Maricopa Medical Center Research Articles

Abstract PO4-09-10: A successful method for treatment of an uninsured underprivileged breast cancer population

Abstract Background Improvements in breast cancer treatment and care have resulted in improved outcomes and decreased mortality. These improvements, however, come with great expense. Despite efforts from health care systems, a significant proportion of the population remains uninsured. The uninsured population is often underprivileged, undereducated and more likely to come from racial/ethnic minority groups. This combination of factors results in a delay in diagnosis, presentation at later stage, and decreased access and compliance with treatment. The goal of the current study is to describe a method for treating an uninsured, underprivileged breast cancer population and the resulting outcomes. Methods Retrospective review was performed of all breast cancer patients seen at Maricopa Medical Center, the safety net hospital in Phoenix, AZ. All breast cancer patients seen from January 1, 2000 to December 31, 2020 were included. Baseline data for every patient was compiled prospectively, supplemented by retrospective chart review. The data included sociodemographic information, health literacy assessment, and diagnostic tests. Health literacy was assessed using the Newest Vital Sign (NVS). Breast cancer treatment, follow up, and mortality were documented. Beginning on July 1, 2006 a new process was implemented to facilitate care of uninsured patients. More details will be included in the poster presentation. Briefly, however, core needle biopsies were performed in the Breast Clinic by the Breast surgeon or Physician assistant during the initial consultation. Rather than requiring full payment of the planned operation upfront, instead a down payment was made with a plan for payment in installments of the remainder of the cost. For chemotherapy and targeted therapy, a process was implemented to apply for discounted medications for appropriate regimens. There are no radiation therapy facilities at Maricopa Medical Center. An agreement was therefore made with a Radiation oncology group in Phoenix to provide discounted radiation therapy. The treatment was paid through treatment grants as well as fundraising activities by the Health Foundation of the hospital. In 2011, the Breast surgeon underwent training for genetic counseling at City of Hope Medical Center to provide genetic counseling for these patients. Results A total of 1,797 patients were included. Among them, 661 patients were seen before the process (BP) was started, while 1,136 patients were seen after the new process (NP) was implemented. Overall, the mean age of the patients was 52 years with most patients being Hispanic (56%). On average the patients had 10 yrs of education and 18% had adequate health literacy. The majority of patients were not employed (70%) and completely uninsured (56%) or underinsured (31%). Only 18% of patients underwent screening mammography and as a result 67% of patients presented at stage II or later. Despite the barriers mentioned above, the NP group underwent a higher percentage of breast conservation procedures (75% versus 47%, p < 0.001). A higher percentage of the NP group received adjuvant therapy: Chemotherapy (91% vs 70%, p < 0.001), Radiation therapy (91% versus 70%, p < 0.001), and initiated endocrine therapy (87% versus 67%, p < 0.001). At a mean follow up of 8 years, these improvements in adjuvant therapy resulted in a lower incidence of both ipsilateral breast tumor recurrence and chest wall recurrence (2% vs 16%, p < 0.001 and 5% versus 8%, p = 0.21, respectively) and improvement in overall survival (90% vs 81%, p < 0.001). Conclusions Despite treatment of a population with many barriers to breast cancer management, implementation of a treatment process improved access to diagnosis and surgical therapy as well as recommended adjuvant therapy. These improvements resulted in lower local recurrence rates and improved survival in an uninsured population. Citation Format: Ian Komenaka, Trevin Reyes, Jacqueline Gilbert, Chiu-Hsieh Hsu, Waqas Arslan, Gilbert Ramos, John Dover, Herbert Hitchon, Jesse Nodora, Elena Martinez. A successful method for treatment of an uninsured underprivileged breast cancer population [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-09-10.

Abstract P1-17-10: Breast pain is a common complaint after breast cancer treatment but not a sign of recurrence

