Jennifer Alford-Teaster

Spatial Access and Local Demand for Major Cancer Care Facilities in the United States

The Cancer Centers designated by the National Cancer Institute (NCI Centers) and academic medical centers (AMCs) form the “backbone” of the cancer care system in the United States. We conducted a nationwide analysis and generated a high-resolution map detailing spatial variation in the potentially unfulfilled demand for these facilities. A local demand value incorporates spatial access to the facilities and the number of local potential patients. The spatial access was estimated using the two-step floating catchment area method, taking into account both travel time and facility capacity. The travel time was measured using service-area rings created around each facility based on road networks. The facility capacity was measured as the ratio between the bed count of the facility and the number of potential patients in its three-hour catchment. The number of local potential patients was estimated from local demography and standard cancer rates. The demographic information is a combination of LandScan data and U.S. Census data, and the cancer rates are from the Surveillance Epidemiology and End Results. The final demand map shows distinctive patterns in the western and eastern halves of the contiguous United States. The demand in the east is spatially continuous but relatively low, whereas in the west it is sporadic but tends to have high values. We also examined the inherent relationships between several methods for measuring spatial access and found that the differences between them are technical rather than conceptual, which sets a theoretical basis for selecting and adapting those methods.

Disparities in the use of screening magnetic resonance imaging of the breast in community practice by race, ethnicity, and socioeconomic status.

Uptake of breast magnetic resonance imaging (MRI) coupled with breast cancer risk assessment offers the opportunity to tailor the benefits and harms of screening strategies for women with differing cancer risks. Despite the potential benefits, there is also concern for worsening population‐based health disparities.

Multilevel factors associated with long-term adherence to screening mammography in older women in the U.S.

In the U.S., guidelines recommend that women continue mammography screening until at least age 74, but recent evidence suggests declining screening rates in older women. We estimated adherence to screening mammography and multilevel factors associated with adherence in a longitudinal cohort of older women. Women aged 66-75years receiving screening mammography within the Breast Cancer Surveillance Consortium were linked to Medicare claims (2005-2010). Claims data identified baseline adherence, defined as receiving subsequent mammography within approximately 2years, and length of time adherent to guidelines. Characteristics associated with adherence were investigated using logistic and Cox proportional hazards regression models. Analyses were stratified by age to investigate variation in relationships between patient factors and adherence. Among 49,775 women, 89% were adherent at baseline. Among women 66-70years, those with less than a high school education were more likely to be non-adherent at baseline (odds ratio [OR] 1.96; 95% confidence interval [CI] 1.65-2.33) and remain adherent for less time (hazard ratio [HR] 1.41; 95% CI 1.11-1.80) compared to women with a college degree. Women with ≥1 versus no Charlson co-morbidities were more likely to be non-adherent at baseline (OR 1.46; 95% CI 1.31-1.62) and remain adherent for less time (HR 1.44; 95% CI 1.24-1.66). Women aged 71-75 had lower adherence overall, but factors associated with non-adherence were similar. In summary, adherence to guidelines is high among Medicare-enrolled women in the U.S. receiving screening mammography. Efforts are needed to ensure that vulnerable populations attain these same high levels of adherence.

Utilization of breast cancer screening with magnetic resonance imaging in community practice

BackgroundBreast cancer screening with magnetic resonance imaging (MRI) may be a useful adjunct to screening mammography in high-risk women, but MRI uptake may be increasing rapidly among low- and average-risk women for whom benefits are unestablished. Comparatively little is known about use of screening MRI in community practice.ObjectiveTo assess relative utilization of MRI among women who do and do not meet professional society guidelines for supplemental screening, and describe utilization according to breast cancer risk indications.DesignProspective cohort study conducted between 2007 and 2014.ParticipantsIn five regional imaging registries participating in the Breast Cancer Surveillance Consortium (BCSC), 348,955 women received a screening mammogram, of whom 1499 underwent screening MRI.Main measuresLifetime breast cancer risk (< 20% or ≥ 20%) estimated by family history of two or more first-degree relatives, and Gail model risk estimates. Breast Imaging Reporting and Data System breast density and benign breast diseases also were assessed. Relative risks (RR) for undergoing screening MRI were estimated using Poisson regression.Key resultsAmong women with < 20% lifetime risk, which does not meet professional guidelines for supplementary MRI screening, and no first-degree breast cancer family history, screening MRI utilization was elevated among those with extremely dense breasts [RR 2.2; 95% confidence interval (CI) 1.7–2.8] relative to those with scattered fibroglandular densities and among women with atypia (RR 7.4; 95% CI 3.9–14.3.) or lobular carcinoma in situ (RR 33.1; 95% CI 18.0–60.9) relative to women with non-proliferative disease. Approximately 82.9% (95% CI 80.8%–84.7%) of screening MRIs occurred among women who did not meet professional guidelines and 35.5% (95% CI 33.1–37.9%) among women considered at low-to-average breast cancer risk.ConclusionUtilization of screening MRI in community settings is not consistent with current professional guidelines and the goal of delivery of high-value care.

