Impact of a pre-existing diagnosis of mental illness on stage of breast cancer diagnosis among older women.

PURPOSE: Having a mental illness increases risk of mortality for women with breast cancer, partly due to barriers to accessing recommended care (e.g., cancer screening). Early detection is one important factor in breast cancer survival. To further understand this disparity in survival, we examined whether older women with mental illness are more likely to be diagnosed with later-staged breast cancers compared to women without mental illnesses. METHODS: We used 2005-2015 SEER-Medicare data to identify AJCC stage I-IV breast cancer patients with and without a history of mental illness prior to cancer diagnosis. We used generalized ordinal regression to examine associations between mental illness diagnoses and stage at diagnosis, controlling for age, race/ethnicity, income, comorbidities, primary care use, rurality, and marital status. RESULTS: Among 96,034 women with breast cancer, 1.7% have a serious mental illness (SMI), 19.9% depression or anxiety, and 7.0% other mental illness. Those with SMI have 40% higher odds of being diagnosed with AJCC Stages II, III than Stage I; women with depression/anxiety have 25% lower odds of being diagnosed with Stage IV cancer than Stage I; and women with other mental illnesses have similar odds of being diagnosed in later stages. CONCLUSION: Women with SMI have higher odds of being diagnosed at later stages, which likely contributes to higher mortality after breast cancer. Surprisingly, women with depression and anxiety have a lower risk of being diagnosed with Stage IV cancer. Earlier breast cancer diagnosis in women with SMI is an important goal for reducing disparities breast cancer survival.

Measuring Primary Care Exam Length Using Electronic Health Record Data.

BACKGROUND: Physicians' time with patients is a critical input to care, but is typically measured retrospectively through survey instruments. Data collected through the use of electronic health records (EHRs) offer an alternative way to measure visit length. OBJECTIVE: To measure how much time primary care physicians spend with their patients, during each visit. RESEARCH DESIGN: We used a national source of EHR data for primary care practices, from a large health information technology company. We calculated exam length and schedule deviations based on timestamps recorded by the EHR, after implementing sequential data refinements to account for non-real-time EHR use and clinical multitasking. Observational analyses calculated and plotted the mean, median, and interquartile range of exam length and exam length relative to scheduled visit length. SUBJECTS: A total of 21,010,780 primary care visits in 2017. MEASURES: We identified primary care visits based on physician specialty. For these visits, we extracted timestamps for EHR activity during the exam. We also extracted scheduled visit length from the EHR's practice management functionality. RESULTS: After data refinements, the average primary care exam was 18.0 minutes long (SD=13.5 min). On average, exams ran later than their scheduled duration by 1.2 minutes (SD=13.5 min). Visits scheduled for 10 or 15 minutes were more likely to exceed their allotted time than visits scheduled for 20 or 30 minutes. CONCLUSIONS: Time-stamped EHR data offer researchers and health systems an opportunity to measure exam length and other objects of interest related to time.

Barriers to Care and Health Care Utilization Among the Publicly Insured.

BACKGROUND: Although the Affordable Care Act has been successful in expanding Medicaid to >17 million people, insurance alone may not translate into access to health care. Even among the insured, substantial barriers to accessing services inhibit health care utilization. OBJECTIVES: We examined the effect of selected barriers to health care access and the magnitude of those barriers on health care utilization. RESEARCH DESIGN: Data come from a 2008 survey of adult enrollees in Minnesota's public health care programs. We used multivariate logistic regression to estimate the effects of perceived patient, provider, and system-level barriers on past year delayed, foregone, and lack of preventive care. SUBJECTS: A total of 2194 adults enrolled in Minnesota Health Care Programs who were mostly female (66%), high school graduates (76%), unemployed (62%), and living in metro areas (67%) were included in the analysis. RESULTS: Reporting problems across all barriers increased the odds of delayed care from 2 times for provider-related barriers (OR=2.0; 95% CI, 1.2-3.3) to >6 times for access barriers (OR=6.2; 95% CI, 3.8-10.2) and foregone care from 2.6 times for family/work barriers (OR=2.6; 95% CI, 1.3-5.1) to >7 times for access barriers (OR=7.1; 95% CI, 3.9-13.1). Perceived discrimination was the only barrier consistently associated with all 3 utilization outcomes. CONCLUSIONS: Multiple types of barriers are associated with delayed and foregone care. System-level barriers and discrimination have the greatest effect on health care seeking behavior.

