Treatment Patterns and Survival Outcomes in Patients With Breast Cancer on Medicaid, Pre- and Post-Expansion.

BACKGROUND: The objective of this study was to evaluate the impact of Medicaid expansion on breast cancer treatment and survival among Medicaid-insured women in Ohio, accounting for the timing of enrollment in Medicaid relative to their cancer diagnosis and post-expansion heterogeneous Medicaid eligibility criteria, thus addressing important limitations in previous studies. METHODS: Using 2011-2017 Ohio Cancer Incidence Surveillance System data linked with Medicaid claims data, we identified women aged 18 to 64 years diagnosed with local-stage or regional-stage breast cancer (n=876 and n=1,957 pre-expansion and post-expansion, respectively). We accounted for women's timing of enrollment in Medicaid relative to their cancer diagnosis, and flagged women post-expansion as Affordable Care Act (ACA) versus non-ACA, based on their income eligibility threshold. Study outcomes included standard treatment based on cancer stage and receipt of lumpectomy, mastectomy, chemotherapy, radiation, hormonal treatment, and/or treatment for HER2-positive tumors; time to treatment initiation (TTI); and overall survival. We conducted multivariable robust Poisson and Cox proportional hazards regression analysis to evaluate the independent associations between Medicaid expansion and our outcomes of interest, adjusting for patient-level and area-level characteristics. RESULTS: Receipt of standard treatment increased from 52.6% pre-expansion to 61.0% post-expansion (63.0% and 59.9% post-expansion in the ACA and non-ACA groups, respectively). Adjusting for potential confounders, including timing of enrollment in Medicaid, being diagnosed in the post-expansion period was associated with a higher probability of receiving standard treatment (adjusted risk ratio, 1.14 [95% CI, 1.06-1.22]) and shorter TTI (adjusted hazard ratio, 1.14 [95% CI, 1.04-1.24]), but not with survival benefits (adjusted hazard ratio, 1.00 [0.80-1.26]). CONCLUSIONS: Medicaid expansion in Ohio was associated with improvements in receipt of standard treatment of breast cancer and shorter TTI but not with improved survival outcomes. Future studies should elucidate the mechanisms at play.

Accounting for Medicaid expansion and regional policy and programs to advance equity in cancer prevention in the United States.

BACKGROUND: Many studies compare state-level outcomes to estimate changes attributable to Medicaid expansion. However, it is imperative to conduct more granular, demographic-level analyses to inform current efforts on cancer prevention among low-income adults. Therefore, the authors compared the volume of patients with cancer and disease stage at diagnosis in Ohio, which expanded its Medicaid coverage in 2014, with those in Georgia, a nonexpansion state, by cancer site and health insurance status. METHODS: The authors used state cancer registries from 2010 to 2017 to identify adults younger than 64 years who had incident female breast cancer, cervical cancer, or colorectal cancer. Multivariable Poisson regression was conducted by cancer type, health insurance, and state to examine the risk of late-stage disease, adjusting for individual-level and area-level covariates. A difference-in-differences framework was then used to estimate the differences in risks of late-stage diagnosis in Ohio versus Georgia. RESULTS: In Ohio, the largest increase in all three cancer types was observed in the Medicaid group after Medicaid expansion. In addition, significantly reduced risks of late-stage disease were observed among patients with breast cancer on Medicaid in Ohio by approximately 7% and among patients with colorectal cancer on Medicaid in Ohio and Georgia after expansion by approximately 6%. Notably, the authors observed significantly reduced risks of late-stage diagnosis among all patients with colorectal cancer in Georgia after expansion. CONCLUSIONS: More early stage cancers in the Medicaid-insured and/or uninsured groups after expansion suggest that the reduced cancer burden in these vulnerable population subgroups may be attributed to Medicaid expansion. Heterogeneous risks of late-stage disease by cancer type highlight the need for comprehensive evaluation frameworks, including local cancer prevention efforts and federal health policy reforms. PLAIN LANGUAGE SUMMARY: This study looked at how Medicaid expansion affected cancer diagnosis and treatment in two states, Ohio and Georgia. The researchers found that, after Ohio expanded their Medicaid program, there were more patients with cancer among low-income adults on Medicaid. The study also found that, among people on Medicaid, there were lower rates of advanced cancer at the time of diagnosis for breast cancer and colon cancer in Ohio and for colon cancer in Georgia. These findings suggest that Medicaid expansion may be effective in reducing the cancer burden among low-income adults.

