Disparities In Screening Rates Research Articles

Abstract C131: Disparities in breast cancer screening resumption among health plan enrollees in the US following the COVID-19 pandemic: Are all groups back on track?

Abstract Purpose: The COVID-19 pandemic disproportionately impacted racial/ethnic minority and low-income individuals and resulted in significant disruptions in preventive care for all groups. While severe declines in routine cancer screening were observed during pandemic shutdown periods, it is unclear whether return-to-screening rates following healthcare reopening are consistent across all groups. In this study we examine rates of breast cancer screening pre- and post- pandemic shutdown periods across race/ethnicity, age, and income among health plan enrollees in the United States (US) to inform screening catch-up strategies after COVID-19 disruptions. Methods: We conducted a retrospective analysis of breast cancer screening claims (including codes for mammography, breast MRI, digital breast tomography, and breast imaging) from Optum Clinformatics Data Mart among female enrollees from 2019-2021. Eligible enrollees included women, ages 40-75 with continuous enrollment 12 months prior to screening index month. Screening volume was calculated each calendar month during the three-year period, with January 2019-February 2020 as the pre-pandemic period, March 2020 through June 2020 as the pandemic closure period, and July 2020-December 2021 as the post-closure (reopening) pandemic period. We conducted an event study to calculate group-level monthly predicted probabilities of screening using a linear probability model with group interactions by month, controlling for demographic variables and comorbidities. Additionally, we used difference-in-difference (DD) regressions including group interacted with a post-closure pandemic dummy. The pandemic closure period months were excluded from our DD analysis. Results: Our study included 8,378,296 health plan enrolled women. Overall mammography screening decreased significantly during the pandemic closure phase (March-June 2020) but rebounded to higher levels in the post-closure period relative to baseline (3.76% to 3.96%). Screening rates were highest among non-Hispanic White women in the pre-pandemic period compared to other racial-ethnic groups. Our DD model suggests that White-Asian disparities increased in the post-pandemic period while other race/ethnic disparities remained constant. Additionally, disparities in screening by age changed during the pandemic. Although the oldest age group (65-75) had the highest screening rates in the pre-closure phase, they were slower to return to pre-pandemic levels of screening compared to younger age groups. Implications: Return to breast cancer screening among health plan enrollees in the US was robust. However, disparities in screening rates between groups in the pre-pandemic period were again observed in the reopening period, signaling lost opportunities to revamp structural inequities in care delivery following the pandemic. Further monitoring of return-to-screening disparities, particularly among more medically underserved groups, will be critical in informing interventions to address the long-term consequences resulting from the disruption of COVID-19 on cancer care. Citation Format: Jennifer Tsui, Sarah Axeen, John Thacker, Sonali Saluja, Laura Solano, Willow Pastard, Chun Nok Lam, Todd Schneberk, Cameron Kaplan. Disparities in breast cancer screening resumption among health plan enrollees in the US following the COVID-19 pandemic: Are all groups back on track? [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C131.

Social Determinants of Health and Perceived Barriers to Care in Diabetic Retinopathy Screening