Abstract Background: Mastalgia, breast pain without other signs or symptoms, is a very common complaint, yet occurs in only approximately 5% of patients with breast cancer. Most clinicians are aware of this lack of association with cancer. Mastalgia is also a common complaint after breast cancer treatment. This symptom is very worrisome to many women, and when seen in the office, clinicians tend to give in to the fear of patients and order various tests. In 2017, we presented an abstract at SABCS that showed that breast pain was not associated with breast cancer diagnosis. Many attendees were interested in the incidence of breast pain after breast cancer treatment. The current study was performed to evaluate the incidence and significance of mastalgia after breast cancer treatment. Methods: Maricopa Medical Center, the county safety net hospital in Phoenix, Arizona serves a patient base which is 34.5% non-English speaking. The majority of these patients are uninsured or underinsured. A total of 1635 breast cancer patients were seen at least once at the Breast Clinic from June 1, 2006 to December 31, 2018. Sociodemographic variables were collected on all patients. All patients who were treated for breast cancer and then presented with a complaint of breast pain during follow up were evaluated. Additionally, all patients who complained of a breast mass but were found to have pain with no mass were evaluated in a similar fashion. Results: A total of 1577 patients were seen during the time period. The mean age of the patients was age 52. Of the patients, 144 presented with or developed metastatic disease prior to their operation. 116 patients transferred their care to another facility. Of the remaining patients, 36% of patients (474 of 1317) presented with a complaint of breast pain during their follow up after breast cancer treatment. Of the patients with breast pain, 16 had an ipsilateral breast tumor recurrence or contralateral breast cancer diagnosis, however, none of the patients presented with breast pain. The breast pain occurred after treatment was completed. Nine patients presented with a palpable mass and seven patients presented with abnormal imaging. In contrast, 6.0% patients (51 of 843) without breast pain developed an ipsilateral breast tumor recurrence, chest wall recurrence, or contralateral breast cancer. 35 patients presented with a painless breast mass and the remaining 26 recurrences or contralateral breast cancer were found on routine imaging. Local recurrence or contralateral breast cancer were more common in patients without breast pain during follow up (p = 0.036). The two most common factors related to any breast cancer recurrence and death were noncompliance with recommended treatment and presentation with T4 (Stage 3B) breast cancer. Conclusions: Mastalgia is a very common complaint in patients seen for follow up after breast cancer treatment. Patients and providers may believe a complaint of breast pain warrants further workup and often results in additional, repeat, or interval imaging. With normal physical examination and routine imaging, however, breast pain alone does not appear to be an indication of breast cancer recurrence. Additional or repeat imaging as well as laboratory tests do not appear beneficial in patients with breast pain. Reassurance and patient education is necessary to avoid continued use of unnecessary medical resources. Citation Format: Ian Komenaka, Anushi Shah, Tina Wong, Daniela Cocco, Chiu-Hsieh Hsu, Jesse Nodora, Waqas Arslan, Maria Elena Martinez. Breast pain is a common complaint after breast cancer treatment but not a sign of recurrence [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-17-10.

143EMF Adaption and Implementation of Emergency Department Naloxone Distribution in Inpatient and Outpatient Settings

This study created and implemented an opioid curriculum for Maricopa Medical Center (MMC) residents and staff as well as improved the cumbersome process for clinicians to provide patient education on opioid use and naloxone prescriptions. Our curriculum addressed current MMC prescriber knowledge about opioids and was made available for dissemination. Resident curriculum employed competitive, trivia-based format with Jeopardy style review and use of Kahoot software to test knowledge application. Staff curriculum was offered as continuing medical education (CME) in cooperation with direct service community organizations and local addiction medicine, toxicology and pain management specialists. CME specifically aimed to address issues of stigma by incorporating education from patients and groups with lived experience. Ongoing data collection included resident and staff completed pre- and post- training surveys regarding their opinions and experiences with patients using or misusing opioids as well as regarding the effectiveness of the training. The primary outcome was the rate of naloxone prescriptions pre- and post- training among resident providers. Lack of prescriber knowledge and confidence in providing patient education on opioid overdose and the prescription of naloxone serve as major barriers in improving services to MMC patients who use and misuse opioids. Development and adaption of emergency department opioid overdose and naloxone distribution programing for inpatient and outpatient prescribers targeted these barriers. Our curriculum aimed to both address prescriber barriers as well as improve quality of patient education and services.

Living Longer, Living Well

Living Longer, Living Well

Maggot Debridement Therapy of a Leg Wound From Kaposi's Sarcoma: A Case Report.

Yuankai Lin, Molly Amin, Xuan Nguyen, and Surabhi Amar, Maricopa Medical Center, Phoenix; Abigail F.W. Donnelly, Mayo Clinic, Scottsdale, AZ; and Surabhi Amar, University of Arizona College of MedicinePhoenix, Phoenix, AZ Authors’ disclosures of potential conflicts of interest and contributions are found at the end of this article. Corresponding author: Surabhi Amar, MD, Division of HematologyOncology, Maricopa Integrated Health System, 2601 East Roosevelt St, Phoenix, AZ 85008; e-mail: surabhi_amar@dmgaz. org. INTRODUCTION

Using a configurable EMR and decision support tools to promote process integration for routine HIV screening in the emergency department.

