System Strategies for Colorectal Cancer Screening at Federally Qualified Health Centers

Objectives. We assessed the protocols and system processes for colorectal cancer (CRC) screening at federally qualified health centers (FQHCs) in 4 midwestern states.Methods. We identified 49 FQHCs in 4 states. In January 2013, we mailed their medical directors a 49-item questionnaire about policies on CRC screening, use of electronic medical records, types of CRC screening recommended, clinic tracking systems, referrals for colonoscopy, and barriers to providing CRC.Results. Forty-four questionnaires (90%) were returned. Thirty-three of the respondents (75%) estimated the proportion of their patients up-to-date with CRC screening, with a mean of 35%. One major barrier to screening was inability to provide colonoscopy for patients with a positive fecal occult blood test (59%). The correlation of system strategies and estimated percentage of patients up-to-date with CRC screening was 0.43 (P = .01).Conclusions. CRC system strategies were associated with higher CRC screening rates. Implementing system strategies for CRC screening takes time and effort and is important to maintain, to help prevent, or to cure many cases of CRC, the second leading cause of cancer in the United States.Federally qualified health centers (FQHCs) attempt to provide comprehensive, quality primary health care services to medically underserved communities and vulnerable populations. Approximately 1198 centers receive operating grants from the Public Health Service Act and thus qualify for reimbursement from Medicare and Medicaid.1 FQHCs served 21 million patients in 2012, of whom 36% were uninsured and 92% were living below the 200% poverty level.1 One of the services provided by FQHCs is colorectal cancer (CRC) screening through stool testing for occult blood.2 This service is covered under the Medicare FQHC benefit for persons aged 65 years and older and for those who qualify for the Medicaid program.3CRC is the second leading cause of cancer deaths in the United States.4 Only 63% of US adults report being up-to-date with CRC screening.5 CRC is a disease that is largely preventable; colonoscopy, through detection of early tumors and removal of precancerous polyps, could prevent 65% of CRC cases.6,7 Several national organizations have guidelines for CRC screening.8,9 National guidelines promote any of several tests for CRC screening: tests that pick up occult bleeding and endoscopic tests that visualize all or part of the colon.8–10Clinical tests to directly visualize colorectal cancer and precancerous polyps are colonoscopy, flexible sigmoidoscopy, double-contrast barium enema, and computed tomographic colonography (virtual colonoscopy). Fecal occult blood tests (FOBTs), which detect blood in the stool that is not visible and that indicates possible cancer, are the guaiac-based test and the fecal immunochemical test (FIT). FOBTs are recommended annually, and colonoscopy is recommended every 10 years, if no polyps are found.8–10 FOBTs are much less expensive than colonoscopy and are often preferred by patients. In many safety net settings, FOBTs are the initial option for patients, because of the prohibitive cost and limited availability of colonoscopy.11,12Through an infrastructure grant to enhance community-based cancer control in Iowa, we visited 4 FQHCs in Iowa and learned that FOBTs were available for use, but were for the most part not given to patients to avoid having to arrange and pay for a follow-up colonoscopy if FOBT results were positive. One FQHC director explained that the annual budget included a fund for extra tests that might be needed for any medical reason, and once these funds were exhausted, no more funding was available in that year. Thus, CRC screening was not a top priority, because of many other competing health care needs.To enhance CRC screening, system strategies are appropriate. A system strategy is a group of interrelated items that are part of a plan of action to accomplish a specific goal, such as improving CRC screening. Many different system strategies have been identified for improving CRC screening, such as physician recommendation,13,14 mailed patient reminders,15–17 and electronic medical record (EMR) physician reminders.18,19Patients at greatest risk for not receiving CRC screening are racial and ethnic minorities, Asians and Hispanics, and individuals who lack a usual source of health care or health insurance.20 Underuse of CRC screening is frequently associated with socioeconomic disadvantage21 and is associated with higher late-stage CRC rates.22 Because many of our nation’s most disadvantaged individuals make use of FQHCs, we assessed the protocols and system processes in place for CRC screening at FQHCs in 4 midwestern states and estimated rates of CRC screening in these FQHCs.     

Characteristics of Emergency Department Visits by Older Versus Younger Homeless Adults in the United States

Objectives. We compared the characteristics of emergency department (ED) visits of older versus younger homeless adults.Methods. We analyzed 2005–2009 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of visits to hospitals and EDs, and used sampling weights, strata, and clustering variables to obtain nationally representative estimates.Results. The ED visits of homeless adults aged 50 years and older accounted for 36% of annual visits by homeless patients. Although demographic characteristics of ED visits were similar in older and younger homeless adults, clinical and health services characteristics differed. Older homeless adults had fewer discharge diagnoses related to psychiatric conditions (10% vs 20%; P = .002) and drug abuse (7% vs 15%; P = .003) but more diagnoses related to alcohol abuse (31% vs 23%; P = .03) and were more likely to arrive by ambulance (48% vs 36%; P = .02) and to be admitted to the hospital (20% vs 11%; P = .003).Conclusions. Older homeless adults’ patterns of ED care differ from those of younger homeless adults. Health care systems need to account for these differences to meet the needs of the aging homeless population.The average age of the US homeless population is increasing. Whereas 11% of the homeless population was aged 50 years or older in 1990, this percentage had increased to 32% by 20031 and has continued to rise since then.2 The median age of single homeless adults has increased from 37 years in 19901 to between 49 and 50 years today.2,3 This trend is thought to be because of the aging of individuals born in the second half of the baby boom generation (those born 1954–1965), who have a higher risk of homelessness than do other age cohorts.3 Most homeless adults aged 50 years and older are aged between 50 and 64 years, with adults aged 65 years and older making up less than 5% of the total homeless population.1,3In the general population, adults aged 50 to 64 years are considered middle aged and have lower rates of chronic conditions than do those considered elderly, adults aged 65 years and older.4,5 However, homeless adults aged 50 years and older have rates of chronic illnesses and geriatric conditions similar to or higher than those of housed adults 15 to 20 years older, including conditions often thought to be limited to the elderly, such as falls and memory loss.6,7 Because middle-aged homeless adults face the same geriatric problems as do elderly housed adults, experts consider them to be elderly when aged 50 years, despite their relatively younger age.6,8 Similar patterns of premature aging have been found in other vulnerable populations, including prisoners9 and patients with developmental disabilities.10Despite the growth of the older homeless population, relatively little is known about use of health services among older homeless adults. Homeless health services and research have focused on problems that are common among younger homeless adults, including infectious disease,11 substance use,12 and mental illness.13 The few studies that have focused on older homeless adults found that they have medical problems that differ from those of younger homeless adults, including higher rates of chronic illnesses6,14 and geriatric syndromes6 and lower rates of substance use.15 New frameworks for providing care to the vulnerable and growing older population are needed but cannot be developed until more is known about their use of health services.Homeless adults aged 50 years and older use the emergency department (ED) frequently and at rates nearly 4 times those of the general population.16–18 Knowledge about ED care that older homeless adults receive may allow researchers and clinicians to design interventions to reduce use of the ED and improve ED care for this vulnerable older population. Therefore, we have identified the demographic, clinical, and health services characteristics of ED visits in older versus younger homeless adults, using a nationally representative survey of US ED visits.     

