Impact of the Affordable Care Act on Colorectal Cancer Outcomes: A Systematic Review.

CONTEXT: The Patient Protection and Affordable Care Act increases healthcare access and includes provisions that directly impact access to and cost of evidence-based colorectal cancer screening. The Affordable Care Act's removal of cost sharing for colorectal cancer screening as well as Medicaid expansion have been hypothesized to increase screening and improve other health outcomes. However, since its passage in 2010, there is little consensus on the Affordable Care Act's impact. EVIDENCE ACQUISITION: Data from March 2010 to June 2019 were reviewed and 21 relevant studies were identified; 19 studies examined colorectal cancer screening with most finding increased screening rates. EVIDENCE SYNTHESIS: Eleven studies found significant increases, 5 found nonsignificant increases, 3 found nonsignificant decreases, and 1 study found a significant decrease in colorectal cancer screening. Three studies examined the impact on colorectal cancer incidence and stage of diagnosis, where a significant 2.4% increase in early diagnosis was found in one and a nonsignificant increase in incidence in another. However, survival improved after Medicaid expansion. CONCLUSIONS: Free preventive colorectal cancer screening and Medicaid expansion because of passage of the Affordable Care Act have been, in general, positively associated with modest improvements in screening rates across the country. Future studies are needed that investigate the longer-term impact of the Affordable Care Act on colorectal cancer morbidity and mortality rates, as screening is only the first step in treatment of cancerous and precancerous lesions, preventing them from progressing. Moreover, more studies examining subpopulations are needed to better assess where gaps in care remain.

Assessing the reliability and validity of direct observation and traffic camera streams to measure helmet and motorcycle use.

There is a need to develop motorcycle helmet surveillance approaches that are less labour intensive than direct observation (DO), which is the commonly recommended but never formally validated approach, particularly in developing settings. This study sought to assess public traffic camera feeds as an alternative to DO, in addition to the reliability of DO under field conditions. DO had high inter-rater reliability, κ=0.88 and 0.84, respectively, for cycle type and helmet type, which reinforces its use as a gold standard. However, traffic camera-based data collection was found to be unreliable, with κ=0.46 and 0.53 for cycle type and helmet type. When bicycles, motorcycles and scooters were classified based on traffic camera streams, only 68.4% of classifications concurred with those made via DO. Given the current technology, helmet surveillance via traffic camera streams is infeasible, and there remains a need for innovative traffic safety surveillance approaches in low-income urban settings.