Disparities
Call for Papers
Disparities & the Care of Children
Chair: Anne Beal, M.D., M.P.H.
Monday, June 7 • 8:30 a.m.-10:00 a.m.
• Disparities for Latino Children in Receipt of Timely
Medical Care
David Brousseau, M.D., M.S., Jennifer Yauck, M.S., Raymond
Hoffmann, Ph.D., Ann Nattinger, M.D., M.P.H., Glenn Flores,
M.D.
Presented by: David Brousseau, M.D., M.S., Assistant
Professor, Pediatrics, Medical College of Wisconsin, 9000 W
Wisconsin Avenue, Milwaukee, WI 53226; Tel: 414.266.2625;
Fax: 414.266.2635; E-mail: dbrousse@mail.mcw.edu
Research Objective: Latinos (Ls) are now the largest minority
population in the US, but little is known about whether L
children experience disparities in their ability to access
healthcare in a timely fashion. Our objective was to compare
the parent-reported ability of children to get timely care among
L, White (W) and African-American (AA) children.
Study Design: Cross-sectional analysis of the 2000 Medical
Expenditure Panel Survey
Population Studied: We analyzed data from the 2000
Medical Expenditure Panel Survey for children 0-17 years old
with a usual source of care. Data were weighted to provide
national population based estimates. Parental survey
responses were used to evaluate the timeliness of care
children receive in four areas: 1) timely routine care from a
provider, 2) timely illness or injury care from an office, clinic or
ED, 3) phone help from a provider, and 4) brief wait time with
appointment. The percent of children always receiving timely
care was compared between L and W and AA children.
Multiple logistic regression, with Ls as the referent group to
allow comparisons to both Ws and AAs, was done to
determine the odds of always receiving timely care, adjusting
for known confounders. The regression was then repeated
adding the effect of interview language.
Principal Findings: 4,120 children, weighted to represent 47
million children, were included in the analysis. The average
age was 8 years, 51% were male, 24% were covered by
Medicaid. 30% were Ls, 53% Ws and 17% AAs. In univariate
analysis, L children were significantly (p<0.005) less likely to
always receive timely care compared to Ws and AAs
respectively in 3 areas: routine care 44% vs. 54% and 54%;
phone help 40% vs. 49% and 47%; and brief wait time 36%
vs. 55% and 44%, but not illness care 61% vs. 66% and 64%.
Multivariate regression revealed increased odds (OR, 95% CI),
compared to Ls, for Ws and AAs, in the same 3 areas: routine
care: W (1.28,1.04-1.56), AA (1.48, 1.15-1.98); phone help: W
(1.37, 1.16-1.62), AA (1.29, 1.05-1.58); brief wait time: W (1.96,
1.66-2.32), AA (1.43, 1.16-1.76). Adding interview language to
the regression decreased the differences between groups:
routine care: W (1.19, 0.95-1.50), AA (1.38, 1.04-1.82); phone
help: W (1.28, 1.07-1.54), AA (1.20, 0.96-1.50); brief wait times:
W (1.65, 1.38-1.99), AA (1.19, 0.95-1.49).
Conclusions: Latino children experience marked disparities in
obtaining timely medical care. These differences are only
partially explained by language differences.
Implications for Policy, Delivery or Practice: Improvements
are needed in the delivery and efficiency of medical care for
Latino children.
Primary Funding Source: Ambulatory Pediatric Association
• Children at Risk of Receiving Sub-standard Asthma Care Findings from a Nationally Representative Sample
Alex Chen, M.D., MSHS, Jose Escarce, M.D., Ph.D., Ronald
Ferdman, M.D., M.Ed.
Presented by: Alex Chen, M.D., MSHS, Assistant Professor,
Pediatrics, Childrens Hospital Los Angeles, 4650 Sunset
Boulevard, MS# 30, Los Angeles, CA 90027; Tel: 323.671.7620;
E-mail: alexchen_y@yahoo.com
Research Objective: To examine socioeconomic and
demographic factors associated with sub-standard quality of
care in children with asthma.
Study Design: This is a secondary data analysis of the
Medical Expenditure Panel Survey (MEPS) using the
Household Full Year File and the Prescribed Medicines Event
File from 1996-2000. All children 5-17 years of age with
asthma were identified using ICD-9 codes. The Event File for
those children was linked to the Household File. The name,
formulation, and quantity of prescribed medicine filled during
the year for those children were counted and categorized as
inhaled short-acting beta2 agonists (SAB), inhaled
corticosteroids, inhaled cromolyn, oral corticosteroids, longacting beta2 agonists, leukotriene modifiers, and theophylline.
Guidelines for the Diagnosis and Management of Asthma
(NHLBI expert panel reports) were used to establish four
criteria, based on medication usage, for sub-standard asthma
care: 1) >= 4 months supply of SAB filled per year without any
primary controller (defined as inhaled corticosteroids, inhaled
cromolyn, leukotriene modifiers) in the same year; 2) >= 2
Emergency Department visits per year without a primary
controller prescription; 3) >= 1 hospital admissions per year
without a primary controller prescription; and 4) >= 2 courses
of oral corticosteroids per year without a primary controller
prescription. Univariate and multivariate logistic regression
analyses were conducted using person-year as the unit of
analysis. All analyses were weighted to account for sample
design and survey nonresponse. Standard errors were
adjusted for clustering at the person level.
Population Studied: A nationally representative sample of
children 5-17 years of age with asthma who are also eligible for
any one of the four sub-standard care criteria (for example, a
child is eligible for criteria 1 if he/she had >= 4 months supply
of SAB during the year; a child fulfills criteria 1 if he/she also
did not have a prescription for any primary controller).
Principal Findings: Among U.S. children 5-17 years of age
with asthma, 21.4 % received >= 4 months supply of SAB
during the year. Among those that received >= 4 months
supply of SAB, 52.8 % did not receive a prescription for any
primary controller that year. Among children eligible for any
one of the four criteria, children of mothers with high school
diploma or higher were less likely to have sub-standard care
compared to children of mothers with lower education
(O.R.=0.32, p=0.02), adjusted for race, age, family income,
health status, and insurance status. Having Medicaid or
SCHIP was also protective against sub-standard asthma care
(O.R.=0.23, p=0.06).
Conclusions: A substantial percentage of children in the U.S.
received sub-standard quality of care for asthma as assessed
by medication usage and visit patterns. Children of mothers
who have not completed high school were at significantly
increased risk for sub-standard care, Medicaid and SCHIP
reduced the risk of sub-standard care.
Implications for Policy, Delivery or Practice: Efforts should
continue to enroll children in SCHIP or Medicaid. Additional
resources may need to be directed toward children of mothers
with low educational backgrounds. Health Plans can adopt
standards from practice guidelines to identify patients
receiving sub-standard care using pharmacy and/or claims
data.
Primary Funding Source: Intramural
• Does Disadvantage Start at Home? Racial and Ethnic
Disparities in Early Childhood Home Routines, Safety, and
Educational Practices/Resources
Glenn Flores, M.D., Lynn Olson, Ph.D, Sandra Tomany, M.S.
Presented by: Glenn Flores, M.D., Director, Community
Outcomes; Associate Director, Center for the Advancement of
Urban Children, Pediatrics, Medical College of
Wisconsin/Children's Hospital of Wisconsin, 8701 Watertown
Plank Road, Milwaukee, WI 53226; Tel: 414.456.4454; Fax:
414.456.6385; E-mail: gflores@mail.mcw.edu
Research Objective: Little is known about whether
racial/ethnic differences exist in the home environment in
family activities, safety, and educational opportunities known
to impact healthy development, behavior, and future school
success in young children. The study goal was to examine
whether there are racial/ethnic disparities in early childhood
home routines, safety, and educational practices/resources.
Study Design: The 2000 National Survey of Early Childhood
Health is a telephone survey of a national random sample of
responsible parents/guardians of 2,608 children aged 4 to 35
months. Differences in selected shared family activities, safety
practices, and educational practices and resources were
examined for non-Latino white (W), non-Latino AfricanAmerican (AA), and Latino (L) children (sample sizes were
inadequate to analyze other racial/ethnic groups). STATA was
used for statistical analyses, national estimates, and to obtain
odds ratios (ORs) and 95% confidence intervals (CIs) by
multivariate analyses adjusting for insurance coverage, health
status, family income, age, parental education, and language
of interview.
Population Studied: A national random sample from all 50
states of parents/guardians of 2,608 children aged 4 to 35
months.
Principal Findings: W children are significantly more likely
than minority children to have their meals at the same time
each day (80% vs. 70% for Ls and 65% for AAs; P<0.001) and
go to bed at the same time each day (76% vs. 69% for Ls and
65% for AAs; P<0.001). Minority children are significantly
more likely to never eat lunch or dinner together with their
family or to do so only 1-2 days/week (AAs, 26%; Ls, 26%; Ws,
10%; P<0.001). Minority parents are significantly more likely
to want to spend a lot more time with their child (AAs, 29%;
Ls, 29%; Ws, 20%; P<0.001). Minority parents are
significantly less likely to install baby gates (AAs, 62%; Ls,
67%; Ws, 82%; P<0.001) and put safety latches/locks on
cabinets (AAs, 73%; Ls, 78%; Ws, 85%), and AA parents are
less likely to turn down hot water settings (45% vs. 56% in Ws
and 60% in Ls; P<0.001). There are high rates (> 90%) of
putting plugs in electrical outlets that do not differ by
race/ethnicity, and minorities are more likely to put padding
on hard/sharp surfaces (AAs, 58%; Ls, 58%; Ws, 46%;
P<0.001). Minority parents are significantly less likely to read
every day to their child (Ls, 29%; AAs, 46%; Ws, 61%;
P<0.001), Latino parents are more likely to never read to their
child (15% vs. 5% for AAs and 3% in Ws; P<0.001) and
minority households have a lower mean number of children’s
books (Ls, 33; AAs, 41; Ws, 83; P<0.001). AA children average
a significantly greater number of hours watching TV daily (2.4
vs. 1.6 in Ws and 1.6 in Ls), but AA parents are most likely to
play music and sing with their child (84% vs. 76% in Ws and
65% in Ls; P<0.001). Disparities persisting in multivariate
analyses included: AA children not having regular meal times
(OR, 1.8; 95% CI, 1.2-2.6), eating lunch or dinner together less
than every day (OR, 2.0; 95% CI, 1.4-2.8), and watching an
average of about 1 more hour of TV daily; AA parents wanting
to spend a lot more time with their children (OR, 1.6; 95% CI,
1.1-2.4), not turning down hot water settings (OR, 1.5; 95% CI,
1.1-2.1), and not installing cabinet safety locks (OR, 1.8; 95%
CI, 1.2-2.7); minority parents having about twice the odds of
not reading to their child daily (Ls: OR, 1.9; 95% CI, 1.3-2.6;
AAs: OR, 1.7; 95% CI, 1.2-2.4) and of not putting up baby gates
(AAs: OR, 2.4; 95% CI, 1.6-3.5; Ls: OR, 1.8; 95% CI, 1.2-2.7);
and minority homes having significantly fewer children’s
books (adjusted mean number of books per household: AAs: 32 [95% CI, -42, -22]; Ls: -23 [95% CI, -36, -12]). Language of
interview adjustment eliminated L disparities for never reading
to children and mitigated the number of children’s books at
home. In multivariate analyses, children whose parents
completed surveys in Spanish also experienced multiple
disparities (compared with children completing English
surveys), including quadruple the odds of never being read to
by their parents, almost triple the odds of the parents not
putting stoppers or plugs in electrical outlets, an average of 33
fewer children’s books in the household, and increased odds
of irregular meal times.
Conclusions: Young minority children experience multiple
disparities in home routines, safety, and educational practices
and resources that have the potential to impede their healthy
development, behavior, personal safety, and future school
success. The greatest number and severity of disparities
generally occur in African-American children, and daily reading
and children’s books in the home are alarmingly uncommon
for Latino children. Children of parents completing surveys in
Spanish also experience multiple disparities.
Implications for Policy, Delivery or Practice: The study
findings suggest that disparities in early childhood home
routines, safety, and educational practices and resources for
minority children and those whose parents complete surveys
in Spanish might be reduced or eliminated through targeted
family education and interventions by pediatric providers.
Primary Funding Source: RWJF, Agency for Healthcare
Research and Quality
• Unequal Treatment for Young Children? Racial and
Ethnic Disparities in Early Childhood Health and
Healthcare
Glenn Flores, M.D., Lynn Olson, Ph.D., Sandra Tomany, M.S.
Presented by: Glenn Flores, M.D., Director, Community
Outcomes; Associate Director, Center for the Advancement of
Urban Children, Pediatrics, Medical College of
Wisconsin/Children's Hospital of Wisconsin, 8701 Watertown
Plank Road, Milwaukee, WI 53226; Tel: 414.456.4454; Fax:
414.456.6385; E-mail: gflores@mail.mcw.edu
Research Objective: Racial/ethnic disparities in healthcare
recently have received much national attention, but few
studies have focused on disparities in children, especially in
the youngest age groups. The study aim was to examine
racial/ethnic disparities in early childhood health and
healthcare using a nationally representative sample.
Study Design: The 2000 National Survey of Early Childhood
Health is a telephone survey of a national random sample of
parents/guardians of 2,608 children aged 4 to 35 months.
Differences in selected health and healthcare measures were
examined for non-Latino white (W), non-Latino AfricanAmerican (AA), and Latino (L) children (sample sizes were
inadequate to analyze other racial/ethnic groups). STATA was
used for statistical analyses, national estimates, and to obtain
odds ratios (ORs) and 95% confidence intervals (CIs) by
multivariate analyses adjusting for insurance coverage, health
status, family income, age, parental education, and language
of interview.
Population Studied: A national random sample from all 50
states of parents/guardians of 2,608 children aged 4 to 35
months.
Principal Findings: L and AA children are significantly less
likely than W children to be in excellent or very good health
(72% vs. 79% vs. 90%, respectively; P<.001), but more likely
to have been uninsured at some time in the past year (31% vs.
18% vs. 9%; P<.001), to have no regular healthcare provider,
and to have been assigned their provider when they have one.
L parents are significantly more likely than AA and W parents
to report their child’s provider did not spend enough time with
the child during the visit. Only 60% of L parents and 77% of
AA parents are very likely to recommend their child’s provider
to others, compared to 84% of W parents (P<.001).
Compared with W parents, minority parents are more likely to
report their child’s regular provider never or only sometimes
understands how the parent prefers to raise the child (W: 35%;
AA: 45%; L: 46%; P<.001) and never/only sometimes respects
that the parent is the expert on the child. L parents were more
likely than others to report that the provider never/only
sometimes understands the specific needs of their child (L:
30%; AA: 15%; W: 10%; P<.001). Providers significantly more
often asked minority parents about community violence,
difficulty paying for children’s needs, and household members
smoking, drinking or using drugs, but also significantly more
often asked minority parents about car seat use, childcare
arrangements, and reading to children. Minority parents
averaged fewer phone calls to their child’s doctor in the past
year (L: 2.0; AA: 3.1; W: 4.3; P<.001), and minority children
were more likely to have made an emergency department (ED)
visit. Pediatric providers significantly less often referred
minority children to specialists, at 22% for Ws, 17% for AAs,
and 11% for Ls (P<.001). In multivariate analyses, some
disparities disappeared for minority children, including having
an assigned provider, and for L children, having no regular
provider, providers not spending enough time with the child,
and a lower likelihood of excellent/very good health.
Disparities persisting in multivariate analysis included L
parents being more likely to not recommend their child’s
provider (OR, 1.9; 95% CI, 1.1-3.3) and to report providers
never/only sometimes understand the child’s needs (OR, 2.3;
95% CI, 1.4-3.6); AA children not being in excellent/very good
health (OR, 2.1; 95% CI, 1.3-3.3), being more likely to have
made ED visits in the past year (OR, 1.5; 95% CI, 1.1-2.2) and
having providers who more often asked about household
smoking, trouble paying for the child’s needs, spouse/partner
support of parenting, childcare arrangements, and the
importance of reading to children; minority children being
more likely to be uninsured (L: OR, 2.3; 95% CI, 1.4-3.8; AA:
OR, 1.7, 95% CI 1.02–2.9), minority parents reporting
providers never/only sometimes understand parents’
childrearing preferences, minorities being asked about
community violence and household drinking and drug use,
minority parents making fewer calls to their child’s doctor, and
minority children being least likely to be referred to specialists
(AA: OR, 1.8; 95% CI, 1.1-2.9; L: OR, 1.7; 95% CI, 1.1-2.8). In
multivariate analyses, children whose parents completed
surveys in Spanish also experience multiple disparities,
including increased odds of being uninsured, poorer health
status, not receiving care in a private/group practice, providers
never/only sometimes understanding the child’s specific
needs, discussion of community violence and household
alcohol and drug use, fewer calls to the child’s doctor, and not
being referred to specialists.
Conclusions: Certain health disparities for minority children
can be accounted for by prevalence differences in income,
insurance coverage, and language of interview. But compared
to white children, minority children experience multiple
disparities in health status, lack of insurance coverage, the
content of pediatric visits, parents feeling understood by
pediatric providers, parental satisfaction with care, phone calls
to providers, and referrals to specialty care. Children whose
parents complete surveys in Spanish also experienced
multiple disparities in health and healthcare.
Implications for Policy, Delivery or Practice: The U.S. is
experiencing a demographic surge in minority children,
particularly among the youngest age groups; by 2030,
minorities will outnumber non-Hispanic whites by 1.1 million
among children 0-5 years old. As the number and proportion
of minority U.S. children grow, racial/ethnic disparities in early
childhood health will take on even greater importance as
pediatric providers care for increasingly diverse populations.
Elimination of such inequities may require more research on
possible root causes of disparities, additional education for
healthcare providers, and ongoing monitoring for disparities
by health plans, the State Children’s Health Insurance
Program, Medicaid, and other healthcare systems.
Primary Funding Source: RWJF, Agency for Healthcare
Research and Quality
• Mortality Among Very Low Birthweight Infants in
Hospitals Serving Minority Populations
Leo Morales, M.D., Ph.D., Douglas Staiger, Ph.D., Jeffery
Horbar, M.D., Joseph Carpenter, M.A., Michael Kenny, M.A.,
Jeannette Rogowski, Ph.D.
Presented by: Leo Morales, M.D., Ph.D., Assistant Professor,
Medicine, UCLA, 911 Broxton Avenue, Los Angeles, CA 90024;
Tel: 310.794.2296; E-mail: morales@rand.org
Research Objective: It is not known whether very low birth
weight (VLBW) infants treated in minority-serving hospitals
receive the same quality of care as those treated in other
hospitals. The purpose of this study is to investigate whether
neonatal mortality is higher for infants treated in minorityserving hospitals compared to other hospitals.
Study Design: This study was set in three hundred thirty two
neonatal intensive care units in the United States participating
in the Vermont Oxford Network. Medical records were
reviewed and linked to secondary data sources including the
American Hospital Association’s survey of hospitals, the area
resource file and the 1990 US Census. The main outcome
investigated was neonatal mortality, defined as death prior to
discharge home during the first 28 days after live birth.
Detailed risk-adjustment was performed using patient
characteristics available immediately after birth.
Population Studied: The study sample consisted of 74, 050
black and white VLBW infants (501 grams to 1500 grams)
treated in participating hospitals from 1995 to 2000.
Principal Findings: Overall, 57% of VLBW black infants and
17% of VLBW white infants were treated in minority-serving
hospitals (defined as hospitals where more than 35% of VLBW
infants treated in the NICU were black). Risk-adjusted
neonatal mortality was higher for both black and white infants
in minority-serving hospitals relative to hospitals where less
than 15% of the VLBW infants were black (whites: OR=1.30,
95% CI 1.09-1.56; blacks: OR=1.29, 95% CI 1.01=1.64; pooled:
OR=1.28, 95% CI 1.10-1.50). Higher mortality in minorityserving hospitals could not be explained by other factors
including financial factors, urban versus rural location, patient
volume, level of care in the NICU, or the use of surfactants
and antenatal steroids. Black neonatal mortality among VLBW
infants would have been reduced by 8.5% if black infants had
been treated in minority-serving hospitals in the same
proportions as white infants.
Conclusions: VLBW infants treated in minority-serving
hospitals have higher mortality than infants treated in other
hospitals. Because VLBW black infants are disproportionately
treated in minority-serving hospitals, higher neonatal mortality
rates at minority-serving hospitals may contribute to racial
disparities in infant mortality in the United States.
Implications for Policy, Delivery or Practice: Our results
suggest that neonatal morality was similarly elevated for
VLBW black and white infants treated by minority-serving
hospitals compared with other hospitals. These results
suggest that, at least among VLBW infants, system level
factors may be more important than infant level factors, such
as race per se, in understanding racial disparities in care.
Interventions to reduce neonatal infant mortality at minorityserving hospitals are needed.
Primary Funding Source: AHRQ
Call for Papers
Disparities in Primary Care
Chair: Kevin Fiscella, M.D., M.P.H.
Monday, June 7 • 2:00 p.m.-3:30 p.m.
• Characteristics of primary care physicians who treat
whites and blacks in the United States
Peter Bach, M.D., MAPP, Hoangmai Pham, M.D., M.P.H.,
Deborah Schrag, M.D., M.P.H., J. Lee Hargraves, Ph.D.
Presented by: Peter Bach, M.D., MAPP, Assistant Attending,
Epidemiology and Biostatistics, Memorial Sloan-Kettering
Cancer Center, 1275 York Avenue, Box 221, New York, NY
10021; Tel: 646.735.8100; Fax: 646.735.0011; E-mail:
bachp@mskcc.org
Research Objective: To examine whether black patients
receive their care from a subset of US primary care physicians
who have inferior qualifications or resources
Study Design: Cross sectional analysis of black and white
Medicare beneficiaries who were treated by physicians
participating in the Community Tracking Study survey.
Population Studied: 4,355 primary care physicians in visits
with 43,032 patients.
Principal Findings: Black Medicare beneficiaries received
primary care from a small group of physicians (80% of visits
provided by 25% of physicians). Compared to white patients,
black patients were more likely to have visits with physicians
who were black (22.4% vs. 0.7%, p< 0.001), not board
certified (22.6% vs. 13.9%, p = 0.02), and who derived a
greater percentage of their practice revenue from Medicaid
(13.4% vs. 9.3%, p< 0.001). Blacks also had a higher
proportion of visits with physicians who reported that they
were not able to consistently provide high quality care (27.8%
vs. 19.3%, p= 0.005), or secure access for their patients to
high quality ancillary services (37.7% vs. 27.8%, p = 0.02), high
quality diagnostic imaging (25.2% vs. 17.0%, p= 0.01), or
elective admission to the hospital (47.8% vs. 36.1%, p <
0.001).
Conclusions: A small subset of primary care physicians is
responsible for most of the care received by black Medicare
patients. These physicians appear to have poorer
qualifications and fewer resources than those who treat
whites.
Implications for Policy, Delivery or Practice: Interventions
to reduce racial disparities should target providers who
assume most responsibility for treating blacks, and address
gaps in their training and access to resources.
Primary Funding Source: RWJF, National Cancer Institute
• The Role of Race in Physician Participation in Medicaid:
What Happens When Poverty and Race are Conflated?
Jessica Greene, Ph.D., Beth Weitzman, Ph.D., Jan Blustein,
M.D., Ph.D., Dahlia Remler, Ph.D.
Presented by: Jessica Greene, Ph.D., Assistant Professor,
Planning, Public Policy and Management, University of
Oregon, 1209 University of Oregon, Eugene, OR 97403; Tel:
541.346.0138; Fax: 541.346.2040; E-mail:
jessicag@uoregon.edu
Research Objective: Getting physicians to participate in
Medicaid has been a challenge since the program’s inception.
While low reimbursement rates have been a barrier, other
factors matter. In surveys, physicians have expressed concern
about mixing Medicaid patients with their existing patient
base. Studies have shown that physicians are less likely to
participate in Medicaid if they practice in areas with greater
racial segregation, leading some to hypothesize that racial
dissimilarity between Medicaid and non-Medicaid patients
may be a barrier to participation. This study examines the
degree to which racial dissimilarity between poor and nonpoor populations affects the likelihood that a physician will
participate in Medicaid.
Study Design: This was a cross sectional study of the
association between physician participation in Medicaid and
the racial/economic environment of the county in which they
practice. County-level data from Census 2000 were used to
construct a race/poverty dissimilarity ratio (RPDR) that
compares the percent of poor county residents that are white
to the percent of non-poor residents that are white. Analyses
of the association between physician participation in Medicaid
and RPDR controlled for physician and practice characteristics
(gender, age, race, type of primary care provider, board
certification status, US or foreign medical school graduate,
and private or institution-based practice) as well as
characteristics of the county of practice (county per capita
income and urban/rural practice) and Medicaid policy
variables (Medicaid/Medicare reimbursement ratio,
standalone or Medicaid expansion SCHIP program, and
Medicaid managed care penetration rates).
Population Studied: A nationally representative sample of
over 6,500 primary care physicians who provide at least 20
hours a week of patient care, and who participated in the
1998/1999 Community Tracking Survey.
Principal Findings: Primary care physicians were substantially
less likely to participate in Medicaid if the poor population in
their county was racially dissimilar from the non-poor
population, after adjusting for individual and county-level
factors that are known to influence participation.
Conclusions: Physician reluctance to participate in Medicaid
may be partly driven by the racial dissimilarity between their
traditional (non-poor) patient base and the race of poor
Medicaid patients.
Implications for Policy, Delivery or Practice: Policies aimed
at improving physician participation in Medicaid, such as
increasing Medicaid reimbursement rates and Medicaid
managed care implementation, may not be sufficient to
eliminate disparities in access for poor people of color,
particularly in communities where poverty and race are highly
correlated.
Primary Funding Source: CWF
• The Effects of Survey Methodology on Race, Ethnicity
and Health Status Reporting
Verna Lamar-Welch, Ph.D., M.P.H., Natalia Oster, R.N.,
M.P.H., Junling Ren, M.Ed., Claire Spettell, Ph.D., Elizabeth
Lowry, R.N., B.S.N., Joette Majerus, B.S.
Presented by: Verna Lamar-Welch, Ph.D., M.P.H., Researcher,
Health Policy and Management, Emory University, Rollins
School of Public Health, Emory Center on Health Outcomes
and Quality, 1518 Clifton Road, Atlanta, GA 30322; Tel:
404.712.8531; Fax: 404.727.9198; E-mail:
vlamar@sph.emory.edu
Research Objective: To explore whether collection
methodology impacts racial and ethnic self-reporting among
those enrolled in a managed care organization’s (MCO)
DDMP.
Study Design: Approximately 19,000 MCO members were
enrolled into the diabetes disease management program
(DDMP) over the phone, and were asked to self-identify their
race/ethnicity. Identification of race/ethnicity was optional,
and participants could move to the next question if desired.
Within 1 to 3 months of enrollment, participants were mailed a
self-administered health assessment survey, and were asked
again to self-identify race/ethnicity. In both collection
methods, identifying information was separated from health
related responses to protect the respondents’ anonymity and
privacy. Cross-sectional analyses of data from those who
returned the health assessment surveys were conducted.
Population Studied: Enrollees in a MCO's diabetes disease
management program (n=19,078).
Principal Findings: Of the 19,078 health assessment surveys
mailed, 6,433 were returned for a response rate of 34%.
Nineteen percent (1214) of enrollees provided race/ethnicity
data during enrollment on the phone. Of those, 209 (17%)
were African American, 99 (8%) were Hispanic and 871 (72%)
were Caucasian; the remaining 35 (3%) were from other
races/ethnicities. Via the mailed health assessment survey,
5147 (81%) self-identified racial and ethnic data, and of those
15% were African American, 7% were Hispanic and 72% were
Caucasian; the remaining 6% were from other
races/ethnicities. Of the 1198 (19%) participants that reported
racial and ethnic data over both the phone and in the mailed
health assessment survey, 92% reported the same
race/ethnicity regardless of data collection method (96%
African Americans, 91% Hispanics, and 98% Caucasians). An
additional 16 participants (<1%) self-identified racial and
ethnic data via the phone, but not in the mailed health
assessment survey.
Differences were observed in health status reporting by data
collection method. Excellent or very good overall health status
was reported by 23% of mail only respondents, 7% of phone
only respondents, and 20% of those responding to both
(p=0.03). Self-management behaviors such as annual
cholesterol screening (p=0.01), annual eye exam (p=0.001),
regular exercise (p=0.005), and pneumococcal and influenza
vaccinations (p<0.001) also differed by data collection
method. No differences were observed in receiving dental
exam, foot screening, urinalysis, and glycosolated hemoglobin
screening by data collection method.
Conclusions: In our study, the type of collection methodology
used did affect rates of racial, ethnic and health status selfreporting.
Implications for Policy, Delivery or Practice: Clearly more
research is needed to explore why participants may be more or
less willing to self-report demographic and health status data
depending on collection methodology.
Primary Funding Source: Academic Medicine and Managed
Care Forum
• Ethnic Disparities in the Impact of Copayment on
Adherence to Anti-Hypertensive Medications among Asian
Pacific Americans
Deborah Taira, Sc.D., M.P.A., James Davis, Ph.D., Todd Seto,
M.D., M.P.H.
Presented by: Deborah Taira, Sc.D., M.P.A., Research
Manager, Care Management, HMSA (BCBS of Hawaii), 818
Keeaumoku Street, P.O. Box 860, Honolulu, HI 96808-0860;
Tel: 808.948.5337; Fax: 808.948.6043; E-mail:
deb_taira@hmsa.com
Research Objective: To determine whether there are ethnic
differences in the impact of copayment on adherence to antihypertensive medications among Asian Pacific Americans.
Study Design: This retrospective observational study
examined adherence based on possession ratios, using
administrative data from a large health plan in Hawaii. Loglinear regression models were used to determine the percent
change in days of adherence to anti-hypertensive medications
resulting from a 1 percent increase in copayment level.
Interaction terms were used to examine whether this “price
elasticity of adherence” differed by patient ethnicity after
controlling for age, gender, type of coverage (HMO vs. PPO),
specific therapeutic class of anti-hypertensive medication,
education level, morbidity level, geographic location, diabetes,
congestive heart failure, and coronary artery disease. All
analyses were conducted in STATA 8.0 and adjusted for
member clustering.
Population Studied: Adult health plan members with a
diagnosis of hypertension who filled at least one prescription
for an anti-hypertensive medication between July 1999 and
June 2003 (n=74,740). Members were followed for up to three
years after their first prescription.
Principal Findings: Ethnic differences in cost sensitivity were
significant, with elasticities ranging from –0.29 for Japanese to
-0.37 for Koreans, p<0.001. Based on these estimates, we
found that a $1 increase in copayment per month was
associated with annual decreased adherence of 7.4 days for
Japanese, 7.8 days for Hawaiians, 8.3 days for Chinese, 8.7
days for whites, 8.9 days for Filipinos, and 9.1 days for
Koreans. Other key variables were type of coverage and isle of
residence. For HMO members, a $1 increase in copayment
was associated with a 10-day decrease in adherence, while
living on the rural islands of Molokai or Lanai was associated
with 10- and 15-day decreases, respectively.
Conclusions: While increases in copayment were associated
with decreased adherence to anti-hypertensive medications for
all groups, the level of response differs by ethnicity, even after
adjustment for patient characteristics. The significant
variation found among Asian Pacific Islander groups
highlights the need to examine sub-groups separately.
Implications for Policy, Delivery or Practice: Programs,
including generic drug promotion and mail order substitution,
may lower copayments and improve adherence for all groups.
Certain sub-groups, who are the most cost sensitive, such as
Koreans, Filipinos, or rural residents, may need targeted
interventions, such as educational material on generic drug
usage in appropriate languages, to maintain adherence when
copayment increases are anticipated. Alternatively, health
plans, through their disease management programs, may find
it cost-effective to provide discounted pharmaceutical
coverage for members most at risk of dropping essential
medications.
Primary Funding Source: AHRQ
• Perceived Racism and Delay of Pharmacy Prescriptions
Courtney Van Houtven, Ph.D., Corrine Voils, Ph.D., Eugene
Oddone, M.D., MHSc., Kevin Weinfurt, Ph.D., Joelle
Friedman, M.P.A., Hayden Bosworth, Ph.D.
Presented by: Courtney Van Houtven, Ph.D., Health
Economist/Research Assistant Professor, Health Services
Research/General Internal Medicine, VA and Duke Medical
Centers, 508 Fulton Street, Durham, NC 27705; Tel:
919.286.6936; Fax: 919.416.5839; E-mail:
courtney.vanhoutven@duke.edu
Research Objective: Delaying filling pharmacy prescriptions
can lead to poor medication adherence and poor health
outcomes. In this study, we investigated whether perceptions
of unfair treatment in the health care system due to race or
ethnicity are associated with pharmacy prescription delays,
controlling for resource constraints and demographic factors.
Study Design: Telephone interviews elicited people’s care
seeking behavior for pharmacy prescriptions, as well as
demographic information, insurance status, economic
resources, and self-reported health and depression. Logistic
regression was used to model the effect of perceived racism
on the likelihood of delaying filling a pharmacy prescription.
Robust standard errors are estimated.
Population Studied: A community sample of 181 Blacks, 148
Latinos, and 224 Whites in Durham County, North Carolina.
A sample of Whites and Blacks was obtained using standard
list-assisted random-digit dialing methodology. Census tracks
that had 10% or more Black households were identified to
ensure oversampling of Blacks; these census tracks were then
matched to phone exchanges. Because Durham has few
Latino households in general, and the Latino population is not
clustered, Latinos were recruited from a Durham County list of
Latino surname households.
Principal Findings: Nearly 17 percent of the sample had
delayed or not filled a prescribed medication. Fifty-two
percent of the sample felt that race or ethnicity caused unfair
treatment in healthcare. After controlling for insurance,
resource availability, and self-reported health, the odds of
delaying a pharmacy prescription was 2.11 higher for persons
who perceived unfair treatment. The odds of Blacks delaying
pharmacy treatment were not significantly different from the
odds of Whites doing so. The odds of Latinos delaying
treatment was significantly lower than Whites; the odds-ratio
was 0.46. People with self-reported depression were also
significantly more likely to delay pharmacy tests; the odds-ratio
was 2.44. Significant results reported had p-values less than
.05.
Conclusions: Perceptions of racism and self-reported
depression were important factors in explaining delays in
filling pharmacy prescriptions. Economic resource and health
insurance constraints did not explain delays in pharmacy
prescriptions.
Implications for Policy, Delivery or Practice: Our findings
echo what other disparities researchers have found: Economic
and insurance constraints do not fully explain disparate
utilization patterns by race and ethnicity. In fact, in our study,
perceived general racism in health care was more important
than economic constraints in explaining prescription delays.
Being Latino and being depressed also were associated with a
higher odds of delaying filling prescriptions. Ameliorating
perceived racism in the health care system may reduce
prescription delays and improve prescription adherence and
health outcomes.
Call for Papers
Strategies to Address Health Disparities
Chair: Kaytura Felix-Aaron, M.D.
Monday, June 7 • 4:00 p.m.-5:30 p.m.
• Racial/Ethnic Disparities in the Appropriate Use of HighVolume Hospitals
Bradford Gray, Ph.D., Shannon Mitchell, Ph.D., Emily
Horowitz, Ph.D., Mark Schlesinger, Ph.D.
Presented by: Bradford Gray, Ph.D., Director, Health &
Science Policy, The New York Academy of Medicine, 1216 Fifth
Avenue, New York, NY 10029; Tel: 212.822.7287; Fax:
212.822.7369; E-mail: bgray@nyam.org
Research Objective: This project addresses a largely
unexamined source of racial/ethnic disparities in health
services and outcomes--the use of providers of different
quality. Specifically the study examines racial/ethnic
disparities in the use of high-volume hospitals (HVHs) for 22
procedures and conditions for which a positive volumeoutcome relationship has been documented in prior research.
We examine patient characteristics (insurance status,
education, proximity) that may explain such disparities and
whether the disparities are mitigated by managed care and
public policies that concentrate care in fewer institutions.
Study Design: The study examines racial/ethnic disparities in
the use of high-volume hospitals among residents of New
York City and adjacent counties. “High volume” is defined by
available threshold standards published by AHRQ and the
LeapFrog Group or by alternative measures such as top decile
or quartile. Logistic regression analysis is used to determine
the amount of disparities between Whites, Blacks, and
Hispanics in the use of HVHs, controlling for patient
characteristics including insurance status, co-morbidities,
proximity to a HVH, and education (measured at census
tract). Separate models are estimated for each procedure and
condition.
Population Studied: Data come from NY’s Statewide
Planning and Research Cooperative System (SPARCS) inpatient discharge records. The patients included in the study
will consist of residents of NYC and adjacent NY counties who
were treated in a NY hospitals 2001 or 2002 for the
procedures and conditions included in the study.
Principal Findings: In preliminary analyses, we found that
Whites were about twice as likely as African-Americans to have
their carotid endarterectomy done at a HVH. Patients of other
racial/ethnic groups were also substantially less likely than
Whites to use a HVH. Whites were also twice as likely as
African-Americans to use a HVH for cancer surgery.
Differences with the other ethnic groups were smaller. These
effects remain stable even after uninsured persons were
excluded. For the presentation at AcademyHealth, we will
have results for the full analysis of results for 22
procedures/conditions, with appropriate statistical controls as
mentioned earlier. We will also examine whether disparities
are smaller for HMO enrollees and for procedures
concentrated in fewer institutions.
Conclusions: Our analyses are still underway, so we do not
offer conclusions at this time. However, there are striking
differences in the racial/ethnic composition of the patient
population of hospitals in NYC. The volume-outcome
literature suggests that the hospital used affects outcomes for
many procedures and conditions. Racial/ethnic differences in
the use of high-volume hospitals have not been previously
identified as a source of disparities in services and outcomes.
Implications for Policy, Delivery or Practice: Our findings
will contribute to the goal of reducing racial/ethnic disparities
in quality. First, the findings will provide empirical evidence of
a heretofore unrecognized source of disparities in care.
Documenting its dimensions is a first step toward a solution.
Second, our data analysis strategy is defined in policy-relevant
terms. That is, we are planning our data analysis to shed light
on (a) causes of the problem and (b) the feasibility of different
approaches to solution.
Primary Funding Source: AHRQ, The Commonwealth Fund
• Providing Health Care Services to the Formerly
Homeless: A Quasi-Experimental Evaluation of Outcomes
Andrea Ciaranello, M.D., Richard Kravitz, M.D., Fred Molitor,
Ph.D., Martin Leamon, M.D., Daniel Tancredi, Ph.D., Christina
Kuenneth, M.S., Alison Diamant, M.D.
Presented by: Richard Kravitz, M.D., Professor; Director,
Center for Health Services Research in Primary Care, Internal
Medicine, UC Davis Medical Center, 4150 V. Street, Suite
2400, Sacramento, CA 95822; Tel: 916.734.2818; E-mail:
rlkravitz@ucdavis.edu
Research Objective: Transitional housing programs are
designed to re-integrate homeless individuals into the
community, but housing alone is unlikely to alleviate chronic
health problems acquired during homelessness. Using a
quasi-experimental design, we evaluated the effects of a
focused health care intervention (the HEALTH Project) on
access to needed care, delivery of preventive services, and
health status for residents of transitional housing facilities
(THFs) in one northern California city.
Study Design: Beginning in Fall, 1999, a multidisciplinary
team provided direct services (comprehensive physical
examinations, diagnostic studies, referrals, social services, and
counseling) to residents at 4 intervention THF sites. Survey
and physical examination data were collected from residents
of the 4 intervention sites and 2 control sites at baseline and 6
and 18 months later. Outcomes were evaluated using mixed
effects models that accounted for missing observations and
clustering by site and estimated the effects of the program
(intervention vs. control) over time while adjusting for
residents´ baseline sociodemographic characteristics.
Population Studied: The HEALTH Project's target population
was single adult THF residents. At any given time, there were
approximately 450 members of the target population living at
the intervention sites. Approximately 50 residents lived at the
control sites.
Principal Findings: Survey and physical examination
participation rates exceeded 70% at all sites. HEALTH Project
staff delivered services to 511 THF residents in more than
2400 clinical encounters. The Project significantly reduced the
odds of "not receiving medical care when needed" (adjusted
OR 0.42, 95%CI 0.26-0.69, p < 0.05). There was also a
significant improvement in the receipt of gynecologic
preventive services: Papanicolaou tests within the past year
among female residents 18 years of age or older (AOR 7.52;
95%CI 2.37-23.86) and mammograms within the preceding
two years among women aged 40 years or older (AOR 9.54,
95%CI 1.36-67.02). The intervention had no effect on access to
specialists, dentists, or optometrists; on frequency of
emergency department visits or hospital admissions; on
timeliness of care; on self-reported health status; or on blood
pressure or vision (p>.05 in all cases).
Conclusions: The HEALTH Project reflected successful
community collaboration and met several clinically relevant
goals in improving access to care. The intervention had robust
effects on proximal outcomes (those directly provided or
easily arranged by the on-site health care team) but failed to
impact more distal outcomes.
Implications for Policy, Delivery or Practice: These results
highlight the challenges of implementing health care outreach
for residents of transitional housing programs and may
inform the design of future interventions. Specifically,
improved outcomes may result from prioritization of project
goals, assessment of community needs, and efficient use of
community and medical resources.
Primary Funding Source: California Healthcare Foundation
• Examination and Evaluation of Initial State
Implementation of the Breast and Cervical Cancer
Prevention and Treatment Act
Kathleen Maloy, J.D., Ph.D., Chaya Merrill, M.P.H., Dr.PH
Candidate, Sarah Blake, M.A., Kyle Kenney, M.P.H.
Presented by: Chaya Merrill, M.P.H., Dr.PH (candidate),
Senior Research Associate, Department of Health Policy, The
George Washington University, 2021 K Street, NW, Suite 800,
Washington, DC 20006; Tel: 202.530.2337; Fax: 202.296.0025;
E-mail: cmerrill@gwu.edu
Research Objective: The BCCPTA established a new coverage
option under Medicaid that permits states to extend Medicaid
to uninsured women under 65 who are diagnosed with breast
and/or cervical cancer through a national screening program.
This coverage option is groundbreaking in its use of
population-wide public health screening program as pathway
for publicly funded health insurance. As states did not begin
to implement BCCPTA until 2001, little is known about states’
implementation experiences and how women’s access to
breast and cervical cancer treatment might be affected. The
research objectives are to (1) describe and evaluate initial
BCCPTA implementation, and (2) design research to measure
and assess the effect of BCCPTA on health outcomes for
women with breast and cervical cancer.
