Persistence with Mammography Screening and Stage at Breast Cancer Diagnosis among Elderly Appalachia-West Virginia Women

The objective of this study is to evaluate the association between persistence with mammography screening and stage at breast cancer diagnosis in elderly Appalachia-West Virginia women diagnosed with first incident breast cancer. The study utilized West Virginia Cancer Registry-Medicare linked database to identify women age 70 and above diagnosed with first incident breast cancer in 2007. Persistence to mammography screening was defined as having had at least three mammography screenings before breast cancer diagnosis. A multiple logistic regression was conducted to assess the association between persistence with mammography screening and stage at breast cancer diagnosis in these women. Of the 221 elderly Appalachia-West Virginia women included in the analysis, 113 women (51.1%) were persistent to mammography screening before their diagnosis with breast cancer. In a multiple logistic regression after adjusting for all the variables, as compared to elderly women who were not persistent with mammography screening, women who were persistent with mammography screening were significantly more likely to be diagnosed with early stage breast cancer (adjusted odds ratio=4.25, 95% confidence interval=1.96-9.19). Persistence with mammography screening is significantly associated with earlier stages of breast cancer in the rural and underserved Appalachia-West Virginia women. The study findings suggest targeting interventions to encourage regular mammography in these women for whom there are no clear guidelines

Predictors of Adherence to Mammography Screening Guidelines and Preferences for Intervention Strategies in a Mobile Mammography Program

Early detection of breast cancer (BC) in women can lead to long-term survival and better quality of life. Mammography screening is considered to be the \u27gold standard\u27 for women at an average risk to detect BC early and hence reduce BC-related mortality. West Virginia (WV) has a lower incidence of BC but higher rates of advanced and unstaged BC which has been attributed to lower mammography screening rates in women in WV. Mobile mammography programs have been in use for more than two decades to overcome barriers and increase mammography screening rates in rural and hard-to-reach populations. WV has one such mobile mammography program named Bonnie Wells Wilson Mobile Mammography Program (called Bonnie\u27s Bus hereafter). There are no reported studies on the profiles of women who utilize mobile mammography services and those who utilize stationary mammography facility and predictors of adherence to mammography screening guidelines in these two populations. Not much has been reported about what types of intervention strategies linked with mobile mammography are likely to improve screening rates thereby the effectiveness of a mobile mammography program. Though, many interventions effective in increasing screening rates have been reported in the literature, no studies have assessed the perspective of women at whom these interventions are targeted, such as their receptiveness towards these interventions and their perception of whether they would be successful with their peers and in their communities. Therefore, the objectives of this research study were: (1) to describe the profiles of women who utilize mobile mammography services, at the Bonnie\u27s Bus and those who utilize a stationary mammography facility, Betty Puskar Breast Care Center (BPBCC) in Morgantown, WV, and to identify the predictors of adherence to mammography screening guidelines in these populations, and (2) to determine what types of targeted educational interventions coupled with mobile mammography are perceived as likely to be acceptable and effective by women who had their first mammogram at the Bonnie\u27s Bus. A cross-sectional study was conducted with the primary data collected from 1,161 women age 40 years and above who utilized Bonnie\u27s Bus and 1,104 women age 40 years and above who utilized BPBCC using the \u27Mammography Screening and Preventive Care Survey\u27. The \u27expanded\u27 version of Andersen Behavioral Model for Health Services Utilization was utilized as the conceptual model. Structured telephone interviews of 16 women age 40 years and above residing in WV who reported never having had a mammogram prior to getting one through the Bonnie\u27s Bus were conducted. Descriptive statistics were used to separately describe the characteristics of women who utilized Bonnie\u27s Bus and the BPBCC. Chi-square statistics for categorical variables and t-tests for continuous variables were used separately in both the study samples to determine significant differences between self-reported adherent and non-adherent groups. Logistic regressions were also performed to analyze the relationship between self-reported adherence with all the constructs of Andersen model, after controlling for all the independent variables, separately for both the study samples. To determine whether or not women who did not participate in the study were different from women who participated, non-response bias was assessed in both the study samples. Thematic analysis of audio-recorded data from the telephone interviews was conducted to identify women\u27s receptiveness and preferences for various interventions. Among women who utilized mobile mammography unit, only 48.15% were adherent to mammography screening guidelines and among women who utilized stationary mammography facility, an overwhelming 92.3% were adherent to mammography screening guidelines. The predictors of self-reported adherence to mammography screening guidelines in women who utilized mobile mammography services were older age (adjusted odds ratio (AOR) = 2.025, 95% confidence interval (CI) = 1.489-2.754 for age group 50-64 years; AOR = 3.181, 95% CI = 1.904-5.314 for age 65 and above), unemployed status, extreme obesity (AOR = 1.880, 95% CI = 1.161-3.046) and morbid obesity (AOR = 1.918, 95% CI = 1.128-3.261), no reported delay in care due to transportation problem, family history of BC, breast biopsy in the past, and adherence to Pap test and routine screenings such as blood glucose, blood cholesterol, blood pressure and bone mineral density test. While the predictors of adherence to mammography screening guidelines in women who utilized stationary mammography facility were health insurance coverage, no reported delay in care due transportation problem, adherence to clinical breast exam (CBE), Pap test and other routine screenings, and having strong agreement with the positive views about mammography screening. The sources of information about health and mammography screening used by rural women who had their first mammogram at the Bonnie\u27s Bus mostly included doctors or obstetrician / gynecologist (OB/GYN), materials from library, health fairs, and internet. Among community-based interventions, community-based health educational programs that could be held at public places such as library or church or work-sites and among individual-level interventions, mailed educational materials were perceived to be the most helpful interventions. BC-related events such as family history of BC and having had biopsy, and adherence to screening tests were associated with adherence to mammography screening guidelines in older women who utilized mobile mammography services. While access factors, adherence to other screening tests such as CBE, Pap test and having strong positive views about mammography screening were associated with adherence to mammography screening guidelines in women who utilized stationary mammography facility. Intervention strategies such as community-based educational programs and mailed educational materials could be developed along with the mobile mammography unit that may be effective in attracting rural and underserved women in WV. Incorporating various information sources such doctor and/or OB/GYN, and internet in the intervention strategies may help gain synergistic effect on the mammography screening rates in women in WV

