The Radiology Health Equity Research Database is a comprehensive database of >250 articles looking at racial health equity within radiology. It is intended as an open-access resource to assist students and researchers by providing rapid access to the existing body of health equity literature in radiology. The database is updated annually in late summer. If you have an article that should be included but is not in the database, please email the citation to ARoss@uwhealth.org.
| Year | Study Id | Title | Whole Title | Age | Sex | Care Setting | Clinical Setting | Country | Population | dataLevel | dataType | dataSource | freeText | abstract |
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| 2020 | Tailor 2020 | Utilization of Lung Cancer | Utilization of Lung Cancer Screening in the Medicare Fee-for-Service Population | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Multiple Groups | National | Medicare Data | 100% Outpatient Claims, Carrier Claims, and Master Beneficiary Summary Files | Background: A number of organizations, including the US Preventive Services Task Force (USPSTF), recommend lung cancer screening (LCS) with low-dose CT (LDCT) imaging for high-risk current and former smokers. In 2015, Medicare issued a decision to cover LCS as a preventive health benefit; however, utilization by the Medicare population has not been thoroughly examined. Research Question: Our objective was to evaluate the early use of LCS in the Medicare fee-for-service (FFS) population and determine the relationship(s) among beneficiary sociodemographic characteristics, geographic location, and use. Study Design and Methods: This cross-sectional observational study used 100% Medicare FFS claims files for Medicare beneficiaries receiving LCS between January 1, 2016 and December 31, 2016. We estimated the LCS-eligible Medicare population using population and smoking data from the US Census Bureau and Centers for Disease Control and Prevention. We assessed variation in LCS rates by beneficiary characteristics and geography, using univariate and multivariate regression, the latter also including how interactions between geographic location and race/ethnicity influence screening. Results: A total of 103,892 Medicare FFS beneficiaries received LCS in 2016, comprising 4.1% (95% CI, 3.9%-4.3%) of the estimated LCS-eligible Medicare population. Accounting for the interactions between race/ethnicity and US region, nonwhite (black, Hispanic) beneficiaries in all US regions were screened with lower frequency than white beneficiaries (P <. 001). Screening rates in the Northeast were significantly higher than in other regions (adjusted rate ratio [95% CI] of Northeast relative to South: 1.83 [1.36-2.46]). Interpretation: The early adoption of LCS among Medicare beneficiaries was low. Our results suggest geographic and racial disparities in screening use, with populations in the South and those of nonwhite race/ethnicity being screened with lower frequency. Further work is needed to improve LCS uptake and ensure consistent use by all at-risk populations. | |
| 2019 | Loomer 2019 | Racial and socioeconomic | Racial and socioeconomic disparities in adherence to preventive health services for ovarian cancer survivors | Adult Only | Female | Outpatient Ambulatory and Primary Care | Osteoporosis Screening | United States | Black | National | Medicare Data | 5% Medicare Beneficiary File | Purpose: To examine ovarian cancer survivors' adherence to evidence-based guidelines for preventive health care. Methods: A case-control, retrospective study of Medicare fee-for-service beneficiaries diagnosed with stage I, II, or III epithelial ovarian cancer from 2001 to 2010 using the Surveillance, Epidemiology, and End Results-Medicare database. Survivors were matched 1:1 to non-cancer controls from the 5% Medicare Beneficiary file on age, race, state of residence, and follow-up time. Receipt of flu vaccination, mammography, and bone density tests were examined in accordance with national guidelines. Adherence was assessed starting 1 year after cancer diagnosis, across 2 years of claims. Interaction with the health care system, including outpatient and cancer surveillance visits, was tested as a potential mechanism for receipt of services. Results: 2437 survivors met the eligibility criteria (mean age, 75; 90% white). Ovarian cancer survivors were more likely to be adherent to flu vaccination (5 percentage points (pp); < 0.001) and mammography guidelines (10pp.; < 0.001) compared to non-cancer controls, but no differences were found for bone density test guidelines (- 1pp.; NS). Black women were less likely to be adherent to flu vaccination and bone density tests compared with white women. Women dually eligible for Medicare and Medicaid were less likely to be adherent compared to those without such support. Adherence was not influenced by measures of outpatient visits. Conclusion: Ovarian cancer survivors are receiving preventive services with the same or better adherence than their matched counterparts. Minority and dual-eligible survivors received preventive services at a lower rate than white survivors and those with higher income. The number of outpatient visits was not associated with increased preventive health visits. Implications for Cancer Survivors: Ovarian cancer survivors are receiving adequate follow-up care to be adherent to preventive health measures. Efforts to improve care coordination post-treatment may help reduce minority and low SES disparities. | |
| 2020 | Moreno 2021 | Use of Screening CT Colonography by | Use of Screening CT Colonography by Age and Race: A Study of Potential Access Barriers Related to Medicare Noncoverage Based on Data From the ACR's National CT Colonography Registry | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Colorectal Cancer Screening | United States | Multiple Groups | National | Disease Registry | ACRs National Radiology Data Registry CTC Registry | Objective: The primary objectives of this investigation were to evaluate the use of screening CT colonography (CTC) examinations by age comparing individuals of Medicare-eligible age to younger cohorts and to determine if the association between use of CTC and Medicare-eligible age varies by race. Although the Affordable Care Act requires commercial insurance coverage of screening CTC, Medicare does not cover screening CTC. Materials and Methods: Using the ACR's CTC registry, the distribution of procedures by age was evaluated using a negative binomial model with patient age (to capture overall trend), indicator of Medicare-eligible age (to capture immediate changes in trend at age 65), and their interaction (to capture gradual changes after age 65) as independent variables. The association between the number of screening CTCs and age was compared by racial identity. Results: The CTC registry contained data on 12,648 screening examinations. Between ages 52 and 64, the number of screening examinations increased; each additional age year was associated with a 5.3% (P < .001) increase in the number of screenings. However, after age 65, the number of screening examinations decreased by -6.9% per additional year of age above 65 compared with the trend between ages 52 and 64 (P < .001). The modal age group for CTC use was 65 to 69 years in white and 55 to 59 in black individuals. Conclusion: After age 65, the number of screening CTC examinations decreased, likely due, at least in part, to lack of Medicare coverage. Medicare noncoverage may have a disproportionate impact on black patients and other racial minorities. | |
| 2000 | Mascarenhas 2000 | Access and use of specific dental | Access and use of specific dental services in HIV disease | All Ages | All Sexes | Outpatient Ambulatory and Primary Care | Dental | United States | Multiple Groups | National | Disease Registry | AIDS Cost and Service Utilization Surveys | Objectives: This study examined factors associated with the use of specific dental services by persons with HIV disease. Methods: The data were derived from 1,588 adults who participated in a series of up to six interviews as part of the AIDS Cost and Service Utilization Surveys. Use of dental services such as examinations, x-rays, cleaning, fillings, extractions, root canals, crown and bridge or dentures, and periodontal procedures were evaluated using logistic regression and generalized estimating equations were applied. Results: Multivariate analyses showed that medical insurance, an education beyond high school, income higher than $1,300 per month, high ambulatory visits, and receipt of psychological counseling were generally associated with higher service use. Blacks, those with an inpatient admission, and CD4+ cell counts less than 500 cells/microL were significantly less likely to use most types of dental services. Conclusions: The study concludes that disparities exist in the use of several dental services similar to those seen in the general population. | |
| 2022 | Hagan 2022 | Socioeconomic and Psychosocial | Socioeconomic and Psychosocial Predictors of Magnetic Resonance Imaging After Cervical and Thoracic Spine Trauma in the United States | All Ages | All Sexes | Emergency Department | Trauma imaging | United States | Multiple Groups | National | Disease Registry | American College of Surgeons National Trauma Data Bank | OBJECTIVE: Socioeconomic factors are known to influence outcomes after spinal trauma, but it is unclear how these factors affect health care utilization in acute care settings. We aimed to elucidate if sociodemographic and psychosocial factors are associated with obtaining magnetic resonance imaging (MRI), a costly imaging modality, after cervical or thoracic spine fracture. METHODS: Data from the 2012-2016 American College of Surgeons National Trauma Data Bank were used. We assessed the relationship between receipt of MRI and patient-level sociodemographic and psychosocial factors as well as hospital characteristics while correcting for injury-specific characteristics. Multiple logistic regression was performed to assess for associations between these variables and MRI after spine trauma. RESULTS: A total of 213,071 patients met the inclusion criteria, of whom 13.0% had an MRI (n=27,757). After adjusting for confounders in multivariate regression, patients had increased odds of MRI if they were Hispanic (odds ratio [OR], 1.09; P=0.001) or black (OR, 1.14; P< 0.001) or were diagnosed with major psychiatric disorder (OR, 1.06; P=0.009), alcohol use disorder (OR, 1.05; P< 0.001), or substance use disorder (OR, 1.10; P< 0.001). Patients with Medicare (OR, 0.88; P< 0.001) or Medicaid (OR, 0.94; P< 0.011) were less likely to have an MRI than were those with private insurance, whereas patients treated in the Northeast (OR, 1.48; P<0.001) or at for-profit hospitals (OR, 1.12; P<0.001) were more likely. CONCLUSIONS: After adjusting for injury severity and spinal cord injury diagnosis, psychosocial comorbidities and for-profit hospital status were associated with higher odds of MRI, whereas public insurance was associated with lower odds. Results highlight potential biases in the provision of MRI as a costly imaging modality. | |
| 2018 | Milani 2018 | Associations of Race and Ethnicity | Associations of Race and Ethnicity With Patient-Reported Outcomes and Health Care Utilization Among Older Adults Initiating a New Episode of Care for Back Pain | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Back Pain Imaging | United States | Multiple Groups | Multi-Institution | Disease Registry | Back Pain Outcomes using Longitudinal Data | STUDY DESIGN: Secondary analysis of the Back Pain Outcomes using Longitudinal Data (BOLD) cohort study. OBJECTIVE: To characterize associations of self-reported race/ethnicity with back pain (BP) patient-reported outcomes (PROs) and health care utilization among older adults with a new episode of care for BP. SUMMARY OF BACKGROUND DATA: No prior longitudinal studies have characterized associations between multiple race/ethnicity groups, and BP-related PROs and health care utilization in the United States. METHODS: This study included 5117 participants 65 years from three US health care systems. The primary BP-related PROs were BP intensity and back-related functional limitations over 24 months. Health care utilization measures included common diagnostic tests and treatments related to BP (spine imaging, spine-related relative value units [RVUs], and total RVUs) over 24 months. Analyses were adjusted for multiple potential confounders including sociodemographics, clinical characteristics, and study site. RESULTS: Baseline BP ratings were significantly higher for blacks vs. whites (5.8 vs. 5.0; P < 0.001). Participants in all race/ethnicity groups showed statistically significant, but modest improvements in BP over 24 months. Blacks and Hispanics did not have statistically significant improvement in BP-related functional limitations over time, unlike whites, Asians, and non-Hispanics; however, the magnitude of differences in improvement between groups was small. Blacks had less spine-related health care utilization over 24 months than whites (spine-related RVU ratio of means 0.66, 95% confidence interval [CI] 0.51-0.86). Hispanics had less spine-related health care utilization than non-Hispanics (spine-related RVU ratio of means 0.60; 95% CI 0.40-0.90). CONCLUSION: Blacks and Hispanics had slightly less improvement in BP-related functional limitations over time, and less spine-related health care utilization, as compared to whites and non-Hispanics, respectively. Residual confounding may explain some of the association between race/ethnicity and health outcomes. Further studies are needed to understand the factors underlying these differences and which differences reflect disparities. LEVEL OF EVIDENCE: 3. | |
| 2002 | Coughlin 2002 | Breast and cervical cancer | Breast and cervical cancer screening practices among Hispanic Women in the United States and Puerto Rico, 1998-1999 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance Survey | Background: Results from recent studies suggest that Hispanic women in the United States may underuse cancer screening tests and face important barriers to screening. Methods: We examined the breast and cervical cancer screening practices of Hispanic women in 50 states, the District of Columbia, and Puerto Rico from 1998 through 1999 by using data from the Behavioral Risk Factor Surveillance System. Results: About 68.2% (95% confidence interval [CI] = 66.3 to 70.1%) of 7,253 women in this sample aged 40 years or older had received a mammogram in the past 2 years. About 81.4% (95% CI = 80.3 to 82.5%) of 12,350 women aged 18 years or older who had not undergone a hysterectomy had received a Papanicolaou test in the past 3 years. Women with lower incomes and those with less education were less likely to be screened. Women who had seen a physician in the past year and those with health insurance coverage were much more likely to have been screened. For example, among those Hispanic women aged 40 years or older who had any health insurance coverage (n = 6,063), 72.7% (95% CI 70.7-74.6%) had had a mammogram in the past 2 years compared with only 54.8% (95% CI 48.7-61.0%) of women without health insurance coverage (n = 1,184). Conclusions: These results underscore the need for continued efforts to ensure that Hispanic women who are medically underserved have access to cancer screening services. | |
| 2012 | Oh 2012 | Breast Cancer Screening Practices | Breast Cancer Screening Practices Among Asian Americans and Pacific Islanders | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance Survey | Objective: To compare the breast cancer screening practices and related factors between Asian Americans and Pacific Islanders (PIs) and non-Hispanic whites. Methods: Using 2008 Behavioral Risk Factor Surveillance System data, reported mammogram usage among women aged 40+ were compared. Covariates included demographics, risk behaviors, health perception, care access, and general health practice behavior. Results: PIs had higher rates of screening mammogram usage than did Asian Americans. Most covariates had different levels of influence on mammogram screening for the 2 groups, with a few in opposite directions. Conclusion: Understanding the magnitude and predictors of these disparities for racial/ethnic groups can help inform targeted interventions. | |
| 2006 | Sassi 2006 | Reducing racial/ethnic disparities | Reducing racial/ethnic disparities in female breast cancer: screening rates and stage at diagnosis | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance Survey | OBJECTIVES: We assessed whether population rates of mammography screening, and their changes over time, were associated with improvements in breast cancer stage at diagnosis and whether the strength of this association varied by race/ethnicity. METHODS: We analyzed state cancer registry data linked to socioeconomic characteristics of patients' areas of residence for 1990-1998 time trends in the likelihood of early stage diagnosis. We appended each cancer registry record with matching subgroup estimates of self-reported mammography screening. RESULTS: Trends in screening and stage at diagnosis were consistent within groups, but African American women had a significantly lower proportion of early stage cancers despite an advantage in screening. Population screening rates were significantly associated with early diagnosis, with a weaker association in African American women than White women (odds ratio [OR] = 1.70; P<.0001 vs OR=2.02; P<.0001, respectively). CONCLUSIONS: Improvements in screening rates during the 1990s across racial/ethnic groups appear to have contributed significantly to earlier diagnosis within each group, but a smaller effect in African American women should raise concerns. A key health policy challenge is to ensure that screening effectively translates into earlier diagnosis. | |
| 2021 | Benavidez 2021 | Disparities in Meeting USPSTF | Disparities in Meeting USPSTF Breast, Cervical, and Colorectal Cancer Screening Guidelines Among Women in the United States | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance System | INTRODUCTION: Many sociodemographic factors affect women's ability to meet cancer screening guidelines. Our objective was to examine which sociodemographic characteristics were associated with women meeting US Preventive Services Task Force (USPSTF) guidelines for breast, cervical, and colorectal cancer screening. METHODS: We used 2018 Behavioral Risk Factor Surveillance System data to examine the association between sociodemographic variables, such as race/ethnicity, rurality, education, and insurance status, and self-reported cancer screening for breast, cervical, and colorectal cancer. We used multivariable log-binomial regression models to estimate adjusted prevalence ratios and 95% CIs. RESULTS: Overall, the proportion of women meeting USPSTF guidelines for breast, cervical, and colorectal cancer screening was more than 70%. The prevalence of meeting screening guidelines was 6% to 10% greater among non-Hispanic Black women than among non-Hispanic White women across all 3 types of cancer screening. Women who lacked health insurance had a 26% to 39% lower screening prevalence across screening types than women with health insurance. Compared with women with $50,000 or more in annual household income, women with less than $50,000 in annual household income had a 3% to 8% lower screening prevalence across all 3 screening types. For colorectal cancer, the prevalence of screening was 7% less among women who lived in rural counties than among women in metropolitan counties. CONCLUSION: Many women still do not meet current USPSTF guidelines for breast, cervical, and colorectal cancer screening. Screening disparities are persistent among socioeconomically disadvantaged groups, especially women with low incomes and without health insurance. To increase the prevalence of cancer screening and reduce disparities, interventions must focus on reducing economic barriers and improving access to care. | |
| 2000 | Bolen 2000 | State-specific prevalence of | State-specific prevalence of selected health behaviors, by race and ethnicity--Behavioral Risk Factor Surveillance System, 1997 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance System | PROBLEM/CONDITION: In the United States, disparities in risks for chronic disease (e.g., diabetes, cardiovascular disease, and cancer) and injury exist among racial and ethnic groups. This report summarizes findings from the 1997 Behavioral Risk Factor Surveillance System (BRFSS) of the distribution of access to health care, health-status indicators, health-risk behaviors, and use of clinical preventive services across five racial and ethnic groups (i.e., whites, blacks, Hispanics, American Indians or Alaska Natives, and Asians or Pacific Islanders) and by state. REPORTING PERIOD COVERED: 1997. DESCRIPTION OF SYSTEM: The BRFSS is a state-based telephone survey of the civilian, noninstitutionalized, adult (i.e., persons aged > or = 18 years) population. In 1997, all 50 states, the District of Columbia, and Puerto Rico participated in the BRFSS. RESULTS: Variations in risk for chronic disease and injury among racial and ethnic groups exist both within states and across states. For example, in Arizona, 11.0% of whites, 26.2% of Hispanics, and 50.5% of American Indians or Alaska Natives reported having no health insurance. Across states, the median percentage of adults who reported not having this insurance ranged from 10.8% for whites to 24.5% for American Indians or Alaska Natives. Other findings are as follows. Blacks, Hispanics, American Indians or Alaska Natives, and Asians or Pacific Islanders were more likely than whites to report poor access to health care (i.e., no health-care coverage and cost as a barrier to obtaining health care). Blacks, Hispanics, and American Indians or Alaska Natives were more likely than whites and Asians or Pacific Islanders to report fair or poor health status, obesity, diabetes, and no leisure-time physical activity. Blacks were substantially more likely than other racial or ethnic groups to report high blood pressure. Among all groups, American Indians or Alaska Natives were the most likely to report cigarette smoking. Except for Asians or Pacific Islanders, the median percentage of adults who reported not always wearing a safety belt while driving or riding in a car was > or = 30%. The Papanicolaou test was the most commonly reported screening measure: > or = 81% of white, black, and Hispanic women with an intact uterine cervix reported having had one in the past 3 years. Among white, black, and Hispanic women aged > or = 50 years, > or = 63% reported having had a mammogram in the past 2 years. Approximately two thirds of white, black, and Hispanic women aged > or = 50 years reported having had both a mammogram and a clinical breast examination in the past 2 years; this behavior was least common among Hispanics and most common among blacks. Screening for colorectal cancer was low among whites, blacks, and Hispanics aged > or = 50 years: in each racial or ethnic group, < or = 20% reported having used a home-kit blood stool test in the past year, and < or = 30% reported having had a sigmoidoscopy within the last 5 years. INTERPRETATION: Differences in median percentages between racial and ethnic groups, as well as between states within each racial and ethnic group, are likely mediated by various factors. According to published literature, socioeconomic factors (e.g., age distribution, educational attainment, employment status, and poverty), lifestyle behaviors (e.g., lack of physical activity, alcohol intake, and cigarette smoking), aspects of the social environment (e.g., educational and economic opportunities, neighborhood and work conditions, and state and local laws enacted to discourage high-risk behaviors), and factors affecting the health-care system (e.g., access to health care, and cost and availability of screening for diseases and health-risk factors) may be associated with these differences. ACTION TAKEN: States will continue to use the BRFSS to collect information about health-risk behaviors among various racial and ethnic groups. (ABSTRACT TRUNCATED) | |
| 2002 | Coughlin 2008 | Contextual analysis of breast and | Contextual analysis of breast and cervical cancer screening and factors associated with health care access among United States women, 2002 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance System | This research explored the relationships between race/ethnicity and area factors affecting access to health care in the United States. The study represents an advance on previous research in this field because, in addition to including data on rurality, it incorporates additional contextual covariates describing aspects of health care accessibility. Individual-level data were obtained from the 2002 Behavioral Risk Factor Surveillance System (BRFSS). The county of residence reported by BRFSS respondents was used to link BRFSS data with county-level measures of health care access from the 2004 Area Resource File (ARF). Analyses of mammography were limited to women aged 40 years with known county of residence (n = 91,492). Analyses of Pap testing were limited to women aged 18 years with no history of hysterectomy and known county of residence (n = 97,820). In addition to individual-level covariates such as race, Hispanic ethnicity, health insurance coverage and routine physical exam in the previous year. We examined county-level covariates (residence in health professional shortage area, urban/rural continuum, racial/ethnic composition, and number of health centers/clinics, mammography screening centers, primary care physicians, and obstetrician-gynecologists per 100,000 female population or per 1000 square miles) as predictors of cancer screening. Both individual-level and contextual covariates are associated with the use of breast and cervical cancer screening. In the current study, covariates associated with health care access, such as health insurance coverage, household income, Black race, and percentage of county female population who were non-Hispanic Black, were important determinants of screening use. In multivariate analysis, we found significant interactions between individual-level covariates and contextual covariates. Among women who reside in areas with lower primary care physician supply, rural women are less likely than urban women to have had a recent Pap test. Black women were more likely than White women to have had a recent Pap test. Women with a non-rural county of residence were more likely to have had a recent mammogram than rural women. A significant interaction was also found between individual-level race and number of health centers or clinics per 100,000 population(p-value = 0.0187). In counties with 2 or more health centers or clinics per 100,000 female population, Black women were more likely than White women to have had a recent mammogram. A significant interaction was also observed between the percentage of county female population who were Hispanic and the percentage who were non-Hispanic Black. | |
| 2008 | Kang-Kim 2008 | Access to care and use of | Access to care and use of preventive services by Hispanics: State-based variations from 1991 to 2004 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Hispanic | National | Government Survey | Behavioral Risk Factor Surveillance System | BACKGROUND: State-level disparities in access to physicians and preventive services between Hispanics and whites may have changed over time. OBJECTIVE: To assess state-based changes in Hispanics' access to physicians and preventive services from 1991 to 2004. METHODS: Using data from the Behavioral Risk Factor Surveillance System in the 10 states with the largest Hispanic populations, we examined 4 preventive services for eligible adults (mammography, Papanicolaou testing, colorectal cancer screening, and cholesterol testing) and 2 measures of access to physicians (obtaining routine checkup in prior 2 years and avoiding seeing physician when needed due to cost in prior year). In each state we assessed unadjusted and adjusted Hispanic-white access gaps and changes over time. RESULTS: Hispanic-white access gaps persisted over time and varied widely by state. Disparities narrowed and became nonsignificant in 2 states (Arizona and California) for mammography and 3 states (Nevada, New Mexico, and New York) for Pap testing. Other disparities increased and became significant (mammography in Texas; colorectal cancer screening in California, Colorado, and Texas; cholesterol testing in Florida and Nevada; routine checkups in Arizona and New Mexico). Disparities in lacking doctor visits due to cost remained large and significant over time in all states. Insurance status and education were the main contributors to Hispanic-white disparities and their impact increased over time. CONCLUSIONS: Although use of preventive services and access to physicians improved for both whites and Hispanics nationally, access gaps varied widely among states. Therefore, efforts to monitor and eliminate disparities should be conducted at both the national and state levels. | |
| 2014 | Monnat 2014 | Race/ethnicity and the | Race/ethnicity and the socioeconomic status gradient in women's cancer screening utilization: A case of diminishing returns? | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance System | Using three years (2006, 2008, 2010) of nationally representative data from the Behavioral Risk Factor Surveillance System, I assessed the socioeconomic status (SES) gradient for odds of receiving a mammogram in the past two years and a Pap test in the past three years among White, Black, Hispanic, and Asian women living in the U.S. Mammogram and Pap test utilization were less likely among low-SES women. However, women of color experience less benefit than Whites from increasing SES for both screenings; as income and education increased, White women experienced more pronounced increases in the likelihood of being screened than did women of color. In what might be referred to as paradoxical returns, Asian women actually experienced a decline in the likelihood of obtaining a recent Pap test at higher levels of education. My findings suggest that women of color differ from Whites in the extent to which increasing socioeconomic resources is associated with increasing cancer screening utilization. | |
| 2021 | Narayan 2021 | Racial and ethnic disparities in | Racial and ethnic disparities in lung cancer screening eligibility | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance System | BACKGROUND: To address disparities in lung cancer screening (LCS) that may exclude large numbers of high-risk African American smokers, revised U.S. Preventive Services Task Force (USPSTF) recommendations lowered LCS eligibility thresholds. However, there are limited recent data about the impact of newly revised guidelines on disparities in LCS eligibility. PURPOSE: To evaluate the impact of revised USPSTF guidelines on racial and ethnic disparities in LCS eligibility. MATERIALS AND METHODS: Cross-sectional survey data from 20 states were retrospectively evaluated from the 2019 Behavioral Risk Factor Surveillance System survey (median response rate, 49.4%). Respondents without a history of lung cancer aged 55-79 years (ie, under the previous guidelines) or aged 50-79 years (ie, under the revised guidelines) were included. Multivariable logistic regression analyses were performed to evaluate the association between race and ethnicity and LCS eligibility. All analyses were performed accounting for complex survey design features (ie, weighting, stratification, and clustering). RESULTS: Under previous guidelines, 11% of 67 567 weighted survey respondents were eligible for LCS (White [12%], Hispanic [4%], African American [7%], American Indian [17%], Asian or Pacific Islander [4%], and other [12%]). Under revised USPSTF guidelines, 14% of 77 689 weighted survey respondents were eligible for LCS (White [15%], Hispanic [5%], African American [9%], American Indian [21%), Asian or Pacific Islander [5%], and other [18%]). Compared with White respondents, African American respondents (adjusted odds ratio [OR] = 0.36; 95% CI: 0.27, 0.47; P < .001) and Hispanic respondents (adjusted OR = 0.15; 95% CI: 0.09, 0.24; P < .001) were less likely to be eligible for LCS under previous guidelines. African American respondents (adjusted OR = 0.39; 95% CI: 0.32, 0.47; P < .001) and Hispanic respondents (adjusted OR = 0.15; 95% CI: 0.10, 0.23; P < .001) were less likely to be eligible under the revised guidelines. The Wald test showed no evidence of differences in the degree to which racial and ethnic minority groups were less likely to be eligible for LCS when comparing previous versus revised USPSTF guidelines (P = .76). CONCLUSION: The revised U.S. Preventive Services Task Force guidelines (version 2.0) may perpetuate lung cancer disparities, as racial and ethnic minority groups are still less likely to be eligible for lung cancer screening. | |
| 2000 | Qureshi 2000 | Differences in breast cancer | Differences in breast cancer screening rates: an issue of ethnicity or socioeconomics? | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance System | Previous reports suggest that use of preventive measures, such as screening mammography (SM), differs by ethnicity. It is unclear, however, if this is determined directly by ethnicity or indirectly by related socioeconomic factors. We studied self-reported data from 18,245 women aged 40-49 who participated in the Behavioral Risk Factor Surveillance System telephone survey in 1992 and 1993. Of these, 11,509 (63%) reported having obtained mammography within the preceding 2 years for screening purposes only. Using reports of other preventive healthcare behaviors, education level, socioeconomic status, and healthcare access problems as independent variables, bivariate associations were assessed, and a logistic regression model was developed. Models for each ethnic group were developed, with consistent results. Women who engaged in other preventive health measures, such as Pap smear (odds ratio [OR] 8.99, 95% confidence interval [CI] = 7.6-10.7), cholesterol measurement (OR 2.64, 95% CI = 2.3-3.0), and seatbelt use, were more likely to obtain SM. Women with healthcare access or insurance problems (OR 0. 59, 95% CI = 0.5-0.7) and current smokers (OR 0.71, CI = 0.6-0.8) had a lower likelihood of obtaining SM. Ethnicity, alcohol use, marital status, and education level were not significantly associated with women's reports of SM. Although ethnicity apparently does not influence a woman's likelihood of obtaining SM, access to healthcare and insurance and engaging in other healthy behaviors do. Health policy planners should consider the importance of these related factors when developing preventive health programs for women. | |
| 2022 | Rustagi 2022 | Likelihood of Lung Cancer Screening | Likelihood of Lung Cancer Screening by Poor Health Status and Race and Ethnicity in US Adults, 2017 to 2020 | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Black | National | Government Survey | Behavioral Risk Factor Surveillance System | IMPORTANCE: Lung cancer screening (LCS) via low-dose chest computed tomography can prevent mortality through surgical resection of early-stage cancers, but it is unknown whether poor health is associated with screening. Though LCS may be associated with better outcomes for non-Hispanic Black individuals, it is unknown whether racial or ethnic disparities exist in LCS use. OBJECTIVE: To determine whether health status is associated with LCS and whether racial or ethnic disparities are associated with LCS independently of health status. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional, population-based study of community-dwelling US adults used data from Behavioral Risk Factor Surveillance System annual surveys, 2017 to 2020. Participants were aged 55 to 79 years, with a less than 30 pack-year smoking history, and were current smokers or those who quit within 15 years. Data were analyzed from August to November 2021. EXPOSURES: Self-reported health status and race and ethnicity. MAIN OUTCOMES AND MEASURES: Self-reported LCS in the last 12 months. RESULTS: Of 14 550 individuals (7802 men [55.5%]; 7527 [55.0%] aged 65-79 years [percentages are weighted]), representing 3.68 million US residents, 17.0% (95% CI, 15.1%-18.9%) reported undergoing LCS. The prevalence of LCS was lower among non-Hispanic Black than non-Hispanic White individuals but not to a significant degree (12.0% [95% CI, 4.3%-19.7%] vs 17.5% [95% CI, 15.6%-19.5%]; P = .57). Health status was associated with LCS: 468 individuals in poor health vs 96 individuals in excellent health reported LCS (25.2% [95% CI, 20.6%-29.9%] vs 7.6% [95% CI, 5.0%-10.3%]; P < .001), and those with difficulty climbing stairs were more likely to report LCS than those without this functional limitation. Adjusting for sociodemographic factors, functional status, and comorbidities, self-rated health status remained associated with LCS (adjusted odds ratio, 1.19 per each 1-step decline in health; 95% CI, 1.03-1.38), and non-Hispanic Black individuals were 53% less likely to report LCS than non-Hispanic White individuals (adjusted odds ratio, 0.47; 95% CI, 0.24-0.90). Results were robust in sensitivity analyses in which health was alternatively quantified as number of comorbidities. CONCLUSIONS AND RELEVANCE: LCS in the US is more common among those who may be less likely to benefit from screening because of poor underlying health. Furthermore, racial or ethnic disparities were evident after accounting for health status, with non-Hispanic Black individuals nearly half as likely as non-Hispanic White individuals to report LCS despite the potential for greater benefit of screening this population. | |
| 2016 | Samson 2016 | Disparities in Breast Cancer | Disparities in Breast Cancer Incidence, Mortality, and Quality of Care among African American and European American Women in South Carolina | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Black | State | Government Survey | Behavioral Risk Factor Surveillance System | Objectives Breast cancer is the most frequently diagnosed cancer among women and the second-leading cause of female cancer deaths in the United States. African Americans and other minorities in the United States experience lower survival rates and have a worse prognosis than European Americans despite European Americans having a much higher incidence of the disease. Adherence to breast cancer treatment-quality measures is limited, particularly when the data are stratified by race/ethnicity. Methods We aimed to examine breast cancer incidence and mortality trends in South Carolina by race and explore possible racial disparities in the quality of breast cancer treatment received in South Carolina. Results African Americans have high rates of mammography and clinical breast examination screenings yet suffer lower survival compared with European Americans. For most treatment-quality metrics, South Carolina fairs well in comparison to the United States as a whole; however, South Carolina hospitals overall lag behind South Carolina Commission on Cancer-accredited hospitals for all measured quality indicators, including needle biopsy utilization, breast-conserving surgeries, and timely use of radiation therapy. Accreditation may a play a major role in increasing the standard of care related to breast cancer diagnosis and treatment. Conclusions These descriptive findings may provide significant insight for future interventions and policies aimed at eliminating racial/ethnic disparities in health outcomes. Further risk-reduction approaches are necessary to reduce minority group mortality rates, especially among African American women. | |
| 2003 | Schootman 2003 | Disparities related to | Disparities related to socioeconomic status and access to medical care remain in the United States among women who never had a mammogram | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Behavioral Risk Factor Surveillance System | Objective: This study examined whether disparities in mammography use between women of differing socioeconomic status (SES; income and education) and varying access to medical care (healthcare insurance and routine medical check-up) remained over time despite overall increased breast cancer screening. Methods: Analysis of changes over time were made using data from the 1992, 1996, and 2000 Behavioral Risk Factor Surveillance System data from 53,846 women 50-69 years of age. Women who reported that they never had a mammogram were compared with those who ever had a mammogram. Multivariate logistic regression was used to determine whether and to what extent disparities between subgroups of women changed over time. Results: The percentage of women 50-69 years of age who had never had a mammogram declined 65% from 22.1% in 1992 to 7.7% in 2000. Racial and ethnic differences in mammography prevalence disappeared over time. However, disparities among women of differing SES and among those with varying access to medical care remained based on multivariate analysis. Conclusions: Despite a substantial reduction in the proportion of women who had never had a mammogram among women 50-69 years of age from 1992 tO 2000, disparities in use of mammography among the various population subgroups persisted. | |
| 2016 | Haas 2016 | Disparities in the use of screening | Disparities in the use of screening magnetic resonance imaging of the breast in community practice by race, ethnicity, and socioeconomic status | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Disease Registry | Breast Cancer Surveillance Consortium | BACKGROUND: Uptake of breast magnetic resonance imaging (MRI) coupled with breast cancer risk assessment offers the opportunity to tailor the benefits and harms of screening strategies for women with differing cancer risks. Despite the potential benefits, there is also concern for worsening population-based health disparities. METHODS: Among 316,172 women aged 35 to 69 years from 5 Breast Cancer Surveillance Consortium registries (2007-2012), the authors examined 617,723 negative screening mammograms and 1047 screening MRIs. They examined the relative risks (RRs) of MRI use by women with a <20% lifetime breast cancer risk and RR in the absence of MRI use by women with a 20% lifetime risk. RESULTS: Among women with a <20% lifetime risk of breast cancer, non-Hispanic white women were found to be 62% more likely than nonwhite women to undergo an MRI (95% confidence interval, 1.32-1.98). Of these women, those with an educational level of some college or technical school were 43% more likely and those who had at least a college degree were 132% more likely to receive an MRI compared with those with a high school education or less. Among women with a 20% lifetime risk, there was no statistically significant difference noted with regard to the use of screening MRI by race or ethnicity, but high-risk women with a high school education or less were less likely to undergo screening MRI than women who had graduated from college (RR, 0.40; 95% confidence interval, 0.25-0.63). CONCLUSIONS: Uptake of screening MRI of the breast into clinical practice has the potential to worsen population-based health disparities. Policies beyond health insurance coverage should ensure that the use of this screening modality reflects evidence-based guidelines. | |
| 2021 | Lee 2021 | Comparative Access to and Use of | Comparative Access to and Use of Digital Breast Tomosynthesis Screening by Women's Race/Ethnicity and Socioeconomic Status | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Disease Registry | Breast Cancer Surveillance Consortium | IMPORTANCE: Digital breast tomosynthesis (DBT) has reduced recall and increased cancer detection compared with digital mammography (DM), depending on women's age and breast density. Whether DBT screening access and use are equitable across groups of women based on race/ethnicity and socioeconomic characteristics is uncertain. OBJECTIVE: To determine women's access to and use of DBT screening based on race/ethnicity, educational attainment, and income. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included 92 geographically diverse imaging facilities across 5 US states, at which a total of 2 313 118 screening examinations were performed among women aged 40 to 89 years from January 1, 2011, to December 31, 2017. Data were analyzed from June 13, 2019, to August 18, 2020. EXPOSURES: Women's race/ethnicity, educational level, and community-level household income. MAIN OUTCOMES AND MEASURES: Access to DBT (on-site access) at time of screening by examination year and actual use of DBT vs DM screening by years since facility-level DBT adoption ( 5 years). RESULTS: Among the 2 313 118 screening examinations included in the analysis, the proportion of women who had DBT access at the time of their screening appointment increased from 11 558 of 354 107 (3.3%) in 2011 to 194 842 of 235 972 (82.6%) in 2017. In 2012, compared with White women, Black (relative risk [RR], 0.05; 95% CI, 0.03-0.11), Asian American (RR, 0.28; 95% CI, 0.11-0.75), and Hispanic (RR, 0.38; 95% CI, 0.18-0.80) women had significantly less DBT access, and women with less than a high school education had lower DBT access compared with college graduates (RR, 0.18; 95% CI, 0.10-0.32). Among women attending facilities with both DM and DBT available at the time of screening, Black women experienced lower DBT use compared with White women attending the same facility (RRs, 0.83 [95% CI, 0.82-0.85] to 0.98 [95% CI, 0.97-0.99]); women with lower educational level experienced lower DBT use (RRs, 0.79 [95% CI, 0.74-0.84] to 0.88 [95% CI, 0.85-0.91] for non-high school graduates and 0.90 [95% CI, 0.89-0.92] to 0.96 [95% CI, 0.93-0.99] for high school graduates vs college graduates); and women within the lowest income quartile experienced lower DBT use vs women in the highest income quartile (RRs, 0.89 [95% CI, 0.87-0.91] to 0.99 [95% CI, 0.98-1.00]) regardless of the number of years after facility-level DBT adoption. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, women of minority race/ethnicity and lower socioeconomic status experienced lower DBT access during the early adoption period and persistently lower DBT use when available over time. Future efforts should address racial/ethnic, educational, and financial barriers to DBT screening. | |
| 2014 | Wernli 2014 | Patterns of breast magnetic | Patterns of breast magnetic resonance imaging use in community practice | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Disease Registry | Breast Cancer Surveillance Consortium | Importance: Breast magnetic resonance imaging (MRI) is increasingly used for breast cancer screening, diagnostic evaluation, and surveillance. However, we lack data on national patterns of breast MRI use in community practice. Objective: To describe patterns of breast MRI use in US community practice during the period 2005 through 2009. Design, setting, and participants: Observational cohort study using data collected from 2005 through 2009 on breast MRI and mammography from 5 national Breast Cancer Surveillance Consortium registries. Data included 8931 breast MRI examinations and 1,288,924 screening mammograms from women aged 18 to 79 years. Main outcomes and measures: We calculated the rate of breast MRI examinations per 1000 women with breast imaging within the same year and described the clinical indications for the breast MRI examinations by year and age. We compared women screened with breast MRI to women screened with mammography alone for patient characteristics and lifetime breast cancer risk. Results: The overall rate of breast MRI from 2005 through 2009 nearly tripled from 4.2 to 11.5 examinations per 1000 women, with the most rapid increase from 2005 to 2007 (P = .02). The most common clinical indication was diagnostic evaluation (40.3%), followed by screening (31.7%). Compared with women who received screening mammography alone, women who underwent screening breast MRI were more likely to be younger than 50 years, white non-Hispanic, and nulliparous and to have a personal history of breast cancer, a family history of breast cancer, and extremely dense breast tissue (all P < .001). The proportion of women screened using breast MRI at high lifetime risk for breast cancer (>20%) increased during the study period from 9% in 2005 to 29% in 2009. Conclusions and relevance: Use of breast MRI for screening in high-risk women is increasing. However, our findings suggest that there is a need to improve appropriate use, including among women who may benefit from screening breast MRI. | |
| 2010 | Suga 2010 | Racial disparities on the use of | Racial disparities on the use of invasive and noninvasive staging in patients with non-small cell lung cancer | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | State | Disease Registry | California Cancer Registry | INTRODUCTION: Racial disparities have been reported in non-small cell lung cancer (NSCLC) staging and therapeutic outcomes. We investigated whether such disparities exist in the era of modern noninvasive staging modalities, including positron emission tomography scan use. METHODS: NSCLC patients from the California Cancer Registry diagnosed between January 1, 1994, and December 31, 2004, were included. The likelihood of obtaining invasive (thoracoscopy, bronchoscopy, and mediastinoscopy) and noninvasive staging procedures (computed tomography, magnetic resonance imaging, and positron emission tomography scans), along with surgical resection, were analyzed using logistic regression adjusted for known confounders. RESULTS: Of 13,762 NSCLC patients, 12,395 with adequate staging information were included. 10,217 patients (82%) were classified as white, 2178 patients (18%) were non-white, and 738 were black patients (6%). No association was seen between race and the use of either noninvasive (odds ratio [OR] = 1.02; p = 0.76) or invasive staging procedures (OR = 0.96; p = 0.44). However, compared with white patients, black patients had a lower likelihood of undergoing surgery, regardless of noninvasive (OR = 0.6; p <0.001) or invasive staging use (OR = 0.63; p = 0.02). There was no survival difference for those who underwent surgery between white and non-white patients, regardless of noninvasive (hazard ratio = 0.95; p = 0.45) or invasive staging (hazard ratio = 1.03; p = 0.79). CONCLUSIONS: In contrast to prior published work, we found no difference in rates of both invasive and noninvasive staging between white and non-white patients. However, non-white patients-particularly blacks-were less likely to receive surgery. The reason for the apparent difference in surgical rates could not be explained by the variables we evaluated. Thus, other factors such as personal preference or access to care require further investigation. | |
| 2009 | Breslau 2010 | Cancer screening practices among | Cancer screening practices among racially and ethnically diverse breast cancer survivors: results from the 2001 and 2003 California health interview survey | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | State | Government Survey | California Health Interview Survey | INTRODUCTION: Women treated for breast cancer are at increased risk for developing second or new cancers. This study examined behavioral and health care utilization practices associated with screening behaviors for mammography, Papanicolaou (Pap), home fecal occult blood test (FOBT) and endoscopy (flexible sigmoidoscopy, colonoscopy, proctoscopy) among racially and ethnically diverse female breast cancer survivors (BCS) and women without a cancer history. METHODS: Data from the 2001 and 2003 California Health Interview Survey (CHIS), a random-digit dial population-based survey of adult respondents was used to examine self-reported screening practices of BCS (n = 1,502) and women without a cancer history (n = 31,911). RESULTS: Compared to women without a cancer history, BCS reported more recent screening for all tests. Among BCS, Hispanics reported lowest screening for routine mammography (84.2% versus 68.9%; P < 0.05) but highest screening for Pap test (95.4% versus 85.4%; P > 0.01). White and Asian BCS reported more endoscopic examinations (58.9% versus 46.5%; P < 0.001; 61.2% versus 38.4%; P < 0.05) than the comparison population. After adjustment for demographic, socioeconomic, and health status differences, screening rates for BCS showed higher mammography use (odds ratio [OR] 1.97; 95% confidence interval [95% CI] 1.58-2.46), Pap test (OR 1.44; 95% CI 1.22-1.70), and endoscopic use (OR 1.35; 95% CI 1.16-1.58), but not higher for FOBT. CONCLUSIONS: Even though BCS generally had higher cancer screening rates than women without a cancer history, racial/ethnic differences exist among the type of test received. Narrowing these differences is essential to lessen disparities. IMPLICATIONS FOR CANCER SURVIVORS: The need for screening guidelines for BCS remains a high priority. Survivors would benefit from the frequency of screening for all cancers post-treatment. | |
| 2005 | Chen 2005 | Racial/ethnic disparities in the | Racial/ethnic disparities in the use of preventive services among the elderly | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | State | Government Survey | California Health Interview Survey | Objectives: Minorities have worse health outcomes compared to whites, which are partially explained by racial/ethnic disparities in use of health services. Less well known, however, are whether these disparities persist among the elderly, the only group that possesses near universal health insurance coverage by Medicare, and how variation in Medicare coverage affects the receipt of preventive services. The scope of racial/ethnic disparities in the use of preventive services in the elderly was assessed, and the impact of the type of health insurance coverage on the use of preventive services was measured. Methods: Data were derived from the 2001 California Health Interview Survey, a random-digit-dial population-based survey, collected between November 2000 and October 2001. Analysis for this project was conducted in 2004. The association of race/ethnicity and type of health insurance with receipt of preventive services was assessed using bivariate and multivariate logistic regression models. Results: African Americans and Latinos were significantly less likely to be vaccinated for influenza, and Asian Americans were significantly less likely to obtain a mammogram compared to whites, while controlling for other explanatory factors. Moreover, those with Medicare plus Medicaid coverage were significantly less likely to use all four preventive services compared to those with Medicare plus private supplemental insurance. Conclusions: Despite near-universal coverage by Medicare, racial/ethnic disparities in the use of some preventive services among the elderly persist. Further research should focus on identifying potential cultural and structural barriers to receipt of preventive services aimed at designing effective intervention among high-risk groups. | |
| 2020 | McMenamin 2020 | The Importance of Health Insurance | The Importance of Health Insurance in Addressing Asian American Disparities in Utilization of Clinical Preventive Services: 12-Year Pooled Data from California | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Asian | State | Government Survey | California Health Interview Survey | Purpose: Previous research has shown that Asian Americans are less likely to receive recommended clinical preventive services especially for cancer compared with non-Hispanic whites. Health insurance expansion has been recommended as a way to increase use of these preventive services. This study examines the extent to which utilization of preventive services by Asians overall and by ethnicity compared with non-Hispanic whites is moderated by health insurance. Methods: Data from the California Health Interview Survey (CHIS) was used to examine preventive service utilization among non-Hispanic whites, Asians, and Asian subgroups 50-64 years of age by insurance status. Six waves of CHIS data from 2001 to 2011 were combined to allow analysis of Asian subgroups. Logistic regression models were run to predict the effect of insurance on receipt of mammography, colorectal cancer (CRC) screening, and flu shots among Asians overall and by ethnicity compared with whites. Results: Privately insured Asians reported significantly lower adjusted rates of mammography (83.1% vs. 87.6%) and CRC screening (54.7% vs. 59.4%), and higher rates of influenza vaccination (48.7% vs. 38.5%) than privately insured non-Hispanic whites. Adjusted rates of cancer screening were lower among Koreans and Chinese for mammography, and lower among Filipinos for CRC screening. Conclusion: This study highlights the limitations of providing insurance coverage as a strategy to eliminate disparities for cancer screening among Asians without addressing cultural factors. | |
| 2009 | Meersman 2009 | Access to mammography screening in | Access to mammography screening in a large urban population: a multi-level analysis | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Hispanic | State | Government Survey | California Health Interview Survey | Objective To understand area-based sociodemographics, physician and medical practice characteristics, and community indicators associated with mammography use in Los Angeles County. An earlier multi-level analysis by Gumpertz et al. found that distance to the nearest mammography facility helped explain the higher proportion of Latinas diagnosed with late stage breast cancer compared with non-Latina Whites in Los Angeles County. Our study examined whether Latinas also have lower rates of mammography use. Methods We used a multi-level spatial modeling approach to examine individual and community level associations with mammography use among a diverse group of women aged 40-84 years in Los Angeles County. To build our multi-level spatial data set, we integrated five data sources: (1) 2001 California Health Interview Survey (CHIS) data, (2) 2001 Food and Drug Administration (FDA) certified mammography facility data, (3) 2003 LA Transit Authority data, (4) 2000 US Decennial Census data, and (5) 2001 Community Tracking Study (CTS) Physician's Survey data. Results Our study confirmed for Los Angeles County many associations for mammography use found in other locations. An unexpected finding was that women with limited English proficiency (predominantly Latina) were significantly more likely to have had a recent mammogram than English-proficient women. We also found that, after controlling for other factors, mammography use was higher in neighborhoods with a greater density of mammography facilities. Conclusion Women with limited English proficiency were especially likely to report recent mammography in Los Angeles. This unexpected finding suggests that the intensive Spanish-language outreach program conducted by the Every Woman Counts (EWC) Program in low-income Latina communities in Los Angeles has been effective. Our study highlights the success of this targeted community-based outreach conducted between 1999 and 2001. These are the same populations that Gumpertz et al. identified as needing intervention. It would be useful to conduct another study of late-stage diagnosis in Los Angeles County to ascertain whether increased rates of mammography have also led to less late-stage diagnosis among Latinas in the neighborhoods where they are concentrated in Los Angeles. | |
| 2012 | Ponce 2012 | Disparities in cancer screening in | Disparities in cancer screening in individuals with a family history of breast or colorectal cancer | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | State | Government Survey | California Health Interview Survey | BACKGROUND: Understanding racial/ethnic disparities in cancer screening by family history risk could identify critical opportunities for patient and provider interventions tailored to specific racial/ethnic groups. The authors evaluated whether breast cancer (BC) and colorectal cancer (CRC) disparities varied by family history risk using a large, multiethnic population-based survey. METHODS: By using the 2005 California Health Interview Survey, BC and CRC screening were evaluated separately with weighted multivariate regression analyses, and stratified by family history risk. Screening was defined for BC as mammogram within the past 2 years for women aged 40 to 64 years; for CRC, screening was defined as annual fecal occult blood test, sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years for adults aged 50 to 64 years. RESULTS: The authors found no significant BC screening disparities by race/ethnicity or income in the family history risk groups. Racial/ethnic disparities were more evident in CRC screening, and the Latino-white gap widened among individuals with family history risk. Among adults with a family history for CRC, the magnitude of the Latino-white difference in CRC screening (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.11-0.60) was more substantial than that for individuals with no family history (OR, 0.74; 95% CI, 0.59-0.92). CONCLUSIONS: Knowledge of their family history widened the Latino-white gap in CRC screening among adults. More aggressive interventions that enhance the communication between Latinos and their physicians about family history and cancer risk could reduce the substantial Latino-white screening disparity in Latinos most susceptible to CRC. | |
| 2005 | Rodrguez 2005 | Breast and cervical cancer | Breast and cervical cancer screening: impact of health insurance status, ethnicity, and nativity of Latinas | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Hispanic | State | Government Survey | California Women's Health Survey | PURPOSE: Although rates of cancer screening for Latinas are lower than for non-Latina whites, little is known about how insurance status, ethnicity, and nativity interact to influence these disparities. Using a large statewide database, our study examined the relationship between breast and cervical cancer screening rates and socioeconomic and health insurance status among foreign-born Latinas, US-born Latinas, and non-Latina whites in California. METHODS: Data from the1998 California Women's Health Survey (CWHS) were analyzed (n = 3,340) using multiple logistic regression models. Utilization rates of mammography, clinical breast examinations, and Papanicolaou (Pap) smear screening among foreign-born Latinas, US-born Latinas, and non-Latina whites were the outcome measures. RESULTS: Foreign-born Latinas had the highest rates of never receiving mammography, clinical breast examinations, and Pap smears (21%, 24%, 9%, respectively) compared with US-born Latinas (12%, 11%, 7%, respectively) and non-Latina whites (9%, 5%, 2%, respectively). After controlling for socioeconomic factors, foreign-born Latinas were more likely to report mammography use in the previous 2 years and Pap smear in the previous 3 years than non-Latina whites. Lack of health insurance coverage was the strongest independent predictor of low utilization rates for mammography (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.53-2.76), clinical breast examinations (OR = 2.29; 95% CI, 1.80-2.90) and Pap smears (OR = 2.89; 95% CI, 2.17-3.85.) CONCLUSIONS: Breast and cervical cancer screening rates vary by ethnicity and nativity, with foreign-born Latinas experiencing the highest rates of never being screened. After accounting for socioeconomic factors, differences by ethnicity and nativity are reversed or eliminated. Lack of health insurance coverage remains the strongest predictor of cancer screening underutilization. | |
| 2021 | Abdel-Rahman 2021 | Patterns and Trends of Cancer | Patterns and Trends of Cancer Screening in Canada: Results From a Contemporary National Survey | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Canada | Multiple Groups | National | Government Survey | Canadian Community Health Survey | BACKGROUND: The aim of this study was to assess the patterns and trends of colorectal, breast, and cervical cancer screening within a contemporary cohort of Canadian adults. METHODS: Canadian Community Health Survey datasets (2007-2016) were accessed and 3 cohorts were defined: (1) a colorectal cancer (CRC) screening cohort, defined as men and women aged 50 to 74 years with complete information about CRC screening tests and their timing; (2) a breast cancer screening cohort, defined as women aged 40 to 74 years with complete information about mammography and its timing; and (3) a cervical cancer screening cohort, defined as women aged 25 to 69 years with complete information about the Papanicolaou (Pap) test and its timing. Multivariable logistic regression analysis was then performed to evaluate factors associated with not having timely screening tests at the time of survey completion. RESULTS: A total of 99,820 participants were considered eligible for the CRC screening cohort, 59,724 for the breast cancer screening cohort, and 46,767 for the cervical cancer screening cohort. Among eligible participants, 43% did not have timely recommended screening tests for CRC, 35% did not have timely mammography (this number decreased to 26% when limiting the eligible group to ages 50-74 years), and 25% did not have a timely Pap test. Lower income was associated with not having a timely recommended screening tests for all 3 cohorts (odds ratios [95% CI]: 1.86 [1.76-1.97], 1.89 [1.76-2.04], and 1.96 [1.79-2.14], respectively). Likewise, persons self-identifying as a visible minority were less likely to have timely recommended screening tests in all 3 cohorts (odds ratios for White race vs visible minority [95% CI]: 0.87 [0.83-0.92], 0.85 [0.80-0.91], and 0.66 [0.61-0.70], respectively). CONCLUSIONS: More than one-third of eligible individuals are missing timely screening tests for CRC. Moreover, at least one-quarter of eligible women are missing their recommended breast and cervical cancer screening tests. More efforts from federal and provincial health authorities are needed to deal with socioeconomic disparities in access to cancer screening. | |
