Background: Persons of low socioeconomic status, including those with Medicaid coverage, are more likely to be diagnosed with cancer at an advanced stage, but little is known about cancer screening practices among Medicaid recipients. Our objective was to identify cancer screening rates among older Medicaid recipients seen in a primary care setting, and to identify patient and physician characteristics associated with screening. Methods: We used a stratified cluster sampling design to select a representative sample of 1951 North Carolina Medicaid recipients 50 years and older. Medical records were reviewed in the office of the primary care provider. Principal outcomes were the documentation of physician recommendations for and patient receipt of screening examinations for colorectal, breast, and cervical cancer. Results: Documentation that colorectal, breast, and cervical cancer screening was recommended by the primary care provider was found for only 52.7%, 60.4%, and 51.5% of eligible patients, respectively. Documented rates of adequate screening were 28.2% for colorectal cancer, 31.7% for mammography within 2 years, and 31.6% for Papanicolaou test within 3 years. When medical record and claims data were combined, approximately half of eligible patients had evidence of screening. Length of the patient-physician relationship and African American race were positively associated with screening. Conclusions: Cancer screening rates among older Medicaid recipients fall far short of national objectives. Lack of a screening recommendation by the physician, rather than patient refusal of recommended tests, accounted for most instances of screening delinquency. Efforts to increase cancer screening rates among Medicaid recipients must address patient, physician, and organizational barriers to the routine identification and delivery of preventive services.
Our results indicate that enhancement of PCCM programs is one way for Medicaid programs to improve care, but may require substantial investments by states.
Failure to adjust hypertension therapy despite elevated blood pressure (BP) levels is an important contributor to lack of BP control. One possible explanation is that small elevations above goal BP are not concerning to clinicians. BP levels farther above goal, however, should be more likely to prompt clinical action. We reviewed one year’s worth of primary care records of 3,742 North Carolina Medicaid recipients 21 years and older with hypertension (a total of 15,516 office visits) to examine variations in hypertension management stratified by level of BP above goal and the association of BP level above goal with documented anti-hypertensive medication change. Among the 53% of patients not at goal BP, 42% were within 10/5 mm Hg of goal; 11% had a BP ≥40/20 mm Hg above goal. Higher level of BP above goal was independently associated with anti-hypertensive medication change. Compared to visits at which BP was <10/5 mm Hg above goal, the adjusted odds of medication change were 7.9 (95% CI 6.2-10.2) times greater at visits when patients’ BP was ≥ 40/20 mm Hg above goal. However, even when BP was above goal at this level, treatment change occurred only 46% (95% CI 40.2-51.8) of the time.
Although fundoplication is thought to be a curative procedure, the current findings suggest that many patients take symptomatic therapies and report symptoms and diminished health status up to 2 years after the procedure. These outcomes are associated with physiologic findings. Thus, these findings suggest that symptom-free status and absence of medication use cannot be assumed for all patients after Toupet fundoplication.
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