Charles A. Walker

Abstract C88: Novel use of electronic health records (EHRs) to facilitate free community prostate screening events

Introduction Free screening events, while a valuable means to educate and provide cancer screening for individuals in socioeconomically disadvantaged communities, suffer from a number of limitations including: limited scope, poor patient follow up, and lack of long term tracking of individuals with high risk screening outcomes. The Center for Medicare and Medicaid Services advocates for electronic health records (EHRs) to flag opportunities for “reduction of disparities, research, or outreach.” EHRs represent a potentially powerful tool to assimilate and track individual screening outcomes. However, implementation of electronic health records a to facilitate free screening events such as for prostate cancer has not been reported. Among the barriers to EHR use for free screenings is the requirement to create billable encounters for each patient for whom personal health information is to be entered. Therefore, we reconfigured our EHR to create HIPAA compliant, non-billable encounters for the purposes of entering demographic information, tracking screening results, and generating follow-up letters to participants and their primary care physicians (PCPs) after a free community screening event in an at risk community. Materials & Methods Between 2013 and 2015 our group hosted three annual free prostate cancer community-screening events in the city of New Haven, CT. To facilitate tabulation of demographic information and screening results we prevailed upon our EHR administrators to design workflows to allow for patient registration and patient data capture unique to our screening events that would not be associated with a billable encounter. Providers counseled patients on prostate specific antigen (PSA) testing, ordered testing if appropriate, and performed a digital rectal examination (DRE) for each encounter. Demographic information and DRE results were manually entered into the EHR by a registered nurse for all patients and PSA testing performed by our own hospital-based ancillary service with direct resulting of PSA tests into the EHR. Automatic electronic alerts were generated for all PSA results and were preconfigured to be routed to the MD directing the event and two nurse managers. Results In the most recent screening year, 93 men were screened of whom 27 (29%) were flagged for follow-up: 21 (23%) for abnormal screening results and six for benign urologic issues who requested follow-up with our physicians. Using demographic information entered at the time of registration, 26 of the 27 (96%) participants flagged for follow-up were successfully contacted and only one participant could not be reached for follow-up. Letters to PCPs were successfully transmitted for all participants who had provided PCP information during the intake process. Of 21 participants with abnormal screening, 3 were known to have a preexisting diagnosis of prostate cancer and were actively under the care of a urologist and/or oncologist, 3 had established relationships with urologists and indicated their intent to follow-up with their regular urologist, 9 underwent repeat PSA testing and were offered follow-up with one of our urologists at no cost, 3 were scheduled for MRI of the prostate for further stratification of risk, and 3 were scheduled for prostate biopsy with one of our physicians. All tracking of results, coordination of care, and external communication to participants and their PCPs was executed through the EHR Conclusion The electronic health record when reconfigured to serve as a platform for a community screening event, allows for a novel, secure and multidimensional tool to enhance screening, provide appropriate follow-up, and establish vital long-term relationships with participants. Citation Format: Charles Walker, Meghan Curran, Jay Patel, Beth A. Jones. Novel use of electronic health records (EHRs) to facilitate free community prostate screening events. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C88.

Abstract C70: Selected Prospective Predictors of Mammography Screening in Hispanic/Latinas Living in the Northeast, US

Background & Objectives: Hispanic/Latinas (H/Las) are more likely to be diagnosed with later staged breast cancer when compared with White women. Mammography screening, an important early detection tool, is effective when received at regular intervals. National data suggest that mammography screening rates in H/Las are lower than reported for Whites and African Americans. However, little is known about the predictors of screening adherence in the largely immigrant population of Hispanic/Latinas living in the Northeast, US. This is the first report of prospectively measured predictors of non-adherence to mammography screening guidelines in a largely unstudied population, Hispanic/Latinas living in the Northeast, US. As a starting point, we report here on selected core socio-demographic, acculturation, access to care, and medical variables as predictors of mammography screening over 2 to 4 years of follow-up. Methods: We conducted hour long telephone interviews with 1600 community-living Hispanic/Latino women, ages 40-75, seeking care at primary care clinics in the 4 cities with the largest Hispanic populations in Connecticut, US. Women with no prior history of breast cancer or biopsy were eligible for inclusion in our study. We collected detailed information on socio-demographic, access to care, medical, health knowledge and belief variables. Screening mammography that occurred during 2-4 years of follow-up was derived from radiology records (n=1570; 98% consented to record review). Bivariate and multivariate predictors (core socio-demographic, access to care, acculturation, and medical variables) of adherence to annual screening guidelines in place at the time of study are reported. Results: Of the 1570 women included in the final cohort, 870 (55.4%) were non-adherent to guidelines calling for annual mammography screening and 610 (38.9%) were non-adherent to guidelines calling for biennial mammography screening. In multivariate analyses that controlled for marital status, education, income, insurance status, continuity of care, selected health factors and acculturation variables, younger (age less than 50), OR = 1.52 (95% CI, 1.22, 1.89) and women who reported fair or poor compared with good or very good self-rated health (OR = 1.30, 95% CI 1.0, 1.62) were non-adherent to guidelines calling for annual screening. In contrast, women with relatively poor English language skills were 30% less likely to be non-adherent (OR 0.70, 95% CI 0.56, 0.96). Conclusions: In a study of a large cohort of mostly immigrant Hispanic/Latino women living in the Northeast, US, preliminary results suggest that younger women and those women who report that they are not in good health are at risk for non-adherence to mammography screening guidelines. There is a suggestion that despite a language barrier, some immigrant women may screen more than women who were born in the US. A better understanding of how acculturation factors interact with other patient characteristics is needed. Citation Format: Beth A. Jones, Inginia Genao, Marcella Nunez-Smith, Elizabeth Claus, Hosanna Soler-Vila, Charles Walker, Emma Claye, Justin H. Markowski, Susan Nappi. Selected Prospective Predictors of Mammography Screening in Hispanic/Latinas Living in the Northeast, US. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C70.