Regular screening for diabetic retinopathy often is crucial for the health of patients with diabetes. However, many factors may be barriers to regular screening and associated with disparities in screening rates. To evaluate the associations between visiting an eye care practitioner for diabetic retinopathy screening and factors related to overall health and social determinants of health, including socioeconomic status and health care access and utilization. This retrospective cross-sectional study included adults aged 18 years or older with type 2 diabetes who answered survey questions in the All of Us Research Program, a national multicenter cohort of patients contributing electronic health records and survey data, who were enrolled from May 1, 2018, to July 1, 2022. The associations between visiting an eye care practitioner and (1) demographic and socioeconomic factors and (2) responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys were investigated using univariable and multivariable logistic regressions. The primary outcome was whether patients self-reported visiting an eye care practitioner in the past 12 months. The associations between visiting an eye care practitioner and demographic and socioeconomic factors and responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys in All of Us were investigated using univariable and multivariable logistic regression. Of the 11 551 included participants (54.55% cisgender women; mean [SD] age, 64.71 [11.82] years), 7983 (69.11%) self-reported visiting an eye care practitioner in the past year. Individuals who thought practitioner concordance was somewhat or very important were less likely to have seen an eye care practitioner (somewhat important: adjusted odds ratio [AOR], 0.83 [95% CI, 0.74-0.93]; very important: AOR, 0.85 [95% CI, 0.76-0.95]). Compared with financially stable participants, individuals with food or housing insecurity were less likely to visit an eye care practitioner (food insecurity: AOR, 0.75 [95% CI, 0.61-0.91]; housing insecurity: AOR, 0.86 [95% CI, 0.75-0.98]). Individuals who reported fair mental health were less likely to visit an eye care practitioner than were those who reported good mental health (AOR, 0.84; 95% CI, 0.74-0.96). This study found that food insecurity, housing insecurity, mental health concerns, and the perceived importance of practitioner concordance were associated with a lower likelihood of receiving eye care. Such findings highlight the self-reported barriers to seeking care and the importance of taking steps to promote health equity.

Promoting Health Equity Through Family-Centered Social Needs Screening and Intervention in the Inpatient Setting.

Promoting Health Equity Through Family-Centered Social Needs Screening and Intervention in the Inpatient Setting.

A novel sparse model-based algorithm to cluster categorical data for improved health screening and public health promotion

Screening for interpersonal violence is critical to mitigate the consequences of violence and improve women’s health. Current guidelines recommend that health care providers screen all women for experiences of violence. Despite these recommendations, studies have noted a large variation in provider-reported interpersonal violence screening rates ranging from 10% to 90%. Given the disparity in screening rates, identifying variables correlated with providers’ screening practices is an important contribution. A survey of healthcare providers previously collected was utilized for this analysis and consisted of the providers’ socio-demographics, attitudes and beliefs, practice environment characteristics as well as self-reported screening practices. The objective of the study was to stratify healthcare providers into relatively homogeneous clusters based on mixed types of categorical nominal and ordinal variables and correlate the identified clusters with the violence screening rates. This paper proposes a sparse categorical Factor Mixture Model (sc-FMM) to cluster a large number of categorical variables, in which an norm was used for variable selection. An Expectation Maximization framework integrated with Gauss-Hermite approximation was developed for model estimation. Simulation studies show significantly better performance of sc-FMM than competing methods. sc-FMM was applied to identify clusters/subgroups of healthcare providers. The identified clusters were further correlated with interpersonal violence screening rates. The findings reveal how the providers’ screening rate for interpersonal violence are associated with multi-source impacting factors which inform the formation of policy and intervention development to promote the uptake of routine screening for interpersonal violence in women.

Highlighting strengths and resources that increase ownership of cervical cancer screening for Indigenous communities in Northern British Columbia: Community-driven approaches.

ObjectiveTo examine the unique and diverse strengths held by rural and remote Indigenous communities in northern British Columbia, including multi‐generational support systems in health and wellness, profound connections to the land, and strong cultural foundations, and harness these strengths, allowing communities to engage in innovative and empowering health and wellness programs.MethodsBuilding on these pre‐existing and fundamental strengths, an alternative option to cervical cancer screening was introduced to nine Carrier Sekani health centers located in northern interior British Columbia in response to disparities in screening rates. Introduced in 2019, CervixCheck uses a self‐collection approach that is private, safe, convenient, and offered at local community health centers by trained and supportive health staff.ResultsUsing a strengths‐based and community directed and descriptive approach, the process was outlined for a successful and ongoing health screening opportunity that is put into the hands of community members within Indigenous communities in the region of northern British Columbia.ConclusionThrough collaborative partnerships, in‐person engagement sessions, and the utilization of pre‐existing infrastructure and health and wellness teams, this project was successfully integrated into primary care centers using culturally safe and community‐based approaches.

Black and White Differences in Colorectal Cancer Screening and Screening Outcomes: A Narrative Review.