Given the clinical and public health benefits of routine Human Immunodeficiency Virus (HIV) testing in the emergency department (ED) and Centers for Disease Control and Prevention recommendations, Maricopa Medical Center, as part of Maricopa Integrated Health System, started Test, Educate, Support, and Treat Arizona (TESTAZ) and became the first and, to-date, only hospital in Arizona to implement routine, non-targeted, opt-out, rapid HIV screening in the ED. The authors describe the implementation of a universal, routine, opt-out HIV screening program in the adult ED of an urban safety-net hospital serving under-served populations, including the uninsured and under-insured. Through a controlled and collaborative process, the authors integrated custom documentation elements specific to HIV screening into the triage/intake process, implemented and utilized clinical decision support tools to guide clinicians in each step of the process, and used electronic data collection and reporting to drive new screening protocols that led to a significant increase in overall HIV testing rates.

Abstract P1-11-05: Womens' opinion on when to start screening mammography and reasons for not undergoing screening

Abstract Background: In late 2009 significant controversy arose when some screening recommendations were changed to advocate screening mammography starting at age 50 rather than the long standing recommendation of starting at age 40 years. More recently some studies have called into question the benefit of screening mammography. The current study was performed to evaluate patients’ opinion on when women should start screening mammography and reasons for not undergoing screening. Methods: Maricopa Medical Center is the safety net hospital in Phoenix, Arizona. 1,157 consecutive patients were seen at the Breast Clinic from May 2013 to May 2014. Sociodemographic variables were collected including health literacy assessment using the Newest Vital Sign (NVS) validated screening instrument. Patients were asked when they felt women should start screening mammography. In addition, in women at least 40 years of age, if they did not undergo screening mammography, they were asked for the primary reason for not undergoing screening. Differences in patient characteristics were evaluated based on a Fisher’s exact test for categorical variables and one-way ANOVA for continuous variables. Results: Thirteen of the 1,157 consecutive patients were male and excluded. The average age of the 1,144 consecutive female patients was 45 years. Most patients were Hispanic, underinsured, and had limited health literacy. Overall use of screening mammography was poor at only 24%. 402 women (35%) felt that age 40 years was the most appropriate time to start screening. Only 30 women (3%) felt that age 50 years was the most appropriate age. More women, 470 (41%), chose an age younger than age 40 to start screening. More than half (55%) of these women who chose an age 50 years or younger, however, did not undergo screening because they felt they had "no problems" or "didn’t know" they should get a mammogram despite choosing an age to start that was below their current age. Only 187 women (32%) cited cost as the reason for not undergoing screening. Other reasons for not undergoing screening were: physician did not recommend and other medical problems/forgot/too busy. Few patients (4%) cited problems with mammograms for not undergoing screening and none cited concerns about false positives. Multivariate analysis showed that patients with adequate health literacy and insurance were more likely to use screening mammography than patients who were uninsured or had limited health literacy. Family history of breast cancer was not associated with use of screening mammography. Conclusions: Use of screening mammography was poor in this underinsured population. Most women felt that screening mammography should start at age 40 years or younger. More than half of women who did not undergo screening did not do so because they had "no problems" or "didn't know" they should. Although many women feel that screening should start at age 40, most women in this population do not understand the concepts of screening and early detection. Interventions to increase use of screening mammography should focus of the concept of screening as well as the age. Citation Format: Ian K Komenaka, Meredith Heberer, Jesse Nodora, Chiu-Hsieh Hsu, Lisa Winton, Marcia Bouton, Maria Elena Martinez. Womens' opinion on when to start screening mammography and reasons for not undergoing screening [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-05.

