Dataset Information

Prevalence of advanced colorectal neoplasia in white and black patients undergoing screening colonoscopy in a safety-net hospital.

ABSTRACT: Chinese translationBlack persons are more likely than white persons to be diagnosed with colorectal cancer and to die from it. The extent to which genetic or biological factors versus disparities in screening rates explain this variance remains controversial.To define the prevalence and location of presymptomatic advanced colorectal neoplasia (ACN) among white and black persons undergoing screening colonoscopy, controlling for other epidemiologic risk factors.Cross-sectional survey between 22 March 2005 and 31 January 2012.Urban, open-access, academic, safety-net hospital in Massachusetts.Asymptomatic, average-risk white (n = 1172) and black (n = 1681) persons aged 50 to 79 years undergoing screening colonoscopy.Adjusted prevalence and location of ACN, defined as a tubular adenoma 10 mm or more in size, any adenoma with villous features or high-grade dysplasia, any dysplastic serrated lesion, or invasive cancer.The prevalence of ACN was higher among white patients than black patients (6.8% vs. 5.0%; P = 0.039) but varied by sex (white vs. black men, 9.3% vs. 5.7%; white vs. black women, 3.5% vs. 4.3%; interaction P = 0.034). After controlling for many risk factors, black men were 41% less likely than white men (adjusted odds ratio [AOR], 0.59 [95% CI, 0.39 to 0.89]) to have ACN. No statistically significant difference was seen for women (AOR, 1.32 [CI, 0.73 to 2.40]). Black patients with ACN had a higher percentage of proximal disease (52% vs. 39%) after adjustment for age and sex (P = 0.055).Single-institution study with inadequate statistical power for subgroup analyses and recall bias.Black men are less likely than white men to have ACN at screening colonoscopy in a safety-net health care setting. Disparities in access to screening and differential exposure to modifiable risk factors rather than genetic or biological factors may be largely responsible for the higher incidence of CRC among black men. Genetic or biological factors may explain the predilection for proximal disease.

SUBMITTER: Schroy PC

PROVIDER: S-EPMC4218749 | biostudies-other | 2013 Jul

REPOSITORIES: biostudies-other

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Prevalence of advanced colorectal neoplasia in white and black patients undergoing screening colonoscopy in a safety-net hospital.

Schroy Paul C PC Coe Alison A Chen Clara A CA O'Brien Michael J MJ Heeren Timothy C TC

Annals of internal medicine 20130701 1

<h4>Unlabelled</h4>Chinese translation<h4>Background</h4>Black persons are more likely than white persons to be diagnosed with colorectal cancer and to die from it. The extent to which genetic or biological factors versus disparities in screening rates explain this variance remains controversial.<h4>Objective</h4>To define the prevalence and location of presymptomatic advanced colorectal neoplasia (ACN) among white and black persons undergoing screening colonoscopy, controlling for other epidemi ...[more]

PMID: 23817700

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Project description:BackgroundAdapting screening strategy to colorectal cancer (CRC) risk may improve efficiency for all stakeholders however limited tools for such risk stratification exist. Colorectal cancers usually evolve from advanced neoplasms that are present for years. We applied the National Cancer Institute (NCI) CRC Risk Assessment Tool, which calculates future risk of CRC, to determine whether it could be used to predict current advanced neoplasia (AN) in a veteran cohort undergoing a baseline screening colonoscopy.MethodsThis was a prospective assessment of the relationship between future CRC risk predicted by the NCI tool, and the presence of AN at screening colonoscopy. Family, medical, dietary and physical activity histories were collected at the time of screening colonoscopy and used to calculate absolute CRC risk at 5, 10 and 20?years. Discriminatory accuracy was assessed.ResultsOf 3121 veterans undergoing screening colonoscopy, 94% had complete data available to calculate risk (N =?2934, median age 63?years, 100% men, and 15% minorities). Prevalence of AN at baseline screening colonoscopy was 11 % (N =?313). For tertiles of estimated absolute CRC risk at 5?years, AN prevalences were 6.54% (95% CI, 4.99, 8.09), 11.26% (95% CI, 9.28-13.24), and 14.21% (95% CI, 12.02-16.40). For tertiles of estimated risk at 10?years, the prevalences were 6.34% (95% CI, 4.81-7.87), 11.25% (95% CI, 9.27-13.23), and 14.42% (95% CI, 12.22-16.62). For tertiles of estimated absolute CRC risk at 20?years, current AN prevalences were 7.54% (95% CI, 5.75-9.33), 10.53% (95% CI, 8.45-12.61), and 12.44% (95% CI, 10.2-14.68). The area under the curve for predicting current AN was 0.60 (95% CI; 0.57-0.63, p <?0.0001) at 5?years, 0.60 (95% CI, 0.57-0.63, p <?0.0001) at 10?years and 0.58 (95% CI, 0.54-0.61, p <?0.0001) at 20?years.ConclusionThe NCI tool had modest discriminatory function for estimating the presence of current advanced neoplasia in veterans undergoing a first screening colonoscopy. These findings are comparable to other clinically utilized cancer risk prediction models and may be used to inform the benefit-risk assessment of screening, particularly for patients with competing comorbidities and lower risk, for whom a non-invasive screening approach is preferred.

