Distance to endoscopy services amplifies racial inequities in colorectal cancer mortality in Washington state.

BACKGROUND: This study evaluates relationships among race, access to endoscopy services, and colorectal cancer (CRC) mortality in Washington state (WA). METHODS: We overlayed the locations of ambulatory endoscopy services with place of residence at time of death, using Department of Health data (2011-2018). We compared CRC mortality data within and outside a 10 â€‹km buffer from services. We used linear regression to assess the impact of distance and race on age at death while adjusting for gender and education level. RESULTS: Age at death: median 72.9y vs. 68.2y for white vs. non-white (p â€‹< â€‹0.001). The adjusted model showed that non-whites residing outside the buffer died 6.9y younger on average (p â€‹< â€‹0.001). Non-whites residing inside the buffer died 5.2y younger on average (p â€‹< â€‹0.001), and whites residing outside the buffer died 1.6y younger (p â€‹< â€‹0.001). We used heatmaps to geolocate death density. CONCLUSIONS: Results suggest that geographic access to endoscopy services disproportionately impacts non-whites in Washington. These data help identify communities which may benefit from improved access to alternative colorectal cancer screening methods.

Travel Burden to Cancer Screening and Treatment Facilities Among Washington Women: Data From an Integrated Healthcare Delivery System.

PURPOSE: To characterize distance traveled for breast cancer screening and to sites of service for breast cancer treatment, among rural and urban women served by a Washington State healthcare network. METHODS: Data for this study came from one of the largest not-for-profit integrated healthcare delivery systems in Washington State. Generalized linear mixed models with gamma log link function were used to examine the associations between travel distance and sociodemographic and contextual characteristics of patients. RESULTS: Median travel distance for breast cancer screening facilities, hematologist/oncologists, radiation oncologists, or surgeons was 11, 19, 23, or 11 miles, respectively. Travel distance to breast cancer screening or referral facilities was longer in non-core metropolitan ZIP codes compared to metropolitan ZIP codes. AI/AN and Hispanic women travelled longer distances to reach referral facilities compared to other racial and ethnic groups. CONCLUSION: Disparities exist in travel distance to breast cancer screening and treatment. Further research is needed to describe sociodemographic and system level characteristics that contribute to such disparities and to discover novel approaches to alleviate this burden.

Racial and socioeconomic inequities in breast cancer screening before and during the COVID-19 pandemic: analysis of two cohorts of women 50 years + .

BACKGROUND: Routine screening mammography at two-year intervals is widely recommended for the prevention and early detection of breast cancer for women who are 50 years + . Racial and other sociodemographic inequities in routine cancer screening are well-documented, but less is known about how these long-standing inequities were impacted by the disruption in health services during the COVID-19 pandemic. Early in the pandemic, cancer screening and other prevention services were suspended or delayed, and these disruptions may have had to disproportionate impact on some sociodemographic groups. We tested the hypothesis that inequities in screening mammography widened during the pandemic. METHODS: A secondary analysis of patient data from a large state-wide, non-profit healthcare system in Washington State. Analyses were based on two mutually exclusive cohorts of women 50 years or older. The first cohort (n = 18,197) were those women screened in 2017 who would have been due for repeat screening in 2019 (prior to the pandemic's onset). The second cohort (n = 16,391) were women screened in 2018 due in 2020. Explanatory variables were obtained from patient records and included race/ethnicity, age, rural or urban residence, and insurance type. Multivariable logistic regression models estimated odds of two-year screening for each cohort separately. Combining both cohorts, interaction models were used to test for differences in inequities before and during the pandemic. RESULTS: Significant sociodemographic differences in screening were confirmed during the pandemic, but these were similar to those that existed prior. Based on interaction models, women using Medicaid insurance and of Asian race experienced significantly steeper declines in screening than privately insured and white women (Odds ratios [95% CI] of 0.74 [0.58-0.95] and 0.76 [0.59-0.97] for Medicaid and Asian race, respectively). All other sociodemographic inequities in screening during 2020 were not significantly different from those in 2019. CONCLUSIONS: Our findings confirm inequities for screening mammograms during the first year of the COVID-19 pandemic and provide evidence that these largely reflect the inequities in screening that were present before the pandemic. Policies and interventions to tackle long-standing inequities in use of preventive services may help ensure continuity of care for all, but especially for racial and ethnic minorities and the socioeconomically disadvantaged.

