Abstract
Purpose
Mental illness may be a barrier to achieving timely and appropriate cancer screening. We evaluated the association of mental illness with receipt of and adherence to breast, cervical, and colorectal cancer screening among women Veterans.
Methods
The study population included all female Veterans ages 50 to 65 who obtained care at the New Mexico VA Health Care System continuously from fiscal years 2004 to 2006 (n = 606). Measures were odds ratios (OR) for receipt of any cancer screening, and adherence to recommended cancer screening frequency, adjusted for age, insurance, service connection, and primary care and women’s clinic visits.
Results
Overall, 53% of the women had a mental health diagnosis (MHD). Women with an MHD were less likely to adhere to recommended breast cancer screening than women without MHD: unadjusted OR (95% CI): 0.73 (0.54–0.98; p < .05), adjusted OR (aOR) (95% CI) 0.60 (0.44–0.82; p < .01). Women with an MHD were as likely as women without MHD to receive any breast, cervical, and colon cancer screening: Respective aORs (95% CI): 0.79 (0.50–1.25); 1.71 (0.91–3.21); and 0.85 (0.56–1.28).
Conclusion
Women with a mental illness are at risk for not adhering to recommended routine breast cancer screening, and may require more intensive efforts to achieve optimal rates of recommended breast cancer screening.
Introduction
Breast, cervical, and colorectal cancer are important public health problems. Periodic screening reduces the mortality from these cancers (
Berry et al., 2005
, Hewitson et al., 2007
, International Agency for Research on Cancer (IARC) Working Group on the Evaluation of Cervical Cancer Screening Programmes, 1986
, International Agency for Research on Cancer (IARC) Working Group on the Evaluation of Cervical Cancer Screening Programmes
Screening for squamous cervical cancer: Duration of low risk after negative results of cervical cytology and its implication for screening policies.
Screening for squamous cervical cancer: Duration of low risk after negative results of cervical cytology and its implication for screening policies.
British Medical Journal. 1986; 293: 659-664
Sasieni et al., 1996
, U.S. Preventive Services Task Force (USPSTF), 2003, January
, U.S. Preventive Services Task Force (USPSTF). (2003, January). Screening for cervical cancer. Recommendations and rationale. U.S. Preventive Services Task Force. AHRQ Pub. No. 03–515A. Available: http://www.uspreventiveservicestaskforce.org. Accessed October 5, 2010.
U.S. Preventive Services Task Force (USPSTF), 2010, July
, U.S. Preventive Services Task Force (USPSTF). (2010, July). Screening for breast cancer, topic page. U.S. Preventive Services Task Force. Available: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. Accessed October 5, 2010.
Whitlock et al., 2008
), and is recommended in widely-accepted guidelines (Agency for Healthcare Research and Quality (AHRQ), 2010, September
, American College of Obstetricians and Gynecologists (ACOG),
, American College of Obstetricians and Gynecologists (ACOG). (N.D.) Publications. Educational bulletins. Available: http://www.acog.org/publications/educational_bulletins/pb109.cfm. Accessed October 5, 2010.
Canadian Task Force on Preventive Health Care,
, Canadian Task Force on Preventive Health Care. (N.D.). Putting prevention into practice. Past recommendations. Available: http://www.canadiantaskforce.ca/. Accessed October 5, 2010.
Smith et al., 2011
). However, screening for these cancers in women is often inadequate (Hiatt et al., 2001
, Meissner et al., 2006
, Meissner et al., 2007
, Rodríguez et al., 2005
). Optimal rates may not be achieved even in the Veterans Health Administration system (Department of Veterans Affairs, Veterans Health Administration, 2008
, Department of Veterans Affairs, Veterans Health Administration. (2008). Hospital report card to the Appropriations Committee of the United States House of Representatives in response to Conference Committee Report to PL 110–186, accompanying Public Law 110–161, The Consolidated Appropriations Act, 2008. Available: http://www1.va.gov/health/docs/Hospital_Quality_Report.pdf. Accessed November 24, 2010.
Department of Veterans Affairs. Veterans Health Administration, 2009, October
), where cancer screening is available and included in systematically tracked performance measurement and incentives. Achieving screening may be hampered in part by comorbid mental illness.Department of Veterans Affairs. Veterans Health Administration. (2009, October). VHA facility quality and safety report. Department of Veterans Affairs. Veterans Health Administration. Office of Quality and Safety. Available: http://www1.va.gov/health/docs/HospitalReportCard2009.pdf. Accessed November 24, 2010.
