Safety Net Health Care System Research Articles

Outcomes Among Minority Patients With Metastatic Colorectal Cancer in a Safety-net Health Care System

BackgroundMetastatic colorectal cancer (CRC) outcomes continue to improve, but they vary significantly by race and ethnicity. We hypothesize that these disparities arise from unequal access to care. Materials and MethodsThe Harris Health System (HHS) is an integrated health delivery network that provides medical care to the underserved, predominantly minority population of Harris County, Texas. As the largest HHS facility and an affiliate of Baylor College of Medicine’s Dan L. Duncan Comprehensive Cancer Center, Ben Taub Hospital (BTH) delivers cancer care through multidisciplinary subspecialty that prioritize access to care, adherence to evidence-based clinical pathways, integration of supportive services, and mitigation of financial toxicity. We performed a retrospective analysis of minority patients diagnosed with and treated for metastatic CRC at BTH between January 2010 and December 2012. Kaplan-Meier survival curves were compared with survival curves from randomized control trials reported during that time period. ResultsWe identified 103 patients; 40% were black, 49% were Hispanic, and 12% were Asian or Middle Eastern. Thirty-five percent reported a language other than English as their preferred language. Seventy-four percent of patients with documented coverage status were uninsured. Eighty-four percent of patients received standard chemotherapy with a clinician-reported response rate of 63%. Overall survival for BTH patients undergoing chemotherapy was superior to that of subjects enrolled in the CRYSTAL (Cetuximab Combined with Irinotecan in First-Line Therapy for Metastatic Colorectal Cancer) trial (median, 24.0 vs. 19.9 months; P = .014). ConclusionHHS provides a health delivery infrastructure through which minority patients with socioeconomic challenges experience clinical outcomes comparable with highly selected patients enrolled in randomized control trials. Efforts to resolve CRC disparities should focus on improving access of at-risk populations to high-quality comprehensive cancer care.

Primary Care Behavioral Health Integration for Anxiety Management in a Safety-Net Health Care System.

This report describes the implementation of a primary care behavioral health integration program for anxiety management at Cambridge Health Alliance (CHA), a safety-net health care system. Using a staged implementation process, CHA built upon existing capacities to create a comprehensive infrastructure for managing behavioral health conditions in primary care.

Hospitalization and Critical Illness in Chronic Kidney Disease

Background: Patients with chronic kidney disease (CKD) who are hospitalized with a critical illness are at increased risk for adverse outcomes. We studied the predictors of hospitalization with critical illness among patients with non-dialysis-dependent CKD stages 3 and 4 in a safety-net healthcare setting. Methods: A retrospective cohort study was conducted among patients ≥18 years of age with CKD stages 3 and 4 using a CKD registry from a safety-net healthcare system. Hospitalizations with critical illness were identified among patients requiring nonelective admission or transfer to the intermediate or intensive care unit during a 3-year period after the diagnosis of CKD. Poisson regression was used to determine associations between baseline characteristics and hospitalization requiring intermediate or intensive care among all CKD patients and in those with different stages of CKD. Outcomes of these hospitalizations were also tabulated. Results: Among 8,302 patients with CKD stages 3 and 4, 1,298 were hospitalized and 495 required intermediate or intensive care during a 3-year follow-up period. In the adjusted analysis, advanced CKD, Hispanics (incident rate ratio [IRR]: 1.88), non-Hispanic Blacks (IRR: 1.48), presence of congestive heart failure (IRR: 2.09), cardiovascular disease (IRR: 1.57), chronic pulmonary disease (IRR: 1.60), liver disease, malignancy, and anemia were associated with higher risk of hospitalization requiring intermediate or intensive care. The association of age, gender, race/ethnicity, congestive heart failure, anemia, and body mass index with hospitalization requiring intermediate or intensive care differed significantly by CKD stage (p value for interaction term <0.05). Congestive heart failure and severity of anemia were associated with a higher risk of hospitalization requiring intermediate or intensive care among patients with mild CKD, and the magnitude of association attenuated among patients with advanced CKD. Conclusions: The burden of hospitalization with critical illness among patients with non-dialysis-dependent CKD stages 3 and 4 remains high and was associated with demographic factors and comorbid medical conditions, especially among those with congestive heart failure and cardiovascular disease. Targeted, effective interventions to reduce the burden of hospitalization and critical illness in CKD patients within safety-net healthcare systems are needed.