Population-based geographic access to parent and satellite National Cancer Institute Cancer Center Facilities

Satellite facilities of National Cancer Institute (NCI) cancer centers have expanded their regional footprints. This study characterized geographic access to parent and satellite NCI cancer center facilities nationally overall and by sociodemographics.

Availability of Advanced Breast Imaging at Screening Facilities Serving Vulnerable Populations

Objective Among vulnerable women, unequal access to advanced breast imaging modalities beyond screening mammography may lead to delays in cancer diagnosis and unfavourable outcomes. We aimed to compare on-site availability of advanced breast imaging services (ultrasound, magnetic resonance imaging [MRI], and image-guided biopsy) between imaging facilities serving vulnerable patient populations and those serving non-vulnerable populations. Setting 73 imaging facilities across five Breast Cancer Surveillance Consortium regional registries in the United States during 2011 and 2012. Methods We examined facility and patient characteristics across a large, national sample of imaging facilities and patients served. We characterized facilities as serving vulnerable populations based on the proportion of mammograms performed on women with lower educational attainment, lower median income, racial/ethnic minority status, and rural residence. We performed multivariable logistic regression to determine relative risks of on-site availability of advanced imaging at facilities serving vulnerable women versus facilities serving non-vulnerable women. Results Facilities serving vulnerable populations were as likely (Relative risk [RR] for MRI = 0.71, 95% Confidence Interval [CI] 0.42, 1.19; RR for MRI-guided biopsy = 1.07 [0.61, 1.90]; RR for stereotactic biopsy = 1.18 [0.75, 1.85]) or more likely (RR for ultrasound = 1.38 [95% CI 1.09, 1.74]; RR for ultrasound-guided biopsy = 1.67 [1.30, 2.14]) to offer advanced breast imaging services as those serving non-vulnerable populations. Conclusions Advanced breast imaging services are physically available on-site for vulnerable women in the United States, but it is unknown whether factors such as insurance coverage or out-of-pocket costs might limit their use.

Why Health Services Research Needs Geoinformatics: Rationale and Case Example

Delivery of health care in the United States has become increasingly complex over the past 50 years, as health care markets have evolved, technology has diffused, population demographics have shifted, and cultural expectations of health and health care have been transformed. Identifying and understanding important patterns of health care services, accessibility, utilization, and outcomes can best be accomplished by combining data from all of these dimensions in near-real time. The Big Data paradigm provides a new framework to bring together very large volumes of data from a variety of sources and formats, with computing capacity to derive new information, hypotheses, and inferences [1,2]. The complementary fields of genomics and bioinformatics have already made great advances only made possible by Big Data approaches. Similar gains can be made by pairing health services research with geoinformatics –- defined as “the science and technology dealing with the structure and character of spatial information, its capture, its classification and qualification, its storage, processing, portrayal and dissemination, including the infrastructure necessary to secure optimal use of this information” [3]. Integrating geospatial technologies with health services research brings informatics approaches, data sciences, and spatial theories of health and healthcare together to explore relationships among geography, health, and delivery of care in novel ways made possible through geoinformatics. synergy between the two disciplines will enhance our ability to discover how health care is delivered most effectively for the greatest health benefits across populations.