Patients with mental illness may have multiple issues with health care, including problems accessing medical care (
Benjamin-Johnson et al., 2009
, Bradford et al., 2008
, Druss and Rosenheck, 1998
, Kilbourne et al., 2006
), limited financial resources, deficits in cognitive and social skills, and unstable living situations (Drapalski et al., 2008
). Other issues include a lack of trust in the system, inability to follow through with appointments (Miller et al., 2007
), and noncompliance with medical treatment recommendations (DiMatteo et al., 2000
). System factors such as scheduling challenges and delays (Kahn et al., 2005
, Meissner et al., 2007
), long wait times, lack of transportation, and no follow-up for missed appointments may contribute to screening disparities (Miller et al., 2007
). Among Veterans, financial and structural barriers to mental and medical health care may play less of a role than other barriers such as personal factors (Drapalski et al., 2008
, Washington et al., 2006
). These personal factors include personal crises, inability to explain oneself, inability to make an appointment, and forgetting appointments (Drapalski et al., 2008
).Previous research examining cancer screening in patients with mental illness found inconsistent results (
Lord et al., 2010
). Some of the inconsistencies in the literature may be due to different methods to ascertain screening (self-report, medical record review, databases), different recruitment methods and settings (inpatient, outpatient, community clinics, university clinics), and different definitions of mental illness. Studies have also been limited by focusing on one type of cancer screening, one type of mental illness, or not accounting for health care utilization and frequency of visits.We undertook this study to address gaps in the literature regarding mental illness and cancer screening in women Veterans. Women Veterans are a vulnerable population with consistently and markedly poorer physical and mental health status compared with non-Veteran women (
Frayne et al., 2006
, Skinner and Furey, 1998
). The VA electronic medical record system allows for data capture and identification of all women Veterans eligible for cancer screening. We examined VA electronic records for a cohort of New Mexico women Veterans to study the association of having a mental illness diagnoses with receipt of breast, cervical, and colon cancer screening. Our data provide greater detail than previous studies on this especially vulnerable population.Methods
Data Source
We used the VA electronic health record system, the Veterans Health Information Systems and Technology Architecture to identify the entire cohort of New Mexico VA Health Care System (NMVAHCS) female Veteran patients who were eligible for breast, cervical, and colorectal cancer screenings. We searched databases generated from the VA electronic health record for Veterans utilizing the NMVAHCS, which includes the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico, and 11 rural/non-metropolitan Community Based Outpatient Clinics and contract clinics.
Subjects
We identified all NMVAHCS living female patients who were ages 50 to 65 as of September 30, 2006 (n = 763). Women within this age range were selected because they would be eligible for breast, cervical, and colon cancer screenings. We then excluded non-Veteran women such as employees, Civilian Health and Medical Program of the Department of Veterans Affairs patients, and Department of Defense dependents (n = 10). Women for whom screening was deemed not warranted owing to illness or limited life expectancy were also excluded (n = 5). These five women were identified by notation made on an electronic clinical reminder by their health care provider. We also excluded 142 women who were not continuously enrolled (not assigned to a primary care team) during all 3 years at the NMVAHCS for the period from October 1, 2003 to September 30, 2006 (fiscal year 2004 to 2006). Our final cohort included 606 eligible women Veterans. Women with a history of breast (n = 32), cervical (n = 7), or colorectal cancer (n = 5) were excluded from the respective screening-eligible cohorts; 123 women with hysterectomies and no cervical cancer history were excluded from the cervical cancer screening cohort.
Measurements
Available extractable data included International Classification of Diseases-Ninth Revision (ICD-9) Codes (Appendix 1, Appendix 2), Common Procedural Terminology codes (Appendix 2), pathology records, and clinical screening reminders. We also performed a supplemental manual chart abstraction by searching/reading through the electronic health records for evidence of breast, cervical, and colon cancer screening to capture screening that may have been performed at facilities outside of the NMVAHCS, or testing done at the NMVAHCS not captured by the extracted data (such as screening information that was entered in a progress note, but not in a clinical reminder).
Independent Variables
The main independent variable was having a mental health diagnosis (MHD). We classified women as having an MHD if they had one or more ICD-9 psychiatric disorders coded in their electronic record from the fiscal year 2004 to 2006 period. We utilized the mental health ICD-9 diagnoses (Appendix 1) categorized by
Frayne et al., 2010
, where all conditions from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Primary Care Version, were reviewed by a panel of practicing internists who identified 10 categories representing psychiatric illness: Anxiety, depressed mood, dissociative symptoms, eating disorders, impulse control disorders, manic symptoms, personality disorders, psychosis, somatoform disorders, and substance use disorders. Panel consensus determined which codes would be omitted from the categories (e.g., “nicotine dependence,” 305.10, was omitted from the substance use disorder category because this was an individual non-psychiatric code). These ICD-9 codes categories were felt to be especially relevant for our study as we sought to determine receipt of and adherence to cancer screening (a primary care issue) for women Veterans with an MHD.Dependent Variables
The outcome variables for cancer screening included 1) having any screening test and 2) adhering to screening tests. Any screening was defined as receipt of (from the referent date of September 30, 2006): 1) breast cancer screening with mammography within the past 3 years, 2) cervical cancer screening with a Pap smear within the past 3 years, and 3) colorectal cancer with fecal occult blood tests (FOBT) within the past 3 years, flexible sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years (time frames consistent with colorectal cancer screening guidelines). Screening and diagnostic mammograms, flexible sigmoidoscopies, and colonoscopies were included because it was not always possible to discern between a screening and diagnostic examination.