Burden of Breast Cancer and Associated Health and Economic Outcomes in Elderly Women in West Virginia: Comparison with National Estimates

West Virginia (WV) which is the only state which lies entirely in Appalachia and which is predominantly rural and medically underserved region, has lower incidence of breast cancer (BC) but a higher BC-related mortality as compared to the national averages in elderly women age 65 and above. This may be due to lower mammography utilization in these rural elderly women, limited physical access to services, shortage of healthcare professionals and services, and untimely and/or inappropriate care. This is dearth of epidemiological studies that have focused on understanding the factors associated with these disparities among these rural and underserved population such as WV. The purpose of this project was to do a detailed evaluation of burden of BC and its associated health and economic outcomes in elderly women in WV, and to compare these estimates with the national estimates. Three retrospective observational studies were conducted using West Virginia Cancer Registry-Medicare and Surveillance, Epidemiology, and End Results (SEER)-Medicare linked datasets for the years 2002-2007. In the first study, persistence with mammography screening and its effect on stage at BC diagnosis was investigated for the elderly rural WV women and was compared to the national estimates from SEER-Medicare data. The study found no significant differences in the representation of disease between WV-Medicare and SEER-Medicare cohorts even after controlling for persistence with mammography screening. In the second study, timeliness of BC care in regards to diagnosis and treatment as per the published opinion-based recommendations and its effect on chances of being alive at the follow-up period was determined for the WV-Medicare cohort and then was compared to the SEER-Medicare cohort. The study found that the WV-Medicare cohort was significantly less likely to receive timely diagnosis of BC as per recommendations when compared to the SEER-Medicare cohort. However, there were no significant differences between these cohorts for the timely treatment of BC. Also, delayed diagnosis was not associated with poorer prognosis in the WV-Medicare cohort. In the third study, average total healthcare costs in the initial phase of 12-months following BC diagnosis and costs by types of specific services were estimated for the WV-Medicare cohort and these were compared to the national estimates derived from the SEER-Medicare cohort. This study reported that average total healthcare costs, inpatient costs and physician services costs were significantly lower for the WV-Medicare cohort as compared to the SEER-Medicare cohort. Also, the decomposition analyses only explained total 16% of the differences in the average costs due to the cohorts\u27 characteristics. Overall, the findings of this project highlight the importance of persistence with mammography screening and timely BC care in the elderly, rural and underserved women diagnosed with BC. Moreover, these studies can serve as a foundation for larger studies aimed at decreasing BC disparities in a rural and geographically challenged state such as WV, through the development of strategies and interventions to foster early detection and timely treatment of BC among rural populations

Impact of Depression Treatment on Health-Related Quality of Life Among Adults with Cancer and Depression: A Population-Level Analysis.