Police Brutality and Black Health: Setting the Agenda for Public Health Scholars.

We investigated links between police brutality and poor health outcomes among Blacks and identified five intersecting pathways: (1) fatal injuries that increase population-specific mortality rates; (2) adverse physiological responses that increase morbidity; (3) racist public reactions that cause stress; (4) arrests, incarcerations, and legal, medical, and funeral bills that cause financial strain; and (5) integrated oppressive structures that cause systematic disempowerment. Public health scholars should champion efforts to implement surveillance of police brutality and press funders to support research to understand the experiences of people faced with police brutality. We must ask whether our own research, teaching, and service are intentionally antiracist and challenge the institutions we work in to ask the same. To reduce racial health inequities, public health scholars must rigorously explore the relationship between police brutality and health, and advocate policies that address racist oppression.

Propensity score matching to measure the effect of survey mode on reports of racial and ethnic discrimination in health care.

OBJECTIVE: To examine the effect of survey mode (mail vs. telephone) on the likelihood of reporting health care-related discrimination based on race, ethnicity, or nationality. METHODS: We use data from a mixed-mode, mail and telephone survey of public health care program enrollees (N=2807), including Somali, Hmong, African American, American Indian, and Latino populations. Self-reported discrimination was measured as the experience of unfair treatment by health care providers due to race, ethnicity, or nationality. We use propensity score matching to create exchangeable groups of phone and mail respondents based on the probability of completing the survey by phone. RESULTS: Overall, 33.1% of respondents reported having experienced discrimination in health care, but only 23.6% of telephone respondents reported discrimination compared with 36.8% of mail respondents. After matching phone and mail respondents based on probability of responding by telephone, all observable significant differences between respondents that were brought about by differential self-selection into mode were erased, allowing us to estimate the effect of survey mode on report of discrimination. Even after matching, the mode effect remains, where report of health care discrimination for telephone respondents would have been 12.6 percentage points higher had they responded by mail (22.6% vs. 35.2%). CONCLUSIONS: Survey mode has a significant effect on report of discrimination. Respondents may be more willing to disclose experiences of discrimination in a mail survey than to a telephone interviewer. Findings have substantial policy and clinical significance as variation in report of discrimination based on mode may lead to underestimation of the extent of the problem.

Barriers to care in an ethnically diverse publicly insured population: is health care reform enough?

BACKGROUND: The Affordable Care Act provides for the expansion of Medicaid, which may result in as many as 16 million people gaining health insurance coverage. Yet it is unclear to what extent this coverage expansion will meaningfully increase access to health care. OBJECTIVE: The objective of the study was to identify barriers that may persist even after individuals are moved to insurance and to explore racial/ethnic variation in problems accessing health care services. RESEARCH DESIGN: Data are from a 2008 cross-sectional mixed-mode survey (mail with telephone follow-up in 4 languages), which is unique in measuring a comprehensive set of barriers and in focusing on several select understudied ethnic groups. We examine racial/ethnic variation in cost and coverage, access, and provider-related barriers. The study adhered to a community-based participatory research process. SUBJECTS: Surveys were obtained from a stratified random sample of adults enrolled in Minnesota Health Care Programs who self-report ethnicity as white, African American, American Indian, Hispanic, Hmong, or Somali (n=1731). RESULTS: All enrollees reported barriers to getting needed care; enrollees from minority cultural groups (Hmong and American Indian in particular) were more likely to experience problems than whites. Barriers associated with cost and coverage were the most prevalent, with 72% of enrollees reporting 1 or more of these problems. Approximately 63% of enrollees reported 1 or more access barriers. Provider-related barriers were the least prevalent (about 29%) yet revealed the most pervasive disparities. CONCLUSIONS: Many challenges to care persist for publicly insured adults, particularly minority racial and ethnic groups. The ACA expansion of Medicaid, although necessary, is not sufficient for achieving improved and equitable access to care.

