Abstract C10: Insurance “instability” and colorectal cancer screening utilization

Abstract Introduction: Colorectal cancer (CRC) is a leading cause of cancer-related death in the United States. While CRC-specific mortality has been decreasing, significant disparities by race/ethnicity and socioeconomic factors persist. Unfortunately, despite evidence that CRC screening and early detection are cost effective and reduce incidence and mortality, less than 2/3 of age-eligible adults meet screening guidelines. Research has consistently shown that patients who are insured by Medicaid or are uninsured are even less likely to be screened than those who are privately insured. However, while much research treats insurance status as a stable factor, many low income people cycle on and off insurance. Thus, studies may oversimplify the association between insurance status and preventive care. Our goal in this analysis is to describe how patient demographic characteristics, specifically the varied experience of insurance, are associated with CRC screening rates in “real world” settings. Methods: We analyzed baseline data from patients in four urban federally qualified health centers participating in a randomized controlled trial to promote CRC screening. These in-person interviewer-administered surveys included items on socioeconomic factors, healthcare, and screening utilization. We examined bivariate associations to determine differences in past screening utilization. Patients were defined as screening “up-to-date” if they had received a fecal occult blood test in the past year and/or a flexible sigmoidoscopy or colonoscopy within the past 5 years. Based on current screening guidelines, we excluded people under the age of 50 from our analysis. Of the 329 patients surveyed across the 4 centers, 289 (87.8%) were age ≥50 and were included in this analysis. Results: Of these 289 patients, 115 (39.8%) met the criteria for being screening up-to-date. The sample had slightly more females than males (54.3% vs. 45.7%) and was primarily African-American (84.4%). Initial results show statistically significant demographic differences by screening status (p&amp;lt;0.05). The up-to-date patients were older (mean age, 57 vs. 55), and more likely to be female (64.1% vs. 46.9%), have a personal healthcare provider (95.7% vs. 67.2%) and feel “very” or “extremely” comfortable discussing CRC screenings with a primary care doctor (92.3% vs. 75.6%) than patients who were not up-to-date. Additionally, up-to-date patients were less likely to have been homeless in the past 12 months (12.8% vs 31.1%) and less likely to have put off healthcare needs in the past 12 months due to cost concerns (24.8% vs 41.2%) or lack of transportation (17.9% vs. 28.8%). We saw no significant differences in screening status by education level or race. Up-to-date patients were significantly more likely to be currently insured (86.3% vs. 61.9%) than not up-to-date patients. Among those insured (n=210; 71.4%), up-to-date patients were less likely to have had a period without insurance in the past 12 months (19.8% vs. 33.9%) and had different distributions of insurance type than not up-to-date patients. Discussion: Less than 40% of age-eligible patients were screening up-to-date in our study. Examining differences between up-to-date and not up-to-date patient populations can provide insight into what factors might be important in promoting CRC screening in medically underserved populations. Our preliminary findings indicate that insurance stability might play a positive role in CRC screening adherence. Statistical modeling might better characterize the role of insurance in screening. Researchers might consider the nuances of measuring insurance and the stability of insurance when studying the association between insurance status and healthcare utilization. In addition to guiding future research, these findings could drive future politico-structural improvements to health care policy. Citation Format: Kunal M. Mathur, Meera Muthukrishnan, Graham A. Colditz, Aimee S. James. Insurance “instability” and colorectal cancer screening utilization. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C10.</jats:p

Abstract PR01: Systems-level intervention to increase CRC screening in community health centers

