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Colorectal cancer (CRC) screening guidelines recommend frequent colonoscopies and consideration of genetic testing in individuals with ≥10 cumulative adenomas. However, it is unclear how these guidelines apply to routine practice. We estimated the proportion of participants found to have ≥10 cumulative adenomas in a screening population and described their outcomes of advanced neoplasia (AN), CRC, and extra-colonic malignancy. We performed a secondary analysis of VA CSP#380, which includes 3121 veterans aged 50–75 who were followed up to 10 years after screening colonoscopy. We calculated the cumulative risk of ≥10 cumulative adenomas by Kaplan–Meier method. We compared baseline risk factors in those with and without ≥10 cumulative adenomas as well as the risk for AN (adenoma ≥1 cm, villous adenoma or high-grade dysplasia, or CRC) and extra-colonic malignancy by multivariate logistic regression. The cumulative risk of ≥10 cumulative adenomas over 10.5 years was 6.51% (95% CI 4.38%–9.62%). Age 60–69 or 70–75 at baseline colonoscopy was the only factors associated with the finding of ≥10 cumulative adenomas. Compared to those with 0–9 cumulative adenomas, participants with ≥10 cumulative adenomas were more likely to have had AN (OR 17.03; 95% CI 9.41–30.84), including CRC (OR 7.00; 95% CI 2.84–17.28), but not extra-colonic malignancies. Approximately 6.5% of participants in this screening population were found to have ≥10 cumulative adenomas over 10.5 years, which was uncommon before age 60. These participants were found to have AN and CRC significantly more often compared to those with lower cumulative adenomas.

Understanding patient accumulation of comorbidities can facilitate healthcare strategy and personalized preventative care. We applied a directed network graph to electronic health record (EHR) data and characterized comorbidities in a cohort of healthy veterans undergoing screening colonoscopy. The Veterans Affairs Cooperative Studies Program #380 was a prospective longitudinal study of screening and surveillance colonoscopy. We identified initial instances of three-digit ICD-9 diagnoses for participants with at least 5 years of linked EHR history (October 1999 to December 2015). For diagnoses affecting at least 10% of patients, we calculated pairwise chronological relative risk (RR). iGraph was used to produce directed graphs of comorbidities with RR > 1, as well as summary statistics, key diseases, and communities. A directed graph based on 2210 patients visualized longitudinal development of comorbidities. Top hub (preceding) diseases included ischemic heart disease, inflammatory and toxic neuropathy, and diabetes. Top authority (subsequent) diagnoses were acute kidney failure and hypertensive chronic kidney failure. Four communities of correlated comorbidities were identified. Close analysis of top hub and authority diagnoses demonstrated known relationships, correlated sequelae, and novel hypotheses. Directed network graphs portray chronologic comorbidity relationships. We identified relationships between comorbid diagnoses in this aging veteran cohort. This may direct healthcare prioritization and personalized care.

Wellbeing trajectories around key life events are calculated using HILDA data for Australia. Employing a panel quantile approach, a pan-distributional analysis of these major events identifies distinctive adjustment patterns across the subjective wellbeing distribution and differing orders of magnitudes. For all life aspects analysed, immediate impacts tend to be more acute at the lower end of the wellbeing distribution. The implication of this is that if we are concerned with measuring changes in wellbeing, the point at which we measure these changes is important. Given the increasing importance of wellbeing to broader measures of economic prosperity, these findings touch upon a number of important policy areas. A focus upon social ostracization and a reduction in the persistence of long-term unemployment are all suggested as ways of alleviating the detrimental impact of this important policy variable.

BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) infection rates continue to rise. Screening guidelines have largely focused on sexually active females and men who have sex with men (MSM) populations. Healthcare-system testing and infection rates, particularly among heterosexual males, are poorly understood. Our aim was to evaluate CT and GC testing and prevalence among 12–24 year-old patients in an urban Federally Qualified Health Center (FQHC) system. METHODS: This retrospective study analyzed electronic health record data from 2017–2019 in a large system of FQHCs in Denver, CO. Abstracted data included demographics, sexual activity, sexual orientation, and laboratory results. Chi square tests were used to evaluate differences between groups. RESULTS: Of the 44,021 patients included, 37.6% were tested, 15.0% were positive for CT, and 3.4% were positive for GC. Heterosexual males had a testing rate of 22.8%, and positivity rates of CT and GC at 13.1% and 3.0% respectively. Among tested patients documented as not sexually active, 7.5% were positive for CT. Multiple or re-infections were detected in 29% of patients. CONCLUSIONS: This study shows low testing rates and high rates of CT and GC infections among all patients, including heterosexual males and those documented as not sexually active. Improved screening of these populations in the primary care setting may be key to combating the sexually transmitted disease epidemic. SUMMARY: A study of 12–24-year-old patients in a system of FQHCs found low STI testing rates and high rates of positivity, including among heterosexual males and those who reported no sexual activity.

Background: While the use of vitamin K antagonists (VKAs) has markedly reduced since the introduction of direct oral anticoagulants (DOACs), they are still the anticoagulant of choice for certain patients. The COVID-19 pandemic has resulted in anticoagulation clinics having to adapt services to ensure that anticoagulation is safely monitored, while minimising viral transmission to patients and staff. Contingency planning for staff absences also needed to be considered. Aims: To review the success of the strategies adapted for outpatient management of VKAs during the Covid-19 pandemic. Methods: Patients attending the anticoagulation clinic were managed as per the algorithm in Figure 1. Performance of the clinic was monitored using time in therapeutic range (TTR) and extreme INR values 4.5 during this time period using DAWN® anticoagulation software. Results: 504 patients required INR monitoring during the pandemic (See Figure 2). A total of 8588 INR tests were carried out with an overall TTR of 74% and 6% of extreme INR values. The percentage time in range of the Covid-19 pathway patients was 39% (15/39) of which 17% (7/39) had extreme INR values. There were a total of 314 days of Covid-19 leave due to contact isolation and vulnerable staff in the department. Conclusions: Under normal circumstances, patients on VKAs require regular monitoring to ensure safe and efficacious anticoagulation. Covid-19 patients require more frequent monitoring when ill due to changes in their oral intake and commencement of interacting medications. The global Covid-19 pandemic has made regular monitoring of these patients more difficult due to the potential for spread of the virus between patients and staff. However, following a global review of the service, proper monitoring and patient care has been safely achieved by the careful triage of patients, the use of personal protective equipment and the use of virtual consultations.