| 2006 | Quan 2006 | Variation in health services | Variation in health services utilization among ethnic populations | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Canada | Multiple Groups | National | Government Survey | Canadian Community Health Survey | Background: Although racial and ethnic disparities in health services utilization and outcomes have been extensively studied in several countries, this issue has received little attention in Canada. We therefore analyzed data from the 2001 Canadian Community Health Survey to compare the use of health services by members of visible minority groups and nonmembers (white people) in Canada. Methods: Logistic regression was used to compare physician contacts and hospital admissions during the 12 months before the survey and recent cancer screening tests. Explanatory variables recorded from the survey included visible minority status, sociodemographic factors and health measures. Results: Respondents included 7057 members of visible minorities and 114 255 white people for analysis. After adjustments for sociodemographic and health characteristics, we found that minority members were more likely than white people to have had contact with a general practitioner (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.14-1.42), but not specialist physicians (OR 1.01, 95% CI 0.93-1.10). Members of visible minorities were less likely to have been admitted to hospital (OR 0.83, 95% CI 0.70-0.98), tested for prostate-specific antigen (OR 0.64, 95% CI 0.52-0.79), administered a mammogram (OR 0.68, 95% CI 0.59-0.80) or given a Pap test (OR 0.47, 95% CI 0.39-0.56). Interpretation: Use of health services in Canada varies considerably by ethnicity according to type of service. Although there is no evidence that members of visible minorities use general physician and specialist services less often than white people, their utilization of hospital and cancer screening services is significantly less. | |
| 2009 | Shields 2009 | An update on mammography use in | An update on mammography use in Canada | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Canada | Immigrants | National | Government Survey | Canadian Community Health Survey | BACKGROUND: This article updates mammography use by Canadian women aged 50 to 69, and reports trends from 1990 to 2008 among the provinces. Characteristics of non-users are examined. DATA SOURCES AND METHODS: Data from the 2008 Canadian Community Health Survey (CCHS) were used to update mammography use and to examine factors associated with non-use. Historical estimates were produced using the 2000/2001,2003 and 2005 CCHS, the 1994/1995, 1996/1997 and 1998/1999 National Population Health Survey and the 1990 Health Promotion Survey. Frequency estimates, cross-tabulations and logistic regression analysis were used. RESULTS: In 2008, 72% of women aged 50 to 69 reported having had a mammogram in the past two years, up from 40% in 1990. The increase occurred from 1990 to 2000/2001; rates then stabilized. Between 1990 and 2000/2001, the difference in participation between women in the highest and lowest income quintiles gradually narrowed-from a 26- to a 12-percentage-point difference. In 2008, the disparity widened to 18 percentage points. Non-use was high in British Columbia, Prince Edward Island and Nunavut. Non-use was associated with being an immigrant, living in a lower income household, not having a regular doctor and smoking. | |
| 2013 | Lpez 2013 | Ductal carcinoma in situ (DCIS): | Ductal carcinoma in situ (DCIS): Posttreatment follow-up care among Latina and non-Latina White women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Hispanic | State | Disease Registry | Cancer registry | BACKGROUND: There is a lack of information about posttreatment care among patients with ductal carcinoma in situ (DCIS). This study compares posttreatment care by ethnicity-language and physician specialty among Latina and White women with DCIS. METHODS: Latina and White women diagnosed with DCIS between 2002 and 2005 identified through the California Cancer Registry completed a telephone survey in 2006. Main outcomes were breast surveillance, lifestyle counseling, and follow-up physician specialty. KEY RESULTS: Of 742 women (396 White, 349 Latinas), most (90 %) had at least one clinical breast exam (CBE). Among women treated with breast-conserving surgery (BCS; N = 503), 76 % had received at least two mammograms. While 92 % of all women had follow-up with a breast specialist, Spanish-speaking Latinas had the lowest specialist follow-up rates (84 %) of all groups. Lifestyle counseling was low with only 53 % discussing exercise, 43 % weight, and 31 % alcohol in relation to their DCIS. In multivariable analysis, Spanish-speaking Latinas with BCS had lower odds of receiving the recommended mammography screening in the year following treatment compared to Whites (OR 0. 5; 95 % CI, 0. 2-0. 9). Regardless of ethnicity-language, seeing both a specialist and primary care physician increased the odds of mammography screening and CBE (OR 1. 6; 95 % CI, 1. 2-2. 3 and OR 1. 9; 95 % CI, 1. 3-2. 8), as well as having discussions about exercise, weight, and alcohol use, compared to seeing a specialist only. CONCLUSIONS: Most women reported appropriate surveillance after DCIS treatment. However, our results suggest less adequate follow-up for Spanish-speaking Latinas, possibly due to language barriers or insurance access. IMPLICATIONS FOR CANCER SURVIVORS: Follow-up with a primary care provider in addition to a breast specialist increases receipt of appropriate follow-up for all women. | |
| 2008 | Nathan 2008 | Medical care in long-term survivors | Medical care in long-term survivors of childhood cancer: A report from the childhood cancer survivor study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Disease Registry | Cancer registry | Purpose: To evaluate whether childhood cancer survivors receive regular medical care focused on the specific morbidities that can arise from their therapy. Patients and Methods: We conducted a cross-sectional survey of health care use in 8,522 participants in the Childhood Cancer Survivor Study, a multi-institutional cohort of childhood cancer survivors. We assessed medical visits in the preceding 2 years, whether these visits were related to the prior cancer, whether survivors received advice about how to reduce their long-term risks, and whether screening tests were discussed or ordered. Completion of echocardiograms and mammograms were assessed in patients at high risk for cardiomyopathy or breast cancer. We examined the relationship between demographics, treatment, health status, chronic medical conditions, and health care use. Results: Median age at cancer diagnosis was 6.8 years (range, 0 to 20.9 years) and at interview was 31.4 years (range, 17.5 to 54.1 years). Although 88.8% of survivors reported receiving some form of medical care, only 31.5% reported care that focused on their prior cancer (survivor-focused care), and 17.8% reported survivor-focused care that included advice about risk reduction or discussion or ordering of screening tests. Among survivors who received medical care, those who were black, older at interview, or uninsured were less likely to have received risk-based, survivor-focused care. Among patients at increased risk for cardiomyopathy or breast cancer, 511 (28.2%) of 1,810 and 169 (40.8%) of 414 had undergone a recommended echocardiogram or mammogram, respectively. Conclusion: Despite a significant risk of late effects after cancer therapy, the majority of childhood cancer survivors do not receive recommended risk-based care. | |
| 2002 | Fiscella 2002 | Disparities in health care by race, | Disparities in health care by race, ethnicity, and language among the insured - Findings from a national sample | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Community Tracking Survey | BACKGROUND: Racial and ethnic disparities in health care have been well documented, but poorly explained. OBJECTIVE: To examine the effect of access barriers, including English fluency, on racial and ethnic disparities in health care. RESEARCH DESIGN: Cross-sectional analysis of the Community Tracking Survey (1996-1997). SUBJECTS: Adults 18 to 64 years with private or Medicaid health insurance. MEASURES: Independent variables included race, ethnicity, and English fluency. Dependent variables included having had a physician or mental health visit, influenza vaccination, or mammogram during the past year. RESULTS: The health care use pattern for English-speaking Hispanic patients was not significantly different than for non-Hispanic white patients in the crude or multivariate models. In contrast, Spanish-speaking Hispanic patients were significantly less likely than non-Hispanic white patients to have had a physician visit (RR, 0.77; 95% Cl, 0.72-0.83), mental health visit (RR, 0.50; 95% Cl, 0.32-0.76), or influenza vaccination (RR, 0.30; 95% Cl, 0.15-0.52). After adjustment for predisposing, need, and enabling factors, Spanish-speaking Hispanic patients showed significantly lower use than non-Hispanic white patients across all four measures. Black patients had a significantly lower crude relative risk of having received an influenza vaccination (RR, 0.73; 95% Cl, 0.58-0.87). Adjustment for additional factors had little impact on this effect, but resulted in black patients being significantly less likely than non-Hispanic white patients to have had a visit with a mental health professional (RR, 0.46; 95% Cl, 0.37-0.55). CONCLUSIONS: Among insured nonelderly adults, there are appreciable disparities in health-care use by race and Hispanic ethnicity. Ethnic disparities in care are largely explained by differences in English fluency, but racial disparities in care are not explained by commonly used access factors. | |
| 2013 | Enewold 2013 | Surveillance mammography among | Surveillance mammography among female Department of Defense beneficiaries: a study by race and ethnicity | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Disease Registry | Department of Defense Central Cancer Registry | BACKGROUND: Annual surveillance mammography is recommended after a diagnosis of breast cancer. Previous studies have suggested that surveillance mammography varies by demographics and initial tumor characteristics, which are related to an individual's access to health care. The Military Health System of the Department of Defense provides beneficiaries with equal access health care and thus offers an excellent opportunity to assess whether racial differences in surveillance mammography persist when access to care is equal. METHODS: Among female beneficiaries with a history of breast cancer, logistic regression was used to assess racial/ethnic variations in the use of surveillance mammography during 3 periods of 12 months each, beginning 1 year after diagnosis adjusting for demographic, tumor, and health characteristics. RESULTS: The rate of overall surveillance mammography decreased from 70% during the first year to 59% during the third year (P < .01). Although there was an overall tendency for surveillance mammography to be higher among minority women compared with non-Hispanic white women, after adjusting for covariates, the difference was found to be significant only during the first year among black women (odds ratio [OR], 1.46; 95% confidence interval [95% CI], 1.10-1.95) and the second year among Asian/Pacific Islander (OR, 2.29; 95%CI, 1.52-3.44) and Hispanic (OR, 1.92; 95%CI, 1.17-3.18) women. When stratified by age at diagnosis and type of breast cancer surgery performed, significant racial differences tended to be observed among younger women (aged < 50 years) and only among women who had undergone mastectomies. CONCLUSIONS: Minority women were equally or more likely than non-Hispanic white women to receive surveillance mammography within the Military Health System. The racial disparities in surveillance mammography reported in other studies were not observed in a system with equal access to health care. | |
| 2013 | Martin-Lopez 2013 | Inequalities in uptake of breast | Inequalities in uptake of breast cancer screening in Spain: analysis of a cross-sectional national survey | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Spain | Immigrants | National | Government Survey | European Health Interview Survey | Objectives: Breast cancer remains a public health problem worldwide. Early detection through mammography practice has been shown to be effective in improving survival among women. Nevertheless, it is necessary to have high participation in mammography screening to achieve that goal. The aim of this study is to estimate the adherence to recommended preventive practices for breast cancer (mammography) in Spain and to identify predictors of uptake according to sociodemographic variables, health related variables and lifestyles. Study design: This is a descriptive cross-sectional study based on data from the European Health Interview Survey for Spain. Breast cancer screening included self-reported mammography in the last two years. The age target range was 40-69 years (n = 5771). The following independent variables were analysed: sociodemographic (marital status, educational level, monthly income, and nationality), visit to a general practitioner, chronic conditions and lifestyles. Predictors of mammography adherence were explored using multivariate logistic regression. Results: The screening coverage in the target population was 67.7% (95% CI: 66.2-69.1). Mammography uptake was positively associated with being married, higher educational and income levels, Spanish nationality, having visited a general practitioner in the previous four weeks and suffering from musculoskeletal disease. Otherwise, the youngest age group studied (40-49 years) and obesity was associated with lower adherence to mammography. Conclusions: Compliance with mammography practice in Spain is acceptable to achieve the goal of reducing mortality from breast cancer among women. However significant inequalities in uptake of breast screening in Spain were found. Future campaigns must aim to improve participation especially among women with disadvantaged socio-economic situations and immigrants. | |
| 2021 | Polineni 2021 | Sex and race-ethnic disparities in | Sex and race-ethnic disparities in door-to-ct time in acute ischemic stroke: The florida stroke registry | Adult Only | All Sexes | Inpatient and Outpatient | Stroke Imaging | United States | Multiple Groups | State | Disease Registry | Florida Stroke Registry | BACKGROUND: Less than 40% of acute stroke patients have computed tomography (CT) imaging performed within 25 minutes of hospital arrival. We aimed to examine the race-ethnic and sex differences in door-to-CT (DTCT) 25 minutes in the FSR (Florida Stroke Registry). METHODS AND RESULTS: Data were collected from 2010 to 2018 for 63 265 patients with acute ischemic stroke from the FSR and secondary analysis was performed on 15 877 patients with intravenous tissue plasminogen activator-treated ischemic stroke. Generalized estimating equation models were used to determine predictors of DTCT 25. DTCT 25 was achieved in 56% of cases of suspected acute stroke, improving from 36% in 2010 to 72% in 2018. Women (odds ratio [OR], 0.90; 95% CI, 0.87-0.93) and Black (OR, 0.88; CI, 0.84-0.94) patients who had strokes were less likely, and Hispanic patients more likely (OR, 1.07; CI, 1.01-1.14), to achieve DTCT 25. In a secondary analysis among intravenous tissue plasminogen activator-treated patients, 81% of patients achieved DTCT 25. In this subgroup, women were less likely to receive DTCT 25 (0.85, 0.77-0.94) whereas no significant differences were observed by race or ethnicity. CONCLUSIONS: In the FSR, there was considerable improvement in acute stroke care metric DTCT 25 in 2018 in comparison to 2010. However, sex and race-ethnic disparities persist and require further efforts to improve performance and reduce these disparities. | |
| 2021 | Miller-Kleinhenz 2021 | Racial Disparities in Diagnostic | Racial Disparities in Diagnostic Delay Among Women With Breast Cancer | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Black | Single Institution | Disease Registry | Georgia Cancer Registry | PURPOSE: Early diagnosis is fundamental to reducing breast cancer (BC) mortality, and understanding potential barriers from initial screening to confirmed diagnosis is essential. The aim of this study was to evaluate patient characteristics that contribute to delay in diagnosis of screen-detected cancers and the contribution of delay to tumor characteristics and BC mortality. METHODS: Three hundred sixty-two White and 368 Black women were identified who were screened and received subsequent BC diagnoses within Emory Healthcare, a part of Emory University health care system (2010-2014). Multivariable-adjusted logistic regression was used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) associating patient characteristics with delay to diagnostic evaluation (30 versus <30 days), delay to biopsy (15 versus <15 days), and total delay (45 versus <45 days). Additionally, the ORs and 95% CIs associating delay with tumor characteristics and BC mortality were computed. RESULTS: Black women and women diagnosed at later stages, with larger tumor sizes, and with triple-negative tumors were more likely to experience 45 days to diagnosis. In multivariable-adjusted models, Black women had at least a two-fold increase in the odds of delay to diagnostic evaluation (OR, 1.98; 95% CI, 1.45-2.71), biopsy delays (OR, 2.41; 95% CI, 1.67-3.41), and total delays 45 days (OR, 2.22; 95% CI, 1.63-3.02) compared with White women. A 1.6-fold increased odds of BC mortality was observed among women who experienced total delays 45 days compared with women without delays in diagnosis (OR, 1.57, 95% CI, 0.96-2.58). CONCLUSION: The study demonstrated racial disparities in delays in the diagnostic process for screen-detected malignancies. Total delay in diagnosis was associated with an increase in BC mortality. | |
| 2018 | Woods 2018 | Breast screening participation and | Breast screening participation and retention among immigrants and nonimmigrants in British Columbia: A population-based study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Canada | Immigrants | National | Government Survey | Government database | Breast cancer screening programs operate across Canada providing mammography to women in target age groups with the goal of reducing breast cancer mortality through early detection of tumors. Disparities in breast screening participation among socio-demographic groups, including immigrants, have been reported in Canada. Our objectives were to: (1) assess breast screening participation and retention among immigrant and nonimmigrant women in British Columbia (BC), Canada; and (2) to characterize factors associated with screening among screening-age recent immigrant women in BC. We examined 2 population-based cohorts of women eligible for breast screening participation (537783 women) and retention (281 052 women) using linked health and immigration data. Breast screening rates were presented according to socio-demographic and health-related variables stratified by birth country. Factors associated with screening among recent immigrant women were explored using Poisson regression. We observed marked variation in screening participation across birth country cohorts. Eastern European/Central Asian women showed low participation (37.9%) with rates from individual countries ranging from 35.0% to 49.0%. Participation rates for immigrant women from the most common birth countries, such as China/Macau/Hong Kong/Taiwan (45.7%), India (44.5%), the Philippines (45.9%), and South Korea (39.0%), were lower than the nonimmigrant rates (51.2%). Retention rates showed less variation by birth country; however, some disparities between immigrant and nonimmigrant groups persisted. Associations between screening indicators and study factors varied considerably across immigrant groups. Primary care physician visits were consistently positively associated with screening participation; this variable was also the only predictor associated with screening within each of the groups of recent immigrants. Our study provides unique data on both screening participation and retention among Canadian immigrant women compiled by individual country of birth. Our results are further demonstration that screening disparities exist among immigrant populations as well as in comparison with nonimmigrant women. | |
| 2017 | Vagal 2017 | Age, sex, and racial differences in | Age, sex, and racial differences in neuroimaging use in acute stroke: A population-based study | Adult Only | All Sexes | Inpatient General Care | Stroke Imaging | United States | Black | Regional | Disease Registry | Greater Cincinnati/Northern Kentucky Stroke Study | BACKGROUND AND PURPOSE: Limited information is available regarding differences in neuroimaging use for acute stroke work-up. Our objective was to assess whether race, sex, or age differences exist in neuroimaging use and whether these differences depend on the care center type in a population-based study. MATERIALS AND METHODS: Patients with stroke (ischemic and hemorrhagic) and transient ischemic attack were identified in a metropolitan, biracial population using the Greater Cincinnati/Northern Kentucky Stroke Study in 2005 and 2010. Multivariable regression was used to determine the odds of advanced imaging use (CT angiography/MR imaging/MR angiography) for race, sex, and age. RESULTS: In 2005 and 2010, there were 3471 and 3431 stroke/TIA events, respectively. If one adjusted for covariates, the odds of advanced imaging were higher for younger (55 years or younger) compared with older patients, blacks compared with whites, and patients presenting to an academic center and those seen by a stroke team or neurologist. The observed association between race and advanced imaging depended on age; in the older age group, blacks had higher odds of advanced imaging compared with whites (odds ratio, 1.34; 95% CI, 1.12-1.61; P < .01), and in the younger group, the association between race and advanced imaging was not statistically significant. Age by race interaction persisted in the academic center subgroup (P < .01), but not in the nonacademic center subgroup (P < .58). No significant association was found between sex and advanced imaging. CONCLUSIONS: Within a large, biracial stroke/TIA population, there is variation in the use of advanced neuroimaging by age and race, depending on the care center type. | |
| 2008 | Edwards 2009 | Ethnic differences in the use of | Ethnic differences in the use of regular mammography: The multiethnic cohort | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Regional | Private Survey | Hawaii and Los Angeles Multiethnic Cohort | Women's regular use of mammography over a 6 year interval was examined among women aged 45-75 in the Hawaii and Los Angeles Multiethnic Cohort (MEC). The analyses included 81,722 African American, Japanese, Latina, Native Hawaiian, and White females using self-reported mammography history from 1993 to 1998. Ninety-one percent of MEC women reported ever having a mammogram, however only 36% reported regular annual and 48% reported regular biennial mammography over the interval. Mammography was lowest among women who were obese, had a high school education or less, or who were aged 70 and over. Regular mammography use during follow-up was low compared to prior studies reporting on recent mammography. African American, Latina, and Native Hawaiian women had significantly lower annual and biennial mammography use compared to White women even after controlling for age, education, family history, body mass index and hormone therapy indicating that gaps exist in mammography that remain unexplained by known predictors of screening behavior. | |
| 2020 | Lee 2020 | Cancer screening among | Cancer screening among racial/ethnic groups in health centers | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Health Center Patient Survey | Background: Underserved and low-income population are placed at a disadvantage for receiving necessary cancer screenings. This study aims to measure the rates of receiving three types of cancer screening services, Pap test, mammogram and colorectal cancer screening, among patients seen at U.S. health centers (HCs) to investigate if cancer screening among patients varies by race/ethnicity. Methods: We analyzed data from the 2014 U.S. Health Center Patient Survey, and included samples age 21 and above. We examined three cancer screening indicators as our dependent variables including cervical, breast, and colorectal cancer screening. Logistic regressions were used to assess the racial/ethnic disparities on cancer screening, while controlling for potentially confounding factors. Results: The rates of receiving three types of cancer screening were comparable and even higher among HC patients than those for the U.S. general population. Both bivariate and multivariate results showed there were racial/ethnic differences in the likelihood of receiving cancer screening services. However, the differences did not favor non-Hispanic Whites. African Americans had higher odds than Whites (OR: 1.92, 95% CI: 1.44-2.55, p < 0.001) of receiving Pap tests. Similar results were also found in measures of the receipt of mammogram (OR = 1.96, 95% CI: 1.46-2.64, P < 0.001) and colorectal cancer screening (OR = 1.28, 95% CI: 1.02-1.60, p < 0.05). Conclusion: The current study presents U.S. nationally representative estimates and imply that HCs are helping fulfill an important role as a health care safety-net in reducing racial/ethnic disparities in the delivery of cancer screening services. | |
| 2016 | Hirth 2016 | Racial/Ethnic Differences Affecting | Racial/Ethnic Differences Affecting Adherence to Cancer Screening Guidelines Among Women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Health Information National Trends Survey | BACKGROUND: Race/ethnicity has been shown to modify the effects between obesity and cancer screening among women. The purpose of this article is to update the literature with recent data to examine how the association between different characteristics, including body mass index (BMI), and cancer screening compliance varies by race/ethnicity in a national sample of women. MATERIALS AND METHODS: Three cycles of the Health Information National Trends Survey (HINTS) were combined for this cross-sectional study. Weighted descriptive statistics were evaluated using chi-square tests. Multivariable logistic regression evaluated associations between women with underweight or normal (<25), overweight (25-29.9), and obese (>30) BMIs and cancer screening concordant with guidelines (Papanicolaou [Pap] testing 3 years, ages 21+ years; mammography 2 years, ages 40+ years) in analyses stratified by race/ethnicity. We also assessed variance between racial/ethnic groups in how age, income, and insurance status were associated with cancer screening compliance. RESULTS: This study included 4992 women who were evaluated for Pap testing and 3773 for mammography. In analyses stratified by race/ethnicity, whites with a higher household income were more likely to report having a Pap test (adjusted prevalence ratio [aPR] 2.16, 95% confidence interval [95% CI] 1.38-3.40) and a mammogram (aPR 1.63, 95% CI 1.04-2.55) compared to lower income white women. Black women with BMIs between 25 and 30 were less likely to receive a Pap test (aPR 0.38, 95% CI 0.19-0.76) than black women with BMIs <25, while no association was observed among the other groups. Insurance was associated with increased likelihood of Pap testing among white and black women. Insurance coverage was positively associated with mammography only among white and Hispanic women. CONCLUSIONS: We found variations in adherence to cancer screening guidelines by age, insurance coverage, and income between racial/ethnic groups. Little evidence was observed for variations in screening by BMI. | |
| 2015 | Calo 2016 | Area-level Socioeconomic | Area-level Socioeconomic Inequalities in the Use of Mammography Screening: A Multilevel Analysis of the Health of Houston Survey | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Regional | Private Survey | Health of Houston Survey | Background: An emerging literature reports that women who reside in socioeconomically deprived communities are less likely to adhere to mammography screening. This study explored associations between area-level socioeconomic measures and mammography screening among a racially and ethnically diverse sample of women in Texas. Methods: We conducted a cross-sectional, multilevel study linking individual-level data from the 2010 Health of Houston Survey and contextual data from the U.S. Census. Women ages 40 to 74 years (= 1,541) were included in the analyses. We examined tract-level poverty, unemployment, education, Hispanic and Black composition, female-headed householder families, and crowding as contextual measures. Using multilevel logistic regression modeling, we compared most disadvantaged tracts (quartiles 2-4) to the most advantaged tract (quartile 1). Results: Overall, 64% of the sample was adherent to mammography screening. Screening rates were lower (< .05) among Hispanics, those foreign born, women aged 40 to 49 years, and those with low educational attainment, unemployed, and without health insurance coverage. Women living in areas with high levels of poverty (quartile 2 vs. 1: odds ratio [OR], 0.50; 95% CI, 0.30-0.85), Hispanic composition (quartile 3 vs. 1: OR, 0.54; 95% CI, 0.32-0.90), and crowding (quartile 4 vs. 1: OR, 0.53; 95% CI, 0.29-0.96) were less likely to have up-to-date mammography screening, net of individual-level factors. Conclusion: Our findings highlight the importance of examining area-level socioeconomic inequalities in mammography screening. The study represents an advance on previous research because we examined multiple area measures, controlled for key individual-level covariates, used data aggregated at the tract level, and accounted for the nested structure of the data. | |
| 2020 | Lake 2020 | Black patients referred to a lung | Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Black | Single Institution | Disease Registry | Jane and Leonard Korman Respiratory Institute Lung Cancer Screening Program | Background: Racial disparities are well-documented in preventive cancer care, but they have not been fully explored in the context of lung cancer screening. We sought to explore racial differences in lung cancer screening outcomes within a lung cancer screening program (LCSP) at our urban academic medical center including differences in baseline low-dose computed tomography (LDCT) results, time to follow-up, adherence, as well as return to annual screening after additional imaging, loss to follow-up, and cancer diagnoses in patients with positive baseline scans. Methods: A historical cohort study of patients referred to our LCSP was conducted to extract demographic and clinical characteristics, smoking history, and lung cancer screening outcomes. Results: After referral to the LCSP, blacks had significantly lower odds of receiving LDCT compared to whites, even while controlling for individual lung cancer risk factors and neighborhood-level factors. Blacks also demonstrated a trend toward delayed follow-up, decreased adherence, and loss to follow-up across all Lung-RADS categories. Conclusions: Overall, lung cancer screening annual adherence rates were low, regardless of race, highlighting the need for increased patient education and outreach. Furthermore, the disparities in race we identified encourage further research with the purpose of creating culturally competent and inclusive LCSPs. | |
| 2007 | Blackwell 2008 | Women's Compliance with Public | Women's Compliance with Public Health Guidelines for Mammograms and Pap tests in Canada and the United States. An Analysis of Data from the Joint Canada/United States Survey of Health | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | North America | Multiple Groups | International | Government Survey | Joint Canada/United States Survey of Health | Objectives: We use the Joint Canada/United States Survey of Health (JCUSH) to examine use of mammograms and Pap tests among Canadian and US women during 2002 and 2003. Unlike previous data, the JCUSH data are bi-nationally comparable, in that the same instrument was used for interviewing both Canadian and US respondents at the same time. Furthermore, when appropriately weighted, these data are representative of the populations of both countries. Methods: Descriptive statistics were used to provide a basic profile of screening practices among women in Canada and the United States. Logistic regression was then used to examine the determinants of compliance with mammogram and Pap test guidelines in the 2 countries, statistically controlling for demographic and socioeconomic characteristics, health status, and other indicators suggested from previous research. To increase comparability, these analyses were restricted to the age ranges covered in common by the screening guidelines of both countries. Results: Among women covered by the guidelines in both countries, screening rates were higher in the United States than in Canada at all ages, which is puzzling given the existence of Canada's universal health care system. Multivariate analyses revealed that whether a woman had had a mammogram within the last 2 years (when predicting last Pap test) or had had a Pap test within the last 3 years (when predicting last mammogram) were the strongest and most consistent predictors of compliance in both countries. Race/ethnicity, nativity, marital status, socioeconomic status, insurance coverage in the United States, and various health status indicators also predicted compliance in some, but not all, models. | |
| 2017 | Hayek 2017 | Factors Associated with Breast | Factors Associated with Breast Cancer Screening in a Country with National Health Insurance: Did We Succeed in Reducing Healthcare Disparities? | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Israel | Multiple Groups | National | Government Survey | Knowledge attitudes and Practices Survey | BACKGROUND: The effectiveness of breast cancer screening programs in reducing mortality is well established in the scientific literature. The National Breast Cancer Screening Program in Israel provides biennial mammograms for women of average risk aged 50-74 and annual mammograms for women aged 40-49 at higher risk. Compliance is high, but differential. This study explores different factors associated with breast cancer screening attendance among women aged 40-74 years. MATERIALS AND METHODS: Two main outcomes were studied: ever been screened and been screened in the 2 years preceding the study, using the cross-sectional Knowledge, Attitudes and Practices (KAP) Survey conducted in 2010-2012 among 2575 Israeli women aged 21+ years. The independent variables were sociodemographic characteristics, perceived health status, lifestyle habits, and healthcare fund membership. Bivariate and multivariable logistic regressions were conducted. RESULTS: Of the 943 participants aged 50-74, 87% had ever been screened and 74.8% had attended screening for breast cancer in the last 2 years. In multivariable models, Jewish compared to Arab women (adjusted prevalence ratio [APR] = 2.09, 95% confidence interval [CI]: 1.02-4.32), and unmarried compared to married women (APR = 2.9, 95% CI: 1.2-7.2), were more likely to have ever been screened. The only factor associated with breast cancer screening in the 2 years preceding the study was healthcare fund membership. In women aged 40-49 years, ethnicity was the only contributing factor associated with breast cancer screening, with higher screening rates in the 2 years preceding the study in Jewish versus Arab women (APR = 3.7, 95% CI: 1.52-9.3). CONCLUSIONS: Breast cancer screening attendance in Israel is high. However, significant differences are observed by membership of healthcare fund and by ethnicity, calling for better targeted outreach programs at this level. | |
| 2011 | Addo 2011 | Provision of acute stroke care and | Provision of acute stroke care and associated factors in a multiethnic population: prospective study with the South London Stroke Register | Adult Only | All Sexes | Inpatient General Care | Stroke Imaging | UK | Multiple Groups | Regional | Disease Registry | Local data | OBJECTIVES: To investigate time trends in receipt of effective acute stroke care and to determine the factors associated with provision of care. DESIGN: Population based stroke register. SETTING: South London. PARTICIPANTS: 3800 patients with first ever ischaemic stroke or primary intracerebral haemorrhage registered between January 1995 and December 2009. MAIN OUTCOME MEASURES: Acute care interventions, admission to hospital, care on a stroke unit, acute drugs, and inequalities in access to care. RESULTS: Between 2007 and 2009, 5% (33/620) of patients were still not admitted to a hospital after an acute stroke, particularly those with milder strokes, and 21% (124/584) of patients admitted to hospital were not admitted to a stroke unit. Rates of admission to stroke units and brain imaging, between 1995 and 2009, and for thrombolysis, between 2005 and 2009, increased significantly (P<0.001). Black patients compared with white patients had a significantly increased odds of admission to a stroke unit (odds ratio 1.76, 95% confidence interval 1.35 to 2.29, P<0.001) and of receipt of occupational therapy or physiotherapy (1.90, 1.21 to 2.97, P=0.01), independent of age or stroke severity. Patients with motor or swallowing deficits were also more likely to be admitted to a stroke unit (1.52, 1.12 to 2.06, P=0.001 and 1.32, 1.02 to 1.72, P<0.001, respectively). Length of stay in hospital decreased significantly between 1995 and 2009 (P<0.001). The odds of brain imaging were lowest in patients aged 75 or more years (P=0.004) and those of lower socioeconomic status (P<0.001). The likelihood of those with a functional deficit receiving rehabilitation increased significantly over time (P<0.001). Patients aged 75 or more were more likely to receive occupational therapy or physiotherapy (P=0.002). CONCLUSION: Although the receipt of effective acute stroke care improved between 1995 and 2009, inequalities in its provision were significant, and implementation of evidence based care was not optimal. | |
| 2016 | Ajayi 2016 | Disparities in staging prostate | Disparities in staging prostate magnetic resonance imaging utilization for nonmetastatic prostate cancer patients undergoing definitive radiation therapy | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | Single Institution | EHR | Local data | Purpose: There is growing evidence supporting incorporating multiparametric (mp) magnetic resonance imaging (MRI) scans into risk stratification, active surveillance, and treatment paradigms for prostate cancer. The purpose of our study was to determine whether demographic disparities exist in staging MRI utilization for prostate cancer patients. Methods and materials: An institutional database of 705 nonmetastatic prostate cancer patients treated with radiation therapy from 2005 through 2013 was used to identify patients undergoing versus not undergoing pretreatment diagnostic prostate mpMRI. Uni- and multivariable logistic regression evaluated the relationship of clinical and demographic characteristics with MRI utilization. Results: All demographic variables assessed, except the other race category, were significantly associated with MRI utilization (all P < .05), including age (odds ratio [OR], 0.92), black race (OR, 0.51), poverty (OR, 0.53), closer distance to radiation facility (OR, 1.79), and nonprivate primary insurance (OR, 0.57) on univariable analysis, while clinical stage T3 (OR, 3.37) was the only clinical characteristic. On multivariable analysis stratified by D'Amico risk group, age remained significant across all risk groups, whereas the black versus white racial (OR, 0.21; 95% confidence interval, 0.08-0.55) and nonprivate versus private insurance type (OR, 0.37; 95% confidence interval, 0.16-0.86) disparities persisted in the low-risk group. Clinical stage T3 remained associated in the high-risk group. For race specifically, the percentages of whites, blacks, and others undergoing MRI in the overall cohort and by risk group were, respectively: overall, 80% (343/427), 68% (156/231), and 85% (40/47); low risk, 86%, 56%, and 63%; intermediate risk, 79%, 72%, and 95%; and high risk, 72%, 72%, and 100%. Conclusions: In this urban, academic center cohort, older patients across all risk groups and black or nonprivate insurance patients in the low risk group were less likely to undergo staging prostate MRI scans. Further research should investigate these differences to ensure equitable utilization across all demographic groups considering the burden of prostate cancer disparities. | |
| 2021 | Alsheik 2021 | Outcomes by Race in Breast Cancer | Outcomes by Race in Breast Cancer Screening With Digital Breast Tomosynthesis Versus Digital Mammography | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Multi-Institution | Disease Registry | Local data | PURPOSE: Digital breast tomosynthesis (DBT) in conjunction with digital mammography (DM) is becoming the preferred imaging modality for breast cancer screening compared with DM alone, on the basis of improved recall rates (RR) and cancer detection rates (CDRs). The aim of this study was to investigate racial differences in the utilization and performance of screening modality. METHODS: Retrospective data from 63 US breast imaging facilities from 2015 to 2019 were reviewed. Screening outcomes were linked to cancer registries. RR,CDR per 1,000 examinations, and positive predictive value for recall (cancers/recalled patients) were compared. RESULTS: A total of 385,503 women contributed 542,945 DBT and 261,359 DM screens. A lower proportion of screenings for Black women were performed using DBT plus DM (referred to as DBT) (44% for Black, 48% for other, 63% for Asian, and 61% for White). Non-White women were less likely to undergo more than one mammographic examination. RRs were lower for DBT among all women (8.74 versus 10.06, P<.05) and lower across all races and within age categories. RRs were significantly higher for women with only one mammogram. CDRs were similar or higher in women undergoing DBT compared with DM, overall (4.73 versus 4.60, adjusted P= .0005) and by age and race. Positive predictive value for recall was greater for DBT overall (5.29 versus 4.45, adjusted P <.0001) and by age, race, and screening frequency. CONCLUSIONS: All racial groups had improved outcomes with DBT screening, but disparities were observed in DBT utilization. These data suggest that reducing inequities in DBT utilization may improve the effectiveness of breast cancer screening. | |
| 2021 | Ambinder 2021 | Disparities in the uptake of | Disparities in the uptake of digital breast tomosynthesis for breast cancer screening: A retrospective cohort study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | We present a retrospective cohort study evaluating the utilization and effectiveness of digital breast tomosynthesis (DBT) for breast cancer screening with a focus on racial differences. 46,236 females underwent screening mammography between 4/1/2013 and 3/30/2020, during which there was an increase in DBT utilization from 18.8% in year 1 to 89.6% in year 7. Black and Asian women were significantly less likely to have a screening study with DBT compared to White women. Overall, the DBT group had a lower recall rate (9.1% versus 11.2%, p< 0.001) and higher cancer detection rate (6.0 vs 4.1, p< 0.001) compared to the FFDM group. | |
| 2008 | Amin 2008 | Breast cancer screening compliance | Breast cancer screening compliance among young women in a free access healthcare system | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | Background and Objectives: To examine mammographic screening compliance among young military healthcare beneficiaries and to examine factors related to one time and recent mammographic compliance. Methods: Medical records were reviewed for 1,073 subjects (age 41-47) recording dates of the two most recent screening mammograms. Examined outcomes were: whether the woman ever had mammography and, if so, whether she had a mammogram within 400 days. Examined predictors were: ethnicity, age, Gail Model risk score, family history, whether the woman knew a young woman with breast cancer, and importance attributed to breast cancer screening. Results: 90.4% of women studied had at least one mammogram. 71.1% underwent screening within 400 days. Rates of ever having mammography were higher for women with family history of breast cancer and Asian, Pacific Islander, Black or Hispanic women. No measured covariate correlated with having mammography within 400 days. Conclusions: One time screening participation was high in this select group of women for whom cost and access barriers were removed, but was lower with regard to having a recent mammogram. Correlates of ever having and recent mammography are not synonymous. | |
| 2021 | Amornsiripanitch 2021 | Patients characteristics related to | Patients characteristics related to screening mammography cancellation and rescheduling rates during the COVID-19 pandemic | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | PURPOSE: To identify patient characteristics associated with screening mammography cancellations and rescheduling during the COVID-19 pandemic. METHODS: Scheduled screening mammograms during three time periods were retrospectively reviewed: state- mandated shutdown (3/17/2020-6/16/2020) during which screening mammography was cancelled, a period of 2 months immediately after screening mammography resumed (6/17/2020-8/16/2020), and a representative period prior to COVID-19 (6/17/2019-8/16/2019). Relative risk of cancellation before COVID-19 and after reopening was compared for age, race/ethnicity, insurance, history of chronic disease, and exam location, controlling for other collected variables. Risk of failure to reschedule was similarly compared between all 3 time periods. RESULTS: Overall cancellation rate after reopening was higher than before shutdown (7663/16595, 46% vs 5807/ 15792, 37%; p <0.001). Relative risk of cancellation after reopening increased with age (1.20 vs 1.27 vs 1.36 for ages at 25th, 50th, and 75th quartile or 53, 61, and 70 years, respectively, p <0.001). Relative risk of cancellation was also higher among Medicare patients (1.41) compared to Medicaid and those with other providers (1.26 and 1.21, respectively, p <0.001) and non-whites compared to whites (1.34 vs 1.25, p =0.03). Rescheduling rate during shutdown was higher than before COVID-19 and after reopening for all patients (10,658/13593, 78%, 3569/5807, 61%, and 4243/7663, respectively, 55%, p <0.001). Relative risk of failure to reschedule missed mammogram was higher in hospitals compared to outpatient settings both during shutdown and after reopening (0.62 vs 0.54, p =0.005 and 1.29 vs 1.03, p <0.001, respectively). CONCLUSION: Minority race/ethnicity, Medicare insurance, and advanced age were associated with increased risk of screening mammogram cancellation during COVID-19. | |
| 2021 | Amram 2021 | Socioeconomic and Racial Inequities | Socioeconomic and Racial Inequities in Breast Cancer Screening During the COVID-19 Pandemic in Washington State | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | State | EHR | Local data | NA | |
| 2021 | Anjorin 2021 | Underutilization of Guideline-based | Underutilization of Guideline-based Abdominal Aortic Aneurysm Screening in an Academic Health System | Adult Only | Male | Outpatient Ambulatory and Primary Care | Abdominal Aortic Aneurysm Screening | United States | Multiple Groups | Single Institution | EHR | Local data | OBJECTIVES: The US Preventive Services Task Force (USPSTF) recommends a 1 time screening for AAA with ultrasonography in men aged 65-75 who have ever smoked. Our objectives were to identify the AAA screening rates in a large academic health system and assess factors associated with receipt of screening. METHODS: Data were extracted from electronic health records from the Duke University Health System and the US Census Bureau. Index screening eligibility date was defined as the 65th birthdate for male patients with a history of smoking. Patients with an index screening eligibility date between January 1, 2016 and December 31, 2018 were included in the study population and followed through December 31, 2019. Screened patients were identified by procedure codes for ultrasonography, CT or MRI. RESULTS: Among 6,682 eligible patients who turned 65 years old between January 1, 2016 and December 31, 2018 with at least 1 year of follow-up, only 463 (6.9%) received AAA screening during the study period. The odds of receiving AAA screening within 1 year of index eligibility were 27% lower for Black patients compared to whites [OR= 0.73, 95% CI (0.58, 0.93)]. Patients who visited a PCP or were diagnosed with hypertension had 75% and 41% greater odds of receiving screening, respectively [OR 1.75, 95% CI(1.36, 2.25)] and [OR 1.41 95% CI (1.11, 1.80)] compared with patients who did not. Among 4,580 men with 2 years of follow-up, AAA screening rate increased to 13.0%. Patients who visited a PCP had 64% greater odds of receiving screening within 2 years of index eligibility compared to those who did not [OR=1.64, 95% CI (1.30, 2.06)]. CONCLUSIONS: Screening for AAA per USPSTF guidelines is under utilized with evidence of a racial disparity. Although PCP visit is the most consistent predictor of screening, provider screening rates are low. | |
| 2019 | Arana 2019 | Racial/Ethnic Disparities in | Racial/Ethnic Disparities in Mammogram Frequency Among Women With Intellectual Disability | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Regional | Private Survey | Local data | Little information exists on the associations between intellectual disability (ID) and race/ethnicity on mammogram frequency. This study collected survey and medical record data to examine this relationship. Results indicated that Hispanic and Black women with ID were more likely than White women with ID to have mammograms every 2 years. Participants who live in a state-funded residence, were aged 50+, and had a mild or moderate level of ID impairment were more likely to undergo mammography compared to participants living with family or alone, were <50, and had severe ID impairment. Further research is needed to understand the mechanisms explaining disparities in mammograms between these racial/ethnic groups. | |
| 2022 | Balthazar 2022 | Effect of Sociodemographic Factors | Effect of Sociodemographic Factors on Utilization of an Online Patient Portal to Self-Schedule Screening Mammography: A Cross-Sectional Study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | PURPOSE: The aim of this study was to assess for sociodemographic factors associated with the use of an online patient portal to self-schedule screening mammography (SM) compared with the traditional scheduling pathway (phone call and referral system). METHODS: A retrospective study was conducted at an urban quaternary care academic medical center with patient portal access to the electronic health record. All female patients undergoing SM at the institution from January 1, 2019, to December 31, 2019, were included. The institutional data warehouse was queried to extract the following variables: patient scheduling pathway (online self-scheduled vs traditional), age, language, race/ethnicity, health insurance provider, and ZIP code. ZIP code was linked to census data to extract the following: computer with Internet access, median household income, and education level. Multivariable logistic regression was used to identify independent factors associated with using the online self-scheduling pathway for SM. RESULTS: A total of 46,083 patients met the inclusion criteria. Three hundred two (0.7%) used the online self-scheduling pathway. Patients using the online self-scheduling pathway had higher odds of being younger (odds ratio [OR] for age in years, 0.94; 95% confidence interval [CI], 0.93-0.96), being English speakers (OR, 21.3; 95% CI, 2.9-153.9), being White non-Hispanic (OR, 1.7; 95%CI, 1.2-2.5), and having commercial insurance (OR, 1.5; 95% CI, 1.1-2.1). Patients using the online self-scheduling pathway had higher odds of living in ZIP-code areas with higher access to computers with Internet connection (OR, 1.04; 95% CI, 1.01-1.07) and lower rates of education at or above the college level (OR, 0.98; 95% CI, 0.97-1.00). Patient median household income by ZIP code was not significantly associated with use of the online self-scheduling pathway. CONCLUSIONS: Patients with limited English proficiency, those of racial/ethnic minorities, those who were older, and those without commercial insurance were less likely to use an online self-scheduling pathway for SM. | |
| 2012 | Banegas 2012 | Breast cancer knowledge, attitudes, | Breast cancer knowledge, attitudes, and early detection practices in United States-Mexico border Latinas | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Hispanic | Regional | Private Survey | Local data | Introduction: Evidence suggests Latinas residing along the United States-Mexico border face higher breast cancer mortality rates compared to Latinas in the interior of either country. The purpose of this study was to investigate breast cancer knowledge, attitudes, and use of breast cancer preventive screening among U.S. Latina and Mexican women residing along the U.S.-Mexico border. Methods: For this binational cross-sectional study, 265 participants completed an interviewer-administered questionnaire that obtained information on sociodemographic characteristics, knowledge, attitudes, family history, and screening practices. Differences between Mexican (n=128) and U.S. Latina (n=137) participants were assessed by Pearson's chi-square, Fischer's exact test, t tests, and multivariate regression analyses. Results: U.S. Latinas had significantly increased odds of having ever received a mammogram/breast ultrasound (adjusted odds ratio [OR]=2.95) and clinical breast examination (OR=2.67) compared to Mexican participants. A significantly greater proportion of Mexican women had high knowledge levels (54.8%) compared to U.S. Latinas (45.2%, p<0.05). Age, education, and insurance status were significantly associated with breast cancer screening use. Conclusions: Despite having higher levels of breast cancer knowledge than U.S. Latinas, Mexican women along the U.S.-Mexico border are not receiving the recommended breast cancer screening procedures. Although U.S. border Latinas had higher breast cancer screening levels than their Mexican counterparts, these levels are lower than those seen among the general U.S. Latina population. Our findings underscore the lack of access to breast cancer prevention screening services and emphasize the need to ensure that existing breast cancer screening programs are effective in reaching women along the U.S.-Mexico border. | |
| 2019 | Banham 2019 | Disparities in breast screening, | Disparities in breast screening, stage at diagnosis, cancer treatment and the subsequent risk of cancer death: a retrospective, matched cohort of aboriginal and non-aboriginal women with breast cancer | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Australia | Indigenous | National | Disease Registry | Local data | BACKGROUND: Australia's Aboriginal and Torres Strait Islander women have poorer survival and twice the disease burden from breast cancer compared to other Australian women. These disparities are influenced, but not fully explained, by more diagnoses at later stages. Incorporating breast screening, hospital and out of hospital treatment and cancer registry records into a person-linked data system can improve our understanding of breast cancer outcomes. We focussed one such system on a population-based cohort of Aboriginal women in South Australia diagnosed with breast cancer and a matched cohort of non-Aboriginal women with breast cancer. We quantify Aboriginal and non-Aboriginal women's contact with publicly funded screening mammograms; quantify exposure to a selection of cancer treatment modalities; then assess the relationship between screening, treatment and the subsequent risk of breast cancer death. METHODS: Breast cancers registered among Aboriginal women in South Australia in 1990-2010 (N = 77) were matched with a random selection of non-Aboriginal women by birth and diagnostic year, then linked to screening records, and treatment 2 months before and 13 months after diagnosis. Competing risk regression summarised associations of Aboriginality, breast screening, cancer stage and treatment with risk of breast cancer death. RESULTS: Aboriginal women were less likely to have breast screening (OR = 0.37, 95%CIs 0.19-0.73); systemic therapies (OR = 0.49, 95%CIs 0.24-0.97); and, surgical intervention (OR = 0.35, 95%CIs 0.15-0.83). Where surgery occurred, mastectomy was more common among Aboriginal women (OR = 2.58, 1.22-5.46). Each of these factors influenced the risk of cancer death, reported as sub-hazard ratios (SHR). Regional spread disease (SHR = 34.23 95%CIs 6.76-13.40) and distant spread (SHR = 49.67 95%CIs 6.79-363.51) carried more risk than localised disease (Reference SHR = 1). Breast screening reduced the risk (SHR= 0.07 95%CIs 0.01-0.83). So too did receipt of systemic therapy (SHR = 0.06 95%CIs 0.01-0.41) and surgical treatments (SHR = 0.17 95%CIs 0.04-0.74). In the presence of adjustment for these factors, Aboriginality did not further explain the risk of breast cancer death. CONCLUSION: Under-exposure to screening and treatment of Aboriginal women with breast cancers in South Australia contributed to excess cancer deaths. Improved access, utilisation and quality of effective treatments is needed to improve survival after breast cancer diagnosis. | |
| 2009 | Baron-Epel 2009 | Reducing disparities in | Reducing disparities in mammography-use in a multicultural population in Israel | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Israel | Multiple Groups | National | Private Survey | Local data | BACKGROUND: In the past mammography-use has been reported to be low in Israel compared to other western countries. The objectives of this study were (1) to assess the increase in mammography-use during the years 2002 to 2007 in four population groups in Maccabi Healthcare Services (MHS), Israel: non-immigrant non-ultraorthodox, ultraorthodox, and immigrant Jewish women and Arab women; (2) to assess ethnic and socioeconomic disparities in mammography-use. METHODS: A random telephone survey of 1,550 women receiving healthcare services from MHS was performed during May-June 2007. Information from MHS claims-records database regarding mammography-use was obtained for each woman for the period 2002 to 2007. Since mammography-use serves as a quality assurance measure for primary care, MHS sent mail and telephone invitations for mammography to all women since the end of 2004. RESULTS: At the beginning of the follow-up period (2002) mammography-use among Jewish non-immigrant non-ultraorthodox and ultraorthodox women was higher than among Arab and Jewish immigrant women. During the 5 year follow-up these disparities decreased significantly. In 2007, mammography-use by Arab women was only slightly lower compared to all groups of Jewish women. In 2007, after adjustment for socioeconomic factors there was only a borderline significant difference between Jewish and Arab women. The socioeconomic variables were not associated with mammography-use in 2002 and 2007 in any of the groups except for marital status in immigrant women in 2002. CONCLUSION: The interventions implemented by MHS may have increased mammography-use in all population groups, decreasing disparities between the groups, however the differences between Jewish and Arab women have not been completely eliminated and indicate a need for further targeted interventions. No significant socioeconomic disparities in mammography-use were observed. | |
| 2021 | Barta 2021 | Racial Differences in Lung Cancer | Racial Differences in Lung Cancer Screening Beliefs and Screening Adherence | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Black | Single Institution | Private Survey | Local data | Area: Lung cancer screening is a multistep process requiring adherence with annual or short-interval follow-up scans Overall result: Race, education, insurance, and barriers to screening were significantly associated with lung cancer screening adherence. General significance: Efforts to improve adherence with lung cancer screening should focus on overcoming modifiable barriers to the screening process, with an emphasis on vulnerable populations. Background: One challenge in high-quality lung cancer screening (LCS) is maintaining adherence with annual and short-interval follow-up screens among high-risk individuals who have undergone baseline low-dose CT (LDCT). This study aimed to characterize attitudes and beliefs toward lung cancer and LCS and to identify factors associated with LCS adherence. Methods: We administered a questionnaire to 269 LCS participants to assess attitudes and beliefs toward lung cancer and LCS. Clinical data including sociodemographics and screening adherence were obtained from the LCS Program Registry. Results: African- American individuals had significantly greater lung cancer worries compared with Whites (6.10 vs. 4.66, P<.001). In making the decision to undergo LCS, African- American participants described screening convenience and cost as very important factors significantly more frequently than Whites (60% vs. 26.8%, P<.001 and 58.4% vs. 37.8%, P=.001; respectively). African-American individuals with greater than high school education had significantly higher odds of LCS adherence (aOR 2.55; 95% CI, 1.14- 5.60) than Whites with less than high school education. Participants who described screening convenience and cost as "very important" had significantly lower odds of completing screening follow-up after adjusting for demographic and other factors (aOR 0.56; 95% CI, 0.33-0.97 and a OR 0.54; 95% CI, 0.33-0.91, respectively). Conclusion: Racial differences in beliefs about lung cancer and LCS exist among African-American and White individuals enrolled in an LCS program. Cost, convenience, and low educational attainment may be barriers to LCS adherence, specifically among African-American individuals. Impact: More research is needed on how barriers can be overcome to improve LCS adherence. | |
| 2019 | Batta 2019 | Equality of care between First | Equality of care between First Nations and nonFirst Nations patients in Saskatoon emergency departments | All Ages | All Sexes | Emergency Department | General Diagnostic Imaging | Canada | Indigenous | Multi-Institution | EHR | Local data | Objective: Studies show that First Nations patients have worse health outcomes than non-First Nations patients, raising concerns that treatment within the healthcare system, including emergency care, is inequitable. Methods: We performed a retrospective chart review of Status First Nations and non-First Nations patients presenting to two emergency departments in Saskatoon, Saskatchewan with abdominal pain and a Canadian Triage and Acuity Scale score of 3. From 190 charts (95 Status First Nations and 95 non-First Nations), data extracted included time to doctor, time to analgesia, length of stay, specialist consult, bloodwork, imaging, physical exam and history, and disposition. Univariate comparisons and multiple regression modelling were performed to compare care outcomes between patient groups. Equivalence testing comparing time intervals was also undertaken. Results: No statistically significant differences in presentation characteristics were observed, although Status First Nations subjects showed a greater tendency towards weekend presentation and younger age. Care parameters were similar, although a marginally significant difference was observed in Status First Nations versus non-First Nations subjects for imaging (46% versus 60%, p=0.06), which resolved on adjustment for age and weekend presentation. Time to physician was found to be similar among First Nations patients on equivalence testing within a 15-minute margin. Conclusion: In this study, First Nations patients presenting with abdominal pain did not receive delayed care. There were no detectable differences in the time-related care parameters/variables that were provided relative to non-First Nations patients. Meaningful and important qualitative factors need to be examined in the future. | |
