3623Background: Early diagnosis of recurrence may provide the opportunity for cure among colon ca... more 3623Background: Early diagnosis of recurrence may provide the opportunity for cure among colon cancer survivors. Randomized studies comparing post-treatment surveillance strategies suggest that pat...
BackgroundStandard clinical practice and national guidelines dictate somatic testing of metastati... more BackgroundStandard clinical practice and national guidelines dictate somatic testing of metastatic colorectal cancer (mCRC) tumors to guide appropriate therapy; however, previous studies suggest that not all patients are tested. The objective of this study was to investigate potential differences in testing for mCRC by demographic and clinical factors.MethodsWe performed a retrospective review of de‐identified patient data derived from electronic health records (EHRs) of 25,469 patients diagnosed with mCRC between the years 2013 and 2020. Our outcome was a receipt of the following tests: (a) biomarker testing (BRAF, KRAS, NRAS, MMR/MSI) and (b) next‐generation sequencing (NGS). We interrogated our data using the machine‐learning algorithm Classification and Regression Tree (CART), a unique approach to identifying combinations of, rather than individual demographic and clinical characteristics associated with receipt of testing.ResultsA total of 25,469 patients were identified with mCRC. Of these, 21,133 (83%) received either biomarker testing only (n = 12,485) or any testing (biomarker + NGS) (n = 8648). The proportion of patients who received any testing increased over calendar time for all age, race, and sex categories. Receipt of any testing was highest (90%) among younger and patients with better performance status, and there was no difference in receipt of any testing by race. The highest percentage of NGS testing was among those with better performance status, <70 years old, commercial or other governmental program payers, and low comorbidity burden; however, those who were Black or Hispanic had a lower prevalence of NGS testing than those who were White.Conclusions and RelevanceConsiderable variations exist in somatic biomarker testing across subgroups of the population. Identification of genomic alterations can aid in determining targeted treatment and improving clinical outcomes; therefore, equitable use of these testing strategies, particularly NGS, is necessary.
Background.The objective of this study is to understand the effect of Medicaid expansion under th... more Background.The objective of this study is to understand the effect of Medicaid expansion under the Affordable Care Act (ACA) on patterns of surgical care among low-income breast cancer patients. Emerging literature suggests cancer patients in Medicaid expansion states are presenting with earlier stages of disease. However, less is known regarding the implications of Medicaid expansion on patterns of surgical care in low-income women.Patients and Methods.We compared nonmetastatic 30–64-year-old uninsured or Medicaid-insured Ohio breast cancer patients diagnosed 4 years before and 4 years after the state’s 2014 Medicaid expansion (study group); the control group was the privately insured. Time-to-surgery (TTS) was defined as days from diagnosis to surgery. Demographic and treatment variables before and after expansion were examined in multivariate analysis.Results.There was a 10.4% point increase in breast conservation therapy (BCT) in the study group (pre-ACA 26.3%, post-ACA 36.7%; p < 0.01) compared with a 5.8% point increase in the control group (pre-ACA 36.0%, post-ACA 41.8%; p < 0.01). Disparities in reconstruction narrowed between the study (pre-ACA 21.4%, post-ACA 34.5%; p < 0.01) and the control (37.0% pre-ACA, 44.1% post-ACA group p < 0.01) groups. There was no statistically significant change in mean TTS in the study group (pre-ACA 42.1 days, post-ACA 43.1 days p = 0.18) but there was an increase in TTS in the control group (pre-ACA 35.0 days, post ACA 37.0 days; p < 0.01).Conclusions.Medicaid expansion appears to have narrowed disparities in the utilization of BCT and reconstruction in low-income women. However, there was no improvement in surgical delay.
Journal of Alternative and Complementary Medicine, Jul 1, 2019
Objectives: For CenteringParenting-an integrated, group participatory approach to maternal and ch... more Objectives: For CenteringParenting-an integrated, group participatory approach to maternal and child health-this study aimed to explore maternal participants' experiences and children's clinical metrics compared with those receiving traditional well-care visits in the same community health center. Design: A mixed-methods approach evaluated the impact of the CenteringParenting program on infant outcomes and maternal and staff experiences. Settings/Location: This study was conducted at Neighborhood Family Practice (NFP), an urban federally qualified community health center on the west side of Cleveland, Ohio. NFP is an accredited Centering Health care Institute site for both CenteringPregnancy and CenteringParenting. Subjects: Consecutive participants from the CenteringParenting program at NFP were included with age-matched controls. Outcome measures: Quantitative outcome measures included the number of well-child visits attended, immunization and lead screening rates, as well as breastfeeding initiation and duration. Semistructured interviews assessed maternal, provider, and program staff satisfaction with the program. Results: Children participating in CenteringParenting as compared with traditional individual care were demographically similar. Well-child care visits in the first 15 months of life were higher in the CenteringParenting Group (9.19 vs. 5.28, p < 0.001), which also exhibited a trend toward higher rates of completing noninfluenza immunizations. There was no difference in lead screening, with high percentages of completion in both groups. Interviews discovered strong maternal, clinician, and staff satisfaction with the program. Mothers noted the unique benefits of learning from and building relationships with each other. Conclusions: This study in a community health center indicates that innovative group care models, such as CenteringParenting, hold promise for delivering value-added elements of social interaction between parents and health care staff, in addition to increasing the number of visits attended by parents and children in the first 15 months of life. Future study is needed to further elucidate maternal, population health, and cost benefits.