PURPOSE: Cancer diagnosis in adults is often accompanied by negative impacts, which increase the risk of depression thereby lowering health-related quality of life (HRQoL). We examined the association between depression treatment and HRQoL among US adults with cancer and depression. METHODS: Patients age 18 and above, with self-reported cancer and depression diagnoses were identified from Medical Expenditure Panel Survey database for 2006-2013. Baseline depression treatment was categorized as antidepressants only, psychotherapy with or without antidepressant use, and no reported use of antidepressants or psychotherapy. HRQoL was measured using SF-12 physical component summary (PCS) and mental component summary (MCS) scores. Adjusted ordinary least squares regressions estimated the association between type of depression treatment and HRQoL. RESULTS: Out of 450 (weighted per calendar year: 2.1 million) cancer adults included in the study, 51% received antidepressants only, while 16% received psychotherapy with or without antidepressants. In bivariate analyses, the mean MCS score was lowest among those who received psychotherapy with or without antidepressants compared to those receiving antidepressants only and those with no reported use of either modality, p \u3c 0.05. In multivariate analyses, there was no significant difference in HRQoL by type of depression treatment. CONCLUSION: Despite treatment for depression, HRQoL did not improve during the measurement timeframe. Quality of life is a priority health outcome in cancer treatment, yet our findings suggest that current clinical approaches to ameliorate depression in cancer patients appear to be suboptimal. IMPLICATIONS FOR CANCER SURVIVORS: Adults with cancer and comorbid depression should receive appropriate depression care in order to improve their HRQoL

Development and Application of a Measurement Framework to Evaluate Safe, Effective and Efficient Medication Use Among Older Adults

Background A majority of older adults in the United States (US) use prescription medications. Comprehensive population-level approaches to examine medication safety, effectiveness, and costs among older adults are needed. Objectives The objectives of this study were to develop a framework of quality measures spanning the domains of safety, effectiveness, and efficiency of prescription medication use among older adults, and to apply those measures using pharmacy claims data. Methods We performed a retrospective study among adults age 65 years and older of a US East Coast state who filled at least one prescription from a particular pharmacy chain during 2016 (N = 99,056). Firstly, we performed an environmental scan to identify quality measures and potentially relevant measures addressing prescription medication use. These measures were reviewed and rated by local geriatric pharmacotherapy experts. After evaluating feasibility, evidence, and relevance, a total of 19 measures representing the domains of safety (n = 7), effectiveness (n = 7), and efficiency (n = 5) were identified. These measures were then applied to an older adult population using prescription data for the year 2016 provided by a national pharmacy chain. All measures were configured such that a score of 100% corresponded to optimal performance. Results For the domain of safety, 12.8% of patients received a benzodiazepine chronically, 23.6% received central nervous system depressants, 16.7% received fluoroquinolones as first-line antibiotic therapy, and 21.9% of those who were prescribed opioids received them in excessive quantities. For the domain of effectiveness, one-fourth of the diabetes patients did not receive statins and angiotensin-acting medications, while 18.0% were not adherent to oral anticoagulant medications and 54% were not adherent to respiratory inhalers. For the domain of efficiency, 12.0% of the patients received prescriptions from five or more unique prescribers. Overall, 85.7%, 76.1%, and 87.9% of the older adults showed safe, effective, and efficient prescription medication use, respectively. Conclusion A novel approach to comprehensively examine the quality of medication use among older adults using prescription claims data is provided in our study. A considerable proportion of the older adults in our study received safe, effective, and efficient prescription medications. However, within each domain, several opportunities for improving the alignment of prescription medication use with current recommendations were identified. Key Points A novel approach/measurement framework to comprehensively assess safe, effective, and efficient prescription medication use among older adults using pharmacy claims data is presented. Overall, 14%, 24%, and 12% of older adults did not show safe, effective, and efficient prescription medication use, respectively. Many opportunities for quality improvement within the domains of safety, effectiveness, and efficiency of prescription medication use among older adults were identified

