Kristi L. Allgood

Disparities in screening mammography services by race/ethnicity and health insurance.

BACKGROUND Black and Hispanic women are diagnosed at a later stage of breast cancer than white women. Differential access to specialists, diffusion of technology, and affiliation with an academic medical center may be related to this stage disparity. METHODS We analyzed data from a mammography facility survey for the metropolitan region of Chicago, Illinois, to assess in part whether quality breast imaging services were equally accessed by non-Hispanic white, non-Hispanic black, and Hispanic women and by women with and without private insurance. Of 49 screening facilities within the city of Chicago, 43 facilities completed the survey, and 40 facilities representing about 149,000 mammograms, including all major academic facilities, provided data on patient race/ethnicity. RESULTS Among women receiving mammograms at the facilities we studied, white women were more likely than black or Hispanic women to have mammograms at academic facilities, at facilities that relied exclusively on breast imaging specialists to read mammograms, and at facilities where digital mammography was available (p<0.001). Women with private insurance were similarly more likely than women without private insurance to have mammograms at facilities with these characteristics (p<0.001). CONCLUSIONS Black and Hispanic women and women without private insurance are more likely than white women and women with private insurance to obtain mammography screening at facilities with less favorable characteristics. A disparity in use of high-quality mammography may be contributing to disparities in breast cancer mortality.

Implementing peer-based interventions in clinic-based settings: Lessons from a multi-site HIV prevention with positives initiative

ABSTRACT Interventions for people with HIV/AIDS became a national priority in 2003. While the importance of involving HIV-positive people in the design, delivery, and evaluation of prevention programs is widely recognized, information about how to implement peer-based services in clinic settings is sparse. The four projects described in this article implemented peer-based interventions as part of larger, multi-site Special Projects of National Significance (SPNS) initiative. Common themes reported by Project Directors/Evaluators describe the challenges and benefits of peer-based interventions across these programs, including infrastructural, clinical and research-related issues. We also discuss the benefits to Peers, researchers, and the clinics sites.

Recall and Cancer Detection Rates for Screening Mammography: Finding the Sweet Spot

OBJECTIVE The purpose of this study is to identify the optimal screening mammography recall rate range on the basis of cancer detection rates among breast imaging specialists at an academic institution. MATERIALS AND METHODS Medical outcome audit data collected in accordance with the Mammography Quality Standards Act from September 1, 2007, through August 31, 2012, were reviewed. Cancer detection rates were calculated from 984 screen-detected cancers identified in 188,959 total digital screening mammograms. The percentages of minimally invasive and early-stage cancers were also calculated. The 75 annual recall rates were analyzed two ways. First, they were separated into recall groups to assess cancer detection rate variation by the recall categories using rate ratios: less than 10%, 10% to less than 12%, 12% to less than 14%, and 14% or higher. Next, a linear regression with bootstrap bias correction was performed to assess changes in cancer detection rate with each unit increase in the recall rate up to 20%, with the recall category of less than 7% taken as reference. Annual cancer detection rates for a physician were grouped according to annual percentage recall rate. RESULTS Statistically significantly higher cancer detection rates were seen for recall rates 12% or higher, with rate ratios of 1.75 (95% CI, 1.40-2.19) and 2.06 (95% CI, 1.72-2.46) for the recall groups 12% to less than 14% and 14% and higher, respectively, compared with the less than 10% group. When taking the category 12% to less than 14% as the reference, there were no statistically significant differences between recall groups 12% to less than 14% and 14% or higher in cancer detection rate. A statistically significant increase in the cancer detection rate with each unit increase in the recall rate was seen only for recall rates 12% or higher. CONCLUSION These observations suggest that the sweet spot for optimal cancer detection is in the recall rate range 12% to less than 14% with the incremental benefit above this to be relatively small. A recall rate less than 10% may be too low.

Metrics for the Systematic Evaluation of Community-Based Outreach

There is an extensive literature on the use of community-based outreach for breast health programs. While authors often report that outreach was conducted, there is rarely information provided on the effort required for outreach. This paper seeks to establish a template for the systematic evaluation of community-based outreach. We describe three types of outreach used by our project, explain our evaluation measures, present data on our outreach efforts, and demonstrate how these metrics can be used to inform a project’s decisions about which types of outreach are most effective.

Keys to the Successful Implementation of Community-Based Outreach and Navigation: Lessons from a Breast Health Navigation Program.

The well-documented racial disparities in breast cancer mortality have prompted an aggressive response from the public health community, including the development and implementation of breast health education and breast cancer navigation programs. Many programs are successfully reaching women and providing education and motivation to get screened, and separately, many programs are successfully navigating women who have received abnormal results from a screening mammogram and need follow-up. However, a crucial gap in services remains, where women in the community are not receiving systematic navigation to their initial screening mammogram. This paper describes a community-based, community health worker-led breast health education and screening navigation program, details the metrics used to measure navigation outcomes, and discusses unique features of this project which could be adapted within other settings to initiate similar programming.

Validating Self-Reported Mammography Use in Vulnerable Communities: Findings and Recommendations

Background: Most health surveys ask women whether they have had a recent mammogram, all of which report mammography use (past 2 years) at about 70% to 80% regardless of race or residence. We examined the potential extent of overreporting of mammography use in low income African-American and Latina women, and whether self-report inaccuracies might bias estimated associations between patient characteristics and mammography use. Methods: Using venue-based sampling in two poor communities on the west side of Chicago, we asked eligible women living in two west side communities of Chicago to complete a survey about breast health (n = 2,200) and to provide consent to view their medical record. Of the 1,909 women who screened eligible for medical record review, 1,566 consented (82%). We obtained medical records of all women who provided both permission and a valid local mammography facility (n = 1,221). We compared the self-reported responses from the survey with the imaging reports found in the medical record (documented). To account for missing data, we conducted multiple imputations for key demographic variables and report standard measures of accuracy. Results: Although 73% of women self-reported a mammogram in the last 2 years, only 44% of self-reports were documented. Overreporting of mammography use was observed for all three ethnic groups. Conclusions: These results suggest considerable overestimation of prevalence of use in these vulnerable populations. Impact: Relying on known faulty self-reported mammography data as a measure of mammography use provides an overly optimistic picture of utilization, a problem that may be exacerbated in vulnerable minority communities. Cancer Epidemiol Biomarkers Prev; 23(8); 1649–58. ©2014 AACR.