School-based health centers (SBHCs) are unique health care settings for our nation’s school-aged children and adolescents. SBHCs represent the collaboration between the health and school communities to support the health and mental health needs and the academic achievements of children and adolescents, particularly students with health disparities or poor access to health care. SBHCs improve access to health care services for students by decreasing financial, geographic, age, and cultural barriers. This policy statement provides an overview of SBHCs, including the scope of services as well as some of the documented benefits and challenges. This policy statement also reviews the role of SBHCs in working with the pediatric medical home and provides recommendations that support the coordination of SBHCs with pediatric primary care providers and the pediatric medical home.

The relationship between sexual identity and wellbeing is analysed in an unconditional panel quantile setting. There is heterogeneity across sexual identity and gender for homosexuals and, for all but lesbians, sexual minorities are less satisfied than heterosexuals below the median of the wellbeing distribution. Meanwhile, bisexuals of any gender are the least satisfied of any sexual group, and this is apparent across the entire wellbeing distribution. In contrast, the happiest individuals who report an ‘other’ sexual orientation are happier than the happiest heterosexuals.

Despite increases in BRCA mutation testing, racial/ethnic disparities in counseling and testing have persisted for decades. The purpose of the review was to summarize recent literature as it relates to detecting, understanding, and reducing disparities in BRCA counseling and testing. This is a narrative review of articles published January 2012 to July 2017 relevant to genetic testing and counseling, breast and ovarian cancer, and minority health and heath disparities. Twenty-three articles were included in this review. Studies report lower counseling and/or testing rates for eligible racial/ethnic minorities among family members of high-risk individuals as well as among breast cancer survivors. Key barriers and facilitators of disparate BRCA counseling/testing that emerged in this review included awareness, cost-related factors, stress and distrust, family concerns and communication, and provider communication and referral. To address differential access to and use of BRCA testing services and expand testing in minority populations, it is necessary for interventions to focus on improving awareness, risk-perception, and family and patient-provider communication. Multi-level and targeted interventions are needed to reduce persistent racial/ethnic disparities and improve assessment, provider recommendations, counseling and testing among minority populations.

Concussions have been shown to result in autonomic dysfunction and altered cerebral vascular function. We tested the hypothesis that concussed athletes (CA) would have altered cerebral vascular function during acute decreases and increases in blood pressure compared to healthy controls (HC). Ten CA (age: 20 ± 2 y, 7 females) and 10 HC (age: 21 ± 2 y, 6 females) completed 5 min of lower body negative pressure (LBNP; −40 mmHg) and 5 min of lower body positive pressure (LBPP; 20 mmHg). Protocols were randomized and separated by 10 min. Mean arterial pressure (MAP) and middle cerebral artery blood velocity (MCAv) were continuously recorded. Cerebral vascular resistance (CVR) was calculated as MAP/MCAv. Values are reported as change from baseline to the last minute achieved (LBNP) or 5 min (LBPP). There were no differences in baseline values between groups. During LBNP, there were no differences in the change for MAP (CA: −23 ± 18 vs. HC: −21 ± 17 cm/s; P = 0.80) or MCAv (CA: −13 ± 8 vs. HC: −18 ± 9 cm/s; P = 0.19). The change in CVR was different between groups (CA: −0.08 ± 0.26 vs. HC: 0.18 ± 0.24 mmHg/cm/s; P = 0.04). Total LBNP time was lower for CA (204 ± 92 s) vs. HC (297 ± 64 s; P = 0.04). During LBPP, the change in MAP was not different between groups (CA: 13 ± 6 vs. HC: 10 ± 7 mmHg; P = 0.32). The change in MCAv (CA: 7 ± 6 vs. HC: −4 ± 13 cm/s; P = 0.04) and CVR (CA: −0.06 ± 0.27 vs. HC: 0.38 ± 0.41 mmHg/cm/s; P = 0.03) were different between groups. CA exhibited impaired tolerance to LBNP and had a different cerebral vascular response to LBPP compared to HC.

BACKGROUND AND OBJECTIVES Rates of chlamydia and gonorrhea among adolescents continue to rise. We aimed to evaluate if a universal testing program for chlamydia and gonorrhea improved testing rates in an urban general pediatric clinic and an urban family medicine clinic within a system of federally qualified health care centers and evaluated the feasibility, cost, and logistic challenges of expanding implementation across 28 primary care clinics within a federally qualified health care centers system. METHODS A universal testing quality improvement program for male and female patient 14 to 18 years old was implemented in a general pediatrics and family medicine clinic in Denver, Colorado. The intervention was evaluated by using a controlled pre-post quasi-experimental design. The difference in testing rates due to the intervention was assessed by using a difference-in-differences regression model weighted with the inverse probability of treatment. RESULTS In total, 15 541 pediatric encounters and 5420 family medicine encounters were included in the analyses. In pediatrics, the unadjusted testing rates increased from 32.0% to 66.7% in the intervention group and from 20.9% to 28.9% in the comparison group. For family medicine, the rates increased from 38.5% to 49.9% in the intervention group and decreased from 26.3% to 24.8% in the comparison group. The intervention resulted in an adjusted increase in screening rates of 25.2% (P < .01) in pediatrics and 11.8% (P < .01) in family medicine. The intervention was well received and cost neutral to the clinic. CONCLUSIONS Universal testing for chlamydia and gonorrhea in primary care pediatrics and family medicine is a feasible approach to improving testing rates .

