Integrated Behavioral Health Adaptations During the COVID-19 Pandemic

INTRODUCTION

COVID-19 pandemic lockdowns threatened standard components of integrated behavioral health (IBH) such as in-person communication across care teams, screening, and assessment. Restrictions also exacerbated pre-existing challenges to behavioral health (BH) access.

METHODS

Semistructured interviews were completed with clinicians from family medicine residency programs on the impact of the pandemic on IBH care delivery along with adaptations employed by care teams to ameliorate disruption.

RESULTS

Participants (n = 41) from 14 family medicine residency programs described the rapid shift to virtual care, creating challenges for IBH delivery and increased demand for BH services. With patients and care team members at home, virtual warm handoffs and increased attention to communication were necessary. Screening and measurement were more difficult, and referrals to appropriate services were challenging due to higher demand. Tele-BH facilitated continued access to BH services but was associated with logistic challenges. Participants described adaptations to stay connected with patients and care teams and discussed the need to increase capacity for both in-person and virtual care.

DISCUSSION

Most practices modified their workflows to use tele-BH as COVID-19 cases increased. Participants shared key learnings for successful implementation of tele-BH that could be applied in future health care crises.

CONCLUSION

Practices adapted readily to challenges posed by pandemic restrictions and their ability to sustain key elements of IBH during the COVID-19 pandemic demonstrates innovation in maintaining access when in-person care is not possible, informing strategies applicable to other scenarios.

Integrated Behavioral Health Implementation and Training in Primary Care: A Practice-Based Research Network Study

INTRODUCTION

Integrating behavioral health services into primary care has a strong evidence base, but how primary care training programs incorporate integrated behavioral health (IBH) into care delivery and training has not been well described. The goal of this study was to evaluate factors related to successful IBH implementation in family medicine (FM) residency programs and assess perspectives and attitudes on IBH among program leaders.

METHODS

FM residency programs, all which are required to provide IBH training, were recruited from the American Academy of Family Physicians National Research Network. After completing eligibility screening that included the Integrated Practice Assessment Tool (IPAT) questionnaire, 14 training programs were included. Selected practices identified 3 staff in key roles to be interviewed: medical director or similar, behavioral health professional (BHP), and chief medical officer or similar.

RESULTS

Forty-one individuals from 14 FM training programs were interviewed. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration). Screening, outcome tracking, and treatment differed among and within practices. Use of curricula and trainee experience also varied with little standardization. Most participants described similar approaches to communication and collaboration between primary care clinicians and BHPs and believed that IBH should be standard practice. Participants reported space, staff, and billing support as critical for sustainability.

CONCLUSIONS

Delivery and training experiences in IBH varied widely despite recognition of the value and benefits to patients and care delivery processes. Standardizing resources and training and simplifying and assuring reimbursement for services may promote sustainable and high quality IBH implementation.

Commentary: Some water in the data desert: the Cancer Intervention and Surveillance Modeling Network's capacity to guide mitigation of cancer health disparities

Despite significant progress in cancer research and treatment, a persistent knowledge gap exists in understanding and addressing cancer care disparities, particularly among populations that are marginalized. This knowledge deficit has led to a "data divide," where certain groups lack adequate representation in cancer-related data, hindering their access to personalized and data-driven cancer care. This divide disproportionately affects marginalized and minoritized communities such as the U.S. Black population. We explore the concept of "data deserts," wherein entire populations, often based on race, ethnicity, gender, disability, or geography, lack comprehensive and high-quality health data. Several factors contribute to data deserts, including underrepresentation in clinical trials, poor data quality, and limited access to digital technologies, particularly in rural and lower-socioeconomic communities.The consequences of data divides and data deserts are far-reaching, impeding equitable access to precision medicine and perpetuating health disparities. To bridge this divide, we highlight the role of the Cancer Intervention and Surveillance Modeling Network (CISNET), which employs population simulation modeling to quantify cancer care disparities, particularly among the U.S. Black population. We emphasize the importance of collecting quality data from various sources to improve model accuracy. CISNET's collaborative approach, utilizing multiple independent models, offers consistent results and identifies gaps in knowledge. It demonstrates the impact of systemic racism on cancer incidence and mortality, paving the way for evidence-based policies and interventions to eliminate health disparities. We suggest the potential use of voting districts/precincts as a unit of aggregation for future CISNET modeling, enabling targeted interventions and informed policy decisions.

Narratives from African American/Black, American Indian/Alaska Native, and Hispanic/Latinx community members in Arizona to enhance COVID-19 vaccine and vaccination uptake

The state of Arizona has experienced one of the highest novel coronavirus disease 2019 (COVID-19) positivity test rates in the United States with disproportionally higher case rates and deaths among African-American/Black (AA/B), American Indian/Alaska Native (Native), and Hispanic/Latinx (HLX) individuals. To reduce disparities and promote health equity, researchers from Arizona State University, Mayo Clinic in Arizona, Northern Arizona University, and the University of Arizona formed a partnership with community organizations to conduct state-wide community-engaged research and outreach. This report describes results from 34 virtually-held focus groups and supplemental survey responses conducted with 153 AA/B, HLX, and Native community members across Arizona to understand factors associated with COVID-19 vaccine hesitancy and confidence. Focus groups revealed common themes of vaccine hesitancy stemming from past experiences of research abuses (e.g., Tuskegee syphilis experiment) as well as group-specific factors. Across all focus groups, participants strongly recommended the use of brief, narrative vaccination testimonials from local officials, community members, and faith leaders to increase trust in science, vaccine confidence and to promote uptake.