COVID-19 and inequities in colorectal and cervical cancer screening and diagnosis in Washington State.

INTRODUCTION: Studies have shown that cancer screenings dropped dramatically following the onset of the coronavirus diseases 2019 (COVID-19) pandemic. In this study, we examined differences in rates of cervical and colorectal cancer (CRC) screening and diagnosis indicators before and during the first year of the COVID-19 pandemic. METHODOLOGY: We used retrospective data from a large healthcare system in Washington State. Targeted screening data included completed cancer screenings for both CRC (colonoscopy) and cervical cancer (Papanicolaou test (Pap test)). We analyzed and compared the rate of uptake of colorectal (colonoscopies) and cervical cancer (Pap) screenings done pre-COVID-19 (April 1, 2019-March 31, 2020) and during the pandemic (April 1, 2020-March 31, 2021). RESULTS: A total of 26,081 (12.7%) patients underwent colonoscopies in the pre-COVID-19 period, compared to only 15,708 (7.4%) patients during the pandemic, showing a 39.8% decrease. A total of 238 patients were referred to medical oncology for CRC compared to only 155 patients during the first year of the pandemic, a reduction of 34%. In the pre-COVID-19 period, 22,395 (10.7%) women were administered PAP tests compared to 20,455 (9.6%) women during the pandemic, for a 7.4% reduction. period 1780 women were referred to colposcopy, compared to only 1680 patients during the pandemic, for a 4.3% reduction. CONCLUSION: Interruption in screening and subsequent delay in diagnosis during the pandemic will likely lead to later-stage diagnoses for both CRC and cervical cancer, which is known to result in decreased survival. IMPACT: The results emphasize the need to prioritize cancer screening, particularly for those at higher risk.

Disparities in Access to Radiation Therapy Facilities Among American Indians/Alaska Natives and Hispanics in Washington State.

PURPOSE: Racial and ethnic minorities in the state of Washington experience higher cancer mortality relative to whites. We sought to characterize differences in travel distance to radiation therapy (RT) facilities in Washington by race and ethnicity with a special focus on non-Hispanic American Indians and Alaska Natives as a contributor to limited access and cancer disparities. METHODS AND MATERIALS: Geocoded mortality data from Washington Department of Health (2011-2018) were used to identify decedents with mortality related to all-causes, all cancers, and cancers likely requiring access to RT. This was determined from optimal RT usage estimates by diagnosis. RT facility locations were ascertained from the Directory of Radiation Therapy Centers and confirmed. Distance from decedents' address listed on death certificates to nearest RT facility was calculated. Generalized mixed models were used for statistical analysis. RESULTS: We identified 418,754 deaths; 109,134 were cancer-related, 60,973 likely required RT. Among decedents with cancers likely requiring RT, non-Hispanic American Indians and Alaska Natives decedents would have had to travel 1.16 times (95% confidence interval [CI], 1.09-1.24) farther from their residences to reach the nearest treatment facility compared with non-Hispanic whites. This association existed in metro counties but was more pronounced in nonmetro counties (1.39 times farther; 95% CI, 1.22-1.58). In addition, Hispanics would have had to travel 1.11 times farther (95% CI, 1.06-1.16) to reach the nearest facility compared with non-Hispanic whites, primarily due to differences in urban counties. Decedents in nonmetro counties lived on average 35 miles (SD = 29) from RT centers and non-Hispanic American Indians and Alaska Natives in nonmetro counties 53 miles (SD = 38). Compared with non-Hispanic white decedents, those who were non-Hispanic black, non-Hispanic Asian, and non-Hispanic Native Hawaiian decedents lived closer to RT facilities. CONCLUSIONS: We observed significant disparities in access to RT facilities in Washington, specifically for non-Hispanic American Indians and Alaska Natives and rural decedents. The findings call for initiatives to improve access to critical cancer treatment services for these underserved populations with known disparities in cancer deaths.