Background Elective total knee replacement (TKR) is a safe and cost-effective surgical procedure for treating severe knee osteoarthritis (OA). Although complications following surgery are rare, prediction tools could help identify those patients who are at particularly high risk who could then be targeted with preventative interventions. We aimed to develop a simple model to help inform treatment choices. Methods We trained and externally validated adverse event prediction models for patients with TKR using electronic health records (EHR) and claims data from the US (OPTUM, CCAE, MDCR, and MDCD) and general practice data in the UK (IQVIA Medical Research Database ([IMRD], incorporating data from The Health Improvement Network [THIN], a Cegedim database). The target population consisted of patients undergoing a primary TKR, aged ≥40 years and registered in any of the contributing data sources for ≥1 year before surgery. LASSO logistic regression models were developed for four adverse outcomes: post-operative (90-day) mortality, venous thromboembolism (VTE), readmission, and long-term (5-year) revision surgery. A second model was developed with a reduced feature set to increase interpretability and usability. Findings A total of 508,082 patients were included, with sample size per data source ranging from 1,853 to 158,549 patients. Overall, 90-day mortality, VTE, and readmission prevalence occurred in a range of 0.20%-0.32%, 1.7%-3.0% and 2.2%-4.8%, respectively. Five-year revision surgery was observed in 1.5%-3.1% of patients. The full model predicting 90-day mortality yielded AUROC of 0.78 when trained in OPTUM and yielded an AUROC of 0.70 when externally validated on THIN. We then developed a 12 variable model which achieved internal AUROC of 0.77 and external AUROC of 0.71 in THIN. The discriminative performances of the models predicting 90-day VTE, readmission, and 5-year revision were consistently poor across the datasets (AUROC Interpretation We developed and externally validated a simple prediction model based on sex, age, and 10 comorbidities that can identify patients at high risk of short-term mortality following TKR. Our model had a greater discriminative ability than the Charlson Comorbidity Index in predicting 90-day mortality. The 12-feature mortality model is easily implemented and the performance suggests it could be used to inform evidence based shared decision-making prior to surgery and for appropriate precautions to be taken for those at high risk. The other outcomes examined had low performance. Funding This activity under the European Health Data & Evidence Network (EHDEN) has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 806968. This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA. The sponsor of the study did not have any involvement in the writing of the manuscript or the decision to submit it for publication. The research was supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC). DPA is funded by a National Institute for Health Research Clinician Scientist award (CS-2013-13-012). TDS is funded by the Department of Health of the Generalitat de Catalunya under the Strategic Plan for Research and Innovation in Health (PERIS; SLT002/16/00308). The views expressed in this publication are those of the authors and not those of the NHS, the National Institute for Health Research or the Department of Health. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. Key Points Question Is it possible to predict adverse events following total knee replacement? Findings Mortality was the only adverse event studied that we were able to predict with adequate performance. We produced a 12 variable prediction model for 90-day post-operative mortality that achieved an AUROC of 0.77 on internal test validation (Optum) and 0.71 when externally validated in THIN. The model also showed adequate calibration. Meaning Patients can now be presented with an accurate risk assessment for short term mortality such that they are well-informed before the decision for surgery is taken. Importance Total Knee Replacement is generally a safe, effective procedure that is performed on thousands of patients each year. However, a small number of those patients will experience adverse events. Due to the surgery’s elective nature, a well calibrated, high performing risk model could pre-emptively inform the patient and clinician decision making process and help to guide preventative treatment.

The delivery of healthcare including the provision of pharmacy services globally is highly regulated internationally in order to protect public health and welfare. However, the onset of the COVID-19 pandemic has precipitated the need internationally to amend the model of regulation in order to ensure that people were able to continue to access a range of healthcare services in a timely and effective manner. Many of the changes introduced to the regulation of pharmacy services in Ireland have been replicated in other countries. These include the introduction of electronic means to transmit prescriptions and other orders for medications, relaxing the legal restrictions in place controlling the emergency supply of prescription only medicines and more fully utilizing the professional competency of pharmacists by empowering them to use their expertise and judgment to support their patients accessing the healthcare services that they need. Many of the regulatory changes that have been introduced to support the COVID-19 public health emergency effort are ones that pharmacists have previously sought to enable them provide a more effective and expanded model of pharmaceutical care to their patients. Accordingly, many pharmacists will want these regulatory changes to be retained and further expanded in the aftermath of the COVID-19 public health emergency in order to extend their scope of practice and support them in the care of their patients.

INTRODUCTION: Inferior vena cava (IVC) diameter decreases under conditions of hypovolemia. Point-of-care ultrasound (POCUS) may be useful to emergently assess IVC diameter. This study tested the hypothesis that ultrasound measurements of IVC diameter decreases during severe simulated blood loss. METHODS: Blood loss was simulated in 14 healthy men (22±2 years) using lower body negative pressure (LBNP). Pressure within the LBNP chamber was reduced 10 mmHg of LBNP every four minutes until participants experienced pre-syncopal symptoms or until 80 mmHg of LBNP was completed. IVC diameter was imaged with POCUS using B-mode in the long and short axis views between minutes two and four of each stage. RESULTS: Maximum IVC diameter in the long axis view was lower than baseline (1.5±0.4 cm) starting at −20 mmHg of LBNP (1.0±0.3 cm; p

Tisagenlecleucel (Kymriah; Novartis Pharmaceuticals) is a CD19-directed genetically modified autologous T-cell immunotherapy. On August 30, 2017, the FDA approved tisagenlecleucel for treatment of patients up to 25 years of age with B-cell precursor acute lymphoblastic leukemia (ALL) that is refractory in second or later relapse. Approval was based on the complete remission (CR) rate, durability of CR, and minimal residual disease (MRD) See related commentary by Geyer, p. 1133

Underutilization of effective screening is one driver of disparities in cervical cancer incidence and mortality. Consideration of patient preferences could help to improve screening rates in populations facing substantial barriers to preventive care. We conducted a systematic review of the literature on cervical cancer screening preferences among medically underserved patients in the United States. We searched six electronic databases (PubMed, Web of Science, EMBASE, Scopus, CINAHL, and PsycINFO) for articles published through February 2019 (Prospero ID: CRD42019125431). Among the 43 articles included, 23 reported screening modality preferences, 11 reported preferences related to provider demographics and attributes, six reported screening scheduling and results delivery preferences, and nine reported preferences related to health education and communication. This review demonstrates the wide variety of medically underserved patient preferences related to cervical cancer screening. It also draws attention to two key preference trends that emerged despite heterogeneity in study design, populations, and preference assessment. Consistent preferences for human papillomavirus self-testing over traditional Pap testing highlight a key potential mechanism for increasing cervical cancer screening uptake among medically underserved populations. In addition, preferences for gender- and language-concordant providers underscore the need for continued efforts toward expanding diversity among medical professionals.

This paper takes a brief review of the labour market performance of Wales over the last 20 to 30 years, and some of the challenges it has faced and will face going forward. These include, public sector pay and employment, the quality of education, trends to more flexible labour markets, and Brexit.

