Underinsured Women Research Articles

The cost of inaction: the economic consequences of denying underinsured women post partum sterilization

The cost of inaction: the economic consequences of denying underinsured women post partum sterilization

Successful changes in the diagnosis of earlier stages in invasive cervical cancer following a cancer detection program in Tucuman, Argentina

1544 Background: The PDCCUT provides annually free cancer screening to many low-income, underinsured women. Effective control of cervical cancer depends primarily on early detection of precancerous lesions and also on the diagnosis of earlier stages of invasive lesions through use of the Papanicolaou test, followed by timely evaluation and treatment. The goal of this study is to determine the impact of the PDCCUT on the stage at initial diagnosis of invasive cervical cancer. Methods:This is a retrospective, cross-sectional and exploratory study of data registered in CRRCGMT from 376 women with cervical cancer diagnosis. UICC/FIGO is the staging system used. Every 3 years -from 1985 to 2005- rates were calculated; also trend of stages I-IIa and IIb-IV were estimated. Patients-stages were analyzed, before and after 2001 (beginning of the program). Changes in cervical cancer rates before and after the introduction of organized screening were compared. Conclusion: The results showed a progressive increase in the diagnosis of earlier stages of cervical cancer indicating the impact of PDCCUT. The last trienium rate is coincident with the increase of citological diagnosis (Papanicolaou). A lower rate in the diagnosis of EIIb-IV stages is expected in the next trienium. Evaluation of clinical practice in a Cancer Program allows to improve asistencial quality. [Table: see text] [Table: see text] No significant financial relationships to disclose.

4–25 Effect of Direct Mail as a Population-Based Strategy to Increase Mammography Use Among Low-Income Underinsured Women Ages 40 to 64 Years

4–25 Effect of Direct Mail as a Population-Based Strategy to Increase Mammography Use Among Low-Income Underinsured Women Ages 40 to 64 Years

Impact of Women’s Experiences During Mammography on Adherence to Rescreening (United States)

To examine the relationship between womens' experiences during mammography and their likelihood of being rescreened after receiving a negative or benign mammogram. Telephone interview and medical record data were collected from a random sample of enrollees from four states in a national screening program targeting uninsured and underinsured women at least 30 months after they had undergone an index mammogram in 1997. We calculated 30-month rescreening rates by prior mammography characteristics including pain and embarrassment, worry, convenience of appointment time, treatment by staff, and financial considerations. Of the 2,000 women in the sampling frame, 1,895 (93.6%) were located, 1,685 (88.6%) were interviewed and 1,680 provided data required for our analysis. Overall, 81.5% of the women had undergone rescreening. More than 90% of the women reported being 'satisfied' or 'very satisfied' with treatment by facility staff, facility location and wait time during the appointment. Statistically significant decreased rescreening rates were seen for women who reported feeling embarrassed and for women reporting dissatisfaction with ability to schedule a convenient appointment time. These results suggest that providing additional reassurance and privacy may increase rescreening rates.

Sustaining a Safety Net Breast and Cervical Cancer Detection Program

For the past six years, the Chicago-area faith-based Reach Out Consortium has mobilized low-income uninsured and underinsured African American women and Latinas to seek screening for breast and cervical cancer. The funding history for this program illustrates how funds for a small community-based program were leveraged into a broader program, and that grew to serve low-income women across the state. Further, as the program reached more and more uninsured women, community activism led to a further state investment in services for the uninsured. Program sustainability and expansion depended on a combination of public and private competitive grants and grassroots advocacy.

