Background:Despite strong efforts, HPV vaccine uptake remains low, especially in rural areas. This study examined general and HPV vaccine hesitancy among parents of children aged 9-17 in rural, low-vaccination areas, its link to HPV vaccination rates, and key factors influencing hesitancy. Methods:We surveyed parents from three counties in Virginia and collected information about their beliefs and opinions regarding adolescent vaccines, particularly the HPV vaccine, and their child's HPV vaccination status. General and HPV vaccine hesitancy were assessed using validated scales. Bayesian index logistic regression models were used to examine the relationship between each index and the child's HPV vaccination status, and also to identify the most important factor within each index. Results:The final analytical sample included 249 complete responses. The average reported child age was 12.4 years; 62.0% of parents reported that their child had received the HPV vaccine. In the adjusted general vaccine hesitancy model, hesitancy was significantly associated with a lower likelihood of a child's HPV vaccination (OR = 0.43, 95% CI: 0.26, 0.73), with perceived vaccine safety (weight = 0.363) the most influential factor estimated within the index. Similarly, in the adjusted HPV vaccine hesitancy model, hesitancy was significantly associated with a child's HPV vaccination (OR = 0.39, 95% CI: 0.20-0.72), with provider recommendation (weight = 0.198) the dominant estimated factor. Conclusion:Vaccine hesitancy remains a substantial challenge for HPV vaccination. Engaging providers to give strong vaccine recommendations and sharing information about vaccine safety, among other strategies, could help improve HPV vaccine uptake in rural and low-vaccination areas.

OBJECTIVE:This study examines the impact of accountable care organization (ACO) maturity on inpatient costs, quality of care, and patient safety for hospitals participating in ACOs initiated by CMS relative to nonparticipants. STUDY DESIGN:Quasi-experimental evaluation of hospitals before and after joining a CMS ACO using a difference-in-differences design during the period from 2010 to 2013. METHODS:Propensity score-matched groups of hospitals were used to estimate the combined effects of ACO maturity and CMS ACO participation on inpatient costs, quality, and patient safety outcomes. Total treatment costs, mortality rates for 4 common conditions, and 4 perioperative adverse events were investigated. Analyses were based on state-level data from the Healthcare Cost and Utilization Project. RESULTS:We matched 121 CMS ACO-participating hospitals and 853 nonparticipating hospitals. Hospitals with an ACO maturity score of 0 had significantly worse acute myocardial infarction mortality and perioperative pulmonary embolism or deep vein thrombosis rates than nonparticipants. These differences were no longer significant with increasing ACO maturity. Higher ACO maturity was associated with significant improvements in accidental punctures and lacerations among hospital CMS ACO participants. No other significant trends were observed. CONCLUSIONS:Findings suggest a potential positive effect of hospital CMS ACO participation with increasing maturity. However, use of early ACO data, a short follow-up period, and other limitations hindered the ability to identify significant trends. Nonetheless, ACO maturity scores and new outcome measures may offer a promising approach for tracking the long-term impact of hospital ACO participation in future research and policy evaluations.

AbstractBackgroundColorectal cancer screening rates remain suboptimal, particularly among low‐income populations. Our objective was to evaluate the long‐term effects of Medicaid expansion on colorectal cancer screening.Design, Setting, and ParticipantsThis cross‐sectional study analyzed data from 354,384 individuals aged 50–64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference‐in‐difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods.Main Outcomes and MeasuresThe primary outcome was the likelihood of receiving colorectal cancer screening for low‐income adults aged 50–64.ResultsMedicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50–64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries.ConclusionsMedicaid expansion was found to be associated with increased colorectal cancer screening rates among low‐income individuals aged 50–64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.