Midwest rural-urban disparities in use of patient online services for COVID-19

PURPOSE

Rural populations are disproportionately affected by the COVID-19 pandemic. We characterized urban-rural disparities in patient portal messaging utilization for COVID-19, and, of those who used the portal during its early stage in the Midwest.

METHODS

We collected over 1 million portal messages generated by midwestern Mayo Clinic patients from February to August 2020. We analyzed patient-generated messages (PGMs) on COVID-19 by urban-rural locality and incorporated patients' sociodemographic factors into the analysis.

FINDINGS

The urban-rural ratio of portal users, message senders, and COVID-19 message senders was 1.18, 1.31, and 1.79, indicating greater use among urban patients. The urban-rural ratio (1.69) of PGMs on COVID-19 was higher than that (1.43) of general PGMs. The urban-rural ratios of messaging were 1.72-1.85 for COVID-19-related care and 1.43-1.66 for other health care issues on COVID-19. Compared with urban patients, rural patients sent fewer messages for COVID-19 diagnosis and treatment but more messages for other reasons related to COVID-19-related health care (eg, isolation and anxiety). The frequent senders of COVID-19-related messages among rural patients were 40+ years old, women, married, and White.

CONCLUSIONS

In this Midwest health system, rural patients were less likely to use patient online services during a pandemic and their reasons for its use differ from urban patients. Results suggest opportunities for increasing equity in rural patient engagement in patient portals (in particular, minority populations) for COVID-19. Public health intervention strategies could target reasons why rural patients might seek health care in a pandemic, such as social isolation and anxiety.

Connecting community-delivered evidence-based programs and the healthcare system: Piloting a learning "wellcare" system

INTRODUCTION

Many evidence-based programs (EBPs) have been determined in randomized controlled trials to be effective, but few studies explore the real-world effectiveness of EBPs implemented in the natural community setting. Our study evaluated whether a novel linked infrastructure would enable such insights and continuous improvement as part of a learning healthcare-community bridged "wellcare" ecosystem.

METHODS

We created a secure, web-based data entry and storage platform with a network of Minnesota community-based organizations to record EBP participants' demographics and attendance, and program details. We then linked participant's information to their Rochester Epidemiology Project (REP) medical records. With this infrastructure, we conducted a proof of concept, retrospective cohort study by matching EBP participants to REP controls and comparing medical record-documented outcomes over 1 year follow-up.

RESULTS

We successfully linked EBP participant records with medical records in 77.6% of cases, and the infrastructure proved feasible and scalable. Still, key challenges remain in obtaining participant consent for data sharing. Upfront resource investments and the availability of REP-like warehouses limit generalizability. Optimal learning will be improved by enhancements that better track program fidelity. Our pilot study established a proof-of-concept, but sample sizes (n = 99 for falls prevention and n = 97 chronic disease/pain management EBP completers) were too small to detect significant differences in hospital admittance as compared to matched controls for either EBP group, (OR = 0.66[0.36, 1.19]) and (OR = 0.81[0.43, 1.54]), respectively. Events were too rare to gather meaningful information about effects on fall rates.

CONCLUSIONS

Our pilot demonstrates the feasibility of developing an online infrastructure that connects information from community leaders with medical record documented health outcomes, bridging the knowledge gap between community programs and the health care system. Insights gleaned from our infrastructure can be used to continuously shape community program delivery to reduce the need for formal health care services.

ANALYSES OF PREVENTIVE CARE MEASURES WITH INCOMPLETE HISTORICAL DATA IN ELECTRONIC MEDICAL RECORDS: AN EXAMPLE FROM COLORECTAL CANCER SCREENING

The calculation of quality of care measures based on electronic medical records (EMRs) may be inaccurate because of incomplete capture of past services. We evaluate the influence of different statistical approaches for calculating the proportion of patients who are up-to-date for a preventive service, using the example of colorectal cancer (CRC) screening. We propose an extension of traditional mixture models to account for the uncertainty in compliance, which is further complicated by the choice of various screening modalities with different recommended screening intervals. We conducted simulation studies to compare various statistical approaches and demonstrated that the proposed method can alleviate bias when individuals with complete prior medical history information were not representative of the targeted population. The method is motivated by and applied to data from the National Cancer Institute-funded consortium Population-Based Research Optimizing Screening through Personalized Regiments (PROSPR). Findings from the application are important for the evaluation of appropriate use of preventive care and provide a novel tool for dealing with similar analytical challenges with EMR data in broad settings.

Time to Follow-up After Colorectal Cancer Screening by Health Insurance Type

INTRODUCTION

The purpose of this study was to test the hypothesis that patients with Medicaid insurance or Medicaid-like coverage would have longer times to follow-up and be less likely to complete colonoscopy compared with patients with commercial insurance within the same healthcare systems.

METHODS

A total of 35,009 patients aged 50-64years with a positive fecal immunochemical test were evaluated in Northern and Southern California Kaiser Permanente systems and in a North Texas safety-net system between 2011 and 2012. Kaplan-Meier estimation was used between 2016 and 2017 to calculate the probability of having follow-up colonoscopy by coverage type. Among Kaiser Permanente patients, Cox regression was used to estimate hazard ratios and 95% CIs for the association between coverage type and receipt of follow-up, adjusting for sociodemographics and health status.

