Receipt Of Appropriate Care Research Articles

Does structural racism impact receipt of NCCN guideline-concordant breast cancer treatment?

Disparities in breast cancer survival remain a challenge. We aimed to analyze the effect of structural racism, as measured by the Index of Concentration at the Extremes (ICE), on receipt of National Cancer Center Network (NCCN) guideline-concordant breast cancer treatment. We identified patients treated at two institutions from 2005 to 2017 with stage I-IV breast cancer. Census tracts served as neighborhood proxies. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed to create 5 models, controlling for economic segregation, non-Hispanic Black (NHB) segregation, NHB/economic segregation, Hispanic segregation, and Hispanic/economic segregation. Multi-level logistic regression models were used to determine the association between individual and neighborhood-level characteristics on receipt of NCCN guideline-concordant breast cancer treatment. 5173 patients were included: 55.2% were Hispanic, 27.5% were NHW, and 17.3% were NHB. Regardless of economic or residential segregation, a NHB patient was less likely to receive appropriate treatment [(OR)Model1 0.58 (0.45-0.74); ORModel2 0.59 (0.46-0.78); ORModel3 0.62 (0.47-0.81); ORModel4 0.53 (0.40-0.69); ORModel5 0.59(0.46-0.76); p < 0.05]. To our knowledge, this is the first analysis assessing receipt of NCCN guideline-concordant treatment by ICE, a validated measure for structural racism. While much literature emphasizes neighborhood-level barriers to treatment, our results demonstrate that compared to NHW patients, NHB patients are less likely to receive NCCN guideline-concordant breast cancer treatment, independent of economic or residential segregation. Our study suggests that there are potential unaccounted individual or neighborhood barriers to receipt of appropriate care that go beyond economic or residential segregation.

Effect of Immediate Referral vs a Brief Problem-solving Intervention for Screen-Detected Peripartum Depression

The US Preventive Services Task Force recommends screening adults for depression in settings with programs in place to ensure receipt of appropriate care. Best practices regarding how to ensure such care are unknown, particularly for pregnant and postpartum persons. To compare the effectiveness of 2 strategies for the initial management of screen-detected peripartum depressive symptoms. This randomized comparative effectiveness trial was performed from February 1, 2018, to June 30, 2020, at the prenatal clinic, postpartum unit, and pediatric clinic within an urban safety-net hospital. Participants included peripartum persons with positive depression screen results. Data were analyzed from July 6, 2020, to September 21, 2022, based on intention to treat. Engagement-focused care coordination (EFCC), which used shared decision-making and motivational techniques to refer patients to outside mental health services, and problem-solving education (PSE), a brief cognitive-behavioral program delivered at the screening site. The primary outcome consisted of severity of depressive symptoms; secondary outcomes included severity of anxiety symptoms and engagement with care, each measured bimonthly over 12 months. Rates of symptom elevations were modeled using negative binomial regression; rates of symptom trajectories were modeled using treatment × time interactions. Among the 230 participants (mean [SD] age, 29.8 [5.8] years), 125 (54.3%) were Black and 101 (43.9%) were Hispanic or Latina. At baseline, 117 participants (50.9%) reported at least moderately severe depressive symptoms (Quick Inventory of Depressive Symptomatology score ≥11), and 56 (24.3%) reported clinically significant anxiety symptoms (Beck Anxiety Inventory score ≥21). Across 6 assessment time points, the mean (SD) number of moderately severe depressive symptom episodes in EFCC was 2.2 (2.2), compared with 2.2 (2.1) in PSE, for an adjusted rate ratio (aRR) of 0.95 (95% CI, 0.77-1.17). The mean (SD) number of anxiety symptom elevations in EFCC was 1.1 (1.8), compared to 1.1 (1.6) in PSE, for an aRR of 0.98 (95% CI, 0.69-1.39). There were significant treatment × time interactions relative to mean depressive symptom scores (-0.34 [95% CI, -0.60 to -0.08]; P = .009 for interaction term), favoring EFCC. There were no differences in engagement with care. In this randomized comparative effectiveness trial, there were no differences in depressive or anxiety symptom burden across comparators; however, the evidence suggested improved depressive symptom trajectory with immediate referral. Further work is necessary to guide approaches to management following depression screening for peripartum persons. ClinicalTrials.gov Identifier: NCT03221556.