Proximity to Screening Site, Rurality, and Neighborhood Disadvantage: Treatment Status among Individuals with Sexually Transmitted Infections in Yakima County, Washington.

Background: Early sexually transmitted infections (STIs) diagnosis facilitates prompt treatment initiation and contributes to reduced transmission. This study examined the extent to which contextual characteristics such as proximity to screening site, rurality, and neighborhood disadvantage along with demographic variables, may influence treatment seeking behavior among individuals with STIs (i.e., chlamydia, gonorrhea, and syphilis). Methods: Data on 16,075 diagnosed cases of STIs between 2007 and 2018 in Yakima County were obtained from the Washington State Department of Health Database Surveillance System. Multilevel models were applied to explore the associations between contextual and demographic characteristics and two outcomes: (a) not receiving treatment and (b) the number of days to receiving treatment. Results: Contextual risk factors for not receiving treatment or having increased number of days to treatment were living ≥10 miles from the screening site and living in micropolitan, small towns, or rural areas. Older age was a protective factor and being female was a risk for both outcomes. Conclusions: Healthcare providers and facilities should be made aware of demographic and contextual characteristics that can impact treatment seeking behavior among individuals with STIs, especially among youth, females, and rural residents.

Access to Primary Care Physicians and Mortality in Washington State: Application of a 2-Step Floating Catchment Area.

OBJECTIVE: To measure access to primary care physicians (PCPs) using a 2-step floating catchment area and explore the associations between access to PCPs and mortality related to all-causes, cancers, and heart disease in Washington State. METHODS: An ecological study employing generalized linear regression models of access to PCPs and mortality rates in 4,761 block groups in Washington State in 2015. To measure access to PCPs, we used a 2-step floating catchment area approach, taking into account area-level population, supply of PCPs, and travel time between PCPs, as well as area-level population with a distance decay function. RESULTS: A 1-unit increase in PCP access score was associated with a reduction of 4.2 all-cause deaths per 100,000 people controlling for socioeconomic characteristics. A 1-unit increase in PCP access score was associated with a reduction of 2.7 cancer deaths and a reduction of 2.1 heart disease deaths per 100,000 people controlling for socioeconomic characteristics. CONCLUSIONS: Better access to PCPs was associated with lower mortality from all-causes, cancers, and heart disease. The 2-step floating catchment area approach can help with the identification of PCP shortage areas, the development of rural residency programs, and the expansion of the physician workforce in Washington State and other regions.

Availability of licensed cannabis businesses in relation to area deprivation in Washington state: A spatiotemporal analysis of cannabis business presence between 2014 and 2017.

INTRODUCTION AND AIMS: In states where recreational use of cannabis has been legalised, increasing numbers of cannabis licensed cannabis businesses resulted in concerns about their potential social and health impacts. This study examined spatiotemporal variations in availability of cannabis licensed cannabis businesses (i.e. producers, processors and retailers) in relation to area deprivation in Washington state from 2014 to 2017. DESIGN AND METHODS: Data on licensed cannabis businesses were obtained from the Washington State Liquor and Cannabis Board. The number of licensed cannabis businesses was estimated for Washington's 1446 census tracts. Census tracts were stratified into tertiles based on the Singh's Area Deprivation Index showing socio-economic characteristics of communities (least-deprived, middle-deprived and most-deprived). The Integrated Nested Laplace Approximation approach allowed for the spatial and temporal characterisation of cannabis businesses, accounting for similarities based on neighbouring census tracts. RESULTS: The density of all licensed cannabis outlets increased over time. Most-deprived areas have increased likelihood of licensed cannabis outlet density when compared to least-deprived areas. No differences were observed in the likelihood of licensed cannabis outlet density in middle-deprived areas when compared to least-deprived areas. DISCUSSION AND CONCLUSIONS: The results of this study showed disparity with respect to licensed cannabis outlet density in Washington state over time. The findings call for initiatives, policies and research that decrease disparities in cannabis outlet locations.

Comparing pyloromyotomy outcomes across Canada.