Prevalence of Psychotropic Polypharmacy and Associated Healthcare Resource Utilization during Initial Phase of Care among Adults with Cancer in USA

Background: The use of psychotropic medications is not uncommon among patients with newly diagnosed cancer. However, the impact of psychotropic polypharmacy on healthcare utilization during the initial phase of cancer care is largely unknown. Methods: We used a claims database to identify adults with incident breast, prostate, lung, and colorectal cancers diagnosed during 2011–12. Psychotropic polypharmacy was defined as concurrent use of two or more psychotropic medication classes for at least 90 days. A multivariable logistic regression was performed to identify significant predictors of psychotropic polypharmacy. Multivariable Poisson and negative binomial regressions were used to assess the associations between psychotropic polypharmacy and healthcare utilization. Results: Among 5604 patients included in the study, 52.6% had breast cancer, 30.6% had prostate cancer, 11.4% had colorectal cancer, and 5.5% had lung cancer. During the year following incident cancer diagnosis, psychotropic polypharmacy was reported in 7.4% of patients, with the highest prevalence among patients with lung cancer (14.4%). Compared with patients without psychotropic polypharmacy during the initial phase of care, patients with newly diagnosed cancer with psychotropic polypharmacy had a 30% higher rate of physician office visits, an 18% higher rate of hospitalization, and a 30% higher rate of outpatient visits. The rate of emergency room visits was similar between the two groups. Conclusion: Psychotropic polypharmacy during the initial phase of cancer care was associated with significantly increased healthcare resource utilization, and the proportion of patients receiving psychotropic polypharmacy differed by type of cancer. Impact: Findings emphasize the importance of evidence-based psychotropic prescribing and close surveillance of events causing increased healthcare utilization among patients with cancer receiving psychotropic polypharmacy

Do Acute Coronary Events Affect Lipid Management and Cholesterol Goal Attainment in Germany?

Objective To document utilization of lipid-lowering therapy, attainment of low-density lipoprotein cholesterol target values, and cardiovascular outcomes in patients hospitalized for acute coronary syndrome in Germany. Methods The Dyslipidemia International Study II was a multicenter, observational study of the prevalence of dyslipidemia and lipid target value attainment in patients surviving any acute coronary syndrome event. Among patients on lipid-lowering therapy for ≥3 months, use of lipid-lowering therapy and lipid profiles were assessed at admission and again at 120 ± 15 days after admission (the follow-up time point). Multivariate logistic regression was used to identify variables predictive of low-density lipoprotein cholesterol target value attainment in patients using lipid-lowering therapy. Results A total of 461 patients hospitalized for acute coronary syndrome were identified, 270 (58.6%) of whom were on lipid-lowering therapy at admission. Among patients on lipid-lowering therapy, 90.7% and 85.9% were receiving statin monotherapy at admission and follow-up, respectively. Mean (SD) lowdensity lipoprotein cholesterol levels in patients on lipid-lowering therapy were 101 (40) mg/dl and 95 (30) mg/dl at admission and follow-up, respectively. In patients with data at both admission and followup (n= 61), low-density lipoprotein cholesterol target value attainment rates were the same (19.7%) at both time points. Smoking was associated with a 77% lower likelihood of attaining the low-density lipoprotein cholesterol target value. Conclusion Hospitalization for an acute event does not greatly alter lipid management in acute coronary syndrome patients in Germany. Both lipid-lowering therapy doses and rates of low-density lipoprotein cholesterol target value attainment remained essentially the same several months after the event

Prevalence of Lipid Abnormalities and Cholesterol Target Value Attainment in Patients with Stable and Acute Coronary Heart Disease in the United Arab Emirates