| 2022 | Baughman 2022 | Racial Disparity in Pediatric | Racial Disparity in Pediatric Radiography for Forearm Fractures | Pediatric Only | All Sexes | Inpatient and Outpatient | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | EHR | Local data | INTRODUCTION: The most common pediatric fractures involve the upper extremity. But there is limited study on racial disparity in diagnostic radiography for pediatric fractures. The literature has described the diagnostic accuracy of alternative diagnostic modalities with promising evidence of its ability to mitigate health inequity in primary care. Our objective was to understand if racial disparity exists in radiography for pediatric fractures. METHODS: In this four-year retrospective cohort study, we analyzed rates of radiographic imaging and abnormal radiograph detection in 4280 pediatric patients (ages 3-18 years) who presented with chief complaints of arm or wrist pain and trauma-related International Classification of Diseases 10th Revision (ICD-10) codes. We compared White children to all other races and stratified by emergency departments (ED) vs all other primary care ambulatory service lines. RESULTS: Non-White patients had lower imaging rate differences and lower odds receiving imaging in both ambulatory settings (0.65915, P=0.0162;-5.4%, P=0.0143) and in EDs (0.7732, P=0.0369; -4.7%, P=0.0368). Additionally, non-Whites in the ED had lower rates and lower odds of abnormal radiographs (-7.3%, P=0.0084; 0.6794, P=0.0089). CONCLUSION: Non-White patients seen in emergency and ambulatory settings had lower imaging rates for traumatic arm and wrist pain compared to White patients, indicating a healthcare disparity in pediatric imaging. Higher-level studies investigating the effect of social determinants of health, more detailed patient data, and provider bias on facture care equity are needed to understand underlying reasons for observed differences. | |
| 2012 | BenMorrison 2012 | Disparities in preventive health | Disparities in preventive health services among Somali immigrants and refugees | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Immigrants | Multi-Institution | EHR | Local data | African immigrants and refugees-almost half of them from Somalia-account for one of the fastestgrowing groups in the United States. There is reason to suspect that Somali-Americans may be at risk for low completion of recommended preventive health services. This study's aim was to quantify disparities in preventive health services among Somali patients compared with non-Somali patients in an academic primary care practice in Rochester, Minn. It also examined the effect of medical interpreters, emergency department visits, and primary care visits on the completion of preventive services. Rates of pap smears, vaccinations (influenza, pneumococcus, and tetanus), lipid screening, colorectal cancer screening, and mammography were assessed in Somali and non-Somali patients during the second quarter of 2008. Data were collected regarding the utilization of medical interpreters, emergency services, and primary care services among Somali patients. Results were reported using standard descriptive statistics. Of the 91,557 patients identified in the database, 810 were Somali. Somali patients had significantly lower completion rates of colorectal cancer screening, mammography, pap smears, and influenza vaccination than non-Somali patients. Use of medical interpreters and primary care services were generally associated with higher completion rates of preventive services. There are significant discrepancies in the provision of preventive health services to Somali patients compared with that of non-Somali patients. These findings suggest the need to identify the root causes of these discrepancies so that interventions may be crafted to close the gap. | |
| 2010 | Boomer 2010 | Acute Appendicitis in Latino | Acute Appendicitis in Latino Children: Do Health Disparities Exist? | Pediatric Only | All Sexes | Inpatient General Care | General Diagnostic Imaging | United States | Hispanic | Single Institution | EHR | Local data | Background. Significant racial and socioeconomic disparities have been found in the diagnosis and treatment of acute appendicitis in children. There has been little focus on the outcomes of Latino children with appendicitis. This study evaluates whether ethnicity or insurance status are associated with differences in presentation and outcomes of children with acute appendicitis. Materials and Methods. A retrospective analysis was performed for all children between the ages of 2 and 18 y with acute appendicitis between July 1, 2005 and December 31, 2008 at the only teaching hospital in the region. chi(2) and regression analyses were used to evaluate the impact of ethnicity and insurance status on perforation rates and outcomes. Results. A total of 410 children with acute appendicitis were identified, of whom 259 (63.2%) were Latino. Latino children were on public insurance in greater proportion (34.8% versus 19.9%) compared with non-Latino children (P = 0.001). The perforation rate for the entire sample was 29.6%. There were no significant differences in perforation rates with respect to ethnicity, insurance status (private, public, none), or age. Once within the medical system, there were no significant differences in radiologic studies performed, types of operations received, length of stay, or number of complications between ethnic groups. Conclusions. There have been multiple reports showing disparities in the rates of perforated appendicitis in children. At our institution, we observed no differences in the presentation and care of children with acute appendicitis with respect to ethnicity and insurance status. | |
| 2009 | Brown 2009 | Racial disparities in health | Racial disparities in health care-emergency department management of minor head injury | Adult Only | All Sexes | Emergency Department | Neurologic | Australia | Indigenous | Single Institution | EHR | Local data | Background/Aim: International research has demonstrated disparities in the Emergency Department care of patients of certain racial or ethnic backgrounds. The management of minor head injuries requires a careful clinical assessment to determine the requirement of a CT scan of the head. The aim of this study was to determine if there was any disparity, based on race, in the management of minor head injury. Methods: This was a retrospective, structured, medical record review of patients presenting to The Townsville Hospital Emergency Department, between September 2004 and April 2007, with minor head injury. The main outcome measure was whether or not patients received a CT head scan when clinically indicated. The Canadian CT Head Rule was considered the standard for clinical indication for a CT head scan. Secondary outcome measures included triage category, waiting time, level of care provider, disposition and serum ethanol. Results A total of 270 patients (73 indigenous and 196 nonindigenous) were enrolled. There was no statistically significant difference in ordering CT head scans when clinically indicated between indigenous and non-indigenous patients. However, a trend indicating that indigenous patients were less likely to receive a CT head scan when clinically indicated (OR 0.35; 95% CI=0.07 to 1.77) was noted. Indigenous patients had a mean waiting time of 44.6 min (SD 49.6) compared to non-indigenous with 31.1 min (SD 36.4; p=0.02). Conclusion: This study concluded that there was no statistically significant disparity based upon race in the management of minor head injuries with regard to decision to perform a CT head scan. There is some evidence that indigenous patients waited longer to be seen. A multi-centre prospective study is necessary to confirm these findings. | |
| 2022 | Brown 2022 | Evaluation of Differences Between | Evaluation of Differences Between Non-Hispanic White and African American Patients With Sports Medicine-Related Hip Disabilities | All Ages | All Sexes | Outpatient Ambulatory and Primary Care | General Diagnostic Imaging | United States | Black | Multi-Institution | EHR | Local data | BACKGROUND: Racial disparities within the field of orthopaedics are well-documented in the spinal surgery, knee arthroplasty, and hip arthroplasty literature. Not much is known about racial differences in patients with sports medicine-related hip disabilities. PURPOSE: To investigate whether differences exist between African American and non-Hispanic White (White) patients evaluated for hip disabilities. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a multicenter retrospective cohort study of 905 patients who were evaluated over a 1-year period for hip-related orthopaedic concerns. Patient demographic data, disability characteristics, and hip radiographic findings were obtained from electronic medical records. We also obtained data on whether patients were offered physical therapy, magnetic resonance imaging (MRI), and/or surgery. Comparisons by race and insurance status were evaluated using univariate and multivariate analyses. RESULTS: African Americans comprised a significantly lower proportion of the patients evaluated for hip-related disabilities compared with Whites (6.5% vs 93.5%; P < .001). A significantly smaller proportion of African Americans with hip disabilities was recommended for surgery than White patients (35.6% vs 54.6%; P = .007). Cam deformities were more common in White vs African American patients (39.7% vs 23.7%; P =.021), as were labral tears (54.1% vs 35.6%; P = .009). Logistic regression demonstrated that neither race nor insurance status were significant determinants in surgery recommendations. Conversely, race was a determinant of whether an MRI was performed, as White patients were 2.74 times more likely to have this procedure. There were no differences with respect to obtaining an MRI between private and Medicaid insurance. CONCLUSION: Compared with White patients, there were differences in both the proportion of African Americans evaluated for hip-related disabilities and the proportion receiving a surgery recommendation. African Americans with sports medicine-related hip issues were also less likely to obtain an MRI. With regard to observed pathology, African American patients were less likely to have cam deformities and labral tears than White patients. | |
| 2021 | Bucknor 2021 | Disparities in PET imaging for | Disparities in PET imaging for prostate cancer at a tertiary academic medical center | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | Single Institution | EHR | Local data | The purpose of this study was to evaluate differences between patients receiving 18F-fluciclovine and 68Ga-prostate-specific membrane antigen (68Ga-PSMA-11) for biochemically recurrent prostate cancer at a tertiary medical center. METHODS: All 18F-fluciclovine and 68Ga-PSMA-11 PET studies performed at the University of California San Francisco from October 2015 to January 2020 were reviewed. Age, race/ethnicity, primary language, body mass index, insurance type, and home address were obtained through the electronic medical record. A logistic regression model was used to evaluate the predictor variables. RESULTS: In total, 1,502 patients received 68Ga-PSMA-11 and 254 patients received 18F-fluciclovine. Black patients had increased odds of receiving imaging with 18F-fluciclovine versus 68Ga-PSMA-11 compared with non-Hispanic White patients (odds ratio, 3.88; 95% CI, 1.90-7.91). There were no other statistically significant differences. CONCLUSION: In patients receiving molecular imaging for prostate cancer at a single U.S. tertiary medical center, access to 68Ga-PSMA-11 for Black patients was limited, compared with non-Hispanic White patients, by a factor of nearly 4. | |
| 2013 | Burman 2014 | Hepatitis B Management in | Hepatitis B Management in Vulnerable Populations: Gaps in Disease Monitoring and Opportunities for Improved Care | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | Regional | Private Survey | Local data | Background Hepatitis B (HBV) is prevalent in certain US populations and regular HBV disease monitoring is critical to reducing associated morbidity and mortality. Adherence to established HBV monitoring guidelines among primary care providers is unknown. The purpose of this study was to evaluate HBV disease monitoring patterns and factors associated with adherence to HBV management guidelines in the primary care setting. Primary providers within the San Francisco safety net healthcare system were surveyed for HBV management practices, knowledge, attitudes, and barriers to HBV care. Medical records from 1,727 HBV-infected patients were also reviewed retrospectively. Of 148 (45 %) responding providers, 79 % reported ALT and 44 % reported HBV viral load testing every 6-12 months. Most providers were knowledgeable about HBV but 43 % were unfamiliar with HBV management guidelines. Patient characteristics included: mean age 51 years, 54 % male and 67 % Asian. Within the past year, 75 % had ALT, 24 % viral load, 21 % HBeAg tested, and 40 % of at-risk patients had abdominal imaging for HCC. Provider familiarity with guidelines (OR 1.02, 95 % CI 1.00-1.03), Asian patient race (OR 4.18, 95 % CI 2.40-7.27), and patient age were associated with recommended HBV monitoring. Provider HBV knowledge and attitudes were positively associated, while provider age and perceived barriers were negatively associated with HCC surveillance. Comprehensive HBV disease monitoring including HCC screening with imaging were suboptimal. While familiarity with AASLD guidelines and patient factors were associated with HBV monitoring, only provider and practice factors were associated with HCC surveillance. These findings highlight the importance of targeted provider education to improve HBV care. | |
| 2018 | Cain 2018 | Emergency department use of | Emergency department use of neuroimaging in children and adolescents presenting with headache | Pediatric Only | All Sexes | Emergency Department | Neurologic | United States | Multiple Groups | Single Institution | EHR | Local data | Objectives: To evaluate emergency department use and outcomes of neuroimaging for headache in a free-standing children's hospital system. Study design: We prospectively enrolled children aged 6-18 years who presented to the emergency department with a chief complaint of headache from September 2015 to September 2016. Standardized data collection was performed in real time, including telephone follow-up as needed, and imaging outcome was determined through a chart review. Using multivariable logistic regression, we estimated the associations between clinically important patient characteristics and neuroimaging. Results: Of 294 enrolled patients, 53 (18%) underwent neuroimaging (computed tomography or magnetic resonance imaging) and 2 (0.7%) had clinically important intracranial findings. Presenting with abnormal neurologic examination findings (OR, 11.55; 95% CI, 3.24-41.22), no history of similar headaches (OR, 2.13; 95% CI, 1.08-4.18), and white race (OR, 3.04; 95% CI, 1.51-6.12) were significantly associated with an increased odds of undergoing imaging in multivariable regression models. Conclusions: Our observed emergency department imaging rate was 26.5 times higher than our positive result rate, suggesting there is room to decrease unnecessary neuroimaging. Associations for abnormal examination and new headache type are consistent with the American Academy of Neurology clinical imaging recommendations. The increased odds of imaging white patients suggests bias that should be addressed. The low rate of positive findings supports the need for an evidence-based clinical decision tool for neuroimaging in the acute care setting. | |
| 2004 | Carrasquillo 2004 | The role of health insurance on Pap | The role of health insurance on Pap smear and mammography utilization by immigrants living in the United States | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Immigrants | National | Private Survey | Local data | Background: Nearly half of recent immigrants to the United States lack health insurance. Access to cancer screening services for this group is problematic. We examine the role of health insurance and having a usual source of care (USC) on Pap smear and mammography utilization by immigrant women using a nationally representative sample. Methods: We used a telephone survey that oversampled racial and ethnic minorities. We analyzed data on 3,622 women age 18-70. We classified the 822 foreign-born women as recent immigrants if they had resided in the United States for under 10 years; LT immigrants were those with a longer tenure. Results: Among recent immigrants, 73% and 78% (SE 4%) reported a Pap smear or mammogram, respectively, in the previous 2 years versus 89% and 89% of U.S.-born women (P < 0.05 for both comparisons). Among those with insurance or a USC, differences in screening between recent immigrants and U.S.-born women were four percentage points or less and not statistically significant. However, uninsured recent immigrants were less likely than uninsured U.S.-born women to have Pap smears [60% (SE 7%) versus 71%, P < 0.05]. Adjusting for differences in sociodemographics, health attitudes or beliefs, patient or provider communication, and the medical care environment, insurance remained the strongest predictor of screening. Conclusion: Disparities in screening were greatly attenuated among the insured population. Increasing awareness of available safety net sources of care may also improve cancer screening among uninsured recent immigrants. | |
| 2022 | Chan 2022 | Trends and Predictors of Imaging | Trends and Predictors of Imaging Utilization by Modality within an Academic Health System's Active Patient Population | All Ages | All Sexes | Outpatient Ambulatory and Primary Care | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | EHR | Local data | RATIONALE AND OBJECTIVES: Evaluate trends and demographic predictors of imaging utilization at a university-affiliated health system. MATERIALS AND METHODS: In this single-institution retrospective study, per capita estimates of imaging utilization among patients active in the health system were computed by cross-referencing all clinical encounters (2004-2016) for 1,628,980 unique patients with a listing of 6,157,303 diagnostic radiology encounters. Time trends in imaging utilization and effects of gender, race/ethnicity, and age were assessed, with subgroup analyses performed by imaging modality. Utilization was analyzed as both a continuous and binary outcome variable. RESULTS: Over 13 years, total diagnostic exams rose 6.8% a year (285,947-622,196 exams per annum), while the active population size grew 7.0% a year (244,238-543,290 active patients per annum). Per capita utilization peaked in 2007 at 1.33 studies/patient/year before dropping to 1.06 from 2011 to 2015. Latest per capita utilization was 0.22 for computed tomography, 0.10 for MR, 0.20 for US, 0.03 for NM, 0.51 for radiography, and 0.07 for mammography. Over the study period, ultrasound utilization doubled, whereas NM and radiography utilization decreased. computed tomography, MR, and mammography showed no significant net change. Univariate analysis of utilization as a continuous variable showed statistically significant effects of gender, race/ethnicity, and age (P <0.0001), with utilization higher in males and Blacks and lower in Asian/Pacific Islanders and Hispanics. Utilization increased with age, except for a decline after age 75. Many of the effects of age, gender, and race/ethnicity were also found when analyzing the binarized utilization variable. CONCLUSIONS: Although absolute counts of imaging studies more than doubled, the net change in per capita utilization over the study period was minimal. Variations in utilization across age, gender, and race/ethnicity may reflect differential health needs and/or access disparities, warranting future studies. | |
| 2018 | Cho 2019 | Patient Factor Disparities in | Patient Factor Disparities in Imaging Follow-Up Rates After Incidental Abdominal Findings | All Ages | All Sexes | Outpatient Ambulatory and Primary Care | Incidental Finding Follow Up | United States | Multiple Groups | Single Institution | EHR | Local data | OBJECTIVE: The effect of demographics and societal determinants on imaging follow-up rates is not clear. The purpose of this study was to compare characteristics of patients with imaging findings representing possible cancer who undergo follow-up imaging versus those who do not to better understand factors that contribute to follow-up completion. MATERIALS AND METHODS: The records of 1588 patients with indeterminate abdominal imaging findings consecutively registered between July 1, 2013, and March 20, 2014, were reviewed. Several patient characteristics, including distance between patients' home zip codes and the flagship hospital of the health system were compared between the groups who did and did not undergo follow-up imaging. Subgroup analyses based on the location of the index examination were also performed. RESULTS: Among the 1513 (36.62%) included patients, 554 did not undergo follow-up abdominal imaging within 1 year of the index examination. The same was true of 270 of 938 (28.78%) outpatients and 168 of 279 (60.21%) emergency department patients. Eighty-nine of 959 (9.28%) patients who underwent follow-up imaging were younger than 40 years, compared with 76 of 554 (13.72%) patients who did not undergo follow-up imaging (p = 0.005). Fifty-four of 959 (5.63%) patients who underwent follow-up imaging were older than 80 years, compared with 70 of 554 (12.64%) patients who did not undergo follow-up imaging (p < 0.001). More white patients (587 of 959 vs 301 of 554, p = 0.007) and fewer black patients (204 of 554 versus 270 of 959, p < 0.001) were found in the follow-up imaging group. Greater distance from the flagship hospital correlated with less follow-up in the outpatient subgroup only (p = 0.03). CONCLUSION: Emergency department patients and patients at the extremes of age are less likely to complete follow-up imaging. Insurance status and race and ethnicity may affect follow-up completion rates. The relationship between distance to hospital and follow-up completion requires further investigation. | |
| 2021 | Choe 2021 | Evaluation of Patterns in Access to | Evaluation of Patterns in Access to Breast Cancer Care and Breast Cancer Presentation in a Safety Net Patient Population | Adult Only | Female | Inpatient and Outpatient | Cancer Care | United States | Multiple Groups | Single Institution | EHR | Local data | BACKGROUND: While prior studies have shown the apparent health disparities in breast cancer diagnosis and treatment, there is a gap in knowledge with respect to access to breast cancer care among minority women. METHODS: We performed a retrospective analysis of patients with newly diagnosed breast cancer from 2014 to 2016 to evaluate how patients presented and accessed cancer care services in our urban safety net hospital. Patient demographics, cancer stage, history of breast cancer screening, and process of referral to cancer care were collected and analyzed. RESULTS: Of the 202 patients identified, 61 (30%) patients were younger than the age of 50 and 75 (63%) were of racial minority background. Only 39% of patients with a new breast cancer were diagnosed on screening mammogram. Women younger than the age of 50 (P < .001) and minority women (P < .001) were significantly less likely to have had any prior screening mammograms. Furthermore, in patients who met the screening guideline age, more than half did not have prior screening mammograms. DISCUSSION: Future research should explore how to improve breast cancer screening rates within our county patient population and the potential need for revision of screening guidelines for minority patients. | |
| 2012 | Consedine 2012 | The demographic, system, and | The demographic, system, and psychosocial origins of mammographic screening disparities: Prediction of initiation versus maintenance screening among immigrant and non-immigrant women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Immigrants | Regional | Private Survey | Local data | Disparities in breast screening are well documented. Less clear are differences within groups of immigrant and non-immigrant minority women or differences in adherence to mammography guidelines over time. A sample of 1,364 immigrant and non-immigrant women (African American, English Caribbean, Haitian, Dominican, Eastern European, and European American) were recruited using a stratified cluster-sampling plan. In addition to measuring established predictors of screening, women reported mammography frequency in the last 10 years and were (per ACS guidelines at the time) categorized as never, sub-optimal (<1 screen/year), or adherent (1+ screens/year) screeners. Multinomial logistic regression showed that while ethnicity infrequently predicted the never versus sub-optimal comparison, English Caribbean, Haitian, and Eastern European women were less likely to screen systematically over time. Demographics did not predict the never versus sub-optimal distinction; only regular physician, annual exam, physician recommendation, and cancer worry showed effects. However, the adherent categorization was predicted by demographics, was less likely among women without insurance, a regular physician, or an annual exam, and more likely among women reporting certain patterns of emotion (low embarrassment and greater worry). Because regular screening is crucial to breast health, there is a clear need to consider patterns of screening among immigrant and non-immigrant women as well as whether the variables predicting the initiation of screening are distinct from those predicting systematic screening over time. | |
| 2008 | Cronan 2008 | Predictors of mammography screening | Predictors of mammography screening among ethnically diverse low-income women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Regional | Private Survey | Local data | Background and purpose: Breast cancer is the second leading cause of cancer deaths among women in the United States. Minority women are less likely to be screened and more likely to die from breast cancer than are Caucasian women. Although some studies have examined ethnic disparities in mammography screening, no study has examined whether there are ethnic disparities among low-income, ethnically diverse women. The present study was designed to determine whether there are ethnic disparities in mammography screening and predictors of screening among low-income African American, Mexican American, and Caucasian women, and to determine whether the disparities and predictors vary across ethnic groups. Methods: The participants were 146 low-income women who were Mexican American (32%), African American (31%), or Caucasian (37%). Statistical analyses were performed to assess the relationships between mammography screening during the past 2 years and potential predictors of screening, both within ethnic groups and for the combined sample. Results: The results varied depending on whether analyses combined ethnic groups or were performed within each of the three ethnic groups. Conclusions: It is, therefore, important to examine within-group differences when examining ethnic disparities in predictors of mammography. | |
| 2022 | Dontchos 2022 | Disparities in Same-Day Diagnostic | Disparities in Same-Day Diagnostic Imaging in Breast Cancer Screening: Impact of an Immediate-Read Screening Mammography Program Implemented During the COVID-19 Pandemic | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | BACKGROUND: The need for second visits between screening mammography and diagnostic imaging contributes to disparities in the time to breast cancer diagnosis. During the COVID-19 pandemic, an immediate-read screening mammography program was implemented to reduce patient visits and decrease time to diagnostic imaging. OBJECTIVE: The purpose of this study was to measure the impact of an immediate-read screening program with focus on disparities in same-day diagnostic imaging after abnormal findings are made at screening mammography. METHODS. In May 2020, an immediate-read screening program was implemented whereby a dedicated breast imaging radiologist interpreted all screening mammograms in real time; patients received results before discharge; and efforts were made to perform any recommended diagnostic imaging during the visit (performed by different radiologists). Screening mammographic examinations performed from June 1, 2019, through October 31, 2019 (preimplementation period), and from June 1, 2020, through October 31, 2020 (postimplementation period), were retrospectively identified. Patient characteristics were recorded from the electronic medical record. Multivariable logistic regression models incorporating patient age, race and ethnicity, language, and insurance type were estimated to identify factors associated with same-day diagnostic imaging. Screening metrics were compared between periods. RESULTS: A total of 8222 preimplementation and 7235 postimplementation screening examinations were included; 521 patients had abnormal screening findings before implementation, and 359 after implementation. Before implementation, 14.8% of patients underwent same-day diagnostic imaging after abnormal screening mammograms. This percentage increased to 60.7% after implementation. Before implementation, patients who identified their race as other than White had significantly lower odds than patients who identified their race as White of undergoing same-day diagnostic imaging after receiving abnormal screening results (adjusted odds ratio, 0.30; 95% CI, 0.100.86; p = .03). After implementation, the odds of same-day diagnostic imaging were not significantly different between patients of other races and White patients (adjusted odds ratio, 0.92; 95% CI, 0.501.71; p = .80). After implementation, there was no significant difference in race and ethnicity between patients who underwent and those who did not undergo same-day diagnostic imaging after receiving abnormal results of screening mammography (p > .05). The rate of abnormal interpretation was significantly lower after than it was before implementation (5.0% vs 6.3%; p < .001). Cancer detection rate and PPV1 (PPV based on positive findings at screening examination) were not significantly different before and after implementation (p > .05). CONCLUSION: Implementation of the immediate-read screening mammography program reduced prior racial and ethnic disparities in same-day diagnostic imaging after abnormal screening mammograms. CLINICAL IMPACT: An immediate-read screening program provides a new paradigm for improved screening mammography workflow that allows more rapid diagnostic workup with reduced disparities in care. | |
| 2019 | Duggan 2019 | County of Residence and Screening | County of Residence and Screening Practices among Latinas and Non-Latina Whites in Two Rural Communities | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Hispanic | Regional | Private Survey | Local data | OBJECTIVES: Latinas are less likely than non-Latina Whites (NLW) to utilize mammographic screening and are more likely to be diagnosed with late-stage breast cancer. Here, we examine the effects of county-level factors on guideline-concordant breast-cancer screening behaviors in Latinas and NLWs. DESIGN: Latinas (N=108) and NLW women (N=132) aged >40 years, residing in two adjacent rural, medically underserved counties in eastern Washington State, completed a baseline questionnaire on mammography utilization and demographics. MAIN OUTCOME MEASURES: Differences in socioeconomic variables and knowledge of screening practices were examined by ethnicity and county of residence. Predictors of having had a mammogram within the past two years were analyzed using multivariate logistic regression. RESULTS: Ethnicity was not associated with having a guideline-concordant mammogram; however, age (odds ratio [OR]=1.04, 95%CI:1.01-1.08); having >12 years of education (OR=2.09, 95%CI:1.16-3.79); having a regular clinic for health care (OR=2.22, 95%CI:1.05-4.70); having had a prior clinical breast exam (OR=5.07, 95%CI:1.71-15.02), and county of residence (OR=2.27, 95%CI:1.18-4.37) were all associated with having had a guideline-concordant mammogram. CONCLUSIONS: County of residence and having had a prior CBE were strong predictors of screening utilization. Community-level factors in medically underserved areas may influence screening patterns. | |
| 2020 | Ezratty 2020 | Racial/ethnic differences in | Racial/ethnic differences in supplemental imaging for breast cancer screening in women with dense breasts | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | Background: Mammography is limited when analyzing dense breasts for 2 reasons: (1) breast density masks underlying cancers and (2) breast density is an independent risk factor for cancer. We undertook this study to assess whether there is a racial/ethnic difference in supplemental image ordering for women with dense breasts. Methods: We conducted a retrospective, observational cohort study of women aged 50-75 from an academic medical center who had completed a screening mammogram between 2014 and 2016 that was read as BI-RADS 1 with heterogeneously or extremely dense breasts or BI-RADS 2 with extremely dense breasts. Data were abstracted on type, timing and frequency of supplemental imaging tests ordered within two years of an initial screening mammogram. Patient characteristics (age, race/ethnicity, insurance, and comorbidities) were also abstracted. We used bivariate and multivariate logistic regression to assess for differences in supplemental imaging ordered by race/ethnicity. Results: Three hundred twenty-six women met inclusion criteria. Mean age was 58years: 25% were non-Hispanic white, 30% were non-Hispanic black, 27% were Hispanic, 6% were Asian and 14% unknown. Seventy-nine (24%) women were ordered a supplemental breast ultrasound after the initial screening mammogram. Non-Hispanic black and Hispanic women were less likely to have supplemental imaging ordered compared to non-Hispanic white women (15% and 10%, respectively, vs. 45%, p < 0.0001). After controlling for patient age, ordering physician specialty, insurance, BI-RADS score, breast density, and family history of breast cancer, non-Hispanic black and Hispanic women remained less likely to be ordered supplemental imaging (OR 0.38 [95% CI 0.17-0.85] and OR 0.24 [95% CI 0.10-0.61], respectively, p < 0.0001). Conclusion: Minority women with dense breasts are less likely to be ordered supplemental breast imaging. Further research should investigate physician and patient behaviors to determine barriers in supplemental imaging. Understanding these differences may help reduce disparities in breast cancer care and mortality. | |
| 2019 | Flores 2019 | Impact of Primary Care Physician | Impact of Primary Care Physician Interaction on Longitudinal Adherence to Screening Mammography Across Different Racial/Ethnic Groups | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | Purpose: Regular contact with a primary care physician (PCP) is associated with increased participation in screening mammography. Older studies suggested that PCP interaction may have a smaller effect on screening mammography uptake among racial and ethnic minorities compared with whites, but there is limited contemporary evidence about the effect of PCP interaction on screening mammography uptake across different racial and ethnic groups. The purpose of this study was to evaluate the association between PCP contact and longitudinal adherence with screening mammography guidelines over a 10-year period across different racial/ethnic groups. Methods: This HIPAA-compliant and institutional review board-approved retrospective single-institution study included women between the ages of 50 and 64 years who underwent screening mammography in the calendar year of 2005. The primary outcome of interest was adherence to recommended screening mammography guidelines (yes or no) at each 2-year interval from their index screening mammographic examination in 2005 until 2015. Patients were defined as having a high level of PCP interaction if their PCPs were listed in the electronic medical record within the top three providers with whom the patients had the most visits during the study period. Generalized estimating equation models were used to estimate the effect of high PCP interaction on screening mammography adherence while adjusting for correlated observations and patient characteristics. Results: Patients in the high PCP interaction group had increased longitudinal adherence to recommended screening mammography (adjusted odds ratio [OR], 1.51; 95% confidence interval [CI], 1.42-1.73; P <.001). This was observed in stratified analyses for all self-reported racial groups, including white (adjusted OR, 1.51; 95% CI, 1.36-1.68; P <.001), black (adjusted OR, 1.93; 95% CI, 1.31-2.86; P =.001), Hispanic (adjusted OR, 1.92; 95% CI, 1.27-2.87; P =.002), Asian (adjusted OR, 1.55; 95% CI, 1.01-2.39; P =.045), and other (adjusted OR, 2.18; 95% CI, 1.32-3.56; P =.002), with no evidence of effect modification by race/ethnicity (P =.342). Medicaid (adjusted OR, 0.41; 95% CI, 0.31-0.53) and self-pay or other (adjusted OR, 0.39; 95% CI, 0.27-0.56) insurance categories were associated with decreased longitudinal adherence to recommended screening mammography (P <.001 for both). Conclusions: High levels of PCP interaction result in similar improvements in longitudinal screening mammography adherence for all racial/ethnic minority groups. Future efforts will require targeted outreach to assist Medicaid and uninsured patient populations overcome barriers to screening mammography adherence. | |
| 2021 | Flores 2021 | Analysis of socioeconomic and | Analysis of socioeconomic and demographic factors and imaging exam characteristics associated with missed appointments in pediatric radiology | Pediatric Only | All Sexes | Outpatient Ambulatory and Primary Care | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | EHR | Local data | BACKGROUND: Missed appointments can have an adverse impact on health outcomes by delaying appropriate imaging, which can be critical in influencing treatment decisions. OBJECTIVE: To assess for socioeconomic and imaging exam factors associated with missed appointments among children scheduled for diagnostic imaging. MATERIALS AND METHODS: We retrospectively analyzed children (< 18 years) scheduled for outpatient diagnostic imaging during a 12-month period. In doing so, we obtained socioeconomic and radiology exam characteristics (modality, intravenous contrast administration, radiation and use of sedation) data from the electronic medical record. We employed multivariate logistic regression to assess the association of socioeconomic, demographic and imaging exam characteristics with imaging missed appointments. RESULTS: In total, 7,275 children met inclusion criteria. The mean age was 8.8 years (standard deviation [SD] = 6.2 years) and the study population consisted of 52% female gender, 69% White race, 38% adolescent age group and 32% with a median household income by ZIP-code category of <$50,000. Logistic regression showed increased likelihood of missed appointments among children of Black/African-American race (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.42.5); with insurance categories including Medicaid (OR=2.0; 95% CI=1.62.4), self-pay (OR=2.1; 95% CI=1.33.6) and other (OR=2.7; 95% CI=1.35.4); with < $50,000 median household income by ZIP-code category (OR=1.7; 95% CI=1.42.0); and with examination wait time of 721 days (OR=2.7; 95% CI=2.13.5) and > 21 days (OR=3.7; 95% CI=2.94.8). The use of radiation, intravenous contrast agent or sedation was not associated with increased likelihood of missed appointments. CONCLUSION: Expanding our knowledge of how different socioeconomic and imaging-related factors influence missed appointments among children can serve as a foundational step to better understand existing and emerging disparities and inform strategies to advance health equity efforts in radiology. | |
| 2017 | Glover 2017 | Socioeconomic and Demographic | Socioeconomic and Demographic Predictors of Missed Opportunities to Provide Advanced Imaging Services | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | EHR | Local data | Purpose: The extent to which racial and socioeconomic disparities exist in accessing clinically appropriate, advanced diagnostic imaging has not been well studied. This study assesses the relationship between demographic and socioeconomic factors and the incidence of imaging missed care opportunities (IMCOs). Methods: We performed a retrospective review of outpatient CT and MRI appointments at a quaternary academic medical center and affiliated outpatient facilities during a 12-month period. Missed appointments not rescheduled in advance were classified as IMCOs. Appropriateness criteria scores and demographics were also obtained. Univariate and multivariate analyses were performed to determine if demographic and socioeconomic factors were predictive of IMCOs. Results: Overall, 57,847 patients met inclusion criteria, representing 89,943 scheduled unique imaging appointments of which 5,840 (6.1%) were IMCOs; 0.8% of IMCO appointments had low appropriateness scores compared with 1.2% of completed appointments (P < .01). Appointments covered by commercial insurance (5.2%) had significantly lower rate of IMCOs than other payers: Medicare = 6.3%, Medicaid = 14.5%, self-pay = 12.0% (P < .05). The following factors were independent predictors of a patient having >= 1 IMCO: noncommercial insurance [odds ratio (OR) = 1.7-2.6], African American (OR = 1.8), Hispanic (OR = 1.2), other race (OR = 1.1), language other than English or Spanish (OR = 1.2), male gender (OR = 1.2), age >= 65 (OR = 0.71), and median household income of patient home zip code <$50,000 (OR = 1.4). Conclusions: Race and socioeconomic status are independent predictors of IMCOs. In efforts to enhance patient engagement, radiologists should be aware of the impact of race and socioeconomic status on access to clinically appropriate advanced diagnostic imaging. | |
| 2011 | Gould 2011 | Disparities in lung cancer staging | Disparities in lung cancer staging with positron emission tomography in the cancer care outcomes research and surveillance (cancors) study | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | Regional | Disease Registry | Local data | Introduction: Disparities in treatment exist for nonwhite and Hispanic patients with non-small cell lung cancer, but little is known about disparities in the use of staging tests or their underlying causes. Methods: Prospective, observational cohort study of 3638 patients with newly diagnosed non-small cell lung cancer from 4 large, geographically defined regions, 5 integrated health care systems, and 13 VA health care facilities. Results: Median age was 69 years, 62% were men, 26% were Hispanic or nonwhite, 68% graduated high school, 50% had private insurance, and 41% received care in the VA or another integrated health care system. After adjustment, positron emission tomography (PET) use was 13% lower among nonwhites and Hispanics than non-Hispanic whites (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.77-0.97), 13% lower among those with Medicare than those with private insurance (RR 0.87, 95% CI 0.76-0.99), and 24% lower among those with an elementary school education than those with a graduate degree (RR 0.76, 95% CI 0.57-0.98). Disparate use of PET was not observed among patients who received care in an integrated health care setting, but the association between race/ethnicity and PET use was similar in magnitude across all other subgroups. Further analysis showed that income, education, insurance, and health care setting do not explain the association between race/ethnicity and PET use. CONCLUSIONS:: Hispanics and nonwhites with non-small cell lung cancer are less likely to receive PET imaging. This finding is consistent across subgroups and not explained by differences in income, education, or insurance coverage. | |
| 2006 | Hamrick 2006 | Health care disparities in | Health care disparities in postmenopausal women referred for DXA screening | Adult Only | Female | Outpatient Ambulatory and Primary Care | Osteoporosis Screening | United States | Black | Single Institution | EHR | Local data | Background: Racial disparities have been identified in a number of areas in clinical medicine. Limited data are available on osteoporosis screening rates between races. We assessed the racial distribution in Dual Energy X-ray Absorptiometry (DXA) screening rates among African American and Caucasian women referred from our primary care clinics. Methods: We obtained DXA results during the years 1998-2002 for all 546 women ages >= 50 years referred for bone mineral density (BMD) testing from a primary care population. We compared the DXA screening rates between African American and Caucasian women with the racial demographics of the referring primary care clinic population. Results: African American women represented 45.9% and Caucasian women 51.7% of our primary care clinic population. Yet, only 14.5% (n = 79) of the DXA screened women were African American, while 82.8% (n = 452) were Caucasian. Age and recognized risk factors only explained a small portion of this difference. In women 65 years and older with universal screening recommendations, 19.4% (n = 46) of the screened women were African American, and 80.6% (n = 191) were Caucasian. The prevalence of osteoporosis was similar in both populations, 21.5% and 20.1% for African American and Caucasian women, respectively. Conclusions: Significantly fewer African American women had BMD screening even though national guidelines do not differentiate by race. The large disparity between the proportion of African American and Caucasian women screened calls for more equitable BMD screening among races. | |
| 2012 | Hamrick 2012 | Osteoporosis Healthcare Disparities | Osteoporosis Healthcare Disparities in Postmenopausal Women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Osteoporosis Screening | United States | Black | Single Institution | EHR | Local data | Background: Previous studies in referral populations have shown that fewer African American women complete dual-energy x-ray absorptiometry (DXA) screening and are prescribed medications for osteoporosis. This study examines if these disparities exist in primary care practices. Methods: Of 4748 eligible women >= 60 years of age in primary care practices, we randomly selected 500 African American and 500 Caucasian women. We compared the DXA screening referral rate and results, follow-up rate, and medication prescribing for low bone mineral density (BMD) between African American and Caucasian women and analyzed provider demographics. We used logistic regression analysis to control confounding variables, such as age and BMI. Results: Among the initial 1000 women, only 29.8% African American Women were referred to DXA compared to 38.4% Caucasian women (p < 0.05), and 20.8% African American vs. 27.0% Caucasian (p < 0.05) women completed the test. Among women with a diagnosis of osteoporosis, African Americans were less likely to receive medication (79.6% vs. 89.2%, p < 0.05), without a difference in follow-up visit pattern between races. Female providers were more likely to refer women for DXA (27.7%) than male providers (21.7%) (p = 0.035), and this gender difference in referral was more pronounced for African American patients. Conclusions: Not enough eligible women are being screened and treated for osteoporosis in primary care. Even fewer African American women receive DXA screenings and are treated for osteoporosis. Controlling for age and BMI attenuated but did not eliminate the difference. Female providers were more likely than male providers to refer women for DXA. | |
| 2009 | Harris 2009 | Disparities in use of computed | Disparities in use of computed tomography for patients presenting with headache | Adult Only | All Sexes | Emergency Department | Neurologic | United States | Multiple Groups | Single Institution | EHR | Local data | Objective: Headache is a common presenting complaint in the emergency department (ED). Physicians may choose to screen for causes of headache using computed tomography (CT). It is not known whether patient characteristics influence this decision. This study sought to identify patient demographic factors associated with CT evaluation for adult patients with headache. Methods: This study used a retrospective cohort review at an academic, urban ED. Study eligibility was based on chief complaint of headache and final diagnosis of the same. Detailed demographic (age, sex, race/ethnicity, insurance) and clinical (Emergency Severity Index [ESI], Charlson comorbidity score, pain score) data were abstracted from the ED medical record. The main outcome studied was whether a head CT was part of clinical evaluation. Results: One hundred fifty-five patients were reviewed. Mean age was 42 years (SD, 18 years); 75% female, 17% white, 41% black, and 33% Hispanic; 73% were insured; mean ESI was 3.06 (SD, 0.64); and Charlson score was 0.60 (SD, 1.55). Thirty-seven percent of patients underwent head CT. In multivariable analyses, patients were more likely to undergo head CT if they had greater acuity (ESI < or = 3; odds ratio [OR], 5.11; P < .01) but were less likely to undergo head CT if they were black (OR, 0.21; P < .01) when adjusting for each other as well as older age, sex, comorbidity, insurance status, and history of migraine. Conclusion: In this study, patients who were black were significantly less likely to undergo head CT during their ED evaluation for headache, independent of clinical and demographic factors. | |
| 2016 | Haviland 2016 | Racial and ethnic disparities in | Racial and ethnic disparities in universal cervical length screening with transvaginal ultrasound | Adult Only | Female | Outpatient Ambulatory and Primary Care | Prenatal | United States | Multiple Groups | Single Institution | EHR | Local data | Objective: Determine if race or ethnicity is associated with missed or late transvaginal cervical length screening in a universal screening program. Methods: Retrospective cohort study of nulliparous women with singleton gestations and a fetal anatomical ultrasound from 16-24 weeks gestation from January 2012 to November 2013. We classified women into mutually exclusive racial and ethnic groups: non-Hispanic black (black), Hispanic, Asian, non-Hispanic white (white), and other or unknown race. We used log-binomial regression to calculate the risk ratio (RR) and 95% confidence interval (CI) of missed or late ( 20 weeks' gestation) screening versus optimally timed screening between the different racial and ethnic groups. Results: Among the 2967 women in our study population, 971 (32.7%) had either missed or late cervical length screening. Compared to white women, black (RR: 1.3; 95% CI: 1.1-1.5) and Hispanic (RR:1.2; 95% CI: 1.01-1.5) women were more likely to have missed or late screening. Among women screened, black (versus white) women were more likely to be screened late (RR: 2.2; 95% CI: 1.6-3.1). Conclusions: Black and Hispanic women may be more likely to have missed or late cervical length screenings. | |
| 2001 | Hiatt 2001 | Community-based cancer screening | Community-based cancer screening for underserved women: design and baseline findings from the Breast and Cervical Cancer Intervention Study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Regional | Private Survey | Local data | BACKGROUND: Underutilization of breast and cervical cancer screening has been observed in many ethnic groups and underserved populations. Effective community-based interventions are needed to eliminate disparities in screening rates and thus to improve prospects for survival. METHODS: The Breast and Cervical Cancer Intervention Study was a controlled trial of three interventions in the San Francisco Bay Area from 1993 to 1996: (1) community-based lay health worker outreach; (2) clinic-based provider training and reminder system; and (3) patient navigator for follow-up of abnormal screening results. Study design and a description of the interventions are reported along with baseline results of a household survey conducted in four languages among 1599 women, aged 40-75. RESULTS: Seventy-six percent of women ages 40 and over had had at least one mammogram, and most had had a clinical breast examination (88%) and Pap smear (89%). Rates were significantly lower for non-English-speaking Latinas and Chinese women (56 and 32%, respectively, for mammography), and maintenance screening (three mammograms in the past 5 years) varied from 7% (non-English-speaking Chinese) to 53% (Blacks). Pap smear screening in the past 3 years was low among non-English-speaking Latinas (72%) and markedly lower among non-English-speaking Chinese women (24%). The strongest predictors of screening behavior were having private health insurance and frequent use of medical services. Having a regular clinic and speaking English were also important. Race/ethnicity, education, household income, and employment status were, overall, not significant predictors of screening behavior. CONCLUSIONS: These baseline results support the importance of cancer screening interventions targeted to persons of foreign origin, particularly those less acculturated. | |
| 2020 | Hoge 2020 | Racial disparity in the utilization | Racial disparity in the utilization of multiparametric MRI-ultrasound fusion biopsy for the detection of prostate cancer | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | Single Institution | EHR | Local data | BACKGROUND: Black men have significantly higher incidence and are up to three times more likely to die of prostate cancer (PCa) than White men. Multiparametric magnetic resonance imaging-ultrasound fusion biopsy (FBx) has emerged as a promising modality for the detection of PCa. The goal of our study is to identify differences in utilization of FBx between Black and White men presenting with suspicion of PCa. METHODS: We performed a retrospective review of Black and White men who presented with suspicion of PCa and required biopsy from January 2014 to December 2018. Multivariate logistic regression analysis was done to study the influence of race on the utilization of FBx. RESULTS: Six hundred nineteen (Black: 182, White: 437) men were included in the study. Forty-one out of 182 (22.5%) Black men underwent FBx compared with 225/437 (51.5%) of White men (P < 0.001). After adjusting for age, race, prostate-specific antigenlevel, digital rectal exam, family history of PCa and health insurance provider, Black race was found to be a significant negative predictor of obtaining FBx (OR:0.32, 95% CI: 0.21-0.51, P < 0.001). Black race stayed an independent negative predictor (OR: 0.36, 95% CI: 0.20-0.64, P < 0.001) in the cohort of patients who were biopsy nave; however, although reduced, there was no significant difference in the cohort with a prior negative biopsy (OR: 0.51, 95% CI: 0.19-1.36, P = 0.179). CONCLUSIONS: Although FBx is a superior modality for early detection of PCa, we found that Black men were less likely to undergo FBx when presenting with PCa suspicion. Further investigation is needed to evaluate if this difference is patient preference or if there are underlying socioeconomic, cultural or provider biases influencing this disparity. | |
| 2016 | Horner 2016 | Variation in advanced imaging for | Variation in advanced imaging for pediatric patients with abdominal pain discharged from the ED | Pediatric Only | All Sexes | Emergency Department | GI/Abdominal | United States | Black | Multi-Institution | EHR | Local data | Background: Pediatric abdominal pain visits to emergency departments (ED) are common. The objectives of this study are to assess variation in imaging (ultrasound computed tomography [CT]) and factors associated with isolated CT use. Methods: This was a retrospective cohort study of ED visits for pediatric abdominal pain resulting in discharge from 16 regional EDs from 2007 to 2013. Primary outcome was ultrasound or CT imaging. Secondary outcome was isolated CT use. We used multivariable logistic regression to evaluate patient- and hospital-level covariates associated with imaging. Results: Of the 21 152 visits, imaging was performed in 29.7%, and isolated CT in 13.4% of visits. In multivariable analysis, black patients (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.4-0.5) and Medicaid (OR, 0.6; 95% CI, 0.5-0.7) had lower odds of advanced imaging compared with white patients and private insurance, respectively. General EDs were less likely to perform imaging (OR, 0.6; 95% CI, 0.5-0.7) compared with the pediatric ED; however, for visits with imaging, 3.5% of visits to the pediatric ED compared with 76% of those to general EDs included an isolated CT (P<.001). Low pediatric volume (OR, 1.8; 95% CI, 1.5-2.2) and rural (OR,1.8; 95% CI, 1.3-2.5) EDs had higher odds of isolated CT use, compared with higher pediatric volumes and nonrural EDs, respectively. Conclusion: There are racial and insurance disparities in imaging for pediatric abdominal pain. General EDs are less likely than pediatric EDs to use imaging, but more likely to use isolated CT. Strategies are needed to minimize disparities and improve the use of "ultrasound first." | |
| 2017 | Japuntich 2018 | Racial Disparities in Lung Cancer | Racial Disparities in Lung Cancer Screening: An Exploratory Investigation | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Black | Single Institution | Private Survey | Local data | Background/Purpose: Lung cancer is the leading cause of cancer death in the United States. Black Americans have the highest rate of lung cancer mortality, due to being diagnosed at later stage. Lung Cancer Screening (LCS) facilitates earlier detection and has been associated with a reduction in cancer death. We investigated LCS utilization and explored racial disparities (Black vs. non-Black) in LCS among patients for whom LCS is clinically indicated. Methods: Using electronic medical records from the Lifespan Medical System, we randomly selected 200 patients who were likely to meet U. S. Preventive Services Taskforce (USPSTF) guidelines for LCS and mailed each patient a survey to assess LCS eligibility and uptake. Results: Nearly three-quarters (n = 146, 73%) completed the survey and, of survey respondents, 92% (n = 134) were eligible for the study. Among eligible patients, 35% met criteria for LCS; non-Black patients were 90% more likely to meet criteria for LCS than Black patients (44% vs. 27%). Of the patients meeting USPSTF criteria, only 21% reported being screened; eligible non-Black patients were 2.8 times more likely to have had LCS than eligible Black patients (30% vs. 12%). Conclusions: LCS utilization is low despite coverage provided through the Affordable Care Act. Black patients are less likely to qualify for screening and disproportionately less likely to be screened for lung cancer compared with non-Black patients. Targeted intervention strategies are needed to increase referral for and uptake of LCS in patients who are at high risk for developing lung cancer, and for Black patients in particular. | |
| 2021 | Jones 2021 | Racial/ethnic disparities in | Racial/ethnic disparities in management of acute gastroenteritis in a pediatric emergency department | Pediatric Only | All Sexes | Emergency Department | GI/Abdominal | United States | Multiple Groups | Single Institution | EHR | Local data | NA | |
| 2013 | Kempe 2013 | Breast Cancer screening in an | Breast Cancer screening in an insured population: Whom are we missing? | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Multi-Institution | EHR | Local data | Introduction: Kaiser Permanente Colorado is an integrated health care system that uses automatic reminder programs and reduces barriers to access preventive services, including financial barriers. Breast cancer screening rates have not improved during the last five years, and rates differ between subgroups: for example, black and Latina women have lower rates of mammography screening than other racial groups. Methods: We retrospectively evaluated data from 47,946 women age 52 to 69 years who had continuous membership for 24 months but had not undergone mammography. Poisson regression models estimated relative risk for the impact of self-identified race/ethnicity, socioeconomic characteristics, health status, and use of health care services on screening completion. Results: The distribution of race/ethnicity among unscreened women was 55.5% white, 7.0% Latina, and 3.7% black, but race/ethnicity data were missing for 29%. Of these, no record of race/ethnicity was available for 86.7%, and for 5.1%, the data request was recorded but the women declined to identify their race/ethnicity. Nonwhite ethnicity increased risk of screening failure if black, Latina, "other" (eg, American Indian), or missing race/ethnicity. Population-attributable risks were low for minorities compared with the group for whom race/ethnicity data was missing. A greater number of office visits in any setting was associated with greater likelihood of undergoing mammography. Women with missing race/ethnicity data had fewer visits and were less likely to have an identified primary care physician. Conclusions: Greater improvement in mammography screening rates could be achieved in our population by increasing screening among women with missing race/ethnicity data, rather than by targeting those who are known to be of racial/ethnic minorities. Efforts to address screening disparities have been refocused on inreach and outreach to our "missing women." | |
| 2022 | Kim 2022 | Racial Disparities in Adherence to | Racial Disparities in Adherence to Annual Lung Cancer Screening and Recommended Follow-up Care: A Multicenter Cohort Study | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Multiple Groups | Multi-Institution | EHR | Local data | RATIONALE: Black patients receive recommended lung cancer screening (LCS) follow-up care less frequently than White patients, but it is unknown if this racial disparity persists across both decentralized and centralized LCS programs. OBJECTIVES: To determine adherence to American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS) recommendations among individuals undergoing LCS at either decentralized or centralized programs, and to evaluate the association of race with LCS adherence. METHODS: We performed a multicenter retrospective cohort study of patients receiving LCS at five heterogeneous U.S. healthcare systems. We calculated adherence to annual LCS among patients with a negative baseline screen (Lung-RADS 1 or 2) and recommended follow-up care among those with a positive baseline screen (Lung-RADS 3, 4A, 4B, or 4X) stratified by type of LCS program and evaluated the association between race and adherence using multivariable modified Poisson regression. RESULTS: Of the 6,134 total individuals receiving LCS, 5,142 (83.8%) had negative baseline screens, and 992 (16.2%) had positive baseline screens. Adherence to both annual LCS (34.8% vs 76.1%; P<0.001) and recommended follow-up care (63.9% vs 74.6%; P<0.001) was lower at decentralized compared to centralized programs. Among individuals with negative baseline screens, a racial disparity in adherence was observed only at decentralized screening programs (interaction term, P<0.001). At decentralized programs, Black race was associated with 27% reduced adherence to annual LCS (adjusted relative risk [aRR], 0.73; 95% CI, 0.63-0.84) while at centralized programs, no effect by race was observed (aRR, 0.98; 95% CI, 0.91-1.05). In contrast, among those with positive baseline screens, there was no significant difference by race for adherence to recommended follow-up care by type of LCS program (decentralized aRR, 0.95; 95% CI, 0.81-1.11; centralized aRR, 0.81; 95% CI, 0.71-0.93; interaction term, P=0.176). CONCLUSIONS: In this large multicenter study of individuals screened for lung cancer, adherence to both annual LCS and recommended follow-up care was greater at centralized screening programs. Black patients were less likely to receive annual LCS compared to White patients at decentralized compared to centralized LCS programs. Our results highlight the need for further study of healthcare system-level mechanisms to optimize longitudinal LCS care. | |
| 2011 | Kristiansen 2012 | Participation in mammography | Participation in mammography screening among migrants and non-migrants in Denmark | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Denmark | Immigrants | National | Disease Registry | Local data | BACKGROUND: Inequality in use of mammography screening across population groups is a concern since migrants are more likely to become non-users compared to the general population. The aim of this study was to a) identify determinants of participation among migrant groups and Danish-born women with emphasis on the effect of household size, socioeconomic position and use of healthcare services, and b) test whether effects of determinants were consistent across migrant and non-migrant groups. MATERIAL AND METHODS: We used data from the first eight invitation rounds of the mammography screening programme in Copenhagen, Denmark (1991-2008) in combination with register-based data. RESULTS: The crude odds ratio (OR) for not participating in mammography screening was 1.38 (95% CI, 1.30-1.46) for women born in other-Western and 1.80 (95% CI, 1.71-1.90) for women born in non-Western countries compared to Danish-born women. The adjusted OR was 1.14 (95% CI, 1.06-1.21) for other-Western and 1.19 (95% CI, 1.11-1.27) for women born in non-Western countries. Lack of contact with a general practitioner or dental services, and not being employed had a significant negative effect on use of mammography screening. Higher-educated women were significantly less likely to use mammography screening in all groups whilst hospitalisation had a significant effect among Danish-born women. Living alone was consistently associated with non-use of mammography screening. The probability of becoming a non-user was significantly less among women living within households of two to four persons compared to women living alone. Except in the case of age and hospitalisation, trends were similar across country of birth, but the relative importance of specific determinants in explaining use of mammography screening differed. CONCLUSION: Household size, socioeconomic position and use of healthcare services were determinants of participation in mammography screening. This study emphasises the need for conducting refined analyses distinguishing among subgroups within diverse populations when explaining differences in screening behaviour. | |