Study Design: Case study methods were used to examine
sixteen states that were among the first to implement
BCCPTA. Data collection, conducted during July through
December 2002, included structured interviews with key
stakeholders, including state Medicaid officials, Title XV (i.e.,
NBCCEDP) grantees, community/advocacy organizations, and
document review. Data collection and analysis focused on (1)
designs of states’ Medicaid expansions, (2) collaboration
between Medicaid and Title XV officials; (3) development of
BCCPTA Medicaid enrollment procedures; (4) effect of
BCCTPA implementation on Title XV agencies; and (6) states’
experiences in implementing BCCPTA.
Population Studied: State Medicaid and Title XV officials
Principal Findings: (1) Relatively smooth implementation
with states using existing provider screening networks; (2)
Wide range across states of enrollment procedures and
redetermination practices. (2) Substantial variation across
states in their experiences with Medicaid enrollment and
expenditures versus prior estimations/expectations; (3)
Notable and variable impact on the activities of Title XV
agencies; and (4) Uncertainty about long-term costs
associated with BCCPTA coverage due to early stage of
implementation.
Conclusions: Study findings suggest that screening programs
can be an effective pathway to publicly-funded insurance
coverage (i.e., Medicaid). Uncertainty about costs may present
longer-term challenges to ongoing implementation. A
summary of the findings includes: (1) Early success in
enrolling women in BCCPTA Medicaid, (2) Effective
collaboration between Medicaid and Title XV to implement
this unique coverage expansion, and (3) Substantial state
support for BCCPTA.
Implications for Policy, Delivery or Practice: Study findings
provide the essential first step toward conducting impact
evaluation research that will (1) evaluate the effectiveness of
BCCPTA in improving the ability of uninsured women with
breast and/or cervical cancer to secure earlier and better
treatment and, thereby, to experience improved outcomes,
and (2) assess whether using prevention programs as a
pathway for publicly-funded insurance coverage promotes
access to quality care and improves health outcomes.
Primary Funding Source: CDC
• Reducing Racial and Ethnic Health Disparities:
Estimating the Impact of High Health Center Penetration
in Low-Income Communities
Peter Shin, Ph.D., M.P.H., Karen Jones, M.S., Sara
Rosenbaum, J.D.
Presented by: Peter Shin, Ph.D., M.P.H., Assistant Research
Professor, Health Policy, George Washington University, 2021
K Street, NW, Suite 800, Washington, DC 20006; Tel:
202.530.2313; Fax: 202.296.6922; E-mail: pshin@gwu.edu
Research Objective: The health disparities literature suggests
that although the lack of health insurance is the most basic
barrier to health care, improved access to clinically
appropriate care is key, particularly in the case of minority and
low-income populations where the health risks are greatest.
This study examines the relationship between health
center penetration into medically underserved communities
and the reduction of statelevel health disparities.
Study Design: We designed this study to permit a
comparison between the magnitude of state-level racial and
ethnic disparities for certain key health indicators and the
proportion of low-income persons served by health centers for
each state.
We first compiled measures of health status available by state
and race, as well as state and income level. Data collection
was restricted primarily to those data sources for which data
already were compiled for all states and the
District of Columbia. Our specific focus was on health
measures that have been shown in the literature to reveal
significant disparities between white and minority
populations. We also were interested in measures that have
been shown to be ambulatory care sensitive, that is, that are
amenable to control through comprehensive primary health
care aimed at both preventing the onset of health conditions
and treating and managing conditions at early stages. Six
point-in-time indicators with sufficient reliable state-level data
were selected to permit disparities calculations between white
persons and black persons, and white persons and Hispanic
persons. Because of limitations in the
data, state-level comparisons could not be drawn for other
health measures. Furthermore, data limitations prevented
comparisons for other racial and ethnic subgroups. Thus, this
analysis is limited to black/white and Hispanic/white health
disparities. The measures that ultimately were chosen for this
analysis were: infant mortality (2000); total death rate (1999),
heart disease death rate (1999); diabetes death rate (1999);
tuberculosis case rate (2000) and level of prenatal care
(2000).
We conducted multiple regression models which included
health center penetration (i.e., percent of the state’s lowincome population served by health centers) and controlled
for age, education, population density, per capita income, and
percent of the state population without health insurance.
A measure of the generosity of the state Medicaid program
was also examined in the health disparities models, in view of
the well established association between health insurance and
access to health care. The purpose of this measure was to
determine whether health center penetration still mattered as
an independent consideration even in those states with
relatively generous Medicaid eligibility levels. In addition, we
supplemented our quantitative estimates with interviews
conducted during the first half of 2003 with the staff of five
health centers. These health centers are located in five
communities selected on the basis of geography, urban/rural
location, and a is proportionately high volume of minority and
low income patients relative to the already high average rate
for health centers nationally.
Population Studied: Community health center presence (as
measured by the proportion of low-income resident served by
health centers); black, Hispanic, and white populations.
Principal Findings: The results of our analysis showed that
greater levels of health center penetration (i.e., proportion of
low-income individuals served) were associated with
significant and positive reductions in minority health
disparities. In the case of black/white health disparities, we
found that penetration was significantly associated with a
narrowing of the health disparities gap in the case of total
death rate and prenatal care. The infant mortality gap also
narrowed as penetration increased, although the reduction
was not as great. In the case of Hispanic/white disparities,
health center penetration was significantly associated with
health disparity reductions in the case of the tuberculosis case
rate and prenatal care. Our interviews with individual health
centers confirm that clinics actively pursue the overall
program mission of bringing affordable and clinically
appropriate health care to low-income communities.
By themselves, state Medicaid eligibility levels were
determined to have no significant association with state level
measures of health disparities. However, because one third of
health center operating revenue is derived from
Medicaid, state Medicaid coverage and payment policies are
integral to the ability of health centers to achieve high
penetration. Therefore, if health centers are shown to have a
significant relationship with reduced health disparities, state
Medicaid policy remains a critical component of health center
efforts to reduce health disparity.
Conclusions: The results of our regression analysis showed a
significant association between health center penetration and
reduced racial and ethnic health disparities for certain key
outcomes measures. Specifically, greater penetration levels
were associated with larger reductions in disparities.
Implications for Policy, Delivery or Practice: Although the
goal of reducing health disparities is national, in the end it is
the underserved communities themselves -- and the states in
which these communities are located -- that shoulder much of
the practical burden of achieving the types of health systems
changes (such as better insurance coverage and greater health
care access) that have been associated with a reduction in
minority health disparities. In this regard, health centers are a
principal strategy for anchoring accessible, high quality
primary health care in pervasively poor and uninsured
communities that, without such an investment, could not
hope to independently attract and support sufficient private
medical care practices. This study suggests that a national
policy that aims for increased health center penetration,
coupled with adequate operational support via strengthened
insurance coverage of lower income persons, can be expected
to make a significant difference in minority health status at the
local community level.
Primary Funding Source: National Association of
Community Health Centers
• Developing an Intervention to Improve Quality of Care
and Reduce Health Disparities in Minority Communities
Jane Sisk, Ph.D., Paul Hebert, Ph.D., Mary Ann McLaughlin,
M.D., M.P.H., Carol Horowitz, M.D., M.P.H., Cheryl
Goldstein, M.D., Leah Tuzzio, M.P.H.
Presented by: Jane Sisk, Ph.D., Professor, Health Policy,
Mount Sinai School of Medicine, One Gustave L. Levy Place,
New York, NY 10029-6574; Tel: 212.659.9567; Fax:
212.423.2998; E-mail: jane.sisk@mssm.edu
Research Objective: Hypertension exacts a greater burden on
Black than White populations, with earlier and more severe
onset and higher rates of sequelae, including coronary-heart
disease, stroke, and renal failure. Despite proven-effective
therapies, only 28% of hypertensive Black people nationally
have controlled blood pressures. We sought to identify
problems underlying uncontrolled hypertension among
treated African-Americans and Latinos in Harlem, and design
an intervention to address them.
Study Design: To identify underlying problems, we used the
following qualitative and quantitative methods: interviews
with key informants, focus groups with patients, and a survey
of clinicians. The clinician survey included hypothetical
clinical vignettes in which patients’ demographic
characteristics were randomly assigned. This allowed us to
estimate whether patient demographics affected care. We
also performed retrospective chart review to assess whether
clinical care manifested the problems suggested by key
informants, focus-group participants, and surveyed clinicians.
Population Studied: Key informants consisted of
administrators and clinicians at the four hospitals, Harlem,
New York City. Nine focus groups in English and Spanish
included African-American and Latino hypertensive patients
from hospital clinics managing hypertension. We surveyed
the 469 clinicians in those clinics. We reviewed charts of 99
consecutive uncontrolled hypertensives with scheduled
appointments who had been treated at least six months and
whose blood pressures exceeded guidelines by 10mmHg
systolic or 5mmHg diastolic.
Principal Findings: Key informants noted access problems;
patients’ profound life problems; and patient mistrust of the
health system. Focus-group patients were well aware of the
importance of medications and lifestyle, but sometimes
skeptical about their medication regimens. Some reported
lack of respect at certain medical centers, access problems,
and interest in home blood-pressure monitors. From the 79%
of surveys completed, clinicians were knowledgeable about
evidence-based blood-pressure targets (86% or more), except
for renal disease (9%). Clinicians’ blood-pressure targets
were not significantly associated with patient demographic
characteristics in the hypothetical vignettes. But clinicians’
expectations about achieving control had significant negative
associations with patients’ being unemployed, employed as
cashiers, African-American, or Hispanic.
According to chart review, in the year before the scheduled
appointment, patients averaged 5.1 clinic visits after the first
uncontrolled blood pressure. For visits with uncontrolled
pressures, physicians incorrectly noted control for 11%,
entered no comments for 28%, noted patients’ non-adherence
for 24%, and recorded no action for 51%.
Conclusions: Problems underlying uncontrolled hypertension
among treated Harlem patients relate to patient selfmanagement, lack of clinical adjustments despite frequent
contacts, and system and cultural barriers.
Implications for Policy, Delivery or Practice: Based on these
exploratory studies, we designed and implemented a nursemanagement intervention to target the problems underlying
hypertension control in this community, and are evaluating its
effectiveness and cost-effectiveness in a randomized
controlled trial. Bilingual nurses counsel patients; train them
to use home blood-pressure monitors; follow-up regularly by
telephone and provide social support; interact with clinicians
to adjust medications until control is attained; and facilitate
access to social work and insurance coverage. The program
has strong clinical and administrative support.
Primary Funding Source: AHRQ
Call for Papers
Health Literacy, Cultural Competence & Perceived Racism
Chair: Joseph Betancourt, M.D., M.P.H.
Tuesday, June 8 • 9:15 a.m.-10:45 a.m.
• Cultural Competence: A Systematic Review of Health
Care Provider Educational Interventions
Mary Catherine Beach, M.D., M.P.H., Eboni Price, M.D.,
Tiffany Gary, Ph.D., Karen Robinson, M.Sc., Aysegul Gozu,
M.D., Ana Palacio, M.D., M.P.H., Carole Smarth, M.D., Mollie
Jenckes, M.H.S., R.N., Carolyn Feuerstein, B.A., Eric Bass,
M.D., M.P.H., Neil Powe, M.D., M.P.H., M.B.A., Lisa Cooper,
M.D., M.P.H.
Presented by: Mary Catherine Beach, M.D., M.P.H., Assistant
Professor, Medicine, and Health Policy and Management,
Johns Hopkins University, 2024 East Monument Street, Suite
2-500, Baltimore, MD 21287; Tel: 410.614.1134; Fax:
410.614.0588; E-mail: mcbeach@jhmi.edu
Research Objective: To reduce racial and ethnic disparities in
care, efforts have been made to improve the cultural
competence of health professionals. We synthesized the
findings of studies evaluating interventions to improve
cultural competence.
Study Design: We performed a systematic review of literature
from 1980 through June 2003 using electronic and hand
searches to identify studies that evaluated interventions
designed to improve the cultural competence of health
professionals.
Population Studied: Eligible studies were in English, with
original data, and described an intervention evaluated with a
pre- and a post- test or by comparison to a control arm. Two
reviewers abstracted data on the effectiveness and cost of
cultural competence training, and graded the strength of the
evidence as excellent, good, fair or poor using predetermined
criteria.
Principal Findings: Thirty-four studies were included in our
review. Four studies were published between 1980-1989, 14
between 1990-1999, and 18 between 2000-2003. Targeted
learners were most often nurses (n=17) and physicians (n=18).
Most curricula focused on specific cultural content (n=26),
general concepts of culture (n=19), language (n=10), and
patient-provider interaction (n=8); fewer focused on health
care access (n=3), racism (n=2), and socio-economic status
(n=2). Most curricular interventions used more than one
training method. The most common training methods were
group discussion (n=17), lectures (n=17), case scenarios
(n=12), clinical experiences (n=10), presentations by members
of another culture (n=9), small group work (n=9), and cultural
immersion (n=8). Evidence is excellent that training improves
the knowledge of health professionals (17 of 19 studies
demonstrated a beneficial effect). Evidence is good that
training improves the attitudes and skills of health
professionals (21 of 25 studies demonstrated a beneficial
effect and 14 of 14 studies demonstrated a beneficial effect,
respectively). Evidence is good that training impacts patient
satisfaction (3 of 3 studies demonstrated a beneficial effect)
and poor that training impacts patient adherence (although
the one study designed to do this demonstrated a beneficial
effect). No studies have evaluated patient health status
outcomes. There is insufficient evidence to determine the
costs of cultural competence training.
Conclusions: Cultural competence training shows promise as
a strategy for improving the knowledge, attitudes and skills of
health professionals. However, evidence is lacking that it
improves patient adherence, health outcomes and equity of
services across racial and ethnic groups.
Implications for Policy, Delivery or Practice: Future cultural
competence research should include an assessment of the
impact of training on patient adherence, health outcomes and
equity of services across racial and ethnic groups, determine
which teaching methods and content are most effective, and
use evaluation strategies that adhere to basic principles of
study design and performance. This work will help health care
managers and educators determine whether cultural
competence training for health professionals is an effective
strategy to eliminate minority healthcare disparities.
Primary Funding Source: AHRQ
• Serving Diverse Communities in Hospitals and Health
Systems
Edward Martinez, M.S., Linda Cummings, Ph.D., Linda
Cummings, Ph.D., Lindsay Davison, B.A., Ingrid Singer,
M.H.S., Arsenio DeGuzman, M.P.A., Marsha Regenstein,
Ph.D.
Presented by: Linda Cummings, Ph.D., Director of Research,
National Public Health and Hospital Institute, 1301
Pennsylvania Avenue, N.W., Suite 950, Washington, DC
20004; Tel: 202.585.0130; Fax: 202.585.0101; E-mail:
lcummings@naph.org
Research Objective: The patient population served by large,
urban safety net health systems is highly diverse, both
culturally and linguistically. Quality health care in this setting
reflects strategies that address the disparities in health
services and health outcomes experienced by minority and
low-income patients. NPHHI undertook a study to identify
promising and innovative practices designed to improve care
for cultural and linguistic minorities and to address health
disparities.
Study Design: The study team reviewed federal standards for
culturally and linguistically appropriate services and conducted
a literature review of research on health disparities and care
for diverse populations. Structured interviews were conducted
with senior executives at 35 public hospitals and health
systems, and a focus group was held with the chief executive
officers of major safety net institutions. Case studies of
selected practices at safety net health systems were developed
to identify promising and innovative approaches. The
practices were organized under six headings: leadership,
interpreter services, community relations and outreach,
infrastructure, staff training, and clinical services.
Population Studied: Large safety net hospitals and health
systems geographically dispersed across the country were
selected for the case studies. The participating institutions
have highly diverse patient populations in terms of race,
ethnicity, language and insurance status.
Principal Findings: Public hospitals and health systems have
undertaken the provision of culturally and linguistically
appropriate services because these practices are a
fundamental component of their mission.
The most highly developed practices to serve diverse
communities are in the area of interpreter services.
Leadership is crucial to initiating and sustaining practices that
focus on disparities and serving diverse communities.
Technological applications are highly promising in the
development of practices to serve diverse populations.
The need for comprehensive, timely data is crucial to the
development of metrics that will enable hospitals and health
systems to measure performance in providing culturally and
linguistically appropriate care and to measure impact on
disparities.
Conclusions: For major safety net systems across the
country, providing health care in a culturally competent
manner is crucial to quality of care, patient satisfaction,
successful staff training and recruitment and the financial
viability of safety net institutions. Although these practices are
central to efforts to reduce disparities, they are generally the
result of entrepreneurial activity by senior executives and
undertaken without supplemental resources, burdening
already constrained safety net institutions.
Implications for Policy, Delivery or Practice: At the federal
level more effective coordination is needed among agencies
issuing standards, guidelines, and directives in the area of
cultural and linguistically appropriate services. Additional
resources should be directed at supporting those safety net
institutions that are providing care to diverse populations,
many of whom are uninsured, on Medicaid, and do not speak
English. Resources are also needed to develop data systems
to provide timely, accurate metrics to monitor performance in
providing this care and to measure efforts to reduce health
disparities for diverse populations.
• Development of an Easy-to-Use Spanish Health Literacy
Assessment Tool
Shoou-Yih Lee, Ph.D., Rafael Ruiz, Sc.M., Debra Bender,
Ph.D., M.P.H., Young Cho, Ph.D.
Presented by: Shoou-Yih Lee, Ph.D., Assistant Professor,
Health Policy and Administration, University of North Carolina
at Chapel Hill, 1101 McGavran-Greenberg Hall, Chapel Hill,
NC 27599-7411; Tel: 919.966.7770; Fax: 919.966.6961; E-mail:
sylee@email.unc.edu
Research Objective: The study was intended to develop and
validate a health literacy assessment tool, termed the Short
Assessment of Health Literacy for Spanish Adults (SAHLSA),
for the Spanish-speaking population. Health literacy means
the degree to which individuals have the capacity to obtain,
process, and understand basic health information and
services needed to make appropriate health decisions.
Research has shown that low health literacy may be associated
with low health status, and increased rates of emergency room
use and hospitalization. Healthy People 2010 Objectives: Draft
for the Public Comment notes that health literacy is
"increasingly vital to help people critically evaluate health
information." The 2000 census showed that America’s Latino
population increased 58 percent during the 1990s. In 2003,
Latinos surpassed African Americans as the nation’s largest
minority group. Given the rapid growth of the Latino
population, development of a reliable and easy-to-use health
literacy assessment tool in Spanish cannot be
overemphasized.
Study Design: The design of SAHLSA was based on the Rapid
Estimates of Adult Literacy in Medicine (REALM), known as
the most easily administered tool for assessing health literacy
in English. In addition to the word-recognition test in REALM,
SAHLSA incorporates a comprehension test using multiplechoice questions designed by an expert panel. Validation of
SAHLSA involved testing and comparing the tool with other
health literacy assessment instruments in a sample of 201
Spanish-speaking and 202 English-speaking subjects recruited
from the Ambulatory Care Center at the University of North
Carolina Hospitals.
Population Studied: Spanish- and English-speaking
populations.
Principal Findings: With only the word recognition test,
REALM could not differentiate the level of health literacy in
Spanish. Incorporation of the comprehension test in SAHLSA
significantly improved the differentiation among Spanishspeaking subjects. The correlation between SAHLSA and the
Test of Functional Health Literacy in Adults (TOFHLA),
another health literacy assessment instrument, was 0.66 in
the Spanish-speaking subjects, comparable with the
correlation (r=0.74) in the English-speaking sample. SAHLSA
was also significantly correlated with educational attainment
(years of schooling) and health status in both the Spanishand English-speaking samples. Finally, we tested and found
SAHLSA to have high test-retest reliability (r=0.90).
Conclusions: The new instrument, SAHLSA, was satisfactory
based on reliability and validity tests.
Implications for Policy, Delivery or Practice: With further
improvement and validation, SAHLSA could be used in clinics
and public health settings to assess the health literacy level of
Spanish-speaking patients. This would enhance health
professionals’ ability to communicate with and, thus, deliver
better medical services, to their Spanish-speaking patients.
SAHLSA, used as a health literacy screening tool in local
Latino communities, could improve our understanding of the
specific health and personal needs of Latino residents and
help policy-makers, researchers and community groups
design intervention and educational programs that suit the
health literacy level of this under-served population.
Primary Funding Source: AHRQ
• Language Barriers and Seniors: Implications for
Medicare Policies
Ninez Ponce, M.P.P., Ph.D., Leighton Ku, Ph.D., William
Cunningham, M.D., M.P.H.
Presented by: Ninez Ponce, M.P.P., Ph.D., Assistant
Professor, Health Services, UCLA School of Public Health, 31254B CHS, Los Angeles, CA 90095-1772; Tel: 310.206.4021;
Fax: 310.455.9475; E-mail: nponce@ucla.edu
Research Objective: Most research concerning health
disparities related to limited English proficiency (LEP) or
immigration status has focused on low-income children and
families and, therefore, on Medicaid policies. This study
investigates whether such disparities also occur among
seniors covered by Medicare.
Study Design: We assessed language barriers as a 3-level
measure of English language proficiency: 1) LEP, in which the
individual speaks English well or not well; 2) bilingual, in
which the individual speaks English well or very well and
speaks another language; and 3) speaks English only. We
measure whether and to what extent there are disparate
patterns by English language proficiency in self-reported
physical and mental health, having a usual source of care,
seeing a doctor over the past year, and utilization of recent
breast and colorectal cancer screening tests. We employed
simple logit regressions, weighted to the California 2000
population, adjusting for relevant demographic and
socioeconomic covariates.
Population Studied: We studied the 2001 California
population, age 65 and older, covered by Medicare. Our data
source was the population-based 2001 California Health
Interview Survey (n =10, 509), conducted in English, Spanish,
Mandarin, Cantonese, Vietnamese, Korean and Khmer.
Principal Findings: We compared health status, access and
utilization measures of LEP and bilingual seniors to the
referent: seniors who speak English only. LEP was associated
with higher rates of reporting fair or poor health; both LEP
and bilingual seniors were more likely to report sadness most
or all of the time; and LEP seniors were also more likely to not
have a usual source of care. We found no differences by
language ability in having seen a doctor over the past year.
Although LEP was not associated with lower use of
mammograms and colorectal cancer tests, seniors who lived
in the U.S. less than ten years were less likely to receive these
screening tests.
Conclusions: LEP played a significant role in a senior’s
assessment of their physical and emotional health and in their
lack of a usual source of care. The language effect diminished
for utilization and cancer screening tests. The effect on
utilization may have been attenuated because of high visit
rates among the insured elderly (95% ) across all language
groups. For cancer screening tests, years lived in the U.S., had
a significant effect suggesting that US tenure confers
increasing social support and familiarity with the health care
system in a way that promotes adherence to cancer screening
guidelines. Thus, though language had no effect, the
immigrant dimension in utilization of preventive tests was still
important.
Implications for Policy, Delivery or Practice: Federal civil
rights policy, based on Title VI of the Civil Rights Act, requires
that health care providers and other organizations that receive
federal funds offer language assistance to those with limited
English proficiency. Our study demonstrates that language
and immigrant-related barriers exist for seniors in Medicare,
so that federal policy-makers, such as the Congress or the
Department of Health and Human Services, may become
more broadly interested in language assistance policies.
Primary Funding Source: NIA, Commonwealth Fund
• Impact of Perceived Discrimination on Use of Preventive
Services
Amal Trivedi, M.D., M.P.H., John Ayanian, M.D., M.P.P.
Presented by: Amal Trivedi, M.D., M.P.H., Fellow,
Department of Health Care Policy, Harvard Medical School,
180 Longwood Avenue, Boston, MA 02115; Tel: 617.432.3138;
E-mail: trivedi@hcp.med.harvard.edu
Research Objective: Prior research has documented
disparities in the use of health services based on race, gender,
and insurance status. We examined the frequency of perceived
discrimination in the health care system, and the relation
between perceived discrimination and the receipt of preventive
services.
Study Design: We conducted a cross-sectional study of the
2001 California Health Interview Survey, a random–digit
telephone survey, to assess the relation between the
perception of having been discriminated against in a health
care setting over the past 12 months and receipt of the
following preventive health services over this time period:
aspirin use and cholesterol testing among people with heart
disease or hypertension, foot examination and HbA1C testing
among people with diabetes, colon cancer screening for adults
>age 50, PSA testing among men >age 50 , flu vaccination
among adults >age 65, mammography among women age 5079, and Pap testing among women age 18-65. We used
multivariate logistic regression to control for multiple
demographic and clinical characteristics with SUDAAN
software.
Population Studied: 54,968 Californian adults aged 18 and
older.
Principal Findings: Of the 54,968 subjects, 2830 (4.7%)
reported experiencing discrimination in a health care setting
over the past 12 months; among these individuals, the most
frequent types of perceived discrimination was related to
insurance type (27.4%), race (13.7%), and income (6.6%).
Female gender, non-white race, lack of insurance, rural
residence, low income, lack of high school education, limited
English proficiency, presence of comorbid medical conditions,
more frequent physician visits, fair or poor health status,
current tobacco use, unmarried status, and obesity were
significantly associated with reporting discrimination (all
p<0.05). Persons who reported discrimination were less likely
than those not reporting discrimination to have had HbAIC
testing (78.5% vs. 86.1% p=0.04), cholesterol testing (71.0%
vs. 79.2% p<0.01), mammography (78.4% vs. 83.6% p=0.03)
and PSA testing (37.1% vs. 45.7% p=0.03.) There was no
significant difference in aspirin use (33.4 vs. 35.2% p=0.38),
foot examination (60.8% vs. 67.6% p=0.12), colon cancer
screening (41.8% vs. 44.0% p=0.26), flu vaccination (62.5%
vs. 67.5% p=0.10) and Pap testing (87.7% vs. 87.1% p=0.61).
After adjustment, there was no significant relation between
perceived discrimination and use of preventive services except
for cholesterol testing (OR 0.69, 95% CI: 0.55-0.88, p<0.01).
Conclusions: The adjusted association between perceived
discrimination and decreased use of preventive health services
was relatively small in magnitude and significant only for
cholesterol testing. Given these limited associations and the
small percentage of adults who reported discrimination,
perceived discrimination is unlikely to account for a large
portion of observed disparities in use of preventive health
services.
Implications for Policy, Delivery or Practice: Future studies
should validate the results of this study using longitudinal
data, focus on specific experiences related to perceived
discrimination in the health care system, and examine whether
discrimination has other impacts on use of health services.
Primary Funding Source: NIH NRSA Research Training
Grant
Call for Papers
Disparities in Hospital Care
Chair: Edward Guadagnoli, Ph.D.
Tuesday, June 8 • 11:15 a.m.-12:45 p.m.
• Racial and Ethnic Differences in the Time to Acute
Reperfusion Therapy for Patients Hospitalized with
Myocardial Infarction
Elizabeth Bradley, Ph.D., Yongfei Wang, M.S., Jeph Herrin,
Ph.D., Tashonna Webster, M.P.H., Martha Blaney, D.Pharm.,
Harlan Krumholz, M.D.
Presented by: Elizabeth Bradley, Ph.D., Associate Professor,
Health Policy and Administration, Yale School of Public
Health, 60 College Street, New Haven, CT 06520; Tel:
203.785.2937; Fax: 203.785.6287; E-mail:
elizabeth.bradley@yale.edu
Research Objective: Racial and ethnic disparities in
cardiovascular care are well documented. Recent reports
indicate that patients with acute myocardial infarction
identified as non-white experience significantly longer door-todrug and door-to-balloon times than patients identified as
white, raising concerns of health care disparities. However,
we know little about the reasons for these differences. We
sought to examine the extent to which sociodemographic
factors, insurance, clinical characteristics, and hospital-level
factors mediate, and thus potentially explain, racial and ethnic
differences in time to acute reperfusion. Door-to-drug and
door-to-balloon times are critical quality indicators for
cardiovascular care because prompt reperfusion substantially
reduces subsequent morbidity and mortality.
Study Design: This is a retrospective, observation study using
patient level data from the National Registry of Mypcardial
Infarction (NRMI) and hospital-level data from the American
Hospital Association Hospital Survey from 2000. We use
sequential, hierarchical modeling to examine crude and
adjusted racial/ethnic differences in time to treatment patients
receiving primary reperfusion therapy after acute myocardial
infarction.
Population Studied: Patients admitted to hospitals
participating in NRMI, the largest longitudinal registry for
myocardial infarctions in the U.S., from January 1, 1999
through December 31, 2002, with a diagnosis of ST-elevation
myocardial infarction or left bundle branch block and who
underwent primary reperfusion therapy (fibrinolytic therapy:
n=73,278 patients; percutaneous coronary intervention (PCI):
n = 37,214 patients).
Principal Findings: We found marked differences in time to
reperfusion by race/ethnicity, with patients identified as
African American/black on average having about 20% longer
door-to-drug and door-to-balloon times than patients
identified as white. This difference translates into times that
are 7 minutes longer for door-to-drug time and 19 minutes
longer for door-to-balloon time. We also found significant
differences in times to acute reperfusion therapy for patients
identified as Hispanic although the magnitude of these
differences were modest (P-values < 0.01). A substantial
portion of the differences were mediated by hospital-level
factors. Even after additional adjustment for
sociodemographic, insurance type, clinical, and admission
data, patients identified as African American/black or Hispanic
had significantly longer times to treatment after hospital
arrival (P-values < 0.01)
Conclusions: Differences by race and ethnicity persist in key
quality indicators for cardiovascular care. Much of the
differences are reduced after accounting for hospital-specific
effects, suggesting that a substantial portion of the
racial/ethnic disparities may be due to differences in the
hospitals where minority patients are more likely to be treated,
rather than differential treatment inside the hospital.
Implications for Policy, Delivery or Practice: Our study has
important implications for efforts to eliminate disparities in
time to acute reperfusion. Although efforts to raise awareness
of racial/ethnic disparities are important, our finding suggests
the need for parallel efforts directed toward improving the care
at hospitals around the country that are lagging in their
quality, as measured by prompt treatment for patients with
acute myocardial infarction. Interventions to eliminate
racial/ethnic disparities are likely to fall short of their goals
unless they are accompanied by systemic changes that can
ensure all patients have access to high quality hospitals.
Primary Funding Source: National Heart, Lung, Blood
Institute
• Veteran Status Is not an Independent Risk Factor for
CABG Mortality
William Weeks, M.D., M.B.A., Dorothy Bazos, Ph.D., David
Bott, Ph.D., Edward Hannan, Ph.D., Michael Racz, M.A.,
Steven Wright, Ph.D., Elliott Fisher, M.D.
Presented by: Dorothy Bazos, Ph.D., Associate Director, Rural
Health Initiative, VA Medical & Regional Office Center-White
River Junction, VT, VAMC(11Q), White River Junction, VT
05009; E-mail: Dorothy.Bazos@med.va.gov
Research Objective: Recent studies demonstrating poorer
cardiac care outcomes in VHA compared to the private sector
raise the question of whether veteran status is an independent
risk factor that explains these differences.
Study Design: From New York’s Cardiac Surgery Reporting
System (CSRS), we identified 3,032 enrolled veterans and
54,118 non-veterans who obtained isolated CABG between
1997-1999. Using the CSRS logistic regression model that
adjusts mortality rates for patient and surgical characteristics,
we compared risk-adjusted mortality rates for veterans to
those for non-veterans undergoing surgery in private sector
hospitals in New York. Using veteran status as a dummy
variable in the regression model, we also calculated odds
ratios for veteran compared to non-veteran mortality for each
year and for the three-year period.
Population Studied: 57,150 male residents of New York who
obtained isolated Coronary Artery Bypass Grafting (CABG)
from 1997-1999.
Principal Findings: Although the expected mortality rate was
somewhat higher for veterans (2.42 (95% CI:1.92-2.95)) vs.
2.19 (95%CI:2.07-2.31), veterans had slightly lower riskadjusted mortality rates compared to non-veterans
undergoing CABG in private sector hospitals (2.05:95%
CI:1.59-2.59 vs. 2.21:95%CI:2.09-2.34). We found no statistical
difference in risk-adjusted mortality rates when comparing
mortality rates in each year.
Conclusions: In New York, although veterans have more
severe disease than non-veterans, veteran status is not an
independent risk factor for CABG mortality in the private
sector, after adjustment for the case-mix measures available in
the CSRS.
Implications for Policy, Delivery or Practice: Additional
studies are needed to assess whether factors other than
illness burden account for the higher mortality seen within
VHA. In areas where access is challenging and monitoring
systems are in place, VHA should consider contracting for
CABG services.
Primary Funding Source: VA
• Separate and Unequal: Hospital Racial Segregation and
Disparity in Pressure Ulcers in New York State
Kevin Fiscella, M.D., M.P.H., Sean Meldrum, M.S., Steve
Barnett, M.D., Peter Franks, M.D.
Presented by: Kevin Fiscella, M.D., M.P.H., Associate
Professor, Family Medicine, University of Rochester School of
Medicine & Dentistry, 1381 South Avenue, Rochester, NY
14620; Tel: 585.506.9484 Ext. 106; Fax: 585.473.2245; E-mail:
Kevin_Fiscella@urmc.rochester.edu
Research Objective: To examine the extent to which patient
racial composition of hospitals explains racial disparity in
pressure ulcers in New York State.
Study Design: Cross-sectional, marginal effects models of
hospital discharge data for adult acute care patients (New
York State Inpatient Data 1998-2000). Initial model included
patient characteristics (type of admission and length of stay,
age, gender, ethnicity, income and insurance, and comorbidity) and hospital characteristics (bed size, ownership,
teaching status, nursing and resident to bed ratios and total
number of annual discharges). Final model included
proportion of hospital discharges of black patients.
Population Studied: 2.1 million patient discharges from acute
care facilities in New York State 1998-2000.
Principal Findings: African Americans (3.4%) had higher
adjusted rates (0.9%; 95% CI 0.4 - 1.4%) of pressure ulcers
than whites (2.5%) after controlling patient and hospital
characteristics. This disparity was eliminated when proportion
of black discharges by hospital was included in the model
(0.01 %; 95% CI -0.1 - 0.3). Hospitals with larger percentage of
black discharges showed significantly higher rates of pressure
ulcers. Percentage of black discharges was strongly associated
with percentage of hospital discharges that were insured
through Medicaid and MSA size of the hospital location.
Nonetheless, the relationship between percent black and
pressure ulcer rate remained after adjusting for these factors.
Conclusions: Racial disparity in pressure ulcers is largely
explained by a single hospital characteristic: percentage of
black patient discharges suggesting that hospital segregation
is associated with adverse effects.
Implications for Policy, Delivery or Practice: Further
research is needed to confirm these findings for other quality
measures and to determine whether they reflect the financial
stress of heavily black hospitals.
Primary Funding Source: AHRQ
• Technology Diffusion, Geographic Variation, and Racial
Disparities among Elderly Medicare Beneficiaries: 19892000
Peter Groeneveld, M.D., M.S., Sara Laufer, M.A., Alan Garber,
M.D., Ph.D.
Presented by: Peter Groeneveld, M.D., M.S., Assistant
Professor of Medicine, University of Pennsylvania School of
Medicine, 1122 Blockley Hall, 423 Guardian Drive,
Philadelphia, PA 19104-6021; Tel: 215.898.2569; Fax:
215.573.8779; E-mail: petergro@mail.med.upenn.edu
Research Objective: To determine if geographic differences in
utilization of emerging medical technologies contributed to
racial disparity in healthcare, and if reductions over 12 years in
geographic variation in the use of selected procedures were
accompanied by decreases in national rates of racial disparity
for these technologies.
Study Design: This was a retrospective cohort study. The
outcome of interest was receipt of a selected emerging
technology within 90 days of a hospital admission for a
diagnosis that indicated eligibility. Multivariate logistic
regression models were constructed to assess the effect of
race, year of admission, and residence in a health service area
with >30% black population on the primary outcome.
Covariates included age, sex, clinical comorbidity, urban
residence, race-specific, community levels of education and
income, and admission to an academic hospital. For each
technology, the interaction between year of admission and
race was examined to assess for time trends in racial disparity.
Similarly, interactions between year of admission and living in
an health service area with >30% black population were
examined to assess geographic diffusion into areas with larger
black populations.
Population Studied: 3,630,819 hospitalized, elderly Medicare
beneficiaries potentially eligible, as determined by prespecified International Classification of Diseases-Ninth
Revision diagnosis codes, for one of eight emerging medical
technologies between 1989-2000.
Principal Findings: Racial disparities were identified in seven
of the eight selected technologies. Dual-chamber pacemaker
implants, lumbar/lumbosacral spinal fusion, and cardiac
electrophysiologic study rates, which showed no significant
temporal changes in racial disparity from 1989-2000,
demonstrated less variation (trend p<0.001 for all) between
white and black geographic areas with time. Endoscopic biliary
procedures were performed with progressively greater
geographic variation (trend p=0.03), yet there was no
concurrent exacerbation in national rates of racial disparity.
Internal mammary artery coronary bypass grafting
demonstrated decreased racial disparity with time (p=0.03 for
trend), but with no observed change in geographic variation.
The remaining 3 procedures (aortic valve replacement with
tissue, interruption of the vena cava, and vaginal
suspension/fixation) had no temporal change in either racial
disparity or geographic variation.
Conclusions: Reduction in the geographic variation of
technology utilization in black and white areas was not
associated with decreasing racial disparity. Conversely, the
sole emerging technology for which racial disparity diminished
had no change in geographic variation. We find little evidence
to support the role of reduction in geographic heterogeneity as
a driver of racial equity in healthcare.
Implications for Policy, Delivery or Practice: Policies
designed to reduce racial disparities by increasing procedure
use in localities with large minority populations may not be
effective. Local factors, rather than geographic variation
among localities, may be the predominant cause of persistent
racial disparity in health care.
Primary Funding Source: NIA
• The Effect of Cuts in Medicare Reimbursement on
Quality of Hospital Care
Meena Seshamani, Ph.D., Kevin Volpp, M.D., Ph.D.
Presented by: Meena Seshamani, Ph.D., Medical Student, ,
University of Pennsylvania School of Medicine, Box 265, 3450
Hamilton Walk, Philadelphia, PA 19104; Tel: 215.901.6419; Fax:
215.573.8778; E-mail:
meena.seshamani@marshallscholarship.org
Research Objective: The Balanced Budget Act (BBA) of 1997
was introduced as a cost-saving measure that was designed to
reduce Medicare reimbursements to health care providers by
$116.4 billion from 1998 to 2002. There is concern that the
financial strain induced by these revenue reductions could
adversely affect the quality of patient care in hospitals. This
study seeks to determine if hospitals under different levels of
financial strain from the BBA had differential changes in 30day mortality for a variety of conditions, and to see if
vulnerable patient populations such as the uninsured or
minorities were disproportionately affected.
Study Design: Pennsylvania hospital discharge data was
obtained for fiscal years 1997 to 2001 for six conditions
identified by the Agency for Health Care Research and Quality
as Inpatient Quality Indicators. The hospital impact of the
BBA was estimated using an American Hospital Association
simulator that projected Medicare reimbursements with and
without the BBA effects. A patient-level logistic regression
analysis (n=807,723) examined the likelihood of dying within
30 days of admission in relation to fiscal year and hospital
BBA impact (measured as top quartile, bottom quartile, and
middle 50%), controlling for other hospital and patient
characteristics. Differential effects of the BBA on uninsured
patients and blacks were assessed using interaction terms
with the BBA impact variable. To illustrate the effects of the
BBA on health outcomes, the likelihood of death was
estimated for the different hospital impact groups for insured
and uninsured patients and for whites and blacks, holding all
other patient and hospital characteristics constant.
Population Studied: All patients in Pennsylvania hospitalized
with one of six conditions, divided into conditions for which
admission is non-discretionary (hip fracture, stroke, acute
myocardial infarction, stroke) and for which admission may be
discretionary (congestive heart failure, pneumonia).
Principal Findings: The average magnitude of Medicare
payment reduction on overall hospital net revenues was
estimated at 2.0% for the low impact group and 4.1% in the
high impact group in 1998, worsening to 2.9% and 5.2%,
respectively, by 2000. Insured patients treated in high impact
hospitals were found to have an increased likelihood of dying
from conditions with non-discretionary admission (from 18.1%
in 1997-98 to 19.4% in 2001) while patients from low impact
hospitals had a decreased likelihood of dying (19.1% to in
1997-98 to 18.5% in 2001). These differences in the rate of
change were significant (p<0.01). Uninsured patients were
found to have a significantly larger increase in the likelihood of
dying than insured patients in the high impact hospitals
(22.8% in 1997-98 to 30.2% in 2001, p<.05) but the difference
in the rate of change in mortality risk between the insured and
uninsured patients in middle and low impact hospitals was
insignificant (p=0.14). There was no differential effect between
whites and blacks, nor were there any significant effects of the
BBA on 30-day mortality rates for conditions with discretionary
admission criteria.
Conclusions: Increased financial strain in hospitals may
adversely affect quality of patient care, particularly within
vulnerable patient groups such as the uninsured.
Implications for Policy, Delivery or Practice: Hospital
reimbursement cuts may exacerbate existing disparities in
care and should be considered in the evaluation of cost-saving
policy reforms.
Primary Funding Source: Doris Duke Foundation
Related Posters
Poster Session B
Tuesday, June 8 • 7:30 a.m.-8:45 a.m.
• Racial Differences in Diabetes Therapy Intensification
and Glycemic Control
Alyce Adams, Ph.D., Connie Mah, M.S., Fang Zhang, M.S.,
Stephen Soumerai, Sc.D., Ken Kleinman, Ph.D., James Meigs,
M.D., M.P.H., Richard Grant, M.D., M.P.H., Steven Simon,
M.D., M.P.H., Dennis Ross-Degnan, Sc.D.
Presented by: Alyce Adams, Ph.D., Assistant Professor,
Ambulatory Care and Prevention, Harvard Medical School, 133
Brookline Avenue, 6th Floor, Boston, MA 02215; Tel:
617.509.9863; Fax: 617.859.8112; E-mail:
aadams@hms.harvard.edu
Research Objective: Previous studies have identified failure
to intensify therapy (“clinical inertia”) as one potential barrier
to glycemic control among diabetes patients. To test this
hypothesis, we assessed therapy intensification (from diet-only
to oral drug therapy to insulin use) and glycemic control in
black vs. white diabetes patients.
Study Design: We used generalized estimating equations to
estimate the odds of therapy intensification and of very poor
glycemic control (HbA1c=10.0) among blacks vs. whites,
controlling for patient characteristics (e.g., age, BMI, baseline
HbA1c).
Population Studied: We analyzed 2,303 patients from a large
multispecialty care group in MA serving mostly privately
insured patients. We included patients with a diagnosis of
diabetes (diagnosis of diabetes on 1 inpatient claim or 2
outpatient encounters or = 1 diabetes drug dispensing; not
gestational diabetes) in 1992 or 1993, who were 18 or older at
diagnosis, and continuously enrolled from 1994 to 1999.
Principal Findings: In multivariate models, blacks had
significantly higher odds of very poor glycemic control (OR:
1.5; 95%CI: 1.2,1.8) but no greater likelihood of therapy
intensification (OR: 0.97; 95%CI: 0.63,1.5) vs. white patients.
