Michael A. Posner

Improving follow-up to abnormal breast cancer screening in an urban population. A patient navigation intervention.

Delays in follow‐up after cancer screening contribute to racial/ethnic disparities in cancer outcomes. We evaluated a patient navigator intervention among inner‐city women with breast abnormalities. A full‐time patient navigator supported patients using the care management model. Female patients 18 years and above, referred to an urban, hospital‐based, diagnostic breast health practice from January to June 2000 (preintervention) and November 2001 to February 2003 (intervention), were studied. Timely follow‐up was defined as arrival to diagnostic evaluation within 120 days from the date the original appointment was scheduled. Data were collected via computerized registration, medical records, and patient interview. Bivariate and multivariate logistic regression analyses were conducted, comparing preintervention and intervention groups, with propensity score analysis and time trend analysis to address the limitations of the pre–post design. 314 patients were scheduled preintervention; 1018, during the intervention. Overall, mean age was 44 years; 40% black, 36% non‐Hispanic white, 14% Hispanic, 4% Asian, 5% other; 15% required an interpreter; 68% had no or only public insurance. Forty‐four percent of referrals originated from a community health center, 34% from a hospital‐based practice. During the intervention, 78% had timely follow‐up versus 64% preintervention (P < .0001). In adjusted analyses, women in the intervention group had 39% greater odds of having timely follow‐up (95% CI, 1.01–1.9). Timely follow‐up in the adjusted model was associated with older age (P = .0003), having private insurance (P = .006), having an abnormal mammogram (P = .0001), and being referred from a hospital‐based practice, as compared to a community health center (P = .003). Our data suggest a benefit of patient navigators in reducing delay in breast cancer care for poor and minority populations. Cancer 2007.

Using Claims Data to Examine Mortality Trends Following Hospitalization for Heart Attack in Medicare

OBJECTIVE To see if changes in the demographics and illness burden of Medicare patients hospitalized for acute myocardial infarction (AMI) from 1995 through 1999 can explain an observed rise (from 32 percent to 34 percent) in one-year mortality over that period. DATA SOURCES Utilization data from the Centers for Medicare and Medicaid Services (CMS) fee-for-service claims (MedPAR, Outpatient, and Carrier Standard Analytic Files); patient demographics and date of death from CMS Denominator and Vital Status files. For over 1.5 million AMI discharges in 1995-1999 we retain diagnoses from one year prior, and during, the case-defining admission. STUDY DESIGN We fit logistic regression models to predict one-year mortality for the 1995 cases and apply them to 1996-1999 files. The CORE model uses age, sex, and original reason for Medicare entitlement to predict mortality. Three other models use the CORE variables plus morbidity indicators from well-known morbidity classification methods (Charlson, DCG, and AHRQs CCS). Regressions were used as is--without pruning to eliminate clinical or statistical anomalies. Each model references the same diagnoses--those recorded during the pre- and index admission periods. We compare each models ability to predict mortality and use each to calculate risk-adjusted mortality in 1996-1999. PRINCIPAL FINDINGS The comprehensive morbidity classifications (DCG and CCS) led to more accurate predictions than the Charlson, which dominated the CORE model (validated C-statistics: 0.81, 0.82, 0.74, and 0.66, respectively). Using the CORE model for risk adjustment reduced, but did not eliminate, the mortality increase. In contrast, adjustment using any of the morbidity models produced essentially flat graphs. CONCLUSIONS Prediction models based on claims-derived demographics and morbidity profiles can be extremely accurate. While one-year post-AMI mortality in Medicare may not be worsening, outcomes appear not to have continued to improve as they had in the prior decade. Rich morbidity information is available in claims data, especially when longitudinally tracked across multiple settings of care, and is important in setting performance targets and evaluating trends.

Post-Hospital Medical Respite Care and Hospital Readmission of Homeless Persons

Medical respite programs offer medical, nursing, and other care as well as accommodation for homeless persons discharged from acute hospital stays. They represent a community-based adaptation of urban health systems to the specific needs of homeless persons. This article examines whether post-hospital discharge to a homeless medical respite program was associated with a reduced chance of 90-day readmission compared to other disposition options. Adjusting for imbalances in patient characteristics using propensity scores, respite patients were the only group that was significantly less likely to be readmitted within 90 days compared to those released to Own Care. Respite programs merit attention as a potentially efficacious service for homeless persons leaving the hospital.