BACKGROUND:Performance-based budgeting (PBB) is a variation of pay for performance that has been used in government hospitals but could be applicable to any integrated system. It works by increasing or decreasing funding based on preestablished performance thresholds, which incentivizes organizations to improve performance. In late 2006, the U.S. Army implemented a PBB program that tied hospital-level funding decisions to performance on key cost and quality-related metrics.PURPOSE:The aim of this study was to estimate the impact of PBB on quality improvement in U.S. Army health care facilities.APPROACH:This study used a retrospective difference-in-differences analysis of data from two Defense Health Agency data repositories. The merged data set encompassed administrative, demographic, and performance information about 428 military health care facilities. Facility-level performance data on quality indicators were compared between 187 Army PBB facilities and a comparison group of 241 non-PBB Navy and Air Force facilities before and after program implementation.RESULTS:The Army's PBB programs had a positive impact on quality performance. Relative to comparison facilities, facilities that participated in PBB programs increased performance for over half of the indicators under investigation. Furthermore, performance was either sustained or continued to improve over 5 years for five of the six performance indicators examined long term.CONCLUSION:Study findings indicate that PBB may be an effective policy mechanism for improving facility-level performance on quality indicators.PRACTICE IMPLICATIONS:This study adds to the extant literature on pay for performance by examining the specific case of PBB. It demonstrates that quality performance can be influenced internally through centralized budgeting processes. Though specific to military hospitals, the findings might have applicability to other public and private sector hospitals who wish to incentivize performance internally in their organizational subunits through centralized budgeting processes.

Objective: To examine the role of social support and health behaviors in the association between discrimination and mental health (e.g., anxiety/depressive symptoms, suicidal ideation) among college students experiencing various forms of discrimination. Participants: Data were collected from 709 college students (42.8% White; 72.2% female) at a large urban university in Fall 2017. Methods: Students completed an online survey assessing perceived discrimination, anxiety/depressive symptoms, suicidal behavior, health behaviors, and social support. Moderation and parallel mediation analyses were conducted in PROCESS SPSS. Results: Results indicated that preventive health behaviors and social support partially mediated associations between discrimination and mental health outcomes. Conclusions: Findings highlight the need to increase awareness regarding engaging in preventive health behaviors on college campuses. For students experiencing discrimination, prevention, and social support might be key factors in improving mental health.

Social Determinants of Health (SDOH) impact health outcomes; thus, a pilot to screen for important SDOH domains (food, housing, and transportation) and address social needs in hospitalized patients was implemented in an urban safety-net academic medical center. This study describes the pilot implementation and examines patient characteristics associated with SDOH-related needs. An internal medicine unit was designated as a pilot site. Outreach workers approached eligible patients (n = 1,135) to complete the SDOH screening survey at time of admission with 54% (n = 615) completing the survey between May 2019 and July 2020. Data from patient screening survey and electronic health records were linked to allow for examination of associations between SDOH needs for food, housing, and transportation and various demographic and clinical characteristics of patients in multivariate logistic regression models. Of 615 screened patients, 45% screened positive for any need. Of 275 patients with needs, 33% reported needs in 2, and 34% - in 3 domains. Medicaid beneficiaries were more likely than patients with private health insurance to screen positive for 2 and 3 needs; Black patients were more likely than White patients to screen positive for 1 and 3 needs; Patients with no designated primary care physician status screened positive for 1 need; Patients with a history of substance use disorder screened positive for all 3 needs. SDOH screening assisted in addressing social risk factors of inpatients, informed their discharge plans and linkage to community resources. SDOH screening demonstrated significant correlations of positive screens with race/ethnicity, insurance type, and certain clinical characteristics.

