COVID-19 pandemic impact on the potential exacerbation of screening mammography disparities: A population-based study in Ontario, Canada.

Strategies to ramp up breast cancer screening after COVID-19 require data on the influence of the pandemic on groups of women with historically low screening uptake. Using data from Ontario, Canada, our objectives were to 1) quantify the overall pandemic impact on weekly bilateral screening mammography rates (per 100,000) of average-risk women aged 50-74 and 2) examine if COVID-19 has shifted any mammography inequalities according to age, immigration status, rurality, and access to material resources. Using a segmented negative binomial regression model, we estimated the mean change in rate at the start of the pandemic (the week of March 15, 2020) and changes in weekly trend of rates during the pandemic period (March 15-December 26, 2020) compared to the pre-pandemic period (January 3, 2016-March 14, 2020) for all women and for each subgroup. A 3-way interaction term (COVID-19*week*subgroup variable) was added to the model to detect any pandemic impact on screening disparities. Of the 3,481,283 mammograms, 8.6 % (n = 300,064) occurred during the pandemic period. Overall, the mean weekly rate dropped by 93.4 % (95 % CI 91.7 % - 94.8 %) at the beginning of COVID-19, followed by a weekly increase of 8.4 % (95 % CI 7.4 % - 9.4 %) until December 26, 2020. The pandemic did not shift any disparities (all interactions p > 0.05) and that women who were under 60 or over 70, immigrants, or with a limited access to material resources had persistently low screening rate in both periods. Interventions should proactively target these underserved populations with the goals of reducing advanced-stage breast cancer presentations and mortality.

Developing a Health Equity Impact Assessment 'Indigenous Lens Tool' to address challenges in providing equitable cancer screening for indigenous peoples.

BACKGROUND: In spite of past efforts to increase screening uptake, the rates of screening-detectable cancers including breast, cervical, colorectal and lung are rising among Indigenous persons in Ontario compared to other Ontarians. The Ontario Ministry of Health has an equity framework, the Health Equity Impact Assessment (HEIA) Tool, that was developed to guide organizations in the provision of more equitable health and social services. Although the HEIA Tool identifies that the health of Indigenous persons may benefit from more equitable provision of health and social services, it provides very little specific guidance on how to apply the HEIA Tool in a culturally relevant way to policies and programs that may impact Indigenous peoples. DISCUSSION: Guided by the Calls to Action from the Truth and Reconciliation Commission of Canada and the United Nations Declaration on the Rights of Indigenous Peoples, an Indigenous Lens Tool was developed through a collaborative and iterative process with stakeholders at Cancer Care Ontario and with representatives from Indigenous community-based organizations. The Indigenous Lens Tool consists of four scenarios, with supporting documentation that provide context for each step of the HEIA Tool and thereby facilitate application of the equity framework to programs and policies. The document is in no way meant to be comprehensive or representative of the diverse health care experiences of Indigenous peoples living in Canada nor the social determinants that surround health and well-being of Indigenous peoples living in Canada. Rather, this document provides a first step to support development of policies and programs that recognize and uphold the rights to health and well-being of Indigenous peoples living in Canada. CONCLUSIONS: The Indigenous Lens Tool was created to facilitate implementation of an existing health equity framework within Cancer Care Ontario (now Ontario Health). Even though the Indigenous Lens Tool was created for this purpose, the principles contained within it are translatable to other health and social service policy applications.

Overall Health Care Cost During the Year Following Diagnosis of Colorectal Cancer Stratified by History of Colorectal Evaluative Procedures.