Abstract Introduction: Colorectal cancer (CRC) is a leading cause of cancer death in the US. Although routine screening is effective in reducing CRC incidence and mortality, only 59% of adults are reportedly up-to-date. With even lower rates of screening and higher rates of late-stage diagnoses among under- and uninsured patients, there is a critical need for interventions that are effective, practical, and sustainable in this population. Many of these patients are served in the healthcare safety-net, including federally qualified health centers, which serve patients regardless of their insurance. System- or multi-level interventions have been effective at increasing screening in previous studies, but most have been implemented and evaluated in higher-resource settings. Using community based participatory research (CBPR) methods and a randomized trial design, we aim to select, implement, and test evidence-based systems-level strategies aimed at increasing CRC screening in safety-net healthcare settings that serve patients who are under- or uninsured. Methods: To meet CBPR principles, health centers were engaged in determining study procedures and interventions at their sites. After recruiting eleven safety-net health centers in two networks (one mostly urban, one mostly rural), six health centers were randomly assigned to the intervention arm. Provider reminders, changes to the patient materials, and patient reminders were the most common strategies selected. The primary outcome is CRC screening adherence at 12-months post-baseline as measured by self-report. Data were collected regarding patient socioeconomic factors, healthcare, and screening utilization. Data analysis included examination of bivariate associations as well as logistic regression with GEE robust standard error to assess CRC screening in intervention and control sites. Results: The study population included 490 participants at baseline from 11 health centers in 2 separate health networks; 273 (55.7%) participants completed the 12-month follow-up survey. Of this final sample, most were black (53.5%), unemployed (53.9%), had a monthly income &amp;lt;$1200/month (63.4%), had public insurance (65.6%), and reported they had a particular doctor or health care provider (84.3%). Participants were also evenly divided between the 2 health networks (50.9% and 49.1%). Most participants were up-to-date with any type of CRC screening at 12 months (65.6%) compared to 46.1% at baseline. The up-to-date screening rate was not significantly different between intervention and control (OR=1.06, p&amp;gt;0.05), in an adjusted model. Discussion: We reached a very low income sample, who experienced occasional homelessness, unexpected changes in contact information, and had relatively high unemployment rates. Participants had a relatively high baseline screening rate, but our participatory recruitment methods may have over-selected people who were already screened. The health centers were also under-resourced and faced challenges, particularly in helping patients access colonoscopy. Despite safety-net health centers adopting and adapting evidence-based intervention strategies to fit the needs of their patients, screening rates were not significantly higher in intervention clinics compared to control. There are several possible explanations. Control clinics may have been affected by the intervention, as they were in the same health network and there was occasional but unmeasured cross-over in terms of patients and providers. The lack of Medicaid expansion in Missouri meant that many patients remain uninsured. Also, the urban specialty clinic providing colonoscopy to under- and uninsured patients closed during the study, complicating access and creating long wait times for appointments. The study offers valuable insights into the challenges of implementing screening interventions with low-resource patients in low-resource settings. This abstract is also presented as Poster A43. Citation Format: Meera Muthukrishnan, Yan Yan, Jean Wang, Graham Colditz, Aimee S. James. Systems-level intervention to increase CRC screening in community health centers. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr PR01.</jats:p

Abstract B04: Using CBPR to develop a systems-level colorectal cancer screening intervention.

