Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults.

PURPOSE: In recent years, colorectal cancer (CRC) screening rates have increased steadily in the USA, though racial and ethnic disparities persist. In a community-based randomized controlled trial, we investigated the effect of patient navigation on increasing CRC screening adherence among older African Americans. METHODS: Participants in the Cancer Prevention and Treatment Demonstration were randomized to either the control group, receiving only printed educational materials (PEM), or the intervention arm where they were assigned a patient navigator in addition to PEM. Navigators assisted participants with identifying and overcoming screening barriers. Logistic regression analyses were used to assess the effect of patient navigation on CRC screening adherence. Up-to-date with screening was defined as self-reported receipt of colonoscopy/sigmoidoscopy in the previous 10 years or fecal occult blood testing (FOBT) in the year prior to the exit interview. RESULTS: Compared with controls, the intervention group was more likely to report being up-to-date with CRC screening at the exit interview (OR 1.55, 95 % CI 1.07-2.23), after adjusting for select demographics. When examining the screening modalities separately, the patient navigator increased screening for colonoscopy/sigmoidoscopy (OR 1.53, 95 % CI 1.07-2.19), but not FOBT screening. Analyses of moderation revealed stronger effects of navigation among participants 65-69 years and those with an adequate health literacy level. CONCLUSIONS: In a population of older African Americans adults, patient navigation was effective in increasing the likelihood of CRC screening. However, more intensive navigation may be necessary for adults over 70 years and individuals with low literacy levels.

Randomized trial of a case management program for assault-injured youth: impact on service utilization and risk for reinjury.

OBJECTIVES: The purposes of this study were to (1) assess receptiveness of families to violence prevention interventions initiated after an assault injury and (2) assess the effectiveness of a case management program on increasing service utilization and reducing risk factors for reinjury among assault-injured youth presenting to the emergency department. DESIGN/METHODS: A randomized controlled trial of youth, aged 12 to 17 years, presenting to a large urban hospital with peer assault injury was conducted. Youth and parents were interviewed at baseline and 6 months to measure service utilization, risk behavior, attitudes about violence, mental health, and injury history. INTERVENTION: Intervention families received case management services by telephone or in person during 4 months by a counselor who discussed sequelae of assault injury and assessed family needs and facilitated service use. Controls received a list of community resources. RESULTS: Eighty-eight families were enrolled; 50 (57%) completed both youth and parent follow-up interviews. Intervention and control groups were not significantly different at baseline on demographics, service utilization, and risk factors. Fighting was common in both groups. Most parents and youth identified service needs at baseline, with recreational programs, educational services, mentoring, and counseling as most frequently desired. There was no significant program effect on service utilization or risk factors for injury. Although intervention families were satisfied with case management services, there was no significant increase in service utilization compared with controls. CONCLUSIONS: Youth and parents were receptive to this violence prevention intervention initiated after an emergency department visit. This pilot case management program, however, did not increase service utilization or significantly reduce risk factors for injury. More intensive violence prevention strategies are needed to address the needs of assault-injured youths and their families.

The Relationship Between Education and Prostate-Specific Antigen Testing Among Urban African American Medicare Beneficiaries.

PURPOSE: We examined the association between socioeconomic status (SES) and prostate-specific antigen (PSA) cancer screening among older African American men. METHODS: We analyzed baseline data from a sample of 485 community-dwelling African American men who participated in the Cancer Prevention and Treatment Demonstration Trial. The outcome was receipt of PSA screening within the past year. SES was measured using income and educational attainment. Sequential multivariate logistic regression models were performed to study whether health care access, patient-provider relationship, and cancer fatalism mediated the relationship between SES and PSA screening. RESULTS: Higher educational attainment was significantly associated with higher odds of PSA screening in the past year (odds ratio (OR) 2.08 for college graduate compared to less than high school graduate, 95 % confidence interval (CI) 1.03-4.24); income was not. Health care access and patient-provider communication did not alter the relationship between education and screening; however, beliefs regarding cancer fatalism partially mediated the observed relationship. CONCLUSION: Rates of prostate cancer screening among African American men vary by level of educational attainment; beliefs concerning cancer fatalism help explain this gradient. Understanding the determinants of cancer fatalism is a critical next step in building interventions that seek to ensure equitable access to prostate cancer screening.

Comparison of significance level at the true location using two linkage approaches: LODPAL and GENEFINDER.