Decreasing Overall and Inappropriate Proton Pump Inhibitor Use: Perspective From a Large Safety-Net Healthcare System

Decreasing Overall and Inappropriate Proton Pump Inhibitor Use: Perspective From a Large Safety-Net Healthcare System

Neighborhood Disadvantage and Lung Cancer Incidence in Ever-Smokers at a Safety Net Health-Care System: A Retrospective Study

Neighborhood circumstances have an influence on multiple health outcomes, but the association between neighborhood conditions and lung cancer incidence has not been studied in sufficient detail. The goal of this study was to understand whether neighborhood conditions are independently associated with lung cancer incidence in ever-smokers after adjusting for individual smoking exposure and other risk factors. A cohort of ever-smokers aged≥ 55 years was assembled from 19 years of electronic health record data from our academic community health-care system. Patient demographic characteristics and other measures known to be associated with lung cancer were ascertained. Patient addresses at their index visit were geocoded to the census block group level to determine the area deprivation index (ADI), drawn from 5-year estimates from the American Community Survey. A multivariate Cox proportional hazards model was fit to assess the association between ADI and time to lung cancer diagnosis. Tests of statistical significance were two-sided. The study included 19,867 male subjects and 21,748 female subjects. Fifty-three percent of the patients were white, 38%were black, and 5%were Hispanic. Of these, 1,149 developed lung cancer. After adjusting for known risk factors, patients residing in the most disadvantaged areas had a significantly increased incidence of lung cancer compared with those in the least disadvantaged areas (hazard ratio, 1.29; 95%CI 1.07-1.55). Census-derived estimates of neighborhood conditions have a powerful association with lung cancer incidence, even when adjusting for individual variables. Further research investigating the mechanisms that link neighborhood conditions to lung cancer is warranted.

Engaging users in the design of an mHealth, text message-based intervention to increase physical activity at a safety-net health care system.

ObjectivesText-messaging interventions are a promising approach to increasing physical activity in vulnerable populations. To better inform the development of a text-messaging intervention, we sought to identify barriers and facilitators to using text messaging and engaging in physical activity among patients with diabetes and comorbid depression.Materials and MethodsWe conducted interviews with primary care patients at a safety-net health care system (N = 26). Data were collected at 3 stages, including a focus group (stage 1), and individual interviews (stage 2 and 3). Patients in stage 1 and 2 previously participated in a text-messaging intervention as part of depression treatment. Discussions focused on participant experience of previously using a text-messaging intervention, influences and perceptions of physical activity, and mobile phone use. We analyzed all transcripts for emerging themes.ResultsParticipants were 56.2 years (±9.7); 69.2% were female, 65.4% identified as Hispanic/Latino(a), and 46.2% reported having less than a high school education. All had depression and 61.5% had diabetes. Specific barriers that emerged included low literacy and only basic use of mobile phones in everyday life, in combination with a high prevalence of comorbid health conditions and limited mobility. These were each addressed with a specific content or intervention delivery change in the overall intervention design.ConclusionsConducting a focus group and individual interviews with end users of an mHealth intervention under development has implications for tailoring and modifying components of the content and format to ensure that the final intervention will engage end users most effectively.