| 2020 | Lacson 2020 | Factors Associated With Optimal | Factors Associated With Optimal Follow-up in Women With BI-RADS 3 Breast Findings | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | Disease Registry | Local data | Objective: Assess rate of and factors associated with optimal follow-up in patients with BI-RADS 3 breast findings. Methods: This Institutional Review Board-approved, retrospective cohort study, performed at an academic medical center, included all women undergoing breast imaging (ultrasound and mammography) in 2016. Index reports for unique patients with an assessment of BI-RADS 3 (retrieved via natural language processing) comprised the study population. Patient-specific and provider-related features were extracted from the Research Data Warehouse. The Institutional Cancer Registry identified patients diagnosed with breast cancer. Optimal follow-up rate was calculated as patients with follow-up imaging on the same breast 3 to 9 months from the index examination among patients with BI-RADS 3 assessments. Univariate analysis and multivariable logistic regression determined features associated with optimal follow-up. Malignancy rate and time to malignancy detection were recorded. Results: Among 93,685 breast imaging examinations, 64,771 were from unique patients of which 2,967 had BI-RADS 3 findings (4.6%). Excluding patients with off-site index examinations and those with another breast examination <3 months from the index, 1,125 of 1,511 patients (74%) had optimal follow-up. In univariate and multivariable analysis, prior breast cancer was associated with optimal follow-up; younger age, Hispanic ethnicity, divorced status, and lack of insurance were associated with not having optimal follow-up. Malignancy rate was 0.86%, and mean time to detection was 330 days. Discussion: Follow-up of BI-RADS 3 breast imaging findings is optimal in only 74% of women. Further interventions to promote follow-up should target younger, unmarried women, those with Hispanic ethnicity, and women without history of breast cancer and without insurance coverage. | |
| 2021 | Lagerlund 2021 | Population-based mammography | Population-based mammography screening attendance in Sweden 2017-2018: A cross-sectional register study to assess the impact of sociodemographic factors | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Sweden | Immigrants | Multi-Institution | Government Survey | Local data | Sweden has a population-based mammography screening programme for women aged 40-74. The objective of this study was to examine the association between mammography screening attendance and sociodemographic factors in 15 of Sweden's 21 health care regions. Register-based information was collected on all mammography screening invitations and attendance during 2017 and 2018, and linked to individual-level sociodemographic data from Statistics Sweden. Odds ratios (ORs) and 95% confidence intervals (CIs) for attendance were computed by sociodemographic factor. The study sample included 1.5 million women, aged 40-75, with an overall screening attendance of 81.3%. The lowest odds of attending were found for women living without a partner (OR=0.52, 95% CI: 0.52-0.53), low-income women(OR=0.57, 95% CI: 0.56-0.57), and non-Nordic women born in Europe (OR=0.60, 95% CI: 0.59-0.61). Other groups with lower odds of attending were women whose main source of income was social assistance or benefits (OR=0.62, 95% CI: 0.62-0.63), those not owning their home (OR=0.66, 95% CI: 0.66-0.67), and those with low level of education (OR=0.72, 95% CI: 0.71-0.73). Having multiple of these sociodemographic characteristics further lowered the odds of attending. Although overall mammography screening attendance in Sweden is high, sociodemographic inequalities exist, and efforts should be made to address these. Particular attention should be given to low-income women who live without a partner. | |
| 2002 | Lane 2002 | Racial differences in the | Racial differences in the evaluation of pediatric fractures for physical abuse | Pediatric Only | All Sexes | Emergency Department | NAT | United States | Multiple Groups | Single Institution | EHR | Local data | Context: Child maltreatment is a significant problem within US society, and minority children have higher rates of substantiated maltreatment than do white children. However, it is unclear whether minority children are abused more frequently than whites or whether their cases are more likely to be reported. Objectives: To determine whether there are racial differences in the evaluation and Child Protective Services (CPS) reporting of young children hospitalized for fractures. Design, setting, and patients: Retrospective chart review conducted at an urban US academic children's hospital among 388 children younger than 3 years hospitalized for treatment of an acute primary skull or long-bone fracture between 1994 and 2000. Children with perpetrator-admitted child abuse, metabolic bone disease, birth trauma, or injury caused by vehicular crash were excluded. Main outcome measures: Ordering of skeletal surveys and filing reports of suspected abuse. Results: Reports of suspected abuse were filed for 22.5% of white and 52.9% of minority children (P<.001). Abusive injuries, as determined by expert review, were more common among minority children than among white children (27.6% vs 12.5%; P<.001). Minority children aged at least 12 months to 3 years (toddlers) were significantly more likely to have a skeletal survey performed compared with their white counterparts, even after controlling for insurance status, independent expert determination of likelihood of abuse, and appropriateness of performing a skeletal survey (adjusted odds ratio [OR], 8.75; 95% confidence interval [CI], 3.48-22.03; P<.001). This group of children was also more likely to be reported to CPS compared with white toddlers, even after controlling for insurance status and likelihood of abuse (adjusted OR, 4.32; 95% CI, 1.63-11.43; P =.003). By likelihood of abuse, differential ordering of skeletal surveys and reporting of suspected abuse were most pronounced for children at least 12 months old with accidental injuries; however, differences were also noted among toddlers with indeterminate injuries but not among infants or toddlers with abusive injuries. Minority children at least 12 months old with accidental injuries were more than 3 times more likely than their white counterparts to be reported for suspected abuse (for children with Medicaid or no insurance, relative risk [RR], 3.08; 95% CI, 1.37-4.80; for children with private insurance, RR, 3.74; 95% CI, 1.46-6.01). Conclusion: While minority children had higher rates of abusive fractures in our sample, they were also more likely to be evaluated and reported for suspected abuse, even after controlling for the likelihood of abusive injury. This suggests that racial differences do exist in the evaluation and reporting of pediatric fractures for child abuse, particularly in toddlers with accidental injuries. | |
| 2021 | Larsen 2021 | Addressing ethnic disparities in | Addressing ethnic disparities in imaging utilization and clinical outcomes for COVID-19 | Adult Only | All Sexes | Inpatient and Outpatient | Chest Pain Imaging | United States | Hispanic | Single Institution | EHR | Local data | PURPOSE: Racial and ethnic disparities have exacerbated during the COVID-19 pandemic as the healthcare system is overwhelmed. While Hispanics are disproportionately affected by COVID-19, little is known about ethnic disparities in the hospital settings. This study investigates imaging utilization and clinical outcomes between Hispanic and non-Hispanic COVID-19 patients in the Emergency Department (ED) and during hospitalization. METHODS: Through retrospective chart review, we included 331 symptomatic COVID-19 patients (mean age 53.2 years) at a metropolitan healthcare system from March to June 2020. Poisson regression was used to compare diagnostic imaging utilization and clinical outcomes between Hispanic and non-Hispanic patients. RESULTS: After adjusting for confounders, no statistically significant difference was found between Hispanic and non-Hispanic patients for the number of weekly chest X-rays. Results were categorized into four clinical outcomes: ED management (0.16 0.05 vs. 0.14 0.8, p: 0.79); requiring inpatient management (1.31 0.11 vs. 1.46 0.16, p: 0.43); ICU admission without invasive ventilation (1.4 0.17 vs. 1.35 0.26, p: 0.86); and ICU admission and ventilator support (3.29 0.22 vs. 3.59 0.37, p: 0.38). There were no statistically significant relative differences in adjusted prevalence rate between ethnic groups for all clinical outcomes (p > 0.05). There was a statistically significant longer adjusted length of stay (days) in non-Hispanics for two subcohorts: inpatient management (8.16 0.31 vs. 9.72 0.5, p < 0.01) and ICU admission without invasive ventilation (10.39 0.57 vs. 13.45 1.13, p < 0.01). CONCLUSIONS: For Hispanic and non-Hispanic COVID-19 patients in the ED or hospitalized, there were no statistically significant differences in imaging utilization and clinical outcomes. | |
| 2021 | Lawrence 2021 | Emergency Department Evaluation of | Emergency Department Evaluation of Abdominal Pain in Female Adolescents | Pediatric Only | Female | Emergency Department | General Diagnostic Imaging | United States | Black | Single Institution | EHR | Local data | STUDY OBJECTIVE: Evaluation of acute abdominal pain in an adolescent female patient should include consideration of all potential sources of pain, including gynecologic etiologies. The goal of our study was to determine the frequency of evaluation of gynecologic causes of abdominal pain in adolescent girls seen in a pediatric emergency department. STUDY DESIGN: A retrospective review was performed of girls between 12 and 21 years of age presenting to the emergency department or urgent care centers at a single pediatric institution with the chief complaint of abdominal pain during 2016. Frequency analyses of demographic and clinical characteristics are presented. RESULTS: A total of 1082 girls presented with a chief complaint of abdominal pain. Menarche was documented in 85% of patients, sexual history in 52% of patients, and assessment of contraception use in 28%. Pregnancy testing was performed in 77%. Sexually transmitted infection (STI) testing was performed in 31%, and in only 73% of patients who reported being sexually active. Imaging was performed in 52%. In the subgroup of patients who reported being sexually active and presented with abdominal pain and vaginal discharge, only 37% had a pelvic examination performed. In multivariable modeling, Black patients were significantly more likely than White patients to have STI testing performed (adjusted risk ratio [aRR]=1.39; confidence interval [CI]=1.13-1.70) and to undergo a pelvic examination (aRR=2.45; CI=1.34-4.50), and less likely to undergo imaging (aRR=0.69; CI=0.59-0.81). CONCLUSION: The assessment of abdominal pain in adolescent girls should include gynecologic etiologies. Our results raise concerns that there are deficiencies in the evaluation of gynecologic sources of abdominal pain in girls treated at pediatric facilities, and evidence of potential racial disparities. | |
| 2022 | Lehman 2022 | Screening Mammography Recovery | Screening Mammography Recovery After COVID-19 Pandemic Facility Closures: Associations of Facility Access and Racial and Ethnic Screening Disparities | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | BACKGROUND: Screening mammography facilities closed during the COVID-19 pandemic in spring 2020. Recovery of screening volumes has varied across patient sub-groups and facilities. OBJECTIVE: We compared screening mammography volumes and patient and facility characteristics between periods before COVID-19 and early and later postclosure recovery periods. METHODS: This retrospective study included screening mammograms performed in the same 2-month period (May 26-July 26) in 2019 (pre-COVID-19), 2020 (early recovery), and 2021 (late recovery after targeted interventions to expand access) and across multiple facility types (urban, suburban, community health center). Suburban sites had highest proportion of White patients and the greatest scheduling flexibility and expanded appointments during initial reopening. Findings were compared across years. RESULTS: For White patients, volumes decreased 36.6% from 6550 in 2019 (4384 in 2020) and then increased 61.0% to 6579 in 2021; for patients with races other than White, volumes decreased 53.9% from 1321 in 2019 (609 in 2020) and then increased 136.8% to 1442 in 2021. The percentage of mammograms in patients with races other than White was 16.8% in 2019, 12.2% in 2020, and 18.0% in 2021.The proportion performed at the urban center was 55.3% in 2019, 42.2% in 2020, and 45.9% in 2021; the proportion at suburban sites was 34.0% in 2019, 49.2% in 2020, and 43.5% in 2021. Pre-COVID-19 volumes were reached by the sixth week after reopening for suburban sites but were not reached during early recovery for the other sites. The proportion that were performed on Saturday for suburban sites was similar across periods, whereas the proportion performed on Saturday for the urban site was 7.6% in 2019, 5.3% in 2020, and 8.8% in 2021; the community health center did not offer Saturday appointments during recovery. CONCLUSION: After reopening, screening shifted from urban to suburban settings, with a disproportionate screening decrease in patients with races other than White. Initial delayed access at facilities serving underserved populations exacerbated disparities. Interventions to expand access resulted in late recovery volumes exceeding prepandemic volumes in patients with races other than White. CLINICAL IMPACT: Interventions to support equitable access across facilities serving diverse patient populations may mitigate potential widening disparities in breast cancer diagnosis during the pandemic. | |
| 2006 | Leong-Wu 2006 | Correlates of breast cancer | Correlates of breast cancer screening among Asian Americans enrolled in ENCOREplus | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Immigrants | National | Private Survey | Local data | This study examines the correlates of mammogram utilization among predominantly low income Asian American women using cross sectional data of women recruited through the ENCOREplus program (n = 1695) between July 1996 and June 1998. Logistic regression was used to examine the independent effect of variables corresponding to Andersen's behavioral model of health services utilization on mammography screening behavior. Foreign-born women living in the U.S. < 5 years and between 5 and 10 years were significantly less likely to have ever had a mammogram than women who were born in the U.S. (OR 0.22; CI 0.12, 0.40 and OR 0.48; CI 0.27, 0.86, respectively). Women 40-49 years old were half as likely to adhere to mammography screening recommendations as women 50-64 years (CI 0.33, 0.76). Health insurance was positively associated with adherence to mammography screening guidelines (OR 1.59; CI 1.02, 2.48). The results of this study highlight the need for health education about breast cancer and mammography among Asian American women. Policy work also needs to be directed toward improving access to health care in this community. | |
| 2014 | Levas 2014 | Effect of Hispanic ethnicity and | Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children | Pediatric Only | All Sexes | Emergency Department | GI/Abdominal | United States | Hispanic | Multi-Institution | EHR | Local data | OBJECTIVE: To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain. STUDY DESIGN: We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models. RESULTS: Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95). CONCLUSION: Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation. | |
| 2008 | Lian 2008 | Racial and geographic differences | Racial and geographic differences in mammography screening in St. Louis City: A multilevel study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Black | Regional | Private Survey | Local data | To examine racial differences in mammography use and its determinants in the City of St. Louis, MO, USA, we recruited women age 40 or older using randomdigit dialing to (1) examine the difference in mammography use between white women and African American women and (2) identify individual- and census-tract-level risk factors of nonadherence to mammography. During telephone interviews, we inquired about mammography use and several demographic, psychosocial, and health behavior variables. We determined the residential census tracts of study subjects using a geographic information system. The rate of mammography use was 68.0% among white women and 74.7% among African American women (P=0.022). African American women were more likely to have mammograms than white woman (adjusted odds ratio [OR]=1.71; 95% confidence interval [CI]=1.09-2.69). System-level barriers to mammography and heavy smoking were associated with lower mammography use among both white and African American women. Personal-experience barriers to mammography and no physician recommendation also were independently associated with mammography use among white women. White women residing within a historic geographic cluster area of late-stage breast cancer were less likely to have mammograms (adjusted OR=0.42, 95% CI=0.22-0.80), while African American women residing within a historic geographic cluster area of late-stage breast cancer were equally likely to have mammograms (adjusted OR=0.79, 95% CI=0.28-2.24). Neither individual nor census-tract-level socioeconomic status was associated with mammography screening. These findings suggest that there may be a greater need for increasing mammography use among white women, especially in the historic cluster area of latestage breast cancer in St. Louis. | |
| 2019 | Liao 2019 | Location, Location, Location: The | Location, Location, Location: The Association Between Imaging Setting and Follow-Up of Findings of Indeterminate Malignant Potential | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Incidental Finding Follow Up | United States | Black | Single Institution | EHR | Local data | Purpose: To evaluate the relationship between patient location at time of imaging and completion of relevant imaging follow-up for findings with indeterminate malignant potential. Methods: We used a mandatory hospital-wide standardized assessment categorization system to analyze all ultrasound, CT, and MRI examinations performed over a 7-month period. Multivariate logistic regression, adjusted for imaging modality, characteristics of patients, ordering clinicians, and interpreting radiologists, was used to evaluate the relationship between patient location (outpatient, inpatient, or emergency department)at the time of index examination and completion of relevant outpatient imaging follow-up. Results: Relevant follow-up occurred in 49% of index examinations, with a greater percentage among those performed in the outpatient setting compared with those performed in the inpatient or emergency department settings (62% versus 18% versus 17%, respectively). Compared with examinations obtained in the outpatient setting, examinations performed in the emergency department (adjusted odds ratio [aOR]0.07; 95% confidence interval [CI], 0.03-0.19)and inpatient (aOR 0.14; 95% CI, 0.09-0.23) settings were less likely to be followed up. Black patients and those residing in lower-income neighborhoods were also less likely to receive relevant follow-up. Few lesions progressed to more suspicious lesions (4.6%). Conclusions: Patient location at time of imaging is associated with the likelihood of completing relevant follow-up imaging for lesions with indeterminate malignant potential. Future work should evaluate health system-level care processes related to care setting, as well as their effects on appropriate follow-up imaging. Doing so would support efforts to improve appropriate follow-up imaging and reduce health care disparities. | |
| 2009 | Lopez 2009 | Screening mammography: a | Screening mammography: a cross-sectional study to compare characteristics of women aged 40 and older from the deep South who are current, overdue, and never screeners | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Black | State | Private Survey | Local data | PURPOSE: We sought to identify unique barriers and facilitators to breast cancer screening participation among women aged 40 and older from Mississippi who were categorized as current, overdue, and never screeners. METHODS: Cross-sectional data from a 2003 population-based survey with 987 women aged 40 and older were analyzed. Chi-square analysis and multinomial logistic regression examined how factors organized under the guidance of the Model of Health Services Utilization were associated with mammography screening status. RESULTS: Nearly one in four women was overdue or had never had a mammogram. Enabling factors, including poor access to care (no annual checkups, no health insurance) and to health information, lack of social support for screening, and competing needs, were significantly associated with being both overdue and never screeners. Pertaining to factors unique to each screening group, women were more likely to be overdue when they had no usual source of health care and believed that treatment was worse than the disease. In turn, women were more likely to be never screeners when they were African American, lacked a provider recommendation for screening, and held the fatalistic view that not much could be done to prevent breast cancer. CONCLUSION: Similar and unique factors impact utilization of mammography screening services among women. Those factors could inform efforts to increase screening rates. | |
| 2008 | Lubetkin 2008 | Predictors of cancer screening | Predictors of cancer screening among low-income primary care patients | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Multi-Institution | EHR | Local data | Although population-based studies report lower rates of cancer screening among racial/ethnic minorities than among Whites in the U.S., few studies have examined predictors of screening among low-income Hispanic, Black, and Chinese primary care patients. We examined utilization of mammography, Pap smear, digital rectal examination, fecal occult blood testing, sigmoidoscopy/ colonoscopy, and prostate-specific antigen testing in 833 patients from 2 community health centers in New York City, ascertaining relationships between use of screening and race/ethnicity, income, education, years in the U.S., insurance, cancer risk perception, family disease history, and physician recommendation. Despite similar access to primary care, Hispanics and Blacks reported higher utilization rates of all screening tests than Chinese (p<.01). Physician recommendation and more years in the U.S. were associated with greater use of all screening services (p<.001), with physician recommendation most strongly associated with screening. Interventions to enhance screening by at-risk groups should emphasize both physician recommendation and culturally-sensitive patient education. | |
| 2014 | Ly 2014 | Ethnicity as a predictive factor | Ethnicity as a predictive factor for hepatocellular carcinoma screening among patients in Hawaii | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Other: Cancer Screening | United States | Multiple Groups | State | EHR | Local data | Objectives: Although hepatocellular carcino ma (HCC) surveillance is associated with mortality reduction, it continues to be underutilized. The failure to conduct screening tests is a significant factor in the late diagnosis of hepatocellular carcinoma when curative interventions may not be feasible. Reasons for these low surveillance rates are unclear and need to be elucidated. Design, Setting, Patients: This retrospective study reviewed 616 cases of HCC from a hepatobiliary surgery office in Hawaii for age, sex, ethnicity, birthplace, residence, education, employment, insurance, and obesity to determine their influence on HCC screening. Main Outcome Measures: HCC screening. Results: Of the 616 cases, only 132 patients (21.4%) had undergone screening. Although the majority of patients were male, those who were screened were more likely to be female (P=.0082). However, multivariate analysis found ethnicity to be the sole determinant of screening (P<.0005). Koreans were more likely than Whites to have had screening, whereas Japanese, Pacific Islanders, and Filipinos were less likely. Age >60 years, sex, American birthplace, urban residence, high school completion, employment status, insurance, and BMI>35 kg/m2 were not predictors of screening. Conclusions: Of the sociodemographic factors, ethnicity was important in predicting screening. Further research is needed to understand the reasons for these ethnic differences and to develop targeted interventions to improve hepatocellular carcinoma surveillance utilization rates. | |
| 2022 | Mateo 2022 | Sociodemographic and Appointment | Sociodemographic and Appointment Factors Affecting Missed Opportunities to Provide Neonatal Ultrasound Imaging | Pediatric Only | All Sexes | Outpatient Ambulatory and Primary Care | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | EHR | Local data | PURPOSE: The aim of this study was to assess disparities in outpatient imaging missed care opportunities (IMCOs) for neonatal ultrasound by sociodemographic and appointment factors at a large urban pediatric hospital. METHODS: A retrospective review was performed among patients aged 0 to 28 days receiving one or more outpatient appointments for head, hip, renal, or spine ultrasound at the main hospital or satellite sites from 2008 to 2018. An IMCO was defined as a missed ultrasound or cancellation <24 hours in advance. Population-average correlated logistic regression modeling estimated the odds of IMCOs for six sociodemographic (age, sex, race/ethnicity, language, insurance, and region of residence) and seven appointment (type of ultrasound, time, day, season, site, year, and distance to appointment) factors. The primary analysis included unknown values as a separate category, and the secondary analysis used multiple imputation to impute genuine categories from unknown variables. RESULTS: The data set comprised 5,474 patients totaling 6,803 ultrasound appointments. IMCOs accounted for 4.4% of appointments. IMCOs were more likely for Black (odds ratio [OR], 3.31; P <.001) and other-race neonates (OR, 2.66; P <.001) and for patients with public insurance (OR, 1.78; P = .002). IMCOs were more likely for appointments at the main hospital compared with satellites (P <.001), during work hours (P = .021), and on weekends (P <.001). Statistical significance for primary and secondary analyses was quantitatively similar and qualitatively identical. CONCLUSIONS: Marginalized racial groups and those with public insurance had a higher rate of IMCOs in neonatal ultrasound. This likely represents structural inequities faced by these communities, and more research is needed to identify interventions to address these inequities in care delivery for vulnerable neonatal populations. | |
| 2016 | Melvin 2016 | Predictors of Participation in | Predictors of Participation in Mammography Screening among Non-Hispanic Black, Non-Hispanic White, and Hispanic Women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Private Survey | Local data | Introduction: Many factors influence womens decisions to participate in guideline-recommended screening mammography. We evaluated the influence of womens socioeconomic characteristics, health-care access, and cultural and psychological health-care preferences on timely mammography screening participation. Materials and methods: A random digit dial survey of United States non-Hispanic Black, non-Hispanic White, and Hispanic women aged 4075, from January to August 2009, determined self-reported time of most recent mammogram. Screening rates were assessed based on receipt of a screening mammogram within the prior 12 months, the interval recommended at the time by the American Cancer Society. Results: Thirty-nine percent of women reported not having a mammogram within the last 12 months. The odds of not having had a screening mammography were higher for non-Hispanic White women than for non-Hispanic Black (OR = 2.16, 95% CI = 0.26, 0.82, p = 0.009) or Hispanic (OR = 4.17, 95% CI = 0.12, 0.48, p = 0.01) women. Lack of health insurance (OR = 3.22, 95% CI = 1.54, 6.73, p = 0.002) and lack of usual source of medical care (OR = 3.37, 95% CI = 1.43, 7.94, p = 0.01) were associated with not being screened as were lower self-efficacy to obtain screening (OR = 2.43, 95% CI = 1.26, 4.73, p = 0.01) and greater levels of religiosity and spirituality (OR = 1.42, 95% CI = 1.00, 2.00, p = 0.05). Neither perceived risk nor present temporal orientation was significant. Discussion: Odds of not having a mammogram increased if women were uninsured, without medical care, non-Hispanic White, older in age, not confident in their ability to obtain screening, or held passive or external religious/spiritual values. Results are encouraging given racial disparities in health-care participation and suggest that efforts to increase screening among minority women may be working. | |
| 2005 | Mikuls 2005 | Racial disparities in the receipt | Racial disparities in the receipt of osteoporosis related healthcare among community-dwelling older women with arthritis and previous fracture | Adult Only | Female | Outpatient Ambulatory and Primary Care | Osteoporosis Screening | United States | Black | State | Private Survey | Local data | Objective. To examine potential racial/ethnic disparities in osteoporosis care among community-dwelling older women with self-reported arthritis and previous fracture. Methods. We conducted a computer assisted telephone interview using a population based random sample drawn from 6 counties in Alabama, USA. Eligible respondents had self-reported arthritis and were over 50 years of age; 1424 people responded to the survey. Logistic regression was used to examine the association of race/ethnicity with the receipt of dual energy x-ray absorptiometry (DEXA) and prescription osteoporosis treatments (including bisphosphonates, calcitonin, hormone replacement, or selective estrogen receptor modulators) among older women with a history of fracture. Results. Of eligible African American and Caucasian female respondents, 251 (25%) reported a history of fracture after 45 years of age. Women with a history of self-reported fracture were predominantly Caucasian (n = 178, 71%) and had a mean age of 68 11 years. After multivariable adjustment, African American women with a fracture history were less likely than Caucasian women with a history of fracture to receive a DEXA (OR 0.39, 95% CI 0.19-0.81) or prescription osteoporosis medicines (OR 0.17, 95% CI 0.08-0.37). Conclusion. In this population of community-dwelling older women, African American respondents at high risk for fracture were far less likely than Caucasians to receive osteoporosis related healthcare. | |
| 2018 | Miller 2019 | ACES (Accelerated Chest Pain | ACES (Accelerated Chest Pain Evaluation With Stress Imaging) Protocols Eliminate Testing Disparities in Patients With Chest Pain | Adult Only | All Sexes | Emergency Department | Chest Pain Imaging | United States | Black | Single Institution | EHR | Local data | Background: Patients from racial and ethnic minority groups presenting to the Emergency Department (ED) with chest pain experience lower odds of receiving stress testing compared with nonminorities. Studies have demonstrated that care pathways administered within the ED can reduce health disparities, but this has yet to be studied as a strategy to increase stress testing equity. Methods: A secondary analysis from 3 randomized clinical trials involving ED patients with acute chest pain was performed to determine whether a care pathway, ACES (Accelerated Chest pain Evaluation with Stress imaging), reduces the racial disparity in index visit cardiac testing between African American (AA) and White patients. Three hundred thirty-four participants with symptoms and findings indicating intermediate to high risk for acute coronary syndrome were enrolled in 3 clinical trials. Major exclusions were ST-segment elevation, initial troponin elevation, and hemodynamic instability. Participants were randomly assigned to receive usual inpatient care, or ACES. The ACES care pathway includes placement in observation for serial cardiac markers, with an expectation for stress imaging. The primary outcome was index visit objective cardiac testing, compared among AA and White participants. Results: AA participants represented 111/329 (34%) of the study population, 80/220 (36%) of the ACES group and 31/109 (28%) of the usual care group. In usual care, objective testing occurred less frequently among AA (22/31, 71%) than among White (69/78, 88%, P = 0.027) participants, primarily driven by cardiac catheterization (3% vs. 24%; P = 0.012). In ACES, testing rates did not differ by race [AA 78/80 (98%) vs. White 138/140 (99%); P = 0.623]. At 90 days, death, MI, and revascularization did not differ in either group between AA and White participants. Conclusions: A care pathway with the expectation for stress imaging eliminates the racial disparity among AA and White participants with chest pain in the acquisition of index-visit cardiovascular testing. | |
| 2022 | Monsivais 2022 | Racial and socioeconomic inequities | Racial and socioeconomic inequities in breast cancer screening before and during the COVID-19 pandemic: analysis of two cohorts of women 50 years + | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | State | Private Survey | Local data | BACKGROUND: Routine screening mammography at two-year intervals is widely recommended for the prevention and early detection of breast cancer for women who are 50 years+ . Racial and other sociodemographic inequities in routine cancer screening are well-documented, but less is known about how these long-standing inequities were impacted by the disruption in health services during the COVID-19 pandemic. Early in the pandemic, cancer screening and other prevention services were suspended or delayed, and these disruptions may have had to disproportionate impact on some sociodemographic groups. We tested the hypothesis that inequities in screening mammography widened during the pandemic. METHODS: A secondary analysis of patient data from a large state-wide, non-profit healthcare system in Washington State. Analyses were based on two mutually exclusive cohorts of women 50 years or older. The first cohort (n = 18,197) were those women screened in 2017 who would have been due for repeat screening in 2019 (prior to the pandemic's onset). The second cohort (n = 16,391) were women screened in 2018 due in 2020. Explanatory variables were obtained from patient records and included race/ethnicity, age, rural or urban residence, and insurance type. Multivariable logistic regression models estimated odds of two-year screening for each cohort separately. Combining both cohorts, interaction models were used to test for differences in inequities before and during the pandemic. RESULTS: Significant sociodemographic differences in screening were confirmed during the pandemic, but these were similar to those that existed prior. Based on interaction models, women using Medicaid insurance and of Asian race experienced significantly steeper declines in screening than privately insured and white women (Odds ratios [95% CI] of 0.74 [0.58-0.95] and 0.76 [0.59-0.97] for Medicaid and Asian race, respectively). All other sociodemographic inequities in screening during 2020 were not significantly different from those in 2019. CONCLUSIONS: Our findings confirm inequities for screening mammograms during the first year of the COVID-19 pandemic and provide evidence that these largely reflect the inequities in screening that were present before the pandemic. Policies and interventions to tackle long-standing inequities in use of preventive services may help ensure continuity of care for all, but especially for racial and ethnic minorities and the socioeconomically disadvantaged. | |
| 2015 | Morrison 2015 | Health Literacy Affects Likelihood | Health Literacy Affects Likelihood of Radiology Testing in the Pediatric Emergency Department | Pediatric Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | EHR | Local data | Objective To test the hypothesis that the effect of race/ethnicity on decreased radiologic testing in the pediatric emergency department (ED) varies by caregiver health literacy. Study design This was a secondary analysis of a cross-sectional study of caregivers accompanying children <= 12 years to a pediatric ED. Caregiver health literacy was measured using the Newest Vital Sign. A blinded chart review determined whether radiologic testing was utilized. Bivariate and multivariate analyses, adjusting for ED triage level, child insurance, and chronic illness were used to determine the relationship between race/ethnicity, health literacy, and radiologic testing. Stratified analyses by caregiver health literacy were conducted. Results Five hundred four caregivers participated; the median age was 31 years, 47% were white, 37% black, 10% Hispanic, and 49% had low health literacy. Black race and low health literacy were associated with less radiologic testing (P < .01). In stratified analysis, minority race was associated with less radiologic testing only if a caregiver had low health literacy (aOR 0.5; 95% CI 0.3-0.9), and no difference existed in those with adequate health literacy (aOR 0.7; 95% CI 0.4-1.3). Conclusions Caregiver low health literacy modifies whether minority race/ethnicity is associated with decreased radiologic testing, with only children of minority caregivers with low health literacy receiving fewer radiologic studies. Future interventions to eliminate disparities in healthcare resource utilization should consider health literacy as a mutable factor. | |
| 2020 | Mwinyogle 2020 | Use of CT Scans for Abdominal Pain | Use of CT Scans for Abdominal Pain in the ED: Factors in Choice | Adult Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | EHR | Local data | Overutilization of healthcare resources is a threat to long-term healthcare sustainability and patient outcomes. CT is a costly but efficient means of assessing abdominal pain; however, 97 per cent of ED physicians acknowledge its overutilization. This study sought to understand factors that influence ED providers' decision regarding CT use in the evaluation of abdominal pain. After evaluating a patient for acute abdominal pain, ED providers filled in a form in which the primary diagnosis and index of suspicion were recorded. Bivariate and multivariate analyses were used to identify predictors of outcomes. The CT scan utilization rate was 54.82 per cent. Whereas 34.11 per cent of CT scans were normal, 30 per cent yielded an acute abdominal pathology. Tenderness and rebound tenderness were positive predictors of high index of suspicion [odds ratio (OR) 2.09 and 2.54, respectively]. These variables were also predictive of obtaining a CT scan [OR 2.64 and 3.41, respectively]. Compared with whites, the index of suspicion was 26 per cent and 56 per cent less likely to be high when patients were black [OR 0.73] or Hispanic [OR 0.44] respectively. Blacks and Hispanics were less likely to have CT scans performed than whites [OR 0.58 and 0.48, respectively]. Leukocytosis significantly affected the index of suspicion for acute abdominal pathology, obtaining a CT scan and the acuity of CT scan diagnosis on multivariate analysis. Patients aged 60 years had 2.03 odds of acute CT finding compared with those aged <60 years. There is a need for committed efforts to optimize CT scan utilization and eliminate socioeconomic disparities in health care. | |
| 2021 | Naidich 2021 | Imaging Utilization During the | Imaging Utilization During the COVID-19 Pandemic Highlights Socioeconomic Health Disparities | All Ages | All Sexes | Inpatient and Outpatient | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | Private Insurance Data | Local data | OBJECTIVE: The devastating impact from the coronavirus disease 2019 (COVID-19) pandemic highlights long-standing socioeconomic health disparities in the United States. The purpose of this study was to evaluate socioeconomic factors related to imaging utilization during the pandemic. METHODS: Retrospective review of consecutive imaging examinations was performed from January 1, 2019, to May 31, 2020, across all service locations (inpatient, emergency, outpatient). Patient level data were provided for socioeconomic factors (age, sex, race, insurance status, residential zip code). Residential zip code was used to assign median income level. The weekly total imaging volumes in 2020 and 2019 were plotted from January 1 to May 31 stratified by socioeconomic factors to demonstrate the trends during the pre-COVID-19 (January 1 to February 28) and post-COVID-19 (March 1 to May 31) periods. Independent-samples t tests were used to statistically compare the 2020 and 2019 socioeconomic groups. RESULTS: Compared with 2019, the 2020 total imaging volume in the post-COVID-19 period revealed statistically significant increased imaging utilization in patients who are aged 60 to 79 years (P = .0025), are male (P < .0001), are non-White (Black, Asian, other, unknown; P < .05), are covered by Medicaid or uninsured (P < .05), and have income below $80,000 (P < .05). However, there was a significant decrease in imaging utilization among patients who are younger (<18 years old; P < .0001), are female (P < .0001), are White (P = .0003), are commercially insured (P < .0001), and have income $80,000 (P < .05). DISCUSSION: During the pandemic, there was a significant change in imaging utilization varying by socioeconomic factors, consistent with the known health disparities observed in the prevalence of COVID-19. These findings could have significant implications in directing utilization of resources during the pandemic and subsequent recovery. | |
| 2012 | Natale 2012 | Cranial computed tomography use | Cranial computed tomography use among children with minor blunt head trauma: association with race/ethnicity | Pediatric Only | All Sexes | Emergency Department | Neurologic | North America | Multiple Groups | National | Private Survey | Local data | OBJECTIVE: To determine if patient race/ethnicity is independently associated with cranial computed tomography (CT) use among children with minor blunt head trauma. DESIGN: Secondary analysis of a prospective cohort study. SETTING: Pediatric research network of 25 North American emergency departments. PATIENTS: In total, 42 412 children younger than 18 years were seen within 24 hours of minor blunt head trauma. Of these, 39 717 were of documented white non-Hispanic, black non-Hispanic, or Hispanic race/ethnicity. Using a previously validated clinical prediction rule, we classified each child's risk for clinically important traumatic brain injury to describe injury severity. Because no meaningful differences in cranial CT rates were observed between children of black non-Hispanic race/ethnicity vs Hispanic race/ethnicity, we combined these 2 groups. MAIN OUTCOME MEASURE: Cranial CT use in the emergency department, stratified by race/ethnicity. RESULTS: In total, 13 793 children (34.7%) underwent cranial CT. The odds of undergoing cranial CT among children with minor blunt head trauma who were at higher risk for clinically important traumatic brain injury did not differ by race/ethnicity. In adjusted analyses, children of black non-Hispanic or Hispanic race/ethnicity had lower odds of undergoing cranial CT among those who were at intermediate risk (odds ratio, 0.86; 95% CI, 0.78-0.96) or lowest risk (odds ratio, 0.72; 95% CI, 0.65-0.80) for clinically important traumatic brain injury. Regardless of risk for clinically important traumatic brain injury, parental anxiety and request was commonly cited by physicians as an important influence for ordering cranial CT in children of white non-Hispanic race/ethnicity. CONCLUSIONS: Disparities may arise from the overuse of cranial CT among patients of nonminority races/ethnicities. Further studies should focus on explaining how medically irrelevant factors, such as patient race/ethnicity, can affect physician decision making, resulting in exposure of children to unnecessary health care risks. | |
| 2016 | Natale 2016 | Relationship of | Relationship of physician-identified patient race and ethnicity to use of computed tomography in Pediatric blunt torso trauma | Pediatric Only | All Sexes | Emergency Department | Trauma imaging | United States | Multiple Groups | Multi-Institution | EHR | Local data | Objectives: The objective was to determine whether a child's race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma. Methods: We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007-2010. Treating physicians documented race/ethnicity as white non-Hispanic, black non-Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child's risk for having an intra-abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals. Results: Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non-Hispanic (n = 5,847, 54.0%), black non-Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non-Hispanic, 32.7% of black non-Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra-abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non-Hispanic than for white non-Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non-Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1). Conclusions: After blunt torso trauma, pediatric patients identified by the treating physicians as black non-Hispanic were less likely to receive abdominal CT imaging than those identified as white non-Hispanic. This suggests that nonclinical factors influence clinician decision-making regarding use of abdominal CT in children. Further studies should focus on explaining how patient race can affect provider choices regarding ED radiographic imaging. | |
| 2021 | Nguyen 2021 | Disparities Associated With Patient | Disparities Associated With Patient Adherence of Post-Breast-Conserving Surgery Surveillance Imaging Protocols | Adult Only | Female | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | Single Institution | EHR | Local data | OBJECTIVE: Currently, national and international breast imaging practices utilize variable postsurgical surveillance protocols without uniform recommendations. Because of the innate differences between screening versus diagnostic mammography from scheduling flexibility to out-of-pocket costs, this creates the opportunity for lapses in patient adherence, which has the potential to impact clinical outcomes. The purpose of this study is to evaluate the relationship between sociodemographic factors and postsurgical surveillance imaging protocols on patient adherence rates. METHODS: This retrospective study reviewed 3 years of surveillance imaging for all patients having breast-conserving surgery at our institution from January 2011 to December 2016. Follow-up adherence was defined as returning for all of the first 3 years of annual follow-up after breast-conserving surgery (institutional surveillance protocol). Associations between adherence to surveillance imaging and patient sociodemographic characteristics were evaluated using univariate and multivariate logistic regression. RESULTS: The study included 1,082 patients after breast surgery, 715 of whom adhered completely to the first 3 years of annual follow-up (66.1%). Black women were 1.36 times less likely to follow up annually compared with White women (95% confidence interval 1.02-1.80). Similarly, patients with Medicare were 1.84 times less likely to follow up annually compared with patients with private insurance (95% confidence interval 1.34-2.51). Women with benign breast disease after breast-conserving surgery were significantly less likely to adhere to annual surveillance than women with breast cancer. CONCLUSION: Sociodemographic disparities exist as barriers for annual mammography surveillance in patients after breast-conserving surgery. | |
| 2006 | Nwomeh 2006 | Racial and socioeconomic disparity | Racial and socioeconomic disparity in perforated appendicitis among children: Where is the problem? | Pediatric Only | All Sexes | Emergency Department | GI/Abdominal | United States | Multiple Groups | Single Institution | EHR | Local data | OBJECTIVE. Significant racial, ethnic, and socioeconomic disparities have been observed in the rates of perforated appendicitis among children, by using large administrative databases. This study evaluated whether these factors had an impact on the care of patients with appendicitis at a major children's hospital with a well-established, comprehensive, primary referral system. METHODS. A retrospective analysis was performed for all children between the ages of 2 and 20 years who were treated for appendicitis between January 1, 2001, and December 31, 2003. Demographic variables included patient age, gender, race, insurance status, parental educational status, and income level. Coding data were used to identify patients with perforated appendicitis. The use of radiologic imaging was also analyzed. RESULTS. During the 3-year period, 788 patients were treated for appendicitis. The racial distribution (white: 81%; black: 12%; other: 7%) was consistent with the demographic composition of the local population. The overall perforation rate was 25%, and the rate was significantly greater in the age group of <6 years, compared with older children. However, there were no significant differences in the perforation rate with respect to race, insurance status, educational level, or income status. Rates of radiologic imaging use were similar among all racial and socioeconomic groups. CONCLUSIONS. Although racial and socioeconomic disparities in the rates of perforated appendicitis among children have been reported, we found no significant evidence for such inequality at our institution. This may reflect improved access, early diagnosis, and referral by primary care physicians in the community. Pooled national and multiple-state administrative databases have been used to highlight persistent disparities in health care. This study illustrates how single-institution data sources can be used to test a local hypothesis generated by national data, with surprisingly different results. | |
| 2022 | Oshiro 2022 | Lung Cancer Screening by Race and | Lung Cancer Screening by Race and Ethnicity in an Integrated Health System in Hawaii | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | IMPORTANCE: Racial and ethnic differences in lung cancer screening (LCS) completion and follow-up may be associated with lung cancer incidence and mortality rates among high-risk populations. Aggregation of Asian American, Native Hawaiian, and Pacific Islander racial and ethnic groups may mask the true underlying disparities in screening uptake and diagnostic follow-up, creating barriers for targeted, preventive health care. OBJECTIVE: To examine racial and ethnic differences in LCS completion and follow-up rates in a multiethnic population. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study was conducted at a health maintenance organization in Hawaii. LCS program participants were identified using electronic medical records from January 1, 2015, to December 31, 2019. Study eligibility requirements included being aged 55 to 79 years, a 30 pack-year smoking history, a current smoker or having quit within the past 15 years, at least 5 years past any lung cancer diagnosis and treatment, and cancer free. Data analysis was performed from June 2019 to October 2020. EXPOSURE: Eligible for LCS. MAIN OUTCOMES AND MEASURES: Screening rates were analyzed by self-reported race and ethnicity and completion of a low-dose computed tomography (LDCT) test. Diagnostic follow-up results were based on the Lung Imaging Reporting and Data System (Lung-RADS) staging system. RESULTS: A total of 1030 eligible LCS program members had an order placed; their mean (SD) age was 65.5 (5.8) years, and 633 (61%) were men. The largest racial and ethnic groups were non-Hispanic White (381 participants [37.0%]), Native Hawaiian or part Native Hawaiian (186 participants [18.1%]), and Japanese (146 participants [14.2%]). Men and Filipino, Chinese, Japanese, and non-Hispanic White individuals had a higher proportion of screen orders for LDCT compared with women and individuals of the other racial and ethnic groups. The overall LCS completion rate was 81% (838 participants). There was a 14% to 15% screening completion rate gap among groups. Asian individuals had the highest screening completion rate (266 participants [86%]) followed by Native Hawaiian (149 participants [80%]) and non-Hispanic White individuals (305 participants [80%]), Pacific Islander (50 participants [79%]) individuals, and individuals of other racial and ethnic groups (68 participants [77%]). Within Asian subgroups, Korean (31 participants [94%]) and Japanese (129 participants [88%]) individuals had the highest completion rates followed by Chinese individuals (28 participants [82%]) and Filipino individuals (78 participants [79%]). Of the 54 participants with Lung-RADS stage 3 disease, 93% (50 participants) completed a 6-month surveillance LDCT test; of 37 individuals with Lung-RADS stage 4 disease, 35 (97%) were followed-up for additional procedures. CONCLUSIONS AND RELEVANCE: This cohort study found racial and ethnic disparities in LCS completion rates after disaggregation of Native Hawaiian, Pacific Islander, and Asian individuals and their subgroups. These findings suggest that future research is needed to understand factors that may be associated with LCS completion and follow-up behaviors among these racial and ethnic groups. | |
| 2013 | Parish 2013 | Receipt of mammography among women | Receipt of mammography among women with intellectual disabilities: Medical record data indicate substantial disparities for African American women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Black | State | EHR | Local data | Background: Little information exists on the receipt of mammography by African American women with intellectual disabilities. Given the high rates of mortality from breast cancer among African American women and low screening rates among women with intellectual disabilities, it is important to understand the health screening behavior of this population. Objective: We compared rates of mammography receipt among African American and White women with intellectual disabilities (n = 92) living in community settings in one Southeastern state in the United States. Method: Data were collected from women's medical records or abstraction forms obtained from medical practices. Multivariate logistic regressions were modeled for receipt of mammography in one year, one of two years, or both study years (2008e 2009). Covariates included the women's age, living arrangement, severity of impairment, and urban/rural residence location. Results: In 2009, 29% of African American women and 59% of White women in the sample received mammograms. Similar disparities were found for receipt of mammography in either 2008 or 2009 and both 2008 and 2009. These disparities persisted after inclusion of model covariates. White women with intellectual disabilities received mammograms at adjusted rates that were nearly three to five times higher than African American women. Conclusion: African American women with intellectual disabilities receive mammography at significantly lower rates than White women with intellectual disabilities. Assertive measures to improve the screening rates for African American women with intellectual disabilities are urgently needed. | |
| 2022 | Patt 2022 | Considerations to increase rates of | Considerations to increase rates of breast cancer screening across populations | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Private Survey | Local data | OBJECTIVES: COVID-19 has caused considerable drops in utilization of breast cancer screening services during the pandemic, especially among certain racial and ethnic groups. Members of the Community Oncology Alliance (COA)-including the COA president, South Carolina oncologist Kashyap Patel, MD-have reported increases in patients, particularly those of color, presenting with stage III and IV cancer at diagnosis. According to data released by the Biden administration, more than 9.5 million recommended cancer screenings had been missed in the United States as a result of the COVID-19 pandemic, as of February 2022. President Joe Biden and First Lady Jill Biden, EdD, aim to address this in the 2022 revitalized Cancer Moonshot Initiative. The findings made by COA as well as by Avalere also suggest that the pandemic has exacerbated existing health care disparities. METHODS: Using a multipayer database, we analyzed breast cancer screening rates for 2 periods-March 1 to September 30, 2019, and March 1 to September 30, 2020-among Medicare fee-for-service (FFS), managed Medicaid, and commercial insurance beneficiaries to understand the potential impact of the COVID-19 pandemic on adherence to the US Preventive Services Task Force breast cancer screening recommendations, which are currently undergoing review. Screening rates were evaluated across 5 racial/ethnic groups and by payer type. RESULTS: Mean monthly mammogram screening rates among eligible White Medicare FFS beneficiaries dropped to 0.6% in April 2020, but these screening rates recovered to 6.5% by June 2020. Screening rates for eligible Black Medicare FFS beneficiaries recovered on a pace slightly slower than that of White beneficiaries, but more rapidly than that of other groups. By comparison, American Indian/Alaska Native beneficiaries had a mean monthly screening rate of 0.5% in April 2020, which recovered to 3.1% in June 2020; these were below 2019 screening rates of 4.2% for April and 3.9% for June. Differences in screening rates by payer type were also observed. Patients with commercial insurance had higher screening rates compared with those covered by Medicare FFS and managed Medicaid. CONCLUSIONS: Our principal finding shows that mean breast cancer screening rates decreased in April 2020 across all payers, but recovery to prepandemic screening levels has occurred more slowly among certain racial and ethnic minority groups. Differences in recovery rates by payer type highlight a strong relationship between income level and screening utilization. | |
| 2013 | Payne 2013 | Racial Disparities in Ordering | Racial Disparities in Ordering Laboratory and Radiology Tests for Pediatric Patients in the Emergency Department | Pediatric Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | Multi-Institution | EHR | Local data | Objective: The objective of this study was to examine the association of race and language on laboratory and radiological testing in the pediatric emergency department (ED). Methods: This retrospective, case-cohort study examined laboratory and radiological testing among patients discharged home from 2 urban, pediatric EDs between March 2, 2009, and March 31, 2010. Results: There were 75,254 visits among 49,164 unique patients, of whom 31.0% had laboratory and 30.5% had radiological testing. African American (adjusted odds ratio [aOR], 0.93; confidence interval [CI], 0.89-0.98; P = 0.004) and biracial racial categories (aOR, 0.91; CI, 0.86-0.98; P = 0.007) were associated with decreased odds of laboratory testing compared with non-Hispanic whites. Similarly, Native American (aOR, 0.82; CI, 0.73-0.94), African American (aOR0.81; CI, 0.72-0.81), biracial (aOR, 0.82; CI, 0.77-0.88), Hispanic (aOR.76; CI, 0.72-0.81), and "other" (aOR, 0.84; CI, 0.73-0.97) racial categories were each associated with lower odds of radiological testing compared with non-Hispanic whites. Subgroup analysis of visits with a final diagnosis of fever and upper respiratory tract infection, conditions for which there were few treatment protocols, confirmed the racial differences. Subgroup analysis in visits for head injury, for which there is an established evaluation protocol, did not find a lower odds of laboratory or radiological testing by race compared with non-Hispanic whites. Conclusions: Racial disparities in laboratory and radiological testing were present in pediatric ED visits. No racial differences were seen in the radiological and laboratory charges in the head injury subgroup, suggesting that evaluation algorithms can ameliorate racial disparities in pediatric ED care. | |
| 2017 | Payne 2017 | Inequity in timing of prenatal | Inequity in timing of prenatal screening in New Zealand: Who are our most vulnerable? | Adult Only | Female | Outpatient Ambulatory and Primary Care | Prenatal | New Zealand | Indigenous | National | EHR | Local data | BACKGROUND: In New Zealand (NZ), Maori and Pacific women are less likely to complete prenatal screening for Down syndrome and other aneuploidies than other ethnic groups. Young women <20 have low rates of completed screening compared with women >20years. Women living in deprived areas have lower completed screen rates than women living in more affluent areas. Combined first trimester screening has a superior sensitivity (85%) compared with second trimester screening (75%) for trisomy 21. The relative contribution of demographic factors to timing of screening uptake (first vs second trimester) has not previously been examined. AIM: To evaluate the association of ethnicity, deprivation, District Health Board (DHB) of domicile and maternal age with timing of prenatal screening (first vs second trimester) in pregnant women screened in NZ from 2010 to 2013. METHODS AND MATERIALS: Univariate logistic regression analyses were used to explore the association between timing of completed screening and each of ethnicity, deprivation index, DHB of domicile and maternal age. Multivariate logistic regression models were developed to calculate odds ratios (OR) and 95% confidence intervals (CI). Statistical analyses were performed using SAS v9.3 RESULTS: Of completed prenatal screens, 88% were completed in the first trimester. Ethnicity, age, deprivation and DHB were all significant predictors of completed first versus second trimester screening. Maori women were almost 60% less likely (adjusted OR 0.37, CI 0.35-0.39) and Pacific women almost 80% less likely (adjusted OR 0.23, CI 0.21-0.24) than NZ European women to have completed first versus second trimester screening. Women <30years were less likely to have completed first trimester screening, as were more deprived women. Variation was also seen by DHB with women living in Whanganui DHB less likely to have completed first versus second trimester screening than women living in Auckland (adjusted OR 0.76, CI 0.71-0.81). Women living in Bay of Plenty DHB were more likely to be screened in the first versus second trimester compared with women living in Auckland (adjusted OR 1.55, CI 1.38-1.74). Within Auckland itself, women living in Counties Manukau DHB were less likely to be screened in the first versus second trimester than women living in Auckland DHB even after adjusting for ethnicity, deprivation and maternal age. CONCLUSION: Maori and Pacific women have the lowest uptake of completed first versus second trimester screening after adjusting for age, deprivation and DHB. Research is required to understand if this relates to characteristics of the carer making the offer of screening, language and/or cultural barriers to care or specific collective cultural or religious views held by women from these ethnicities. The lower completed first trimester versus second trimester prenatal screening in deprived areas, as well as variation by DHB, may relate to the availability of ultrasound and/or laboratory services in specific regions. Cost may be a contributing factor to inequity in timing of completed prenatal screening uptake, as first trimester screening incurs a part-charge to the individual, while second trimester screening is fully funded. Systemic factors within the NZ maternity model of care may also be contributory with a potential disconnect occurring for the woman between primary medical care and later registration with a Lead Maternity Carer in the first trimester. | |
| 2022 | Perumalswami 2022 | Hepatocellular carcinoma | Hepatocellular carcinoma surveillance, incidence, and tumor doubling times in patients cured of hepatitis C | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Other: Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | BACKGROUND: Hepatocellular carcinoma (HCC) incidence and mortality vary by race/ethnicity and both are higher in Black patients than in Whites. For HCC surveillance, all cirrhotic patients are advised to undergo lifelong twice-annual abdominal imaging. We investigated factors associated with surveillance and HCC incidence in a diverse HCC risk group, cirrhotic patients recently cured of hepatitis C virus (HCV) infection. METHODS: In this observational cohort study, all participants (n = 357) had advanced fibrosis/cirrhosis and were cured of HCV with antiviral treatment. None had Liver Imaging Reporting and Data System (LI-RADS) 2-5 lesions prior to HCV cure. Ultrasound, computed tomography, and/or magnetic resonance imaging were used for surveillance. RESULTS: At a median follow-up of 40 months [interquartile range (IQR) = 28-48], the median percentage of time up-to-date with surveillance was 49% (IQR) = 30%-71%. The likelihood of receiving a first surveillance examination was not significantly associated with race/ethnicity, but was higher for patients with more advanced cirrhosis, for example, bilirubin [odds ratio (OR) = 3.8/mg/dL, p = 0.002], private insurance (OR = 3.4, p = 0.006), and women (OR = 2.3, p = 0.008). The likelihood of receiving two or three examinations was significantly lower for non-Hispanic Blacks and Hispanics versus non-Hispanic Whites (OR = 0.39, and OR = 0.40, respectively, p < 0.005 for both) and for patients with higher platelet counts (OR = 0.99/10,000 cells/l, p = 0.01), but higher for patients with private insurance (OR = 2.8, p < 0.001). Incident HCC was associated with higher bilirubin (OR = 1.7, p = 0.02) and lower lymphocyte counts (OR = 0.16, p = 0.01). CONCLUSIONS: Contrary to best practices, HCC surveillance was associated with sociodemographic factors (insurance status and race/ethnicity) among patients cured of HCV. Guideline-concordant surveillance is needed to address healthcare disparities. | |
