Talar Markossian

Impact of patient navigation in eliminating economic disparities in cancer care

Patient navigation may reduce cancer disparities associated with socioeconomic status (SES) and household factors. This study examined whether these factors were associated with delays in diagnostic resolution among patients with cancer screening abnormalities and whether patient navigation ameliorated these delays.

Increasing Cervical Cancer Screening in a Hispanic Migrant Farmworker Community through Faith-Based Clinical Outreach

Objective. Partnerships between academic medical centers and faith-based community organizations have been associated with increased screening rates in low-income minority women. We describe clinical outcomes of an outreach partnership between a cancer center and a faith-based outreach clinic offering gynecologic screening services in central Florida to increase cervical cancer screening adherence in a priority population of primarily Hispanic farmworker women. Methods. Data sources included a retrospective chart review. This descriptive study examined patterns of cervical cancer screening behavior among the patient population of the faith-based outreach clinic. Results. Findings suggest that among this group of patients, the demographic factors that predict adherence with cervical cancer screening recommendations are number of years having lived in the United States and marital status. Women residing in the United States for more than 5 years were significantly more adherent with cervical cancer screening recommendations compared with women who have resided in the United States for 5 years or less (p = .05), and married women were more likely to be adherent than unmarried women (p = .02). Conclusions. The partnership was successful in increasing cervical cancer screening adherence in this medically underserved population. When enabling barriers to screening adherence are removed through faith-based clinical outreach and engaged continuously for a number of years, uninsured, low-income Hispanic women are more likely to receive recommended preventive services.

Geographic and Racial Disparities in Breast Cancer–Related Outcomes in Georgia

OBJECTIVE To measure the effects of race/ethnicity, area measures of socioeconomic status (SES) and geographic residency status, and health care supply (HCS) characteristics on breast cancer (BC)-related outcomes. DATA SOURCES/STUDY SETTING Female patients in Georgia diagnosed with BC in the years 2000-2009. STUDY DESIGN Multilevel regression analysis with adjustment for variables at the county, census tract (CT), and individual level. The county represents the spatial unit of analysis for HCS. SES and geographic residency status were grouped at the CT level. PRINCIPAL FINDINGS Even after controlling for area-level characteristics, racial and ethnic minority women suffered an unequal BC burden. Despite inferior outcomes for disease stage and receipt of treatment, Hispanics had a marginally significant decreased risk of death compared with non-Hispanics. Higher CT poverty was associated with worse BC-related outcomes. Residing in small, isolated rural areas increased the odds of receiving surgery, decreased the odds of receiving radiotherapy, and decreased the risk of death. A higher per-capita availability of BC care physicians was significantly associated with decreased risk of death. CONCLUSIONS Race/ethnicity and area-level measures of SES, geographic residency status, and HCS contribute to disparities in BC-related outcomes.

Controversies Regarding Lipid Management and Statin Use for Cardiovascular Risk Reduction in Patients With CKD

Adults with chronic kidney disease (CKD) are at heightened risk for dying of cardiovascular disease. Results from randomized clinical trials of statin drugs versus placebo demonstrate that statin drugs or statin plus ezetimibe reduce the absolute risk for coronary heart disease and mortality among adults with non-dialysis-dependent CKD. The Kidney Disease: Improving Global Outcomes 2013 clinical practice guideline for lipid management in CKD recommends that adults 50 years or older with non-dialysis-dependent CKD be treated with a statin or statin plus ezetimibe regardless of low-density lipoprotein cholesterol levels. However, at least 9 guidelines published during the last 5 years address lipid management for primary and secondary prevention of atherosclerotic cardiovascular disease, and not all guidelines address the utility of lipid-lowering therapy in adults with CKD. Because most patients with CKD receive most of their clinical care from non-nephrologists, differences in recommendations for lipid-lowering therapy for cardiovascular disease prevention may negatively affect the clinical care of adults with CKD and cause confusion for both patients and providers. This review addresses the identification and management of lipid levels in patients with CKD and discusses the existing controversies regarding testing and treatment of lipid levels in the CKD population.

Potential impact of the Affordable Care Act's preventive services provision on breast cancer stage: A preliminary assessment

INTRODUCTION The Affordable Care Acts (ACA) preventive services provision (PSP) removes copayments for preventive services such as cancer screening. We examined: 1) whether a shift in breast cancer stage occurred, and 2) the impact of the provision on racial/ethnic disparities in stage. MATERIALS AND METHODS Data from the National Cancer Database were used. The pre- and post-PSP periods were identified as 2007-2009 and 2011-2013, respectively. Proportion differences (PDs) and 95% confidence Intervals (CIs) were calculated. RESULTS All three racial/ethnic groups experienced a statistically significant shift toward Stage I breast cancer. Pre-PSP, the black:white disparity in Stage I cancer was -9.5 (95% CI: -8.9, -10.4) and the Latina:white disparity was -5.2 (95% CI: -4.0, -6.1). Post-PSP, the disparities improved slightly. DISCUSSION Preliminary data suggest that the ACAs PSP may have a meaningful impact on cancer stage overall and by race/ethnicity. However, more time may be needed to see reductions in disparities.