Latent Tuberculosis Infection Screening in Foreign-Born Populations: A Successful Mobile Clinic Outreach Model

Objectives. We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis.Methods. A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011.Results. Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI.Conclusions. Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings.Foreign-born populations are at greatest risk for having both latent tuberculosis infection (LTBI) and developing tuberculosis (TB) disease within high-income countries and, in 2012, accounted for 63.0% of the 9951 TB cases in the United States.1 Newly diagnosed and reactivated TB infection among foreign-born individuals in the United States is currently 12 times greater (15.8 vs 1.4 cases per 100 000 population) than among US-born persons.1 Among foreign-born individuals, LTBI often reactivates within 5 to 10 years after arrival to the United States.2,3 Undocumented migrants and visitors from high-TB-prevalence countries, however, do not undergo routine LTBI screening and thus remain outside traditional health care screening and treatment programs in primary or specialty care settings except when they are acutely ill.3,4 Thus, identifying and treating LTBI cases among these high-risk populations before transforming to TB disease and resultant transmission to others is crucial to ending the cycle of ongoing TB infection within the United States.Workplace screening,4,5 mandatory criminal justice system screening,6–8 screening for entry into medication-assisted therapy and drug treatment programs,9 and refugee and naturalization programs10,11 have been successful for reaching legal and domestic populations, but innovative options are needed to target foreign-born populations that are not yet integrated into mainstream care.Culturally and geographically isolated foreign-born groups may be overlooked especially if there is low self-perception of tuberculosis risk.12 Tuberculin skin testing (TST), though imperfect, is internationally recognized and has been shown to be a reasonably accurate assessment of LTBI status in immunocompetent adults, despite receiving previous Bacillus Calmette-Guérin vaccine.13 Whereas other studies have focused on traditional clinics or statewide programs,14 we present an innovative mobile medical clinic (MMC) as a model to target “hidden” foreign-born populations for LTBI screening.New Haven, Connecticut, the country’s fourth poorest city for its size, with a census of 130 000, is a medium-sized urban setting in New England that has experienced extraordinary social and medical disparities including a high prevalence of poverty, drug addiction, HIV/AIDS, and unemployment and is disproportionately comprised of people of color, including 35.4% and 27.4% being Black or Hispanic, respectively.15 As New Haven is an industrial city with low-paying jobs, there has been an influx of foreign-born people, now officially comprising 11.6% of the population, with many having an undocumented residency status. Health care access for this group is absent unless individuals pay directly for fee-for-service, and concern for deportation and arrest further hinders willingness to seek care.16The Community Health Care Van (CHCV) is an MMC that provides free health care 5 days per week in 4 impoverished neighborhoods in New Haven. Though at inception the program was linked to the needle and syringe exchange program,17 it has since expanded over 20 years to become a vital bridge to a diverse array of health and addiction treatment services that includes services for medically underserved populations, including directly administered antiretroviral therapy to treat HIV,18–21 buprenorphine maintenance therapy,22–25 community transitional programs from the criminal justice system,26–33 hepatitis B vaccination,34 rapid hepatitis C screening,35 and other ongoing primary health care programs such as screening and monitoring of sexually transmitted infections,36 diabetes, and hypertension. In addition, the CHCV provides outreach and intensive case management services.37 Screening for LTBI and TB disease began in 2003 to target high-risk undocumented and foreign-born clients, as well as clients entering drug treatment programs or homeless shelters, who were concerned about TB infection yet were reluctant to seek care in traditional health care settings for fear of deportation, prohibitive cost, or language barriers. The LTBI screening program shortly thereafter became successfully incorporated into the country’s first mobile buprenorphine maintenance therapy program.9     

Pathways to Colonoscopy in the South: Seeds of Health Disparities

Objectives. We aimed to highlight sociodemographic differences in how patients access colonoscopy.Methods. We invited all eligible patients (n = 2500) from 2 academy-affiliated colonoscopy centers in Alachua County, Florida (1 free standing, 1 hospital based), to participate in a precolonoscopy survey (September 2011–October 2013); patients agreeing to participate (n = 1841, response rate = 73.6%) received a $5.00 gift card.Results. We found sociodemographic differences in referral pathway, costs, and reasons associated with obtaining the procedure. Patients with the ideal pathway (referred by their regular doctor for age-appropriate screening) were more likely to be Black (compared with other minorities), male, high income, employed, and older. Having the colonoscopy because of symptoms was associated with being female, younger, and having lower income. We found significant differences for 1 previously underestimated barrier, having a spouse to accompany the patient to the procedure.Conclusions. Patients’ facilitators and barriers to colonoscopy differed by sociodemographics in our study, which implies that interventions based on a single facilitator will not be effective for all subgroups of a population.Colorectal cancer (CRC), the second leading cause of US cancer deaths in 2013 (50 830),1 is not distributed equally. Nationally, it is estimated that incidence is 25% higher, and mortality from CRC 50% higher, in Black Americans than in Whites.2,3 Most CRC diagnoses follow evaluation by colonoscopy. Although consumers have a range of CRC screening tests, from least invasive (fecal occult blood test, fecal immunochemical test) to most invasive (sigmoidoscopy, colonoscopy),4 if polyps are indicated, a colonoscopy is required as follow-up. Thus, colonoscopy is both an entry point and a pivotal event in the process of preventing, detecting, and treating CRC. CRC can be prevented through the removal of precancerous polyps or detected at an early, easily treatable stage5; findings indicate6 that colonoscopy with polypectomy reduces mortality from CRC by 53%. Although rates of CRC screening have increased,3 there is need for improvement. More than one third of Americans are not in compliance with screening guidelines,7 with rates being lower in the southern United States.8In 2008, Etzioni et al.9 presented a model of patient and provider-level factors that influence decision-making in colon cancer and that can lead to health disparities in disease recurrence and survival. The Etzioni model identifies key points of vulnerability in the treatment process where the potential to achieve high-quality, guideline-recommended care can be lost. The model captures patients after surgery, beginning with the decision to refer patients to a medical oncologist for adjuvant treatment; it is relevant because there is considerable evidence of inequities in who receives adjuvant treatment based on older age,10,11 comorbidities,12,13 low income,7 coverage with Medicaid rather than Medicare,13 Black race,14 female gender,15,16 and being unmarried.9We propose that this model starts too late in the process; health disparities originate prior to colonoscopy and can increase at each decision point along a continuum. In an elaborated model (Figure 1), we suggest that CRC health disparities research should begin with an investigation of entry into the health care system and the subsequent pathways to colonoscopy. Referral patterns, costs, and patient demographics influence patient access to care, colonoscopy compliance, and postcolonoscopy decision-making.Open in a separate windowFIGURE 1—Pathways to colonoscopy, treatment, and outcomes.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