Racial disparities in colorectal cancer incidence are widely documented. There are two potential mechanisms for these disparities: differences in access to screening, including screening follow-up, and differences in underlying risk of colorectal cancer. We reviewed the literature for evidence of these two mechanisms. We show that higher colorectal cancer incidence in blacks relative to whites emerged only after the dissemination of screening and describe evidence of racial disparities in screening rates. In contrast to the strong evidence for differences in colorectal cancer screening utilization, there is limited evidence for racial differences in adenoma prevalence. In general, black and white patients who are screened have similar adenoma prevalence, though there is some evidence that advanced adenomas and adenomas in the proximal colon are somewhat more likely in black than white patients. We conclude that higher rates of colorectal cancer incidence among black patients are primarily driven by lower rates of colorectal cancer screening. Our findings highlight the need to increase black patients' access to quality screening to reduce colorectal cancer incidence and mortality.

Abstract B054: Development of a decisional values measure for lung cancer screening among long-term African American smokers

Abstract Introduction: The burden of lung cancer is significant for African Americans, especially African American men, who have the highest lung cancer death rates compared to all other racial and ethnic groups. There is mounting evidence that lung cancer screening via low-dose computed tomography (LDCT) reduces lung cancer-specific mortality. However, due to the limitations and possible harms associated with LDCT, most medical organizations are endorsing the process of informed and shared decision-making. To promote informed decision-making in this context, individuals’ decisional needs must be met, including addressing any gaps in knowledge about lung cancer and lung cancer screening, considering personal values related to screening, and the role the patient wants to play in the decision-making process. To avoid racial disparities in screening rates for LDCT, which will ultimately increase the racial disparity in lung cancer mortality, it is important to uncover any considerations unique to patients who are eligible for LDCT. Methods: Key informant interviews (N=9) identified factors important to African American smokers’ screening decisions. Based on these interviews, we developed decisional values items for LDCT and report initial psychometric properties. The pool of items was administered to a convenience sample of 119 African American smokers. Results: An exploratory factor analysis revealed two components explaining 64% of the variance. The components were Cons of Screening (e.g., ‘…screening will not find all lung cancers or all lung cancer early’) and Pros of Screening (e.g., ‘lowering your risk of dying from lung cancer’). The final 12-item measure had very good internal consistency (α=.89 overall; α=.86 and .88 for subscales, respectively). To determine whether the decisional values items predicted participants’ intention to be screened for lung cancer via LDCT in the next six months, linear regression analyses were conducted with the sub-scales. The Pros of Screening sub-scale significantly predicted screening intentions such that higher reported pros were associated with greater likelihood of screening intention (B=.10, SE=.04, p<.05). The Cons of Screening sub-scale was not significantly associated with likelihood of screening. Conclusion: Values may be specific to the type of decision and the characteristics of those making the decision. This tool provides a promising values measure for lung cancer screening among African Americans and could inform future values clarification tools promoting informed decision-making. Our next steps in this line of research will include conducting cognitive testing of the items and assessing the reliability of this tool in sub-groups. Citation Format: Randi M. Williams, Kathryn L. Taylor, Cheryl L. Knott. Development of a decisional values measure for lung cancer screening among long-term African American smokers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B054.

Accuracy of Autism Screening in a Large Pediatric Network.

Universal screening is recommended to reduce the age of diagnosis for autism spectrum disorder (ASD). However, there are insufficient data on children who screen negative and no study of outcomes from truly universal screening. With this study, we filled these gaps by examining the accuracy of universal screening with systematic follow-up through 4 to 8 years. Universal, primary care-based screening was conducted using the Modified Checklist for Autism in Toddlers with Follow-Up (M-CHAT/F) and supported by electronic administration and integration into electronic health records. All children with a well-child visit (1) between 16 and 26 months, (2) at a Children's Hospital of Philadelphia site after universal electronic screening was initiated, and (3) between January 2011 and July 2015 were included (N = 25 999). Nearly universal screening was achieved (91%), and ASD prevalence was 2.2%. Overall, the M-CHAT/F's sensitivity was 38.8%, and its positive predictive value (PPV) was 14.6%. Sensitivity was higher in older toddlers and with repeated screenings, whereas PPV was lower in girls. Finally, the M-CHAT/F's specificity and PPV were lower in children of color and those from lower-income households. Universal screening in primary care is possible when supported by electronic administration. In this "real-world" cohort that was systematically followed, the M-CHAT/F was less accurate in detecting ASD than in previous studies. Disparities in screening rates and accuracy were evident in traditionally underrepresented groups. Future research should focus on the development of new methods that detect a greater proportion of children with ASD and reduce disparities in the screening process.