Health and health risks among sexual minority women: an examination of 3 subgroups.

We used 2001-2010 National Health and Nutrition Examination Survey data to examine insurance status, source of routine care, cigarette and alcohol use, and self-rated health among lesbian, bisexual, and heterosexual women who have sex with women, compared with heterosexual women who do not have sex with women. We found higher risks of being uninsured among lesbian and bisexual women, worse self-rated health among bisexual women, higher alcohol use among bisexual and heterosexual women who have sex with women, and higher smoking across all subgroups.

State LGBTQ policy environments and the cancer burden in sexual and gender minoritized communities in the United States.

PURPOSE: Our objective was to assess the association between state policies related to sexual orientation and gender identity (SOGI) and cancer prevalence and survivorship indicators in a sexual and gender minoritized (SGM) population in the United States. METHODS: Data from the 2017-2021 Behavioral Risk Factor Surveillance System were used to measure cancer diagnosis, physical and mental health, and substance use for SGM adult cancer survivors. A state policy Z-score, ranging from most restrictive to most protective state policies related to SOGI, was computed from data available from the Movement Advancement Project. Survey-weighted logistic regression was used to test the relationship between state policies and cancer-related outcomes for SGM people. RESULTS: More protective state policies were associated with lower odds of a cancer diagnosis (adjusted odds ratio [AOR]: 0.92; 95% confidence interval [CI]: 0.87-0.97). Among SGM cancer survivors, increasing protective state policies were associated with lower odds of poor physical health (AOR: 0.83; 95% CI: 0.74-0.94), lower odds of difficulty walking or climbing stairs (AOR: 0.90; 95% CI: 0.80-1.00), and lower odds of difficulty concentrating or remembering (AOR: 0.87; 95% CI: 0.78-0.98). No significant associations were found between state policies and mental health, depression, substance use, diabetes, or cardiovascular disease among SGM cancer survivors. CONCLUSION: SGM people diagnosed with cancer are more likely to live in restrictive policy states, and survivors in those states have worse physical health and cognitive disability. Additional research should investigate potential causal relationships between state policies and SGM cancer outcomes.

An Evidence Map for Social and Structural Determinants for Maternal Morbidity and Mortality: A Systematic Review.

OBJECTIVE: To identify the social-structural determinants of health risk factors associated with maternal morbidity and mortality in the United States during the prenatal and postpartum periods. DATA SOURCES: We searched MEDLINE, CINAHL, and Social Sciences Citation Index through November 2022 for eligible studies that examined exposures related to social and structural determinants of health and at least one health or health care-related outcome for pregnant and birthing people. METHODS OF STUDY SELECTION: After screening 8,378 unique references, 118 studies met inclusion criteria. TABULATION, INTEGRATION, AND RESULTS: We grouped studies by social and structural determinants of health domains and maternal outcomes. We used alluvial graphs to summarize results and provide additional descriptions of direction of association between potential risk exposures and outcomes. Studies broadly covered risk factors including identity and discrimination, socioeconomic, violence, trauma, psychological stress, structural or institutional, rural or urban, environment, comorbidities, hospital, and health care use. However, these risk factors represent only a subset of potential social and structural determinants of interest. We found an unexpectedly large volume of research on violence and trauma relative to other potential exposures of interest. Outcome domains included maternal mortality, severe maternal morbidity, hypertensive disorders, gestational diabetes, cardiac and metabolic disorders, weathering depression, other mental health or substance use disorders, and cost per health care use outcomes. Patterns between risk factors and outcomes were highly mixed. Depression and other mental health outcomes represented a large proportion of medical outcomes. Risk of bias was high, and rarely did studies report the excess risk attributable to a specific exposure. CONCLUSION: Limited depth and quality of available research within each risk factor hindered our ability to understand underlying pathways, including risk factor interdependence. Although recently published literature showed a definite trend toward improved rigor, future research should emphasize techniques that improve the ability to estimate causal effects. In the longer term, the field could advance through data sets designed to fully ascertain data required to robustly examine racism and other social and structural determinants of health, their intersections, and feedback loops with other biological and medical risk factors. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022300617.

