Melissa Ward-Peterson

Association Between Race/Ethnicity and Survival of Melanoma Patients in the United States Over 3 Decades: A Secondary Analysis of SEER Data.

AbstractMelanoma is a treatable and preventable skin cancer. It is responsible for 75% of deaths among all skin cancers. Previous studies have found that race/ethnicity may play a role in survival among melanoma patients. However, there are no studies that cover 30 years and take race into account for the U.S. population.This study is a secondary analysis of the National Cancer Institutes Surveillance, Epidemiology, and End Result (SEER) Program. Adults with primary cutaneous melanoma from 1982 to 2011 were included; the final sample size was 185,219. The outcome was survival; both cause-specific and all-cause mortality were examined. The main exposure was race/ethnicity. Kaplan–Meier survival analysis was used to estimate overall survival. Cox proportional hazards regression was used to estimate unadjusted and adjusted hazard ratios (HRs). A P-value less than 0.05 was considered statistically significant.More than 50% of patients in all races/ethnicities were diagnosed at the in situ or localized stage. Non-Hispanic White patients were more frequently diagnosed at the in situ stage. Overall, more men were diagnosed than women. The majority of cases among all races were men. Non-Hispanic Black females represented the smallest percentage of melanoma cases among all races. The smallest number of diagnoses across all races/ethnicities was made from 1982 to 1991. Median follow-up was 81 months and no collinearity was observed in the adjusted models. When examining cause-specific mortality and controlling for site and stage at diagnosis, gender, age and decade of diagnosis, the HR for non-Hispanic Black patients was lower than that for non-Hispanic White patients (HR 0.7; 95% confidence interval (CI): 0.6–0.8). However, when examining all-cause mortality, this difference disappeared (HR 1.1; 95% CI: 1.0–1.2). Stage at diagnosis impacted HR; patients diagnosed with distant metastases had significantly worse survival.When taking cause-specific mortality into consideration and after controlling for stage and site at diagnosis, gender, and age and decade of diagnosis, non-Hispanic Black patients had a lower HR compared to non-Hispanic White patients. However, this difference disappeared when examining all-cause mortality. Further research is needed to explore this finding and to determine what factors may be associated with late-stage melanoma diagnosis.

Physician tracking in sub-Saharan Africa: current initiatives and opportunities

BackgroundPhysician tracking systems are critical for health workforce planning as well as for activities to ensure quality health care - such as physician regulation, education, and emergency response. However, information on current systems for physician tracking in sub-Saharan Africa is limited. The objective of this study is to provide information on the current state of physician tracking systems in the region, highlighting emerging themes and innovative practices.MethodsThis study included a review of the literature, an online search for physician licensing systems, and a document review of publicly available physician registration forms for sub-Saharan African countries. Primary data on physician tracking activities was collected as part of the Medical Education Partnership Initiative (MEPI) - through two rounds over two years of annual surveys to 13 medical schools in 12 sub-Saharan countries. Two innovations were identified during two MEPI school site visits in Uganda and Ghana.ResultsOut of twelve countries, nine had existing frameworks for physician tracking through licensing requirements. Most countries collected basic demographic information: name, address, date of birth, nationality/citizenship, and training institution. Practice information was less frequently collected. The most frequently collected practice fields were specialty/degree and current title/position. Location of employment and name and sector of current employer were less frequently collected. Many medical schools are taking steps to implement graduate tracking systems. We also highlight two innovative practices: mobile technology access to physician registries in Uganda and MDNet, a public-private partnership providing free mobile-to-mobile voice and text messages to all doctors registered with the Ghana Medical Association.ConclusionWhile physician tracking systems vary widely between countries and a number of challenges remain, there appears to be increasing interest in developing these systems and many innovative developments in the area. Opportunities exist to expand these systems in a more coordinated manner that will ultimately lead to better workforce planning, implementation of the workforce, and better health.