BACKGROUND: The cost-effectiveness of colorectal screening has been modeled; however, the cost of health care following the diagnosis of colorectal cancer has not been described stratified by history of colorectal evaluative procedures. METHODS: We identified persons with first diagnosis of colorectal cancer between 2015 and 2017 from the Ontario Cancer Registry, and categorized them by history of colorectal evaluative procedures during Period 1 (the 10 years before the 6-month prediagnostic interval) with or without procedures during Period 2 (the 6 month prediagnostic interval), versus only during Period 2, versus none. We extracted overall health care cost 1 year following diagnosis from population-wide administrative databases. RESULTS: Among cases diagnosed at 52 to 74 years, overall health care cost among those with no colorectal evaluative procedures on or before the date of diagnosis is $71,039.65 (SD $51,825.18), compared to $48,406.15 (SD $38,843.64) among those who received colorectal evaluative procedures during Period 1, with or without procedures during Period 2. Among the population aged 20 to 74 years at diagnosis, cases with ≥1 screening colonoscopies for hereditary CRC syndrome, the mean overall initial cost was between $32,300.32 (SD) and $33,084.67 (SD $39,905.77), and those with ≥1 screening colonoscopies because of a first-degree relative with CRC, was between $36,344.71 (SD $35,539.85) and $45,456.41 (SD $49,818.59). CONCLUSIONS: Overall health care cost is lower among cases who received colorectal evaluative procedures during Period 1, with or without procedures during Period 2, and among those with screening colonoscopy for hereditary CRC syndromes or affected first-degree relatives.

Harms, benefits and costs of fecal immunochemical testing versus guaiac fecal occult blood testing for colorectal cancer screening.

BACKGROUND: The ColonCancerCheck screening program for colorectal cancer (CRC) in Ontario, Canada, is considering switching from biennial guaiac fecal occult blood test (gFOBT) screening between age 50-74 years to the more sensitive, but also less specific fecal immunochemical test (FIT). The aim of this study is to estimate whether the additional benefits of FIT screening compared to gFOBT outweigh the additional costs and harms. METHODS: We used microsimulation modeling to estimate quality adjusted life years (QALYs) gained and costs of gFOBT and FIT, compared to no screening, in a cohort of screening participants. We compared strategies with various age ranges, screening intervals, and cut-off levels for FIT. Cost-efficient strategies were determined for various levels of available colonoscopy capacity. RESULTS: Compared to no screening, biennial gFOBT screening between age 50-74 years provided 20 QALYs at a cost of CAN$200,900 per 1,000 participants, and required 17 colonoscopies per 1,000 participants per year. FIT screening was more effective and less costly. For the same level of colonoscopy requirement, biennial FIT (with a high cut-off level of 200 ng Hb/ml) between age 50-74 years provided 11 extra QALYs gained while saving CAN$333,300 per 1000 participants, compared to gFOBT. Without restrictions in colonoscopy capacity, FIT (with a low cut-off level of 50 ng Hb/ml) every year between age 45-80 years was the most cost-effective strategy providing 27 extra QALYs gained per 1000 participants, while saving CAN$448,300. INTERPRETATION: Compared to gFOBT screening, switching to FIT at a high cut-off level could increase the health benefits of a CRC screening program without considerably increasing colonoscopy demand.

Population-based assessment of the outcomes in patients with postcolonoscopy colorectal cancers.

OBJECTIVE: The potential for cancers to not be detected on colonoscopy is increasingly recognised, but little is known about patient outcomes. The objective of this study was to assess the outcomes of patients diagnosed with postcolonoscopy colorectal cancers (PCCRCs). DESIGN: We conducted a population-based retrospective cohort study, including all patients diagnosed with colorectal cancer (CRC) in Ontario, Canada from 2003 to 2009. Patients were categorised into three groups: DETECTED (diagnosed within 6 months of first colonoscopy), PCCRC (diagnosed 6-36 months after first colonoscopy) or NOSCOPE (no colonoscopy within 36 months of diagnosis). Univariate and multivariable analyses were conducted to study overall survival, surgical treatment, emergency presentation and surgical complications. RESULTS: Overall, 45 104 patients were included, with 2804 being classified as having a PCCRC. Compared with the DETECTED group, PCCRC was associated with a significantly higher likelihood of stage IV disease (17.2% vs 12.9%), worse overall survival (5 year OS: 60.8% vs 68.3%, p<0.0001; adjusted HR: 1.25, 95% CI 1.17 to 1.32, p<0.0001), a higher likelihood of emergency presentation (OR: 2.86, 95% CI 2.56 to 3.13, p<0.001) and lower likelihood of surgical resection (OR: 0.61, 95% CI 0.55 to 0.67, p<0.001). However, patients with PCCRC had significantly better outcomes than those in the NOSCOPE group (stage IV: 37.1%, 5 year OS: 38.9%) CONCLUSIONS: Compared with CRC detected by colonoscopy, PCCRCs are associated with a higher risk of emergent presentation, a lower likelihood of surgical resection and most notably, significantly worse oncological outcomes. However, they have better outcomes than patients with no recent colonoscopy.