Prevalence of HCV Infection Among Clients in Community-Based Health Settings in Hawaii, 2002–2010: Assessing Risk Factors

Objectives. We sought to determine the prevalence of HCV infection and identify risk factors associated with HCV infection among at-risk clients presenting to community-based health settings in Hawaii.Methods. Clients from 23 community-based sites were administered risk factor questionnaires and screened for HCV antibodies from December 2002 through May 2010. We performed univariate and multivariate logistic regression analyses.Results. Of 3306 participants included in the analysis, 390 (11.8%) tested antibody positive for HCV. Highest HCV antibody prevalence (17.0%) was in persons 45 to 64 years old compared with all other age groups. Significant independent risk factors were current or prior injection drug use (P < .001), blood transfusion prior to July 1992 (P = .002), and having an HCV-infected sex partner (P = .03). Stratification by gender revealed sexual exposure to be significant for males (P = .001).Conclusions. Despite Hawaii’s ethnic diversity, high hepatocellular carcinoma incidence, and a statewide syringe exchange program in place since the early 1990s, our HCV prevalence and risk factor findings are remarkably consistent with those reported from the mainland United States. Hence, effective interventions identified from US mainland population studies should be generalizable to Hawaii.Hepatitis C is the most prevalent chronic blood-borne viral infection in the United States, with an estimated 1.3% of the population chronically infected.1 Chronic HCV infection is often asymptomatic; approximately 75% of infected persons may be unaware that they are infected.2 Transmission is mainly through direct blood-to-blood contact, and the most common risk factor in the United States is the sharing of injection drug use equipment.1,2 Complications from HCV infection include cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver disease; more than one third of liver transplants in the United States can be attributed to HCV.3 There is currently no vaccine,4 and until recently, standard therapy with pegylated interferon and ribavirin achieved a sustained virologic response in only 40% to 50% of patients.5,6In May 2011, the US Food and Drug Administration approved 2 new HCV-specific protease inhibitors for the treatment of chronic genotype 1 HCV infections: boceprevir7,8 and telaprevir.9,10 In combination with standard therapy, these drugs have achieved significantly higher rates of sustained virologic response: up to 67% to 75%.7,10 Achieving sustained virologic response is key to reducing mortality, HCC, and other comorbidities.11,12 With such a large percentage of HCV-infected individuals unaware of their status and new successful treatments available, there is now increased rationale for health providers to screen their clients for chronic HCV infection.The population of Hawaii differs from that of the mainland United States on a number of key factors related to HCV and HCC. Hawaii has the highest incidence of HCC nationally.13 Asian/Pacific Islanders have the highest incidence of HCC in the United States,13 and 57% of the Hawaii’s population is Asian, either alone or in combination with other ethnic groups.14 The high HCC incidence among Asian/Pacific Islanders is attributed in large part to chronic hepatitis B virus (HBV) infection,13,15 and the identification and treatment of persons with chronic HBV or HCV infection is an important public health priority in Hawaii. In addition, Hawaii implemented a statewide syringe exchange program in the early 1990s, the first state to do so.16 The risk factor demonstrating the strongest association with HCV infection in the United States is injection drug use,1,17 and syringe exchange programs have demonstrated efficacy in reducing HCV infection among injection drug users.18,19To our knowledge, only 3 HCV prevalence studies have been conducted in Hawaii; however, each focused on a specific well-defined subgroup population: patients with HCC,20 HIV-infected persons enrolled in a state drug assistance plan,21 and adults from a homeless shelter.22The Adult Viral Hepatitis Prevention Program of the Hawaii State Department of Health, which offers risk-based HCV antibody testing based on reported national risk factors,1,23 has been collecting data on persons undergoing screening since 2002. We investigated the prevalence of HCV antibody positivity among at-risk clients of community-based health programs in Hawaii and identified demographic characteristics and independent risk factors associated with HCV infection.     

Factors Explaining Racial/Ethnic Disparities in Rates of Physician Recommendation for Colorectal Cancer Screening

Objectives. Physician recommendation plays a crucial role in receiving endoscopic screening for colorectal cancer (CRC). This study explored factors associated with racial/ethnic differences in rates of screening recommendation.Methods. Data on 5900 adults eligible for endoscopic screening were obtained from the National Health Interview Survey. Odds ratios of receiving an endoscopy recommendation were calculated for selected variables. Planned, sequenced logistic regressions were conducted to examine the extent to which socioeconomic and health care variables account for racial/ethnic disparities in recommendation rates.Results. Differential rates were observed for CRC screening and screening recommendations among racial/ethnic groups. Compared with Whites, Hispanics were 34% less likely (P < .01) and Blacks were 26% less likely (P < .05) to receive this recommendation. The main predictors that emerged in sequenced analysis were education for Hispanics and Blacks and income for Blacks. After accounting for the effects of usual source of care, insurance coverage, and education, the disparity reduced and became statistically insignificant.Conclusions. Socioeconomic status and access to health care may explain major racial/ethnic disparities in CRC screening recommendation rates.Colorectal cancer (CRC) is the third most common cause of cancer death in the United States and a major cause of cancer morbidity.1 Annually in the United States, an estimated 150 000 people are diagnosed and 50 000 people die from this disease.2 With early detection and removal of precancerous polyps, CRC can be preventable, with a 5-year survival rate as high as 90%.3,4Current CRC screening guidelines consist of sigmoidoscopy every 5 years and colonoscopy every 10 years for those aged 50 to 75 years.4 Although an annual fecal occult blood test is also recommended, sigmoidoscopy and colonoscopy have higher sensitivity and specificity for the detection of cancerous lesions.5 Sensitivity ranges from 25% to 87% for fecal occult blood test, compared with 92% to 95% for endoscopy (sigmoidoscopy and colonoscopy).6 Colonoscopy, the most widely used test for CRC detection and prevention, is considered the gold standard because it can detect and remove precancerous polyps, and a positive result from any other screening test must be followed by this advanced modality.1,7,8 Endoscopy has played a major role in the decreasing trend of CRC mortality in the United States9,10Still, minority groups—especially Blacks—carry a disproportionately higher CRC burden.1,11 From the 1980s to 2007—a period of advance in early detection and treatment—the inequality between Blacks and Whites increased to a 44% difference in CRC mortality rates.1 This disparity could be attributable in part to the fact that, compared with Whites, members of racial/ethnic minority groups were less likely to be screened and diagnosed at the localized, more treatable stage of CRC.1 These lower screening rates partially account for the higher rates of late stage detection and subsequent increases in CRC morbidity and mortality rates among racial/ethnic minorities and low-income populations.1,10,12 Thus, it is necessary to promote utilization of effective screening methods, such as endoscopy, to detect CRC in its early stages, especially among minority groups.Trends in CRC screening from 1992 to 2005 show widening gaps between Whites and minority groups: the disparity increased to 10.3% for Blacks and to 20.5% for Hispanics.13,14 Lower rates of cancer screening, including CRC screening, have been strongly associated with lower rates of physician recommendation, particularly among low-income populations, racial/ethnic minority groups, and women.15,16The health care provider’s role in CRC screening is essential because a physician recommendation is necessary for endoscopic screening.17,18 A study found that more than 90% of people who did not undergo endoscopic screening reported not receiving the necessary recommendation.16 A systematic review discovered that patients identified physician recommendation as the sole CRC-screening facilitator and absence of recommendation as the only barrier.19 It is thus crucial to identify factors that influence the likelihood of receiving a CRC screening recommendation.The present study seeks to build on the work of 2 previous analyses of CRC-screening barriers and predictors among respondents to the 2000 National Health Interview Survey (NHIS). Seeff et al. found that “frequent doctor visits in the past year” was the strongest predictor of CRC screening.20 Among the barriers, a “lack of awareness of the need to be screened” was most common, followed by “not receiving a physician recommendation.”20 In bivariate analysis, Coughlin and Thompson found that, among screening-eligible adults who had visited a physician in the past year, members of racial/ethnic minority groups were less likely than Whites to receive an endoscopy recommendation.21 The study mainly focused on reasons for having CRC screenings.We used multivariate analyses and planned sequenced logistic regression to explore patient factors that may explain unequal rates of physician recommendation for endoscopy among Blacks and Hispanics compared with Whites. Factors deemed to have relative importance in terms of statistical significance may help indicate areas of intervention to improve rates of physician recommendation for CRC screening in disadvantaged populations.     

