Electra D. Paskett, Ph.D. The Ohio State University Multi-level Approaches to Addressing Cancer Disparities February 3-5, 2016 Lansdowne Resort, Leesburg, VA
Models to Understand and Address Disparities Socio-ecological framework Social Determinants of Health Causes of (and solutions to) disparities are multi-factorial and multi-level From biology to policy Levels interact Interventions can be directed to one or more levels Warnecke Model from the Centers for Population Health and Health Disparities (CPHHDs)
Model for Analysis of Population Health and Health Disparities Upstream Factors Upstream Upstream Factors Factors Downstream Factors Downstream Factors Social Conditions and Policies Institutions Social/Physical Context Social Relationships Individual Risk Factors Fundamental Causes Social and Physical Context Individual Demographic and Risk Factors Disparate Health Outcomes Biologic/Genetic Pathways Biologic Responses and Pathways (Warnecke et al., AJPH 2008)
February 3-5, 2016 Lansdowne Resort, Leesburg, VA Example 1: The Delaware Experiment J Clin Oncol 2013
Delaware Cancer Consortium Plan: Top Down and Bottom Up Buy-in from Governor, legislature, healthcare and communities Improve CRC screening rates among African-Americans: Statewide CRC screening program Screening Navigator and Coordinator Screening for Life program paid for screening Engage and recruit underserved populations for screening Case management of abnormal results Timely resolution and treatment: Delaware Cancer Treatment Program (Began in 2004) Reimbursement of up to 24 months of cancer treatment for uninsured
Percentage (Adults 50+) Success in Delaware Percentage of Adults Ages 50+ Who Have Ever Had a Sigmoidoscopy/Colonoscopy, by Race, 2002-2010 100 90 80 69.7 74.7 74.0 70 62.3 58.0 73.5 74.9 60 62.0 50 58.4 40 47.8 30 African American DE 20 Caucasian DE 10 0 2002 2004 2006 2008 2010
Success in Delaware Colorectal Cancer by Stage of Diagnosis, African Americans, Delaware 2001 and 2009 Distant 23% Unstaged 6% Local 15% Unstaged 10% Distant 7% Local 50% Regional 56% 2001 2009 Regional 33% 235% increase in local stage diagnoses in African Americans
Rate per 100,000 Success in Delaware 80 Age-Adjusted CRC Incidence Rates, Rolling 3-Year Averages, by Race: Delaware, 1999-2009 70 60 50 40 30 20 10 All Races African American Caucasian 0 99-01 00-02 01-03 02-04 03-05 04-06 05-07 06-08 07-09 Diagnosis Years
Rate per 100,000 Success in Delaware 35 30 31.27 Age-Adjusted CRC Mortality Rates, Rolling 3-Year Averages, by Race: Delaware, 1999-2008 25 20 15 10 19.45 18.35 16.94 5 All Races African American Caucasian 0 99-01 00-02 01-03 02-04 03-05 Diagnosis Years 04-06 05-07 06-08
Impact of Delaware Initiative Screening rates increased and disparity was eliminated Incidence rates decreased in all groups and racial disparities were eliminated Mortality decreased by 20% over 10 years DE mortality now in top 15 states of lowest mortality Greater rate of mortality drop among African Americans compared to Caucasians (42% vs. 13%) Due to reduction in percent diagnosed at late stage Increased access to treatment J Clin Oncol 2013
February 3-5, 2016 Lansdowne Resort, Leesburg, VA Example 2: Improving Access to and Quality of Breast Health Services in Chicago Metropolitan Chicago Breast Cancer Task Force, 2014
The Problem African-American women in Chicago experienced higher breast cancer mortality rates Call to Action mobilized physicians, community leaders and advocates in 2007 Identified 3 causes for high rates: Less access to mammography Lower quality of mammography services Less access to and lower quality of treatment Task Force focused on addressing inequity in health care for minority and underserved populations
Black: White 3 Year Age-Adjusted Aggregate Breast Cancer Mortality Rates in Chicago, 1981-2007
Mammography Access: Chicago Inadequate screening mammography capacity machines Shortage of fellowship-trained radiologists and specialized radiology technologists Inequitable geographic distribution of these providers Quality care is concentrated in high volume/academic centers These facilities were less likely to serve majority Black or Hispanic populations Several facilities that provided mammograms decreased their services Black and Hispanic women are less likely to: Have mammograms read by breast imaging specialists Present with early stage cancers Receive timely diagnosis and treatment Have cancers diagnosed while asymptomatic Mortel et al., CEBP, 2015
Chicago Community Areas with the Highest 2006-2010 Average Annual Breast Cancer Mortality Rates
What Did the Task Force Do? Focused on Quality Care by measuring breast cancer care Chicago Breast Cancer Quality Consortium Established systems to measure screening and treatment quality Variation in ability to meet screening benchmarks Fragmented care system limited resources and services Incorporated quality measurement into state Medicaid program Facilities submit data and get higher reimbursement (80% participation) Radiologist quality and facility care process quality
Average Number of Benchmarks Met by Calendar Year
What Did the Task Force Do? Advocacy and Public Policy - 2010 Screening Saves Lives advocacy campaign community mobilized Increased funding for IBCCP free mammograms and treatment Preserved $8.2 million in funding New legislation Breast Excellence in Screening and Treatment Act (HB6285) - Improve care delivery system to facilitate access to high quality care Community Navigation Programs- 2012 Outreach and media campaigns Reach and connect women with quality care screening through treatment Shared Nurse Navigator at community hospitals (2014)
Black: White 3 Year Age-Adjusted Aggregate Breast Cancer Mortality Rates in Chicago, 1981-2010
Where Do We Go From Here? The causes of disparities in cancer outcomes in minority and underserved populations are varied A multi-level framework for understanding the causes is necessary to then address these causes Biology tumor and clinical characteristics SES lack of resources to use prevention and detection services Community dictates where care is delivered Health care providers quality of care Policy mandates for access and quality of care Just because you build it does not mean they will get it