Background Racial and ethnic minorities generally receive fewer medical interventions than Whites, but racial and ethnic patterns in Medicare expenditures and interventions may be quite different at life's end. Methods Based on a random, stratified sample of Medicare decedents (n=158,780) in 2001, we used regression to relate differences in age, sex, cause of death, total morbidity burden, geography, life-sustaining interventions (e.g., ventilators), and hospice to racial/ethnic differences in Medicare expenditures in the last 6 months of life. Results In the final 6 months of life, costs for Whites average $20,166; Blacks, $26,704 (32% more); Hispanics, $31,702 (57% more). Similar differences exist within sexes, age groups, all causes of death, all sites of death, and within similar geographic areas. Differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic status, and hospice account for 53% and 63% of the higher costs for Blacks and Hispanics respectively. While Whites use hospice most frequently (Whites 26%, Blacks 20%, and Hispanics 23%), this affects racial and ethnic differences in end-of-life expenditures only minimally. However, fully 85% of the observed higher costs for non-Whites are accounted for after additionally modeling their greater end-of-life use of the ICU and various intensive procedures (such as, gastrostomies, used by 10.5% of Blacks, 9.1% of Hispanics, 4.1% of Whites). Conclusions At life's end, Black and Hispanic decedents have substantially higher costs than Whites. Over half of this is related to geographic, socio-demographic and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest.

Background: Delays and/or lack of follow up after an abnormal breast cancer screening test among minority and low-income women contribute to increased morbidity and mortality from breast cancer. Objective: To evaluate the effect of a patient navigation intervention on adherence rates to timely diagnostic follow up among women seeking care at an inner city academic medical center; and to develop ongoing quality improvement metrics to monitor its success longitudinally and determine best practices. Design: Quality improvement intervention with an historical control group. Timely follow-up was defined as arrival to diagnostic evaluation within 120 days from the first scheduled diagnostic appointment date. Data were collected via computerized registration, medical records, and patient interview. Bivariate and multivariate logistic regression analyses were conducted, comparing preintervention and intervention groups, with propensity score analysis and time trend analysis to address the limitations of the pre-post design. The following continuous quality improvement metrics were created to monitor success of the program longitudinally: secular trend of Navigator Contact Level, secular trend of Appointment Completion Rate by Navigator Contact Level, and logistic regression to evaluate odds of completing appointment within months by Navigator Contact Level. Study Subjects: All women referred to a diagnostic breast health practice at an inner city academic safety-net institution from January to June 2000 (preintervention), November 2001 to February 2003 (intervention), and from January 2007 to June 2009 (intervention). Intervention: Patient navigators are trained to identify individual patient barriers to accessing care and working with the team of providers to overcome those barriers by linking patients to available resources. Two fulltime navigators are integrated into the diagnostic provider team and interacted directly with patients, providers, and radiology to coordinate and ensure timely follow up to recommended care. Navigators interact with patients through a combination of telephone calls, in-person visits and reminder letters. Navigators adhere to protocols for outreach and utilize an electronic report to track subjects. Key Results: 314 patients were scheduled preintervention and 1,018 during the initial intervention period. Overall, mean age was 44 years; 40% were black, 36% non-Hispanic white, 14% Hispanic, 4% Asian, 5% other; 15% required an interpreter; 68% had no or only public insurance. Forty-four percent of referrals originated from a community health center, 34% from a hospital-based practice. During the intervention, 78% had timely follow-up versus 64% preintervention (P < .0001). In adjusted analyses, women in the intervention group had 39% greater odds of having timely follow-up (95% CI, 1.01-1.9). Timely follow-up in the adjusted model was associated with older age (P = .0003), having private insurance (P = .006), having an abnormal mammogram (P = .0001), and being referred from a hospital-based practice (compared to a community health center) (P = .003). Among 2,020 patients scheduled in the longitudinal intervention group, secular trends in the ability of navigators to directly contact patients via telephone outreach were found. Direct telephone contact between navigator and patient results in more women completing their first appointment, and doing so in a shorter timeframe Conclusions: Our data document the benefit of patient navigators in reducing delays in breast cancer care for poor and minority populations and suggest best practices for monitoring program success longitudinally. Developing and utilizing measures of navigator effectiveness can improve quality of care. Citation Information: Cancer Prev Res 2010;3(12 Suppl):CN03-04.