Project description:BackgroundMaternal mortality is higher among Black than White people in the United States. Whether Black-White disparities in maternal in-hospital mortality during the delivery hospitalization vary across hospital types (Black-serving vs nonBlack-serving and teaching vs nonteaching) and whether overall maternal mortality differs across hospital types is not known.ObjectiveThe aims of this study were to determine whether risk-adjusted Black-White disparities in maternal mortality during the delivery hospitalization vary by hospital types (this is analysis of disparities in mortality within hospital types) and compare risk-adjusted in-hospital maternal mortality among Black-serving and nonBlack-serving teaching and nonteaching hospitals regardless of race (this is an analysis of overall mortality across hospital types).Study designWe performed a population-based, retrospective cohort study of 5,679,044 deliveries among Black (14.2%) and White patients (85.8%) in 3 states (California, Missouri, and Pennsylvania) from 1995 to 2009. A hospital discharge disposition of "death" defined maternal in-hospital mortality. Black-serving hospitals had at least 7% Black obstetrical patients (top quartile). We performed risk adjustment by calculating expected death rates using predictions from logistic regression models incorporating sociodemographics, rurality, comorbidities, multiple gestations, gestational age at delivery, year, state, and mode of delivery. We calculated risk-adjusted risk ratios of mortality by comparing observed-to-expected ratios among Black and White patients within hospital types and then examined mortality across hospital types, regardless of patient race. We quantified the proportion of Black-White disparities in mortality attributable to delivering in Black-serving hospitals using causal mediation analysis.ResultsThere were 330 maternal deaths among 5,679,044 patients (5.8 per 100,000). Black patients died more often (11.5 per 100,000) than White patients (4.8 per 100,000) (relative risk, 2.38; 95% confidence interval, 1.89-2.98). Examination of Black-White disparities revealed that after risk adjustment, Black patients had significantly greater risk of death (adjusted relative risk, 1.44; 95% confidence interval, 1.17-1.79) and that the disparity was similar within each of the hospital types. Comparison of mortality, regardless of race, across hospital types revealed that among teaching hospitals, mortality was similar in Black-serving and nonBlack-serving hospitals. However, among nonteaching hospitals, mortality was significantly higher in Black-serving vs nonBlack-serving hospitals (adjusted relative risk, 1.47; 95% confidence interval, 1.15-1.87). Notably, 53% of Black patients delivered in nonteaching, Black-serving hospitals compared with just 19% of White patients. Among nonteaching hospitals, 47% of Black-White disparities in maternal in-hospital mortality were attributable to delivering at Black-serving hospitals.ConclusionMaternal in-hospital mortality during the delivery hospitalization among Black patients is more than double that of White patients. Our data suggest this disparity is caused by excess mortality among Black patients within each hospital type, in addition to excess mortality in nonteaching, Black-serving hospitals where most Black patients deliver. Addressing downstream effects of racism to achieve equity in maternal in-hospital mortality will require transparent reporting of quality metrics by race to reduce differential care and outcomes within hospital types, improvements in care delivery at Black-serving hospitals, overcoming barriers to accessing high-quality care among Black patients, and eventually desegregation of healthcare.