Significant predictors (p<0.01) of therapy intensification
included: number of physician visits, diet-only regimen at
baseline, current HbA1c level, higher BMI, and higher baseline
HbA1c.
Conclusions: Black race was an independent predictor of very
poor glycemic control but not of intensification of
hypoglycemic therapy.
Implications for Policy, Delivery or Practice: These findings
suggest that observed racial differences in diabetes outcomes
may be due more to system and patient level factors
contributing to differences in control than to differences in
treatment by race.
Primary Funding Source: NIDDK
• Predictors of Patient Compliance with Endoscopic
Colorectal Cancer Screening Recommendations
Nasar Ahmed, Ph.D., Tabassum Insaf, M.P.H., Ashar Ata,
M.P.H., Steven Stain, M.D.
Presented by: Nasar Ahmed, Ph.D., Director, Epi-Stat
Division, Internal Medicine, Meharry Medical College, 1005
D.B. Todd Boulevard, Nashville, TN 37208; Tel: 615.327.5800;
Fax: 615.327.5847; E-mail: nahmed@mmc.edu
Research Objective: Colorectal Cancer (CRC) is the third
leading cause of cancer death in the United States. Regular
screening can greatly reduce the CRC mortality rates and the
disease burden. Endoscopic screening has been shown to be
effective in early diagnosis of CRC yet screening rates remain
low. Physician recommendation is the determining factor for
the screening. Among those who receive a physician’s
recommendation a considerable portion is still not compliant.
Not much is known about the correlates of their noncompliance. Our study examined predictors of patient
compliance with endoscopic screening recommendation in
US population.
Study Design: We used the NHIS 2000 data. Bivariate and
multivariate logistic regression analyses were used to evaluate
the predictors of compliance with screening recommendation.
Population Studied: There were 5733 adults over the age of 50
who were eligible for screening, did not have past history of
colorectal cancer and visited a physician in the past year.
Among these 1488 (27%) received a recommendation for
endoscopic screening. 76% of those who received a
recommendation were compliant.
Principal Findings: Bivariate analysis shows that the elderly,
males and retired personnel were more likely to be compliant.
Insurance coverage and frequency of doctor visits were
positively associated with compliance. Multivariate analyses
showed increasing compliance with increasing age with the
elderly (>74 years) being more than 3 times as likely to be
compliant as 50-54 year old. Females were 53% less likely to be
compliant. Blacks were 68% more likely to be compliant than
Whites. Compliance increased with increasing level of
education. College graduates were twice as likely to comply as
compared to subjects who had not completed high school.
The underweight were 77% less likely and the obese were 32%
less likely to comply as compared to those with normal BMI.
Current alcohol drinkers were 39% less likely to be compliant
than lifetime abstainers of alcohol.
Conclusions: Level of education, age and gender of patients,
frequency of doctor visit, body mass index, alcohol use and
being African American play a significant role in compliance
with physician recommendation.
Implications for Policy, Delivery or Practice: Physicians
could educate the identified non-compliant groups to increase
the effectiveness of screening recommendations.
Interventions targeted to increase awareness of the risk of
CRC among non-compliant groups should be developed.
Primary Funding Source: NCI
• Disadvantaged at Discharge: The Influence of Race and
Education on Post-Acute Placement in Low Quality
Nursing Homes
Joseph Angelelli, Ph.D., David Grabowski, Ph.D., Vincent Mor,
Ph.D.
Presented by: Joseph Angelelli, Ph.D., Assistant Professor,
Health Policy & Administration, Pennsylvania State, 116
Henderson, University Park, PA 16802; Tel: 814.865.5177; Fax:
814.863.2905; E-mail: jangel@psu.edu
Research Objective: To determine whether African-American
and other minority patients over age 65 are at greater risk of
being discharged to the lowest quality nursing homes within a
given Hospital Service Area (HSA).
Study Design: The 2002 national Minimum Data Set (MDS)
is used to examine patient and market factors predictive of
admission into nursing homes.
Population Studied: The sample is restricted to 150 HSAs
with at least four freestanding nursing homes and at least 50
African-American patients age 65 and over admitted to those
nursing homes in the calendar year, yielding a nationwide
sample of 121,443 unique admissions to nursing homes.
Principal Findings: Controlling for education, other
demographic factors and clinical severity measures, AfricanAmericans are 32% (95% CI, 14-54) more likely than whites to
be admitted to the lowest quality nursing homes in areas with
multiple hospitals and 70% (95% CI, 4-279) more likely to be
admitted to low quality nursing homes in markets with just
one hospital. Individuals with no college education are 20%
(95% CI, 7-34) more likely to be admitted to the lowest quartile
of nursing homes in a given HSA.
Conclusions: Our findings offer evidence that existing racial
disparities in nursing home care are attributable in part to
hospital discharge practices that direct minorities to lower
quality nursing homes.
Implications for Policy, Delivery or Practice: Education is
also negatively related to placement in lower quality post-acute
settings, suggesting the need for a new emphasis in the
training of hospital discharge planners to better translate
publicly available information about nursing home quality to
prospective nursing home admissions and their families.
Primary Funding Source: NIA
• Racial and Socioeconomic Disparities in Mortality after
Injury
Melanie Arthur, Ph.D., Richard Mullins, M.D., Jerris Hedges,
M.D., M.S.
Presented by: Melanie Arthur, Ph.D., assistant professor,
Sociology, Portland State University, P.O. Box 751, Portland,
OR 97207-0751; Tel: 503.725.3615; Fax: 503.725.3957; E-mail:
arthurm@pdx.edu
Research Objective: Injury is a major cause of death in
adults. Though racial disparities in access to medical care and
health outcomes are well documented, trauma care is
generally assumed to represent an exception to this pattern.
We sought, using a nationally representative sample, to
determine whether race was associated with risk of in-hospital
death after injury.
Study Design: We performed a risk-adjusted analysis of inhospital mortality after injury, controlling for age, gender, preexisting conditions, injury severity, primary payer, median
income of zip code of residence, region and hospitalization at
an urban teaching hospital, urban non-teaching hospital or
rural hospital. Multivariate models were estimated using
generalized estimating equations to control for clustering of
patients within hospitals.
Population Studied: From the Healthcare Cost and
Utilization Project, years 1998-2000, we selected for analysis
all patients age 18-64 with a primary diagnosis consistent with
injury (ICD-9-CM codes 800-959, excluding late effects of
injury). Excluded were all patients with discharge disposition
indicating transfer to another acute care facility, and patients
hospitalized in any of five states which do not release patient
race data.
Principal Findings: Relative to injured white patients, black
patients had a higher likelihood of in-hospital mortality (2.1%
versus 1.5%, multivariate odds ratio=1.15, p<.05). Other
race/ethnicity groups showed no significant difference from
white patients. There were significant differences in cause of
injury between black and white patients, with 25% versus 32%
injured in motor vehicle crashes and 26% versus 5% injured in
an assault or attempted homicide. In stratified analyses, we
found the largest racial disparities among mild to moderately
injured patients (multivariate odds ratio=1.52, p<.001).
Socioeconomic variables also showed an association with
mortality, but did not eliminate the observed black/white
disparity. Residence in a zip code with a median income of
<$45000 was associated with higher odds of death for black
patients but not for white patients, and lack of insurance was
associated with increased mortality for patients of all ethnic
groups (OR=1.72 relative to private insurance, p<.001).
Conclusions: These data show that black patients have a
higher risk of death after injury, even in models which control
for health status, injury characteristics, and limited
socioeconomic indicators. This association is strongest
among hospitalized patients with mild to moderate injuries,
where there is likely to be more discretion in treatment
decisions. Further, we found evidence of socioeconomic
disparities in mortality after injury, especially for black
patients. It is unclear whether the observed disparities in
mortality after injury are related to access to care or other
unmeasured differences in injury characteristics and preexisting health status.
Implications for Policy, Delivery or Practice: While these
data do not offer the depth of information necessary to draw
firm conclusions as to the cause of the observed disparities,
they raise important questions about access to quality trauma
care for black patients, residents of poor neighborhoods and
the uninsured.
Primary Funding Source: CDC
• A Comparison of Title III Agencies Funded by the
Minority AIDS Initiative Vs. All Other Title III Agencies
Jill Ashman, Ph.D.
Presented by: Jill Ashman, Ph.D., Health Statistician,
HIV/AIDS Bureau Office of Science and Epidemiology,
DHHS/HRSA, 5600 Fishers Lane, Room 7-90, Parklawn
Building, Rockville, MD 20857; Tel: 301.443.4364; Fax:
301.594.2511; E-mail: JAshman@hrsa.gov
Research Objective: To examine whether the characteristics
of and clients served by Ryan White Title III agencies that were
funded by the Minority AIDS Initiative were different from
other Title III agencies.
Study Design: The Means procedure in SPSS as well as
Standard chi-square tests, when appropriate, were used to test
for statistically significant differences (p<0.05) between the
characteristics of and clients served by organizations receiving
MAI funding with those agencies that did not receive MAI
funding.
Population Studied: Data are from the 2002 CARE Act Data
Report, a required annual report for agencies receiving
funding through the Ryan White Comprehensive AIDS
Resources Emergency (CARE) Act. The 415 Title III agencies,
all of which provide comprehensive primary health care
services for individuals living with HIV disease, were divided
into two groups, those that received funding through the
Minority AIDS Initiative (MAI) (n=109) and those that did not
(n=306). Congress established the MAI in 1999 in response to
both the disproportionate impact of the HIV epidemic in
minority communities and the disparities in documented
morbidity and mortality data for African American persons
with HIV/AIDS. The MAI was implemented as part of the
existing Title III program and used to expand Title III funding
to organizations serving communities of color in order to
increase access to HIV primary care for highly impacted
and/or underserved communities.
Principal Findings: MAI-funded agencies were 1.5 times more
likely to be located in the Southeast (34% vs. 20%) and
Midwest (12% and 8%) and half as likely to be located in the
Northeast, Northwest, Rocky Mountain, and Plains states (8%
and 22%). They were equally likely to be located in CA, NJ, NY,
and the Mid-Atlantic States. They were more likely to be
publicly-funded community health centers (47% vs. 29%) and
less likely to be hospitals (18% vs. 32%). Twice as many of the
MAI funded agencies (56% vs. 27%) had over 50% of their
staff and board members who were members of minority
groups. The size of the agency, as measured by the number of
HIV positive clients served, was the same for both groups.
However, a larger percentage of patients at MAI-funded
agencies were new HIV positive patients (an average of 33% of
patients vs. 27%) and African American patients (an average
of 56% of patients vs. 39%), and a smaller percentage of
patients were White (on average 29% of patients vs. 45%) and
male (on average 65% of patients vs. 69%).
Conclusions: The Minority AIDS Initiative is a success. On
average, they are reaching a larger percentage of new HIV
patients as well as a larger percentage of African American
patients than other Title III agencies, suggesting that they may
be better equipped to outreach to these groups.
Implications for Policy, Delivery or Practice: The MAI is
reaching and providing quality care to African American
patients living in areas that are disproportionately impacted by
the HIV epidemic, and Congress should continue to earmark
part of the Ryan White CARE Act Title III appropriation to this
worthwhile program.
• Are the Characteristics and Service Utilization Patterns of
HIV-infected Individuals Who Were Reported as Deceased
by the End of the Calendar Year Different from Those
Patients Who Were Not Reported as Deceased?
Jill Ashman, Ph.D.
Presented by: Jill Ashman, Ph.D., Health Statistician,
HIV/AIDS Bureau Office of Science and Epidemiology, Health
Resources and Services Administration, 5600 Fishers Lane,
Room 7-90, Parklawn Building, Rockville, MD 20857; Tel:
301.443.4364; Fax: 301.594.2511; E-mail: jashman@hrsa.gov
Research Objective: To examine whether the characteristics
and service utilization patterns of HIV-infected individuals
who were reported as deceased at the end of the calendar year
were different from those who were not reported as deceased.
Study Design: Standard chi-square tests were used to test for
statistically significant differences (p<0.05) between the
demographic characteristics and service utilization patterns of
HIV-positive patients who died by the end of the calendar year
with HIV positive individuals who did not die. Data examined
include client characteristics, health indicators, and service
utilization including primary care as well as services that
support individuals’ entry and retention in primary care.
Population Studied: 2002 Year End Data from the Health
Resources and Services Administration’s (HRSA) Client
Demonstration Project (CDP) are used.
Principal Findings: There were no statistically significant
differences between the two groups for gender, race, being
homeless and their likelihood to receive the following services:
mental health and substance abuse treatment/counseling,
dental care, housing assistance and emergency financial
assistance. Individuals who died were more likely to be older,
and they were less likely to be Hispanic. In addition, those
who died were more likely to have either injecting drug use
(IDU) or men having sex with men and injecting drug use
(MSM&IDU) as their HIV exposure category (26% vs. 15%).
Conclusions: Not surprisingly, HIV-infected patients who
died in 2002 tended to be sicker than HIV-infected patients
who did not die. The patients who died were more likely to
receive hospice services as well as home health services,
services that are designed for patients who are too sick to go
to the doctor’s office. Individuals who died were also more
likely to be IDUs.
Implications for Policy, Delivery or Practice: More
emphasis needs to be placed on getting IDUs into care early
in their disease and finding effective ways to manage both
their HIV and drug abuse so that IDUs stay healthy.
• Diabetes Risk: Obesity and Physical Inactivity among
Latino Ethnic Groups in California
Susan Babey, Ph.D., Allison Diamant, M.D., MSHS, Neetu
Chawla, M.P.H., E. Richard Brown, Ph.D.
Presented by: Susan Babey, Ph.D., Research Scientist, School
of Public Health, UCLA Center for Health Policy Research,
10911 Weyburn Avenue, Suite 300, Los Angeles, CA 90024;
Tel: 310.794.6961; Fax: 310.794.2686; E-mail:
sbabey@ucla.edu
Research Objective: To estimate the prevalence of obesity
and physical inactivity among Latino ethnic groups in
California, and to identify the factors related to obesity and
physical inactivity among Latino adults as indicators of
diabetes risk.
Study Design: We used data from the 2001 California Health
Interview Survey (CHIS). CHIS 2001, a random-digit dial
(RDD) telephone survey of more than 55,000 households
drawn from every county in California, is the largest statewide
health survey in the United States. The sample was designed
to provide estimates for California's overall population, its
major racial and ethnic groups, and a number of smaller
ethnic groups. Logistic regression analyses were used to
determine factors associated with obesity and physical
inactivity among Latino adults. Factors examined included
age, gender, and Latino ethnic group, as well as measures of
access to health care, indicators of acculturation, physical
activity and eating five or more servings of fruits and
vegetables per day.
Population Studied: We focused on adults, age 18 and older,
who reported being of Latino or Hispanic origin and who
reported they had not been diagnosed with diabetes.
Principal Findings: Among Latino adults not diagnosed with
diabetes, 22.7% were obese and 18.1% did not participate in
physical activity. Obesity varied by Latino ethnic group with
Latinos of Mexican heritage having the highest rate and South
Americans the lowest rate of obesity (24.0% vs. 13.2%, p <
0.0001). After controlling for age, gender, education, income,
and measures of access to care – Mexicans, those living in
rural areas, those who do not participate in physical activity,
and those who eat fewer than five servings of fruits and
vegetables a day were more likely to be obese. Latino adults
who lived in the US less than half of their lives were less likely
to be obese than those born in the US. Lack of physical activity
also varied by Latino ethnic group ranging from 11.3% among
South Americans to 22.4% among Central Americans (p <
0.05). After controlling for age, gender, education, income,
and measures of access to care – Latinos who eat fewer than
five servings of fruits and vegetables a day and those who
speak Spanish at home were more likely not to participate in
physical activity.
Conclusions: These findings suggest that the prevalence of
obesity and physical activity level, both risk factors for
diabetes, vary among Latino/Hispanic ethnic groups in
California. In addition, mutable risk factors for obesity and
participation in physical activity are present among Latinos.
Implications for Policy, Delivery or Practice: Diabetes is a
growing problem in California and the rest of the United
States and Latinos are at particularly high risk for type 2
diabetes. Obesity and lack of physical activity are factors that
increase the risk of developing type 2 diabetes. Identification
of factors associated with obesity and lack of physical activity
among Latinos can aid in the development of targeted
interventions to reduce the risk factors for and thereby
minimize the risk of developing diabetes among individuals in
this population.
Primary Funding Source: The California Endowment
• Access to Specialty Care for Rural American Indians in
Two States
Laura-Mae Baldwin, M.D., M.P.H., Walter Hollow, M.D.,
Susan Casey, Ph.D., L. Gary Hart, Ph.D., Eric Larson, Ph.D.,
David Grossman, M.D., M.P.H.
Presented by: Laura-Mae Baldwin, M.D., M.P.H., Associate
Professor, Family Medicine, University of Washington, Box
354982, Seattle, WA 98195; Tel: 206.685.4799; Fax:
206.616.4768; E-mail: lmb@u.washington.edu
Research Objective: The Indian Health Service (IHS) per
capita expenditure for American Indian and Alaska Native
(AI/AN) health services is less than half that spent per year on
the U.S. civilian population. Many AI/ANs, especially in rural
areas, depend on the IHS as their only source of funding for
health care. Concerns have been raised that specialty services,
which are largely funded through contracts with outside
practitioners, are limited by this insufficient IHS funding. In
this study, we explore medical providers’ perceptions of the
level of access to specialty consultation services among rural
AIs compared to their non-AI counterparts.
Study Design: Cross-sectional study design in which three
mailings of a 31-item questionnaire addressing access to
specialty physicians, perceived barriers to access, and access
to nonphysician clinical services were sent to primary care
providers working in rural Indian and non-Indian health clinics
in two Western states.
Population Studied: 115 physicians, nurse practitioners, and
physician assistants working in rural Indian health clinics in
Montana and New Mexico and 96 physicians, nurse
practitioners, and physician assistants working in rural nonIndian clinics within 25 miles of the Indian clinics.
Principal Findings: Montana’s rural Indian clinic providers
reported poorer patient access to specialty care than providers
in rural non-Indian clinics, while New Mexico’s providers
reported comparable access. Rural Indian clinic providers in
both states most frequently cited financial barrier to specialty
care. Rural Indian clinics providers in both states reported
better access to several nonphysician services than rural nonIndian clinic providers.
Conclusions: Rural primary care providers report restricted
specialist access for Indian patients compared to non-Indian
patients in Montana, where they are dependent on private,
community-based specialists, but not New Mexico, where a
contractual agreement with a tertiary-care university hospital
exists. In both states, financial factors serve as significant
barriers to rural Indian and non-Indian patients’ access to
specialists. The multidisciplinary approach to care taken in
many IHS and tribal-administered clinics is associated with
greater perceived access to nonphysician services among rural
Indian compared to non-Indian clinic providers.
Implications for Policy, Delivery or Practice: Ensuring
specialty care access for rural Indian patients nationwide will
require equitable and adequate funding for the Indian Health
Service as well as well developed specialty referral
relationships and systems.
Primary Funding Source: Federal Office of Rural Health
Policy
• Improving Health Care Quality For Racial/Ethnic
Minorities: A Systematic Review of Interventions
Mary Catherine Beach, M.D., M.P.H., Tiffany Gary, Ph.D.,
Eboni Price, M.D., Karen Robinson, M.Sc., Aysegul Gozu,
M.D., Ana Palacio, M.D., M.P.H., Carole Smarth, M.D., Mollie
Jenckes, M.H.S., R.N., Carolyn Feuerstein, B.A., Eric Bass,
M.D., M.P.H., Neil Powe, M.D., M.P.H., M.B.A., Lisa Cooper,
M.D., M.P.H.
Presented by: Mary Catherine Beach, M.D., M.P.H., Assistant
Professor, Medicine, and Health Policy & Management, Johns
Hopkins University, 2024 East Monument Street, Suite 2-500,
Baltimore, MD 21287; Tel: 410.614.1134; Fax: 410.614.0588; Email: mcbeach@jhmi.edu
Research Objective: Racial and ethnic disparities in health
care quality have been extensively documented, but little is
known about the effectiveness and cost of strategies to
improve the quality of care for racial/ethnic minorities. We
synthesized findings of studies evaluating interventions
targeted at health care providers to improve health care quality
and/or reduce disparities in care for racial/ethnic minorities.
Study Design: We performed a systematic review of literature
from 1980 through June 2003 using electronic and hand
searches to identify studies that evaluated interventions
designed to improve health care quality and/or reduce
disparities in care for racial/ethnic minorities.
Population Studied: Eligible studies were in English, had
original data, were conducted in the United States, focused on
providers or organizations and were either randomized
controlled trials or concurrent controlled trials. Two reviewers
abstracted data on the effectiveness and cost of these
interventions. We synthesized and graded the strength of the
evidence as excellent, good, fair or poor using predetermined
criteria.
Principal Findings: There were 27 studies that met criteria for
review. Almost all (n=26) took place in the primary care
setting, and most (n=19) focused on improving the provision
of preventive services. Only two studies were designed
specifically to meet the needs of racial/ethnic minority
patients. All 10 studies that used a provider reminder system
for the provision of standardized services (mostly
preventive)reported favorable outcomes (excellent evidence).
The following quality improvement strategies demonstrated
favorable results but were used in a small number of studies:
bypassing the physician using a nurse or medical assistant to
offer preventive services directly to patients (2 of 2 studies
favorable), provider education alone (2 of 2 studies favorable),
use of a structured questionnaire to assess adolescent health
behaviors (1 of 1 study favorable), and use of remote
simultaneous translation (1 of 1 study favorable). Interventions
that used more than one main strategy (multifaceted) were
used in 9 studies with inconsistent results (fair evidence).
There are limited data on the costs of these strategies because
only one study reported data on costs.
Conclusions: There are several promising strategies that may
improve health care quality for racial/ ethnic minorities, but a
lack of studies specifically targeting the disease areas and the
processes of care for which disparities have been
documented.
Implications for Policy, Delivery or Practice: Further
research is needed to evaluate strategies designed to reduce
disparities in health care quality for racial/ ethnic minorities.
These studies will determine whether generic quality
improvement strategies are adequate to eliminate minority
health care disparities or whether interventions need to be
specifically targeted to reduce disparities. This work will also
guide decision-making regarding health resource allocation
and organization and delivery of health services to ethnic
minorities.
Primary Funding Source: AHRQ
• Beyond Race & Ethnicity: A Statewide Strategic Approach
to Reducing Asthma in California
Lisa Benton, M.D., M.P.H., Barbara Cowan, M.P.H, Rick
Kreutzer, M.D.
Presented by: Lisa Benton, M.D., M.P.H., Public Health
Medical Officer/ Health Disparities Specialist, California
Department of Health Services, California Breathing, 1515 Clay
Street, Suite 1700, Oakland, CA 94612; Tel: 510.622.4453; Fax:
510.622-4902; E-mail: lbenton@dhs.ca.gov
Research Objective: Interventions targeting inequity in
asthma morbidity and mortality focus on eliminating health
disparity primarily through introducing culturally-appropriate
training and education to patients and providers, and by
targeting unequal access to health care services. Strategies
and interventions addressing other indicators of health
disparity and poorer health outcomes are less widely
implemented. Alternative strategies that highlight improving
intermediate outcomes in environmental asthma triggers and
promote “asthma friendly” homes, communities, schools, and
work places, will redistribute the economic and social burden
of asthma and mobilize stakeholders for advocacy and
sustainable change. Through introduction of participatory
action research models focused on the objectives of the
Strategic Plan for Asthma in California, the California
Department of Health Services intends to promote formation
of broad-based coalitions for education, advocacy, and
treatment of asthma.
Study Design: The five (5) goals and twenty-eight (28)
objectives of the Strategic Plan for Asthma in California were
examined. Strategies targeting each objective were identified
within the five-year California Breathing initiative beginning in
2003. Key informant interviews, case studies, and focus
groups were conductive and combined with available
descriptive epidemiology studies of asthma prevalence within
California. Follow-up stakeholder meetings and expanded
epidemiology studies were convened in response to
stakeholder needs for information, technical assistance,
intervention formulation, and outcome analyses.
Population Studied: Key informant interviews, case studies,
and focus groups composed of individuals having distinct
roles for actualizing the CA Strategic Plan for Asthma:
patients, parents, caretakers, health care providers, educators,
community based organizations and stakeholder advocacy
organizations, scientists, and researches with interests in
reducing gaps in asthma morbidity and mortality within CA.
Principal Findings: The literature is replete with data
supporting disparities of health outcomes attributable to race
and/or ethnicity. A much smaller body of literature posits
sustainable strategies to eliminate these disparities or
expands the examination of health disparities to alternate
inequities. Key informants and focus group participants
express wide awareness of disparities related to race/ethnicity,
and also significant recognition of disparities associated with
access, quality of life, and other social and economic
determinants of health such as housing, food, transportation,
and work. Participants wanted solutions rather than further
descriptions of the problem from researchers and health care
agencies, provided local knowledge, and focused study
questions. Participants readily conceptualized solutions that
addressed their immediate needs and involved their larger
communities.
Conclusions: In the case of asthma disparities in California,
the frame of racial and/ethnic disparities is emphasized. While
racial and/ethnic differences probably contribute to the
unequal burden of asthma, dynamic disparities such as those
pertaining to quality of life, work, and play seem to hold
distinct roles in the California asthma morbidity and mortality
patterns. Key informants, focus groups, and other
stakeholders implicitly recognize this and believe that building
partnerships for education, research, and advocacy to address
asthma triggers and wider societal disparities will lead to
sustainable declines in asthma morbidity and mortality.
Implications for Policy, Delivery or Practice: In an
environment of decreasing resources and increasing gaps in
health care services, interventions targeting racial and ethnic
disparities would become more effective when integrated into
a global health disparities framework that will shift the
economic and social burden to improve asthma outcomes to
a wider circle of stakeholders.
Primary Funding Source: CDC
• Variation in Expectations and Satisfaction of Health Care
Services among Disabled Minorities in the Medicare Feefor-Service Program
Shulamit Bernard, Ph.D., R.N., Nathan West, MPA, Elvessa
Aragon-Logan, M.S.
Presented by: Shulamit Bernard, Ph.D., R.N., Director,
Program on Health Care Quality and Outcomes, Division of
Health Economics Research, RTI International, 3040
Cornwallis Road, Research Triangle Park, NC 27709; Tel:
919.967.9393; Fax: 919.990.8454; E-mail: sbernard@rti.org
Research Objective: To examine patterns of reported
experiences and satisfaction with health care services among a
population of disabled Medicare Fee-for-Service beneficiaries.
We give particular attention to disabled minorities since
preliminary findings indicate greater differences in reported
health care experiences and satisfaction levels among racial
minority groups.
Study Design: Data from the 2000-2002 Medicare CAHPS®
Fee-for-Service surveys were combined to create an analysis
file with 344,342 survey respondents. In order to identify the
original reason for Medicare eligibility, we created a variable
that determines whether a sample member has ever been
entitled to Medicare benefits due to disability (prior to turning
65 years of age) from the CMS Enrollment Database (EDB).
We determined that 16.1 % of the respondents had ever been
entitled due to disability alone or disability and End Stage
Renal Disease (ESRD). Survey data were weighted, then casemix adjusted using the CAHPS® 3.4 Survey and Reporting Kit
macros
Population Studied: Beneficiaries enrolled in the Medicare
Fee-for-Service program between 2000-2002.
Principal Findings: We found that disabled Medicare
beneficiaries consistently report more problems in all
composites and ratings as compared with the non-disabled,
and these differences are even greater among disabled
minorities. For instance, approximately 14 percent of disabled
Native Americans reported having a big problem getting
necessary care compared to only 6 percent of non-disabled
Native Americans during 2000 - 2002. Similarly, about twice
the proportion of disabled African-Americans reported having
a big problem getting necessary care compared to nondisabled African Americans during the same period (9 percent
vs. 4 percent). With regards to satisfaction levels of health
care services, disabled and non-disabled beneficiaries gave
similarly high ratings for their personal doctor and specialists.
However, disabled beneficiaries gave lower ratings for their
overall health care and the Medicare plan. This is particularly
true among disabled African Americans and Native
Americans, who gave fewer most positive (“10”) ratings than
their non-disabled counterparts.
Conclusions: Our findings suggest that disabled minorities in
the Medicare program experience greater problems obtaining
needed care, getting care quickly, and communicating with
their physicians as compared with non-disabled minorities as
well as lower satisfaction with the Medicare program and their
overall health care. This pattern persists for the over 65
disabled population as well as for the younger disabled
beneficiaries.
Implications for Policy, Delivery or Practice: The findings
suggest that despite the insurance coverage offered by the
Medicare program, the disabled experience more barriers and
delays to obtaining health care services. This is particularly
true for certain racial minorities, among them African
Americans and Native Americans. Further studies are needed
to examine the impact of these differences in perceived access
and satisfaction on the quality of health care and outcomes for
the disabled.
Primary Funding Source: CMS
• Hispanic vs. non-Hispanic White Disparities in Access
among Rural Elders
Tyrone Borders, Ph.D.
Presented by: Tyrone Borders, Ph.D., Assistant Professor and
Chief, Health Services Research, Texas Tech University Health
Sciences Center, 3601 4th Street, MS 8161, Lubbock, TX
79430; Tel: 806.743.6984; Fax: 806.743.1292; E-mail:
tyrone.borders@ttuhsc.edu
Research Objective: The purpose of this study was to
examine whether there were Hispanic versus non-Hispanic
disparities in reports of eight dimensions of health care access
among community-dwelling elders residing in a rural region of
the southwestern United States.
Study Design: A cross-sectional, population-based telephone
survey of approximately 2,100 Hispanic and non-Hispanic
whites age 65 and older. Reports of several dimensions of
access were adapted from the CAHPS. These included reports
of the ability to obtain care (see personal doctor/nurse, see
specialist, obtain help over phone, and obtain transportation
to the clinic) and reports of the ability to obtain care without a
long wait (get help over the phone without a long wait, see
provider for illness/injury when wanted, see provider for
routine care when wanted, and have short office waiting
times). Independent variables included predisposing,
enabling, and need factors. Univariate and multivariate
logistic regression analyses were conducted.
Population Studied: The study data were collected among
community-dwelling elderly persons (age 65 years and older)
residing in the 46 rural (counties with fewer than 50,000
persons) and 50 frontier counties (counties with fewer than
50,000 persons and fewer than 7 persons per square mile) of
West Texas.
Principal Findings: In unadjusted analyses, Hispanic elders
had worse reports of their ability to always/usually see their
personal doctor, see a specialist, obtain transportation to the
clinic, see a doctor for illness/injury when wanted, and see a
doctor for routine care when wanted. In adjusted analyses,
only two reports (always/usually able to see a doctor/nurse for
illness or injury when wanted and always/usually able to see a
doctor/nurse for routine care when wanted) differed
significantly by ethnicity.
Conclusions: The results indicate that rural, older Hispanics
experience greater problems with several dimensions of
access, but many of their problems are attributable to
enabling factors, rather than ethnicity itself.
Implications for Policy, Delivery or Practice: Rural medical
care providers and managers should consider directly
targeting Hispanics to improve their timely access to acute
and routine care. Strategies may include expanding office
hours or transportation services. Moreover, health policy
makers should consider expanding health insurance benefits
to improve the accessibilty of personal doctors and specialists
among Hispanic and non-Hispanic white elders alike.
Primary Funding Source: AHRQ
• The Meaning of Self Rated Health in Different
Populations
Ann Boulis, Ph.D., Judith Long, M.D.
Presented by: Ann Boulis, Ph.D., Post Doctoral Fellow,
Sociology, University of Pennsylvania, 3718 Locust Walk,
Philadelphia, PA 19104-6299; Tel: 215.8986722; Fax:
215.573.2081; E-mail: aboulis@pop.upenn.edu
Research Objective: To better understand how social
characteristics affect the determinants of self-rated health, and
to ultimately examine whether persistent race, class and sex
based differences in self-rated health stem, in part from
differences in how these groups define health.
Study Design: Data from the 1995-96 National Survey of
Midlife Development were used to assess how the correlates
of self-rated health differ for more and less educated
individuals, men and women, and whites and non-whites.
The survey’s measure of self-rated health was dichotomized to
equal 1 if respondents indicated they had very good or
excellent health and 0 otherwise. This variable was then
regressed on a series of covariates measuring respondents’
physical and emotional health as well as key aspects of their
current and past life conditions.
Population Studied: The National Survey of Midlife
Development in the U.S. (MIDUS) is a nationally
representative random-digit-dial sample of 4,242 noninstitutionalized, English-speaking adults, aged 25 to 74.
Principal Findings: hese analyses suggest a striking similarity
in the correlates of self rated health for those with a bachelor’s
degree or more and those with less than a bachelor’s degree.
The one exception is effort put into work. Regardless of
educational level, self reported work effort is positively
associated with self-rated health. However, the strength of
this relationship is significantly more pronounced for those
with less than a college degree. In contrast to our assessment
of education, we find that gender interacts with several
correlates of self-rated health. Most notably, health problems
or chronic conditions are a stronger correlate of self-rated
health for women than for men, while work effort is a stronger
determinant of self-rated health for men than for women.
Finally, we find two key differences between the correlates of
self rated health for whites and non-whites. First, BMI is a
significant correlate for whites and not for non-whites. Second,
perceived neighborhood quality is a significant correlate for
whites, but not for non-whites.
Conclusions: These results suggest that social characteristics
such as education, gender and race influence a person’s
definition of their overall health. They also imply that social
conditions such as job characteristics and neighborhood
quality can contribute to individuals’ understanding of the
overall health.
Implications for Policy, Delivery or Practice: Public health
professionals may enhance their ability to promote minority
health by developing a better understanding of how such
communities define health.
• What Modifies the Negative Effect of Poverty on
Functional and General Health Status Measures?
Janet Bronstein, Ph.D., Shailender Swaminathan, Ph.D.,
Joshua Klapow, Ph.D.
Presented by: Janet Bronstein, Ph.D., Professor, Health Care
Organization and Policy, University Alabama at Birmingham,
1350 Third Avenue South, Birmingham, AL 35294-0022; Tel:
205.975.8962; Fax: 205-934-3347; E-mail: jbronste@uab.edu
Research Objective: Most studies show a clear gradient in
health status measures related to individual poverty levels,
with the steepest gradient occurring at the lowest income
levels. This study compares the relationship between poverty
levels and the physical component of the SF12 and a global
rating of health status and assesses the extent to which other
demographic factors modify the impact of poverty for the two
measures.
Study Design: We group individuals surveyed in the
household survey component of the Community Tracking
Study (a study of 60 representative communities in the U.S.)
into four poverty level categories, (1) below 125% FPL, (2) 125200% FPL, (3) 200%-300% FPL and (4) above 300% FPL. We
successively add measures of race, education, region, rurality
and a measure of income inequality in the county and assess
the relationship between these factors and the PCS12
(reported physical health status) and global health status
(reports of health status ranging from excellent through poor).
Standard errors are corrected for the stratified nature of
sampling design.
Population Studied: We include all adults over age 17
responding to Round 3 of the household survey component of
the Community Tracking Study and those adults responding
in Rounds 1 and 2 who were not represented in Round 3, for a
total sample size of 90,276. Fifty seven percent of the sample
was above 300% of the FPL; the remaining respondents were
almost equally distributed across the other three income
categories.
Principal Findings: Controlling for age and sex, poverty level
is highly correlated to both health status measures, with the
lowest income groups most likely to have both lower PCS12
scores and more respondents reporting poor overall health.
All non-white individuals report worse health status than white
individuals, with African Americans reporting lowest scores for
both health measures. When poverty level is controlled , all
non-white individuals report lower health status than white
individuals, but Hispanics are not different from whites on the
PCS12. When education is controlled, Hispanics score
significantly higher than whites on the PCS12, but still report
worse overall health. Education is positively correlated to both
health measures, and reduces the negative effect of poverty
on the health status measures by about 25%. Controlling for
individual factors, residents of very rural areas and Southern
states have lower PCS12 scores. Residents of Southern and
Midwestern states also report worse global health on the
general health status measure. Our measure of income
inequality in the county of residence was not significantly
associated with health status measures.
Conclusions: Poverty is a persistent risk factor for poor
perceived health status, measured either as level of physical
functioning or report of overallperceived health quality.
African American and Native/Asian ethnicities are additional
but much less influential risk factors. Education is protective
for the health risks of poverty. Some geographic areas have
residents of poorer health across all income, ethnicity and
education categories.
Implications for Policy, Delivery or Practice: Income
differences are the major source of disparities in health status
for the U.S. population.
Primary Funding Source: University of Kentucky Center for
Poverty Research
• Disparities in Diabetes Management: Self-Monitoring of
Blood Glucose and Medication Use in a Population-Based
Sample
Neetu Chawla, M.P.H., Susan Babey, Ph.D., Allison Diamant,
M.D., M.S.HS, E. Richard Brown, Ph.D.
Presented by: Neetu Chawla, M.P.H., Research Associate,
UCLA Center for Health Policy Research, 10911 Weyburn
Avenue, Suite #300, Los Angeles, CA 90024; Tel:
310.794.8362; Fax: 310.794.2686; E-mail: nchawla@ucla.edu
Research Objective: To identify disparities in glucose
monitoring and medication use as indicators of diabetes
management in a population-based sample of California
adults.
Study Design: This study used data from the 2001 California
Health Interview Survey (CHIS). CHIS 2001 is a random-digit
dial (RDD) telephone survey of 55,428 households drawn from
every county in California and is the largest statewide health
survey conducted in the United States. The sample was
designed to provide estimates for California's overall
population, its major racial and ethnic groups, and a number
of ethnic subgroups. Logistic regression analyses were used to
determine factors associated with glucose monitoring
practices and medication use among adults with diabetes.
Factors studied include age, gender, race/ethnicity, income
level, education, level of acculturation, insurance status,
having a usual source of care, and duration of diabetes.
Population Studied: The population studied was California
adults, age 18 and older, who reported that they had been
diagnosed with diabetes.
Principal Findings: Latinos and Asian/Pacific Islanders had
higher rates of inadequate glucose monitoring compared to
whites (p<0.01). After controlling for factors such as gender,
race/ethnicity, income, and education, multivariate regression
analysis showed that Latinos, recent immigrants, adults 65
and older, the uninsured, those without a usual source of care,
and those who had a shorter duration of diabetes (3 years or
less) were significantly more likely to inadequately monitor
their blood glucose compared to other groups. Similar
analyses were conducted for medication use, examining the
outcome of not taking any medications for diabetes. Latinos
had higher rates of not using medication compared to
Asian/Pacific Islanders (p<0.01), American Indian/Alaska
Natives (p<0.05), African Americans (p<0.001), and whites
(p<0.001). In a multivariate model, our results showed that
the following groups were more likely to not use medications:
younger adults, females, those with no usual source of care,
and adults who have shorter diabetes duration.
Conclusions: These findings suggest that Latinos, recent
immigrants, those with shorter diabetes duration, and those
lacking access to health care are more likely to inadequately
monitor their glucose. In addition, young adults, women,
those without a usual source of care, and those having shorter
diabetes duration may not be taking needed medications.
Therefore, these groups may be at increased risk for
inappropriate management of diabetes.
Implications for Policy, Delivery or Practice: Inadequate
glucose monitoring and lack of medication use are indicators
of poorly managed diabetes, which can result in increased risk
of complications, poorer health, and increased healthcare
costs. Programs promoting self-monitoring of blood glucose
should be implemented, particularly targeting Latinos, recent
immigrants, adults with diabetes who are 65 and older, those
who have shorter diabetes duration, and those lacking health
insurance or a usual source of care. In addition, interventions
that help ensure continuity of diabetes care and target adults
with no usual source of care, younger adults, women, and
those who have shorter diabetes duration could improve rates
of medication use among California’s adults with diabetes.
Primary Funding Source: The California Endowment
• Cost of Hospital Admissions Attributable to Minority
Health Disparities in South Carolina
Kit Simpson, Dr.P.H., Elinor Chumney, Ph.D., Patrick Mauldin,
Ph.D., Helen Gary, M.P.H., Jennifer Mazyck-Brown, Pharm.D.
Presented by: Elinor Chumney, Ph.D., Assistant Professor,
Pharmacy Practice, Medical University of South Carolina, 280
Calhoun Street, Charleston, SC 29425; Tel: 843.876.1242; Fax:
843.792.1712; E-mail: Chumneye@musc.edu
Research Objective: To measure the cost of racial health
disparities resulting in hospital admissions over a five year
period.
Study Design: Retrospective analysis of archival data to
measure expected versus observed admission rates, charges,
and estimated costs for black and white patients stratified by
major diagnostic category (MDC) and age.
Population Studied: All patients admitted to SC hospitals
during the 1998-2002 time period with a code of black or
white on the race variable.
Principal Findings: The admission rate for black patients was
higher than the observed rate for white patients in all but the 2
MDCs containing joint replacement and mental health
admissions. Annual charges for hospital admissions
attributable to disparities in health status between white and
black patients of similar age range from $253 to $423 million.
The largest contributers to the cost of admissions due to
minority health disparities were admissions for stroke,
seizures, headache, pneumonia, bronchitis, amputations,
heart failure, diabetes, nutritional/metabolic problems, renal
failure, kidney and UTI infection, medically complicated
deliveries, sickle cell disease, septicemia, and HIV/AIDS.
Conclusions: Large disparities in the health of black and white
patients of similar age result in much higher age-adjusted
hospital admission rates for black patients in SC when
compared to whites. These disparities resulted in more than
1.6 billion in hospital charges over 5 years. Many admissions
were for conditions that could be avoided with preventive
interventions, or which would be managed in a community
setting if patients had access to primary care. While some of
these differences in hospital admission rates could be due to
patient or provider preferences, we expect that most of the
differences observed in this study are due to true differences
in health status and medical care needs.
Implications for Policy, Delivery or Practice: The existence
of minority health disparities is enormously costly to the
health care system and should be actively addressed by
improving minority access to primary and preventive care.
Primary Funding Source: AHRQ, National Institute of Ageing
• Obstetric and Sociodemographic Factors Associated with
Epidural Anesthesia During Labor and Vaginal Delivery
Emily Belmont Conn, Ron Keren, M.D., M.P.H.
Presented by: Emily Belmont Conn, Student, Pediatrics,
University of Pennsylvania/Children's Hospital of Philadelphia,
166 Gramercy Road, Bala Cynwyd, PA 19004; Tel:
267.679.4017; Fax: 215.590.0426; E-mail:
ebconn@sas.upenn.edu
Research Objective: The decision to use epidural anesthesia
during childbirth is a complex one, involving considerations of
patient preferences, obstetric history, and provider practice
style. The objective of this study was to explore the
relationship of obstetric and sociodemographic factors to
receipt of epidural anesthesia during labor and vaginal
delivery.
