HMGT 400 Research and Data Analysis in Healthcare
Comparing average percent of female Medicare enrollees age 67-69 having at least one mammogram over a two-year period between Blacks and Whites Group 3 Campoalegre, Heather Lawyer, Lisa Puii, Lian Stanford, Wendell University of Maryland Global Campus HMGT 400 Research and Data Analysis in Health Care Professor Ifeoma Inneh February 27, 2024 1.0 Introduction Breast cancer is the most diagnosed cancer among women in the United States and continues to pose significant health concerns (Centers for Disease Control and Prevention, 2023). By 2025, it is projected that approximately 169,347 women in the U.S. will be diagnosed with breast cancer (National Breast Cancer Coalition, 2024). Although white women have higher incidence rates, black women face higher mortality rates due to disparities in access to screening and care (McDowell, 2022). Despite recommendations for regular mammography screenings, screening rates have plateaued, underscoring the need to understand screening behaviors among different demographic groups. Mammogram screenings are crucial for women’s health, regardless of ethnicity or risk factors, as they significantly reduce breast cancer mortality rates. This study aims to explore the differences in mammography screening rates between black and white women aged 67-69 enrolled in Medicare. Combining qualitative and quantitative research methods, the study will analyze available data comprehensively. Through the examination of relevant articles and quantitative analyses, the research seeks to validate hypotheses regarding mammogram utilization among Medicare enrollees. 2.0 Literature Review and Qualitative Analysis County-Level Factors Predicting Low Uptake of Screening Mammography (Lian Puii) In a recent publication from the American Journal of Roentgenology, researchers conducted an investigation into the geographical distribution of mammographic screening across the United States. The study highlighted the concerning trend that women in rural areas face a higher risk of being diagnosed with advanced-stage breast cancer compared to their urban counterparts, possibly due to limited access to screening services. Utilizing a descriptive study database, the researchers analyzed population health at the county level to determine the prevalence of mammogram screenings in each state. Through multivariable regression analysis, they examined the relationship between states and the screening uptake among black and white women, identifying clusters of states with similar uptake levels. The study revealed significant variations in screening uptake, with an overall mean uptake of 60.5% ± 7.5%, indicating disparities in access to screening services based on geographic location. Among the observed states, approximately 50-60% of women had undergone mammograms, with no significant difference in screening percentage observed in rural or small urban populations of Medicare enrollees aged 67-69. Despite the known benefits of mammographic screening in reducing mortality rates from breast cancer, marked disparities in screening uptake persist, even among populations covered by Medicare Part B without cost-sharing. These findings underscore the importance of addressing geographic disparities in screening uptake to improve breast cancer detection and reduce mortality rates. Efforts to enhance access to screening services and raise awareness about the importance of early detection are crucial in mitigating the impact of geographic barriers on breast cancer outcomes (Heller et al., 2018). Mammography Utilization among Black and White Medicare Beneficiaries in High Breast Cancer Mortality US Counties (Wendell Stanford) This research looked at how older Black and White women in areas with high Black breast cancer death rates use mammograms. By studying Medicare records of women aged 65-74 in 203 specific counties, the study found that fewer Black women got screened than White women. However, Black women were more likely to have at least one mammogram. Factors like how much managed care was available in the area affected screening rates. The study suggests more research is needed to understand why older women in these areas might not get mammograms regularly. In total, data from 406,602 women in the same age group in the high-risk counties were examined. Of these, 17% were Black women. The study showed that fewer Black women had mammograms compared to White women overall, with 51.6% of Black women and 56.9% of White women getting screened at least once. The gap was wider for regular screening (having three or more mammograms): 32.9% of Black women versus 43.1% of White women. When considering factors like cervical cancer screening and flu shots, Black women were more likely to have at least one mammogram but less likely to undergo regular screening compared to White women. The findings of the study indicate disparities in mammography utilization between older Black and White women in counties with high Black breast cancer mortality rates are significant. Identifying these disparities is crucial for understanding and addressing