2986 Celiac Disease Among Hispanics Undergoing EGD for Workup of Unexplained Anemia in a Safety Net Population

INTRODUCTION: Celiac disease (CD) affects roughly 1% of the population globally and 0.75% of the general US population. In individuals with confirmed iron deficiency anemia (IDA), the prevalence of CD is much higher, with nearly 4% of such individuals affected in large cohort studies. The prevalence of CD in Hispanics however remains largely unknown due to over representation of non-Hispanic whites in the studies. We aimed to examine the prevalence of CD in Hispanics with unexplained anemia and in those with confirmed IDA presenting to a large safety net health care system. METHODS: Electronic health records of all Hispanic patients (self-identified) referred for workup of unexplained anemia at our institution from 8/2013 to 4/2018 were retrospectively analyzed. Data were collected with regards to comorbidities, pre-procedure hemoglobin, and pre-procedure ferritin. All patients underwent EGD with duodenal biopsies from both the first and second portion of the duodenum as part of routine workup for unexplained anemia. Anemia was defined using the established World Health Organization criteria (hemoglobin &lt;12 g/d for women, &lt;13 g/dL for men). Pathology reports were reviewed for biopsy proven CD utilizing the Marsh classification system. Subgroup analysis of patients with confirmed IDA (ferritin &lt;15 ng/mL) was also performed. Mean hemoglobin and ferritin were calculated in all patients. In those with biopsy confirmed CD, a mean Marsh classification score was also determined. Means and standard deviations were calculated for all continuous variables to better characterize our population cohort. RESULTS: 96 Hispanic patients with unexplained anemia were identified; 36 were male; average age 53.9. In our patient cohort peptic ulcer disease 14.4% (14/96) and malignancy 6.2% (6/96), were most common identified etiologies of anemia. There were 5 cases of biopsy proven CD with an overall prevalence of 5.2% (5/96). Prevalence of CD among patients with confirmed IDA was 2.4% (1/41) (Table 1). At the time of diagnosis average Marsh score was 3 for all patients and for patients with IDA. CONCLUSION: Our data from large safety net health care system shows high rate CD among Hispanics with unexplained anemia suggesting the continued utility of screening for CD in work up of unexplained anemia in Hispanic patient population.

315 Can Adenoma Detection Rates Predict a Benchmark for Serrated Polyp and Advanced Adenoma Detection Rates in a Diverse Urban Population?

INTRODUCTION: Adenoma detection rate (ADR) benchmark of &gt;25% has been shown to reduce interval colorectal cancer (CRC). Serrated polyp detection rate (SDR) and advanced adenoma detection rate (AADR) can also serve as additional benchmarks to reduce interval CRC, although a standardized benchmark for AADR and SDR doesn’t exist. Recent studies have shown correlation between ADR, SDR and AADR, but in a homogenous patient population. Our study evaluated the correlation between ADR, SDR and AADR and approximated a benchmark for SDR and AADR in a diverse urban population, while attempting to identify any patient variables affecting detection rates. METHODS: We reviewed screening colonoscopies performed at our midwest urban, safety-net health care system over a period of one year (2017). We calculated ADR, SDR and AADR for individual providers and established correlation using non-parametric Spearman correlation coefficients between the 3 entities. Logistic regression analysis was used to calculate predictors of adenomas, advanced adenomas and serrated polyps. RESULTS: Of the 3000 colonoscopies reviewed, 1488 were screening colonoscopies performed by 9 experienced staff gastroenterologists. The patient population included 48% African-Americans, 42% Caucasians, and 10% others. Median (Interquartile range) ADR of all providers was 42.5 (27-61), SDR 8.4 (3.6-23), and AADR was 2.9 (0.6-4.8). All providers had an overall ADR above 25%. There was a weak positive correlation for ADR and SDR (rho = 0.13), and ADR and AADR (rho = 0.13). Logistic regression analysis identified male gender (P &lt; 0.01) and body mass index (P = 0.02) as predictors of adenomas, while longer withdrawal time was a significant predictor for all types of polyps. We did not find statistical significance for gender or body mass index and SDR. CONCLUSION: Based on our study, previously suggested benchmark SDR of 7% seems appropriate. Our AADR of 2.9 was lower than suggested AADR of &gt;6%. Additionally, a weak positive correlation was noted between ADR and SDR, and ADR with AADR although the patient population was heterogeneous and diverse making the results more generalizable for the real world.

Surgical Epilepsy Care in a Safety-Net and Private Healthcare System: A Comparative Analysis

