Subprime outcomes: turmoil in the mortgage market

Until 2007, few Americans had probably heard the word “subprime” - including many homeowners who would come to learn that their own mortgage was a subprime mortgage. Today, subprime mortgages are much discussed because they lie at the center of the turmoil that roiled credit markets in 2007 and 2008.Subprime mortgage

Ethnic Disparities in Cervical Cancer Survival Among Medicare Eligible Women in a Multiethnic Population

To determine predictors of cervical cancer survival by socioeconomic status (SES), urbanization, race/ethnicity, comorbid conditions, and treatment among elderly Medicare-eligible women whose conditions were diagnosed with cervical cancer in a multiethnic population. Methods: A total of 538 women with cervical cancer aged 65 years or older were identified from 1999 to 2001 from the Texas Cancer Registry and were linked with the state Medicare data and Texas Vital Records to determine survival times. All women had similar access to care through Medicare fee-for-services insurance. A composite measure of SES was created using census tract-level data as was urbanization. Treatment and comorbid conditions were available from the Medicare data. Cox proportional hazards modeling was used for all-cause and cervical cancer-specific survival analysis. Results: Increased age (P \u3c 0.0001) and advanced tumor stage (P \u3c 0.0001) were associated with poorer all-cause and cervical cancer-specific survival. Having a comorbid condition was associated with all-cause survival (P \u3c 0.01) but not cervical cancer-specific mortality. After adjusting for confounders, women receiving some form of treatment were almost half as likely to die with cervical cancer (adjusted hazard ratio = 0.68; 95% confidence interval, 0.52-0.89). After adjustment for all confounders, Hispanic women consistently had lower all-cause and cervical cancer-specific mortality rates relative to non-Hispanic white and non-Hispanic black women. Conclusions: Among women with similar health care coverage, Hispanic women had consistently lower all-cause and cervical cancer-specific mortality rates than other older women whose conditions were diagnosed with this disease in Texas. The presence of comorbid conditions and treatment were important predictors of survival, yet these factors do not explain the survival advantage for Hispanic women

Adherence to Recommendations for Follow-up to Abnormal Pap Tests

OBJECTIVE: To evaluate whether timely adherence rates differ by race among women with abnormal Pap tests participating in a cost-free or reduced-cost program. METHODS: Eligible subjects included women aged 47-64 years who received a referral for follow-up care after an abnormal Pap test from 1999 to 2002 in South Carolina (n=330). Adherence was measured as days to receipt of follow-up care after an abnormal Pap test. Cox proportional hazards modeling was used to estimate risk factors associated with time to adherence within 60 and 365 days by race. RESULTS: African-American and non-Hispanic white women had similar adherence to follow-up. Among white women, those with high-grade lesions were less likely to adhere in a timely manner relative to those with low-grade lesions (hazard ratio 0.6, 95% confidence interval [CI] 0.4-1.0). For African-American women, rural residence (hazard ratio: 0.5, 95% CI 0.2-0.9) and history of abnormal Pap tests (hazard ratio 0.6, 95% CI 0.3-1.0) were associated with decreased adherence, whereas less education (hazard ratio 2.3, 95% CI 1.3-3.9) was associated with increased adherence. CONCLUSION: Adherence rates do not differ by race. However, risk factors for adherence within race are variable. Interventions tailored to the differential needs of racial and ethnic groups may prove effective toward increasing timely adherence rates. LEVEL OF EVIDENCE: I

Racial/Ethnic Disparities in Survival among Men Diagnosed with Prostate Cancer in Texas

BACKGROUND: To the authors\u27 knowledge, few studies to date have examined racial differences in prostate cancer survival while controlling for socioeconomic status (SES). No such studies have examined this association in Texas, a large state with significant ethnic and racial diversity. The objective of this analysis was to determine whether racial disparities in survival for men diagnosed with prostate cancer in Texas from 1995 through 2002 remained after adjusting for SES, rural residence, and stage of disease. METHODS: A cohort of 87,449 men who were diagnosed with prostate cancer was identified from the Texas Cancer Registry. The SES measure was based on census tract data reflecting median household income, median home value, and percentages of men living below poverty, with a college education, and with a management or professional occupation. The 5-year survival rates were calculated using the Kaplan-Meier method and Cox proportional hazard modeling was used to estimate hazard ratios (HRs) for race and all-cause and disease-specific mortality. RESULTS: After adjusting for SES, age, stage of disease, tumor grade, year of diagnosis, and rural residence, both black and Hispanic men were more likely (adjusted HR [aHR], 1.70 [95% confidence interval (95% CI), 1.58-1.83] and aHR, 1.11 [95% CI, 1.02-1.20], respectively) to die of prostate cancer compared with white men. The pattern of survival disadvantage for black men held for those diagnosed with localized disease and advanced disease, and for those with an unknown stage of disease at diagnosis. CONCLUSIONS: Substantial racial disparities in prostate cancer survival were found for men in Texas. Future studies should incorporate treatment data as well as comorbid conditions because this information may explain noted survival disparities

