Anne C. Kirchhoff

Washington State Cancer Patients Found To Be At Greater Risk For Bankruptcy Than People Without A Cancer Diagnosis

Much has been written about the relationship between high medical expenses and the likelihood of filing for bankruptcy, but the relationship between receiving a cancer diagnosis and filing for bankruptcy is less well understood. We estimated the incidence and relative risk of bankruptcy for people age twenty-one or older diagnosed with cancer compared to people the same age without cancer by conducting a retrospective cohort analysis that used a variety of medical, personal, legal, and bankruptcy sources covering the Western District of Washington State in US Bankruptcy Court for the period 1995-2009. We found that cancer patients were 2.65 times more likely to go bankrupt than people without cancer. Younger cancer patients had 2-5 times higher rates of bankruptcy than cancer patients age sixty-five or older, which indicates that Medicare and Social Security may mitigate bankruptcy risk for the older group. The findings suggest that employers and governments may have a policy role to play in creating programs and incentives that could help people cover expenses in the first year following a cancer diagnosis.

Improving and sustaining diabetes care in community health centers with the health disparities collaboratives.

Background:In 1998, the Health Resources and Services Administration’s Bureau of Primary Health Care began the Health Disparities Collaboratives (HDC) to improve chronic disease management in community health centers (HCs) nationwide. The HDC incorporates rapid quality improvement, a chronic care model, and best practice learning sessions. Objectives:To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further. Subjects:Chart review of 2364, 2417, and 2212 randomly selected patients with diabetes from 34 HCs in 17 states in 1998, 2000, and 2002, respectively. Measures:American Diabetes Association standards. Research Design:We performed a randomized controlled trial with an embedded prospective longitudinal study. We randomized 34 HCs that had undergone 1–2 years of the HDC. The standard-intensity arm continued the baseline HDC intervention. High-intensity arm centers received 4 additional learning sessions, provider training in behavioral change, and patient empowerment materials. To assess the impact of the HDC, we analyzed changes in clinical processes and outcomes in the standard-intensity centers. To determine the effect of more intensive interventions, we compared the standard- and high-intensity centers. Results:Between 1998 and 2002, HCs undertaking the standard HDC improved 11 diabetes processes and lowered hemoglobin A1c [−0.45%; 95% confidence interval (CI), −0.72 to −0.17] and low-density lipoprotein cholesterol (−19.7 mg/dL; 95% CI, −25.8 to −13.6). High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors [adjusted odds ratio (OR), 1.47; 95% CI, 1.07–2.01] and aspirin (OR, 2.20; 95% CI, 1.28–3.76), but lower use of dietary (OR, 0.24; 95% CI, 0.08–0.68) and exercise counseling (OR, 0.34; 95% CI, 0.15–0.75). Conclusions:Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.

Limitations in health care access and utilization among long-term survivors of adolescent and young adult cancer.

Health care outcomes for long‐term survivors of adolescent and young adult (AYA) cancer were compared with young adults without a cancer history, using the 2009 Behavioral Risk Factor Surveillance System data.

Occupational outcomes of adult childhood cancer survivors: A report from the Childhood Cancer Survivor Study

The authors examined whether survivors from the Childhood Cancer Survivor Study were less likely to be in higher‐skill occupations than a sibling comparison and whether certain survivors were at higher risk for lower‐skill jobs.

Physical, Mental, and Neurocognitive Status and Employment Outcomes in the Childhood Cancer Survivor Study Cohort

