resident physicians and gastroenterology fellows. Pre-focus group surveys, including the Wake Forest Physician Trust Scale (WFPTS) and a colon cancer screening knowledge survey, were administered. Audio recording of the focus group was transcribed with subsequent thematic analysis. A post-focus group survey evaluated the colorectal cancer screening barriers identified during the focus group. Analysis of pre- and post- focus group surveys was performed using Fisher Exact test with significance set at p<0.05.

RESULTS

The focus group consisted of 18 members (7 African-American community members, 11 non-African American health care learners). WFPTS revealed that 83% (86% community members, 82% health care learners; p = 1.0) strongly agree / agree that their physician would advocate for their health. 77% (86% community members, 73% health care learners; p = 1.0) strongly agree / agree that they trusted their physician. 100% recognized that colon cancer screening is recommended. The focus group identified lack of awareness (81%), colonoscopy preparation (81%), trust in physician (60%), lack of insurance coverage (56%), transportation (56%), colonoscopy wait time (50%), insufficient physician discussion (50%) and fear of procedure or cancer (35%) as screening barriers. Post-focus group surveys revealed that community members more frequently identified racial disparity in health care (p = 0.0474), physician respect toward patients (p = 0.0128) and insufficient physician discussion (p = 0.0006) as screening barriers.

CONCLUSIONS

Focus group discussion identified multiple barriers for colorectal cancer screening. Notably, differences in the perceptions of African-American community members and non-African-American health care learners about racial disparity in health care, physician respect toward patients and insufficient physician discussion were revealed. The integration of bi-directional focus group learning can be considered as a potential strategy to assist in the development of focused screening interventions.

Predictors of intent to utilize the emergency department among a free clinic's patients

OBJECTIVE

Primary care use helps reduce utilization of more expensive modes of care, such as the emergency department (ED). Although most studies have investigated this association among patients with insurance, few have done so for patients without insurance. We used data from a free clinic network to assess the association between free clinic use and intent to use the ED.

METHODS

Data were collected from a free clinic network's electronic health records on adult patients from January 2015 to February 2020. Our outcome was whether patients reported themselves as 'very likely' to visit the ED if the free clinics were unavailable. The independent variable was frequency of free clinic use. Using a multivariable logistic regression model, we controlled for other factors, such as patient demographic factors, social determinants of health, health status, and year effect.

RESULTS

Our sample included 5008 visits. When controlling for other factors, higher odds of expressing ED interest were observed for patients who are non-Hispanic Black, older, not married, lived with others, had lower education, were homeless, had personal transportation, lived in rural areas, and had a higher comorbidity burden. In sensitivity analyses, higher odds were observed for dental, gastrointestinal, genitourinary, musculoskeletal, or respiratory conditions.

CONCLUSIONS

In the free clinic space, several patient demographic, social determinants of health and medical conditions were independently associated with greater odds of reporting intent on visiting the ED. Additional interventions that improve access and use of free clinics (e.g., dental) may keep patients without insurance from the ED.

Diminishing racial disparities in the treatment of colon adenocarcinoma

Background

Prior research has demonstrated racial disparities in the treatment of colon cancer. We sought to determine if treatment disparities persist.

Methods

Patients with colon adenocarcinoma diagnosed from 2012 to 2016 were identified using the Surveillance, Epidemiology and End Results database. Associations between race and clinical characteristics were assessed using Chi square tests. The likelihood of receiving treatment based on race was assessed using logistic regression.

Results

Of 18,841 patients, 69.7% were White, 10.2% Black, 8.7% Hispanic and 11.4% Asian. Among patients with early-stage disease (stage I or II), 96.1% of Whites, 94.6% of Blacks, 95.6% of Hispanics and 97.7% of Asians underwent surgery (p = 0.01), while 8.9% of Whites, 9.3% of Blacks, 12.4% of Hispanics and 8.9% of Asians received chemotherapy (p = 0.03). For years 2012 to 2016 collectively, Blacks with early-stage disease were less likely than Whites to undergo any surgery (aOR = 0.54; 95% CI: 0.36 - 0.81) and more likely to receive neither surgery nor chemotherapy (aOR = 1.91; 95% CI: 1.25 - 2.93). However, when assessing each year individually, the most recent years revealed no difference in the likelihood of receiving surgery in (aOR = 0.45; 95% CI: 0.16 - 1.29 in 2016) or receiving neither surgery nor chemotherapy (aOR = 2.17; 95% CI: 0.70 - 6.70 in 2016).

Conclusion

Racial disparities in the treatment of colon adenocarcinoma have improved in recent years. Health care providers must continue to provide equitable, evidence-based care to ensure that treatment disparities are eliminated.

Pandemic Recovery: Persistent Disparities in Access to Elective Surgical Procedures

OBJECTIVE

To examine potential disparities in patient access to elective procedures during the recovery phase of the COVID-19 pandemic.

SUMMARY OF BACKGROUND DATA

Elective surgeries during the pandemic were limited acutely. Access to surgical care was restored in a recovery phase but backlogs and societal shifts are hypothesized to impact surgical access.

METHODS

Adults with electronic health record orders for procedures ("procedure requests"), from March 16 to August 25, 2019 and March 16 to August 25, 2020, were included. Logistic regression was performed for requested procedures that were not scheduled. Linear regression was performed for wait time from request to scheduled or completed procedure.