Study Design: This was a retrospective cohort study. The
outcome variable was receipt of epidural anesthesia during
labor and vaginal delivery. The predictor variables were
obstetric and sociodemographic factors.
Population Studied: The population studied was 2568
women who delivered vaginally between 1993 and 1997 at an
urban community teaching hospital in Pennsylvania and took
part in the hospital supervised early discharge follow-up
program.
Principal Findings: 1753 (68.26%) women received epidural
anesthesia during labor. In a multivariable logistic regression
model, the following factors were associated with receipt of
epidural anesthesia: race/ethnicity (as compared to white):
African American (odds ratio [OR] = 0.75; 95% confidence
interval [95 % CI], 0.57-0.97), Hispanic (OR = 0.70; 95% CI,
0.42-1.19), Asian (OR = 0.47; 95% CI, 0.30-0.72), and other
(OR = 0.42; 95% CI, 0.19-0.93); infant birth weight (/kg) (OR
= 1.37; 95% CI, 1.07-1.75); forceps delivery (OR = 11.79; 95% CI,
4.59-30.25); vacuum delivery (OR = 2.53; 95% CI 1.75-3.67);
oxytocin induction or augmentation (OR = 6.01; 95% CI, 4.917.36); and parity (OR = 0.75; 95% CI, 0.69-0.82). The model
controlled for median household income, maternal age,
driving time to the hospital, gestational age, prolonged
rupture of membranes, and the gender of the infant.
Conclusions: Controlling for known predictors of epidural
anesthesia, women of Asian, African American, and other
racial background received epidural anesthesia during labor
and vaginal delivery less often than white women.
Implications for Policy, Delivery or Practice: Additional
research is needed to understand whether healthcare system
factors, educational and cultural differences, patient
preference, and/or provider bias are responsible for these
disparities.
• Gender, Race, and Age Differences in the Receipt of
Preventive Services for Cardiovascular Risk Factors
Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D., Sari Siegel, MA,
Ernest Moy, M.D., Denise Remus, Ph.D., R.N., Francis
Chesley, M.D.
Presented by: Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D.,
Senior Advisor on Women's Health, Agency for Healthcare
Research and Quality, 540 Gaither Road, Rockville, MD 20850;
Tel: 301.427.1550; Fax: 301.427.1562; E-mail: rcorrea@ahrq.gov
Research Objective: Coronary heart disease accounts for the
majority of cardiovascular disease deaths in women,
disproportionately affecting minorities. Because the condition
is often fatal and nearly 2/3 of women who die suddenly have
no prior recognized symptoms, it is critical that this priority
population be targeted with adequate delivery of preventive
services. This study compares the effectiveness of primary
care for cardiovascular disease risk factors in both women and
men in age groups below and above 65 years old.
Study Design: Evaluation of 5 quality measures used in the
National Health Care Quality and National Health Care
Disparities Reports. These measures were derived from a
variety of national data sources reflecting health care
information for year 2000 (National health Interview Survey
[NHIS] and Medical Expenditure Panel Survey [MEPS]).
Population Studied: Both women and men age 18 and
over,from a variety of national data sources reflecting health
care information for year 2000 (National health Interview
Survey [NHIS] and Medical Expenditure Panel Survey [MEPS]).
Principal Findings: Elderly individuals (65 and up) are more
likely to receive preventive services (blood cholesterol
measurement, blood pressure measurement, and smoking
cessation counseling) compared to younger adults. Gender
and race differences among younger adults indicate that:
women of lower socioeconomic status are less likely to have
their blood cholesterol checked; both black women and men
have higher rates of blood pressure measurement, while
women and men with low income status are less likely to have
their blood pressure measured and to receive counseling to
quit smoking; Hispanic women are less likely than nonHispanic white women and men to receive advice to quit
smoking; data are limited or show no significant differences in
the percentage of young adults with diabetes who had their
HbA1c measured at least once in the past year.
Conclusions: Elderly individuals seem to receive adequate
preventive services, while among younger adults opportunities
for prevention are frequently missed particularly among
minorities. Black women and men are doing well as relates to
blood pressure measurement, but due to the seriousness of
risk factors in the development of fatal cardiovascular
outcomes in these populations improvements in preventive
care are recommended.
Implications for Policy, Delivery or Practice: These results
are useful for health care professionals, policymakers, and
health system leaders working to reduce disparities
by improving access, receipt, and quality of care.
Primary Funding Source: AHRQ
• A Qualitative Assessment of Charlotte REACH: An
Ecological Perspective for Decreasing CVD and Diabetes
among African Americans
Rita DeBate, Ph.D., M.P.H., CHES, Marcus Plescia, M.D.,
M.P.H., Denis Joyner, M.P.H., LaPronda Spann, BS
Presented by: Rita DeBate, Ph.D., M.P.H., CHES, Assistant
Professor, Health Behavior and Administration, University of
North Carolina at Charlotte, 9201 University City Boulevard,
Charlotte, NC 29201; Tel: 704.687.2866; Fax: 704.687.6122;
E-mail: rdigioac@email.uncc.edu
Research Objective: The Charlotte REACH 2010 project is
part of a national collaborative effort of the Centers for
Disease Control and Prevention to eliminate health disparities
among identified population groups through community
driven interventions. The Charlotte initiative focuses on the
reduction and control of cardiovascular disease and diabetes
in the Northwest Corridor of Charlotte. An ecological
perspective of health promotion was utilized as the framework
for a Charlotte community-based intervention to eliminate
health disparities in cardiovascular disease and diabetes. This
ecological approach involves interventions targeted on five
levels of influence with interaction between levels creating a
supportive system for sustained change. In order to create
sustained change, all levels of influence must be addressed
and designed to work together to create a strong, supportive
environment for change. Due to the complexity of
multileveled ecological interventions, feedback on the process
and impacts of the activities is crucial for ensuring
success.The purpose of this qualitative assessment was to
explore changes that have occurred among and between the
following levels of influence: intrapersonal, interpersonal,
organizational, community, and policy.
Study Design: An exploratory assessment of the Charlotte
REACH initiative was conducted using focus group
methodology. A qualitative approach was chosen for this
assessment as it enabled the researchers to facilitate an
exploration of the process and initial impacts of the
ecologically framed health promotion program. Qualitative
methodology included 10 focus groups. Three independent
coders hand-coded all focus groups utilizing modified coding
methods developed by Spradley. Coding was then compared
and an agreement of final codes was reached. Final codes
were entered into NVivo qualitative analysis software. Once
entered, codes were compared and contrasted into
overarching themes and sub-themes.
Population Studied: The geographic area of this initiative is
bordered by three connected thoroughfares and contains a
population of 19,670 of which approximately 95% are African
American. Local health disparities in cardiovascular disease
and diabetes have been documented in community health
surveys and assessments. This qualitative assessment
consisted of 10 focus groups. The focus groups were
conducted with the Charlotte REACH Lay Health Advisors (1)
Charlotte REACH program staff (1), residents of the target
population who have participated in Charlotte REACH
program activities (4), and residents of the target area who
had not participated in Charlotte REACH activities (4).
Principal Findings: A total of 84 participants were involved in
the focus groups; 12 Lay Health Advisors, 6 program staff, and
66 community residents (29 who participated in REACH
activities and 37 who have not participated in REACH
activities).
The focus group methodology implemented in this exploratory
assessment yielded rich descriptive data regarding the status
of the development of supportive system for sustained
change. Overall, the findings from this study support positive
changes within and between levels of change. Intrapersonal
level changes were identified among target area residents who
have participated in REACH activities. Changes in knowledge,
attitudes, and behavior regarding cardiovascular disease and
diabetes prevention strategies were voiced among participants
in various REACH activities including nutrition groups,
diabetes support groups, and exercise interventions.
Participants also noted improvements in health status. In
addition, LHAs changed their perception of health from a
diseased focus definition to a prevention oriented one.
Interpersonal mediators include support and role definition
from peers, family, and friends. LHAs have been established
as peer role models and provide individual support for
residents in the target community. These findings
demonstrate interpersonal support among program
participants through camaraderie that has been developed
within the various program activities. Participants expressed
that this fellowship is a motivating factor for continuation of
health promoting activities. Evidence of interaction between
intrapersonal and interpersonal levels is supported by the
diffusion of knowledge, skills, and behaviors from REACH
participants to various family members.
Organizational level changes include
institutional/organizational rules, policies or informal
structures that promote targeted behavior change. The
majority of REACH program participants stated their primary
care physician referred them to REACH activities. The informal
structure of utilizing the prescription pads when referring
patients who are in need of nutritional changes, exercise or
smoking cessation provided a cue to action for their patients.
Additionally, a formal communication structure was
developed with the LHA as the liaison between the community
residents and the REACH program staff. The results of this
evaluation suggest that both program staff and LHAs note
existence and importance of this collaboration, but agree that
improvements can be made to increase the level and process
of the two-way communication flow.
Community and public policy level changes include social
norms in addition to local, state and federal policies and laws
that promote preventative health behaviors. It is evident from
this assessment that all levels identify the establishment of the
neighborhood farmer’s market as a positive community
change. Interaction between interpersonal and community
levels is supported by the LHAs’ work in overcoming cultural
barriers.
Conclusions: This initiative was designed to stimulate
community based prevention research and support
community-based demonstration projects that promote health
and eliminate racial and ethnic disparities. In establishing a
community-based intervention in which the mission is to
eliminate health disparities in cardiovascular disease and
diabetes, the Charlotte REACH 2010 initiative was developed
within an ecological framework. This ecological approach to
eliminating health disparities involves interventions targeted
on five levels of influence with interaction between levels
creating a supportive system for sustained change. Due to
nature of this multi-leveled approach an assessment of
program processes and initial impacts is necessary. The
qualitative nature of this evaluation enabled researchers to
assess program progress by exploring changes that have
occurred within levels in addition to assessing interaction
between levels. Findings from the assessment are
encouraging in that they reveal positive steps toward
mobilizing community efforts to influence healthy behavior
change and risk reduction for cardiovascular disease and
diabetes. The findings also demonstrate the challenge of
implementing multifaceted, connected interventions from an
ecological perspective. A primary concern is the need for ongoing, effective communication between community
representatives, project staff and service providers in order to
maximize understanding of local needs and strengths and to
identify further opportunities for planning or modifying
community sensitive intervention strategies for sustained
change.
Implications for Policy, Delivery or Practice: Effective health
promotion programs are grounded in theories suitable for
reaching the anticipated outcome. The projected outcome of
the REACH 2010 demonstration project includes eliminating
disparities in six health priority areas. This initiative was
designed to stimulate community based prevention research
and support community-based demonstration projects that
promote health and eliminate racial and ethnic disparities. In
establishing a community-based intervention in which the
mission is to eliminate health disparities in cardiovascular
disease and diabetes, the Charlotte REACH 2010 initiative was
developed within an ecological framework. This ecological
approach to eliminating health disparities involves
interventions targeted on five levels of influence with
interaction between levels creating a supportive system for
sustained change. Implications from this study suggest the
need for ecologically based programs which establish a
supportive social sytem for program institutinalization and
sustained program change.
Primary Funding Source: CDC
• The Characteristics Associated with Adequate Adjuvant
Chemotherapy for Stage III Colon Cancer
Sharon Dobie, M.D., MCP, Barbara Matthews, M.S., Jason
Dominitz, M.D., MHS, Kevin Billingsly, George Wright, Ph.D.,
Laura-Mae Baldwin, M.D., M.P.H.
Presented by: Sharon Dobie, M.D., MCP, Associate Professor,
Family Medicine, University of Washington, Box 356390,
Seattle, WA 98125; Tel: 206.543.9425; Fax: 206.543.3821;
E-mail: dob@u.washington.edu
Research Objective: To explore whether the disparity found in
initiation of chemotherapy for stage III colon cancer between
blacks and whites persists throughout colon cancer treatment,
resulting in less adequate adjuvant chemotherapy for African
Americans compared to Caucasians.
Study Design: Using the 1991-1998 Surveillance,
Epidemiology, and End Results (SEER)-Medicare claims
database with physician data from the American Medical
Association (AMA) Masterfile, we defined adequacy of
chemotherapy for stage III colon cancer as five months of
chemotherapy during the treatment period. Using multiple
logistic regression, we examined the relationship between race
and receipt of adequate chemotherapy, then added patient
(e.g. age, marital status, socio-economic status, location of
residence, comorbidity, and rehospitalization) and physician (
e.g. age, gender, race and ethnicity, specialty, years in practice,
practice volume) characteristics to the model to determine
any influence on this relationship.
Population Studied: 3888 African American and Caucasian
Medicare beneficiaries 66 and older reported to one of the 12
SEER cancer registries with a diagnosis of stage III colon
cancer between January 1, 1992 and December 31, 1996, and
alive for two years after their cancer diagnosis
Principal Findings: Of the 2308 who received adjuvant
chemotherapy, the adequacy rates were similar for African
Americans (87%) and Caucasians (82%).
Increasing age was associated with decreased adequacy: 65-70
years as reference; 71-75 years OR=1.02 (P=.9); 76-80 years
OR=.46 (P<.01); 81-85 OR=.35 (P<.01); =86 OR=.32 (P<.01).
Widowed persons were less likely (OR .59; P=.01) than
married and those living in remote rural areas were more likely
than urban dwellers (OR=2.3; P=.01) to receive adequate
therapy.
Co-morbidity, measured using the Romano-Charlson index,
was not associated with differences in adequate
chemotherapy, while hospital re-admissions were (no
readmission as reference; readmission in weeks 7-16 OR=.39;
P=.01; weeks 17-30 OR=.52; P=.01).
Volume of chemotherapy patients was the only physician
characteristic associated with adequate chemotherapy
(physicians < 4 patients per year as reference; 8-12 patients
annually OR= 1.4; P=.05; 13+ patients annually OR=1.5; P=.05).
Conclusions: African Americans are equally likely to complete
their chemotherapy course once begun, making initiation of
care crucial to his group. An alternate explanation is that the
African Americans most likely to complete therapy are those
who initiate it, whereas a more diverse group of Caucasians
initiates therapy. The negative association of increasing age
and rehospitalizations with adequate chemotherapy suggests
that these variables represent more powerful measures of case
severity than the Romano-Charlson index. Of interest are the
lower adequacy rates for widowed individuals and higher rates
for those living in remote areas. The former suggests lack of
social support, while the latter may relate to relocation for the
duration of therapy.
Implications for Policy, Delivery or Practice: This study
demonstrates the utility of administrative claims in examining
the quality of chemotherapy. These findings can be used to
develop programs that identify and facilitate receipt of
adequate chemotherapy by vulnerable groups. In the case of
African Americans, our findings underscore the need for
policies that ameliorate their barriers to initiating adjuvant
therapy.
Primary Funding Source: NCI
• ER Utilization Among Washington State's Medicaid
Recipients
Jean Du, Ph.D.
Presented by: Jean Du, Ph.D., Program Evaluation Manager,
Medical Assistance Administration, State of Washington, 1011
Plum Street, Olympia, WA 98504-5562; Tel: 360.725.1033; Fax:
360.586.9548; E-mail: dujj@dshs.wa.gov
Research Objective: Using a standard and consistent
measure of ER visit, track Washington State Medicaid ER
utilization overtime to 1) describe system characteristics and
patterns of ER utilization by Medicaid recipients; 2) identify
possible disparities in ER utilization by ethnicity, age groups,
and geographic location; 3) inform policy and programs where
to target limited resources for better program benefits.
Study Design: For the first time in Washington State’s
Medicaid program, this study distinguishes ER visits that
result in hospital admissions and those that do not. The
distinction is believed to be important in addressing issues
like access-to-care (where more providers may be recruited) or
inappropriate use of ER (where education and/or utilization
management may be needed).
Using Medicaid claims data maintained by the State, the study
tracks the same measures for five years, from 1999 through
2003.
Population Studied: This is a study of the entire Fee for
Service (those not served by a managed care plan) Medicaid
population in Washington State.
Principal Findings: ER visits that do not end up in hospital
admission make up the overwhelming majority of total ER
visits and are growing from 86% of total ER in 1999 to 89% in
2003. During the last five years, this type of ER saw a much
faster growth than ER visits that result in admissions (82.8%
v. 33.7%). While much of the increase in ER utilization was
driven by caseload expansion (up 48% during the same time
period), total ER visits per 1,000 recipients climbed 19%, from
789 per 1,000 in 1999 to 941 per 1,000 in 2003, with 2003
seeing the biggest one-year increase (7.1%). On a per-cap
basis, ER visits that result in hospital admissions dropped 9%
over the five-year period while those that do not result in
admissions increased 24%.
Native Americans, African Americans, and Caucasian
recipients have disproportionately higher ER utilization.
Adults between ages 30 and 44 have disproportionately higher
ER utilization than any other age group under consideration
(new-born, 1-3, 4-12, 13-17, 18-29, 30-44, 45-64, 65 and over).
Of all FFS recipients, 44% used ER in 2003. Most ER users
(80%) had between one to two ER visits per year while a small
portion (less than 2% ER users) had twelve or more ER visits
per year and incurred 14% of total ER visits among the FFS
population.
Conclusions: Consistent with many studies of ER utilization
across the nation, Washington state experienced rapid growth
in ER visits. While much of the increase is attributable to
caseload expansion, the findings also point a lack of access to
care for some recipients and possibly inappropriate use of ER
among others.
Implications for Policy, Delivery or Practice: The findings
suggest that Washington Medicaid program should consider
two policy/program directions: 1) expand efforts in recruiting
FFS providers to keep up with the client caseload increase; 2)
develop programs with its partners (providers, client
advocates, and the community) in ER utilization education
and case management, including closer monitoring of
frequent ER users.
Primary Funding Source: State Funds
• Utilization of Pediatric Care by Latino Children: The
Effects of Limited English Proficiency among Parents
O. Kenrik Duru, M.D., MSHS, Leo Morales, M.D., M.P.H.
Presented by: O. Kenrik Duru, M.D., MSHS, NRSA Research
Fellow, Division of General Internal Medicine, University of
California, Los Angeles, 911 Broxton Plaza, 3rd Floor, Los
Angeles, CA 90024; Tel: 310.794.8138; E-mail:
kduru@mednet.ucla.edu
Research Objective: Studies in adult populations have
documented that limited English proficiency (LEP) is
associated with decreased access to care, and may explain a
significant component of racial/ethnic health disparities in
utilization. Children depend on parents to access health care
on their behalf, and minority children of LEP parents may be
less likely to receive appropriate care. Latino children are less
likely than white children to receive care, but few analyses have
examined the possible unmeasured effect of primary language
on children´s utilization of care.
Study Design: Race/language pairings were used as the
primary independent variable (white, Latino/English,
Latino/Spanish), for three probit regressions predicting the
likelihood of a clinic visit in different settings. In the first, we
assessed whether the child had a clinic visit in the setting of
an acute or chronic illness. In the second, we assessed
whether the child had a clinic visit if an appointment had been
made. In the third, we assessed whether children under two
had any lifetime well child visit or immunization visit. To ease
interpretation of our results, we estimated predicted
probabilities and standard errors of a clinic visit for children
from each race/language pairing. Errors were adjusted to
control for clustering by health plans.
Population Studied: We used 2000/2001 CAHPS survey data
on 29,564 children enrolled in 27 health plans participating in
the State of California Children´s Health Insurance Program.
Principal Findings: For each analysis, predicted clinic visit
rates for white children were significantly higher than for
Latino/Spanish children. With an illness, the probability of a
visit for white children within six months was 92%, but only
79% for Latino/Spanish children. If an appointment was
successfully made, the probability of a visit within six months
was 94% for white children as compared to 82% for
Latino/Spanish children. The predicted probability of a
lifetime well child or immunization visit for children under two
years of age was 93% for white children, whereas it was only
79% for Latino/Spanish children. In each case, there was no
statistical difference between predicted probabilities for visits
by white children and Latino/English children. All reported
results were significant at the p<0.05 level.
Conclusions: Within the insured population of children we
studied, differences in utilization of care by primary language
exist in different situations measuring a perceived or evaluated
need for care. These findings suggest that racial/ethnic
disparities in utilization of pediatric care between Latinos and
whites may in fact reflect issues related to LEP.
Implications for Policy, Delivery or Practice: Strategies to
reduce racial/ethnic disparities in utilization of pediatric care
should target parents with limited English proficiency.
Primary Funding Source: HRSA training grant
• Blood Pressure Treatment and Control among African
American and Caucasian Hypertensive Patients in South
Carolina
Brent Egan, M.D., Katharine Hendrix, Ph.D., Jan Basile, M.D.,
Shakaib Rehman, M.D., Daniel Lackland, Dr.PH
Presented by: Brent Egan, M.D., Professor of Medicine and
Pharmacology, General Internal Medicine, Medical University
of South Carolina, 96 Jonathan Lucas Street, 826 CSB,
Charleston, SC 29425; Tel: 843.792.1715; Fax: 843.792.0816; Email: eganbm@musc.edu
Research Objective: Although evidence now more than 20
years old indicates that better BP control is attainable and will
reduce disparities, the promise of this research has not been
realized. The purpose of this research was to better quantify
the current disparity in BP control.
Study Design: We compared data on treatment patterns and
control rates among African Americans and Caucasians in our
database.
Population Studied: ~75,000 hypertensive patients in South
Carolina.
Principal Findings: Mean BP values are ~3/4 mmHg higher
and control rates to <140/90 mmHg ~8% lower in African
American than Caucasian hypertensives. The disparities in BP
control do not appear to reflect a less intensive therapeutic
effort, since providers are prescribing an equal or greater
amount of all major classes of antihypertensive mediations
with the exception of b- and a,b-blockers to African American
than Caucasian hypertensives.
Conclusions: These data suggest that hypertension is more
difficult to control in African Americans than Caucasians with
traditional medical care and could reflect biological,
socioeconomic, and/or cultural differences that impact
response to treatment. It is also likely that access, affordability
of care, and compliance with medication and lifestyle
recommendations contribute to these differences.
Implications for Policy, Delivery or Practice: Interventions
to ensure more effective implementation of the hypertension
guidelines have significant potential for improving
cardiovascular and renal health, especially in the African
American community.
Primary Funding Source: AHRQ
• Substance Abuse and Not Race Determines Outpatient
Mental Health Service Use: The BASIS-R Study
A. Rani Elwy, Ph.D., Susan Eisen, Ph.D.
Presented by: A. Rani Elwy, Ph.D., Postdoctoral Fellow, Center
for Health Quality, Outcomes and Economic Research,
Department of Veterans Affairs, 200 Springs Road (152),
Bedford, MA 01730; Tel: 781.687.2000 Ext. 6707; Fax:
781.687.3106; E-mail: relwy@bu.edu
Research Objective: Substance use disorders are a frequent
comorbid illness for individuals with serious psychiatric
illness. Patients with comorbidities are more likely to have
higher rates of healthcare utilization. African Americans have
a greater number of dual diagnoses of schizophrenia and
substance abuse than similar white patients, yet African
Americans have previously been found to receive less specialty
mental healthcare than whites. Our objective was to examine
whether race, substance abuse (SA) disorders, or dual
diagnoses of psychiatric and substance abuse, determines
outpatient mental health (MH) service use.
Study Design: Self-reported symptom and problem difficulty,
including problems due to alcohol and/or drug use was
assessed at patients’ first outpatient visit and two months
later using the revised Behavior and Symptom Identification
Scale (BASIS-R). Demographic and clinical data including up
to five DSM-IV diagnoses were retrieved from chart review.
Using analysis of covariance we examined the main effects of
patient race (African American, Native American, Asian,
Native Hawaiian/Pacific Islander, multiracial, or white),
diagnoses, and program type (MH, or SA including dual
diagnoses) on MH outpatient use. We controlled for patient
age, sex, marital status, education and comorbidities. We also
examined interactions between patient race, diagnoses and
program type on MH outpatient use in the two months
following intake.
Population Studied: 1843 clients from outpatient MH or
MH/SA delivery sites in each of the four US census regions.
12 percent of patients were African American, 79 percent were
white and 9 percent were from other racial groups. 56
percent of patients were female. 58 percent had an MH
diagnosis only, 20 percent had a SA diagnosis only and 22
percent had both mental health and substance abuse
diagnoses.
Principal Findings: A main effect of having a SA diagnosis
was found, in that patients with a SA diagnosis only had a
greater number of outpatient visits during the two month
study period than patients without a diagnosis of SA (F=4.6,
p=.03). There was no main effect for patient race on number
of outpatient visits. However, there was a significant
interaction between patient race and program type, such that
African Americans received more services from SA programs
than from MH only programs (F=2.7, p=.01).
Conclusions: A diagnosis of SA and not patient race
determined greater MH outpatient service use.
Implications for Policy, Delivery or Practice: Patients with
SA disorders may require more intensive outpatient treatment
than patients with MH disorders only. Increasing healthcare
providers’ ability to treat SA disorders is necessary for
effectively serving this population. An awareness of SA
disorders occurring in all races is important for accurately
diagnosing and treating patients who require this intensive
treatment.
Primary Funding Source: NIMH
• Variation in Quality of Care Received by American Men
Kaytura Felix Aaron, M.D., Ernest Moy, M.D., M.P.H., Minsun
Kang, M.P.H., Mona Patel, Francis Chesley, M.D., Carolyn
Clancy, M.D.
Presented by: Kaytura Felix Aaron, M.D., Senior Advisor on
Minority Health, HHS, AHRQ, 540 Gaither Road, Rockville,
MD 20850; Tel: 301.427.1395; Fax: 301.427.1562; E-mail:
kfaaron@ahrq.gov
Research Objective: Men have been characterized as “an
invisible population,” overlooked by public and private efforts
to improve health status of women, children and the elderly.
However, policy makers; researchers and advocates are
increasingly addressing men’s health care needs. This study
compares the quality of care received by racial and ethnic
minority men with that of non-Hispanic white men.
Study Design: Several aspects of quality of care issues, i.e.,
preventative services, chronic disease management, avoidable
hospitalizations, surgical safety and post-operative safety are
evaluated. Measures are derived from the National Health
Interview Survey, the Medical Expenditure Panel Survey, the
CMS End Stage Renal Disease Clinical Performance Measures
Project, the U.S. Renal Data System and the Healthcare Cost
and Utilization Project State Inpatient Database 16-state
database. The relative difference between each racial/ethnic
group and a fixed reference group is used to assess
differences in use of services. Statistical significance is
assessed using
z-tests.
Principal Findings: : Hispanic men were much less likely to
receive colorectal cancer screening (relative risk [RR] range:
0.61-0.69), cardiovascular risk factor screening and
management (RR: 0.84-0.88) and vaccinations (RR: 0.470.94). African American and Asian men were significantly less
likely to have received selected preventive services (adult
immunization and colorectal cancer screening). The
differences in end-stage renal disease care that African
American and white men received were statistically significant
(RR: 0.39-0.97); with African American men consistently
receiving worse care. For some measures of management of
end-stage renal disease, Asian men received care that was
similar to, or better than, that received by non-Hispanic
whites. For example, they were more likely to be placed on a
kidney transplant waiting list. However, despite being placed
on the waiting list at higher rates, Asian men received kidney
transplants at about half as often as non-Hispanic whites.
With respect to avoidable hospitalizations, African American;
Hispanic and Asian men, respectively, almost always;
sometimes and almost never had higher rates than nonHispanic whites. In contrast, patient safety problems were
experienced more often by all three groups relative to nonHispanic whites.
Conclusions: Racial/ethnic minority men are at a markedly
elevated risk for the receipt of poor health care quality in
multiple, diverse domains of clinical care. However, there is
considerable variation in the magnitude, direction and
significance of these risks for different minority groups.
Implications for Policy, Delivery or Practice: Generalizations
about “minority” men are likely to be misleading and
incomplete. Further exploration of the differences between
racial/ethnic minority groups can enhance our understanding
of which factors are most important in generating significant
differences – an understanding likely to help improve quality
for all men.
• Aligning Public Health Insurance Recertification with the
Process of Graduating from Elementary, Junior and Senior
High Schools in Order to Provide Children with
Continuous Health Care Coverage
Bertha Fertil, MGA, M.P.H., Tracy Grant, B.S., M.S.W., DelRoy
Williams
Presented by: Bertha Fertil, MGA, M.P.H., Director, NYC HRA
Medical Insurance and Community Services Administration,
15934 Riverside Drive, #2B, New York, NY 10032; Tel:
212.928.9264; E-mail: BFertil@aol.com
Research Objective: No child in the United States should be
without health insurance. The number of uninsured children
(18 and under) in the United States is approximately 10
million. Of this group half a million reside in New York State.
Further complicating their lives, many of these children live in
poverty or in households with little income security where
financial resources do not enter the home in a consistent
manner. In addition, because of numerous social, health and
economic issues (employment with inflexible work hours,
substance abuse, mental health issues, food and housing
insecurity) the parents of these children do not recertify their
children’s public health insurance on a regular basis even
when the face-to-face recertification interview is eliminated
and a mail-in recertification application process is put in place.
After having their Medicaid case closed, these individuals are
returning an average of 1.62 years later to reapply. This is
usually after the child is in need of medical care or is reengaged by a health plan. As a result, many of these children
during the most critical years of their lives go without health
insurance for more than a year and half.
The objective of this study is to find a means by which
children can retain their health care coverage in a manner that
enables for continous coverage without overwhelming their
parents.
Study Design: In a case review of 4,000 new applications for
public health insurance, we analyzed the following: the
number of times the individual had Medicaid coverage and
the case was closed, the number of children on the case
record, family income over five year, case type and whether the
case was submitted by a plan.
Population Studied: During a three month period we studied
the case records of 4,000 New York City residents who
submitted a new application for public health insurance. The
study was completed using a confidence level of 99% and a
margin of error of +/-2.
Principal Findings: In our study of 4,000 New York City
individuals who submitted a new application for public health
insurance during the months of June to August 2003 it was
found that 80% of the children only cases where already
known to Medicaid. However, their cases were closed
because the parents fail to mail-in the recertification
application even after the face-to-face interview process was
eliminated. More interestingly the parents did return to apply
for public health insurance more than a year and a half (1.62
years) after the case closed. In addition, it was found that the
parent’s income did not significantly change over a five-year
period.
Conclusions: By extending the annual recertification to four
years for these children only cases, the states would be
aligning the recertification period with the graduation from
different schools levels (elementary/primary,
intermediate/junior and senior high). By aligning the
recertifying with school, the state can partner with the school
systems in getting children enrolled in public health insurance.
In homes with more than one child, the graduation date of the
youngest child could be used to provide the longest possible
continuous coverage period for the children.
Implications for Policy, Delivery or Practice: The current
annual recertification works as an access barrier to health care
for many of New York City’s most vulnerable populations.
The extended recertification period would provide children
with a continuum of care. This process would enable children
to be able to meet their preventative health care milestones
without overwhelming parents, individuals who are already
stressed by negotiating the public welfare system. If the
incomes of the parents of the children only cases are looked
over a five-year period, especially parents of children under five
years old, the income either remains the same or is reduced.
In addition for children with chronic health care issues the
annual recertification process potentially puts their lives at
risk. Lastly, this process would save the state monies by
reducing the cost of processing the applications on an annual
basis. Presently, it cost the state approximately $220 - $280
per application per year to complete a new application.
Therefore, each time a parent fails to renew a child’s public
health insurance, the state (the taxpayers) pays the cost.
• The Effect of Gender on Treatment of Acute Myocardial
Infarction Patients
Janet Young, M.D., M.H.S.A., David Foster, Ph.D., M.P.H.,
David Foster, Ph.D., M.P.H., Sivana Heller, M.D., M.P.H.
Presented by: David Foster, Ph.D., M.P.H., Vice President,
Clinical Informatics, Solucient, LLC, 5400 Data Court, Ann
Arbor, MI 48108; Tel: 734.930.7982; Fax: 734.930.7611; E-mail:
dfoster@solucient.com
Research Objective: To compare treatment of male and
female inpatients diagnosed with acute myocardial infarction
(AMI).
Study Design: Retrospective cohort study.
Population Studied: Data for 23,017 patients with a principal
diagnosis of AMI discharged between October 1, 2002 and
September 30, 2003 was extracted from ACTracker,
Solucient’s proprietary database with detailed inpatient
diagnostic, demographic, and drug information.
Principal Findings: Women with a principal diagnosis of AMI
admitted to hospitals with a catheterization lab are
significantly less likely than men to undergo surgical
intervention – either percutaneous coronary intervention (PCI)
or coronary artery bypass graft (CABG), adjusting for age,
race, payer, hospital characteristics and subendocardial
infarction (OR .698, 95% CI .657, .742). However, there was
no statistical difference in the likelihood of receiving a stent by
gender among AMI patients who underwent PCI (OR .987, 95
% CI .844, 1.155). Although women undergoing PCI were
somewhat less likely than men to receive a glycoprotein
IIb/IIIa inhibitor, this finding was not statistically significant
(OR .907 ,95% CI .812, 1.011).
Women treated medically for a transmural infarction are
significantly less likely than men to receive a thrombolytic
agent (OR .754, 95% CI .629, .904).
Conclusions: Recent data shows that women with a principal
diagnosis of AMI remain less likely than men to receive
treatments that have been reported to improve outcomes (i.e.
survival, reinfarction), including surgical intervention and
thrombolytic agents. However, women who undergo PCI are
as likely as men to receive a stent, a device which has been
reported to decrease restenosis.
Implications for Policy, Delivery or Practice: Cardiovascular
disease remains the most common cause of death in women.
Additional studies are required to determine why women are
less likely than men to receive treatments that have been
reported to improve outcomes.
Primary Funding Source: Solucient, LLC
• "They Don't Hear What I am Saying at All." Language
Access Disparities among Haitian, Latino and Russian
Immigrant Parents Seeking Health Care for Their Children
in New York City
Jennifer Fuld, M.A., Ph.D. Candidate, Linda Weiss, Ph.D.,
Tamar Bauer, J.D.
Presented by: Jennifer Fuld, M.A., Ph.D. Candidate, Research
Associate, New York Forum for Child Health, The New York
Academy of Medicine, 1216 Fifth Avenue, New York, NY
10029; Tel: 212.822.7390; Fax: 212.822.7369; E-mail:
jfuld@nyam.org
Research Objective: Immigrant families and particularly
children face many obstacles to accessing health services in
New York City. Research demonstrates that children in
immigrant families are more likely to be uninsured, have no
regular source of care and face other barriers than children in
native citizen families, but little is known qualitatively about
these issues. This research examines the experiences
immigrant parents have navigating the health insurance and
health care system in NYC. In this current analysis, we
compared Haitian, Latino and Russian parents' experiences
with language access issues during children's health care
visits over the past two years.
Study Design: We conducted 75 semi-structured interviews of
immigrant parents living in New York City, from August 2003 December 2003 (25 Haitian, 25 Latino, 25 Russian).
Interviews were conducted in Haitian-Creole, Spanish and
Russian and audio-taped. Respondents were recruited using
purposive sampling through collaboration with communitybased organizations. All eligible respondents had to be an
immigrant parent caring for a child (under age 18). The child
had to be uninsured at the time of the parent's interview, or
insured with CHP A (Medicaid) or CHP B but to also have
also had a period of uninsurance within the past two years.
Coding and analysis of qualitative data was conducted with
the aid of Atlas.ti.
Population Studied: The population studied was Haitian,
Latino, and Russian immigrant parents and children living in
New York City. We limited our sample to children in
immigrant families who are uninsured but eligible for CHP A
(Medicaid) or CHP B and children who are insured with CHP
A or CHP B. Children in immigrant families with private
insurance were excluded.
Principal Findings: Most parents were limited English
proficient (LEP) and were caring for young children. Parents
described being continually frustrated and feeling that they
were getting only a partial picture of their children's health
during many health care visits. Parents who had taken their
children to the emergency room described experiences where
they were not provided any type of language assistance, they
were not properly informed about their child's health, they
were told to sign forms in English that they could not read and
they felt dismissed by the doctors because they were LEP and
doctors were not bilingual. In contrast, parents described
experiences at community-based health centers as more
positive and as visits with doctors and staff who were
bilingual. Parents believed that as these visits, in relation to
hospital visits, they left with a better understanding of their
child's health and healthcare needs. Differences among the
three groups included: Haitian parents often bring along a
Haitian friend or family member who speaks English to
children's health care visits since they expect to be provided
with no language assistance in Haitian-Creole; Latino parents
often resign themselves to a stranger or staff person with very
poor Spanish to provide language assistance during a child's
visit since they feel that it is likely someone at the location will
speak some Spanish, even if it is extremely limited; and
Russian parents seek out Russian doctors in their community.
Conclusions: Immigrant parents in all three immigrant
groups, face many barriers during children's health care visits
when there is limited language assistance available. Parents
negotiate a health care system that provides limited language
assistance at many places by relying on culturally-based norms
that reflect factors such as the size of the immigrant group,
geographic settlement patterns, social support and coping
strategies. Overall, parents report that their knowledge of
their children's health is comprised by limited language
assistance and that each negative health care visit
cumulatively impacts their ability to care for their child's
development.
Implications for Policy, Delivery or Practice: It is critical that
immigrant parents are able to communicate with and
understand the health care providers who care for their
children. These findings add to the growing evidence that
New York City health care providers, especially hospitals, need
to improve language access services and that ad-hoc
interpreters such as strangers, friends and other family
members are not a substitute for medical interpretation.
Primary Funding Source: Foundation for Child Development
• Racial Differences in Consumer Empowerment and
Health Care Experiences in the US Health System
Lisa Gary, M.S., M.P.H., Mark Schlesinger, Ph.D.
Presented by: Lisa Gary, M.S., M.P.H., Ph.D. Candidate,
Health Policy and Administration, Yale University School of
Public Health, 60 College Street, P.O. Box 208034, New
Haven, CT 06520; Tel: 203.787.9943; Fax: 203.785.6287;
E-mail: lisa.gary@yale.edu
Research Objective: Objective: To investigate racial
differences in consumer empowerment behavior and health
care experiences in the American health system and to
investigate the role of consumer trust in that process. This
study also explores whether these racial differences vary
significantly across 3 domains of health care experiences:
interactions with physicians, health plans and hospitals.
Background: Studies show that racial minorities have worse
health outcomes than whites across a large array of health
indicators. Recent studies suggest that the racial differences in
health outcomes are in part due to racial minorities receiving
lower quality health care than their white counterparts.
Controlling for socioeconomic status, minority patients have
less adequate communication with their physicians and are
less likely to receive appropriate preventive care.
To understand the origins of racial disparities in care, it is
important to assess whether minority patients are
experiencing a higher rate of problematic treatment in the first
instance; and secondly are they less able to effectively address
the inadequacies that occur in the course of their medical
care. Essentially, are minority consumers empowered enough
to voice when they experience problems with their health care?
What are the consumer characteristics and health system
characteristics that are associated with consumer
empowerment behavior?
Study Design: Data are from the Yale/New York Academy of
Medicine Survey of Consumer Experiences in Health Care
conducted from June 2002 to early September 2002, a
telephone survey of approximately 5000 individuals
representing the US non-institutionalized population. The
conceptual model for this research builds on two models of
health behavior and health care utilization to examine the
phenomenon of consumer self-advocacy. Data have been
analyzed to assess the prevalence of problematic experiences
in the health care system for African Americans compared to
whites. Further analysis focuses on their responses to those
perceived problems i.e. - their level of consumer
empowerment/self-advocacy. In addition to describing the
nature and distribution of the health care problems
experienced by consumers, data on satisfaction with the
problem resolution within the health care system will be
analyzed. Additional multiple logistic regression and Poisson
regression models will focus on the role of self-efficacy and
consumer trust as well as health plan characteristics in
promoting empowerment behavior.
Population Studied: There are 485 black/African American
and 3825 white insured adults in the study.
Principal Findings: Initial analyses show that minority
consumers experience more problems with their health care.
The possible problems with their health care range from
delays in care to being treated unfairly due to their race.
Preliminary analysis also shows that minority consumers often
feel mislead by their health plans when trying to address a
health care problem.
Conclusions: Although the study is in progress, the
implications for this research are far-reaching. This research
will be beneficial for developing interventions within health
plans that encourage a sense of agency and empowerment for
minority health care consumers and non-minority consumers
as well. Additionally, consumer empowerment may have
significant effects on medical care practice. For instance,
empowered consumers
Primary Funding Source: NIMH and Atlantic Philanthropies
• Examining Racial and Ethnic Disparities in Site of Usual
Source of Care
Darrell Gaskin, Ph.D., Joses Arbelaez, M.D., Fernando
Wagner, ScD, Jorielle Brown, Ph.D, Hanno Petras, Ph.D.
Presented by: Darrell Gaskin, Ph.D., Associate Professor,
Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, 624 N. Broadway, Room 441,
Baltimore, MD 21205; Tel: 443.287.5297; Fax: 410.614.8964;
E-mail: dgaskin@jhsph.edu
Research Objective: To examine the disparities in site of
usual source of care by race and ethnicity. Minority
subgroups have a lower propensity to use private doctors’
offices for their usual source of care than Whites. We attempt
to explain this observed difference. In particular, we
determine whether observed differences persist after
controlling for other factors, such as demographic,
socioeconomic and individuals’ values and beliefs about
health care. We also identify which factors were most
important for each race/ethnic subgroup.
Study Design: We estimated a multinomial logistic regression
model where the dependent variable is the site of the
respondents’ usual source of care using those who use a
doctor’s office as the reference group. Using this model, we
computed the relative risk ratios for each minority group
compared to Whites of using a community health center
relative a doctor’s office and hospital outpatient department
relative to a doctor’ office, and hospital emergency room/ no
regular source of care relative to a doctor’s office. We also
estimated model separately for each subgroup to ascertain
whether the relative importance of factors differ across
groups.
Population Studied: This study used the Commonwealth
Fund’s Health Care Quality Survey of adults conducted
between April and November 2001. African Americans,
Hispanics and Asians were over-sampled to enable
researchers to examine differences by race and ethnicity. The
survey covered several domains including usual source of
care, health care utilization, unmet medical needs,
satisfaction, health status, socioeconomic status, attitudes
about value of medical care and perceptions about the
presence of racial/ethnic bias in medical treatment.
Principal Findings: While insurance and income play a major
role in determining whether minorities obtain their care at the
private doctor’s office, other factors such as demographic,
education, health status and attitudes towards health care
matter too. The relative importance of these factors differs
across subgroups. Whites who felt there was racial/ethnic
bias in the delivery of health care were less likely to use
community health centers while minorities who felt this way
were more likely to use community health centers. African
Americans and Hispanics perceptions of racial and ethnic bias
in the delivery of health care did not explain the within
subgroup variation in site of care. Only income and the lack
of health insurance were statistically significant factors for all
four subgroups as a determinant of hospital emergency room
use or reporting no usual source of care.
Conclusions: To encourage minorities the rely more care in
private doctors’ office, policy makers will have to use more
than financial mechanisms (i.e. insurance coverage and
income subsidies) to achieve this goal. Outreach and
education programs targeted to particular segments within
each minority community may be required to change care
seeking patterns. In addition, improving the viability of private
physician practices in urban and rural areas is an important
consideration.