Delayed and unmet need for medical care among publicly insured adults with disabilities.

BACKGROUND: While Medicaid is an important source of insurance coverage for persons with disabilities, barriers remain to accessing care for this population. OBJECTIVES: This study addresses 3 research questions: (1) do adults with disabilities experience greater unmet need/delayed care?; (2) do barriers related to cost, providers, or structure vary by disability status?; and (3) do barriers mediate the relationship between disability and access to care? RESEARCH DESIGN: Data were obtained from a 2008 stratified random sample of Minnesota Health Care Program's nonelderly adult enrollees (n=1880). The survey was administered by mail, with a telephone follow-up for nonresponders. MEASURES: Disability is defined by self-report. Access to care is measured by reported delayed and unmet need for medical care within the past year. Respondents were asked about their experiences with a variety of cost-related, provider-related, and structural barriers to care. RESULTS: Respondents with a disability were more likely to experience delayed (40%) and unmet need (23%) for medical care than persons without disabilities (24% and 10%, respectively). Persons with disabilities also reported multiple barriers to health care, especially structural barriers, such as making a timely appointment and accessing transportation (74% vs. 59%). The greater likelihood of facing a structural barrier partially explained increased risk of delayed or unmet care among adults with disabilities. CONCLUSIONS: Disparities in access to health care based on disability status remain even for persons who have insurance. These disparities deserve further research and policy attention to better address the particular needs of this population.

Stigma, discrimination, or symptomatology differences in self-reported mental health between US-born and Somalia-born Black Americans.

OBJECTIVES: We examined differences in self-reported mental health (SRMH) between US-born and Somalia-born Black Americans compared with White Americans. We tested how SRMH was affected by stigma toward seeing a mental health provider, discrimination in the health care setting, or symptoms of depression. METHODS: Data were from a 2008 survey of adults in Minnesota and were limited to US-born and Somalia-born Black and White Americans (n = 938). RESULTS: Somalia-born adults were more likely to report better SRMH than either US-born Black or White Americans. They also reported lower levels of discrimination (18.6%) than US-born Black Americans (33.4%), higher levels of stigma (23.6% vs 4.7%), and lower levels of depressive symptoms (9.1% vs 31.6%). Controlling for stigma, discrimination, and symptomatology, Somalia-born Black Americans reported better SRMH than White and Black Americans (odds ratio = 4.76). CONCLUSIONS: Mental health programming and health care providers who focus on Black Americans' mental health might be missing important sources of heterogeneity. It is essential to consider the role of race and ethnicity, but also of nativity, in mental health policy and programming.

Ethnic group differences in the relationship between depressive symptoms and smoking.

