IMPORTANCE Despite advances in cancer treatment and cancer-related outcomes, disparities in cancer mortality remain. Lower rates of cancer prevention screening and consequent delays in diagnosis may exacerbate these disparities. Better understanding of the association between arealevel social determinants of health and cancer screening may be helpful to increase screening rates. OBJECTIVE To examine the association between area deprivation, rurality, and screening for breast, cervical, and colorectal cancer in patients from an integrated health care delivery system in 3 US Midwest states (Minnesota, Iowa, and Wisconsin). DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study of adults receiving primary care at 75 primary care practices in Minnesota, Iowa, and Wisconsin, rates of recommended breast, cervical, and colorectal cancer screening completion were ascertained using electronic health records between July 1, 2016, and June 30, 2017. The area deprivation index (ADI) is a composite measure of social determinants of health composed of 17 US Census indicators and was calculated for all census block groups in Minnesota, Iowa, and Wisconsin (11 230 census block groups). Rurality was defined at the zip code level. Using multivariable logistic regression, this study examined the association between the ADI, rurality, and completion of cancer screening after adjusting for age, Charlson Comorbidity Index, race, and sex (for colorectal cancer only). MAIN OUTCOMES AND MEASURES Completion of recommended breast, cervical, and colorectal cancer screening. RESULTS The study cohorts were composed of 78 302 patients eligible for breast cancer screening (mean [SD] age, 61.8 [7.1] years), 126 731 patients eligible for cervical cancer screening (mean [SD] age, 42.6 [13.2] years), and 145 550 patients eligible for colorectal cancer screening (mean [SD] age, 62.4 [7.0] years; 52.9% [77 048 of 145 550] female). The odds of completing recommended screening were decreased for individuals living in the most deprived (highest ADI) census block group quintile compared with the least deprived (lowest ADI) quintile: the odds ratios were 0.51 (95% CI, 0.46-0.57) for breast cancer, 0.58 (95% CI, 0.54-0.62) for cervical cancer, and 0.57 (95% CI, 0.53-0.61) for colorectal cancer. Individuals living in rural areas compared with urban areas also had lower rates of cancer screening: the odds ratios were 0.76 (95% CI, 0.72-0.79) for breast cancer, 0.81 (95% CI, 0.79-0.83) for cervical cancer, and 0.93 (95% CI, 0.91-0.96) for colorectal cancer. CONCLUSIONS AND RELEVANCE Individuals living in areas of greater deprivation and rurality had lower rates of recommended cancer screening, signaling the need for effective intervention strategies that may include improved community partnerships and patient engagement to enhance access to screening in highest-risk populations.

BackgroundEvidence suggests that transgender (trans) individuals in Canada are a medically underserved population; barriers range from lack of provider knowledge on trans issues to refusal of care. This paper provides the first formal estimation of health care inequalities between trans and cisgender individuals in Ontario, Canada.MethodsWeighted statistics from the Ontario-wide Trans PULSE Project (n = 433) were compared with age-standardized Ontario data from the Canadian Community Health Survey (n = 39,980) to produce standardized prevalence differences (SPDs). Analysis was also conducted separately for trans men and trans women, each compared to the age-standardized Ontario population.ResultsAn estimated 33.2% (26.4,40.9) of trans Ontarians reported a past-year unmet health care need in excess of the 10.7% expected based on the age-standardized Ontario population. Inequality was greatest comparing trans with cisgender men (SPD = 34.4% (23.0, 46.1). While trans Ontarians evaluated health care availability in Ontario similarly to the broader population, they were significantly more likely to evaluate availability in their community as fair or poor.ConclusionsTrans Ontarians experience inequalities in perception and reported experiences of health care access, with 43.9% reporting a past-year unmet health care need.

Patient-centered care requires that treatments respond to the problematic situation of each patient in a manner that makes intellectual, emotional, and practical sense, an achievement that requires shared decision making (SDM). To implement SDM in practice, toolsdsometimes called conversation aids or decision aidsdare prepared by collating, curating, and presenting high-quality, comprehensive, and up-to-date evidence. Yet, the literature offers limited guidance for how to make evidence support SDM. Herein, we describe our approach and the challenges encountered during the development of Anticoagulation Choice, a conversation aid to help patients with atrial fibrillation and their clinicians jointly consider the risk of thromboembolic stroke and decide whether and how to respond to this risk with anticoagulation.

No abstract