Disparities in colorectal cancer mortality for rural populations in the United States: Does screening matter?

IntroductionRural compared to urban populations in the US have increased colorectal cancer (CRC) incidence with known disparity in screening rates and mortality. We hypothesize that rural-urban disparities are different at a regional level. MethodsWe assessed screening rates according to the 2016 Behavioral Risk Factor Surveillance System guidelines using state and city-level data for county level estimates and correlating with county CRC mortality data from the National Cancer Institute. We used multivariable modeling to examine associations between rurality, screening rates, and mortality. ResultsHighest screening rate states had the smallest urban-rural disparities; lowest screening rate states had the largest disparities. Percent screened and urban-rural classification correlated significantly with mortality. Rural counties experienced ∼5 more deaths per 100,000 population even controlling for screening rates. ConclusionsNational urban-rural disparities in CRC screening mask greater state/regional disparities, not fully explaining the urban-rural mortality gap. Other factors (i.e. access to care, treatment differences) must be considered.

Exploration of factors associated with perceived barriers to cervical cancer screening among Chinese American women

This study explored factors associated with perceived barriers to Pap smear testing among Chinese American women (CAW). A total of 121 CAW, ages 21–65, living in California and Nevada completed a self-report questionnaire. Data included demographics, prior screening behavior, risk factors, and perceived barriers to screening. Logistic regression models revealed that participants with less education, and who have never been screened were more likely to report (I) worry about getting a Pap smear, (II) expense of a Pap smear, and (III) not knowing where to get a Pap smear. Partner’s resistance to the women’s participation in screening was another barrier among the never screened. Uninsured women were more likely to worry about getting a Pap test and embarrassment associated with getting a Pap test. Women who had never been screened, those with lower education, and those who were uninsured reported more barriers. Attention to these common and unique barriers may help address health disparities in screening rates. These findings reinforce the importance of literacy- and culturally-appropriate educational interventions designed for improving knowledge of cervical cancer and improving screening rates.

A systems approach for modeling health information complexity

Information complexity issues such as poor data integration and quality and timely access to information can impair the implementation of information artifacts. Clinical practice guidelines (CPGs) are an information artifact used to guide a patient’s care delivery over time. Despite evidence on the effectiveness of CPGs, they remain underutilized in certain contexts of medicine. One such example is colorectal cancer screening where disparities in screening rates and incidences of colorectal cancer are particularly prevalent between rural and urban populations. To address that issue, we need to better understand the information complexity factors that impact CPG implementation. This paper addresses the above shortcoming and uses a case study of colorectal cancer screening in remote and rural Northern Canada to develop a systems approach for modeling health information complexity. We describe a set of health information system components and interrelationships and a method for system mapping using the system components and interrelationships. We then provide exploratory system models from our case study and use them to characterize health information complexity according to interaction complexity and information behavior complexity. Our results highlight that information artifacts such as CPGs are not complex per se, but rather confounding factors is what causes information complexity. Our findings have implications for modeling information complexity and the design of policy and technological solutions to address health information complexity.

Colorectal cancer screening among Hispanics/Latinos in the HCHS/SOL sociocultural ancillary study.

