Cheryl Raskind-Hood

Sociodemographic, insurance, and risk profiles of maternal smokers post the 1990s: how can we reach them?

Declines in prenatal smoking rates have changed the composition of maternal smokers while public policy during the 1990s has likely made it more difficult to reach them. Medicaid expansions during the 1980s/early 1990s insured more women some time during pregnancy, but the 1996 welfare reform unexpectedly reduced enrollment in Medicaid by eligible pregnant women; overall, insurance coverage has declined since 2000. As the public sector struggles with fewer resources, it is important to understand the sociodemographic characteristics of prenatal smokers, their patterns of care, and nonsmoking risk behaviors. Targeting scarce dollars to certain settings or sub-populations can strengthen the infrastructure for tobacco policy change. We provide more current information on maternal smokers in 2002 based on the Pregnancy Risk Assessment Monitoring System (PRAMS) for 21 states. Data on urban/rural location, insurance coverage, access patterns, and nonsmoking risk behaviors (e.g., abuse) among low-income (<16,000) and other maternal smokers are included. Low-income maternal smokers are the working poor living in predominately urban areas with fewer health care resources than low-income nonsmokers. Over 50% of low-income maternal smokers are uninsured pre-pregnancy and use a clinic as their usual source of care. Regardless of income, smokers exhibit rates of nonsmoking risks that are two to three times those of nonsmokers and high rates of unintended pregnancy (68%) of low-income smokers. These characteristics likely call for a bundle of social support services beyond cessation for smokers to quit and remain smoke-free postpartum.

The Breast and Cervical Cancer Prevention and Treatment Act in Georgia : Effects on Time to Medicaid Enrollment

Implementation of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA) allowed states to extend Medicaid to any woman aged <65 without insurance screened and found to need treatment either for breast or cervical cancer or for a precancerous cervical condition through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) or in Georgia, other provider sites.

Positioning for partnerships. Assessing public health agency readiness.

BACKGROUND Public health organizations are redefining their roles and aligning their structures with other components of the evolving American health system. Health departments must proactively and strategically plan how to position themselves for the coming years. Prior to implementing changes in functioning, structure, and/or future strategies, an organization should assess its internal readiness to commit to creating these substantial alterations. METHODS Using a diagnostic tool developed by study investigators, employees of the Cobb and Douglas Counties Boards of Health were surveyed in order to assess their organizational readiness to enter into a strategic partnership with Promina Northwest, a not-for-profit hospital network in the Atlanta, Georgia area. Frequency distributions were conducted for each categorical variable and data were analyzed in aggregate and by job category. RESULTS The 122 analyzed questionnaires revealed some significant trends. Respondents ranked the six factors having the greatest impact on an organizations ability to change in the following order: leadership, planning, teamwork, mission, information and operations. Interestingly, this rank ordering parallels the perceived strengths and weaknesses of the health departments as determined by the frequency of the most positive responses. CONCLUSION Cobb and Douglas Counties Boards of Health have taken many key steps to prepare the organizations for significant proactive changes. Survey results emphasized the need for open channels of communication within the organizations and with the external environment so that effective planning can guide the strategic alignment of the health departments with community partners.

Determining the impact of US mammography screening guidelines on patient survival in a predominantly African American population treated in a public hospital during 2008

In November 2009, the US Preventive Service Task Force (USPSTF) published updated breast cancer screening guidelines. This marked a change from the 2002 recommendations and a significant divergence from the American Cancer Society (ACS) guidelines. In the current study, the potential effect of using the revised 2009 USPSTF guidelines on patient disease stage and survival were evaluated and compared with those actually observed and to predicted under ACS recommendations.

The State Children's Health Insurance Program (SCHIP) and prepregnancy coverage of teenage mothers.

Background:The 1997 State Childrens Health Insurance Program (SCHIP) program allowed states to expand Medicaid to uninsured children through age 18 in families under 200% of the federal poverty level. Prepregnancy insurance coverage of adolescents may help reduce unintended pregnancies, address other medical issues, and allow for early and adequate prenatal care for those carrying to term. Objectives:We tested the effects of SCHIP implementation on insurance coverage for teenage mothers and investigated whether these effects varied by type of state SCHIP program—Medicaid expansion, stand-alone program, or some combination of these. Research Design:We used Pregnancy Risk Assessment Monitoring System data from 1996 through 2000 and difference-in-differences analysis to analyze coverage changes for teenage mothers (age <20) relative to those for mothers aged 20–24 years old, a group whose Medicaid eligibility was not affected by SCHIP policies. Population Studied:Our raw sample of teenage and older mothers in Alaska, Oklahoma, South Carolina, Florida, Maine, New York, and West Virginia equaled 23,171 (811,638 weighted). Results:SCHIP implementation was associated with an almost 10 percentage point increase in prepregnancy coverage among teens under age 17. Although there were increases in both public and private coverage only the latter was statistically significant. The only statistically significant increase in Medicaid coverage, equal to almost 16 percentage points, was among 18-year-olds in states with Medicaid expansion programs. Conclusions:The temporary extension of SCHIP allows time to consider how to maintain the programs potentially positive effect on the reproductive health of adolescents.