Associations Between Patient Experience With Care, Race and Ethnicity, and Receipt of CRC Treatment Among SEER-CAHPS Patients With Multiple Comorbidities.

BACKGROUND: Patients with colorectal cancer (CRC) and multiple comorbidities are less likely to receive guideline-concordant treatment (GCT), a disparity exacerbated by racial and ethnic disparities in GCT. Yet, positive patient experiences with care are associated with more appropriate care use. We investigated associations between patient experiences with care, race and ethnicity, and receipt of GCT for CRC among older adults with multiple comorbidities. METHODS: We used SEER-Consumer Assessment of Healthcare Providers and Systems (CAHPS) data to identify participants diagnosed with CRC from 2001 to 2017 at age ≥67 years with additional chronic conditions. Stage-specific GCT was identified following recommendations in the NCCN Guidelines for Colon and Rectal Cancer. Patient experiences with care were identified from CAHPS surveys. Multivariable log-binomial regression estimated associations between race and ethnicity and receipt of GCT by experiences with care. RESULTS: A total of 2,612 patients were included. Those reporting excellent experience with getting care quickly were 5% more likely to receive GCT than those reporting less-than-excellent experience (relative risk [RR], 1.05; 95% CI, 1.04-1.05). When reporting less-than-excellent experience with getting care quickly, non-Hispanic Black (NHB) patients were less likely than non-Hispanic White (NHW) patients to receive GCT (RR, 0.80; 99.38% CI, 0.78-0.82), yet NHB patients were more likely to receive GCT than NHW patients when reporting excellent experience (RR, 1.05; 99.38% CI, 1.02-1.09). When reporting less-than-excellent experience with getting needed care, Hispanic patients were less likely than NHW patients to receive GCT (RR, 0.91; 99.38% CI, 0.88-0.94), yet Hispanic patients were more likely to receive GCT than NHW patients when reporting excellent experience (RR, 1.06; 99.38% CI, 1.03-1.08). CONCLUSIONS: Although excellent patient experience among those with multiple comorbidities may not be strongly associated with receipt of GCT for CRC overall, improvements in experiences of accessing care among NHB and Hispanic patients with CRC and additional comorbidities may aid in mitigating racial and ethnic disparities in receipt of GCT.

Examining health care access disparities in Hispanic populations with peripheral artery disease and diabetes.

INTRODUCTION: This study investigated disparities in health care access for Hispanic adults with diabetes and peripheral artery disease (PAD) who are at risk of lower-extremity amputation and other cardiovascular morbidities and mortalities. METHODS: We utilized the health care access survey data from the All of Us research program to examine adults (⩾ 18 years) with either diabetes and/or PAD. The primary associations evaluated were: could not afford medical care and delayed getting medical care in the past 12 months. Multivariable logistic regression models were used to assess the association of Hispanic ethnicity and survey responses, adjusting for age, sex, income, health insurance, and employment status. RESULTS: Among 24,104 participants, the mean age was 54.9 years and 67% were women. Of these, 8.2% were Hispanic adults. In multivariable analysis, Hispanic adults were more likely to be unable to afford seeing a health care provider, and receiving emergency care, follow-up care, and prescription medications (p < 0.05) than non-Hispanic adults. Furthermore, Hispanic adults were more likely to report being unable to afford medical care due to cost (odds ratios [OR] 1.72, 95% CI 1.50-1.99), more likely to purchase prescription drugs from another country (OR 2.20, 95% CI 1.69-2.86), and more likely to delay getting medical care due to work (OR 1.46, 95% CI 1.22-1.74) and child care (OR 1.80, 95% CI 1.35-2.39) issues than non-Hispanic White adults. CONCLUSION: The Hispanic population with diabetes and PAD faces substantial barriers in health care access, including a higher likelihood of delaying medical care and being unable to afford it.

Examining multilevel influences on parental HPV vaccine hesitancy among multiethnic communities in Los Angeles: a qualitative analysis.