The Effect of an Evidence-Based Medicine Curriculum on Breast Cancer Knowledge and Satisfaction of Surgical Residents

The current study was performed to determine if evidence-based medicine (EBM) curriculum would affect education of surgical residents. A 5-year prospective study was designed to determine if EBM curriculum could improve residents' satisfaction and understanding of breast cancer management during a breast surgical oncology rotation. During the first 2 years, 45 journal articles were used. During the subsequent 3 years, journal articles were not used. The proportion of patients seen in clinic was collected as an objective measure of the "effort" made by the resident. The final assessment was a 120-question examination. Maricopa Medical Center, Phoenix, AZ. Safety net institution with General Surgery residency program. Postgraduate year 2 general surgery residents. Over 5 years, 30 postgraduate year 2 residents were involved. Univariate analysis showed that female sex (p = 0.04), residents with peer-reviewed publications (p = 0.03), younger age (p = 0.04), American Board of Surgery in-service training examination score (p = 0.01), and clinical effort (p < 0.01) were associated with higher scores. Although residents taught using the journal articles scored 7 points higher on the final examination, this was not significant (p = 0.10). Multivariate analysis showed that American Board of Surgery in-service training examination score and clinic efficiency remained statistically significant. Residents who were taught using the EBM curriculum had significantly higher satisfaction (4.4 vs 3.5, p = 0.001) compared with those who did not go through the EBM curriculum. The current study demonstrates that an EBM curriculum significantly improved resident satisfaction with the rotation. The EBM curriculum may improve residents' breast cancer knowledge. The most important predictor of resident performance was the effort of resident.

Abstract No. 456 - Image-guided percutaneous treatment of aneurysmal bone cyst of the jaw with bone allograft and autologous bone marrow: a case report with five-year follow-up

No. 456 Image-guided percutaneous treatment of aneurysmal bone cyst of the jaw with bone allograft and autologous bone marrow: a case report with five-year follow-up R. Freitas, K. Fonseca, R. Procopio, L. Lehman; Radiology, Universidade de Sao Paulo Medical School, Sao Paulo, Brazil; Oncology pediatrics, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Interventional Radiology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Buco-maxillo Surgery, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil Purpose: A six-year old boy with an aneurysmal bone cyst of the jaw was treated by percutaneous injection of bone allograft particles mixed with autogenous bone marrow under computed tomography (CT) guidance and general anesthesia. Materials and Methods: A six-year old boy presented with a mass at the left angle of mandible, self-limited recurrent oral bleeding, pallor and severe pain partially controlled with opioids. Open surgical biopsy revealed a fibrous bone lesion with giant cells. A thin-walled 7 x 6 x 6 cm diameter (132 cc) expansible bone lesion at the left angle of mandible containing fluid-fluid levels was detected by X-ray plain film, CT scan, ultrasound, and magnetic resonance imaging. A diagnosis of an aneurysmal bone cyst was stated. A minimally invasive percutaneous approach was proposed after multidisciplinary review and an informed consent was obtained. Frozen dried bone allograft particles obtained from tissue bank were crushed, mixed with fresh autogenous bone marrow and injected into the lesion by a percutenous 11-gauge needle under CT and fluoroscopy guidance. No complications were observed. Results: The patient was discharged from the hospital the next day without symptoms. After two weeks he returned at consultation without bleeding or pain complaints. Normal serum hemoglobin was observed three months later. CT scans performed during five years of follow up showed progressive healing, ossification of the left branch of the jaw, tumor shrinking and remodeling. No pain or bleeding was reported since the percutaneous treatment. Conclusion: This case report shows excellent healing of a locally aggressive aneurysmal bone cyst after image-guided percutaneous injection of autogenous bone marrow mixed with elements of allograft bone matrix. Five years of follow-up showed excellent functional and cosmetic results. Further research is required to clarify the exact mechanisms of this potential treatment. Educational Exhibit Abstract No. 457 Ultrasound guided percutaneous tenotomy/ fasciotomy: indications, technique, and initial experience A.S. Johar, M.C. Switzer, A. Braun; Radiology, Maricopa Medical Center, Phoenix, AZ Learning Objectives: The objective of this poster is to 1) Discuss the pathophysiology of tendinosis and the common clinical presentations. 2) Review the US findings of chronic tendinopathy. 3) Describe the percutaneous tenotomy technique and its advantages over traditional tendinopathy treatments. 4) Outline our initial experience with outpatient ultrasound tenotomy. Background: Tendinopathy is a common and underdiagnosed pathology which often impairs daily and recreational activities. Given its debilitating nature, a range of treatment options exist, many of which are conservative and few of which provide durable complete symptom relief. Ultrasound guided percutaneous tenotomy is a relatively new and promising technique with the ability to remove pain causing diseased tendon tissue without damaging the adjacent healthy tendon tissue. This technique is gaining traction due to its minimally invasive nature, quick recovery time, low cost, low morbidity and durable positive outcomes. Clinical Findings/Procedure Details: We will demonstrate the findings of tendinopathy by presenting supporting US images from multiple cases. We will detail the percutaneous ultrasonic tendon cutting and debriding technique while describing pertinent pearls and pitfalls. Finally, we will discuss the outcomes from our cases. Conclusion and/or Teaching Points: After reviewing the poster, viewers will be familiar with the pathology, presentation and imaging findings of chronic tendinopathy. Viewers should appreciate US guided percutaneous tenotomy as a minimally invasive, fast and effective treatment option for tendinopathy pain. Educational Exhibit Abstract No. 458 Lymphangiography: not gone, not forgotten E. Lindgren, J. Friese, C.E. Bender; Radiology, Mayo Clinic, Rochester, MN JVIR ’ Posters and Exhibits S199