RESULTS

The number of patients with procedure requests decreased 20.8%, from 26,789 in 2019 to 21,162 in 2020. Patients aged 36-50 and >65 years, those speaking non-English languages, those with Medicare or no insurance, and those living >100 miles away had disproportionately larger decreases. Requested procedures had significantly increased adjusted odds ratios (aORs) of not being scheduled for patients with primary languages other than English, Spanish, or Cantonese [aOR 1.60, 95% confidence interval (CI) 1.12-2.28]; unpartnered marital status (aOR 1.21, 95% CI 1.07-1.37); uninsured or self-pay (aOR 2.03, 95% CI 1.53-2.70). Significantly longer wait times were seen for patients aged 36-65 years; with Medi-Cal insurance; from ZIP codes with lower incomes; and from ZIP codes >100 miles away.

CONCLUSIONS

Patient access to elective surgeries decreased during the pandemic recovery phase with disparities based on patient age, language, marital status, insurance, socioeconomic status, and distance from care. Steps to address modifiable disparities have been taken.

American Indian/Alaska native access to colorectal cancer screening: Does gastroenterologist density matter?

BACKGROUND

American Indians/Alaska Natives (AI/AN) receive less colorectal cancer (CRC) screening than other populations. Using gastroenterologist (GI) locations as a measure of colonoscopy access, we correlate GI density and AI/AN CRC screening rates.

METHODS

We identified GIs from the 2016 National Provider Identifier registry, and calculated GI density per 100,000 people. We identified screening, demographic, and socioeconomic variables from the 2016 Behavioral Risk Factor Surveillance System Survey. GI density and CRC screening rates were analyzed with Multivariable Poisson regression.

RESULTS

In states with GI Density greater than 3.98/100,000, odds of AI/AN CRC screening are 1.27-1.37 times higher than in states below this threshold (p < 0.036).

CONCLUSIONS

GI density has a limited association on CRC screening, with decrease impact beyond threshold of 3.98 GI/100,000. Minimal access to GIs is important in improving AI/AN CRC screening; however, further research is required to elucidate the most critical factors contributing to CRC screening.

Artificial intelligence in gastroenterology and hepatology: how to advance clinical practice while ensuring health equity

Artificial intelligence (AI) and machine learning (ML) systems are increasingly used in medicine to improve clinical decision-making and healthcare delivery. In gastroenterology and hepatology, studies have explored a myriad of opportunities for AI/ML applications which are already making the transition to bedside. Despite these advances, there is a risk that biases and health inequities can be introduced or exacerbated by these technologies. If unrecognised, these technologies could generate or worsen systematic racial, ethnic and sex disparities when deployed on a large scale. There are several mechanisms through which AI/ML could contribute to health inequities in gastroenterology and hepatology, including diagnosis of oesophageal cancer, management of inflammatory bowel disease (IBD), liver transplantation, colorectal cancer screening and many others. This review adapts a framework for ethical AI/ML development and application to gastroenterology and hepatology such that clinical practice is advanced while minimising bias and optimising health equity.

Regional variations and associations between colonoscopy resource availability and colonoscopy utilisation: a population-based descriptive study in Ontario, Canada

Objective

There is substantial variation in colonoscopy use and evidence of long wait times for the procedure. Understanding the role of system-level resources in colonoscopy utilisation may point to a potential intervention target to improve colonoscopy use. This study characterises colonoscopy resource availability in Ontario, Canada and evaluates its relationship with colonoscopy utilisation.

Design

We conducted a population-based study using administrative health data to describe regional variation in colonoscopy availability for Ontario residents (age 18–99) in 2013. We identified 43 colonoscopy networks in the province in which we described variations across three colonoscopy availability measures: colonoscopist density, private clinic access and distance to colonoscopy. We evaluated associations between colonoscopy resource availability and colonoscopy utilisation rates using Pearson correlation and log binomial regression, adjusting for age and sex.

Results

There were 9.4 full-time equivalent colonoscopists per 100 000 Ontario residents (range across 43 networks 0.0 to 21.8); 29.5% of colonoscopies performed in the province were done in private clinics (range 1.2%–55.9%). The median distance to colonoscopy was 3.7 km, with 5.9% travelling at least 50 km. Lower colonoscopist density was correlated with lower colonoscopy utilisation rates (r=0.53, p<0.001). Colonoscopy utilisation rates were 4% lower in individuals travelling 50 to <200 km and 11% lower in individuals travelling ≥200 km to colonoscopy, compared to <10 km. There was no association between private clinic access and colonoscopy utilisation.

Conclusion

The substantial variations in colonoscopy resource availability and the relationship demonstrated between colonoscopy resource availability and use provides impetus for health service planners and decision-makers to address these potential inequalities in access in order to support the use of this medically necessary procedure.

Disparities in Screening for Colorectal Cancer Based on Limited Language Proficiency

BACKGROUND

This study analyzes the association between limited language proficiency and screening for colorectal cancer.

METHODS

This is a retrospective cohort study from the 2015 sample of the National Health Interview Survey database utilizing univariate and multivariate regression analysis. The study population includes subjects between 50 and 75 years of age. The main outcome analyzed was rates of screening colonoscopies between limited English-language proficiency (LEP) subjects and those fluent in English. Secondary outcomes included analysis of baseline, socioeconomic, access to health care variables, and other modalities for colorectal cancer screening between the groups.

