Lisa Dubay

Disparities in diabetes: The nexus of race, poverty, and place

OBJECTIVES We sought to determine the role of neighborhood poverty and racial composition on race disparities in diabetes prevalence. METHODS We used data from the 1999-2004 National Health and Nutrition Examination Survey and 2000 US Census to estimate the impact of individual race and poverty and neighborhood racial composition and poverty concentration on the odds of having diabetes. RESULTS We found a race-poverty-place gradient for diabetes prevalence for Blacks and poor Whites. The odds of having diabetes were higher for Blacks than for Whites. Individual poverty increased the odds of having diabetes for both Whites and Blacks. Living in a poor neighborhood increased the odds of having diabetes for Blacks and poor Whites. CONCLUSIONS To address race disparities in diabetes, policymakers should address problems created by concentrated poverty (e.g., lack of access to reasonably priced fruits and vegetables, recreational facilities, and health care services; high crime rates; and greater exposures to environmental toxins). Housing and development policies in urban areas should avoid creating high-poverty neighborhoods.

A New Framework for Childhood Health Promotion: The Role of Policies and Programs in Building Capacity and Foundations of Early Childhood Health

Although the connection between early life experiences and later health is becoming increasingly clear, what is needed, now, is a new organizing framework for childhood health promotion, grounded in the latest science. We review the evidence base to identify the steps in the overall pathway to ensuring better health for all children. A key factor in optimizing health in early childhood is building capacities of parents and communities. Although often overlooked, capacities are integral to building the foundations of lifelong health in early childhood. We outline a framework for policymakers and practitioners to guide future decision-making and investments in early childhood health promotion.

Access to Primary and Preventive Care among Foreign-Born Adults in Canada and the United States

OBJECTIVE To conduct cross-country comparisons and assess the effect of foreign birth on access to primary and preventive care in Canada and the United States. DATA SOURCES Secondary data from the 2002 to 2003 Joint Canada-United States Survey of Health. STUDY DESIGN Descriptive and comparative analyses were conducted, and logistic regression models were used to assess the effect of immigrant status and country of residence on access to care. Outcomes included measures of health care systems and processes, utilization, and patient perceptions. PRINCIPAL FINDINGS In adjusted analyses, immigrants in Canada fared worse than nonimmigrants regarding having timely Pap tests; in the United States, immigrants fared worse for having a regular doctor and an annual consultation with a health professional. Immigrants in Canada had better access to care than immigrants in the United States; most of these differences were explained by differences in socioeconomic status and insurance coverage across the two countries. However, U.S. immigrants were more likely to have timely Pap tests than Canadian immigrants, even after adjusting for potential confounders. CONCLUSIONS In both countries, foreign-born populations had worse access to care than their native-born counterparts for some indicators but not others. However, few differences in access to care were found when direct cross-country comparisons were made between immigrants in Canada versus the United States, after accounting for sociodemographic differences.

The Impact of CHIP on Children's Insurance Coverage: An Analysis Using the National Survey of America's Families

OBJECTIVE To assess the impact of the Childrens Health Insurance Program (CHIP) on the distribution of health insurance coverage for low-income children. DATA SOURCE The primary data for the study were from the 1997, 1999, and 2002 National Survey of Americas Families (NSAF), which includes a total sample of 62,497 children across all 3 years, supplemented with data from other data sources. STUDY DESIGN The study uses quasi-experimental designs and tests the sensitivity of the results to using instrumental variable and difference-in-difference approaches. A detailed Medicaid and CHIP eligibility model was developed for this study. Balanced repeated replicate weights were used to account for the complex sample of the NSAF. Descriptive and multivariate analyses were conducted. PRINCIPLE FINDINGS The results varied depending on the approach utilized but indicated that the CHIP program led to significant increases in public coverage (14-20 percentage points); and declines in employer-sponsored coverage (6-7 percentage points) and in uninsurance (7-12 percentage points). The estimated share of CHIP enrollment attributable to crowd-out ranged from 33 to 44 percent. Smaller crowd-out effects were found for Medicaid-eligible children. CONCLUSIONS Implementation of the CHIP program resulted in large increases in public coverage with estimates of crowd-out consistent with initial projections made by the Congressional Budget Office. This paper demonstrates that public health insurance expansions can lead to substantial reductions in uninsurance without causing a large-scale erosion of employer coverage.