Identification of Acute HIV Infection Using Fourth-Generation Testing in an Opt-Out Emergency Department Screening Program

Acute HIV infection is a clinical diagnosis aided by technology. Detecting the highly infectious acute stage of HIV infection is critical to reducing transmission and improving long-term outcomes. The Maricopa Integrated Health System implemented nontargeted, opt-out HIV screening with a fourth-generation antigen/antibody combination HIV assay test in our adult emergency department (ED) at Maricopa Medical Center to assess the prevalence of both acute and chronic unrecognized HIV. Eligible patients aged 18 to 64 years were tested for HIV if they did not opt out and had blood drawn as part of their ED care. Patients were not eligible if they had a known HIV or AIDS diagnosis, exhibited altered mental status, were a current resident of a long-term psychiatric or correctional facility, or prompted a trauma activation. Reactive test results were delivered by a physician with the assistance of a linkage-to-care specialist. Specimens with a reactive fourth-generation assay result underwent confirmatory testing. From July 11, 2011, through January 5, 2014, 27,952 HIV screenings were performed for 22,468 patients tested for HIV; 78 (0.28%) had new HIV diagnoses. Of those, 18 (23% of all new diagnoses) were acute HIV infections, and 22 patients (28%) had a CD4 count of less than 200 cells/mL, or an opportunistic infection. HIV testing with a fourth-generation antigen/antibody laboratory test producing rapid results is feasible in an ED. Unexpectedly, nearly one fourth of patients with undiagnosed HIV had acute infections, which would have been more difficult to detect with previous testing technology.

Predictors of &amp;lt;i&amp;gt;H. pylori&amp;lt;/i&amp;gt; infection in a safety-net hospital in Arizona

Objective: The purpose of this study was to determine the risk factors associated with having H. pylori infection as proven by endoscopic biopsy at Maricopa Medical Center (MMC), a safety-net hospital in phoenix, Arizona which serves primarily patients with limited financial and insurance resources. Methods: A total of 1116 biopsies were identified in a Department of Pathology database searched from November 2004 to March 2013. To be included, the subjects had to have an endoscopy with gastric biopsy. After the inclusion criteria were applied, 282 control subjects without histological evidence of H. pylori infection and 256 cases with histological evidence of H. pylori infection were identified. Patient charts were reviewed to extract information on variables collected for this study. Results: The mean age of cases and controls was 50.5 and 52.3 years respectively. The BMI of the cases and controls was 28.1 and 28.0 respectively. The mean number of upper endoscopic exams performed was 1.3 in cases and 1.4 in controls respectively. Potential predictors examined were gender, history of drug abuse, history of alcohol abuse, chronic pain medication use, smoking, employment status, outpatient vs. inpatient upper endoscopy exam, language spoken (English, Spanish, or bilingual), race/ ethnicity, type of insurance, heart burn, dysphagia, abdominal pain, gastroduodenal ulcers, intestinal metaplasia, and having vs. not having a primary care physician. Based on univariate analyses, having a gastroduodenal ulcer, having a history of abdominal pain, Hispanic race, government insurance status, self-pay insurance status, and speaking Spanish only were found to be significantly related to having H. pylori infection. These variables were next entered into a multivariate analysis. The multivariate analysis revealed that gastroduodenal ulcer, abdominal pain, Hispanic race and self-pay insurance status remained significant predictors of H. pylori infection. For the last 119 subjects, information regarding the country of their birth was available. These 119 subjects were separately analyzed. Country of birth, age, sex, Hispanic race, self-pay insurance status, Spanish speaker, and having government insurance were included in a multivariate analysis. Twenty seven percent of patients without H. pylori were born in the US, compared to fifty eight percent H. pylori positive patients who were born outside of the US. Conclusion: Hispanics are at high risk for H. pylori infection. In a multivariate model, patients with H. pylori were found to have a higher risk of ulcers, Hispanic race, abdominal pain and self-insurance status. When self-insurance and Hispanic race were included in another analysis with place of birth, only birth outside US remained significant.