Understanding how human papillomavirus (HPV) vaccination coverage varies by geography can help to identify areas of need for prevention and control efforts. A systematic review of the literature was conducted using a combination of keywords (HPV vaccination, geography, neighborhoods, and sociodemographic factors) on Medline and Embase databases. Studies had to provide information on HPV vaccination by area-level variables, be conducted in the United States, and be published in English (analyzing data from January 2006 to February 2020). Conference abstracts and opinion pieces were excluded. Of 733 records identified, 25 were included for systematic review. Across studies, the average initiation rate was 40.5% (range, 6.3%-78.0%). The average rate of completion was 23.4% (range, 1.7%-55.2%). Geographic regions and area-level factors were associated with HPV vaccination, including zip code tabulation area-level poverty, urbanicity/rurality, racial/ethnic composition, and health service region characteristics. Only three studies utilized geospatial approaches. None accounted for geospatial-temporal associations. Individual-level and area-level factors and their interactions are important for characterizing HPV vaccination. Results demonstrate the need to move beyond existing multilevel methods and toward the adoption of geospatial approaches that allow for the mapping and detection of geographic areas with low HPV vaccination coverage.

Understanding how human papillomavirus (HPV) vaccination coverage varies by geography can help to identify areas of need for prevention and control efforts. A systematic review of the literature was conducted using a combination of keywords (HPV vaccination, geography, neighborhoods, and sociodemographic factors) on Medline and Embase databases. Studies had to provide information on HPV vaccination by area-level variables, be conducted in the United States, and be published in English (analyzing data from January 2006 to February 2020). Conference abstracts and opinion pieces were excluded. Of 733 records identified, 25 were included for systematic review. Across studies, the average initiation rate was 40.5% (range, 6.3%–78.0%). The average rate of completion was 23.4% (range, 1.7%–55.2%). Geographic regions and area-level factors were associated with HPV vaccination, including zip code tabulation area-level poverty, urbanicity/rurality, racial/ethnic composition, and health service region characteristics. Only three studies utilized geospatial approaches. None accounted for geospatial–temporal associations. Individual-level and area-level factors and their interactions are important for characterizing HPV vaccination. Results demonstrate the need to move beyond existing multilevel methods and toward the adoption of geospatial approaches that allow for the mapping and detection of geographic areas with low HPV vaccination coverage.

Background: Human papillomavirus (HPV) is the most common sexually transmitted infection within the United States (US). Despite clinical agreement on the effectiveness and widespread availability of the prophylactic HPV vaccine, vaccination coverage in the US is suboptimal and varies by geographic region and area-level variables. The goals of this article were to model the variation in vaccination rates among boys and girls within ZIP Codes in Virginia, determine whether neighborhood sociodemographic variables explain variation in HPV vaccination, and identify areas with significantly depressed vaccination coverage. Methods: We used Bayesian hierarchical spatial regression models with statewide immunization registry data to consider the correlation in vaccination among boys and girls, as well as the spatial correlation in vaccination for each sex. Results: The results showed low vaccination coverage in our birth cohort (28.9% in girls and 23.8% in boys) relative to the national level (56.8% and 51.8%, respectively). Several area-level variables were significantly and positively associated with vaccination coverage, including population density, percentage of Hispanic population, and average number of vehicles. In addition, there were several areas of significantly lowered vaccination coverage, including predominantly rural ones, and overall large geographic disparities in HPV vaccination. Conclusions: Determining the geospatial patterning and area-level factors associated with HPV vaccination within a prescribed geographic area helps to inform future planning efforts. Impact: The results of this study will help inform future planning efforts for geographically targeted interventions and policies, as well as drive new research to implement clinical and community strategies to increase HPV vaccination.

Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA Background and Objective: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. COPD is expensive to treat, whereas the quality of care is difficult to evaluate due to the high prevalence of multi-morbidity among COPD patients. In the US, the Hospital Readmissions Reduction Program (HRRP) was initiated by the Centers for Medicare and Medicaid Services to penalize hospitals for excessive 30-day readmission rates for six diseases, including COPD. This study examines the difference in 30-day readmission risk between COPD patients with and without comorbidities. Methods: In this retrospective cohort study, we used Cox regression to estimate the hazard ratio of 30-day readmission rates for COPD patients who had no comorbidity and those who had one, two or three, or four or more comorbidities. We controlled for individual, hospital and geographic factors. Data came from three sources: Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), Area Health Resources Files (AHRF) and the American Hospital Association’s (AHA's) annual survey database for the year of 2013. Results: COPD patients with comorbidities were less likely to be readmitted within 30 days relative to patients without comorbidities (aHR from 0.84 to 0.87, p < 0.05). In a stratified analysis, female patients with one comorbidity had a lower risk of 30-day readmission compared to female patients without comorbidity (aHR = 0.80, p < 0.05). Patients with public insurance who had comorbidities were less likely to be readmitted within 30 days in comparison with those who had no comorbidity (aHR from 0.79 to 0.84, p < 0.05). Conclusion: COPD patients with comorbidities had a lower risk of 30-day readmission compared with patients without comorbidity. Future research could use a different study design to identify the effectiveness of the HRRP.