BACKGROUND: Human papillomavirus (HPV) vaccine hesitancy is a growing concern in the United States, yet understudied among racial/ethnic minority parents. We conducted qualitative research to understand parental HPV vaccine hesitancy and inform community-specific, multilevel approaches to improve HPV vaccination among diverse populations in Los Angeles. METHODS: We recruited American Indian/Alaska Native (AI/AN), Hispanic/Latino/a (HL) and Chinese parents of unvaccinated children (9-17 years) from low-HPV vaccine uptake regions in Los Angeles for virtual focus groups (FGs). FGs were conducted in English (2), Mandarin (1), and Spanish (1) between June-August 2021. One English FG was with AI/AN-identifying parents. FGs prompted discussions about vaccine knowledge, sources of information/hesitancy, logistical barriers and interpersonal, healthcare and community interactions regarding HPV vaccination. Guided by the social-ecological model, we identified multilevel emergent themes related to HPV vaccination. RESULTS: Parents (n = 20) in all FGs reported exposure to HPV vaccine information from the internet and other sources, including in-language media (Mandarin) and health care providers (Spanish). All FGs expressed confusion around the vaccine and had encountered HPV vaccine misinformation. FGs experienced challenges navigating relationships with children, providers, and friends/family for HPV vaccine decision-making. At the community-level, historical events contributed to mistrust (e.g., forced community displacement [AI/AN]). At the societal-level, transportation, and work schedules (Spanish, AI/AN) were barriers to vaccination. Medical mistrust contributed to HPV vaccine hesitancy across the analysis levels. CONCLUSION: Our findings highlight the importance of multilevel influences on parental HPV vaccine hesitancy and decision-making and the need for community-specific messaging to combat medical mistrust and other barriers to HPV vaccination among racial/ethnic minority communities.

Understanding medical mistrust and HPV vaccine hesitancy among multiethnic parents in Los Angeles.

Determinants of parental HPV vaccine hesitancy, including medical mistrust and exposure to negative vaccine information, are understudied in racial/ethnic minority communities where vaccine uptake is low. We conducted a cross-sectional survey (March 2021) among parents of adolescents, ages 9-17 years, from an academic enrichment program serving low-income, first-generation, underrepresented minority families in Los Angeles to understand determinants of parental HPV vaccine hesitancy. Parents completed self-administered surveys, including a 9-item HPV vaccine hesitancy scale, in either English, Spanish, or Chinese. Logistic regression was used to identify individual and interpersonal factors associated with parental hesitancy and adolescent HPV vaccination. One-fifth of parents (n = 357) reported high HPV vaccine hesitancy and > 50% reported concerns about safety or side effects. High medical mistrust was associated with high parental HPV vaccine hesitancy (adjusted-OR 1.69, 95% CI: 1.13, 2.37). Community-tailored and multilevel strategies to increase vaccine confidence are needed to improve HPV and other adolescent vaccinations.

Understanding Clinic and Community Member Experiences with Implementation of Evidence-Based Strategies for HPV Vaccination in Safety-Net Primary Care Settings.

HPV vaccination rates remain below target levels among adolescents in the United States, which is particularly concerning in safety-net populations with persistent disparities in HPV-associated cancer burden. Perspectives on evidence-based strategies (EBS) for HPV vaccination among key implementation participants, internal and external to clinics, can provide a better understanding of why these disparities persist. We conducted virtual interviews and focus groups, guided by the Practice Change Model, with clinic members (providers, clinic leaders, and clinic staff) and community members (advocates, parents, policy-level, and payers) in Los Angeles and New Jersey to understand common and divergent perspectives on and experiences with HPV vaccination in safety-net primary care settings. Fifty-eight interviews and seven focus groups were conducted (n = 65 total). Clinic members (clinic leaders n = 7, providers n = 12, and clinic staff n = 6) revealed conflicting HPV vaccine messaging, lack of shared motivation to reduce missed opportunities and improve workflows, and non-operability between clinic electronic health records and state immunization registries created barriers for implementing effective strategies. Community members (advocates n = 8, policy n = 11, payers n = 8, and parents n = 13) described lack of HPV vaccine prioritization among payers, a reliance on advocates to lead national agenda setting and facilitate local implementation, and opportunities to support and engage schools in HPV vaccine messaging and adolescents in HPV vaccine decision-making. Participants indicated the COVID-19 pandemic complicated prioritization of HPV vaccination but also created opportunities for change. These findings highlight design and selection criteria for identifying and implementing EBS (changing the intervention itself, or practice-level resources versus external motivators) that bring internal and external clinic partners together for targeted approaches that account for local needs in improving HPV vaccine uptake within safety-net settings.