Racial disparities in cancer-related survival in patients with squamous cell carcinoma of the esophagus in the US between 1973 and 2013

Background Esophageal cancer makes up approximately 1% of all diagnosed cancers in the US. There is a persistent disparity in incidence and cancer-related mortality rates among different races for esophageal squamous cell carcinoma (SCC). Most previous studies investigated racial disparities between black and white patients, occasionally examining disparities for Hispanic patients. Studies including Asians/Pacific Islanders (API) as a subgroup are rare. Our objective was to determine whether there is an association between race and cancer-related survival in patients with esophageal SCC. Methods and findings This was a retrospective cohort study using the National Cancer Institute’s Surveillance, Epidemiology, and End Result (SEER) database. The SEER registry is a national database that collects information on all incident cancer cases in 13 states of the United States and covers nearly 26% of the US population Patients aged 18 and over of White, Black, or Asian/Pacific Islander (API) race with diagnosed esophageal SCC from 1973 to 2013 were included (n = 13,857). To examine overall survival, Kaplan-Meier curves were estimated for each race and the log-rank test was used to compare survival distributions. Cox proportional hazards models were used to estimate unadjusted and adjusted hazard ratios with 95% confidence intervals. The final adjusted model controlled for sex, marital status, age at diagnosis, decade of diagnosis, ethnicity, stage at diagnosis, and form of treatment. Additional analyses stratified by decade of diagnosis were conducted to explore possible changes in survival disparities over time. After adjustment for potential confounders, black patients had a statistically significantly higher hazard ratio compared to white patients (HR 1.08; 95% confidence interval (CI) 1.03–1.13). However, API patients did not show a statistically significant difference in survival compared with white patients (HR 1.00; 95% CI 0.93–1.07). Patients diagnosed between 1973 and 1979 had twice the hazard of death compared to those diagnosed between 2000 and 2013 (HR 2.05, 95% CI 1.93–2.19). Patients diagnosed in 1980–1989 and 1990–1999 had had HRs of 1.59 (95% CI 1.51–1.68) and 1.33 (95% CI 1.26–1.41), respectively. After stratification according to decade of diagnosis, the HR for black patients compared with white patients was 1.14 (95% CI 1.02–1.29) in 1973–1979 and 1.12 (95% CI 1.03–1.23) in 1980–1989. These disparities were not observed after 1990; the HR for black patients compared with white patients was 1.03 (95% CI 0.93–1.13) in 1990–1999 and 1.05 (95% CI 0.96–1.15) in 2000–2013. Conclusions Black patients with esophageal SCC were found to have a higher hazard of death compared to white and API patients. Survival disparities between races appear to have decreased over time. Future research that takes insurance status and other social determinants of health into account should be conducted to further explore possible disparities by race.

The association between pregnancy intendedness and experiencing symptoms of postpartum depression among new mothers in the United States, 2009 to 2011: A secondary analysis of PRAMS data.

Abstract Postpartum depression (PPD) is a form of major depressive disorder affecting approximately 13% of women worldwide. Unintended pregnancies, reaching close to 50% of the pregnancies in the United States, have become a major health concern. While many physiologic and psychosocial causes have been analyzed, few studies have examined the relationship between unintended pregnancy and symptoms of PPD. A cross-sectional study was conducted using surveillance data from the Centers for Disease Control and Preventions Pregnancy Risk Assessment Monitoring System (PRAMS) from 2009 to 2011. The PRAMS population-based random sample included women who have had recent live births and is representative of 78% of the United States population. The chi-squared test was used to examine bivariate associations. Binary logistic regression was utilized to study unadjusted and adjusted associations between PPD and pregnancy intendedness, as well as other demographic and clinical characteristics of mothers in the sample. Multicollinearity in the adjusted model was evaluated using variance inflation factors. Sampling weights were used to account for PRAMS’ complex sampling design. Of the 110,231 mothers included in the sample, only 32.3% reported desiring the pregnancy at the time of conception. Women with pregnancies categorized as mistimed: desired sooner, mistimed: desired later, or unwanted were 20% (adjusted odds ratio [AOR] = 1.2; 95% confidence interval [CI]: 1.1–1.3), 30% (AOR = 1.3; 95% CI: 1.2–1.4), and 50% (AOR = 1.5; 95% CI: 1.3–1.7) more likely to experience symptoms of PPD, respectively, compared to women with desired pregnancies. Other factors found to be associated with experiencing symptoms of PPD were a gestational age of <27 weeks (AOR = 3.1; 95% CI: 2.5–4.0), having a previous history of depression (AOR = 1.8; 95% CI: 1.6–2.0), and being abused during or before pregnancy (AOR = 1.6; 95% CI: 1.4–2.0). We found that women with mistimed or unwanted pregnancies were more likely to experience symptoms of PPD. Our findings support the current US Preventive Services Task Force and American Academy of Pediatrics recommendations for an integrated approach to screening for depression, aiding in the maximization of intervention and early referral for women at risk for PPD.