RESULTS

Even within the same integrated system with organized follow-up, patients with Medicaid were 24% less likely to complete follow-up as those with commercial insurance. Percentage receiving colonoscopy within 3 months after a positive fecal immunochemical test was 74.6% for commercial insurance, 63.10% for Medicaid only, and 37.5% for patients served by the integrated safety-net system.

CONCLUSIONS

This study found that patients with Medicaid were less likely than those with commercial insurance to complete follow-up colonoscopy after a positive fecal immunochemical test and had longer average times to follow-up. With the future of coverage mechanisms uncertain, it is important and timely to assess influences of health insurance coverage on likelihood of follow-up colonoscopy and identify potential disparities in screening completion.

Abstract B25: Black-white differences in colorectal cancer screening and incidence over time by age and sex

Introduction: Blacks have the highest colorectal cancer (CRC) burden of any racial/ethnic group and the underlying reason for this disparity has not been fully elucidated. Continued examination of incidence in relation to screening, which is recommended for men and women beginning at age 50 years, may provide valuable insights into these disparities. The present study examined black-white differences in CRC incidence and screening patterns by age and sex over time.

Methods: National Health Interview Surveys between 2000-2015 were used to estimate screening prevalence and prevalence ratios (PR) among adults 50 years and older by non-Hispanic white/black race and sex. Data from the SEER were used to estimate age-sex-specific incidence rates from 1992-2013.

Results: From 2000 to 2015, CRC screening prevalence in age 50 years and older increased by 69% in whites (from 39.4% to 66.5%) and by 98% in blacks (from 31.1% to 61.4%) on a relative scale. Increases in CRC screening were evident in both men and women. During this time period, black-white differences also narrowed, such that CRC screening in blacks was 19% lower than in whites in 2000 (PR=0.81, 95%CI 0.71,0.92) but only 6% lower in 2015 (PR=0.94, 95%CI 0.88, 1.00). Absolute black-white differences in CRC incidence rates were slightly larger for men than for women (men: 3.0-6.0 versus women: 2.8-5.4 per 100,000) in people 35-49 years old, but decreased overtime in both groups. In 50-79-year-olds, absolute black-white incidence differences were larger for men prior to 2003 (men: 19.8-28.9 versus women: 28.3-33.1 per 100,000) and during 2004-2013 (men: 27.7-53.3 versus women: 20.6-38.7 per 100,000). In 35-49-year-olds, black-white incidence rate ratios (IRR) decreased overtime from 1992-2000 to 2009-2013 in both men (1.47 to 1.19) and women (1.49 to 1.17), but increased in both men (1.06 to 1.38) and women (1.15 to 1.49) for those 50 years and older.

Conclusions: Black-white differences in CRC incidence in both absolute and relative terms are greatest in screening-eligible adults and have persisted in recent years whereas absolute differences in incidence in those younger than 50 are relatively small. These patterns may reflect racial gaps in screening uptake. However, disparities in CRC screening prevalence have narrowed in recent years and may portend convergence in CRC incidence rates.

Note: This abstract was not presented at the conference.

Citation Format: Stacey A. Fedewa, Douglas Corley, Ahmedin Jemal, Rebecca Siegel, Michael Goodman, Chyke Doubeni. Black-white differences in colorectal cancer screening and incidence over time by age and sex. [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer: From Initiation to Outcomes; 2016 Sep 17-20; Tampa, FL. Philadelphia (PA): AACR; Cancer Res 2017;77(3 Suppl):Abstract nr B25.

Occurrence of Distal Colorectal Neoplasia Among Whites and Blacks Following Negative Flexible Sigmoidoscopy: An Analysis of PLCO Trial

BACKGROUND

It is unclear whether the higher rate of colorectal cancer (CRC) among non-Hispanic blacks (blacks) is due to lower rates of CRC screening or greater biologic risk.

OBJECTIVE

We aimed to evaluate whether blacks are more likely than non-Hispanic whites (whites) to develop distal colon neoplasia (adenoma and/or cancer) after negative flexible sigmoidoscopy (FSG).

DESIGN

We analyzed data of participants with negative FSGs at baseline in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial who underwent repeat FSGs 3 or 5 years later. Subjects with polyps or masses were referred to their physicians for diagnostic colonoscopy. We collected and reviewed the records of diagnostic evaluations.

PARTICIPANTS

Our analytic cohort consisted of 21,550 whites and 975 blacks.

MAIN MEASURES

We did a comparison by race (whites vs. blacks) in the findings of polyps or masses at repeat FSG, the follow-up of abnormal test results and the detection of colorectal neoplasia at diagnostic colonoscopy.

KEY RESULTS

At the follow-up FSG examination, 304 blacks (31.2 %) and 4183 whites (19.4 %) had abnormal FSG, [adjusted relative risk (RR) = 1.00; 95 % confidence interval (CI), 0.90-1.10]. However, blacks were less likely to undergo diagnostic colonoscopy (76.6 % vs. 83.1 %; RR = 0.90; 95 % CI, 0.84-0.96). Among all included patients, blacks had similar risk of any distal adenoma (RR = 0.86; 95 % CI, 0.65-1.14) and distal advanced adenoma (RR = 1.01; 95 % CI, 0.60-1.68). Similar results were obtained when we restricted our analysis to compliant subjects who underwent diagnostic colonoscopy (RR = 1.01; 95 % CI, 0.80-1.29) for any distal adenoma and (RR = 1.18; 95 % CI, 0.73-1.92) for distal advanced adenoma.

CONCLUSIONS

We did not find any differences between blacks and whites in the risk of distal colorectal adenoma 3-5 years after negative FSG. However, follow-up evaluations were lower among blacks.