.................................................................................................... more ........................................................................................................8 Chapters 1 – Introduction.................................................................................10 Chapter 2 – Aim 1 – Projecting Vaccine Efficacy: Accounting for Geographic Strain Variations.............................................................................................24 Chapter 3 – Aim 2 – A Model-based Analysis of the Public Health Impact and Cost-effectiveness of Mass Vaccination Using Live Attenuated Human Rotavirus Vaccine (RIX4414) in India.................................................................34 Chapter 4 – Aim 3 – A discrete event simulation to examine the public health impact and cost-effectiveness of rotavirus vaccination in India..................................61 Chapter 5 – Dissertation conclusion: Perspectives and future directions.....................83 Tables..........................................................................................................86 Figures.......................................................................................................103 Appendix.....................................................................................................111 References..................................................................................................127
The proportion of patients diagnosed with colorectal cancer (CRC) at age < 50 (early-onset CRC... more The proportion of patients diagnosed with colorectal cancer (CRC) at age < 50 (early-onset CRC, or EOCRC) has steadily increased over the past three decades relative to the proportion of patients diagnosed at age ≥ 50 (late-onset CRC, or LOCRC), despite the reduction in CRC incidence overall. An important gap in the literature is whether EOCRC shares the same community-level risk factors as LOCRC. Thus, we sought to (1) identify disparities in the incidence rates of EOCRC and LOCRC using geospatial analysis and (2) compare the importance of community-level risk factors (racial/ethnic, health status, behavioral, clinical care, physical environmental, and socioeconomic status risk factors) in the prediction of EOCRC and LOCRC incidence rates using a random forest machine learning approach. The incidence data came from the Surveillance, Epidemiology, and End Results program (years 2000–2019). The geospatial analysis revealed large geographic variations in EOCRC and LOCRC incidence r...
3623Background: Early diagnosis of recurrence may provide the opportunity for cure among colon ca... more 3623Background: Early diagnosis of recurrence may provide the opportunity for cure among colon cancer survivors. Randomized studies comparing post-treatment surveillance strategies suggest that pat...
BackgroundStandard clinical practice and national guidelines dictate somatic testing of metastati... more BackgroundStandard clinical practice and national guidelines dictate somatic testing of metastatic colorectal cancer (mCRC) tumors to guide appropriate therapy; however, previous studies suggest that not all patients are tested. The objective of this study was to investigate potential differences in testing for mCRC by demographic and clinical factors.MethodsWe performed a retrospective review of de‐identified patient data derived from electronic health records (EHRs) of 25,469 patients diagnosed with mCRC between the years 2013 and 2020. Our outcome was a receipt of the following tests: (a) biomarker testing (BRAF, KRAS, NRAS, MMR/MSI) and (b) next‐generation sequencing (NGS). We interrogated our data using the machine‐learning algorithm Classification and Regression Tree (CART), a unique approach to identifying combinations of, rather than individual demographic and clinical characteristics associated with receipt of testing.ResultsA total of 25,469 patients were identified with mCRC. Of these, 21,133 (83%) received either biomarker testing only (n = 12,485) or any testing (biomarker + NGS) (n = 8648). The proportion of patients who received any testing increased over calendar time for all age, race, and sex categories. Receipt of any testing was highest (90%) among younger and patients with better performance status, and there was no difference in receipt of any testing by race. The highest percentage of NGS testing was among those with better performance status, &lt;70 years old, commercial or other governmental program payers, and low comorbidity burden; however, those who were Black or Hispanic had a lower prevalence of NGS testing than those who were White.Conclusions and RelevanceConsiderable variations exist in somatic biomarker testing across subgroups of the population. Identification of genomic alterations can aid in determining targeted treatment and improving clinical outcomes; therefore, equitable use of these testing strategies, particularly NGS, is necessary.