Background Patient preferences are important to consider in the decision-making process for colorectal cancer (CRC) screening. Vulnerable populations, such as racial/ethnic minorities and low-income, veteran, and rural populations, exhibit lower screening uptake. This systematic review summarizes the existing literature on vulnerable patient populations' preferences regarding CRC screening. Methods We searched the CINAHL, PsycINFO, PubMed, Scopus, and Web of Science databases for articles published between January 1, 1996 and December 31, 2017. We screened studies for eligibility and systematically abstracted and compared study designs and outcomes. Results A total of 43 articles met the inclusion criteria, out of 2,106 articles found in our search. These 43 articles were organized by the primary sub-population(s) whose preferences were reported: 27 report on preferences among racial/ethnic minorities, eight among low-income groups, six among veterans, and two among rural populations. The majority of studies (n=34) focused on preferences related to test modality. No single test modality was overwhelmingly supported by all sub-populations, although veterans seemed to prefer colonoscopy. Test attributes such as accuracy, sensitivity, cost, and convenience were also noted as important features. Furthermore, a preference for shared decision-making between vulnerable patients and providers was found. Conclusion The heterogeneity in study design, populations, and outcomes of the selected studies revealed a wide spectrum of CRC screening preferences within vulnerable populations. More decision aids and discrete choice experiments that focus on vulnerable populations are needed to gain a more nuanced understanding of how vulnerable populations weigh particular features of screening methods. Improved CRC screening rates may be achieved through the alignment of vulnerable populations' preferences with screening program design and provider practices. Collaborative decision-making between providers and vulnerable patients in preventive care decisions may also be important.

Hepatitis B virus (HBV) reactivation may occur with high risk immunosuppression, such as anti‐cluster of differentiation (CD)20 antibodies (Abs). Appropriate HBV prophylaxis during anti‐CD20 Ab therapy averts hepatitis, chemotherapy disruption, and death. Serologic evidence of prior HBV exposure is present in one in nine veterans in the Veterans Health Administration (VHA). In 2014, most (61%‐73%) patients in the VHA who were receiving anti‐CD20 Ab treatment underwent HBV testing, yet 90% and antiviral prophylaxis to >80%.

New Findings What is the central question of the study? Is central chemosensitivity blunted during thermoneutral head out water immersion in healthy humans? What is the main finding and its importance? Central chemosensitivity is augmented during thermoneutral head out water immersion in healthy men and women. Thus, we suggest that the central chemoreceptors do not contribute CO2 retention during head out water immersion. Abstract Carbon dioxide (CO2) retention occurs during water immersion. Therefore, we tested the hypothesis that central chemosensitivity to hypercapnia is blunted during two hours of thermoneutral head out water immersion (HOWI) in healthy young adults. Twenty-six participants (age: 22 ± 2 years, BMI: 24 ± 3 kg/m2, 14 women) participated in two experimental visits: a HOWI visit (HOWI) and a dry time-control visit (Control). Central chemosensitivity was assessed via a rebreathing test at baseline, 10 minutes, 60 minutes, 90 minutes, 120 minutes, and post HOWI and Control. End tidal CO2 tension (PETCO2), minute ventilation, blood pressure, and heart rate were recorded continuously. PETCO2 increased from baseline throughout HOWI (peak increase at 120 minutes: 2 ± 2 mmHg; p

Background Migraine is a neurological disease involving recurrent attacks of moderate-to-severe and disabling head pain. Worsening of pain with routine physical activity during attacks is a principal migraine symptom; however, the frequency, individual consistency, and correlates of this symptom are unknown. Given the potential of this symptom to undermine participation in daily physical activity, an effective migraine prevention strategy, further research is warranted. This study is the first to prospectively evaluate (a) frequency and individual consistency of physical activity-related pain worsening during migraine attacks, and (b) potential correlates, including other migraine symptoms, anthropometric characteristics, psychological symptoms, and daily physical activity. Methods Participants were women (n = 132) aged 18–50 years with neurologist-confirmed migraine and overweight/obesity seeking weight loss treatment in the Women’s Health and Migraine trial. At baseline, participants used a smartphone diary to record migraine attack occurrence, severity, and symptoms for 28 days. Participants also completed questionnaires and 7 days of objective physical activity monitoring before and after diary completion, respectively. Patterning of the effect of physical activity on pain was summarized within-subject by calculating the proportion (%) of attacks in which physical activity worsened, improved, or had no effect on pain. Results Participants reported 5.5 ± 2.8 (mean ± standard deviation) migraine attacks over 28 days. The intraclass correlation (coefficient = 0.71) indicated high consistency in participants’ reports of activity-related pain worsening or not. On average, activity worsened pain in 34.8 ± 35.6% of attacks, had no effect on pain in 61.8 ± 34.6% of attacks and improved pain in 3.4 ± 12.7% of attacks. Few participants (9.8%) reported activity-related pain worsening in all attacks. A higher percentage of attacks where physical activity worsened pain demonstrated small-sized correlations with more severe nausea, photophobia, phonophobia, and allodynia (r = 0.18 – 0.22, p Conclusions There is large variability in the effect of physical activity on pain during migraine attacks that can be accounted for by individual differences. For a minority of participants, physical activity consistently contributed to pain worsening. More frequent physical activity-related pain worsening was related to greater severity of other migraine symptoms and pain sensitivity, which supports the validity of this diagnostic feature. Study protocol ClinicalTrials.govIdentifier: NCT01197196

OBJECTIVE The objective of this study was to test whether behavioral weight loss (BWL) intervention decreases headaches in women with comorbid migraine and overweight or obesity. METHODS This randomized, single-blind trial allocated women 18 to 50 years old with 4 to 20 migraine days per month and a BMI = 25.0-49.9 kg/m2 to 16 weeks of BWL (n = 54), which targeted exercise and eating behaviors for weight loss, or to migraine education control (ME, n = 56), which delivered didactic instruction on migraine and treatments. Participants completed a 4-week smartphone headache diary at baseline, posttreatment (16-20 wk), and follow-up (32-36 wk). The primary outcome was posttreatment change in migraine days per month, analyzed via linear mixed effects models. RESULTS Of 110 participants randomly assigned, 85 (78%) and 80 (73%) completed posttreatment and follow-up. Although the BWL group achieved greater weight loss (mean [95% CI] in kilograms) than the ME group at posttreatment (-3.8 [-2.5 to -5.0] vs. + 0.9 [-0.4 to 2.2], P