We defined adherence to recommended screening for breast cancer and colorectal screening (proportional odds regression) by examining 1) the number of mammograms received in 3 years for breast cancer screening, and 2) the number of FOBTs received in 3 years, or receipt of one flexible sigmoidoscopy in 5 years or receipt of one colonoscopy in 10 years. Because Pap smears are recommended periodically every 1 to 3 years for cervical cancer screening, we only examined whether women had any Pap smears within 3 years and did not include cervical cancer screening as a dependent variable in the proportional odds regression.
Co-Variables
We abstracted socioeconomic and demographic data (age, race/ethnicity, insurance, service connection-eligibility for VA services based on disability by illness or injury in the line of duty during military service which confers priority access to VA health care; (
Druss et al., 2002
), clinical data (body mass index [kg/m2]; cancer history—diagnosis of breast cancer, cervical cancer, or colon cancer; history of hysterectomy); and health care utilization during fiscal 2004 to 2006 (visits to primary care, women’s health, and mental health clinics [Appendix 3, Appendix 4, Appendix 5]; and hospitalizations and visits to the emergency department).The Institutional Human Research and Review Committee at the University of New Mexico approved the study protocol.
Statistical Analysis
We compared demographic and clinical characteristics of women with an MHD to women without an MHD using t-tests for continuous data and chi-square tests for categorical data. Considering the cancer screening frequencies as response variables, we analyzed binary responses for ‘no screening’ versus ‘any screening.’ We coded receipt of one or more mammograms in 3 years as any breast cancer screening; one or more Pap smears in 3 years as any cervical cancer screening; and one or more FOBT in 3 years, one or more flexible sigmoidoscopy within 5 years, or one or more colonoscopy in 10 years as any colon cancer screening.
We also examined adherence to breast and colon cancer screening with a proportional odds analysis. Ordinal categorical responses were analyzed for three screening levels: 0 versus 1 or 2 or 3; 0 or 1 versus 2 or 3; and 0 or 1 or 2 versus 3, where 0 was no screening. For breast cancer screening, receipt of one mammogram in 3 years was coded as 1; two mammograms in 2 years was coded as 2; and three mammograms in 3 years was coded as 3. For colon cancer, completion of one FOBT in 3 years was coded as 1, two FOBTs in 3 years was coded as 2, and three FOBTs in 3 years, and/or one flexible sigmoidoscopy within 5 years, and/or one or more colonoscopies in 10 years were coded as 3. For colon cancer screening, we examined women who were 50 years and older in 2004 (52 years and older in 2006, n = 498) so as not to include women younger than 50 in the colon cancer screening analysis.
We calculated unadjusted odds ratios using logistic regression to determine whether receipt of cancer screening differed with having an MHD or not, then adjusted for the following potential confounding variables: Age, VA service connection, insurance status, and ambulatory care visits to primary care and women’s health clinics (where screening referrals would most likely occur). We did not include visits to mental health clinics in the adjustment as these are highly related to having an MHD. All analyses were performed using SAS 9.2 (SAS Institute, Inc., Cary, NC).
Results
Patient Characteristics
We identified 606 women who met inclusion criteria with a mean age of 57 ± 5 years (Table 1). Among the subjects, 53% had at least one mental health illness diagnosis: 42% had depression, 22% had anxiety, 16% had posttraumatic stress disorder, 4% had a substance use disorder, 4% had manic symptoms, 2% had psychosis, and 1% had a personality disorder. Women with an MHD were significantly more likely than women without an MHD to be service connected (49% vs. 36%), and have more hospital discharges and visits in the 3-year study period to primary care clinics, women’s health clinics, mental health clinics, and the emergency department.
Table 1Characteristics of Sample by Presence or Absence of an MHD
| Characteristics | All Subjects (n = 606) | MHD (n = 321) | No MHD (n = 285) | p-Value (Any MHD vs. No MHD) |
|---|---|---|---|---|
| Age (years) ± SD | 57.4 ± 5.4 | 57.2 ± 5.1 | 57.7 ± 5.7 | .20 (NS) |
| Body mass index (kg/m2) ± SD | 30.3 ± 7.3 | 30.1 ± 7.4 | 30.1 ± 6.9 | .67 (NS) |
| Insurance | 112 (15%) | 53 (13%) | 59 (17%) | .08 (NS) |
| Service connection | 321 (43%) | 192 (49%) | 129 (36%) | <.001 |
| Race/ethnicity | ||||
| Non-Hispanic White | 192 (32%) | 135 (42%) | 57 (20%) | <.0001 |
| Hispanic | 45 (7%) | 23 (7%) | 22 (8%) | |
| Black | 14 (2%) | 9 (3%) | 5 (2%) | |
| Native American | 12 (2%) | 5 (2%) | 7 (2%) | |
| Asian/Pacific Islander | 1 (<1%) | 1 (<1%) | 0 (0%) | |
| Unknown | 342 (56%) | 148 (46%) | 194 (68%) | |
| Breast cancer history | 32 (5%) | 21 (6%) | 11 (4%) | .14 (NS) |
| Cervical cancer history | 7 (1%) | 3 (1%) | 4 (1%) | .59 (NS) |
| Colon cancer history | 5 (1%) | 3 (1%) | 2 (1%) | .75 (NS) |
| Visits to Mental Health Clinics (fiscal 2004–2006), mean ± SD | 10 ± 39 | 18 ± 52 | 0.4 ± 2.0 | <.0001 |
| Number of visits to primary care clinics (fiscal 2004–2006), mean ± SD | 11 ± 11 | 13 ± 14 | 9 ± 7 | <.0001 |
| Number of visits to women’s health clinics (fiscal 2004–2006), mean ± SD | 1.9 ± 2.4 | 2.1 ± 2.7 | 1.7 ± 1.8 | <.05 |
| Number of visits to emergency department (fiscal 2004–2006), mean ± SD | 1 ± 2 | 2 ± 3 | 1 ± 2 | <.0001 |
| Number of hospital discharges (fiscal 2004–2006), mean ± SD | 0.33 ± 0.99 | 0.42 ± 1.1 | 0.22 ± 0.85 | <.01 |
Abbreviations: MHD, mental health diagnosis; NS, not significant; SD, standard deviation.
