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Objective To evaluate the sensitivity and specificity of the 6‐item Identify Chronic Migraine screener (ID‐CM[6]), designed to improve the detection of chronic migraine (CM). Background CM is often undertreated and underdiagnosed. Survey‐based studies have found that approximately 75–80% of people meeting criteria for CM do not report having received an accurate diagnosis. Methods This study used claims data of patients enrolled in a large medical group who had at least one medical claim with an International Classification of Diseases 9th/10th revision diagnostic code for migraine in the 12‐month prescreening period. The Identify Chronic Migraine survey was administered by e‐mail, in‐person, or over the telephone to all enrolled patients. A Semi‐Structured Diagnostic Interview (SSDI) was administered by telephone by a trained physician. The ID‐CM(6) and SSDI classifications of CM status were compared to evaluate sensitivity and specificity of the ID‐CM(6) screening tool. Results The analysis of the ID‐CM(6) screening tool included 109 patients, with 65/109 (59.6%) positive for CM based on the SSDI. The mean (standard deviation) age of the patient sample was 49 (15) years and 100/109 (91.7%) were female. Using the SSDI as the diagnostic gold standard, the ID‐CM(6) had a sensitivity of 70.8% (46/65) and a specificity of 93.2% (41/44). Conclusion The ID‐CM(6) demonstrated acceptable sensitivity and good specificity in determining CM status. The results of this analysis support the real‐world utility of the ID‐CM(6) as a simple and useful tool to identify patients with CM.

Background Identification and treatment of malnutrition across the care continuum can help prevent illness onset or relapse and maximize the effectiveness of other medical treatments. This study aimed to evaluate the effect of a nutrition‐focused quality improvement program (QIP) conducted in a home health agency (HHA) on hospitalization rates and healthcare costs incurred over 90 days. Methods This was a multisite, pre‐post QIP implemented at 2 branches of an Illinois‐based HHA. The QIP included 1546 patients who were (1) at‐risk or malnourished hospitalized patients discharged to the HHA, (2) referred by a physician during an outpatient visit, or (3) enrolled in the HHA through a skilled nursing facility. A historic (n = 7413 patients) and concurrent group (n = 5235) of patients were used for comparisons. Propensity score matching was used to account for imbalances in patient characteristics. Results The QIP led to reduced relative risk of hospitalization post‐enrollment to the QIP by 24.3%, 22.8%, and 18.3% at 30, 60, and 90 days, respectively, when compared with the historic group, and by 18.2%, 16.2%, and 12.1% when compared with the concurrent group. Total cost savings from reduced 90‐day healthcare resource utilization was $2,318,894, or $1500 per patient treated. Conclusions Rates of hospitalization and healthcare resources can be significantly reduced through the implementation of a nutrition‐focused QIP delivering oral nutritional supplements in home health settings for adults at‐risk/malnourished. These results highlight the importance of nutrition as a strategy for HHAs and other post‐acute care institutions to improve patients' health outcomes and generate cost savings.

Aortic valve calcification (AVC) may be associated with atherogenic processes arising from endothelial dysfunction (ED). Limited data is available about the relationship between ED, defined by flow mediated dilation (FMD%) and biomarkers, and the prevalence and progression of AVC in a multiethnic population.A sample of 3475 individuals from the Multi-Ethnic Study of Atherosclerosis (MESA), with both initial and repeat CT scans at a mean of 2.65 ± 0.84 years and FMD% and serologic markers of ED [ C-reactive protein (CRP), Von Willebrand factor (vWF), Plasminogen Activator Inhibitor (PAI), fibrinogen, Interleukin 6 (IL6), E-selectin and ICAM-1 (Intercellular Adhesion Molecule 1)], were analyzed. Multivariate modeling evaluated the association between ED and the prevalent AVC and AVC progression.The median levels of FMD% was lower and vWF%, fibrinogen, IL6 and ICAM-1 were significantly higher in the AVC prevalence group versus no AVC prevalence (all p 0.001). In the fully adjusted model for established risk factors, decreasing FMD% or increasing biomarkers was not independently associated with AVC prevalence [OR FMD% 1.028 (0.786, 1.346), CRP 0.981 (0.825, 1.168), vWF 1.132 (0.559, 2.292), PAI 1.124 (0.960, 1.316), fibrinogen 1.116 (0.424, 2.940), IL6 1.065 (0.779, 1.456), E-selectin 0.876 (0.479, 1.602) and ICAM-1 1.766 (0.834, 3.743)]. In the AVC progression group, FMD%, vWF%, fibrinogen and IL6 were significantly different (p 0.05). After adjusting for cardiac risk factors, AVC progression was not independently associated with decreasing FMD% or increasing biomarkers [OR FMD% 1.105 (0.835, 1.463), CRP 1.014 (0.849, 1.210), vWF% 1.132 (0.559, 2.292), PAI 1.124 (0.960, 1.316), fibrinogen 0.909 (0.338, 2.443), IL6 1.061 (0.772, 1.459), E-selectin 0.794 (0.426, 1.480) and ICAM-1 0.998 (0.476, 2.092)].Endothelial dysfunction by FMD% and biomarkers is not significantly associated with the prevalence or progression of aortic valve calcification after adjustment for cardiac risk factors.