Abstract INTRODUCTION Access to and delivery of quality surgical epilepsy care remains a challenge in both safety-net and private hospital systems. Underserved populations are more likely to utilize safety-net hospital systems, but to date there have been no published reports on epilepsy surgery outcomes in this setting. This study aimed to prospectively analyze and compare surgical epilepsy care in a safety-net versus private hospital system. METHODS We prospectively collected evaluation and treatment data in patients undergoing resective surgery for refractory epilepsy at the multi-institutional Los Angeles County Department of Health Services Comprehensive Epilepsy Program between 2010 and 2017. Seizure characteristics, pre-surgical evaluation, perioperative complications, and postsurgery seizure outcomes as measured by the Engel classification were recorded. This cohort was compared to patients treated in a private hospital system with which it collaborated during the same time period. RESULTS Data from 102 patients in the safety-net and 145 patients in the private hospital system were analyzed. There was a higher proportion of African American (P = .02) and Hispanic patients (P = .03) in the safety-net hospital system. There was no difference in mean time from epilepsy onset to surgery between groups (P = .54). The presurgical evaluation was equivalent (P &gt; .18), except for more frequent use of magnetoencephalography in the private system (P = .02). Seizure freedom outcomes were excellent, and complication rates were low with no difference between groups (P = .95 and P &gt; .22, respectively). However, patients from safety-net hospital systems were more likely to be lost to follow up (P = .04). CONCLUSION Quality surgical epilepsy care can be delivered in a safety-net hospital system and intrinsic factors of safety-net hospital do not limit quality. Partnership of safety-net hospital systems with established comprehensive epilepsy centers is essential for the delivery of quality surgical epilepsy care. The expansion of these services is vital for providing modern epilepsy care for the underserved population.

Hepatitis C Screening in an Underserved U.S. Cohort of Reproductive Age Women.

The opioid epidemic has recently increased the rates of hepatitis C virus (HCV) infection among young women. We therefore aimed to characterize the cascade of HCV care in a cohort of underserved women of reproductive age. Medical records of 19,121 women between the ages of 15 and 44 years, receiving primary care in the San Francisco safety‐net health care system, were reviewed. Cohort characteristics were as follows: median age 33 years (interquartile range 26‐38), 18% white (12% black, 46% Latina, 22% Asian, 2% other race), 1.3% hepatitis B surface antigen (HBsAg)‐positive, and 0.9% human immunodeficiency virus (HIV) co‐infection. HCV antibody (HCVAb) testing occurred in 38.7% (n = 7,406), of whom 2.8% (n = 206) were HCVAb‐positive and 2.4% (n = 177) had a detectable HCV viral load. Of the 5% (n = 1,017) with a history of pregnancy, 61% (n = 615) had HCVAb testing (2.6% were positive). On multivariable analysis, HBsAg testing (odds ratio [OR] 8.25 [95% confidence interval (CI)] 6.80‐10.01]; P < 0.001), HIV infection (OR 5.98 [95% CI 1.86‐19.20]; P = 0.003), and log alanine aminotransferase (ALT) (OR 1.30 [95% CI 1.16‐1.45]; P < 0.001) were associated with HCV screening. Compared with whites, women of Latina (OR 0.45 [95% CI 0.37‐0.55]; P < 0.001) and Asian (OR 0.74 [95% CI 0.58‐0.94]; P = 0.01) race were less likely to receive HCV screening. Age (OR 1.80 per decade [95% CI 1.26‐2.57]; P = 0.001), white race (versus non‐white; OR 10.48 [95% CI 7.22‐15.21]; P < 0.001), HIV infection (OR 3.25 [95% CI 1.40‐7.55]; P = 0.006), and log ALT (OR 1.93 [95% CI 1.49‐2.49]; P < 0.001) were associated with HCVAb positivity. Conclusion: Most (>60%) underserved women of reproductive age were not tested for HCV. Moreover, women of Latina and Asian race were less likely to receive HCV screening. Given the known high HCV risk in the underserved population, targeted interventions, especially for racial minority women of reproductive age, are needed to enhance HCV screening in those at risk.

2378-PUB: Barriers and Facilitators to National Diabetes Prevention Program Engagement by Women of Peak Child-Bearing Age