| 2022 | Poulson 2022 | Redlining, structural racism, and | Redlining, structural racism, and lung cancer screening disparities | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Black | Single Institution | EHR | Local data | OBJECTIVE: The objective of this study was to understand the effect of historical redlining (preclusion from home loans and wealth-building for Black Americans) and its downstream factors on the completion of lung cancer screening in Boston. METHODS: Patients within our institution were identified as eligible for lung cancer screening on the basis of the United State Preventive Service Task Force criteria and patient charts were reviewed to determine if patients completed low-dose computed tomography screening. Individual addresses were geocoded and overlayed with original 1930 Home Owner Loan Corporation redlining vector files. Structural equation models were used to estimate the odds of screening for Black and White patients, interacted with sex, in redlined and nonredlined areas. RESULTS: Black patients had a 44% lower odds of screening compared with White (odds ratio [OR], 0.66; 95% CI, 0.52-0.85). With race as a mediator, Black patients in redlined areas were 61% less likely to undergo screening than White patients (OR, 0.39; 95% CI, 0.24-0.64). Similarly, in redlined areas Black women had 61% (OR, 0.39; 95% CI, 0.21-0.73) and Black men 47% (OR, 0.53; 95% CI, 0.29-0.98) lower odds of screening compared with White men in redlined areas. CONCLUSIONS: Despite higher rates of lung cancer screening in redlined areas, Black race mediated worse screening rates in these areas, suggesting racist structural factors contributing to the disparities in lung cancer screening completion among Black and White patients. Furthermore, these disparities were more apparent in Black women, suggesting that racial and gender intersectional discrimination are important in lung cancer screening completion. | |
| 2009 | Rangel 2009 | Eliminating disparity in evaluation | Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline | Pediatric Only | All Sexes | Emergency Department | NAT | United States | Black | Single Institution | EHR | Local data | PURPOSE: Minority and disadvantaged children are evaluated for nonaccidental trauma (NAT) at higher rates than other children. At our institution, we implemented a guideline to perform skeletal surveys to screen for occult fractures in all infants with unwitnessed head injury (UHI). The goal was to determine if this guideline decreased disparities in the screening of African American (AA) and uninsured children. PATIENTS AND METHODS: For 54 months, rates of skeletal surveillance and abuse determination were compared between AA and white infants admitted with UHI before and after implementation of our guideline. Logistic regression was used to control for confounders. RESULTS: Before the guideline, AAs underwent skeletal surveillance more than whites (n = 208; 90.5% vs 69.3%; P = .01), with 20% of screened infants determined to be probable victims of NAT. Whites with private insurance were less likely to be screened compared to those without private insurance (50.0% vs 88.1%; P < .001). After the guideline, AA and whites were surveyed equally (n = 52; 92.3% vs 84.6%; P = 1.0), with 22% found to be probable cases of NAT. CONCLUSIONS: This is the first report of a successful policy-based intervention to decrease disparity in care. The maintenance of a stable rate of NAT determination despite increased screening suggests more victims of abuse may be identified with guideline use, and therefore, this may be an additional benefit of the guideline. | |
| 2020 | Richmond 2020 | Evaluating Potential Racial | Evaluating Potential Racial Inequities in Low-dose Computed Tomography Screening for Lung Cancer | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Black | Single Institution | EHR | Local data | Background: Lung cancer is the leading cause of cancer death in the US, and significant racial disparities exist in lung cancer outcomes. For example, Black men experience higher lung cancer incidence and mortality rates than their White counterparts. New screening recommendations for low-dose computed tomography (LDCT) promote earlier detection of lung cancer in at-risk populations and can potentially help mitigate racial disparities in lung cancer mortality if administered equitably. Yet, little is known about the extent of racial differences in uptake of LDCT. Objective: To evaluate potential racial disparities in LDCT screening in a large community-based cancer center in central North Carolina. Methods: We conducted a retrospective study of the initial patients undergoing LDCT in a community-based cancer center (n = 262). We used the Pearson chi-squared test to assess potential racial disparities in LDCT screening. Results: Study results suggest that Black patients may be less likely than White patients to receive LDCT screening when eligible (2 = 51.41, p < 0.0001). Conclusion: Collaboration among healthcare providers, researchers, and decision makers is needed to promote LDCT equity. | |
| 2016 | Riddell 2016 | Differences in obstetric care among | Differences in obstetric care among nulliparous First Nations and non-First Nations women in British Columbia, Canada | Adult Only | Female | Outpatient Ambulatory and Primary Care | Prenatal | Canada | Indigenous | Regional | EHR | Local data | Background: Canada's Aboriginal population faces significantly higher rates of stillbirth and neonatal and postnatal death than those seen in the general population. The objective of this study was to compare indicators of obstetric care quality and use of obstetric interventions between First Nations and non-First Nations mothers in British Columbia, Canada. Methods: We linked obstetrical medical records with the First Nations Client File for all nulliparous women who delivered single infants in British Columbia from 1999 to 2011. Using logistic regression models, we examined differences in the proportion of women who received services aligned with best practice guidelines, as well as the overall use of obstetric interventions among First Nations mothers compared with the general population, controlling for geographic barriers (distance to hospital) and other relevant confounders. Results: During the study period, 215 993 single births occurred in nulliparous women in British Columbia, 9152 of which were to members of our First Nations cohort. First Nations mothers were less likely to have early ultrasonography (adjusted risk difference = 10.2 fewer women per 100 deliveries [95% confidence interval {CI} -11.3 to -9.3]), to have at least 4 antenatal care visits (3.6 fewer women per 100 deliveries [95% CI -4.6 to -2.6]), and to undergo labour induction after prolonged (> 24 hours) prelabour rupture of membranes (-5.9 [95% CI -11.8 to 0.1]) or at post-dates gestation (-10.6 [95% CI -13.8 to -7.5]). Obstetric interventions including epidural, labour induction, instrumental delivery and cesarean delivery were used less often in First Nations mothers. | |
| 2010 | Roudsari 2010 | Trend in the utilization of CT for | Trend in the utilization of CT for adolescents admitted to an adult level I trauma center | Pediatric Only | All Sexes | Emergency Department | Trauma imaging | United States | Multiple Groups | Single Institution | EHR | Local data | Purpose: The aims of this study were to evaluate the trend in the utilization of CT for adolescents admitted to an adult level I trauma center and to compare the utilization pattern between adolescents and adults during the past 11 years. Methods: Trauma registry data (1996-2006) from an adult level I trauma center were used. Patients aged 13 years were eligible to be admitted to this hospital. From this trauma registry, the following variables were extracted: age; sex; ethnicity; insurance status; mechanism of injury; injury severity score; length of hospital and intensive care unit stay; International Classification of Diseases, Ninth Revision (ICD-9), codes; and patient disposition. Patients were categorized on the basis of their age in the following groups: 13 to 18, 19 to 55, and 56 years. ICD-9 procedure codes were used to create new variables that were reflective of the frequency of use of head CT (ICD-9 code 87.03), abdominal CT (ICD-9 code 88.01), thoracic CT (ICD-9 code 87.41), and other CT studies, including CT of the extremities and spine (ICD-9 code 88.38). Results: All age groups experienced substantial increases in the utilization of CT, and there were minimal differences in crude utilization rates among different age categories. After adjustment for potential confounders, adolescents had a slightly higher chance of being evaluated by head CT (incident risk ratio [IRR], 1.16; 95% confidence interval [CI], 1.11-1.22) and a significantly lower chance of undergoing thoracic CT (IRR, 0.54; 95% CI, 0.48-0.61) in comparison with adults aged 19 to 55 years. Among adolescents, the chance of undergoing head CT was significantly higher in 2006 relative to 1996 (IRR, 1.50; 95% CI, 1.20-1.86). However, there was no linear increase in utilization pattern from 1996 to 2006. Abdominal CT demonstrated a similar pattern. Thoracic CT and other CT studies demonstrated the most drastic increases in utilization pattern among adolescents. The IRR for the use of thoracic CT increased from 1.15 (95% CI, 0.26-5.20) in 1997 (relative to 1996) to 10.53 (95% CI, 3.24-34.26) in 2006. The IRRs for other CT studies in 2005 and 2006, relative to 1996, were 7.24 and 6.91, respectively. Conclusions: Treatment of adolescents in adult level I trauma centers is challenging. Trauma centers should adopt strategies that could potentially decrease unnecessary utilization, especially among adolescents. To do this, these facilities should be familiar with patient-related and system-related characteristics that might influence overutilization. Furthermore, physicians in adult trauma centers should be reeducated with regard to potential hazardous consequences of CT for adolescents. | |
| 2020 | Rutledge 2020 | Racial Diversity in Hepatocellular | Racial Diversity in Hepatocellular Carcinoma in a Predominately African-American Population at an Urban Medical Center | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | Single Institution | EHR | Local data | Purpose: Surveillance, treatment, and outcomes for African-American (AA) populations with hepatocellular carcinoma (HCC) remain under evaluated. This study evaluated demographics, surveillance, therapy, and outcomes for a predominately AA population. Methods: The electronic medical records of a large health-care provider were used to identify 274 patients with visits for HCC between 2010 and 2017. Tumor size at diagnosis was defined by imaging with 5 cm being defined as "small." Surveillance for HCC was defined based on ultrasound (US) assessments. Results: Patients were primarily AA (78%) and male (76%) with an average age at diagnosis of 62 years. Hepatitis C virus (HCV) was more likely to be a risk factor for the development of HCC in AA as compared to non-AA (92% vs 67%; p < 0.005). Surveillance rates were low (16% for AA vs 7% for non-AA). An aspartate aminotransferase platelet ratio index (APRI) value > 0.7 within 2 years of tumor diagnosis was a strong predictor for the risk of the development of HCC (86% AA vs 79 % non-AA). In this study, race was not a factor in treatment or outcomes, and most patients received tumor ablative treatment. Conclusion: Given the low surveillance rates and the demonstrated increased survival for patients with small tumors, ways to increase surveillance must be initiated. The results of this study demonstrate the need for physician/patient education on the importance of surveillance US. Further, this study supports routine assessment of APRI in AA patients in an effort to identify patients in whom intensive surveillance will significantly improve earlier detection of tumors. | |
| 2020 | Schoenfeld 2020 | Disparities in care among patients | Disparities in care among patients presenting to the emergency department for urinary stone disease | Adult Only | All Sexes | Emergency Department | GI/Abdominal | United States | Multiple Groups | Single Institution | EHR | Local data | To determine whether patients with ureteral stones received different standard of care in the emergency department (ED) according to various sociodemographic factors. We conducted a retrospective study of patients presenting to EDs in a large tertiary-care hospital in the Bronx, New York with a diagnosis of ureteral stones. Electronic chart review was used to assess each patient's ED course and to gather socio-demographic information. The primary outcomes of interest were administration of pain medication, prescription of alpha-1 antagonists to facilitate stone passage, and whether or not patients received CT scan or ultrasound. Associations of these outcomes with age categories, sex, race/ethnicity, BMI category, socioeconomic status and insurance status were examined using multivariate logistic regression models. 1200 patients were included in this analysis of which 616 (51%) were women. A large proportion of patients were minorities: 40% Hispanic, 15% non-Hispanic Black, and 20% other/multiracial. Patients aged 55-64years and those 65 or older were less likely to receive pain medication compared to patients < 35 years (OR = 0.48, 95% CI 0.27-0.86, p = 0.01 and OR = 0.46, 95% CI 0.21-1.00, p = 0.05, respectively). Women were less likely than men to undergo any form of diagnostic imaging (OR = 0.52, 95% CI 0.35-0.76, p = 0.001). Similarly, patients in the lowest quintile of SES received less imaging than patients in the highest SES group (OR = 0.50, 95% CI 0.27-0.90, p = 0.02). Finally, women were less likely to receive alpha blockade compared to men (OR = 0.68, 95% CI 0.49-0.92, p = 0.014). Multiple disparities exist among patients presenting to the emergency department for ureteral stones. | |
| 2020 | Schut 2020 | Racial/Ethnic Disparities in | Racial/Ethnic Disparities in Follow-Up Adherence for Incidental Pulmonary Nodules: An Application of a Cascade-of-Care Framework | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Incidental Finding Follow Up | United States | Multiple Groups | Single Institution | EHR | Local data | Purpose: The aim of this study was to evaluate racial/ethnic disparities in follow-up adherence for incidental pulmonary nodules (IPNs) using a cascade-of-care framework, representing the multistage pathway from IPN diagnosis to timely follow-up adherence. Methods: A cohort of 1,562 patients diagnosed with IPNs requiring follow-up in a tertiary health care system in 2016 were retrospectively identified. Racial/ethnic disparities in follow-up adherence were examined by developing a multistep cascade-of-care model (provider communication, follow-up examination ordering and scheduling, adherence) to identify where patients were most likely to fall off the path toward adherence. Racial/ethnic adherence disparities were measured using descriptive statistics and multivariate modeling, controlling for sociodemographic, communication, and health characteristics. Results: Among 1,562 patients whose IPNs required follow-up, unadjusted results showed that nonwhite patients were less likely to meet each step on the cascade than White patients: for provider-patient IPN communication, 55% among Black patients and 80% among White patients; for follow-up ordering and scheduling, 42% and 41% among Black patients and 66% and 64% among White patients; and for timely adherence, 29% among Black patients and 54% among White patients. Adjusting for provider communication, sociodemographic, and health characteristics, Black patients had increased odds of never adhering to and delaying follow-up compared with White patients (odds ratios, 1.30 [95% confidence interval, 0.90-1.89] and 2.51 [95% confidence interval, 1.54-4.09], respectively). Conclusions: These findings demonstrate substantial racial/ethnic disparities in IPN follow-up adherence that persist after adjusting for multiple characteristics. The cascade of care demonstrates where on the adherence pathway patients are at risk for falling off, enabling specific targets for health policy and clinical interventions. Radiologists can play a key role in improving IPN follow-up via increased patient care involvement. | |
| 2001 | Selim 2001 | Racial differences in the use of | Racial differences in the use of lumbar spine radiographs: results from the Veterans Health Study | Adult Only | Male | Outpatient Ambulatory and Primary Care | Back Pain Imaging | United States | Multiple Groups | Single Institution | EHR | Local data | STUDY DESIGN: We analyzed data from the Veterans Health Study, a longitudinal study of male patients receiving VA ambulatory care. OBJECTIVE: To determine whether clinical differences and/or race account for disparities between white and nonwhite patients in the use of lumbar spine radiographs. SUMMARY AND BACKGROUND DATA: Four hundred one patients with low back pain (LBP) receiving ambulatory care services in four VA outpatient clinics in the greater Boston area were followed for 12 months. METHODS: Participants were mailed the Medical Outcome Study Short Form Health Survey (SF-36) and had scheduled interviews that included the completion of a low back questionnaire, a comorbidity index, and a straight leg raising (SLR) test. Using self-reported racial data, patients were grouped as whites (315 patients) and nonwhites (among whom 22 were black, 4 nonwhite Hispanics, and 1 other race). RESULTS: Nonwhite patients had lumbar spine films more often (13 of 27, 48%) than white patients (87 of 315, 27%) (P = 0.02). Nonwhite patients had higher pain intensity scores than white patients (63 +/- 21 vs. 48 +/- 21, P < 0.01) and were more likely to have radiating leg pain (20 of 27, 76%; compared with 171 of 315, 55%; P = 0.01) than white patients. Nonwhite patients had worse physical functioning (P = 0.01), general health perception (P = 0.05), social functioning (P = 0.02), and role limitations because of emotional problems (P < 0.01). At higher LBP intensity level, nonwhite patients received more lumbar spine films (20 of 27, 74%) than did white patients (155 of 315, 50%) (P < 0.01). Among patients with positive SLR test, nonwhite patients also had lumbar spine films more often (5 of 22, 23%) than white patients (29 of 315, 11%) (P < 0.01). However, after adjusting for multiple clinical characteristics, race was no longer found to be an independent predictor of lumbar spine radiograph use. A positive SLR test remained to be associated with higher radiograph use, whereas better mental health status was associated with lower radiograph use. CONCLUSIONS: There was greater use of lumbar spine radiographs by nonwhite patients compared with white patients. This remained true when patients were subcategorized by severity of LBP or SLR test. However, race had no influence when multiple clinical characteristics of the patients were controlled for simultaneously. This study demonstrates the importance of careful and comprehensive case-mix adjustment when assessing apparent differences in the use of medical services. | |
| 2022 | Shin 2022 | The Impact of Social Determinants | The Impact of Social Determinants of Health on Lung Cancer Screening Utilization | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Lung Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | PURPOSE: The purpose of this study was to understand how social determinants of health might influence lung cancer screening (LCS) adherence. METHODS: All LCS low-dose CT appointments scheduled at an urban, tertiary care academic medical center in the New England region between January 1, 2015, and December 31, 2018, were included. Demographics, insurance type, information on social determinants of health, and appointment status were obtained from the electronic medical records. Multivariate logistic regression was performed to evaluate the associations between the appointment status and the explanatory variables. RESULTS: During the study period, 2,797 patients had 4,747 scheduled LCS appointments. Forty-one percent of patients had at least one missed appointment, and 32.7% of all scheduled appointments were missed. The retention rate of patients after the baseline examination was approximately 50%. Self-reported Black race was independently associated with 1.5 times the odds of missing appointments compared with White race (P = .012). Patients with Medicaid had 6.1 times the odds of missing appointments compared with patients with private insurance and 4.6 times the odds of missing appointments compared with patients with Medicare (P < .0001). Housing insecurity was a risk factor for failing to follow up after the baseline examination, with an odds ratio of 5.3 (P = .0013). CONCLUSIONS: The high rate of missed LCS appointments underscores the need to improve screening compliance. The identification of specific social determinants of health that contribute to disparities in access to LCS could empower policymakers, hospital systems, and providers to use targeted interventions to promote more equitable access. | |
| 2017 | Singal 2017 | Mailed Outreach Program Increases | Mailed Outreach Program Increases Ultrasound Screening of Patients With Cirrhosis for Hepatocellular Carcinoma | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Other: Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | Background & aims: Surveillance of patients with cirrhosis increases early detection of hepatocellular carcinoma (HCC) and prolongs survival. However, its effectiveness is limited by underuse, particularly among racial/ethnic minorities and individuals of low socioeconomic status. We compared the effectiveness of mailed outreach strategies, with and without patient navigation, in increasing the numbers of patients with cirrhosis undergoing surveillance for HCC in a racially diverse and socioeconomically disadvantaged cohort. Methods: We performed a prospective study of patients with documented or suspected cirrhosis at a large safety-net health system from December 2014 through March 2016. Patients were assigned randomly (1:1:1) to groups that received mailed invitations for an ultrasound screening examination (n = 600), mailed invitations for an ultrasound screening examination and patient navigation (barrier assessment and motivational education for patients who declined screening; n = 600), or usual care (visit-based screening; n = 600). Patients who did not respond to outreach invitations within 2 weeks received up to 3 reminder telephone calls. The primary outcome was completion of abdominal imaging within 6 months of randomization. Results: Baseline characteristics were similar among groups. Cirrhosis was documented, based on International Classification of Diseases, 9th revision, codes, for 79.6% of patients, and suspected, based on noninvasive markers of fibrosis, for 20.4%. In an intent-to-treat analysis, significantly greater proportions of patients who received the mailed invitation and navigation (47.2%) or the mailed invitation alone (44.5%) underwent HCC screening than patients who received usual care (24.3%) (P < .001 for both comparisons). However, screening rates did not differ significantly between outreach the outreach groups (P = .25). The effects of the outreach program were consistent in all subgroups, including Caucasian vs non-Caucasian race, documented vs suspected cirrhosis, Child-Pugh A vs B cirrhosis, and receipt of gastroenterology care. Conclusions: In a prospective study, we found outreach strategies to double the percentage of patients with cirrhosis who underwent ultrasound screening for HCC. However, adding patient navigation to telephone reminders provided no significant additional benefit. ClinicalTrials.gov no: NCT02312817. | |
| 2004 | Somkin 2004 | The effect of access and | The effect of access and satisfaction on regular mammogram and papanicolaou test screening in a multiethnic population | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | State | Private Survey | Local data | Background: Access and satisfaction are determinants of preventive service use, but few studies have evaluated their role in breast and cervical cancer screening in multiethnic populations. Objectives: We sought to investigate the relationship between race/ethnicity, access, satisfaction, and regular mammogram and Papanicolaou test receipt in 5 racial/ethnic groups. Research Design: We conducted a telephone survey in 4 languages. Subjects: Our subjects were black, Chinese, Filipino, Latino, or white women aged 40 to 74 residing in Alameda County, California. Measures: Outcome: regular mammograms (last test within 15 months and another within 2 years prior) and Papanicolaou tests (36 months and 3 years, respectively). Independent: race/ethnicity, sociodemographic variables, access (health insurance, usual site of care, regular doctor, check-up within 12 months, knowing where to go, copayment for tests), and satisfaction (overall satisfaction scale, waiting times, test-related pain and embarrassment, test satisfaction). Results: Among women who had ever had a mammogram or Papanicolaou test, 54% and 77%, respectively, received regular screening. In multivariate analyses, regular mammography was positively associated with increased age (odds ratio [OR] 1.05 per year), private insurance (OR 1.7), check-up in the past year (OR 2.3), knowing where to go for mammography (OR 3.0), and greater satisfaction with processes of care (OR 1.04 per unit), and negatively with not knowing copayment amount (OR 0.4), too many forms to fill out (OR 0.5), embarrassment at the last mammogram (OR 0.6), and Filipino race/ethnicity. Similar results were found for regular Papanicolaou tests. Conclusions: Access and satisfaction are important predictors of screening but do little to explain racial/ethnic variation. Tailored interventions to improve regular mammography and Papanicolaou test screening in multiethnic populations are needed. | |
| 2021 | Su 2021 | Lack of racial and ethnic-based | Lack of racial and ethnic-based differences in acute care delivery in intracerebral hemorrhage | Adult Only | All Sexes | Emergency Department | Neurologic | United States | Multiple Groups | Single Institution | EHR | Local data | BACKGROUND AND AIM: Early diagnosis and treatment of intracerebral hemorrhage (ICH) is thought to be critical for improving outcomes. We examined whether racial or ethnic disparities exist in acute care processes in the first hours after ICH. METHODS: We performed a retrospective review of a prospectively collected cohort of consecutive patients with spontaneous primary ICH presenting to a single urban tertiary care center. Acute care processes studied included time to computerized tomography (CT) scan, time from CT to inpatient bed request, and time from bed request to hospital admission. Clinical outcomes included mortality, Glasgow Outcome Scale, and modified Rankin Scale. RESULTS: Four hundred fifty-nine patients presented with ICH between 2006 and 2018 and met inclusion criteria (55% male; 75% non-Hispanic White [NHW]; mean age of 73). In minutes, median time to CT was 43 (interquartile range [IQR] 28, 83), time to bed request was 62 (IQR 33, 114), and time to admission was 142 (IQR 95, 232). In a multivariable analysis controlling for demographic factors, clinical factors, and disease severity, race/ethnicity had no effect on acute care processes. English language, however, was independently associated with slower times to CT ( = 30.7 min, 95% CI 9.9 to 51.4, p = 0.004) and to bed request ( = 32.8 min, 95% CI 5.5 to 60.0, p = 0.02). Race/ethnicity and English language were not independently associated with worse outcome. CONCLUSIONS: We found no evidence of racial/ethnic disparities in acute care processes or outcomes in ICH. English as first language, however, was associated with slower care processes. | |
| 2021 | Tang 2021 | Health Equity Within Inequity: | Health Equity Within Inequity: Timing of Diagnostic Breast Cancer Care in an Underserved Medical Population | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Single Institution | EHR | Local data | BACKGROUND/AIM: We evaluated timeliness of care at a safety-net hospital after implementation of a multidisciplinary breast program. PATIENTS AND METHODS: A prospective database of patients with breast cancer was created after multidisciplinary breast program initiation in 2018. Patients were tracked to obtain time to completion of diagnostic imaging, biopsy, and treatment initiation. Patients with breast cancer diagnosed from 2015-2017 were reviewed for comparison. RESULTS: A total of 102 patients were identified. There was no statistical difference in time to completion of imaging, biopsy, and initial treatment between the 2018 and the 2015-2017 cohorts (p>0.05). No statistical difference was observed in time to completion of imaging, biopsy, and initial treatment between different races (p>0.05). CONCLUSION: Within the same socioeconomic status, there was no differential delivery of screening, work-up, and treatment by race. Despite protocol implementations, efficiency of care remained limited in a safety-net hospital with lack of financial resources. | |
| 2022 | Thompson 2022 | The impact of ethnicity on stroke | The impact of ethnicity on stroke care access and patient outcomes: a New Zealand nationwide observational study | Adult Only | All Sexes | Inpatient and Outpatient | Stroke Imaging | New Zealand | Multiple Groups | National | Private Survey | Local data | BACKGROUND: Ethnic inequities in stroke care access have been reported internationally but the impact on outcomes remains unclear. In New Zealand, data on ethnic stroke inequities and resultant effects on outcomes are generally limited and conflicting. METHODS: In a prospective, nationwide, multi-centre observational study, we recruited consecutive adult patients with confirmed stroke from 28 hospitals between 1 May and 31 October 2018. Patient outcomes: favourable functional outcomes (modified Rankin Scale 0-2); quality of life (EQ-5D-3L); stroke/vascular events; and death at three, six and 12 months. Process measures: access to reperfusion therapies, stroke-units, investigations, secondary prevention, rehabilitation. Multivariate regression analyses assessed associations between ethnicity and outcomes and process measures. FINDINGS: The cohort comprised 2,379 patients (median age 78 (IQR 66-85); 51.2% male; 76.7% European, 11.5% Mori, 4.8% Pacific peoples, 4.8% Asian). Non-Europeans were younger, had more risk factors, had reduced access to acute stroke units (aOR=0.78, 95% CI, 0.60-0.97), and were less likely to receive a swallow screen within 24 hours of arrival (aOR=0.72, 0.53-0.99) or MRI imaging (OR=0.66, 0.52-0.85). Mori were less frequently prescribed anticoagulants (OR=0.68, 0.47-0.98). Pacific peoples received greater risk factor counselling. Fewer non-Europeans had a favourable mRS score at three (aOR=0.67, 0.47-0.96), six (aOR=0.63, 0.40-0.98) and 12 months (aOR=0.56, 0.36-0.88), and more Mori had died by 12 months (aOR=1.76, 1.07-2.89). INTERPRETATION: Non-Europeans, especially Mori, had poorer access to key stroke interventions and experience poorer outcomes. Further optimisation of stroke care targeting high-priority populations are needed to achieve equity. | |
| 2019 | Tiedeman 2019 | Management of stroke in the | Management of stroke in the Australian Indigenous population: from hospitals to communities | Adult Only | All Sexes | Inpatient General Care | Stroke Imaging | Australia | Indigenous | Single Institution | EHR | Local data | BACKGROUND: Ischaemic strokes lead to significant morbidity and mortality within the Australian Indigenous population, with known variances in the management of strokes between indigenous and non-indigenous populations. AIMS: To compare investigations and management of indigenous and non-indigenous patients presenting to a New South Wales rural referral hospital with an ischaemic stroke to the national stroke standards across inpatient and outpatient settings. METHODS: Historical cohort study of 43 indigenous and 167 non-indigenous patients admitted to Tamworth Rural Referral Hospital with an ischaemic cerebrovascular accident. RESULTS: Indigenous patients were significantly less likely to have investigations completed, including carotid imaging (93.8% vs 100%, P = 0.012) and echocardiography (73.3% vs 97.7%, P = 0.004). Discharge follow up was significantly lower for the indigenous population (74.4% vs 87.4%, P = 0.034). Indigenous stroke patients were 15.8 years younger than non-indigenous subjects (56.8 vs 72.6 years old; P < 0.001). Indigenous patients were more likely to have stroke risk factors, including smoking (51.2% vs 15.0%; P < 0.001), diabetes mellitus (37.2% vs 16.8%, P = 0.003) and past history of cerebrovascular accident or transient ischaemic attack (50.2% vs 31.1%, P = 0.032). CONCLUSIONS: The investigation and post-discharge care of indigenous ischaemic stroke patients is inferior to non-indigenous patients. Indigenous patients within rural NSW have a higher prevalence of preventable disease, including those that confer a higher stroke risk. Further research is needed to investigate the cause of these discrepancies and to improving indigenous stroke care between hospitals and primary care providers. | |
| 2020 | Toy 2020 | Imaging Utilization and Outcomes in | Imaging Utilization and Outcomes in Vulnerable Populations during COVID-19 in New York City | Adult Only | All Sexes | Inpatient and Outpatient | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | EHR | Local data | BACKGROUND: Coronavirus disease 2019 (COVID-19) affects vulnerable populations (VP) adversely. PURPOSE: To evaluate overall imaging utilization in vulnerable subgroups (elderly, racial/ethnic minorities, socioeconomic status [SES] disadvantage) and determine if a particular subgroup has worse outcomes from COVID-19. MATERIALS/METHODS: Of 4110 patients who underwent COVID-19 testing from March 3-April 4, 2020 at NewYork-Presbyterian Hospital (NYP) health system, we included 1121 COVID-19 positive adults (mean age 59 18 years, 59% male) from two academic hospitals and evaluated imaging utilization rates and outcomes, including mortality. RESULTS: Of 897 (80%) VP, there were 465 (41%) elderly, 380 (34%) racial/ethnic minorities, and 479 (43%) SES disadvantage patients. Imaging was performed in 88% of patients and mostly portable/bedside studies, with 87% of patients receiving chest radiographs. There were 83% hospital admissions, 25% ICU admissions, 23% intubations, and 13% deaths. Elderly patients had greater imaging utilization, hospitalizations, ICU/intubation requirement, longer hospital stays, and >4-fold increase in mortality compared to non-elderlies (adjusted hazard ratio[aHR] 4.79, p<0.001). Self-reported minorities had fewer ICU admissions (p=0.03) and reduced hazard for mortality (aHR 0.53, p=0.004; complete case analysis: aHR 0.39, p<0.001 excluding "not reported"; sensitivity analysis: aHR 0.61, p=0.005 "not reported" classified as minorities) with similar imaging utilization, compared to non-minorities. SES disadvantage patients had similar imaging utilization and outcomes as compared to their counterparts. CONCLUSIONS: In a predominantly hospitalized New York City cohort, elderly patients are at highest mortality risk. Racial/ethnic minorities and SES disadvantage patients fare better or similarly to their counterparts, highlighting the critical role of access to inpatient medical care during the COVID-19 pandemic. | |
| 2018 | Veras 2018 | Lack of disparities in screening | Lack of disparities in screening for associated anomalies in children with anorectal malformations | Pediatric Only | All Sexes | Inpatient General Care | GI/Abdominal | United States | Black | Single Institution | EHR | Local data | Introduction: Patients with anorectal malformations (ARM) often have associated congenital anomalies and should undergo several screening exams in the first year of life. We hypothesized that racial and socioeconomic disparities exist in the screening processes for these patients. Methods: After IRB approval, a retrospective review of patients with ARM born between 2005 and 2016 was performed at a quaternary care children's hospital. Demographics including gender, race, insurance, and zip code were collected. Zip code was used as a surrogate for median income. Chart review was performed to identify anomaly type and whether Vertebral defects, Anorectal malformations, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities screening was performed within 1 y of age. Descriptive statistics and chi square analyses were performed. Results: One hundred patients (59% male, 68% low malformation) were identified. African American and Caucasian subjects represented 41% and 40% of the population, respectively. Overall, 68 of 100 patients had at least one screening test for each of the Vertebral defects, Anorectal malformations, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities associations. Although some minor differences were noted (more African Americans received skeletal survey than Caucasians, 80.5% versus 60%, P = 0.00335), no pattern of systematic bias in the receipt or timing of screening was evident based on race, insurance, or income. Conclusions: There do not appear to be racial or socioeconomic disparities in screening for associated anomalies in patients with ARM. However, overall gaps in screening still exist, and work must be carried out to appropriately screen all patients for associated anomalies. | |
| 2005 | Wall 2005 | Impact of patient race on receiving | Impact of patient race on receiving head CT during blunt head injury evaluation | All Ages | All Sexes | Emergency Department | Neurologic | United States | Multiple Groups | Single Institution | EHR | Local data | Objectives: Prior evidence suggests that physicians may alter process of care based on race/ethnicity. The objective of this study was to determine whether race/ethnicity predicts whether a patient receives computed tomography of the head (head CT) during evaluation of blunt head injury. Methods: This was a nonconcurrent cohort study set in an emergency department of a Level 1 trauma center in a university medical center. Consecutive patients presenting with blunt head injury from January 2000 to December 2000 were enrolled. The main outcome measure was whether or not a patient received head CT during evaluation of blunt head injury. Results: The unadjusted probability of receiving head CT was similar among minority (33.9%; 95% confidence interval [CI] = 30.0% to 38.1%) and non-Hispanic white patients (36.4%; 95% CI = 33.5% to 39.3%). After adjusting for important clinical and socioeconomic predictors, minority patients had a probability of receiving head CT 0.84 times as high as that of non-Hispanic whites, but this result was not statistically significant (95% CI = 0.67 to 1.09). Conclusions: Minority and non-Hispanic white patients may not have significantly different rates of receiving head CT during evaluation of blunt head injury. A multicenter prospective study is necessary to confirm these preliminary findings. | |
| 2019 | Walton 2019 | Barriers to obtaining prostate | Barriers to obtaining prostate multi-parametric magnetic resonance imaging in African-American men on active surveillance for prostate cancer | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | Single Institution | EHR | Local data | Purpose: Magnetic resonance imaging is playing an ever-bigger role in the management of prostate cancer. This study investigated barriers to obtaining multi-parametric MRI (mpMRI) in African-American men on active surveillance for prostate cancer in comparison to white men affected by the same type of cancer. Materials and Methods: Retrospective review of prostate mpMRI orders from August 2015 to October 2017 at a single health organization treating a diverse population was performed. Data was extracted from the electronic medical records and cancellations were examined based on the documented reason for mpMRI cancellation, race, median zip code household income, and distance from healthcare facility. Results: Out of 793 prostate mpMRI orders, 201 (25%) went unscanned. Access to care issues accounted for 46% of unscanned orders. Patient cancellations were the most common, followed by difficulty contacting patients, and insurance denials. African-American patients disproportionately went unscanned because institution staff were unable to contact patients (29% vs 10% in white men, P=0.0015). Median zip code household income was significantly different between racial groups but did not vary between indication for cancellation. Conclusions: African-American prostate cancer patients' access to mpMRI is hindered more by barriers to care than White patients. Urology providers must consider these issues before using prostate mpMRI within their active surveillance pathways. | |
| 2012 | Yoo 2012 | The Effect Modification of | The Effect Modification of Supplemental Insurance on the Relationship Between Race and Bone Mineral Density Screening in Female Medicare Beneficiaries | Adult Only | Female | Outpatient Ambulatory and Primary Care | Osteoporosis Screening | United States | Black | Single Institution | EHR | Local data | To determine the effect modification of supplemental insurance on the relationship between race and bone mineral density (BMD) in female Medicare beneficiaries. Retrospectively analyzing hospital administrative claim and clinical data of female Medicare beneficiaries (n = 1,398), we performed multivariate logistic regressions of BMD testing including data from all study participants and the subsets of health insurance. Significantly fewer Black than White female Medicare beneficiaries received the BMD testing in the overall sample (odds ratio, OR = 0.63; p = 0.02) and those without supplementary health insurance (n = 709; OR = 0.38; p = 0.004). By contrast, the magnitude of this racial disparity in the BMD testing was diminished among those with supplementary private health insurance (n = 689). We found a significant racial disparity in BMD testing for Black and White female Medicare beneficiaries. This disparity became more pronounced among those without supplementary private health insurance. | |
| 2019 | Zook 2019 | Racial/Ethnic Variation in | Racial/Ethnic Variation in Emergency Department Care for Children with Asthma | Pediatric Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | Regional | EHR | Local data | Objective To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients. Methods This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED. Results The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01). Conclusions In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care. | |
| 2007 | Tandeter 2007 | Ethnic differences in preventive | Ethnic differences in preventive medicine: The example of Jewish Ethiopian women in Israel | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Israel | Immigrants | Single Institution | Private Survey | Local telephone survey | Background: Studies have found ethno-cultural disparities in health care delivery in different countries. Minority populations may receive lower standards of care. Objectives: To test a hypothesis that Jewish Ethiopian women may be receiving fewer preventive recommendations than other women in Israel. Methods: A telephone survey was conducted using a structured questionnaire designed specifically for the study in Hebrew, Russian and Amharic (Semitic language of Ethiopia). The study group included 51 post-menopausal women of Ethiopians origin, aged 50-75. The control group included 226 non-Ethiopian matched for age, some of whom were immigrants from the former Soviet Union. The questionnaire dealt with osteoporosis and breast cancer screening and prevention. Results: All the parameters measured showed that the general population received more preventive recommendations and treatment that did Jewish Ethiopian women, including manual breast examination, mammography, osteoporosis prevention, bone density scans, and recommendations for a calcium-rich diet, calcium supplementation, hormone replacement therapy, biphosphonates and raloxifen. On a logistic regression model the level of knowledge of the Hebrew language, age, ethnicity and not visiting the gynecoogist were significantly related to not having received any preventive medicine recommendations. Conclusions: Differences in cultural backgrounds and language between physicians and their patients may obstruct the performance of screening and preventive medicine. Recognizing this potential for inequity and using methods to overcome these barriers may prevent it in the future. | |
| 2016 | Wilcox 2016 | Racial/ethnic disparities in annual | Racial/ethnic disparities in annual mammogram compliance among households in Little Haiti, Miami-Dade County, Florida: An observational study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | State | Private Survey | Local telephone survey | INTRODUCTION: Breast cancer is the most commonly diagnosed cancer and the 2nd leading cause of cancer-related deaths among women in the U.S. Although routine screening via mammogram has been shown to increase survival through early detection and treatment of breast cancer, only 3 out of 5 women age 40 are compliant with annual mammogram within the U.S. and the state of Florida. A breadth of literature exists on racial/ethnic disparities in compliance with mammogram; however, few such studies include data on individual Black subgroups, such as Haitians. This study assessed the association between race/ethnicity and annual mammogram compliance among randomly selected households residing in the largely Haitian community of Little Haiti, Miami-Dade County (MDC), Florida. METHODS: This study used cross-sectional, health data from a random-sample, population-based survey conducted within households residing in Little Haiti between November 2011 and December 2012 (n = 951). Mammogram compliance was defined as completion of mammogram by all female household members within the 12 months prior to the survey. The association between mammogram compliance and race/ethnicity was assessed using binary logistic regression models. Potential confounders were identified as factors that were conservatively associated with both compliance and race/ethnicity (P 0.20). Analyses were restricted to households containing at least 1 female member age 40 (n = 697). RESULTS: Overall compliance with annual mammogram was 62%. Race/ethnicity was significantly associated with mammogram compliance (P = 0.030). Compliance was highest among non-Hispanic Black (NHB) households (75%), followed by Hispanic (62%), Haitian (59%), and non-Hispanic White (NHW) households (51%). After controlling for educational level, marital status, employment status, the presence of young children within the household, health insurance status, and regular doctor visits, a borderline significant disparity in mammogram compliance was observed between Haitian and NHB households (adjusted odds ratio = 1.63, P = 0.11). No other racial/ethnic disparities were observed. DISCUSSION: Compliance with annual mammogram was low among the surveyed households in Little Haiti. Haitian households underutilized screening by means of annual mammogram compared with NHB households, although this disparity was not significant. Compliance rates could be enhanced by conducting individualized, mammogram screening-based studies to identify the reasons behind low rate of compliance among households in this underserved, minority population. | |
| 2017 | Mobley 2017 | Breast Cancer Screening Among Women | Breast Cancer Screening Among Women with Medicaid, 2006-2008: a Multilevel Analysis | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Medicaid Data | Medicaid | INTRODUCTION: Nationally, about one third of women with breast cancer (BC) are diagnosed at late stage, which might be reduced with greater utilization of BC screening. The purpose of this paper is to examine the predictors of BC mammography use among women with Medicaid, and differences among Medicaid beneficiaries in their propensity to use mammography. METHODS: The sample included 2,450,527 women drawn from both fee-for-service and managed care Medicaid claims from 25 states, during 2006-2008. The authors used multilevel modeling of predictors at person, county, and state levels of influence and examined traditional factors affecting access and the expanded scope of practice allowed for the nurse practitioner (NP) in some states to provide primary care independent of physician oversight. RESULTS: Black [OR =0.87; 95% CI (0.87-0.88)] and American Indian women [OR=0.74; 95% CI (0.71-0.76)] had lower odds ratio of mammography use than white women, while Hispanic [OR = 1.06; 95% CI (1.05-1.07)] had higher odds ratio of mammography use than white women. Living in counties with higher Hispanic residential segregation [OR= 1.16; 95% CI (1.10-1.23)] was associated with a higher odds ratio of mammography use compared to areas with low Hispanic residential segregation, whereas living among more segregated black [OR=0.78; 95% CI (0.75-0.81)] or Asian [OR= 0.19; 95% CI (0.17-0.21)] communities had lower odds ratio compared to areas with low segregation. Holding constant statistically the perceived shortage of MDs, which was associated with significantly lower mammography use, the NP regulatory variable [OR= 1.03; 95% CI (1.01-1.07)] enhanced the odds ratio of mammography use among women in the six states with expanded scope of practice, compared with women residing in 19 more restrictive states. CONCLUSIONS: Racial and ethnic disparities exist in the use of mammography among Medicaid-insured women. More expansive NP practice privileges in states are associated with higher utilization, and may help reduce rural disparities. | |
| 2017 | Tangka 2017 | Racial and ethnic disparities among | Racial and ethnic disparities among state Medicaid programs for breast cancer screening | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Medicaid Data | Medicaid claims and enrollment files | Breast cancer screening by mammography has been shown to reduce breast cancer morbidity and mortality. The use of mammography screening though varies by race, ethnicity, and, sociodemographic characteristics. Medicaid is an important source of insurance in the US for low-income beneficiaries, who are disproportionately members of racial or ethnic minorities, and who are less likely to be screened than women with higher socioeconomic statuses. We used 2006-2008 data from Medicaid claims and enrollment files to assess racial or ethnic and geographic disparities in the use of breast cancer screening among Medicaid-insured women at the state level. There were disparities in the use of mammography among racial or ethnic groups relative to white women, and the use of mammography varied across the 44 states studied. African American and American Indian women were significantly less likely than white women to use mammography in 30% and 39% of the 44 states analyzed, respectively, whereas Hispanic and Asian American women were the minority groups most likely to receive screening compared with white women. There are racial or ethnic disparities in breast cancer screening at the state level, which indicates that analyses conducted by only using national data not stratified by insurance coverage are insufficient to identify vulnerable populations for interventions to increase the use of mammography, as recommended. | |
| 2007 | Fiscella 2007 | Impact of primary care patient | Impact of primary care patient visits on racial and ethnic disparities in preventive care in the United States | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Medicare Data | Medicaire Current Beneficiary Survey | Background: The causes of racial and ethnic disparities in preventive care are not fully understood. We examined the hypothesis that fewer primary care visits by minority patients contribute to these disparities. Methods: We analyzed claims for Medicare beneficiaries 65 and older who participated in the Medicare Current Beneficiary Survey, 1998 to 2002. Five preventive services were included: colorectal cancer testing, influenza vaccination, lipid screening, mammography, and Papanicolaou smear screening. In separate multivariate analyses, we examined the effect of minority status (self-report of African American race or Hispanic ethnicity) on having a claim in the past 12 months for each preventive service after successive control for number of primary care visits and other patient characteristics. Results: The final sample included 15,962 subjects. In age-adjusted analyses, minorities had statistically lower rates of claims for each of the 5 procedures. After controlling for number of primary care visits, the effect of minority status was slightly attenuated but remained statistically significant for receipt of each procedure. After adding low income, low educational level and supplementary insurance, health status, and year, minority status was significantly associated only with colorectal cancer screening (odds ratio [OR] 0.79; 95% confidence interval [CI] 0.67 to 0.94) and influenza vaccinations (OR 0.56; 95% CI 0.49 to 0.64). Conclusions: The frequency of primary care visits seems to contribute minimally to racial and ethnic disparities in preventive services. Other patient characteristics, particularly those associated with poverty, explain much of these disparities. | |
| 2004 | Benjamins 2004 | County characteristics and racial | County characteristics and racial and ethnic disparities in the use of preventive services | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Medical Expenditure Panel Survey | BACKGROUND: Studies examining predictors of preventive service utilization generally focus on individual characteristics and ignore the role of contextual variables. To help address this gap in the literature, the present study investigates whether county-level characteristics, such as racial and ethnic composition, are associated with the use of preventive services. METHODS: Data from the Medical Expenditure Panel Survey and the Area Resource Files (1996-1998) are used to identify the individual- and county-level predictors of five types of preventive services (n = 49,063). RESULTS: County racial or ethnic composition is associated with the utilization of certain preventive services, net of individual-level characteristics. Specifically, individuals in high percent Hispanic counties are more likely to report cholesterol screenings, while those in counties with more blacks are more likely to have regular mammograms. Moreover, county racial or ethnic composition modifies the relationship between individual race or ethnicity and preventive use. In particular, Hispanic individuals who reside in high percent black counties report higher levels of utilization for most preventive services compared to Hispanics living in other counties. CONCLUSIONS: Physical and social environments are key determinants of health behaviors and outcomes. Future studies should take into account the racial or ethnic composition of an area and how this interacts with individual race or ethnicity when investigating predictors of preventive care use. | |
| 2002 | DeLaet 2002 | Receipt of preventive services | Receipt of preventive services among privately insured minorities in managed care versus fee-for-service insurance plans | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Medical Expenditure Panel Survey | OBJECTIVE: We compare preventive services utilization among privately insured African Americans and Hispanics in managed care organizations (MCOs) versus fee-for-service (FFS) plans. We also examine racial/ethnic disparities in the receipt of preventive services among enrollees in FFS or MCO plans. DESIGN: Analysis of the nationally representative 1996 Medical Expenditure Panel Survey. PARTICIPANTS: Participants included 1,120 Hispanic, 929 African-American, and 6,383 non-Hispanic white (NHW) adults age 18 to 64 years with private health insurance. MEASUREMENTS AND MAIN RESULTS: We examined self-reported receipt of physical examination, blood pressure measurement, cholesterol assessment, Papanicolau testing, screening mammography, and breast and prostate examinations. Multivariate modeling was used to adjust for age, gender, education, household income, and health status. Hispanics in MCOs were more likely than their FFS counterparts to report having preventive services, with adjusted differences ranging from 5 to 19 percentage points (P <.05 for physical examination, blood pressure measurement, breast examination and Pap smear). Among African Americans, such patterns were of a smaller magnitude. In both MCOs and FFS plans the proportion of African Americans reporting preventive services was equal to or greater than NHWs. In contrast, among Hispanic women in FFS, a non-statistically significant trend of fewer cancer screening tests than NHW's was observed (Pap smears 75% vs 80%; mammograms 66% vs 74%, respectively). In both MCO and FFS plans, Hispanics were less likely than NHWs to report having blood pressure and cholesterol measurement (P <.05). CONCLUSIONS: With the demise of traditional MCOs, reform efforts should incorporate those aspects of MCOs that were associated with greater preventive service utilization, particularly among Hispanics. Existing ethnic disparities warrant further attention. | |
| 2015 | Holden 2015 | Preventive care utilization among | Preventive care utilization among the uninsured by race/ethnicity and income | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Medical Expenditure Panel Survey | Background: Health insurance status affects access to preventive services. Effective use of preventive services is a key factor in the reduction of important health concerns and has the potential to enable adults to live longer, healthier lives. Purpose: To analyze the use of U.S. Preventive Services Task Force (USPSTF)-recommended preventive services among uninsured adults, with a focus on variation across race, ethnicity, and household income. Methods: Using pooled 2004-2011 Medical Expenditure Panel Survey data, this study conducted multivariate logistic regressions to estimate variation in receipt of eight USPSTF-recommended preventive services by race/ethnicity among adults aged 18 years and older uninsured in the previous year. Stratified analyses by household income were applied. Data were analyzed in 2013. Results: Uninsured adults received preventive services far below Healthy People 2020 targets. Among the uninsured, African Americans had higher odds of receiving Pap tests, mammograms, routine physical checkups, and blood pressure checks according to guidelines than whites.Moreover, compared to whites, Hispanics had higher odds of receiving Pap tests, mammograms, influenza vaccinations, and routine physical checkups and lower odds of receiving blood pressure screening and advice to quit smoking. When results were stratified by household income, racial/ethnic differences persisted except for the highest income levels (400% Federal Poverty Level), where they were largely non-significant. Conclusions: Generally, uninsured African American and Hispanic populations fare better than uninsured whites in preventive service utilization. Future research should examine reasons behind these racial/ethnic differences to inform policy interventions aiming to increase preventive service utilization among the uninsured. | |
| 2022 | Jacobs 2022 | Changes in preventive service use | Changes in preventive service use by race and ethnicity after medicare eligibility in the United States | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Medical Expenditure Panel Survey | Use of recommended preventive care services in the United States is not universal and varies considerably by socio-economic status. We examine whether widespread eligibility for Medicare at age 65 narrows disparate preventive service use by race and ethnicity. Using data across 12 cycles of the Household Component of the Medical Expenditure Panel Survey (20052016), we employ a regression discontinuity design to assess changes in the use of preventive services. Our sample included: 8847 Hispanic respondents, 9908 non-Hispanic Black respondents, and 29,527 non-Hispanic White respondents. We examined six preventive services: routine check-ups, blood cholesterol screenings, receipt of the influenza vaccine, blood pressure screenings, mammograms, and colorectal cancer screenings. For non-Hispanic Black adults, we found that preventive service use increased after age 65 across a range of measures including a 4.8 percentage-point (95% confidence interval (CI) 1.4, 8.2) increase in blood cholesterol screening, and a 9.1 percentage-point (95% CI 2.1, 15.9) increase in mammograms for Black women. For all four preventive health measures that were lower for Hispanic adults compared with non- Hispanic White adults prior to age 65, service use was indistinguishable (p > 0.10) between these groups after reaching the Medicare eligibility age. Medicare eligibility appeared to reduce most racial and ethnic disparities in preventive service use. | |
| 2011 | Miranda 2011 | Breast cancer screening and | Breast cancer screening and ethnicity in the United States: Implications for health disparities research | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Medical Expenditure Panel Survey | Ethnic and racial minority women within the U.S. are less likely to use breast cancer screening (BCS) procedures than non-Latina White women, and are more likely to be diagnosed with cancer at later stages of disease. Previous studies examining Latina rates of screening and disease have used aggregated populations for comparison, possibly attenuating important ethnic healthcare disparities and yielding misleading findings. The purpose of this study was to examine if ethnicity matters in understanding current estimates of BCS patterns among U.S. women; to test if healthcare disparities in BCS are present, and if any ethnic/racial groups are primarily affected. The authors used multivariate multinomial regression to examine self-reported mammogram and clinical breast exam in the 2007 full-year U.S. Medical Expenditure Panel Survey. Mexican origin women reported the lowest rates of past-year mammograms and clinical breast examination. Factors enabling healthcare moderated the group's lower likelihood of mammograms and clinical breast examination. Some breast cancer screening parity appears to have been achieved in 2007 for Black and some Latina groups; however, those rates lag behind for the largest Latino ethnic group, Mexican. Factors enabling healthcare access, such as education, income and insurance, attenuated the BCS inequalities found for Mexican origin women. Findings suggest that successful efforts to reduce BCS disparities be strategically redirected to include women of Mexican origin in addition to other underserved populations. | |
| 2012 | Miranda 2012 | Breast Cancer Screening Trends in | Breast Cancer Screening Trends in the United States and Ethnicity | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Medical Expenditure Panel Survey | Background: The study objectives were to compare and examine mammography use trends among ethnic/racial women in the context of United States Healthy People 2010 goals. Methods: We analyzed pooled, multistage probability sample data from the 1996-2007 Medical Expenditure Panel Survey. Included in the sample were female respondents of ages 40 to 75 years (N = 64,811) from six ethnic/racial groups (Black, White, Mexican, Other Latinas, Puerto Rican, and Cuban). The primary outcome was self-reported, past two-year mammography use consistent with screening practice guidelines. Results: We found that for most U.S. women, the Healthy People 2010 mammography goal (70%) was achieved between 1996 and 2007. Puerto Rican and White women, respectively, had the highest mammography rates, and Black and Cuban women had rates that approached the 2010 goal. Conclusion: Mexican Latinas reported the lowest rates of past two-year mammography; however, factors enabling healthcare access markedly moderated this lower likelihood. From 2000, Mexican Latinas' mammography use was markedly below (10%) the Healthy People 2010 goal and remained there for the duration. Impact: Our findings indicate that healthcare equity goals are attainable if efforts are made to reach a sizeable portion of vulnerable populations. | |