Integrating Mobile and Portable Technologies With In-Person and Telehealth Care to Increase Perinatal Healthcare Equity for the Unstably Housed.

Pregnant people living in rural areas are at an increased risk of experiencing poor perinatal outcomes due, in part, to the need to travel long distances to see a perinatal care provider. Telehealth care has been used successfully to increase access to perinatal care but requires patients to have access to broadband Internet access and devices capable of establishing secure connections so they can participate in their care. This places an additional burden on unstably housed pregnant persons who may not have access to the required technology. The Midwifery Integrated Home Visitation Program was developed to bridge this digital divide by bringing perinatal care services to the unstably housed at their desired location of care. The included case studies outline how telehealth and portable technology were used to address the medical and nonmedical needs of unstably housed pregnant people. They also outline how bridging the digital divide by combining in-person perinatal care with mobile technology, portable technology, and telehealth care has the potential to decrease unnecessary emergency department care and ambulance use while facilitating the receipt of appropriate care and thus potentially preventing poor perinatal outcomes.

Mode of Arrival to the Emergency Department and Outcomes in Nontraumatic Critically Ill Adults.

Mode of Arrival to the Emergency Department and Outcomes in Nontraumatic Critically Ill Adults.

Racial Equity among African-American and Non-Hispanic White Men Diagnosed with Prostate Cancer in the Veterans Affairs Healthcare System

African-American (AA) men in the general U.S. population are more than twice as likely to die from prostate cancer than Non-Hispanic White (NHW) men. Racial disparities decrease after the age of 65 when patients become eligible for equal-access Medicare insurance. We hypothesized that receipt of healthcare through the Veterans Affairs Health System, an equal-access medical system, would attenuate disparities between AA and NHW men of all ages. We identified patients diagnosed with prostate cancer between 2000-2015 using the Department of Veterans Affairs (VA) Informatics and Computing Infrastructure (VINCI). We used a combination of database/registry coded values and chart review to assemble tumor, treatment, comorbidity, and sociodemographic data and then ascertained date and cause of death using the Social Security death index. Prostate cancer-specific mortality (PCSM) was evaluated using Fine-Gray regression and cumulative incidence function plots. A mediation analysis was performed using sequential variable analysis. The cohort included 60,035 men (18,201 (30.3%) AA, 41,834 (69.7%) NHW) followed for a median of 5.9 years. AA men were more likely to be from regions with lower median income (AA 45,069 vs NHW 51,973, p<0.001) and lower high school graduation rates (AA 0.83% vs NHW 0.87%, p <0.001). They were also younger (AA mean age 63.6 vs NHW 67.2, p<0.001), and had higher median PSA at presentation (AA 6.7 vs NHW 6.2, p<0.001). However, AA men were equally or less likely to present with Gleason 8-10 disease (AA 18.8% vs NHW 19.7%, p<0.001), clinical T-stage 3 or higher (AA 2.2% vs NHW 2.9%, p<0.001), clinical node positive disease (AA 1.4% vs NHW 1.5%, p=0.33) or distant metastatic disease (AA 2.7 vs NHW 3.1, p = 0.01). The unadjusted 10-year incidence of PCSM for AA and NWH men was 4.4% versus 5.1%, respectively. On multivariable analysis, AA men had improved PCSM (subdistribution hazard ratio: 0.85; 95% confidence interval: 0.78-0.93; p < 0.001). Sequential variable analysis did not identify any variables mediating this effect. AA men demonstrated an improved 10-year overall survival (AA 18% vs NHW 23%), with adjusted hazard ratio of 0.84 (0.81-0.88; p<0.001). African-American men diagnosed with prostate cancer in the VA system do not present with more advanced disease or suffer from worse outcomes compared to NHW men despite generally residing in regions with lower socioeconomic status. These findings suggest that access to care is an important determinant of racial equity in prostate cancer diagnosis, receipt of appropriate care, and survival outcomes.

Are the needs of people with mental health problems met?