Racial/ethnic disparities in annual mammogram compliance among households in Little Haiti, Miami-Dade County, Florida: An observational study.

IntroductionBreast cancer is the most commonly diagnosed cancer and the 2nd leading cause of cancer-related deaths among women in the U.S. Although routine screening via mammogram has been shown to increase survival through early detection and treatment of breast cancer, only 3 out of 5 women age ≥40 are compliant with annual mammogram within the U.S. and the state of Florida. A breadth of literature exists on racial/ethnic disparities in compliance with mammogram; however, few such studies include data on individual Black subgroups, such as Haitians. This study assessed the association between race/ethnicity and annual mammogram compliance among randomly selected households residing in the largely Haitian community of Little Haiti, Miami-Dade County (MDC), Florida. MethodsThis study used cross-sectional, health data from a random-sample, population-based survey conducted within households residing in Little Haiti between November 2011 and December 2012 (n = 951). Mammogram compliance was defined as completion of mammogram by all female household members within the 12 months prior to the survey. The association between mammogram compliance and race/ethnicity was assessed using binary logistic regression models. Potential confounders were identified as factors that were conservatively associated with both compliance and race/ethnicity (P ⩽ 0.20). Analyses were restricted to households containing at least 1 female member age ≥40 (n = 697). ResultsOverall compliance with annual mammogram was 62%. Race/ethnicity was significantly associated with mammogram compliance (P = 0.030). Compliance was highest among non-Hispanic Black (NHB) households (75%), followed by Hispanic (62%), Haitian (59%), and non-Hispanic White (NHW) households (51%). After controlling for educational level, marital status, employment status, the presence of young children within the household, health insurance status, and regular doctor visits, a borderline significant disparity in mammogram compliance was observed between Haitian and NHB households (adjusted odds ratio = 1.63, P = 0.11). No other racial/ethnic disparities were observed. DiscussionCompliance with annual mammogram was low among the surveyed households in Little Haiti. Haitian households underutilized screening by means of annual mammogram compared with NHB households, although this disparity was not significant. Compliance rates could be enhanced by conducting individualized, mammogram screening-based studies to identify the reasons behind low rate of compliance among households in this underserved, minority population.

Association of ventricular arrhythmia and in-hospital mortality in stroke patients in Florida: A nonconcurrent prospective study.