Background and Objective Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. COPD is expensive to treat, whereas the quality of care is difficult to evaluate due to the high prevalence of multi-morbidity among COPD patients. In the US, the Hospital Readmissions Reduction Program (HRRP) was initiated by the Centers for Medicare and Medicaid Services to penalize hospitals for excessive 30-day readmission rates for six diseases, including COPD. This study examines the difference in 30-day readmission risk between COPD patients with and without comorbidities. Methods In this retrospective cohort study, we used Cox regression to estimate the hazard ratio of 30-day readmission rates for COPD patients who had no comorbidity and those who had one, two or three, or four or more comorbidities. We controlled for individual, hospital and geographic factors. Data came from three sources: Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), Area Health Resources Files (AHRF) and the American Hospital Association’s (AHA's) annual survey database for the year of 2013. Results COPD patients with comorbidities were less likely to be readmitted within 30 days relative to patients without comorbidities (aHR from 0.84 to 0.87, p < 0.05). In a stratified analysis, female patients with one comorbidity had a lower risk of 30-day readmission compared to female patients without comorbidity (aHR = 0.80, p < 0.05). Patients with public insurance who had comorbidities were less likely to be readmitted within 30 days in comparison with those who had no comorbidity (aHR from 0.79 to 0.84, p < 0.05). Conclusion COPD patients with comorbidities had a lower risk of 30-day readmission compared with patients without comorbidity. Future research could use a different study design to identify the effectiveness of the HRRP.

Abstract Building a culture of precision public health requires research that includes health delivery model with innovative systems, health policies, and programs that support this vision. Health insurance mandates are effective mechanisms that many state policymakers use to increase the utilization of preventive health services, such as colorectal cancer screening. This study estimated the effects of health insurance mandate variations on colorectal cancer screening post Affordable Care Act (ACA) era. The study analyzed secondary data from the Behavioral Risk Factor Surveillance System (BRFSS) and the NCI State Cancer Legislative Database (SCLD) from 1997 to 2014. BRFSS data were merged with SCLD data by state ID. The target population was U.S. adults, age 50 to 74, who lived in states where health insurance was mandated or nonmandated before and after the implementation of ACA. Using a difference-in-differences (DD) approach with a time-series analysis, we evaluated the effects of health insurance mandates on colorectal cancer screening status based on U.S. Preventive Services Task Force guidelines. The adjusted average marginal effects from the DD model indicate that health insurance mandates increased the probability of up-to-date screenings versus noncompliance by 2.8% points, suggesting that an estimated 2.37 million additional age-eligible persons would receive a screening with such health insurance mandates. Compliant participants' mean age was 65 years and 57% were women (n = 32,569). Our findings are robust for various model specifications. Health insurance mandates that lower out-of-pocket expenses constitute an effective approach to increase colorectal cancer screenings for the population, as a whole. Prevention Relevance: The value added includes future health care reforms that increase access to preventive services, such as CRC screening, are likely with lower out-of-pocket costs and will increase the number of people who are considered “up-to-date”. Such policies have been used historically to improve health outcomes, and they are currently being used as public health strategies to increase access to preventive health services in an effort to improve the nation's health.