BackgroundHigh levels of mental ill-health have resulted in increasing delays in the receipt of appropriate care. However, the size of the gap between mental health needs and the likelihood of receiving treatment has not been thoroughly investigated on a population-level within Northern Ireland.&#x0D; ObjectivesTo that end we investigated the link between self-reported mental ill-health and likelihood of being in receipt of treatment in a population cohort.&#x0D; MethodsThe 2011 Northern Ireland Census was linked to a population-wide prescribing database. The presence of a chronic mental health condition, as assessed through the Census self-reported mental health question, was compared to regular psychotropic medication use in the six and twelve months following the Census. Of the 23,803 individuals (aged 25 to 74) who reported chronic mental ill-health at the Census, 22% were not in receipt of medication over the following six months, with this being reduced down to 18.5% by the twelve month mark.&#x0D; FindingsAfter adjusting logistic regression models for socio-demographic factors, men (OR=0.56: 95%CI=0.52-0.60), those of non-white ethnicity (OR=0.38: 95%CI=0.26-0.54), never married (OR=0.67: 95%CI=0.61-0.82), unemployed (OR=0.65: 95%CI=0.53-0.81) and living in a rural area (OR=0.88: 95%CI=0.79-0.98) were less likely to receive regular medication, indicating mental health unmet need.&#x0D; ConclusionsA level of discord was observed between mental-ill health and medication receipt on a population level. Further focus on mental health needs and the impact of low prescribing rates on mental health patients could help ameliorate the current inequalities and reduce potential gaps in mental health treatment.

Care Seeking Behaviour of Older Adults with Hip Fracture in India: A Qualitative Study

Background: Hip fractures among older adults is a serious public health issue in India due to increase in ageing population. Availability and timely access to surgical care is essential for reduction of mortality and morbidity from hip fractures and thereby decreasing inequalities among older adults. The notion of access to care is multi-dimensional and the “three-delay” framework can be applied to understand the causes for delay between sustaining a hip fracture and receipt of appropriate care. The aim of this study is to determine the processes in decision-making, identify cause for delays in obtaining care, and the potential barriers and facilitators to seeking appropriate care in time. Methods: A qualitative study was conducted (30 in-depth interviews) in seven healthcare facilities (4 public; 2 private and 1 alternative care center) in two administrative district of Odisha, India. The study was undertaken by George Institute for Global Health, India, in collaboration with Indian Institute of Public Health-Bhubaneswar from July 2014 to January 2015.Participants were aged 50 years or older with hip fracture including males and females. Data was categorized using NVIVO software and analyzed by thematic analysis. Results: Majority of participants perceived hip fracture injury will heal on its own and does not require surgery. They were not aware of the consequences of such an injury, comorbid conditions and available healthcare facilities. Family/community members played a significant role in the choice of surgeon and in accessing health care facility. Participants who had an injury outside their home were taken immediately to the hospital whereas those who fell inside home get delayed in reaching hospital. The delay from time of injury till access of care varied from few hours to months. People with a hip fracture and their relatives had strong faith and belief in traditional health care system, i.e. Traditional bonesetters within their local community. Conclusion: Our study findings emphasize on the need for quick decision- making to access nearest health facility with the provision of surgical care. We recommended further research studies to be conducted in varied settings to widen our knowledge in care pathways for the management of hip fractures in India.

Hepatitis C Virus Testing and Treatment Among Persons Receiving Buprenorphine in an Office-Based Program for Opioid Use Disorders

