Extent of Follow-Up on Abnormal Cancer Screening in Multiple California Public Hospital Systems: A Retrospective Review.

BACKGROUND: Inequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist. OBJECTIVE: This report describes patterns of performance on follow-up of abnormal colon and breast cancer screening tests and explores the extent to which racial/ethnic disparities exist in public hospital systems. DESIGN: We conducted a retrospective cohort study using data from five California public hospital systems. We used multivariable robust Poisson regression analyses to examine whether patient-level factors or site predicted receipt of follow-up test. MAIN MEASURES: Using data from five public hospital systems between July 2015 and June 2017, we assessed follow-up of two screening results: (1) colonoscopy after positive fecal immunochemical tests (FIT) and (2) tissue biopsy within 21 days after a BIRADS 4/5 mammogram. KEY RESULTS: Of 4132 abnormal FITs, 1736 (42%) received a follow-up colonoscopy. Older age, Medicaid insurance, lack of insurance, English language, and site were negatively associated with follow-up colonoscopy, while Hispanic ethnicity and Asian race were positively associated with follow-up colonoscopy. Of 1702 BIRADS 4/5 mammograms, 1082 (64%) received a timely biopsy; only site was associated with timely follow-up biopsy. CONCLUSION: Despite the vulnerabilities of public-hospital-system patients, follow-up of abnormal cancer screening tests occurs at rates similar to that of patients in other healthcare settings, with colon cancer screening test follow-up occurring at lower rates than follow-up of breast cancer screening tests. Site-level factors have larger, more consistent impact on follow-up rates than patient sociodemographic traits. Resources are needed to identify health system-level factors, such as test follow-up processes or data infrastructure, that improve abnormal cancer screening test follow-up so that effective health system-level interventions can be evaluated and disseminated.

The effect of financial crises on deforestation: a global and regional panel data analysis.

Managing our transition to sustainability requires a solid understanding of how conditions of financial crisis affect our natural environment. Yet, there has been little focus on the nature of the relationship between financial crises and environmental sustainability, especially in relation to forests and deforestation. This study addressed this gap by providing novel evidence on the impact of financial crises on deforestation. A panel data approach is used looking at Global Forest Watch deforestation data from > 150 countries in > 100 crises in the twenty-first century. This includes an analysis of crises effects on principle drivers of deforestation; timber and agricultural commodities-palm oil, soybean, coffee, cattle, and cocoa. At a global level, financial crises are associated with a reduction in deforestation rates (- 36 p.p) and deforestation drivers; roundwood (- 6.7 p.p.), cattle (- 2.3 p.p.) and cocoa production (- 8.3 p.p.). Regionally, deforestation rates in Asia, Africa, and Europe decreased by - 83, - 43, and 22 p.p, respectively. Drivers behind these effects may be different, from palm oil (- 1.3 p.p.) and cocoa (- 10.5 p.p.) reductions in Africa, to a combination of timber (- 9.5 p.p) and palm oil in Asia. Moreover, financial crises have a larger effect on deforestation in low-income, than upper middle- and high-income countries (- 51 vs - 39 and - 18 p.p. respectively). Using another main dataset on yearly forest cover-the ESA-Climate Change Initiative-a picture arises showing financial crises leading to small global decreases in forest cover (- 0.1 p.p.) with a small agricultural cover increase (0.1 p.p). Our findings point to financial crises as important moments for global deforestation dynamics. Yet, to consolidate benefits on decreasing deforestation, governments need to enhance their sustainable forest management during crisis periods rather than let it slip down national agendas. Finally, to achieve the SDGs related to forests, better global forest cover datasets are needed, with better forest loss/gain data, disturbance history, and understanding of mosaicked landscape dynamics within a satellite pixel.

Examining Neighborhood Socioeconomic Status as a Mediator of Racial/Ethnic Disparities in Hypertension Control Across Two San Francisco Health Systems.

BACKGROUND: A contextual understanding of hypertension control can inform population health management strategies to mitigate cardiovascular disease events. This retrospective cohort study links neighborhood-level data with patients' health records to describe racial/ethnic differences in uncontrolled hypertension and determine if and to what extent these differences are mediated by neighborhood socioeconomic status (nSES). METHODS: We conducted a mediation analysis using a sample of patients with hypertension from 2 health care delivery systems in San Francisco over 2 years (n=47 031). We used generalized structural equation modeling, adjusted for age, sex, and health care system, to estimate the contribution of nSES to disparities in uncontrolled hypertension between White patients and Black, Hispanic/Latino, and Asian patients, respectively. Sensitivity analysis removed adjustment for health care system. RESULTS: Over half the cohort (62%) experienced uncontrolled hypertension during the study period. Racial/ethnic groups showed substantial differences in prevalence of uncontrolled hypertension and distribution of nSES quintiles. Compared with White patients, Black, and Hispanic/Latino patients had higher adjusted odds of uncontrolled hypertension: odds ratio, 1.79 [95% CI, 1.67-1.91] and odds ratio, 1.38 [95% CI, 1.29-1.47], respectively and nSES accounted for 7% of the disparity in both comparisons. Asian patients had slightly lower adjusted odds of uncontrolled hypertension when compared with White patients: odds ratio, 0.95 [95% CI, 0.89-0.99] and the mediating effect of nSES did not change the direction of the relationship. Sensitivity analysis increased the proportion mediated by nSES to 11% between Black and White patients and 13% between Hispanic/Latino and White patients, but did not influence differences between Asian and White patients. CONCLUSIONS: Among patients with hypertension in this study, nSES mediated a small proportion of racial/ethnic disparities in uncontrolled hypertension. Population health management strategies may be most effective by focusing on additional structural and interpersonal pathways such as racism and discrimination in health care settings.