RESULTS

Incidence of limited language proficiency was 4.8% (n = 1978, count = 4 453 599). They reported lower rates of screening colonoscopies (61% vs 34%, P < .001), less physician recommendation for a colonoscopy (87 vs 60%, P < .001), fewer polyps removed in the previous 3 years (24% vs 9.1%; P < .001), and fewer fecal occult blood samples overall (P < .001). Additionally, Hispanic non-LEP subjects have higher rates of colonoscopies compared to those with language barriers (50% vs 33%, P < .001). On multivariate analysis, LEP was associated with a lower likelihood to have a screening colonoscopy (OR .67 95% CI .49-.91). A second regression model with "Spanish language" and "other language" variables included, associated Spanish speakers with a lower likelihood for a screening colonoscopy (OR .71 95% CI .52-.97) when controlling for baseline, socioeconomic, and access to health care covariates.

DISCUSSION

Patients with limited English-language proficiency are associated with lower rates of screening for colorectal cancer, in particular the Spanish speaking subgroup.

Disparities in Colorectal Cancer Screening in Latinos and Non-Hispanic Whites

INTRODUCTION

Colorectal cancer is the second leading cause of cancer deaths in Latinos in the U.S., but it is unclear, from previous research, whether Latinos have differing rates of colorectal cancer screening methods from those of non-Hispanic Whites.

METHODS

This study used electronic health records from 686 community health centers across 21 states in the Accelerating Data Value Across a National Community Health Center of the National Patient-Centered Clinical Research Network. Records from English-preferring Latinos, Spanish-preferring Latinos, and non-Hispanic Whites aged 50-75 years were included. A total of 5 outcomes were compared between 2012 and 2017 to provide a comprehensive view of colorectal cancer screening: (1) any colorectal cancer screening, (2) stool-based screening, (3) annual rates of stool testing, (4) any referral for lower gastrointestinal endoscopy, and (5) endoscopy referral among patients with a positive stool-based screening.

RESULTS

In this study (N=204,243), Spanish-preferring Latinos had higher odds of any colorectal cancer screening (OR=1.44, 95% CI=1.23, 1.68) and stool-based testing (OR=1.82, 95% CI=1.55, 2.13) than non-Hispanic Whites. English- and Spanish-preferring Latinos had lower odds of having ever had a referral for endoscopy in the study period than non-Hispanic Whites (English: OR=0.23, 95% CI=0.15, 0.34; Spanish: OR=0.55, 95% CI=0.40, 0.74), even with a positive stool-based screening (English: OR=0.14, 95% CI=0.06, 0.33; Spanish: OR=0.33, 95% CI=0.19, 0.57).

CONCLUSIONS

In a multistate network of community health centers, Latino patients aged >50 years were more likely to receive stool-based screening tests for colorectal cancer than non-Hispanic Whites but were less likely to receive endoscopy referrals than non-Hispanic Whites, even when experiencing a positive stool-based screening test. Initiatives to improve Latino colorectal cancer outcomes should encourage indicated referrals for lower gastrointestinal endoscopy.

Decomposing socioeconomic disparities in the use of colonoscopy among the insured elderly population before and after the Affordable Care Act

BACKGROUND

Out-of-pocket costs may significantly dampen patients' willingness to adopt preventive procedures. This is especially true for colonoscopies, which typically involved relatively high cost-sharing requirements prior to the Affordable Care Act (ACA) implementation in 2011.

PURPOSE

We aim to examine the effects of income-related disparities in colonoscopy use in the years prior to and immediately after the implementation of the ACA. Further, we quantify the contributions of different factors in explaining the disparities in the use of colonoscopies among elderly population with health insurance coverage.

METHODS

Five cycles (2008, 2010, 2012, 2014, and 2016) of Behavioral Risk Factor Surveillance System data were utilized. To examine income-related disparities in the use of CRC, individuals aged 65-75 were included, and the concentration index (CI) was calculated before and after the implementation of ACA. To identify and quantify the contribution of different factors, a decomposition analysis of CI was conducted.

RESULTS

CIs decreased from 0.1935 in pre-ACA years to 0.1813 in the post-ACA years among the elderly, indicating that the disparities in the use of colonoscopy was relatively low and the disparities index declined after the implementation of ACA. Decomposition analyses showed that whereas decreases in disparities derived largely from income and educational level, higher level of income and educational attainment were major contributors to the observed disparities in colonoscopy use.

CONCLUSIONS

Our findings indicate that the ACA's removal of financial barriers may have contributed toward the reduction in disparities of colonoscopy use. More direct interventions, e.g., improved knowledge, better access and lower indirect cost will be helpful in improving screening among low-income and low-educational attainment households.

Regional variations in the use of statutory skin cancer screenings in Germany: population-based spatial multisource analysis

BACKGROUND

Due to the increasing incidence of skin cancer, programmes for the prevention of skin cancer have been developed and implemented in Germany. However, utilization of skin cancer screenings shows marked regional differences. Reasons and predictors of such variations are unclear.

OBJECTIVES

The objective of the study is to identify predictors for regional use of skin cancer screening variations in Germany.

METHODS

Analysis of the population set of ambulatory claims data (2009-2015) of the statutory health insurances (SHI) in Germany (70.2 million people in 2015). Skin cancer screening utilization rate was determined on county level. Descriptive, cluster and multivariate analyses were performed to identify spatial patterns in skin cancer screening utilization.