Latino adults are more likely to be diagnosed with colorectal cancer (CRC) at later stages compared to white adults which may be explained by disparities in screening rates. The aim of this study was to examine factors associated with three CRC screening indicators [i.e., 1) any CRC screening ever (via, fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy); 2) FOBT in last year, 3) sigmoidoscopy/colonoscopy in last 10 years) among US Hispanics/Latinos. We analyzed population-based data collected in 2008–2011 from 2265 adults aged 50–75 from San Diego, Bronx, Miami and Chicago from the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study. Based on the Behavioral Model of Health Services Use, the following correlates of CRC screening were examined: predisposing (i.e., age, education, income, acculturation), enabling (i.e., recent physician visit, insurance, recent mammogram), and need (i.e., health-related quality of life and family/personal history of cancer) factors. Separate logistic regression models were analyzed for the three CRC screening indicators. Enabling factors associated with all CRC screening indicators included: health insurance, a recent physician visit, and a mammogram in the last year (women only). For women, being older, more acculturated (i.e., English language or foreign-born but in the US for 10 or more years), and having a personal history of cancer was associated with at least one CRC screening. Findings suggest that improving access and utilization of care among Hispanics/Latinos may be critical for earlier CRC diagnosis and survival.

Can Cross-Sector Partnerships Increase Breast Cancer Screening in Hard-to-Reach Migrant Populations?

Background and context: BreastScreen Victoria (BSV) provides free breast screening to women aged 40+; targeting women aged 50-74. The program reduces breast cancer-related deaths by up to 28%. BSV aims to ensure equitable participation for all women in the target age; however there are large disparities in screening rates for different subpopulations. Emerging migrant women participate in breast screening at lower rates than the general population. These women face complex barriers including cultural factors, low health literacy, and access. BSV identified cross-sector partnerships, with local trusted organizations who engage with emerging migrant women, as an approach to tackle the multidimensional problems in screening inequalities. Aim: Through cross-sector partnerships BSV aims to bring together diverse skills, knowledge and resources for more effective health promotion outcomes, including: 1. Increasing awareness of breast screening in emerging migrant communities, 2. Providing a culturally safe environment for women to access breast screening. Strategy/Tactics: BSV partnered with organizations beyond the traditional health sector. One key partnership is with AMES Australia, who provide settlement services for refugees and migrants. The main approach of this model is two-way capacity building between organizations. BSV built the capacity of AMES to deliver BreastScreen's key messages, and promote screening to eligible women accessing their service. This included training for staff, resource development/sharing, and support. AMES built the capacity of BSV by providing insight into barriers for women they engage, and guidance adapting traditionally clinical environments ensuring cultural safety. To date BSV has undertaken screening initiatives with AMES in 2 Melbourne locations. Outcomes: - Migrant women are introduced to breast screening by a trusted organization - BSV's key messages are delivered in a culturally appropriate manner - Development of sustainable skills, structures and resources in both organizations - Utilization of AMES relationship with their clients to engage women who BSV may not reach -not on the Victorian Electoral Roll - 6 group bookings with specific languages groups - Familiar case worker and in person translator supporting group bookings - Engaging mainly first time screeners who may not have accessed a breast screen - Overcoming cultural, language, and health literacy barriers - Tailored appointments for groups and walk-ins. What was learned: A lack of tailored strategies to engage women in breast screening compounds barriers for migrant women. Cross-sector partnerships increase the efficiency of systems that impact health by making the best use of different but complementary resources. Collaborations, joint resourcing and planned action should be considered ongoing practice, particularly for disengaged populations, to address the many determinants of health that lie outside the reach of the health system.