Comparing Standard Regression, Propensity Score Matching, and Instrumental Variables Methods for Determining the Influence of Mammography on Stage of Diagnosis

In situations where randomized trials are not feasible, analysis of observational data must be used instead. However, when using observational data, there is often selection bias for which we must account in order to adjust for pre-treatment differences between groups in their baseline characteristics. As an example of this, we used the Linked Medicare-Tumor Registry Database created by the National Cancer Institute and the Centers for Medicare and Medicaid Services to look at screening with mammography in older women to determine its effectiveness in detecting cancer at an earlier stage. The standard regression method and two methods of adjusting for selection bias are compared. We start with the standard analysis, a logistic regression predicting stage at diagnosis that includes as independent variables a set of covariates to adjust for differences in baseline risk plus an indicator variable for whether the woman used screening. Next, we employ propensity score matching, which evens out the distribution of measured baseline characteristics across groups, and is more robust to model mis-specification than the standard analysis. Lastly, we conduct an instrumental variable analysis, which addresses unmeasured differences between the users and non-users. This article compares these methods and discusses issues of which researchers and analysts should be aware. It is important to look beyond the standard analysis and to consider propensity score matching when there is concern about group differences in measured covariates and instrumental variable analysis when there is concern about differences in unmeasured covariates.

Pap smear rates among Haitian immigrant women in eastern Massachusetts.

Objective. Given limited prior evidence of high rates of cervical cancer in Haitian immigrant women in the U.S., this study was designed to examine self-reported Pap smear screening rates for Haitian immigrant women and compare them to rates for women of other ethnicities. Methods. Multi-ethnic women at least 40 years of age living in neighborhoods with large Haitian immigrant populations in eastern Massachusetts were surveyed in 2000–2002. Multivariate logistic regression analyses were used to examine the effect of demographic and health care characteristics on Pap smear rates. Results. Overall, 81% (95% confidence interval 79%, 84%) of women in the study sample reported having had a Pap smear within three years. In unadjusted analyses, Pap smear rates differed by ethnicity (p=0.003), with women identified as Haitian having a lower crude Pap smear rate (78%) than women identified as African American (87%), English-speaking Caribbean (88%), or Latina (92%). Women identified as Haitian had a higher rate than women identified as non-Hispanic white (74%). Adjustment for differences in demographic factors known to predict Pap smear acquisition (age, marital status, education level, and household income) only partially accounted for the observed difference in Pap smear rates. However, adjustment for these variables as well as those related to health care access (single site for primary care, health insurance status, and physician gender) eliminated the ethnic difference in Pap smear rates. Conclusions. The lower crude Pap smear rate for Haitian immigrants relative to other women of color was in part due to differences in (1) utilization of a single source for primary care, (2) health insurance, and (3) care provided by female physicians. Public health programs, such as the cancer prevention programs currently utilized in eastern Massachusetts, may influence these factors. Thus, the relatively high Pap rate among women in this study may reflect the success of these programs. Public health and elected officials will need to consider closely how implementing or withdrawing these programs may impact immigrant and minority communities.

Evaluation of the Centers for Disease Control and Prevention's Recommendations Regarding Routine Testing for Human Immunodeficiency Virus by an Inpatient Service: Who Are We Missing?

OBJECTIVE To assess the proportion of hospitalized patients who tested positive for human immunodeficiency virus (HIV) by a routine inpatient testing service, as recommended by the Centers for Disease Control and Prevention, who might not have been identified had routine testing not been offered. PATIENTS AND METHODS In this retrospective cohort study, the medical records of patients who tested HIV positive by the inpatient testing service between 1999 and 2003 were compared with the medical records of inpatients who tested HIV negative by the inpatient testing service and the medical records of patients who tested HIV positive in ambulatory settings. We compared HIV risk factors, discharge diagnoses, CD4 cell counts, and HIV RNA concentrations. RESULTS A total of 243 patients participated in this study: 81 patients who tested HIV positive and 81 who tested HIV negative by the inpatient testing service, and 81 patients who tested HIV positive in ambulatory settings. Both HIV-positive inpatients and HIV-positive outpatients had similar frequencies of HIV risk factors (46% vs 43%; P=.75). Both groups differed significantly from HIV-negative inpatients (4%; P<.001). Comparing HIV-positive inpatients with HIV-positive outpatients, CD4 cell counts were lower (196 vs 371 cells/mm3; P<.001), and HIV RNA levels were higher (4.61 vs 4.09 Iog, HIV RNA; P=.001). At diagnosis, 64 HIV-positive inpatients (79%) met criteria for acquired immunodeficiency syndrome compared with 21 HIV-positive outpatients (26%) (P<.001). CONCLUSION Patients who tested HIV positive through inpatient testing have more advanced disease than those identified as outpatients. Half of these patients would not have been identified had testing not been routinely offered. Routine inpatient HIV testing offers an important opportunity to identify patients with HIV infection.