Intrauterine exposure to maternal obesity and type 2 diabetes increases chronic disease risks in offspring. The National Diabetes Prevention Program (National DPP) is an evidence-based model for promoting weight loss to prevent diabetes in adults; however, women of peak child-bearing age (18-39 years) do not engage sufficiently, limiting the program’s potential to reduce risks across generations. We assessed participation barriers and facilitators among English- or Spanish-speaking young women who enrolled in the program at an urban safety-net healthcare system. Interviewees included 30 women who enrolled but did not attend (n=10), attended few classes (n=10), or completed the program (n=10). Individual semi-structured interviews explored motivations, challenges, and successes regarding participation and suggestions for improvement. Interviews were analyzed using a grounded hermeneutic approach. Qualitative analysis revealed four primary domains (enrollment, attendance, experience, and suggestions) with multiple sub-themes. Most women were motivated to enroll per concern for health and family. Non-attending and minimally engaged women reported confusion about the program’s aim and relevancy, logistical barriers (scheduling conflicts, lack of childcare or transportation), and lack of connection with fellow participants or coaches. Highly engaged women noted persistent motivation to attend, successful weight loss, and supportive relationships in the program. Taken together, multiple barriers/facilitators arose that may be addressable in future adaptations via enhanced education and motivational support throughout the program, providing childcare and transportation, introducing a mobile app, a more flexible class format, and activities to strengthen group cohesion. Future research is needed to explore strategy implementation and effectiveness, with an ultimate goal of reducing risks prior to initial or subsequent child-bearing. Disclosure C. Harrison: Employee; Spouse/Partner; Virta Health Corp. P. Phimphasone-Brady: None. B. DiOrio: None. N. Ritchie: None. K.A. Sauder: None. Funding Centers for Disease Control and Prevention

Ethical Challenges in Caring for Unrepresented Adults: A Qualitative Study of Key Stakeholders.

The decision-making process on behalf of unrepresented adults (ie, those who lack capacity to make medical decisions and have no identifiable surrogate) is at risk for not incorporating their interests, raising ethical concerns. We performed semistructured interviews with key stakeholders across multiple sectors in an urban county who participate in the care of or decision-making process for unrepresented adults. This included a safety net healthcare system, social services, and legal services. Participants were healthcare, social service, and legal professionals who worked with unrepresented adults (n = 25). Our interview questions explored the current process for proxy decision making in cases of unrepresented adults and potential alternatives. We recorded, transcribed, and analyzed interviews using the constant comparative method to identify major themes related to ethical challenges if they were raised. Participants grappled with multiple ethical challenges around the care of unrepresented adults. Themes described by participants were: (1) prioritizing autonomy; (2) varying safety thresholds; (3) distributing resources fairly; and (4) taking a moral toll on stakeholders. In conclusion, all stakeholders identified ethical challenges in caring for unrepresented adults. An applied ethical framework that takes these dilemmas into account could improve ethical practice for unrepresented adults and lessen the emotional toll on stakeholders. J Am Geriatr Soc 67:1724-1729, 2019.

Tu1011 – Characteristics of Individuals Undergoing Fit for Colorectal Cancer Screening in a Midwest Urban Safety Net Health Care System

Tu1011 – Characteristics of Individuals Undergoing Fit for Colorectal Cancer Screening in a Midwest Urban Safety Net Health Care System

The Impact of Increased Hydrocodone Regulation on Opioid Prescribing in an Urban Safety-Net Health Care System.

Hydrocodone-combination analgesics were changed from Schedule III to Schedule II to discourage the prescribing of these analgesics. Our primary aim was to explore the effect of hydrocodone rescheduling on opioid prescribing within an urban safety-net health care system. Data were extracted from electronic records of ambulatory patients (N = 82,432 patients) prescribed hydrocodone-combination, codeine-combination, or tramadol opioid analgesics (N = 200,675 prescriptions) between October 6, 2013 and October 6, 2015. Data analyses modeled predicted probabilities of hydrocodone-combination prescriptions (HCPs). Chronic opioid therapy (COT) for chronic pain (ie, ≥3 opioid prescriptions/12 months) and morphine milligram equivalency (MME) levels were also examined. The probability of providers writing HCPs decreased significantly from pre- to postrescheduling (0.525 vs 0.158, respectively, P < .0001). However, this coincided with large probability increases in codeine-combination (0.064 vs 0.269) and tramadol prescriptions (0.412 vs 0.573). The probability of HCPs varied across physician specialty (P < .0001), patient diagnoses (P < .0001), COT versus non-COT patients (P < .0001), and patient characteristics (sex, race/ethnicity, and age; P < .05). COT patients received significantly more opioid prescriptions in the postrescheduling period (M = 4.81 vs M = 4.27; P < .0001). Patients on <20 MME/day increased slightly from pre- to postrescheduling (P < .0001). Significant declines in HCPs occurred after rescheduling; however, one third of patients prescribed opioids remained on doses ≥20 MME/day. Codeine- and tramadol-prescription probabilities increased significantly and providers may have an increased perception of safety about these medications. Physicians and health care systems must reduce their overreliance on opioids in treating pain, especially chronic pain, as all opioids incur some level of risk.