AimsIn the United States, hepatitis C virus (HCV) infection is primarily spread through injection drug use. There is an urgent need to improve access to care for HCV among persons with opioid use disorders who inject drugs. The purpose of our study was to determine the prevalence of HCV, patient characteristics, and receipt of appropriate care in a sample of patients treated with buprenorphine for their opioid use disorders in a primary care setting. MethodsThis study used retrospective clinical data from the electronic medical record. The study population included patients receiving buprenorphine in the Office Based Opioid Treatment (OBOT) clinic within the adult primary medicine clinic at Boston Medical Center between October 2003 and August 2013 who received a conclusive HCV antibody (Ab) test within a year of clinic entry. We compared characteristics by HCV serostatus using Pearson's chi-square and provided numbers/percentages receiving appropriate care. ResultsThe sample comprised 700 patients. Slightly less than half of all patients (n=334, 47.7%) were HCV Ab positive, and were significantly more likely to be older, Hispanic or African American, have diagnoses of post-traumatic stress disorder (PTSD) or bipolar disorder, have prior heroin or cocaine use, and be HIV-infected. Among the 334 HCV Ab positive patients, 226 (67.7%) had detectable HCV ribonucleic acid (RNA) indicating chronic HCV infection; only 5 patients (2.21%) with chronic HCV infection ever initiated treatment. ConclusionsNearly half of patients (47.7%) receiving office-based treatment with buprenorphine for their opioid use disorder had a positive hepatitis C virus antibody screening test although initiation of HCV treatment was nearly non-existent (2.21%).

PCN158 - Determinants for guideline appropriate care among Elderly Women with stage I-III Breast Cancer in a Seer-Medicare Population

Evidenced-based guidelines for the treatment of breast cancer have been put forth by agencies such as the National Comprehensive Cancer Network (NCCN). Yet, even with specific guidelines, gaps in the receipt of appropriate care exist. This study examined factors associated with receipt of appropriate vs. inappropriate treatment among elderly women with breast cancer in the U.S. A sample of 11,948 women age > 66 with pathologically staged I, II, and III breast cancer diagnosed from 2004 to 2006 were selected from the SEER-Medicare linked dataset. Algorithms based on clinical cancer characteristics and types of treatments and testing received were used to determine appropriateness of care (yes vs. no). Logistic regression models were used to examine the relationship between appropriateness of care and various independent factors. Less than 32% of elderly women received guideline appropriate care. The likelihood of receiving appropriate care decreased for women with increasing age (>80 vs. 66-69) (AOR, 0.23; 95%CI, 0.20-0.27), comorbidity (>2 vs. 0) (AOR, 0.85; 95%CI, 0.75-0.97), stage (III vs. I) (AOR, 0.50; 95%CI, 0.40-0.61) and (II vs. I) (AOR, 0.33; 95%CI, 0.28-0.38), and were of non-white race vs. white (AOR, 0.83; 95%CI, 0.73-0.96). Women with node negative cancer, poorly differentiated tumors, borderline/unknown tumor receptors were also less likely to receive appropriate care. Yet, the likelihood of appropriate care was increased for women who saw both a general and oncology surgeon vs. general surgeon only (AOR, 1.35; 95%CI, 1.19-1.53), lived in areas of higher income vs. lower (AOR, 1.15; 95%CI, 1.01-1.30), and higher education vs. lower (AOR, 1.15; 95%CI, 1.03-1.29). Irrespective of guidelines, less complex patients with greater resources are more likely to receive appropriate care. Better efforts should be made for all elderly women with breast cancer to receive appropriate care regardless of their age, health, or resources.

A Bayesian Approach to Modeling Risk of Hospital Admissions Associated With Schizophrenia Accounting for Underdiagnosis of the Disorder

Background/Aims: Schizophrenia is a debilitating serious mental illness (SMI) characterized by a complex array of symptoms. Patients tend to seek treatment only intermittently, contributing to difficulty in diagnosing the disorder. A misdiagnosis may potentially bias and reduce the validity of a study based on recorded diagnoses. It also may impact patient outcomes by delaying receipt of appropriate care. Thus, we present a statistical model to compare the odds of 1-year hospitalization among patients with schizophrenia versus patients with or without other SMIs when schizophrenia is underreported in administrative databases.

Race and Mortality Revisited.