BACKGROUND: We compare two new software packages for linkage analysis, LODPAL and GENEFINDER. Both allow for covariate adjustment. Replicates 1 to 3 of Genetic Analysis Workshop 13 simulated data sets were used for the analyses. We described the results of searching for evidence of loci contributing to a simulated quantitative trait related to systolic blood pressure (SBP). Individuals with SBP greater than 130 mm Hg were defined as affected individuals, and all others as unaffected. Total cholesterol was treated as a covariate. RESULTS: Using LODPAL, the power of detecting one of the three major genes related to SBP is 44.4% when a LOD score of 1 is used as the cut-off point. The power of GENEFINDER is lower than that of LODPAL. It is 22.2%. CONCLUSIONS: Based on the limited comparison, LODPAL provided the more reasonable power to detect linkage compared to GENEFINDER. After adjusting for the total cholesterol covariate, the current version of both programs appeared to give a high number of false positives.

Gender differences in correlates of colorectal cancer screening among Black Medicare beneficiaries in Baltimore.

BACKGROUND: Previous research has shown colorectal cancer (CRC) screening disparities by gender. Little research has focused primarily on gender differences among older Black individuals, and reasons for existing gender differences remain poorly understood. METHODS: We used baseline data from the Cancer Prevention and Treatment Demonstration Screening Trial. Participants were recruited from November 2006 to March 2010. In-person interviews were used to assess self-reported CRC screening behavior. Up-to-date CRC screening was defined as self-reported colonoscopy or sigmoidoscopy in the past 10 years or fecal occult blood testing in the past year. We used multivariable logistic regression to examine the association between gender and self-reported screening, adjusting for covariates. The final model was stratified by gender to examine factors differentially associated with screening outcomes for males and females. RESULTS: The final sample consisted of 1,552 female and 586 male Black Medicare beneficiaries in Baltimore, Maryland. Males were significantly less likely than females to report being up-to-date with screening (77.5% vs. 81.6%, P = 0.030), and this difference was significant in the fully adjusted model (OR: 0.72; 95% confidence interval, 0.52-0.99). The association between having a usual source of care and receipt of cancer screening was stronger among males compared with females. CONCLUSIONS: Although observed differences in CRC screening were small, several factors suggest that gender-specific approaches may be used to promote screening adherence among Black Medicare beneficiaries. IMPACT: Given disproportionate CRC mortality between White and Black Medicare beneficiaries, gender-specific interventions aimed at increasing CRC screening may be warranted among older Black patients.

The status of academic general pediatrics: no longer endangered?

Our study objective was to assess the current state of general academic pediatrics in the United States. A confidential survey of division directors was conducted. At the beginning and end of the survey period, programs were called to verify the director's name. Of 199 divisions surveyed, 119 were returned. The number of physician and nonphysician division faculty has grown from a mean of 12.1 (+/-8.2) and 1.7 (+/-1.8), respectively, 5 years ago to 15.6 (+/-11.7) and 2.1 (+/-2.6). Over a 15- to 18-month period, 21% of programs had a change in division director leadership. Over 90% of divisions rated the clinical care and education missions as "very important," with research and advocacy thus rated by 29% and 50%. Ninety-five percent of divisions have primary responsibility for residency continuity clinics, 51% residency program, and 64% medical student clerkship. The mean number of annual outpatient visits was 29,821 (26,487). Academic general pediatrics divisions have grown and play a large role in clinical care, education, and research at their institutions. There is a need for continued focus on recruitment, fellowship training, faculty development, and leadership development. Although these divisions are now well established, many continue to feel "endangered" because of funding uncertainties in supporting their missions.

Three surveys of HIV-1 prevalence and risk factors among men working at a sugar estate in Malawi.

BACKGROUND: HIV-1 surveys in defined populations identify underlying risks and trends useful to mount interventions. GOAL: The goal of the study was to determine HIV-1 prevalence and risk factors among men working at a Malawian sugar estate. STUDY DESIGN: Three independent surveys were conducted in 1994, 1997, and 1998. Procedures included obtaining informed consent, interviewing, and drawing blood for HIV and syphilis testing. Analyses determined prevalence of HIV and associated risk factors. RESULTS: HIV prevalence was 24.3% in 1994 (n = 1691), 22.8% in 1997 (n = 615), and 20.9% in 1998 (n = 1354; P < 0.03). From 1994 to 1998, the percentage of subjects with a history of sexually transmitted disease (STD) decreased from 43.6% to 29.5% (P < 0.0001), accompanied by a substantial rise in STDs confirmed by physical examination (from 7.5% to 16.8%; P < 0.0001) and by laboratory testing for syphilis (from 6.5% to 10.4%; P < 0.0001). The percentage with multiple sex partners declined (from 62.0% to 35.2%; P < 0.0001), and condom use rose (from 10.9% to 18.9%; P < 0.0001). STDs were significantly associated with prevalent HIV infection each year. CONCLUSIONS: The prevalence of HIV has remained relatively stable and high in this cohort.