Association Between Mental Illness and Receipt of Any Breast, Cervical, or Colon Cancer Screening
Table 2 presents the findings for the bivariate analysis of receipt of any breast, cervical or colon cancer screening for women with an MHD compared with women without an MHD. Overall, 82% (468/571) of eligible women had breast cancer screening with one or more mammograms in 3 years; 82% (390/476) had cervical cancer screening with one or more Pap smear in 3 years, and 69% (346/498) had colon cancer screening with one or more FOBT in 3 years, one or more flexible sigmoidoscopy in 5 years, or one or more colonoscopy in 10 years. Women with an MHD were as likely as women without an MHD to receive any screening for breast cancer (81% vs. 83%), cervical cancer (84% vs. 80%), and colon cancer (69% vs. 70%) (all p-values were nonsignificant). Odds ratios (95% confidence intervals [CI]) for any breast cancer screening were: 1.12 (0.73–1.72) unadjusted, 0.79 (0.50–1.25) adjusted; for any cervical cancer screening: 0.75 (0.47–1.19), unadjusted, 1.71 (0.91–3.21), adjusted, and for any colon cancer screening: 0.90 (0.61–1.31) unadjusted, 0.85 (0.56–1.28) adjusted (all p-values were nonsignificant).
Table 2Any Cancer Screening Among Women Veterans With and Without MHD
| Any Cancer Screening | MHD (n = 321) | No MHD (n = 285) | Unadjusted OR (95% CI) | Adjusted OR (95% CI) |
|---|---|---|---|---|
| Breast | 241 (81%) | 227 (83%) | 1.12 (0.73–1.72) | 0.79 (0.50–1.25) |
| Cervical | 205 (84%) | 185 (80%) | 0.75 (0.47–1.19) | 1.71 (0.91–3.21) |
| Colon | 186 (69%) | 160 (70%) | 0.90 (0.61–1.31) | 0.85 (0.56–1.28) |
Abbreviation: MHD, mental health diagnosis (comparison is MHD vs. no MHD).
All p-values are nonsignificant.
Adjusted for age, service connection, insurance, visits to primary care and women’s health clinics.
Any breast cancer screening refers to receipt of ≥1 mammography in 3 years among the 571 women eligible for breast cancer screening. Any cervical cancer screening refers to receipt of ≥1 pap smear in 3 years among the 476 women eligible for cervical cancer screening. Any colon cancer screening refers to receipt of ≥1 FOBT in 3 years, or 1 flexible sigmoidoscopy in 5 years, or 1 colonoscopy in 10 years among the 498 women eligible for colon cancer screening.
Association Between Mental Illness and Adherence to Breast and Colon Cancer Screening
Table 3 presents the results of the proportional odds analysis examining adherence to recommended breast and colon cancer screening. Cervical cancer screening was not included in the proportional odds analysis because guidelines recommend Pap smears every 1 to 3 years, and we considered receipt of one Pap smear in 3 years to be adherent (these results are included in the bivariate analysis of any cervical cancer screening in women with MHD versus no MHD; Table 2). Women with an MHD were significantly less adherent to breast cancer screening compared with women without MHD, OR (95% CI) 0.73 (0.54–0.98; p < .05), unadjusted; OR (95% CI) 0.60 (0.44–0.82; p < .01), adjusted. Women with MHD were as likely to be adherent to colon cancer screening as women without MHD: OR (95% CI) 1.01 (0.73–1.38; p = .97), unadjusted, and OR 0.98 (0.70–1.37; p = .93), adjusted.
Table 3Adherence to Recommended Breast and Colon Cancer Screening Among Women Veterans With and Without an MHD
| MHD | No MHD | Unadjusted OR (95% CI) | Adjusted OR (95%CI) | |
|---|---|---|---|---|
| Breast cancer screening | ||||
| 0 | 56 (19%) | 47 (17%) | 0.73 (0.54–0.98) | 0.60 (0.44–0.82) |
| 1 | 100 (34%) | 69 (25%) | ||
| 2 | 101 (34%) | 110 (40%) | ||
| 3 | 40 (13%) | 48 (17%) | ||
| Colon cancer screening | ||||
| 0 | 85 (31%) | 67 (29%) | 1.01 (0.73–1.38) | 0.98 (0.70–1.37) |
| 1 | 43 (16%) | 41 (18%) | ||
| 2 | 42 (16%) | 43 (19%) | ||
| 3 | 99 (37%) | 78 (34%) | ||
Abbreviations: CI, confidence interval; MHD, mental health diagnosis (comparison is MHD vs. no MHD); OR, odds ratio.
