A Closer Look: Health Services Structure and Organization, Health Disparities, and Receipt of High Quality Breast Cancer Treatment

Racial/ethnic disparities in breast cancer outcomes have been well documented; however, the reasons why certain groups have widely different health experiences are not well understood. Recognizing that variation in quality of cancer care may correlate with socio-demographic and health system characteristics, the overall objectives of this dissertation were (1) to investigate the relationships between race/ethnicity and structural/organizational aspects of health services in terms of post-operative receipt and timing of initiation of radiation therapy and adjuvant chemotherapy, and (2) to determine whether timing of adjuvant therapy initiation affects mortality. This dissertation used population-based SEER-Medicare data to examine these issues in female Medicare beneficiaries ages 65 and older diagnosed with primary breast cancer in the years 1994 to 2002. Structural/organizational variables examined included characteristics of the surgical facility (i.e., type/ownership, teaching status, size, institutional affiliations, and presence of on-site radiation services), distance traveled to surgical facilities, distance to nearest radiation therapy provider, and distance to nearest chemotherapy provider. Racial/ethnic groups examined included non-Hispanic white, non-Hispanic black, and Hispanic patients. We found significant racial/ethnic disparities in terms of receipt and timing of initiation of radiation therapy, as well as all-cause and breast cancer specific mortality, whereas we found no evidence of racial/ethnic disparities in adjuvant chemotherapy. We also found evidence that certain health services characteristics, including type/ownership and size of surgical facility, presence of on-site radiation at surgical facility, and distance from patient residence to adjuvant therapy providers, were associated with quality of care received, suggesting that health care systems or policies may be designed in such a way to improve outcomes for all breast cancer patients, and particularly, among minority women at risk for undertreatment. Finally, we found evidence that earlier initiation of radiation therapy and adjuvant chemotherapy may correspond to better health outcomes. This study documents the important role that health services characteristics may play in determining quality of care. Additionally, considering that black women are more likely to be diagnosed with aggressive, advanced stage cancers and more likely to die from breast cancer, this study suggests that earlier initiation of treatment may help minimize racial disparities in breast cancer mortality

MidExDB: A database of Drosophila CNS midline cell gene expression

<p>Abstract</p> <p>Background</p> <p>The <it>Drosophila </it>CNS midline cells are an excellent model system to study neuronal and glial development because of their diversity of cell types and the relative ease in identifying and studying the function of midline-expressed genes. In situ hybridization experiments generated a large dataset of midline gene expression patterns. To help synthesize these data and make them available to the scientific community, we developed a web-accessible database.</p> <p>Description</p> <p>MidExDB (<it>Drosophila </it>CNS Midline Gene Expression Database) is comprised of images and data from our in situ hybridization experiments that examined midline gene expression. Multiple search tools are available to allow each type of data to be viewed and compared. Descriptions of each midline cell type and their development are included as background information.</p> <p>Conclusion</p> <p>MidExDB integrates large-scale gene expression data with the ability to identify individual cell types providing the foundation for detailed genetic, molecular, and biochemical studies of CNS midline cell neuronal and glial development and function. This information has general relevance for the study of nervous system development in other organisms, and also provides insight into transcriptional regulation.</p

Predicting Liver Transplant Capacity Using Discrete Event Simulation

The number of liver transplants (LTs) performed in the US increased until 2006 but has since declined despite an ongoing increase in demand. This decline may be due in part to decreased donor liver quality and increasing discard of poor-quality livers. We constructed a discrete event simulation (DES) model informed by current donor characteristics to predict future LT trends through the year 2030. The data source for our model is the United Network for Organ Sharing database, which contains patient-level information on all organ transplants performed in the US. Previous analysis showed that liver discard is increasing and that discarded organs are more often from donors who are older, are obese, have diabetes, and donated after cardiac death. Given that the prevalence of these factors is increasing, the DES model quantifies the reduction in the number of LTs performed through 2030. In addition, the model estimatesthe total number of future donors needed to maintain the current volume of LTs and the effect of a hypothetical scenario of improved reperfusion technology.We also forecast the number of patients on the waiting list and compare this with the estimated number of LTs to illustrate the impact that decreased LTs will have on patients needing transplants. By altering assumptions about the future donor pool, this model can be used to develop policy interventions to prevent a further decline in this lifesaving therapy. To our knowledge, there are no similar predictive models of future LT use based on epidemiological trends