Anne M. McNamara, PhD, RN

Anne McNamara, PhD, RN, is the dean and professor of nursing at Grand Canyon University (GCU), where the College of Nursing enrollment is more than 5,000 students in both traditional and online programs. Their educational programs consist of traditional undergraduate (BSN), registered nurse (RN) to bachelor of science in nursing (BSN) options and a range of master of science in nursing (MSN) programs. In the past, she held important quality positions in the Maricopa Health System. She is active in a number of professional groups, having served as American Nurses Association treasurer and, most recently, on the American Nurses Credentialing Center (ANCC) board. She was recently recognized as Nursing Advocate of the Year at the fifth annual Healthcare Leadership Awards sponsored by Arizona Business Magazine .

P5-09-03: Health Literacy Affects Use of Screening Mammography in an Underinsured Population.

Abstract Background: In late 2009 significant controversy arose when some screening recommendations were changed to advocate screening mammography starting at age 50 rather than the long standing recommendation of starting at age 40 years. Few would argue, by contrast, that patient compliance with screening mammography, starting at either 40 years or 50 years, is at optimal levels. National data indicate that many more lives would be saved by improving compliance with screening recommendations in individuals ≥50 than would be saved with screening individuals age 40–50 years. The current study was performed to determine if health literacy was associated with use of screening mammography in an underinsured population. Methods: Maricopa Medical Center is the county safety net hospital in Phoenix, Arizona. 944 patients were seen at the Breast Clinic from January 2010 to January 2011. 638 were at least 40 years old and therefore candidates for screening mammography. Sociodemographic variables were collected. Use of mammography was asked of patients and checked by medical records. Health literacy was assessed using the Newest Vital Sign (NVS) validated screening instrument, which categorizes health literacy on 6-point scale as low health literacy likely (0-1 point), low health literacy possible (2-3 points), or health literacy adequate (4-6 points). Differences in patient characteristics were evaluated based on a Fisher's exact test for categorical variables and one-way ANOVA for continuous variables. Multivariate analysis was then performed to determine which patient factors were associated with use of screening mammography. Results: Among women 40 years or older, only 35% used routine screening mammography. For women 50 years or older, 38% underwent screening mammography. Among women 40 years or older and those 50 years or older, significantly more with health literacy adequate (NVS 4–6) obtained screening mammography than did women in the two lower literacy (NVS 0–1 and 2–3) groups (40+: 65% vs. 30% and 30%, p = 0.001. 50+: 65% vs. 33% and 37%, p = 0.001). Multivariate analyses adjusted for insurance status, employment, white race, Hispanic ethnicity, marital status, language, use of alcohol, family history, NVS and education level demonstrated that patients with adequate health literacy were more likely to use screening mammography (OR 3.66; 95% CI 2.14 — 6.27; p &amp;lt; 0.01) than patients in the two lower literacy groups. Similarly, uninsured patients were significantly less likely to undergo screening mammography (OR 0.57; 95% CI 0.38 — 0.86; p = 0.01) than those with insurance. Patients with adequate health literacy and insurance were (OR 8.61) more likely to use screening mammography than patients who were uninsured and were in the two low literacy groups. Patient race, ethnicity, language, employment, income, education level, and family history of breast cancer were not associated with use of screening mammography in this underinsured, undereducated population. Conclusions: Use of screening mammography was poor in this underinsured population. Limited health literacy and lack of insurance are risk factors for failure to obtain mammography. Interventions to increase use of screening mammography among uninsured patients with limited health literacy are needed. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-09-03.