Project description:ImportanceNo consensus exists on how to define safety-net hospitals (SNHs) for research or policy decision-making. Identifying which types of hospitals are classified as SNHs under different definitions is key to assessing policies that affect SNH funding.ObjectiveTo examine characteristics of SNHs as classified under 3 common definitions.Design, setting, and participantsThis cross-sectional analysis includes noncritical-access hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases from 47 US states for fiscal year 2015, linked to the Centers for Medicare & Medicaid Services Hospital Cost Reports and to the American Hospital Association Annual Survey. Data were analyzed from March 1 through September 30, 2018.ExposuresHospital characteristics including organizational characteristics, scope of services provided, and financial attributes.Main outcomes and measuresDefinitions of SNH based on Medicaid and Medicare Supplemental Security Income inpatient days historically used to determine Medicare Disproportionate Share Hospital (DSH) payments; Medicaid and uninsured caseload; and uncompensated care costs. For each measure, SNHs were defined as those within the top quartile for each state.ResultsThe 2066 hospitals in this study were distributed across the Northeast (340 [16.5%]), Midwest (587 [28.4%]), South (790 [38.2%]), and West (349 [16.9%]). Concordance between definitions was low; 269 hospitals (13.0%) or fewer were identified as SNHs under any 2 definitions. Uncompensated care captured smaller (200 of 523 [38.2%]) and more rural (65 of 523 [12.4%]) SNHs, whereas DSH index and Medicaid and uncompensated caseload identified SNHs that were larger (264 of 518 [51.0%] and 158 of 487 [32.4%], respectively) and teaching facilities (337 of 518 [65.1%] and 229 of 487 [47.0%], respectively) that provided more essential services than non-SNHs. Uncompensated care also distinguished remarkable financial differences between SNHs and non-SNHs. Under the uncompensated care definition, median (interquartile range [IQR]) bad debt ($27.1 [$15.5-$44.3] vs $12.8 [$6.7-$21.6] per $1000 of operating expenses; P < .001) and charity care ($19.9 [$9.3-$34.1] vs $9.1 [$4.0-$18.7] per $1000 of operating expenses) were twice as high and median (IQR) unreimbursed costs ($32.6 [$12.4-$55.4] vs $23.6 [$9.0-$42.7] per $1000 of operating expenses; P < .001) were 38% higher for SNHs than for non-SNHs. Safety-net hospitals defined by uncompensated care burden had lower median (IQR) total (4.7% [0%-9.9%] vs 5.8% [1.2%-11.2%]; P = .003) and operating (0.3% [-8.0% to 7.2%] vs 2.3% [-3.9% to 8.9%]; P < .001) margins than their non-SNH counterparts, whereas differences between SNH and non-SNH profit margins generally were not statistically significant under the other 2 definitions.Conclusions and relevanceDifferent SNH definitions identify hospitals with different characteristics and financial conditions. The new DSH formula, which accounts for uncompensated care, may lead to redistributed payments across hospitals. Our results may inform which types of hospitals will experience funding changes as DSH payment policies evolve.

Project description:ObjectivesSafety-net health care systems, serving vulnerable populations, see longer delays to timely colonoscopy after a positive fecal occult blood test (FOBT), which may contribute to existing disparities. We sought to identify root causes of colonoscopy delay after positive FOBT result in the primary care safety net.MethodsWe conducted a multisite root cause analysis of cases of delayed colonoscopy, identifying cases where there was a delay of greater than 6 months in completing or scheduling a follow-up colonoscopy after a positive FOBT. We identified cases across 5 California health systems serving low-income, vulnerable populations. We developed a semistructured interview guide based on precedent work. We conducted telephone individual interviews with primary care providers (PCPs) and patients. We then performed qualitative content analysis of the interviews, using an integrated inductive-deductive analytic approach, to identify themes related to recurrent root causes of colonoscopy delay.ResultsWe identified 12 unique cases, comprising 5 patient and 11 PCP interviews. Eight patients completed colonoscopy; median time to colonoscopy was 11.0 months (interquartile range, 6.3 months). Three patients had advanced adenomatous findings. Primary care providers highlighted system-level root causes, including inability to track referrals between primary care and gastroenterology, lack of protocols to follow up with patients, lack of electronic medical record interoperability, and lack of time or staffing resources, compelling tremendous additional effort by staff. In contrast, patients' highlighted individual-level root causes included comorbidities, social needs, and misunderstanding the importance of the FOBT. There was a little overlap between PCP and patient-elicited root causes.ConclusionsCurrent protocols do not accommodate communication between primary care and gastroenterology. Interventions to address specific barriers identified include improved interoperability between PCP and gastroenterology scheduling systems, protocols to follow-up on incomplete colonoscopies, accommodation for support and transport needs, and patient-friendly education. Interviewing both patients and PCPs leads to richer analysis of the root causes leading to delayed diagnosis of colorectal cancer.

Dataset Information

Prevalence of advanced colorectal neoplasia in white and black patients undergoing screening colonoscopy in a safety-net hospital.

Publications

Prevalence of advanced colorectal neoplasia in white and black patients undergoing screening colonoscopy in a safety-net hospital.

Similar Datasets

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