The effects of maternal weight and age on pre-eclampsia and eclampsia in Haiti

Abstract Objective: Patient data from Maison de Naissance (MN), a rural maternity clinic in Haiti, were analyzed to determine the prevalence of pregnancy-related hypertensive disorders and the extent to which maternal weight and age are associated with these disorders in the MN population. Methods: A case-control study design was used with cases defined as pregnant women who were presented at MN with pregnancy-related hypertensive disorders (pregnancy-induced hypertension, pre-eclampsia or eclampsia) and controls defined as those women who delivered babies at MN and were not diagnosed with a pregnancy-related hypertensive disorder. The final cohort size was 622 controls and 67 cases. Odds ratios were calculated using multivariate logistic regression. Results: The incidence of pre-eclampsia and eclampsia was 7.0%. Older maternal age at delivery (OR = 3.18; 95%CI: 1.31, 7.76) and higher maternal weight (OR = 3.24; 95%CI: 1.76, 5.98) measured during prenatal care were significantly associated with pregnancy-related hypertensive disorders. Prenatal care was not significantly associated with reduced risk of pre-eclampsia/eclampsia. Conclusions: The prevalence of pregnancy-related hypertensive disorders was high relative to rates in other developing countries. More is required to reduce the rate of pre-eclampsia perhaps by targeting older and women with high weight for preconception and more intensive prenatal care.

ADULTS WITH CONGENITAL HEART DISEASE: LOST IN CARE

Background: Transfer of congenital heart disease (CHD) care from the pediatric to adult setting has been identified as a priority and is associated with better outcomes. Many CHD patients may fail to transfer. The goal of this study was to assess the percentage of CHD patients who transferred out of

P1-10-07: Comparing Breast Cancer Screening Guidelines: A Stage-Survival-Cost Model in a Public Hospital.

Background: Despite advances in diagnosis and treatment of breast cancer in the United States, racial disparities in survival persist. Female breast cancer represented the costliest cancer site in 2010 with further increases projected to 2020. Mammography screening guidelines reflect the inherent difficulty in reconciling mortality reduction with potential harms to patients and cost-effectiveness concerns. Controversy still surrounds the 2009 updated USPSTF recommendations, as critics and advocates alike evaluate lives saved, costs, and how best to compare screening strategies. This study simulates USPSTF and ACS guidelines’ effects on stage, 5-year survival, and cost of treatment vs. usual practice in women treated in an urban public hospital. Methods: Charts of 84 patients diagnosed with Stage I-III breast cancer in 2008 were reviewed. Published tumor doubling times guided a retrospective model to predict size at diagnosis by simulated ACS or USPSTF guidelines. AJCC-7 stages were then assigned to produce 3 distributions: 1) actual stage; 2) stage under ACS; and 3) stage under USPSTF. Survival estimates by stage and year from diagnosis were drawn from NCDB statistics and applied to each stage distribution, yielding average predicted survival for the actual and hypothetical scenarios. Finally, treatment costs for women continuously enrolled in Medicaid for 18 months were calculated from merged claims and registry data and similarly applied. Results: Study patients averaged 55 years; 85% were African American. Forty-nine percent were covered by Medicaid and 23% by Medicare. Comparing actual and predicted stages at diagnosis showed significant shifts in stage distribution between all three scenarios (Table 1). ACS guidelines predicted higher survival (87.5% at 5 years) than actual (85.5%; p Discussion: To our knowledge, no studies have compared the impact of alternative screening guidelines on outcomes in a predominantly African-American, public hospital population. These data support continued use of and adherence to ACS screening recommendations for inner city patients to achieve the best survival and the lowest cost. Given the likelihood of patients to be uninsured or covered by federal programs, this study carries implications for public policy and patient education, especially in low-resource programs caring for underserved patients. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-10-07.

Explaining Racial Differences in Prenatal Care Initiation and Syphilis Screening Among Medicaid-covered Pregnant Women

Sexually transmitted diseases and their outcomes disproportionately affect non-Hispanic Blacks who also receive later prenatal care. We used a sample of low-income pregnant women insured by Medicaid to assess racial disparities in the receipt of first trimester prenatal care and any as well as early (by 2nd trimester) syphilis screening. We used an older but unique file of linked 1995 Georgia Medicaid claims and Pregnancy Risk Assessment Monitoring System (PRAMS) births (n = 1,096) to test the relative explanatory power of factors contained in administrative versus survey data. Using administrative data, we found non-Hispanic Blacks were less likely than non-Hispanic Whites to receive first trimester care but more likely to be screened. Adding in PRAMS survey data eliminated these differences. Having an outpatient department as usual source of care was a key factor. This may reflect unmeasured characteristics of minorities and their neighborhoods or differences in screening practices across provider settings.