Loss-framed minimal intervention increases mammography use

Although mammography is the most effective early detection breast cancer screening technology available, it is underutilized. This study was conducted to test the effectiveness of a loss-framed minimal intervention to increase mammography use. Loss-frame refers to a communication strategy in which messages are framed from the perspective of what a person has to lose by not taking a particular behavioral action. Participants were medically un- and underinsured women 50-64 years old who called one of two urban clinics randomly selected based on demographic statistical equivalency. The women who participated telephoned to inquire about a mammogram during the 6-month study period. The group randomly designated as the experimental group received a loss-framed message conveyed by trained staff telephonically. Members of the comparison group received the "usual" communication, also conveyed telephonically. In the experimental group, 31 of 112 (27%) women who inquired received mammograms, whereas 157 of the 992 (16%) comparison group women who inquired received mammograms. The odds of a mammogram, adjusted for race and breast cancer symptoms, significantly increased for the experimental (odds ratio [OR] = 1.914, chi2 = 7.48, p = .0063, 95% confidence interval [CI] 1.20-3.05) versus comparison group. A loss-framed, in-reach, minimal intervention approach holds promise as a mammography promotion strategy.

Effect of Direct Mail as a Population-Based Strategy to Increase Mammography Use among Low-Income Underinsured Women Ages 40 to 64 Years

Women with inadequate health insurance have lower mammography rates than the general population. Finding successful strategies to enroll eligible women is an ongoing challenge for the National Breast and Cervical Cancer Early Detection Program. To test the effectiveness of a population-based strategy to increase mammography utilization among low-income underinsured women ages 40 to 64 years, a randomized trial was conducted to assess the effect of two mailed interventions on mammography utilization through Sage, the National Breast and Cervical Cancer Early Detection Program in Minnesota. Women (N = 145,467) ages 40 to 63 years [mean (SD), 49.7 (6.8)] with estimated household incomes below 50,000 US dollars (47.9% were < 35,000 US dollars) from a commercial database were randomized to three groups: Mail, Mail Plus Incentive, or Control. Both the Mail and the Mail Plus Incentive groups received two simple mailings prompting them to call a toll-free number to access free mammography services. The Mail Plus Incentive intervention offered a small monetary incentive for a completed mammogram. After 1 year, both intervention groups had significantly higher Sage mammography rates than the Controls, and the Mail Plus Incentive group had a significantly higher rate than the Mail group. The Mail and Mail Plus Incentive interventions were estimated to produce increases in Sage screening rates of 0.23% and 0.75%, respectively, beyond the composite Control rate of 0.83%. Direct mail is an effective strategy for increasing mammography use through Sage. Coupling direct mail with an incentive significantly enhances the intervention's effectiveness. Direct mail should be considered as a strategy to increase mammography use among low-income, medically underserved women.

On-Schedule Mammography Rescreening in the National Breast and Cervical Cancer Early Detection Program

Abstract Objective: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides free cancer screening to many low-income, underinsured women annually but does not routinely collect all data necessary for precise estimation of mammography rescreening rates among enrollees. Materials and Methods: To determine the percentages rescreened and to identify factors that encourage on-schedule rescreening, telephone interview and medical record data were collected from 1685 enrollees in Maryland, New York, Ohio, and Texas at least 30 months after their 1997 index mammogram. Results: Overall, 72.4% [95% confidence interval (95% CI) = 70.1–74.7] were rescreened within 18 months and 81.5% (95% CI = 79.6–83.5) within 30 months. At 30 months, the adjusted odds ratios (ORs) for rescreening were higher among Hispanics (OR = 1.95, 95% CI = 1.15–3.28), women with a history of breast cancer before the index mammogram (OR = 3.36, 95% CI = 1.07–10.53), and those who had used hormone replacement therapy before their index mammogram (OR =1.94, 95% CI = 1.30–2.91). The 30-month adjusted ORs were lower for women who reported poor health status (OR = 0.60, 95% CI = 0.42–0.85), did not have a usual source of care (OR = 0.61, 95% CI = 0.40–0.94), did not know if they could have another free mammogram (OR = 0.28, 95% CI = 0.14–0.51), described their index screen as their first mammogram ever (OR for no prior mammograms versus three or more = 0.40, 95% CI = 0.27–0.60), did not recall receiving a rescreening reminder (OR = 0.35, 95% CI = 0.25–0.48), or did not think they had been encouraged to rescreen by their provider (OR = 0.61, 95% CI = 0.44–0.86). Discussion: Rescreening behavior in this sample of NBCCEDP enrollees was comparable with that observed in other populations. To facilitate routine rescreening among low-income women, ongoing efforts are needed to ensure they receive annual reminders and encouragements from their medical providers and that they know how to obtain the services they need.