Association of Differences in Treatment Intensification, Missed Visits, and Scheduled Follow-up Interval With Racial or Ethnic Disparities in Blood Pressure Control.

Importance: Black patients with hypertension often have the lowest rates of blood pressure (BP) control in clinical settings. It is unknown to what extent variation in health care processes explains this disparity. Objective: To assess whether and to what extent treatment intensification, scheduled follow-up interval, and missed visits are associated with racial and ethnic disparities in BP control. Design, Setting, and Participants: In this cohort study, nested logistic regression models were used to estimate the likelihood of BP control (defined as a systolic BP [SBP] level <140 mm Hg) by race and ethnicity, and a structural equation model was used to assess the association of treatment intensification, scheduled follow-up interval, and missed visits with racial and ethnic disparities in BP control. The study included 16 114 adults aged 20 years or older with hypertension and elevated BP (defined as an SBP level ≥140 mm Hg) during at least 1 clinic visit between January 1, 2015, and November 15, 2017. A total of 11 safety-net clinics within the San Francisco Health Network participated in the study. Data were analyzed from November 2019 to October 2020. Main Outcomes and Measures: Blood pressure control was assessed using the patient's most recent BP measurement as of November 15, 2017. Treatment intensification was calculated using the standard-based method, scored on a scale from -1.0 to 1.0, with -1.0 being the least amount of intensification and 1.0 being the most. Scheduled follow-up interval was defined as the mean number of days to the next scheduled visit after an elevated BP measurement. Missed visits measured the number of patients who did not show up for visits during the 4 weeks after an elevated BP measurement. Results: Among 16 114 adults with hypertension, the mean (SD) age was 58.6 (12.1) years, and 8098 patients (50.3%) were female. A total of 4658 patients (28.9%) were Asian, 3743 (23.2%) were Black, 3694 (22.9%) were Latinx, 2906 (18.0%) were White, and 1113 (6.9%) were of other races or ethnicities (including American Indian or Alaska Native [77 patients (0.4%)], Native Hawaiian or Pacific Islander [217 patients (1.3%)], and unknown [819 patients (5.1%)]). Compared with patients from all racial and ethnic groups, Black patients had lower treatment intensification scores (mean [SD], -0.33 [0.26] vs -0.29 [0.25]; ß = -0.03, P < .001) and missed more visits (mean [SD], 0.8 [1.5] visits vs 0.4 [1.1] visits; ß = 0.35; P < .001). In contrast, Asian patients had higher treatment intensification scores (mean [SD], -0.26 [0.23]; ß = 0.02; P < .001) and fewer missed visits (mean [SD], 0.2 [0.7] visits; ß = -0.20; P < .001). Black patients were less likely (odds ratio [OR], 0.82; 95% CI, 0.75-0.89; P < .001) and Asian patients were more likely (OR, 1.13; 95% CI, 1.02-1.25; P < .001) to achieve BP control than patients from all racial or ethnic groups. Treatment intensification and missed visits accounted for 21% and 14%, respectively, of the total difference in BP control among Black patients and 26% and 13% of the difference among Asian patients. Conclusions and Relevance: This study's findings suggest that racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in BP control, and racial and ethnic differences in visit attendance may also play a role. Ensuring more equitable provision of treatment intensification could be a beneficial health care strategy to reduce racial and ethnic disparities in BP control.

The effect of financial crises on air pollutant emissions: An assessment of the short vs. medium-term effects.

This paper empirically investigates the impact of financial crises on air pollutant emissions (CO2, SO2, NOx and PM2.5). A panel data approach is used, including 419 financial crisis episodes in >150 countries over the period 1970-2014. The short- and medium-term effects of crises are estimated, using a GMM specification (for short-term) and the estimation of impulse response functions (for medium-term). Results show that in the short-term, as a consequence financial crises, emissions decrease for all gases except for PM2.5. In particular, emissions of CO2, SO2 and NOx decrease by 2.6, 1.8, and 1.7% respectively. However, in the medium-term, financial crises cause insignificant effect on emissions, or in some cases even lead to a 1-2% increase, cancelling out the initial benefit. Our analysis also shows that the effect of crises is larger in high income and upper-middle income countries. Moreover, recent crises had a larger short-term impact on air pollutants than crises in previous decades. Our results suggest that the beneficial impact of financial crises on air quality is short-lived. To preserve this beneficial impact in the long run and avert new negative post-crisis emission patterns and dynamics, policy responses to financial crises should encompass tighter environmental regulations and green investments.