Geographic Residency Status and Census Tract Socioeconomic Status as Determinants of Colorectal Cancer Outcomes

Objectives. We examined the impact of geographic residency status and census tract (CT)-level socioeconomic status (SES) on colorectal cancer (CRC) outcomes.Methods. This was a retrospective cohort study of patients diagnosed with CRC in Georgia for the years 2000 through 2007. Study outcomes were late-stage disease at diagnosis, receipt of treatment, and survival.Results. For colon cancer, residents of lower-middle-SES and low-SES census tracts had decreased odds of receiving surgery. Rural, lower-middle-SES, and low-SES residents had decreased odds of receiving chemotherapy. For patients with rectal cancer, suburban residents had increased odds of receiving radiotherapy, but low SES resulted in decreased odds of surgery. For survival, rural residents experienced a partially adjusted 14% (hazard ratio [HR] = 1.14; 95% confidence interval [CI] = 1.07, 1.22) increased risk of death following diagnosis of CRC that was somewhat explained by treatment differences and completely explained by CT-level SES. Lower-middle- and low-SES participants had an adjusted increased risk of death following diagnosis for CRC (lower-middle: HR = 1.16; 95% CI = 1.10, 1.22; low: HR = 1.24; 95% CI = 1.16, 1.32).Conclusions. Future efforts should focus on developing interventions and policies that target rural residents and lower SES areas to eliminate disparities in CRC-related outcomes.For men and women in the United States, colorectal cancer (CRC) ranks third in incidence and mortality among cancers, with an estimated 142 820 new cases and 50 830 deaths in 2013.1 Reflecting the US population distribution according to geography2 and evidence of similar incidence rates3,4 for rural residents, approximately 20% of incident CRC cases are expected to occur in rural populations. Although CRC incidence is equivalent for rural and urban residents, CRC mortality is higher in rural populations,5 and the causes of rural versus urban disparities in CRC mortality are not well understood. Compared with their suburban and urban counterparts, rural citizens are more likely to be older, live in poverty, have less education, lack health insurance, and have no regular health care provider.6–9 These facets of rural living pose challenges to accessing health promotional messages and high-quality primary care, not to mention treatment of cancer.10,11Those of lower socioeconomic status (SES) have worse health-related outcomes than their more affluent counterparts, and SES often has a gradient effect on health.12 A challenge in studying the association between rurality and health is being able to disentangle the confounding effect of SES associated with geographic residency.13 As we previously demonstrated for a sample of urban and rural residents of Georgia with CRC, rural residence was associated with an increased risk of death following diagnosis.14 A limitation of that study was an inability to account for SES differences between urban and rural populations. If adjustment for SES explains the poorer survival that is associated with rural residence, this explanation provides an opportunity to investigate mediators of the SES effect as potential avenues for intervention.15 Identification of these mediating factors will facilitate the development of focused interventions with the goal of eliminating rural CRC-related disparities.16,17Building on our previous work,14 we evaluated the independent and combined effects of rurality and area-level SES on CRC outcomes. In our previous study, (1) we were unable to evaluate the independent and potential confounding effect of SES on rurality,2 (2) our study population was a sample of the Georgia CRC population, and (3) residents were classified as urban or rural at the county level, which may have resulted in misclassification. In the present study, the exposures of interest were geographic residency status (rural, suburban, or urban) and area-level SES, both at the census tract (CT) level. In addition, the study population represents the entire state of Georgia rather than a sample. The primary study outcome was overall survival. Secondarily, we wanted to evaluate the effect of SES and geography adjusted for SES on the odds of late-stage disease at diagnosis and receipt of first-course treatment.The findings of this study are meant to bring importance to a highly relevant area of public health research: disparities related to rural versus urban cancer outcomes, and specifically to rural CRC outcomes. As a result, interventions may be designed and policies developed to address the difficulties of accessing and providing high-quality cancer care in rural areas of the United States.11 It is through the combination of applying what is learned from epidemiological findings to community-level interventions and policymaking that the elimination of health disparities will occur.18     

Directly Observed Antidepressant Medication Treatment and HIV Outcomes Among Homeless and Marginally Housed HIV-Positive Adults: A Randomized Controlled Trial

Objectives. We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008.Methods. We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL).Results. The intervention reduced depression symptom severity (b = −1.97; 95% confidence interval [CI] = −0.85, −3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes.Conclusions. Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.Depressive, pain, and substance use disorders are highly prevalent among persons living with HIV/AIDS1,2 and among the homeless and marginally housed.3–5 The triple diagnosis of depression, HIV, and substance use poses unique treatment challenges for clinicians: successful management of one condition is often dependent on successful management of the others, and the optimal sequencing of depression treatment, substance use treatment, and stabilization of psychosocial comorbidities remains unclear. Adherence to the entire continuum of HIV care is often hampered by depression6–8 and substance use.9,10 For homeless persons, the need to address subsistence concerns such as obtaining food and shelter may not only adversely affect mental well-being11 but may also divert attention away from medication adherence and regular clinic attendance.12 Timely and effective depression treatment is critical for HIV-positive persons, because depression has been associated with CD4⁺ T-lymphocyte cell count decline,13 progression to AIDS,14 and AIDS-related mortality.15 Yet depression remains pervasively underdiagnosed and undertreated among the homeless16–18 and among HIV-positive persons.19,20Depression treatment might be expected to improve virological or immunologic outcomes through improved adherence, but this has not been conclusively demonstrated.21–23 We therefore sought to determine whether treatment with once-weekly fluoxetine reduced depression symptom severity among homeless and marginally housed persons with comorbid depression and HIV. Because this population faces many psychosocial barriers to successful medication adherence,12,24 in addition to depression,25 we employed a directly observed treatment strategy similar to that used for treatment and management of patients with tuberculosis and HIV.26 This strategy reduced the potential for incomplete adherence to reduce the effectiveness of antidepressant treatment. A secondary aim was to determine whether depression treatment improved antiretroviral therapy (ART) uptake among persons eligible for treatment and ART adherence and viral suppression among treated persons.     