Abstract C71: Validity of self-reported mammography screening in prospective study of Hispanic / Latino women living in the Northeast, US

Background & Objectives: Hispanic/Latinas (H/Las) are more likely to be diagnosed with later staged breast cancer when compared with White women. Mammography screening, an important early detection tool, is effective when received at regular intervals. National data suggest that mammography screening rates in H/Las are lower than reported for Whites and African Americans. However, little is known about the predictors of screening adherence in the largely immigrant population of Hispanic/Latinas living in the Northeast, US. From a prospective study that examined the roles of social determinants, health beliefs, knowledge and attitudes, acculturation, and medical factors that are hypothesized to predict adherence to mammography screening guidelines, we report here on multiple outcome measure of adherence to mammography screening guidelines in place at the time of this study (2008-2014). Our goal is to report on the validity of self-reported screening history during the follow-up period using abstracted radiology record data as the gold standard. Methods: We enrolled and conducted hour long interviews with 1600 community-living Hispanic/Latino women, ages 40-75, seeking care at primary care clinics in the 4 Connecticut cities with the largest Hispanic populations. Women with no prior history of breast cancer or biopsy were eligible for inclusion in our study. In an extensive baseline interview, we collected detailed information on socio-demographic, access to care, medical, health knowledge and belief variables. Information on screening mammography that occurred during 2-4 years of follow-up was derived from 2 sources: 1) radiology records (n = 1570; 98% consented to record review) and 2) follow-up interviews conducted beginning no earlier than 30 months from enrollment (n = 772, 49.2%). Cohen9s Kappa agreement statistics with 95% Confidence Intervals (CI) are reported. Multivariate analyses were used to characterize over-reporters from under-reporters using the radiology record as the gold standard. Results: Among the 1570 women who returned signed consent forms allowing medical record review, non-adherence to guidelines calling for annual mammography was 55.4% (n = 870) and 38.9% (n = 610) calling for biennial mammography screening. Compared with self-reported mammography screening available from the sub-cohort of women with follow-up interview information (n = 772), the percent agreement between self-reported and medical record screening history was 59.2% (n = 457) with kappa = 0.18 (95% CI: 0.11, 0.25) for annual screening and 71.4% with kappa = 0.27 (95% CI: 0.20, 0.34) for biennial screening. Among the 315 (40.8%) women whose self-reports did not agree with the medical record, 192 (61.0%) over-reported and 123 (39.0%) under-reported adherence to annual mammography recommendations. Prospective predictors of over-reporting, derived from multivariate adjusted models included history of mammography screening before enrollment in study and fair/poor self-rated health (p Conclusions: In this large prospective study of cancer screening in Hispanic/Latinas living in the Northeast, US, adherence to mammography screening guidelines was lower than is reported in retrospective self-reported survey data used by most public health practitioners. Importantly, when self-reported mammography screening was compared with radiology record review, the agreement was lower than ideal at less than 60%, with over-reporting more frequent than under-reporting. These results have implications for cancer prevention and control efforts and discussions regarding mammography screening guidelines, as it may be that actual non-adherence to mammography screening guidelines is higher than indicated by self-report. Citation Format: Beth A. Jones, Justin H. Markowski, Inginia Genao, Marcella Nunez-Smith, Hosanna Soler-Vila, Elizabeth Claus, Emma Claye, Susan Nappi, Margaret Doyle, Alejandra Miranda, Charles Walker. Validity of self-reported mammography screening in prospective study of Hispanic / Latino women living in the Northeast, US. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C71.