UCSF Study of Medi-Cal Recipients Shows Barriers to Screening
Women enrolled in California’s Medicaid program (Medi-Cal) who have been diagnosed with severe mental illness have been screened for cervical cancer at much lower rates than other women, according to a new study by researchers at UC San Francisco.
In an examination of California Medicaid administrative records for 31,308 women from 2010 and 2011, the UCSF scientists found that only 20.2 percent of women with severe mental illness were screened for cervical cancer during the one-year study period. Over the same period, the screening rate for the general population of women in California was calculated to be 42.3 percent.
Although women with severe mental health problems are less likely to be screened for cervical cancer, they are at greater risk for developing the disease, according to the senior author of the study, Christina Mangurian, MD, associate professor of clinical psychiatry at UCSF. She directed the study with Dean Schillinger, MD, a UCSF professor of medicine and member of the UCSF Helen Diller Family Comprehensive Cancer Center.
“The women were receiving services in a public health setting, but were not receiving preventive services as often as women in the general population,” Mangurian said. “The results of this very large study indicate that we need to better prioritize cervical cancer screening for these high-risk women with severe mental illnesses.”
In their analysis of the data, published online April 17, 2017, in the journal Psychiatric Services, the researchers considered possible predictors of screening rates, including age, race or ethnicity, rural versus urban residence, severe mental illness diagnosis, drug or alcohol use, and evidence for use of health care services.
They discovered that factors significantly associated with cervical cancer screening in the study population included age, race or ethnicity, specific mental health diagnosis — and most of all, utilization of primary care services, not just specialty mental health services.
Among the women with severe mental illness included in the study, 42 percent had some form of schizophrenia, 29 percent had major depression, 18 percent had bipolar disorder, and the remainder had a diagnosis of anxiety or another psychiatric diagnosis.
While any psychiatric diagnosis of severe mental illness in the study was associated with a lower screening rate than found in the general population, when the researchers adjusted the analysis to account for a history of drug or alcohol use, they found that women with bipolar disorder, major depressive disorder, or generalized anxiety disorder were more likely than those with schizophrenia to have been screened. Overall, the researchers did not identify any significant difference in screening rates related to a history of drug or alcohol use.
Previous research shows that there are increased rates of smoking and larger numbers of lifetime sexual partners among women with severe mental illness, putting them at higher risk for cervical cancer, Mangurian said.
Using data on Pap test collection from this cohort of women with a severe mental health diagnosis, the study authors found that, although the differences were not great, compared to white women, women from minority groups had significantly higher screening rates for cervical cancer. Asian women had the highest screening rate overall at 22.5 percent. Black women were screened at a rate of 20.9 percent and white women at a rate of 19.0 percent.
The researchers found that younger women ages 18 to 27 with severe mental illness ages were 30 percent less likely to be screened than similarly afflicted women ages 28 to 47, mirroring differences in screening by age in the broader population of California women.
The 74 percent of patients with evidence of primary care visits were three times more likely to have been screened than those for whom there was no evidence of such health care use. Health care use was the factor most closely linked to likelihood of screening in the study.
“More research is required to better understand why cervical cancer rates are so much higher in this population of women with severe mental illnesses, but I think we already know enough to begin evaluating strategies for removing barriers to care,” said Schillinger.
Schillinger and Mangurian suggested that using specialty mental health clinics as the “medical home” for women with severe mental illness by periodically providing “women’s mini-clinics” on site could help alleviate screening disparities.
Additional UCSF coauthors of the study are Melanie Thomas, MD, assistant professor of psychiatry; medical resident Latoya Frolov, MD, MPH; research assistant Nick Riano; and Eric Vittinghoff, PhD, professor of epidemiology and biostatistics.
Major sources of funding for the study were grants from the National Institutes of Health to Mangurian and Schillinger.
UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland – and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.