Environmental scan of anal cancer screening practices: worldwide survey results.

Anal squamous cell carcinoma is rare in the general population but certain populations, such as persons with HIV, are at increased risk. High-risk populations can be screened for anal cancer using strategies similar to those used for cervical cancer. However, little is known about the use of such screening practices across jurisdictions. Data were collected using an online survey. Health care professionals currently providing anal cancer screening services were invited to complete the survey via email and/or fax. Information was collected on populations screened, services and treatments offered, and personnel. Over 300 invitations were sent; 82 providers from 80 clinics around the world completed the survey. Fourteen clinics have each examined more than 1000 patients. Over a third of clinics do not restrict access to screening; in the rest, eligibility is most commonly based on HIV status and abnormal anal cytology results. Fifty-three percent of clinics require abnormal anal cytology prior to performing high-resolution anoscopy (HRA) in asymptomatic patients. Almost all clinics offer both anal cytology and HRA. Internal high-grade anal intraepithelial neoplasia (AIN) is most often treated with infrared coagulation (61%), whereas external high-grade AIN is most commonly treated with imiquimod (49%). Most procedures are performed by physicians, followed by nurse practitioners. Our study is the first description of global anal cancer screening practices. Our findings may be used to inform practice and health policy in jurisdictions considering anal cancer screening.

Decreasing mortality from acute biliary diseases that require endoscopic retrograde cholangiopancreatography: a nationwide cohort study.

BACKGROUND & AIMS: The management of acute biliary diseases often involves endoscopic retrograde cholangiopancreatography (ERCP), but it is not clear whether this technique reduces mortality. We investigated whether mortality from acute biliary diseases that require ERCP has been reduced over time and explored factors associated with mortality. METHODS: We conducted a cohort study using the Nationwide Inpatient Sample (1998-2008). We identified hospitalizations for choledocholithiasis, cholangitis, and acute pancreatitis that involved ERCP. Multivariate analyses were used to determine the effects of time period, patient factors, hospital characteristics, features of the ERCP procedure, and types of cholecystectomies on mortality, length of stay, and costs. RESULTS: From 1998 to 2008 there were 166,438 admissions for acute biliary conditions that met the inclusion criteria, corresponding to more than 800,000 patients nationwide. During this interval, mortality decreased from 1.1% to 0.6% (adjusted odds ratio [aOR], 0.7; 95% confidence interval [CI], 0.6-0.8), diagnostic ERCPs decreased from 28.8% to 10.0%, hospitals performing fewer than 100 ERCPs per year decreased from 38.4% to 26.9%, open cholecystectomies decreased from 12.4% to 5.8%, and unsuccessful ERCPs decreased from 6.3% to 3.2% (P < .0001 for all trends). Unsuccessful ERCP (aOR, 1.7; 95% CI, 1.4-2.2), open cholecystectomy (aOR, 3.4; 95% CI 2.7-4.3), cholangitis (aOR, 1.9; 95% CI, 1.5-2.3), older age, having Medicare health insurance, and comorbidity were associated with increased mortality. CONCLUSIONS: In-hospital mortality from acute biliary conditions requiring ERCP in the United States has decreased over time. Reductions in the rate of unsuccessful ERCPs and open cholecystectomies are associated with this trend.

Open-access colonoscopy on Ontario: associated factors and quality.