Abstract Introduction: Colorectal cancer (CRC) is a leading cause of cancer death. Despite compelling evidence that screening and early detection reduce CRC incidence and mortality; about 50% of adults are screening adherent. CRC screening rates are low in our region and have been identified by our community partners as a priority. However, many interventions have only moderate impact, at best. In this study, we used a Community-Based Participatory Research (CBPR) approach to collaborate with community health centers to develop and test a systems-level intervention. CBPR assures that those who would benefit from and be affected by research fully participate in and influence decision-making. The resultant intervention is being tested in a cluster randomized controlled trial. Methods: Using a systematic approach, we reviewed literature for evidence-based recommendations for systems-intervention for CRC screening, and worked with our community partners to select intervention options by assessing acceptability, appropriateness, feasibility, and estimated sustainability. Together, we decided that our intervention would be a “menu” of intervention options, thereby allowing more choice for individual sites. Strategic planning with the health center included organizational assessments and interviews with key personnel of the health center to gauge context factors including current health center practices, capacities, and needs. We used snowball sampling to conduct additional interviews with relevant and knowledgeable personnel at each clinic, as well as presentations to group-provider meetings when possible. Results: Based on the literature, interventions in the following areas were determined to be effective: patient reminders, provider reminder and recall systems, provider assessment and feedback, and reducing structural barriers. Working with our community partners, we developed an initial intervention “menu” that included the following: instructional checklists for patients, provider checklists for referring colonoscopy, and a variety of cues and reminders for patients. Partners provided input as every stage of development. Research staff assisted the health center in implementing the chosen intervention strategies. The outcome evaluation will measure changes in screening rates but also track which strategies were adopted and how they were implemented as well as short-term maintenance of the change once the study has ended. Conclusion: Using CBPR to develop intervention content and implementation strategies is novel, and has both benefits and challenges. Challenges include the additional time spent and an increased burden placed on our community partners. However, in addition to tapping the expertise of our community partners, having their input and perspective produced an intervention that may be more sustainable, as it reflects the voice of all stakeholders. Furthermore, the process allowed stakeholders to take ownership of the intervention, enhancing the relevance and utility of the study. Last, such a process may result in a program that is more likely to be disseminated because it reflects, and works within, the reality of providing healthcare in diverse settings. Although the effort was time consuming, building in the extra time for CBPR allowed for meaningful community involvement and resulted in a more relevant intervention product. Citation Format: Aimee James, Meera Muthukrishnan, Matthew Brown, Rebekah Jacob, Nancy Mueller, Graham Colditz. Using CBPR to develop a systems-level colorectal cancer screening intervention. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr B04.</jats:p

Abstract 268: Tracking HPV vaccination of young boys: is parental recall as dependable as physician records

Abstract Introduction: HPV vaccine is administered to young boys and girls aged 11-12 years in multiple doses rather than single dose. The interval between doses is critical as well as completion of the dose series. Moreover, the administration of the HPV vaccine in 2 doses is a recent change from the 3 doses previously recommended for children aged 11-12 years. Therefore, it is critical that HPV vaccination uptake records are accurately kept as interventions are developed to increase HPV vaccine uptake. Previous studies on the validity of parental reported HPV vaccine uptake have focused only on adolescent girls. This is because the HPV vaccine recommendation for boys came 5 years after that for girls. Currently, vaccination rates among boys lag behind those for girls across the United States. This study compared the validity of parent- vs. provider-reported HPV vaccine initiation and completion rates among a national sample of adolescent boys in the United States. Methods: We analyzed the 2014 National Immunization Survey-Teen data for adolescent boys only (n = 9,493), and obtained information on the records of HPV vaccine uptake [initiation (≥1 dose) and completion (≥ 3 doses)] for both parents (parental recall) and provider reports (electronic medical records). We compared the validity of parent- versus provider-reported HPV vaccination by computing validity measures [sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and kappa]. Results: Rates reported by provider and parental recall were similar for HPV vaccine initiation (41.8% vs. 42.7%, respectively), and completion (19.6% vs. 21.9%, respectively). Compared to provider report, parent-reported HPV vaccine initiation had a sensitivity of 83.0%, a specificity of 88.8%, a PPV of 84.1%, a NPV of 87.9%, and a kappa coefficient of 0.72. Compared to provider report, parent-reported HPV vaccine completion had a sensitivity of 68.6%, a specificity of 92.9%, a PPV of 72.9%, a NPV of 91.4%, and a kappa coefficient of 0.63. Conclusions: Both parent- and provider-reported HPV vaccine initiation and completion rates were comparable; however, parental recall of HPV vaccine completion among boys was less sensitive. Ongoing surveillance of HPV vaccination rates among boys is important as more studies are designed to improve HPV vaccine uptake and understand parental HPV vaccine barriers. In this regard, parental recall may be used as an effective alternative in assessing HPV vaccine uptake in the United States. Note: This abstract was not presented at the meeting. Citation Format: Nosayaba Osazuwa-Peters, Betelihem B. Tobo, Meera Muthukrishnan, Daphne Lew, Betty Chen, Eric Adjei Boakye. Tracking HPV vaccination of young boys: is parental recall as dependable as physician records [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 268. doi:10.1158/1538-7445.AM2017-268</jats:p