Background Mailed reminders to promote colorectal cancer (CRC) screening by fecal immunochemical testing (FIT) have been shown to be effective in the Medicaid population, in which screening is underused. However, little is known regarding the cost-effectiveness of these interventions, with or without an included FIT kit. Methods The authors conducted a cost-effectiveness analysis of a randomized controlled trial that compared the effectiveness of a reminder + FIT intervention versus a reminder-only intervention in increasing FIT screening. The analysis compared the costs per person screened for CRC screening associated with the reminder + FIT versus the reminder-only alternative using a 1-year time horizon. Input data for a cohort of 35,000 unscreened North Carolina Medicaid enrollees ages 52 to 64 years were derived from the trial and microcosting. Inputs and outputs were estimated from 2 perspectives-the Medicaid/state perspective and the health clinic/facility perspective-using probabilistic sensitivity analysis to evaluate uncertainty. Results The anticipated number of CRC screenings, including both FIT and screening colonoscopies, was higher for the reminder + FIT alternative (n = 8131; 23.2%) than for the reminder-only alternative (n = 5533; 15.8%). From the Medicaid/state perspective, the reminder + FIT alternative dominated the reminder-only alternative, with lower costs and higher screening rates. From the health clinic/facility perspective, the reminder + FIT versus the reminder-only alternative resulted in an incremental cost-effectiveness ratio of $116 per person screened. Conclusions The reminder + FIT alternative was cost saving per additional Medicaid enrollee screened compared with the reminder-only alternative from the Medicaid/state perspective and likely cost-effective from the health clinic/facility perspective. The results also demonstrate that health departments and state Medicaid programs can efficiently mail FIT kits to large numbers of Medicaid enrollees to increase CRC screening completion.

This article investigates what has been happening to the public‐sector wage differential in Great Britain over the period 1994–2017. The evidence indicates that apart from men in the lower part of the pay distribution, the public‐sector pay premium has declined for all public‐sector workers. This decline has coincided with a decline in the overall pay gap, which is associated with changes in the composition of public‐ and private‐sector workforces. As the relative pay disadvantage experienced by public‐sector workers at the top of the pay distribution has worsened over time this must raise serious concerns about the ability of the public sector to recruit and retain the staff it needs to deliver public services.

Background Adapting screening strategy to colorectal cancer (CRC) risk may improve efficiency for all stakeholders however limited tools for such risk stratification exist. Colorectal cancers usually evolve from advanced neoplasms that are present for years. We applied the National Cancer Institute (NCI) CRC Risk Assessment Tool, which calculates future risk of CRC, to determine whether it could be used to predict current advanced neoplasia (AN) in a veteran cohort undergoing a baseline screening colonoscopy. Methods This was a prospective assessment of the relationship between future CRC risk predicted by the NCI tool, and the presence of AN at screening colonoscopy. Family, medical, dietary and physical activity histories were collected at the time of screening colonoscopy and used to calculate absolute CRC risk at 5, 10 and 20 years. Discriminatory accuracy was assessed. Results Of 3121 veterans undergoing screening colonoscopy, 94% had complete data available to calculate risk (N = 2934, median age 63 years, 100% men, and 15% minorities). Prevalence of AN at baseline screening colonoscopy was 11 % (N = 313). For tertiles of estimated absolute CRC risk at 5 years, AN prevalences were 6.54% (95% CI, 4.99, 8.09), 11.26% (95% CI, 9.28-13.24), and 14.21% (95% CI, 12.02-16.40). For tertiles of estimated risk at 10 years, the prevalences were 6.34% (95% CI, 4.81-7.87), 11.25% (95% CI, 9.27-13.23), and 14.42% (95% CI, 12.22-16.62). For tertiles of estimated absolute CRC risk at 20 years, current AN prevalences were 7.54% (95% CI, 5.75-9.33), 10.53% (95% CI, 8.45-12.61), and 12.44% (95% CI, 10.2-14.68). The area under the curve for predicting current AN was 0.60 (95% CI; 0.57-0.63, p p p Conclusion The NCI tool had modest discriminatory function for estimating the presence of current advanced neoplasia in veterans undergoing a first screening colonoscopy. These findings are comparable to other clinically utilized cancer risk prediction models and may be used to inform the benefit-risk assessment of screening, particularly for patients with competing comorbidities and lower risk, for whom a non-invasive screening approach is preferred.

IntroductionSecure forensic mental health services have a dual role, to treat mental illness and reduce violent recidivism. Those admitted to secure forensic services have a significant history of violence and treatment needs in multiple domains including psychiatric illness, violence and other areas such as substance misuse and physical health.ObjectivesThe aim of this study was to ascertain if the units in a medium secure forensic hospital are stratified according to individual risks and needs. We also aimed to clarify if there were differences in the symptom level, risks and needs of those with and without community leave and to clarify the risks and needs of the female patients and ID patients.MethodsThis is a cross sectional study a cohort of patients (n=138) in a secure forensic hospital.ResultsThere was a total of 138 patients, the majority of whom were male (n=123, 89.1%). The most common diagnosis was schizophrenia (n=99, 71.7%). Placements in the care pathway of the medium secure forensic hospital were associated with level of symptomatology (PANSS positive), dynamic violence risk (F=26.880,PConclusionsStratifying secure forensic psychiatric hospitals according to individual risks and needs provides in-patient care in the least restrictive setting appropriate for individuals, however niche groups such as female forensic patients and ID patients may need special consideration.