Abstract IA32: Con: The ACA will not eliminate disparities in cancer screening

Abstract While hopes have risen that the Affordable Care Act (ACA) will eliminate screening health disparities, we argue that disparities will persist. In this session we will discuss differences in mortality by age and race for breast cancer, colon, and cervical cancer. Let's be clear, however, that differences are not disparities. Biologic differences may account for some differences in morbidity and mortality and these causes cannot be addressed by screening alone. In this discussion we use the term disparity as suggested by Health People 2020 to mean differences due to “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage”. Though 20 million people have gained coverage under the ACA, that coverage alone will not eliminate health disparities because that is only one factor in a multilevel problem. Factors in multilevel problems interact with each other so the ACA is a major step forward that will affect the healthcare environment in states, healthcare organizations, provider teams and the mind of individuals seeking health. But that is exactly why the ACA is only a start; the ACA will not eliminate the other socio-economic barriers that still exist at those levels and will even increase barriers in some cases; state policies, organizational culture and assets, medical team practices and functioning, and individual attitudes all must be addressed to eliminate differential screening rates and reduce disparities in cancer morbidity and mortality. There has been progress in reducing disparities in screening rates for breast, colorectal, and cervical cancer by some criteria. Screening rates for breast, colorectal, and cervical cancer across race have narrowed according National Health Interview Data through 2011. For example, for breast cancer screening, the proportion of women with a mammogram in the previous 18 months was 37.5% in 2000 for Non-Hispanic Asian Americans and 53.9% for Non-Hispanic Whites. By 2011 the proportions had converged to between 50% and 55% across Hispanic, Non-Hispanic Black, Non-Hispanic White, and Non-Hispanic Asians. A similar convergence is seen for cervical cancer screening as well (40-60%), though the spread across race was less dramatic in 2000 for this cancer. Colon cancer screening rates in the previous year are lowest among the three cancers but the same trend occurs; screening rates varied from 18% among Non-Hispanic Asians to 25% among Non Hispanic Whites in 2000, and converged to 24% and 25% respectively in 2011. Across all three cancers screening rates remained lowest for American Indians and Alaska Natives. The single most important disparity is differential screening rates across educational levels, and educational attainment will not be addressed by the ACA. To reduce health disparities we must take advantage of the major change that the ACA represents but not assume it will fix the problem of differential screening and mortality due to cancer of the breast, cervix, colon and rectum among people living in the United States. The undocumented aliens in the US will have increased challenges seeking care because they are not eligible for coverage through the ACA. The 22 states that do not expand Medicaid coverage will have persistent health care access issues for low-income women. Furthermore, there are challenges to using our care system and seeking screening once people have coverage. In studies of late-stage breast and invasive cervical cancers occurring among people enrolled in 7 managed care plans for at least 3 years, living in areas of high poverty or having low educational levels were associated with higher risks of invasive cervical cancer (1.72, 95% CI 1.11-2.67; 1.52, 95% CI 1.07-2.16 for high poverty and low income respectively). To address disparities in screening we must address the underlying issues associated with poverty, and low education. More research is needed to understand these associations and consider factors such as organizational culture, physical distance, and social support as they may become more salient determinants of differential screening rates as financial barriers are reduced. We must also, however, continue to recognize that financial barriers exist for some populations, and for some where screening is coverage by diagnostic processes are not. Citation Format: Stephen Taplin, Ekland Abdiwahab, Felisa Gonzales. Con: The ACA will not eliminate disparities in cancer screening. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA32.

Patient-centered medical home implementation and use of preventive services: the role of practice socioeconomic context.

The patient-centered medical home (PCMH) model of primary care is being implemented in a wide variety of socioeconomic contexts, yet there has been little research on whether its effects differ by context. Clinical preventive service use, including cancer screening, is an important outcome to assess the effectiveness of the PCMH within and across socioeconomic contexts. To determine whether the relationship between the PCMH and cancer screening is conditional on the socioeconomic context in which a primary care physician practice operates. A longitudinal study spanning July 1, 2009, through June 30, 2012, using data from the Blue Cross Blue Shield of Michigan Physician Group Incentive Program was conducted. Michigan nonpediatric primary care physician practices that participated in the Physician Group Incentive Program (5452 practice-years) were included. Sample size and outlier exclusion criteria were applied to each outcome. We examined the interaction between practices' PCMH implementation scores and their socioeconomic context. The implementation of a PCMH was self-reported by the practice's affiliated physician organizations and was measured as a continuous score ranging from 0 to 1. Socioeconomic context was calculated using a market-based approach based on zip code characteristics of the practice's patients and by combining multiple measures using principal components analysis. Breast, cervical, and colorectal cancer screening rates for practices' Blue Cross Blue Shield of Michigan patients. The implementation of a PCMH was associated with higher breast, cervical, and colorectal cancer screening rates across most market socioeconomic contexts. In multivariable models, the PCMH was associated with a higher rate of screening for breast cancer (5.4%; 95% CI, 1.5% to 9.3%), cervical cancer (4.2%; 95% CI, 1.4% to 6.9%), and colorectal cancer (7.0%; 95% CI, 3.6% to 10.5%) in the lowest socioeconomic group but nonsignificant differences in screening for breast cancer (2.6%; 95% CI, -0.1% to 5.3%) and cervical cancer (-0.5%; 95% CI, -2.7% to 1.7%) and a higher rate of colorectal cancer (4.5%; 95% CI, 1.8% to 7.3%) screening in the highest socioeconomic group. Because PCMH implementation was associated with larger increases in screening in lower socioeconomic practice settings, models suggest reduced disparities in screening rates across these contexts. For example, the model-predicted disparity in breast cancer screening rates between the highest and lowest socioeconomic contexts was 6% (77.9% vs 72.2%) among practices with no PCMH implementation and 3% (80.3% vs. 77.0%) among practices with full PCMH implementation. In our study, the PCMH model was associated with improved cancer screening rates across contexts but may be especially relevant for practices in lower socioeconomic areas.