healthcare inequities that may contribute to differences in breast cancer outcomes between racial groups. Targeted mailed materials and the Medicare beneficiary: increasing mammogram screening among the elderly. (Lisa Lawyer) The article I found gave a very interesting history of the beginning of mammography coverage in the Medicare program. In 1991 the Health Care Financing Administration’s (HCFA’s) Medicare program began partially covering the cost of biennial screening for all Medicare eligible women. However, it was found that older women continue to be under screened for breast cancer. Under screening for breast cancer in the elderly is a problem, due to the rates of breast cancer incidence continuing to rise throughout a woman’s life span and do not level off until a woman is older than 75 years. The question that this study was researching was; Would an intervention that informed Medicare eligible women about the Medicare benefit have an effect on mammography rates? (Fox et al., 2001) In this article a list frame method of subject selection was used to select random samples of eligible women from the Health Care Financing Administration’s master beneficiary file. Women were interviewed by telephone in 1991 (N=917) before the targeted mailing and in 1993 (N=922). Subjects were older White, Black and Hispanic women from 3 sites in southern California. One site acted as a control sample, and the other two sites represented treatment samples. The intervention was based on the Health Belief Model, which includes subjects’ awareness of breast cancer, lowering screening barriers, and providing information on where to get breast cancer screening. A targeted 2-page mailing was designed especially for older women. (Fox et al., 2001) Data collection was performed through telephone interviews, with a computer-assisted telephone interviewing system, before and after the mailing with a randomly selected group of Medicare beneficiaries. Everyone was interviewed over the telephone except Medicare enrollees with non-published telephone numbers who were then mailed questionnaires. Those who did not return questionnaires and could not be reached by phone were interviewed in person by field interviewers. The response rate for the eligible women in the control group was 66.5% in 1991, and 74.6% in 1993. The treatment sites had combined response rates of 57.8% in 1991 and 71.0% in 1993 for all eligible women. (Fox et al., 2001) A total of 13 logistic regressions were performed. An example of one of the tests would be the first logistic regression that was performed on the entire sample over the 2 years to test for selected interactions. This analysis found significant 2-way interaction for the treatment x year (P=.016) and year x Black (P=.001). Non-significant 2-way interactions were found for treatment x Black (P=.22), treatment x Hispanic (P=.77), and year x Hispanic (P=.23). (Fox et al., 2001) It is reported in the study, that there were no significant differences found between the treatment and the control communities in the use of mammography during the baseline period of 1991. White women in the intervention community reported an increase in their mammography use from 57% to 69%. Black women reported a slight increase from 57% to 60%, and Hispanic women decreased from 50% 6o 44%. It was also found that there were significant treatment effects in the 1992 post intervention samples of Black and Hispanic women. Black and Hispanic women who resided in the treatment intervention communities, and received the targeted mail intervention, had a significantly greater likelihood of having obtained a mammogram (P< .05 for Black and Hispanic women). Black women from the treatment community were twice as likely as the Black women from the control community to have had a mammogram in the 2-year period after the benefit was implemented. Some trends of note were identified, for example, women older than 75 years had a significantly lower likelihood of receiving a mammogram in 4 of the 6 logistic regressions. (Fox et al., 2001) The intervention tested a targeted mailed health education package based on the Health Belief Model, that was designed to increase awareness and use of the federally funded health benefit. Because Medicare beneficiaries historically have been unaware of their benefits, and there was little promotional activity, it was safe to assume the awareness of the program was very low. Knowledge of the Medicare benefit was a significant predictor of mammogram use across all racial/ethnic groups, and 4 times more likely to take advantage of it. (Fox et al., 2001) The study results indicated that regular access to care and physician visits did not contribute to mammogram use. However, women who had seen an internist or gynecologist were more likely to be screened, which suggests that mammogram support differs among specialties. With such disparities, more study is warranted, and it is suggested that this could be corrected through professional education. It was also found that household income and insurance status, having supplemental insurance, played a role in