BACKGROUND: Open-access (OA) colonoscopy may increase efficiency and decrease wait times; however, because the patient is seen for the first time at the endoscopy appointment, previous processes, such as information about the procedure, preparation and appropriate triage, may be suboptimal. OBJECTIVE: To identify factors associated with OA colonoscopy and to determine the relationship between OA colonoscopy and an important quality measure, incomplete colonoscopy. METHODS: A population-based analysis of all adult outpatients undergoing a first-time colonoscopy between 1997 and 2007 in Ontario was performed. Colonoscopy was considered to be OA if there were no visits in the preceding five years with the physician performing the colonoscopy. Using logistic regression, patient, physician and institution factors associated with OA colonoscopy were identified. Using propensity score matching, the relationship between OA colonoscopy and incomplete colonoscopy in 2006 was examined. RESULTS: A total of 1,079,259 colonoscopies were performed. Of these, 14% were OA in 1997 compared with 26% in 2007. Patients 50 to 69 years of age, those from higher-income neighbourhoods and those with less comorbidity were more likely to undergo OA colonoscopy. The odds of receiving OA colonoscopy were six times greater in a nonhospital clinic compared with a community hospital. Colonoscopy was more likely to be complete if the procedure was OA (OR 1.3 [95% CI 1.2 to 1.4]; P<0.0001). CONCLUSIONS: Rates of OA colonoscopy have increased substantially since 1997. Institution type was most strongly associated with OA colonoscopy. Colonoscopy completeness, a recognized quality indicator, does not appear to be compromised by OA colonoscopy.

Postoperative health-care utilization in Crohn's disease: the impact of specialist care.

OBJECTIVES: Crohn's disease (CD) patients frequently require surgery. We sought to characterize postoperative health-care utilization and its impact on outcomes. METHODS: We assembled a population-based cohort of CD patients who underwent first surgery in Ontario, Canada, between 1996 and 2009. We compared intra-individual preoperative and postoperative health-care utilization and characterized utilization of early postoperative gastrointestinal care (EPGIC) and its impact on health outcomes. RESULTS: For the 2,943 CD patients who underwent surgery, the 5-year risk of recurrent surgery was 26%. In the 5th postoperative year, the average annual number of inflammatory bowel disease (IBD)-related clinic visits, emergency department visits, endoscopy procedures, radiological procedures, and hospitalizations decreased by 62, 62, 82, 78, and 89% compared with prior to surgery. Regional utilization of EPGIC varied between 18 and 62% and correlated with the number of gastroenterologists within a regional local health integration network (ρ=0.71; P=0.006). EPGIC was associated with reduced risk of late postoperative CD-related hospitalizations (at least 1 year after surgery; adjusted incidence ratio (IRR), 0.82; 95% confidence interval (CI): 0.72-0.94). Other predictors of late hospitalizations included having an emergency department visit within 6 months (adjusted IRR, 2.60; 95% CI: 2.21-3.05), lower income, and higher comorbidity. Individuals residing in regions with high aggregate EPGIC utilization experienced lower rates of hospitalization compared with those in regions with low utilization (adjusted IRR, 0.83; 95% CI: 0.70-0.95). CONCLUSIONS: IBD-related health-care utilization decreased significantly up to 5 years following surgery. EPGIC may reduce late CD-related hospitalizations following surgery.

Reactions to a targeted intervention to increase fecal occult blood testing among average-risk adults waiting for screening colonoscopy.

BACKGROUND: Increasing demand combined with limited capacity has resulted in long wait times for average-risk adults referred for screening colonoscopy for colorectal cancer. Management of patients on these growing wait lists is an emerging clinical issue. OBJECTIVE: To inform the content and design of a mailed targeted invitation for patients to undergo annual fecal occult blood testing (FOBT) while awaiting colonoscopy. METHODS: Focus groups (FGs) with average-risk patients on a wait list for screening colonoscopy at a high-throughput academic outpatient colonoscopy facility were conducted. During each FG session, feedback regarding a range of materials under consideration for the planned intervention was elicited using a semistructured facilitator guide. The FG sessions were recorded and transcribed verbatim, and analyzed using the constant comparative method to identify key themes. RESULTS: Findings from the three FGs (n=28) suggested that average risk patients on a wait list for screening colonoscopy would be receptive to a targeted intervention recommending they undergo FOBT while waiting. Participants indicated that the invitation to undergo FOBT was an important acknowledgement that they were on an actively managed list, and that a mechanism to ensure that they were correctly triaged while waiting was in place. Several specific suggestions to improve the design of the targeted intervention were obtained. CONCLUSIONS: Results of the present study provide useful information for developing effective strategies to manage average-risk individuals facing long wait times for screening colonoscopy.