| 2003 | Sambamoorthi 2003 | Racial, ethnic, socioeconomic, and | Racial, ethnic, socioeconomic, and access disparities in the use of preventive services among women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Medical Expenditure Panel Survey | BACKGROUND: In this article we estimate the variations in receipt of age-appropriate preventive services among adult women between 21 and 64 years of age, by race and ethnic group, socioeconomic status, and access to health care. We also assess whether differences in access to care and socioeconomic status may explain racial and ethnic differences in the use of preventive services. METHOD: Nationally representative data on adult women from the Medical Expenditure Panel Survey were used to estimate the effect of socioeconomic characteristics on the receipt of each preventive service. Receipt of each of four preventive services-cholesterol test, blood pressure reading, and two cancer screening tests (Papanicolaou smear, mammogram)-according to the 1996 recommendations of the U.S. Preventive Services Task Force were examined. RESULTS: An overwhelming majority of adult women (93%) had had a blood pressure reading within the last 2 years. Eighty-four percent of women had had their cholesterol checked within the last 5 years. Seventy-five percent of women had received a mammogram and 80% received Pap tests. College education, high income, usual source of care, and health insurance consistently predicted use of preventive services. These factors also explained ethnic disparities in the receipt of preventive services between Latinas and white women. CONCLUSIONS: The results from our study are encouraging because only a minority of women do not receive age-appropriate preventive services. However, low socioeconomic status, lack of insurance, and lack of a usual source of care represent significant barriers to preventive care for adult women. | |
| 2018 | Agirdas 2018 | Effects of the ACA on Preventive | Effects of the ACA on Preventive Care Disparities | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | Medical Expenditure Panel Survey | Background: The Affordable Care Act (ACA) requires non-grandfathered private insurance plans, starting with plan years on or after September 23rd, 2010, to provide certain preventive care services without any cost sharing in the form of deductibles, copayments or co-insurance. This requirement may affect racial and ethnic disparities in preventive care as it provides the largest copay reduction in preventive care. Objectives: We ask whether the ACA's free preventive care benefits are associated with a reduction in racial and ethnic disparities in the utilization of four preventive services: cholesterol screenings, colonoscopies, mammograms, and Pap smears. Methods: We use a data set of over 6000 individuals from the 2009, 2010, and 2013 Medical Expenditure Panel Surveys (MEPS). We restrict our data set only to individuals who are old enough to be eligible for each preventive service. Our difference-in-differences logistic regression model classifies privately insured Hispanics, African Americans, and Asians as the treatment groups and 2013 as the after-policy year. Our control group consists of non-Hispanic whites on Medicaid as this program already covered preventive care services for free or at a low cost before the ACA. Results: After controlling for income, education, marital status, preferred interview language, self-reported health status, employment, having a usual source of care, age and gender, we find that the ACA is associated with increases in the probability of the median, privately insured Hispanic person to get a colonoscopy by 3.6% and a mammogram by 3.1%, compared to a non-Hispanic white person on Medicaid. Similarly, we find that the median, privately insured African American person's probability of receiving these two preventive services improved by 2.3 and 2.4% compared to a non-Hispanic white person on Medicaid. We do not find any significant improvements for any racial or ethnic group for cholesterol screenings or Pap smears. Furthermore, our results do not indicate any significant changes for Asians compared to non-Hispanic whites in utilizing the four preventive services. These reductions in racial/ethnic disparities are robust to reconfigurations of time periods, previous diagnosis, and residential status. Conclusions: Early effects of the ACA's provision of free preventive care are significant for Hispanics and African Americans. Further research is needed for the later years as more individuals became aware of these benefits. | |
| 2021 | Hanna 2021 | Disparities in the use of emergency | Disparities in the use of emergency department advanced imaging in medicare beneficiaries | Adult Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | National | Medicare Data | Medicare data | OBJECTIVE. The purpose of our study was to assess potential disparities in the utilization of advanced imaging during emergency department (ED) visits. MATERIALS AND METHODS. This retrospective study was conducting using 5% Research Identifiable Files. All CT and MRI (together defined as "advanced imaging") examinations associated with ED visits in 2015 were identified for continuously enrolled Medicare beneficiaries. Individuals with medical claims 30 days before the index ED event were excluded, and encounters that occurred in hospitals without advanced imaging capabilities were also excluded. Patient characteristics were identified using Medicare files and hospital characteristics using the American Hospital Association Annual Survey of Hospitals. Multivariate logistic regression was used for the analysis. RESULTS. Of 86,976 qualifying ED encounters, 52,833 (60.74%) ED encounters were for female patients; 29.03% (n = 25,245) occurred at rural hospitals and 15.81% (n = 13,750) at critical access hospitals. Race distribution was 83.13% White, 11.05% Black, and 5.82% Other. Compared with ED patients at urban hospitals, those at rural and critical access hospitals were 6.9% less likely (odds ratio [OR] = 0.931, p = 0.015) and 18.0% less likely (OR = 0.820, p < 0.0001), respectively, to undergo advanced imaging. Compared with White patients, Black patients were 31.6% less likely (OR = 0.684, p < 0.0001) to undergo advanced imaging. Relative to their urban counterparts, both White (OR = 0.941, p = 0.05) and Black (OR = 0.808, p = 0.047) rural ED patients were less likely to undergo advanced imaging. CONCLUSION. Among Medicare beneficiaries receiving care in U.S. EDs, significant disparities exist in advanced imaging utilization. Although imaging appropriateness was not investigated, these findings suggest inequity. Further research is necessary to understand why consistent health benefits do not translate into consistent imaging access among risk-adjusted ED patients. | |
| 2004 | Morales 2004 | Sociodemographic differences in use | Sociodemographic differences in use of preventive services by women enrolled in Medicare+Choice plans | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Regional | Medicare Data | Medicare data | BACKGROUND: We examined the effect of sociodemographic factors on the receipt of mammography, colorectal cancer screening, and influenza vaccinations by women enrolled in two Medicare+Choice health plans. METHODS: Administrative and survey data for 2,698 female health plan members was analyzed using multivariate logistic and ordinal logistic regression to assess the effects of enrollee characteristics on use of preventive services. RESULTS: Age, race and wealth were associated with the receipt of one or more preventive services. Older women were less likely to receive mammograms, wealthier women were more likely to receive mammograms and CRC screening, and Black women were more likely to receive CRC screening but less likely to receive influenza vaccinations. Wealthier women received a greater number of preventive services, other things equal, while older women received fewer preventive services. CONCLUSIONS: Race and wealth continue to be important factors in the receipt of preventive services by elderly women, though not always consistent with historical trends. Medicare+Choice plans should consider strategies to further reduce racial and wealth disparities in the use of preventive services. | |
| 2012 | Onega 2012 | Geographic and sociodemographic | Geographic and sociodemographic disparities in PET use by Medicare beneficiaries with cancer | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | National | Medicare Data | Medicare data | PURPOSE: PET use for cancer care has increased unevenly, possibly because of regional health care market characteristics or underlying population characteristics. The aim of this study was to examine variation in advanced imaging use among individuals with cancer in relation to population and hospital service area (HSA) characteristics. METHODS: A retrospective national study of fee-for-service Medicare beneficiaries with diagnoses of 1 of 5 cancers covered by Medicare for PET (2004-2008) was conducted. Crude and adjusted rates of PET, CT, and MRI were estimated for HSAs and sociodemographic subgroups. Generalized linear mixed models were used to assess the effects of race/ethnicity, area-level income, and HSA-level physician supply and spending on imaging utilization. RESULTS: On the basis of an annual average of 116,452 beneficiaries with cancer, adjusted PET rates (imaging days per person-year) showed significantly higher use for whites compared with blacks in both 2004 (whites, 0.35 [95% confidence interval, 0.34-0.36]; blacks, 0.31 [95% confidence interval, 0.30-0.33]) and 2008 (whites, 0.64 [95% confidence interval, 0.63-0.65]; blacks, 0.57 [95% confidence interval, 0.55-0.59]). This trend was similar for the highest quartile of group-level median household income but was opposite for CT use, with blacks having higher rates than whites. The highest Medicare-spending HSAs had significantly higher adjusted PET rates compared with lower spending areas (0.57 [95% confidence interval, 0.55-0.60] vs 0.69 [95% confidence interval, 0.67-0.71] imaging days/person-year). CONCLUSIONS: The use of PET among Medicare beneficiaries with cancer increased from 2004 to 2008, with higher rates observed among whites, among higher socioeconomic groups, and in higher Medicare spending areas. Sociodemographic differences in advanced imaging use are modality specific. | |
| 2009 | Pham 2009 | Rapidity and modality of imaging | Rapidity and modality of imaging for acute low back pain in elderly patients | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Back Pain Imaging | United States | Black | National | Medicare Data | Medicare data | Background: Most quality metrics focus on underuse of services, leaving unclear what factors are associated with potential overuse. Methods: We analyzed Medicare claims from 2000-2002 and 2004-2006 for 35 039 fee-for-service Medicare beneficiaries with acute low back pain (LBP) who were treated by 1 of 4567 primary care physicians responding to the 2000-2001 or 2004-2005 Community Tracking Study Physician Surveys. We modified a measure of inappropriate imaging developed by the National Committee on Quality Assurance. We characterized the rapidity (<28 days, 29-180 days, none within 180 days) and modality of imaging (computed tomography or magnetic resonance imaging [CT/MRI], only radiograph, or no imaging). We used ordered logit models to assess relationships between imaging and patient demographics and physician/practice characteristics including exposure to financial incentives based on patient satisfaction, clinical quality, cost profiling, or productivity. Results: Of 35 039 beneficiaries with LBP, 28.8% underwent imaging within 28 days and an additional 4.6% between 28 and 180 days. Among patients who received imaging, 88.2% received radiography, while 11.8% received CT/MRI as their initial study. White patients received higher levels of imaging than black patients or those of other races. Medicaid patients received less rapid or advanced imaging than other patients. Patients had higher levels of imaging if their primary care physician worked in large practices. Compared with no incentives, clinical quality-based incentives were associated with less advanced imaging (10.5% vs 1.4% for within 28 days; P < .001), whereas incentive combinations including satisfaction measures were associated with more rapid and advanced imaging. Results persisted in multivariate analyses and when the outcome was redefined as the number of imaging studies performed. Conclusions: Rapidity and modality of imaging for LBP is associated with patient and physician characteristics but the directionality of associations with desirable care processes is opposite of associations for measures targeting underuse. Metrics that encompass overuse may suggest new areas of focus for quality improvement. | |
| 2012 | Pisu 2012 | Diagnostic Tests and Neurology Care | Diagnostic Tests and Neurology Care for Medicare Beneficiaries With Seizures Differences Across Racial Groups | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Neurologic | United States | Multiple Groups | National | Medicare Data | Medicare data | Background: Seizures and epilepsy are common in older adults especially in some minorities. Despite the importance of medical care to maximize seizure control, little is known about its quality across racial groups. One indicator of quality care is the receipt of electroencephalograms (EEG), and magnetic resonance imaging (MRIs) or computer tomography scans (CTs) after a first seizure. Neurologists' care is also important, given associated diagnosis and treatment challenges in older patients. Objective: To examine seizure-related care in the year after a first seizure for Medicare beneficiaries by race. Research Design: Retrospective administrative claims analysis for 186,547 beneficiaries with claims for seizure or epilepsy in 2003-2005. Logistic regressions determined the association between care and race (White, Asian, African and Native Americans) adjusting for beneficiary, seizure, and community factors. Measures: EEGs, CTs or MRIs, and neurology visits. Results: About 60% received EEGs, 80% had MRIs or CT scans, and only 55.9% had an EEG and CT scan or an MRI. CT use (74%) was higher than MRI use (41%). About 79% had neurology visits. Compared with Whites, Native Americans were less likely to have neurology visits (66.9% vs. 78.8%; adjusted odds ratio: 0.72; 95% CI, 0.55-0.92). No clinically significant differences (>5%) were found for care received by other minorities compared with Whites. Conclusions: Medicare beneficiaries with new-onset seizures commonly visit a neurologist, with some groups lagging behind. Use of some diagnostic tests is less common. Studies should continue investigating the quality of medical care for older adults with seizures. | |
| 2013 | Virk-Baker 2013 | Mammography utilization among Black | Mammography utilization among Black and White Medicare beneficiaries in high breast cancer mortality US counties | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Black | Regional | Medicare Data | Medicare data | BACKGROUND: Disparities in US breast cancer mortality between older Black and White women have increased in the last 20 years. Regular mammography use is important for early detection and treatment: its utilization among older Blacks especially in counties with high Black mortality is of interest, but its extent and determinants are unknown. METHODS: We used Medicare claims for Black and White women 6574 years old in 203 counties with the highest Black breast cancer mortality. Outcomes over 6 years were as follows: ever mammogram, i.e., C 1 screening mammogram, and regular mammogram, i.e., C 3 mammograms. With logistic regressions, we examined the independent effect of race on screening controlling for individual- and county-level factors. RESULTS: Of 406,602 beneficiaries, 17 % were Black. Ever and regular mammogram was significantly lower among Blacks (51.6 vs. 56.9 %; 32.9 vs. 43.1 %, respectively). Controlling for covariates, including use of cervical cancer screening, flu shots, or lipids tests, Black women were more likely to have ever mammogram (OR 1.23, CI 1.20-1.25), but not regular mammogram (OR 0.95, CI 0.93-0.97) than White women. County-level managed care penetration was negatively associated with ever and regular mammograms. CONCLUSIONS: In Medicare enrollees from these counties, breast cancer screening was low. Black women had same or better odds of screening than White women. Some health care factors, e.g., managed care, were negatively associated with screening. Further studies on the determinants of mammography utilization in older women from these counties are warranted. | |
| 2012 | Martin 2012 | Comparing the use of diagnostic | Comparing the use of diagnostic imaging and receipt of carotid endarterectomy in elderly black and white stroke patients | Adult Only | All Sexes | Inpatient General Care | Stroke Imaging | United States | Black | National | Disease Registry | Medicare Health Care Quality Improvement Programs National Stroke Project | Background: Previous studies show that black patients undergo carotid endarterectomy (CEA) less frequently than white patients. Diagnostic imaging is necessary to determine whether a patient is a candidate for the operation. We determined whether there were differences in the use of diagnostic carotid imaging and the frequency of CEA between elderly black and white ischemic stroke patients. Methods: Medicare fee-for-service beneficiaries with discharge diagnoses of ischemic stroke (International Classification of Diseases, 9th revision codes 433, 434, and 436) were randomly selected for inclusion in the National Stroke Project 1998-1999, 2000-2001. Receipt of at least one type of carotid imaging study was compared for black and white patients. Binomial logistic regression models were used to evaluate the associations between race and receipt of carotid imaging and CEA with adjustment for demographics, degree of carotid artery stenosis, and other clinical covariates. Results: Among 19,639 stroke patients (1974 black, 17,655 white), 69.6% received at least 1 diagnostic carotid imaging test (blacks 68.4%; whites 69.7%; P =.233). After risk adjustment, blacks were less likely to receive carotid imaging (adjusted odds ratio [OR] 0.87; 95% confidence interval [CI] 0.78-0.97). There was no relationship between race and the receipt of CEA after adjustment for degree of carotid stenosis and other covariates (adjusted OR 1.14; 95% CI 0.66-1.96). Conclusions: Black ischemic stroke patients were less likely to receive diagnostic carotid imaging than white patients, although the difference was small and only significant after risk adjustment. There was no difference in the proportion having CEA after adjustment for degree of carotid artery stenosis and other clinical factors. | |
| 2013 | Zafar 2013 | Predictors of CT colonography | Predictors of CT colonography utilization among asymptomatic medicare beneficiaries | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Colorectal Cancer Screening | United States | Multiple Groups | National | Medicare Data | Medicare Outpatient and Carrier files | BACKGROUND: Although the Centers for Medicare and Medicaid Services (CMS) denied coverage for screening computed tomography colonography (CTC) in March 2009, little is understood about whether CTC was targeted to the appropriate patient population prior to this decision. OBJECTIVE: Evaluate patient characteristics and known relative clinical indications for screening CTC among patients who received CTC compared to optical colonoscopy (OC). DESIGN/PARTICIPANTS: Cross-sectional study of all 10,538 asymptomatic Medicare beneficiaries who underwent CTC between January 2007 and December 2008, compared to a cohort of 160,113 asymptomatic beneficiaries who underwent OC, matched on county of residence and year of examination. MAIN MEASURES: Patient characteristics and known relative appropriate and inappropriate clinical indications for screening CTC. KEY RESULTS: CTC utilization was higher among women, patients > 65 years of age, white patients, and those with household income > 75 % (p = 0.001). Patients with relatively appropriate clinical indications for screening CTC were more likely to undergo CTC than OC including presumed incomplete OC (OR 80.7, 95 % CI 76.01-85.63); sedation risk (OR 1.11, 95 % CI 1.05-1.17); and chronic anticoagulation risk (OR 1.46, 95 % CI 1.38-1.54), after adjusting for patient characteristics and known clinical indications. Conversely, patients undergoing high-risk screening, an inappropriate indication, were less likely to receive CTC (OR 0.4, 95 % CI 0.37-0.42). Overall, 83 % of asymptomatic patients referred to CTC had at least one clinical indication relatively appropriate for CTC (8,772/10,538). CONCLUSION: During the 2 years preceding CMS denial for screening, CTC was targeted to asymptomatic patients with relatively appropriate clinical indications for CTC/not receiving OC. However, CTC utilization was lower among certain demographic groups, including minority patients. These findings raise the possibility that future coverage of screening CTC might exacerbate disparities in colorectal cancer screening while increasing overall screening rates. | |
| 2012 | Akinyemiju 2012 | Healthcare access and mammography | Healthcare access and mammography screening in Michigan: A multilevel cross-sectional study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Black | State | Disease Registry | Michigan Special Cancer Behavioral Risk Factor Survey | Background: Breast cancer screening rates have increased over time in the United States. However actual screening rates appear to be lower among black women compared with white women. Purpose. To assess determinants of breast cancer screening among women in Michigan USA, focusing on individual and neighborhood socio-economic status and healthcare access. Methods. Data from 1163 women ages 50-74 years who participated in the 2008 Michigan Special Cancer Behavioral Risk Factor Survey were analyzed. County-level SES and healthcare access were obtained from the Area Resource File. Multilevel logistic regression models were fit using SAS Proc Glimmix to account for clustering of individual observations by county. Separate models were fit for each of the two outcomes of interest; mammography screening and clinical breast examination. For each outcome, two sequential models were fit; a model including individual level covariates and a model including county level covariates. Results: After adjusting for misclassification bias, overall cancer screening rates were lower than reported by survey respondents; black women had lower mammography screening rates but higher clinical breast examination rates than white women. However, after adjusting for other individual level variables, race was not a significant predictor of screening. Having health insurance or a usual healthcare provider were the most important predictors of cancer screening. Discussion. Access to healthcare is important to ensuring appropriate cancer screening among women in Michigan. | |
| 2015 | Vahabi 2015 | Breast cancer screening disparities | Breast cancer screening disparities among urban immigrants: A population-based study in Ontario, Canada Health behavior, health promotion and society | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Canada | Immigrants | Regional | Government Survey | Multiple groups | Background: Breast cancer is one of the leading cause of mortality and morbidity in Canada. Screening is the most promising approach in identification and treatment of the disease at early stage of its development. Research shows higher rate of breast cancer mortality among ethno-racial immigrant women despite their lower incidence which suggests disparities in mammography screening. This study aimed to compare the prevalence of appropriate mammography screening among immigrant and native borne women and determine predicators of low mammography screening. Methods: We conducted secondary data analyses on Ontario linked social and health databases to determine the proportion of women who were screened during the two- year period of 2010-2012 among 1.4 million screening-eligible women living in urban centres in Ontario. We used multivariate Poisson regression to adjust for various socio-demographic, health care-related and migration related variables. Results: 64 % of eligible women were appropriately screened. Screening rates were lowest among new and recent immigrants compared to referent group (Canadian-born women and immigrant who arrived before 1985) (Adjusted Rate Ratio (ARR) (0.87, 95 % CI 0.85 -0.88 for new immigrants and 0.90, 95 % CI 0.89-0.91 for recent immigrants. Factors that were associated with lower rates of screening included living in low- income neighborhoods, having a male physician, having internationally- trained physician and not being enrolled in primary care patient enrolment models. Those not enrolled were 22 % less likely to be screened compared to those who were (ARR 0.78, 95 % CI 0.77-0.79). Conclusion: To enhance immigrant women screening rates efforts should made to increase their access to primary care patient enrolment models and preferably female health professionals. Support should be provided to interventions that address screening barriers like language, acculturation limitations and knowledge deficit. Health professionals need to be educated and take an active role in offering screening guidelines during health encounters. | |
| 2005 | Dembe 2005 | Racial and ethnic variations in | Racial and ethnic variations in office-based medical care for work-related injuries and illnesses | All Ages | All Sexes | Outpatient Ambulatory and Primary Care | General Diagnostic Imaging | United States | Multiple Groups | National | Government Survey | National Ambulatory Medical Care Survey | OBJECTIVES: This exploratory study uses nationally representative data to evaluate the extent to which ambulatory care for work-related conditions varies by patients' race and ethnicity. METHODS: Using the National Ambulatory Medical Care Survey (NAMCS) for 1997 and 1998, we describe medical care for work-related conditions, stratifying by whether the patient self-identified as African-American, white, Hispanic and/or non-Hispanic. Multivariate regression analyses were conducted to evaluate the impact of patient race and ethnicity on care, controlling for age, gender, geographical region and MSA (urban/rural) status. RESULTS: Compared to white patients, African-American patients were more likely to receive mental health counseling and physical therapy and less likely to see a nurse, after controlling for age, gender, geographical region and MSA status. Hispanic patients were more likely to receive x-rays and need insurer authorization for care and less likely to receive a prescription drug or to see a physician, compared to non-Hispanics. CONCLUSIONS: This is the nation's first study to describe socially based differences in medical care provided for patients with work-related injuries and illnesses. Identifying areas in which these variations in care exist is a critical first step in ensuring that equitable care is afforded to all injured workers. | |
| 2008 | Chagpar 2008 | Racial trends in mammography rates: | Racial trends in mammography rates: a population-based study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | BACKGROUND: The rates of mammography have been declining over the last 5 years. The objective of this study was to examine racial disparities in this trend. METHODS: The National Health Interview Survey is a population-based interview survey conducted annually. Caucasian and African-American women over 40 years of age who completed the cancer module of this survey in 2000 and 2005 formed the cohort of interest for this study. RESULTS: In 2000, 69.8% of Caucasian and 64.4% of African-American women over the age of 40 had had a mammogram within the preceding 2 years. In 2005, these rates declined to 66.7% and 62.9% respectively. This decline only reached statistical significance in the Caucasian population (P = .0006 vs P = .4998). While on univariate analysis a significant difference was seen between rates of mammography in Caucasian and African-American women (P < .0001), multivariate analysis controlling for education, income, and insurance status, did not find race to be a significant independent predictor of mammography rates in each year. CONCLUSION: Rates of mammography are declining, particularly in Caucasian populations. While minority women are less likely to report having had a mammogram, this apparent racial disparity is explained by differences in education, income and insurance status. | |
| 2004 | Coughlin 2004 | Breast cancer screening practices | Breast cancer screening practices among women in the United States, 2000 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | Results from recent studies indicate that many women in the US undergo routine screening for breast cancer, but some groups of women are under-screened. In this study, we examined the breast cancer screening practices of white and black women in the United States, according to Hispanic ethnicity and other factors, using data from the 2000 National Health Interview Survey. Among women aged 40 years, 71.2% (95% confidence interval, CI: 70.0-72.4%) of the 8201 white women and 67.6% (95% CI: 64.5-70.6%) of the 1474 black women in this sample reported having a mammogram in the past two years. About 60.3% (95% CI: 56.7-70.3%) of 970 Hispanic women (including those who reported they were white or black) and 71.5% (95% CI: 70.3-72.7%) of 8705 non-Hispanic women reported having a mammogram in the past two years. About 74.8% (95% CI: 73.8-76.8%) of 8176 white women and 73.8% (95% CI: 71.1-76.6%) of 1471 black women aged > 40 years had received a clinical breast examination in the past two years. About 60.1% (95% CI: 56.1-64.0%) of 969 Hispanic women (including those who reported they were white or black) and 75. 6% (95% CI: 74.6-76.6%) of 8678 non-Hispanic women had received a clinical breast examination in the past two years. Women with lower incomes, those with less education, and recent immigrants were less likely to be screened. Women who had a usual source of health care and those with health insurance coverage were more likely to have been screened. These results underscore the need for continued efforts to ensure that uninsured women and those who are medically underserved have access to cancer screening services. | |
| 2014 | Dallo 2015 | Disparities in Vaccinations and | Disparities in Vaccinations and Cancer Screening Among U.S.- and Foreign-Born Arab and European American Non-Hispanic White Women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | Background: Disparities in vaccinations and cancer screening exist when comparing foreign-born and U.S.-born women collectively and disaggregated by race and ethnicity. The purpose of this study was to estimate and compare the age-adjusted prevalence of not receiving a flu or pneumonia vaccine, clinical breast examination, mammogram or Pap smear among U.S.- and foreign-born White women by region of birth and examine associations while controlling for potential confounders. Methods: We pooled 12years of National Health Interview Survey data (n=117,893). To approximate an "Arab-American" ethnicity, we identified 15 "Arab" countries from the Middle East region that comprise the Arab Nations. Data was requested from the National Center for Health Statistics Research Data Center. We used the (2) statistic to compare descriptive statistics and odds ratios (ORs) with 95% CIs were used for inferential statistics. Findings: Compared to U.S.-born, foreign-born Whites from the Arab Nations had higher estimates of not receiving recommended vaccinations and cancer screenings. In crude and adjusted analyses, foreign-born Arab-American women were less likely to report receiving a flu vaccine (OR,0.34; 95% CI,0.21-0.58), pneumonia vaccine (OR,0.14; 95% CI,0.06-0.32), Pap smear (OR,0.13; 95% CI,0.05-0.31), or clinical breast examination (OR,0.16; 95% CI,0.07-0.37) compared with U.S.-born White women. There were no differences for mammography. Conclusions: This national study examining uptake of flu and pneumonia vaccines and preventive cancer screenings suggests that estimates are lower for foreign-born Arab-American women compared with U.S.-born White women. Future studies should collect qualitative data that assess the cultural context surrounding prevention and screening behaviors among Arab-American women. | |
| 2018 | Elewonibi 2018 | Examining Mammography Use by Breast | Examining Mammography Use by Breast Cancer Risk, Race, Nativity, and Socioeconomic Status | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | Minority and foreign-born women report lower rates of mammograms compared to non-Hispanic white, U.S.-born women, even though they have increased risk for developing breast cancer. We examine disparities in mammography across breast cancer risk groups and determine whether disparities are explained by socioeconomic factors. Propensity score methodology was used to classify individuals from the 2000, 2005, and 2010 National Health Interview Survey according to their risk for developing breast cancer. Logistic regression models were used to predict the likelihood of mammography. Compared to non-Hispanic white women, Mexicans, Asians and "other" racial/ethnic origins were less likely to have undergone a mammogram. After controlling for breast cancer risk, socioeconomic status and health care resources, Mexican, Cuban, Dominican, Central American, Black, and foreign-born women had an increased likelihood of receiving a mammogram. Using propensity scores makes an important contribution to the literature on sub-population differences in the use of mammography by addressing the confounding risk of breast cancer. While other factors related to ethnicity or culture may account for lower breast cancer screening rates in Asian and Mexican women, these findings highlight the need to consider risk, in addition to socioeconomic factors, that may pose barriers to screening in determining mammography disparities. | |
| 2020 | Hong 2020 | Utilization Pattern of Computed | Utilization Pattern of Computed Tomographic Colonography in the United States: Analysis of the U.S. National Health Interview Survey | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Colorectal Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | CT colonography for colorectal cancer screening has been proved to be effective and cost-saving. CT colonography uses minimally invasive evaluation of colorectum and has better patient acceptance, which appears to be a promising screening modality to improve low colorectal cancer screening rate. This study investigated the utilization patterns of CT colonography and factors associated with its use among U.S. adult population. This retrospective cross-sectional study analyzed the National Health Interview Survey 2015 and 2018. U.S. adults ages 45 or older without a history of colorectal cancer were included. Survey design-adjusted Wald F tests were used to compare the utilization of CT colonography during the study period. Multivariable logistic regression was used to identify the predictors of CT colonography among individual socioeconomic and health-related characteristics. The study sample included 34,768 individuals representing 129,430,319 U.S. adult population ages 45 or older. The overall utilization of CT colonography increased from 0.79% in 2015 to 1.33% in 2018 (P < 0.001). 54.5% study participants reported being up-to-date on recommended colorectal cancer screening; of those, 1.8% used CT colonography. Compared with individuals ages 65+, those ages 45-49 years were 2.08 times (OR, 2.08, 95% confidence interval, 1.01-4.35) more likely to use CT colonography. Socioeconomically disadvantaged characteristics (e.g., racial/ethnic minority, low income, publicly funded insurance) were associated with a greater likelihood of CT colonography. This study demonstrated an increasing trend in utilization of CT colonography for colorectal cancer screening in U.S. adults. Younger individuals, racial/ethnic minorities, or those with lower income appear to have a higher CT colonography utilization. PREVENTION RELEVANCE: Although computed tomographic (CT) colonography has been proved to be cost-effective and have better patient acceptance, its overall utilization for colorectal cancer (CRC) screening is low (<1.4%) among US adults aged 45+ in 2018. More efforts are needed to implement strategies to increase CT colonography for effective CRC prevention. | |
| 2008 | Kapp 2009 | Racial and ethnic differences in | Racial and ethnic differences in mammography use among U.S. women younger than age 40 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | Objective: Evidence-based recommendations for routine breast cancer screening suggest that women begin mammography at age 40, although some women receive a mammogram before that age. Little is known about mammography use among younger women, especially with respect to race and ethnicity. Methods: We used data from the 2005 National Health Interview Survey to examine racial/ethnic differences in mammography use among U.S. women ages 30-39. We examined descriptive characteristics of women who reported ever having a mammogram, and used logistic regression to estimate associations between race/ethnicity and mammography use among women at average risk for breast cancer. Results: Our sample comprised 3,098 women (18% Hispanic, 13% non-Hispanic [NH] black, 69% NH white), of whom 29% reported having ever had a mammogram. NH black women were more likely than NH white women to report ever having a mammogram and receiving multiple mammograms before age 40 among women of average risk. Patterns of mammography use for Hispanic women compared to NH white women varied. Conclusion: Findings suggest differential utilization of mammograms by race/ethnicity among women outside current recommendations and of average risk. Future studies should examine the role of practice patterns and patient-provider communication. | |
| 2005 | Lees 2005 | Comparison of racial/ethnic | Comparison of racial/ethnic disparities in adult immunization and cancer screening | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | Background: Racial/ethnic disparities in adult influenza and pneumococcal vaccination are marked and poorly understood. The purpose of this study was to contrast these disparities with disparities in other clinical preventive services - mammography and colorectal cancer screening - that are targeted to older populations. Methods: Data from the 2000 National Health Interview Survey were analyzed in 2004 to determine to what degree race/ethnicity remains a predictor of the receipt of each service after adjusting for personal and health characteristics, socioeconomic status (SES), and access to and utilization of care variables. Results: Blacks and Hispanics were significantly less likely to report receipt of nearly all preventive services examined. Among whites, 57%, 67%, 67%, and 40% reported pneumococcal vaccination, influenza vaccination, mammography, and colorectal cancer screening, respectively. Among blacks, those proportions were 31%, 48%, 60% and 33%, respectively; among English-speaking Hispanics, 35%, 60%, 60%, and 30%, respectively; and among Spanish-speaking Hispanics, 24%, 49%, 52%, and 19%, respectively. After adjusting for personal and health characteristics, socioeconomic factors, and measures of access to and utilization of care, blacks and English- and Spanish-speaking Hispanics remained significantly less likely than whites to report the receipt of pneumococcal vaccination; blacks remained significantly less likely to report influenza vaccination than whites; and Spanish-speaking Hispanics remained significantly less to report colorectal cancer screening than whites. Conclusions: Most racial/ethnic disparities seen in breast and colorectal cancer screening are explained by differences in SES. In contrast, racial/ethnic disparities in adult immunization persist, and especially for pneumococcal vaccination, suggesting that different barriers may be involved. | |
| 2013 | Miller 2013 | Breast MRI use uncommon among U.S. | Breast MRI use uncommon among U.S. women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | BACKGROUND: The goal of breast cancer screening is to reduce breast cancer mortality. Mammography is the standard screening method for detecting breast cancer early. Breast MRI is recommended to be used in conjunction with mammography for screening subsets of women at high risk for breast cancer. We offer the first study to provide national estimates of breast MRI use among women in the United States. METHODS: We analyzed data from women who responded to questions about having a breast MRI on the 2010 National Health Interview Survey. We assessed report of having a breast MRI and reasons for it by sociodemographic characteristics and access to health care and computed five-year and lifetime breast cancer risk using the Gail model. RESULTS: Among 11,222 women who responded, almost 5% reported ever having a breast MRI and 2% reported having an MRI within the 2 years preceding the survey. Less than half of the women who reported having a breast MRI were at increased risk. Approximately 60% of women reported having the breast MRI for diagnostic reasons. Women who ever had a breast MRI were more likely to be older, Black, and insured and to report a usual source of health care as compared with women who reported no MRI. CONCLUSIONS: Breast MRI use may be underused or overused in certain subgroups of women. IMPACT: As access to health care improves, the use of breast MRI and the appropriateness of its use for breast cancer detection will be important to monitor. | |
| 2022 | O'Connor 2022 | Predictors of CT Colonography Use: | Predictors of CT Colonography Use: Results From the 2019 National Health Interview Cross-Sectional Survey | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Colorectal Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | PURPOSE: CT colonography (CTC) is a minimally invasive screening test with high sensitivity for colonic polyps (>1 cm). Prior studies suggest that CTC utilization remains low. However, there are few studies evaluating recent CTC utilization and predictors of CTC utilization. Our purpose was to estimate recent nationwide CTC utilization and evaluate predictors of CTC utilization using 2019 nationally representative cross-sectional survey data. METHODS: Participants between ages 50 and 75 without colorectal cancer history in the 2019 National Health Interview Survey cross-sectional data were included. The proportion of participants reporting utilization of CTC was estimated, accounting for complex survey design elements. Multiple variable logistic regression analyses evaluated predictors of CTC utilization. Analyses were conducted accounting for complex survey design elements to obtain valid estimates for the civilian, noninstitutionalized US population. RESULTS: In all, 13,709 respondents were included, and 1.4% reported undergoing CTC, of whom 39.9% underwent CTC within the last year, 18.5% within the last 2 years, 13.0% within the last 3 years, 7.8% within the last 5 years, 11.2% within the last 10 years, and 9.6% underwent CTC 10 years ago or more. Multiple variable logistic regression analyses revealed that Hispanic (odds ratio 2.67, 95% confidence interval 1.66-4.29, P < .001) and Black (odds ratio 2.47, 95% confidence interval 1.60-3.82, P < .001) participants were more likely than White participants to undergo CTC. CONCLUSION: Survey results suggest that nationwide utilization of CTC remains low. Black and Hispanic participants were more likely than White participants to report undergoing CTC. Promotion of CTC may reduce racial and ethnic disparities in colorectal cancer screening. | |
| 2022 | Paranjpe 2022 | Disparities in Breast Cancer | Disparities in Breast Cancer Screening Between Caucasian and Asian American Women | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Asian | National | Government Survey | National Health Interview Survey | INTRODUCTION: Asian American women have lower breast cancer incidence and mortality than their non-Hispanic White (NHW) counterparts. We sought to determine whether differences in screening practices could explain, in part, the variation in breast cancer detection rate. METHODS: The 2015 National Health Interview Survey, an annual survey that is representative of the civilian, noninstitutionalized American population, was used to determine whether mammography usage was different between Asian and NHW women. Women 40 y of age who identified as either Asian or NHW were included. RESULTS: A total of 7990 women 40 y of age (6.12% Asian, 93.88% NHW), representing 53,275,420 women in the population, were included in our cohort of interest; 71.49% of Asian and 74.46% of NHW women reported having had a mammogram within the past 2 y (P = 0.324). Controlling for education, insurance, family income, marital status, and whether they were born in the United States, Asians were less likely to have had a mammogram within the past 2 y than their NHW counterparts (odds ratio = 0.68; 95% confidence interval: 0.46-0.99, P = 0.047). Of patients who had an abnormal mammogram, there was no difference in the biopsy rate (20.35% versus 25.97%, P = 0.4935) nor in the rate of cancer diagnosis among those who had a biopsy (7.70% versus 12.86%, P = 0.211) between Asian and NHW women, respectively. CONCLUSIONS: Our findings suggest that the lower breast cancer incidence among the Asian population may, in part, be explained by a lower screening mammography rate in this population. | |
| 2022 | Ross 2022 | Racial and/or Ethnic Disparities in | Racial and/or Ethnic Disparities in the Use of Imaging: Results from the 2015 National Health Interview Survey | Adult Only | All Sexes | Inpatient and Outpatient | General Diagnostic Imaging | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | NA | |
| 2008 | Sabatino 2008 | Disparities in mammography use | Disparities in mammography use among US women aged 40-64 years, by race, ethnicity, income, and health insurance status, 1993 and 2005 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | OBJECTIVE: To examine current disparities in mammography use, and changes in disparities over time by race, ethnicity, income, insurance, and combinations of these characteristics. RESEARCH DESIGN:: Comparison of cross-sectional surveys of mammography use using the 1993 and 2005 National Health Interview Survey. SUBJECTS: Women aged 40-64 (1993, n = 4167; 2005, n = 7434). MEASURES: Mammogram within prior 2 years. RESULTS: In 2005, uninsured women reported the lowest mammography use (38.3%). Though screening increased 6.9 percentage points among low-income, uninsured women, the overall disparity between insured and uninsured women did not change significantly between 1993 and 2005. Screening seems to have declined among middle-income, uninsured women, increasing the gap compared with middle-income, insured women. The lower mammography use in 1993 among American Indian/Alaska Native compared with white women was not present in 2005; however, lower use among Asian compared with white women emerged in 2005. We found no differences between African American and white women. Hispanic women were less likely than non-Hispanic women to report screening in 2005 (58.1% vs. 69.0%). CONCLUSIONS: Although mammography use increased for some groups between 1993 and 2005, low-income, uninsured women continued to have the lowest screening rates in 2005 and the disparity for this group was not reduced. The gap in screening use for middle-income, uninsured women increased, resulting from possible declines in mammography even for uninsured women not in poverty. Asian women became less likely to receive screening in 2005. Continuing efforts are needed to eliminate disparities. Increased efforts are especially needed to address the large persistent disparity for uninsured women, including middle-income uninsured women. | |
| 2011 | Shi 2011 | Cancer screening among | Cancer screening among racial/ethnic and insurance groups in the United States: a comparison of disparities in 2000 and 2008 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | Using the National Health Interview Survey, we examined associations among race/ ethnicity, insurance coverage, and cancer screening, and assessed changes in the magnitude of disparities over the past decade. Outcomes included recent cervical, breast, and colorectal cancer screening. Rates of colorectal screening increased for all racial/ethnic groups and some insurance groups from 2000 to 2008. However, rates of Pap tests and mammograms remained stagnant, and even decreased for certain groups. Some Hispanic-White and Asian-White disparities in cancer screening were reduced or eliminated over this time period. However, in 2008 Asians continued to have lower odds of Pap tests and Hispanics lower odds of colorectal cancer screening, even after accounting for potential confounders. There were no significant changes in Black-White disparities. The uninsured continued to be at a disadvantage for all three types of cancer screening, relative to the privately insured, as were publicly insured individuals with respect to colorectal cancer screening. | |
| 2014 | Yaghjyan 2014 | Racial disparities in healthy | Racial disparities in healthy behaviors and cancer screening among breast cancer survivors and women without cancer: National Health Interview Survey 2005 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Health Interview Survey | Purpose: We investigated racial disparities in healthy behaviors and cancer screening in a large sample from the US population. Methods: This analysis used the data from 2005 National Health Interview Survey and included women at age 40 years who completed the cancer questionnaires (2,427,075 breast cancer survivors and 57,978,043 women without cancer). Self-reported information on cancer history, healthy behaviors (body mass index, smoking, alcohol use, physical activity, fruit/vegetable consumption, sunscreen use) was collected. We compared distributions of each factor among Caucasian, African American, and Hispanic women with and without breast cancer history. Results: Caucasian breast cancer survivors as compared to their cancer-free counterparts were less likely to be current smokers (8.3 vs. 16.9 %, p < 0.001) and to have regular mammograms (51.5 vs. 36.9 %, p < 0.05). Differences in associations between cancer survivors and respondents without cancer among African American and Hispanic women did not reach statistical significance. Conclusions: Certain breast cancer survivor groups can benefit from tailored preventive services that would address concerns related to selected healthy behaviors and screening practices. However, most of the differences are suggestive and do not differ by race. | |
| 2010 | Zhou 2010 | Trends in cancer screening among | Trends in cancer screening among hispanic and white non-hispanic women, 2000-2005 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Hispanic | National | Government Survey | National Health Interview Survey | Background: Hispanics are the largest and fastest growing ethnic group in the United States. Compared with white non-Hispanic women, however, Hispanic women have significantly lower cancer screening rates. Programs designed to increase cancer screening rates, including the national Screen for Life campaign, which specifically promoted colorectal cancer (CRC) screening, regional educational/research programs, and state cancer control programs, have been launched. Screen for Life and some of these other intervention programs have targeted Hispanic populations by providing educational materials in Spanish in addition to English. Methods: The objective of this study was to compare changes in colorectal, breast, and cervical cancer screening rates from 2000 to 2005 among Hispanic and white non-Hispanic women, using data from the National Health Interview Survey (NHIS). The age ranges of study subjects and the definitions of cancer screening were site specific and based on the American Cancer Society (ACS) screening recommendations. Results: Although overall screening rates were found to be lower among Hispanic women, CRC screening increased about 1.5-fold among both Hispanic and white non-Hispanic women, mainly driven by endoscopic screening, which increased 2.1-fold and 2.9-fold, respectively, from 2000 to 2005 (p<0.01). Fecal occult blood testing (FOBT) for CRC declined among white non-Hispanic women and remained stable among Hispanic women during the same period. Mammogram and Pap smear screening tended to decline during the study period for both ethnic groups, especially white non-Hispanic women. Conclusion: Although cancer screening rates may be affected by multiple factors, culturally sensitive and linguistically appropriate national educational programs may have contributed to the increase in endoscopic CRC screening compliance. | |
| 2004 | Abrado-Lanza 2004 | Breast and cervical cancer | Breast and cervical cancer screening among Latinas and non-Latina whites | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Hispanic | National | Government Survey | National Health Interview Survey | OBJECTIVES: We examined whether Latinas differ from non-Latinas in having undergone recent mammography, clinical breast examination, or Papanicolaou testing, as well as the contribution of sociodemographic and health care variables to screening. METHODS: We used data from the 1991 National Health Interview Survey Health Promotion and Disease Prevention supplement. RESULTS: Latinas were less likely than non-Latina Whites to have undergone mammography (odds ratio [OR] = 0.71; 95% confidence interval [CI] = 0.57, 0.88), but this difference was attenuated when we controlled for socioeconomic factors (OR = 0.90; 95% CI = 0.70, 1.15). Latinas did not differ from Whites on Papanicolaou tests or clinical breast examinations. Quality of and access to health care predicted screening. CONCLUSIONS: Latina ethnicity does not predict breast and cervical cancer screening behavior independent of sociodemographic and structural factors. | |
| 2014 | Yao 2014 | Disparities in mammography rate | Disparities in mammography rate among immigrant and native-born women in the U.S.: Progress and challenges | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Immigrants | National | Government Survey | National Health Interview Survey | Disproportionately low mammography rates among U.S. immigrants have been of persistent concern. In light of policies to increase access to screening, this study identifies differences in factors associated with screening among immigrant and native-born women in 2000 and 2008. Data from immigrant and native-born women aged 40+ years in the 2000 and 2008 National Health Interview Surveys were included in descriptive and multivariate regression analyses. Mammography rates rose from 60.2 to 65.5 % among immigrant women, remaining lower than the 68.9 % rate among native-born in 2008. Among immigrants, short length of residency and lower education were associated with lower screening rates in 2000 but not in 2008, while public insurance coverage was positively associated with screening only in 2008. In contrast to immigrants, among the native-born education and income were associated with mammography receipt in 2008, and in both groups health care access was associated with greater screening rates. Policy initiatives aimed at increasing access to mammography may be positively affecting immigrant screening disparities. Access to primary care and public insurance coverage are likely to be very important in maintaining and furthering improvements in mammography rates. | |
| 2002 | Siahpush 2002 | Sociodemographic variations in | Sociodemographic variations in breast cancer screening behavior among Australian women: Results from the 1995 National Health Survey | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Australia | Multiple Groups | National | Government Survey | National Health Survey | Background. Knowledge of sociodemographic variations in breast cancer screening can help identify population groups that are at risk of underutilization of breast cancer screening procedures and practices. We examined sociodemographic variations in breast cancer screening behavior among Australian women. Methods. We used a subsample of women aged 18 years and older (n = 10,179) from the 1995 National Health Survey. We examined the association of sociodemogarphic variables with mammography, clinical breast examination, and breast self-examination. Results. Being in the oldest age group, never being or previously being married, living in rural regions (except in the case of breast self-examination), residing in more disadvantaged areas (except in the case of breast self-examination), and having lower levels of education were all associated with a smaller likelihood of screening. Ethnicity was also significantly associated with screening. Conclusion. Strategies to promote breast cancer screening practices should pay particular attention to the underserved groups and should be part of a more comprehensive policy that ensures the accessibility to regular health care of these population groups. | |
| 2020 | Usera-Clavero 2020 | Inequalities in the use of | Inequalities in the use of gynecological visits and preventive services for breast and cervical cancer in Roma women in Spain | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Spain | Indigenous | National | Government Survey | National Health Survey | OBJECTIVES: The Roma population in Spain makes up about two percent of the population and has worse health indicators than the general population. We analyzed both populations in 2006 and 2014 to discover whether there are differences in terms of gynecological visits and preventive services for breast and cervical cancer in Spain. METHODS: Cross-sectional study is based on the Spanish National Health Survey (SNHS) of 2006 and 2012 and the National Health Survey of the Roma Population (NHSRP) of 2006 and 2014. RESULTS: Roma women used gynecological visits less than the general population in 2006 (ORa 0.5 [0.4; 0.6] and in 2014 (ORa 0.2 [0.2; 0.3)]. In addition, use of the mammogram was lower in Roma women (ORa 0.7 [0.6; 0.8]), especially in the ages of the screening tests, and they had lower probability of receiving cervical examinations in 2006 (ORa 0.5 [0.4; 0.6]) and in 2014 (ORa 0.7 [0.6; 0.9]). CONCLUSIONS: This study shows that the inequality gap in gynecological visits and preventive services for breast and cervical cancer in Roma women has persisted during the years studied (2006 and 2014), despite Spanish prevention policies. | |
| 2022 | Al-Dulaimi 2022 | Revisiting racial disparities in ED | Revisiting racial disparities in ED CT utilization during the Affordable Care Act era: 2009-2018 data from the NHAMCS | Adult Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | OBJECTIVE: To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010. MATERIALS AND METHODS: Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009-2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed. RESULTS: Between 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups. CONCLUSION: Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial. | |
| 2018 | Burstein 2018 | Use of CT for head trauma: | Use of CT for head trauma: 2007-2015 | Pediatric Only | All Sexes | Emergency Department | Neurologic | United States | Black | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Background and objectives: International efforts have been focused on identifying children at low risk of clinically important traumatic brain injury in whom computed tomography (CT) neuroimaging can be avoided. We sought to determine if CT use for pediatric head trauma has decreased among US emergency departments (EDs). Methods: This was a cross-sectional analysis of the National Hospital Ambulatory Care Medical Survey database of nationally representative ED visits from 2007 to 2015. We included children <18 years of age evaluated in the ED for head injury. Survey weighting procedures were used to estimate the annual proportion of children who underwent CT neuroimaging and to perform multivariable logistic regression. Results: There were an estimated 14.3 million pediatric head trauma visits during the 9-year study period. Overall, 32% (95% confidence interval [CI]: 29%-35%) of children underwent CT neuroimaging with no significant annual linear trend (P trend = .50). Multivariate analysis similarly revealed no difference by year (adjusted odds ratio [aOR]: 1.02; 95% CI: 0.97-1.07) after adjustment for patient- and ED-level covariates. CT use was associated with age 2 years (aOR: 1.51; 95% CI: 1.13-2.01), white race (aOR: 1.43; 95% CI: 1.10-1.86), highest triage acuity (aOR: 8.24 [95% CI: 4.00-16.95]; P < .001), and presentation to a nonteaching (aOR: 1.47; 95% CI: 1.05-2.06) or nonpediatric (aOR: 1.53; 95% CI: 1.05-2.23) hospital. Conclusions: CT neuroimaging did not decrease from 2007 to 2015. Findings suggest an important need for quality improvement initiatives to decrease CT use among children with head injuries. | |
| 2022 | Dubey 2022 | Contemporary national trends and | Contemporary national trends and disparities for head CT use in emergency department settings: Insights from National Hospital Ambulatory Medical Care Survey (NHAMCS) 2007-2017 | All Ages | All Sexes | Emergency Department | Neurologic | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | BACKGROUND: The exponential growth in CT utilization in emergency department (ED) until 2008 raised concerns regarding cost and radiation exposure. Head CT was one of the commonest studies. This led to mitigating efforts such as appropriate use guidelines, policy and payment reforms. The impact of these efforts is not fully understood. In addition, disparities in outcomes of acute conditions presenting to the ED is well known however recent trends in imaging utilization patterns and disparities are not well understood. In this study, we describe nationwide trends and disparities associated with head CT in ED settings between 2007 and 2014. METHODS: We analyzed 20072017 National Hospital Ambulatory Medical Care Survey (NHAMCS) with the primary goal to assess the rate and patterns of head CT imaging in ED. RESULTS: There were an estimated 117 million in 2007 and 139 million ED visits in 2017. There was a 4% increase in the any CT use in 2017 compared to 2007. No significant change in head CT utilization rate was seen. The 2007 head CT rate was 6.7% (95% CI: 6.17.3) compared to 7.7% (95% CI: 6.8-8.6) in 2017. Trauma, Headache and Dizziness are the top three indications for head CT use in the ED respectively. On adjusted analyses, significantly higher head CT utilization was seen in elderly, (age > 65 yrs) and significantly lower utilization rate was seen in Non-Hispanic Black and Medicaid patients, and patients in rural locations. CONCLUSIONS: Previously reported exponential growth of CT use in ED is no longer seen. In particular, there was no significant change in ED head CT use between 2007 and 2017. Headache and Dizziness remain commonly used indications despite limited utility in most clinical scenarios, indicating continued need for appropriate use of imaging. There is significantly lower CT utilization in Non- Hispanic Black, Medicaid patients and those in rural locations, suggesting disparities in diagnostic work-up in marginalized and rural populations. This underscores the need for standardizing care regardless of race, insurance status and location. | |
| 2012 | Fahimi 2012 | Computed tomography use among | Computed tomography use among children presenting to emergency departments with abdominal pain | Pediatric Only | All Sexes | Emergency Department | GI/Abdominal | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Objective: To evaluate trends in and factors associated with computed tomography (CT) use among children presenting to the emergency department (ED) with abdominal pain. Methods: This study was a cross-sectional, secondary analysis of the National Hospital Ambulatory Medical Care Survey data from 1998 to 2008. We identified ED patients aged <19 years with abdominal pain and collected patient demographic and hospital characteristics, and outcomes related to imaging, hospital admission, and diagnosis of appendicitis. Trend analysis was performed over the study period for the outcomes of interest, and a multivariate regression model was used to identify factors associated with CT use. Results: Of all pediatric ED visits, 6.0% were for abdominal pain. We noted a rise in the proportion of these patients with CT use, from 0.9% in 1998 to 15.4% in 2008 (P < .001), with no change in ultrasound/radiograph use, diagnosis of appendicitis, or hospital admission. Older and male patients were more likely to have a CT scan, whereas black children were one-half as likely to undergo a CT scan compared with white children (odds ratio: 0.50 [95% confidence interval: 0.31-0.81]). Admitted children had much higher odds of undergoing a CT scan (odds ratio: 4.11 [95% confidence interval: 2.66-6.35]). There was a plateau in CT use in 2006 to 2008. Conclusions: There was a dramatic increase in the utilization of CT imaging in the ED evaluation of pediatric patients with abdominal pain. Some groups of children may have a differential likelihood of receiving CT scans. | |