Improving Coverage And Access For Immigrant Latino Children: The Los Angeles Healthy Kids Program

A large number of California counties have recently taken bold steps to extend health insurance to all poor and near-poor children through county-based Childrens Health Initiatives. One initiative, the Los Angeles Healthy Kids program, extends coverage to uninsured children in families with incomes below 300 percent of the federal poverty level who are ineligible for Medi-Cal (California Medicaid) and Healthy Families (its State Childrens Health Insurance Program). A four-year evaluation of Healthy Kids finds that the program has improved access for more than 40,000, most of whom are immigrant Latino children, who have almost no access to employer coverage. However, sustaining this effective program has proved to be challenging.

Trends of human papillomavirus testing in cervical cancer screening at a large academic cytology laboratory.

OBJECTIVE: To estimate time trends of actual provider use of human papillomavirus (HPV) testing in cervical cancer screening by using laboratory and administrative data from the Johns Hopkins Hospital Division of Cytopathology in Baltimore, Maryland. METHODS: In this ecologic trend study, we analyzed 178,510 Pap specimen records and 12,221 HPV tests among 85,048 patients from 2001 to 2007. Monthly frequencies and proportions of HPV reflex testing and HPV cotesting with Pap (stratified by patient ages 30 and older and 18–29 years) were calculated. Time trends of monthly HPV testing proportions were analyzed using joinpoint regression methods. RESULTS: From April 2002, when the American Society for Colposcopy and Cervical Pathology added HPV reflex testing to its guidelines, to December 2007, the monthly the proportion of reflex testing was 95.8%. From February 2004, when the society added HPV cotesting with Pap among women aged 30 years or older to its guidelines, to December 2007, the overall proportion HPV cotesting with Pap among patients aged 30 years or older was 7.8% (compared with 4.9% among patients 18–29 years [P<.01]). The highest proportion of HPV cotesting among women aged 30 years or older, 15%, was observed in September 2006, and the trend later plateaued around 13%. The monthly proportions of HPV reflex testing and cotesting with Pap changed significantly over time. CONCLUSION: These data reveal that a small percentage of women aged 30 years or older received HPV cotesting with Pap, thus identifying a significant opportunity for providers to improve patient care in cervical cancer prevention. LEVEL OF EVIDENCE: III

Abstract B94: The effect of clinic on identifying predictors of HPV co-testing with Pap in routine cervical cancer screening

Background: Human papillomavirus (HPV) co-testing with Pap is recommended for cervical cancer screening among women ≥ 30 years. However, little has been reported regarding actual provider use of HPV co-testing with Pap in clinical practice. Purpose: We sought to identify predictors of HPV co-testing with Pap among women ≥ 30 years by utilizing laboratory and administrative data from the Johns Hopkins Hospital Division of Cytopathology in Baltimore, MD. Methods: We analyzed 51,027 Pap specimen records and 4,148 HPV test records among 30,272 women ≥ 30 years in 88 clinics from February 2004 to December 2007. The outcome was HPV co-testing with Pap among women ≥ 30 years, and covariates included patient race, age, insurance type, ZIP code median household income, and calendar year. We constructed population-average logistic regression models. These included robust standard error estimation for clinic clustering and, at times, a fixed-effects estimator for within-clinic effects. We also stratified our analyses to five individual clinics. Results: The overall proportion of HPV co-testing with Pap was 8.1%. Notably, 12.8% of Pap specimens of black women received HPV co-testing compared to 5.2% for specimens of white women and 6.2% for those of women of other races (p Conclusions: Under a population-average public health approach, the predictors of HPV co-testing with Pap varied between the pooled analyses and clinic stratified analyses. Using fixed-effects estimation to account for between-clinics effects in the pooled analyses provided further evidence for the substantial influence of clinics on the findings. This research suggests that the predictors of HPV co-testing with Pap among women ≥ 30 years likely lay at the provider and/or clinic level(s). Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B94.