Primary Funding Source: National Institute of Minority
Health and Health Disparities
• Racial Disparities in the Enjoyment of Cancer Survival
Advances over the Past 30 Years in the United States:
Evidence of Institutionalized Racism
Kevin Gorey, Ph.D., M.S.W., Isaac Luginaah, Ph.D., Emma
Bartfay, Ph.D.
Presented by: Kevin Gorey, Ph.D., M.S.W., Professor, School
of Social Work, University of Windsor, 401 Sunset Avenue,
Windsor, N9B 3P4; Tel: 519.253.3000; Fax: (519) 973-7036; Email: gorey@uwindsor.ca
Primary Funding Source: Canadian Institutes of Health
Research
• Urgent Need for Specialist Care among Homeless
Pediatric Patients
Roy Grant, M.A., Peter Sherman, M.D., Irwin Redlener, M.D.
Presented by: Roy Grant, M.A., Director of Research,
Research, The Children's Health Fund, 317 East 64th Street,
New York, NY 10021; Tel: 212.535.9400; Fax: 212.535.7699;
E-mail: rgrant@chfund.org
Research Objective: 1. To determine the specialist referral
needs of homeless children when they begin a primary care
medical home program. 2. To replicate findings of an initial
study completed in 2000, which found a very high level of
need in the population.
Study Design: Retrospective review of electronic and paper
charts of all patients of the New York Children’s Health Project
referred to a specialist based on initial pediatric assessment in
1998 (2,205 patients). Virtually all were domiciled in a
homeless or domestic violence shelter. To test whether the
initial findings were representative, this was repeated for
patients seen during 2001 (2,425) to allow for virtually 100%
patient turnover.
Population Studied: Homeless children experience more
acute and chronic conditions, and worse health status, than
housed low-income children (Weinreb et al, 1998; Parker et al.,
1991; Wood et al., 1990). Prior to becoming homeless, they
may have had inadequate access to health care services,
reflected by, among other indicators, under-immunization
(Fierman et al., 1993; Orenstein et al., 1992; Miller and Lamm,
1988).
Principal Findings: In the 1998 cohort, 509 patients (23.1%)
required at least one specialist referral. Two ore more
specialist referrals were required by 183 patients (8.3% of
patients; 35.9% of referred patients). Conditions identified
suggest that serious medical conditions were not identified or,
if identified, not adequately treated in this predominantly
Medicaid eligible population. Conditions include club foot,
hearing loss, visual impairment, seizure disorder, and
hydrocephaly. In 2000, for a new cohort of patients who,
based on improved immunization status were likely to have
had better prior access to care, 544 patients were referred
(22.2%), of whom 150 (6.1% of patients; 27.6% of referred
patients) required two or more specialist referrals. Similar
conditions were identified.
Conclusions: Medically underserved pediatric patients may
present with serious needs when they begin a medical home
progam. Based on the nature of conditions identified, EPSDT
standards may not be consistently met for these high-risk
Medicaid eligible patients.
Implications for Policy, Delivery or Practice: Because of
prior access or quality of care issues, high-risk pediatric
patients may require longer primary care visits than typical.
They may present urgent need for specialist referral, requiring
enhanced access to specialist care. These findings may have
an impact on cost of care whether by capitation or fee for
service.
Primary Funding Source: BPHC
• Race/Ethnicity, Socioeconomic Experience and Adult
Health
Lisa Green, Ph.D. Candidate
Presented by: Lisa Green, Ph.D. Candidate, Student, Health
Policy & Management, Johns Hopkins Bloomberg School of
Public Health, 3601 Greenway #601, Baltimore, MD 21218; Tel:
410.889.5916; E-mail: ligreen@jhsph.edu
Research Objective: To better elucidate the role of
socioeconomic experience in the race/ethnicity and health
relationship among working-age adults, this study examines
multiple domains of socioeconomic experience within a
lifecourse paradigm. The aims of this study are to identify the
racial/ethnic differences in global health outcomes among
working age adults, and to determine what role individual-level
socioeconomic experience has in explaining these differences.
Study Design: Sex and sex-race stratified multivariate linear
regression models were used to examine the impact of
education, occupational prestige and 19 year income on five
health outcomes (SF-12 Physical and Mental Health Summary
Scores, depression, major morbidities and minor morbidities)
measured at age 40. Data were drawn from the National
Longitudinal Survey of Youth 1979 for the years 1979-2000.
Population Studied: The NLSY79 cohort is a nationally
representative sample of the non-institutionalized, civilian
population aged 14-21 in 1979 with an over-sample of civilian
Hispanic and Black respondents. Respondents were surveyed
annually from 1979 to 1994 and then biennially through the
present. Those who have reached age 40 and answered the
age 40 health module were included (n=3,154) in this study.
Principal Findings: In sex stratified models, socioeconomic
factors alone fully accounted for observed disparities, and
provided a protective effect for major and minor morbidities
among black and Mexican respondents, compared to white
counterparts. Income in particular played a strong role in
explaining racial/ethnic differences. The sex and race stratified
models revealed that socioeconomic factors impact different
population groups in different ways. Income appeared to have
a lagged effect among black men and women, and no effect
on Mexican men and women. Education exhibited a gradient
effect for most sex-race categories and occupational prestige
had minimal to no effect on health outcomes.respondents,
compared to white counterparts. Income in particular played a
strong role in explaining racial/ethnic differences. In sex and
race stratified models, income appeared to have a lagged
effect among black men and women, and no effect on
Mexican men and women. Education exhibited a gradient
effect for most sex-race categories and occupational prestige
had minimal to no effect on health outcomes.
Conclusions: This study addresses gaps in the literature on
whether more complex and perhaps more robust definitions
of socioeconomic experience attenuate observed racial/ethnic
disparities in health, and on how such socioeconomic
patterns over the life course predict health in adulthood.
Health status is also key to understanding the health of
working adults, where morbidity is relatively low and mortality
is disproportionately dominated by HIV, injury and homicide.
The working age population represents the most productive
segment of the U.S. population, both economically and
socially, and represents a much overlooked subgroup ripe for
preventive health intervention. Understanding the health
differentials and needs during this productive time period,
prior to more significant and rapid health declines in later life,
are critical. Prior reviews have examined mortality or disease
endpoints (e.g. cardiovascular, cancer, other morbidity) with
substantially less attention paid to more global concepts of
health. Additional research capturing both the longitudinal
and contextual dimensions of socioeconomic experience in a
broader population is still needed.
Implications for Policy, Delivery or Practice: Results
suggest that policies addressing socioeconomic inequities
may reap significant health benefits. Programs aimed at
improving education, income distribution and earnings
should be considered in the health disparities discussion.
However, additional research on the pathways between
socioeconomic factors and health are needed to better guide
such program endeavors.
Primary Funding Source: NIH NRSA Training Grant
• Racial and Ethnic Differences in Need and Unmet Need
for Mental Health Care
Katherine Harris, Ph.D., Sharon Larson, Ph.D.
Presented by: Katherine Harris, Ph.D., Research Fellow,
Office of Applied Studies, Substance Abuse and Mental
Health Services Administration, 5600 Fishers Lane, 16-105,
Rockville, MD 20856; Tel: 301.443.0747; E-mail:
kharris@samhsa.gov
Research Objective: To compare need for and use of mental
health care across a wide range of racial and ethnic subgroups
and to measure the robustness of observed differences to
clinical and socio-demographic covariates.
Study Design: We analyze data from combined rounds of the
2001 National Household Survey on Drug Abuse (NHSDA)
and the renamed 2002 National Survey on Drug Use and
Health (NSDUH, formally called NHSDA).
We present rates of mental health need (one or more mental
health symptoms and probable serious mental illness), use of
mental health care, and self-reported unmet need for mental
health care by racial and ethnic group. We use multivariate
logistic regression to assess the sensitivity of observed
differences to covariates and report odds ratios from adjusted
and unadjusted models.
Population Studied: Our sample is large enough to permit us
to examine a wider array of racial and ethnic subgroups
compared those compared in the existing literature on racial
disparities in mental health care: (1) white (n=62,072), (2)
African American (n=10,188), (3) American Indian/Native
Alaskan(n=1,105), (4) Asian (n=2,793), (5) multiple racial
categories (n=1,428), (6) Mexican (n=6,885), (7) Puerto Rican
(n=1,375), (8)Central and South American (n=1,888), and (9)
other Hispanic-Latinos (1,190).
Principal Findings: We found substantial variation in mental
health need and use across racial groups. The highest rates of
serious mental illness were observed among American
Indian/Native Alaskan (12%) and multiple racial category
(11%) groups. The lowest rates of serious mental illness were
observed among Asian (4%) and Central and South American
(4%) groups. However, the two groups with the highest rates
of mental health need used mental health services at rates
statistically comprable to whites. At the same time, groups
with low need used mental health care at substantially lower
rates compared to whites (p<.05). The American
Indian/Native Alaskan group reported the highest rates of
unmet need for mental health care (35% vs. 17% for whites
and 6% for Asians). The ability of covariates to explain group
differences was not uniform across groups or measures. In
general, covariates explained differences in rates of mental
health care use among those with mental health need and
mental health care need and use between whites and Asians.
We find substantial variation in need and use among
Hispanic-Latino subgroups with highest rates of need and use
among Puerto Rican groups and the lowest rates of need and
use among Mexican and Central and South Americans. The
use of covariates increased differences in the rates of mental
health need between whites and African Americans.
Conclusions: Our results reveal wide differences in need, use,
and unmet need both between and whites and racial
minorities and among minority groups that have been either
observed elsewhere in the literature or hypothesized based on
indirect comparisons using single group studies. The impact
of controls on inferences about racial and ethnic differences
varied across groups and across dependent variables in ways
that are complex and not anticipated by the disparities
literature.
Implications for Policy, Delivery or Practice: The sensitivity
of group differences in rates of mental health care use to
clinical and socio-demograhpic covariates suggests that
policies aimed at reducing economic barriers to access may
reduce disparities in treatment rates.
Primary Funding Source: Substance Abuse and Mental
Health Services Administration/Office of Applied Studies.
• Collection of Race, Ethnicity, and Primary Language Data
in Hospitals: Barriers and Facilitators
Romana Hasnain-Wynia, Ph.D., Romana Hasnain-Wynia,
Ph.D., David Nerenz, Ph.D., Connie Currier, DrPH, Debra
Pierce, BA
Presented by: Romana Hasnain-Wynia, Ph.D., Director,
Research and Evaluation, Health Research and Educational
Trust/AHA, One North Franklin, 30th Floor, Chicagto, IL
60606; Tel: 312.422.4568; Fax: 312.422.4568; E-mail:
rhasnain@aha.org
Research Objective: As attention shifts from the
documentation of disparities to the testing of initiatives to
reduce disparities, the role of hospitals is crucial. Yet little is
known about the collection of data on race, ethnicity and
primary language in hospitals. The research objectives are to:
1 assess whether hospitals collect information on patient race,
ethnicity, and primary language;2 assess who provides the
information; 3 assess when and where the information is
collection 4 understand what the information is used for; 5
understand the barriers and facilitators to collecting this
information.
Study Design: The study design incorporated the
development and implementation of a survey to hospitals and
site visits to select hospitals to conduct key informant
interviews.
Population Studied: The survey was sent to a nationally
representative sample of 1000 hospitals stratified along four
dimensions: whether hospital was in a state where there was
a mandate to collect race and ethnicity data; urban and rural
hospitals; teaching hospital status; and whether the hospital
was part of a system or a stand alone. We conducted site
visits to six hospitals including Northwestern Memorial
Hospital, Henry Ford Health System, University of Pittsburgh
Medical Center Health System, Massachusetts General
Hospital, Parkland Memorial Hospital, and Kaiser Permanente
(Northern California) to conduct key informant interviews
about each organizations' data collection policy and to
understand the barriers and facilitators to collecting race and
ethnicity data in hospitals.
Principal Findings: Survey findings indicate that the majority
of hospitals (78)percent indicate that they collect data on
patient race,ethnicity, and lanuage. Hospitals located in states
where there is a state mandate to collect race and ethnicity
data, urban hospitals, and teaching hospitals are more likely to
say they collect these data. There was not a significant
difference between hospitals that are part of a system versus
stand alone in regard to race ethnicity data collection. In
addition, the findings highlight who provides the information
in the hospital setting, when the data are collected in the
hospital, reasons for collecting the data, race and ethnicity
categories used by hospitals, who has access to race and
ethnicity data. Those hospitals that stated that they do not
collect race and ethnicity data, the findings highlight reasons
for not collecting the data. The key informant interviews
conducted during the site visits provide contextual
information regarding the barriers and facilitators to data
collection.
Conclusions: Seventy-eight percent of hospitals that
responded to the survey state that they collect data on patient
race and ethnicity. Given the effort being made to collect this
information several general conclusions can be made about
collecting race, ethnicity and primary language information in
hospitals. Barriers and facilitators to data collection are
defined coupled with recommendations to hospitals, other
health care organizations,practitioners, and policy makers.
Implications for Policy, Delivery or Practice: Collection of
data on patients' race and ethnicity should be standardized
with regard to:
Who provides the information
When it is collected in a hospital setting
What racial and ethnic categories are used
Where data are stored
Ensuring that data are collected in a meaningful context
e.g.,efficiently and respectfully
Primary Funding Source: CWF, National Academies of
Science
• Racial Differences in Pharmacotherapy and Healthcare
Expenditures for the Treatment of Asthma in a Medicaid
Population
Kevin Hawkins, Ph.D., Richard Stanford, PharmD, M.S.,
Lucinda Orsini, DPM, M.P.H., Ron Ozminkowski, Ph.D.,
Chang Jiang, Ph.D.
Presented by: Kevin Hawkins, Ph.D., Senior Economist,
Outcomes Research & Econometrics, The Medstat Group, 777
E. Eisenhower, Ann Arbor, MI 49230; Tel: 734.913.3145; Fax:
734.913.3200; E-mail: kevin.hawkins@medstat.com
Research Objective: To compare pharmacotherapy and
healthcare expenditures by race for asthma patients in a
Medicaid population.
Study Design: This analysis used the MarketScan® claims
and eligibility data for a multistate Medicaid population
between 1999 - 2000. Because Medicaid eligibility is updated
monthly, 24 monthly files were constructed to capture all
Medicaid asthmatic patients in 1999 and 2000. Patients were
included in the study if they had an asthma diagnosis or
prescription for an asthma-related drug in any given month.
Patients were grouped by race, a variable often not found in
healthcare claims data sets. Type of pharmacotherapy,
demographics, health status, healthcare utilization, and
expenditures were measured to assess differences between
the racial groups. Descriptive analysis was used to determine
medication use and healthcare costs across racial cohorts.
Population Studied: 2,724,008 subjects were eligible for
evaluation over the 2 year observational period.
Principal Findings: Overall, patients used 1.8 times as many
rescue medications compared to long term controller
medications per month. Hispanics used 2.5 times more
rescue medications. African-Americans (AA) used 2 times
more rescue medications, and Caucasians used 1.6 times
more rescue medications. Compared to Caucasians, asthmarelated drug expenditures were 20% and 69% lower for AA
and Hispanics respectively. However, asthma-related
inpatient costs were 94% higher for AA and 58% higher for
Hispanics compared to Caucasians. Similarly, asthma-related
emergency room (ER) costs were 48% higher for AA and 13%
higher for Hispanics compared to Caucasians. Overall, the
largest component of the asthma care among all groups was
pharmacotherapy, at 50% of total asthma expenditures ($64
per month).
Conclusions: term controller asthma medications were
underused by all, but more so among minorities. This
difference in use was reflected in the cost of inpatient and ER
asthma care across the racial cohorts.
Implications for Policy, Delivery or Practice: Further
research is needed to understand why minorities are receiving
sub-optimal pharmacotherapy for asthma. Once this problem
is better understood, interventions can be designed to help
correct it.
Primary Funding Source: GlaxoSmithKline
• Racial and Gender Differences in Access to Substance
Abuse Services among Medicaid Adolescents
Craig Anne Heflinger, Ph.D., Jamie Chatman, B.S., Robert
Saunders, M.P.P.
Presented by: Craig Anne Heflinger, Ph.D., Associate
Professor, Human and Organizational Development,
Vanderbilt University, 230 Appleton Way, Box 90 Peabody
College, Nashville, TN 37203; Tel: 615.322.8275; Fax: (615) 3432661; E-mail: c.heflinger@vanderbilt.edu
Research Objective: This study examined the disparities in
access to substance abuse treatment among minority and
female Medicaid adolescents in one state.
Study Design: Data were extracted from Medicaid
claims/encounter and enrollment data sets for July 1995
through June 2001. Access to substance abuse services for
the population of Medicaid-enrolled adolescents was
examined in two ways. The first considered annual access
rates (proportion of the population who used a service) and
probability of substance use. The second subset the data to
consider the pool of adolescents who used their first
substance abuse service within the time period by studying
the age at which their first substance abuse service was
received. Each of these approaches addressed a slightly
different aspect of the disparity question: the annual analysis
considered whether race or gender differences in access
existed in this population; the “first use” analysis considered
whether there were system-wide differences in the detection of
substance abuse problems for black and female adolescents,
as compared to whites and males. Descriptive and regression
analyses were used to examine racial and gender disparities in
annual access rate, probability of service use, and age at first
substance abuse service. Youth age, Medicaid eligibility
category, and previous use of mental health services were
included as covariates.
Population Studied: Statewide Medicaid-enrolled 12-17 year
olds.
Principal Findings: The study demonstrated significant
differences by race and gender in all access measures. Whites
were nearly two times as likely as blacks (OR 1.96) to access
substance abuse services, while males accessed services at a
75% greater rate(OR 1.78) than females. Gender and race
were also both significant predictors of age at first substance
abuse service, controlling for other covariates, with female and
white adolescents being significantly younger as they entered
treatment.
Conclusions: This study’s findings that white adolescents are
gaining access to substance abuse treatment at significantly
higher rates and an earlier age than black adolescents may be
explained by previous research findings that the use of alcohol
and drugs is higher among whites than blacks. However, the
disparities found in this study are greater than differences in
prevalence rates explain. Each comparison between these
groups shows white males being treated at a higher rate than
any of the other groups, almost twice the rate of white females
and black males, and more than six times that of black
females. These proportions clearly are discrepant with the
information available on differing prevalence rates for these
groups. By far the most underserved group according to this
and other measures in this study is black females.
Implications for Policy, Delivery or Practice: The low access
rates, in general, and the differential access rates by race and
gender raise questions regarding the identification of
substance abuse problems at the system level. The
implementation of guidelines for screening by primary care
physicians and psychiatrists is discussed, along with barriers
to implementation and accurately reporting substance abuse
diagnoses.These findings indicate the importance of
appropriate monitoring of and research about access, not only
broadly but for key population groups, such as adolescents
and minority groups.
Primary Funding Source: NIDA
• Ethnic, Gender, and Age Related Differences in
Treatment and Control of Dyslipidemia among
Hypertensive Patients
Katharine Hendrix, Ph.D., Jessica Riehle, R.N., Brent Egan,
M.D.
Presented by: Katharine Hendrix, Ph.D., Executive
Administrator, Hypertension Initiative, General Internal
Medicine, Medical University of South Carolina, 96 Jonathan
Lucas Street, 826 CSB, Charleston, SC 29425; Tel:
843.792.6340; Fax: 843.792.0816; E-mail: hendrikh@musc.edu
Research Objective: Assess demographic differences in lipid
control rates and treatment patterns among dyslipidemic,
hypertensive patients in primary care.
Study Design: Demographic information, blood pressure,
LDL-cholesterol, and medications were obtained on 72,351
hypertensive patients from 262 primary care providers at 69
sites in the Southeast.
Population Studied: 72,351 hypertensive patients from the
Hypertension Initiative database. 38,116 of these patients were
also diagnosed with concomittant dyslipidemia.
Principal Findings: Fifty-two percent of patients did not have
a cholesterol measurement documented in the past year.
Women and patients <40 years old were less likely to have an
annual cholesterol measurement than men and older, samerace counterparts (p<0.001). Thirty-five percent of all
hypertensive dyslipidemic patients had not been prescribed
any anti-lipidemic medication, whereas 15% were on a statin
and another anti-lipidemic. Women received fewer statin
prescriptions than men (48.8% vs. 63.7%, p<0.0001). Fewer
African Americans (AA) than Caucasians (C) reached LDL
levels of <100 or <130 mg/dL (p<0.0001). Among C and AA
patients, those <40 years old were less likely than older, samerace counterparts to have reached LDL <100 or <130 mg/dL
(p<0.001). Younger patients had fewer annual cholesterol
measurements and were less likely to receive anti-lipidemic
medication and to have LDL controlled than older, same-race
counter-parts in each ethnic group(p<0.0001)
Conclusions: Demographic characteristics of hypertensive
patients, especially younger age group, are associated with
significant differences in diagnostic testing, treatment and
control of hyperlipidemia in primary care. This primary care
information can be used to guide education and policy
interventions to improve outcomes and reduce disparities.
Implications for Policy, Delivery or Practice: This primary
care information can be used to guide education and policy
interventions to improve outcomes and reduce disparities.
Primary Funding Source: Duke Endowment
greater probability of choosing a plan, rather than being
assigned. Sample members who learned about plans from
their doctors were more likely to report the information was
very useful, but these sample members were less likely to
choose their plans. People with mental retardation were more
likely to rely on friends and family for information, but these
sources were not associated with choosing plans and
providers. Less than half of SSI enrollees rated providers’
information about tests and procedures very good or
excellent, and a fifth rated it poor or fair. Adults with
communications impairments were the least satisfied with
information about tests and procedures.
Conclusions: Although SSI enrollees faced barriers to
informed participation, most were able to overcome the
barriers. Others, especially people with cognitive and
communication impairments, were less able to receive
information or make informed decisions.
Implications for Policy, Delivery or Practice: Information
dissemination should be tailored to the diverse needs of
people with disabilities. While most people with disabilities
appear to be able to overcome barriers to receiving and using
information to make health care decisions about plans and
providers, greater efforts may be needed to assist people with
communications and cognitive impairments. Information
resources targeted to the family and friends of people with
mental retardation may improve their ability to make informed
decisions. Additional assistance is needed to facilitate
information sharing between providers and people with
communication impairments.
Primary Funding Source: DHHS Assistant Secretary for
Planning and Evaluation
• Barriers to and Enablers of People with Disabilities’
Informed Participation in Health Care: Evidence from SSI
Enrollees in TennCare
Steven Hill, Ph.D., Judith Wooldridge, MA
• Predictors of Early Prenatal Care Use, Preterm Birth and
Low Birthweight Among Rural and Urban Women
Marianne Hillemeier, Ph.D., M.P.H., Carol Weisman, Ph.D.,
Gary Chase, Ph.D., Megan Darnell, M.S.
Presented by: Steven Hill, Ph.D., Service Fellow Economist,
CFACT, AHRQ, 540 Gaither Road, Rockville, MD 20850; Tel:
301.427.1672; Fax: 301.427.1276; E-mail: shill@ahrq.gov
Research Objective: Describe people with disabilities’
barriers to informed participation in health care for people
with disabilities, and assess which information sources are
more useful and associated with choosing plans and
providers, rather than being assigned.
Study Design: Telephone survey of Supplemental Security
Income (SSI) enrollees in TennCare, Tennessee’s Medicaid
managed care program.
Population Studied: SSI enrollees in TennCare in Shelby
County, Tennessee, 1998-1999.
Principal Findings: Some SSI enrollees have cognitive
impairments, difficulty using a telephone, and difficulty
communicating, which can hinder informed participation in
health care. In TennCare, most SSI enrollees chose their plan
and providers, but a minority did not know they could choose
and were assigned to them. Most SSI enrollees received
information to help them choose plans, and most were
confident they could find out how to change providers. On
the other hand, a minority did not know they could choose
plans and were dissatisfied with the choice of providers.
Information from the state and plans was associated with a
Presented by: Marianne Hillemeier, Ph.D., M.P.H., Assistant
Professor, Health Policy & Administration, Pennsylvania State
University, 116 Henderson Building, University Park, PA 16802;
Tel: 814.863.0873; Fax: 814.863.2905; E-mail:
mmh18@psu.edu
Research Objective: To examine predictors of prenatal care
use, preterm birth, and low birthweight at the individual and
community levels and to examine the impact of urban-rural
maternal residence using measures that capture the
differences among types of rural communities.
Study Design: Birth certificate records were analyzed for the
28-county central Pennsylvania region, which contains urban
areas as well as a sizable rural population. Birth record data
were merged with county-level indicators of socioeconomic
status and health care resources from the Area Resource File
and U.S. Census data. Multiple logistic regression analyses
were conducted to model the determinants of 1) receipt of
early (first trimester) prenatal care; 2) preterm birth (<37
weeks gestation); and 3) low birthweight (<2500 grams).
Independent variables included measures of maternal
sociodemographics (age, education, race/ethnicity), maternal
health (smoking, chronic high blood pressure, diabetes), and
county-level socioeconomic and health care resources
(percent high school graduates, percent nonwhite, percent of
persons below poverty level, primary care physicians/100,000
population), and urban-rural maternal residence. Rurality was
measured in two ways: 1) using RUCA codes aggregated into
four categories; and 2) using 9-category Urban Influence
Codes for counties. Each regression model was estimated for
all births, all singleton births (using previous preterm birth as
a covariate), and for all first births in 2002.
Population Studied: All births, all singleton births, and all
first births in the 28-county central Pennsylvania region in
2002.
Principal Findings: Maternal education was a strong
predictor of early prenatal care (adjusted odds ratio=5.91, 95%
CI 5.49 to 6.36, p<.0001). Maternal health was also a
significant predictor of early prenatal care, as well as preterm
birth and low birthweight. For example, the adjusted odds
ratio for chronic hypertension as a predictor of early prenatal
care was 1.57 (95% CI 1.06 to 2.34, p=.0258), and the
corresponding odds ratio for low birthweight was 3.50 (95% CI
2.64 to 4.63, p=<.0001). County-level characteristics were not
uniformly informative, but the percent of persons in poverty
predicted preterm birth, low birthweight, and reduced
likelihood of early prenatal care. Results for the two measures
of rurality were similar. Urban focused areas had the highest
levels of early prenatal care, while isolated smaller rural areas
had the lowest levels. Isolated rural towns had significantly
lower rates of early prenatal care than all other areas, but the
pattern of increase was not monotonic with decreasing
rurality.
Conclusions: Women’s health status is an important
predictor of early prenatal care use, and has implications for
adverse infant outcomes. Women in isolated small rural areas
have the least optimal prenatal care patterns, however the
association between decreasing rurality and greater likelihood
of early prenatal care use is not linear.
Implications for Policy, Delivery or Practice: Access and
appropriate utilization of prenatal care among women in
isolated small rural areas is of particular concern. Detailed
study of the relationships between degree of rurality and
medical care use is needed to optimally target intervention
activities.
• Racial and Ethnic Disparities and Perceptions of Health
Care: Does Health Plan Type Matter?
Kelly Hunt, M.P.P., Ayorkor Gaba, B.A., Risa Lavizzo-Mourey,
M.D., M.B.A.
Presented by: Kelly Hunt, M.P.P., Research Officer, Research
and Evaluation, The Robert Wood Johnson Foundation, Route
1 and College Road East, Princeton, NJ 08543; Tel:
609.627.5994; E-mail: khunt@rwjf.org
Research Objective: To examine whether differences in the
distribution of health plans by race and ethnicity explain
differences in satisfaction and trust with health care providers
across racial/ethnic groups.
Study Design: Multivariate analyses used regression methods
to detect independent effects of patient/respondent race and
ethnicity on satisfaction and trust with health care provider,
while controlling for demographics, geography, and
enrollment in different types of health plans.
Population Studied: Data were derived from the 1998-99
Community Tracking Household and Followback Studies
(CTS) and consisted of a nationwide sample of adults (18 and
over).
Principal Findings: Racial and ethnic minorities are more
likely than whites to have lower levels of trust and satisfaction
with their health care provider. Plan type does not mitigate
the relationship between race/ethnicity and trust and
satisfaction.
Conclusions: Disparate levels of trust and satisfaction exist
within ethnic and minority populations, even when controlling
for the distribution of individuals across types of health plans.
The results demonstrate a need to consider the issue of
disparate trust and satisfaction as fundamentally about race
and ethnicity and not plan type.
Implications for Policy, Delivery or Practice: Our findings
suggest that trust and satisfaction should be carefully
considered as interventions are designed to address racial and
ethnic disparities in health care. In evaluating programs
designed to reduce disparities in trust and satisfaction, we
need the ability to measure patient assessments of care as
well as other health outcomes to be sure we address the issue
on all levels because they have been linked to patient
assessments of health care, service utilization, the decision to
switch health plans, and treatment compliance.
• Racial/Ethnic Disparities in Hospital Readmissions for
Diabetes-Related Conditions
H. Joanna Jiang, Ph.D., Roxanne Andrews, Ph.D., Daniel
Stryer, M.D., Bernard Friedman, Ph.D.
Presented by: H. Joanna Jiang, Ph.D., Social Scientist, Center
for Delivery, Organization, and Markets, Agency for
Healthcare Research and Quality, 540 Gaither Road, Rockville,
MD 20850; Tel: 301.427.1436; Fax: 301-427-1430; E-mail:
jjiang@ahrq.gov
Research Objective: Considerable differences in prevalence of
diabetes and management of the disease exist among
racial/ethnic groups. More needs to be known about the
relationship of race/ethnicity, health care treatment, and
health outcomes for diabetes. The purpose of this study is to
examine racial/ethnic differences in hospital readmissions for
diabetes-related conditions. Effective outpatient follow-up
care can help reduce readmission rates.
Study Design: Logistic regressions were employed to
estimate racial/ethnic differences in the likelihood of sixmonth readmission by payer adjusting for patient
demographic, clinical, and socioeconomic characteristics and
hospital attributes.
Population Studied: Nonmaternal adult insured patients
hospitalized for diabetes-related conditions in five states (CA,
MO, NY, TN, VA) identified from the 1999 hospital discharge
data of the Healthcare Cost and Utilization Project (HCUP).
Principal Findings: The risk-adjusted likelihood of
readmission was significantly (p<.05) higher for Hispanics
(odds=1.12, 1.14, 1.29 among private, Medicaid, and Medicare
patients, respectively) and nonHispanic blacks (odds=1.12
among Medicare patients) compared with nonHispanic
whites. In the Medicare subpopulation, nonHispanic blacks
and Hispanics had higher percents of readmissions for acute
complications and microvascular disease while nonHispanic
whites had higher percents of readmissions for macrovascular
conditions.
Conclusions: Racial/ethnic minorities have higher hospital
readmission rates for diabetes-related conditions even
controlling for demographic, clinical, and socioeconomic
characteristics. The racial/ethnic differences are greater
among Medicare patients than among patients with private
insurance or Medicaid coverage. Readmission diagnoses also
vary by race/ethnicity with some of the complications that are
potentially preventable with effective postdischarge care.
Implications for Policy, Delivery or Practice: The finding
that disparities are strongest among the Medicare population
underscores the importance of the new national initiatives
that the Centers for Medicare & Medicaid Services (CMS) is
undertaking through the Quality Improvement Organizations
(QIOs) for improving outpatient diabetes care among the
underserved populations. Among the three largest
racial/ethnic groups, Hispanics have the highest likelihood of
poor outcomes across the entire adult population.
Considering that the Hispanic population is growing faster
than the nation as a whole and Hispanics have a substantially
high risk of developing diabetes, policy makers and clinicians
need to devote more attention to address the special needs of
this population.
Primary Funding Source: AHRQ
• A Model of Health Determinants and Health Status
Among Midlife Low-Income Women
Teresa Barry, M.S.N, RNC, Katherine Kaiser, Ph.D., APRN, BC,
Katherine Laux Kaiser, Ph.D., APRN, BC
Presented by: Katherine Kaiser, Ph.D., APRN, BC, Associate
Professor, College of Nursing, University of Nebraska Medical
Center, 985330 Nebraska Medical Center, Omaha, NE 681985330; Tel: 402.559.6576; Fax: 402.559.6379; E-mail:
kkaiser@unmc.edu
Research Objective: The primary objective was to pilot the
Population Health Determinants and Health Status Model
(Barry, 2003) with a midlife low-income population of women.
The secondary objective was to describe the perceived health
status of midlife low-income women.
Study Design: This research study used a descriptive
correlational design to pilot test the model and describe the
relationship of health determinants and health status. The
study was conducted using a secondary analysis of selected
cross-sectional extant enrollment data from the Nebraska
Medicaid Managed Care program.
Population Studied: The study population included 1,100
low-income women in Nebraska aged 40-64 who enrolled in
Medicaid Managed Care from July 2000 through June 2002.
Principal Findings: The results of the pilot study indicate that
the model is predictive of the influence of multiple health
determinant indicators on perceived health status in midlife
low-income women. Results demonstrate that health
determinant indicators accounted for 31.3% to 43.6% of the
variance in perceived health status. Preliminary results from
this study provide a foundation for further research with the
Population Health Determinants and Health Status Model.
Descriptive results indicate the illness burden of this
population is great, with only 16% reporting no medical
conditions, and nearly half of the sample reporting their
overall perceived health status as fair/poor. Health Status
Questionnaire-12 (HSQ-12) mean scores overall were lower for
this population than other studies have found.
Conclusions: Poverty is a systemic and ongoing source of
vulnerability and poor health for women. The cumulative
burden of social, economic, and political disparities as well as
individual conditions and life events negatively impacts
perceived health status for women, especially as they reach
midlife. In addition, poverty and illness burden of midlife
women has a profound impact on society, particularly their
potential influence on the health status of the next generation,
their children. 25% or more of the children in the US are
reared in female-headed households, and almost 50% of these
children are in poverty. Policy, practice, and service delivery
are all influenced by the long-term consequences of
vulnerability and poor health.
Implications for Policy, Delivery or Practice: Reducing
disparities for midlife low-income women will take
improvement in three arenas of policy, practice and delivery.
Related to policy, preventive health policies for women of all
ages are critically important, but crucial to those populations
with increased illness burden. Understanding and shaping
the interaction of determinants, perceived health, and
interventions to reduce illness burden, promote health
management, and increase quality of life is needed to meet
the needs of this vulnerable population. In practice, we need
to raise awareness of vulnerability of this age group, and their
influence on the health of their children. Increasing focus
should be placed on primary prevention strategies such as
promoting healthy lifestyles, health management, early
detection, and disability limitations. Service delivery
implications include understanding patterns of health service
use, the influence of women on their children’s health, and
interventions to increase the use of primary prevention
services.
Primary Funding Source: , Lincoln/Lancaster County Health
Department/Nebraska Health and Human Services System
• Neighborhood and Individual Determinants of Low Birth
Weight in Los Angeles County
Judith Katzburg, Ph.D, M.P.H., R.N., Ronald Andersen, Ph.D.
Presented by: Judith Katzburg, Ph.D, M.P.H., R.N., AHRQ
Post doctoral Fellow, Health Services, UCLA, 801 Sassafras
Way, Oak Park, CA; Tel: 818.889.8739; E-mail:
jkatzbur@ucla.edu
Research Objective: Significant low birth weight disparities
exist by race/ethnicity as well as by geographic region in Los
Angeles County. Current public health planning considers
geographic as well as racial and ethnic disparities in funding
allocations. This research intends to inform policy by
identifying individuals and areas of the County wherein exists
the greatest need to reduce low birth weight infants and
improve pregnancy outcomes. This study intends to examine
both individual and neighborhood determinants of low birth
weight. The appropriateness of targeting geographic regions
will be considered.
Study Design: This is a retrospective study using logistic
regression and multilevel modeling to analyze the outcome of
low birth weight in Los Angeles County. A unique data set was
created by linking the year 2000 birth certificate data with the
year 2000 U.S. census data. Selected individual
characteristics of the mothers as well as selected
neighborhood effects of their respective census tracts were
evaluated. In particular, racial and ethnic effects at both the
individual and census tract level are evaluated. In addition,
outcomes at the level of the eight service planning areas of
Los Angeles County is currently being evaluated.
Population Studied: The population studied includes over
150,000 infants born in the year 2000 to mothers who are
residents of Los Angeles County. Selected individual
characteristics of the mothers as well as selected
neighborhood effects of their respective census tracts were
evaluated.
Principal Findings: Only certain groups appear to be at risk.
In multivariate analyses, Latina women do not appear to be at
increased risk for low birth weight in comparison to White
women. However, both Asian and African American women
have increased odds for having a low birth weight infant in
comparison to Latinas. Other significant determinants at the
individual level include infant's birth order and gender,
mother's place of birth (with women born in Mexico
appearing to have a protective effect), mother's marital status
and age, and early and adequate access to prenatal care. The
neighborhood effects were particularly informative.
Race/ethnicity had no significant effect at the neighbor level.
However, the socio-economic status of the neighborhood did
make a difference. In neighborhoods with higher levels of
education, the odds of having a low birth weight infant were
significantly reduced.
Conclusions: Disparities at the individual level do exist with
African American and Asian women at greatest risk. Socioeconomic disparities at the neighborhood level appear to play
a role in outcomes as well. However, racial and ethnic
differences in neighborhoods do not appear to be
determinants in low birth weight outcomes.
Implications for Policy, Delivery or Practice: Racial and
ethnic disparities in birth outcomes continue to be of concern
in Los Angeles County. However, policies that target
interventions to geographic regions based on racial and ethnic
differences may be misguided. Rather, neighborhoods might
better be targeted according to their economic risk, with lower
SES neighborhoods receiving more intensive interventions.
Within these neighborhoods, programs interventions
developed to target specific racial and ethnic groups at risk
may be appropriate. Nonetheless, given that Latina births
account for the highest number of births in the County, it
would be misguided to ignore the issue of low birth weight
among this population, given that many of the county’s LBW
babies come from this population.
Primary Funding Source: AHRQ
• Impact of Medical Mistrust and Perceptions of Racism
on Breast Cancer Screening
Amal Khoury, Ph.D., M.P.H., Nedra Lisovicz, Ph.D., M.P.H.,
Amanda Avis, M.P.H., Deonna Allen, M.P.H.
Presented by: Amal Khoury, Ph.D., M.P.H., Assistant
Professor, Center for Community Health, University of
Southern Mississippi, 118 College Drive #5122, Hattiesburg,
MS 39406; Tel: 601.266.5435; Fax: 601.266.5043; E-mail:
amal.khoury@usm.edu
Research Objective: Breast cancer is a major cause of
morbidity and mortality in American women. Disparities in
breast cancer screening rates and mortality rates among
subgroups of women are well-documented. Researchers have
examined the association between women's adherence to
screening guidelines and such factors as knowledge and
attitudes about breast cancer and sociodemographic
characteristics. This study examines the association between
utilization of screening services among women in the deep
south and medical mistrust and perceptions of racism. We
hypothesize that mistrust and perceptions of racism are
independent predictors of screening utilization after
controlling for other variables.
Study Design: A cross-sectional survey of women 40 years of
age and older was conducted in summer 2003. Computerassisted telephone interviewing, CATI, was used. A survey
questionnaire was developed, pilot tested with 30 women,
revised, and finalized. An extensive literature review
established face validity of the questionnaire. The
questionnaire took 15 minutes to complete and collected data
about 1) general healthcare utilization; 2) knowledge,
attitudes, and practices regarding breast cancer screening; 3)
medical trust and perceptions of racism within the healthcare
system; and 4) sociodemographic data.
Population Studied: The target population was all women 40
years of age and older residing in the state of Mississippi. A
representative sample of 1052 was surveyed.
Principal Findings: Two-thirds of surveyed women reported
having a mammogram wihin the year preceding survey, and
72% reported having a clinical breast exam within the past
year. Screening rates were lower among minorities and lowincome groups. Three items assessed women's trust of the
healthcare system. Approximately 2 of 3 women agreed that
rich people received better medical care than poor people, and
3 of 4 women agreed that health insurance affected the kind of
care that a person received. Almost half of the respondents
indicated that hospitals sometimes did not tell patients the
truth. Three other items assessed women's perceptions of
racism. A majority of women believed that doctors took the
medical complaints of people of their race seriously.
However, 31% reported that doctors hid information from
patients of their race, and 42% believed that hospitals did not
provide the same kind of care to people of different racial
groups. Analysis of the association between screening
utilization and medical mistrust and perceptions of racism is
underway
Conclusions: Significant proportions of women in Mississippi
do not adhere to breast cancer screening guidelines.
Disadvantaged women are less likely to adhere to screening
guidelines and report higher levels of medical mistrust and
perceptions of racism than other groups.
Implications for Policy, Delivery or Practice: Medical
mistrust and perceptions of racism appear to be barriers to
screening. Research is needed to better understand the
reasons behind the relatively high levels of medical mistrust.
Interventions are needed to address those barriers, particularly
among disadvantaged groups. Such interventions should
complement the efforts to eliminate healthcare disparities.
Primary Funding Source: The Susan G. Komen Breast
Cancer Foundation
• Socioeconomic Disparities in Children's Out-of-Pocket
Health Care Expenditures
Sabrina Wong, Ph.D., Sue Kim, Ph.D., M.P.H., Alison
Galbraith, M.D., Paul Newacheck, Dr.PH
Presented by: Sue Kim, Ph.D., M.P.H., Postdoctoral Scholar,
Department of Medicine, University of California, San
Francisco, 3333 California Street, Suite 335, San Francisco, CA
94143-0856; Tel: 415.502.4078; Fax: 415.502.8291; E-mail:
sekim@medicine.ucsf.edu
Research Objective: Attention has focused on identifying and
ameliorating disparities in health and health care, including
economic disparities. While Medicaid expansions in the 198090s were designed to improve financial access to health
services for low-income children, little is known about
economic disparities in the financial burden of children's outof-pocket (OOP) health care expenditures. This study’s
objective is to examine whether poor children experience
similar financial burden of OOP health care expenditures
compared to children in other income groups, and to examine
the effect of insurance on financial burden.
Study Design: The primary outcome, financial burden, was
measured as the amount of money spent OOP for each child
per $1000 of family income. All OOP health care expenditures
for each child were aggregated for the year. Each child's family
income was categorized by Federal Poverty Level (FPL).
Multivariate linear regression was used to model the degree of
financial burden for different income groups, controlling for
insurance status, age, sex, race/ethnicity, family size, and
region. Due to the existence of skewed data in the outcome,
analyses were done using log-transformed data, then backtransformed. Stata was used in the analyses to account for the
complex survey design.
Population Studied: We selected children 0-18 years of age
from the 2000 Medical Expenditure Panel Survey (MEPS)
(n=7,714) with household income>0.