Abstract Stroke remains one of the leading causes of death in the United States. Current evidence identified electrocardiographic abnormalities and cardiac arrhythmias in 50% of patients with an acute stroke. The purpose of this study was to assess whether the presence of ventricular arrhythmia (VA) in adult patients hospitalized in Florida with acute stroke increased the risk of in-hospital mortality. Secondary data analysis of 215,150 patients with ischemic and hemorrhagic stroke hospitalized in the state of Florida collected by the Florida Agency for Healthcare Administration from 2008 to 2012. The main outcome for this study was in-hospital mortality. The main exposure of this study was defined as the presence of VA. VA included the ICD-9 CM codes: paroxysmal ventricular tachycardia (427.1), ventricular fibrillation (427.41), ventricular flutter (427.42), ventricular fibrillation and flutter (427.4), and other – includes premature ventricular beats, contractions, or systoles (427.69). Differences in demographic and clinical characteristics and hospital outcomes were assessed between patients who developed versus did not develop VA during hospitalization (&khgr;2 and t tests). Binary logistic regression was used to estimate unadjusted and adjusted odds ratios and 95% confidence intervals (CIs) between VA and in-hospital mortality. VA was associated with an increased risk of in-hospital mortality after adjusting for all covariates (odds ratio [OR]: 1.75; 95% CI: 1.6–1.2). There was an increased in-hospital mortality in women compared to men (OR: 1.1; 95% CI: 1.1–1.14), age greater than 85 years (OR: 3.9, 95% CI: 3.5–4.3), African Americans compared to Whites (OR: 1.1; 95% CI: 1.04–1.2), diagnosis of congestive heart failure (OR: 2.1; 95% CI: 2.0–2.3), and atrial arrhythmias (OR: 2.1, 95% CI: 2.0–2.2). Patients with hemorrhagic stroke had increased odds of in-hospital mortality (OR: 9.0; 95% CI: 8.6–9.4) compared to ischemic stroke. Identifying VAs in stroke patients may help in better target at risk populations for closer cardiac monitoring during hospitalization. The impact of implementing methods of quick assessment could potentially reduce VA associated sudden cardiac death.

Effect of charted mental illness on reperfusion therapy in hospitalized patients with an acute myocardial infarction in Florida

Abstract Patients with mental illness carry risk factors that predispose them to excess cardiovascular mortality from an acute myocardial infarction (AMI) compared to the general population. The aim of this study was to determine if patients with AMI and charted mental illness (CMI) received less reperfusion therapy following an AMI, compared to AMI patients without CMI in a recent sample population from Florida. A secondary analysis of data was conducted using the Florida Agency for Health Care Administration (FL-AHCA) hospital discharge registry. Adults hospitalized with an AMI from 01/01/2010 to 12/31/2015 were included for the analysis. The dependent variable was administration of reperfusion therapy (thrombolytic, percutaneous coronary intervention [PCI], and coronary artery bypass graft [CABG]), and the independent variable was the presence of CMI (depression, schizophrenia, and bipolar disorder). Multivariate logistic regression models were used to test the association controlling for age, gender, ethnicity, race, health insurance, and comorbidities. The database included 61,614 adults (31.3% women) hospitalized with AMI in Florida. The CMI population comprised of 1036 patients (1.7%) who were on average 5 years younger than non-CMI (60.2 ±12.8 versus 65.2 ±14.1; P < .001). Compared with patients without CMI, patients with CMI had higher proportions of women, governmental health insurance holders, and those with more comorbidities. The adjusted odds ratio indicated that patients with CMI were 30% less likely to receive reperfusion therapy compared with those without CMI (OR = 0.7; 95% CI = 0.6–0.8). Within the AMI population including those with and without CMI, women were 23% less likely to receive therapy than men; blacks were 26% less likely to receive reperfusion therapy than whites; and those holding government health insurances were between 20% and 40% less likely to receive reperfusion therapy than those with private health insurance. Patients with AMI and CMI were statistically significantly less likely to receive reperfusion therapy compared with patients without CMI. These findings highlight the need to implement AMI management care aimed to reduce disparities among medically vulnerable patients (those with CMI, women, blacks, and those with governmental health insurance).

Examining the association between possessing a regular source of healthcare and adherence with cancer screenings among Haitian households in Little Haiti, Miami-Dade County, Florida.