Introduction: We examined the relationship of physical, mental, and neurocognitive function with employment and occupational status in the Childhood Cancer Survivor Study. Methods: We included survivors 25 years or older with available short form-36 (physical and mental health component scores), brief symptom inventory (depression, anxiety, and somatization), and neurocognitive questionnaire (task efficiency, emotional regulation, organization, and memory). We generated relative risks (RR) from generalized linear models for these measures on unemployment (n = 5,386) and occupation (n = 3,763) outcomes adjusted for demographic and cancer-related factors and generated sex-stratified models. Results: Poor physical health was associated with an almost eightfold higher risk of health-related unemployment (P < 0.001) compared to survivors with normal physical health. Male survivors with somatization and memory problems were approximately 50% (P < 0.05 for both) more likely to report this outcome, whereas task efficiency limitations were significant for both sexes (males: RR = 2.43, P < 0.001; females: RR = 2.28, P < 0.001). Employed female survivors with task efficiency, emotional regulation, and memory limitations were 13% to 20% (P < 0.05 for all) less likely to work in professional or managerial occupations than unaffected females. Conclusions: Physical problems may cause much of the health-related unemployment among childhood cancer survivors. Whereas both male and female survivors with neurocognitive deficits—primarily in task efficiencies—are at risk for unemployment, employed female survivors with neurocognitive deficits may face poor occupational outcomes more often than males. Impact: Childhood cancer survivors are at risk for poor employment outcomes. Screening and intervention for physical, mental, and neurocognitive limitations could improve employment outcomes for this population. Cancer Epidemiol Biomarkers Prev; 20(9); 1838–49. ©2011 AACR.

Insurance Status and Quality of Diabetes Care in Community Health Centers

OBJECTIVESnWe sought to compare quality of diabetes care by insurance type in federally funded community health centers. Method. We categorized 2018 diabetes patients, randomly selected from 27 community health centers in 17 states in 2002, into 6 mutually exclusive insurance groups. We used multivariate logistic regression analyses to compare quality of diabetes care according to 6 National Committee for Quality Assurance Health Plan Employer Data and Information Set diabetes processes of care and outcome measures.nnnRESULTSnThirty-three percent of patients had no health insurance, 24% had Medicare only, 15% had Medicaid only, 7% had both Medicare and Medicaid, 14% had private insurance, and 7% had another insurance type. Those without insurance were the least likely to meet the quality-of-care measures; those with Medicaid had a quality of care similar to those with no insurance.nnnCONCLUSIONSnResearch is needed to identify the major mediators of differences in quality of care by insurance status among safety-net providers such as community health centers. Such research is needed for policy interventions at Medicaid benefit design and as an incentive to improve quality of care.

Strategies for physical activity maintenance in African American women.

OBJECTIVEnTo examine whether African American women who were exercise maintainers reported the same barriers to and benefits from exercise as currently inactive women and to describe maintainers strategies for exercise maintenance.nnnMETHODSnSemistructured qualitative interviews.nnnRESULTSnTen women were classified as exercise maintainers and 9 as relapsers. Both groups reported similar benefits from and barriers to exercise. Maintainers reported strategies they used to sustain their exercise programs: wanting to act as a role model, seeking out social support, and setting goals.nnnCONCLUSIONSnPrograms that address barriers to exercise may not be successful unless coupled with facilitators that promote maintenance.

The Cost Consequences of Improving Diabetes Care: The Community Health Center Experience

BACKGROUNDnDespite significant interest in the business case for quality improvement (QI), there are few evaluations of the impact of QI programs on outpatient organizations. The financial impact of the Health Disparities Collaboratives (HDC), a national QI program conducted in community health centers (HCs), was examined.nnnMETHODSnChief executive officers (CEOs) from health centers in two U.S. regions that participated in the Diabetes HDC (N = 74) were surveyed. In case studies of five selected centers, program costs/revenues, clinical costs/revenues, overall center financial health, and indirect costs/benefits were assessed.nnnRESULTSnCEOs were divided on the HDCs overall effect on finances (38%, worsened; 48%, no change; 14%, improved). Case studies showed that the HDC represented a new administrative cost (

Prospective predictors of return to work in the 5 years after hematopoietic cell transplantation

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Childhood Cancer Survivor Study participants' perceptions and knowledge of health insurance coverage: implications for the Affordable Care Act.

22/patient, year 1) without a regular revenue source. In centers with billing data, the balance of diabetes-related clinical costs/revenues and payor mix did not clearly worsen or improve with the programs start. The most commonly mentioned indirect benefits were improved chronic illness care and enhanced staff morale.nnnDISCUSSIONnCEO perceptions of the overall financial impact of the HDC vary widely; the case studies illustrate the numerous factors that may influence these perceptions. Whether the identified balance of costs and benefits is generalizable or sustainable will have to be addressed to optimally design financial reimbursement and incentives.