Principal Findings: Children in families in the poorest income
groups had significantly increased financial burden of OOP
medical expenditures. Compared to children in families with
incomes greater or equal to 400% FPL, children in families
with incomes less than 100% FPL had about 3 times greater
financial burden (P<.01), 100-199% FPL had 1.3 times greater
financial burden (P<.01), and 200-300% FPL had about 0.5
times greater financial burden (P<.01). Uninsured children
had financial burden that was about 65% greater than that of
insured children (P<.01).
Conclusions: Economic disparities exist in the financial
burden of children’s OOP health care expenditures, with the
poorest children having three times the financial burden as
children in the highest income group. However, having
insurance has a salutary effect in reducing financial burden.
Implications for Policy, Delivery or Practice: Despite the
large scale expansions of Medicaid coverage and
implementation of the State Children’s Health Insurance
Program (SCHIP), families in the lowest income groups
experience higher financial burden. It would be important to
examine provisions that limit cost-sharing and consider
policies that will alleviate the regressive pattern of financial
burden.
Primary Funding Source: AHRQ
• Understanding Rural-Urban Differences in Access to
Care: Is It Who You Are or Where You Live?
Sharon Long, Ph.D., Jennifer King, B.A., Terri Coughlin,
M.P.H.
Presented by: Sharon Long, Ph.D., Principal Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street, N.W., Washington, DC 20036; Tel: 202.261.5656; Fax:
202-223-1149; E-mail: slong@ui.urban.org
Research Objective: To examine rural-urban differences in
access to health care for the overall adult population and for
low-income adults. To describe the share of observed
disparities in access to care due to individual and community
characteristics and the share which cannot be explained by
differences in observed characteristics.
Study Design: We compare the characteristics of urban and
rural adults and examine differences in their access to health
care using three broad measures: having a usual source of
care, doctor visits, and unmet need for medical care. Through
regression-based decomposition methods, we determine the
share of the observed differences in these access measures
that can be explained by differences in individual and family
characteristics, health and disability status, the local health
care market, and community characteristics. In addition to
conducting this analysis for the overall population, we
examine access disparities between low-income urban and
rural adults, an especially vulnerable subgroup.
Population Studied: A nationally representative sample of
adults from the 1997, 1999, and 2002 National Survey of
America’s Families. County-level community characteristics
and local health care market data are from a variety of sources
including the Area Resource File and the U.S. Census.
Principal Findings: Preliminary findings indicate that adults
in rural areas have less access to health care than those in
urban areas, both in the overall population and the lowincome population. Some, but not all, of this disparity can be
attributed to differences in the characteristics of the
individuals in rural areas and the communities in which they
reside.
Conclusions: Given our preliminary findings, it appears that
adults in rural areas face additional access barriers compared
to adults with similar characteristics in urban areas.
Implications for Policy, Delivery or Practice: Public efforts
to reduce disparities in access to health care for rural
residents should take into account the unique circumstances
of those individuals and their communities. These include the
greater share of elderly persons (and their long term care
needs) and the more dispersed and small scale of providers
that are available in rural areas.
Primary Funding Source: CMS
• Socioeconomic and Cultural Factors: African Americans
and Tuberculosis
Ana Lopez - De Fede, Ph.D, Muriel Harris, M.P.H.,Ph.D.
Presented by: Ana Lopez - De Fede, Ph.D, Research Associate
Professor, Institute for Families in Society, University of South
Carolina, 937 Assembly Street - Carolina Plaza, Columbia, SC
29208; Tel: 803.777.5789; Fax: 803.777.1793; E-mail:
adefede@sc.edu
Research Objective: African Americans have a
disproportianate share of TB cases in the United States - 48%
of all US -born cases. The disparity remains as a legacy of
poverty. racism, and poor access to care. The primary
objective of this study was to identify and examine the impact
of knowledge, beliefs and values of African Americans on
health seeking and adherence behaviors.
Study Design: Data were collected through in-depth
interviewing using a semi-structure interview guide. Snowball
and purposive sampling techniques were used with
community advocates as gatekeepers. Standard qualitative
analytic methods were used to interpret the data, including
taxonomic and content analysis and code mapping.
Population Studied: Fifty-two African Americans were
interviewed with a diagnosis of TB residing in one of nine rural
communities in South Carolina.
Principal Findings: Results suggest a strong association
between socioeconomic factors (poverty, rural residence,
educational attainment,unemployment and accessto health
care) and adherence to treatment. Cultural factors identified
suggest the need for careful attention to trainig nurses and
related personnel with increased emphasis on culturally
appropriate outreach methods. TB carries a stigma within the
community with an association with HIV/AIDS preventing
effective case identification and treatment.
Conclusions: Stigma and the legacy of racial relationships in
the South cannot be ignored - TB is a disease that has
traditionally been associated with issues of disparity and
poverty. The ability of health care professionals to provide
effective treatment will require careful attention to
socioeconomic and cultural factors.
Implications for Policy, Delivery or Practice: The research in
the United States on TB has been limited to urban and
foreign-born populations. This study provides insight into a
growing problem among US-born African Americans residing
in rural communities.
Primary Funding Source: CDC
• Gender Differences in the Diagnosis and Treatment of
Schizophrenia and Other Serious Mental Illnesses in the
VHA: Special Issues for Women Veterans
Kristen Barry, Ph.D., John McCarthy, Ph.D., John McCarthy,
Ph.D., Frederic Blow, Ph.D., Deborah Welsh, M.S., Laurie
Brockmann, M.P.H., M.S.W.
Presented by: John McCarthy, Ph.D., Research Investigator,
HSR&D Field Program, Department of Veterans Affairs, P.O.
Box 130170, Ann Arbor, MI 48113-0170; Tel: 734.769.7100 Ext.
6253; Fax: 734-761.2617; E-mail: John.McCarthy2@med.va.gov
Research Objective: Women veterans constitute a small but
growing minority of all patients receiving care in the Veteran
Affairs (VA) health care system. In general, women appear to
use disproportionately more mental health services than men,
with particular concerns raised for patients with schizophrenia
and other serious mental illnesses. The purpose of this study
was to evaluate gender differences in utilization of physical
and psychiatric health services among veterans with
schizophrenia and other serious mental illnesses in the VA
health care system.
Study Design: This was a two-year cohort study. Study
variables included demographics, diagnoses, cumulative days
of hospitalization, outpatient visits, prescription drugs by
diagnosis and age, and comorbidities. Changes in care and
status for these veterans between Fiscal Year (FY) 1999 and
FY 2000 were analyzed with specific analyses on veterans with
schizophrenia.
Population Studied: The sample in this study was drawn
from the VA’s National Psychosis Registry, a data base used to
monitor and provide feedback to the VA on all veterans with
psychosis treated in the system, and consisted of 12,166
women (7%) and 161,576 men (93%) treated in the VA in FY
1999.
Principal Findings: Women and men differed along two
important dimensions: diagnosis and age. Women were
younger and more likely to have a bipolar diagnosis. Women
also had more outpatient visits in FY 1999 than men.
However, significantly more men (47%) than women (43%)
with schizophrenia were prescribed any atypical antipsychotic
medications.
Conclusions: Women suffering from schizophrenia and other
serious mental illnesses present unique treatment issues and
challenges in the VA health care system and their care will
require focused research and policy attention.
Implications for Policy, Delivery or Practice: While a
substantial gender minority in the VA health care system,
there has been little research to examine gender differences
among VA patients with serious mental illness. This is the
first national study on one of the largest populations of
women with serious mental illnesses to determine differences
in diagnoses and care of women with schizophrenia
compared to men. Best practices recommendations are given
to address concerns for this vulnerable population of female
veterans with schizophrenia and other serious mental
illnesses.
Primary Funding Source: VA
• Functional Limitation and Chronic Disease in American
Indian and Alaska Native Elders
Leander McDonald, Ph.D., Patricia Moulton, Ph.D., Kyle
Muus, Ph.D., Alana Knudson, Ph.D.
Presented by: Leander McDonald, Ph.D., Assistant Professor,
Center for Rural Health, University of North Dakota, 501 N.
Columbia Road, Grand Forks, ND 58202-9037; Tel:
701.777.3848; Fax: 701-777-6779; E-mail:
rmcdonal@medicine.nodak.edu
Research Objective: There is a paucity of information about
the prevalence of chronic disease and functional limitations
among American Indian and Alaska Native elderly
populations, and there is no information available about
rural/urban differences among the tribes. The objective of this
study is to determine if there are differences in prevalence of
chronic disease among Native elders across age groups (5564, 65-74, 75-84 and 85+) in urban vs. rural vs. frontier
counties. In addition, the relationship between functional
limitation and chronic disease rates will be determined.
Study Design: The data for this study were derived from a
nationwide assessment survey of rural Native American
elders’ health and social needs conducted in 2000 by
researchers at the University of North Dakota Center for Rural
Health’s National Resource Center on Native American Aging
(NRCNAA). The survey included self-reported chronic disease
measures (arthritis, congestive heart failure, stroke, asthma,
cataracts, breast cancer, colon/rectal cancer, lung cancer,
other cancer, high blood pressure and diabetes). Activities of
daily living (ADLS) and instrumental activities of daily living
(IADLs) were also included. Regression analysis was used to
assess the influence of functional limitation on prevalence of
chronic disease.
Population Studied: The Native elder data set (N=9,403) is
comprised of American Indian and Alaska Native elders (age
55+) from throughout the United States. The data set
represents over 133 tribes from 89 different sites with 11 of 12
Indian Health Service regions represented.
Principal Findings: It is generally hypothesized that higher
rates of self-reported rates of chronic disease will be
associated with areas of low population density and
individuals with greater functional limitation. Preliminary
results indicate that differences in disease prevalence exist
across severity of functional limitation.
Conclusions: Findings illustrate, rural America’s American
Indian and Alaskan Native elders experience significant health
problems in regard to chronic disease that lead to a loss of the
quality of life.
Implications for Policy, Delivery or Practice: Policy
implications for improving access to needed health and social
services among this swiftly expanding age/ethnic cohort will
be provided. These implications will be of interest to health
care facilities which serve Native elders. Information about
functional limitation and chronic disease in older individuals
may also be relevant to the general population when
considering quality of life issues.
Primary Funding Source: HRSA
• How Do Homeless Veterans Fare in Usual VA Primary
Care?
Jim McGuire, Ph.D.
Presented by: Jim McGuire, Ph.D., Program Evaluation
Director, Homeless Services, Community Care, VA Greater
Los Angeles Healthcare System, 11301 Wilshire Boulevard,
Bldg 500, Room 6651 (Mail: 10H-5), Los Angeles, CA 90073;
Tel: 301.478.3711 Ext. 41450; Fax: (310) 268-4946; E-mail:
James.McGuire@med.va.gov
Research Objective: To determine predictors among
homeless veterans referred to standard VA primary care
providers for a. use of primary care services and b. receipt of
preventive care interventions.
Study Design: This study uses interview and medical record
data from the comparison group (N=130) in a quasiexperimental longitudinal program evaluation.
Population Studied: Homeless veterans with serious mental
illness who had no primary care during the year prior to study
enrollment and were assigned at study entry to usual VA
primary care.
Principal Findings: Fifty eight per cent of the sample were
assigned and met with a primary care provider. Regression
analyses based on Gelberg’s access to care for vulnerable
populations model identified the following significant
predictors: a. for primary care service use (adjusted model R
square = .30, p<.001), social support for medical care (.393),
SF-36 physical functioning score (.057), and having an
assigned primary care provider (2.486); b. for appropriate
prevention interventions received (adjusted model R square =
.25, p<.001), years of education (.049), having an assigned
primary care provider (.243), and number of primary care
visits (.043).
Conclusions: Homeless veterans in this sample have a much
lower rate of access to usual VA primary care than other
veterans. Once connected with a primary care provider, health
care need and social support are related to use of services,
and use of services and education are related to receipt of
primary care prevention.
Implications for Policy, Delivery or Practice: Alternative
models of connecting homeless people to primary care and
encouraging and ensuring their return for care could improve
care for this vulnerable patient population.
Primary Funding Source: VA
• Community-Based Innovative Approaches to Meeting
Rural Health Care Demands
Heather McIlvaine-Newsad, Ph.D., Heather McIlvaineNewsad, Mary Jane Clark, R.N., M.S., CHES
Presented by: Heather McIlvaine-Newsad, Assistant
Professor, Illinois Institute for Rural Affairs and Sociology &
Anthropology, Western Illinois University, Stipes Hall 525, 1
University Circle, Macomb, IL 61455; Tel: 309.298.1613; E-mail:
h-mcilvaine-newsad@wiu.edu
Research Objective: Rural residents of Illinois are
disproportionately more likely to encounter barriers to health
care than their urban counterparts. First the health care needs
of rural residents exceed those of their urban counterparts,
and second the resources to address those needs are usually
inadequate. This study identifies innovative strategies rural
communities in Illinois and Ohio have implemented to
provide their residents with improved health care.
Study Design: This study applied a three-prong approach.
First data were collected through a questionnaire
administered to non-metro municipalities, critical access
hospitals, and economic development organizations in
Illinois. Second, a qualitative case study approach was
applied using key informant interviews with community
leaders, health care providers, and social services, public and
school health providers, and focus groups of health care
leaders. Finally, a secondary analysis of 2003 Census Data,
and state and county data on health care resources and
demographics was performed.
Population Studied: In-depth case studies of six innovative
strategies were conducted in Illinois and Ohio.
Principal Findings: Findings indicate twenty of the twentyseven counties in Illinois designated as having under-served
populations are rural counties. Despite the dire state of health
care services in rural Illinois and Ohio, communities and
agencies have been implementing creative strategies to help
meet the needs of those individuals who are under-served.
These approaches include volunteer rural emergency medical
services departments, mobile mammography clinics, inschool wellness centers, telemedicine clinics, community
based health care clinics for the uninsured, urgent care
centers for patients with non-emergency needs, and
innovative group insurance policies for self-employed
individuals.
Conclusions: Regardless of the focus or scope of the project,
three main variables were present in all of the projects
surveyed including: (1) Collaboration with a plethora of
federal, state, and private agencies. Evidence of a collaborative
approach to problem solving and resource sharing was
present in all successful projects. (2) Community involvement
and support. Those projects that were most sustainable
reported community involvement and support as one of the
key reasons why the project succeeded. (3)Funding continues
to be the most significant barrier for attaining long-term
success of a project. Agency directors, community leaders,
and project managers spoke in depth about the importance of
finding, attaining, and maintaining funding to support
projects.
Implications for Policy, Delivery or Practice: Additional
follow-up work is needed to make this general information
more useful and available for health care providers and others
involved in meeting the health care needs of Illinois’ rural
population. Collaboration, networking, and sharing of
resources are effective ways for those working on innovative
health care projects to attain funding and develop effective
community-based models.
Demographic, economic, and cultural barriers influence rural
health care decisions made by consumers’ about when and
where to seek health care. Primary care providers should be
encouraged to work in rural areas, or to provide services on a
routine basis to rural clients. Many successful and innovative
projects are providing valuable services to rural health care
consumers.
Primary Funding Source: Illinois Governor’s Rural Affairs
Council & Illinois Department of Public Health-Center for
Rural Health
Gender also had an effect on utilization of various health
services: women were more likely than men to use a service or
report a doctor visit. Specialist visits were the only service that
females were less likely to use than males.
In terms of race and ethnicity, two nonwhite groups had
greater utilization than whites did for certain services: blacks
for ER visits, taking prescription medicines, using medical
equipment and home health care; and American Indians for
hospitalizations and ER visits. Otherwise, utilization by
nonwhite groups tended to be the same as or less than that of
whites.
Conclusions: Although all health condition variables were
found to be statistically significant predictors of every health
utilization measure, it does not necessarily mean that whether
or not a person has a particular health condition makes a
great deal of difference in the propensity to use health care
services. For many types of services, demographic factors
were as important--if not more important--in explaining
variations in use.
Implications for Policy, Delivery or Practice: Even if chronic
conditions were ameliorated, it would have only a small
impact on use of such health care services as emergency
rooms, special therapy, and home care.
Primary Funding Source: CMS
• Health Services Utilization among M+C Enrollees with
Chronic Health Conditions
James Moser, Ph.D., Ioana Montel
• Relationship between Unmet Health Needs, Age, Gender
and Rurality in American Indian and Alaskan Native Elders
Patricia Moulton, Ph.D., Brent King, M.A., Alana Knudson,
Ph.D., Russ McDonald, Ph.D., Kyle Muus, Ph.D.
Presented by: James Moser, Ph.D., Manager, BearingPoint,
1676 International Drive, McLean, VA 22102; Tel:
703.747.6962; Fax: 703.747.8750; E-mail:
jwmoser@bearingpoint.net
Research Objective: The focus of this study is on how the
utilization of health services by Medicare+Choice enrollees is
affected by having or not having at least one of five chronic
health conditions.
Study Design: Using data from the MMC-CAHPS Enrollee
surveys, estimate models of health services utilization while
controlling for characteristics of enrollees and other
exogenous factors.
Population Studied: Persons enrolled in Medicare+Choice
(M+C) plans in 1997, 1998, or 1999.
Principal Findings: For all five chronic conditions, persons
with the condition were more likely to utilize health services
than those without the condition. Health conditions were an
important predictor of utilization for inpatient hospitalization,
prescription drugs use and emergency room visits.
Aged (65 and over) enrollees were less likely than non-aged
enrollees to use all services. Aged beneficiaries were less likely
to report a doctor’s office visit compared with respondents
under age 65. Among the aged, the tendency to utilize services
rose with age, in contrast to the finding for doctor’s office
visits.
Doctor visits were positively associated with years of
schooling. College graduates were more likely to have had a
doctor’s office visit than were those in the least educated
group. Level of education was also positively associated with
use of specialist visits, medical equipment and special
therapy; for other services, however, level of education did not
matter.
Presented by: Patricia Moulton, Ph.D., Assistant Professor,
Center for Rural Health, University of North Dakota, 501 N.
Columbia Road, Grand Forks, ND 58202-9037; Tel:
701.777.6781; Fax: (701) 777-6779; E-mail:
pmoulton@medicine.nodak.edu
Research Objective: Little information exists regarding the
health needs of Native elders. The objective of this study was
to asess the qualitative nature of American Indian and Alaskan
Native elders unmet health needs and examine response
differences by rurality of gender and age categories.
Study Design: The data for this study were derived from a
nationwide assessment survey of rural Native American
elders’ health and social needs conducted in 2000 by
researchers at the University of North Dakota Center for Rural
Health’s National Resource Center on Native American Aging
(NRCNAA). The survey included an open-ended question
"Do you have any unmet health needs that haven't been
addressed?" Responses were analyzed for overlying themes
and the number of responses for each theme. In addition,
data were delinated and analyzed by rurality of respondents'
residential location, gender and age category.
Population Studied: The Native elder data set (N=9,403) is
comprised of American Indian and Alaska Native elders (age
55+) from throughout the United States. The data set
represents over 133 tribes from 89 different sites with 11 of 12
Indian Health Service regions represented.
Principal Findings: Findings suggest differences between
elders living in urban vs. rural vs. frontier areas in self-reported
unmet health needs. These needs included dental, vision and
hearing services/equipment, transportation to health care
services and medical equipment, including new wheel chairs
and other items.
Conclusions: The need for increased access to health care
services and medical equipment was indicated by American
Indian and Alaskan Native elders and attitudinal differences
were found depending on the population of the area the elder
resided.
Implications for Policy, Delivery or Practice: Policy
implications for improving access to needed health and social
services among this swiftly expanding age/ethnic cohort will
be provided. These implications will be of interest to health
care providers and facilities which serve American Indian and
Alaskan Native elders. Information about health needs of
older individuals may also be relevant to the general
population.
Primary Funding Source: HRSA
• Relationship between Access to Health Care and
Prevalence of Chronic Disease in American Indian and
Alaska Native Elders
Kyle Muus, Ph.D., Leander McDonald, Ph.D., Patricia
Moulton, Ph.D., Alana Knudson, Ph.D.
Presented by: Kyle Muus, Ph.D., Assistant Professor, Center
for Rural Health, University of North Dakota, 501 N. Columbia
Road, Grand Forks, ND 58202-9037; Tel: 701.777.3848; Fax:
701-777-6779; E-mail: klmuus@medicine.nodak.edu
Research Objective: There is a paucity of information about
prevalence of chronic disease among American Indian and
Alaskan Native populations and there is no information about
rural/urban differences in older Native elders. Furthermore,
limited research is available on the association between
chronic disease and availability of health services among
Native elders. The objective of this study is determine if there
are differences in prevalence of chronic disease in American
Indian and Alaskan Native elders across age groups (55-64,
65-74, 75-84 and 85+) in urban vs. rural vs. frontier counties.
In addition the relationships between measures of health care
access and rates of chronic disease among Native Elders will
be determined.
Study Design: The data for this study were derived from a
nationwide assessment survey of rural Native American
elders’ health and social needs conducted in 2000 by
researchers at the University of North Dakota Center for Rural
Health’s National Resource Center on Native American Aging
(NRCNAA). The survey included self-reported chronic
disease measures (arthritis, congestive heart failure, stroke,
asthma, cataracts, breast cancer, colon/rectal cancer, lung
cancer, other cancer, high blood pressure and diabetes).
Native elder data records were linked via state/county FIPS
code with a subset of the 2003 Area Resource File (ARF). ARF
is a health resource information system that contains more
than 6,000 variables for each county in the U.S., including
geographic codes and classifications; health personnel
demographics; health facility numbers and types; hospital
utilization; population characteristics and economic data;
environment; and health professions training resources.
Regression analysis was used to assess the influence of health
care access on prevalence of chronic disease.
Population Studied: The Native elder data set (N=9,403) is
comprised of American Indian and Alaska Native elders (age
55+) from throughout the United States. The data set
represents over 133 tribes from 89 different sites with 11 of 12
Indian Health Service regions represented.
Principal Findings: It is generally hypothesized that higher
self-reported rates of chronic disease will be associated with
areas of low population density and poor access to hospital
and physician care. Preliminary results indicate that
differences in disease prevalence exist across categories of
health care access.
Conclusions: Findings illustrate specific, significant problems
regarding the health status of rural Native elders and gaps in
care access.
Implications for Policy, Delivery or Practice: Policy
implications for improving access to needed health and social
services among this swiftly expanding age/ethnic cohort will
be provided. These implications will be of interest to health
care facilities which serve American Indian and Alaskan Native
elders. Information about health care access and chronic
disease in older individuals may also be relevant to the general
population.
Primary Funding Source: HRSA
• Socioeconomic Determinants of Farmers' Health in the
Lower Mississippi Delta
Ari Mwachofi, Ph.D.
Presented by: Ari Mwachofi, Ph.D., Post-Doctoral Research
Fellow, Institute for Health Services Research and Policy
Studies, Northwestern University, 339 E Chicago Avenue, 7th
Floor, Chicago, IL 60611; Tel: 312.503.0448; Fax: 312.503.2936;
E-mail: a-mwachofi@northwestern.edu
Research Objective: What are the significant socioeconomic
determinants of health of minority and majority farmers in the
Mississippi Delta?
Study Design: The study interviewed a stratified random
sample of 649 farm households in Arkansas, Louisiana and
Mississippi. The study over-sampled minority farm
households in order to learn more about this population.
Socioeconomic and self-assessed health data were collected
through structured interviews.
The study estimated the following six equations by logistic
regression:
1. Self-assessed health = f(wealth, age, gender, marital status,
years of schooling, and ethnicity)
2. Self-assessed health = f(household money income, age,
gender, marital status, years of schooling, and ethnicity).
3. Self-assessed health = f(relative household income, age,
gender, marital status, years of schooling, and ethnicity)
4. Changes in self-assessed health = f(wealth, age, gender,
marital status, years of schooling, and ethnicity)
5. Changes in self-assessed health = f(household money
income, age, gender, marital status, years of schooling, and
ethnicity)
6. Changes in self-assessed health = f(relative household
income, age, gender, marital status, years of schooling, and
ethnicity)
Population Studied: Minority and majority farmers in
Arkansas, Louisiana and Mississippi.
Principal Findings: The significant determinants of health
are: wealth, age, race, schooling. Money income, relative
income are statistically insignificant in explaining variations in
health. Minority farmers have a higher probability of having
poor health than majority farmers.
Conclusions: 1.There is a significant and positive relationship
between socioeconomic status and health. 2.Minority farmers
have a higher probability of poor health than majority farmers
3. Wealth is a better measure of socioeconomic status than
money income.
Implications for Policy, Delivery or Practice: To be effective
in improving health policies have to be wholistic to include
improvement of socioeconomic status of farm households.
Primary Funding Source: NIDRR
• The Influence of Informal Care on Home Health Care
Characteristics and Disparities
Maryam Navaie-Waliser, Dr.P.H., Aubrey Spriggs, M.A., Shiela
Neder, R.N., M.S.N., M.P.H.
Presented by: Maryam Navaie-Waliser, Dr.P.H., Senior
Research Associate, Center for Home Care Policy and
Research, Visiting Nurse Service of New York, 5 Penn Plaza,
11th Floor, New York, NY 10001; Tel: 212.609.5762; Fax:
212.290.3756; E-mail: maryam.navaie@vnsny.org
Research Objective: Although the literature has identified
environmental, provider, and consumer characteristics as
contributors to disparities in health care delivery, little is
known about support factors that impact care processes,
especially in a home health setting. This study examined
whether informal (i.e., unpaid family/friends) care influenced
the content and intensity of formal (i.e., paid professionals)
home health services.
Study Design: A prospective cohort study was conducted
during 2001-2002 with home health recipients, their primary
informal caregivers, and their formal home healthcare
coordinators (nurses or therapists). In-person and telephone
interviews were performed to gather primary data that were
linked to secondary clinical and administrative data.
Descriptive and multivariate analyses were performed.
Population Studied: Formal home healthcare coordinators
(n=186) and informal (n= 121) caregivers of cognitively-intact
adults, 50 years of age or older, receiving post-acute home
health services following orthopedic or cardiac surgery
(n=313).
Principal Findings: Most home care recipients were women,
racial/ethnic minorities, of low income and limited education.
Roughly 1 in 5 care recipients had no informal caregiver. Care
recipients with no informal care received a broader and more
intensive array of formal home health services than care
recipients with informal care, including more social work (30%
vs. 15%) and home health aide services (76% vs. 45%), and a
greater average volume of nursing visits (22 vs. 13). As
compared to care recipients with informal care, in the absence
of informal care, care recipients’ length of stay was longer
(average 77 days vs. 47 days), the total number of home care
visits was greater (36 vs. 23), and hours of home health aide
provided were greater (315 vs. 242). In addition, care
recipients without informal care were significantly more likely
than those with informal care to receive assistance with ADL
(82% vs. 68%), entitlements counseling (49% vs. 36%),
health behavior management (74% vs. 58%), and care
instruction and coordination. Reduced formal services to care
recipients with informal care appeared to be offset by
family/friends who despite health problems and little/no
formal training, provided an average of 37 hours/week of
intensive care. Case-mix adjusted regression models revealed
significant associations between informal and formal
caregiving intensity, where care recipients with no/low
informal care were more likely to receive moderate/high
formal care in disease management (AOR=2.68, CI=1.10,
6.63), health promotion (AOR=2.31, CI=1.12, 3.61), and
functional care (AOR=2.31, CI=1.67, 4.29).
Conclusions: Disparities exist in the type, quantity, and
content of formal home health services based on informal
care support. The appropriateness and comparability of this
“substitution effect” between informal and formal home
health care warrants further exploration.
Implications for Policy, Delivery or Practice: The influence
of informal care on home health delivery has both positive and
negative implications. On one hand, care recipients with
little/no informal support are more vulnerable, thus formal
caregivers are addressing an important gap. On the other
hand, most informal caregivers lack training in caregiving
tasks and experience high caregiving burden, therefore
disparities in health care delivery could adversely affect their
well-being and presents equity concerns for care recipients.
Primary Funding Source: The Langeloth Foundation
• Racial and Ethnic Differences in Obtaining Lung
Resection for Lung Cancer at Higher Operative Volume
Hospitals
Charles Neighbors, Ph.D., M.B.A., Michelle Rogers, Ph.D.,
Scott Novak, Ph.D., Christopher Sciamanna, M.D., Edmund
Shenassa, Sc.D., Melissa Clark, Ph.D.
Presented by: Charles Neighbors, Ph.D., M.B.A., Assistant
Professor (Research), Centers for Behavioral and Preventative
Medicine, Brown Medical School, Coro Building, Suite 500,
One Hoppin Street, Providence, RI 02903; Tel: 401.793.8130;
Fax: (401)793-8059; E-mail: Charles_Neighbors@brown.edu
Research Objective: This study examined ethnic and racial
differences among lung cancer patients undergoing lung
resection at hospitals with varying levels of experience with the
procedure. The hypothesis was that African Americans,
Latinos, and Other Non-European ethnicities (e.g. Asians,
Native Americans) would undergo lung resection in hospitals
that performed these procedures infrequently.
Study Design: Four years of data (1998-2001) were combined
from the National Inpatient Survey (NIS), a nationally
representative sample of all US hospitalizations. These data
were also merged with hospital level data from the Area
Resource File, allowing the computation of both individual
and hospital level variables. Total volume of lung resection
procedures over four years was computed for each hospital.
Two sets of analyses examined whether the above ethnic
groups were associated with resections at lower volume
hospitals, controlling for demographic and hospital level
covariates, including medical comorbidities, secondary
malignancies, number of hospitals and ethnic density in the
hospitals’ demographic area. Regression analysis on logtransformed hospital volume examined whether there were
overall trends in hospitalization of above ethnic groups in
lower volume hospitals. Additionally, potential non-linear
effects across the distribution of procedure volume were
tested by grouping hospitals into quintiles (1st = lowest, 5th =
highest) and computing an adjacent category logistic model.
Population Studied: A subset of all NIS cases with both lung
resection and lung cancer diagnosis were examined,
producing a sample size of 22,231. The sample was 87.5%
non-Latino White, 6.9% African American, 2.7% Latino, 2.9%
other non-European ethnicity, and balanced between males
and females.
Principal Findings: Regression analysis found that that each
of the ethnicities under study was associated with
hospitalization in a lower volume hospital as compared to
non-Latino Whites. Standardized parameter estimates (betas)
were -.09, -.06, and -.06 for African Americans, Latinos, and
other non-European ethnicities respectively (all p < .0001).
Quintile comparisons in the adjacent category logit model
generally supported the finding that ethnicity was associated
as hypothesized with procedures conducted in lower volume
hospitals. Exceptions to the general finding included nonsignificant differences for Latinos compared to non-Latino
Whites in undergoing resection in a 2nd quintile versus 1st
quintile hospital or in a 5th versus 4th quintile hospital.
Additionally, comparisons between the 4th and 3rd quintiles
indicated no significant differences in procedures undergone
in lower volume hospitals between non-Latino Whites and
African Americans or non-European ethnicities.
Conclusions: Despite prior research indicating that greater
experience with lung resection leads to more favorable lung
cancer treatment outcomes, this study found that African
Americans, Latinos, and individuals of non-European ethnicity
have this procedure performed in lower volume hospitals
compared to non-Latino Whites. Controlling for the number of
hospitals in the hospital’s region (a proxy for limited choice)
and the ethnic density of the hospital region (a proxy for
hospital proximity) did not account for these relationships.
Implications for Policy, Delivery or Practice: The study
supports the need for more research on the causes of this
phenomena as well as targeted policies that increase the
likelihood of lung resection procedures in larger volume
hospitals for African Americans, Latinos, and individuals of
non-European ethnicity.
Primary Funding Source: NCI
• Perceived Efficacy and its Influence on Follow-up to
Abnormal Mammography
Debora Paterniti, Ph.D., Linda Stelljes, MA, Sharon Eason,
M.P.H., Julianne Souchek, Ph.D., Tracie Collins, M.D., M.P.H.,
Carol Ashton, M.D., M.P.H.
Presented by: Debora Paterniti, Ph.D., Assistant Adjunct
Professor, Internal Medicine, University of California, Davis,
2103 Stockton Boulevard, Suite 2224, Sacramento, CA 95817;
Tel: 916.734.2367; Fax: 916.734.2349; E-mail:
dapaterniti@ucdavis.edu
Research Objective: We seek to understand barriers to
follow-up (FU) to abnormal mammography for diverse
women over 50 years of age.
Study Design: Research assistants, trained to use a record
abstraction form and to take notes on the process of follow-up
and care, reviewed clinic records from January 2000 through
December 2001. A nonprobability sample of 37 women
matching the population characteristics was invited to
participate in a total of four focus group interviews. Guiding
questions for focus groups were developed based on
conceptual models of self-efficacy (Bandura) and adherence to
medical recommendations (Becker & Rosenstock). Data
gathered during record review and chart abstraction were
analyzed using descriptive statistics. Women’s race/ethnicity
and likelihood of follow-up to inconclusive or abnormal
mammograms were compared. A multidisciplinary team of
investigators inductively developed categories for qualitative
interview data that reflected prominent themes related to
efficacy and barriers to follow-up on abnormal mammography.
Coding categories were developed through an iterative
process; a code book was developed, and transcripts were
uploaded to the qualitative software program and coding
categories assigned to all focus group data.
Population Studied: We studied women receiving
mammograms at a nonprofit breast clinic in the Houston
area. Inclusion criteria were women 50 years of age and over
who received an inconclusive or abnormal mammogram
requiring follow-up.
Principal Findings: Data from patient medical records show
white women to be twice as likely to follow-up on abnormal
mammography than non-white women (p=.003). Patient
reports of family history of breast cancer were not significantly
related to FU. Qualitative analysis suggests women’s
perspectives on insurance are inversely related to their
perceived self-efficacy and intent to FU. Those who reported
having no insurance or having problems with insurance were
more likely to describe greater self-efficacy and social network
support related to FU than those with no perceived financial
or insurance barriers. Faith played an important role in the
perceptions of efficacy related to FU in African American
women and in those women with late FU.
Conclusions: Perceived efficacy not only impacted women's
reports of intent to follow-up but was influenced by other
factors, such as insurance status, social network support, and
faith. Women's descriptions of the impact of other factors on
perceived efficacy and FU were linked to patient self-reported
ethnicity. Perceived efficacy is an important aspect of
intention for action and may encode barriers to health-related
behaviors, such as FU on inconclusive or abnormal clinical
results.
Implications for Policy, Delivery or Practice: Untimely
follow-up to abnormal mammograms, that which extends
three months or longer past identification of an abnormal
mammogram, may have serious implications for potential
cancer cure and survival rates. Attention to differential rates of
follow-up among diverse women might include
communication-based interventions that address self-reported
barriers to perceived efficacy in FU to clinically inconclusive or
abnormal results.
Primary Funding Source: AHRQ
• Health Care Market Structure & Colorectal Cancer
Screening Among High-Risk Asians & Pacific Islanders
Ninez Ponce, M.P.P., Ph.D., Soonim Huh, M.P.H., Roshan
Bastani, Ph.D.
Presented by: Ninez Ponce, M.P.P., Ph.D., Assistant
Professor, Health Services, UCLA School of Public Health, 31254 CHS, Los Angeles, CA 90029-1774; Tel: 310.206.4021; Fax:
310.455.9475; E-mail: nponce@ucla.edu
Research Objective: To examine the effects of salient health
care market characteristics (HMO penetration, competition;
percent group/staff model HMOs) on colorectal cancer
screening behaviors among Asians and Pacific Islander (AAPI)
compared to white adults, ages 40+, with a family history of
cancer.
Study Design: Random intercept multilevel logit analysis of
individuals nested in health care markets defined by
metropolitan-statistical area (MSA).
Population Studied: First-degree relatives, ages 40-80
recruited through a random sample of colorectal cancer cases
from the population-based California Cancer Registry; HMO
data from InterStudy
Principal Findings: Controlling for individual characterisitcs
including income, insurance coverage and percent lifetime in
the U.S., even among this high-risk group, a higher percent of
staff group model HMOs within an MSA-bound market area
lowers the likelihood of AAPIs receipt of a
sigmoidoscopy/colonoscopy in the past 5 years. A higher
degree of HMO competition was also associated with lower
FOBT receipt among AAPIs.
Conclusions: Our results are counter to the general intuition
that staff and group model HMOs and competition --which
leads to more choices, are market factors that promote cancer
screening. Thus market conditions that are "favorable" to
increasing cancer screening among the general population
appear to penalize high-risk AAPIs.
Implications for Policy, Delivery or Practice: Policies that
promote competition and types of HMO market structure
should consider their differential impact on vulnerable groups
such as AAPIs, who have lower cancer screening rates than
most other groups.
Primary Funding Source: NCI
• The Link between Socio-Economic Status and
Hospitalization
Gary Pickens, Ph.D., Paul Presken, M.P.P., Adam Sales, B.A.,
Paul Presken, BA, MPP
Presented by: Paul Presken, M.P.P., VP, Content
Development, Solucient, 1800 Sherman Avenue, Evanston, IL
60201; Tel: 847.440.9735; Fax: 847.475.7830; E-mail:
ppresken@solucient.com
Research Objective: Primary Goal: To design a method of
assigning a socio-economic status (SES) score to every
community in Arizona, California, and Nevada in order to
compare relative community need between hospitals in that
region. Secondary Goal: To link the SES scores to the health
status and healthcare utilization of communities.
Study Design: The following 5 measures and 9 indicators
were used to score each and every ZIP code in CA, AZ and
NV:
INCOME BARRIERS – Percentage of elderly, children and
single parent poverty
CULTURAL BARRIERS – Percentage non-White/non-Hispanic
and percentage with poor English-speaking skills
EDUCATIONAL BARRIERS – Percentage without high school
diploma
INSURANCE BARRIERS - Percentage uninsured and
percentage unemployed
HOUSING BARRIERS – Percentage renting houses
For each of the five indicators, every ZIP code for the entire
region was rank ordered (1 to 2089)
For each of the five indicators, every ZIP code was assigned a
score on a 5-point scale based on the quintile of their rank
order (e.g. 1,2,3,4 or 5)
For every ZIP code, all five indicators were averaged together
for a final score. All five indicators were given equal weight
(20% each) in the average.
Population Studied: 3 States: California, Arizona, Nevada
2043 Populated ZIP Codes
43,000,000 Population in 2003
4,300,000 Admissions in 2002
Principal Findings: There is a strong correlation (95.5%)
between the SES score of a community and the hospitalization
rate of a community.
Conclusions: In these three states, various demographic
variables can be combined to predict socio-economic status of
a community. In addition, these variables can also be used as
a very good predictor of variation in health status, access and
utilization of hospital services.
Implications for Policy, Delivery or Practice: Such analysis
can be used to identify communities particularly vulnerable to
access to care issues so that funding can be properly allocated
from the government or providers.
Primary Funding Source: Solucient, LLC
• Validity of Using Surnames to Define Chinese Ethnicity:
A Cross Sectional Survey
Hude Quan, M.D. Ph.D., William Ghali, M.D. M.P.H., Stafford
Dean, M.A., Peter Faris, Ph.D., Diane Galbraith, B.N., Michelle
Graham, M.D. and Merril Knudtson M.D.
Presented by: Hude Quan, M.D. Ph.D., assistant professor,
Community Health Sciences, University of Calgary, 3330
Hospital Dr., N.W., Calgary, T2N 4N1; Tel: 403.944.8912; Fax:
403.944.8950; E-mail: hquan@ucalgary.ca
Research Objective: Ethnic and racial diversity in population
health and health care delivery has been increasingly studied.
To overcome lack information on the ethnicity of individual
patients in secondary databases, researchers have commonly
used surnames as an alternative source of information for
defining ethnicity. Although surname methodologies are
promising, little is know about their validity. In this study we
assessed the agreement between self-perceived Chinese
ethnicity and ethnicity defined using Chinese surnames.
Study Design: We conducted a telephone survey in a
randomly selected sample in Calgary, Alberta, Canada in 2003
to collect information on self-reported ethnicity and surname.
Chinese ethnicity was assigned using the Chinese surname list
developed by Tjam following Cantonese and Mandarin
phonological rules. (Can J Public Health 2001;2:138-42). The
list included 226 distinctive possible Chinese surnames. We
subsequently revised the list by removing surnames that were
common in both Chinese and other ethnic groups and adding
some Chinese surnames. Chinese ethnicity was then reassigned using the revised surname list.
Principal Findings: Of the 2808 people surveyed, 5.4% were
self reported as Chinese. This was higher than the 4.8% of
people identified as Chinese using Tjam's original surname
list and was the same as the 5.4% identified by our revised
surname list. Compared with self-reported Chinese ethnicity
(reference standard), the original surname list had a
sensitivity of 73.0%, positive predictive value (PPV) of 82.2%,
specificity of 99.1% and negative predictive value (NPV) of
98.5%. The revised surname list had 92.8% sensitivity, 93.4%
PPV, 99.6% specificity and 99.6% NPV. The senstivity of the
revised surname list varied by age (89.8% for 18-34 years,
95.1% for 35-64 and 91.7% for 65 or over), by sex (96.8% for
male and 90.0% for female) and by marital status (93.3% for
married/common law/separated/widowed and 91.5% for
never married/divorced). When stratifing by sex and marital
status, the sensitivity was 100% for married men, 95.0% for
never married men, 89.8% for married women and 90.5% for
never married women.
Conclusions: The validity of defining Chinese ethnicity using
Tjam's surname list is moderate. The revised Chinese
surname list has excellent agreement with self-reported
ethnicity.
Primary Funding Source: Calgary Health Region and
Institute of Health Economics, Alberta, Canada
• Prehospital Delay in African Americans Presenting with
Acute Myocardial Infarction
Mark Callahan, M.D., Debra Quinn, M.D. M.P.H., Kawai
Oneida, M.P.H., Maryelena Vargas, RN, Rachel Skeete, M.D.,
Eliot Lazar, M.D., Alvin Mushlin, M.D., Sc.M.
Presented by: Debra Quinn, M.D., M.P.H., Assistant
Professor, Public Health, Weill Medical College of Cornell
University, 411 East 69th Street, New York, NY 10021; Tel:
212.746.3087; Fax: 212.746.8544; E-mail:
daq2002@med.cornell.edu
Research Objective: This study is designed to evaluate quality
of care and predictors of outcomes for patients with acute
myocardial infarction, with the goal of understanding
predictors of R/E disparities.
Study Design: Retrospective cohort of patients admitted to 12
hospitals in the New York metropolitan region. A random
sample of patients from each institution was abstracted and
multivariate logistic regression was used to analyze predictors
of mortality.
Population Studied: 673 patients from the 12 study
institution were selected based on DRG assignment for acute
myocardial infarction.
Principal Findings: 36 % of African American (AA) patients
presented within 24 hours of onset of chest pain, as compared
to 54% of Hispanic-Latino (H-L), 50% of Caucasian (C)(P =
0.02). Once admitted to the hospital, patients from all ethnic
groups had similar quality of care, including similar door-toneedle times for thrombolytic therapy, equivalent use of
aspirin, beta-blockers, ACE-inhibitors, anti-cholesterol therapy
and diagnostic services. However, mortality rates for AA
patients were significantly higher (30% AA, 14% H, 18% C)(P
<0.001), which persisted after multivariate adjustment for
patient demographics, payer status, and co-morbidities.