whether a woman would have mammograms across all women. (Fox et al., 2001) Racial and Ethnic Differences in use of Mammography between Medicare Advantage and traditional Medicare (Heather Campoalegre) As one of the main causes of death for women, breast cancer requires efficient screening programs to lessen its effects. This research examines the differences in mammography rates amongst female Medicare enrollees, ages 65 to 69, with a particular emphasis on regular Medicare, PPOs, and Health Maintenance Organizations (HMOs). As the primary cause of death for women in many different racial and ethnic groups, breast cancer represents a serious threat to their health. Disparities in access to healthcare emerge when women switch to Medicare at age 65. The increasing ubiquity of Medicare Advantage plans, such as PPOs and HMOs, complicates the process of identifying and resolving these differences. A cohort of 495,836 women enrolled in HMOs, 81,480 women in PPOs, and traditional Medicare enrollees between the ages of 65 and 69 in 2009 were examined in this study. Important conclusions consist of: Compared to White women, Black, Hispanic, and Asian/Pacific Islander women in HMOs had much greater mammography rates. There were statistically significant variations seen in the rates; Black, Hispanic, and Asian/Pacific Islander women had higher rates by 6.1%, 5.4%, and 0.9%, respectively. Compared to White women, all three minority groups had lower mammography rates under traditional Medicare. There were statistically significant variations seen, with Black, Hispanic, and Asian/Pacific Islander women experiencing declines of 3.3%, 7.4%, and 7.7%, respectively. PPOs, or preferred provider organizations: Comparing PPOs to regular Medicare, similar results were seen, with greater mammography rates for women of color. In PPOs, the rates for Asian/Pacific Islander women were 3.1% higher, the rates for Black women were 3.8% higher, and the rates for Hispanic women were 5.6% higher than for White women. The conversation emphasizes how racial and ethnic disparities seen in traditional Medicare were reversed in HMOs and PPOs with greater mammography rates. Lower patient cost-sharing, improved preventive service promotion systems, and unmeasured features of minority women in managed care plans are some of the factors that contribute to these discrepancies. Implications: The policy and practice of healthcare could be greatly impacted by these findings. Reducing cost-sharing obstacles, promoting organized systems for preventive treatments, and considering the distinctive characteristics of minority women are all necessary ways to address the disparities in breast cancer screening. Comprehending and addressing these factors is crucial in the context of evolving healthcare systems to ensure more equitable access to mammography services and, eventually, lower breast cancer death rates among varied populations. Table 1. Literature Review Analysis Authors, Year of Publication Intervention/ Study Policy design/ evaluated Time Period Data/Study Population Relevant Findings/ Recommendations Samantha L. Heller, Andrew B. Rosenkrantz, Yiming Gao and Linda Moy, 2018 N Y Y Y Virk-Baker, M.K. et al. (2013) N Y Y Y Fox et al., (2001) Y Y Y Y Ayanian et al., 2013 Y Y Y Y Table 2. Literature Review, Table of Biases Selection Bias Performance Bias Authors Samantha L. Heller, Andrew B. Rosenkrantz, Yiming Gao and Linda Moy, 2018 Detection Bias Attrition Bias Reporting Bias Systematic differences between groups in Systematic the care that is Systematic Systematic Systematic differences provided, or in differences differences differences between baseline exposure to between between between characteristics of factors other than groups in how groups in reported and the groups that the interventions outcomes are withdrawals unreported are compared. of interest. determined. from a study. findings. U U U U U Virk-Baker, M.K. et al. (2013) L U U U U Fox et al., (2001) L U Y Y U Ayanian et al., (2013) Y Y Y Y Y Note: Y: Low risk, N: High risk, U: Unclear 3.0 Quantitative Analysis Research Question or Research Hypothesis Research Question: Comparing average percent of female Medicare enrollees age 67-69 having at least one mammogram over a two-year period between blacks and whites? Hypothesis: The average percentage of mammogram utilization among female Medicare enrollees aged 67-69 over a two-year period is significantly different between Black and White individuals. Research Method a) Description of the Dataset The Medicare National Data by County dataset offers a comprehensive analysis of mammogram percentages and key health indicators for black and white individuals. These indicators include ambulatory visits, diabetic cases, hemoglobin levels, eye examinations, lipid profiles, and female Medicare beneficiaries. The dataset aims to compare and analyze these variables across black and white populations as well as assess differences among the 3,141 counties included in the dataset. b) Description of Variables The variables in this analysis are related to mammography utilization among female Medicare enrollees