RESULTS

Overall, 6.5-7.9 million people participated in skin cancer screenings. Utilization rates of people ≥35 years of age were 9.74% (2009) and 10.96% (2015). Marked regional variations were identified between the counties. Dermatologists in Saxony and Westphalia-Lippe as well as general practitioners in Lower Saxony and North Rhine showed particularly high utilization rates. Multiple regression analyses demonstrated e.g. positive associations between the skin cancer screening utilization rates and employees with higher vocational qualifications and shorter travel time by car to the nearest major urban centre.

CONCLUSION

Utilization rates of skin cancer screening vary largely in Germany with specific spatial patterns. Multivariate analyses demonstrate associations with socio-economic and geographical determinants. The results indicate the importance of health policy measures. These should be used in a more targeted manner in the regions in order to increase utilization of skin cancer screening.

Effects of the Affordable Care Act on the Receipt of Colonoscopies among the Insured Elderly

Background: The Affordable Care Act (ACA) waived deductibles and eliminated coinsurance for colonoscopies for Medicare beneficiaries beginning in January 1, 2011. This study investigated the effect of the ACA’s directive to remove the financial barriers on the receipt of colonoscopies among the elderly insured, who are predominantly covered by Medicare. Methods: Data from the 2008–2016 Behavioral Risk Factor Surveillance System (BRFSS) were used to examine the receipt of colonoscopies in two years prior to the implementation of the ACA (2008 and 2010) and three years after the change (2012, 2014, and 2016). Multivariate logistic regressions were estimated to examine the change in colonoscopy use before and after the introduction of the ACA, adjusting for patient characteristics and availability of health care providers in the geographic region. Results: Of 349,899 eligible elderly insured in the age group 65 to 75 years, 236,275 (67.2%) had received a colonoscopy in the previous ten years. The receipt of colonoscopies increased from 63.5% in pre-ACA years to 69.2% in the post-ACA years (p < 0.001). Compared with the pre-ACA period, the odds ratio of colonoscopy uptake in post-ACA years was 1.15 (95% CI = 1.08–1.22). Conclusions: A statistically significant increase in colonoscopy use was observed in the post-ACA years. However, achieving the target coverage rate of 80% will require additional interventions to encourage higher levels of screenings.

Impact of Primary Care Access on Mortality of Lung Cancer Patients in an Underserved Community

BACKGROUND

Lack of access to primary care physicians (PCPs) may be an important contributor to mortality differences attributed to race/ethnicity. This study examined the effects of primary care access on mortality of lung cancer patients in an underserved community.

METHODS

Medical records of all newly diagnosed patients with primary lung cancer from 2012 to 2016 at a National Cancer Institute (NCI)-designated center in Bronx, New York were reviewed. Demographic data, PCP status, and residence in primary care shortage areas (PCSAs) were collected. Survival data from time of first imaging to death or the end of follow-up on January 1, 2018 were recorded. Survival analysis was performed using Kaplan-Meier and Cox hazards modeling.

RESULTS

Among 1062 patients, 874 (82%) were PCSA residents, 314 (30%) were Hispanic, and 445 (42%) were African American. PCSA residents were likely Hispanics (P<0.001), African Americans (P<0.001), of lower income (P<0.001), and had advanced disease at diagnosis (P=0.01). Patients without established PCPs had more comorbidities (P=0.04), more advanced disease (P<0.001), and less in-network cancer treatment (P<0.001). PCSA residence (P=0.03, hazard ratio [HR]=1.27) and no established PCP (P<0.001, HR=1.50) were associated with increased mortality. In multivariable modeling, lack of established PCP remained a predictor of increased mortality (P=0.02, HR=1.25).

DISCUSSION

Among newly diagnosed lung cancer patients, lack of established PCP is associated with increased mortality. Hispanics and African Americans increasingly resided in PCSAs, suggesting race/ethnicity mortality differences may be mediated by primary care shortage. Patients without PCPs had worse health outcomes. Effective health policy efforts to reduce mortality in lung cancer patients must include approaches to improve primary care access.

Geographic and population-level disparities in colorectal cancer testing: A multilevel analysis of Medicaid and commercial claims data

Morbidity and mortality from colorectal cancer (CRC) can be attenuated through guideline concordant screening and intervention. This study used Medicaid and commercial claims data to examine individual and geographic factors associated with CRC testing rates in one state (Oregon). A total of 64,711 beneficiaries (4516 Medicaid; 60,195 Commercial) became newly age-eligible for CRC screening and met inclusion criteria (e.g., continuously enrolled, no prior history) during the study period (January 2010-December 2013). We estimated multilevel models to examine predictors for CRC testing, including individual (e.g., gender, insurance, rurality, access to care, distance to endoscopy facility) and geographic factors at the county level (e.g., poverty, uninsurance). Despite insurance coverage, only two out of five (42%) beneficiaries had evidence of CRC testing during the four year study window. CRC testing varied from 22.4% to 46.8% across Oregon's 36 counties; counties with higher levels of socioeconomic deprivation had lower levels of testing. After controlling for age, beneficiaries had greater odds of receiving CRC testing if they were female (OR 1.04, 95% CI 1.01-1.08), commercially insured, or urban residents (OR 1.14, 95% CI 1.07-1.21). Accessing primary care (OR 2.47, 95% CI 2.37-2.57), but not distance to endoscopy (OR 0.98, 95% CI 0.92-1.03) was associated with testing. CRC testing in newly age-eligible Medicaid and commercial members remains markedly low. Disparities exist by gender, geographic residence, insurance coverage, and access to primary care. Work remains to increase CRC testing to acceptable levels, and to select and implement interventions targeting the counties and populations in greatest need.