Conducting a randomized trial in rural and urban safety-net health centers: Added value of community-based participatory research

Background: Colorectal cancer (CRC) is the second most common cancer in the US. Despite evidence that screening reduces CRC incidence and mortality, screening rates are sub-optimal with disparities by race/ethnicity, income, and geography. Rural-urban differences in CRC screening are understudied even though approximately one-fifth of the US population lives in rural areas. This focus on urban populations limits the generalizability and dissemination potential of screening interventions. Methods: Using community-based participatory research (CBPR) principles, we designed a cluster-randomized trial, adaptable to a range of settings, including rural and urban health centers. We enrolled 483 participants across 11 health centers representing 2 separate networks. Both networks serve medically-underserved communities; however one is primarily rural and one primarily urban. Results: Our goal in this analysis is to describe baseline characteristics of participants and examine setting-level differences. CBPR was a critical for recruiting networks to the trial. Patient respondents were predominately female (61.3%), African-American (66.5%), and earned <$1200 per month (87.1%). The rural network sample was older; more likely to be female, white, disabled or retired, and have a higher income, but fewer years of education. Conclusions: Variation in the samples partly reflects the CBPR process and partly reflects inherent differences in the communities. This confirmed the importance of using CBPR when planning for eventual dissemination, as it enhanced our ability to work within diverse settings. These baseline findings indicate that using a uniform approach to implementing a trial or intervention across diverse settings might not be effective or efficient. Keywords: Colorectal cancer screening, Community-based participatory research, Health disparities, Medically underserved populations, Dissemination and implementation, Randomized tria

Abstract P680: Stroke, Stroke Risk Factors and Physical Activity Among Overweight and Obese Women of Reproductive Age

Background: Stroke is a concern for women of reproductive age, as pregnant women have an increased risk of stroke. Primary prevention is critical to reducing this burden among this group. High physical activity levels (compared to low physical activity levels) can decrease stroke risks in adults, though this is not well-researched among women of reproductive age. Methods: Using NHANES 2013-2017 data, we examined the impact of physical activity on self-reported stroke and risk factors for stroke among overweight and obese women of reproductive age (20-44) using logistic regression models. Covariates include age, race, and smoking status. Risk factors examined were stroke history, hypertension, elevated total cholesterol, LDL cholesterol, triglycerides, and blood glucose levels. Results: Logistic regression models showed that getting at least 150 minutes of exercise per week reduced the odds of having elevated glucose levels by 58% (aOR=0.425, 95% CI=0.19-0.95). While physical activity did not show any significant differences in the other stroke risk factors, there was a trend toward a lower percentage of women having hypertension and elevated triglycerides if they were physically active. Further, compared to white women, Black women had nearly two times higher odds of having hypertension (aOR=1.97, 95%CI 1.41-2.76). Conclusions: Previous studies show that increasing physical activity can lower stroke risk, including lowering blood pressure and insulin levels. While our results show lower blood glucose among physically active overweight or obese women of reproductive age, a similar effect was not seen for hypertension. In this population, hypertension may result in adverse maternal outcomes such as pre-eclampsia, eclampsia or stroke during pregnancy, should a woman become pregnant. This demonstrates the importance of managing stroke-related risk factors during a woman’s reproductive years. </jats:p

Correlates of human papillomavirus (HPV) vaccination initiation and completion among 18–26 year olds in the United States