We compared the performance characteristics of 297,629 full field digital (FFDM) and 416,791 screen film mammograms (SFM). Sensitivity increased with age, decreased with breast density, and was lower for more aggressive and lobular tumors. While sensitivity did not differ significantly by modality, specificity was generally 1–2 percentage points higher for FFDM than for SFM across age and breast density categories. The lower recall rate for FFDM vs. SFM in our study may partially explain performance differences by modality. In this large healthcare organization, modest gains in performance were achieved with the introduction of FFDM as a replacement for SFM.

Compared to non-Latina (nL) white women, nL black women are diagnosed with more aggressive breast cancers, which in turn should be more likely to go undetected on screening mammography and subsequently arise as interval breast cancer (IBC). We sought to estimate the extent of an anticipated racial disparity in IBC within a single, large health care organization.The present analysis focuses on 4357 breast cancers diagnosed between 2001 and 2012 and within 18 months of a screening mammogram (N = 714,218). We used logistic regression with model-based standardization (predictive margins) to estimate adjusted prevalence differences corresponding to a racial disparity in IBC.Overall, prevalence of IBC within 18 months was 20.7%. Contrary to expectation, in patient-adjusted models, there was no IBC racial disparity (percentage point disparity = -2.1, 95% confidence interval: -4.7, 2.6). However, when controlling for facility characteristics, including proportion of nL black patients, the model coefficient for the IBC disparity reversed sign and changed substantially (P .0001) and a racial disparity emerged (percentage point disparity = +5.1, 95% confidence interval: -0.3, 9.9).The sorting of patients by race across facilities appears to have mitigated an otherwise anticipated disparity in IBC. Possible explanations are discussed.

Objective To develop a claims-based algorithm to identify undiagnosed chronic migraine among patients enrolled in a healthcare system. Methods An observational study using claims and patient survey data was conducted in a large medical group. Eligible patients had an International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) migraine diagnosis, without a chronic migraine diagnosis, in the 12 months before screening and did not have a migraine-related onabotulinumtoxinA claim in the 12 months before enrollment. Trained clinicians administered a semi-structured diagnostic interview, which served as the gold standard to diagnose chronic migraine, to enrolled patients. Potential claims-based predictors of chronic migraine that differentiated semi-structured diagnostic interview-positive (chronic migraine) and semi-structured diagnostic interview-negative (non-chronic migraine) patients were identified in bivariate analyses for inclusion in a logistic regression model. Results The final sample included 108 patients (chronic migraine = 64; non-chronic migraine = 44). Four significant predictors for chronic migraine were identified using claims in the 12 months before enrollment: ≥15 versus Conclusions The claims-based algorithm identified undiagnosed chronic migraine with sufficient sensitivity and specificity to have potential utility as a chronic migraine case-finding tool using health claims data. Research to further validate the algorithm is recommended.

PURPOSE: In order to use a breast cancer prediction model in clinical practice to guide screening and prevention, it must be well calibrated and validated in samples independent from the one used for development. We assessed the accuracy of the Breast Cancer Surveillance Consortium (BCSC) model in a racially diverse population followed for up to 10 years. METHODS: The Breast Cancer Surveillance Consortium (BCSC) model combines breast density with other risk factors to estimate a woman’s 5 and 10-year risk of invasive breast cancer. We validated the model in an independent cohort of 252,997 women in the Chicago area. We evaluated calibration using the ratio of expected to observed (E/O) invasive breast cancers in the cohort and discrimination using the area under the receiver operating characteristic curve (AUROC). RESULTS: In an independent cohort of 252,997 women (median age 50 years, 26% non-Hispanic Black), the BCSC model was well calibrated (E/O = 0.94, 95% confidence interval [CI] 0.90–0.98), but underestimated the incidence of invasive breast cancer in younger women and in women with low mammographic density. The AUROC was 0.633, similar to that observed in prior validation studies. CONCLUSIONS: The BCSC model is a well validated risk assessment tool for breast cancer that may be particularly useful when assessing the utility of supplemental screening in women with dense breasts.

The purpose of this study was to identify a correlation between the screening BI-RADS 0 (recall) rates and diagnostic BI-RADS 3 (short-interval follow-up) rates of individual interpreting radiologists, with the goal of utilizing the BI-RADS 3 rate as an acceptable performance metric in the diagnostic population. A multicenter retrospective analysis of medical audit statistics was conducted on annual radiologist performance data collected over a 14-year period in a community hospital-based practice. Mixed regression models were used to estimate the association between screening BI-RADS 0 and diagnostic BI-RADS 3 examinations while adjusting for calendar year, annual radiologist screening volume, annual radiologist diagnostic volume, and diagnostic examination indication. A moderate statistically significant positive correlation was established between the screening BI-RADS 0 rates and Diagnostic BI-RADS 3 rates (Pearson correlation coefficient + 0.349, P ≤ .001). Furthermore, when utilizing a national benchmark range of 8%-12% as an acceptable BI-RADS 0 rate within a screening population, the correlative BI-RADS 3 assessment rate was demonstrated to be approximately 16%. We propose that this BI-RADS category 3 rate may represent an additional acceptable performance metric in the diagnostic population. Routine inclusion of an interpreting mammographer's diagnostic BI-RADS 3 rate in the annual medical audit may help reduce inappropriate and/or excess use of the BI-RADS 3 category, which may lead to significant potential reductions in follow-up examinations with their associated healthcare-related costs, resource expenditure, and induced patient anxiety.