In an article in the January/February 2000 issue of Society titled “Race and Mortality,” I explained the statistical pattern, inherent in other than highly irregular risk distributions, whereby the rarer an outcome, the greater tends to be the relative (percentage) difference between the rates at which advantaged and disadvantaged groups experience the outcome and the smaller tends to be the relative difference between rates at which such groups avoid the outcome. By way of example with respect to the health and healthcare outcomes on which the article principally focused, as mortality declines, relative differences in mortality tend to increase while relative differences in survival tend to decrease; as healthcare generally improves, relative differences in receipt of appropriate care tend to decrease while relative differences in failing to receive such care tend to increase. In 2000, however, this pattern was virtually unknown to health disparities researchers or anyone else examining demographic differences in favorable or adverse outcomes. Consequently, most efforts to appraise demographic differences in such outcomes were fundamentally unsound. This article addresses the extent to which the appraisal of demographic differences in outcome rates is any sounder today than it was in 2000. In summary, while there has been increasing recognition of the ways that relative differences in outcome rates tend to be systematically affected by the prevalence (frequency) of an outcome, that recognition has yet to affect the way observers analyze group differences in outcome rates in any context. Though today vastly greater resources are devoted to the study of disparities in health and healthcare outcomes than in 2000, almost nothing said about such things as whether those disparities have increased or decreased over time or are otherwise larger in one setting than another, or even whether a disparity should be deemed large or small, has had a sound statistical basis. Meanwhile, federal regulators encourage mortgage lenders and public schools to reduce the frequency of adverse borrowing and student discipline outcomes in order to reduce the commonly observed severalfold racial and ethnic differences in rates of experiencing those outcomes. Neither the regulators, the congressional committees monitoring regulator policies, nor the institutions reducing the frequency of those outcomes in response to federal encouragements understand that reducing any outcome tends to increase, not reduce, relative differences in experiencing it. More broadly, events since 2000 do little to bolster one’s faith in the validity of accepted scholarship or the capability of individuals or institutions to recognize and acknowledge that things they have been doing for decades or generations have been incorrect or misleading.

Why Are Women Dying When They Reach Hospital on Time? A Systematic Review of the ‘Third Delay’

BackgroundThe ‘three delays model’ attempts to explain delays in women accessing emergency obstetric care as the result of: 1) decision-making, 2) accessing services and 3) receipt of appropriate care once a health facility is reached. The third delay, although under-researched, is likely to be a source of considerable inequity in access to emergency obstetric care in developing countries. The aim of this systematic review was to identify and categorise specific facility-level barriers to the provision of evidence-based maternal health care in developing countries.Methods and FindingsFive electronic databases were systematically searched using a 4-way strategy that combined search terms related to: 1) maternal health care; 2) maternity units; 3) barriers, and 4) developing countries. Forty-three original research articles were eligible to be included in the review. Thirty-two barriers to the receipt of timely and appropriate obstetric care at the facility level were identified and categorised into six emerging themes (Drugs and equipment; Policy and guidelines; Human resources; Facility infrastructure; Patient-related and Referral-related). Two investigators independently recorded the frequency with which barriers relating to the third delay were reported in the literature. The most commonly cited barriers were inadequate training/skills mix (86%); drug procurement/logistics problems (65%); staff shortages (60%); lack of equipment (51%) and low staff motivation (44%).ConclusionsThis review highlights how a focus on patient-side delays in the decision to seek care can conceal the fact that many health facilities in the developing world are still chronically under-resourced and unable to cope effectively with serious obstetric complications. We stress the importance of addressing supply-side barriers alongside demand-side factors if further reductions in maternal mortality are to be achieved.

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Following efforts made in recent years to provide effective mental health treatments based on evidence-based guidelines, a working definition was developed in the literature detailing a minimum level of "adequate mental health care" for serious mental illness. However, little is known about racial or ethnic disparities in receipt of adequate mental health care for individuals affected with serious mental illness. The objective of this study was to examine disparities among Caucasian and Hispanic youths in receipt of adequate mental health care for past-year major depressive episodes. Data for this study were drawn from the 2005 National Survey on Drug Use and Health. The study sample was composed of 1,169 Caucasian youths and 316 Hispanic youths aged 12 to 17 with past-year major depressive episodes. The percentages of youths in the sample who received adequate mental health care for past-year major depressive episodes were estimated, and the correlates of receipt of adequate mental health care were examined. Thirty-four percent of the full sample received adequate mental health care for past-year major depressive episodes, but separate analyses indicated that adequate mental health care was received by a significantly higher proportion of Caucasian youths (36%) than Hispanic youths (27%). The odds of receiving adequate mental health care for past-year major depressive episodes for Caucasians were 1.55 times that of Hispanics (p=.01). Having Medicaid or coverage via the State Children's Health Insurance Program significantly increased the odds of receiving adequate mental care for past-year major depressive episodes for both Hispanics and Caucasians. As mental health problems of adolescents from diverse racial or ethnic backgrounds become more easily identified and a larger proportion of these groups is referred to mental health treatment services, it is important to examine the degree to which treatment should be tailored to engage and retain specific racial or ethnic groups so that they will receive the minimum of adequate mental health care.