Conclusions: Once admitted to hospitals, AA patients receive
similar quality of care for acute myocardial infarction.
However, AA patients are more likely to delay presenting to
the hospital after onset of symptoms, and suffer a higher
mortality rate in-hospital despite similar patterns of treatment.
Implications for Policy, Delivery or Practice: Significant
delays in presenting to the hospital exist for all ethnic/racial
groups, but these delays are worse for AA patients. Delays in
presentation may lead to worse outcomes, as many of the
cardiovascular treatment options for patients with an AMI are
less effective the longer the intervention is delayed. Further
research is warranted to understand the causes of the delays,
and to identify effective strategies for reducing the excess
cardiovascular mortality suffered by AA patients.
Primary Funding Source: Institutional
• Racial Disparities in the Use of Assistive Devices for
Mobility
Linda Resnik, Ph.D., PT, Susan Allen, Ph.D.
Presented by: Linda Resnik, Ph.D., PT, Postdoctoral Fellow,
Center for Gerontology and Health Care Research, Brown
University, 2 Stimson Avenue, Providence, RI 02906; Tel:
501.863.9214; E-mail: Linda_Resnik@Brown.edu
Research Objective: Use of mobility devices, such as canes,
walkers or wheelchairs, are an important strategy for providing
assistance with mobility that can supplement or substitute for
personal assistance, and enhance safety. Although mobility
device use can be an effective resource for managing mobility
impairments, little is known about patterns of use in minority
populations. Thus, the purpose of this study was to quantify
the association between race/ ethnicity and mobility device
use in a national sample of adults reporting difficulty walking.
Study Design: The study is a secondary analysis of the Adult
Disability Follow-Back Survey (NHIS-D Phase II). Race was
grouped into three categories; black, Hispanic non-black, and
white non-Hispanic. The dependent variable was use of any
assistive device for mobility in the past two weeks. Factors
hypothesized to be related to assistive device use were
examined using chi-square analyses. Logistic regression
models were developed adjusting for these predictors of
device use. Interactions between race/ethnicity and age were
examined using relative excess risk attributable to interaction
as advocated by Rothman.
Population Studied: The analytic sample consisted of 7336
adults with reported difficulty walking. This figure represents
an estimated population of 41,003,809 US residents.
Principal Findings: Bivariate analyses revealed a disparity in
mobility device use with Hispanics less likely to use any device
(OR.79, CI .65-.96 P=.02), and blacks more likely to use any
device (OR 1.2, CI 1.0-1.4 P<.000) Controlling for age of
respondents eliminated the decreased likelihood of device use
for Hispanics, but did not eliminate the increased likelihood of
device use among blacks. Logistic regressions controlling for
predictors found a positive association between black race and
mobility device use (OR 1.6 CI, 1.4-2.0 P=<000), however, the
relative excess risk attributable to the interaction of being over
75 years of age and black was a 50% decrease in likelihood of
using a device. In addition, the relative excess risk attributable
to the interaction of over 75 years of age and Hispanic was an
84% increase in likelihood of using an assistive device.
Conclusions: The reduced likelihood of mobility device use
among Hispanics was explained by adjusting for the
population’s younger age. Overall, blacks were more likely to
use devices, but the effect of race varied across categories of
age. An interaction between race/ethnicity and oldest age was
observed, with the oldest blacks being less likely to use
devices than expected and the oldest Hispanics being more
likely to use devices than expected.
Implications for Policy, Delivery or Practice: Assistive
devices for mobility are an important strategy for preventing
injury and promoting independence, yet are often
underutilized. Underutilization of assistive devices for mobility
is a growing problem given the aging of the population. This is
a particular concern for the growing population of minority
elders who have greater prevalence of disability. More
research is needed to understand the reasons for differential
rates of assistive device use among minority groups to guide
the design of culturally appropriate interventions aimed at
promoting device use for people with mobility impairments.
• Patterns of Utilization for Asthma Patients in a Rural
Hispanic Border Community
Mary Rimsza, M.D., William Johnson, Ph.D., Tricia Johnson,
Ph.D., Amy Bartels, M.P.H.
Presented by: Mary Rimsza, M.D., Adjunct Professor, School
of Health Administration & Policy, Arizona State University,
Box 2104, Tempe, AZ 85287-2104; Tel: 480.965.1145; Fax:
480.965.4605; E-mail: Mary.Rimsza@asu.edu
Research Objective: This study uses micro-data from a
unique community health data system to identify patters of
health care utilization for Hispanic and non-Hispanic asthma
patients in a rural border community.
Study Design: We use data from health care providers and
health-related organizations in Yuma County, Arizona to
create the Yuma County Community Health Data System
(CHDS). The Yuma County CHDS merges data from the
hospital system, federally qualified community health centers,
private pediatric practices, state Medicaid and immunization
data, employer-based health insurance and a survey of
primarily Hispanic neighborhoods. More than 60% of children
ages 0-19 are Hispanic. After identifying patients with asthma
we study the treatment received and use a logistic regression
model to measure the influence of predictor variables
including age, sex, race, geographic distribution and insurance
type.
Population Studied: Participants include Hispanic and nonHispanic asthmatic children 0 to 19 years of age, living in a
semi-rural border county in Arizona in 1999.
Principal Findings: 981 children were diagnosed with asthma
in 1999 and utilized care in 1999, 2000 and 2001. Seventythree percent of the children are Hispanic. We evaluate and
describe the pediatric asthma medical utilization patterns of
Hispanic and non-Hispanic children in this border
community.
Conclusions: Proximity to health care services is an important
predictor of service utilization. Furthermore, while lack of
insurance coverage increases the likelihood of using the
emergency department and inpatient hospital care, it has no
effect on the likelihood of using physician services.
Implications for Policy, Delivery or Practice: Asthma is a
significant cause of morbidity and mortality in children and
has been associated with high rates of emergency department
utilization. The use of longitudinal data from a community
data system provides detailed information for several years on
the care provided to children. The CHDS model offers the
advantage of following individuals over time and providing
extensive information on the type and quantity of health care
utilized by the persons included in the data. The results can be
used to identify disparities and create strategies for
eliminating them.
Primary Funding Source: The Flinn Foundation & Arizona
State University
• Spatial Variations in Access to AIDS Services in Los
Angeles County: Implications for Service Availability and
Health Outcomes
Paul Robinson, Ph.D., Keisha Paxton, Ph.D., Arleen Leibowitz,
Ph.D.
Presented by: Paul Robinson, Ph.D., Assistant Professor,
RCMI, Charles R. Drew University, 5266 Eageldale Avenue, Los
Angeles, CA 90041; Tel: 313.868.8069; Fax: 313.631.1495;
E-mail: parobins@cdrewu.edu
Research Objective: This project explores the relationship
between persons living with HIV/AIDS, the geographic
distribution of primary and ancillary services in Los Angeles
County, California, and post antiretroviral treatment mortality
rates(1996-2002). The principal research objectives were 1) to
determine how HIV/AIDS service providers are stratified
geographically and by type within the study area, 2)how the
locations of these services correspond with the residence
areas of HIV/AIDS patients. 3) To determine the relationship
between distance to HIV/AIDS services and AIDS longevity in
Los Angeles County.
Study Design: The AIDS Project Los Angeles comprehensive
HIV/AIDS services database was geo-coded. Estimated
number of Persons Living with AIDS in each Zip Code was
calculated. Service availability by type of service was analyzed
by Service Planning Area. Distances between each zip codes
weighted population centers and primary and ancillary
services were calculated. Estimated annual AIDS mortality
rates (1988-2002) were calculated for zip codes.
Population Studied: Persons living with HIV/AIDS
Principal Findings: The location of AIDS service intake points
is an important influence upon the longevity and quality of life
of PLWA. The Antelope Valley has a shortage of services of all
types. South Los Angeles has a shortage of targeted youth
services. Geographic distance from a AIDS medical service
provider is an important factor in the longevity of PLWA. This
relationship is moderated by distance to ancillary service
providers.
Conclusions: Although the importance of physical distance
on utilization of health services is well established, it is often
not considered with respect to the relationship it has with
health outcomes. Particularly for Persons living with
HIV/AIDS, physical distance alone can stand as a barrier to a
sound treatment regimen. The strategic placement of ancillary
services can serve as a forward linkage to good primary care.
Implications for Policy, Delivery or Practice: As HIV/AIDS
moves into new population groups, the placement of AIDS
services both primary and ancillary, should consider the
distance decay relationship. Strategically placed ancillary
services, such as transportation services, can counteract the
distance decay relationship.
Primary Funding Source: NIH/NCRR
• Disparity in Use of Highly Active Anti-Retroviral Therapy
(HAART) for Medicaid Patients with HIV/AIDS in South
Carolina.
Kit Simpson, Dr.P.H, Rajesh Sarang, M.D., M.P.H, Rajesh
Sarang, M.D., M.P.H, Shayna Padgett, M.S, Jennifer MazyckBrown, Pharm.D., Pamela Mazyck, Pharm.D.
Presented by: Rajesh Sarang, M.D., M.P.H, Statistical Data
Analyst III, Pharmacy Practice, Medical University of South
Carolina, 280 Calhoun Street, Charleston, SC 29425; Tel:
843.792.5535; Fax: 843.792.1712; E-mail: sarangry@musc.edu
Research Objective: To assess the disparity of drug
prescription and usage of HAART among HIV/AIDS patients
of South Carolina using Medicaid Data.
Study Design: Retrospective analysis of archival data to
determine the factors influencing the prescription and use of
Highly Active Anti-Retroviral Therapy(HAART)in the state of
South Carolina (SC). A retrospective analysis using multiple
logistic regression with HAART as the dependent variable and
gender, location, race, school, age, marriage, total cost, total
paid, eligible days, total patients per physician, whether a
person visits a physician in an outpatient hospital or office,
and Miles traveled by the patient to visit his physician as
independent variables.
Population Studied: All Medicaid patients with a diagnosis
code of HIV/AIDS during the years 2000-2001.
Principal Findings: People who see their physician in the
office have a higher probability of getting HAART as compared
to those who visit their doctor at a hospital clinic (p<0.02)CI=
1.061-2.052).
Females are less likely to get HAART as compared to males
(p=0.01) (CI= 0.463-0.901).
Patient age is not significantly associated with HAART use
(p=0.07)(CI=0.953-2.440).
Patients who receive care from hysicians with many AIDS
patients a physician have higher likelyhood getting HAART
(p<0.0001) (CI =1.010-1.019).
Patients who travel a greater distance as compared to those
who visit physician close by have a greater chance of receiving
HAART. (p=0.02) (CI=1.062-2.738).
The weighted mean rate of HAART use was 40-45% in most of
the ACSA’s for the year 2000, this number increased by
approximately 5% in the year 2001. Even though the weighted
mean use of HAART was around 45% in most of the ACSA’s, 3
out of the 11 areas had mean rates of 30-35%, which was far
less as compared to other areas. These areas will be the target
areas for programs to increase the usage of HAART.
Conclusions: Disparities in the use of HAART were found
which are associated with patient gender, the number of AIDS
patient in a practice, and whether a patient visits a doctor in
an outpatient clinic or in a private office. HAART use is also
significantly associated with the place of residence of a patient
and the amount of distance he/she travels to see his/her
physician.
Implications for Policy, Delivery or Practice: Programs must
make special efforts to target African American and Female
HIV/AIDS patients to assure that these patients understand
the potential life saving benefits of HAART. Once a patient is
in care, physicians must develop culturally sensitive methods
for regular assessment of patients' readiness to initiate
HAART. Geographic areas with low use of HAART should be
targeted for programs to help support local medical
practitioners in HIV-disease management, and referral
networks should be strenghtened where needed.
Primary Funding Source: AHRQ
• Literacy as a Socioeconomic Determinant of Health:
Clarifying the Nature of the Relationship in a Nationally
Representative Sample
Tetine Sentell, Ph.D.
Presented by: Tetine Sentell, Ph.D., Postdoctoral Fellow,
Psychiatry, USCF, 2727 Mariposa, Suite 100, San Francisco,
CA 94110; Tel: 415.437.3075; Fax: 415.437.3020; E-mail:
tsentell@itsa.ucsf.edu
Research Objective: Existing studies finding a positive
relationship between adult literacy and health have typically
operationalized literacy as a dichotomous variable, comparing
those with inadequate vs. adequate skills. This ignores three
important research questions with key implications for
disparities research: 1) Is higher literacy associated with better
health among those with inadequate skills?; 2) Does the
health/literacy relationship end at the threshold of basic skill
attainment or continue across a gradient?; and 3) Does the
strength of the health/literacy relationship vary between those
who have inadequate and adequate literacy? These questions
were tested in a nationally representative sample.
Study Design: Using 1992 National Adult Literacy Survey, a
nationally representative sample of US residents, continuous
literacy was measured by a score of 0 (lowest) to 500 on an
extensive functional literacy test. Using this score, literacy was
also coded dichotomously as inadequate (<225) or adequate
(225+) based on published guidelines. Health status was
measured by 2 yes-or-no questions: 1) Do you have a
condition that keeps you from work? 2) Do you have a longterm health condition? Logistic models using continuous
literacy to predict health status were run using separate
samples for adults with inadequate and adequate literacy
skills. Sociodemographic variables were controlled. Odds
ratios (OR) are reported for 50-point literacy score intervals
and were used to compare the strength of the health literacy
relationship between the two proficiency groups.
Population Studied: Blind (243), mentally retarded (54), and
respondents under 18 (776) were excluded from analyses,
leaving 23,889 individuals. Nineteen percent of the sample
(4,537) had inadequate literacy.
Principal Findings: For adults with inadequate literacy,
continuous literacy was significantly negatively associated with
having a work-impairing condition (OR: 0.92; p<.01), but not
with a long-term illness (p=.36). For adults with adequate
literacy, continuous literacy was significantly negatively
associated with having a work-impairing condition (OR: 0.89;
p<.01) and a long-term illness (OR: 0.95; p<.01).
Conclusions: In a nationally representative sample, literacy
did not have a threshold effect, as previous health literacy
research has implicitly assumed. Even slightly better literacy
has health benefits for adults with both inadequate and
adequate reading skills. However, at least for some measures
of health status, the marginal benefit for the same increase in
literacy skills actually confers greater health advantages for
those with adequate skills compared to those with inadequate
skills. A fifty point increase in literacy is associated with a 11%
less likelihood of having a work-impairing condition among
those with adequate literacy and an 8% less likelihood among
those with inadequate literacy. The relationship between
literacy and health appears to vary by health status measure,
with literacy having a stronger association with work-impairing
conditions than with long-term illness.
Implications for Policy, Delivery or Practice: Low adult
literacy has been recently recognized as a key contributor to
health disparities. Even a little bit more literacy skill may
improve health at all reading proficiency levels indicating that
collaborations between adult literacy and health care may reap
multiple benefits. Literacy is associated more strongly with
certain health conditions suggesting that interventions
targeting those areas may be most effective.
Primary Funding Source: National Institute of Mental Health
• Trends In Health Insurance Coverage among Latinos,
1993-2002
N. Sarita Shah, M.D., Andrea Guerra, B.A., Olveen
Carrasquillo, M.D., M.P.H.
Presented by: N. Sarita Shah, M.D., Post-doctoral Research
Fellow, Medicine, Columbia University College of Physicians &
Surgeons, 200 E. 72nd Street, Apartment 30-H, New York, NY
10021; Tel: 212.706.2668; Fax: 212.305.9349; E-mail:
ns597@columbia.edu
Research Objective: One third of Latinos are uninsured and
during the last decade the number of uninsured Latinos has
increased by 60%. In contrast, the number of uninsured nonHispanic whites and blacks has either decreased or remained
stable, respectively. Given the diversity of the Latino
population, we examine trends in the number of uninsured
Hispanics by sub-group and immigration status.
Study Design: We analyzed data from the Census Bureau’s
Current Population Survey (CPS) from 1993 to 2002. All
estimates were derived using weights that account for the
sample design and non-response (16.2% in 2002). Consistent
with conventions for demographic data, differences were
significant if the 90 percent confidence interval (CI) for point
estimates did not overlap.
Population Studied: Prior to 1999 the CPS sample consisted
of approximately 160,000 persons. Subsequently the sample
was expanded to about 210,000 persons. Other changes in
CPS methodology during this 10-year period have included a
revision of insurance questions and use of updated
population controls based on the 2000 Census data. Based
on the four largest sub-groups, Latinos were categorized as
Mexican, Puerto Rican, Cuban, Dominican, or other (primarily
Central and South Americans). By immigration status,
Hispanics were categorized as US-born (born in the United
States or foreign-born with at least one American parent),
immigrant citizens (foreign-born naturalized citizens) or noncitizen immigrants (foreign-born persons residing in the US
who are not US citizens, including undocumented persons).
Principal Findings: From 1993-2002, the number of
uninsured Dominicans and Cubans did not increase.
However, there was a significant increase in the number of
uninsured Mexicans 5.7 (CI,5.5-5.9) to 9.5 million (CI,9.2-9.8),
Puerto Ricans 480,000 (CI,390-580,000) to 720,000 (CI,640810,000), and other 1.6 (CI,1.4-1.7) to 2.3 million (CI,2.2-2.5).
Similarly, the number of uninsured US-born Latinos and
immigrant citizen Latinos also increased 3.7 (CI,3.5-3.9) to 5.5
million (CI,5.2-5.7) and 0.50 (CI, 0.40-0.59) to 1.1 million (CI,
.096-1.2), respectively. However, these increases were
primarily due to population growth as for most groups the
percent uninsured did not change e.g. the percent of US-born
Hispanics without insurance fluctuated between 22 to 23%. In
contrast, both the number and percent of uninsured noncitizen immigrants increased 4.2 (CI, 4.0-4.4) to 6.7 million
(CI, 6.6-6.9) and 50.0% (CI,47.6-52.3) to 56.5% (CI,55.0-57.9),
respectively. The percentage change was primarily due to
reductions in employer-provided coverage.
Conclusions: The rise in the number of uninsured Hispanics
from 1993 to 2002 was primarily due to population growth
and occurred among various Latino sub-groups as well as
both US born and immigrant Latinos. However the most
dramatic increase was among non-citizen immigrants.
Implications for Policy, Delivery or Practice: These findings
support the need for additional targeted outreach as well as
specific policy initiatives.
Primary Funding Source: HRSA
• The Role of GIS in Establishing Boundaries for
Vulnerable Health Services Areas in Rural America
Keith Mueller, Ph.D., Michael Shambaugh-Miller, Ph.D., M.A.,
B.A., Louis Pol, Ph.D., Julie Stoner, Ph.D., Woodrow Lucas,
B.A.
Presented by: Michael Shambaugh-Miller, Ph.D., M.A., B.A.,
Faculty Medical Geographer, Preventive and Societal
Medicine, University of Nebraska Medical Center, 984350
Nebraska Medical Center, Omaha, NE 68198-4350; Tel:
402.559.7858; Fax: 402.559.7259; E-mail: mdmiller@unmc.edu
Research Objective: Through the use of Geographic
Information Systems and Principal Components Analysis, to
define those rural communities in which providers are very
unlikely to generate sufficient revenue from patient care to
sustain their business. That is, we would expect their
operating margins to be consistently negative.
Study Design: Three conceptual criteria were used to
determine vulnerable areas: 1) Population characteristics
associated with patient revenue: too few people to support
providers, too few users of the
service (e.g., racial and ethnic minorities that are less frequent
users of health care services); 2) Insufficient payment from
clients due to high percentages of low income uninsured
households, Medicaid clients, and Medicare beneficiaries; 3)
Lower percentage of paying clients who pay above costs: high
income households, patients with full coverage through
private insurance. A community is vulnerable if its population
size and/or composition make it unlikely that a health service
provider (e.g., a clinic or a hospital) can operate and realize
financial success in that community without public sector
support. Moreover, a vulnerable community is one that is not
within a reasonable travel time/distance from another
community where adequate health services are offered.
Vulnerable communities were determined through a two step
process. First through population and spatial considerations
using a GIS, communities were formed by merging census
block groups based around core census places of 3500 to
50,000 persons. These new communities were then limited to
total populations of no more than 100,000 persons. The
remaining communities were then classified using a technique
(principle components analysis) that clustered them
according to proportions of the study variables; those
communities in the most dissimilar clusters (high positive
scores based on proportions low income, unemployed, and
minority households) are considered vulnerable.
Population Studied: Selected demographic data collected at
the Census block group level for 20 U.S. states of the Great
Plains region (11 study states along with 9 bordering states).
Principal Findings: In delineating vulnerable rural
communities in 11 sample states, an initial determination is
that those rural areas falling outside of 25 mile buffers around
towns/cities of 3,500 or more persons are vulnerable areas.
That criterion defines areas in 20 study area states as
vulnerable, with sizeable proportions of the region vulnerable
by population density. The definition of community as a core
town of 3,500 or more and the surrounding 25 miles defined
447 communities in the 20 state region. However, several of
those communities contained 100,000 or more persons,
which would argue there is sufficient population to sustain
health care delivery systems, even with above average
proportions of populations deemed to generate less revenue
than the cost of care. In addition, it was determined that
vulnerability of a community is positively associated with the
four community characteristics under investigation, the
minority proportion, the below poverty proportion, the
proportion 25 and over with less than a high school education,
the unemployment proportion, and the proportion of the
population aged 65 and older. The vulnerable communities
are likely to be those with high principal component scores, or
very low principal component scores. It is clear that the
increased scores are being driven primarily by the minority
proportion and the proportion below poverty. In total, 138
communities were designated as vulnerable places, where
health care providers cannot be expected to generate sufficient
revenue from paying patients to sustain viable operations.
Those communities are in addition to those places where low
populations would indicate extreme difficulties in sustaining
local health care systems.
Conclusions: The approach developed in this project can be
used as a guide for public policy by replacing the current
myriad of policies by exception: hospitals are paid through
prospective except for those; physicians are paid by a fee
schedule, except those in shortage areas can earn a bonus;
etc. However, replacing one system (albeit a conglomeration
of policies) with another would create winners and losers.
Recognizing this reality, two adjustments could be made.
First, if this or another new approach is adopted, it could be
done in phases to permit early testing of its impacts. Second,
if a single approach is used, exceptions could be permitted
that are consistent with the framework that created the
approach. For example, if the geography of an area is such
that the 25 mile buffer is meaningless due to impassable
mountains or lakes, lines could be redrawn and a remote area
declared vulnerable. In another example, if the proportions of
elderly and low income households are insufficient to achieve
cluster scores making the community vulnerable, but because
of patterns of care the proportions of patients actually seen
originates disproportionately from those groups, an exception
could be made. The technique developed here to assess the
implications of place for providing health care services will be
useful to three audiences. State government health
departments, specifically offices of rural health, can use this
approach to identify those places in their states that should be
targeted with programs designed to sustain health care
providers. These might include loan repayments as financial
incentives, technical assistance to providers to help them
achieve efficiencies that help survival with lower revenues,
incentives to establish regional systems of care, and direct
assistance where needed. Federal policy makers can use this
approach to identify those places in which providers can
qualify for special payment considerations. This technique also
identifies places that can be targeted by special federal
programs, including placing health care providers committed
to locate in under served areas. Finally, health care providers,
such as hospital administrators, can use this technique to
identify places based on likely revenues, which becomes input
into strategic planning. For example, hospitals located in
vulnerable communities might approach network
arrangements differently than those located in communities
with more potential for payment from privately insured
patients.
Implications for Policy, Delivery or Practice: Implications
for Policy, Delivery or Practice: Access to primary health care
services in rural areas.
Primary Funding Source: Federal Office of Rural Health
Policy
• Changes in Breastfeeding Patterns among Ethiopian
Immigrants to Israel
Michal Shani, M.D., Eric Shinwell, M.D.
Presented by: Michal Shani, M.D., Family Physician,
Department of Family Medicine, Central District, Clalit Health
Service, Israel, 3814 N.E. 75th, Suite #2, Seattle, WA 98115; Tel:
206.892.9491; Fax: 206.616.9204; E-mail:
shani99@medscape.com
Research Objective:
To describe the changes in breastfeeding patterns among
Ethiopian women following immigration to Israel.
Study Design: During the months of February to April 1999
we distributed questionnaires to the mothers in the maternity
department in Kaplan Hospital, Rehovot,Israel. The
questionnaires included demographic data, questions relating
to the desire to breastfeed and questions about previous
breastfeeding experience. The women were contacted by
phone after 4-6 months and their breastfeeding history was
noted. For those women who were still breastfeeding at that
time, another phone call was made 12-15 months after
delivery.
Principal Findings: During the above period there were 733
births in the hospital. Approximately 600 questionnaires were
distributed. 515 (85.8%) women responded to the
questionnaire.
Forty (7.7%) of the women were born in Ethiopia. These
women breastfed their child for a longer duration (mean 6.0
months) than the general population (mean 3.9 months,
p<0.0004). There was also a decrease in breastfeeding
duration between the current (mean 5.6 months) and the
previous child (7.9 months, p<0.030). The main reasons for
stopping breastfeeding among Ethiopian women were
insufficient milk (54.5%), and the child’s refusal to nurse
(18.1%). Eighty-five percent of the Ethiopian women did not
receive any help concerning breastfeeding outside the
maternity hospital.
Conclusions: The immigration of Ethiopian Jews to Israel
caused a decrease in breastfeeding duration, although it was
still longer then the breastfeeding duration of the general
population in Israel. The lack of lactation counseling and
support may contribute to this trend.
The medical authorities in Israel should consider ways to
preserve breastfeeding habits among Ethiopian immigrants.
Implications for Policy, Delivery or Practice: The medical
authorities in Israel should consider ways to preserve
breastfeeding habits among Ethiopian immigrants.
• Evaluating Accessible and Culturally Competent Hispanic
Health Care
Windsor Westbrook Sherrill, Ph.D., M.H.A., Rachel Mayo,
Ph.D., Linda Crew, M.B.A.
Presented by: Windsor Westbrook Sherrill, Ph.D., M.H.A.,
Assistant Professor, Health Sciences, Clemson University, 528
Edwards Hall, Clemson, SC 29634; Tel: 864.656.0263; Fax:
864-656-6227; E-mail: wsherri@clemson.edu
Research Objective: The purpose of the project was to
develop a program to address the health care needs of rural,
minority, and uninsured/underinsured populations in upstate
of SC, particularly Hispanic individuals. Providing culturally
appropriate, sensitive, accessible and affordable care is one of
the objectives of this HRSA funded program.
Study Design: The program brings primary care to the
community through (1) mobile health van services and staff
with experience in working with the Hispanic popuation, (2)
the use of a cultural competence preparatory course for all
practitioners, ( 3) the lay health advisor model utilizing
members of the Hispanic community as liaisons and outreach
workers.
Population Studied: Through a three-year grant from HRSA,
health services needs of rural, primarily Hispanic patients in
the upstate area of SC were assessed and a service program
developed. Evaluation was an important component of this
study.
Principal Findings: There were 900 patient encounters in
year one of the project. A majority, 70%, of the patients using
program services were uninsured, had no access to regular
medical services and lacked up-to-date preventive services
such as immunizations and mammograms. Barriers to care
for this particular population were accessed as well as
disparities in health access, health status and outcomes.
Conclusions: For populations particularly difficult to reach in
rural areas, several strategies have been developed,
implemented and assessed: the "promotora model", mobile
health clinic services, and translation and other support
services. Improvements in health status among populations
have been assessed with particular focus on chronic health
problems such as diabetes, hypertension and women's health
problems.
Implications for Policy, Delivery or Practice: Culturally and
linguistically competent primary and preventive health
services can improve access and health disparities among
medically underserved and minority populations. Improved
utilization of health care services and improved health status
can be achieved by services which empower individuals and
communities to have a role and responsibility in their own
health care. The program creating an inclusive partnership
with the community is the most effective and sustainable.
This unique partnership model as well as evaluation outcomes
will be presented.
Primary Funding Source: HRSA
• Racial Variations in Adjuvant Chemotherapy Regimens
for Breast Cancer
Melony Sorbero, Ph.D., M.S., M.P.H., Andrew Dick, Ph.D.,
Jennifer Griggs, M.D., M.P.H.
Presented by: Melony Sorbero, Ph.D., M.S., M.P.H., Associate
Scientist, RAND Corporation, 201 North Craig Street, Suite
202, Pittsburgh, PA 15213; Tel: 412.683.2300; Fax:
412.683.2800; E-mail: Melony_Sorbero@rand.org
Research Objective: Black women have been found to receive
lower breast cancer adjuvant chemotherapy dose proportion
than white women, but we don’t know whether systematic
differences exist in the types of adjuvant chemotherapy
regimens received for breast cancer treatment. Anthracyclinecontaining regimens have been shown to have the best
efficacy. The purpose of this study is to determine whether
black women receiving adjuvant chemotherapy for breast
cancer receive the same drug combinations and delivery
methods as white women.
Study Design: Women with breast cancer were identified
using tumor registries at our study sites. Patient and
treatment data were collected from oncology medical records,
including age, comorbid conditions, tumor characteristics,
chemotherapy course and dates of diagnosis and treatment.
The six adjuvant chemotherapy regimens were categorized by
their delivery method (intravenous vs. oral), and four of the
regimens contained an anthracycline. Multinomial logistic
regression was used to examine the relationship between
patient race and six chemotherapy regimen, controlling for
age, comorbidity, tumor characteristics, type of insurance, year
of treatment and treatment region. Joint tests of significance
were performed to determine the statistical significance of
race across regimens. Multivariate logistic regressions were
estimated to examine the relationship between race and
delivery method, and the relationship between race and
receipt of an anthracycline-containing regimen. All analyses
included robust standard errors clustering on physician to
account for the lack of independence among patients treated
by the same medical oncologist.
Population Studied: A sample of 745 black and non-Hispanic
white women treated with adjuvant chemotherapy for a
primary localized or regional breast cancer from 1985-2001 in
11 treatment sites in three regions.
Principal Findings: Black women were significantly more
likely than white women to receive their chemotherapy
intravenously if receiving an anthracycline-containing regimen
(p=.02). In bivariate analyses, there was not a significant
difference in whether the regimen received contained an
anthracycline. Regions varied in their use of regimens. Two
regions varied in the use of regimens by race (p<.001) while
one (that with the smallest minority population) did not
(p=.21). Adjuvant chemotherapy regimen received also varied
with nodal status, tumor size, patient age and year of
treatment. The use of anthracycline-containing regimens did
not vary significantly by region. Blacks in one of the regions
were significantly less likely to receive anthracycline-containing
regimens than were whites in the region (p<.001).
Conclusions: The existence and magnitude of racial
differences in the type and quality of adjuvant chemotherapy
regimens used in the treatment of breast cancer varied by
region. Variations in the types of chemotherapy regimens
used in the adjuvant setting may in part account for the
poorer breast cancer outcomes experienced by black women.
Implications for Policy, Delivery or Practice: Racial
variations were larger in areas with greater minority
populations. This included a lower use of anthracyclinecontaining regimens for blacks versus whites. We know little
about the structural causes for these disparities. More work
needs to be done to identify these causes and develop policies
to address them.
Primary Funding Source: U.S. Army Medical Research and
Materiel Command
• Rural/Urban and Racial Disparities in Geographic Access
to Hospital-Based Perinatal Care in South Carolina
John Stewart, M.S., M.P.H., Ana Lopez-DeFede, Ph.D.
Presented by: John Stewart, M.S., M.P.H., GIS Manager,
Institute for Families in Society, University of South Carolina,
937 Assembly Street, Suite 618, Columbia, SC 29208; Tel:
803.777.5516; Fax: (803) 777-1793; E-mail:
jstewart@gwm.sc.edu
Research Objective: Identify and map women at risk for poor
perinatal outcomes in a South Carolina perinatal care region.
Evaluate rural/urban and racial disparities in geographic
access to appropriate health services by comparing travel
distance to hospital-based perinatal care for at-risk
subpopulations.
Study Design: Data from the 2000 Census were used to
determine the number of African American and White/NonHispanic women at risk for poor perinatal outcomes (women
ages 15 to 17 and 35 to 44) in 24,949 rural and urban census
blocks comprising the Pee Dee perinatal care region in South
Carolina. Using a geographic information system (GIS), area
hospitals providing basic and/or specialty perinatal care were
geocoded at the street address level. A GIS network tool then
was used to determine actual road distance from each
populated block centroid (point representing the geographic
center of a census block with one or more at-risk women) to
the nearest hospital(s) providing basic perinatal care and
specialty perinatal services.
Population Studied: African American women ages 15 to 17
(N=5,355) and 35 to 44 (N=15,989) and White/Non-Hispanic
women ages 15 to 17 (N=6,013) and 35 to 44 (N=26,983) in an
eight-county perinatal care region in South Carolina.
Principal Findings: On average, rural women live nearly twice
as far from hospitals providing basic perinatal care as urban
women (ages 15 to 17, 12.4 miles vs. 6.4 miles; ages 35 to 44,
12.3 miles vs. 6.7 miles). Similarly, rural women reside almost
two times as far from specialty perinatal care hospitals as
urban women (ages 15 to 17, 20.6 miles vs. 11.1 miles; ages 35
to 44, 19.9 miles vs. 10.7 miles). In both rural and urban
areas, geographic access to basic perinatal care is similar for
African American and White/Non-Hispanic women. On
average, however, African American women must travel
farther for specialty perinatal care than White/Non-Hispanics
(rural: ages 15 to 17, 22.9 miles vs. 18.5 miles; ages 35 to 44,
22.5 miles vs. 18.2 miles; urban: ages 15 to 17, 12.6 miles vs.
9.9 miles; ages 35 to 44, 12.3 miles vs. 9.8 miles).
Conclusions: Distance from care may limit access to hospitalbased perinatal services, particularly for rural African American
women needing specialty care. GIS technology can be used to
evaluate rural/urban and racial disparities in perinatal care
accessibility and to locate/allocate services to reduce existing
disparities. In addition, a GIS can be used to identify
geographically remote at-risk subpopulations, locate
community-based perinatal care specialists (e.g.,
obstetricians, gynecologists) serving remote areas, coordinate
neonatal and maternal transportation to and from appropriate
perinatal care sites, and target perinatal health education
initiatives.
Implications for Policy, Delivery or Practice: Enhanced
coordination of regional perinatal care to reduce rural/urban
and racial disparities in care accessibility and to improve
perinatal outcomes for geographically remote at-risk women.
Primary Funding Source: SC Department of Health and
Human Services
• A National Survey of Accessibility of Medical
Instrumentation
Molly Story, M.S., Jill Winters, Ph.D., R.N., Kris Barnekow,
Ph.D., O.T., Brenda Premo, M.B.A., June Isaacson Kailes,
M.S.W., Erin Schwier, O.T.D., and Jack Winters, Ph.D.
Presented by: Molly Story, M.S., Co-Director, , RERC on
Accessible Medical Instrumentation, 3717 Deauville Place,
Santa Rosa, CA 95403-0980; Tel: 707.578.6839; Fax:
707.578.9435; E-mail: molly@humanspectrumdesign.com
Research Objective: This project is conducting activities to
identify the nature of obstacles related to medical
instrumentation (and related policies) that prevent people
with disabilities from receiving healthcare services.
Study Design: A national survey was developed to assess
difficulties experienced by people with disabilities as patients
using medical instrumentation for healthcare. The project staff
employed a range of strategies to recruit a diverse national
sample, and preliminary results from the survey are available.
A Delphi approach was used to construct the instrument to be
distributed in the national survey. The questionnaire asked
about experiences respondents have had with fifteen specific
categories of medical equipment representing the full range of
classifications. The survey was available in a wide variety of
formats: as an online form, as a Word form, as a text
document, and as a PDF document in either regular or large
print that could be printed out and completed by hand. The
survey could also be completed over the telephone or in
person.
Population Studied: To identify obstacles related to medical
instrumentation preventing people with disabilities from
receiving healthcare services, the questionnaire was
disseminated to a diverse array of organizations and
individuals throughout the United States. The desired sample
for this study needed to contain individuals with disabilities
who were diverse in age, abilities, ethnicity, geographic
location, and socio-economic status.
Principal Findings: As of this writing, only preliminary
analyses of the data have been performed. Early results have
helped to identify some types of instrumentation that cause
difficulties for patients with disabilities when using the
healthcare system. For example, of the 93% of respondents
with experience with examination tables, 34% had moderate
and 33% had extreme difficulty. Eight percent of participants
indicated they were impossible to use. Of the 77% with
experience using various types of medical chairs, 30% had
moderate and 17% had extreme difficulty. Four percent of
respondents said chairs were impossible to use. Of the 85% of
people with x-ray equipment experience, 32% had moderate
and 32% had extreme difficulty. Again, four percent indicated
that these machines were impossible to use. More complete
survey results will be available for presentation at the Academy
Health Annual Research Meeting in June 2004.
Conclusions: While the scope of the problem of access to and
utilization of healthcare services is vast, one of the major
barriers can be identified as the accessibility and usability of
medical instrumentation. Unfortunately, the scope of
problems resulting from inaccessible equipment has not been
documented. To date, there have been few studies focusing
on access, utilization, and frequency of use and usability of the
medical instrumentation used by and for persons with
disabilities.
Implications for Policy, Delivery or Practice: Carefully
structured national needs assessments are needed in order
(a) to improve both access to healthcare services and
utilization of these services by individuals with disabilities, and
(b) to improve access to healthcare equipment by healthcare
providers with disabilities. The activities of the research
project described herein will begin to provide this necessary
information.
Primary Funding Source: NIDRR, U.S. Dept. of Education
• Drug Treatment Disparities among African Amerians
Carleen Stoskopf, Sc.D., Jong-Deuk Baek, Ph.D., Junho Jeon,
M.S.
Presented by: Carleen Stoskopf, Sc.D., Professor and Chair,
Health Services Policy and Management, University of South
Carolina, Arnold School of Public Health, Columbia, SC
29208; Tel: 803.777.4781; Fax: 803.777.1836; E-mail:
cstoskopf@sc.edu
Research Objective: The objective of this research is to
determine if there are significant differences is the drug
treament of HIV/AIDS between Whites and other minorities,
especially African Americans.
Study Design: This study is based on a secondary data
analysis using the "HIV Cost and Service Utilization Study"
data available from the Health Resources and Services
Administration. The use of specific categories of drugs, such
as antiretroviral drugs, etc., as well as specific drugs is used as
the dependent variable in a series of logistic regressions.
Race/ethnicity is the primary independent variable and age,
gender, education, employment, income, and insurance status
are used as control variables. Because the data is a weighted
national sample, SUDDAN was used for the data analysis.
Population Studied: This data is based on a national survey
of persons who are HIV positive. The sample was collected
from a population who had seen at least one medical
professional. N = 231,414 (population estimate).
Principal Findings: African Americans have a significant risk
of not taking antiretroviral drugs (odds ratio = 0.71), anti-CMV
(Cytomegalovirus) drugs (odds ratio = 0.54), drugs for
treatment of pneumocystis carinii pneumonia and/or
protozoal diseases (odds ratio = 0.66), drugs for fungal
infections (odds ratio = 0.57), drugs for treating
Mycobacterium avium complex (TB/MAC) disease (odds ratio
= 0.72), and anit-herpes drugs (odds ratio = 0.57) as
compared to Whites. Hispanics are significantly less likely to
receive drugs for CMV (odds ratio = 0.30) and TB/MAC (odds
ratio = 0.63).
Conclusions: African Americans are less likely to receive drug
therapies for HIV/AIDS or related illnesses than their White
counterparts after controlling for major demographic and
social economic status variables such as age, gender,
education, employment, income, and insurance status. Other
minorities fair better, although Hispanics are less likely to be
treated for TB/MAC and CMV.
Implications for Policy, Delivery or Practice: African
Americans have been found to have different levels and types
of treatment for a number of diseases, such as treatment for
heart disease (acute and chronic) and various cancers. This
data indicates that this pattern is consistent in the treatment
of HIV/AIDS. This has serious implications for this vulnerble
group since new HIV cases are occurring at a higher rate in
minorities. This challenges health care providers and policy
makers to develop the means and methods to reach more
African Americans with validated treatment regimens. Since
the common charactersistics such as demographic and social
economic variables do not explain this difference of drug use,
it is imperative that further research be conducted into finding
the reason(s) African Americans, and to a lesser extent
Hispanics, perform so poorly in terms of getting access to
treatment or in terms of bridging other barriers such as
cultural differences between providers and patients.
• Factors Affecting Gender and Racial/Ethnic Differences
in the Onset of Depression in Older Adults
Joseph Sudano, Jr., Ph.D.
Presented by: Joseph Sudano, Jr., Ph.D., Associate Professor,
Medicine, Case Western Reserve University, 2500 Metrohealth
Drive, Cleveland, OH 44109; Tel: 216.778.1399; Fax:
216.778.3945; E-mail: jsudano@metrohealth.org
Research Objective: To (1) determine the independent effect
of 8 factors on the onset of depression in older adults; (2) to
explain observed racial/ethnic differences in the onset of
depression; and (3) to examine whether or not these factors
operate differently for women and men.
Study Design: Prospective cohort observational study. The
data is from the 1994 (wave 2) and 1996 (wave 3) of the
Health and Retirement Study (HRS), a nationallyrepresentative sample of U.S. adults age 55-65 as of their 1996
interview. Using self-reports, depression was first defined at
each wave using an 8-measure modified CES-D scale, with
those respondents scoring 4 or more categorized as
depressed. Only respondents categorized as not depressed at
wave 2 (1994) were included in the analysis. Independent
variables included 1994 baseline information as well as
changes in those variables across the study period (2 years).
Logistic regression was used to determine the independent
effect of socioeconomic status, insurance status, marital
status, self-reported overall health, physical limitations,
chronic disease, health behaviors and employment in
explaining the onset of depression as well as racial/ethnic
differences. Stratified analysis examined gender differences in
the explanatory factors.
Population Studied: 9,824 persons were interviewed in the
initial interview in 1992. 8,683 persons responded to both the
1994 and 1996 depression items. A total of 67 persons had
incomplete 1994 and 1996 interviews, leaving a total of 6,765
persons were categorized as not depressed as of the 1994
interview and available for analysis in this study. For males,
the sample included 2,468 whites, 412 blacks, and 204
Hispanics. For females, 2,836 whites, 593 blacks, and 253
Hispanics.
Principal Findings: Incidence of depression between 1994
and 1996 was higher among blacks and Hispanics compared
whites, but this relationship held across gender for only
Hispanics. Unadjusted odds ratios for onset of depression
were 1.47 (95% CI =1.03-2.07) and 2.16 (95% CI=1.37-3.39) for
black and Hispanic females, respectively, compared to whites,
and 1.39 (95% CI=0.82-2.36) and 2.12 (95% CI=1.40-3.21) for
black and Hispanic males, respectively, compared to whites.