How can we boost colorectal and hepatocellular cancer screening among underserved populations?

Colorectal cancer (CRC) and hepatocellular carcinoma (HCC) are common causes of cancer incidence and mortality in the USA, particularly among underserved populations such as racial/ethnic minorities, the under-/uninsured, and individuals with low socioeconomic status. Although screening can reduce cancer-related mortality, participation is suboptimal among underserved populations, likely serving as the largest contributor to observed inequities in HCC and CRC outcomes among US populations. In this narrative review, we highlight inequities across populations in the USA with respect to incidence and mortality for CRC and HCC and highlight potential causes, with a focus on screening rates. In addition, drawing from the recent literature, we highlight promising strategies for increasing screening for HCC and CRC and propose future research and policy solutions to optimize screening rates. With focused implementation of screening strategies and novel research, the burden of HCC and CRC can be reduced among underserved populations.

Short- and long-term risk of colorectal adenoma recurrence among whites and blacks

BACKGROUND

It is unclear whether the higher burden from colorectal cancer among blacks is due to an increased biological susceptibility.

OBJECTIVE

To determine whether non-Hispanic blacks (blacks) have a higher risk of adenoma recurrence than non-Hispanic whites (whites) after removal of colorectal adenoma.

DESIGN

Secondary analysis of the Polyp Prevention Trial (PPT) data.

SETTING

United States.

PATIENTS

Patients were 1668 self-identified whites and 153 blacks who completed the 4-year trial. Of these, 688 whites and 55 blacks enrolled in a posttrial, passive Polyp Prevention Trial Continued Follow-up Study (PPT-CFS) and underwent another colonoscopy.

MAIN OUTCOME MEASUREMENTS

Recurrence and location of the adenoma and advanced adenoma by race-ethnicity during PPT and cumulative recurrence over a mean follow-up of 8.3 years (range, 4.9-12.4 years) among PPT-CFS enrollees.

RESULTS

Blacks had similar risk of recurrence of adenoma (39.2% vs 39.4%; incidence risk ratio [RR] = .98; 95% CI, .80-1.20) and advanced adenoma (8.5% vs 6.4%; RR = 1.18; 95% CI, .68-2.05) as whites at the end of PPT. Recurrence risk did not differ by colon subsite. Among PPT-CFS enrollees, the cumulative recurrence rate over a maximal follow-up period of 12 years was similar for blacks and whites for adenoma (67.3% vs 67.0%; RR = 1.01; 95% CI, .84-1.21) and advanced adenoma (14.5% vs 16.9%; RR = 1.03; 95% CI, .60-1.79).

LIMITATION

There were few blacks in the long-term follow-up study.

CONCLUSIONS

Adenoma and advanced adenoma recurrence did not differ by race. Our study does not support more frequent surveillance colonoscopies for blacks with a personal history of adenoma as an intervention to reduce colorectal cancer disparity.

Factors associated with the risk of adenoma recurrence in distal and proximal colon

BACKGROUND/AIMS

Colonoscopy may be less effective in preventing cancer in the proximal colon. We evaluated whether risk factors for adenoma recurrence exhibit differential effect on adenoma recurrence by colon subsite.

METHODS

We examined the association of age, sex, body mass index, smoking status and use of nonsteroidal anti-inflammatory drugs (NSAIDs) on proximal and distal adenoma recurrence among 1,864 participants in the Polyp Prevention Trial. We used multinomial logistic regression models to calculate the relative risk ratios (RRR) and 95% CI.

RESULTS

733 (39.3%) participants had adenoma recurrence (228 distal only, 369 proximal only and 136 synchronous proximal and distal adenoma). When compared to participants without adenoma recurrence, no factor was associated with an increased risk of distal only adenoma recurrence. Age 65-69 years (RRR = 1.47, 95% CI 1.00-2.16), age ≥70 years (RRR = 2.24, 95% CI 1.57-3.20), and male sex (RRR = 1.73, 95% CI 1.32-2.27) were positively associated with proximal only adenoma recurrence. NSAIDs use was associated with a reduced risk of adenoma recurrence by similar magnitude in distal (RRR = 0.78, 95% CI 0.58-1.07) and proximal colon (RRR = 0.77, 95% CI 0.60-1.00).

CONCLUSIONS

We did not find any modifiable risk factor that differentially increases proximal as compared to distal adenoma recurrence to be clinically useful for targeted intervention.

Obesity, weight change, and risk of adenoma recurrence: a prospective trial

BACKGROUND AND STUDY AIMS

Obesity is a risk factor for colorectal neoplasia. Lifestyle modifications, including weight loss, have been advocated to reduce the risk. However, no prospective study has evaluated whether weight loss actually affects adenoma recurrence. The aim of this study was to examine whether weight change (loss or gain) over 4 years is associated with adenoma recurrence.

PATIENTS AND METHODS

A total of 1826 patients with colorectal adenoma in the Polyp Prevention Trial had their height and weight measured at baseline. Adenoma recurrence was determined by end of trial colonoscopy 4 years after study entry when patients' weights were re-measured. Poisson regression models were used to evaluate body mass index (BMI), weight change over 4 years, and the risk of any adenoma and advanced adenoma recurrence.