Adjusted for age, service connection, insurance, visits to primary care and women’s health clinics. Odds ratios are from a proportional odds regression.
Breast cancer screening 0, 1, 2, and 3 refers to number of mammograms received in 3 years. Colon cancer screening 0, 1, 2, and 3 refers to number of FOBTs received in 3 years; receipt of 1 flexible sigmoidoscopy in 5 years or receipt of 1 colonoscopy in 10 years are coded as 3. Cervical cancer screening was not included in the proportional odds regression as guidelines recommend Pap smears every 1–3 years, and receipt of one Pap smear in 3 years was considered to be adherent.
∗ p < .05.
† p < .01.
Discussion
In our study of women Veterans using VA health care services, women with an MHD were less likely to be adherent to breast cancer screening compared with women without an MHD, but were as likely to be adherent to colon cancer screening, and to undergo any breast, cervical, and colon cancer screening. Previous studies show conflicting results regarding receipt of cancer screening for patients with mental illness (
Lord et al., 2010
). Our study differed from other studies in several important ways. First, our time frames to assess for screening and adherence may have been different. We used a 3-year time frame to account for any breast cancer screening with mammography, any cervical cancer screening with Pap smear, or any colon cancer screening with FOBT; a 5-year time frame for sigmoidoscopy; and a 10-year time frame for colonoscopy. Second, we used any MHD as our main independent variable. Other studies have used individual MHD as the main independent variable. Because the number of women in certain diagnostic categories in our sample was very small, we did not use individual diagnoses as the independent variable. Third, our sample included the entire cohort of women ages 50 to 65 eligible for breast, cervical, and colon cancer screening, enabling us to compare all women with an MHD with all women without an MHD. Fourth, screening was determined by using actual data from the electronic records and did not rely on patient recall.Our study finding of decreased adherence to breast cancer screening in women with MHD is similar to two studies that examined receipt of follow-up mammography as an outcome.
Carney and Jones, 2006
examined the influence of type and severity of mental illness on receipt of mammography screening. Severity was based on inpatient and outpatient mental health utilization and presence of comorbid substance use disorder. Having a mental disorder of medium severity or high severity was associated with decreased receipt of a follow-up mammogram within a 10- to 26-month time period from an initial mammogram. There was no association with low severity MHD and receipt of mammography. Pirraglia et al., 2004
found that women scoring highly on the Centers for Epidemiological Studies—Depression Score (a validated depression scale) were less likely to have a mammogram in the subsequent year after a baseline mammogram.We found no differences in the receipt of any breast (within 3 years), any cervical (within 3 years), or any colon (FOBT within 3 years, flexible sigmoidoscopy within 5 years, or colonoscopy within 10 years) cancer screening in women with MHD compared with women without MHD. However,
Druss et al., 2002
, found a negative association. Veterans with psychiatric and substance abuse disorders underwent less breast, cervical, and colon cancer screening (this last screening cohort included men and women). They used a more restrictive time frame of any mammography in the past 2 years, and any FOBT in the past year, or sigmoidoscopy or colonoscopy in the past 5 years. Their time frame for any Pap smear in the past 3 years was similar to ours.In studies examining the association of cancer screening with an individual MHD, schizophrenia was associated with a lower likelihood of having a mammogram in 2 years (
Chochinov et al., 2009
), and having a Pap smear in 3 years (Martens et al., 2009
). Data from the 1999 National Health Interview Survey found that subjects with depression were more likely to never have a mammogram than non-depressed women (Druss et al., 2008
). A case-control study found that women with psychosis (schizophrenia, bipolar disorder, schizoaffective disorder, or psychosis not determined) were less likely to have cervical cancer screening with a Pap smear in 3 years (Tilbrook et al., 2010
).Studies have also shown a positive association with cancer screening and an individual MHD. In a survey of randomly sampled women in a large health maintenance organization, those with past depressive symptoms were more likely to ever have had a mammogram (
Green and Pope, 2000
). An electronic medical record review found that women with depression were significantly more likely to receive colonoscopies and Pap smears than a control group of women with hypertension (Stecker et al., 2009
).Although the primary focus of our study was to examine MHD-related differences in cancer screening, the absolute screening proportions are notable as well. The majority of patients with an MHD received screening, but proportions were consistently below performance measure targets and lower than concurrently reported in the fiscal 2006 VA national data showing 85% adherence for breast cancer screening (defined as one or more mammograms in the past 2 years compared with our definition of one or more mammograms in the past 3 years), 91% for cervical cancer screening, and 76% for colorectal cancer screening (
Department of Veterans Affairs, Veterans Health Administration, 2008
). These proportions slightly increased by fiscal 2009: 87% for breast cancer screening, 92% for cervical cancer screening, and 80% for colorectal cancer screening (Department of Veterans Affairs, Veterans Health Administration. (2008). Hospital report card to the Appropriations Committee of the United States House of Representatives in response to Conference Committee Report to PL 110–186, accompanying Public Law 110–161, The Consolidated Appropriations Act, 2008. Available: http://www1.va.gov/health/docs/Hospital_Quality_Report.pdf. Accessed November 24, 2010.