Potential capacity of endoscopic screening for gastric cancer in Japan

In 2016, the Japanese government decided to introduce endoscopic screening for gastric cancer as a national program. To provide endoscopic screening nationwide, we estimated the proportion of increase in the number of endoscopic examinations with the introduction of endoscopic screening, based on a national survey. The total number of endoscopic examinations has increased, particularly in clinics. Based on the national survey, the total number of participants in gastric cancer screening was 3 784 967. If 30% of the participants are switched from radiographic screening to endoscopic screening, approximately 1 million additional endoscopic examinations are needed. In Japan, the participation rates in gastric cancer screening and the number of hospitals and clinics offering upper gastrointestinal endoscopy vary among the 47 prefectures. If the participation rates are high and the numbers of hospitals and clinics are small, the proportion of increase becomes larger. Based on the same assumption, 50% of big cities can provide endoscopic screening with a 5% increase in the total number of endoscopic examinations. However, 16.7% of the medical districts are available for endoscopic screening within a 5% increase in the total number of endoscopic examinations. Despite the Japanese government's decision to introduce endoscopic screening for gastric cancer nationwide, its immediate introduction remains difficult because of insufficient medical resources in rural areas. This implies that endoscopic screening will be initially introduced to big cities. To promote endoscopic screening for gastric cancer nationwide, the disparity of medical resources must first be resolved.

Racial/Ethnic Disparities in Colorectal Cancer Screening Across Healthcare Systems

INTRODUCTION

Racial/ethnic disparities in colorectal cancer (CRC) screening and diagnostic testing present challenges to CRC prevention programs. Thus, it is important to understand how differences in CRC screening approaches between healthcare systems are associated with racial/ethnic disparities.

METHODS

This was a retrospective cohort study of patients aged 50-75 years who were members of the Population-based Research Optimizing Screening Through Personalized Regimens cohort from 2010 to 2012. Data on race/ethnicity, CRC screening, and diagnostic testing came from medical records. Data collection occurred in 2014 and analysis in 2015. Logistic regression models were used to calculate AORs and 95% CIs comparing completion of CRC screening between racial/ethnic groups. Analyses were stratified by healthcare system to assess differences between systems.

RESULTS

There were 1,746,714 participants across four healthcare systems. Compared with non-Hispanic whites (whites), odds of completing CRC screening were lower for non-Hispanic blacks (blacks) in healthcare systems with high screening rates (AOR=0.86, 95% CI=0.84, 0.88) but similar between blacks and whites in systems with lower screening rates (AOR=1.01, 95% CI=0.93, 1.09). Compared with whites, American Indian/Alaskan Natives had lower odds of completing CRC screening across all healthcare systems (AOR=0.76, 95% CI=0.72, 0.81). Hispanics had similar odds of CRC screening (AOR=0.99, 95% CI=0.98, 1.00) and Asian/Pacific Islanders had higher odds of CRC screening (AOR=1.16, 95% CI=1.15, 1.18) versus whites.

CONCLUSIONS

Racial/ethnic differences in CRC screening vary across healthcare systems, particularly for blacks, and may be more pronounced in systems with intensive CRC screening approaches.

Regional differences in recommended cancer treatment for the elderly

BACKGROUND

Little is known about regional variation in cancer treatment and its determinants. We compare rates of adherence to treatment guidelines for elderly patients across Texas and whether local specialist supply is an important determinant of treatment variation.

METHODS

Previous literature reviewed indicated 7 recommended courses of treatment for colorectal, pancreatic, and prostate cancer. We analyzed Texas Cancer Registry data linked with Medicare claims for the years 2004 to 2007 to study patients with these cancers. We tested for unadjusted and adjusted differences in treatment rates across 22 hospital referral regions (HRR). We tested whether variation in the local supply of specialists treating each cancer was an important determinant of treatment.

RESULTS

We found significant differences in adjusted treatment rates across regions. For removal and examination of 12+ lymph nodes with colon cancer resection, 13 of 22 HRRs had rates significantly different from the median region. For adjuvant chemotherapy for regional colon cancer, five HRRs significantly differed from the median. For prostate cancer treatment with a favorable diagnosis, nine HRRs differed from the median HRR. Of the 7 treatments, only the local availability of surgeons was an important determinant for excision of lymph nodes for colon cancer patients.

CONCLUSIONS

There are significant variations across Texas for seven recommended cancer treatments. No one region has consistently higher or lower treatments than other regions, and local specialist supply is not an important predictor of treatment. Different factors may be determining regional variation in treatment rates across cancer types and treatment options.