Brief Substance Abuse Treatment with Urban Adolescents: A Translational Research Study.

The purpose of this translational research study was to test a brief, manualized adolescent substance abuse treatment protocols effects in an urban community setting compared to a sample in an experimental study from which the treatment was first employed. One hundred two adolescents who were treated with a manualized protocol of five sessions of Motivational Enhancement Therapy/Cognitive Behavioral Therapy (MET/CBT-5) were followed for six months and outcomes were analyzed against a comparison sample (n = 102). Both groups were treated with (MET/CBT-5). The community setting group showed reduced alcohol use relative to the comparison group at six months using unadjusted measures and at three and six months using propensity score analyses to adjust for the differences in baseline characteristics of the two groups. These findings support using brief, manualized treatments for diverse, urban adolescents in outpatient community settings.

Four Perspectives on Flipping the Statistics Classroom: Changing Pedagogy to Enhance Student-Centered Learning

Abstract The term “flipped” or “inverted” classroom includes a broad range of pedagogical innovations, and has recently received a significant amount of press. Although flipping an entire course might be a more extreme step than most are able to take, we discuss modular ideas for change that can be more easily implemented. This paper offers the perspective of four faculty members at different institutions who have all flipped material in statistics courses that were already highly interactive and activity-based. We share common pitfalls and core ideas that were found among diverse environments.

Engagement in High-Risk Behaviors Among Young Adult Survivors of Childhood Cancer Compared to Healthy Same-Age Peers Surveyed in the National Longitudinal Study of Adolescent Health

PURPOSE This secondary data analysis compared smoking rates, alcohol consumption, and binge drinking, and examined risk factors for engaging in these behaviors among 90 young adult-aged childhood cancer survivors (CSS) with 15,490 young adults in the general population. METHODS The sample was drawn from the National Longitudinal Study of Adolescent Health. The sampling distribution of these healthy matched young adults was estimated through the use of bootstrapping, which involved randomly repeated for 10,000 samples of healthy controls. RESULTS The findings of repeated sampling analysis revealed that CCS were more likely to smoke daily (34.5% vs. 20.6 healthy matched controls; p = 0.03). The proportion of respondents who had any signs of alcohol abuse symptoms was 72.2% of CCS compared with 81.1% of matched controls (p = 0.16), while CCS with severe alcohol abuse was 51.1% compared with 59.1% of matched controls (p = 0.28). Whether they engaged in binge drinking in the past 12 months was 43.3% for CCS and 46.4% for healthy respondents. Logistic regression analyses were performed to examine predictors of smoking, alcohol use, and binge drinking among CCS. Smoking was very strongly associated with optimism. An optimism score of one unit higher was associated with a 39% reduction in odds of smoking (odd ratio [OR] = 0.61, p < 0.0001). Black CSS were less likely to smoke (OR = 0.15, p < 0.05). CCS in good health were more likely to binge drink (OR = 3.67, p < 0.05). CONCLUSIONS Data generated from this secondary data analyses add to the evidence base about the engagement in high risk behaviors among young adult-aged CCS. These findings further emphasize the need for widespread, available effective theory-based screening guidelines and interventions.

Psychological distress between young adult female survivors of childhood cancer and matched female cohorts surveyed in the adolescent health study.

Background: The psychological health of childhood cancer survivors is an essential treatment outcome. Female survivors are a subgroup of survivors with an increased risk for poor psychological outcomes. Objective: This study compared psychological distress in young adult female survivors of childhood cancer with that in young adult females in the general population with no history of childhood cancer. Psychological distress was measured by assessing respondents’ subjective degree of depressive symptoms, anxiety, and somatization. Methods: The study was a secondary data analysis. The sample was drawn from the National Longitudinal Study of Adolescent Health, which used a representative, probability-based sampling technique. The sample included 66 young adult female survivors of childhood cancer and 8186 young adult females with no history of cancer. Randomized, nonparametric testing was used to construct 10 000 different age-matched female cohort samples from the general population. Results: Young adult female survivors of childhood cancer had more depressive symptoms (P < .05) as compared with matched cohorts with 589 of the 10 000 matched samples. There were no statistically significant differences between the cancer survivors and the matched cohort groups on anxiety and somatization symptoms. Conclusion: Young adult female survivors of childhood cancer are at an increased risk of experiencing depression, which can decrease their psychological functioning and emotional well-being. Implications for Practice: Healthcare professionals who care for these cancer survivors need to be aware that female survivors are at risk for depression and should screen and refer accordingly.