Post-Affordable Care Act Improvements in Cancer Stage Among Ohio Medicaid Beneficiaries Resulted From an Increase in Stable Coverage.

BACKGROUND: The mechanisms underlying improvements in early-stage cancer at diagnosis following Medicaid expansion remain unknown. We hypothesized that Medicaid expansion allowed for low-income adults to enroll in Medicaid before cancer diagnosis, thus increasing the number of stably-enrolled relative to those who enroll in Medicaid only after diagnosis (emergently-enrolled). METHODS: Using data from the 2011-2017 Ohio Cancer Incidence Surveillance System and Medicaid enrollment files, we identified individuals diagnosed with incident invasive breast (n=4850), cervical (n=1023), and colorectal (n=3363) cancer. We conducted causal mediation analysis to estimate the direct effect of pre- (vs. post-) expansion on being diagnosed with early-stage (-vs. regional-stage and distant-stage) disease, and indirect (mediation) effect through being in the stably- (vs. emergently-) enrolled group, controlling for individual-level and area-level characteristics. RESULTS: The percentage of stably-enrolled patients increased from 63.3% to 73.9% post-expansion, while that of the emergently-enrolled decreased from 36.7% to 26.1%. The percentage of patients with early-stage diagnosis remained 1.3-2.9 times higher among the stably-than the emergently-enrolled group, both pre-expansion and post-expansion. Results from the causal mediation analysis showed that there was an indirect effect of Medicaid expansion through being in the stably- (vs. emergently-) enrolled group [risk ratios with 95% confidence interval: 1.018 (1.010-1.027) for breast cancer, 1.115 (1.064-1.167) for cervical cancer, and 1.090 (1.062-1.118) for colorectal cancer. CONCLUSION: We provide the first evidence that post-expansion improvements in cancer stage were caused by an increased reliance on Medicaid as a source of stable insurance coverage.

Disparities in HPV vaccine knowledge and adolescent HPV vaccine uptake by parental nativity among diverse multiethnic parents in New Jersey.

BACKGROUND: Suboptimal human papillomavirus (HPV) vaccination rates persist among adolescents in the United States (U.S.). New Jersey (NJ), among the top, most racially/ethnically diverse states in the U.S., had among the lowest HPV vaccine initiation rates, prior to 2018. This study examined parental HPV vaccine knowledge and adolescent HPV vaccine initiation among multiethnic parents in NJ, where access to language concordant HPV vaccine information and vaccination services may differ, for immigrant parents. METHODS: We surveyed parents of adolescents (ages 11-18) at community events in NJ to examine parental HPV vaccine knowledge and adolescent HPV vaccine uptake. Vaccine knowledge was assessed using an 11-item question stem that covered vaccine efficacy, gender recommendation, vaccine protection, and myths. Multivariable models assessed the association of parent nativity on HPV vaccine knowledge scores and adolescent HPV vaccine initiation, controlling for sociodemographic factors. RESULTS: Of the 77 parents, most parents (84%) were aware of the HPV vaccine. However, knowledge scores were low and differed by parent nativity. Non-U.S. born parents had significantly lower knowledge scores - 1.7 [- 3.1, - 0.4] and lower odds of adolescent children initiating the HPV vaccine 0.3 [0.1, 0.9] compared to U.S.-born parents after adjusting demographic characteristics. CONCLUSIONS: Our findings reveal that parental HPV vaccine knowledge remains low among suburban dwelling, immigrant parents, even though they have higher education and access to health care. Multilevel strategies to reduce missed opportunities for HPV vaccine education among parents and HPV vaccination for adolescents are needed, including for suburban, immigrant communities.

