Browsing by Author "Crego, Nancy"

Background: Acute myeloid leukemia (AML), a rare blood cancer affecting white blood cells, currently impacts approximately 20,380 people living in the U.S. Currently, the 5-year survival rate of AML is 31.7% with Black patients experiencing higher rates of mortality compared to White patients. Black patients have been disproportionately impacted by socioeconomic distress related to historical trauma, social injustices, higher levels of poverty, minimal insurance coverage, and experience higher cancer burden compared to Whites. However, additional research is needed to understand factors that may have contributed to racial disparities among adults with AML. The impact of the cancer care system on health disparities among Black patients has not been well described in the literature. The purpose of this dissertation is to increase understanding of racial disparities in adults with AML and explore factors that may impact disparate outcomes among Black patients.

Methods: A literature review, a qualitative study and a secondary data analysis were used to understand racial disparities in AML and factors that contribute to poor outcomes. The literature review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement to explore disparities in health outcomes among adult survivors of acute leukemias. A total of twenty-five full text published articles were analyzed and included in the synthesis. A qualitative descriptive design was used to explore barriers and facilitators of navigating the cancer care system among a sample of 16 Black adult patients treated with AML at a large comprehensive cancer center. Study findings were analyzed using thematic analysis. Interviews were recorded and coded by two independent coders using Braun and Clark’s method of thematic analysis. A secondary data analysis of cancer registry data was conducted to assess the impact of facility type on the relationship between race and cancer health outcomes (i.e., time to death and time to hematopoietic stem cell transplant) among a sample of 1201 patients with AML. Descriptive statistics were used to explore the structure of the dataset and assess the distribution of the variables. Bivariate analysis was used to examine the differences in facility types across race. Mediation analysis was used to test the mediation effect of facility type on the relationships between race and the health outcomes (time to death and time to HSCT).Results: Identifying as Black, having Hispanic ethnicity, being male, older age, living in areas of high poverty, lack health insurance, and having Medicaid as primary insurance were least favorable conditions for survival among adult AML patients. However, there were limited published qualitative studies exploring the experience of navigating cancer care among adult Black patients with AML. There were also limited published quantitative studies examining causal factors of health disparities among Black patients with AML. The qualitative descriptive study found that Black patients perceived barriers to positive cancer care experiences were discriminatory practices and scarcity in available matched hematopoietic stem cell transplant (HSCT) donors. However, social support, patient-centered care, and empathy from others were perceived as facilitators to care. The secondary data analysis provided evidence the type of facility patients present to for cancer screening may not facility the relationship between race and health outcomes time to death and time to HSCT; however, structural racism does facility this relationship. More research is needed to identify how access to cancer care may contribute to structural racism.

Conclusion: Findings from this dissertation provide empirical data for expanding our understanding factors of the existing racial disparities in cancer care, barriers and facilitators to successful navigation of the cancer care system for Black patients and evidence to identify factors that contribute to structural racism within cancer care. Improving educational curriculum to help clinicians identify signs and symptoms of AML in smaller healthcare and primary care settings, improving insurance coverage for AML treatments and supportive care needs, increasing disease-specific cancer care navigators or social workers, and developing pathways to care for diagnosing AML may be needed to mitigate racial disparities in AML.

In the United States of America, Sickle Cell Disease (SCD) affects 100,000 Americans, predominantly African Americans. In North Carolina (NC), there are approximately 5,578 people living with SCD, which includes both children and adults. Of those affected, 39% are 18 years of age or younger. Strokes are a major disease-related complication that children with SCD too often experience. Some complications include motor and cognitive delays, neurodevelopmental delays (NDD), decline in academic learning and attainment, poor test scores, high school dropout and/or unemployment (later in life). The purpose of this dissertation was to address the problems of stroke prevention and NDD in children with SCD. Therefore, we analyzed hydroxyurea (HU) adherence as well as transcranial Doppler (TCD) screening prevalence and proportion in a statewide Medicaid sample in an attempt to evaluate primary stroke prevention in children ages 2 to 16 years old with SCD. The purpose of this dissertation was achieved through a systematic literature review that explored the prevalence, severity, and associated risk factors for NDD in children with SCD less than or equal to 5 years. Secondary data analyses of the NC Medicaid database was used to examine the following: 1) HU adherence rates for 12- and 24-month cohorts; 2) associations of individual related sociodemographic characteristics with HU adherence; 3) the prevalence rate of children with annual TCD screenings; 4) the proportion of children with zero, 1, 2, 3 or more TCD screening claims; and 5) the prevalence rate of TCD screening claims for age, sex, residential location, and HU adherence. The methods used in the data chapters were descriptive statistics, frequencies, percentages, and chi-square was used to determine differences in HU adherence for both the 12 and 24-month cohorts (Chapter 3), Cochran-Armitage Trend Test and the Cochran-Mantel-Haenszel Test were used to evaluate the proportion of TCD claims with 2, 3, and more levels (Chapter 4), and a Poisson Regression was used to fit the effect of TCD screening claims on sociodemographic characteristics, HU adherence, and to determine the rate of TCD screenings for each of the individual predictor variables (Chapter 4). The findings from this dissertation highlighted a wide range of motor and language deficits among children ages 0 to 5 years old with SCD (Chapter 2). Other major findings included low HU utilization (Chapter 3) and low TCD screening prevalence (Chapter 4) among children ages 2 to 16 years old with SCD on NC Medicaid. Additionally, children with poor HU adherence were less likely to have TCD screening claims (Chapter 4). Therefore, tailored interventions are needed to help mitigate the problems of poor HU utilization as well as TCD screening rates among children with SCD.