Prevalence of Advanced Colorectal Neoplasia in White and Black Patients Undergoing Screening Colonoscopy in a Safety-Net Hospital

Chinese translation Black persons are more likely than white persons to be diagnosed with colorectal cancer and to die from it. The extent to which genetic or biological factors versus disparities in screening rates explain this variance remains controversial. To define the prevalence and location of presymptomatic advanced colorectal neoplasia (ACN) among white and black persons undergoing screening colonoscopy, controlling for other epidemiologic risk factors. Cross-sectional survey between 22 March 2005 and 31 January 2012. Urban, open-access, academic, safety-net hospital in Massachusetts. Asymptomatic, average-risk white (n = 1172) and black (n = 1681) persons aged 50 to 79 years undergoing screening colonoscopy. Adjusted prevalence and location of ACN, defined as a tubular adenoma 10 mm or more in size, any adenoma with villous features or high-grade dysplasia, any dysplastic serrated lesion, or invasive cancer. The prevalence of ACN was higher among white patients than black patients (6.8% vs. 5.0%; P = 0.039) but varied by sex (white vs. black men, 9.3% vs. 5.7%; white vs. black women, 3.5% vs. 4.3%; interaction P = 0.034). After controlling for many risk factors, black men were 41% less likely than white men (adjusted odds ratio [AOR], 0.59 [95% CI, 0.39 to 0.89]) to have ACN. No statistically significant difference was seen for women (AOR, 1.32 [CI, 0.73 to 2.40]). Black patients with ACN had a higher percentage of proximal disease (52% vs. 39%) after adjustment for age and sex (P = 0.055). Single-institution study with inadequate statistical power for subgroup analyses and recall bias. Black men are less likely than white men to have ACN at screening colonoscopy in a safety-net health care setting. Disparities in access to screening and differential exposure to modifiable risk factors rather than genetic or biological factors may be largely responsible for the higher incidence of CRC among black men. Genetic or biological factors may explain the predilection for proximal disease.

Providing detailed information about latent tuberculosis and compliance with the PPD test among healthcare workers in Israel: A randomized controlled study

BackgroundThe compliance of screening for latent tuberculosis (TB) with the tuberculin purified protein derivative (PPD) test is very low among healthcare workers (HCWs) in Israel. MethodsThis randomized controlled study uses the Health Belief Model (HBM) as a conceptual framework to examine whether providing more information about latent TB and the PPD test increases the response rate for PPD screening among HCWs. All candidate HCWs for latent TB screening were randomly allocated to one of the following two invitations to perform the PPD test: regular letter (control group, n=97), and a letter with information about latent TB and the PPD test (intervention group, n=196). Results293 HCWs were included (185 nurses, and 108 physicians). Overall, 36 (12.3%) HCWs were compliant with the PPD test screening. Compliance with PPD testing in the intervention group was not statistically different from the control group, RR 0.87 (95% CI, 0.46–1.65). ConclusionsCompliance for latent TB screening is low among HCWs in northeastern Israel. Providing detailed information about latent TB was not associated with increased test compliance. Understanding existing disparities in screening rates and potential barriers to latent TB screening among HCWs is important in order to move forward and successfully increase screening rates.

