Sharon Bak

Fear of Falling among the Community-Dwelling Elderly

To assess the incidence of falls and the prevalence, intensity, and covariates of fear of falling among community-dwelling elderly, the authors surveyed a random sample of 196 residents (≥ 58 years of age) of housing developments for the elderly in Brookline and Plymouth, Massachusetts. Forty-three percent reported having fallen in recent years, 28% in the last year. Of those who had fallen within the year prior to the interview, 65% reported injury, 44% sought medical attention, and 15% required hospitalization as a consequence of their fall(s). Fear of falling ranked first when compared to other common fears (i.e., fear of robbery, financial fears). Self-rated health status and experience of previous falls were significantly associated with fear of falling. Further analysis suggests that fear of falling may affect social interaction, independent of risks for falling.

Identifying domestic violence in primary care practice

OBJECTIVE: To improve detection of domestic violence as a problem for women seeking primary care, we compared the addition of a single question about domestic violence on an existing self-administered health history form, to discretionary inquiry alone. We studied 689 consecutive new women patients in an internal medicine practice. Domestic violence identification rose from 0% in the control group with discretionary inquiry alone to 11.6% (95% confidence interval 8.8–14.4%) when the health history form included the following question: “At any time has a partner ever hit you, kicked you, or otherwise physically hurt you?” The addition of a single question can increase identification of domestic violence as a problem in patients’ lives.

BOSTON PATIENT NAVIGATION RESEARCH PROGRAM: The Impact of Navigation on Time to Diagnostic Resolution after Abnormal Cancer Screening

Background: There is a need for controlled studies to assess the impact of patient navigation in vulnerable cancer populations. Methods: Boston Patient Navigation Research Program conducted a quasi-experimental patient navigation intervention across six federally qualified inner-city community health centers, three assigned to a breast cancer navigation intervention and three assigned to a cervical cancer navigation intervention; each group then served as the control for the other. Eligible women had an abnormal breast or cervical cancer screening test conducted at one of the participating health centers during a baseline (2004–2005) or intervention period (2007–2008). Kaplan–Meier survival curves and proportional hazards regression examined the effect of patient navigation on time to definitive diagnosis, adjusting for covariates, clustering by clinic and differences between the baseline and intervention period. Results: We enrolled 997 subjects in the baseline period and 3,041 subjects during the intervention period, of whom 1,497 were in the navigated arm, and 1,544 in the control arm. There was a significant decrease in time to diagnosis for subjects in the navigated group compared with controls among those with a cervical screening abnormality [aHR 1.46; 95% confidence interval (CI), 1.1–1.9]; and among those with a breast cancer screening abnormality that resolved after 60 days (aHR 1.40; 95% CI, 1.1–1.9), with no differences before 60 days. Conclusions: This study documents a benefit of patient navigation on time to diagnosis among a racially/ethnically diverse inner city population. Impact: Patient navigation may address cancer health disparities by reducing time to diagnosis following an abnormal cancer-screening event. Cancer Epidemiol Biomarkers Prev; 21(10); 1645–54. ©2012 AACR.

Predictors of Timely Follow-Up After Abnormal Cancer Screening Among Women Seeking Care at Urban Community Health Centers

We sought to measure time and identify predictors of timely follow‐up among a cohort of racially/ethnically diverse inner city women with breast and cervical cancer screening abnormalities.

Impact of patient and navigator race and language concordance on care after cancer screening abnormalities.

Patient navigation improves the timely diagnosis of cancer among minorities, but little is known about the effects of patient and navigator race and language concordance on health outcomes.

Self-report versus medical record functional status

The importance of assessing functional status in the hospitalized patient is gaining recognition. However, the availability and accuracy of medical record functional status data are uncertain. We collected data on 2,504 patients greater than 65 years of age discharged alive. A personal interview conducted 2 days before discharge recorded the patients self-reported ability to perform 5 activities of daily living scales. Medical record abstraction was used independently to determine ability to perform the same activities of daily living scales. Patients who required any human assistance to perform a function were considered dependent. Patients were also contacted after discharge to determine the site of posthospital care (28% discharged to a nursing home). The amount of missing medical record functional status data varied by function from 20% for bathing to 50% for dressing. Ten percent of patients had no medical record functional status documentation concerning any of the five functions. The prevalence of self-reported dependence at discharge varied by function from 24% for feeding to 93% for bathing. The total number of dependencies differed between the two methods (medical records, 2.3 +/- 1.9; self-report data, 3.2 +/- 1.5). There was exact agreement between the two methods on the total number of dependencies in 28% of cases and differences of greater than or equal to 3 in 20%. In a stepwise logistic model predicting discharge to a nursing home and adjusting for other relevant variables, the number of dependencies as determined by self-report and medical record data each remained significant (Odds Ratios = 1.6). Self-report and medical record functional status data differ substantially, and the medical record data remain independently associated with nursing home placement. Several possible explanations for this finding are explored.

Adherence to conservative management recommendations for abnormal pap test results in adolescents.