Medicaid Expansion Associated With Reduction in Geospatial Breast Cancer Stage at Diagnosis Disparities.

CONTEXT: Prior studies demonstrate that Medicaid expansion has been associated with earlier-stage breast cancer diagnosis among women with low income, likely through increased access to cancer screening services. However, how this policy change has impacted geospatial disparities in breast cancer stage at diagnosis is unclear. OBJECTIVE: To examine whether there were reductions in geospatial disparities in advanced stage breast cancer at diagnosis in Ohio after Medicaid expansion. DESIGN: The study included 33 537 women aged 40 to 64 years diagnosed with invasive breast cancer from the Ohio Cancer Incidence Surveillance System between 2010 and 2017. The space-time scan statistic was used to detect clusters of advanced stage at diagnosis before and after Medicaid expansion. Block group variables from the Census were used to describe the contextual characteristics of detected clusters. RESULTS: The percentage of local stage diagnosis among women with breast cancer increased from 60.2% in the pre-expansion period (2010-2013) to 62.6% in the post-expansion period (2014-2017), while the uninsured rate among those women decreased from 13.7% to 7.5% during the same period. Two statistically significant ( P < .05) and 6 nonsignificant spatial clusters ( P > .05) of advanced stage breast cancer cases were found in the pre-expansion period, while none were found in the post-expansion period. These clusters were in the 4 largest metropolitan areas in Ohio, and individuals inside the clusters were more likely to be disadvantaged along numerous socioeconomic factors. CONCLUSIONS: Medicaid expansion has played an important role in reducing geospatial disparities in breast cancer stage at diagnosis, likely through the reduction of advanced stage disease among women living in socioeconomically disadvantaged communities.

Patterns of chronic disease management and health outcomes in a population-based cohort of Black women with breast cancer.

PURPOSE: Diabetes and hypertension are two common comorbidities that affect breast cancer patients, particularly Black women. Disruption of chronic disease management during cancer treatment has been speculated. Therefore, this study examined the implementation of clinical practice guidelines and health outcomes for these comorbidities before and during cancer treatment. METHODS: We used a population-based, prospective cohort of Black women diagnosed with breast cancer (2012-2016) in New Jersey (n = 563). Chronic disease management for diabetes and hypertension was examined 12 months before and after breast cancer diagnosis and compared using McNemar's test for matched paired and paired t tests. RESULTS: Among this cohort, 18.1% had a co-diagnosis of diabetes and 47.2% had a co-diagnosis of hypertension. Implementation of clinical practice guidelines and health outcomes that differed in the 12 months before and after cancer diagnosis included lipid screening (64.5% before versus 50.0% after diagnosis; p = 0.004), glucose screening (72.7% versus 90.7%; p < 0.001), and blood pressure control < 140/90 mmHg (57.6% versus 71.5%; p = 0.004) among patients with hypertension-only. For patients with diabetes, eye and foot care were low (< 35%) and optimal HbA1c < 8.0% was achieved for less than 50% of patients in both time periods. CONCLUSION: Chronic disease management continued during cancer treatment; however, eye and foot exams for patients with diabetes and lipid screening for patients with hypertension-only were inadequate. Given that comorbidities may account for half of the Black-White breast cancer survival disparity, strategies are needed to improve chronic disease management during cancer, especially for Black women who bear a disproportionate burden of chronic diseases.

Comorbidity Management in Black Women Diagnosed with Breast Cancer: the Role of Primary Care in Shared Care.