Reducing the Use of Ad Hoc Interpreters at a Safety-Net Health Care System

Providing effective communication assistance is critical to ensuring that patients with limited English proficiency (LEP) receive safe and high-quality health care services. Health care providers often use ad hoc interpreters such as patients' family members or friends to communicate with LEP patients; however, this practice presents risks to communication accuracy, patient safety, quality of care, and privacy. Cambridge Health Alliance (CHA) undertook a quality improvement (QI) initiative to reduce the use of patients' family members and friends as interpreters during clinical encounters. A centralized QI team monitored data across clinics and implemented several improvement activities, including systemwide informational campaigns and policy changes, operational improvements within interpreter services, and site-specific outreach. In addition, individual clinics identified and tested improvement strategies with support from the QI team. The number of clinics with high (> 10%) utilization of family/friends as interpreters decreased from 16 to 11 between 2012 and 2018. Trends over time varied across sites, and two clinics had particularly striking and sustained improvement. At these clinics, there were several factors that facilitated improvement, including having trusted leadership champions, using clear and consistent messaging reinforcing CHA's policy, and implementing workflows promoting use of professional interpreters. Changing practice to reduce the use of ad hoc interpreters in a large multisite organization is challenging and takes sustained and prolonged effort. Strong institutional policies and site-specific outreach can help stimulate change, and partnership with leadership champions is critical to success. CHA's experience provides strategies and lessons that can be leveraged by other institutions seeking to improve care for LEP patients.

Augmenting Mental Health in Primary Care: A 1-Year Study of Deploying Smartphone Apps in a Multi-site Primary Care/Behavioral Health Integration Program.

Background: Integrating behavioral health (BH) services into primary care is an evidence-based intervention that can increase access to care, improve patient outcomes, and decrease costs. Digital technology, including smartphone apps, has the potential to augment and extend the reach of these integrated behavioral health services through self-management support impacting lifestyle behaviors. To date, the feasibility and acceptability of using mental health mobile apps within an integrated primary care setting has not yet been explored as part of routine clinical care.Objectives: The objectives of this study were to (a) test the feasibility of using mental health applications to augment integrated primary care services; (b) solicit feedback from patients and providers to guide implementation, and (c) develop a mental health apps toolkit for system-wide dissemination.Methods: Cambridge Health Alliance (CHA) is a safety-net healthcare system that includes three community hospitals and 12 Primary Care (PC) clinics serving nearly 150,000 ethnically and socioeconomically diverse patients around Boston. To select and disseminate mental health apps, a four-phase implementation was undertaken: (1) Evaluation of mental health mobile applications (2) Development of an apps toolkit with stakeholder input, (3) Conducting initial pilot at six primary care locations, and (4) Rolling out the app toolkit across 12 primary care sites and conducting 1-year follow-up survey.Results: Among BH providers, 24 (75%) responded to the follow-up survey and 19 (83%) indicated they use apps as part of their clinical care. Anxiety was the most common condition for which app use was recommended by providers, and 10 (42%) expressed interest in further developing their knowledge of mental health apps. Among patients, 35 (65%) of participants provided feedback; 23 (66%) reported the tools to be helpful, especially for managing stress and anxiety.Conclusions: Our findings indicate mental health apps are applicable and relevant to patients within integrated primary care settings in safety-net health systems. Behavioral health providers perceive the clinical value of using these tools as part of patient care, but require training to increase their comfort-level and confidence applying these tools with patients. To increase provider and patient engagement, mobile apps must be accessible, simple, intuitive and directly relevant to patients' treatment needs.

