J. Soukup

Addressing Social Determinants of Health to Improve Access to Early Breast Cancer Detection: Results of the Boston REACH 2010 Breast and Cervical Cancer Coalition Women's Health Demonstration Project

BACKGROUND The Boston Racial and Ethnic Approaches to Community Health (REACH) 2010 Breast and Cervical Cancer Coalition developed a case management intervention for women of African descent to identify and reduce medical and social obstacles to breast cancer screening and following up abnormal results. METHODS We targeted black women at high risk for inadequate cancer screening and follow-up as evidenced by a prior pattern of missed clinic appointments and frequent urgent care use. Case managers provided referrals to address patient-identified social concerns (e.g., transportation, housing, language barriers), as well as navigation to prompt screening and follow-up of abnormal tests. We recruited 437 black women aged 40-75, who received care at participating primary care sites. The study was conducted as a prospective cohort study rather than as a controlled trial and evaluated intervention effects on mammography uptake and longitudinal screening rates via logistic regression and timely follow-up of abnormal tests via Cox proportional hazards models. RESULTS A significant increase in screening uptake was found (OR 1.53, 95% CI 1.13-2.08). Housing concerns (p < 0.05) and lacking a regular provider (p < 0.01) predicted poor mammography uptake. Years of participation in the intervention increased odds of obtaining recommended screening by 20% (OR 1.20, 95% CI 1.02-1.40), but this effect was attenuated by covariates (p = 0.53). Timely follow-up for abnormal results was achieved by most women (85%) but could not be attributed to the intervention (HR 0.95, 95% CI 0.50-1.80). CONCLUSIONS Case management was successful at promoting mammography screening uptake, although no change in longitudinal patterns was found. Housing concerns and lacking a regular provider should be addressed to promote mammography uptake. Future research should provide social assessment and address social obstacles in a randomized controlled setting to confirm the efficacy of social determinant approaches to improve mammography use.

Preventive care for low-income women in massachusetts post-health reform.

BACKGROUND Before enacting health insurance reform in 2006, Massachusetts provided free breast, cervical cancer, and cardiovascular risk screening for low-income uninsured women through a federally subsidized program called the Womens Health Network (WHN). This article examines whether, as women transitioned to insurance to pay for screening tests after health reform legislation was passed, cancer and cardiovascular disease screening changed among WHN participants between 2004 and 2010. METHODS We examined claims data from the Massachusetts health insurance exchange and chart review data to measure utilization of mammography, Pap smear, and blood pressure screening among WHN participants in five community health centers in greater Boston. We conducted a longitudinal analysis, by insurance type, using generalized estimating equations to examine the likelihood of screening at recommended intervals in the postreform period compared to the prereform period. RESULTS Pre- and postreform, we found a high prevalence of recommended mammography (86% vs. 88%), Pap smear (88% vs. 89%), and blood pressure screening (87% vs. 91%) that was similar or improved for most women postreform. Screening use differed by insurance type. Recommended mammography screening was statistically significantly increased among women with state-subsidized private insurance (odds ratio [OR] 1.58, p<0.05). Women with unsubsidized private insurance or Medicare had decreased Pap smear use postreform. Although screening prevalence was high, 31% of women required state safety-net funds to pay for screening tests. CONCLUSION Our results suggest a continued need for safety-net programs to support preventive screening among low-income women after implementation of healthcare reform.

Mammography use among black women: the role of electronic medical records.

BACKGROUND AND AIMS Accurately documenting mammography use is essential to assess quality of care for early breast cancer detection in underserved populations. Self-reports and medical record reports frequently result in different accounts of whether a mammogram was performed. We hypothesize that electronic medical records (EMRs) provide more accurate documentation of mammography use than paper records, as evidenced by the level of agreement between womens self-reported mammography use and mammography use documented in medical records. METHODS Black women aged 40-75 were surveyed in six primary care sites in Boston, Massachusetts (n = 411). Survey data assessed self-reported mammography prevalence within 2 years of study entry. Corresponding medical record data were collected at each site. Positive predictive value (PPV) of self-report and kappa statistics compared data agreement among sites with and without EMRs. Logistic regression estimated effects of site and patient characteristics on agreement between data sources. RESULTS Medical records estimated a lower prevalence of mammography use (58%) than self-report (76%). However, self-report and medical record estimates were more similar in sites with EMRs. PPV of self-report was 88% in sites with continuous access to EMRs and 61% at sites without EMRs. Kappa statistics indicated greater data agreement at sites with EMRs (0.72, 95% CI 0.56-0.88) than without EMRs (0.46, 95% CI 0.29-0.64). Adjusted for covariates, odds of data agreement were greatest in sites where EMRs were available during the entire study period (OR 4.31, 95% CI 1.67-11.13). CONCLUSIONS Primary care sites with EMRs better document mammography use than those with paper records. Patient self-report of mammography screening is more accurate at sites with EMRs. Broader access to EMRs should be implemented to improve quality of documenting mammography use. At a minimum, quality improvement efforts should confirm the accuracy of paper records with supplemental data.