Health disparities in colorectal cancer among racial and ethnic minorities in the United States

In the 2010 Census, just over one-third of the United States (US) population identified themselves as being something other than being non-Hispanic white alone. This group has increased in size from 86.9 million in 2000 to 111.9 million in 2010, representing an increase of 29 percent over the ten year period. Per the American Cancer Society, racial and ethnic minorities are more likely to develop cancer and die from it when compared to the general population of the United States. This is particularly true for colorectal cancer (CRC). The primary aim of this review is to highlight the disparities in CRC among racial and ethnic minorities in the United States. Despite overall rates of CRC decreasing nationally and within certain racial and ethnic minorities in the US, there continue to be disparities in incidence and mortality when compared to non-Hispanic whites. The disparities in CRC incidence and mortality are related to certain areas of deficiency such as knowledge of family history, access to care obstacles, impact of migration on CRC and paucity of clinical data. These areas of deficiency limit understanding of CRC's impact in these groups and when developing interventions to close the disparity gap. Even with the implementation of the Patient Protection and Affordable Healthcare Act, disparities in CRC screening will continue to exist until specific interventions are implemented in the context of each of racial and ethnic group. Racial and ethnic minorities cannot be viewed as one monolithic group, rather as different segments since there are variations in incidence and mortality based on natural history of CRC development impacted by gender, ethnicity group, nationality, access, as well as migration and socioeconomic status. Progress has been made overall, but there is much work to be done.

Integrating Equity in a Public Health Funding Strategy

OBJECTIVE

Equity can be valuable to guide decision makers about where to target funds; however, there are few studies for modeling vertical equity in public health program funding strategies. This case study modeled vertical equity in the funding strategy of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program.

DESIGN

To integrate vertical equity by using historical funding and health data, we (a) examined the need for colorectal cancer screening, (b) conducted multiple regressions to examine the relationship between factors of need and funding of states, (c) stratified states into similar need groups, (d) estimated vertical equity within groups, and (e) assessed equity in the funding distribution.

RESULTS

Certain states with similar needs had high relative funding, whereas other states with similar needs had low relative funding.

CONCLUSION

The methods used to integrate vertical equity in this case study could be applied in publicly funded programs to potentially minimize inequities and improve outcomes.

Knowledge of Polyp History and Recommended Follow-Up Among a Predominately African American Patient Population and the Impact of Patient Navigation

BACKGROUND AND AIMS

Colorectal screening (CRS) rates in minority and uninsured populations have increased through patient navigation (PN) interventions. However, patient knowledge of colonoscopy results and follow-up recommendations has not been described in an African American (AA) population or following PN. Our objectives were to determine patient knowledge of colonoscopy results and follow-up recommendations within an AA patient population and to compare post-colonoscopy knowledge among patients who received either PN or usual care.

METHODS

This is a prospective observational study of patients who completed a screening colonoscopy in 2014. A semi-structured telephone survey was completed by 96 participants (69 % AA, 78 % female, and mean age 63 years). The survey assessed patient recall of polyp results and follow-up recommendations. Responses were compared with the medical record.

RESULTS

Of 96 patients surveyed (response rate, 68 %), 83 % accurately reported if polyps were detected and 66 % accurately reported their recommended follow-up. The identification of adenomatous polyps on colonoscopy was a predictor of accurate recall of colonoscopy results and follow-up recommendations. Uninsured patients who completed PN (18 of 96) were more likely to accurately report polyp results (100 vs. 80 %; P = 0.036), but the rates of accurate follow-up recall were not statistically significant (44 vs. 71 %; P = 0.053) when compared to usual care patients.

CONCLUSIONS

In an AA population, post-colonoscopy polyp recall rates were similar to those described in white populations. Uninsured patients who completed PN were more likely than insured usual care patients to accurately report the presence of polyps on colonoscopy.

Pathways to colonoscopy in the South: seeds of health disparities

OBJECTIVES

We aimed to highlight sociodemographic differences in how patients access colonoscopy.

METHODS

We invited all eligible patients (n = 2500) from 2 academy-affiliated colonoscopy centers in Alachua County, Florida (1 free standing, 1 hospital based), to participate in a precolonoscopy survey (September 2011-October 2013); patients agreeing to participate (n = 1841, response rate = 73.6%) received a $5.00 gift card.

RESULTS

We found sociodemographic differences in referral pathway, costs, and reasons associated with obtaining the procedure. Patients with the ideal pathway (referred by their regular doctor for age-appropriate screening) were more likely to be Black (compared with other minorities), male, high income, employed, and older. Having the colonoscopy because of symptoms was associated with being female, younger, and having lower income. We found significant differences for 1 previously underestimated barrier, having a spouse to accompany the patient to the procedure.

CONCLUSIONS

Patients' facilitators and barriers to colonoscopy differed by sociodemographics in our study, which implies that interventions based on a single facilitator will not be effective for all subgroups of a population.

Explaining persistent under-use of colonoscopic cancer screening in African Americans: a systematic review

INTRODUCTION

Although African Americans have the highest incidence and mortality from colorectal cancer (CRC), they are less likely than other racial groups to undergo CRC screening. Previous research has identified barriers to CRC screening among African Americans. However we lack a systematic review that synthesizes contributing factors and informs interventions to address persistent disparities.

METHODS

We conducted a systematic review to evaluate barriers to colonoscopic CRC screening in African Americans. We developed a conceptual model to summarize the patient-, provider-, and system-level barriers and suggest strategies to address these barriers.

RESULTS

Nineteen studies met inclusion criteria. Patient barriers to colonoscopy included fear, poor knowledge of CRC risk, and low perceived benefit of colonoscopy. Provider-level factors included failure to recommend screening and knowledge deficits about guidelines and barriers to screening. System barriers included financial obstacles, lack of insurance and access to care, and intermittent primary care visits.