| 2019 | Fahimi 2019 | Computed tomography use plateaus | Computed tomography use plateaus among children with emergency visits for abdominal pain | Pediatric Only | All Sexes | Emergency Department | GI/Abdominal | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Objectives: Abdominal pain is a common pediatric complaint to emergency departments (EDs), and clinicians often rely on imaging for diagnosis. Studies have demonstrated an increase in computed tomography (CT) in this population. Following emphasis on radiation reduction by researchers and organizations, this study evaluates recent national trends in CT use among pediatric patients presenting to EDs with abdominal pain. Methods: This is a cross-sectional analysis of ED patients 18 years or younger with chief complaint of abdominal pain in the National Hospital Ambulatory Medical Care Survey from 2008 to 2011. Outcomes include annual proportions of visits with x-ray, ultrasound, or CT, as well as diagnosis of appendicitis and hospital admission. Results: Of 32,304 ED visits, 2120 (6.6%) were for abdominal pain. Proportions of visits using CT, ultrasound, and plain x-ray were 16.0%, 10.5%, and 23.4%, respectively. For all outcome measures, including imaging, hospital admission, and diagnosis of appendicitis, there was no change from 2008 to 2011. Considering previous data, there was a significant rise in ultrasound use from 5.4% (95% confidence interval, 2.4%-8.4%) in 1998 to 12.1% (95% confidence interval, 9.4%-13.7%) in 2011. Multivariate analysis of CT use found the strongest predictor to be increasing age. Females, black children, and those with Medicaid insurance had lower odds of having a CT. Conclusions: In contrast to the earlier dramatic increase in CT use for pediatric patients with abdominal pain, CT remained constant between 2008 and 2011. There was no associated change in the rate of diagnosis of appendicitis or hospitalization; however, ultrasound is increasing. | |
| 2016 | Fortin 2016 | Privately insured medical patients | Privately insured medical patients are more likely to have a head CT | All Ages | All Sexes | Emergency Department | Neurologic | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Previous studies suggest overuse disparity of head computed tomography (CT) in white pediatric trauma patients with minor head injuries. Our study is meant to determine if race or insurance status impacts the probability of obtaining head CT in patients with a Glasgow Coma Scale (GCS) = 15. Using the 2008-2010 National Hospital Ambulatory Medical Care Survey for Emergency Departments (NHAMCS) database, the following variables were analyzed: race, emergency medical services (EMS) arrival, triage category, admission status, gender, age, and insurance status. Patients with injuries were excluded. All patients included had GCS = 15. In univariate analysis, head CT is more likely to be obtained for patients in the following categories: Medicare insured, private insurance, Medicaid insured, and self-pay, EMS arrival, triage category immediate, and age >75 years. In logistic regression, race (white vs. black) was no longer significant, but there was disparity based on insurance status with privately insured patients more likely to receive a head CT (OR = 1.683, 95% CI = 1.255- 2.259). After controlling for the above inclusion variables and focusing on patients less likely to need CT (non-traumatic with GCS = 15), privately insured patients were more likely to receive a head CT compared with uninsured. Race alone was not associated with an increased probability of receiving a head CT. | |
| 2010 | Hambrook 2010 | Disparities exist in the emergency | Disparities exist in the emergency department evaluation of pediatric chest pain | Pediatric Only | All Sexes | Emergency Department | Chest Pain Imaging | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Objectives: To identify and describe disparities in the provision of Emergency Department (ED) care in pediatric patients presenting with chest pain (CP). Patients and Methods: Nationally representative data were drawn from the National Hospital Ambulatory Medical Care Survey (NHAMCS). All ED visits with a chief complaint of CP and age <19 years from 2002 to 2006 were analyzed. The primary outcome variable was " Anytest" performed (defined as any combination of complete blood count, electrocardiogram, and/or chest x-ray). Univariable analyses were performed with " Anytest" as the dependent variable and patient characteristics as independent variables. Multivariable analysis was performed using logistic regression with the same independent patient characteristics. Results: Eight hundred eighteen pediatric CP visits representing 2 552 193 such visits nationwide were analyzed. Gender and metro/non-metro location were not associated with " Anytest." However, Caucasian patients (p = 0.01) and those with private insurance (p < 0.01) were significantly more likely to receive testing despite otherwise similar demographics and severity of illness. Multivariate analysis revealed race (p = 0.03), expected payer (p = 0.003), and triage level (p = 0.009) were significantly and independently associated with the frequency of testing performed. Conclusion: Disparities exist in the ED care of pediatric patients with CP. Identification of such variations is important and provides an opportunity for targeted interventions that ensure delivery of high-quality, cost-effective health care for children. | |
| 2012 | Hryhorczuk 2012 | Pediatric abdominal pain: use of | Pediatric abdominal pain: use of imaging in the emergency department in the United States from 1999 to 2007 | Pediatric Only | All Sexes | Emergency Department | GI/Abdominal | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Purpose: To evaluate use of imaging in children with acute abdominal pain who present to U.S. emergency departments (EDs). Materials and methods: This study received expedited review by the institutional review board. The National Hospital Ambulatory Medical Care Survey is a government-administered yearly survey of EDs that is used to estimate ED care throughout the United States. This retrospective cohort study interrogated the database for the period from 1999 to 2007. Univariate regression analysis was performed, and a multivariate regression model was developed. Results: From 1999 to 2007, 16 900 000 pediatric ED visits were made for acute abdominal pain. Odds of undergoing computed tomography (CT) in this population increased during each year of the study period. No significant changes occurred in use of ultrasonography, number of patients admitted to the hospital, or number of patients with acute appendicitis. A multivariate model for CT use revealed increased odds of CT use in teens, white patients, the Midwest region, urban settings, patients with private insurance, and patients who were admitted or transferred. Odds of undergoing CT were significantly lower among patients who presented to a pediatric-focused emergency department (adjusted odds ratio, 0.72; 95% confidence interval: 0.58, 0.90). Conclusion: The main findings of this study are that the rate of CT use in the evaluation of abdominal pain in children increased every year between 1999 and 2007 and that the use of CT was greater among children seen in adult-focused EDs. Factors affecting CT use include sex, race, age, insurance status, and geographic region. | |
| 2004 | Isaacs 2004 | Radiograph use in low back pain: a | Radiograph use in low back pain: a United States emergency department database analysis | Adult Only | All Sexes | Emergency Department | Back Pain Imaging | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | We identified factors associated with radiograph evaluation for patients who presented to the Emergency Department (ED) with uncomplicated low back pain (LBP). Using 1998-2000 ED data from the National Hospital Ambulatory Medical Care Survey, a multivariate analysis was performed to assess utilization of radiographs for LBP. Based upon published guidelines, of the over 3 million patients who met our criteria of uncomplicated LBP, 17.8% received an unnecessary radiograph. Patients who arrive via ambulance with moderate pain, who need to be seen within 15 min, and who have 3 or more screening tests ordered are 100% likely to also get a radiograph. There is an increased probability of receiving a radiograph for those patients 40-70 years old, being seen at a metropolitan hospital, having private insurance, and being treated by a resident in training. Multiple factors are associated with the overuse of radiographs for patients presenting with uncomplicated LBP. | |
| 2010 | Mannix 2010 | Neuroimaging for pediatric head | Neuroimaging for pediatric head trauma: do patient and hospital characteristics influence who gets imaged? | Pediatric Only | All Sexes | Emergency Department | Neurologic | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Objectives: The objective was to identify patient, provider, and hospital characteristics associated with the use of neuroimaging in the evaluation of head trauma in children. Methods: This was a cross-sectional study of children (< or =19 years of age) with head injuries from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected by the National Center for Health Statistics. NHAMCS collects data on approximately 25,000 visits annually to 600 randomly selected hospital emergency and outpatient departments. This study examined visits to U.S. emergency departments (EDs) between 2002 and 2006. Multivariable logistic regression was used to analyze characteristics associated with neuroimaging in children with head injuries. Results: There were 50,835 pediatric visits in the 5-year sample, of which 1,256 (2.5%, 95% confidence interval [CI] = 2.2% to 2.7%) were for head injury. Among these, 39% (95% CI = 34% to 43%) underwent evaluation with neuroimaging. In multivariable analyses, factors associated with neuroimaging included white race (odds ratio [OR] = 1.5, 95% CI = 1.02 to 2.1), older age (OR = 1.3, 95% CI = 1.1 to 1.5), presentation to a general hospital (vs. a pediatric hospital, OR = 2.4, 95% CI = 1.1 to 5.3), more emergent triage status (OR = 1.4, 95% CI = 1.1 to 1.8), admission or transfer (OR = 2.7, 95% CI = 1.4 to 5.3), and treatment by an attending physician (OR = 2.0, 95% CI = 1.1 to 3.7). The effect of race was mitigated at the pediatric hospitals compared to at the general hospitals (p < 0.001). Conclusions: In this study, patient race, age, and hospital-specific characteristics were associated with the frequency of neuroimaging in the evaluation of children with closed head injuries. Based on these results, focusing quality improvement initiatives on physicians at general hospitals may be an effective approach to decreasing rates of neuroimaging after pediatric head trauma. | |
| 2014 | Mishuris 2014 | Racial differences in cancer | Racial differences in cancer screening with electronic health records and electronic preventive care reminders | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Health information technology (HIT) can increase preventive care. There are hopes and fears about the impact of HIT on racial disparities in cancer screening. To determine whether electronic health records (EHRs) or electronic preventive care reminders (e-reminders) modify racial differences in cancer screening order rates. Using the 2006-2010 National Ambulatory and National Hospital Ambulatory Medical Care Surveys, we measured (1) visit-based differences in rates of age-appropriate breast, cervical and colon cancer screening orders between white and non-white subjects at primary care visits with and without EHRs, and, at visits with EHRs, with and without e-reminders, and (2) whether EHRs or e-reminders modified these differences. Mammography (N=45,380); Pap smears (N=73,348); and sigmoidoscopy/colonoscopy (N=50,955) orders. Among an estimated 2.4 billion US adult primary care visits, orders for screening for breast, cervical or colon cancer did not differ between clinics with and without EHRs or e-reminders. There was no difference in screening orders between non-white and white patients for breast (aOR=1.1; 95% CI 0.9 to 1.4) or cervical cancer (aOR=1.2; 95% CI 1.0 to 1.3). For colon cancer, non-white patients were more likely to receive screening orders than white patients overall (aOR=1.5; 95% CI 1.1 to 2.0), at visits with EHRs (aOR=1.8; 95% CI 1.1 to 2.8) and at visits with e-reminders (aOR=2.1; 95% CI 1.2 to 3.7). EHRs or e-reminders did not modify racial differences in cancer screening rates. In this visit-based analysis, non-white patients had higher colon cancer screening order rates than white patients. Despite hopes and fears about HIT, EHRs and e-reminders did not ameliorate or exacerbate racial differences in cancer screening order rates. | |
| 2008 | Pallin 2008 | Seizure visits in US emergency | Seizure visits in US emergency departments: epidemiology and potential disparities in care | All Ages | All Sexes | Emergency Department | Neurologic | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Introduction: While epilepsy is a well-characterized disease, the majority of emergency department (ED) visits for "seizure" involve patients without known epilepsy. The epidemiology of seizure presentations and national patterns of management are unclear. The aim of this investigation was to characterize ED visits for seizure in a large representative US sample and investigate any potential impact of race or ethnicity on management. Methods: Seizure visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2003 were analysed. Demographic factors associated with presentation, neuroimaging and hospital admission in the USA were analysed using controlled multivariate logistic regression. Results: Seizure accounts for 1 million ED visits annually [95% confidence interval (CI): 926,000-1,040,000], or 1% of all ED visits in the USA. Visits were most common among infants, at 8.0 per 1,000 population (95% CI: 6.0-10.0), and children aged 1-5 years (7.4; 95% CI: 6.4-8.4). Seizure was more likely among those with alcohol-related visits [odds ratio (OR): 3.2; 95% CI: 2.7-3.9], males (OR: 1.4; 95% CI: 1.3-1.5) and Blacks (OR: 1.4; 95% CI: 1.3-1.6). Neuroimaging was used less in Blacks than Whites (OR: 0.6; 95% CI: 0.4-0.8) and less in Hispanics than non-Hispanics (OR: 0.6; 95% CI: 0.4-0.9). Neuroimaging was used less among patients with Medicare (OR: 0.4; 95% CI: 0.2-0.6) or Medicaid (OR: 0.5; 95% CI: 0.4-0.7) vs private insurance and less in proprietary hospitals. Hospital admission was less likely for Blacks vs Whites (OR: 0.6; 95% CI: 0.4-0.8). Conclusion: Seizures account for 1% of ED visits (1 million annually). Seizure accounts for higher proportions of ED visits among infants and toddlers, males and Blacks. Racial/ethnic disparities in neuroimaging and hospital admission merit further investigation. | |
| 2007 | Pezzin 2007 | Disparities in the emergency | Disparities in the emergency department evaluation of chest pain patients | Adult Only | All Sexes | Emergency Department | Chest Pain Imaging | United States | Black | National | Government Survey | National Hospital Ambulatory Medical Care Survey | BACKGROUND: The existence of race and gender differences in the provision of cardiovascular health care has been increasingly recognized. However, few studies have examined whether these differences exist in the emergency department (ED) setting. OBJECTIVES: To evaluate race, gender, and insurance differences in the receipt of early, noninvasive diagnostic tests among persons presenting to an ED with a complaint of chest pain. METHODS: Data were drawn from the U.S. National Hospital Ambulatory Health Care Survey of EDs. Visits made during 1995-2000 by persons aged 30 years or older with chest pain as a reason for the visit were included. Factors affecting the likelihood of ordering electrocardiography, cardiac monitoring, oxygen saturation measurement using pulse oximetry, and chest radiography were analyzed using multivariate probit analysis. RESULTS: A total of 7,068 persons aged 30 years or older presented to an ED with a primary complaint of chest pain during the six-year period, corresponding to more than 32 million such visits nationally. The adjusted probability of ordering a test was highest for non-African American patients for all tests considered. African American men had the lowest probabilities (74.3% and 62% for electrocardiography and chest radiography, respectively), compared with 81.1% and 70.3%, respectively, among non-African American men. Only 37.5% of African American women received cardiac monitoring, compared with 54.5% of non-African American men. Similarly, African American women were significantly less likely than non-African American men to have their oxygen saturation measured. Patients who were uninsured or self-pay, as well as patients with "other" insurance, also had a lower probability than insured persons of having these tests ordered. CONCLUSIONS: This study documents race, gender, and insurance differences in the provision of electrocardiography and chest radiography testing as well as cardiac rhythm and oxygen saturation monitoring in patients presenting with chest pain. These observed differences should catalyze further study into the underlying causes of disparities in cardiac care at an earlier point of patient contact with the health care system. | |
| 2011 | Raja 2011 | Use of neuroimaging in US emergency | Use of neuroimaging in US emergency departments | All Ages | All Sexes | Emergency Department | Neurologic | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | NA | |
| 2019 | Roberts 2019 | The association between insurance | The association between insurance status and diagnostic imaging for acute abdominal pain among emergency department patients in the United States, 2005-2014 | Adult Only | All Sexes | Emergency Department | GI/Abdominal | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Introduction and objectives: Acute abdominal pain (AAP) is one of the most common complaints in the emergency department (ED). Rapid diagnosis is essential and is often achieved through imaging. Computed tomography (CT) is widely considered an exemplary test in the diagnosis of AAP in adult patients. As previous studies show disparities in healthcare treatment based on insurance status, our objective was to assess the association between insurance status and frequency of CT ordered for adult patients presenting to the ED with AAP from 2005 to 2014. Methods: This study used the National Hospital and Ambulatory Medical Care Survey: Emergency Department Record (NHAMCS) database, which collects data over a randomly assigned 4 week period in the 50 states and DC, to perform an observational retrospective analysis of patients presenting to the ED with AAP. Patients with Medicaid, Medicare or no insurance were compared to patients with private insurance. The association between insurance status and frequency of CT ordered was measured by obtaining odds ratios along with 95% CIs adjusted for age, gender and race/ethnicity. Results: Individuals receiving Medicaid are 20% less likely to receive CT than those with private insurance (OR 0.8, CI 0.6-0.99, p = .046). Those on Medicare or who are uninsured have no difference in odds of obtaining a CT scan compared to patients with private insurance. Additional findings are that black patients are 42% less likely to receive a CT scan than white patients. Conclusions and implications: Patients on Medicaid are significantly less likely to receive a CT when presenting to the ED with AAP. Differences in diagnostic care may correlate to inferior health outcomes in patients without private insurance. | |
| 2020 | Ross 2020 | The influence of patient race on | The influence of patient race on the use of diagnostic imaging in United States emergency departments: Data from the National Hospital Ambulatory Medical Care survey | All Ages | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Background: An established body of literature has shown evidence of implicit bias in the health care system on the basis of patient race and ethnicity that contributes to well documented disparities in outcomes. However, little is known about the influence of patient race and ethnicity on the decision to order diagnostic radiology exams in the acute care setting. This study examines the role of patient race and ethnicity on the likelihood of diagnostic imaging exams being ordered during United States emergency department encounters. Methods: Publicly available data from the National Hospital Ambulatory Medical Care Survey Emergency Department sample for the years 2006-2016 was compiled. The proportion of patient encounters where diagnostic imaging was ordered was tabulated by race/ethnicity, sub-divided by imaging modality. A multivariable logistic regression model was used to evaluate the influence of patient race/ethnicity on the ordering of diagnostic imaging controlling for other patient and hospital characteristics. Survey weighting variables were used to formulate national-level estimates. Results: Using the weighted data, an average of 131,558,553 patient encounters were included each year for the 11-year study period. Imaging was used at 46% of all visits although this varied significantly by patient race and ethnicity with white patients receiving medical imaging at 49% of visits and non-white patients at 41% of visits (p < 0.001). This effect persisted in the controlled regression model and across all imaging modalities with the exception of ultrasound. Other factors with a significant influence on imaging use included patient age, gender, insurance status, number of co-morbidities, hospital setting (urban vs non-urban) and hospital region. There was no evidence to suggest that the disparate use of imaging by patient race and ethnicity changed over the 11-year study time period. Conclusion: The likelihood that a diagnostic imaging exam will be ordered during United States emergency department encounters differs significantly by patient race and ethnicity even when controlling for other patient and hospital characteristics. Further work must be done to understand and mitigate what may represent systematic bias and ensure equitable use of health care resources. | |
| 2019 | Schrager 2019 | Racial and Ethnic Differences in | Racial and Ethnic Differences in Diagnostic Imaging Utilization During Adult Emergency Department Visits in the United States, 2005 to 2014 | All Ages | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Objective: To compare the use of medical imaging (x-ray [XR], CT, ultrasound, and MRI) in the emergency department (ED) for adult patients of different racial and ethnic groups in the United States from 2005 to 2014. Methods: We performed a multilevel stratified regression analysis of the National Hospital Ambulatory Medical Care Survey ED Subfile, a nationally representative database of hospital-based ED visits. We examined race (white, black, Asian, other) and ethnicity (Hispanic versus non-Hispanic) as the primary exposures for the outcomes of ED medical imaging use (XR, CT, ultrasound, MRI, and any imaging). We controlled for other potential patient-level and facility-level determinants of ED imaging use. Results: Approximately half (48.8%) of the 225,037 adult patient ED visits underwent imaging; 36.1% underwent XR, 16.4% CT, 4.1% ultrasound, and 0.8% MRI. White patients received imaging during 51.3% of their encounters, black patients received imaging during 43.6% of their encounters, Asians received imaging during 50.8% of their encounters, and other races received imaging during 46% of their encounters. As compared with white patients, black patients had decreased adjusted odds of receiving imaging in the ED (odds ratio [OR] = 0.86, 95% confidence interval [CI]: 0.84-0.89). Comparatively, black patients had a lower odds of CT scan (OR = 0.80, 95% CI: 0.77-0.83) or MRI (OR = 0.74, 95% CI: 0.65-0.85). Hispanic patients and Asian patients had a higher odds of receiving ultrasound (OR = 1.36, 95% CI: 1.27-1.44 and OR = 1.25, 95% CI: 1.10-1.42), respectively. Implications: We observed significant racial and ethnic differences in medical imaging use in the ED even after controlling for patient- and facility-level factors. | |
| 2019 | Zhang 2019 | Racial and Ethnic Disparities in | Racial and Ethnic Disparities in Emergency Department Care and Health Outcomes Among Children in the United States | Pediatric Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Background: There is an incomplete understanding of disparities in emergency care for children across racial and ethnic groups in the United States. In this project, we sought to investigate patterns in emergency care utilization, disposition, and resource use in children by race and ethnicity after adjusting for demographic, socioeconomic, and clinical factors. Methods: In this cross-sectional study of emergency department (ED) data from the nationally representative National Hospital Ambulatory Medical Survey (NHAMCS), we examined multiple dimensions of ED care and treatment from 2005 to 2016 among children in the United States. The main outcomes include ED disposition (hospital admission, ICU admission, and in hospital death), resources utilization (medical imaging use, blood tests, and procedure use) and patient ED waiting times and total length of ED stay. The main exposure variable is race/ethnicity, categorized as non-Hispanic white (white), non-Hispanic black (Black), Hispanic, Asian, and Other. Analyses were stratified by race/ethnicity and adjusted for demographic, socioeconomic, and clinical factors. Results: There were 78,471 pediatric ( 18 years old) ED encounters, providing a weighted sample of 333,169,620 ED visits eligible for analysis. Black and Hispanic pediatric patients were 8% less likely (aOR 0.92, 95% CI 0.91-0.92) and 14% less likely (aOR 0.86, CI 0.86-0.86), respectively, than whites to have their care needs classified as immediate/emergent. Blacks and Hispanics were also 28 and 3% less likely, respectively, than whites to be admitted to the hospital following an ED visit (aOR 0.72, CI 0.72-0.72; aOR 0.97, CI 0.97-0.97). Blacks and Hispanics also experienced significantly longer wait times and overall visits as compared to whites. Conclusions: Black and Hispanic children faced disparities in emergency care across multiple dimensions of emergency care when compared to non-Hispanic white children, while Asian children did not demonstrate such patterns. Further research is needed to understand the underlying causes and long-term health consequences of these divergent patterns of racial disparities in ED care within an increasingly racially diverse cohort of younger Americans. | |
| 2020 | Zhang 2020 | Trends of Racial/Ethnic Differences | Trends of Racial/Ethnic Differences in Emergency Department Care Outcomes Among Audlts in the United States from 2005 to 2016 | Adult Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | National | Government Survey | National Hospital Ambulatory Medical Care Survey | Importance: While the literature documenting health disparities has advanced in recent decades, less is known about the pattern of racial/ethnic disparities in emergency care in the United States. Objective: To describe the trends and differences of health outcomes and resource utilization among racial/ethnic groups in US emergency care for adult patients over a 12-year period. Design, Setting, and Participants: This cross-sectional study of emergency department (ED) data from the nationally representative National Hospital Ambulatory Medical Survey (NHAMCS) examined multiple dimensions of ED care and treatment from 2005 to 2016 among adults in the US. Main Outcomes and Measures: The main outcomes include ED care outcomes (hospital admission, ICU admission, and death in the ED/hospital), resource utilization outcomes (medical imaging use, blood test, and procedure use), and patients' waiting time in the ED. The main exposure variable is race/ethnicity including white patients (non-Hispanic), black patients (non-Hispanic), Hispanic patients, Asian patients, and Other. Results: During the 12-year study period, NHAMCS collected data on 247,989 adult (> 18 years old) ED encounters, providing a weighted sample of 1,065,936,835 ED visits for analysis. Asian patients were 1.21 times more likely than white patients to be admitted to the hospital following an ED visit (aOR 1.21, 95% CI 1.12-1.31). Hispanic patients presented no significant difference in hospital admission following an ED visit (aOR 1.01, 95% CI 0.97-1.06) with white patients. Black patients were 7% less likely to receive an urgent ESI score than white patients less likely to receive immediate or emergent scores, as opposed to semi- or non-urgent scores. Black patients were also 10% less likely than white patients to be admitted to the hospital and were 1.26 times more likely than white patients to die in the ED or hospital. Conclusions and Relevance: Race is associated with significant differences in ED treatment and admission rates, which may represent disparities in emergency care. Hispanic and Asian Americans were equal or more likely to be admitted to the hospital compared to white patients. Black patients received lower triage scores and higher mortality rates. Further research is needed to understand the underlying causes and long-term health consequences of these disparities. | |
| 2003 | Stein 2003 | Venous thromboembolic disease: | Venous thromboembolic disease: comparison of the diagnostic process in blacks and whites | Adult Only | All Sexes | Inpatient General Care | GI/Abdominal | United States | Multiple Groups | National | Government Survey | National Hospital Discharge Survey | BACKGROUND: There has been concern that a disproportionate use of some health services exists among races. Whether this applies to patients with pulmonary embolism (PE) or deep venous thrombosis (DVT) has not been determined. OBJECTIVE: To assess if there is a racial disparity in the application of diagnostic tests for PE or DVT, or in reaching a diagnosis or using medical facilities. DESIGN: A study of cross-sectional samples of hospitalizations during 21 years using data from the National Hospital Discharge Survey. SETTING: Noninstitutional hospitals in 50 states and the District of Columbia from January 1, 1979, through December 31, 1999. PATIENTS: The National Hospital Discharge Survey abstracts demographic and medical information from the medical records of inpatients. For 1979 through 1999, the number of patients sampled ranged annually from 181 000 to 307 000. Measurements The number of sampled patients with DVT and with PE and the number of diagnostic tests performed were determined from the International Classification of Diseases, Ninth Revision, Clinical Modification codes at discharge. A multistage estimation procedure gave an estimate of values for the entire United States. RESULTS: The age-adjusted rates of diagnosis of PE and of DVT per 100 000 population were not lower in blacks than in whites. Rates of use of radioisotopic lung scans, venous ultrasonography of the lower extremities, and contrast venography were comparable between races. The durations of hospitalization for patients with a primary discharge diagnosis of PE and of DVT were also comparable. CONCLUSIONS: There is nothing to suggest that diagnostic tests are being withheld, and there is no evidence of a failure to reach a diagnosis in blacks with thromboembolic disease. | |
| 2016 | BorgesZda 2016 | Clinical breast examination and | Clinical breast examination and mammography: inequalities in Southern and Northeast Brazilian regions | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | National Household Sampling Survey | OBJECTIVE: To evaluate the prevalence and associated factors of doing clinical breast examinations (CBE) and mammogram (MMG) in the Southern and Northeast Brazilian regions, focusing on some social inequalities. METHODS: This is a cross-sectional study using data from the 2008 National Household Sampling Survey (PNAD). We evaluated the prevalence of CBE during the last year and of the MMG in the last two years, which were analyzed based on demographic (age, skin color, and marital status) and socioeconomic (income and schooling) variables. Gross and adjusted prevalence ratios were obtained using Poisson regression models. All analyses were stratified by region. RESULTS: The sample comprised 27,718 women aged 40 to 69 years. Less than a half of the women followed the recommendation of annual CBE performance in both the regions. The MMG prevalence during the last two years was 58.6 and 45.5% for the Southern and Northeast regions, respectively. More than a quarter of the women had never had a MMG (26.5% in the Southern and 40.6% in the Northeast regions). Not having performed both examinations was almost two times higher in the Northeast region (29.7%) when compared with the Southern (15.9%). The risk for not having performed both examinations was greater among nonwhite women, aged 60 to 69 years, with lower schooling level and family income. CONCLUSION: Important inequalities were seen between the Southern and Northeast regions for CBE and MMG. Health public policies should prioritize the most vulnerable groups to reduce these inequalities. | |
| 2005 | Taylor 2005 | Differences in the work-up and | Differences in the work-up and treatment of conditions associated with low back pain by patient gender and ethnic background | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Back Pain Imaging | United States | Multiple Groups | National | Disease Registry | National registry | Study Design: Retrospective review comparing physician workup of degenerative lumbosacral pathologies between different genders and ethnic groups. Objectives: To investigate whether patient ethnicity and gender influence the workup and treatment of degenerative spinal pathologies. Summary of Background Data: Data from numerous studies suggest that patient gender and ethnicity play a role in medical decision-making, with white males receiving more frequent interventions than women and minorities. Methods: Patients enrolled for an "initial visit" in the National Spine Network database with lumbosacral level degenerative diagnosis were reviewed. Variables included patient gender, ethnicity, age, duration of symptoms, patient-graded severity of symptoms, radicular symptom pattern, and work status. Results: We identified 5690 patients with degenerative lumbosacral pathologies. Although females were more likely than males to have imaging tests ordered, male (18.5%) patients were significantly more likely to have surgery recommended than female (16.3%) patients (P < 0.031). Nonwhite females were 52% less likely to have surgery offered at initial visit, as compared to white males (P < 0.005). More imaging tests were ordered or reviewed among whites (76.6%) than among any other ethnic group (P = 0.162). White (18.3%) and Asian (22.5%) patients were significantly more likely to have surgery recommended or prescribed than black (11.1%) and Hispanic (14.5) patients (P < 0.0001). Conclusions: This study suggests that ethnicity and gender affect the workup and surgical management of degenerative spinal disorders. However, it should be noted that there are a number of confounding factors not identified in the database, including managed care and insurance status and cultural differences, which may affect both test ordering and treatment recommendations. Further study of bias in clinical decision-making is indicated to assure equal delivery of quality care. | |
| 2018 | Phaswana-Mafuya 2018 | Breast and Cervical Cancer | Breast and Cervical Cancer Screening Prevalence and Associated Factors among Women in the South African General Population | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | South Africa | Multiple Groups | National | Government Survey | National survey | Purpose: The aims of the study were to estimate the prevalence of breast and cervical cancer screening among women in the South African general population and assess associated factors. Methods: Data from a national populationbased cross-sectional household survey in South Africa in 2012 for 10,831 women aged 30+ years were analysed using bivariate and multivariable logistic regression. The outcome variables were cervical cancer screening (Papanicolaou smear test) and breast cancer screening (mammography). Exposure variables were sociodemographic factors, lifestyle variables, and chronic conditions. Results: The prevalences of Papanicolaou (PAP) smear test and mammography participation were 52.0% and 13.4%, respectively. On multivariable logistic regression analysis, women with higher education, those who were non-black African, having medical aid and having chronic conditions were more likely to undergo a Pap smear test and mammography. Living in rural areas was related to a lower likelihood of receiving both types of screening. In addition, undertaking moderate or vigorous physical activity was associated with breast cancer screening. Conclusion: Screening for cervical cancer was relatively high but for breast cancer it was low, despite the latter being a major public health problem in South Africa. This may be attributed to the limited availability, affordability, and accessibility of breast cancer screening services among socio-economically disadvantaged individuals There are some socio-economic disparities in adopting both breast and cervical cancer screening guidelines that could be targeted by interventions. | |
| 2015 | Ricardo-Rodrigues 2015 | Social disparities in access to | Social disparities in access to breast and cervical cancer screening by women living in Spain | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Spain | Immigrants | National | Government Survey | National survey | Objectives: To describe uptake of breast and cervical cancer screening by women living in Spain, analyse the possible associated social and health factors, and compare uptake rates with those obtained in previous surveys. Study design: Cross-sectional study using data from the 2011 Spanish national health survey. Methods: Uptake of breast cancer screening was analysed by asking women aged 40-69 years whether they had undergone mammography in the previous two years. Uptake of cervical cancer screening was analysed by asking women aged 25-65 years whether they had undergone cervical cytology in the previous three years. Independent variables included sociodemographic characteristics, and variables related to health status and lifestyle. Results: Seventy-two percent of women had undergone mammography in the previous two years. Having private health insurance increased the probability of breast screening uptake four-fold [odds ratio (OR) 3.96, 95% confidence interval (CI) 2.71-5.79], and being an immigrant was a negative predictor for breast screening uptake. Seventy percent of women had undergone cervical cytology in the previous three years. Higher-educated women were more likely to have undergone cervical cancer screening (OR 2.59, 95% CI 1.97-3.40), and obese women and women living in rural areas were less likely to have undergone cervical cancer screening. There have been no relevant improvements in uptake rates of either breast or cervical cancer screening since 2006. Conclusion: Uptake of breast and cervical cancer screening could be improved in Spain, and uptake rates have stagnated over recent years. Social disparities have been detected with regard to access to these screening tests, indicating that it is necessary to continue researching and optimizing prevention programmes in order to improve uptake and reduce these disparities. | |
| 2021 | Chandra 2021 | Race-insurance disparities in | Race-insurance disparities in prostate patients' magnetic resonance imaging biopsies and their subsequent cancer care: a New York State cohort study | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | State | Government Survey | New York Statewide Planning and Research Cooperative System | For organ-confined prostate cancer, socioeconomic factors influencing Magnetic Resonance Imaging (MRI)-guided biopsy utilization and downstream prostate cancer patients' care are unknown. This retrospective, observational cohort study used the New York Statewide Planning and Research Cooperative System (SPARCS) billing-code driven database to examine the impact of prostate patients' socioeconomic characteristics on prostate cancer care defined as initial biopsy, 2-month post-biopsy cancer diagnoses, and within 1-year cancer-related intervention, controlling for other risk factors. From 2011-2017, the population studied (n = 18,253) included all New York State-based, male, residents aged 18 to 75 without a prior prostatectomy receiving a first-time biopsy; 760 such patient records in 2016 were removed due to data quality concerns. Major exposures included patient age, race, ethnicity and insurance. The major outcome included receipt of MRI biopsy versus standard biopsy and for these sub-populations, subsequent 2-month post-biopsy metastatic versus non-metastatic prostate cancer diagnosis and within 1-year prostate cancer treatment (prostatectomy with or without radiation versus prostatectomy-only) were compared using dichotomous (primary) and time-to-event (secondary) endpoints. Of 17,493 patients with a first-time prostate biopsy, 3.89% had MRI guided biopsies; of the 17,128 patients with no pre-biopsy cancer diagnosis, the subsequent prostate cancer diagnosis rate was 42.59%. For 6,754 non-metastatic prostate cancer patients with 1-year follow-up, 1,674 (24.79%) received surgery (with or without radiation) and 495 (7.33%) received radiation-only. Holding other factors constant, multivariable regression models identified that race-insurance was a primary predictor of MRI-guided biopsy use. Compared to commercially insured White patients, Black patients across all insurance categories received MRI-guided biopsies less frequently; Commercially insured and self-pay Black patients also had increased chance of prostate cancer diagnosis. Across all insurers, Black patients had lower likelihood of prostatectomies. In contrast, Black and White patients with government insurance were more likely to have within 1-year radiation-only treatments versus commercially insured White patients. Thus, across the prostate cancer care continuum, race-insurance affected prostate cancer-related service utilization. Future research should evaluate the generalizability of these New York State findings. | |
| 2021 | Qian 2021 | Use of Diagnostic Testing and | Use of Diagnostic Testing and Intervention for Sensorineural Hearing Loss in US Children from 2008 to 2018 | Pediatric Only | All Sexes | Outpatient Ambulatory and Primary Care | Neurologic | United States | Multiple Groups | National | Private Insurance Data | Optum claims | Importance: Early detection and intervention of pediatric hearing loss is critical for language development and academic achievement. However, variations in the diagnostic workup and management of pediatric sensorineural hearing loss (SNHL) exist. Objective: To identify patient and clinician factors that are associated with variation in practice on a national level. Design, setting, and participants: This cross-sectional study used the Optum claims database to identify 53 711 unique children with SNHL between January 1, 2008, and December 31, 2018. Main outcomes and measures: National use rates and mean costs for diagnostic modalities (electrocardiogram, cytomegalovirus testing, magnetic resonance imaging, computed tomography, and genetic testing) and interventions (speech-language pathology, billed hearing aid services, and cochlear implant surgery) were reported. The associations of age, sex, SNHL laterality, clinician type, race/ethnicity, and household income with diagnostic workup and intervention use were measured in multivariable analyses. Results: Of 53 711 patients, 23 735 (44.2%) were girls, 2934 (5.5%) were Asian, 3797 (7.1%) were Black, 5626 (10.5%) were Hispanic, 33 441 (62.3%) were White, and the mean (SD) age was 7.3 (5.3) years. Of all patients, 32 200 (60.0%) were seen by general otolaryngologists, while 7573 (14.10%) were seen by pediatric otolaryngologists. Diagnostic workup was received by 14 647 patients (27.3%), while 13 482 (25.1%) received intervention. Use of genetic testing increased (odds ratio, 1.22 per year; 95% CI, 1.20-1.24), whereas use of computed tomography decreased (odds ratio, 0.93 per year; 95% CI, 0.92-0.94) during the study period. After adjusting for relevant covariables, children who were seen by pediatric otolaryngologists and geneticists had the highest odds of receiving workup and intervention. Additionally, racial/ethnic and economic disparities were observed in the use of most modalities of diagnostic workup and intervention for pediatric SNHL. Conclusions and relevance: This cross-sectional study identified factors associated with disparities in the diagnostic workup and intervention of pediatric SNHL, thus highlighting the need for increased education and standardization in the management of this common sensory disorder. | |
| 2021 | Goyal 2021 | Racial and ethnic disparities in | Racial and ethnic disparities in the delayed diagnosis of appendicitis among children | Pediatric Only | All Sexes | Emergency Department | GI/Abdominal | United States | Multiple Groups | Multi-Institution | Government Survey | Pediatric Emergency Care Applied Research Network Registry | BACKGROUND: Appendicitis is the most common surgical condition in pediatric emergency department (ED) patients. Prompt diagnosis can reduce morbidity, including appendiceal perforation. The goal of this study was to measure racial/ethnic differences in rates of 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s). METHODS: This was a 3-year multicenter (seven EDs) retrospective cohort study of children diagnosed with appendicitis using the Pediatric Emergency Care Applied Research Network Registry. Delayed diagnosis was defined as having at least one prior ED visit within 7 days preceding appendicitis diagnosis. We performed multivariable logistic regression to measure associations of race/ethnicity (non-Hispanic [NH]-white, NH-Black, Hispanic, other) with 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s). RESULTS: Of 7,298 patients with appendicitis and documented race/ethnicity, 2,567 (35.2%) had appendiceal perforation. In comparison to NH-whites, NH-Black children had higher likelihood of perforation (36.5% vs. 34.9%; adjusted odds ratio [aOR]= 1.21 [95% confidence interval {CI}= 1.01 to 1.45]). A total of 206 (2.8%) had a delayed diagnosis of appendicitis. NH-Black children were more likely to have delayed diagnoses (4.7% vs. 2.0%; aOR= 1.81 [95% CI= 1.09 to 2.98]). Eighty-nine (43.2%) patients with delayed diagnosis had abdominal imaging during their prior visits. In comparison to NH-whites, NH-Black children were less likely to undergo any imaging (28.2% vs. 46.2%; aOR= 0.41 [95% CI= 0.18 to 0.96]) or definitive imaging (e.g., ultrasound/ computed tomography/magnetic resonance imaging; 10.3% vs. 35.9%; aOR= 0.15 [95% CI= 0.05 to 0.50]) during prior visits. CONCLUSIONS: In this multicenter cohort, there were racial disparities in appendiceal perforation. There were also racial disparities in rates of delayed diagnosis of appendicitis and diagnostic imaging during prior ED visits. These disparities in diagnostic imaging may lead to delays in appendicitis diagnosis and, thus, may contribute to higher perforation rates demonstrated among minority children. | |
| 2022 | Henry 2022 | Practice Variation in Use of | Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals | Pediatric Only | All Sexes | Inpatient and Outpatient | NAT | United States | Multiple Groups | Multi-Institution | Private Survey | Pediatric Health Information System | IMPORTANCE: Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement. OBJECTIVE: To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022. EXPOSURES: Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital. MAIN OUTCOMES AND MEASURES: Use of neuroimaging by CT or MRI. RESULTS: Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR]for ages <3 months vs ages 9 to <12 months, 13.2; 95% CI, 9.54-18.2; P< .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P< .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P= .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P= .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P< .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P= .001). CONCLUSIONS AND RELEVANCE: This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement. | |
| 2021 | Honcoop 2021 | Racial and ethnic disparities in | Racial and ethnic disparities in bronchiolitis management in freestanding children's hospitals | Pediatric Only | All Sexes | Inpatient and Outpatient | Bronchiolitis Management | United States | Multiple Groups | Multi-Institution | Private Survey | Pediatric Health Information System | OBJECTIVE: Variation in bronchiolitis management by race and ethnicity within emergency departments (EDs) has been described in single-center and prospective studies, but large-scale assessments across EDs and inpatient settings are lacking. Our objective is to describe the association between race and ethnicity and bronchiolitis management across 37 U.S. freestanding children's hospitals from 2015 to 2018. METHODS: Using the Pediatric Health Information System, we analyzed ED and inpatient visits from November 2015 to November 2018 of children with bronchiolitis 3 to 24 months old. Rates of use for specific diagnostic tests and therapeutic measures were compared across the following race/ethnicity categories: 1) non-Hispanic White (NHW), 2) non-Hispanic Black (NHB), 3) Hispanic, and 4) other. The subanalyses of ED patients only and children < 1 year old were performed. Mixed-effect logistic regression was performed to compare the adjusted odds of receiving specific test/treatment using NHW children as the reference group. RESULTS: A total of 134,487 patients met inclusion criteria (59% male, 28% NHB, 26% Hispanic). Adjusted analysis showed that NHB children had higher odds of receiving medication associated with asthma (odds ratio [OR]=1.27, 95% confidence interval [CI]=1.22 to 1.32) and lower odds of receiving diagnostic tests (blood cultures, complete blood counts, viral testing, chest x-rays; OR=0.78, 95% CI=0.75 to 0.81) and antibiotics (OR=0.58, 95% CI=0.52 to 0.64) than NHW children. Hispanic children had lower odds of receiving diagnostic testing (OR=0.94, 95% CI=0.90 to 0.98), asthma-associated medication (OR=0.92, 95% CI=0.88 to 0.96), and antibiotics (OR=0.74, 95% CI=0.66 to 0.82) compared to NHW children. CONCLUSION: NHB children more often receive corticosteroid and bronchodilator therapies; NHW children more often receive antibiotics and chest radiography. Given that current guidelines generally recommend supportive care with limited diagnostic testing and medical intervention, these findings among NHB and NHW children represent differing patterns of overtreatment. The underlying causes of these patterns require further investigation. | |
| 2022 | Li 2022 | Racial and ethnic differences in | Racial and ethnic differences in low-value pediatric emergency care | Pediatric Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | Multi-Institution | Private Survey | Pediatric Health Information System | BACKGROUND: Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED). METHODS: We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital. RESULTS: We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients. CONCLUSIONS: NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice. | |
| 2021 | Marin 2021 | Racial and Ethnic Differences in | Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019 | Pediatric Only | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | Multi-Institution | Private Survey | Pediatric Health Information System | IMPORTANCE: Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown. OBJECTIVE: To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019. EXPOSURES: Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses. RESULTS: A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category. CONCLUSIONS AND RELEVANCE: In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes. | |
| 2015 | Wang 2015 | Health outcomes in US children with | Health outcomes in US children with abdominal pain at major emergency departments associated with race and socioeconomic status | All Ages | All Sexes | Emergency Department | General Diagnostic Imaging | United States | Multiple Groups | National | Private Survey | Pediatric Health Information System | OBJECTIVE: Over 9.6 million ED visits occur annually for abdominal pain in the US, but little is known about the medical outcomes of these patients based on demographics. We aimed to identify disparities in outcomes among children presenting to the ED with abdominal pain linked to race and SES. METHODS: Data from 4.2 million pediatric encounters of abdominal pain were analyzed from 43 tertiary US children's hospitals, including 2.0 million encounters in the emergency department during 2004-2011. Abdominal pain was categorized as functional or organic abdominal pain. Appendicitis (with and without perforation) was used as a surrogate for abdominal pain requiring emergent care. Multivariate analysis estimated likelihood of hospitalizations, radiologic imaging, ICU admissions, appendicitis, appendicitis with perforation, and time to surgery and hospital discharge. RESULTS: Black and low income children had increased odds of perforated appendicitis (aOR, 1.42, 95% CI, 1.32- 1.53; aOR, 1.20, 95% CI 1.14 - 1.25). Blacks had increased odds of an ICU admission (aOR, 1.92, 95% CI 1.53 - 2.42) and longer lengths of stay (aHR, 0.91, 95% CI 0.86 - 0.96) than Whites. Minorities and low income also had lower rates of imaging for their appendicitis, including CT scans. The combined effect of race and income on perforated appendicitis, hospitalization, and time to surgery was greater than either separately. CONCLUSIONS: Based on race and SES, disparity of health outcomes exists in the acute ED setting among children presenting with abdominal pain, with differences in appendicitis with perforation, length of stay, and time until surgery. | |
| 2010 | Wood 2010 | Disparities in the evaluation and | Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury | Pediatric Only | All Sexes | Inpatient General Care | NAT | United States | Multiple Groups | National | Private Survey | Pediatric Health Information System | OBJECTIVE: To evaluate in a national database the association of race and socioeconomic status with radiographic evaluation and subsequent diagnosis of child abuse after traumatic brain injury (TBI) in infants. METHODS: We conducted a retrospective study of infants with non-motor vehicle-associated TBI who were admitted to 39 pediatric hospitals from January 2004 to June 2008. Logistic regression controlling for age, type, and severity of TBI and the presence of other injuries was performed to examine the association of race and socioeconomic status with the principal outcomes of radiographic evaluation for suspected abuse and diagnosis of abuse. Regression coefficients were transformed to probabilities. RESULTS: After adjustment for type and severity of TBI, age, and other injuries, publicly insured/uninsured infants were more likely to have had skeletal surveys performed than were privately insured infants (81% vs 59%). The difference in skeletal survey performance for infants with public or no insurance versus private insurance was greater among white (82% vs 53%) infants than among black (85% vs 75%) or Hispanic (72% vs 55%) infants (P = .022). Although skeletal surveys were performed in a smaller proportion of white than black or Hispanic infants, the adjusted probability for diagnosis of abuse among infants evaluated with a skeletal survey was higher among white infants (61%) than among black (51%) or Hispanic (53%) infants (P = .009). CONCLUSIONS: National data suggest continued biases in the evaluation for abusive head trauma. The conflicting observations of fewer skeletal surveys among white infants and higher rates of diagnosis among those screened elicit concern for overevaluation in some infants (black or publicly insured/uninsured) or underevaluation in others (white or privately insured). | |
| 2019 | Kim 2021 | Contemporary Trends in Magnetic | Contemporary Trends in Magnetic Resonance Imaging at the Time of Prostate Biopsy: Results from a Large Private Insurance Database | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | National | Private Insurance Data | Private health insurance | BACKGROUND: Magnetic resonance imaging (MRI) of the prostate (MRI-prostate) facilitates better detection of clinically significant prostate cancer (PCa). Yet, the national trends of MRI at the time of prostate biopsy and its ability to increase the detection of PCa in a biopsy-nave population remain unknown. OBJECTIVE: To elucidate the contemporary trends of MRI and prostate biopsy, and whether it improved PCa diagnosis among privately insured patients. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of a large private health insurance database in the USA-the OptumLabs Data Warehouse. We identified all men 40 yr of age who underwent index prostate biopsies from 2010 through 2016. INTERVENTION: MRI-prostate at the time of index biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Utilization of the MRI at the time of biopsy and incident PCa diagnosis constituted the primary outcomes. We enumerated unadjusted and age-specific annual rates of MRI over time to elucidate trends using regression models (trend analysis). Bivariate and multivariable regression analyses identified patient characteristics associated with MRI-prostate, and the association between the use of MRI and PCa diagnosis. RESULTS AND LIMITATIONS: Overall, 119 202 men underwent index prostate biopsies. Unadjusted annual rates of MRI at the time of biopsy significantly increased from 7 per 1000 biopsies in 2010 to 83 per 1000 biopsies in 2016 (p < 0.001 for trend). Age-specific rates increased across all age groups (40-49, 50-59, 60-65, 66-74, and 75+ yr; all p < 0.001). On multivariable analysis, black patients had a lower likelihood of MRI compared with white patients (odds ratio [OR]: 0.6; p < 0.01). MRI at the time of biopsy was not associated with a higher likelihood of incident PCa compared with traditional systematic biopsy (OR: 1.0; p = 0.7). The retrospective design and the inability to detect clinically significant PCa (Gleason 7+) constitute the limitations of this study. CONCLUSIONS: While the use of MRI at the time of biopsy rose markedly, it was not associated with a higher detection rate of PCa. Further research is needed to address effective dissemination of MRI and targeted biopsies, and racial disparities. PATIENT SUMMARY: From 2010 to 2016, our study found a significant rise in the utilization of magnetic resonance imaging of the prostate (MRI-prostate) at the time of index biopsy, although only a minority of patients undergo MRI-prostate. The use of MRI-prostate was not associated with a higher likelihood of diagnosing incident prostate cancer. | |
| 2015 | Wharam 2015 | National trends and disparities | National trends and disparities inmammography among commercially insured women, 2001-2010 | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Private Insurance Data | Private health insurance | Context: Prior research suggests that mammography declined from 2000 to 2005 and that socioeconomic disparities remained wide. Objective: To assess national trends and disparities in mammography among commercially insured women from 2001 to 2010. Design, Setting, Participants: This study used a longitudinal time series design to examine mammography rates among 5.4 million US women aged 40 to 64 years from 2001 to 2010. Adjusted annual rates stratified by age group (40-49 years/50-64 years) and neighborhood-level socioeconomic characteristics including poverty and race/ethnicity were plotted. Mammography disparities were defined as the absolute percentage difference in adjusted screening rates between population subgroups in a given year. Trends in 2001-2010 screening rates and socioeconomic disparities were fitted as annual percentage changes (APCs) using join point analysis, which can determine changes in trends. Main Outcome Measure: Annual and biennial mammogram. Results: Adjusted annual mammography rates among women aged 40 to 49 years increased from 38.5% to 45.5% (0.78% APC, P <.001) over the decade. Among women aged 50 to 64 years, 2001-2004 rates decreased from 49.7% to 47.4% (-0.78% APC, P = .035) and then increased to 51.8% by 2010 (APC of 0.80%, P < .001). Women aged 40 to 49 years had an unchanged high-low neighborhood poverty screening disparity of 11.0% over the decade (APC -0.05%, P = .508). The estimated white-black disparity decreased from 9.6% to 7.7% from 2001 to 2010 (-0.21% APC, P = .042). The white-Hispanic disparity decreased from 9.6% to 6.2% between 2001 and 2003 (APC -1.69%, P = .143) and then to 5.3% by 2010 (APC -0.14%, P = .343). Among women aged 50 to 64 years, estimated high-low poverty and white-black disparities declined (11.0%- 9.5% [-0.16% APC, P = .026] and 8.6%-6.3% [-0.26% APC, P = .008], respectively) while the white-Hispanic disparity decreased from 14.9% to 5.4% between 2001 and 2003 (-4.77% APC, P = .023) and was 6.5% by 2010. Conclusions: Mammography increased among women aged 40 to 49 years from 2001 to 2010 and after 2004 among women aged 50 to 64 years. Women from black and Hispanic neighborhoods experienced reduced disparities, but disparities by poverty level changed little. | |
| 2021 | Abashidze 2021 | Racial and Ethnic Disparities in | Racial and Ethnic Disparities in the Use of Prostate Magnetic Resonance Imaging Following an Elevated Prostate-Specific Antigen Test | Adult Only | Male | Outpatient Ambulatory and Primary Care | Other: Cancer Screening | United States | Multiple Groups | National | Private Insurance Data | Private insurance claims | IMPORTANCE: Prostate cancer screening and diagnosis exhibit known racial and ethnic disparities. Whether these disparities persist in prostate magnetic resonance imaging (MRI) utilization after elevated prostate-specific antigen (PSA) results is poorly understood. OBJECTIVE: To assess potential racial and ethnic disparities in prostate MRI utilization following elevated PSA results. DESIGN, SETTING, AND PARTICIPANTS: This cohort study of 794 809 insured US men was drawn from deidentified medical claims between January 2011 and December 2017 obtained from a commercial claims database. Eligible participants were aged 40 years and older and received a single PSA result and no prior PSA screening or prostate MRI claims. Analysis was performed in January 2021. MAIN OUTCOMES AND MEASURES: Multivariable logistic regression was used to examine associations between elevated PSA results and follow-up prostate MRI. For patients receiving prostate MRI, multivariable regressions were estimated for the time between PSA and subsequent prostate MRI. PSA thresholds explored included PSA levels above 2.5 ng/mL, 4 ng/mL, and 10 ng/mL. Analyses were stratified by race, ethnicity, and age. RESULTS: Of 794 809 participants, 51 500 (6.5%) had PSA levels above 4 ng/mL; of these, 1524 (3.0%) underwent prostate MRI within 180 days. In this sample, mean (SD) age was 59.8 (11.3) years (range 40-89 years); 31 350 (3.9%) were Asian, 75 935 (9.6%) were Black, 107 956 (13.6%) were Hispanic, and 455 214 (57.3%) were White. Compared with White patients, Black patients with PSA levels above 4 ng/mL and 10 ng/mL were 24.1% (odds ratio [OR], 0.78; 95% CI, 0.65-0.89) and 35.0% (OR, 0.65; 95% CI, 0.50-0.85) less likely to undergo subsequent prostate MRI, respectively. Asian patients with PSA levels higher than 4 ng/mL (OR, 0.76; 95% CI, 0.58-0.99) and Hispanic patients with PSA levels above 10 ng/mL (OR, 0.77; 95% CI, 0.59-0.99) were also less likely to undergo subsequent prostate MRI compared with White patients. Black patients between ages 65 and 74 years with PSA above 4 ng/mL and 10 ng/mL were 23.6% (OR, 0.76; 95% CI, 0.64-0.91) and 43.9% (OR, 0.56; 95% CI, 0.35-0.91) less likely to undergo MRI, respectively. Race and ethnicity were not significantly associated with mean time between PSA and MRI. CONCLUSIONS AND RELEVANCE: Among men with elevated PSA results, racial and ethnic disparities were evident in subsequent prostate MRI utilization and were more pronounced at higher PSA thresholds. Further research is needed to better understand and mitigate physician decision-making biases and other potential sources of disparities in prostate cancer diagnosis and management. | |
| 2011 | Wilf-Miron 2011 | The association between | The association between socio-demographic characteristics and adherence to breast and colorectal cancer screening: Analysis of large sub populations | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Israel | Multiple Groups | National | Private Insurance Data | Private insurance claims | Background: Populations having lower socioeconomic status, as well as ethnic minorities, have demonstrated lower utilization of preventive screening, including tests for early detection of breast and colorectal cancer. The objective: To explore socio-demographic disparities in adherence to screening recommendations for early detection of cancer. Methods: The study was conducted by Maccabi Healthcare Services, an Israeli HMO (health plan) providing healthcare services to 1.9 million members. Utilization of breast cancer (BC) and colorectal cancer (CC) screening were analyzed by socio-economic ranks (SERs), ethnicity (Arab vs non-Arab), immigration status and ownership of voluntarily supplemental health insurance (VSHI). Results: Data on 157,928 and 303,330 adults, eligible for BC and CC screening, respectively, were analyzed. Those having lower SER, Arabs, immigrants from Former Soviet Union countries and non-owners of VSHI performed fewer cancer screening examinations compared with those having higher SER, non-Arabs, veterans and owners of VSHI (p < 0.001). Logistic regression model for BC Screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab and having a lower SER. The model for CC screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant. The model estimated for BC and CC screening among females revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant. Conclusion: Patients from low socio-economic backgrounds, Arabs, immigrants and those who do not own supplemental insurance do fewer tests for early detection of cancer. These sub-populations should be considered priority populations for targeted intervention programs and improved resource allocation. | |