Background.The objective of this study is to understand the effect of Medicaid expansion under th... more Background.The objective of this study is to understand the effect of Medicaid expansion under the Affordable Care Act (ACA) on patterns of surgical care among low-income breast cancer patients. Emerging literature suggests cancer patients in Medicaid expansion states are presenting with earlier stages of disease. However, less is known regarding the implications of Medicaid expansion on patterns of surgical care in low-income women.Patients and Methods.We compared nonmetastatic 30–64-year-old uninsured or Medicaid-insured Ohio breast cancer patients diagnosed 4 years before and 4 years after the state’s 2014 Medicaid expansion (study group); the control group was the privately insured. Time-to-surgery (TTS) was defined as days from diagnosis to surgery. Demographic and treatment variables before and after expansion were examined in multivariate analysis.Results.There was a 10.4% point increase in breast conservation therapy (BCT) in the study group (pre-ACA 26.3%, post-ACA 36.7%; p < 0.01) compared with a 5.8% point increase in the control group (pre-ACA 36.0%, post-ACA 41.8%; p < 0.01). Disparities in reconstruction narrowed between the study (pre-ACA 21.4%, post-ACA 34.5%; p < 0.01) and the control (37.0% pre-ACA, 44.1% post-ACA group p < 0.01) groups. There was no statistically significant change in mean TTS in the study group (pre-ACA 42.1 days, post-ACA 43.1 days p = 0.18) but there was an increase in TTS in the control group (pre-ACA 35.0 days, post ACA 37.0 days; p < 0.01).Conclusions.Medicaid expansion appears to have narrowed disparities in the utilization of BCT and reconstruction in low-income women. However, there was no improvement in surgical delay.
Journal of Alternative and Complementary Medicine, Jul 1, 2019
Objectives: For CenteringParenting-an integrated, group participatory approach to maternal and ch... more Objectives: For CenteringParenting-an integrated, group participatory approach to maternal and child health-this study aimed to explore maternal participants' experiences and children's clinical metrics compared with those receiving traditional well-care visits in the same community health center. Design: A mixed-methods approach evaluated the impact of the CenteringParenting program on infant outcomes and maternal and staff experiences. Settings/Location: This study was conducted at Neighborhood Family Practice (NFP), an urban federally qualified community health center on the west side of Cleveland, Ohio. NFP is an accredited Centering Health care Institute site for both CenteringPregnancy and CenteringParenting. Subjects: Consecutive participants from the CenteringParenting program at NFP were included with age-matched controls. Outcome measures: Quantitative outcome measures included the number of well-child visits attended, immunization and lead screening rates, as well as breastfeeding initiation and duration. Semistructured interviews assessed maternal, provider, and program staff satisfaction with the program. Results: Children participating in CenteringParenting as compared with traditional individual care were demographically similar. Well-child care visits in the first 15 months of life were higher in the CenteringParenting Group (9.19 vs. 5.28, p < 0.001), which also exhibited a trend toward higher rates of completing noninfluenza immunizations. There was no difference in lead screening, with high percentages of completion in both groups. Interviews discovered strong maternal, clinician, and staff satisfaction with the program. Mothers noted the unique benefits of learning from and building relationships with each other. Conclusions: This study in a community health center indicates that innovative group care models, such as CenteringParenting, hold promise for delivering value-added elements of social interaction between parents and health care staff, in addition to increasing the number of visits attended by parents and children in the first 15 months of life. Future study is needed to further elucidate maternal, population health, and cost benefits.
.................................................................................................... more ........................................................................................................8 Chapters 1 – Introduction.................................................................................10 Chapter 2 – Aim 1 – Projecting Vaccine Efficacy: Accounting for Geographic Strain Variations.............................................................................................24 Chapter 3 – Aim 2 – A Model-based Analysis of the Public Health Impact and Cost-effectiveness of Mass Vaccination Using Live Attenuated Human Rotavirus Vaccine (RIX4414) in India.................................................................34 Chapter 4 – Aim 3 – A discrete event simulation to examine the public health impact and cost-effectiveness of rotavirus vaccination in India..................................61 Chapter 5 – Dissertation conclusion: Perspectives and future directions.....................83 Tables..........................................................................................................86 Figures.......................................................................................................103 Appendix.....................................................................................................111 References..................................................................................................127
The proportion of patients diagnosed with colorectal cancer (CRC) at age < 50 (early-onset CRC... more The proportion of patients diagnosed with colorectal cancer (CRC) at age < 50 (early-onset CRC, or EOCRC) has steadily increased over the past three decades relative to the proportion of patients diagnosed at age ≥ 50 (late-onset CRC, or LOCRC), despite the reduction in CRC incidence overall. An important gap in the literature is whether EOCRC shares the same community-level risk factors as LOCRC. Thus, we sought to (1) identify disparities in the incidence rates of EOCRC and LOCRC using geospatial analysis and (2) compare the importance of community-level risk factors (racial/ethnic, health status, behavioral, clinical care, physical environmental, and socioeconomic status risk factors) in the prediction of EOCRC and LOCRC incidence rates using a random forest machine learning approach. The incidence data came from the Surveillance, Epidemiology, and End Results program (years 2000–2019). The geospatial analysis revealed large geographic variations in EOCRC and LOCRC incidence r...
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