CONCLUSIONS

There are modifiable barriers to colonoscopic CRC screening among African Americans. Future interventions should confront patient fear, patient and physician knowledge about barriers, and access to healthcare services. As the Affordable Care Act aims to improve uptake of preventive services, focused interventions to increase CRC screening in African Americans are essential and timely.

Predictors of Colorectal Cancer Screening: Does Rurality Play a Role?

PURPOSE

The purpose of this study was to explore the associations between sociodemographic factors such as residence, health care access, and colorectal cancer (CRC) screening among residents of Texas.

METHODS

Using the 2012 Behavioral Risk Factor Surveillance Survey, we performed logistic regression analyses to determine predictors of CRC screening among Texas residents, including rural versus urban differences. Our outcomes of interest were previous (1) CRC screening using any CRC test, (2) fecal occult blood test (FOBT), or (3) endoscopy, as well as up-to-date screening using (4) any CRC test, (5) FOBT, or (6) endoscopy. The independent variable of interest was rural versus urban residence; we controlled for other sociodemographic and health care access variables such as lack of health insurance.

RESULTS

Multivariate analysis showed that individuals who were residents of a rural/non-Metropolitan Statistical Area (MSA) location (OR = 0.70, 95% CI = 0.51-0.97) or a suburban county (OR = 0.61, 95% CI = 0.39-0.95) were less likely to report ever having any CRC screening compared to residents of a center city of an MSA. Residents of a rural/non-MSA location were less likely (OR = 0.49, 95% CI = 0.28-0.87) than residents of a center city of an MSA to be up-to-date using FOBT. There was decreased likelihood of ever being screened for CRC among the uninsured (OR = 0.43, 95% CI = 0.31-0.59).

CONCLUSIONS

Effective development and implementation of strategies to improve screening rates should aim at improving access to health care, taking into account demographic characteristics such as rural versus urban residence.

Reducing inequities in colorectal cancer screening in North America

Colorectal cancer (CRC) is an important cause of mortality and morbidity in North America. Screening using a fecal occult blood test, flexible sigmoidoscopy, or colonoscopy reduces CRC mortality through the detection and treatment of precancerous polyps and early stage CRC. Although CRC screening participation has increased in recent years, large inequities still exist. Minorities, new immigrants, and those with lower levels of education or income are much less likely to be screened. This review provides an overview of the commonly used tests for CRC screening, disparities in CRC screening, and promising methods at the individual, provider, and system levels to reduce these disparities. Overall, to achieve high CRC participation rates and reduce the burden of CRC in the population, a multi-faceted approach that uses strategies at all levels to reduce CRC screening disparities is urgently required.

Challenges and possible solutions to colorectal cancer screening for the underserved

Colorectal cancer (CRC) is a leading cause of cancer mortality worldwide. CRC incidence and mortality can be reduced through screening. However, in the United States, screening participation remains suboptimal, particularly among underserved populations such as the uninsured, recent immigrants, and racial/ethnic minority groups. Increasing screening rates among underserved populations will reduce the US burden of CRC. In this commentary focusing on underserved populations, we highlight the public health impact of CRC screening, list key challenges to screening the underserved, and review promising approaches to boost screening rates. We identify four key policy and research priorities to increase screening among underserved populations: 1) actively promote the message, "the best test is the one that gets done"; 2) develop and implement methods to identify unscreened individuals within underserved population groups for screening interventions; 3) develop and implement approaches for organized screening delivery; and 4) fund and enhance programs and policies that provide access to screening, diagnostic follow-up, and CRC treatment for underserved populations. This commentary represents the consensus of a diverse group of experts in cancer control and prevention, epidemiology, gastroenterology, and primary care from across the country who formed the Coalition to Boost Screening among the Underserved in the United States. The group was organized and held its first annual working group meeting in conjunction with the World Endoscopy Organization's annual Colorectal Cancer Screening Committee meeting during Digestive Disease Week 2012 in San Diego, California.

Disparities in endoscopy use for colorectal cancer screening in the United States

It is well established that disparities exist for colorectal cancer (CRC) incidence rates and death. With screening, death from CRC may be considered a preventable occurrence. Endoscopy (flexible sigmoidoscopy and colonoscopy) is the only modality with therapeutic benefit of removal of pre-cancerous polyps. The Patient Protection and Affordable Care Act mandated that preventive screening services be covered, which includes endoscopy for colon cancer screening. Recent federal rules have eliminated cost sharing for polyp removal during screening colonoscopy in privately insured patients; however, this has not been mandated for Medicare patients. Understanding the current state of disparities in endoscopy use is important, as these policy changes will affect millions of patients. The purpose of this literature review was to summarize the known research on disparities in endoscopy use for colon cancer screening in the United States and highlight areas for future research.

Reducing racial and ethnic disparities in colorectal cancer screening is likely to require more than access to care

Colorectal endoscopy, an effective screening intervention for colorectal cancer, is recommended for people age fifty or older, or earlier for those at higher risk. Rates of colorectal endoscopy are still far below those recommended by the US Preventive Services Task Force. This study examined whether factors such as the supply of gastroenterologists and the proportion of the local population without health insurance coverage were related to the likelihood of having the procedure, and whether these factors explained racial and ethnic differences in colorectal endoscopy. We found evidence that improving access to health care at the county and individual levels through expanded health insurance coverage could improve colorectal endoscopy use but might not be sufficient to reduce racial and ethnic disparities in colorectal cancer screening. Policy action to address these disparities will need to consider other structural and cultural factors that may be inhibiting colorectal cancer screening.