Rationale and Objectives To compare outcomes associated with breast cancer screening with digital mammography (DM) alone versus in combination with digital breast tomosynthesis (DBT) in a large representative cohort. Materials and Methods A total of 325,729 screening mammograms from 247,431 women were analyzed, across two healthcare systems, from June 2015 to September 2017. Patient level demographic, calculated risk levels, and clinical outcomes were extracted from radiology information system and electronic medical records. Multivariable regression modeling adjusting for institution, age, breast density, and first exam was conducted to compare patient characteristics, recall rates, time to biopsy and final diagnosis, clinical outcomes, and diagnostic performance. Participating institutions and the Coordinating Center received Institutional Review Board approval for a waiver of consent to collect and link data and perform analysis. Results A total of 194,437 (59.7%) screens were DBT versus 131,292 (40.3%) with DM. Women with dense breasts and higher calculated risk were more likely to be screened with DBT. Recall rates were lower for DBT overall (8.83% DBT vs 10.98% DM, adjusted odds ratio, 95% confidence interval = 0.85, 0.83–0.87) and across all age groups, races, and breast densities, and at facilities that used predominantly DBT (8.05%) versus predominantly DM (11.22%), or a combination (10.73%). The most common diagnostic pathway after recall was mammography and ultrasound. Women recalled from DBT were more likely to proceed directly to ultrasound. The median time to biopsy (18 vs 22 days) and final diagnosis (10 vs 13 days) was shorter for DBT. The adjusted cancer rate, cancer detection rate, and specificity were higher for DBT. Conclusion DBT demonstrated a more efficient screening pathway and improved quality measures with lower recall rates in all patient types, reduced diagnostic mammography and shorter time to biopsy and final diagnosis.

Background.The extent of coronary artery calcium (CAC) improves cardiovascular disease (CVD) risk prediction. The association between common dyslipidemias (combined hyperlipidemia, simple hypercholesterolemia, metabolic Syndrome (MetS), isolated low high-density lipoprotein cholesterol, and isolated hypertriglyceridemia) compared with normolipidemia and the risk of multivessel CAC is underinvestigated.Objectives.To determine whether there is an association between common dyslipidemias compared with normolipidemia, and the extent of coronary artery involvement among MESA participants who were free of clinical cardiovascular disease at baseline.Methods.In a cross-sectional analysis, 4,917 MESA participants were classified into six groups defined by specific LDL-c, HDL-c, or triglyceride cutoff points. Multivessel CAC was defined as involvement of at least 2 coronary arteries. Multivariate Poisson regression analysis evaluated the association of each group with multivessel CAC after adjusting for CVD risk factors.Results.Unadjusted analysis showed that all groups except hypertriglyceridemia had statistically significant prevalence ratios of having multivessel CAC as compared to the normolipidemia group. The same groups maintained statistical significance prevalence ratios with multivariate analysis adjusting for other risk factors including Agatston CAC score [combined hyperlipidemia 1.41 (1.06–1.87), hypercholesterolemia 1.55 (1.26–1.92), MetS 1.28 (1.09–1.51), and low HDL-c 1.20 (1.02–1.40)].Conclusion.Combined hyperlipidemia, simple hypercholesterolemia, MetS, and low HDL-c were associated with multivessel coronary artery disease independent of CVD risk factors and CAC score. These findings may lay the groundwork for further analysis of the underlying mechanisms in the observed relationship, as well as for the development of clinical strategies for primary prevention.

Background/Purpose: As stroke remains the leading cause of disability, hospitals are challenged to streamline processes that deliver alteplase promptly. A large Midwestern healthcare system (2 comprehensive and 8 primary stroke centers) committed to expand the stroke team approach beyond the walls of individual hospitals to a system stroke team to improve alteplase administration rates and times. A team-based approach is 1 of 11 Target Stroke best practice strategies used to enhance treatment rates and reduce administration times. The team-based approach included review/standardization of processes, clinical outcomes review, and proposals for improvement. Examples of initiatives included EMS partnership, development of standardized stroke orders, direct-to-CT protocol, timers to signal time critical events, and debriefing/feedback tools. Method: A retrospective system data analysis was performed on all patients presenting to an emergency room with acute stroke symptoms who received alteplase between 2012 and 2015. The specific data elements scrutinized were alteplase treatment rates and administration times. Additionally, with the introduction of Target Stroke Phase II in 2014 progression towards those goals between January, 2014 and June, 2016 was examined. Results: Statistical analysis of treatment rates for acute ischemic stroke confirmed an increasing trend in the probability of receiving alteplase over time (6.3% in 2012 vs 11.2% in 2015, p Conclusion: This study substantiated that utilizing a team-based approach at the system level yielded positive results. It has inspired and challenged each hospital’s stroke team to embrace the team approach and implement best practices and improve the administration rates and times for alteplase.