OBJECTIVES: A relationship between depression and smoking has been documented; however, little attention has focused on ethnic variability in how this relationship is manifested. Thus, we examined the interaction between ethnicity and significant depressive symptoms on smoking status. DESIGN: A random digit dial survey (Minnesota Needs Assessment Survey) that oversampled ethnic minorities assessed demographics, smoking status, and depressive symptoms (Patient Health Questionnaire-2 [PHQ-2]). We examined the prevalence of current smoking between individuals with and without depressive symptoms within ethnic group and the interaction of depressive symptoms by ethnic group on smoking status. RESULTS: Of 16,981 participants, 20.8% were current smokers, and 7.7% reported significant depressive symptoms on the PHQ-2 (score ≥3). Ethnic differences were observed in smoking rates (Asians 17.2%, Latinos 19.0%, whites 20.4%, African-Americans 23.4%, American Indians 51.2%) and depressive symptoms (Asians 4.9%, Latinos 13.1%, whites 7.0%, African-Americans 19.1%, American Indians 12.5%). Depressive symptoms were associated with a higher prevalence of smoking among Whites (34.5% vs. 19.4%), African-Americans (43.6% vs. 18.9%), and American Indians (81.9% vs. 47.1%), but not among Latinos (14.5% vs. 19.7%) or Asians (19.6% vs. 17.1%). The interaction between ethnicity and depressive symptomatology on current smoking was significant (p=0.02) among Latinos relative to Whites, controlling for other demographics. CONCLUSION: The relationship between depressive symptoms and smoking differs by ethnicity, particularly for Latinos. Understanding these differences may contribute to the development of culturally specific interventions.

Police brutality, medical mistrust and unmet need for medical care.

Police brutality is a social determinant of health that can directly impact health status. Social determinants of health can also impact health indirectly by shaping how people access health care. In this study, we describe the relationship between perceived police brutality and an indicator of access to care, unmet need. We also examine medical mistrust as a potential mechanism through which perceived police brutality affects unmet need. Using data from the 2018 Survey of the Health of Urban Residents (N = 4,345), direct effects of perceived police brutality on unmet need and indirect effects through medical mistrust were obtained using the Karlson-Holm-Breen method of effect decomposition. Experiencing police brutality was associated with greater odds of unmet need. Controlling for covariates, 18 percent of the total effect of perceived police brutality on unmet need was explained by medical mistrust. Experiences outside of the health care system matter for access to care. Given the association between police brutality and unmet need for medical care, addressing unmet need among marginalized populations requires public health leaders to engage in conversations about reform of police departments. The coronavirus pandemic makes this even more critical as both COVID-19 and police brutality disproportionately impact Black, Indigenous, Latinx and other communities of color.

Employment and economic outcomes of persons with mental illness and disability: The impact of the Great Recession in the United States.

Objective: To examine variation in employment and economic outcomes before, during, and after the great recession by disability and mental health status. Methods: Using a sample of adults in the 1999 to 2016 National Health Interview Survey (N = 419,336), we examined changes in labor force and economic outcomes by mental health and physical disability status. We employed difference-in-differences analyses to determine whether the changes in these outcomes during and after the recession for each comparison group (those with moderate mental illness, serious psychiatric disability, or physical disability) were significantly different from the changes for persons with neither a mental illness nor a disability. Findings: While the recession impacted all groups, those with mental illnesses or physical disabilities were hardest hit. Persons with disabilities were disadvantaged on all outcomes at each period, but persons with mental illnesses were the most disadvantaged. Unemployment, poverty, and use of food stamps increased for all groups, but the increase was greatest for persons with mental health problems who also saw a more substantial decline in wage income. Conclusions and Implications for Practice: The effects of the recession persist well after the recovery period. Practitioners should be aware that although most persons with mental illnesses want to work, they face significant barriers to employment. Following economic shocks such as those brought on by the current coronavirus pandemic, interventions should focus on people who are the most vulnerable, especially those with mental health problems. Renewed focus on employment for people with mental disorders is important. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Barriers to physical and mental condition integrated service delivery.