Writing Your Grant for the Patient-Centered Outcomes Research Institute (PCORI)

The Patient-Centered Outcomes Research Institute (PCORI) represents a new way of doing research by emphasizing patient and stakeholder engagement and supporting comparative effectiveness research. In addition to investigator-initiated projects, PCORI also funded a national data network called PCORnet. PCORnet was established to foster observational and experimental comparative effectiveness research by providing a mechanism to collect electronic medical record data from hospitals, physicians’ offices, and clinics. Two sets of networks were created, one based on system-based networks from hospitals, health plans, and practice-based networks called clinical data research networks (CDRNs). The other network is operated and governed by patient groups and their partners called patient-powered research networks (PPRNs). Five priorities for PCORI funding include the following: assessment of prevention, diagnosis, and treatment options; improving healthcare systems; communication and dissemination research; addressing disparities; and accelerating patient-centered outcomes and methodological research. PCORI has funded 551 projects to date as of November 1, 2016, awarding 1.57 billion dollars in grant support. Even if PCORI is not renewed, it is anticipated that the CDRN and PPRNs established through PCORI will seek and be supported through funding from other agencies taking advantage of the large amounts of data representing populations across the country.

Abstract A88: A Preliminary Assessment of the Potential Impact of the Affordable Care Act on Breast Cancer Stage

Background: The Affordable Care Act (ACA) has provided phased-in changes in health care delivery and reimbursement. As of January 1, 2011, the ACA eliminated copayments/co-insurance for recommended preventive services in Medicare beneficiaries including breast cancer screening. Removing out-of-pocket expenses may encourage an uptake of preventative cancer care. Indeed, one study has found that compared with the pre-ACA period (2009-2010), there was a statistically significant increase in mammography uptake during the ACA coverage period (2011-2012). Mammography screening is associated with detection of breast cancer at early stages. Therefore, this provision of the ACA may increase the proportion of early stage diagnoses which are associated with less invasive treatment and improved outcomes. Furthermore, this ACA provision may help ameliorate racial/ethnic disparities in breast cancer stage because minorities are disproportionately represented among those targeted by the coverage provisions of the ACA. The purpose of the present analysis is to examine the impact of the elimination of copayments for screening on breast cancer stage (disparities) in the Medicare population. Methods: This study is a retrospective analysis of patients with breast cancer diagnosed between 2008 and 2013 who were included in the National Cancer Data Base (NCDB). Sponsored by the Commission on Cancer of the American College of Surgeons and the American Cancer Society, the NCDB is a nationwide cancer database that captures approximately 70% of all newly diagnosed cancers in the United States from approximately 1,500 hospitals accredited by the Commission on Cancer. Patients were included if they were: non-Latina (nL) white, nL black, or Latina; diagnosed with Stage I-IV cancer; Medicare-insured at the time of diagnosis; and age 66 years or older. The pre- and post-ACA periods of the preventative services provision were identified as 2008-2009 and 2011-2013, respectively. The year 2010 wastreated as a washout/phase-in period and was excluded. A pre-post design was used to examine a shift in the distribution of cancer stage and compare changes by race/ethnicity. Proportion differences were calculated. The binomial model with a link function was used to adjust differences by age and zip code-level economic indicators (i.e. median household income, percent with high school education). Results: We identified 213, 385 nL white, 21,452 nL black, and 7,980 Latina patients with an incident breast cancer diagnosis. Between the pre- and post-ACA periods, there was a statistically significant shift in the distribution of cancer stage. The proportion of Stage I cancers increased from 55.6% to 58.1% while it decreased for Stage II cancers from 29.5 to 27.9% (p Conclusion: The ACA9s elimination of copayments/co-insurance for preventive services such as cancer screening may have a meaningful impact on cancer outcomes. A preliminary assessment shows that it may lead to a shift in earlier stage breast cancers. The elimination of these out-of-pocket expenses for mammograms may particularly benefit Latina women who tend to have lower screening rates. These study findings should be interpreted in light of its limitations such as its cross-sectional design and lack of mammography screening assessment. More research is needed to understand the impact of the ACA on cancer care and outcomes. Citation Format: Abigail Silva, Talar Markossian, Yamile Molina. A Preliminary Assessment of the Potential Impact of the Affordable Care Act on Breast Cancer Stage. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A88.