MidExDB: A database of Drosophila CNS midline cell gene expression

Abstract Background The Drosophila CNS midline cells are an excellent model system to study neuronal and glial development because of their diversity of cell types and the relative ease in identifying and studying the function of midline-expressed genes. In situ hybridization experiments generated a large dataset of midline gene expression patterns. To help synthesize these data and make them available to the scientific community, we developed a web-accessible database. Description MidExDB (Drosophila CNS Midline Gene Expression Database) is comprised of images and data from our in situ hybridization experiments that examined midline gene expression. Multiple search tools are available to allow each type of data to be viewed and compared. Descriptions of each midline cell type and their development are included as background information. Conclusion MidExDB integrates large-scale gene expression data with the ability to identify individual cell types providing the foundation for detailed genetic, molecular, and biochemical studies of CNS midline cell neuronal and glial development and function. This information has general relevance for the study of nervous system development in other organisms, and also provides insight into transcriptional regulation

Systematic review of Doppler for detecting intrapartum fetal heart abnormalities and measuring perinatal mortality in low‐ and middle‐income countries

Background: Using Doppler to improve detection of intrapartum fetal heart rate (FHR) abnormalities coupled with appropriate, timely intrapartum care in low-and middle-income countries (LMIC) can save lives. Objective: To review studies using Doppler to improve detection of intrapartum FHR abnormalities and intrapartum care quality in LMIC health facilities. Search strategy: PubMed, Web of Science, Embase, Global Health, and Scopus were searched from inception to October 2018 by combining terms for Doppler, perinatal outcomes, and FHR monitoring. Selection criteria: Selected studies compared Doppler and Pinard stethoscope for detecting/monitoring intrapartum FHR, or described provider and maternal preferences for FHR monitoring in LMIC settings. Data collection and analysis: Two team members independently screened and collected data. Risk of bias was assessed by Cochrane EPOC criteria. Results: Eleven studies from eight countries were included. Doppler was superior at detecting abnormal intrapartum FHR as compared with Pinard stethoscope, but was not associated with improved perinatal outcomes. Using Doppler on admission helped to accurately measure perinatal deaths occurring after facility admission. Conclusion: Studies and program learning are needed to translate improved detection of FHR abnormalities to improved case management in LMICs. Doppler should be used to calculate a facility indicator of intrapartum care quality

Understanding racial differences in health-related quality of life in a population-based cohort of breast cancer survivors

Although racial disparities in health-related quality of life (HRQOL) among women with breast cancer (BC) are well documented, less is known about HRQOL changes over time among women of different races. Our objective was to assess racial differences in HRQOL during active treatment and survivorship phases of BC care

Racial/Ethnic and Socioeconomic Disparities in Endocrine Therapy Adherence in Breast Cancer: A Systematic Review

We examined the current literature to understand factors that influence endocrine therapy (ET) adherence among racial/ethnic and socioeconomic subpopulations of breast cancer patients. We searched PubMed and PsycINFO databases for studies from January 1, 1978, to June 20, 2014, and January 1, 1991, to June 20, 2014, respectively, and hand-searched articles from relevant literature reviews. We abstracted and synthesized results within a social ecological framework

A framework for improving early detection of breast cancer in sub-Saharan Africa: A qualitative study of help-seeking behaviors among Malawian women

Many women in Africa are diagnosed with advanced breast cancer. We explored Malawian breast cancer patients’ perspectives about their diagnosis and ability to access care to identify help-seeking behaviors and to describe factors influencing delay

Patient-Centered Communication for Discussing Oncotype DX Testing

Oncotype DX testing (ODX), a tumor gene expression test, may improve breast cancer care, however communicating results remains challenging. We identified patient-centered communication strategies/gaps for discussing ODX results. We applied a patient-centered communication framework to analyze qualitative interviews with oncologists about how they communicate about ODX with patients, using template analysis in Atlas.ti. Overall, providers discussed four patient-centered communication domains: exchanging information, assessing uncertainty, making decisions and cross-cutting themes. Providers did not report discussing emotional aspects of managing uncertainty, assessing decision-making preferences, and evaluating decisions. A patient-centered approach may be a model for communicating about tumor gene expression tests