Universal Health Insurance and Health Care Access for Homeless Persons

Objectives. We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system.Methods. We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs.Results. Unmet health care needs were reported by 17% of participants. Compared with Toronto''s general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey.Conclusions. Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.Homeless people are among the most marginalized groups in society, and large numbers of homeless individuals are found in the United States, Canada, and throughout the world.^1,2 Although the majority of homeless people are men, women and parents with children represent substantial segments of the homeless population.³ Homeless people suffer from many serious threats to their health, including an increased risk of all-cause mortality.⁴ Common medical conditions in this population include epilepsy, chronic obstructive pulmonary disease, hypertension, diabetes, and musculoskeletal disorders.⁵ Substance abuse, mental illness, and related comorbidities are also highly prevalent.⁵Despite high levels of morbidity and mortality, homeless people face numerous financial and nonfinancial barriers to obtaining needed health services.^6,7 A 1996 nationwide survey of homeless people across the United States found that 57% were uninsured, and lack of health insurance was associated with significantly lower odds of using ambulatory health care.⁷ Nonfinancial barriers have also been described. Competing priorities such as securing adequate food and shelter may lead to delays in seeking health care.⁸ Lack of transportation to health visits, long waiting times in clinics, and feelings of being stigmatized by health care professionals are also obstacles frequently reported by homeless people.^6,9 Lack of appropriate health care for homeless people may contribute to deterioration in health status, prolonged homelessness, and even death.^10,11Most studies of unmet needs for care among homeless individuals have been conducted in the United States.^6,7,12 Unmet needs for medical care in the past year were reported by 25% of respondents in a nationwide survey of homeless people in the United States and were somewhat more common among homeless families than among single homeless persons (27% vs 24%, respectively).^7,13 Studies conducted in various US urban centers have found even higher rates of unmet needs for care. Among homeless people living in urban encampments in Los Angeles, California, 41% felt there was a time in the past 6 months when they had needed to go to a doctor but did not.¹² A study of homeless women in Los Angeles County in 1997 found that 37% of participants had unmet needs for health care in the past 60 days.⁶ In a survey of low-income adults in Baltimore, Maryland, 57% of whom were homeless, 51% reported having difficulty accessing health care services.¹⁴ A recent study conducted in Birmingham, Alabama, found that the prevalence of unmet needs for care among homeless people rose from 32% in 1995 to 54% in 2005.¹⁵ This overall pattern suggests inadequacy of the US health care safety net for low-income and uninsured individuals.¹⁵Canada has a publicly funded system of universal health insurance that consists of single-payer plans administered by each province. All medically necessary physician services and hospital-based care are fully covered with no copayments. However, the extent to which such a system meets the needs of severely disadvantaged individuals has not been well defined.^16,17 Our objectives were to determine the prevalence of unmet needs for health care among homeless single men, single women, and women with dependent children within Canada''s universal health insurance system and to identify individual characteristics associated with having unmet needs.     

Using Organizational Network Analysis to Plan Cancer Screening Programs for Vulnerable Populations

Objectives. We examined relationships among organizations in a cancer screening network to inform the development of interventions to improve cancer screening for South Asians living in the Peel region of Ontario.Methods. From April to July 2012, we surveyed decision-makers, program managers, and program staff in 22 organizations in the South Asian cancer screening network in the Peel region. We used a network analytic approach to evaluate density (range = 0%–100%, number of ties among organizations in the network expressed as a percentage of all possible ties), centralization (range = 0–1, the extent of variability in centrality), and node characteristics for the communication, collaboration, and referral networks.Results. Density was similar across communication (15%), collaboration (17%), and referral (19%) networks. Centralization was greater in the collaboration network (0.30) than the communication network (0.24), and degree centralization was greater in the inbound (0.42) than the outbound (0.37) referral network. Diverse organizations were central to the networks.Conclusions. Certain organizations were unexpectedly important to the South Asian cancer screening network. Program planning was informed by identifying opportunities to strengthen linkages between key organizations and to leverage existing ties.Interorganizational networks are critical to effective coordination of complex programs that provide outreach, education, navigation, and clinical services to promote cancer screening.1–6 By operating as a system through communication, collaboration, and referrals, interorganizational networks can contribute to better-coordinated care and resulting improved health outcomes1,2,7 and can bring about synergy by leveraging scarce resources, reducing redundancies, standardizing messages, and filling gaps in services.1,2,8Community service organizations (public or private nonprofit entities such as churches and social service agencies) meet human, educational, and public safety needs and often represent vulnerable or racial and ethnic minority segments of the community.9 In a previous study of barriers to cancer screening for South Asians in Ontario, we found that community service organizations that served South Asian residents demonstrated a high level of knowledge about these barriers but that health service organizations had limited knowledge about the cancer screening barriers that were most relevant to South Asian residents.10 These findings suggest that community service organizations might be particularly valuable for improving the reach of cancer screening programs to medically underserved populations by leveraging the connections they have with minority groups.11In Canada, where cancer is the leading cause of mortality, population-based cancer screening programs are implemented by the provinces.12 Ontario, the most populous province in Canada,13 has organized screening programs to promote early detection of breast, cervical, and colorectal cancers.14 To maximize reach, these programs use evidence-based strategies to promote use of cancer screening tests, including targeted invitations, facilitated appointment booking, reduced out-of-pocket costs,15,16 public education, and communication of test results to patients and providers.17 Self-reported recent use of mammograms (73%) and Papanicolaou tests (73%) in Ontario are similar to the country as a whole,18,19 and self-reported rates of fecal occult blood test use (50%) are higher in Ontario than in other provinces.20 However, the Ontario cancer screening programs have less reach to immigrant populations than to native-born residents,21–27 which diminishes the effectiveness of these programs28 and may lead to health inequities.29South Asians, who come primarily from India, Pakistan, Afghanistan, Bangladesh, and Sri Lanka, are among the fastest-growing immigrant groups in Canada and Ontario.30 South Asians are particularly likely to be inadequately screened for all 3 types of cancer because they generally have incomes lower than the national average, which is associated with underscreening,31 and because awareness about cancer screening in their countries of origin is typically poor.32–34 Lofters et al. found that cervical cancer screening rates were lower for recent South Asian immigrants than for Canadian-born women and immigrants who arrived before 1985.35 Another study found lower rates of breast self-exam among women from New Delhi, India, than among self-identified Indian, East Asian, or European women living in Canada.36 Although colorectal cancer screening data specific to South Asians are not available, screening rates for colorectal cancer are lower for all immigrant groups than for native Canadians.37We analyzed network structures among organizations that provide cancer screening services to South Asians in the Peel region of Ontario. Our goal was to inform the development of a multilevel intervention to increase participation in cancer screening for this vulnerable population.38     