Abstract B21: Patient health literacy may affect use of screening mammography in an underinsured patient population

Abstract Purpose of Study: Physician-patient communication is critical to patient decisions. In underinsured and racial/ethnic minority patients, the disparity in comprehension may be greater than among insured or non-Hispanic white populations. Previous studies have demonstrated that mammography is underutilized by disadvantaged populations. Previous studies have also demonstrated that minority patients are dissatisfied with the amount of information they receive from physicians. One potential explanation for both the seeming non-compliance by patients and the dissatisfaction experienced by patients may be lack of awareness by the physicians of limited health literacy. The current study examined the feasibility of assessing health literacy in a busy surgical practice in a teaching institution and evaluated the influence of patient health literacy on their use of screening mammography. Experimental Procedures: Maricopa Medical Center, the county safety net hospital in Phoenix, Arizona, serves a patient base which is 34.5% non-English speaking. All patients who were seen at least once at the Maricopa Medical Center Breast Clinic from January 14, 2010 to June 17, 2010 were included. Using the Newest Vital Sign (NVS) instrument to assess health literacy, participants were classified into 3 groups: 1) high likelihood of limited health literacy (NVS score 0 or 1); 2) Possible limited health literacy (NVS score 2 or 3); and 3) adequate health literacy (NVS score 4-6). Data Summary: After exclusions, 504 of 505 patients underwent health literacy assessment as part of the routine history and physical examination during their clinic visit. The majority of the participants were classified as having a high likelihood of limited health literacy (59.9%), while 21.8% and 18.3% were classified as having possible limited health literacy and adequate health literacy, respectively. The vast majority of respondents (97.6%) were underinsured or uninsured. Compared to women with adequate health literacy, those with limited literacy were more likely to be Hispanic (p&amp;lt;0.001) and of lower educational level (p&amp;lt;0.0o1). Although nearly half (49%) of the patients had less than a high school education, limited health literacy was not explained solely by education level. Fifty six percent (56%) of limited health literacy patients had graduated from high school and 30% of these had at least some college education. Among patients who were 40 years or older, only 47% had undergone screening mammography and among those 50 years of age and older, 54% had participated in screening mammography. Among women 40 years of and older, mammography screening was significantly associated with higher level of health literacy; 42%, 39%, and 70% had undergone screening mammography among those with limited health literacy, possible health literacy, and high health literacy, respectively (p&amp;lt;0.0001). The prevalence of screening mammography for women 50 years of age and older also increased with level of health literacy; however, the results were not statistically significant (p=0.15). Conclusions: Assessment of health literacy is feasible in a busy surgical practice at a teaching hospital. Although overall use of screening mammography was suboptimal in this underinsured population, health literacy assessment can help identify patients at increased risk for underutilization of this important screening tool. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B21.

Abstract B31: Implementation of video improves understanding of breast cancer concepts in an undereducated county hospital population

Abstract Purpose of Study: Having accurate knowledge of the risks and benefits of treatment options is critical to informed decision making. Increasing knowledge of patients improves their ability to participate in decision making. Patients of all backgrounds diagnosed with breast cancer must determine an appropriate treatment plan and therefore must possess a general understanding of the concepts related to systemic therapy, radiation therapy, and surgery. The purpose of this study was to evaluate how well patients at a county hospital, who were prepared to undergo their definitive breast cancer operation, understood basic concepts of their disease and treatment. Experimental Procedures: An 11 question multiple choice tool was devised at a Flesch-Kincaid grade level of 5.8. The questions were designed to evaluate the patients’ basic understanding of the significance of a cancer diagnosis, and use of mammography, chemotherapy, radiation therapy, and surgery. A previous study was performed as an initial assessment to obtain baseline information on patients’ understanding. 41 consecutive patients were evaluated at Maricopa Medical Center, the county, safety net hospital in Phoenix, Arizona. Subsequently an eight minute video was designed to facilitate the understanding of these basic breast cancer concepts. The next 40 consecutive patients who saw the video were then administered the same 11 question tool. Data Summary: Eighty-one women agreed to participate in the study, 41 before and 40 after the implementation of a breast cancer educational video. Sixty-eight percent self identified as Hispanic and 51% had less than a high school education. Clinical presentation, stage of disease, and tumor biology was similar in both groups. The group of patients who saw the video answered each question correctly more often and had a higher mean number of total questions answered correctly (6.7 vs. 8.9, p = 0.0007). For the three questions (number 1, 6, 9) which the first group answered correctly less than 50% of the time, the video group correctly answered the three questions correctly 68%, 80%, and 68% of the time (p &amp;lt; 0.05). Interestingly 90% of all respondents correctly answered the question on the value of screening mammography, however, only 37% of these patients underwent screening mammograms. Univariate analysis of the first 41 patients, who did not see the video, demonstrated that employment, years of education, and language of questionnaire (English vs. Spanish) was associated with higher score on the 11 question tool. When patients who saw the video were included and seeing the video (yes vs. no) was added to the analysis, univariate analysis revealed that years of education (p &amp;lt; 0.0001), language of the questionnaire (p = 0.0004), and having seen the video (p = 0.0005) were significantly correlated with higher score. A multiple linear regression model adjusting for years of education, language, and seeing the video, revealed that having seen the video (p = 0.0029) and years of education (p = 0.0002) remained significantly associated with higher score. Conclusion: Implementation of a short eight minute educational video significantly improved understanding of breast cancer concepts in an undereducated, county hospital population. This examination revealed, however, continuing deficits in the understanding of breast cancer concepts in this population. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B31.