Department of Veterans Affairs. Veterans Health Administration, 2010, October
). Although screening adherence has improved nationally, we need to determine whether Veterans with an MHD have seen improvements commensurate to those without an MHD.Department of Veterans Affairs. Veterans Health Administration. (2010, October). VHA facility quality and safety report. Department of Veterans Affairs. Veterans Health Administration. Office of Quality and Safety. Available: http://www.va.gov/health/docs/HospitalReportCard2010.pdf. Accessed November 24, 2010.
Limitations
We note the following limitations of our study. First, information about screening done at other non-NMVAHCS facilities may not have been included in the electronic database from which data was extracted. By performing manual chart abstractions on the electronic health records, we were able to access and review records from other VA sites to search for evidence of breast, cervical, and colon cancer screening. Additionally, our electronic clinical reminders database captures data on screening procedures done at non-VA facilities if this information is entered by a provider. Second, we conducted a post hoc power analysis and noted low power, suggesting the lack of significance for finding no association between an MHD and any screening for breast, cervical, or colon cancer may be an artifact of our relatively low sample sizes. Future research will require larger sample sizes to further examine the details of these relationships. Third, we used ICD-9 codes to identify women with an MHD, which can lead to the underdiagnosis of mental illness if not detected or documented (
Frayne et al., 2005
). Fourth, we could not ascertain providers’ intent; therefore, some diagnostic examinations could have been included in this review of screening. Fifth, we were unable to determine whether race/ethnicity was associated with screening owing to the high proportion of unknown race/ethnicity of the study population. This information is not routinely collected by the NMVAHCS. Data from the 2010 Census shows that New Mexico’s population is 46% Hispanic or Latino, 41% non-Hispanic White, 9% American Indian/Alaskan Native, 2% Black or African American, 1% Asian, and 1% Other (U.S. Census, 2010
). Hispanic ethnicity has been associated with decreased breast cancer screening (U.S. Census 2010. Available: http://2010.census.gov/2010census/data/. Accessed March 29, 2011.
Peek and Han, 2004
), cervical cancer screening (Sambamoorthi and McAlpine, 2003
), and colon cancer screening (Ioannou et al., 2003
).Within the VA, racial/ethnic gaps in colon cancer screening have not been reported for Veterans (Chao et al., 2009
, Dolan et al., 2005
, Yano et al., 2007
). However, in these studies, race/ethnicity was categorized as African American or White (Dolan et al., 2005
), or Black, White, or Other (combined Hispanic, Asian, and other races; Yano et al., 2007
), and did not include a separate category for Hispanic/Latino ethnicity.A strength of this study is that it did not rely on patient recall of screening procedures, but used actual data from the medical record. Recall data may be problematic owing to reliability and validity issues as Pap testing, mammography, sigmoidoscopy, and FOBT all tend to be overreported (
Vernon et al., 2004
). Another strength is that we accounted for relevant outpatient visit frequency. Higher visit frequency is associated with more colorectal cancer screening (Walter et al., 2009
, Yano et al., 2007
, Zimmerman et al., 2006
), perhaps because increased visits provide more opportunities for patients to be offered screening. Kodl et al., 2010
cautioned to account for outpatient visit frequency when examining mental health and colorectal cancer screening. We found that women with an MHD had significantly more primary care and women’s health clinic visits, and adjusted for these variables in the regressions.Conclusion
Women Veterans with mental illness are less likely to adhere to recommended breast cancer screening compared with women Veterans without mental illness. That we found inequities in breast cancer screening adherence in a vulnerable population of women with MHD using the Veterans Health Administration system is concerning. The Veterans Health Administration is the largest integrated health system in the United States, and successfully engineered a system-wide transformation to improve quality of care (
Perlin et al., 2004
). It decreases many barriers to care by providing access to care and services, mandating assignment of a primary care provider to enrolled patients (Chao et al., 2009
), and implementing integrated mental health and medical care through co-located general medical clinicians and nurses, and financial bonuses for mental health program leaders for achieving target quality performance (Escalona et al., 2001
, Kilbourne et al., 2010
). Integrated medical and mental care has demonstrated improved quality of care and outcomes in serious mental illness (Druss et al., 2001
). Such integration, including better communication and linkages between the two disciplines, and addressing patient, provider, and systems barriers to care may help to optimize cancer screening rates among women with mental health problems (Miller et al., 2007
).The VA’s implementation of systematic quality improvement initiatives, performance measurement and reporting, use of clinical information systems, electronic reminders, payment and reimbursement systems may all contribute to improved quality, including cancer screening (
Jha et al., 2003
, Perlin et al., 2004
) and can serve as an example to improve quality of care for all patients. Innovative approaches to care such as population-based approaches to implement cancer screening using clinical information systems to identify eligible patients and monitoring utilization and outcomes may be a way to improve screening rates (Hoffman et al., 2011
). Clinical information systems and population-based screening could be used to identify barriers and to suggest interventions for women who are not accomplishing recommended screening.Women with mental illness may require more intensive efforts to achieve optimal rates of recommended breast cancer screening, but further research is needed in this area. Next steps include obtaining data from larger populations and multiple datasets, longitudinal analyses of cancer screening initiatives and outcomes including population-based screening, and determining the effect of race/ethnicity on cancer screening in women Veterans with mental illness.