Abstract Immigrant minorities regularly experience higher incidence and mortality rates of cancer. Frequently, a variety of social determinants create obstacles for those individuals to get the screenings they need. This is especially true for Haitian immigrants, a particularly vulnerable immigrant population in South Florida, who have been identified as having low cancer screening rates. While Haitian immigrants have some of the lowest cancer screening rates in the country, there is little existing literature that addresses barriers to cancer screenings among the population of Little Haiti in Miami-Dade County, Florida. The objective of this study was to evaluate the association between having a regular source of healthcare and adherence to recommended cancer screenings in the Little Haiti population of Miami. This secondary analysis utilized data collected from a random-sample, population-based household survey conducted from November 2011 to December 2012 among a geographic area approximating Little Haiti in Miami-Dade County, Florida. A total of 421 households identified as Haitian. The main exposure of interest was whether households possessed a regular source of care. Three separate outcomes were considered: adherence with colorectal cancer screening, mammogram adherence, and Pap smear adherence. Analysis was limited to households who met the age criteria for each outcome of interest. Bivariate associations were examined using the chi square test and Fisher exact test. Binary logistic regression was used to estimate unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). After adjusting for the head of households education and household insurance status, households without a regular source of care were significantly less likely to adhere with colorectal cancer screening (OR = 0.33; 95% CI: 0.14–0.80) or mammograms (OR = 0.28; 95% CI: 0.11–0.75). Households with insurance coverage gaps were significantly less likely to adhere with mammograms (OR = 0.40; 95% CI: 0.17–0.97) or Pap smears (OR = 0.28; 95% CI: 0.13–0.58). Our study explored adherence with multiple cancer screenings. We found a strong association between possessing a regular source of care and adherence with colorectal cancer screening and mammogram adherence. Targeted approaches to improving access to regular care may improve adherence to cancer screening adherence among this unique immigrant population.

Non-Directive Pregnancy Options Counseling: Online Instructional Module, Objective Structured Clinical Exam, and Rater and Standardized Patient Training Materials

Introduction Many patients receiving news of an unplanned pregnancy need not only a test result, but also the initiation of pregnancy options counseling. Thus, this online instructional module and objective structured clinical examination (OSCE) aim to provide foundational training for medical students in nondirective pregnancy options counseling. Methods To further the validity of a previously published OSCE, we reconsidered content, revised the checklist, and produced videos for rater training. We also developed a 30-minute preparatory module outlining a stepwise approach and providing a structured opportunity for values clarification. The 10-minute OSCE scenario involves a 24-year-old woman presenting to an urgent care center with persistent nausea who receives the diagnosis of an early, unplanned pregnancy. She responds to the news with shock and emotional silence, asking for guidance. We conducted the OSCE with 46 third-year medical students on the family medicine clerkship. Immediately after the OSCE, students completed a survey and self-assessment, followed by an individualized feedback session with a faculty member. Results In the self-assessment phase, students reflected on how successfully they utilized methods in the online module for handling emotional silence and presenting options. Student self-identified areas for improvement highlighted use of terminology and their response to difficult emotional encounters in the future. Discussion This online module and validated OSCE provide a valued opportunity for learners to practice nondirective pregnancy options counseling skills, including screening for intimate partner violence and reproductive coercion, engagement in self-assessment and receiving feedback, and engaging in personal values clarification.

Using multilevel models to evaluate the influence of contextual factors on HIV/AIDS, sexually transmitted infections, and risky sexual behavior in sub-Saharan Africa: a systematic review

PURPOSE To describe the use of multilevel models (MLMs) in evaluating the influence of contextual factors on HIV/AIDS, sexually transmitted infections (STIs), and risky sexual behavior (RSB) in sub-Saharan Africa. METHODS Ten databases were searched through May 29, 2016. Two reviewers completed screening and full-text review. Studies examining the influence of contextual factors on HIV/AIDS, STIs, and RSB and using MLMs for analysis were included. The Quality Assessment Tool for Quantitative Studies was used to evaluate study quality. RESULTS A total of 118 studies met inclusion criteria. Seventy-four studies focused on HIV/AIDS-related topics; 46 focused on RSB. No studies related to STIs other than HIV/AIDS met the eligibility criteria. Of five studies examining HIV serostatus and community socioeconomic factors, three found an association between poverty and measures of inequality and increased HIV prevalence. Among studies examining RSB, associations were found with numerous contextual factors, including poverty, education, and gender norms. CONCLUSIONS Studies using MLMs indicate that several contextual factors, including community measures of socioeconomic status and educational attainment, are associated with a number of outcomes related to HIV/AIDS and RSB. Future studies using MLMs should focus on contextual-level interventions to strengthen the evidence base for causality.