Implementing Routine HIV Screening in Three Chicago Hospitals: Lessons Learned.

Objective. This study describes routine HIV screening implementation and outcomes in three hospitals in Chicago, Illinois. Methods. Retrospective data from three hospitals were examined, and routine testing procedures, testing volume, reactive test results, and linkage-to-care outcomes were documented. Results. From January 2012 through March 2014, 40,788 HIV tests were administered at the three hospitals: 18,603 (46%) in the emergency department (ED), 7,546 (19%) in the inpatient departments, and 14,639 (36%) in outpatient clinics. The screened patients varied from 1% to 22% of the total eligible patient population across hospitals. A total of 297 patients tested positive for HIV for a seropositivity rate of 0.7%; 129 (43%) were newly diagnosed and 168 (57%) were previously diagnosed, with 64% of those previously diagnosed out of care at the time of screening. The inpatient areas had the highest seropositivity rate (0.6%). The percentage of newly diagnosed patients overall who were linked to care was 77%. Of newly diagnosed patients, 51% had ≥1 missed opportunity for testing (with a mean of 3.8 visits since 2006), and 30% of patients with missed opportunities were late testers (baseline CD4+ counts <200 cells per cubic millimeter). Conclusion. Routine screening is an essential tool for identifying new infections and patients with known infection who are out of care. Hospitals need to provide HIV screening in inpatient and outpatient settings—not just EDs—to decrease missed opportunities. Routine screening success will be driven by how notification and testing are incorporated into the normal medical flow, the level of leadership buy-in, the ability to conduct quality assurance, and local testing laws.

Black:White Disparities in HIV Mortality in the United States: 1990-2009.

ObjectivesThe aim of this study was to assess whether racial disparities in human immunodeficiency virus (HIV) mortality in the USA have changed over time.MethodsUsing vital records from the National Center for Health Statistics and census data from the US Census Bureau, we calculated the race- and gender-specific HIV mortality rates and corresponding racial rate ratios for non-Hispanic Blacks and non-Hispanic Whites in the USA for four 5-year increments from 1990–2009. Rates were age-adjusted using the 2000 USA standard population. Additionally, we calculated excess Black deaths for 2005–2009.ResultsFor the total, male, and female populations, we observed a statistically significant increase in the Black:White HIV mortality disparity between T1 (1990–1994) and T4 (2005–2009). The increasing disparity was due to the fact that the decrease in mortality rates from T1 to T4 was greater among Whites than Blacks. This disparity led to 5603 excess Black deaths in the USA at T4.ConclusionsPrevious research suggests that as HIV becomes more treatable, racial disparities widen, as observed in this study for both men and women. Existing disparities could be ameliorated if access to care were equal among these groups. Equal access would enable more individuals to achieve viral suppression, the final step of the HIV Care Continuum.

History of Traumatic Events in HIV-Positive Individuals: Risk Behavior Implications in an Urban Clinic Setting

As HIV/AIDS continues to disproportionately affect African American communities, the need for culturally appropriate, tailored interventions for this clientele is growing. Although prevention efforts often include information about individual coping and mental health, not all programs address the role of traumatic events, including community violence in relation to HIV risk. The authors implemented the Treatment Advocacy Program-Sinai with HIV-positive individuals at a large urban hospital. After controlling for demographics and other psychosocial factors, they found that a history of traumatic events—domestic, sexual, and community violence—were associated with sexual risk behavior for men and women in our sample; however, community violence was overwhelming associated with sexual risk for women. Based on the prevalence of violence and the relationship with sexual risk, they discuss implications for prevention interventions in urban clinic settings.

Screening Mammography Need, Utilization and Capacity in Chicago: Can We Fulfill Our Mission and Our Promises?

There is a widening Black:White breast cancer mortality disparity in Chicago (Figure 1). In 1980 the mortality rates were equal; by 2005 Black women were nearly twice as likely to die from breast cancer (Ansell et al, 2009; Whitman et al, 2011). This disparity has been increasing since the early 1990’s because the breast cancer mortality rates for Black women in Chicago have remained constant while the rates for White women have decreased substantially (Whitman et al, 2011). Additionally, this disparity in Chicago is unusually high. For example, in 2005 the breast cancer mortality rate for Black women in Chicago was 43.2 per 100,000 population and the rate for White women was 21.8 per 100,000 population (Whitman et al, 2011). This equates to a rate ratio of 1.98 (43.2/21.8) which is interpreted by stating that in 2005 Black women were 98% more likely to die from breast cancer than White women in Chicago. More recent data suggests that Black women in Chicago are 62% more likely to die from breast cancer using the 2005-2007 three-year average (38.3/23.6=1.62) (Figure 1). Disparities are seen in other cities as well. For example, in New York City the Black:White breast cancer disparity in 2005 was 37% (Whitman et al, 2011). These data suggest that Black women in Chicago are not benefiting from the technological advancements that have been made in early detection and treatment over the last two decades (Berry et al, 2005; Smith-Bindman et al, 2006; Tehranifar et al, 2009).