Background: Experiencing a false positive (FP) screening mammogram is economically, physically, and emotionally burdensome, which may affect future screening behavior by delaying the next scheduled mammogram or by avoiding screening altogether. We sought to examine the impact of a FP screening mammogram on the subsequent screening mammography behavior. Methods: Delay in obtaining subsequent screening was defined as any mammogram performed more than 12 months from index mammogram. The Kaplan–Meier (product limit) estimator and Cox proportional hazards model were used to estimate the unadjusted delay and the hazard ratio (HR) of delay of the subsequent screening mammogram within the next 36 months from the index mammogram date. Results: A total of 650,232 true negative (TN) and 90,918 FP mammograms from 261,767 women were included. The likelihood of a subsequent mammogram was higher in women experiencing a TN result than women experiencing a FP result (85.0% vs. 77.9%, P < 0.001). The median delay in returning to screening was higher for FP versus TN (13 months vs. 3 months, P < 0.001). Women with TN result were 36% more likely to return to screening in the next 36 months compared with women with a FP result HR = 1.36 (95% CI, 1.35–1.37). Experiencing a FP mammogram increases the risk of late stage at diagnosis compared with prior TN mammogram (P < 0.001). Conclusions: Women with a FP mammogram were more likely to delay their subsequent screening compared with women with a TN mammogram. Impact: A prior FP experience may subsequently increase the 4-year cumulative risk of late stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 26(3); 397–403. ©2017 AACR.

Background : Little information is available about the long-term management of ischemic stroke (IS) in West Scotland. In this study we aim to describe the management of IS at onset, admission, and during follow-up among patients who survived an IS event. Methods : General practitioners (GPs) ( n= 20) were randomly selected to recruit IS patients and extract data about patient characteristics, hospitalizations, discharge, and ambulatory care from GP databases, hospital letters, and direct contact with patients and their relatives. Descriptive analyses were conducted. Results : One hundred and one patients were included, with a mean age of 65.6±13.4. About half of the patients contacted their GPs at the time of onset (45.4%). Cardiovascular history was prevalent in 29.7% of cases, and 14% of all cases were recurrences. Of the patients, 89 (88%) were hospitalized with mean length of stay (LOS) 11.8 days. Treatment was administered on average within 12.9 hours of admission and 23.6% of the admitted patients received thrombolytic treatment. During the 1-year follow-up period, 33.6% of patients were rehospitalized and the mean LOS was 15.1±29.5 days. Further, patients on average sought nursing care (10.9%), physical therapy (45.5%), occupational therapy (27.7%), speech therapy (12.9%), and professional caregivers (12%). Conclusion : The health-care resource utilization of IS patients is a major driver of economic burden. Keywords: ischemic stroke; health-care resource utilization; thrombolysis; long-term management (Published: 24 September 2015) Citation: Journal of Market Access & Health Policy 2015, 3: 26339 - http://dx.doi.org/10.3402/jmahp.v3.26339

e12081 Background: Half of the women in the US undergoing annual screening mammography over 10 years require at least one additional imaging study. Of these women, 7%-17% undergo biopsies, the majority of which (77%) are benign. We sought to estimate the accuracy of core needle biopsy (CNB) by method of imaging guidance and use of vacuum assistance (VA). Methods: Data were pooled from four registries participating in the Breast Cancer Surveillance Consortium (bcsc-research.org) including facilities that perform both VA and non-VA CNB. Each registry collects data on screening mammography and breast pathology reports linked to their state cancer registries or regional Surveillance, Epidemiology and End Results registry. Sensitivity was defined as the proportion of positive biopsies among all cancers diagnosed within 12 months of biopsy. PPV3 was defined as the percentage of all biopsies performed that were positive for cancer. We estimated the adjusted average population risks/rates by modality using marginal standardization with logistic regression in STATA.Results: : Among the 37,270 CNBs, breast malignancy was found in 9,241 women (28.6%), of which 2,276 (25%) were ductal carcinoma in-situ. Sensitivity was 90.5% (95% CI 82.6-98.4) for non-VA Stereotactic (n = 415), 95.4% (95% CI 94.7-96.1) for VA Stereotactic (n = 18,733), 96.1% (95% CI 95.4-96.7) for non-VA ultrasound (n = 14,803), 95.1% (95% CI 93.7-96.5) for VA Ultrasound (n = 3,271) and 82.3% (95% CI 59.9-104.6) for non-VA MRI (n = 48). PPV3 was 12.2% (95% CI 9.0, 15.3), 17.7% (95% CI 17.2, 18.3), 28.6% (95% CI 27.8-29.4), 32.1% (95% CI 30.4-33.8) and 16.9% (95% CI 5.3, 28.5), respectively. For stereotactic biopsies, VA was associated with improved PPV3 (p = 0.01) without any change in sensitivity compared to non-VA Stereotactic biopsies.Conclusions: Our multicenter data confirm that VA-stereotactic CNB and ultrasound CNB with or without VA have high sensitivity and thus represent effective alternatives to open surgical biopsy.