| 2019 | Le 2019 | Lower attendance rates in | Lower attendance rates in BreastScreen Norway among immigrants across all levels of socio-demographic factors: a population-based study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Norway | Immigrants | National | Disease Registry | Registry | Background: Several studies have shown that immigrants attend mammographic screening less frequently than non-immigrants. Studies have also shown that attendance is influenced by socio-demographic factors. We aimed to describe the relationship between socio-demographic factors and first attendance among immigrant and non-immigrant women invited to BreastScreen Norway. Methods: Our cohort consisted of 885,979 women invited to BreastScreen Norway for their first time between 1996 and 2015. We merged individual-level socio-demographic data to attendance data corresponding to women's first invitation to the program. Using Poisson regression, we calculated rate ratios with 95% confidence intervals (95% CI) for attendance, stratified by region of origin. Covariates of interest included age, income, education level, employment status, marital status, citizenship and years since immigration, among others. Results: Fifty-three percent of immigrants and 76% of non-immigrants attended mammographic screening after their first invitation; immigrants as a whole had lower attendance rates across all socio-demographic factors. However, the association between socio-demographic factors and attendance varied between immigrant groups. For all immigrants, no recorded education demonstrated the strongest association with non-attendance compared with 10years recorded education (RRadj: 0.69, 95% CI: 0.67-0.71). Other factors associated with non-attendance were low income, living in Oslo, not being employed and being a recent immigrant. Conclusion: The association between socio-demographic factors and mammographic screening attendance differed between immigrant groups. Further studies and preventive health measures should take into account that considering immigrants as a homogeneous group may lead to less effective interventions. | |
| 2022 | Benes 2022 | Race and Age Impact Osteoporosis | Race and Age Impact Osteoporosis Screening Rates in Women Prior to Hip Fracture | Adult Only | Female | Outpatient Ambulatory and Primary Care | Osteoporosis Screening | United States | Multiple Groups | Regional | EHR | Research Action for Health Network database | SUMMARY: Bone mineral density screening and clinical risk factors are important to stratify individuals for increased risk of fracture. In a population with no history of fractures or baseline bone density measurement, black women were less likely to be screened than white counterparts prior to hip fracture. PURPOSE: To evaluate overall BMD (bone mineral density) screening rates within two years of hip fracture and to identify any disparities for osteoporosis screening or treatment in a female cohort who were eligible for screening under insurance and national recommendations. METHODS: Data were obtained from 1,109 female patients listed in the Research Action for Health Network (REACHnet) database, which consists of multiple health partner systems in Louisiana and Texas. Patients<65 years old or with a history of hip fracture or osteoporosis diagnosis, screening or treatment more than 2 years before hip fracture were removed. RESULTS: Only 223 (20.1%) females were screened within the two years prior to hip fracture. Additionally, only 23 (10%) of the screened patients received treatment, despite 187 (86.6%) patients being diagnosed with osteoporosis or osteopenia. Screening rates reached a maximum of 27.9% in the 75-80 age group, while the 90+ age group had the lowest screening rates of 12%. We found a quadratic relationship between age and screening rates, indicating that the screening rate increases in age until age 72 and then decreases starkly. After adjusting for potential confounders, we found that black patients had significantly decreased screening rates compared to white patients (adjusted OR=.454, 95% CI=.227-.908, p value=.026) which held in general and for patient ages 65-97. CONCLUSION: Despite national recommendations, overall BMD screening rates among women prior to hip fracture are low. If individuals are not initially screened when eligible, they are less likely to ever be screened prior to fracture. Clinicians should address racial disparities by recommending more screening to otherwise healthy black patients above the age of 65. Lastly, treatment rates need to increase among those diagnosed with osteoporosis since all patients went on to hip fracture. | |
| 2021 | Lacson 2021 | Exacerbation of Inequities in Use | Exacerbation of Inequities in Use of Diagnostic Radiology During the Early Stages of Reopening After COVID-19 | Adult Only | All Sexes | Inpatient and Outpatient | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | EHR | Research Data Warehouse | OBJECTIVE: Assess diagnostic radiology examination utilization and associated social determinants of health during the early stages of reopening after state-mandated shutdown of nonurgent services because of coronavirus disease 2019 (COVID-19). METHODS: This institutional review board-approved, retrospective study assessed all patients with diagnostic radiology examinations performed at an academic medical center with eight affiliated outpatient facilities before (January 1, 2020, to March 8, 2020) and after (June 7, 2020, to July 15, 2020) the COVID-19 shutdown. Examinations during the shut down (March 9, 2020, to June 6, 2020) were excluded. Patient-specific factors (eg, race, ethnicity), imaging modalities, and care settings were extracted from the Research Data Warehouse. Primary outcome was the number of diagnostic radiology examinations per day compared pre- and post-COVID-19 shutdown. Univariate analysis and multivariable logistic regression determined features associated with completing an examination. RESULTS: Despite resumption of nonurgent services, marked decrease in radiology examination utilization persisted in all care settings post-COVID-19 shutdown (869 examinations per day preshutdown [59,080 examinations in 68 days] versus 502 examinations per day postshutdown [19,594 examinations in 39 days]), with more significantly decreased odds ratios for having examinations in inpatient and outpatient settings versus in the emergency department. Inequities worsened, with patients from communities with high rates of poverty, unemployment, and chronic disease having significantly lower odds of undergoing radiology examinations post-COVID-19 shutdown. Patients of Asian race and Hispanic ethnicity had significantly lower odds ratios for having examinations post-COVID-19 shutdown compared with White and non-Hispanic patients, respectively. DISCUSSION: The COVID-19 pandemic has exacerbated known pre-existing inequities in diagnostic radiology utilization. Resources should be allocated to address subgroups of patients who may be less likely to receive necessary diagnostic radiology examinations, potentially leading to compromised patient safety and quality of care. | |
| 2002 | Cummings 2002 | Disparities in mammography | Disparities in mammography screening in rural areas: analysis of county differences in North Carolina | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Black | Regional | Private Survey | Rural Eastern Carolina Health Survey | The extent to which targeted mammography programs have impacted women in rural areas is not well defined. We investigated mammography screening rates among 843 women age 50 and over from a population-based sample in four predominantly rural eastern North Carolina counties. We examined age, race, education level, county of residence, health insurance, and the self-reported completion of mammography in the past year using contingency tables and logistic regression. African American females aged 65 years or older had the lowest reported mammography rates (42%), while white females aged 50 to 64 had the highest rates (58%). Uninsured women and those with less education were less likely to have received a mammogram. Logistic regression demonstrated that age, education, and health insurance were significant predictors of mammography completion. A county-level analysis revealed that three counties had similar rates and one county had substantially lower rates. A higher-than-expected rate of screening-mammography completion among African American women was noted in one predominantly rural county served by a breast cancer screening program. Logistic regression analysis confirmed that county was a significant predictor for mammography completion. In separate regressions run by race, county remained a significant predictor for African American women but not for white women. Differences in mammography screening appear to persist in some predominantly rural areas and are related to age, race, education, and health insurance. Programs that target hard-to-reach women with efforts tailored specifically to their needs may be effective in reducing persistent racial differences. | |
| 2022 | Adams 2022 | Sociodemographic and Geographic | Sociodemographic and Geographic Factors Associated With Non-Obstetrical Ultrasound Imaging Utilization: A Population-Based Study | All Ages | All Sexes | Outpatient Ambulatory and Primary Care | General Diagnostic Imaging | Canada | Indigenous | Regional | Government Survey | Saskatchewan Personal Health Registration System | OBJECTIVE: Ultrasound is one of the most commonly used imaging modalities, though some populations face barriers in accessing ultrasound services, potentially resulting in disparities in utilization. The objective of this study was to assess the association between sociodemographic and geographic factors and non-obstetrical ultrasound utilization in the province of Saskatchewan, Canada. METHODS: All non-obstetrical ultrasound exams performed from 2014 to 2018 in Saskatchewan, Canada were retrospectively identified from province-wide databases. Univariate and multivariate Poisson regression analyses were performed to assess the association between ultrasound utilization and sex, age, First Nations status, Charlson Comorbidity Index, urban vs. rural residence, geographic remoteness, and neighborhood income. RESULTS: A total of 1,324,846 individuals (5,857,044 person-years)were included in the analysis. Female sex (adjusted incidence rate ratio [aIRR], 2.20; 95% confidence interval [CI], 2.19-2.22), age (aIRR, 4.97; 95% CI, 4.90-5.05 for 57 years vs. <11 years), comorbidities (aIRR, 4.36 for Charlson Comorbidity Index > 10 vs. 0; 95% CI, 3.78-5.03), and higher neighborhood income (aIRR, 1.04; 95% CI, 1.02-1.05 for highest vs. lowest quintile) were associated with higher rates of ultrasound utilization. Individuals who were status First Nations (aIRR, 0.91; 95% CI, 0.90-0.92) or resided in geographically remote areas (aIRR, 0.87 for most vs. least remote; 95% CI, 0.83-0.91) had lower rates of ultrasound utilization. Individuals who lived in a rural area also had lower rates of ultrasound utilization (aIRR, 0.93; 95% CI, 0.92-0.94). CONCLUSION: Substantial disparities exist in non-obstetrical ultrasound utilization among individuals in low-income neighborhoods, status First Nations individuals, and individuals in rural and remote communities. | |
| 2015 | Abdollah 2015 | Racial disparities in end-of-life | Racial disparities in end-of-life care among patients with prostate cancer: a population-based study | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | National | Government Survey | SEER Medicare database | Objective: To examine racial disparities in end-of-life (EOL) care among black and white patients dying of prostate cancer (PCa). Methods: Relying on the SEER-Medicare database, 3789 patients who died of metastatic PCa between 1999 and 2009 were identified. Information was assessed regarding diagnostic care, therapeutic interventions, hospitalizations, intensive care unit (ICU) admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life. Logistic regression tested the relationship between race and the receipt of diagnostic care, therapeutic interventions, and high-intensity EOL care. Results: Overall, 729 patients (19.24%) were black. In the 12-months preceding death, laboratory tests (odds ratio [OR], 0.51; 95% CI, 0.36-0.72), prostate-specific antigen test (OR, 0.54; 95% CI, 0.43-0.67), cystourethroscopy (OR, 0.71; 95% CI, 0.56-0.90), imaging procedure (OR, 0.58; 95% CI, 0.41-0.81), hormonal therapy (OR, 0.53; 95% CI, 0.44-0.65), chemotherapy (OR, 0.59; 95% CI, 0.48-0.72), radiotherapy (OR, 0.74; 95% CI, 0.61-0.90), and office visit (OR, 0.38; 95% CI, 0.28-0.50) were less frequent in black versus white patients. Conversely, high-intensity EOL care, such as ICU admission (OR, 1.27; 95% CI, 1.04-1.58), inpatient admission (OR, 1.49; 95% CI, 1.09-2.05), and cardiopulmonary resuscitation (OR, 1.72; 95% CI, 1.40-2.11), was more frequent in black versus white patients. Similar trends for EOL care were observed at 3-month and 1-month end points. Conclusions: Although diagnostic and therapeutic interventions are less frequent in black patients with end-stage PCa, the rate of high-intensity and aggressive EOL care is higher in these individuals. These disparities may indicate that race plays an important role in the quality of care for men with end-stage PCa. | |
| 2006 | Abraham 2006 | Decrease in racial disparities in | Decrease in racial disparities in the staging evaluation for prostate cancer after publication of staging guidelines | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | National | Government Survey | SEER Medicare database | Purpose: We compared how men with incident prostate cancer were staged before and after the 1995 publication of National Comprehensive Cancer Network, American Urological Association and American College of Radiology staging guidelines, and determined whether there were racial differences in the staging evaluation. Materials and methods: We performed a retrospective cohort study of the use of bone scan and pelvic imaging (pelvic computerized tomography or magnetic resonance imaging) in 96,986 men with incident prostate cancer from 1991 to 1994 compared to 1995 to 1999 from Surveillance, Epidemiology and End Results-Medicare linked data files. Results: During 1991 to 1994 bone scan was done in 83.1% and 73.7% of men who would and would not have met guideline criteria for staging, respectively. From 1995 to 1999 bone scan use decreased slightly in men who met guideline criteria (74.4%) but it decreased substantially in men who did not meet guideline criteria (55.2%). Between 1991 to 1994 and 1995 to 1999 rates of pelvic imaging increased for men who did and decreased for men who did not meet guideline criteria for staging (45.5% to 57.2% and 48.4% to 41.5%, respectively). On multivariate analysis in men who did not meet guideline criteria there was no change in the association between the use of staging tests and race from 1991 to 1994, to 1995 to 1999. However, of men who met guideline criteria for staging black men were less likely to undergo bone scan and less likely to undergo pelvic imaging than white men diagnosed in 1991 to 1994 but this racial difference was not seen during 1995 to 1999. Conclusions: Using a population based cohort this study reveals a decrease in racial disparity and an increase in evidence based use of staging tests in men with incident prostate cancer in the period after the publication of National Comprehensive Cancer Network, American Urological Association and American College of Radiology guidelines. | |
| 2016 | Alanee 2016 | Disparities in long-term | Disparities in long-term radiographic follow-up after cystectomy for bladder cancer: Analysis of the SEER-Medicare database | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | National | Government Survey | SEER Medicare database | Introduction: It is uncertain whether there are disparities related to receiving long-term radiographic follow-up after cystectomy performed for bladder cancer, and whether intensive follow-up influences survival. Materials and Methods: We analyzed 2080 patients treated with cystectomy between 1992 and 2004 isolated from the SEER-Medicare database. The number of abdominal computerized tomography scans performed in patients surviving 2 years after surgery was used as an indicator of long-term radiographic follow-up to exclude patients with early failures. Results: Patients were mainly males (83.18%), had a mean age at diagnosis of 73.4 6.6 (standard deviation) years, and mean survival of 4.6 3.2 years. Multivariate analysis showed age >70 (odds ratio [OR]: 0.796, 95% confidence interval [CI]: 0.651-0.974), African American race (OR: 0.180, 95% CI: 0.081-0.279), and Charlson comorbidity score >2 (OR: 0.694, 95% CI: 0.505-0.954) to be associated with lower odds of long-term radiographic follow-up. Higher disease stage (Stage T4N1) (OR: 1.873, 95% CI: 1.491-2.353), higher quartile for education (OR: 5.203, 95% CI: 1.072-9.350) and higher quartile for income (OR: 6.940, 95% CI: 1.444-12.436) were associated with increased odds of long-term radiographic follow-up. Interestingly, more follow-up with imaging after cystectomy did not improve cancer-specific or overall survival in these patients. Conclusion: There are significant age, race, and socioeconomic disparities in long-term radiographic follow-up after radical cystectomy. However, more radiographic follow-up may not be associated with better survival. | |
| 2011 | Brawarsky 2012 | Use of annual mammography among | Use of annual mammography among older women with ductal carcinoma in situ | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | SEER Medicare database | BACKGROUND: As ductal carcinoma in situ (DCIS) is a risk factor for invasive breast cancer, ongoing annual mammography is important for cancer control, yet little is known about racial/ethnic and other disparities in use among older women with DCIS. METHODS: SEER-Medicare data was used to identify women age 65-85 years, diagnosed with DCIS from 1992 to 2005 and treated with surgery, but not bilateral mastectomy. We examined factors associated with receipt of an initial mammogram within 1 year of treatment and subsequent annual mammograms for 3 and 5 years. We examined whether follow-up care, by a primary care physician or cancer specialist, or neighborhood characteristics mediated disparities in mammography use. RESULTS: Overall, 91.3% of women had an initial mammogram. After adjustment, blacks and Hispanics were less likely than whites to receive an initial mammogram (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.55-0.99 and OR 0.65, CI 0.46-0.93, respectively, as were women of lower socioeconomic status (SES), women who had a mastectomy or breast conserving surgery without radiation therapy, and women who did not have a physician visit. Overall rates of annual mammography decreased over time. Disparities by SES, initial treatment type, and physician visit did not diminish over time. Physician visits had a modest effect on reducing initial racial/ethnic disparities. CONCLUSIONS: Annual mammography among women age 65 to 85 with DCIS declines as women get further from diagnosis. Interventions should focus on reducing disparities in the use of initial surveillance mammography, and increasing surveillance over time. | |
| 2015 | Falchook 2015 | Guideline-discordant use of imaging | Guideline-discordant use of imaging during work-up of newly diagnosed prostate cancer | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | National | Government Survey | SEER Medicare database | Purpose: Overuse of radiographic imaging in patients with prostate cancer (CaP) who are unlikely to have metastatic disease is costly and can lead to patient harm from unnecessary procedures. However, underuse of imaging can lead to undiagnosed metastatic disease, resulting in aggressive treatments in patients with incurable disease. The National Comprehensive Cancer Network (NCCN) recommends bone scans and computed tomography (CT) or magnetic resonance imaging (MRI) during initial work-up of select patients with intermediate- or high-risk CaP. We quantify the proportion of patients who received work-up discordant with NCCN guidelines. Methods: Patients in the SEER-Medicare database diagnosed from 2004 to 2007 were included. We report bone scan and CT/MRI from date of diagnosis to the earlier of first treatment or 6 months. Results: Sixty-five percent of patients for whom bone scan was recommended received it, and 49% received recommended CT/MRI. Further, 43% of patients for whom bone scan was not recommended received it, and 38% received CT/MRI when not recommended. Age and race were significantly associated with discordance on multivariable models. There was significant regional variation. Underuse of recommended bone and CT/MRI scans decreased in more recent years, but overuse of unnecessary CT/MRI increased. Conclusion: There is a high prevalence of both overuse and underuse of guideline-recommended imaging in CaP. Additional research is required to examine contributing factors to guideline nonadherence in the imaging work-up of CaP. | |
| 2019 | Fam 2019 | IncreasingUtilization of | IncreasingUtilization of Multiparametric Magnetic Resonance Imagingin Prostate Cancer Active Surveillance | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | National | Government Survey | SEER Medicare database | Objective: To characterize the use of multiparametric magnetic resonance imaging (mpMRI) in male Medicare beneficiaries electing active surveillance for prostate cancer. mpMRI has emerged as a tool that may improve risk-stratification and decrease repeated biopsies in men electing active surveillance. However, the extent to which mpMRI has been implemented in active surveillance has not been established. Methods: Using Surveillance, Epidemiology, and End Results registry data linked to Medicare claims data, we identified men with localized prostate cancer diagnosed between 2008 and 2013 and managed with active surveillance. We classified men into 2 treatment groups: active surveillance without mpMRI and active surveillance with mpMRI. We then fit a multivariable logistic regression models to examine changing mpMRI utilization over time, and factors associated with the receipt of mpMRI.Results: We identified 9467 men on active surveillance. Of these, 8178 (86%) did not receive mpMRI and 1289 (14%) received mpMRI. The likelihood of receiving mpMRI over the entire study period increased by 3.7% (P = .004). On multivariable logistic regression, patients who were younger, white, had lower comorbidity burden, lived in the northeast and west, had higher incomes and lived in more urban areas had greater odds of receiving mpMRI (all P < .05). Conclusion: From 2008 to 2013, use of mpMRI in active surveillance increased gradually but significantly. Receipt of mpMRI among men on surveillance for prostate cancer varied significantly across demographic, geographic, and socioeconomic strata. Going forward, studies should investigate causes for this variation and define ideal strategies for equitable, cost-effective dissemination of mpMRI technology. | |
| 2022 | Leapman 2022 | Mediators of Racial Disparity in | Mediators of Racial Disparity in the Use of Prostate Magnetic Resonance Imaging Among Patients With Prostate Cancer | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | National | Government Survey | SEER Medicare database | IMPORTANCE: Racial disparity in the use of prostate magnetic resonance imaging (MRI) presents obstacles to closing gaps in prostate cancer diagnosis, treatment, and outcome. OBJECTIVE: To identify clinical, sociodemographic, and structural processes underlying racial disparity in the use of prostate MRI among men with a new diagnosis of prostate cancer. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study used mediation analysis to assess claims in the US Surveillance, Epidemiology, and End Results(SEER)-Medicare database for prostate MRI among 39 534 patients with a diagnosis of localized prostate cancer from January 1, 2011, to December 31, 2015. Statistical analysis was performed from April 1, 2020, to September 1, 2021. EXPOSURE: Diagnosis of prostate cancer. MAIN OUTCOMES AND MEASURES: Claims for prostate MRI within 6 months before or after diagnosis of prostate cancer were assessed. Candidate clinical and sociodemographic meditators were identified based on their association with both race and prostate MRI, including the Index of Concentration at the Extremes (ICE), as specified to measure racialized residential segregation. Mediation analysis was performed using nonlinear multiple additive regression trees models to estimate the direct and indirect effects of mediators. RESULTS: A total of 39 534 eligible male patients (3979 Black patients [10.1%] and 32 585 White patients [82.4%]; mean [SD] age, 72.8 [5.3] years) were identified. Black patients with prostate cancer were less likely than White patients to receive a prostate MRI (6.3% vs 9.9%; unadjusted odds ratio, 0.62, 95% CI, 0.54-0.70). Approximately 24% (95% CI, 14%-32%) of the racial disparity in prostate MRI use between Black and White patients was attributable to geographic differences (SEER registry), 19% (95% CI, 11%-28%) was attributable to neighborhood-level socioeconomic status (residence in a high-poverty area), 19% (95% CI,10%-29%) was attributable to racialized residential segregation (ICE quintile), and 11% (95%CI, 7%-16%) was attributable to a marker of individual-level socioeconomic status (dual eligibility for Medicare and Medicaid). Clinical and pathologic factors were not significant mediators. In this model, the identified mediators accounted for 81% (95% CI, 64%-98%) of the observed racial disparity in prostate MRI use between Black and White patients. CONCLUSIONS AND RELEVANCE: In this this population-based cohort study of US adults, mediation analysis revealed that sociodemographic factors and manifestations of structural racism, including poverty and residential segregation, explained most of the racial disparity in the use of prostate MRI among older Black and White men with prostate cancer. These findings can be applied to develop targeted strategies to improve cancer care equity. | |
| 2012 | Makarov 2012 | The population level prevalence and | The population level prevalence and correlates of appropriate and inappropriate imaging to stage incident prostate cancer in themedicarepopulation | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | National | Government Survey | SEER Medicare database | Purpose: According to guidelines most men with incident prostate cancer do not require staging imaging. We determined the population level prevalence and correlates of appropriate and inappropriate imaging in this cohort. Materials and methods: We performed a cross-sectional study of men 66 to 85 years old who were diagnosed with prostate cancer in 2004 and 2005 from the SEER (Surveillance, Epidemiology and End Results)-Medicare database. Low risk (no prostate specific antigen greater than 10 ng/ml, Gleason score greater than 7 or clinical stage greater than T2) and high risk (1 or more of those features) groups were formed. Inappropriate imaging was defined as any imaging for men at low risk and appropriate imaging was defined as bone scan for men at high risk as well as pelvic imaging as appropriate. Logistic regression modeled imaging in each group. Results: Of 18,491 men at low risk 45% received inappropriate imaging while only 66% of 10,562 at high risk received appropriate imaging. For patients at low risk inappropriate imaging was associated with increasing clinical stage (T2 vs T1 OR 1.35, 95% CI 1.27-1.44), higher Gleason score (7 vs less than 7 OR 1.80, 95% CI 1.69-1.92), increasing age and comorbidity as well as decreasing education. Appropriate imaging for men at high risk was associated with lower stage (T4, T3 and T2 vs T1 OR 0.63, 95% CI 0.48-0.82, OR 0.67, 95% CI 0.60-0.80 and OR 0.87, 95% CI 0.80-0.86) and with higher Gleason score (greater than 8 and 7 vs less than 7 OR 2.18, 95% CI 1.92-2.48 and 1.51, 95% CI 1.35-1.70, respectively) as well as with younger age, white race, higher income, lower stage and more comorbidity. Conclusions: We found poor adherence to imaging guidelines for men with incident prostate cancer. Understanding the patterns by which clinicians use imaging for prostate cancer should guide educational efforts as well as research to suggest evidence-based guideline improvements. | |
| 2017 | Martin 2017 | Racial disparities in the | Racial disparities in the utilization of preventive health services among older women with early-stage endometrial cancer enrolled in Medicare | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | National | Government Survey | SEER Medicare database | To assess differences in the receipt of preventive health services by race/ethnicity among older women with endometrial cancer enrolled in Medicare, we conducted a retrospective population-based cohort study of women diagnosed with endometrial cancer from 2001 to 2011 in the Surveillance Epidemiology and End Results (SEER)-Medicare database. Women with stage I or II endometrial cancer of epithelial origin were included. The exposure was race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, and NH Asian/Pacific Islander [PI]). The services examined were receipt of influenza vaccination and screening tests for diabetes mellitus, hyperlipidemia, and breast cancer. We used multivariate logistic regression to estimate odds ratios with 95% confidence intervals (CI) adjusted for age, region, and year of diagnosis. A total of 13,054 women were included. In the 2 years after diagnosis, receipt of any influenza vaccine ranged from 45% among NH Black women to 67% among NH White women; receipt of a mammogram ranged from 65% among NH Black women to 74% among NH White women. Relative to NH White women, NH Black women had a lower likelihood of receiving both influenza vaccination (adjusted odds ratio [aOR] 0.40, 95% CI 0.33-0.44) and screening mammography (aOR 0.64, 95% CI 0.52-0.79). Hispanic women also were less likely to receive influenza vaccination than NH White women (aOR 0.61, 95% CI 0.51-0.72). There were no significant differences across racial groups for diabetes or cholesterol screening services. Among older women with early-stage endometrial cancer, racial disparities exist in the utilization of some preventive services. | |
| 2020 | Morgan 2020 | Ethnic Disparities in Imaging | Ethnic Disparities in Imaging Utilization at Diagnosis of Non-Small Cell Lung Cancer | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | National | Government Survey | SEER Medicare database | Background: Prior research demonstrated statistically significant racial disparities related to lung cancer treatment and outcomes. We examined differences in initial imaging and survival between blacks, Hispanics, and non-Hispanic whites. Methods: The linked Surveillance, Epidemiology, and End Results-Medicare database between 2007 and 2015 was used to compare initial imaging modality for patients with lung cancer. Participants included 28 881 non-Hispanic whites, 3123 black, and 1907 Hispanics, patients age 66 years and older who were enrolled in Medicare fee-for-service and diagnosed with lung cancer. The primary outcome was comparison of positron emission tomography (PET) imaging with computerized tomography (CT) imaging use between groups. A secondary outcome was 12-month cancer-specific survival. Information on stage, treatment, and treatment facility was included in the analysis. Chi-square test and logistic regression were used to evaluate factors associated with imaging use. Kaplan-Meier method and Cox proportional hazards regression were used to calculate adjusted hazard ratios and survival. All statistical tests were two-sided. Results: After adjusting for demographic, community, and facility characteristics, blacks were less likely to undergo PET or CT imaging at diagnosis compared with non-Hispanic whites odds ratio (OR) = 0.54 (95% confidence interval [CI] = 0.50 to 0.59; P <. 001). Hispanics were also less likely to receive PET with CT imaging (OR = 0.72, 95% CI = 0.65 to 0.81; P <. 001). PET with CT was associated with improved survival (HR = 0.61, 95% CI = 0.57 to 0.65; P <. 001). Conclusions: Blacks and Hispanics are less likely to undergo guideline-recommended PET with CT imaging at diagnosis of lung cancer, which may partially explain differences in survival. Awareness of this issue will allow for future interventions aimed at reducing this disparity. | |
| 2011 | Prasad 2011 | Inappropriate utilization of | Inappropriate utilization of radiographic imaging in men with newly diagnosed prostate cancer in the United States | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | National | Government Survey | SEER Medicare database | Background: The use of radiographic imaging (bone scan and computerized tomography) is only recommended for men diagnosed with high-risk prostate cancer characteristics. The authors sought to characterize utilization patterns of imaging in men with newly diagnosed prostate cancer. Methods: The authors performed a population-based observational cohort study using the US Surveillance, Epidemiology, and End Results-Medicare linked data to identify 30,183 men diagnosed with prostate cancer during 2004 to 2005. Results: Thirty-four percent of men with low-risk and 48% with intermediate-risk prostate cancer underwent imaging, whereas only 60% of men with high-risk disease received imaging before treatment. Radiographic imaging utilization was greater for men who were older than 75 years (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.20-1.37; P < .001), were black (OR, 1.11; 95% CI, 1.01-1.21; P = .030), resided in wealthier areas (OR, 1.19; 95% CI, 1.08-1.32 for median income >$60,000 vs <$35,000; P < .001), lived in rural regions (OR, 1.23; 95% CI, 1.12-1.36; P < .001), or underwent standard radiation therapies (OR, 1.71; 95% CI, 1.60-1.84; P < .001). Imaging utilization was less for men living in areas with greater high school education (OR, 0.83; 95% CI, 0.75-0.91 between highest and lowest graduation rates; P < .001) or opting for active surveillance (OR, 0.17; 95% CI, 0.15-0.19 vs radical prostatectomy; P < .001). The estimated cost of unnecessary imaging over this 2-year period exceeded $3.6 million. Conclusions: In the United States, there is widespread overutilization of imaging for low-risk and intermediate-risk prostate cancer, whereas a worrisome number of men with high-risk disease did not receive appropriate imaging studies to exclude metastases before therapy. | |
| 2021 | Quinn 2021 | Disparities in magnetic resonance | Disparities in magnetic resonance imaging of the prostate for traditionally underserved patients with prostate cancer | Adult Only | Male | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | National | Government Survey | SEER Medicare database | BACKGROUND: Prebiopsy magnetic resonance imaging (MRI) of the prostate improves detection of significant tumors, while decreasing detection of less-aggressive tumors. Therefore, its use has been increasing over time. In this study, the use of prebiopsy MRI among Medicare beneficiaries with prostate cancer was examined. It was hypothesized that patients of color and those in isolated areas would be less likely to undergo this approach for cancer detection. METHODS: Using cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked to billing claims for fee-for-service Medicare beneficiaries, men with nonmetastatic prostate cancer were identified from 2010 through 2015 with prostate-specific antigen (PSA) <30 ng/mL. Outcome was prebiopsy MRI of the prostate performed within 6 months before diagnosis (ie, Current Procedural Terminology 72197). Exposures were patient race/ethnicity and rural/urban status. Multivariable regression estimated the odds of prebiopsy prostate MRI. Post hoc analyses examined associations with the registry-level proportion of non-Hispanic Black patients and MRI use, as well as disparities in MRI use in registries with data on more frequent use of prostate MRI. RESULTS: There were 50,719 men identified with prostate cancer (mean age, 72.1 years). Overall, 964 men (1.9% of cohort) had a prebiopsy MRI. Eighty percent of patients with prebiopsy MRI lived in California, New Jersey, or Connecticut. Non-Hispanic Black men (0.6% vs 2.1% non-Hispanic White; odds ratio [OR], 0.28; 95% CI, 0.19-0.40) and men in less urban areas (1.1% vs 2.2% large metro; OR, 0.65; 95% CI, 0.44-0.97) were less likely to have prebiopsy MRI of the prostate. CONCLUSIONS: Non-Hispanic Black patients with prostate cancer and those in less urban areas were less likely to have prebiopsy MRI of the prostate during its initial adoption as a tool for improving prostate cancer detection. | |
| 2021 | Sanchez 2021 | Disparities in post-operative | Disparities in post-operative surveillance testing for metastatic recurrence among colorectal cancer survivors | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | National | Government Survey | SEER Medicare database | PURPOSE: Among colorectal cancer (CRC) survivors, treatment for metastatic recurrence is most effective when malignancies are detected early through surveillance with carcinoembryonic antigen (CEA) level test and computer tomography (CT) imaging. However, utilization of these tests is low, and many survivors fail to meet the recommended guidelines. This population-based study assesses individual- and neighborhood-level factors associated with receipt of CEA and CT surveillance testing. METHODS: We used the Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify Medicare beneficiaries diagnosed with CRC stages II-III between 2010 and 2013. We conducted multivariate logistic regression to estimate the effect of individual and neighborhood factors on receipt of CEA and CT tests within 18 months post-surgery. RESULTS: Overall, 78% and 58% of CRC survivors received CEA and CT testing, respectively. We found significant within racial/ethnic differences in receipt of these surveillance tests. Medicare-Medicaid dual coverage was associated with 39% lower odds of receipt of CEA tests among non-Hispanic Whites, and Blacks with dual coverage had almost two times the odds of receiving CEA tests compared to Blacks without dual coverage. CONCLUSIONS: Although this study did not find significant differences in receipt of initial CEA and CT surveillance testing across racial/ethnic groups, the assessment of the factors that measure access to care suggests differences in access to these procedures within racial/ethnic groups. IMPLICATIONS FOR CANCER SURVIVORS: Our findings have implications for developing targeted interventions focused on promoting surveillance for the early detection of metastatic recurrence among colorectal cancer survivors and improve their health outcomes. | |
| 2011 | Sommer 2011 | Breast MRI utilization in older | Breast MRI utilization in older patients with newly diagnosed breast cancer | Adult Only | Female | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Multiple Groups | National | Government Survey | SEER Medicare database | Background: Recently, use of advanced imaging modalities, such as MRI, has increased dramatically. One novel but still evolving use for MRI is in the diagnosis and clinical staging of newly diagnosed breast cancer patients. Compared with mammography, MRI is more sensitive, but less specific, and far more expensive. The purpose of this study is to examine the prevalence and predictors of MRI use for clinical staging in older women with newly diagnosed breast cancer. Materials and methods: SEER-Medicare data were used to identify incident breast cancer cases between 2003 and 2005. Outpatient Medicare claims data were queried for receipt of breast MRI. Multivariate logistic regression analyses were performed to examine associations between receiving MRI and patient demographics, clinical characteristics, and SEER region. Results: A total of 46,824 patients with breast cancer met inclusion criteria. MRI use increased from 3.9% of women diagnosed in 2003 to 10.1% of women diagnosed in 2005. In the bivariate analyses race, urban/rural location, SEER region, poverty level, education level, stage, surgery type, and tumor size were all significantly associated with receipt of MRI. In the multivariate analysis, those who were younger, white, living in more metropolitan areas, and living in wealthier areas were more likely to receive MRI. There was substantial variability in odds of MRI among different SEER regions. Conclusions: Breast MRI for patients with newly diagnosed breast cancer in the SEER-Medicare population is increasingly common. Ongoing examination of the dissemination of technology is critical to understanding current practice patterns and to the development and implementation of future guidelines. | |
| 2019 | Teysir 2019 | Racial disparities in surveillance | Racial disparities in surveillance mammography among older breast cancer survivors | Adult Only | Female | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | National | Medicare Data | SEER Medicare database | Background: Despite lower incidence rates among black women and a national decline in breast cancer (BC) deaths, there is a widening gap in BC mortality rates between black and white women in the United States. A previous study evaluating data from 1992 to 1999 found a racial disparity in the receipt of surveillance mammography. We sought to evaluate whether this disparity persists between black and white women diagnosed with BC between 2000 and 2011. Methods: Using the SEER-Medicare registry, we conducted an analysis of women 66years diagnosed with early-stage (0-III) BC between 2000 and 2011 who underwent BC surgery. The primary outcome was receipt of surveillance mammography within 12 months of surgery. Chi square analyses were used to compare characteristics between black and white women. Multivariate logistic regression was used to assess receipt of surveillance mammography after controlling for potential confounders. Results: There were 3353 black and 40,564 white women in the final cohort. After adjusting for confounders, black women were still 24% less likely than white women to receive surveillance mammography (Odds ratio 0.76, 95% CI 0.70-0.0.82). Those who were married, younger, in the highest income quartile, diagnosed at earlier stages, had a lower comorbidity score, or who resided in metropolitan areas were more likely to receive surveillance mammography (p < 0.05). Conclusion(s): We found that older black BC survivors continue to experience lower rates of surveillance mammography, even after adjusting for multiple potential confounders. There remains a need to investigate which individual and systemic factors affect disparities in breast cancer care. | |
| 2022 | Talham 2022 | Breast cancer screening among | Breast cancer screening among Hispanic and non-Hispanic White women by birthplace in the Sister Study | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Hispanic | National | Private Survey | Sister Study | BACKGROUND: Hispanic/Latina women are less likely to be diagnosed with local stage breast cancer than White women. Additionally, foreign-born women have lower mammography rates than US-born women. We evaluated the combined effect of birthplace and race/ethnicity on screening habits of women at higher-than-average risk of breast cancer. METHODS: Multinomial logistic regression was used to evaluate breast cancer screening in 44,524 women in the Sister Study cohort. Screening methods ascertained at enrollment (2003-2009) included mammography, ultrasound, and magnetic resonance imaging. Timing of screening was assessed as recently (2 years ago), formerly (>2 years ago), and never screened. Adjustments included sociodemographic, socioeconomic, and health variables. RESULTS: Most women in the sample were US-born non-Hispanic/Latina White (92%), were 50 years old (73%), had one first-degree female relative with breast cancer (73%), and were screened in the past two years (97%). US-born Hispanic/Latina women had higher odds (odds ratio [OR] = 1.47, 95% confidence interval [CI] = 1.08-2.00) than US-born non-Hispanic/Latina White women of not having received a breast cancer screening in the past 2 years, relative to a recent screening. Similarly, foreign-born Hispanic/Latina women had higher odds (OR = 1.63, 95% CI = 1.10-2.41) than US-born non-Hispanic/Latina White women of never having received a breast cancer screening. CONCLUSION: We observed that Hispanic/Latina women have higher odds of never and dated breast cancer screenings compared to US-born White women. Birthplace and race/ethnicity each contribute to disparities in who receives preventative health care in the United States. It is critical to include birthplace when evaluating health behaviors in minority groups. | |
| 2016 | Gibbons 2016 | Determining the spatial | Determining the spatial heterogeneity underlying racial and ethnic differences in timely mammography screening | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | Regional | Private Survey | Southeastern Household Health Survey | BACKGROUND: The leading cause of cancer death for women worldwide continues to be breast cancer. Early detection through timely mammography has been recognized to increase the probability of survival. While mammography rates have risen for many women in recent years, disparities in screening along racial/ethnic lines persist across nations. In this paper, we argue that the role of local context, as identified through spatial heterogeneity, is an unexplored dynamic which explains some of the gaps in mammography utilization by race/ethnicity. METHODS: We apply geographically weighted regression methods to responses from the 2008 Public Health Corporations' Southeastern Household Health Survey, to examine the spatial heterogeneity in mammograms in the Philadelphia metropolitan area. RESULTS: We find first aspatially that minority identity, in fact, increases the odds of a timely mammogram: 74% for non-Hispanic Blacks and 80% for Hispanic/Latinas. However, the geographically weighted regression confirms the relation of race/ethnicity to mammograms varies by space. Notably, the coefficients for Hispanic/Latinas are only significant in portions of the region. In other words, the increased odds of a timely mammography we found are not constant spatially. Other key variables that are known to influence timely screening, such as the source of healthcare and social capital, measured as community connection, also vary by space. CONCLUSIONS: These results have ramifications globally, demonstrating that the influence of individual characteristics which motivate, or inhibit, cancer screening may not be constant across space. This inconsistency calls for healthcare practitioners and outreach services to be mindful of the local context in their planning and resource allocation efforts. | |
| 2017 | Ark 2017 | Variation in the Diagnostic | Variation in the Diagnostic Evaluation among Persons with Hematuria: Influence of Gender, Race and Risk Factors for Bladder Cancer | Adult Only | All Sexes | Outpatient Ambulatory and Primary Care | Cancer Care | United States | Black | Regional | Private Survey | Southern Community Cohort Study | Purpose: We sought to determine whether race, gender and number of bladder cancer risk factors are significant predictors of hematuria evaluation. Materials and Methods: We used self-reported data from SCCS (Southern Community Cohort Study) linked to Medicare claims data. Evaluation of subjects diagnosed with incident hematuria was considered complete if imaging and cystoscopy were performed within 180 days of diagnosis. Exposures of interest were race, gender and risk factors for bladder cancer. Results: Of the 1,412 patients evaluation was complete in 261 (18%). On our adjusted analyses African American patients were less likely than Caucasian patients to undergo any aspect of evaluation, including urology referral (OR 0.72, 95% CI 0.56-0.93), cystoscopy (OR 0.67, 95% CI 0.50-0.89) and imaging (OR 0.75, 95% CI 0.59-0.95). Women were less likely than men to be referred to a urologist (OR 0.59, 95% CI 0.46-0.76). Also, although all patients with 2 or 3 risk factors had 31% higher odds of urology referral (OR 1.31, 95% CI 1.02-1.69), adjusted analyses indicated that this effect was only apparent among men. Conclusions: Only 18% of patients with an incident hematuria diagnosis underwent complete hematuria evaluation. Gender had a substantial effect on referral to urology when controlling for socioeconomic factors but otherwise it had an unclear role on the quality of evaluation. African American patients had markedly lower rates of thorough evaluation than Caucasian patients. Number of risk factors predicted referral to urology among men but it was otherwise a poor predictor of evaluation. There is opportunity for improvement by increasing the completion of hematuria evaluations, particularly in patients at high risk and those who are vulnerable. | |
| 2010 | Carrasco-Garrido 2011 | Health status of Roma women in | Health status of Roma women in Spain | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Spain | Indigenous | National | Government Survey | Spanish National Health Survey | BACKGROUND: The objective of the present study is to describe the health status of Roma women in Spain. Population-based health data have become available for this group, and we can now identify differences with non-Roma women. METHODS: Cross-sectional, epidemiological study from the 2006 Spanish National Health Survey and the first National Health Survey in the Romany population (2006). We analyzed 527 Spanish Roma women aged 16 years and over and 1054 Spanish non-Roma women, age and region matched. RESULTS: Our sample comprised 527 Spanish Roma women and 1054 Spanish non-Roma women. Roma women are more likely to suffer from obesity [odds ratio (OR) 1.91; 95% confidence interval (CI) 1.05-3.50], depression and migraine. Roma women have significantly higher values for alcohol consumption than non-Roma women (OR, 3.77; 95% CI, 2.32-6.13). The percentage of Roma women, who have had a smear test and a mammography, is significantly lower than that of non-Roma women. CONCLUSIONS: Our comparison showed that Spanish Roma women have a poorer health profile, worse lifestyles and more inequality in the use of health-care resources than non-Roma women, especially with respect to prevention. | |
| 2011 | Sanz-Barbero 2011 | Impact of geographic origin on | Impact of geographic origin on gynecological cancer screening in Spain | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | Spain | Multiple Groups | National | Government Survey | Spanish National Health Survey | Objective: To assess the association between geographic origin and the use of screening cervical smears and mammograms. Methods: Data was obtained from the 2006 Spanish National Health Survey that included 13,422 females over 16 years of age. The dependent variable was use of screening mammograms and cervical smears in the past 12 months. The measure of association (odds ratio and its related 95% confi dence interval) was estimated using logistic regression. Results: African women were 0.36 (95% CI 0.21, 0.62), Eastern European 0.40 (95%CI 0.22; 0.74), Western European, American and Canadian 0.60 (95%CI 0.43, 0.84), and Central and South American 0.64 times (95%CI 0.52, 0.81) less likely to undergo a mammogram compared with the general population of Spain. In regard to cervical cancer screening, Eastern European women were 0.38 (95%CI 0.28, 0.50), African 0.47 (95%CI 0.33, 0.67) and Western European, American and Canadian 0.61 times (95%CI 0.46, 0.81) less likely to undergo cervical smears. These associations were independent of age, socioeconomic condition, health status and health insurance coverage. Conclusions: Immigrant women use less screening programs than native Spanish women. This finding may suggest difficult access to prevention programs. | |
| 2018 | Jones 2018 | Surveillance for cancer recurrence | Surveillance for cancer recurrence in long-term young breast cancer survivors randomly selected from a statewide cancer registry | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Black | State | Disease Registry | State cancer registry | Purpose: This study examined clinical breast exam (CBE) and mammography surveillance in long-term young breast cancer survivors (YBCS) and identified barriers and facilitators to cancer surveillance practices. Methods: Data collected with a self-administered survey from a statewide, randomly selected sample of YBCS diagnosed with invasive breast cancer or ductal carcinoma in situ younger than 45years old, stratified by race (Black vs. White/Other). Multivariate logistic regression models identified predictors of annual CBEs and mammograms. Results: Among 859 YBCS (n=340 Black; n=519 White/Other; mean age= 51.0 5.9; diagnosed 11.0 4.0years ago), the majority (>85%) reported an annual CBE and a mammogram. Black YBCS in the study were more likely to report lower rates of annual mammography and more barriers accessing care compared to White/Other YBCS. Having a routine source of care, confidence to use healthcare services, perceived expectations from family members and healthcare providers to engage in cancer surveillance, and motivation to comply with these expectations were significant predictors of having annual CBEs and annual mammograms. Cost-related lack of access to care was a significant barrier to annual mammograms. Conclusions: Routine source of post-treatment care facilitated breast cancer surveillance above national average rates. Persistent disparities regarding access to mammography surveillance were identified for Black YBCS, primarily due to lack of access to routine source of care and high out-of-pocket costs. Implications: Public health action targeting cancer surveillance in YBCS should ensure routine source of post-treatment care and address cost-related barriers. Clinical Trials Registration Number: NCT01612338. | |
| 2002 | Elixhauser 2002 | Differences between Hispanics and | Differences between Hispanics and non-Hispanic Whites in use of hospital procedures for cerebrovascular disease | Adult Only | All Sexes | Inpatient General Care | Stroke Imaging | United States | Hispanic | Multi-Institution | EHR | State inpatient databases | OBJECTIVE: This study examined disparities in the use of in-hospital diagnostic and therapeutic procedures for Hispanics with cerebrovascular disease compared to their non-Hispanic White counterparts. DESIGN: This is a cross-sectional study using 1996 hospital administrative data. METHODS: Hispanics and non-Hispanic Whites with diagnosis codes indicating occlusion or stenosis of precerebral arteries or transient cerebral ischemia were included, with a total of 18,674 New York patients (5.1% Hispanic) and 22,624 California patients (11.1% Hispanic). Adjusted odds ratios compared Hispanics with non-Hispanic Whites for six diagnostic and therapeutic procedures for cerebrovascular disease, controlling for patient and hospital characteristics. RESULTS: Hispanics had higher rates of non-invasive diagnostic procedures (head CT scan, head/neck diagnostic ultrasound, echocardiogram, and head MRI). The odds of invasive diagnostic testing (cerebral arteriogram) and therapeutic procedures (carotid endarterectomy) were lower for Hispanics. Most findings remained unchanged in logistic regression models with patient and hospital characteristics. Adding a measure of the concentration of Hispanic patients by hospital eliminated or reduced observed differences between Hispanics and Whites. CONCLUSIONS: Controlling for each hospital's experience with Hispanic patients eliminated or reduced the magnitude of the disparities in procedure use, suggesting that the concentration of Hispanic patients in a hospital is associated with different patterns of procedure use. | |
| 2002 | Strzelczyk 2002 | Disparities in adherence to | Disparities in adherence to recommended followup on screening mammography: interaction of sociodemographic factors | Adult Only | Female | Outpatient Ambulatory and Primary Care | Breast Cancer Screening | United States | Multiple Groups | State | Disease Registry | State registry | OBJECTIVE: The objective of this study was to examine disparities in adherence to screening mammography and, specifically, to investigate whether race/ethnicity, education, age, health insurance, and family history of breast cancer (FHBC), as unique factors and in interactions, influence adherence to recommended follow up on screening mammography. DESIGN: The study involved retrieval and analyses of data collected by the Colorado Mammography Project (CMAP) for 167,232 diverse (82.8% White, 3.4% Black, 11% Hispanic, 1.6% Asian, 0.6% Native American, and 0.6% "other") screening participants during the 1990-1997 study period. METHODS: Subjects' first mammograms captured by CMAP were tracked in the database to identify women who received follow-up recommendations, women who adhered within 12 months and those that did not. Analyses included comparisons of adherence rates among women with various sociodemographic characteristics. RESULTS: Of the 17,358 women who received follow-up recommendations, 80.7% adhered. Overall, non-White women in each of the racial/ethnic groups were less likely to adhere to recommendations than were White women (P<.05). Also less likely to adhere were the younger, less educated, uninsured/underinsured, and women who reported not having FHBC. CONCLUSION: Race/ethnicity appeared to interact with age, education, health insurance, and FHBC to influence the probability of adherence, suggesting the need to explore further cultural, psychosocial, and situational factors. | |
| 2022 | Wang 2022 | Striving for Socioeconomic Equity | Striving for Socioeconomic Equity in Ischemic Stroke Care: Imaging and Acute Treatment Utilization From a Comprehensive Stroke Center | Adult Only | All Sexes | Inpatient and Outpatient | Stroke Imaging | United States | Multiple Groups | Single Institution | Disease Registry | Stroke Health Outcomes database | PURPOSE: Prior studies have shown socioeconomic disparities in advanced neuroimaging and acute treatment utilization in patients with ischemic stroke. The authors analyzed whether socioeconomic factors were associated with stroke neuroimaging and acute treatment utilization at a comprehensive stroke center. METHODS: A retrospective study of consecutive acute ischemic stroke discharges from 2012 to 2020 at a comprehensive stroke center was performed. Differences in neuroimaging (CT angiography [CTA], CT perfusion, MRI, and MR angiography [MRA]) and acute treatment (intravenous thrombolysis [IVT] and endovascular thrombectomy [EVT]) utilization were evaluated on the basis of socioeconomic factors of age, sex, race, insurance type, and neighborhood-level median household income. Chi-square tests were used for bivariate analyses. Multivariable logistic regression analyses were performed to determine associations between socioeconomic factors and neuroimaging or treatment utilization while controlling for stroke-specific factors and comorbidities. RESULTS: Among 6,140 ischemic stroke discharges, race and insurance type were not significantly associated with lower utilization of neuroimaging (CTA, CT perfusion, MRI, and MRA) or acute stroke treatment (IVT and EVT) after controlling for stroke-specific factors and comorbidities. However, median household income < $80,000/year was associated with lower IVT use (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.63-0.87). In addition, age 80 years had lower CTA (OR, 0.62; 95% CI, 0.51-0.75) and EVT (OR, 0.53; 95% CI, 0.39-0.73) utilization, and female sex had lower CTA (OR, 0.78; 95% CI, 0.65-0.93) utilization. Significantly higher utilization was observed for MRI in Asian (OR, 1.33; 95% CI, 1.04-1.69) and uninsured (OR, 1.64; 95% CI, 1.07-2.50) patients and for MRA (OR, 1.24; 95% CI, 1.04-1.49) and EVT (OR, 1.62; 95% CI, 1.20-2.20) in privately insured patients. CONCLUSIONS: Once access to a comprehensive stroke center is achieved, socioeconomic disparities in the utilization of health care resources, particularly advanced neuroimaging and acute treatment, may be improved in patients with ischemic stroke. | |
| 2013 | Valet 2013 | Increased healthcare resource | Increased healthcare resource utilization for acute respiratory illness among Latino infants | Pediatric Only | All Sexes | Inpatient and Outpatient | General Diagnostic Imaging | United States | Multiple Groups | Single Institution | Disease Registry | Tennessee Childrens Respiratory Initiative | Objective: To examine healthcare resource utilization for acute respiratory illness in Latino infants compared with other racial/ethnic groups. Study design: We studied 674 term-born, previously healthy infants brought in for an unscheduled healthcare visit for an acute respiratory illness. The predictor variable was infant race/ethnicity, and the primary outcome was healthcare resource utilization, adjusted for age and disease severity. Results: The cohort was 14% Latino, 52% white, 22% African American, and 12% other race/ethnicity. More than one-third (37%) of the mothers of Latino infants were Spanish-speaking. The bronchiolitis severity score was higher (indicating more severe disease) in white infants (median, 6.0; IQR, 3.0-9.0 on a scale of 0-12) compared with Latino (median, 3.0; IQR, 1.0-6.0) and African American (median, 3.5; IQR, 1.0-6.0) infants (P <.001 for the comparison of all groups). Disease severity was similar in Latino and African American infants (P =.96). Latino infants were the most likely to receive antibiotics (58%, compared with 47% of whites and 34% of African Americans; P =.005) and to have body fluid cultures drawn. Latino infants also were more likely than African American infants to undergo chest radiography and respiratory virus rapid antigen testing (P .01). Latino infants from Spanish-speaking families had a higher rate of respiratory syncytial virus testing compared with those from English-speaking families (76% vs 51%; P =.016). Conclusion: Providers caring for Latino infants with acute respiratory illness ordered more antibiotics and diagnostic testing for this group, particularly compared with African Americans, even though the 2 groups had similar disease severity and socioeconomic disparities. Language barrier may be a possible explanation for these differences. | |
| 2002 | Goldstein 2003 | Veterans Administration Acute | Veterans Administration Acute Stroke (VAST) study: Lack of race/ethnic-based differences in utilization of stroke-related procedures or services | Adult Only | All Sexes | Inpatient General Care | Stroke Imaging | United States | Multiple Groups | Multi-Institution | Disease Registry | Veterans Administration Acute Stroke Study | Background and Purpose - Race/ethnic-based disparities in the utilization of health-related services have been reported. Data collected as part of the Veterans Administration Acute Stroke Study (VASt) were analyzed to determine whether similar differences were present in patients admitted to Veterans Administration (VA) hospitals with acute ischemic stroke. Methods - VASt prospectively identified stroke patients admitted to 9 geographically separated VA hospitals between April 1995 and March 1997. Demographic characteristics and all inpatient diagnostic tests/procedures were recorded. Frequencies were compared with X2 tests. Results - Of 1073 enrolled patients, 775 (white, n=520; nonwhite, n=255, including 226 blacks and 28 Hispanic-Americans) with ischemic stroke were admitted from home. Mean ages (71.0 0.6 versus 71.9 0.4 years; P=0.25) and Trial of ORG 10172 in Acute Stroke Treatment (TOAST) stroke types (atherothrombotic, 12.9% versus 13.3%; cardioembolic, 16.5% versus 18.0%; lacunar, 26.4% versus 27.1%; other, 1.4% versus 2.0%; unclassified, 42.9% versus 39.6%; P=0.89) for whites versus nonwhites were similar. There were no race/ethnic-based differences in the utilization of brain CT (91.0% versus 92.2%; P=0.58), MRI (36.2% versus 41.6%; P=0.14), transthoracic (52.5% versus 53.7%; P=0.75) or transesophageal echocardiography (10.2% versus 10.6%; P=0.86), 24-hour ECG (3.3% versus 1.6%; P=0.17), carotid ultrasound (64.0% versus 62.0%; P=0.57), carotid endarterectomy (1.5% versus 0.8%; P=0.38), rehabilitation evaluations (71.0% versus 76.5%; P=0.11), speech therapy (9.6% versus 12.6%; P=0.21), recreational therapy (3.1% versus 2.0%; P=0.37), or occupational therapy (16.0% versus 19.6%; P=0.20) for whites versus nonwhites, respectively. Angiography was performed less frequently (3.1% versus 8.5%; P=0.01) and ECG more frequently (81.6% versus 73.5%; P=0.01) in nonwhites. The proportions of patients discharged functionally independent were also similar (52% of whites and 50% of nonwhites had discharge Rankin Scale scores of 0, 1, or 2; P=0.63). Conclusions - Aside from cerebral angiography and ECG, there were no race/ethnic-based disparities in the utilization of a variety of stroke-related procedures and services. The difference in the use of angiography is unlikely to be related to a difference in screening for carotid endarterectomy because there was no difference in the frequency of carotid ultrasonography. The reason ECG was obtained more frequently in nonwhites is uncertain. |