AMIGAS: a multicity, multicomponent cervical cancer prevention trial among Mexican American women.

Considerable efforts have been undertaken in the United States to reduce cervical cancer incidence and mortality by increasing screening; however, disparities in screening rates continue to exist among certain racial and ethnic minority groups. The objective of the current study was to determine the effectiveness of a lay health worker-delivered intervention-AMIGAS (Ayudando a las Mujeres con Informacion, Guia, y Amor para su Salud [helping women with information, guidance, and love for their health])-to increase Papanicolaou (Pap) test screening among 3 populations of women of Mexican origin. Six hundred thirteen women of Mexican origin in 3 treatment sites were randomized among 4 study arms: the full AMIGAS program with a video and a flip chart (n = 151), the AMIGAS program without the video (n = 154), the AMIGAS program without the flip chart (n = 155), and a usual care control group (n = 153). Six months after enrollment, women were surveyed and reported whether or not they had been screened. Women in any of the intervention arms were statistically significantly more likely to report being screened than those in the usual care group in both an intent-to-treat analysis and a per-protocol analysis. In the intent-to-treat analysis, 25% of women in the control group and 52% in the full AMIGAS program group reported having had Pap tests (P < .001); in the per-protocol analysis, the percentages were 29% and 62%, respectively (P < .001). AMIGAS was effective in increasing Pap test screening among women of Mexican descent when used in a 1-to-1 setting. Future research should compare the 1-on-1 intervention with the group-based intervention.

A Comparison of Breast and Cervical Cancer Legislation and Screening in Georgia, North Carolina, and South Carolina

We identified legislation (1989-2005) relating to breast and cervical cancer in Georgia, North Carolina, and South Carolina and examined its impact on screening rates for these cancers and on Black-White disparities in screening rates. Legislation was identified using the National Cancer Institute's (NCI) State Cancer Legislative Database (SCLD) Program. Screening rates were identified using the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System. Georgia and North Carolina enacted more laws on breast and cervical cancer than did South Carolina. The laws specifically intended to increase breast and cervical cancer screening were mandates requiring that insurance policies cover such screening; Georgia and North Carolina enacted such laws, but South Carolina did not. However, we were unable to demonstrate an effect of these laws on either screening rates or disparities. This may reinforce the importance of evidence-based health promotion programs to increase screening.

Diabetes Screening Among Immigrants

OBJECTIVETo examine diabetes screening, predictors of screening, and the burden of undiagnosed diabetes in the immigrant population and whether these estimates differ by ethnicity.RESEARCH DESIGN AND METHODSA population-based retrospective cohort linking administrative health data to immigration files was used to follow the entire diabetes-free population aged 40 years and up in Ontario, Canada (N = 3,484,222) for 3 years (2004–2007) to determine whether individuals were screened for diabetes. Multivariate regression was used to determine predictors of having a diabetes test.RESULTSScreening rates were slightly higher in the immigrant versus the general population (76.0 and 74.4%, respectively; P < 0.001), with the highest rates in people born in South Asia, Mexico, Latin America, and the Caribbean. Immigrant seniors (age ≥65 years) were screened less than nonimmigrant seniors. Percent yield of new diabetes subjects among those screened was high for certain countries of birth (South Asia, 13.0%; Mexico and Latin America, 12.1%; Caribbean, 9.5%) and low among others (Europe, Central Asia, U.S., 5.1–5.2%). The number of physician visits was the single most important predictor of screening, and many high-risk ethnic groups required numerous visits before a test was administered. The proportion of diabetes that remained undiagnosed was estimated to be 9.7% in the general population and 9.0% in immigrants.CONCLUSIONSOverall diabetes-screening rates are high in Canada’s universal health care setting, including among high-risk ethnic groups. Despite this finding, disparities in screening rates between immigrant subgroups persist and multiple physician visits are often required to achieve recommended screening levels.