OBJECTIVE: To assess pragmatic challenges faced when implementing, delivering, and sustaining models of integrated mental health intervention in primary care settings. Thirty percent of primary care patients with chronic medical conditions and up to 80% of those with health complexity have mental health comorbidity, yet primary care clinics rarely include onsite mental health professionals and only one in eight patients receive evidence-based mental health treatment. Integrating specialty mental health into primary care improves outcomes for patients with common disorders, such as depression. METHODS: We used key informant interviews documenting barriers to implementation and components that inhibited or enhanced operational success at 11 nationally established integrated physical and mental condition primary care programs. RESULTS: All but one key informant indicated that the greatest barrier to the creation and sustainability of integrated mental condition care in primary care settings was financial challenges introduced by segregated physical and mental health reimbursement practices. For integrated physical and mental health program initiation and outcome changing care to be successful, key components included a clinical and administrative champion-led culture shift, which valued an outcome orientation; cross-disciplinary training and accountability; use of care managers; consolidated clinical record systems; a multidisease, total population focus; and active, respectful coordination of colocated interdisciplinary clinical services. CONCLUSIONS: Correction of disparate physical and mental health reimbursement practices is an important activity in the development of sustainable integrated physical and mental condition care in primary care settings, such as a medical home. Multiple clinical, administrative, and economic factors contribute to operational success.

Sociology of health care reform: building on research and analysis to improve health care.

Health reform efforts in the United States have focused on resolving some of the fundamental irrationalities of the system whereby costs and services utilization are often not linked to improved patient outcomes. Sociologists have contributed to these efforts by documenting the extent of problems and by confronting central questions around issues of accountability, reimbursement, and rationing that must be addressed in order to achieve meaningful reform that controls costs, expands access, and improves quality. Major reform rarely occurs without "paying off" powerful interests, a particularly difficult challenge in the context of a large and growing deficit. Central to achieving increased coverage and access, high quality, and cost control is change in reimbursement arrangements, increased accountability for both costs and outcomes, and criteria for rationing based on the evidence and accepted as legitimate by all stakeholders. Consensus about health reform requires trust. The traditional trust patients have in physicians provides an important base on which to build.

Treatment Modalities and Perceived Effectiveness of Treatment Among Adults With Depression.

Patient-reported outcomes of mental health treatment, such as perceived effectiveness, are important. They indicate whether treatment is perceived to reduce symptoms and minimize psychiatric disability. Outpatient treatment for depression typically includes medication or counseling, either alone or in combination. This study examines the relationship between treatment modality and perceived effectiveness of treatment. Using a sample of adults who received outpatient treatment for depression from the 2015-2016 National Survey on Drug Use and Health (N = 4169), logistic regressions estimated the odds of rating treatment as effective among persons who received medication only, counseling only, and a combination of medication and counseling. There were no differences in perceived effectiveness between counseling only and medication only. However, receiving both was associated with greater odds of rating treatment as effective. Poor self-rated health and severe mental illness were associated with lower perceived effectiveness of medication. Those with substance use problems had lower odds of rating counseling and both counseling and medication as effective. A combined treatment for depression may be perceived as better than single-modality treatment. Therefore, there might be benefits to increasing access to both forms of treatment for persons less likely to rate either single modality as effective.

Selection Into Mental Health Services Among Persons With Depression.

OBJECTIVE: This study aimed to identify sociodemographic and health characteristics associated with use of different mental health services (medication only, counseling only, or both) among persons with depression. METHODS: The analytic sample consisted of adults who had a major depressive episode in the past year and received outpatient professional mental health services (N=4,169). Multinomial logistic regressions were computed with data from the 2015 and 2016 National Survey on Drug Use and Health to identify factors associated with the relative odds of receiving each modality of mental health service. RESULTS: Sixty-nine percent of the sample received both prescription medication and counseling (talking to a professional health care provider about depression), 22% received counseling only, and 9% received medication only. Being ordered into care and higher probability of having a severe mental illness were associated with higher odds of receiving both medication and counseling. CONCLUSIONS: How people with depression enter care and select into different mental health service modalities might be an indicator of access. Factors that affect selection into these modalities might also be associated with outcomes of care. Findings could inform efforts to remove modality-specific barriers to treatment, improve timely access to care, and reduce unmet need for mental health care among persons with depression.