Benefits of preoperative chemotherapy for operable breast cancer in the community hospital setting

e11594 Background: The benefits of preoperative chemotherapy (PC) for operable breast cancer have been demonstrated in prospective clinical trials. For palpable breast cancers, however, operative intervention remains the most common initial treatment. The benefits of PC for operable breast cancer were examined in a community hospital. Methods: Maricopa Medical Center is the safety net hospital in Arizona. A retrospective review was performed of all breast cancer patients from 2004 to 2008. All patients who were stage IIA - IIIA breast cancer patients were included. Outcomes of breast cancer were evaluated based on whether the patient underwent PC or adjuvant chemotherapy (AC). All patients in the PC group received anthracyclines and a taxane in their treatment. The Fisher's exact test and the Chi-square test were used to determine differences between the two populations. Unpaired t-test was used to compare means of the two populations. Results: During this period, 145 patients were treated. In the PC group, the clinical response rate was 81% and the pathologic complete response rate was 26%. Patients in the PC group underwent lumpectomy more often for T2 (73% vs. 40%, P = 0.01) and for T3 tumors (73% vs. 37%, P = 0.06). The positive margin rate was lower (14% vs.37%, P = 0.02) and the lumpectomy volume was smaller in the PC group compared to the AC group (132 cm3 vs. 245 cm3, P &lt; 0.01). Despite similar demographics, compliance with chemotherapy was improved in the PC group (100% vs. 71%, P &lt; 0.01). In addition, compliance was also improved for adjuvant radiation (97% vs. 70%, P &lt; 0.01) and hormone therapy (100% vs. 76%, P = 0.01) in the PC group. Conclusions: Preoperative chemotherapy improved compliance with chemotherapy. This could represent a significant benefit over AC in populations where compliance with chemotherapy recommendations is not ideal. Improvements in surgical outcomes were also seen in patients who received preoperative chemotherapy in the community hospital setting. No significant financial relationships to disclose.

A new horizon in the treatment of right ventricular failure and pulmonary hypertension associated with acute respiratory distress syndrome?*

Department of Medicine, Maricopa Medical Center, Phoenix, AZ (Carlson) University of Arizona and Mayo Medical School, Phoenix, AZ (Emmans)

Unterschiedliche auswirkungen von nikotin und rauchkondensaten auf osteozythen-stoffwechselt??tigkeit

*Division of Orthopaedic Surgery, Maricopa Medical Center, Phoenix, AZ; and †Harrington Arthritis Research Center, Phoenix, AZ

Insulin and oral hypoglycemic agents should not be used in combination in the treatment of type 2 diabetes.

Insulin and oral hypoglycemic agents should not be used in combination in the treatment of type 2 diabetes.

Financial Aspects of Court-Ordered Evaluations

The authors sought to establish the financial cost of involuntary court-ordered evaluations and potential strategies for reducing these costs. Medical charges from the time of admission to the time of the court hearing were calculated for 998 patients who received involuntary court-ordered evaluations at the department of psychiatry of the Maricopa Medical Center in Phoenix, Arizona, in 1999. The average cost of an involuntary court-ordered evaluation was 8,236 dollars, and the average cost per day was 686 dollars. The analysis showed that several options could be used to reduce costs: expediting evaluations, holding court hearings on weekends and holidays, conducting evaluations on an outpatient basis, and housing patients in a less acute setting.