aged 67-69 over a two-year period, specifically focusing on Black and White individuals. These variables allow for the comparison of mammogram utilization rates between Black and White individuals within the specified age group and time frame, providing insights into potential disparities or differences in healthcare access and utilization patterns between these demographic groups. Table 1. List of variables used for the analysis Variable(s) Definition Percentage of Black female Measurement of Black Medicare enrollees 67-69 having female Medicare enrollees at least one Mammogram in a aged 67-69 having a two-year period mammogram Percentage of White female Measurement of White Medicare enrollees 67-69 having female Medicare enrollees at least one Mammogram in a aged 67-69 having a two-year period mammogram Source: Medicare National Data by County, n.d. Description of code Numeric Numeric Table 2. Definition of variables used in the analysis Variable(s) Definition Description of code Percentage of Percentage of Average percentage of Mammograms Mammograms among Mammograms for Black Black Black females aged 67-69. females/ Mean Percentage of Mammograms White Percentage of Average percentage of Mammograms among Mammograms for White Black females aged 67-69. females/ Mean Source Medicare National Data by County Year n.d. Medicare n.d. National Data by County Source Medicare National Data by County Medicare National Data by County Year n.d. n.d. Source: Medicare National Data by County, n.d. c) Description of the Research Method for Analysis To address the research question and test the hypothesis, the study employed a descriptive quantitative research method. Given the nature of our data, the most suitable statistical test for comparison was determined to be an independent sample t-test, as the two samples under consideration are numerical and possess no inherent relationship. The dataset includes variables such as the percentage of female Medicare enrollees aged 67-69 who had at least one mammogram over a two-year period, which serves as the key metrics for conducting the comparative analysis. d) Description of Statistical Package In the next step, we analyzed the data using RStudio, a statistical tool. We used this software to run a t-test, a common statistical method, to check if the averages of two groups are the same. This test assumes that both groups follow a normal distribution and have similar variances. In statistics, a null hypothesis suggests there is no distinction in specific population characteristics or data processes, while the alternative hypothesis posits the presence of a difference (Hayes, 2023). Results The difference in mean values between the two groups, Black and White individuals, provides insight into the average percentage of mammogram utilization among these groups. In this case, Black individuals have an average percentage of mammogram utilization of approximately 60.29, while White individuals have an average of around 61.37. This difference in means indicates that, on average, White individuals have a slightly higher percentage of mammogram utilization compared to Black individuals within the specified age group. The observations further support this by providing the number of cases or individuals in each group (939 for Black Individuals and 1937 for White individuals), giving context to the sample size and the robustness of the analysis. The difference in standard deviation between two groups, in this case, Black and White individuals, indicates the variability or spread of the data within each group. A larger standard deviation suggests that the data points are more spread out from the mean, while a smaller standard deviation indicates that the data points are closer to the mean. In the context of this analysis, the difference in standard deviation between Black (SD: 8.83) and White (SD: 8.36) individuals may suggest variations in the consistency or dispersion of mammogram utilization percentages within each group. The p-value of 0.0018 indicates a statistically significant distinction in the average mammogram percentages between Black and White individuals. This aligns with the hypothesis that the average mammography utilization among female Medicare enrollees aged 67-69 over a two-year period differs significantly between Black and White individuals, as suggested by the analysis of the provided data. Table 3. Descriptive analysis to compare. Variable(s) Observations (N) Mean Standard Deviation P-value Percentage of Mammograms Black 939 60.29 8.83 0.0018 Percentage of Mammograms White 1937 61.36 8.36 Source: Data generated through RStudio, 2024. 