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment.Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010.Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival.Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.Breast cancer is the most common cancer among women in the United States, and it is the second leading cause of cancer death.1 Despite significant improvements in breast cancer survival from 1992 to 2009,1,2 racial/ethnic and socioeconomic survival disparities have persisted.3,4 African American women have consistently been found to have worse survival after breast cancer,3,5–11 Hispanic women have worse or similar survival,3,9,11,12 and Asian women as an aggregated group have better or similar survival3,9,11,12 than do non-Hispanic White women. Underlying factors thought to contribute to these racial/ethnic disparities include differences in stage at diagnosis,8,12,13 distributions of breast cancer subtypes,14–16 comorbidities,12,13,17 access to and utilization of quality care,13,18 and treatment.12,13Numerous studies also have found poorer survival after breast cancer diagnosis among women residing in neighborhoods of lower socioeconomic status (SES).6,9,19,20 Research has shown that inadequate use of cancer screening services, and consequent late stage diagnosis and decreased survival, contribute to the SES disparities.21,22 Similar to racial/ethnic disparities, SES disparities have been attributed to inadequate treatment and follow-up care and comorbidities.18 Previous population-based studies have continued to observe racial/ethnic survival disparities after adjusting for neighborhood SES, but these studies have not considered the combined influence of neighborhood SES and race/ethnicity.3,9,11,12,23 These disparities may remain because information on individual-level SES, health insurance coverage, comorbidities, quality of care, and detailed treatment regimens have typically not been available.3,8,9,11,13 Even among studies using national Surveillance Epidemiology and End Results–Medicare linked data, in which more detailed information on treatment and comorbidities are available among some patients aged 65 years and older, survival disparities have remained.12,23,24 However, not all data on medical conditions and health care services are captured in Medicare claims, including data on Medicare beneficiaries enrolled in HMOs (health maintenance organizations).25,26Using electronic medical records data from Kaiser Permanente Northern California (KPNC) linked to data from the population-based California Cancer Registry (CCR), we recently reported that chemotherapy use followed practice guidelines but varied by race/ethnicity and neighborhood SES in this integrated health system.27 Therefore, to overcome the limitations of previous studies and address simultaneously the multiple social28 and clinical factors affecting survival after breast cancer diagnosis, we used the linked KPNC–CCR database to determine whether racial/ethnic and socioeconomic differences in short-term overall and breast cancer–specific survival persist in women in a membership-based health system. Our study is the first, to our knowledge, to consider the combined influence of neighborhood SES and race/ethnicity and numerous prognostic factors, including breast cancer subtypes and comorbidities, thought to underlie these long-standing survival disparities among women with uniform access to health care and treatment.     

Clustering of Midlife Lifestyle Behaviors and Subsequent Cognitive Function: A Longitudinal Study

Objectives. We examined the association between individual and clustered lifestyle behaviors in middle age and later in cognitive functioning.Methods. Middle-aged participants (n = 2430) in the Supplémentation en Vitamines et Minéraux Antioxydant study self-reported their low physical activity, sedentary behavior, alcohol use, smoking, low fruit and vegetable consumption, and low fish consumption. We assessed cognition 13 years later via 6 neuropsychological tests. After standardization, we summed the scores for a composite cognitive measure. We estimated executive functioning and verbal memory scores using principal component analysis. We estimated the mean differences (95% confidence intervals [CIs]) in cognitive performance by the number of unhealthy behaviors using analysis of covariance. We identified latent unhealthy behavior factor via structural equation modeling.Results. Global cognitive function and verbal memory were linearly, negatively associated with the number of unhealthy behaviors: adjusted mean differences = −0.36 (95% CI = −0.69, −0.03) and −0.46 (95% CI = −0.80, −0.11), respectively, per unit increase in the number of unhealthy behaviors. The latent unhealthy behavior factor with low fruit and vegetable consumption and low physical activity as main contributors was associated with reduced verbal memory (RMSEA = 0.02; CFI = 0.96; P = .004). No association was found with executive functioning.Conclusions. Comprehensive public health strategies promoting healthy lifestyles might help deter cognitive aging.Noncommunicable diseases with notable lifestyle components are the leading causes of death worldwide.1,2 There is also growing evidence of the critical role of different midlife health and risk behaviors in cognitive aging.3–7 Because lifestyles are inherently modifiable and no treatment of cognitive decline is available, such findings argue for the paramount importance of prevention.8,9Current data support a deleterious effect of alcohol abstinence or abuse (compared with moderate alcohol consumption),10 smoking,7 low fruit and vegetable intake,11 low fish intake,12 and low physical activity (PA) levels13 on cognitive aging. However, it has been widely documented that lifestyle factors are strongly correlated with each other, forming a cluster of healthy or unhealthy behaviors.14 Traditionally, such interrelations have been accounted for by statistical adjustment; however, it is of major public health interest to consider the cumulative and combined effect of the various lifestyle behaviors on health by using multidimensional strategies.14Research that examines the combined effect of lifestyle factors on mortality is plentiful, and data have been colligated in a recent meta-analysis.15 These authors reported a 66% reduction in mortality risk by comparing adherence to 4 or more healthy lifestyle behaviors versus engagement in any number of unhealthy behaviors.The combined effect of lifestyle factors has also been explored in relation to cardiovascular diseases,16–18 cancer,18–22 diabetes,18,23 memory complaints,24 and dementia25–27; however, very few studies have reported findings regarding cognition.28,29 Despite heterogeneity in the definition of a healthy lifestyle, study design, and residual confounding, available, but scarce, data support a critical, protective role of healthy lifestyles in cognitive health through their beneficial properties via oxidative, inflammatory, vascular, and other neuroprotective pathways.30–33Our objectives in this study were to examine the association between individual and clustered lifestyle behaviors and later cognitive functioning. We employed traditional and innovative techniques (structural equation modeling) in our epidemiological pursuit.     

