Unique Breast Cancer Screening Disparities in a Safety-Net Health System.

INTRODUCTION: Breast cancer screening (BCS) disparities leave historically underserved groups more vulnerable to adverse outcomes. This study explores granular associations between BCS and patient sociodemographic factors in a large urban safety-net health system. METHODS: A retrospective review among female patients ages 50-74 within an urban safety-net health system was conducted in 2019. All patients had a primary care visit in the past 2 years. Multiple patient health and sociodemographic characteristics were reviewed, as well as provider gender and specialty. Bivariate analyses and multivariable logistic regression were performed in 2022. RESULTS: The BCS rate among 11,962 women was 69.7%. Over half of patients were non-White (63.6%) and had public insurance (72.3%). Patients with limited English proficiency made up 44.3% of the cohort. Compared to their sociodemographic counterparts, patients with White race, English proficiency, and Medicare insurance had the lowest rates of BCS. Serious mental illness and substance use disorder were associated with lower odds of BCS. In multivariable analysis, when using White race and English speakers as a reference, most other races (Black, Hispanic, and Other) and languages (Spanish, Portuguese, and Other) had significantly higher odds of screening ranging from 8% to 63% higher, except Asian race and Haitian Creole language. Female (versus male) and internal medicine-trained providers were associated with higher screening odds. CONCLUSIONS: Multiple unique variables contribute to BCS disparities, influenced by patient and health system factors. Defining and understanding the interplay of these variables can guide policymaking and identify avenues to improve BCS for vulnerable or traditionally under-resourced populations.

Colorectal cancer screening in a safety-net health system: The intersectional impact of race, ethnicity, language, and mental health.

Though rates of colorectal cancer (CRC) screening continue to improve with increased advocacy and awareness, there are numerous disparities that continue to be defined within different health systems and populations. We aimed to define associations between patients' socio-demographic characteristics and CRC screening in a well-resourced safety-net health system. A retrospective review was performed from 2018 to 2019 of patients between 50 and 75-years-old who had a primary care visit within the last two years. Numerous patient characteristics were extracted from the medical record, including self-reported race, self-reported ethnicity, insurance, preferred language, severe mental health diagnoses (SMHD), and substance use disorder (SUD). Multivariate logistic regression assessed characteristics associated with CRC screening. Of 22,145 included patients, 16,065 (72.5%) underwent CRC screening. <40% of the population was White or of North American/European ethnicity and 38% had limited English proficiency. Hispanic patients had the highest screening rate while White patients had the lowest among races (78.1% vs 68.5%, respectively). White patients had higher rates of SMHD and SUD (p < 0.001). In multivariable analysis, most other races (Black, Asian, and Hispanic), ethnicities, and languages had significantly higher odds of screening, ranging from 20% to 55% higher, when White, North American/European, English-speakers are used as reference. In a well-resourced safety-net health system, patients who were non-White, non-North American/European, and non-English-speaking, had higher odds of CRC screening. This data from a unique health system may better guide screening outreach and implementation strategies in historically under-resourced communities, leading to strategies for equitable colorectal cancer screening.

Impact of United States 2017 Immigration Policy changes on missed appointments at two Massachusetts Safety-Net Hospitals.

INTRODUCTION: Studies have shown mixed findings regarding the impact of immigration policy changes on immigrants' utilization of primary care. METHODS: We used a difference-in-differences analysis to compare changes in missed primary care appointments over time across two groups: patients who received care in Spanish, Portuguese, or Haitian Creole, and non-Hispanic, white patients who received care in English. RESULTS: After adjustment for age, sex, race, insurance, hospital system, and presence of chronic conditions, immigration policy changes were associated with an absolute increase in the missed appointment prevalence of 0.74 percentage points (95% confidence interval: 0.34, 1.15) among Spanish, Portuguese and Haitian-Creole speakers. We estimated that missed appointments due to immigration policy changes resulted in lost revenue of over $185,000. CONCLUSIONS: We conclude that immigration policy changes were associated with a significant increase in missed appointments among patients who receive medical care in languages other than English.