Background: African American (AA) women were until recently less likely to be diagnosed with breast cancer (BC) and remain more likely to die from the disease when compared to non-Latina (nL) White (White) counterparts. High mammographic breast density (HBD) is a well-established risk factor for developing BC, but there is no consensus in the literature regarding whether HBD varies by race/ethnicity (R/E). AA women have been reported to have lower breast density compared to nL Whites, Latinas and Asians in some but not all studies. Only a handful of studies have examined factors (e.g. BMI, age, parity, hormone therapy, menarche and menopause) that might account for racial/ethnic differences in HBD. Therefore, we endeavored to examine racial/ethnic differences in HBD and the potential role of socioeconomic status (SES), obesity and parity in observed racial/ethnic differences in a large cohort of women undergoing screening mammography. Methods: We used data on 133,983 women aged 40-79 undergoing their most recent screening mammogram between 2001 and 2015 within a large healthcare organization and whose R/E was nL White, nL Black, Latina, Native American, or Asian/Pacific Islander (Asian). At the screening mammogram, each breast received a breast density score from the interpreting radiologist using the American College of Radiology Breast Imaging Reporting and Data System (BIRADS 1-4), defined as fatty (BIRADS 1), scattered fibroglandular (BIRADS 2), heterogeneously dense (BIRADS 3) or extremely dense (BIRADS 4). We defined breast density as the maximum value of the two breast density scores. We defined HBD as a breast density BIRADS score of 3 or 4 (versus 1 or 2). SES was defined by creating two census-tract level, aggregate variables for disadvantage and affluence. Body mass index (BMI) was defined from patient reported height and weight. Women also reported their number of live-births (parity) and menopausal status. HBD was modeled in logistic regression with model-based standardization (predictive margins) to estimate age-adjusted prevalence of HBD by R/E, before and after including patient factors in the model that might explain R/E differences in HBD. Results: Lower BMI, lower parity, and higher socioeconomic status were each associated with HBD in all analyses (p Citation Format: Katherine Y. Tossas-milligan, Firas Dabbous, Therese Dolecek, Teresita Macarol, William Summerfelt, Garth Rauscher. Patient risk factors for high mammographic breast density and their contributions to ethnic differences in breast density. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr PR09.

Chest pain accounts for over 7 million emergency department (ED) visits annually in the U.S., with associated inpatient costs of over $11 billion. Most patients with low risk features are determined to have a non-cardiac etiology of their chest pain. This study compares clinical outcomes and cost

Background: It is well established that Non Latina (nL) Black patients are more likely than nL white (white) patients to be diagnosed with more aggressive forms of breast cancer. In addition, prior population-based research conducted in Chicago suggests that black women tend to be screened at lower resource facilities, and may also have screening images of lower quality and be more likely to have their breast cancer missed at interpretation. Consistent with all of these observations, black patients were more likely to report symptomatic awareness of their breast cancer despite a recent asymptomatic screening mammogram in the Breast Cancer Care in Chicago study. Therefore, black women may be more likely than their white counterparts to have a breast cancer diagnosis following a negative screen (so-called interval breast cancer). METHODS: The goal of the present study was to examine potential disparities in interval breast cancer (IBC) using data from approximately 30 mammography sites (including 8 hospital-based sites) within a single large health care organization in metropolitan Chicago. Methods: A screening mammogram was defined as a bilateral mammogram with a description of screening in the radiology database, in women without a prior history of breast cancer, mastectomy, or breast implants, and without any imaging in the 9 months prior to the screen. We linked 761,908 screening examinations conducted between 2001-2010 to breast cancer incidence data from the Illinois state cancer registry, using probabilistic methods. After excluding other race/ethnicities for this analysis, we identified 4829 breast cancers diagnosed between 2001 and 2011 and within 12 months of a screen. An interval breast cancer was defined as a breast cancer diagnosed within 12 months of a negative screening mammogram (BIRADS 1,2). IBC was modeled in logistic regression with generalized estimating equations (to account for multiple screens per woman) while adjusting for age, parity, breast density, race, family history, parity and exam year, ER status, tumor grade, and individual screening facility as covariates. Of the 31 facilities with data, 18 smaller screening facilities with less than 20 associated breast cancer diagnoses were collapsed into a single category. Model-based standardization (predictive margins) was used to estimate adjusted prevalence differences (PDs) in IBC from the logistic regression models, and 95% bias-corrected bootstrap confidence intervals were obtained (1000 replications). Results: Before adjusting for mammography site, black patients were, contrary to expectation, less likely to experience an IBC than white patients (1.36 vs. 1.83 per 1000 screens, adjusted Rate Difference or RD = - 0.47 per 1000 screens, p Conclusion: In this large healthcare organization, we observed a reverse disparity such that white patients were more likely than their black counterparts to experience an IBC, but the association disappeared when we took mammography site into account in the analysis. These results suggest that higher quality mammography screening resources are more widely accessible to black than white patients within this organization. Larger volume facilities within this organization tend to be located in urban areas with higher proportions of black women, whereas smaller standalone facilities tend to be located in the suburbs where there are a higher proportion of white women. These standalone facilities may be less likely to employ breast imaging specialists and less likely provide multimodality breast imaging in a multidisciplinary setting, and these differences may be contributing to differential access to quality screening that benefits black women. The larger implication of these findings is that at a population level, racial disparities in breast cancer could perhaps be ameliorated or even eliminated if resources were disproportionately made more available to black women. In order to overcome breast cancer disparities and create true equity in care, disproportionate resource allocation solutions may be necessary. This abstract is also presented as Poster C61. Citation Format: Garth H. Rauscher, Firas Dabbous, Terry Dolecek, Terry Macarol, Katherine Tossas-Milligan, Jenna Khan, Sarah Friedwald, Wm. Thomas Summerfelt. A reverse, racial disparity with respect to interval breast cancer rates within a large healthcare organization has implications for eliminating disparities more generally. [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 PR03.