RESULTS

Adenoma recurrence was observed in 723 patients (39.6%), 118 (6.5%) of whom had advanced adenoma recurrence. Among those with baseline BMI < 25 kg/m² (n = 466), BMI 25-29 kg/m² (n = 868), and BMI ≥ 30 kg/m² (n = 492), the recurrence rate was 34.5%, 41.0%, and 41.9%, respectively. Obesity was associated with an increased risk of adenoma recurrence (RR = 1.19; 95%CI 1.01-1.39) and advanced adenoma recurrence (RR = 1.62; 95%CI 1.01-2.57). However, when compared with those with relatively stable weight (weight change < 5 lb) over the 4-year trial, weight gain or loss was not associated with adenoma recurrence. This was consistent, regardless of the baseline BMI.

CONCLUSIONS

Weight loss or gain over 4 years does not affect adenoma recurrence. This study does not support weight loss alone as an effective intervention for reducing adenoma recurrence.

Abstract 3565: Colorectal cancer screening among US adults with and without doctor's specific recommendation regarding choice of screening modality

Background: Absence of a physician's recommendation is among the most commonly reported barriers to undergoing colorectal cancer (CRC) screening. It is unknown whether a physician's specific recommendation of a particular screening modality, rather than a patient's choice from a menu of screening options, improves CRC screening uptake. Aim: To assess whether healthcare providers’ discussion of CRC screening options and recommending a specific screening modality improve uptake of screening. Methods: We used the 2007 Health Information National Trends Survey (HINTS) to evaluate how respondents who were 50 years and older (n = 4,342) were informed of CRC screening. We used logistic regression analyses to examine the association of recommendations and being current with CRC screening (Fecal occult blood testing (FOBT) within 1 year, sigmoidoscopy within 5 years, or colonoscopy within 10 years). Results: The mean age of responders was 64.9 years, 60.3% female, 81.5% white, 8.6% black, and 92.7% had health insurance. CRC screening discussions occurred with 3,320 (77.5%) respondents; 94.7% of which occurred with a doctor as opposed to a nurse or other health care professional. Colonoscopy was the most recommended test. Overall, 2,824 (65.0%) respondents were up to date with CRC screening regardless of the screening modality. After adjusting for age, sex, race, highest education, income, marital status and health insurance, having a discussion about screening and receiving a specific test recommendation were associated with being up to date with CRC screening (Table). Conclusion: Uptake of CRC screening is better when providers discuss CRC screening and make specific CRC screening test recommendations. Table: Association of the patterns of CRC screening recommendations with being up to date with CRC screening

Factors associated with inadequate colorectal cancer screening with flexible sigmoidoscopy

BACKGROUND AND STUDY AIM

Inadequate colorectal cancer screening wastes limited endoscopic resources. We examined patients factors associated with inadequate flexible sigmoidoscopy (FSG) screening at baseline screening and repeat screening 3-5 years later in 10 geographically-dispersed screening centers participating in the ongoing Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial.

METHODS

A total of 64,554 participants (aged 55-74) completed baseline questionnaires and underwent FSG at baseline. Of these, 39,385 participants returned for repeat screening. We used logistic regression models to assess factors that are associated with inadequate FSG (defined as a study in which the depth of insertion of FSG was <50 cm or visual inspection was limited to <90% of the mucosal surface but without detection of a polyp or mass).

RESULTS

Of 7084 (11%) participants with inadequate FSG at baseline, 6496 (91.7%) had <50 cm depth of insertion (75.3% due to patient discomfort) and 500 (7.1%) participants had adequate depth of insertion but suboptimal bowel preparation. Compared to 55-59 year age group, advancing age in 5-year increments (odds ratios (OR) from 1.08 to 1.51) and female sex (OR = 2.40; 95% confidence interval (CI): 2.27-2.54) were associated with inadequate FSG. Obesity (BMI > 30 kg/m(2)) was associated with reduced odds (OR = 0.67; 95% CI: 0.62-0.72). Inadequate FSG screening at baseline was associated with inadequate FSG at repeat screening (OR = 6.24; 95% CI: 5.78-6.75).

CONCLUSIONS

Sedation should be considered for patients with inadequate FSG or an alternative colorectal cancer screening method should be recommended.

Likelihood of missed and recurrent adenomas in the proximal versus the distal colon

BACKGROUND

Colonoscopy may be less efficacious in reducing colorectal cancer mortality in the proximal compared with the distal colon. A greater likelihood for missed and recurrent adenomas in the proximal colon may contribute to this phenomenon.

OBJECTIVE

To examine whether a proximal adenoma is associated with the risk and location of missed and recurrent adenomas.

DESIGN

Prospective.

SETTING

Polyp Prevention Trial.

PARTICIPANTS

A total of 1864 patients with an adenoma at baseline underwent a follow-up colonoscopy 4 years later (adenoma recurrence). Of these, 1731 underwent a clearing colonoscopy 1 year after the baseline examination (missed adenoma).

MAIN OUTCOME MEASUREMENTS

Association of baseline adenoma location with the risk and location of adenomas found at colonoscopy performed 1 year and 4 years later.

RESULTS

At the year 1 colonoscopy, 598 patients (34.6%) had an adenoma (missed adenoma). Compared with those with a distal-only adenoma at baseline, patients with a proximal-only adenoma at baseline were more likely to have any missed adenomas (relative risk [RR] 1.28; 95% CI, 1.09-1.49) and a proximal-only missed adenoma (RR 2.05; 95% CI, 1.49-2.80). At the year 4 colonoscopy, 733 patients (39.3%) had adenoma recurrence. Patients with a baseline proximal-only adenoma were more likely to have any adenoma recurrence (RR 1.14; 95% CI, 1.00-1.31) and a proximal-only adenoma recurrence (RR 1.52; 95% CI, 1.15-2.02). Sensitivity analyses involving missed adenomas did not materially affect the risk or location of recurrent adenomas at year 4 colonoscopy.