Monitoring of Technology Adoption Using Web Content Mining of Location Information and Geographic Information Systems: A Case Study of Digital Breast Tomosynthesis

PURPOSE To our knowledge, integration of Web content mining of publicly available addresses with a geographic information system (GIS) has not been applied to the timely monitoring of medical technology adoption. Here, we explore the diffusion of a new breast imaging technology, digital breast tomosynthesis (DBT). METHODS We used natural language processing and machine learning to extract DBT facility location information using a set of potential sites for the New England region of the United States via a Google search application program interface. We assessed the accuracy of the algorithm using a validated set of publicly available addresses of locations that provide DBT from the DBT technology vendor, Hologic. We quantified precision, recall, and F1 score, aiming for an F1 score of ≥ 95% as the desirable performance. By reverse geocoding on the basis of the results of the Google Maps application program interface, we derived a spatial data set for use in an ArcGIS environment. Within the GIS, a host of spatiotemporal analyses and geovisualization techniques are possible. RESULTS We developed a semiautomated system that integrated DBT location information into a GIS that was feasible and of reasonable quality. Initial accuracy of the algorithm was poor using only a search term list for information retrieval (precision, 35%; recall, 44%; F1 score, 39%), but performance dramatically improved by leveraging natural language processing and simple machine learning techniques to isolate single, valid instances of DBT location information (precision, 92%; recall, 96%; F1 score, 94%). Reverse geocoding yielded reliable geographic coordinates for easy implementation into a GIS for mapping and planned monitoring. CONCLUSION Our novel approach can be applicable to technologies beyond DBT, which may inform equitable access over time and space.

Partnering for Success: Expanding Breast and Cancer Screening in Rural Honduras One Clinic at a Time

Abstract 36Background:Women in rural Honduras have limited access to cancer education, screening, and care. With village leaders, we piloted breast and cervical cancer screening in El Rosario, Honduras. Our objectives were to improve awareness and access, mitigate barriers, connect community and Honduran providers, and link patients with abnormal findings to cancer treatment.In 2013, health professionals and staff from Norris Cotton Cancer Center at Dartmouth- Hitchcock joined Honduran clinicians and medical students from La Liga Contra el Cancer for two days of rural cancer screening. Peer educators taught 475 participants from 31 rural communities how to conduct self-breast exams. Of these participants, 238 chose clinical breast exams; 5% were clinically abnormal and 2.9% were referred for services at La Liga with 100% compliance. 34% reported barriers to cervical cancer screening due to distance and lack of transportation. 14.5% tested positive for HPV and 8% were positive for high risk HPV genotypes i...

Advanced Breast Imaging Availability by Screening Facility Characteristics

RATIONALE AND OBJECTIVES To determine the relationship between screening mammography facility characteristics and on-site availability of advanced breast imaging services required for supplemental screening and the diagnostic evaluation of abnormal screening findings. MATERIALS AND METHODS We analyzed data from all active imaging facilities across six regional registries of the National Cancer Institute-funded Breast Cancer Surveillance Consortium offering screening mammography in calendar years 2011-2012 (n = 105). We used generalized estimating equations regression models to identify associations between facility characteristics (eg, academic affiliation, practice type) and availability of on-site advanced breast imaging (eg, ultrasound [US], magnetic resonance imaging [MRI]) and image-guided biopsy services. RESULTS Breast MRI was not available at any nonradiology or breast imaging-only facilities. A combination of breast US, breast MRI, and imaging-guided breast biopsy services was available at 76.0% of multispecialty breast centers compared to 22.2% of full diagnostic radiology practices (P = .0047) and 75.0% of facilities with academic affiliations compared to 29.0% of those without academic affiliations (P = .04). Both supplemental screening breast US and screening breast MRI were available at 28.0% of multispecialty breast centers compared to 4.7% of full diagnostic radiology practices (P < .01) and 25.0% of academic facilities compared to 8.5% of nonacademic facilities (P = .02). CONCLUSIONS Screening facility characteristics are strongly associated with the availability of on-site advanced breast imaging and image-guided biopsy service. Therefore, the type of imaging facility a woman attends for screening may have important implications on her timely access to supplemental screening and diagnostic breast imaging services.