Prevalence of Undiagnosed Acute and Chronic HIV in a Lower-Prevalence Urban Emergency Department

Objectives. We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of emergency department (ED) patients from a region of the United States with low-to-moderate HIV prevalence.Methods. This cross-sectional seroprevalence study consecutively enrolled patients aged 18 to 64 years within randomly selected sampling blocks in a Midwestern urban ED in a region of lower HIV prevalence in 2008 to 2009. Participants were compensated for providing a blood sample and health information. After de-identification, we assayed samples for HIV antibody and nucleic acid.Results. There were 926 participants who consented and enrolled. Overall, prevalence of undiagnosed HIV was 0.76% (95% confidence interval [CI] = 0.30%, 1.56%). Three participants (0.32%; 95% CI = 0.09%, 0.86%) were nucleic acid–positive but antibody-negative and 4 (0.43%; 95% CI = 0.15%, 1.02%) were antibody-positive.Conclusions. Even when the absolute prevalence is low, a considerable proportion of undetected HIV cases in an ED population are acute. Identification of acute HIV in ED settings should receive increased priority.HIV screening is recommended by the US Centers for Disease Control and Prevention as an essential component of the nation’s HIV prevention effort.1,2 Emergency departments (EDs) are particularly emphasized as venues for HIV screening.3–5 Emergency departments serve more than 100 million patients annually, readily accessing vulnerable populations with a high prevalence of undetected HIV.1,4–8To date, most attention has been focused on detection of HIV in the chronic phase, after seroconversion, by assay for antibodies. Yet identification of patients during acute HIV infection could have a significant impact on further transmission.9,10 Testing for acute HIV infection is accomplished by assays that detect viral proteins or viral genetic material before antibody detection is possible. This testing is more expensive, complex, or may delay results compared with antibody testing.9,11,12 Despite these disadvantages, screening for acute HIV is increasingly suggested by various authors.9,13–19 Acute HIV infection is thought to contribute disproportionately to HIV incidence because of high viral replication and increased infectiousness during this phase.15,20–22 Diagnosis prompts many individuals to reduce transmission behaviors,23 and partner notification efforts may be more successful.24 There is also renewed interest in treatment during acute HIV infection, to lower infectiousness and improve long-term patient health outcomes.21,25–27 In light of these benefits, screening for acute HIV infection may ultimately be cost-effective and worthy of increased logistical challenges.9,28Unfortunately, the controversies and implementation barriers in HIV screening have yet to be fully resolved,29–35 particularly in ED settings where patient volumes exceed capacity and acute stabilization takes precedence over preventive health.36–38 Screening in the ED for acute HIV infection will be even more challenging than screening for chronic HIV if it entails additional complexity and expense. Motivation to surmount such barriers is likely to be less in regions of lower HIV prevalence, in which disease incidence would also be presumed lower. Improving our understanding of acute HIV epidemiology in ED settings is fundamental for guiding potential implementation of ED screening interventions targeting acute HIV infection. We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of ED patients from a low-to-moderate HIV prevalence region of the United States.     

Uptake and Predictors of Anal Cancer Screening in Men Who Have Sex With Men

Objectives. We investigated attitudes about and acceptance of anal Papanicolaou (Pap) screening among men who have sex with men (MSM).Methods. Free anal Pap screening (cytology) was offered to 1742 MSM in the Multicenter AIDS Cohort Study, who reported history of, attitudes about, and experience with screening. We explored predictors of declining screening with multivariate logistic regression.Results. A history of anal Pap screening was uncommon among non–HIV-infected MSM, but more common among HIV-infected MSM (10% vs 39%; P < .001). Most participants expressed moderate or strong interest in screening (86%), no anxiety about screening (66%), and a strong belief in the utility of screening (65%). Acceptance of screening during this study was high (85%) across all 4 US sites. Among those screened, most reported it was “not a big deal” or “not as bad as expected,” and 3% reported that it was “scary.” Declining to have screening was associated with Black race, anxiety about screening, and low interest, but not age or HIV status.Conclusions. This study demonstrated high acceptance of anal Pap screening among both HIV-infected and non–HIV-infected MSM across 4 US sites.In the past 3 decades, anal cancer incidence has increased 39% in women and 96% in men in the United States.1–3 In the general US population, anal cancer incidence remains higher among women than men (1.8 vs 1.4 cases per 100 000 annually), but the incidence is especially high among men who have sex with men (MSM; 35 per 100 000).4–6 Indeed, data suggest that anal cancer incidence among MSM may be similar to or higher than incidence of cervical cancer among US women before the introduction of cervical cytology screening in the mid-1950s.1,7–13 Incidence estimates for HIV-infected MSM are even higher and vary from 45.9 per 100 000 person-years14 in meta-analyses to 78.2 per 100 000 person-years15 for US AIDS Surveillance Epidemiology and End Results data.Human papillomavirus (HPV) infection is the major cause of anal cancer.4,14,16,17 Consistent with the increased anal cancer incidence among MSM, anal HPV prevalence and incidence are elevated among MSM compared with the general population.18,19 HIV-infected MSM have even higher anal HPV prevalence, compared with non–HIV-infected MSM (98% vs 57%).20,21 As effective antiretroviral therapy (ART, also referred to as HAART) helps HIV-infected individuals live longer, more may now develop anal cancer.6,22,23 On the basis of initial studies, it is unclear whether ART use reduces risk of anal intraepithelial neoplasia (AIN2/3, precancer)24 or anal cancer,25,26 although low CD4-cell count does appear to increase risk of anal cancer.27Recent research suggests that anal Papanicolaou (Pap) screening may have utility in preventing anal cancer9,28–30 and is a cost-effective screening method for anal cancer prevention among MSM.31,32 Like cervical dysplasia, anal dysplasia is slow-growing and treatable, and studies suggest that anal Pap tests can detect dysplasia with similar sensitivity and specificity to cervical Pap tests.33–35 On the basis of these data and the success of cervical Pap screening in reducing cervical cancer incidence, some have proposed routine anal Pap cytology (referred to as anal Pap screening hereafter) among MSM.9,36 However, these guidelines remain preliminary as researchers have not yet conducted a randomized trial to establish whether anal Pap screening reduces anal cancer deaths. Furthermore, recent studies have suggested that anal precancers (AIN2+) are relatively common among unscreened non–HIV-infected (∼4%) and HIV-infected (15%–30%) MSM, much higher than anal cancer rates, so other researchers have suggested that closer examination of the relative harms and benefits of treating all AIN 2/3 in MSM is first needed.24,35,37–40Despite the high incidence of anal cancer among MSM and recommendations, by some, for screening, MSM currently have low awareness of, access to, and use of anal Pap screening.41,42 Indeed, in our previous research, we observed a low reported prevalence of ever having anal Pap screening among MSM.43 We have expanded on these previous findings by examining acceptance of screening when offered for free. We also examined attitudes about anal Pap screening, experience with screening, and reasons for declining to have an anal Pap test.     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Impact of Health Insurance Status and a Diagnosis of Serious Mental Illness on Whether Chronically Homeless Individuals Engage in Primary Care