LIMITATION

Lesions may still be missed on repeated colonoscopies.

CONCLUSIONS

Missed and recurrent adenomas are more likely to be in the proximal colon.

Abstract 1882: Short- and long-term risk of adenoma recurrence with cigarette smoking: An analysis of the Polyp Prevention Trial and Continued Follow-Up Study

Background: Prospective studies have evaluated the association between cigarette smoking and colorectal adenoma recurrence within 4 years of follow-up, a relatively short duration. We sought to examine short- and long-term risk of adenoma recurrence in association with cigarette smoking among participants in the Polyp Prevention Trial (PPT), a multicenter, randomized controlled trial that evaluated the effect of a low fat, high fiber, fruits and vegetable diet on the risk of colorectal adenoma recurrence.

Methods: A cohort of 774 participants with colorectal adenoma completed a baseline questionnaire including tobacco use and completed the 4-year trial during which they underwent colonoscopy at 1 year and 4 years after enrollment. After the trial was completed, these participants consented to passive follow-up in the Continued Follow-up Study (CFS) during which the colonoscopy reports subsequent to the trial were collected and analyzed. We defined adenoma recurrence as any adenoma detected after the baseline colonoscopy. We used Poisson regression models to evaluate risk of adenoma recurrence up to 4 years (short-term) and up to 12 years of follow-up (long-term).

Results: At baseline, 461 (59.6%) participants had a history of smoking: 379 (49.0%) former smokers and 82 (10.6%) current smokers. Mean age of the patients was 59.6 years and 66.2% were males. The mean total duration of follow-up was 8.4 years (range 4.9 – 12.4 years). When compared with never smokers, there was no association between cigarette smoking and adenoma recurrence with either short- or long-term follow-up (Table).

Conclusions: Cigarette smoking is not associated with adenoma recurrence in the short- or the long-term.

Table: Relative Risk (RR) and 95% confidence interval (CI) for adenoma recurrence during short-term and long-term follow-up according to baseline smoking status

Abstract A49: Colorectal cancer screening practices by race and physician specialty

Primary care physicians play a critical role in the provision of colorectal cancer screening. Differences in CRC screening practices among PCP may contribute to underutilization of CRC screening. Low colorectal cancer screening rates may be attributed to the differences in screening practices among primary care physicians (PCPs). These screening practices may also account for racial disparities in colorectal cancer. The purpose of this study was to compare the colorectal cancer screening practices of black and white Medicare beneficiaries based on the type primary care provider that they had. Study data were obtained from Medicare Current Beneficiary Survey (MCBS) with matched Medicare claims. There were a total of 3666 Medicare beneficiaries included in the study, aged 50 to 75, identified as white or black, and “usually” received care from an internist, family physician, or general practitioner. Two-year longitudinal survey weights were used in all the analyses. Colorectal cancer screening was defined as having had a sigmoidoscopy or colonoscopy within five years and/or a home fecal occult blood test within one year. Unadjusted and adjusted logistic regression analyses were performed with stratification by the race of the beneficiary and the physician specialty. Compared to internist, a significantly lower proportion of beneficiaries that received care from a family physician or a general practitioner had undergone colorectal cancer screening or knew that Medicare provided reimbursement for screenings. Both black and white beneficiaries that had a family physician or general practitioner as their PCP were less likely to undergo screening and less likely receive a recommendation for screening and they were also less likely to know that Medicare helps pay for testing. However, when the analyses were stratified by physician specialty using a specialty-race interaction term, compared to whites, blacks receiving care from a family physician or a general practitioner were less likely to receive a recommendation for a colonoscopy. These results indicate that family physicians and general practitioners may be providing lower quality care regarding colorectal cancer screening services, compared to internists.

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A49.

Race and colorectal cancer disparities: health-care utilization vs different cancer susceptibilities

BACKGROUND

It is unclear whether the disproportionately higher incidence and mortality from colorectal cancer among blacks compared with whites reflect differences in health-care utilization or colorectal cancer susceptibility.

METHODS

A total of 60, 572 non-Hispanic white and black participants in the ongoing Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial underwent trial-sponsored screening flexible sigmoidoscopy (FSG) without biopsy at baseline in 10 geographically dispersed centers from November 1993 to July 2001. Subjects with polyps or mass lesions detected by FSG were referred to their physicians for diagnostic workup, the cost of which was not covered by PLCO. The records of follow-up evaluations were collected and reviewed. We used log binomial modeling with adjustment for age, education, sex, body mass index, smoking, family history of colorectal cancer, colon examination within previous 3 years, personal history of polyps, and screening center to examine whether utilization of diagnostic colonoscopy and yield of neoplasia differed by race.

RESULTS

Among 57 561 whites and 3011 blacks who underwent FSG, 13,743 (23.9%) and 767 (25.5%) had abnormal examinations, respectively. A total of 9944 (72.4%) whites and 480 (62.6%) blacks had diagnostic colonoscopy within 1 year following the abnormal FSG screening. When compared with whites, blacks were less likely to undergo diagnostic evaluation (adjusted risk ratio = 0.88, 95% confidence interval = 0.83 to 0.93). Overall, among subjects with diagnostic colonoscopy (n = 10 424), there was no statistically significant difference by race in the prevalence of adenoma, advanced adenoma, advanced pathology in small adenomas (high-grade dysplasia or villous histology in adenomas <10 mm), or colorectal cancer.