The neutron beam facility at triumf

Abstract The polarized neutron beam facility at TRIUMF has been upgraded for use in high precision neutron scattering experiments. Polarized neutrons are produced via transverse polarization transfer in the D(p,n)2p reaction at 9° in the lab. Proton beam position on the LD2 production target is stabilized to better than ±0.2 mm using a feedback system controlling beam line elements. The region of uniform neutron beam intensity at the experimental target location is a rectangular area 56 mm wide and 40 mm high. In that area the neutron beam intensity is 9 × 103 (100 nA cm2 s) and the neutron polarization is 50%. The facility is being used to determine charge symmetry breaking in n−p elastic scattering, to study neutron radiative capture by hydrogen, and a measurement of the spin correlation parameter Ann.

Case Management Intervention in Cervical Cancer Prevention: The Boston REACH Coalition Women's Health Demonstration Project

Background: The Boston REACH Coalition developed a case management intervention for Black women in primary care settings to identify and reduce medical and social obstacles to cervical cancer screening and following up abnormal results. Methods: The 5-year intervention was evaluated among 732 Black women aged 18 to 75 who were at high risk for inadequate Pap smear screening and follow-up. Case managers provided social services referrals to address patient-identified social concerns (e.g., transportation, housing), as well as navigation to prompt screening and follow-up of abnormal tests. The three study aims were to (1) identify the social factors associated with Pap smear screening at baseline before intervention, (2) evaluate the correlation between exposure to case management intervention and achieving recommended Pap screening intervals, and (3) evaluate the correlation between exposure to case management intervention and having timely follow-up of abnormal Pap smear tests. Results: We found that a lack of a regular clinical provider, concerns communicating with providers, poor self-rated health, and having less than a high school education were important correlates of recent Pap smear screening before the case management intervention. During the case management intervention, we found a significant increase in achieving recommended Pap smear screening intervals among women with a recent Pap smear at study entry (increasing from 52% in the first year to 80% after 4 or more years; p < .01), but not among women who entered the study without a recent Pap smear (increasing from 31% in the first year to 44% after 4 or more years; p = .39). During case management intervention, having social support for childcare was associated with regular screening among women without a recent Pap smear (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.28–9.69). Insurance status was the key factor in timely clinically indicated follow-up of abnormal results (uninsured OR, 0.27; 95% CI, 0.08–0.86), rather than case management intervention. Conclusions: Exposure to case management was associated with regular Pap smear screening among women who recently engaged in screening. Future research should focus on systems changes to address social determinants of health, including strategies to facilitate screening for Black women without social support for childcare. To improve follow-up of abnormal results, financial access to care should be addressed.

The design and calibration of the AHEAD deuteron polarimeter for 120 < Ed < 250 MeV

A new type of deuteron polarimeter to work in the energy range 120 < Ed < 250 MeV has been designed, constructed, and calibrated. The figure of merit (√ϵTkq) has been determined for various polarization components from the calibration data.

Detection equipment for a test of charge symmetry in n−p elastic scattering☆

Detection equipment has been developed to allow precision measurements of n−p elastic scattering of 150 to 500 MeV polarized neutron beams at TRIUMF. The apparatus permits a determination of the difference in angle, ‡θ, at which the neutron and proton analyzing powers An and Ap cross zero with a precision of ±0.04° lab at 500 MeV. From this difference in ‡θ the difference between An and Ap can be obtained to a precision of ±0.001.

The UofA/TRIUMF radioactive beam ECR ion source

One of the objectives of the TISOL (Test Isotope Separator On Line) facility at TRIUMF is the production of low Z radioactive isotopes, with a special interest in those related to nuclear astrophysics. A part of experimental objectives is the installation of an electron cyclotron resonance ion source on‐line to test its suitability for this use. In collaboration with TISOL, the University of Alberta has designed, built, and tested off‐line a single stage ECRIS. As part of the source, testing measurements were carried out to determine the efficiency of the source; some preliminary results indicate efficiencies of 20% for Ne+ and 30% for Ar+. In general, it was attempted to test the source under as wide as possible a set of operating conditions. The final off‐line testing is completed. It is hoped that the source will go on‐line in the early summer of 1989.

A beam intensity profile monitor based on secondary electron emission

Two dual function intensity profile monitors have been designed for a measurement of parity violation in p-p scattering at about 230 MeV using longitudinally polarized protons. Each device contains a set of split secondary electron emission (SEM) foils to determine the median of the beam current distribution (in x and y). The split foils, coupled through servoamplifiers and operational amplifiers to upstream aircore steering magnets, have demonstrated the ability to hold the beam position stable to ±5 μm for beam position fluctuations up to 1000 Hz. These monitors also contain a set of foil strip planes giving information on the intensity distribution projected onto the two orthogonal axes, x and y. Data were acquired using 0.008 mm thick, 0.90 mm wide aluminum foil strips at 1.00 mm centers. The foil strip planes were able to determine the beam centroid to within ±3 μm after one hour of data taking with a 100 nA, 15 mm FWHM Gaussian beam.

Proton target polarization measured with a polarized neutron beam at 477 MeV

Abstract The polarization of a proton target is determined with elastic neutron-proton scattering at 477 MeV. The results agree well with the nuclear magnetic resonance measurements at the error level of 4%.