BACKGROUND: Changing patterns of referral and management of hypertrophic pyloric stenosis (HPS) in North America have recently been described. Comfort with perioperative management, anesthesia, and corrective surgery have been cited as reasons for these changes. Our primary objective was to assess pyloromyotomy outcomes between different hospital types across Canada. The secondary objective was to geospatially map all pyloromyotomies to identify regions of higher HPS incidence across Canada. METHODS: Data of all pyloromyotomies done between 2011 and 2013 were acquired from Canadian Institute for Health Information (CIHI). Complication rates and length of hospital stay (LOS) were analyzed. Postal codes for each patient were used to geospatially map regions of higher HPS incidence. RESULTS: A total of 1261 pyloromyotomies were assessed. There was no difference in LOS or complication rates between different hospital types or surgeon group. Open pyloromyotomies were done in 75% of the cases. Several regions of higher HPS incidence were identified across Canada. CONCLUSION: This study found no difference in complication rate or LOS stay between hospital type and surgeon type across Canada. This may reflect a previously identified referral trend in the United States towards pediatric centers. Several regions of higher HPS incidence were identified, and may aid in identifying genetic elements causing HPS. LEVEL OF EVIDENCE: 2c.

Hypertrophic pyloric stenosis in the Maritimes: examining the waves of change over time.

BACKGROUND: Changing patterns of referral and management of pediatric surgical conditions, including hypertrophic pyloric stenosis (HPS), have recently been described and often relate to comfort with early nonoperative management, anesthesia and corrective surgery. Travelling distance required for treatment at pediatric centres can also be burdensome for families. We assessed referral patterns for HPS in the maritime provinces of Canada over 10 years to quantify the burden on families travelling for surgical care. METHODS: We reviewed the charts of all patients with HPS in the Maritimes. Length of hospital stay (LOS) and complication rates were analyzed in regards to resuscitation and management at a pediatric centre and/or peripheral centres. We used postal codes for each patient to track distance travelled for management. RESULTS: We assessed 751 cases of HPS. During the study period (Jan. 1, 2001-Dec. 31, 2010), referral to pediatric centres increased from 49% to 71%. Postoperative complications were 2.5-fold higher in peripheral centres. Infants referred to pediatric centres were 78% less likely to have an LOS longer than 3 days. Laparoscopic pyloromyotomy, which was performed only in pediatric centres, was associated with a shorter postoperative LOS. CONCLUSION: Our study supports the current literature demonstrating improved outcomes, shorter overall LOS and decreased risk of complications when infants with HPS are treated in pediatric centres. This should be considered when planning access to pediatric surgical resources.

CONTEXTE: Une évolution des tendances dans les pratiques d'orientation des patients et de prise en charge des affections pédiatriques nécessitant une intervention chirurgicale, telles que la sténose hypertrophique du pylore (SHP), a récemment été décrite; elle dépend souvent du degré d'acceptation de la prise en charge non chirurgicale précoce, de l'anesthésie et de la chirurgie correctrice. Le traitement en centre pédiatrique peut exiger des déplacements pénibles pour les familles. Nous avons évalué les pratiques d'orientation des cas de SHP dans les provinces maritimes du Canada sur une période de 10 ans pour quantifier l'ampleur du fardeau qui incombe aux familles devant voyager pour obtenir des soins chirurgicaux. MÉTHODES: Nous avons étudié le dossier de tous les patients atteints de SHP dans les Maritimes et avons comparé la durée de séjour et le taux de complications associés à la réanimation et à la prise en charge dans les centres pédiatriques et les centres périphériques. Nous avons aussi utilisé les codes postaux des patients pour déterminer la distance de déplacement des familles. RÉSULTATS: Nous avons analysé 751 cas de SHP. Pendant la période à l'étude (2001­2010), le taux d'orientation des patients vers les centres pédiatriques est passé de 49 % à 71 %. Les complications postopératoires étaient 2,5 fois plus courantes dans les centres périphériques, et les séjours de plus de 3 jours étaient 78 % moins fréquents chez les nourrissons traités en centre pédiatrique. La pyloromyotomie par laparoscopie, réalisée dans les centres pédiatriques seulement, a été associée à une réduction de la durée de séjour postopératoire. CONCLUSION: Notre étude va dans le même sens que la littérature actuelle, qui indique que le traitement des nourrissons atteints de SHP en centre pédiatrique est associé à de meilleurs résultats postchirurgicaux, à une durée d'hospitalisation moins longue et à un risque de complications plus faible que le traitement dans un centre périphérique. Ces résultats devraient être pris en compte dans la planification de l'accès aux ressources dans le domaine de la chirurgie pédiatrique.