BACKGROUND: Black women are more likely to have comorbidity at breast cancer diagnosis compared with White women, which may account for half of the Black-White survivor disparity. Comprehensive disease management requires a coordinated team of healthcare professionals including primary care practitioners, but few studies have examined shared care in the management of comorbidities during cancer care, especially among racial/ethnic minorities. OBJECTIVE: To examine whether the type of medical team composition is associated with optimal clinical care management of comorbidities. DESIGN: We used the Women's Circle of Health Follow-up Study, a population-based cohort of Black women diagnosed with breast cancer. The likelihood of receiving optimal comorbidity management after breast cancer diagnosis was compared by type of medical team composition (shared care versus cancer specialists only) using binomial regression. PARTICIPANTS: Black women with a co-diagnosis of diabetes and/or hypertension at breast cancer diagnosis between 2012 and 2016 (N = 274). MAIN MEASURES: Outcome-optimal clinical care management of diabetes (i.e., A1C test, LDL-C test, and medical attention for nephropathy) and hypertension (i.e., lipid screening and prescription for hypertension medication). Main predictor-shared care, whether the patient received care from both a cancer specialist and a primary care provider and/or a medical specialist within the 12 months following a breast cancer diagnosis. KEY RESULTS: Primary care providers were the main providers involved in managing comorbidities and 90% of patients received shared care during breast cancer care. Only 54% had optimal comorbidity management. Patients with shared care were five times (aRR: 4.62; 95% CI: 1.66, 12.84) more likely to have optimal comorbidity management compared with patients who only saw cancer specialists. CONCLUSIONS: Suboptimal management of comorbidities during breast cancer care exists for Black women. However, our findings suggest that shared care is more beneficial at achieving optimal clinical care management for diabetes and hypertension than cancer specialists alone.

Financial hardship among cancer survivors in Southern New Jersey.

PURPOSE: To identify predictors of financial hardship, operationalized as foregoing health care, making financial sacrifices, and being concerned about having inadequate financial and insurance information. METHODS: Cancer survivors (n = 346) identified through the New Jersey State Cancer Registry were surveyed from August 2018 to September 2019. Multivariable logistic regression analyses were performed. RESULTS: Cancer survivors with household incomes less than $50,000 annually were more likely than those earning $50,0000-$90,000 to report foregoing health care (15.8 percentage points, p < 0.05). Compared to retirees, survivors who were currently unemployed, disabled, or were homemakers were more likely to forego doctor's visits (11.4 percentage points, p < 0.05), more likely to report borrowing money (16.1 percentage points, p < 0.01), and more likely to report wanting health insurance information (25.7 percentage points, p < 0.01). Employed survivors were more likely than retirees to forego health care (16.8 percentage points, p < 0.05) and make financial sacrifices (20.0 percentage points, p < 0.01). Survivors who never went to college were 9.8 percentage points (p < 0.05) more likely to borrow money compared to college graduates. Black survivors were more likely to want information about dealing with financial and insurance issues (p < 0.01); men were more likely to forego health care (p < 0.05). CONCLUSION: Findings highlight the role of employment status and suggest that education, income, race, and gender also shape cancer survivors' experience of financial hardship. There is a need to refine and extend financial navigation programs. For employed survivors, strengthening family leave policies would be desirable.

Predictors of health-related quality of life among Hispanic and non-Hispanic White breast cancer survivors in New Jersey.

PURPOSE: To examine predictors of health-related quality of life (HRQoL) in Hispanic and non-Hispanic White (NHW) breast cancer (BC) survivors. DESIGN: Cross-sectional study using survey data. PARTICIPANTS: Women diagnosed with BC at ages 21-79 years, between 2012-2014, recruited from the New Jersey State Cancer Registry. METHODS: HRQoL was assessed using the Functional Assessment Cancer Therapy (FACT-G) instrument. Descriptive statistics compared Hispanics and NHWs, and multivariate regression analyses identified predictors of HRQoL. RESULTS: HRQoL was significantly higher scores among NHW (85.7 ± 18.5) than Hispanics (79.4 ± 20.1) (p < 0.05). In multivariate analyses, comorbidities (ß: -13.3, 95%CI: -20.6, -5.92), late-stage diagnosis (ß: -5.67, 95%CI: -10.7, -0.62), lower income (ß: -13.9, 95%CI: -19.8, -7.97) and younger age at diagnosis were associated with lower HRQoL. CONCLUSION: Socio-demographic and clinic characteristics were significant predictors of HRQoL among diverse BC survivors. IMPLICATIONS FOR PSYCHOSOCIAL ONCOLOGY: Supportive psychosocial care interventions tailored to the needs of young, low-income BC survivors with comorbidities are needed.

Patterns of HIV testing among women diagnosed with invasive cervical cancer in the New Jersey Medicaid Program.