CONCLUSIONS

We observed a lower follow-up for screen-detected abnormalities among blacks when compared with whites but little difference in the yield of colorectal neoplasia. Health-care utilization may be playing more of a role in colorectal cancer racial disparity than biology.

Abstract B131: Geographic variation and the role of small-area socioeconomic deprivation in colorectal cancer survival: A multilevel analysis of the NIH-AARP Diet and Health Study

Background: Low-income persons have lower colorectal cancer (CRC) survival, but little is known about area socioeconomic deprivation on CRC survival. In this study, we examined geographic variation, the role of area-level socioeconomic deprivation in CRC survival and potential mechanisms linking neighborhood socioeconomic deprivation to CRC survival using the large, geographically dispersed, population-based NIH-AARP Diet and Health study cohort.

Methods: In the NIH-AARP Diet and Health study cohort, 7024 CRC cases identified in 1995–2003 were followed for their CRC-specific vital status through 2005. The Kaplan-Meier method was used to plot CRC-specific survival curve. An area-level deprivation score was developed using common factor analysis based on 21 census tract-level socioeconomic variables. Multilevel survival models were fitted to determine the extent of the small-area variation and the effect of area deprivation on survival. Six groups of individual factors, including cancer characteristics, sociodemographics, health conditions, health-related behaviors, Mediterranean dietary pattern and self-rated health, were examined to explore potential mediating pathways by which neighborhood socioeconomic deprivation exerted its influence on CRC survival.

Results: There was significant geographic variation in CRC survival (variance: 0.25 – 0.30, median hazard ratio: 1.61 – 1.68, interquartile hazard ratio: 3.19 – 3.52). CRC survival was significantly lower in areas with higher socioeconomic deprivation compared to areas with the lowest socioeconomic deprivation (hazard ratio [HR] for the second least vs. least deprivation quartile: 1.23, 95% confidence interval [CI]: 1.06 – 1.43; the second most vs. least deprivation quartile: 1.23, 95% CI: 1.05 – 1.44; the most vs. least deprivation quartile: 1.23, 95% CI: 1.05 – 1.44). Individual factors investigated partially explained the effect of area socioeconomic deprivation (adjusted HR for the second least vs. least deprivation quartile: 1.20, 95% confidence interval [CI]: 1.02 – 1.41; the second most vs. least deprivation quartile: 1.14, 95% CI: 0.96 – 1.34; the most vs. least deprivation quartile: 1.08, 95% CI: 0.91 – 1.29).

Conclusions: Small-area geographic variation in CRC survival was present. Interventions to improve CRC survival should target patients living in socioeconomically deprived neighborhoods. Future studies should further investigate the exact mechanisms between neighborhood deprivation and CRC survival to maximize their effect of prevention and control.

Citation Information: Cancer Prev Res 2010;3(1 Suppl):B131.

Abstract PR-10: The association of neighborhood socioeconomic context and mortality in a large national cohort in the United States: The NIHA-ARP Diet and Health Study

Background: Although several studies have reported that persons from lower socioeconomic groups have poorer health outcomes, few prospective studies have examined whether neighborhood socioeconomic context is associated with mortality. In this study, we prospectively evaluated whether persons residing in socioeconomically deprived neighborhoods have higher mortality risk compared to more resourced neighborhoods among a large geographically dispersed cohort.

Methods: Between 1995 and 1996, the NIH-AARP Diet and Health Study recruited an ethnically diverse prospective cohort of 566,402 persons, 50–71 years of age, from six U.S. states and two metropolitan areas. Detailed data were collected on diet, lifestyle, and medical history through questionnaires. Neighborhood socioeconomic information was obtained through linkage to the 2000 U.S. Census data at the tract level. We excluded 705 subjects with incomplete information for geocoding and computed an empirically derived index of neighborhood socioeconomic deprivation using principal component analyses. Mortality was ascertained through December 31, 2006. Two-level continuous-time survival models were used to derive hazard ratios of time to death from any cause stratified by gender.

Results: Of the 565,697 eligible subjects at baseline, the mean age was 62 years, 60% were male, 91% were non-Hispanic whites, 4% non-Hispanic blacks and 9% reported a history of cancer. A higher percentage of those in the most deprived neighborhoods reported poorer general health, higher average BMI, and lower Mediterranean diet scores. In multilevel Cox models analyses controlling for dietary and lifestyle factors, the risk of death increased with increasing levels of deprivation in the neighborhood of residence. Compared to the least deprived neighborhood, those residing in areas in the highest quintile of deprivation had a higher risk for death (men: hazard ratio [HR]: 1.22, 95% confidence interval [CI]: 1.18–1.25); women: HR: 1.23, 95% CI: 1.17–1.29).

Conclusion: Our study suggests that living in socioeconomically deprived neighborhoods is associated with a higher risk for death independent of lifestyle and dietary risk factors.

Citation Information: Cancer Prev Res 2010;3(1 Suppl):PR-10.

Under utilization of surveillance mammography among older breast cancer survivors

BACKGROUND

Annual surveillance mammography is recommended for follow-up of women with a history of breast cancer. We examined surveillance mammography among breast cancer survivors who were enrolled in integrated healthcare systems.

METHODS

Women in this study were 65 or older when diagnosed with early stage invasive breast cancer (N = 1,762). We assessed mammography use during 4 years of follow-up, using generalized estimating equations to account for repeated measurements.