A comparison of hospital and nonhospital colonoscopy: wait times, fees and guideline adherence to follow-up interval.

BACKGROUND: Although colonoscopy is increasingly performed in nonhospital facilities, studies to date examining differences between colonoscopy services in hospital and nonhospital settings have been limited, in large part, to administrative databases. OBJECTIVES: To describe the experiences of patients receiving colonoscopy in hospital and nonhospital settings, and to compare these settings with respect to wait times and recommended follow-up interval to the next colonoscopy. METHODS: A postal survey of 2000 patients, 50 to 70 years of age, from an urban academic family practice was conducted. Most recent colonoscopy was classified as either occurring in a hospital or nonhospital setting. Multivariable logistic regression analysis was used to examine the association among wait times, follow-up intervals and patient factors with respect to colonoscopy setting. RESULTS: Patients who underwent their most recent colonoscopy outside of a hospital were more likely to be men (P=0.01) and to have undergone more than one previous colonoscopy (P=0.02). For patients with a normal screening colonoscopy and no family history of colorectal cancer or polyps, nonhospital clinics less often recommended a 10-year follow-up interval (OR 0.13 [95% CI 0.04 to 0.47]). Reported wait times at nonhospital clinics were shorter for patients receiving screening colonoscopy (OR 2.11 [95% CI 1.28 to 3.47]), but not for symptomatic patients (OR 1.74 [95% CI 0.88 to 3.43]). For individuals attending nonhospital clinics, 10% were referred from a hospital by the same specialist performing the procedure; 31.7% reported paying a fee. CONCLUSION: Nonhospital clinics were far less likely to adhere to guidelines regarding follow-up intervals for low-risk patients. Given the implications for both health care costs and patient safety, further study is needed to determine the cause of this disparity.

Cost-effectiveness of screening for anal precancers in HIV-positive men.

OBJECTIVE: To assess the cost-effectiveness of high-resolution anoscopy (HRA), anal cytology, and anal human papillomavirus (HPV) detection in screening for histologic high-grade anal intraepithelial neoplasia (AIN 2/3) in HIV-positive MSM. DESIGN: Participants were 401 HIV-positive MSM who were screened for anal cancer in a tertiary care HIV clinic. METHODS: A decision analytical model was used to determine the cost-effectiveness of three anal cancer screening strategies: the direct use of HRA; HRA only if anal cytology was abnormal; and HRA only if oncogenic HPV was present. The model included the use of different thresholds for abnormal cytology and also combined cytology and HPV testing. The outcome was the number of AIN 2/3 cases detected. Costs were estimated from institutional data and sensitivity/specificity of cytology and HPV tests were obtained from the screening study. RESULTS: The costs ($ US) per procedure for HRA, cytology, and HPV testing were $193, $90, and $95, respectively. The direct use of HRA was the most cost-effective strategy. It detected 98 individuals with AIN 2/3 and had a cost-effectiveness of $809 per AIN 2/3 case detected. Using probabilistic sensitivity analysis, three other strategies had similar costs per case detected and might be as cost-effective as HRA. CONCLUSION: In HIV-infected MSM, the direct use of HRA is the most cost-effective strategy for detecting AIN 2/3. The higher cost per use for HRA was offset by the high sensitivity and low specificity of HPV and cytology testing.

Women's sexual orientation and health: results from a Canadian population-based survey.