Purpose: To examine correlates of HPV vaccination uptake in a nationally representative sample of 18–26-year-old adults. Methods: Young adults aged 18–26 years were identified from the 2014 and 2015 National Health Interview Survey (n = 7588). Survey-weighted multivariable logistic regression models estimated sociodemographic factors associated with HPV vaccine initiation (≥1 dose) and completion (≥3 doses). Results: Approximately 27% of study participants had initiated the HPV vaccine and 16% had completed the HPV vaccine. Participants were less likely to initiate the vaccine if they were men [(adjusted odds ratio) 0.19; (95% confidence interval) 0.16–0.23], had a high school diploma (0.40; 0.31–0.52) or less (0.46; 0.32–0.64) vs. college graduates, and were born outside the United States (0.52; 0.40–0.69). But, participants were more likely to initiate the HPV vaccine if they visited the doctor's office 1–5 times (2.09; 1.56–2.81), or ≥ 6 times (1.86; 1.48–2.34) within the last 12 months vs. no visits. Odds of completing HPV vaccine uptake followed the same pattern as initiation. And after stratifying the study population by gender and foreign-born status, these variables remained statistically significant. Conclusions: In our nationally representative study, only one out of six 18–26 year olds completed the required vaccine doses. Men, individuals with high school or less education, and those born outside the United States were less likely to initiate and complete the HPV vaccination. Our findings suggest that it may be useful to develop targeted interventions to promote HPV vaccination among those in the catch-up age range

Abstract 4221: Factors associated with HPV vaccination initiation and completion among 18-26 year olds in the United States

Abstract Background The HPV vaccine prevents HPV-associated cancers and genital warts, which cause significant morbidity and mortality in the US. While the vaccine is targeted toward 11-12-year-old boys and girls, there is a catch-up vaccination range up to 26 years. However, vaccination rates are very low among eligible young adults, aged 18-26 years, and besides college-related studies, not a lot is known about factors associated with the HPV vaccine uptake in this population. The aim of this study was to assess sociodemographic factors associated with HPV vaccination uptake in a nationally representative sample of 18-26-year-old adults. Methods The National Health Interview Survey 2014-2015 was examined for young adults, aged 18-26 years (n = 7588). HPV vaccine initiation was defined as receipt of at least one dose of the vaccine and completion as receipt of the three doses. Sociodemographic factors included age, gender, race, marital status, education, health insurance, regular provider, number of doctor visits, and geographic region. Survey-weighted multivariable logistic regression models were used to examine the socio-demographic factors that were associated with HPV vaccine uptake. Results Approximately 27% of respondents had initiated the HPV vaccine and 16% had completed the HPV vaccine. After adjusting for covariates, compared to females, males were 81% less likely to initiate HPV vaccine [(adjusted odds ratio) 0.19; (95 % confidence interval) 0.16-0.23]. Other factors associated with HPV vaccine initiation included having health insurance (1.70; 1.32-2.18), visiting the doctor’s office 6+ times (1.86; 1.48-2.34) and 1-5 times (2.09; 1.56-2.81) vs. no doctor’s office within the last 12 months, and having no high school diploma (0.46; 0.32-0.64) and having high school diploma (0.40; 0.31-0.52) vs. college degree or higher. The same factors were associated with HPV vaccine completion; but, being black (0.60; 0.44-0.83) vs. white and having no usual place of care (0.74; 0.57-0.96) were also associated with lower odds of completing the vaccine series. Conclusions Our study shows that there are sociodemographic factors associated with HPV vaccine uptake among young adults in the United States, and males, individuals with a lower education, and those without adequate healthcare access are less likely to initiate and complete the HPV vaccination. Our findings suggest it is necessary to develop targeted interventions to promote HPV vaccination among those in the catch-up age range. Citation Format: Eric Adjei Boakye, Betelihem B. Tobo, Daphne Lew, Meera Muthukrishnan, Vy T. Pham, Rebecca Rohde, Thomas Burroughs, Mark A. Varvares, Nosayaba Osazuwa-Peters. Factors associated with HPV vaccination initiation and completion among 18-26 year olds in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4221. doi:10.1158/1538-7445.AM2017-4221</jats:p