Acknowledgments
The authors thank and acknowledge Ms. Stephanie Maturino for her assistance with this study.
Disclaimer
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or any other individuals or organizations.
Appendix 1. ICD-9 Codes for MHD
Tabled
1
Source:
Frayne et al., 2010
.| Diagnosis | Codes |
|---|---|
| Anxiety | 291.89, 292.89, 300.00–300.02, 300.21–300.23, 300.29, 309.24, 309.81, 300.30, 308.30 |
| Depression | 291.89, 292.84, 296.20–296.25, 296.30–296.35, 296.50–296.55, 296.60–296.65, 296.89, 309.28, 300.40, 309.00, 311.00 |
| Dissociative symptoms | 300.12–300.15, 300.60 |
| Personality disorder | 301.20, 301.22, 301.50, 301.81–301.83, 301.00, 301.40, 301.60, 301.70, 301.90 |
| Impulse control | 312.30–312.34, 312.39 |
| Manic symptoms | 291.89, 292.84, 296.00–296.05, 296.40–296.45, 296.60–296.65, 296.80, 296.89, 301.13, 296.70 |
| Substance abuse | 291.81, 291.89, 292.11–292.12, 292.81, 292.84, 292.89, 303.00, 303.90, 304.00, 304.10, 304.20, 304.30, 304.40, 304.50, 304.60, 304.90, 305.00, 305.20, 305.30, 305.40, 305.50, 305.60, 305.70, 305.90, 291.00, 291.30, 291.50, 291.90, 292.00, 292.90 |
| Psychosis | 295.00–295.40, 295.60, 295.70, 295.90 |
| PTSD | 309.81 |
| Unexplained physical symptoms | 300.11, 300.70, 300.81, 307.80, 307.89 |
| Weight change/eating disorder | 307.10, 307.50, 307.51 |
Appendix 2. ICD-9 and CPT Codes for Cancer Screening
Tabled
1
| Screening | Codes |
|---|---|
| Breast cancer | CPT codes: 77051, 77052, 77056, 77057 |
| ICD-9: V76.11, V76.12 | |
| Cervical cancer | CPT codes: 88141–88143, 88147–88148, 88150, 88152, 88153–88155, 88164–88167, 88174–88175 |
| Colon cancer screening | |
| FOBT | CPT Codes: 82270, 82273, 82274 |
| Colonoscopy | CPT codes: 44388–44394, 45355, 45378–45385 |
| ICD-9: v76.41, v76.51 | |
| Sigmoidoscopy | CPT codes: 45300, 45303, 45305, 45308, 45309, 45315, 45320, 45330–45334, 45337–45339 |
Abbreviations: CPT, Common Procedural Terminology; FOBT, fecal occult blood test; ICD, International Classification of Diseases.
Appendix 3. Mental Health Stop Codes
Tabled
1
| Mental Health Stop Code Name | Stop Code |
|---|---|
| ALCOHOL SCREENING | 706 |
| DAY HOSPITAL-GROUP | 554 |
| DAY HOSPITAL-INDIVIDUAL | 506 |
| DAY TREATMENT-GROUP | 553 |
| DAY TREATMENT-INDIVIDUAL | 505 |
| MENTAL HEALTH CLINIC - INDIVIDUAL | 502 |
| MENTAL HEALTH CLINIC-GROUP | 550 |
| MENTAL HEALTH CONSULTATION | 512 |
| MENTAL HEALTH TELEPHONE | 527 |
| MENTAL HEALTH COMPENSATED WORK THERAPY SUPPORTED EMPLOYMENT FACE TO FACE | 568 |
| MENTAL HEALTH COMPENSATED WORK THERAPY SUPPORTED EMPLOYMENT NON FACE TO FACE | 569 |
| MENTAL HEALTH COMPENSATED WORK THERAPY/TRANSITIONAL WORK EXPERIENCE FACE TO FACE | 574 |
| TRANSITIONAL WORK EXPERIENCE NON FACE TO FACE | 570 |
| MENTAL HEALTH INCENTIVE THERAPY FACE TO FACE | 573 |
| MENTAL HEALTH INTERVENTION BIOMEDICAL CARE GROUP | 565 |
| MENTAL HEALTH INTERVENTION BIOMEDICAL CARE INDIVIDUAL | 533 |
| MENTAL HEALTH PRIMARY CARE - GROUP | 563 |
| MENTAL HEALTH RESIDENTIAL CARE INDIVIDUAL | 503 |
| MENTAL HEALTH RISK FACTOR REDUCTION GROUP | 566 |
| MENTAL HEALTH TEAM CASE MANAGEMENT | 564 |
| MENTAL HEALTH VOCATIONAL ASSISTANCE - INDIVIDUAL | 535 |
| MENTAL HEALTH VOCATIONAL ASSISTANCE - GROUP | 575 |
| MENTAL HEALTH INTENSIVE CASE MANAGEMENT - GROUP | 567 |
| MENTAL HEALTH INTENSIVE CASE MANAGEMENT - INDIVIDUAL | 552 |
| PSYCHIATRY - GROUP | 557 |
| PSYCHIATRY - INDIVIDUAL | 509 |
| PSYCHOGERIATRIC - GROUP | 577 |
| PSYCHOGERIATRIC - INDIVIDUAL | 576 |
| PSYCHOGERIATRIC DAY PROGRAM | 578 |
| PSYCHOLOGICAL TESTING | 538 |
| PSYCHOLOGY-GROUP | 558 |
| PSYCHOLOGY-INDIVIDUAL | 510 |
| PSYCHOSOCIAL REHAB - GROUP | 559 |
| PSYCHOSOCIAL REHAB - INDIVIDUAL | 532 |