Sustained Hyperglycemia Among Patients With Diabetes

OBJECTIVETo estimate prevalence of, and factors associated with, sustained periods of hyperglycemia among patients with diabetes and factors associated with receipt of appropriate care once A1C values are persistently elevated.RESEARCH DESIGN AND METHODSAmong patients initiating oral monotherapy (n = 5,070), Kaplan-Meier and Cox proportional hazards methods were used to estimate time to, and factors associated with, sustained hyperglycemia (defined by two A1cs >8% and no recent medication intensification), and among those experiencing sustained hyperglycemia, time to, and factors associated with, appropriate receipt of care (i.e., medication intensification or achieving A1C ≤7%).RESULTSWithin 1 year, 8% experienced sustained hyperglycemia, with the proportion rising to 38% within 5 years. Patients using sulfonylurea had greater risk of hyperglycemia (hazard ratio [HR] 1.47 [95% CI 1.30–1.66]) compared with those initiating metformin. Risk increased with age (1.89 [1.27–2.83]), was greater for African Americans (1.19 [1.05–1.36]), and increased with A1C levels >7%. Among individuals with sustained hyperglycemia (n = 1,386), mean time to appropriate care was 9.7 months, with 25% not receiving appropriate care within 1 year. Shorter delays to appropriate care receipt were associated with increasing income (1.03 [1.00–1.07]), A1C >9% (1.38 [1.06–1.79]) and >11% (1.65 [1.25–2.18]), increasing medication adherence (1.03 [1.01–1.04]), and visits to primary care (4.22 [3.65–4.88]) or endocrinology (3.89 [2.26–6.70]). Longer delays were associated with increasing drug copayments (0.96 [0.93–0.98]).CONCLUSIONSPatients incurring sustained hyperglycemia are at risk of further delays in appropriate management. Barriers to appropriate care include prescription drug copayments, few physician contacts, and other factors that are likely amenable to intervention.

Facilitated bone mineral density testing versus hospital‐based case management to improve osteoporosis treatment for hip fracture patients: Additional results from a randomized trial

We previously demonstrated that a case manager intervention improved osteoporosis (OP) treatment within 6 months of hip fracture compared with usual care. The second phase of the randomized trial compared a less intensive intervention, facilitated bone mineral density (BMD) testing, with usual care and the case manager intervention. We initially randomized 220 hip fracture patients to either an OP case manager intervention or usual care. After completing the original trial at 6 months postfracture, usual care patients were reallocated to facilitated BMD testing; BMD tests were arranged and results sent to primary care physicians. Main outcomes (bisphosphonate treatment, BMD tests, receipt of appropriate care) were reascertained 1 year following hip fracture and compared with outcomes achieved by the OP case manager intervention and usual care. Compared with usual care, facilitated BMD testing increased testing from 29% to 68% (P < 0.001), bisphosphonate use from 22% to 38% (P < 0.001), and receipt of appropriate care from 26% to 45% (P < 0.001). The more intensive (70 versus 30 minutes) and expensive ($56 versus $24 Canadian per patient) OP case manager intervention led to significantly higher bisphosphonate use (54% versus 38%; P = 0.03), receipt of appropriate care (71% versus 45%; P < 0.001), and more BMD testing (80% versus 68%; P = 0.06) than usual care followed by facilitated BMD testing. Compared with usual care, 2 different inexpensive interventions resulted in significant increases in appropriate management of OP after hip fracture. The magnitude of improvements achieved was directly related to the intensity of the interventions.

Symptom management after breast cancer treatment: is it influenced by patient characteristics?