Abstract P5-09-10: Uptake of genetic testing and prevalence of mutations among minority populations: A retrospective cohort study

Abstract Background: Hereditary cancer syndromes account for 5-10% of cancers. Limited data exists on the uptake of genetic testing and the prevalence of mutations in minority populations. Objective: To estimate genetic testing uptake and prevalence of mutations in a minority population seeking care in a safety net healthcare system. Methods: We conducted a retrospective cohort study of patients who were assessed at John H Stroger Jr., Hospital of Cook County cancer genetics risk clinic between October 2015 and March 2018 to determine the uptake of genetic testing and the prevalence of genetic mutations. Patients who met National Comprehensive Cancer Network (NCCN) guidelines for genetic testing for hereditary breast and ovarian cancer syndrome (HBOC), Lynch syndrome and familial adenomatous polyposis were included. Data was abstracted through chart review to obtain age, socio-demographics, personal cancer history, primary language, personal and family history of cancer including type of cancer and age at diagnosis, insurance status, genetic testing status and test results. Uptake of testing was calculated as the percentage of patients who underwent testing among those patients who met NCCN criteria for testing. Prevalence of mutations among those patients who underwent testing was determined and compared between different ethnicities using Chi-square test. Results: Of 510 patients offered genetic counseling &amp; testing, 478 (94%) underwent genetic testing. Among those who tested, 34% (n=165) were African American and 45% (n=212) were of Hispanic origin. Prevalence of any mutation was 48%(n=232), Pathogenic mutations were identified in 11% (n=54) of testers and variants of uncertain significance (VUS) were identified in 37% (n=178). Deleterious mutations and VUS rates in patients affected with hereditary cancer syndromes were 13% (n=42) and 39 % (n=132) respectively. Deleterious mutations and VUS rates in women unaffected with cancer were 9% (n=12) and 33 % (n=46) respectively. Overall mutation prevalence did not differ between affected and unaffected patients (p=0.12) or between Black and Hispanic patients (p=0.96). Deleterious mutation rate in Hispanic patients was 15.6% (CI 20.5%-10.7%) and in Black patients was 3.6% (CI 3%-4%). There was a significant difference in the percentage of deleterious mutations between Hispanic and Black patients (p=0.0009) . Conclusion: Genetic testing uptake was high in minority populations. In the Population who were tested prevalence of pathogenic mutations was higher among Hispanics than African Americans. Citation Format: Nagireddy P, Ganschow P. Uptake of genetic testing and prevalence of mutations among minority populations: A retrospective cohort study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-09-10.

Abstract P1-02-01: Improvement of breast cancer screening access and quality in an underserved population through system interventions

Abstract Background: Differences in access to and quality of screening and treatment are proposed to contribute to racial disparities in breast cancer outcomes. Interventions designed to improve mammography access and quality encompass strategies at the individual patient, healthcare provider, and system levels. In 2016, an urban safety net healthcare system based in Chicago implemented several changes in response to collected data showing variations in quality at institutions performing mammography. These changes included the installation of digital machines at one of four sites, centralizing reading of images from all four sites to a single site with radiologists specialized in mammography and increasing care coordination including enhanced patient outreach efforts. We examined the impact of these systems-based interventions on the access to and quality of mammography services. Methods: Data was obtained on 15,918 screening mammograms performed across four mammography centers within the Cook County Health &amp; Hospitals System from the six months prior to and one year after implementation of changes. Manual chart abstraction was performed for each study that was assessed as BIRADS 0 (Breast Imaging and Reporting Data System), meaning an incomplete study requiring additional imaging evaluation, or mammograms that appeared suspicious or highly suspicious and categorized as BIRADS 4 or 5. Screening mammogram volume at each site was recorded and compared. Quality of screening mammograms was assessed using eleven metrics reflecting radiologist performance and efficiency of facility care processes. These metrics included the rate of recall, cancer detection rate, proportion of cancers that were early stage or minimal in size, proportion of women with timely follow-up imaging and biopsy, and rates of loss to follow-up. Results: The volume of screening mammograms completed at each of the four sites increased from the six months prior to intervention to the six months after (range of 61-322% increase). At one-year post intervention, there were smaller, but sustained increases in volume (range of 12-70% increase). Improvements were seen in at least one quality metric at each site in the post-intervention period (range 1-8). The proportion of women with timely follow-up after abnormal mammogram also improved across all four sites: from 38% getting follow-up imaging within 30 days pre-intervention to 68% after, and from 62% to 75% of women with biopsy completion within 60 days. Rate of cancer detection improved at two of the sites with the lowest pre-intervention values, from 1.7 to 3.1 and 2.8 to 5.7 per 1,000 mammograms (quality benchmark: 3-10/1,000 screening tests). Conclusion: Improvements in access to and quality of screening mammography demonstrate the value of implementing system level changes in enhancing breast cancer care and may translate to better outcomes for all women. Citation Format: Manst DJ, Gil D, Marcus EA, Mullarkey P, Ganschow PS. Improvement of breast cancer screening access and quality in an underserved population through system interventions [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-02-01.