Barriers to Cervical Screening Among Sex Workers in Vancouver.

OBJECTIVES: We longitudinally examined the social, structural, and geographic correlates of cervical screening among sex workers in Metropolitan Vancouver, British Columbia, to determine the roles that physical and social geography play in routine reproductive health care access. METHODS: Analysis drew on (2010-2013) data from an open prospective cohort of sex workers (An Evaluation of Sex Workers' Health Access). We used multivariable logistic regression with generalized estimating equations (GEE) to model correlates of regular cervical screening. RESULTS: At baseline, 236 (38.6%) of 611 sex workers in our sample had received cervical screening, and 63 (10.3%) were HIV-seropositive. In multivariable GEE analysis, HIV-seropositivity (adjusted odds ratio [AOR] = 1.65; 95% confidence interval [CI] = 1.06, 2.58) and accessing outreach services (AOR = 1.35; 95% CI = 1.09, 1.66) were correlated with regular cervical screening. Experiencing barriers to health care access (e.g., poor treatment by health care staff, limited hours of operation, and language barriers) reduced odds of regular Papanicolaou testing (AOR = 0.81; 95% CI = 0.65, 1.00). CONCLUSIONS: Sex workers in Metropolitan Vancouver had suboptimal levels of cervical screening. Innovative mobile outreach service delivery models offering cervical screening as one component of sex worker-targeted comprehensive sexual and reproductive health services may hold promise.

A comparative analysis of potential spatio-temporal access to palliative care services in two Canadian provinces.

BACKGROUND: Access to health services such as palliative care is determined not only by health policy but a number of legacies linked to geography and settlement patterns. We use GIS to calculate potential spatio-temporal access to palliative care services. In addition, we combine qualitative data with spatial analysis to develop a unique mixed-methods approach. METHODS: Inpatient health care facilities with dedicated palliative care beds were sampled in two Canadian provinces: Newfoundland and Saskatchewan. We then calculated one-hour travel time catchments to palliative health services and extended the spatial model to integrate available beds as well as documented wait times. RESULTS: 26 facilities with dedicated palliative care beds in Newfoundland and 69 in Saskatchewan were identified. Spatial analysis of one-hour travel times and palliative beds per 100,000 population in each province showed distinctly different geographical patterns. In Saskatchewan, 96.7% of the population living within a-1 h of drive to a designated palliative care bed. In Newfoundland, 93.2% of the population aged 65+ were living within a-1 h of drive to a designated palliative care bed. However, when the relationship between wait time and bed availability was examined for each facility within these two provinces, the relationship was found to be weak in Newfoundland (R(2) = 0.26) and virtually nonexistent in Saskatchewan (R(2) = 0.01). CONCLUSIONS: Our spatial analysis shows that when wait times are incorporated as a way to understand potential spatio-temporal access to dedicated palliative care beds, as opposed to spatial access alone, the picture of access changes.

An assessment of air pollution and its attributable mortality in Ulaanbaatar, Mongolia.