Evaluation of a “loss-framed” minimal intervention to increase mammography utilization among medically un- and under-insured women

This study was conducted because mammography is under-utilized, even though it is the most effective early detection screening device for breast cancer. A loss-framed telephonic message based on prospect theory was evaluated for the effects on mammography utilization among medically un- and under-insured women living in demographically similar rural counties in Florida. The sample consisted mostly of White women (≈89%) 50–64 years old. Experimental group participants received the loss-framed message telephonically and those in the comparison group received the “usual telephone procedure.” Logistic regression analyses revealed that women who received the loss-framed message were six times more likely to obtain a mammogram (OR=6.6, P<0.0001). The impact of the loss-framed message persisted even after adjustment for initial versus re-screen mammogram effects. This in-reach, loss-framed, minimal intervention seems to have viability and may serve as an alternative or adjunct program for encouraging women to receive mammograms.

Mass screening in low-income populations: the challenges of securing diagnostic and treatment services in a national cancer screening program.

Funding for many mass screening programs for low-income and uninsured populations provides resources for screening tests, yet only rarely does it provide coverage for necessary follow-up diagnostic and treatment services. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), a federally funded initiative that provides cancer screening to low-income uninsured and underinsured women, covers some diagnostic follow-up tests and no treatment services. We conducted in-depth case studies of seven state programs participating in the NBCCEDP to investigate the strategies and approaches being used to secure diagnostic and treatment services. The results suggest that the program relies on a patchwork of resources--at state and local levels--to provide diagnostic and treatment services. This includes a number of components of local safety nets, all of which are unstable and have uncertain futures. Public health disease-screening initiatives need to reconsider the feasibility of continued reliance on case-by-case appeals to the local safety net for diagnostic follow-up and treatment services.

Factors associated with repeat mammography in a New York State public health screening program.

Screening mammography is the most effective method for early detection of breast cancer, but repeat mammography rates are not optimal in most populations. Since 1988, New York State has supported a program of breast cancer screening for underserved, uninsured, or underinsured women. The present study was designed to identify sociodemographic and clinical factors associated with failure to return for repeat mammography screening after a negative initial mammogram. Of women initially screened between 1988 and 1991 (N = 9,485), 27 percent obtained repeat mammograms by 1993. The final logistic regression model contained program site, race and ethnicity, family income, and time since last mammogram.

Comparison of obstetric outcome of a primary-care access clinic staffed by certified nurse-midwives and a private practice group of obstetricians in the same community

Objective: The purpose of this study was to compare the obstetric outcome of a primary-care access clinic staffed by certified nurse-midwives, supervised by a private practice group of four obstetricians, with the obstetric outcome of that group's private practice patients. Study design: A retrospective cohort study was performed. Obstetric outcome of 496 clinic patients was compared with that of 611 private patients in the same community from Aug. 1, 1991, to March 31, 1994. Results: Obstetric outcomes as measured by (1) perinatal morbidity and mortality, (2) Apgar score, (3) birth weights, and (4) prematurity rates were comparable between the two groups. Significant was the caesarean section rate of 13.1% (10.5% primary) for the clinic patients and 26.4% (18.5% primary) for the private patients and the high percentage (81.8%) of private patients who elected to have repeat cesarean sections. Conclusions: (1) Low-income, uninsured, and underinsured women who have access to excellent prenatal care with supervised certified nurse-midwives can have obstetric outcomes similar to women having prenatal care with private obstetricians. (2) Prenatal care with supervised certified nurse-midwives can reduce the cesarean section rate without compromising infant outcome. (3) Utilization of certified nurse-midwives supervised by obstetricians may provide the optimum model for perinatal care. Particularly for those women who are high risk because of social and economic factors and who are currently underserved.