Cervical Cancer Burden and Opportunities for Prevention in a Safety-Net Healthcare System.

The high prevalence of cervical cancer at safety-net health systems requires careful analysis to best inform prevention and quality improvement efforts. We characterized cervical cancer burden and identified opportunities for prevention in a U.S. safety-net system. We reviewed tumor registry and electronic health record (EHR) data of women with invasive cervical cancer with ages 18+, diagnosed between 2010 and 2015, in a large, integrated urban safety-net. We developed an algorithm to: (i) classify whether women had been engaged in care (≥1 clinical encounter between 6 months and 5 years before cancer diagnosis); and (ii) identify missed opportunities (no screening, no follow-up, failure of a test to detect cancer, and treatment failure) and associated factors among engaged patients. Of 419 women with cervical cancer, more than half (58%) were stage 2B or higher at diagnosis and 40% were uninsured. Most (69%) had no prior healthcare system contact; 47% were diagnosed elsewhere. Among 122 engaged in care prior to diagnosis, failure to screen was most common (63%), followed by lack of follow-up (21%), and failure of test to detect cancer (16%). Tumor stage, patient characteristics, and healthcare utilization differed across groups. Safety-net healthcare systems face a high cervical cancer burden, mainly from women with no prior contact with the system. To prevent or detect cancer early, community-based efforts should encourage uninsured women to use safety-nets for primary care and preventive services. Among engaged patients, strategies to increase screening and follow-up of abnormal screening tests could prevent over 80% of cervical cancer cases.

Highlights of This Issue

African Americans (AAs) experience higher incidence and mortality of lung cancer compared with European Americans (EAs). Inflammation, which is associated with lung cancer, differs between AAs and EAs. Erickson and colleagues investigated whether the anti-inflammatory drug aspirin was associated with lung cancer risk and survival using data from the NCI-Maryland Case-Control Study. The study found aspirin use to be associated with a lower risk of non–small cell lung cancer among men only and provide evidence that the relationship between aspirin and lung cancer risk is confounded by body mass index. The study also found aspirin use to be associated with improved survival, but only among AAs. Aspirin use could be considered in chemoprevention among men and AAs.Using algorithms applied to electronic health record (EHR) and tumor registry data, this study by Pruitt and colleagues identified missed opportunities for cervical cancer prevention among diverse, under-insured, and uninsured women seen at an urban, integrated safety-net healthcare system. Analysis of clinical care pathways demonstrated multiple time points in the screening process to improve delivery of services. Other healthcare systems should harness their EHR data to conduct similar algorithm-driven analyses that can guide selection of evidence-based interventions for cervical cancer prevention.Circulating IGFBP-3 has been associated with prostate cancer (PCa) and preclinical studies have found that vitamin D regulates IGFBP-3 expression. Timpson and colleagues used a combination of observational and Mendelian randomization analyses to reassess relationships between IGFBP-3 and PCa and between inactive vitamin D(25(OH)D) and IGFBP-3. The study confirms IGFBP-3 as a risk factor for PCa but suggests that circulating inactive vitamin D (25(OH)D) is unlikely to be causally related to IGFBP-3. Findings do not preclude associations between 25(OH)D and IGFBP-3 in cancer tissues but urge a need for causal evidence if supplementation is to be justified at a population scale.Aspirin use has been associated with ovarian cancer risk, but the mechanism underlying this association remains unknown. Barnard and colleagues hypothesized that the mechanism may be the downregulation of prostaglandin synthesis and subsequent alteration of immune function. The authors estimated odds ratios for aspirin and nonaspirin nonsteroidal anti-inflammatory drugs and risk of ovarian cancer by high versus low expression of prostaglandin-related markers and tumor associated macrophage (TAM) markers. The study did not observe heterogeneity by prostaglandin-related markers but observed substantial differences by TAM infiltration. Future work should consider prostaglandin-independent mechanisms for the association between aspirin and ovarian cancer risk, including immune mechanisms.