The current study sought to determine whether health status and health risk behaviors of Canadian women varied based on sexual identity. This was a cross-sectional analysis of data from the Canadian Community Health Survey: cycle 2.1, a national population-based survey designed to gather health data on a representative sample of over 135,000 Canadians including 354 lesbian respondents, 424 bisexual women respondents, and 60,937 heterosexual women respondents. Sexual orientation was associated with disparities in health status and health risk behaviors for lesbian and bisexual women in Canada. Bisexual women were more likely than lesbians or heterosexual women to report poor or fair mental and physical health, mood or anxiety disorders, lifetime STD diagnosis, and, most markedly, life-time suicidality. Lesbians and bisexual women were also more likely to report daily smoking and risky drinking than heterosexual women. In sum, sexual orientation was associated with health status in Canada. Bisexual women, in particular, reported poorer health outcomes than lesbian or heterosexual women, indicating this group may be an appropriate target for specific health promotion interventions.

A population-based analysis of outpatient colonoscopy in adults assisted by an anesthesiologist.

BACKGROUND: The use of propofol to sedate patients for colonoscopy, generally administered by an anesthesiologist in North America, is increasingly popular. In the United States, regional use of anesthesiologist-assisted endoscopy appears to correlate with local payor policy. This study's objective was to identify nonpayor factors (patient, physician, institution) associated with anesthesiologist assistance at colonoscopy. METHODS: The authors performed a population-based cross-sectional analysis using Ontario health administrative data, 1993-2005. All outpatient colonoscopies performed on adults were identified. Hierarchical multivariable modeling was used to identify patient (age, sex, income quintile, comorbidity), physician (specialty, colonoscopy volume), and institution (type, volume) factors associated with receipt of anesthesiologist-assisted colonoscopy. RESULTS: During the study period, 1,838,879 colonoscopies were performed on 1,202,548 patients. The proportion of anesthesiologist-assisted colonoscopies rose from 8.4% in 1993 to 19.1% in 2005 (P < 0.0001). In the hierarchical model, patients in low-volume community hospitals were five times more likely to receive anesthesiologist-assisted colonoscopy than patients in high-volume community hospitals (odds ration 4.9; 95% confidence interval 4.4-5.5). Less than 1% of colonoscopies in academic hospitals were anesthesiologist-assisted. Compared to gastroenterologists, surgeons were more likely to perform anesthesiologist-associated colonoscopy (odds ratio 1.7; 95% confidence interval 1.1-2.6). CONCLUSIONS: In Ontario, rates of anesthesiologist-assisted colonoscopy have risen dramatically. Institution type was most strongly associated with this practice. Further investigation is needed to determine the most appropriate criteria for the use of anesthesiology services during colonoscopy.

Hospitalizations for inflammatory bowel disease: profile of the uninsured in the United States.

BACKGROUND: Inflammatory bowel disease (IBD) patients may be at increased risk for having no health insurance. Our objectives were to assess the prevalence of hospitalized IBD patients without insurance in the US and to characterize predictive factors. METHODS: We identified IBD admissions in the Nationwide Inpatient Sample (1999-2005) and a 1% sample of general medical patients. We used population estimates from the US Census Bureau to calculate hospitalization rates, and logistic regression to determine predictors of being uninsured. RESULTS: Although uninsured IBD patients were less likely to be hospitalized than those privately insured (incidence rate ratio [IRR] 0.41; 95% confidence interval [CI]: 0.38-0.45), their hospitalization rate increased from 8.3/100,000 to 12.5/100,000 (P < 0.001) over 7 years, outpacing private admissions. The proportion of uninsured IBD inpatients increased from 4.6% to 6.5% (P < 0.001), and IBD patients were more likely than general medical patients to be uninsured (5.1% vs. 4.1%, P < 0.0001). Predictors of being uninsured were being 21 to 40 years (odds ratio [OR] 1.95; 95% CI: 1.64-2.31), African American (OR 1.51; 95% CI: 1.29-0.76) or Hispanic (OR 2.21; 95% CI: 1.79-2.74), or residing in the southern US (OR 1.63; 95% CI: 1.27-2.11). Being female (OR 0.65; 95% CI: 0.61-0.70), residing in higher income neighborhoods (OR 0.69; 95% CI: 0.62-0.77), and higher comorbidity were protective factors. CONCLUSIONS: The rate of uninsured IBD admissions has risen disproportionately relative to the privately insured and general medical populations. We need measures to alleviate the burden of being uninsured among young and otherwise healthy adults with IBD who are most vulnerable.