| POSTTRAUMATIC STRESS DISORDER - GROUP | 516 |
| POSTTRAUMATIC STRESS DISORDER - INDIVIDUAL | 562 |
| POSTTRAUMATIC STRESS DISORDER CLINICAL TEAM INDIVIDUAL | 540 |
| POSTTRAUMATIC STRESS DISORDER DAY HOSPITAL | 580 |
| POSTTRAUMATIC STRESS DISORDER DAY TREATMENT | 581 |
| POSTTRAUMATIC STRESS | |
| SUBSTANCE USE DISORDER HOME VISIT | 514 |
| SUBST USE DISORDER/PTSD TEAMS | 519 |
| SUBSTANCE USE DISORDER INDIVIDUAL | 513 |
| SUBSTANCE USE DISORDR GROUP | 560 |
| WOMEN’S STRESS DISORDER TEAMS | 525 |
Appendix 4. Women’s Health Stop Codes
Tabled
1
| Stop Code Name | Stop Code |
|---|---|
| COMPREHENSIVE WOMEN'S HEALTH | 322 |
| GYNECOLOGY | 404 |
| WOMEN'S GENDER SPECIFIC PREVENTIVE CARE | 704 |
Appendix 5. Primary Care Stop Codes
Tabled
1
| Stop Code Name | Stop Code |
|---|---|
| GENERAL INTERNAL MEDICINE | 301 |
| PRIMARY CARE SHARED APPOINTMENT | 348 |
| PRIMARY CARE/MEDICINE | 323 |
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Biography
Ellen F. T. Yee, MD, MPH, FACP, is a Professor of Medicine at the New Mexico VA Health Care System (VAHCS) and University of New Mexico School of Medicine. She is a General Internist with an interest in women’s health and cancer screening.
Robert White, MD, MPH, emeritus Professor of Medicine at the New Mexico VAHCS and the University of New Mexico School of Medicine, is the Medical Informatics Director of ABQ Health Partners. His interests are in the Primary Care Medical Home, electronic medical record implementation, use of electronic databases, and improvement of the quality of care.
Sang-Joon Lee, PhD, is an Assistant Professor of Epidemiology and Biostatistics, Department of Internal Medicine at the University of New Mexico School of Medicine. His work focuses on Clinical Trial Design, and Statistical Analysis of Cancer and Hanta Virus research.
Donna L. Washington, MD, MPH, is a Professor of Medicine at the VA Greater Los Angeles HSR&D Center of Excellence and UCLA School of Medicine. She is a General Internist whose research examines health care access and quality for women and racial/ethnic minorities, with a focus on Veterans and VA health care.
Elizabeth M. Yano, PhD, MSPH, is Co-Director and a Research Career Scientist at the VA Greater Los Angeles HSR&D Center of Excellence and Adjunct Professor of Health Services at the UCLA School of Public Health. Her work focuses on organizational influences on quality.
Glen Murata, MD, is a Professor of Medicine at the New Mexico VAHCS and the University of New Mexico School Medicine, and Chief of Outcomes Research at the New Mexico VAHCS. He is a General Internist whose work examines diabetes care and focuses on using databases in outcomes research.
Christine Handanos, MD, was previously a staff physician at the New Mexico VAHCS and previously an Assistant Professor of Medicine at the New Mexico VA Health Care System, University of New Mexico School of Medicine. She is an endocrinologist currently in private practice with the Southern Maine Medical Center Primecare Physicians in Biddeford, Maine.
Richard M. Hoffman, MD, MPH, is a Staff Physician at the New Mexico VAHCS and Professor of Medicine at the University of New Mexico School of Medicine. He is a general internist whose research examines prostate cancer and colon cancer screening and decision making.
Article info
Publication history
Accepted:
April 20,
2011
Received in revised form:
April 19,
2011
Received:
December 1,
2010
Footnotes
Supported by an American Cancer Society Institutional Research Grant. ACS IRG-3R19U.
Dr. Yano's time was covered by a VA HSR&D Research Career Scientist award (Project No. 05-195).
Identification
Copyright
Published by Elsevier Inc.