PURPOSE:Patients with a chronic comorbidity or multiple comorbidities are at much greater risk of serious colonoscopy-related gastrointestinal (GI) adverse events relative to patients with no comorbidity. It is important to identify outpatient facilities that can effectively and safely provide colonoscopy to complex patients. To address this need, the association between outpatient facilities' complex care volume and type (ambulatory surgery center (ASC) and hospital outpatient department (HOPD)) and the risks of serious GI adverse events in colonoscopy patients with single and multiple chronic comorbidities were examined.METHODS:Outpatient colonoscopies of 1,020,372 patients with single and multiple comorbidities were investigated, using a retrospective cohort study. Thirty-day hospitalizations due to colonic perforations and GI bleeding were examined. Ambulatory surgery and hospital discharge datasets from California, Florida, and New York for 2006-2009 were used.RESULTS:Higher complex care volume was associated with lower risks of adverse events in patients with comorbidities (OR 1.69; 95% CI [1.13, 2.54]). ASCs had higher risks of adverse events in patients with comorbidities relative to HOPDs (OR 2.85; 95% CI [2.40, 3.38]). Patients with single and multiple comorbid conditions, patients with systemic diseases, and complex patients of advanced age had higher risks of adverse events.CONCLUSIONS:Referring patients with single and multiple chronic comorbidities to facilities experienced in treating complex patients, or HOPDs, may reduce colonoscopy-related adverse events.

Background: Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012–2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. Purpose: Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. Methodology/Approach: Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012–2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. Results: Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. Conclusion: Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. Practice Implications: ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

Adverse events that occur in urban and rural adults during the posthospitalization period have become a major public health concern. However, postdischarge adverse events for patients receiving home health care have been understudied. The objective of this study was to identify the prevalence and risk factors associated with postdischarge adverse events for patients who received home health care services. We analyzed data from a prospective cohort study that was conducted among patients who were hospitalized in the Tallahassee Memorial Hospital from December 2011 to October 2012. Telephone interviews were conducted by trained nurses who contacted patients within 4 weeks after discharge. Physicians reviewed cases with possible adverse events that were triaged by the nurses. The adverse events that were identified were categorized as preventable, ameliorable, and nonpreventable/nonameliorable. Nearly 39% of 85 patients who received home health care experienced postdischarge adverse events that were predominantly preventable or ameliorable. The associated risk factors were living alone (odds ratio [OR] = 7.860, p = .020), insured by Medicare or Medicaid (OR = 6.402, p = .048), type 2 diabetes mellitus (OR = 6.323, p = .004), pneumonia (OR = 5.504, p = .004), and other infections (OR = 4.618, p = .031). This study was able to identify that nearly one in every two patients who received home health care after hospital discharge experienced an adverse event. Patient safety research needs to focus in the home by developing specific interventions to avert adverse events and improve patient safety during the delivery of home health care services.

Background: In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models. Purpose: The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs. Methodology: Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs. Results: Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician–organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation. Conclusion: MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts. Practice Implications: Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.

Objective: Although Kazakhstan has made significant investments to improve health and life expectancy of itspopulation, high cancer rates persist, with breast cancer being the most prevalent type. Factors contributing to delaysin treatment and late staging for breast cancer patients were assessed. Methods: A retrospective follow-up studywith registry data identified 4,248 breast cancer patients in sixteen regions of Kazakhstan in 2014. We used logisticregressions to estimate (i) associations of treatment delays with patient demographics and cancer center regions; and(ii) associations of late-stage (III and IV) cancer diagnosis with patient demographics and cancer center regions, withand without controlling for treatment delays. Results: Breast cancer patients treated in regions located further awayfrom Almaty City had higher risks of treatment delays. However, the risks of late-stage cancer diagnosis were greaterfor patients treated in Almaty City and those with treatment delays. Conclusion: The main driver of delayed treatmentis cancer center region. Residents of Almaty City, a major urban area of Kazakhstan, may have a better access to atertiary cancer center, resulting in less treatment delays. Referrals of sicker patients from neighboring regions to AlmatyCity for cancer treatment is likely to increase risks of late-stage diagnosis. New or upgraded cancer centers may reducetreatment delays, but their case-mix is likely to increase.