Background Pregnancy associated breast cancer (PABC) is defined as breast cancer (BC) diagnosed during the gestational period (GP) or in the first year postpartum (PP). Despite its infrequent occurrence, the incidence of PABC appears to be rising due to the increasing propensity for women to delay childbirth. We have established the first combined prospective and retrospective registry study of PABC in Ireland to examine specific clinicopathological characteristics, treatments and maternal outcomes. We present the retrospective findings to date. Methods We performed a retrospective multicentre observational study of patients (pts) with PABC treated in the eight Irish cancer centres from August 2001 to March 2017. Data extracted included information on pt demographics, tumour biology, staging, treatment administered and maternal outcomes. Standard biostatistical methods were used for analysis. Results 111 PABC patients were identified. Sixty pts (54%) were diagnosed during the GP and 51 (46%) within 1 year PP. Median age at diagnosis was 36 years (yrs). Table 1 illustrates baseline characteristics. Two thirds of pts were node positive and a similar proportion had grade 3 pathology. Seventy pts (63%) were estrogen receptor (ER) positive, 36 (32%) HER2 positive, 25 (22%) triple negative. Twenty-two pts (20%) were metastatic at presentation. Seven pts (6%) had a known BRCA 1/2 mutation. The median OS (overall survival) and DFS (disease free survival) for the entire cohort was 107.4 and 94.2 months respectively (resp). There was no survival difference between those diagnosed during the GP versus PP. 5 yr DFS and OS was 68.6% and 69.2% resp. This compares unfavourably to results reported by the National Cancer Registry of Ireland in a similar age-matched BC population between 2000-2012 where the 5 yr OS was 86.5%. Variables in our study associated with poorer outcomes included younger age, tumour size, node positivity and lack of estrogen expression. Baseline characteristics PABC patients (n=11) %(n)Diagnosed in GP (n=60) %(n)Diagnosed 1yr PP (n=51) %(n)p valueDemographic Age at diagnosis3636(25-49)36(21-44)0.31Stage I-II54(60)55(33)53(27)0.85III23(26)23(14)23(12)1IV20(22)18(11)22(11)0.81Unknown3(3)3(2)2(1)1Pathology Grade 366(74)70(42)63(32)0.43Node positive66(73)68(41)63(32)0.55ER+/HER2-41(45)38(23)43(22)0.69ER+/HER2+23(25)28(17)16(8)0.17ER-/HER2+14(16)17(10)12(6)0.59Triple negative22(25)17(10)29(15)0.11Surgery Breast conservation23(26)25(15)21(11)0.82Mastectomy56(63)57(34)59(30)0.84Adjuavnt/Neoadjuvant treatment Chemotherapy73(81)77(46)69(35)0.39Anthracycline68(55)78(36)54(19)0.03Taxane89(72)93(43)83(29)0.16Anti HER2 agent21(23)18(11)24(12)0.63Endocrine therapy64(52)63(29)66(23)0.84Radiotherapy79(64)74(34)86(30)0.85Relapse in Stage I-III Local relapse15(13)12(6)18(7)0.55Distant relapse24(21)22(11)25(10)0.80 Conclusions PABC patients may have a poorer outcome. Our study reported higher rates of triple negative and HER2 positive breast cancer which are associated with more aggressive biology. Prospective evaluation of clinicopathological features, pharmacokinetics of treatments selected and maternal and fetal outcomes is imperative in this distinct pt group. Citation Format: Prior L, Teo M, Greally M, Ward C, O'Leary C, Aslam R, Darwish W, Ahmed N, Watson G, Kelly D, Kiely L, Hassan A, Gleeson J, Featherstone H, Lim M, Murray H, Gallagher D, Westrup J, Hennessy B, Leonard G, Grogan L, Breathnach O, Horgan A, Coate L, O'Mahony D, Coate L, O'Reilly S, Gupta R, Keane M, Duffy K, O'Connor M, Kennedy J, McCaffrey J, Higgins M, Kelly C, Carney D, Gullo G, Crown J, Walshe J. Pregnancy associated breast cancer: Evaluating maternal outcomes. A multicentre study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-17.

Objectives: The All Wales Adult Cystic Fibrosis Service (AWACFS) developed a Virtual Healthcare Hub (VHH) during the COVID-19 pandemic to minimise risk whilst continuing patient care. The VHH consists of virtual multidisciplinary team (MDT) clinics, leisure centre, individual physiotherapy reviews and group connects and Q+A sessions. This study explored patient and staff perceptions of the VHH and how this could be improved in the future. Methods: Online patient and staff questionnaires evaluating the use of the VHH in the AWACFS during the COVID-19 pandemic were gathered between 23/12/2020 and 20/01/2021. Results: 67 patient questionnaires were analysed. The most widely used service (92%) was virtual MDT clinics with 83% finding them “very” or “extremely helpful”. 72% of participants would ‘often’ or “always” use virtual MDT clinics following the COVID-19 pandemic. Group connects and Q+A sessions run by the CF psychosocial team were particularly popular, with 85% of users finding these “very” or “extremely helpful”. 77% of patients found the virtual leisure centre run by the physiotherapy team “very” or “extremely helpful”. 20 staff questionnaires were analysed. 95% perceived the VHH to be either “very” or “extremely helpful” to deliver care and 100% of service providers would like to continue delivering the VHH in the future. Both patients and staff considered “reduced risk of infection by COVID-19/other” as the highest ranked advantage of connecting virtually. The highest ranked disadvantage by patients was “preference to see professional in person” and by staff “ability to address physical concerns is limited”.Staff ranked “technological difficulties” as the main barrier and “better technology” as the main way to improve CF virtual services in the future. Conclusion: Both patients and staff considered the majority of virtual connections provided to be successful and helpful during the COVID-19 pandemic, with staff keen to support these VHH services and adapt based on patient feedback.

Objectives: The effect of the COVID-19 pandemic on the quality of life (QOL) of people with cystic fibrosis (pwcf) remains unclear. This study investigated the change in QOL, measured by the CFQ-R, in adult pwcf prior to and during the COVID-19 pandemic. Methods: The CFQ-R scores of 88 adult pwcf completed at two routine clinic appointments (one prior to first COVID-19 case in Wales 28/2/20 and one post) were retrospectively reviewed. Any change in CFTR modulator therapy between these dates was recorded along with demographics, FEV1% and BMI. Results: 88 (52 male, 36 female) with mean age, FEV1% and BMI of 32.2 years, 61.6% and 22.7 kg/m2 respectively had two consecutive CFQ-R results in the above time frame. Overall, mean social domain scores significantly declined (60.4 to 54.2 p < 0.001) and mean emotion scores fell from 69.3 to 65.9 (p = 0.07). Results did not vary between males and females. 59/88 had a change in modulator status during this period, mainly commencing Symkevi® or triple modulator therapy, and this group experienced a significant increase in FEV1% (p < 0.01) and BMI (p = 0.02) and a statistically significant improvement in every domain of the CFQ-R except emotion, eating, digestion and social. Their mean social score dropped significantly 59.5 to 54.2 (p = 0.018). Of the 29 pwcf with no change in modulator status, there was no significant change in FEV1% or BMI. Mean emotion domain scores, which assesses feelings of being sad, useless, lonely and difficulty making future plans, significantly worsened from 78.1 to 70.6 (p = 0.018). Mean social scores decreased from 62.1 to 54.2 (p = 0.037). Conclusion: This is the first study looking at QOL during COVID-19 in pwcf. During the COVID-19 pandemic there have been developments in access to highly effective modulators, but despite improvements in FEV1%, BMI and many CFQ-R domains suggesting improved health, emotion and social domain scores fell. This is likely to reflect the effect of the COVID-19 pandemic.