Background: Careful management of lipid abnormalities in patients with coronary heart disease (CHD) or an acute coronary syndrome (ACS) can reduce the risk of recurrent cardiovascular events. The extent of hyperlipidemia in these very high-risk patients in the United Arab Emirates (UAE), along with the treatment strategies employed, is not clear. Methods: The Dyslipidemia International Study II was a multinational observational analysis carried out from 2012 to 2014. Patients were enrolled if they had either stable CHD or an ACS. Patient characteristics, lipid levels, and use of lipid-lowering therapy (LLT) were recorded at enrollment. For the ACS patients, the LLT used during the 4 months\u27 follow-up period was documented, as were any cardiovascular events. Results: A total of 416 patients were recruited from two centers in the UAE, 216 with stable CHD and 200 hospitalized with an ACS. Comorbidities and cardiovascular risk factors were extremely common. A low-density lipoprotein cholesterol level of \u3c70 mg/dl, recommended for patients at very high cardiovascular risk, was attained by 39.3% of the LLT-treated CHD patients and 33.3% of the LLT-treated ACS patients at enrollment. The mean atorvastatin-equivalent daily statin dose was 29 ± 15 mg for the CHD patients, with 13.7% additionally using ezetimibe. For the ACS patients, the daily dosage was 23 ± 13 mg at admission, rising to 39 ± 12 mg by the end of the 4-month follow-up. The use of nonstatin agents was extremely low in this group. Conclusions: Despite LLT being widely used, hyperlipidemia was found to be prevalent in ACS and CHD patients in the UAE. Treatment strategies need to be significantly improved to reduce the rate of cardiovascular events in these very high-risk patients

Use of guideline-recommended management in established coronary heart disease in the observational DYSIS II study

Abstract Background Guidelines recommend lifestyle modification and medications to control risk factors in coronary heart disease (CHD). Using data from the observational DYSIS II study, we sought to evaluate the use of guideline-recommended treatments at discharge for acute coronary syndromes or in the chronic phase for CHD, and participation in rehabilitation/secondary prevention programs. Methods and results Between 2013 and 2014, 10,661 patients (3867 with ACS, 6794 with stable CHD) were enrolled in 332 primary and secondary care centers in 18 countries (Asia-Pacific, Europe, Middle East/Africa). Patients with incident ACS were younger and more likely to be smokers than patients with recurrent ACS or stable CHD (both p  Conclusions The high prevalence of risk factors in all CHD patients and reduced rates of secondary prevention medications in stable CHD offer areas for improvement. Translational aspects The findings of DYSIS II may reinforce the importance of adopting a healthy lifestyle and prescribing (by clinicians) and adhering (by patients) to evidence-based medications in the management of coronary heart disease, not only during the short-term but also over the longer term after a cardiac ischemic event. The results may help to increase the proportion of ACS patients who are referred to cardiac rehabilitation centres

Association between polypharmacy and health-related quality of life among US adults with cardiometabolic risk factors

Purpose: There are known associations between cardiometabolic risk factors and polypharmacy; however, there is no evidence about how polypharmacy among adults with cardiometabolic risk factors impacts their health-related quality of life (HRQoL). The main objective of this study was to assess the association between polypharmacy and HRQoL among adults with cardiometabolic risk factors living in the USA. Methods: Individuals age ≥ 18 years with at least one of the three cardiometabolic risk factors (diabetes, hyperlipidemia, and hypertension) were identified from the Medical Expenditure Panel Survey 2015 data. We defined polypharmacy as use of at least five classes of prescription medications. Physical component summary (PCS) and mental component summary (MCS) were obtained from the 12-item Short-Form Health Survey version 2 to measure HRQoL. We conducted adjusted ordinary least-square regressions to determine the association between polypharmacy and HRQoL. Results: We identified 7621 (weighted N = 80 million) adults with at least one cardiometabolic risk factors of whom 46.9% reported polypharmacy. Polypharmacy was noted in 29.7% of those with hypertension, whereas 82.4% of those with all the three cardiometabolic risk factors had polypharmacy. The unadjusted mean PCS and MCS scores for those with polypharmacy were lower than those without polypharmacy. In the multivariable regressions, we found that adults with polypharmacy had significantly lower PCS scores (β = − 4.27, p \u3c 0.0001) compared to those without polypharmacy, while the MCS scores between those with and without polypharmacy were no longer significantly different. Conclusion: Surveillance of use of concurrent prescription medications is warranted so as to improve physical functioning in this vulnerable group