PURPOSE: Practice-based guidelines recommend HIV testing during initial invasive cervical cancer (ICC) workup. Determinants of HIV testing during diagnosis of AIDS-defining cancers in vulnerable populations, where risk for HIV infection is higher, are under-explored. METHODS: We examine factors associated with patterns of HIV testing among Medicaid enrollees diagnosed with ICC. Using linked data from the New Jersey State Cancer Registry and New Jersey Medicaid claims and enrollment files, we evaluated HIV testing among 242 ICC cases diagnosed from 2012 to 2014 in ages 21-64 at (a) any point during Medicaid enrollment (2011-2014) and (b) during cancer workup 6 months pre ICC diagnosis to 6 months post ICC diagnosis. Logistic regression models identified factors associated with HIV testing. RESULTS: Overall, 13% of women had a claim for HIV testing during ICC workup. Two-thirds (68%) of women did not have a claim for HIV testing (non-receipt of HIV testing) while enrolled in Medicaid. Hispanic/NH-API/Other women had lower odds of non-receipt of HIV testing compared with NH-Whites (OR: 0.40; 95% CI: 0.17-0.94). Higher odds of non-receipt of HIV testing were observed among cases with no STI testing (OR: 4.92; 95% CI 2.27-10.67) and < 1 year of Medicaid enrollment (OR: 3.07; 95% CI 1.14- 8.26) after adjusting for other factors. CONCLUSIONS: Few women had HIV testing claims during ICC workup. Opportunities for optimal ICC care are informed by knowledge of HIV status. Further research should explore if lack of HIV testing claims during ICC workup is an accurate indicator of ICC care, and if so, to assess testing barriers during workup.

Cancer Survivorship Care Roles for Primary Care Physicians.

PURPOSE: Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors. METHODS: We conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians' perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process. RESULTS: Divergent views exist regarding primary care's role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology's responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge. CONCLUSIONS: This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.

Association of Medicaid enrollee characteristics and primary care utilization with cancer outcomes for the period spanning Medicaid expansion in New Jersey.

BACKGROUND: Cancer outcomes for Medicaid enrollees may be affected by patients' primary care (PC) utilization and complex Medicaid enrollment dynamics, which have recently changed for many states under the Affordable Care Act. METHODS: With New Jersey State Cancer Registry and linked Medicaid claims data, a retrospective cohort study was conducted for patients with incident breast, colorectal, or invasive cervical cancer (aged 21-64 years) diagnosed in 2012-2014. Associations of Medicaid enrollment factors and PC utilization with the stage at diagnosis and treatment delays were examined with multivariate logistic regression models. RESULTS: The study included 19,209 total cancer cases and 3253 linked Medicaid cases. Medicaid cases were more likely to be diagnosed at a late stage and to experience treatment delays in comparison with non-Medicaid cases. In adjusted analyses, Medicaid cases with 1 or more PC visits before the diagnosis had lower odds of a late-stage diagnosis (odds ratio, 0.47; 95% confidence interval, 0.33-0.67) in comparison with Medicaid cases with no outpatient visits. New enrollees (<6 months) and longer term enrollees in fee-for-service (FFS) Medicaid had greater odds of a late-stage diagnosis and treatment delays in comparison with those in Medicaid managed care. CONCLUSIONS: Medicaid patients with cancer diagnosed just before and in the initial year of eligibility expansion had worse outcomes than non-Medicaid cases. Poor outcomes were especially pronounced among new enrollees, those without outpatient visits before their diagnosis, and FFS enrollees. Targeted strategies to enhance care continuity, including access to PC providers before the diagnosis and a better understanding of pathways to cancer care upon Medicaid enrollment, are needed to improve outcomes in this population.

Understanding primary care-oncology relationships within a changing healthcare environment.