RESULTS

Eighty-two percent had mammograms during the first year after treatment; the percentage declined to 68.5% in the fourth year of follow-up. Controlling for age and comorbidity, women who were at higher risk of recurrence by being diagnosed at stage II or receiving breast-conserving surgery (BCS) without radiation therapy were less likely to have yearly mammograms (compared to stage I, odds ratio [OR] for stage IIA 0.72, confidence interval [CI] 0.59, 0.87, OR for stage IIB 0.75, CI 0.57, 1.0; compared to BCS with radiation, OR 0.58, CI 0.43, 0.77). Women with visits to a breast cancer surgeon or oncologist were more likely to receive mammograms (OR for breast cancer surgeon 6.0, CI 4.9, 7.4, OR for oncologist 7.4, CI 6.1, 9.0).

CONCLUSIONS

Breast cancer survivors who are at greater risk of recurrence are less likely to receive surveillance mammograms. Women without a visit to an oncologist or breast cancer surgeon during a year have particularly low rates of mammography. Improvements to surveillance care for breast cancer survivors may require active participation by primary care physicians and improvements in cancer survivorship programs by healthcare systems.

Treatment practices and outcomes of patients with established peripheral arterial disease hospitalized with acute myocardial infarction in a community setting

BACKGROUND

There are little contemporary data available describing the hospital and long-term outcomes of patients with peripheral arterial disease (PAD) who are hospitalized with acute myocardial infarction (AMI). The objectives of our population-based study were to examine the hospital and long-term outcomes, as well as the use of different treatment practices, among patients with established PAD who were hospitalized with AMI.

METHODS

The study sample consisted of 4480 patients hospitalized with AMI at all Worcester, Mass, medical centers in 4 alternate years between 1997 and 2003.

RESULTS

Among the metropolitan Worcester residents hospitalized with AMI, 13.5% had a history of PAD. Prior use of proven cardiac therapies in patients with, and without, PAD was less than optimal though more often used in patients with prior PAD. Patients with PAD were significantly less likely to be treated with thrombolytic therapy during hospitalization than patients without PAD. Patients with PAD were not at significantly increased risk of dying during hospitalization (adjusted OR 1.29, 0.95% CI 0.97-1.71), though they were at a significantly increased risk of dying at 1 year after hospital discharge (adjusted OR 2.00, 95% CI 1.58-2.52) in comparison with patients without prior PAD.

CONCLUSIONS

Approximately 1 in 8 patients presenting with AMI in this community-wide study had a history of clinically recognized PAD. These patients are at increased risk of dying during the first year after hospital discharge. Our data indicate that there is a room for improvement for the enhanced use of effective treatment modalities and implementation of secondary prevention strategies in these high-risk patients.

Trends and outcomes associated with angiotensin-converting enzyme inhibitors

BACKGROUND

Limited recent data are available describing the patterns of use of angiotensin converting enzyme inhibitor (ACEI) therapy in patients with acute myocardial infarction (AMI), particularly from the more generalizable population-based setting. The purpose of this study was to examine trends in the receipt of ACEIs and associated short-term outcomes in patients hospitalized with AMI in a large Northeastern community.

METHODS

We conducted a community-wide study of 7991 patients hospitalized with AMI in all metropolitan Worcester, Massachusetts, medical centers during 8 annual periods between 1990 and 2003.

RESULTS

Among all patients, 44% received ACEI therapy during their acute hospitalization. There was a marked increase in the use of ACEIs between 1990 (23%) and 2003 (68%), particularly among those who were not on ACEIs before hospitalization. Patients who were previously on ACEIs were more likely to receive this therapy during hospitalization for AMI than were patients who were not previously on this therapy. Patients treated with ACEIs were significantly less likely to die (adjusted odds ratio [OR] 0.33; 95% confidence interval [CI] 0.27-0.41) during hospitalization than were patients who did not receive this therapy, with benefits observed across all subgroups examined.

CONCLUSIONS

The results of this observational study demonstrate marked increases in the use of ACEIs in patients with AMI in the community setting and demonstrate the benefits to be gained from use of this therapy. Despite these encouraging trends, there remains room for more optimal use of this therapy.

Disparities and Survival Among Breast Cancer Patients

BACKGROUND

Although rates of survival for women with breast cancer have improved, the survival disparity between African American and white women in the United States has increased.

PURPOSE

To determine whether this survival disparity persists in an insured population with access to medical care.

METHODS

In this retrospective cohort study, we extracted data from the tumor registries of six nonprofit, integrated health care delivery systems affiliated with the Cancer Research Network and assessed the survival of African American (n = 2276) and white (n = 18 879) female enrollees who were diagnosed with invasive breast cancer from January 1, 1993, through December 31, 1998. Cox proportional hazards regression was used to estimate the death rate among African American women relative to that of white women after adjustment for potential explanatory factors including stage at diagnosis, tumor characteristics, and treatment.

RESULTS

Five-year survival was lower for African American women (73.8%) than for white women (81.6%). African American women were less likely to have tumor characteristics with good prognosis. Controlling for age at diagnosis, stage, grade, tumor size, and estrogen and progesterone receptor status, the adjusted hazard rate ratio for African American women was 1.34 (95% confidence interval = 1.22 to 1.46). Similar risks were found among women ages 20-49 and 50 and older. Controlling for treatment slightly lowered the hazard rate ratio to 1.31 (95% confidence interval = 1.20 to 1.43).

CONCLUSIONS

Among women with invasive breast cancer, being insured and having access to medical care does not eliminate the survival disparity for African American women.