Background Colorectal cancer (CRC) screening is underutilized by Medicaid enrollees and the uninsured. Multiple national and state policies were enacted from 2010 to 2014 to increase access to Medicaid and to promote CRC screening among Medicaid enrollees. We aimed to determine the impact of these policies on screening initiation among newly enrolled Oregon Medicaid beneficiaries age-eligible for CRC screening. Methods We identified national and state policies affecting Medicaid coverage and preventive services in Oregon during 2010–2014. We used Oregon Medicaid claims data from 2010 to 2015 to conduct a cohort analysis of enrollees who turned 50 and became age-eligible for CRC screening (a prevention milestone, and an age at which guideline-concordant screening can be assessed within a single year) during each year from 2010 to 2014. We calculated risk ratios to assess whether first year of Medicaid enrollment and/or year turned 50 was associated with CRC screening initiation. Results We identified 14,576 Oregon Medicaid enrollees who turned 50 during 2010–2014; 2429 (17%) completed CRC screening within 12 months after turning 50. Individuals newly enrolled in Medicaid in 2013 or 2014 were 1.58 and 1.31 times more likely, respectively, to initiate CRC screening than those enrolled by 2010. A primary care visit in the calendar year, having one or more chronic conditions, and being Hispanic was also associated with CRC screening initiation. Discussion The increased uptake of CRC screening in 2013 and 2014 is associated with the timing of policies such as Medicaid expansion, enhanced federal matching for preventive services offered to Medicaid enrollees without cost sharing, and formation of Medicaid accountable care organizations, which included CRC screening as an incentivized quality metric. Electronic supplementary material The online version of this article (10.1186/s12913-019-4113-2) contains supplementary material, which is available to authorized users.

Objective This study aimed to evaluate whether consistency in time of day that moderate- to vigorous-intensity physical activity (MVPA) is performed relates to MVPA levels among successful weight loss maintainers in the National Weight Control Registry. Methods Participants (n = 375) reporting MVPA on ≥ 2 d/wk completed measures of temporal consistency in physical activity (PA) (> 50% of MVPA sessions per week occurring during the same time window: early/late morning, afternoon, or evening), PA levels, PA automaticity, and consistency in cues underlying PA habit formation (e.g., location). Results Most (68.0%) participants reported temporally consistent MVPA. These individuals reported higher MVPA frequency (4.8 ± 1.6 vs. 4.4 ± 1.5 d/wk; P = 0.007) and duration (median [IQR]: 350.0 [200.0-510.0] vs. 285.0 [140.0-460.0] min/wk; P = 0.03), and they were more likely to achieve the national MVPA guideline (≥ 150 min/wk) than temporally inconsistent exercisers (86.3% vs. 74.2%, P = 0.004). Among temporally consistent exercisers, 47.8% were early-morning exercisers; MVPA levels did not differ by time of day of routine MVPA performance (P > 0.05). Greater automaticity and consistency in several cues were related to greater MVPA among all participants. Conclusions Most participants reported consistent timing of MVPA. Temporal consistency was associated with greater MVPA, regardless of the specific time of day of routine MVPA performance. Consistency in exercise timing and other cues might help explain characteristic high PA levels among successful maintainers.

Background Migraine accounts for substantial suffering and disability. Previous studies show cross-sectional associations between higher pain acceptance and lower headache-related disability in individuals with migraine, but none has evaluated this association longitudinally during migraine treatment. Purpose This study evaluated whether changes in pain acceptance were associated with changes in headache-related disability and migraine characteristics in a randomized controlled trial (Women's Health and Migraine) that compared effects of behavioral weight loss (BWL) treatment and migraine education (ME) on headache frequency in women with migraine and overweight/obesity. Methods This was a post hoc analysis of 110 adult women with comorbid migraine and overweight/obesity who received 16 weeks of either BWL or ME. Linear and nonlinear mixed effects modeling methods were used to test for between-group differences in change in pain acceptance, and also to examine the association between change in pain acceptance and change in headache disability. Results BWL and ME did not differ on improvement in pain acceptance from baseline across post-treatment and follow-up. Improvement in pain acceptance was associated with reduced headache disability, even when controlling for intervention-related improvements in migraine frequency, headache duration, and pain intensity. Conclusions This study is the first to show that improvements in pain acceptance following two different treatments are associated with greater reductions in headache-related disability, suggesting a potential new target for intervention development. Clinical trials information NCT01197196.

Regional pay? The public/private sector pay differential. Regional Studies. This paper extends the debate on making public sector wages more responsive to those in the private sector. The way in which the public/private sector wage differential is calculated dramatically alters conclusions, and far from there being substantial regional disparity in wages offered to public sector workers, any differences are predominantly concentrated in London and the South East where public sector workers are significantly disadvantaged relative to private sector workers. This has implications for staff recruitment and retention. Such findings question the need for regional market-facing pay, but highlight the necessity to revisit the London-weighting offered to public sector workers.

It is often assumed that some individuals reliably increase energy intake (EI) post-exercise (‘compensators’) and some do not (‘non-compensators’), leading researchers to examine the characteristics that distinguish these two groups. However, it is unclear whether EI post-exercise is stable over time. The present study examined whether compensatory eating responses to a single exercise bout are consistent within individuals across three pairs of trials. Physically inactive, overweight/obese women (n28, BMI 30·3 (sd2·9) kg/m2) participated in three pairs of testing sessions, with each pair consisting of an exercise (30 min of moderate-intensity walking) and resting testing day. EI was measured using a buffet meal 1 h post-exercise/rest. For each pair, the difference in EI (EIdiff= EIex− EIrest) was calculated, where EIexis the EI of the exercise session and EIrestis the EI of the resting session, and women were classified as a ‘compensator’ (EIex>EIrest) or ‘non-compensator’ (EIex≤ EIrest). The average EI on exercise days (3328·0 (sd1686·2) kJ) was similar to those on resting days (3269·4 (sd1582·4) kJ) (P= 0·67). Although EI was reliable within individuals across the three resting days (intraclass correlation coefficient (ICC) 0·75, 95 % CI 0·60, 0·87;PPdiffacross the three pairs of trials was low (ICC 0·20, 95 % CI − 0·02, 0·45;P= 0·04), suggesting that compensatory eating post-exercise is not a stable construct. Moreover, the classification of ‘compensators’/‘non-compensators’ was not reliable (κ =− 0·048;P= 0·66). The results were unaltered when ‘relative’ EI was used, which considers the energy expenditure of the exercise/resting sessions. Acute compensatory EI following an exercise bout is not reliable in overweight women. Seeking to understand what distinguishes ‘compensators’ from ‘non-compensators’ based on a single eating episode post-exercise is not justified.