Objectives. We evaluated the impact of a diagnosis of serious mental illness on use of a primary care provider (vs the emergency department [ED]) as a source of care by people who were chronically homeless.Methods. We used data from 750 chronically homeless adults enrolled in the 11-site Collaborative Initiative to Help End Chronic Homelessness and identified demographic and clinical characteristics independently associated with using a primary care provider rather than an ED.Results. The factor most strongly associated with using the ED as a regular source of medical care was previous-year lack of health insurance. Despite high rates of serious mental illness, neither a diagnosis of serious mental illness nor increased severity of psychiatric symptoms was associated with such use.Conclusions. Findings suggest that people who are chronically homeless and have chronic medical illness would be more likely to access care if they had health insurance. Individual states’ deciding not to expand Medicaid coverage will likely have a tremendous impact on the health outcomes and health care costs associated with this and other vulnerable populations.On a typical night in 2010, approximately 650 000 people were homeless in the United States.1 Although most people are homeless for only a brief period of time, an estimated 10% have experienced chronic homelessness, defined as continuous homelessness for 1 year or more or at least 4 episodes of homelessness in the past 3 years.1 Most people experiencing chronic homelessness have chronic health problems and typically have multiple co-occurring conditions.2 Chronic homelessness has been associated with an increased risk of mortality, with reports of age-adjusted death rates of 2 to 4 times that of the general population3 and even higher mortality rates from trauma and suicide.4 Specific chronic medical conditions (HIV, liver disease, and arrhythmia) have been associated with the greatest risk of death.5For many chronically homeless individuals, competing demands for shelter, food, and safety supersede the subjective need for primary medical care.6 This issue is of critical importance, given recent evidence that improved access to primary care reduces mortality7 and that individuals without a primary care provider (PCP) are less likely to receive recommended preventive care8 and more likely to have poor health outcomes, such as diabetic ketoacidosis9 or severe uncontrolled hypertension.10 Homeless people are less likely than domiciled individuals to use ambulatory care services,11 relying to a greater extent on emergency department (ED) visits and costly inpatient hospitalizations.12 The cost of inpatient services for people who are homeless may substantially affect the health care system because almost one quarter of homeless people in the United States report a hospitalization within the previous year.13 Homeless patients on medical and surgical services remain hospitalized longer than housed patients, resulting in substantial excess costs.14Homeless individuals are 3 times more likely to use the ED than are nonhomeless people.15 A recent large national study of ED use demonstrated that homeless people who seek care in urban EDs come by ambulance, are more likely to lack medical insurance, and have psychiatric and substance use diagnoses than are people who are not homeless.16 Homeless individuals also appear to use the ED for routine, nonemergency medical needs,16,17 often for preventable medical problems.18Previous research has attempted to determine rates and predictors of medical service use among homeless samples.11,19–22 The behavioral model for vulnerable populations is a conceptual model for health service use and medical outcomes of people such as those who are chronically homeless.23 This model predicts the use of health services on the basis of predisposing, enabling, and need factors and identifies the particular challenges vulnerable groups face in obtaining necessary services. This model has been applied to homeless populations, and findings from these studies have suggested that among homeless individuals, drug use increases the risk of medical hospitalization, and psychological distress (self-report of mood over the past 4 weeks) is associated with barriers to obtaining outpatient medical care.24The impact of serious psychiatric illness and psychiatric symptom severity on engagement in primary care has not previously been specifically evaluated among chronically homeless individuals. Serious mental illness (schizophrenia or bipolar disorder) may be a more important determinant of underuse of PCPs among homeless people than are logistical barriers such as lack of insurance. Compared with the general population, people who are homeless have substantially higher rates of psychiatric and substance use disorders.25,26 Evidence has also shown that individuals with serious mental illness underuse primary care even after accounting for their medical need27 and that severity of psychiatric illness might increase the risk of frequent ED use.28 In the current study, we identified factors associated with having a regular PCP, as contrasted with relying on ED services as a usual source of care, in a national sample of chronically homeless individuals. In particular, we evaluated the impact of a diagnosis of serious mental illness and psychiatric symptom severity on having a regular source of care.     

Social Branding to Decrease Smoking Among Young Adults in Bars

Objectives. We evaluated a Social Branding antitobacco intervention for “hipster” young adults that was implemented between 2008 and 2011 in San Diego, California.Methods. We conducted repeated cross-sectional surveys of random samples of young adults going to bars at baseline and over a 3-year follow-up. We used multinomial logistic regression to evaluate changes in daily smoking, nondaily smoking, and binge drinking, controlling for demographic characteristics, alcohol use, advertising receptivity, trend sensitivity, and tobacco-related attitudes.Results. During the intervention, current (past 30 day) smoking decreased from 57% (baseline) to 48% (at follow-up 3; P = .002), and daily smoking decreased from 22% to 15% (P < .001). There were significant interactions between hipster affiliation and alcohol use on smoking. Among hipster binge drinkers, the odds of daily smoking (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.30, 0.63) and nondaily smoking (OR = 0.57; 95% CI = 0.42, 0.77) decreased significantly at follow-up 3. Binge drinking also decreased significantly at follow-up 3 (OR = 0.64; 95% CI = 0.53, 0.78).Conclusions. Social Branding campaigns are a promising strategy to decrease smoking in young adult bar patrons.Tobacco companies1 and public health authorities2–5 recognize young adulthood as a critical time when experimenters either quit or transition to regular tobacco use. Young adults are also aspirational role models for youths.1,6,7 Tobacco companies devote considerable resources to reaching young adults to encourage tobacco use,1,8–11 and young adults have a high prevalence of smoking.12 In California in 2011, young adults had the highest smoking prevalence of any age group, and the Department of Health estimated that 32% of California smokers started smoking between the ages of 18 and 26 years.13 Although they are more likely to intend to quit and successfully quit than older adults,14–17 young adults are less likely to receive assistance with smoking cessation.18,19 Although there are few proven interventions to discourage young adult smoking,20 cessation before age 30 years avoids virtually all of the long-term adverse health effects of smoking.21Tobacco companies have a long history of using bars and nightclubs to reach young adults and to encourage smoking.1,6,9–11,22–24 Bar attendance and exposure to tobacco bar marketing is strongly associated with smoking.25 The 1998 Master Settlement Agreement and Food and Drug Administration regulations that limit tobacco advertising to youths, explicitly permit tobacco marketing in “adult only” venues, including bars and nightclubs.26,27Aggressive tobacco marketing may actually be more intensive in smoke-free bars: a 2010 study of college students attending bars found that students in the community with a smoke-free bar law were more likely to be approached by tobacco marketers, offered free gifts, and to take free gifts for themselves than in communities without a smoke-free bar law.28 Bars and nightclubs also attract young adults who are more likely to exhibit personality traits such as sensation seeking,29 increasing their risk30 independently of receptivity to tobacco advertising; tobacco promotional messages resonate with these personality traits.8,31 Tobacco marketing campaigns are tailored to specific segments of the population defined by psychographics (e.g., values, attitudes, shared interests, such as tastes in music and fashion, and friend groups) and demographic criteria, and they aim to create positive smoker images, identities, and social norms for smoking.1,8 Tobacco marketing campaigns also focus on young adult trendsetters to leverage peer influence to promote smoking.6,10In contrast to the tobacco companies’ efforts, most young adult health interventions take place in colleges or health centers rather than social environments.32–39 Bars and nightclub venues represent an opportunity to reach those at highest risk for long-term smoking morbidity and mortality.40 We evaluated the effectiveness of an intervention to decrease cigarette smoking by countering tobacco industry marketing strategies targeting young adults attending bars and nightclubs in the San Diego, California, “hipster” scene. Because tobacco and alcohol use are strongly linked,41,42 we also examined the effects of the intervention on alcohol use and among binge drinkers. We found a significant decrease in smoking in the community where the intervention took place, including significant decreases among nondaily smokers and binge drinkers, as well as a significant decrease in binge drinking.