Perspectives of Decisional Surrogates and Patients Regarding Critical Illness Genetic Research.

BACKGROUND: Critical illness research is challenging due to disease severity and because patients are frequently incapacitated. Surrogates called upon to provide consent might not accurately represent patient preferences. Though commonplace, genetic data collection adds complexity in this context. We undertook this investigation to understand whether surrogate decision makers would be receptive to permitting participation in a critical illness genetics study and whether their decision making was consistent with that of the patient represented. METHODS: We invited individuals identified as surrogates for critically ill adults, if required, as well as patients once recovered to participate in a survey designed to understand attitudes about genetic research. Associations between dependent (receptivity to participation, concordance of responses) and independent variables were tested using bivariate and multivariate logistic regression analyses. RESULTS: Most of the entire surrogate sample (n=439) reported familiarity with research, including genetic research; tended to view research as useful; and were receptive to allowing their family member participate (with 39.6% and 38.1% stating that this would be "very" and "somewhat likely," respectively) even absent direct benefit. Willingness to participate was similar comparing genetic and non-genetic studies (χ2 [1,n=439]=0.00127, p=0.972), though respondents expressed worry regarding lack of confidentiality of genetic data. Responses were concordant in 70.8% of the 192 surrogate-patient pairs analyzed. In multivariate analysis, African American race was associated with less receptivity to genetic data collection (p<0.05). No factors associated with concordance of surrogate-patient response were identified. CONCLUSIONS: Surrogates' receptivity to critical illness research was not influenced by whether the study entailed collection of genetic data. While more than two-thirds of surrogate-patient responses for participation in genetics research were concordant, concerns expressed regarding genetic data often related to breach of confidentiality. Emphasizing safeguards in place to minimize such breeches might prove an effective strategy for enhancing recruitment.

Does difficulty functioning in the surrogate role equate to vulnerability in critical illness research? Use of path analysis to examine the relationship between difficulty providing substituted judgment and receptivity to critical illness research participation.

PURPOSE: Individuals who struggle to provide substitute judgment for the critically ill often find it challenging to engage in decision making for therapeutic interventions. Although essential to the conduct of research, how these individuals respond to requests for clinical trial participation is poorly understood. METHODS: Survey data collected to examine surrogate attitudes toward research provided the conceptual framework to explore influences on decision making. Path analysis was used to derive the final model (nonlatent, fully recursive, 1 indicator/variable). RESULTS: Surrogates with list-wise complete records (406) were analyzed. The following variables were not retained in the final model: education, income, religiosity, decision-making experience, discussion of patient's wishes, number of individuals assisting with decision making, trust in care providers, difficulty making decisions, and responsibility for decision making. Being white and having experience making treatment decisions for the patient during the current intensive care unit encounter affected the likelihood the surrogate would permit participation in research positively (parameter estimates, 0.281 and 0.06, respectively). No variable reflecting difficulty functioning in the surrogate role was associated with permitting research participation. CONCLUSIONS: We were unable to demonstrate a relationship between perceived difficulty in decision making in the surrogate role and receptivity to clinical trial participation.

Exploring determinants of surrogate decision-maker confidence: an example from the ICU.

This article is an exploratory data analysis of the determinants of confidence in a surrogate decision maker who has been asked to permit an intensive care unit (ICU) patient's participation in genetic research. We pursue the difference between surrogates' and patients' confidence that the surrogate can accurately represent the patient's wishes. The article also explores whether greater confidence leads to greater agreement between patients and surrogates. Our data come from a survey conducted in three hospital ICUs. We interviewed 445 surrogates and 214 patients. The only thing that influences patients' confidence in their surrogate's decision is whether they had prior discussions with him or her; however, there are more influences operating on the surrogate's self-confidence. More confident surrogates are more likely to match their patients' wishes. Patients are more likely to agree to research participation than their surrogates would allow. The surrogates whose response did not match as closely were less trusting of the hospital staff, were less likely to allow patient participation if there were no direct benefits to the patient, had given less thought about the way genetic research is conducted, and were much less likely to have a person in their life who they would trust to make decisions for them if they were incapacitated.