NEW FINDINGS What is the central question of this study? Does passive heat stress attenuate the increase in cardiac parasympathetic stimulation, vascular resistance and blood pressure evoked by face cooling? What is the main finding and its importance? Passive heat stress attenuates the capacity to increase cardiac parasympathetic activation and impairs the ability to increase vascular resistance during sympathoexcitation, which ultimately results in a relative inability to increase blood pressure. These findings cast doubt on the efficacy of face cooling at augmenting blood pressure during orthostasis while heat stressed. ABSTRACT We tested the hypothesis that passive heat stress attenuates the increase in cardiac parasympathetic stimulation, vascular resistance and blood pressure evoked by face cooling. During normothermia and when intestinal temperature was elevated by 1.0 ± 0.2°C, 10 healthy young adults underwent 3 min of face cooling. Face cooling was accomplished by placing a 2.5 litre bag of ice water (0 ± 0°C) over the cheeks, eyes and forehead. Primary variables included forehead skin temperature, mean arterial pressure and systemic, forearm and cutaneous vascular resistances. Indices of heart rate variability in the time domain provided an index of cardiac parasympathetic activity. The magnitude of reduction in forehead skin temperature during face cooling was slightly greater during normothermia (-17.6 ± 1.9 versus -16.3 ± 3.0°C, P = 0.03). Increases in heart rate variability evoked by face cooling were attenuated during heat stress. Changes in systemic, forearm and cutaneous vascular resistances during face cooling were virtually abolished during heat stress (P

Background & Aims Few studies have evaluated long-term outcomes of ongoing colonoscopic screening and surveillance in a screening population. We aimed to determine the 10-year risk for advanced neoplasia (defined as adenomas ≥10mm, adenomas with villous histology or high-grade dysplasia, or colorectal cancer [CRC]) and assessed whether baseline colonoscopy findings were associated with long-term outcomes. Methods We collected data from the Department of Veterans Affairs Cooperative Studies Program Study on 3121 asymptomatic veterans (50–75 years old) who underwent a screening colonoscopy from 1994 through 1997 at 13 medical centers and were then followed for 10 years or until death. We included 1915 subjects with at least 1 surveillance colonoscopy and estimated cumulative incidence of advanced neoplasia by Kaplan-Meier curves. We then fit a longitudinal joint model to estimate risk of advanced neoplasia at each subsequent examination after baseline, adjusting for multiple colonoscopies within individuals. Results Through 10 years of follow-up, there were 146 individuals among all baseline colonoscopy groups found to have at least 1 incident advanced neoplasia. The cumulative 10-year incidence of advanced neoplasia was highest among those with baseline CRC (43.7%; 95% CI 13.0%–74.4%), followed by those with baseline advanced adenoma (AA) (21.9%; 95% CI 15.7–28.1). The cumulative 10-year incidence of advanced neoplasia was 6.3% (95% CI 4.1%–8.5%) and 4.1% (95% CI 2.7%–5.4%) for baseline 1 to 2 small adenomas ( Conclusions Baseline screening colonoscopy findings associate with advanced neoplasia within 10 years. Individuals with only 1 or 2 small adenomas at baseline have a low risk of advanced neoplasia over 10 years. Alternative surveillance strategies, could be considered for these individuals.

Colorectal cancer (CRC) can be effectively prevented or detected with guideline concordant screening, yet Medicaid enrollees experience disparities. We used microsimulation to project CRC screening patterns, CRC cases averted, and life-years gained in the population of 68,077 Oregon Medicaid enrollees 50–64 over a five year period starting in January 2019. The simulation estimated the cost-effectiveness of five intervention scenarios - academic detailing plus provider audit and feedback (Detailing+), patient reminders (Reminders), mailing a Fecal Immunochemical Test (FIT) directly to the patient’s home (Mailed FIT), patient navigation (Navigation), and mailed FIT with Navigation (Mailed FIT+Navigation) – compared to usual care. Each intervention scenario raised CRC screening rates compared to usual care, with improvements as high as 11.6 percentage points (Mailed FIT+Navigation) and as low as 2.5 percentage points (Reminders) after one year. Compared to usual care, Mailed FIT+Navigation would raise CRC screening rates 20.2 percentage points after five years - averting nearly 77 cancer cases (a reduction of 113 per 100,000) and exceeding national screening targets. Over a five year period, Reminders, Mailed FIT and Mailed FIT+Navigation were expected to be cost effective if stakeholders were willing to pay $230 or less per additional year up-to-date (at a cost of $22, $59, and $227 respectively per additional person-year up-to-date), whereas Detailing+ and Navigation were more costly for the same benefits. To approach national CRC screening targets, health system stakeholders are encouraged to implement Mailed FIT with or without Navigation and Reminders.

Although screening is effective in reducing incidence, mortality, and costs of treating colorectal cancer (CRC), it remains underutilized, in part due to limited insurance access. We used microsimulation to estimate the health and financial effects of insurance expansion and reduction scenarios in North Carolina (NC). We simulated the full lifetime of a simulated population of 3,298,265 residents age-eligible for CRC screening (ages 50–75) during a 5-year period starting January 1, 2018, including polyp incidence and progression and CRC screening, diagnosis, treatment, and mortality. Insurance scenarios included: status quo, which in NC includes access to the Health Insurance Exchange (HIE) under the Affordable Care Act (ACA); no ACA; NC Medicaid expansion, and Medicare-for-all. The insurance expansion scenarios would increase percent up-to-date with screening by 0.3 and 7.1 percentage points for Medicaid expansion and Medicare-for-all, respectively, while insurance reduction would reduce percent up-to-date by 1.1 percentage points, compared to the status quo (51.7% up-to-date), at the end of the 5-year period. Throughout these individuals' lifetimes, this change in CRC screening/testing results in an estimated 498 CRC cases averted with Medicaid expansion and 6031 averted with Medicare-for-all, and an additional 1782 cases if health insurance gains associated with ACA are lost. Estimated cost savings – balancing increased CRC screening/testing costs against decreased cancer treatment costs – are approximately $30 M and $970 M for Medicaid expansion and Medicare-for-all scenarios, respectively, compared to status quo. Insurance expansion is likely to improve CRC screening both overall and in underserved populations while saving money, with the largest savings realized by Medicare.