4.0 Discussion and Conclusion The study concludes by highlighting the critical role Medicare Advantage plans—more especially, HMOs and PPOs—play in reducing racial and ethnic differences in mammography rates among female members between the ages of 65 and 69. The impact of policy and structural variations is highlighted by the sharp contrast between higher rates in these managed care settings and lower rates in traditional Medicare. One of the most important factors in closing the gap appears to be the combination of reduced patient cost-sharing and better-organized procedures for promoting preventative care. The results underscore the efficacy of Medicare Advantage in mitigating inequities while also emphasizing the continuous necessity of allencompassing approaches to guarantee impartial access to crucial healthcare services. To reduce breast cancer disparities, policymakers and practitioners must use these insights to inform interventions as healthcare landscapes continue to change. Sustained work ought to concentrate on improving Medicare regulations, stressing the benefits of preventative care, and removing structural obstacles that disproportionately impact communities of color. We may work toward a future where access to mammography and, therefore, breast cancer outcomes are more equitable across varied groups by incorporating these findings into larger healthcare reform initiatives. 5.0 Policy Recommendations Implementing strategies that specifically cater to the needs of diverse communities can significantly reduce disparities in healthcare utilization, such as the notable gap in mammography screening rates between Black and White women. To address this issue, a multifaceted approach that combines community engagement, culturally sensitive education, and improved access to screening services is paramount. Education campaigns tailored to the cultural values and beliefs of Black women can effectively increase awareness about the benefits of mammography, dispel myths, and guide women on how to navigate the healthcare system to access screening services. Moreover, enhancing the accessibility of mammography services in underserved areas by subsidizing costs, extending facility hours, and deploying mobile screening units can remove barriers to access. Crucially, forging strong partnerships between healthcare providers, community organizations, and public health entities can ensure a coordinated approach to promoting screening uptake. This collaboration not only facilitates a seamless referral system but also builds on the trust community members have in local organizations, thereby improving follow-up and engagement in preventive healthcare practices. Such comprehensive strategies, underscored by the U.S. Preventive Services Task Force (USPSTF, 2013), are essential for effectively tackling health disparities and optimizing preventive health outcomes across communities. 6.0 References Ayanian, J. Z., Landon, B. E., Zaslavsky, A. M., & Newhouse, J. P. (2013). Differences in Use of Mammography Between Medicare Advantage and Traditional Medicre. J Natl Cancer Inst, 105(24), 1891-1896. Doi: 10.1093/jnci/djt306 Centers for Disease Control and Prevention. (2023, July 25). Basic information about breast cancer. https://www.cdc.gov/cancer/breast/basic_info/index.htm#:~:text=Except%20for%20skin%20can cer%2C%20breast,cancer%20death%20among%20Hispanic%20women. Cochrane Handbook for Systematic Reviews of Interventions. (n.d.). Retrieved July 12, 2019, from https://training.cochrane.org/handbook Fox, EdD, MSPH, S.A., Stein, PhD, J.a., Sockloskie, R. J., & Ory, PhD, MPH, M. G. (2001). Targeted mailed materials and the Medicare beneficiary: Increasing mammogram screening among the elderly. American Journal of Public Health, 91(1), 55-61. https://doi.org/10.2015/ajph91.1.55 Hayes, A. (2023) Null hypothesis: What is it and how is it used in investing?, Investopedia. Available at: https://www.investopedia.com/terms/n/null_hypothesis.asp (Accessed: 20 February 2024). Heller, S. L., Rosenkrantz, A. B., Gao, Y., & Moy, L. (2018). County-Level factors predicting low uptake of screening mammography. American Journal of Roentgenology, 211(3), 624–629. https://doi.org/10.2214/ajr.18.19541 McDowell, S. (2022, October 3). Breast cancer death rates are highest for Black Women—Again. American Cancer Society. https://www.cancer.org/research/acsresearch-news/breast-cancer-death-rates-are-highest-for-black-womenagain.html#:~:text=Black%20women%20have%20the%20lowest%205%2Dyear%20relat ive%20breast%20cancer,and%20every%20breast%20cancer%20subtype.&text=There%2 0is%20a%206%25%20to,for%20every%20breast%20cancer%20subtype. National Breast Cancer Coalition. (2024, January). Breast Cancer Facts & Figures. https://www.stopbreastcancer.org/information-center/factsfigures/#:~:text=By%202025%2C%20this%20number%20is%20expected%20to%20incr ease%20to%20169%2C347. USPSTF (2013) Integrating evidence-based clinical and community strategies to improve health, Integrating Evidence-Based Clinical and Community Strategies to Improve Health | United States Preventive Services Taskforce. Available at: https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-andprocesses/integrating-evidence-based-clinical-and-community-strategies-improve-health (Accessed: 23 February 2024). Virk-Baker, M.K. et al. (2013) Mammography utilization among black and white Medicare beneficiaries in high breast cancer mortality US counties, Cancer causes & control : CCC. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3955601/ (Accessed: 23 February 2024).
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