Fundoplication for gastroesophageal reflux disease: regional variability and factors predicting operative approach

We have recently shown that the majority of patients undergoing fundoplication in the United States are women. Based on these findings, we hypothesized that nonbiological factors contribute to the decisions on surgical reflux therapy. Using State Inpatient Databases of the Agency for Healthcare Research and Quality, we extracted annual fundoplication rates, sex distribution, age cohorts, racial background, and insurance coverage. To account for potential differences in state populations, the results were normalized and correlated with Census data, adult obesity rates, median income, poverty rates, and physician workforce within the state. Fundoplication rates varied fivefold between states, ranging from 4.1±0.1 per 100,000 in New Jersey to 21.8±0.4 per 100,000 in Oregon. Higher poverty rates and a higher fraction of Caucasians within a state independently predicted higher fundoplication rates. While the majority of operations were performed laparoscopically, surgical approaches also differed between states with rates of laparoscopic ranging from 52.3±1.8% in Oklahoma to 87.4±1.7% in Hawaii. A lower number of pediatric and Medicaid-insured patient and a higher fraction of privately insured patients best predicted higher rates of laparoscopic surgery. Our study shows significant regional variation in surgical reflux management, which cannot be explained by differences in disease mechanisms. Insurance coverage and racial background influenced the likelihood of surgery, suggesting a role of financial incentives.

Examining potential colorectal cancer care disparities in the Veterans Affairs health care system

PURPOSE

Racial disparities in cancer treatment and outcomes are a national problem. The nationwide Veterans Affairs (VA) health system seeks to provide equal access to quality care. However, the relationship between race and care quality for veterans with colorectal cancer (CRC) treated within the VA is poorly understood. We examined the association between race and receipt of National Comprehensive Cancer Network guideline-concordant CRC care.

PATIENTS AND METHODS

This was an observational, retrospective medical record abstraction of patients with CRC treated in the VA. Two thousand twenty-two patients (white, n = 1,712; African American, n = 310) diagnosed with incident CRC between October 1, 2003, and March 31, 2006, from 128 VA medical centers, were included. We used multivariable logistic regression to examine associations between race and receipt of guideline-concordant care (computed tomography scan, preoperative carcinoembryonic antigen, clear surgical margins, medical oncology referral for stages II and III, fluorouracil-based adjuvant chemotherapy for stage III, and surveillance colonoscopy for stages I to III). Explanatory variables included demographic and disease characteristics.

RESULTS

There were no significant racial differences for receipt of guideline-concordant CRC care. Older age at diagnosis was associated with reduced odds of medical oncology referral and surveillance colonoscopy. Presence of cardiovascular comorbid conditions was associated with reduced odds of medical oncology referral (odds ratio, 0.65; 95% CI, 0.50 to 0.89).

CONCLUSION

In these data, we observed no evidence of racial disparities in CRC care quality. Future studies could examine causal pathways for the VA's equal, quality care and ways to translate the VA's success into other hospital systems.

Potentially inappropriate screening colonoscopy in Medicare patients: variation by physician and geographic region

IMPORTANCE

Inappropriate use of colonoscopy involves unnecessary risk for older patients and consumes resources that could be used more effectively.

OBJECTIVES

To determine the frequency of potentially inappropriate colonoscopy in Medicare beneficiaries in Texas and to examine variation among physicians and across geographic regions.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used 100% Medicare claims data for Texas and a 5% sample from the United States from 2000 through 2009. We identified Medicare beneficiaries aged 70 years or older who underwent a colonoscopy from October 1, 2008, through September 30, 2009.

MAIN OUTCOME MEASURES

Colonoscopies were classified as screening in the absence of a diagnosis suggesting an indication for the procedure. Screening colonoscopy was considered potentially inappropriate on the basis of patient age or occurrence too soon after colonoscopy with negative findings. The percentage of patients undergoing potentially inappropriate screening colonoscopy was estimated for each colonoscopist and hospital service area.

RESULTS

A large percentage of colonoscopies performed in older adults were potentially inappropriate: 23.4% for the overall Texas cohort and 9.9%, 38.8%, and 24.9%, respectively, in patients aged 70 to 75, 76 to 85, or 86 years or older. There was considerable variation across the 797 colonoscopists in the percentages of colonoscopies performed that were potentially inappropriate. In a multilevel model including patient sex, race or ethnicity, number of comorbid conditions, educational level, and urban or rural residence, 73 colonoscopists had percentages significantly above the mean (23.9%), ranging from 28.7% to 45.5%, and 119 had percentages significantly below the mean (23.9%), ranging from 6.7% to 18.6%. The colonoscopists with percentages significantly above the mean were more likely to be surgeons, graduates of US medical schools, medical school graduates before 1990, and higher-volume colonoscopists than those with percentages significantly below the mean. Colonoscopist rankings were fairly stable over time (2006-2007 vs 2008-2009). There was also geographic variation across Texas and the United States, with percentages ranging from 13.3% to 34.9% in Texas and from 19.5% to 30.5% across the United States.

CONCLUSIONS AND RELEVANCE

Many colonoscopies performed in older adults may be inappropriate. The likelihood of undergoing potentially inappropriate colonoscopy depends in part on where patients live and what physician they see.