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Factors in the learning environments of residents are associated with responses to medical errors. Organisational safety culture can be measured, and used to evaluate environmental attributes of clinical training that are associated with disclosure of, and apology for, medical error.

Background The Patient Navigation Research Program (PNRP) is a cooperative effort of nine research projects, each employing its own unique study design. To evaluate projects such as PNRP, it is desirable to perform a pooled analysis to increase power relative to the individual projects. There is no agreed upon prospective methodology, however, for analyzing combined data arising from different study designs. Expert opinions were thus solicited from members of the PNRP Design and Analysis Committee Purpose To review possible methodologies for analyzing combined data arising from heterogeneous study designs. Methods The Design and Analysis Committee critically reviewed the pros and cons of five potential methods for analyzing combined PNRP project data. Conclusions were based on simple consensus. The five approaches reviewed included: 1) Analyzing and reporting each project separately, 2) Combining data from all projects and performing an individual-level analysis, 3) Pooling data from projects having similar study designs, 4) Analyzing pooled data using a prospective meta analytic technique, 5) Analyzing pooled data utilizing a novel simulated group randomized design. Results Methodologies varied in their ability to incorporate data from all PNRP projects, to appropriately account for differing study designs, and in their impact from differing project sample sizes. Limitations The conclusions reached were based on expert opinion and not derived from actual analyses performed. Conclusions The ability to analyze pooled data arising from differing study designs may provide pertinent information to inform programmatic, budgetary, and policy perspectives. Multi-site community-based research may not lend itself well to the more stringent explanatory and pragmatic standards of a randomized controlled trial design. Given our growing interest in community-based population research, the challenges inherent in the analysis of heterogeneous study design are likely to become more salient. Discussion of the analytic issues faced by the PNRP and the methodological approaches we considered may be of value to other prospective community-based research programs.

BACKGROUND: Delays in care after abnormal cancer screening contribute to disparities in cancer outcomes. Women with psychiatric disorders are less likely to receive cancer screening and may also have delays in diagnostic resolution after an abnormal screening test. OBJECTIVE: To determine if depression and anxiety are associated with delays in resolution after abnormal mammograms and Pap tests in a vulnerable population of urban women. DESIGN: We conducted retrospective chart reviews of electronic medical records to identify women who had a diagnosis of depression or anxiety in the year prior to the abnormal mammogram or Pap test. We used timeto-event analysis to analyze the outcome of time to resolution after abnormal cancer screening, and Cox proportional hazards regression modeling to control for confounding. PARTICIPANTS: Women receiving care in six Bostonarea community health centers 2004-2005: 523 with abnormal mammograms, 474 with abnormal Pap tests. RESULTS: Of the women with abnormal mammogram and pap tests, 19% and 16%, respectively, had comorbid depression. There was no difference in time to diagnostic resolution between depressed and not-depressed women for those with abnormal mammograms (aHR=0.9, 95 CI 0.7,1.1) or Pap tests (aHR=0.9, 95 CI 0.7,1.3). CONCLUSIONS: An active diagnosis of depression and/ or anxiety in the year prior to an abnormal mammogram or Pap test was not associated with a prolonged time to diagnostic resolution. Our findings imply that documented mood disorders do not identify an additional barrier to resolution after abnormal cancer screening in a vulnerable population of women.KEY WORDS: depression; cancer screening; women's health; minority populations.

Patient navigation is increasingly being used to support vulnerable patients to receive timely and quality medical care. We sought to understand whether patients with depression utilize additional patient navigation services after abnormal cancer screening. We compared depressed and non-depressed women using three different measures of intensity of patient navigation: number of patient-navigator encounters, encounter time, and number of unique barriers to care. The study population consisted of 1,455 women who received navigation after abnormal screening for breast or cervical cancer at one of six community health centers in Boston. Navigators spent a median of 60–75 minutes over one or two encounters per participant, with 49% of participants having one or more documented barrier to care. Depressed women did not differ in total numbers of encounters, encounter time, or unique barriers compared with non-depressed women. Our findings suggest that pre-existing depression does not predict which women will utilize additional navigation services.