BACKGROUND: Management of care transitions from primary care into and out of oncology is critical for optimal care of cancer patients and cancer survivors. There is limited understanding of existing primary care-oncology relationships within the context of the changing health care environment. METHODS: Through a comparative case study of 14 innovative primary care practices throughout the United States (U.S.), we examined relationships between primary care and oncology settings to identify attributes contributing to strengthened relationships in diverse settings. Field researchers observed practices for 10-12 days, recording fieldnotes and conducting interviews. We created a reduced dataset of all text related to primary care-oncology relationships, and collaboratively identified patterns to characterize these relationships through an inductive "immersion/crystallization" analysis process. RESULTS: Nine of the 14 practices discussed having either formal or informal primary care-oncology relationships. Nearly all formal primary care-oncology relationships were embedded within healthcare systems. The majority of private, independent practices had more informal relationships between individual primary care physicians and specific oncologists. Practices with formal relationships noted health system infrastructure that facilitates transfer of patient information and timely referrals. Practices with informal relationships described shared commitment, trust, and rapport with specific oncologists. Regardless of relationship type, challenges reported by primary care settings included lack of clarity about roles and responsibilities during cancer treatment and beyond. CONCLUSIONS: With the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate strengths of informal primary care-oncology relationships in addition to formal system driven relationships.

Factors associated with high-risk human papillomavirus test utilization and infection: a population-based study of uninsured and underinsured women.

BACKGROUND: Current cervical cancer screening guidelines recommend a Pap test every 3 years for women age 21-65 years, or for women 30-65 years who want to lengthen the screening interval, a combination of Pap test and high-risk human papilloma virus testing (co-testing) every 5 years. Little population-based data are available on human papilloma virus test utilization and human papilloma virus infection rates. The objective of this study was to examine the patient-level, cervical cancer screening, and area-level factors associated with human papilloma virus testing and infection among a diverse sample of uninsured and underinsured women enrolled in the New Jersey Cancer Early Education and Detection (NJCEED) Program. METHODS: We used data for a sample of 50,510 uninsured/underinsured women, age ≥ 29 years, who screened for cervical cancer through NJCEED between January 1, 2009 and December 31, 2015. Multivariable logistic regression models were used to estimate associations between ever having a human papilloma virus test or a positive test result, and individual- (age, race/ethnicity, birthplace) and area-level covariates (% below federal poverty level, % minority, % uninsured), and number of screening visits. RESULTS: Only 26.6% (13,440) of the sample had at least one human papilloma virus test. Among women who underwent testing, 13.3% (1792) tested positive for human papilloma virus. Most women who were positive for human papilloma virus (99.4%) had their first test as a co-test. Human papilloma virus test utilization and infection were significantly associated with age, race/ethnicity, birthplace (country), and residential area-level poverty. Rates of human papilloma virus testing and infection also differed significantly across counties in the state of New Jersey. CONCLUSIONS: These findings suggest that despite access to no-cost cervical cancer screening for eligible women, human papilloma virus test utilization was relatively low among diverse, uninsured and underinsured women in New Jersey, and test utilization and infection were associated with individual-level and area-level factors.

What does Medicaid expansion mean for cancer screening and prevention? Results from a randomized trial on the impacts of acquiring Medicaid coverage.

BACKGROUND: The Oregon Medicaid lottery provided a unique opportunity to assess the causal impacts of health insurance on cancer screening rates within the framework of a randomized controlled trial. Prior studies regarding the impacts of health insurance have almost always been limited to observational evidence, which cannot be used to make causal inferences. METHODS: The authors prospectively followed a representative panel of 16,204 individuals from the Oregon Medicaid lottery reservation list, collecting data before and after the Medicaid lottery drawings. The study panel was divided into 2 groups: a treatment group of individuals who were selected in the Medicaid lottery (6254 individuals) and a control group who were not (9950 individuals). The authors also created an elevated risk subpanel based on family cancer histories. One year after the lottery drawings, differences in cancer screening rates, preventive behaviors, and health status were compared between the study groups. RESULTS: Medicaid coverage resulted in significantly higher rates of several common cancer screenings, especially among women, as well as better primary care connections and self-reported health outcomes. There was little evidence found that acquiring Medicaid increased the adoption of preventive health behaviors that might reduce cancer risk. CONCLUSIONS: Medicaid coverage did not appear to directly impact lifestyle choices that might reduce cancer risk, but it did provide access to important care and screenings that could help to detect cancers earlier. These findings could have long-term population health implications for states considering or pursuing Medicaid expansion. Cancer 2016;122:791-797. © 2015 American Cancer Society.