OBJECTIVE: To investigate whether the 2006 American Society for Colposcopy and Cervical Pathology guidelines for conservative management of minimally abnormal Pap test results (atypical squamous cells of undetermined significance, human papillomavirus–positive, and low-grade squamous intraepithelial lesions) and moderate dysplasia (cervical intraepithelial neoplasia 2) in adolescents 1) resulted in fewer colposcopies and loop electrosurgical excision procedures (LEEPs) in adolescents or 2) resulted in unintended treatment changes in older age groups. METHODS: We analyzed data from 1,806 women aged 18 years and older attending one of six community health centers who were diagnosed with abnormal Pap test results between January 1, 2004, and December 31, 2008. We used multivariable logistic regression to examine treatment differences in women with minimally abnormal Pap test results before and after guideline changes. Variables included date of abnormality, site of care, race or ethnicity, language, and insurance type. We used Fisher exact tests to examine rates of LEEP in patients with moderate dysplasia before and after guideline publication. RESULTS: Among 206 women aged 18–20 years, rates of colposcopy after a minimally abnormal Pap test result decreased from 78% (n=102) to 45% (n=34) after guideline changes (P<.001). Colposcopy among women over age 21 (n=1,542) remained unchanged (greater than 90%). Multivariable logistic regression indicated that both date of abnormality and site of care were associated with colposcopy referral. After guideline changes, management of moderate dysplasia with LEEP in women aged 18–23 decreased from 55% to 18% (P=.04); rates remained stable in women ages 24 and older (70% compared with 74%; P=.72). CONCLUSION: Health care providers quickly adopted new conservative management guidelines for low-income, minority adolescents, which may reduce preterm deliveries in these high-risk populations. LEVEL OF EVIDENCE: II

Challenges in the Delivery of Quality Breast Cancer Care: Initiation of Adjuvant Hormone Therapy at an Urban Safety Net Hospital

PURPOSE Breast cancer treatment disparities in racial/ethnic minority and low-income populations are well documented; however, underlying reasons remain poorly understood. This study sought to identify barriers to the delivery of quality breast cancer treatment, addressing compliance with the National Quality Forum (NQF) quality metric for adjuvant hormone therapy (HT; administration of HT within 365 days of diagnosis in eligible patients) at an urban safety net hospital. METHODS This retrospective, observational study included women diagnosed with nonmetastatic, T1c or greater, estrogen and/or progesterone receptor-positive breast cancer from 2006 to 2008. Data sources included the hospital cancer registry and electronic medical record. Compliance with the NQF quality metric was defined as HT prescription within 365 days of diagnosis. Bivariate analysis compared compliant with noncompliant patients. Qualitative analysis assessed reasons for delayed compliance (HT at > 365 days) and never compliance (no HT at 4 years). RESULTS Of 113 eligible patients, the majority were racial/ethnic minority (56%), stage II (54%), unmarried (60%), and had public or no insurance (72%). Sixty-four percent were compliant, and 36% were noncompliant. Of the noncompliant, 78% had delayed compliance, and 22% were never compliant. Noncompliant patients were significantly more likely to be Black, Hispanic, foreign-born, and stage III at diagnosis. Ten reasons for delayed compliance were identified, including patient- and system-level barriers. Most patients (56%) had more than one reason contributing to delay. CONCLUSION Urgently needed interventions to reduce disparities in breast cancer treatment should take into account obstacles inherent among immigrant and indigent populations and complexities of multidisciplinary cancer care.

The Impact of Insurance Coverage during Insurance Reform on Diagnostic Resolution of Cancer Screening Abnormalities

We examined the impact of Massachusetts insurance reform on the care of women at six community health centers with abnormal breast and cervical cancer screening to investigate whether stability of insurance coverage was associated with more timely diagnostic resolution. We conducted Cox proportional hazards models to predict time from cancer screening to diagnostic resolution, examining the impact of 1) insurance status at time of screening abnormality, 2) number of insurance switches over a three-year period, and 3) insurance history over a three-year period. We identified 1,165 women with breast and 781 with cervical cancer screening abnormalities. In the breast cohort, Medicaid insurance at baseline, continuous public insurance, and losing insurance predicted delayed resolution. We did not find these effects in the cervical cohort. These data provide evidence that stability of health insurance coverage with insurance reform nationally may improve timely care after abnormal cancer screening in historically underserved women.

The Impact of Health Insurance Reform on Insurance Instability

We investigated the impact of the 2006 Massachusetts health care reform on insurance coverage and stability among minority and underserved women. We examined 36 months of insurance claims among 1,946 women who had abnormal cancer screening at six community health centers pre-(2004–2005) and post-(2007–2008) insurance reform. We examined frequency of switches in insurance coverage as measures of longitudinal insurance instability. On the date of their abnormal cancer screening test, 36% of subjects were publicly insured and 31% were uninsured. Post-reform, the percent ever uninsured declined from 39% to 29% (p .001) and those consistently uninsured declined from 23% to 16%. To assess if insurance instability changed between the pre- and post-reform periods, we conducted Poisson regression models, adjusted for patient demographics and length of time in care. These revealed no significant differences from the pre- to post-reform period in annual rates of insurance switches, incident rate ratio 0.98 (95%- CI 0.88–1.09). Our analysis is limited by changes in the populations in the pre- and post-reform period and inability to capture care outside of the health system network. Insurance reform increased stability as measured by decreasing uninsured rates without increasing insurance switches.