Understanding Barriers for Adherence to Follow-Up Care for Abnormal Pap Tests

Objective: Approximately 4000 women annually will die from preventable and treatable cervical cancer. Failure to adhere to follow-up recommendations after an abnormal Pap test can lead to development of cervical cancer. This paper summarizes the body of literature on adherence to follow-up after an abnormal Pap test in order to facilitate development of interventions to decrease morbidity and mortality due to cervical cancer. Methods: We conducted a comprehensive search of published literature addressing risk factors for adherence or interventions to improve adherence following an abnormal Pap test as the outcome. We included peer-reviewed original research conducted in the United States from 1990 to 2005. Results: Fourteen analytical and twelve experimental studies that met our criteria were reviewed. Lesion severity and health beliefs were consistently associated with adherence rates. Communication interventions, including telephone reminders, counseling, and educational sessions, increased follow-up compliance across intervention studies. Inconsistent evidence for associations among race, income, and age were found. Conclusions: Further research is needed to reinforce current studies addressing health beliefs and social support. Interventions that focus on the interplay among psychological, educational, and communication barriers are necessary. These interventions should be adapted and applied across various racial/ethnic and socioeconomic groups to reach all women with a high-risk profile for invasive cervical cancer

Cervical Cancer Survival by Socioeconomic Status, Race/Ethnicity, and Place of Residence in Texas, 1995–2001

Objective: The current study explored whether socioeconomic status (SES), race/ethnicity, and rural residence may be linked to poorer cervical cancer survival by stage at diagnosis. Methods: Data from 7,237 cervical cancer cases reported to the Texas Cancer Registry from 1995–2001 were used to address the association by stage at diagnosis and cause of death. Zip code-level census data were used to classify residence and to develop a composite variable for SES. Multilevel Cox proportional hazards modeling was used to estimate hazard ratios (HR) and 95% confidence intervals (CI). Results: Late stage at diagnosis was a strong predictor of cervical cancer mortality (HR _6.2, 95% CI 5.5-7.2). SES and race/ethnicity were independently associated with stage at diagnosis. Women residing in areas with lower SES had significantly shorter survival times when diagnosed at an early stage (HR _ 3.0, 95% CI 2.1-4.3). Hispanic women had a lower probability of dying from cervical cancer during the follow-up period (HR _ 0.7, 95% CI 0.6- 0.8) after adjusting for confounders. The association between lower SES and poorer survival was consistent across all racial/ethnic groups, suggesting the effect of SES may be more important than race. Conclusions: SES and race/ethnicity were independently associated with poorer cervical cancer survival in this large Texas sample. Further research is needed to investigate the role of optimal treatment and comorbid conditions in the association between SES and cervical cancer survival

Harnessing Electronic Health Records for Public Health Surveillance

Electronic medical record (EMR) systems are a rich potential source for detailed, timely, and efficient surveillance of large populations. We created the Electronic medical record Support for Public Health (ESP) system to facilitate and demonstrate the potential advantages of harnessing EMRs for public health surveillance. ESP organizes and analyzes EMR data for events of public health interest and transmits electronic case reports or aggregate population summaries to public health agencies as appropriate. It is designed to be compatible with any EMR system and can be customized to different states’ messaging requirements. All ESP code is open source and freely available. ESP currently has modules for notifiable disease, influenza-like illness syndrome, and diabetes surveillance. An intelligent presentation system for ESP called the RiskScape is under development. The RiskScape displays surveillance data in an accessible and intelligible format by automatically mapping results by zip code, stratifying outcomes by demographic and clinical parameters, and enabling users to specify custom queries and stratifications. The goal of RiskScape is to provide public health practitioners with rich, up-to-date views of health measures that facilitate timely identification of health disparities and opportunities for targeted interventions. ESP installations are currently operational in Massachusetts and Ohio, providing live, automated surveillance on over 1 million patients. Additional installations are underway at two more large practices in Massachusetts