Background: Non-Latina Black (black) women, despite their lower BC incidence, are more likely to die from breast cancer compared to their nL White (white) counterparts. While differential access to care, comorbidities and BC aggressiveness are potential contributors to this difference, the potential impact of HMD on this disparity has rarely been explored. For example, nL black women are disproportionately diagnosed with more aggressive tumors that lack estrogen and progesterone receptors (ER and PR) and that are high grade. Therefore, if the association of HMD with breast cancer incidence varied by tumor subtype this could have implications for disparities in breast cancer aggressiveness and subsequent outcomes. Most of the conclusions establishing high mammographic breast density (HMD) as a risk factor for increased breast cancer incidence are derived from studies conducted primarily in whites, which jeopardizes generalizability. We sought to estimate the association between HMD and breast cancer incidence separately for white and black women and by tumor subtype, using data from a single, large healthcare organization. Methods: We used data from screening mammograms performed in women ages 18-100, between 2001 and 2010, probabilistically linked to incident BC cases recorded in the Illinois State Cancer Registry (ISCR) during 2001-2011. Each screening mammogram received a breast density score from the interpreting radiologist using the American College of Radiology Breast Imaging Reporting and Data System (BIRADS 1-4), defined as fatty (BIRADS 1), scattered fibroglandular (BIRADS 2), heterogeneously dense (BIRADS 3) or extremely dense (BIRADS 4). A mean BIRADS breast density score was calculated using available scores from both breasts at each exam. The mean was dichotomized as high (mean BIRADS score > 2.5) versus low (mean BIRADS score ≤2.5) and the dichotomous variable was modeled in logistic regression with generalized estimating equations (to account for multiple screens per woman) to estimate the association between breast density and the probability of a breast cancer diagnosis within 12 months of the screen. Models included age, race, family history, parity and exam year as covariates, and separate models were estimated for black and white women. Odds ratios were interpreted as rate ratios (RR) due to the rarity of the outcome ( Results: Included in this analysis were 616,466 screens on 201,348 white or black women during 2001-2010, and 4,104 BC in 3,706 women during 2001-2011 (overall rate of 6.7 per 1000 screens, 6.7 for whites and 6.5 for blacks, p=0.21). There were disparities in the distribution of tumor subtypes: breast cancers diagnosed in black women were more likely to be ER negative (23% vs. 15%, p Discussion: Our findings reiterate high breast density as a risk factor for breast cancer incidence. In addition, we found that the association was of roughly equal magnitude among white and black women, and of roughly equal magnitude for ER negative and ER positive tumors. The stronger association of HMD with high grade tumors, however, implies that HMD may be a more detrimental risk factor for black women who are more likely to experience higher grade tumors than white women. Citation Format: Katherine Y. Tossas-Milligan, Firas Dabbous, Garth Rauscher. Is the influence of high mammographic breast density on breast cancer incidence the same for non-Latina black and white women? [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 C43.

Background : Ischemic stroke (IS) poses physical, emotional, and economic burdens on both patients and the healthcare system in Germany. However, the management of IS is not well described, especially after hospital discharge. In this study, we aim to describe the management of IS at onset, admission, and during follow-up. Methods : German general practitioners (GPs) ( n= 40) extracted data on patient characteristics, hospitalizations, discharge, and ambulatory care from both GPs patient databases and hospital letters. Descriptive analyses were conducted. Results : The sample included 185 patients with a mean age of 70 years [standard deviation (SD)=11.7]. Most patients (63%) contacted the Emergency Medical Services, while 36% contacted their GPs. The majority of patients were hospitalized within 1 h from onset, and the length of stay was on average 14 days. Half of the patients (50%) were admitted to the stroke unit, and 16% of patients received thrombolysis treatment with 2 h (SD=2.6) of time to treatment. Of the admitted patients, 32% were discharged to their homes, while the remaining patients were discharged to nursing homes (16.2%) and rehabilitation centers (47.6%). During the 12 months follow-up, 22% of patients were re-hospitalized and patients visited their GP (11.7 times), psychologist or psychiatrist (9.5 times), and neurologist (2.2 times). Death rate after stroke event was 13%. Conclusion : The rate of patients who received thrombolysis is lower than the optimal rate in Germany. More research is needed to determine the factors that could predict the utilization of thrombolysis treatment. Keywords: ischemic stroke; healthcare resource utilization; thrombolysis; long term management (Published: 24 September 2015) Citation: Journal of Market Access & Health Policy 2015, 3: 24223 - http://dx.doi.org/10.3402/jmahp.v3.24223