This study evaluates quality performance of hospitals participating in Medicare Shared Savings and Pioneer Accountable Care Organization (ACO) programs relative to nonparticipating hospitals. Overall, 198 ACO participating and 1210 propensity score matched, nonparticipating hospitals were examined in a difference-in-difference analysis, using data from 17 states in the years 2010-2013. The authors studied preventable hospitalizations for conditions sensitive to high-quality ambulatory care—chronic obstructive pulmonary disease (COPD) and asthma, chronic heart failure (CHF), complications of diabetes—and 30-day all-cause readmissions potentially influenced by hospital care. A decrease was found in preventable hospitalizations for COPD and asthma and for diabetes complications for ACO participating hospitals, but no significant differences for preventable CHF hospitalizations and 30-day readmissions. Mixed results may be attributable to insufficient incentives for ACO participating hospitals to decrease 30-day readmissions, whereas disease-focused initiatives may have a beneficial effect on preventable hospitalizations for COPD and asthma and complications of diabetes.

Abstract 27 Background: Although Kazakhstan (KZ) has made significant investments to improve population health, high cancer rates persist, with breast cancer as the most prevalent. We assessed factors that contribute to delays in treatment and late staging for patients with breast cancer. Methods: A retrospective follow-up study design was used. By using 2014 registry data, we identified 4,248 patients with breast cancer who were treated at cancer centers in the 16 KZ regions. Patients with delays in treatment as a result of medical errors and other reasons were identified. We used logistic regression to estimate associations of delays with patient demographics, occupation, and cancer center region; and associations of late-stage (III and IV) cancer diagnosis with delays in treatment while controlling for patient demographics, occupation, and cancer center region. Results: Approximately 9% (n = 378) of patients experienced delayed treatment. Older and Russian patients as well as those treated in regions further away from Almaty City had significantly higher adjusted risk of delayed treatment. However, risk of late-stage diagnosis was greater for patients who were treated in Almaty City and for those who were Russian, unemployed, or who had delayed treatment. Conclusion: The main driver of delayed treatment was cancer center region. Patients who were treated in Almaty City, where the national cancer research and treatment center is located, had fewer delays in treatment but a higher likelihood of late-stage diagnosis, likely as a result of referrals of sicker patients from neighboring regions. These findings suggest that referrals to new tertiary care centers being developed in KZ may reduce treatment delays but affect facility case mix. Future research will examine the role played by distance to cancer centers in access to specialty care and whether tertiary care is associated with improved outcomes conditional on case mix. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST No COIs from the authors.

BACKGROUND AND OBJECTIVE:Serious GI adverse events in the outpatient setting were examined for patients with a full spectrum of comorbid conditions and combinations of multiple comorbidities.DESIGN:This is a retrospective follow-up study.SETTING:Ambulatory surgery and hospital discharge data sets from California, Florida, and New York, 2006 to 2009, were used.PATIENTS:The outpatient colonoscopies of 4,234,084 adults aged 19 to 85 and over and payers were examined.MAIN OUTCOME:Thirty-day hospitalizations due to colonic perforations and GI bleeding, measured as cumulative outcomes, were investigated.RESULTS:About 24% of patients undergoing outpatient colonoscopy had a comorbid condition. In comparison with patients without comorbidities, the adjusted risks of adverse events were greater for patients with several single comorbidities and combinations of multiple comorbid conditions. Elderly patients and those treated in freestanding Ambulatory Surgery Centers had higher odds of colonic perforations and GI bleeding than younger patients and patients treated in hospital outpatient departments.LIMITATION:The study was constrained by limitations inherent in administrative data.CONCLUSIONS:Given the large number of outpatient colonoscopies performed in the United States, these procedures should be provided with caution to patients with chronic and multiple comorbidities and the elderly, because these populations are associated with higher rates of colonic perforations and GI bleeding.