Epidemiologic studies have consistently reported associations between outdoor fine particulate matter (PM2.5) air pollution and adverse health effects. Although Asia bears the majority of the public health burden from air pollution, few epidemiologic studies have been conducted outside of North America and Europe due in part to challenges in population exposure assessment. We assessed the feasibility of two current exposure assessment techniques, land use regression (LUR) modeling and mobile monitoring, and estimated the mortality attributable to air pollution in Ulaanbaatar, Mongolia. We developed LUR models for predicting wintertime spatial patterns of NO2 and SO2 based on 2-week passive Ogawa measurements at 37 locations and freely available geographic predictors. The models explained 74% and 78% of the variance in NO2 and SO2, respectively. Land cover characteristics derived from satellite images were useful predictors of both pollutants. Mobile PM2.5 monitoring with an integrating nephelometer also showed promise, capturing substantial spatial variation in PM2.5 concentrations. The spatial patterns in SO2 and PM, seasonal and diurnal patterns in PM2.5, and high wintertime PM2.5/PM10 ratios were consistent with a major impact from coal and wood combustion in the city's low-income traditional housing (ger) areas. The annual average concentration of PM2.5 measured at a centrally located government monitoring site was 75 µg/m3 or more than seven times the World Health Organization's PM2.5 air quality guideline, driven by a wintertime average concentration of 148 µg/m3. PM2.5 concentrations measured in a traditional housing area were higher, with a wintertime mean PM2.5 concentration of 250 µg/m3. We conservatively estimated that 29% (95% CI, 12-43%) of cardiopulmonary deaths and 40% (95% CI, 17-56%) of lung cancer deaths in the city are attributable to outdoor air pollution. These deaths correspond to nearly 10% of the city's total mortality, with estimates ranging to more than 13% of mortality under less conservative model assumptions. LUR models and mobile monitoring can be successfully implemented in developing country cities, thus cost-effectively improving exposure assessment for epidemiology and risk assessment. Air pollution represents a major threat to public health in Ulaanbaatar, Mongolia, and reducing home heating emissions in traditional housing areas should be the primary focus of air pollution control efforts.

A web-based model to support patient-to-hospital allocation in mass casualty incidents.

BACKGROUND: In a mass casualty situation, evacuation of severely injured patients to the appropriate health care facility is of critical importance. The prehospital stage of a mass casualty incident (MCI) is typically chaotic, characterized by dynamic changes and severe time constraints. As a result, those involved in the prehospital evacuation process must be able to make crucial decisions in real time. This article presents a model intended to assist in the management of MCIs. The Mass Casualty Patient Allocation Model has been designed to facilitate effective evacuation by providing key information about nearby hospitals, including driving times and real-time bed capacity. These data will enable paramedics to make informed decisions in support of timely and appropriate patient allocation during MCIs. The model also enables simulation exercises for disaster preparedness and first response training. METHODS: Road network and hospital location data were used to precalculate road travel times from all locations in Metro Vancouver to all Level I to III trauma hospitals. Hospital capacity data were obtained from hospitals and were updated by tracking patient evacuation from the MCI locations. In combination, these data were used to construct a sophisticated web-based simulation model for use by emergency response personnel. RESULTS: The model provides information critical to the decision-making process within a matter of seconds. This includes driving times to the nearest hospitals, the trauma service level of each hospital, the location of hospitals in relation to the incident, and up-to-date hospital capacity. CONCLUSION: The dynamic and evolving nature of MCIs requires that decisions regarding prehospital management be made under extreme time pressure. This model provides tools for these decisions to be made in an informed fashion with continuously updated hospital capacity information. In addition, it permits complex MCI simulation for response and preparedness training.

A protocol for determining differences in consistency and depth of palliative care service provision across community sites.

Numerous accounts document the difficulty in obtaining accurate data regarding the extent and composition of palliative care services. Compounding the problem is the lack of standardisation regarding categorisation and reporting across jurisdictions. In this study, we gathered both quantitative and spatial--or geographical--data to develop a composite picture that captures the extent, composition and depth of palliative care in the Canadian province of British Columbia (BC). The province is intensely urban in the southwest and is rural or remote in most of the remainder. For this study, we conducted a detailed telephone survey of all palliative care home care teams and facilities hosting designated beds in BC. We used geographic information systems to geocode locations of all hospice and hospital facilities. In-home care data was obtained individually from each of five BC regional health authorities. In addition, we purchased accurate road travel time data to determine service areas around palliative facilities and to determine populations outside of a 1-hour travel time to a facility. With this data, we were able to calculate three critical metrics: (i) the population served within 1 hour of palliative care facilities--and more critically those not served; (ii) a matrix that determines access to in-home palliative care measured by both diversity of professionals as well as population served per palliative team member; and (iii) a ranking of palliative care services across the province based on physical accessibility as well as the extent of in-home care. In combination, these metrics provide the basis for identifying areas of vulnerability with respect to not meeting potential palliative care need. In addition, the ranking provides a basis for rural/urban comparisons. Finally, the protocol introduced can be used in other areas and provides a means of comparing palliative care service provision amongst multiple jurisdictions.