Introduction: Screening mammography for early detection of breast cancer is subject to both false positive and false negative results. False positive mammograms subject women to unnecessary diagnostic imaging and biopsies that create a burden to the patient and costs to the health care system. False negative mammograms, on the other hand, result in the diagnosis of an “interval” cancer following symptoms and typically at a later stage than if discovered on the prior screen. Prior studies conducted in metropolitan Chicago suggested that differences in both mammogram image quality and quality of the interpretation of the mammogram might contribute to higher false negative rates (FNR) and higher false positive rates (FPR) for ethnic minority patients. We sought to examine predictors of FNR and FPR, and whether ethnic disparities might exist in these outcomes within a single, large healthcare organization. Methods: Screening mammograms during 2001-2009 were linked to incident breast cancer cases for the period 2001-2010 from the Illinois State Cancer Registry (ISCR) using probabilistic linkage methods. Screening mammograms were scored by the interpreting radiologist using the American College of Radiology Breast Imaging Reporting and Data System (BIRADS) and each mammogram was defined as negative (BIRADS 1,2) or positive (BIRADS 0,4,5); BIRADS 3 mammograms were excluded from these analyses. A false positive (FP) mammogram was defined as a screening mammogram with an abnormal interpretation which nonetheless did not result in a breast cancer diagnosis in the subsequent 12 months. A false negative (FN) mammogram was defined as a screening mammogram with a normal interpretation in a woman who nonetheless was diagnosed with breast cancer (“interval cancer”) in the subsequent 12 months. We examined patient factors (race/ethnicity, age at diagnosis, and breast density) and tumor characteristics including hormone (estrogen and progesterone) receptor (ER/PR) status, tumor grade, and behavior (in-situ vs. malignant) and their association with FNR and FPR. Results: A total of 669,222 screens were included in this analysis and 4,058 breast cancer cases were diagnosed in the 12 months subsequent to each screening mammogram (3,071 screen-detected and 988 interval cancers). Overall, the false negative rate was 24.3%. As expected, the FNR decreased with increasing age, and increased with increasing breast density. Also as expected, FNR was higher for ER-/PR- breast cancer than other forms (31% vs. 25%, p=0.01), was higher for high grade/undifferentiated tumors and was higher for malignant than in situ tumors (27% vs. 19%, p Conclusion: Contrary to expectation, we did not find a racial disparity in the probability of a false negative mammogram, though we did find a modestly increased false positive rate in ethnic minorities. Radiologists in this organization are provided feedback on the quality of their screening interpretations on a regular basis, and this quality control program may be responsible for leveling the quality of screening mammography by race/ethnicity. Citation Format: Firas M. Dabbous, Garth Rauscher, Terry Macarol, Jenna Khan, Therese Dolecek, Sally Friedewald, Teena Francois, Tom Summerfelt. Examining racial/ethnic disparities in mammography screening performance in a single, large healthcare organization. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B74. doi:10.1158/1538-7755.DISP13-B74

1612 Background: Compared to screen film mammography (SFM), full field digital mammography (FFDM) may improve detection of lesions in younger women with denser breasts but may also increase false p...

1611 Background: Screening mammography as an early detection tool is susceptible to both false positive and false negative results. We compared false negative probabilities (FNP) for Full Field Dig...

e12519 Background: Race-based mortality differences have been reported for intrinsic breast tumor subtypes. p53 status has recently emerged as a marker of worse prognosis among African-American (AA) women with breast cancer; however, the impact of p53 status on mortality by specific subtype is not clear. Methods: Multivariable (age, stage and race adjusted) stratified (subtype and p53) analyses with proportional hazards regression models [hazard ratios (HR), 95% confidence intervals (CIs)] for all-cause mortality, in a cohort of 331 AA and 203 non-AA women (115 Hispanic, 88 non-Hispanic white) of lower socioeconomic status, consecutively treated for breast cancer at an urban hospital, with 60.4 months median follow-up, and known intrinsic subtype and p53 immunohistochemical status. Results: The Table shows the effect of p53 status and demonstrates increased mortality hazards across all subtype strata for AA women compared to non-AA. The largest change in hazards was observed for luminal A and HER2 subtype tumors with higher stage, but this pattern was also evident for lower stage tumors. Hazards of death were least increased across basal type tumors. Conclusions: Across each level of subtype, p53+ status increased the hazards of death in AA women with breast cancer. However, mortality hazards appeared most increased in women with luminal A and HER2 type tumors. [Table: see text]