In the multivariate analysis, the major independent
contributors to explaining the onset of depression where lower
socio-economic status, loss of insurance, divorce/separation
or loss of a spouse, development of a new physical limitation
associated with mobility. Marked differences in the
independent effect were noted for females compared to
males. Most of the effects in the non-stratified analysis seem
to have been driven by the effect of these factors on females.
Only the marital status changes and the development of new
physical difficulties were significant for males. Most of the
racial/ethnic differences in onset could be attributed to lower
socio-economic status and development of new physical
difficulties.
Conclusions: Very different explanations for the onset of
depression may exist for men and women, in this older
population of adults. Socio-economic status and related
physical limitations explain the majority of racial/ethnic
variations in onset of depression.
Implications for Policy, Delivery or Practice: Attention to
gender differences in the causes of depression must be
emphasized. Social and family stressors as well as the
pernicious effects of lower socio-economic status must be
recognized and addressed if we are to reduce racial/ethic
disparities in mental health.
Primary Funding Source: NIA
• Relationship between Census-Tract Level Measures of
Segregation and Contextual Factors Deleterious to Health
Joseph Sudano, Jr., Ph.D., David Litaker, M.D., Ph.D., Natalie
Colabianchi, Ph.D.
Presented by: Joseph Sudano, Jr., Ph.D., Asst. Professor,
Medicine, Case Western Reserve University, 2500 Metrohealth
Drive, Cleveland, OH 44109; Tel: 216.778.1399; Fax:
216.778.3945; E-mail: jsudano@metrohealth.org
Research Objective: To (1) develop and introduce 2 new
measures (or dimensions) of black/white segregation at the
census tract level; (2) develop and assess the statistical
properties of 3 latent constructs linked to and potentially
deleterious to health; (3) describe various levels of
segregations across 2 dimensions in terms of economic,
physical, and socio-cultural characteristics.
Study Design: Descriptive and correlational study using data
from the US Census 1990. We developed 2 measures of
segregation: (1) a measure of evenness or "S" based on
minority population in the census tract relative to the minority
population in larger metropolitan area, and (2) a measure of
concentration or "C" based the minority density relative to the
minority density in the larger metropolitan area. We then
conducted factor analysis and determined the alpha statistic
(reliability coefficient) for 3 latent "contextual" constructs
using census tract level indicators: economic environment
(percent above poverty, median family income, percent white
collar, percent high school graduates); physical environment
(percent home ownership, median housing value, boarded-up
houses per 100, median age of housing, where higher levels
indicate); and socio-cultural environment (percent femaleheaded household, population density, crowding in housing,
percent unemployed). Finally, we categorized the 2
segregation measures into low, medium, and high levels, and
assessed the distributional characteristics of the constructs
across the levels of segregation.
Population Studied: Of the 63,227 census tracts in the US,
we first eliminated 20,506 that were not located in a primary
statistical metropolitan area (PMSA). Next, we further
eliminated an additional 1,295 tracts with missing data on the
construct items which left a total of 41,426 census tracts
available for this analysis.
Principal Findings: Two of the 3 contextual constructs
exhibited acceptable reliability: economic environment (alpha
= 0.90) and socio-cultural environment (alpha = 0.74).
Physical environment (alpha = 0.56) was below the traditional
acceptable level of 0.70. All 3 constructs exhibited a positive
and linear relationship with both segregation measures:
higher levels of unevenness and concentration were
associated with worse economic, physical and socio-cultural
environments.
Conclusions: Among census tracts located in major
metropolitan statistical areas, black/white segregation
measures of evenness and concentration correlate
dramatically with contextual factors potentially adverse to
health.
Implications for Policy, Delivery or Practice: Public health
officials and policy makers should recognize that adverse
economic, physical and socio-cultural contextual factors
related to segregation are pervasive, and that if these socialstructural factors are not addressed, their "best effort" health
initiatives may be undermined.
Primary Funding Source: NIA
• Differences in Access and Utilization among Hispanics
Enrolled in a Community-Based Access Program: Does
Level of Acculturation Matter?
Erin Taylor, Ph.D., M.P.P., Catherine McLaughlin, Ph.D.,
Jeffrey Kullgren, M.P.H.
Presented by: Erin Taylor, Ph.D., M.P.P., Health Researcher,
Mathematica Policy Research, 600 Maryland Avenue, S.W.,
Suite 550, Washington, DC 20024; Tel: 202.484.5276; Fax:
202.863.1763; E-mail: etaylor@mathematica-mpr.com
Research Objective: Although disparities in health care
access between Hispanics and non-Hispanics have been well
documented in the health services literature, fewer studies
have examined how access differs among subgroups of
Hispanics. In this study, we investigate whether differences in
health care access and utilization exist among Englishspeaking and Spanish-speaking Hispanic enrollees in a
community-based health care access program for low-income
uninsured adults in Austin, Texas.
Study Design: Using self-reported data from a multi-wave
telephone survey of enrollees in a health care access program,
we present descriptive statistics on access and test whether
statistically significant differences exist on these measures
both across subgroups of Hispanics and across time.
Population Studied: 170 English- and Spanish-speaking
Hispanic persons continuously enrolled for 6 months in a
health care access program in Austin, Texas who responded to
a telephone survey. Upon enrollment into the program,
participants were assigned a primary care provider, given an
access card to use when seeking medical services, and
assigned a sliding fee co-payment schedule for various
services. We use the language spoken in the telephone
interviews as a proxy for enrollees’ level of acculturation.
However, we also examine how access and utilization varies
by other acculturation measures, such as enrollees’ nativity
and length of residence in the U.S.
Principal Findings: At the time of enrollment, a statistically
significantly lower rate of Spanish-speaking Hispanics
reported having a usual source of care (47 percent), compared
to English-speaking Hispanics (63 percent). Among those
reporting a usual source, Spanish-speaking Hispanics were
more likely to seek care in a safety-net setting, such as a clinic
or health center (58 percent versus 35 percent for Englishspeaking Hispanics). Spanish-speaking Hispanics also had
lower rates of utilization and preventive care on all measures
studied, though some differences were not statistically
significant. Moreover, Spanish-speaking Hispanics were
significantly more likely never to have had health insurance
coverage in the past (78 percent), relative to English-speaking
Hispanics (44 percent). At six months after enrollment,
several measures of access showed improvement, including
the proportion with a usual source of care (statistically
significant for both groups); the proportion with unmet
prescription drug need (with the decline significant only for
English speakers); and the proportion reporting that they were
very satisfied with their health care (with a dramatic increase
from 47 to 83 percent for Spanish-speaking Hispanics).
Conclusions: Results indicate that a larger proportion of
Spanish-speaking Hispanic participants in a community-based
program studied had experienced difficulties in accessing
health care prior to enrollment, relative to English-speaking
Hispanics. After being enrolled in an access program for six
months, several measures of access improved for both
groups. Despite these improvements over time, Spanishspeaking Hispanics still fared worse than their Englishspeaking counterparts on several measures.
Implications for Policy, Delivery or Practice: Despite
significant improvements in access to care among both
English-speaking and Spanish-speaking Hispanics enrolled in
a community-based program, differences in access persisted
among these two subgroups. With Hispanics now
comprising 13 percent of the U.S. population-- the country’s
largest minority--health services researchers should make
efforts where possible to study differences within subgroups
of this growing segment of the population.
Primary Funding Source: RWJF
• An Evaluation of States’ Capacity to Address Racial and
Ethnic Health Disparities: Creating a State Minority Health
Report Card
Amal Trivedi, M.D., M.P.H., Brian Gibbs, Ph.D., Laurie NsiahJefferson, M.P.H., John Ayanian, M.D., M.P.P., Deborah
Prothrow-Stith, M.D.
Presented by: Amal Trivedi, M.D., M.P.H., Fellow, Health
Care Policy, Harvard Medical School, 180 Longwood Avenue,
Boston, MA 02115; Tel: 617.432.3138; E-mail:
trivedi@hcp.med.harvard.edu
Research Objective: A state minority health report card may
provide an important tool to evaluate and promote state
policies to reduce health disparities. We analyzed state
performance on four measures of minority health: rates of
uninsurance for minorities compared to whites, physician
diversity, creation of an Office of Minority Health (OMH), and
reporting of health data using detailed race/ethnicity
categories.
Study Design: We used data from the Current Population
Survey to determine the relative risk of being uninsured for
minorities compared to Whites among non-elderly, lowincome individuals. Using data from the AMA Physician
Masterfile and U.S. Census, we calculated the degree to which
underrepresented minority physicians (URM) in the state
must be increased in order to reflect the state’s underlying
demographic population. We contacted all state OMH’s
recognized by the federal government to conduct a telephone
survey on their funding, staffing, history and activities. We
determined the number of racial and ethnic categories states
used in reporting all-cause mortality data in their most recent
vital statistics publication. Finally we conducted secondary
analyses of the data to explore three potential predictors of
state performance in minority health - region of the country
(East, Midwest, South, and West), per capita government
spending, and proportion of minorities within the state.
Population Studied: Non-elderly, low-income U.S. residents;
U.S. physicians; representatives of state Offices of Minority
Health.
Principal Findings: Top-quartile states had minimal
insurance disparities between minorities and whites; however,
minorities who live in bottom-quartile states are 50-100%
more likely to be uninsured than Whites. While six states had
a proportion of URM physicians that reflected their
demographic composition, eighteen states would need to
raise their number of URM physicians by a factor of 4.5 to 11
to reach proportional representation. Thirty of fifty states have
an office of minority health; however, of these thirty, 6 had no
budget and 10 had only one employee. Nearly 50% of states
report mortality data using three or fewer racial or ethnic
categories, including 30% that report mortality data using a
“White-Other”, “Black-White,” or “Black-White-Other” racial
breakdown. There was a striking geographic clustering of high
and low-performing states with region a significant predictor
on all four measures (p<0.05). Percentage of minorities in the
state and state fiscal capacity were not significant predictors of
performance.
Conclusions: States vary tremendously in their capacity to
address racial and ethnic health disparities. High and low
performing states tend to cluster geographically.
Implications for Policy, Delivery or Practice: Future research
should be conducted on these and other potential predictors
of state variation in minority health policy and connections
between state policy and health outcomes for minorities.
Primary Funding Source: The California Endowment
Primary Funding Source: RWJF
• The Relationship between Body Mass Index and Health
Services Access for Hispanic Children in a Texas/Mexico
Border Population
Martha Conkling Tromp, MSPH, Miguel Zuniga, M.D., Ph.D.
Presented by: Martha Conkling Tromp, MSPH, Graduate
Research Assistant, Policy and Management, School of Rural
Public Health, 3000 Briarcrest, Suite 300, Bryan, TX 77802;
Tel: 979.458.3031; E-mail: mctromp@srph.tamushsc.edu
Research Objective: The use of Body Mass Index, BMI, as a
measure of health status is well documented. Among the
Hispanic population the increase in obesity and chronic
disease is alarming. This study seeks to quantify the
relationship between child BMI scores and indicators of health
services access.
Study Design: The intervention goals of a project taking place
in Hidalgo County, Texas are to improve the ability of
promotoras, community health workers, to impact health
behaviors of Colonia residents and to increase health services
access and utilization rates. A preliminary household survey
of 646 residents took place from Dec. 2002 to April 2003.
Survey respondents were selected randomly through block
groups, then households, then residents within households.
Interview subjects could be a child, the head of the household,
or another adult in the household. Height and weight data
were collected during the interview.
Population Studied: The children included in the survey
totaled 200, from two intervention Colonias and one control
Colonia. The 102 females and 98 males ranged in age from 4
to 17 years, with a mean age of 11 years. A BMI and age were
available for 117 of the children.
Principal Findings: The children’s mean BMI is 24. This is a
measure of overweight for children 16 years and up and a
measure of obesity in children less than 11 years old. For the
girls the BMI range is between 12.2 and 53.1 with a mean of
23.6. The boys have a range of 8.8 to 50.6 with a mean of 25.
Body Mass Index is sensitive to age and ethnicity. Children in
the 4-8 year age groups have the largest body mass: 71 percent
are in the obese range, 11 percent are overweight. Children in
the 10-12 year age groups: 41 percent obese and 35 percent
overweight. Of the teenagers measured, 69 percent are in the
normal weight range. Characteristics of the children with a
BMI of 17.5 or more are: 43 percent have 1 or more chronic
disease, most live in households earning less than $14,600,
and 65 percent of these children do not have health insurance.
Conclusions: Children in this population have a high risk of
chronic disease as indicated by their BMI scores. Health
conditions associated with obesity include diabetes, high
blood pressure, high cholesterol, and coronary heart disease,
all observed in the adult population of these Colonias. Many
of these children have at least one chronic disease and most
of them do not have health insurance. Their access to health
services are limited by poverty, lack of health insurance and
knowledge.
Implications for Policy, Delivery or Practice: Initiatives in
health care access in Hidalgo County and similar populations
should include BMI as a measure to identify those children
most at risk. Through policy development this measure can
be used by promotoras in prevention efforts in the Colonias
and as a catalyst to assist these children and their families to
access health services in their communities.
• How Do Medicare Beneficiaries’ Assessments of Care
Differ by Race and Ethnicity?
Jennifer Uhrig, Ph.D., M.H.A., Jeffrey Laufenberg, M.S., Celia
Eicheldinger, M.S., Shulamit Bernard, Ph.D.
Presented by: Jennifer Uhrig, Ph.D., M.H.A., Health Services
Researcher, Health Communication, RTI International, 3040
Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC
27709-2194; Tel: 919.316.3311; Fax: 919.990.8454; E-mail:
uhrig@rti.org
Research Objective: To examine whether consumer reports
and ratings of health care in fee-for-service Medicare vary by
race/ethnicity, and to determine whether the consumer
reports and ratings change over time.
Study Design: We used data from the 2000-2002 National
Medicare Fee-for-Service CAHPS surveys. The sample of
beneficiaries was drawn from a sampling frame constructed
from the CMS Enrollment Data Base. In each of the three
years, the frame comprised over 30 million beneficiaries. The
number of respondents and response rates for the surveys
was 103,551 (64%) in 2000, 117,836 (68%) in 2001, and
122,955 (71%) in 2002, respectively. The combined analysis file
contained 344,342 survey respondents. We calculated CAHPS
ratings and composites for each racial and ethnic subgroup
using the CAHPS 3.4 Survey and Reporting Kit macros. We
used two sample tests for differences in proportions for all
pairwise comparisons. We used the combined data set and
compared all racial categories with white, and Hispanic with
Non-Hispanic for each CAHPS rating and composite. We then
stratified by year and compared responses within each
racial/ethnic group to determine whether trends were present
across years.
Population Studied: Beneficiaries enrolled in fee-for-service
Medicare
Principal Findings: Compared with whites, a larger
percentage of all minority racial groups reported problems
with getting needed care. Asians were more likely than whites
to report problems or provide ratings other than a 10 for all
measures except Rate Medicare. African-Americans were less
likely than whites to report problems or provide ratings other
than 10, except for getting needed care. American
Indians/Alaska Natives reported worse experiences than did
whites for getting needed care, communication and customer
service. Hispanics were more likely than non-Hispanics to
report problems getting needed care, respect, and care
quickly. Reports and ratings were fairly stable among
Hispanics, Non-Hispanics, whites, and African-Americans
over the 3 years. However, several statistically significant
differences emerged between years within racial/ethnic
subgroups for some of the measures, and most of the
differences indicate downward trends.
Conclusions: Our findings show that statistically significant
differences in experience and ratings among beneficiaries in
FFS Medicare are associated with race and ethnicity. These
findings are consistent with those reported in other research.
There is often a disconnect between findings from studies that
examine disparities in access, utilization and clinical quality
versus those that examine patient reports of their experiences
and ratings of their care and providers. Attitudes, beliefs, and
preferences all impact health-seeking behaviors and likely have
an impact on the reports and ratings that individuals provide.
It may be that people are using different points of reference
when reporting their experiences and providing their ratings.
Implications for Policy, Delivery or Practice: It is unclear
whether ratings and reports are a direct result of the quality of
care received or rather a result of response bias related to
cultural differences or different historical frames of reference
concentrated within racial/ethnic subgroups. If differences in
reports and ratings are not a direct result of the quality of care
received, it is not immediately apparent how these measures
can be used to monitor quality.
Primary Funding Source: CMS
• Mapping Inequalities in Access to Health and Health
Outcomes in Ontario and the Commonwealth of Virginia
Sorina Vlaicu, M.D., M.P.H., Ph.D.
Presented by: Sorina Vlaicu, M.D., M.P.H., Ph.D., Assistant
Professor, Political Science/Epidemiology and Biostatistics,
University of Western Ontario, 30 Augusta Crescent, London,
Ontario, N6E2E1; Tel: 519.661.2111 Ext. 85114; E-mail:
svlaicu@uwo.ca
Research Objective: Improve our understanding of the
spatial distribution of various determinants of health.
Describe geographical disparities in access to health services
and health outcomes in each community and explore how
they relate to socio-economic, demographic, political and
other determinants of health.
Discuss the role that governmental policies play (or could
play) in widening or narrowing the gaps between advantaged
and disadvantaged groups.
Study Design: This research project promotes an innovative
look at inequalities in access to health and health outcomes,
while looking at the role that governmental policies play in
widening (or narrowing) the gap between ‘have’ and ‘havenots.’ The study provides evidence to inform the design of
programs, policies and practices by employing a comparative
approach. Similar regions from Canada (Province of Ontario)
and the United States (Commonwealth of Virginia) are
analyzed side-by-side, to isolate the effect of governmental
policies (welfare, health, taxation) and national culture on
health disparities and approaches used to address them.
Health varies with socio-economic status. Recent research has
shown that geography matters as well. Where we live not only
defines our individual health, but also what we are getting
back from the community--support and resources--and even
the quantity and quality of health services we have access to.
Traditionally focused on differences in income, the research
on health disparities has lately embraced a more
comprehensive and interdisciplinary approach, by starting to
look at all individual and context factors that have a role in
creating and maintaining health inequalities in a society.
Population Studied: This study defines health as the
resultant of biological, physical, socio-economic and cultural
characteristics. The research is constructed within a
geographical information systems (GIS) rather than classic
(linear) framework. GIS allows the geographic linkage of
outcome variables (access to health services and health
outcomes) with data on population characteristics, such as
socio-economic, community and demographic data, census
and health surveys with administrative information. By
mapping these data, immediate visual information is obtained
on spatial variations in health access and outcomes.
Principal Findings: Several statistical methods are used to
analyze the data, such as descriptive methods (maps) for the
spatial distribution of variables, map smoothing techniques
(Bayesian smoothing), tests for spatial randomness, and
spatial regression. Spatial regression, in particular, provides a
valuable tool for statistical inference, because unlike linear
regression, it allows for pure spatial correlation to be built into
the model. Most analyses on health inequalities have tried to
force the same variables—some of which could be spatially,
but not linearly correlated—into a regular linear regression
model, leading to potentially biased results.
Conclusions: By using GIS, this study emphasizes the
important role of socio-demographic and economic
characteristics in access and health outcomes.
Implications for Policy, Delivery or Practice: The
comparison between the two countries with a radically
different type of health care system (public v. private) also
provides decision makers with the information needed to
design, implement, and evaluate targeted programs to
address health inequalities in their communities. By using
small geographic areas as the unit of analysis- zip/postal
codes- community involvement in policy development is also
encouraged.
Primary Funding Source: University internal grant
• Hispanic Language and Patient Assessments of
Medicare Managed Care
Robert Weech-Maldonado, Ph.D., Peter Gutierrez, M.A., Ron
Hays, Ph.D.
Presented by: Robert Weech-Maldonado, Ph.D., Assistant
Professor, Health Policy & Administration, Pennsylvania State
University, 116 Henderson Building, University Park, PA 16801;
Tel: 814.865.1926; Fax: 8148.63.2905; E-mail: rxw25@psu.edu
Research Objective: Hispanics comprise an increasing
proportion of the total population. Recent studies using the
Medicaid and commercial managed care CAHPS® data show
that Hispanics have lower assessments of care than Whites.
Furthermore, these studies suggest that language has a
stronger effect on assessments of care than Hispanic
ethnicity. The present study analyzes the relationship between
Hispanics’ primary language (English or Spanish) and
assessments of Medicare managed care.
Study Design: The data analyzed are from the 2002 CAHPS
Medicare Managed Care survey. Data were analyzed using
linear regression models. The dependent variables were
CAHPS® 2.0 global rating items (personal doctor, specialist,
health care, health plan) and multi-item reports of care
(getting needed care, timeliness of care, provider
communication, staff helpfulness, plan service). The
independent variables were race/ethnicity (Hispanic, Whites,
African American, Asian, Pacific Islanders, American Indian,
White/African American, American Indian/White, Other),
survey language (English, Spanish), controlling for gender,
age, education, and health status. All regression analyses
adjusted standard errors for the clustered nature of the data
(using the Huber/White correction).
Population Studied: 143,818 adults enrolled in 181 Medicare
managed care plans in 2002.
Principal Findings: Hispanic English speakers had lower
reports of care than Whites for getting needed care (b= -6.18),
timeliness of care (b= -6.18), staff helpfulness (b= -2.18), and
health plan service (b= -3.18). They also had lower ratings than
Whites for specialist (b= -1.92), health care (b= -1.00), and
health plan (b= -1.36). However, Hispanic English speakers
did not differ from Whites in their reports of provider
communication or their ratings for personal doctor. Hispanic
Spanish speakers had lower reports of care than Whites for
timeliness of care (b= -7.69), provider communication (b= 3.46), and staff helpfulness (b= -4.38). However, they had
higher reports of care than Whites for getting needed care (b=
3.97) and plan service (b= 4.39), and higher ratings than
Whites for personal doctor (b= 3.97) and health care (b= 2.97).
Hispanic Spanish speakers did not differ from Whites in their
ratings for specialist and health plan.
Conclusions: Primary language affects the experiences with
Medicare managed care among Hispanics. Both Hispanic
English and Spanish speakers face barriers to care, but the two
groups differ in their assessments for various aspects of care.
While Hispanic Spanish speakers had lower scores than
Whites for provider communication, Hispanic English
speakers did not differ from Whites in this assessment of care.
On the other hand, while Hispanic English speakers had lower
scores than Whites for the health plan-related aspects of care
(getting care needed and plan service), Hispanic Spanish
speakers had higher scores than Whites for these aspects of
care. Similar to previous research with Medicaid managed
care CAHPS®, lower reports of care did not translate
necessarily into worse ratings of care among Spanish
speakers.
Implications for Policy, Delivery or Practice: Medicare
managed care plans need to address the observed disparities
in care among Hispanics as part of their quality improvement
efforts. Particular attention should be paid to how primary
language affects experiences with provider communication.
Primary Funding Source: NIA
• Racial/Ethnic and Language Differences in Patient
Assessments of Hospital Care
Robert Weech-Maldonado, Ph.D., Azza Abu Dagga, MHA, Ron
Hays, Ph.D.
preferences. The independent variables are race/ethnicity
(White, Hispanic, African American, American Indian,
Chinese, Vietnamese, Filipino, Other Asian/Pacific Islander,
Multiracial, Other Race), survey language (English, Spanish,
and Chinese), and primary language spoken at home (English,
Spanish, Chinese, Tagalog, Vietnamese, Other), controlling
for service type, health insurance, gender, age, education, and
health status. All regression analyses adjusted standard errors
for weighting (using the linearization approach) and for the
clustered nature of the data (using the Huber/White
correction).
Population Studied: 25,584 adult patients that received
medical or surgical care in 179 participating hospitals,
representing approximately 48% of hospitals in California.
Principal Findings: Racial/ethnic and linguistic minorities
reported more problems with hospital care compared to
White English speakers, particularly in the areas of
coordination of care, emotional support, information and
education, and respect for patient preferences. Asian
subgroups reported more problems with care compared to
other racial/ethnic groups, and among Asians, non-English
speakers encountered more problems with their care. This
was particularly the case for Vietnamese speakers who
reported more problems than Whites for respect for patient
preferences (b= 19.11), emotional support (b= 13.10),
coordination of care (b= 9.74), and information and education
(b= 8.22).
Conclusions: This study suggests that racial/ethnic minorities
and non-English speakers face barriers to hospital care, even
after controlling for health insurance status. Race/ethnicity
and language have independent positive associations with
reported problems with hospital care. However, language has
a stronger positive effect on reported problems, especially
among Asians.
Implications for Policy, Delivery or Practice: Hospitals
should address the observed racial/ethnic and language
disparities in care as part of their quality improvement efforts.
Staff’s training in cultural competence and use of interpreter
services hold promise as particular mechanisms that may help
reduce the observed disparities in hospital care.
Primary Funding Source: AHRQ
Presented by: Robert Weech-Maldonado, Ph.D., Assistant
Professor, Health Policy & Administration, Pennsylvania State
University, 116 Henderson Building, University Park, PA 16801;
Tel: 814.865.1926; Fax: 814.863.2905; E-mail: rxw25@psu.edu
Research Objective: Previous studies have shown differences
in hospital treatment based on race/ethnicity. However,
relatively few studies have examined racial/ethnic differences
in patient experiences with inpatient hospital care. This study
analyzes whether patient assessments of hospital care vary by
race/ethnicity and primary language.
Study Design: The data analyzed are from the 2002 Patients’
Evaluation of Performance in California (PEP-C). Data were
collected by mail and surveys were administered in English,
Spanish, and Chinese. The average response rate for all
hospitals was 50%.
Data were analyzed using linear regression models. The
dependent variables are 7 dimensions of hospital care:
coordination of care, continuity and transition, emotional
support, information and education, involvement of family
and friends, physical comfort, and respect for patient
• Racial/Ethnic Differences in Assessments of Managed
Care: Medicaid versus Commercial Insurance Status
Robert Weech-Maldonado, Ph.D., Marc Elliott, Ph.D.,
Adetokunbo Oluwole, M.S., Ron Hays, Ph.D.
Presented by: Robert Weech-Maldonado, Ph.D., Assistant
Professor, Health Policy & Administration, Pennsylvania State
University, 116 Henderson Building, University Park, PA 16801;
Tel: 814.865.1926; Fax: 814.863.2905; E-mail: rxw25@psu.edu
Research Objective: The study of racial/ethnic differences in
consumer assessments of managed care plans is important
given the high level of managed care penetration in both the
public and private health care markets. Recent studies using
the CAHPS® data show that racial/ethnic minorities have
worse reports of care than Whites in managed care. This study
assesses the effect of insurance status (commercial versus
Medicaid) on the observed racial/ethnic differences in patient
assessments of care.
Study Design: The data analyzed are from the National
Committee on Quality Assurance (NCQA) Quality Compass
2001. The CAHPS® data were collected by telephone and
mail. The average response rate for all plans was 43%. Data
were analyzed using linear regression models. The dependent
variables were CAHPS® 2.0 global rating items (personal
doctor, specialist, health care, health plan) and multi-item
reports of care (getting needed care, timeliness of care,
provider communication, staff helpfulness, plan service). The
independent variables were interactions of race/ethnicity
(White, Hispanic, African American, Asian, Pacific Islander,
American Indian, White/American Indian, White/African
American, White/Asian, and Other Multiracial) and insurance
status (Medicaid and commercial), controlling for gender,
age, education, and health status. All regression analyses
adjusted standard errors for weighting (using the linearization
approach) and for the clustered nature of the data (using the
Huber/White correction).
Population Studied: 229,790 adults enrolled in 368
commercial managed care plans and 31,622 adults enrolled in
94 Medicaid managed care plans in 2000.
Principal Findings: Asians in Medicaid plans reported worse
experiences with care than their counterparts in commercial
plans for getting needed care, timeliness of care, provider
communication, and staff helpfulness. In addition, Asians in
Medicaid had lower ratings than their commercial
counterparts for personal doctor and health care. Hispanics in
Medicaid plans had lower scores than their commercial
counterparts for getting needed care. Furthermore, the
observed disparity in reports and ratings of care for Asians
and Hispanics in Medicaid managed care was greater than the
disparity observed between Whites in Medicaid and
commercial plans. On the other hand, African Americans and
Hispanics in Medicaid managed care had higher ratings than
their commercial counterparts for personal doctor, specialist,
health care, and health plan. Similarly, American Indians and
Pacific Islanders in Medicaid had higher ratings than their
commercial counterparts for personal doctor and health plan.
Conclusions: Race/ethnicity determines patient experiences
with managed care. While most racial/ethnic minority groups
in Medicaid managed care had similar or better experiences
than their counterparts in commercial plans, Asians in
Medicaid reported lower patient assessments of care than
their commercial counterparts for most dimensions of care.
Furthermore, the disparities observed in Asian experiences
with care were greater than those observed for whites based
on insurance status.
Implications for Policy, Delivery or Practice: The observed
greater disparity in patient experiences for Asians in Medicaid
managed care plans suggests that Medicaid managed care
may be ill prepared to face the cultural and linguistic
challenges of a growing Asian population. Policymakers
should provide incentives to Medicaid managed care plans
with the goal of reducing the observed racial/ethnic disparities
in care.
Primary Funding Source: AHRQ
• Finding from the Racial and Ethnic Adult Disparities in
Immunization Initiative (READII) 2003 Survey
Carla Winston, M.A., Ph.D., Pascale Wortley, M.D., M.P.H.
Presented by: Carla Winston, M.A., Ph.D., Epidemiologist,
Health Services Research and Evaluation Branch, National
Immunization Program / CDC, 1600 Clifton Road, N.E., MS E-
52, Atlanta, GA 30333; Tel: 404.639.6248; Fax: 404.639.8614;
E-mail: ctw3@cdc.gov
Research Objective: Influenza vaccination is recommended
for all people age 65 and over, yet racial/ethnic disparities in
coverage persist. We investigated influenza vaccination
knowledge, attitudes, and practices among African American,
Hispanic, and Caucasian seniors as part of the baseline survey
conducted to evaluate the Racial and Ethnic Adult Disparities
in Immunization Initiative (READII).
Study Design: Using stratified random sampling, we surveyed
Medicare beneficiaries in the five READII demonstration sites
(Chicago, IL, Rochester, NY, San Antonio, TX, Milwaukee, WI,
and 19 counties of the Mississippi delta). From February to
April 2003, we conducted a telephone survey using computer
assisted interviewing.
Population Studied: Seniors were sampled from the
Medicare enrollment database according to zip code of
residence in demonstration project areas. We oversampled by
race/ethnicity to ensure sufficient numbers of completed
interviews with African American and Hispanic seniors.
Sampling weights reflected the inverse of the probability that a
respondent was selected, adjusted for non-response. Data
were analyzed using SUDAAN software to account for the
complex sampling scheme.
Principal Findings: Response rate to the survey was 61%. Of
4633 Medicare beneficiaries surveyed, 22% of African
Americans, 15% of Hispanics, and 9% of Caucasians had
never received a flu shot. Among those who had never
received a flu shot, Caucasians were more likely (65%) than
African American (46%) or Hispanic (28%) participants to
state they would definitely not get vaccinated in the coming
year. Ninety-five percent (95%) of Caucasian seniors knew the
flu shot is recommended for people over age 65, compared to
92% of Hispanics and 88% of African Americans. Overall,
55% of respondents reported that a health care provider
recommended influenza vaccination during fall or winter
2002; there was no significant difference in provider
recommendation by race. Seniors who reported a provider
recommendation were more likely to be vaccinated than
seniors who did not report a provider recommendation (84%
vs. 56%, P <0.0001). Among those who reported provider
recommendation, 88% of Caucasians were vaccinated in
2002, compared to 80% of Hispanics and 66% of African
Americans. Among those who did not report a provider
recommendation, 61% of Caucasians, 50% of Hispanics and
33% of African Americans were vaccinated. Seniors who
believed they had previously gotten sick from vaccination were
less likely to be currently vaccinated, with African Americans
being more likely than Caucasian or Hispanic respondents to
report that they had previously gotten sick from influenza
vaccination.
Conclusions: Provider recommendation for influenza
vaccination did not differ by race in our sample and patients
who reported a provider recommendation were more likely to
be vaccinated than those who did not. However, African
American and Hispanic patients were less likely to be
vaccinated despite provider recommendation.
Implications for Policy, Delivery or Practice: Reasons for
vaccination refusal need to be evaluated so that health
provider messages regarding vaccination may be tailored to
specific patient concerns in order to improve immunization
outcomes.
Primary Funding Source: CDC, Department of Health and
Human Services
• Doing More For Some: The Lives Lost by Prioritizing
Efficacy Over Equity in Health Care
Steven Woolf, M.D., M.P.H., Robert Johnson, Ph.D.
Presented by: Steven Woolf, M.D., M.P.H., Professor,
Departments of Family Practice, Preventive Medicine and
Community Health, Virginia Commonwealth University, 3712
Charles Stewart Drive, Fairfax, VA 22033; Tel: 703.391.2020 Ext.
141; E-mail: swoolf@vcu.edu
Research Objective: The outcomes of health care can be
improved by making treatments more efficacious and by
bridging gaps in the delivery of those treatments to eligible
patients (improving equity). For example, lives can be
saved—independent of making improvements in drug
therapy—by optimizing the degree to which eligible patients
receive drug therapy. Lives can also be saved by developing
more efficacious drugs, an enterprise that attracts $32 billion
annually from the pharmaceutical industry. We sought to
determine how much society benefits from each endeavor to
determine whether the nation’s predominant investment in
the latter is of net benefit to the population.
Study Design: Assume that an established drug therapy
achieves a given relative risk reduction (RRR) in a health
outcome (e.g., mortality) but is delivered to only a fraction of
the eligible population. We can demonstrate that developing
a more efficacious drug is more beneficial than improving
access only if the new RRR exceeds the existing RRR divided by
the percent of the population exposed to treatment. We
applied this principle in two examples: (a) developing
clopidogrel and ticlopidine as an alternative to aspirin for the
prevention of stroke, which is received by 58% of the eligible
population; and (b) developing newer-generation statins as an
alternative to older agents, which are prescribed to 33% of
patients with coronary artery disease.
Population Studied: Hypothetical population cohorts with a
history of (a) transient ischemic attacks or strokes or (b)
coronary artery disease.
Principal Findings: Developing an antiplatelet alternative to
aspirin is more beneficial than improving access to aspirin
only if the newer agent can lower stroke incidence by at least
40%—a proportional improvement over aspirin of 74%—but
clopidogrel and ticlopidine are only 10-12% more effective
than aspirin. Developing a more efficacious statin is more
beneficial than improving access to statin therapy only if the
newer agents can reduce 5-year coronary artery disease
mortality by at least 72%, three times the potency of older
agents such as pravastatin and simvastatin. Although relevant
mortality data are lacking, we found that rosuvastatin, among
the most impressive of the newer statins, is only 26% more
effective than pravastatin and 12-18% more effective than
simvastatin in lowering LDL cholesterol. We can demonstrate
that the lives saved by the incremental superiority of
rosuvastatin over pravastatin are only one seventh the number
of lives that might be saved by refining care processes such as
placing reminders on charts about the need for lipid-lowering
therapy.
Conclusions: Fewer strokes and cardiac deaths might occur if
society invested more in improving access to aspirin and
statin therapy than in developing newer antiplatelet and statin
alternatives.
Implications for Policy, Delivery or Practice: Despite
recommendations in major reports (e.g., Crossing the Quality
Chasm) about the urgent need to redesign systems of care to
improve the delivery of effective health care, the nation
continues to divert most of its research resources toward
enhancing the “technology” of care. We conclude that lives
are put at stake by this disproportion in national priorities.
• Social Support and Breast Cancer Survivorship:
Disparities across Ethnic Groups
Grace Yoo, Ph.D., M.P.H., Caryn Aviv, Ph.D., Ellen Levine,
Ph.D., M.P.H.
Presented by: Grace Yoo, Ph.D., M.P.H., Associate Professor,
Asian American Studies, San Francisco State University, 1600
Holloway, San Francisco, CA 94131; Tel: 415.338.3891; Fax:
415.338.1739; E-mail: gracey@sfsu.edu
Research Objective:
The investigators are particularly interested in reducing the
health disparities that exist in minority communities and in
understanding how social supports impacts quality of life
among breast cancer survivors from diverse populations.
Social support has been documented to help in adjustment
and coping with breast cancer and to impact positively on the
survivor's health. For breast cancer survivors, access to a
supportive environment can prevent long-term psychological
difficulties and positively impact general well-being
Study Design: Twenty women (5 from each ethnic group)
were recruited for in-depth, face to face, qualitative interviews.
Population Studied: The participants selected for this study
were African American, Asian American, Latina, and white
women residing in the San Francisco Bay Area who had been
diagnosed with invasive breast cancer (Stage 1 and Stage 2)
and had completed treatment. Potential participants were
recruited through the UCSF Comprehensive Cancer Center
Clinic and local Bay Area non-profit breast cancer community
advocacy organizations.
Principal Findings: The results of these interviews include the
discussion of definition and types of social support used at
diagnosis, during treatment, after treatment; psycho-social
impact of breast cancer; reactions of family members; and
ways of coping. We are also asking the women if they want to
give advice to other women diagnosed with breast cancer as
well as give recommendations to the community for programs
to support breast cancer patients and survivors.
Implications for Policy, Delivery or Practice: The findings
will contribute to the understanding within the broader health,
social services and policy communities of how to best meet
the needs of breast cancer survivors from diverse populations.
Primary Funding Source: NCI
• Hospital Debt Collection Impact on Profitability and
Access to Healthcare
Mustafa Zeedan Younis, Dr.PH., M.A., M.B.A.
Presented by: Mustafa Zeedan Younis, Dr.PH., M.A., M.B.A.,
Assistant Professor of Health Economic & Finance,
Healthcare Administration, Jackson State University, 350 W.
Woodrow Wilson Avenue, Jackson, MS 39213; Tel:
504.488.9628; Fax: 504.488.9628; E-mail:
younis68@hotmail.com
Research Objective: This study examines changes and
conditions in hospital financial liquidity and debt collection
over a five-year period (1996-2000). Variations in the
characteristics of hospital ownership classification are
analyzed by regression models to identify differences in cash
inflow and financial liquidity.
Study Design: Two comparative groups of For- Profits, (F-P)
and non-profits (N-P) and are the database for analysis of
information that compares all variables by geographic region
(e.g. return on assets, uncompensated care, occupancy rate,
alos, etc.).
Population Studied: 5000 hospitals from the Medicare Cost
Report (MCR) minimum data sets.
Principal Findings: F-P hospitals were more effective in
collecting their debt
than their N-P counterparts. This efficiency in collection
did add to the F-P hospitals profit margins and financial
performance in general. However, these results must be
taken with
grain of salt, because most N-P hospitals tend to be
located in the inner cities and serve a large number of
indigent population. Therefore, one may conclude that N-P
hospitals' strategy is to provide uncompensated care to its
community rather than lacking the effective tools to
manage their account receivables.
Conclusions: Non-Profit and public hospitals play a major
role in supporting healthcare safety net in United States.
Implications for Policy, Delivery or Practice: The finding of
the study are important to all type of hospital ownership to
improve conditions of debt management impacting of profit
margin, preserving growth and assuring strength in their
financial performance.
• Eliminating Health Disparities among Low Income
Pregnant Women by Identifying Psychosocial Factors as
Predictors of Adverse Outcomes of Pregnancy
Rachel Zachariah, R.N., M.S., DNSc
Presented by: Rachel Zachariah, R.N., M.S., DNSc, Associate
Professor, Bouvé College of Health Science, School of
Nursing, Norteastern University, 360 Huntington Avenue,
207H Robinson Hall, Boston, MA 02115; Tel: 617.373.2985;
Fax: 617.373.8675; E-mail: r.zachariah@neu.edu
Research Objective: The purpose of this research was to
examine: (1) the relative strength of attachments with
mother/surrogate and husband (partner), other forms of
social support, life stress, and anxiety as predictors of lowincome women’s psychological well-being; (2) the impact of
these modifiable psychosocial variables on pregnancy
outcomes of low-income women.
Study Design: Attachments, social support, life stress,
anxiety, and psychological well-being of women from obstetric
clinic were measured using self-report questionnaires
administered between 14 and 22 weeks, and 32 and 42 weeks
of pregnancy. The hospital records of the subjects were
reviewed to determine pregnancy, labor, delivery, and newborn
complications. Data analysis included descriptive statistics,
correlational analysis, multiple regression, paired t-tests, and
discriminant analyses.
Population Studied: One hundred and eleven pregnant
women from obstetric clinics, 18 through 35 years of age,
Medicaid eligible, between 14 and 22 weeks of pregnancy,
without preexisting medical conditions, and fluent in English.
Principal Findings: Discriminate analysis was performed to
assess the relative contribution of prenatal attachment, trait
anxiety, psychological well-being, emotional support, bad life
events and the interaction of bad life events with emotional
support at Time 1 (early pregnancy) to predict newborn and
pregnancy complications. These Time 1 measures
significantly classified the Newborn complications in this
study (Wilks’ Lambda=.792 Chi-square=17.09 df=7 p=.017).
The most important discriminating factors were negative life
events and the interaction of emotional support with negative
life events. These Time 1 measures also significantly classified
the complications of pregnancy in this study (Wilks’
Lambda=.816 Chi-square=14.77 df=7 p=.039). The most
important discriminating factors were state anxiety and total
functional social supports.
Conclusions: The findings of the study support the notion of
the presence of positive psychological well-being for those
women with stable family relationships, lower anxiety, life
stress, and strong social support. The most important factors
that discriminated women with complications of pregnancy
and complications of the new born were anxiety, social
support negative life events and emotional support in
interaction with negative life events.
Implications for Policy, Delivery or Practice: Identification
of modifiable psychosocial risk factors as predictors of adverse
outcomes of pregnancy is a major step in reducing negative
outcomes of pregnancy for low-income women. Health care
policies need to be developed to facilitate augmentation of
social support and reduction of life stress and anxiety for lowincome women in order to reduce complications of pregnancy
and the new born. Considering the fact that 84% of the
subjects were African Americans, public policy should
specifically target this population for major interventions
during early pregnancy.
New ways need to be addressed to generate innovative health
promotion strategies to strengthen close attachment
relationships and support systems for low-income women
during pregnancy. The findings need to be tested with larger
sample of low-income pregnant women of different ethnic
backgrounds; however, the identification of significant
predictors of negative outcomes of pregnancy for the socially
high risk low-income pregnant women in this study provides
important information for the development of future
healthcare policies and effective interventions.
Primary Funding Source: National Institutes of Health,
AREA Research Grant
Invited Papers
People with Disabilities: Do They Have the Same Access?
Chair: Susan Palsbo, Ph.D.
Tuesday, June 8 • 11:15 a.m.-12:45 p.m.
•
Panelists: Mari-Lynn Drainoni, Boston University; Holly
Hollingsworth, Washington University, St. Louis; Trudy
Mallison, Northwestern University (no abstracts
provided)