With improved patient survival from breast cancer, more interest has evolved regarding the symptoms women experience in association with breast cancer treatments. We studied the extent to which symptoms for women with incident breast cancer are addressed by their physicians and how symptom management varies with patient characteristics. As part of the Los Angeles Women's (LAW) Study, we categorized women from a population-based study of incident breast cancer (n = 1,219) as having an unmet need if she had at least one severe symptom (any of the following: nausea/vomiting, arm problems, hot flashes, vaginal dryness, difficulty sleeping) for which she did not receive the help she wanted. Multivariable analyses predicted having any unmet need as a function of patient demographic and health characteristics. The prevalence of unmet need varied by the type of symptom with the highest proportion of women receiving help for nausea and vomiting (0.91) and the lowest for vaginal dryness (0.48). Black women (OR = 3.61, 95% CI: [1.57, 8.31]), and Spanish-speaking Hispanic women (OR = 2.69, 95% CI: [1.22, 5.94]) were significantly more likely than white women to report an unmet need. More black and Hispanic women compared to white women cited the doctor not thinking treatment would benefit her (P = 0.02), not appreciating how much the problem bothered her (P = 0.03), not knowing about treatments (P < 0.0001), or insurance/cost barriers (P = 0.009) as reasons for her unmet need. These results show the persistence of racial disparities in the receipt of appropriate care within the health care system.

Persistent problems of access to appropriate, affordable TB services in rural China: experiences of different socio-economic groups

BackgroundLarge-scale Tuberculosis (TB) control programmes in China have been hailed a success. Concerns remain, however, about whether the programme is reaching all sections of the population, particularly poorer groups within rural communities, and whether there are hidden costs. This study takes a household perspective to investigate receipt of appropriate care and affordability of services for different socio-economic groups with TB symptoms in rural China.MethodsSecondary analysis of Chinese National Household Health Survey for 2003: 40,000 rural households containing 143,991 individuals, 2,308 identified as TB suspects. Outcomes: use of services and expenditure of TB suspects, by gender and socio-economic position, indicated by household income, education, material assets, and insurance status.Results37% of TB suspects did not seek any professional care, with low-income groups less likely to seek care than more affluent counterparts. Of those seeking care, only 35% received any of the recommended diagnostic tests. Of the 182 patients with a confirmed TB diagnosis, 104 (57%) received treatment at the recommended level, less likely if lacking health insurance or material assets. The burden of payment for services amounted to 45% of annual household income for the low-income group, 16% for the high-income group.ConclusionAccess to appropriate, affordable TB services is still problematic in some rural areas of China, and receipt of care and affordability declines with declining socio-economic position. These findings highlight the current shortcomings of the national TB control programme in China and the formidable challenge it faces if it is to reach all sections of the population, including the poor with the highest burden of disease.

Understanding cancer patients’ experience and outcomes: development and pilot study of the Cancer Care Outcomes Research and Surveillance patient survey

The National Cancer Institute's Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium is conducting a population-based study of newly diagnosed patients with lung and colorectal cancer to describe the experience of persons living with cancer and to understand which barriers present the most significant obstacles to their receipt of appropriate care. The keystone to this effort is the baseline patient survey administered approximately 4 months after diagnosis. We developed a survey to obtain information from patients newly diagnosed with lung and colorectal cancer about their personal characteristics, decision making, experience of care, and outcomes. We conducted a pilot study to evaluate the feasibility of a lengthy and clinically detailed interview in a convenience sample of patients within 8 months of diagnosis (n=71). The median length of the interviews was 75 min for patients with lung cancer (range 43-130) and 82 min for patients with colorectal cancer (range 46-119). Most patients had received some form of treatment for their cancer: 66.1% had undergone surgery, 28.2% had received radiation therapy, and 54.9% were treated with chemotherapy. In addition, 26.7% reported their overall health was less than 70 on a 0-100 scale, demonstrating that patients with substantial health impairment were able to complete the survey. A clinically detailed survey of newly diagnosed lung and colorectal cancer patients is feasible. A modified version of this survey is being fielded by the CanCORS Consortium and should provide much needed population-based data regarding patients' experiences across the continuum of cancer care and their outcomes.