Background: Zinc is involved in many essential cellular functions. It has been shown that the prostate contains high concentrations of zinc, but zinc levels decrease in prostate cancer tissues. Although, experimental evidence implicates zinc in the pathogenesis of prostate cancer, epidemiological data are inconsistent. We conducted a systematic review of the literature to summarize the evidence regarding the association between zinc and prostate cancer. Methods: Relevant studies were identified by searching PubMed and the Cochrane Library databases through November 2012 and reviewing reference lists of retrieved articles. Inclusion criteria were original and peer-reviewed publications reporting the association between zinc intake or status and prostate cancer outcomes (diagnosis, progression). No reviews, editorials, or comments were included. Two investigators abstracted study information and evaluated quality independently using standardized forms. Results: Sixteen studies met inclusion criteria, including 3 cohorts, 2 nested case-control, 10 case-control, and 1 randomized clinical trial, with a total of 111,288 participants and 11,681 cases of prostate cancer. All studies measured the association between zinc levels and prostate cancer. In most studies, regardless of the study design or source of zinc, the highest dose of zinc was associated with a modest elevation of odds of prostate cancer. Four studies had decreased odds of prostate cancer for the highest dose of zinc but the confidence interval crossed one. There was evidence of a dose-response relationship and subgroup analysis revealed a protective effect of high zinc intake among advanced prostate cancer cases. Conclusions: Although the level of zinc in prostate cancer tissue is reduced, studies assessing the association of zinc intake and prostate cancer have yielded inconsistent results. We performed a systematic review to assess the role of zinc in prostate cancer. As a result of this systematic review, the evidence is still insufficient to recommend zinc supplementation for cancer patients in clinical practice. Citation Format: Abeer M. Mahmoud, Umaima Al-alem, Ebony Shah, Ken Batai, Firas Dabbous, Mohamed Ali, Rick Kittles. Zinc and prostate cancer: a systematic review. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4883. doi:10.1158/1538-7445.AM2013-4883

Introduction: Prostate cancer is a solid malignancy that disproportionately affects men of African descent. Zinc, an essential dietary trace mineral, has been implicated in the pathogenesis of prostate cancer. Total zinc intake is lower in older African American men compared to European Americans (NHANES III). Despite the high prevalence of prostate cancer and decreased levels of zinc intake among African Americans, very little is known about the relationship between zinc intake and prostate cancer in this group. This is significant because dietary factors such as zinc intake are potentially modifiable risk factors. Here, we examine the association between self-reported zinc intake and prostate cancer in a hospital-based case-control study. Methods: Newly diagnosed African American men with histologically confirmed prostate cancer (n=141) were recruited from an urban academic urology clinic in Washington, DC. Controls (n=109) were unaffected volunteers. Usual dietary intake was assessed at the time of recruitment (2000 to 2004) with the use of a food-frequency questionnaire. Two tailed T-Test was used to compare characteristic means between cases and controls. Unconditional logistic regression was used to calculate the unadjusted and adjusted odds ratio (OR) and 95% confidence intervals (95%CI). Results: In this population, cases were older and had higher levels of PSA. Controls had higher zinc intake, with a mean of 13.23 mg/day (SD±13.9) versus 10.67 mg/day (SD±7.3) for cases. An increase of 1 mg/day of zinc decreased the odds of prostate cancer by 3% (OR=0.97 and 95% CI: 0.95-1.002). Controlling for age, body mass index (BMI), PSA and total food energy intake did not affect the observed association. Conclusions: Overall, these results suggest that zinc intake may have slight protective effect on prostate cancer. These analyses should be repeated in large studies to confirm these findings. Citation Format: Firas Dabbous, Umaima Al-alem, Sparkle Springfield, Abeer M. Mahmoud, Ken Batai, Ebony Shah, Chiledum Ahaghotu, Rick A. Kittles. Dietary zinc and prostate cancer: a case-control study in African Americans men. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3621. doi:10.1158/1538-7445.AM2013-3621

Introduction and Objective: Obesity/excessive adiposity in men with clinically organ-confined prostate cancer is of growing concern, because it associates with an increased risk of cancer recurrence after definitive therapy based on post-treatment prognostic parameters. The objective of this study was to evaluate whether body weight status associates with pre-treatment predictors of cancer recurrence in this patient population. Methods: We performed a cross-sectional study of body weight status and pre-treatment risk of PSA failure in 119 men awaiting radical prostatectomy for clinically localized prostate cancer in four urologic clinics in the Chicago area. Body weight status was assessed using the body mass index (BMI) and dual-energy x-ray absorptiometry (DXA). D'Amico risk scores, which are based on clinical tumor stage, biopsy Gleason sum, and pre-treatment PSA, were used to rank each patient's 5-year risk of PSA failure as low, intermediate, or high. Ordinal logistical regression analyzed the association between BMI quartile and D'Amico risk scores after accounting for age, race, total grams of body fat, and study site. Results: The risk of PSA failure increased with increasing quartile of BMI. Relative to the lowest BMI quartile, the cumulative odds of an intermediate or higher D'Amico risk score vs. a low risk score (the “cumulative odds ratio”) for patients in the second BMI quartile (mean BMI = 27.8 kg/m2) was 3.51 (95% CI = 1.07 to 11.5, p = .038). For patients in the third quartile (mean BMI = 32.0 kg/m2) and forth quartile (mean BMI = 37.0 kg/m2), the cumulative OR was 6.52 (95% CI = 1.72 to 24.6, p = .0057) and 7.74 (95% CI = 1.18 to 50.9, p = .033), respectively (OR trend = 1.98, 95% CI = 1.09 to 3.59, p = .0254). Conclusions: Body weight status predicts pre-treatment risk of PSA failure in men with clinically localized prostate cancer. This provides further support for a mechanistic link between body weight status, which reflects energy balance, and prostate cancer prognosis. The results also highlight the potential for using body weight status and other lifestyle-related factors pertinent to prostate cancer to identify men who are at high risk for unfavorable treatment outcomes. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4443. doi:1538-7445.AM2012-4443