Call for Papers
New Approaches to the Determinants of Disparities
Chair: Marshall Chin, University of Chicago
Sunday, June 25 • 8:30 am – 10:00 am
● Socioeconomic and Racial/ethnic Differences in the
Discussion of Cancer Screening: Treated Differently or
Treated by Different Physicians?
Yuhua Bao, Ph.D., Sarah A. Fox, Ed.D., Jose Escarce, M.D.,
Ph.D.
Presented By: Yuhua Bao, Ph.D., Assistant Professor,
Department of Medicine, UCLA, 1100 Glendon Ave., Suite
2010, Los Angeles, CA 90024; Tel: (310) 794-3081; Fax: (310)
794-8529; Email: yuhuabao@mednet.ucla.edu
Research Objective: To determine the extent to which socioeconomic and racial/ethnic differences in cancer screening discussion between a patient and his/her primary care physician are due to “within-physician” differences (the fact that patients were treated differently by the same physicians) versus “between-physician” differences (that they were treated by a different group of physicians).
Study Design: Our main outcomes of interest are whether the physician has ever talked to the patient about fecal occult blood test (FOBT; for colorectal cancer screening), mammogram (for breast cancer screening, female patients only) and the Prostate-specific Antigen Test (PSA, male patients only). We consider five racial/ethnic groups: non-
Hispanic white, non-Hispanic black, Hispanic, Asian and other race/ethnicity. We measure socioeconomic status by both income and education. For each type of cancer screening discussion, we first estimate a probit model that includes patient characteristics as the only covariates to assess the overall differences. We then add physician fixed effects to derive estimates of “within-“ vs. “between-“ physician differences.
Population Studied: We use data from the baseline patient and physician surveys of two community trials from the
Communication in Medical Care (CMC) research series. The two studies combined provide an analysis sample of 5,978 patients ages 50-80 nested within 191 primary care physicians who practiced throughout Southern California.
Principal Findings: There was a strong education gradient in the discussion of all three types of cancer screening and most of the education differences arose within physicians.
Disparities by income were less consistent across different screening methods, but seemed to have arisen mainly because of “between- physician” differences. Asians were much less likely, compared to whites, to have received discussion about FOBT and PSA and these differences were mainly “within-physician” differences. Black female patients, however, were much more likely, compared to whites treated by the same physicians, to have discussed mammogram with their physicians.
Conclusions: Differences in cancer screening discussion along the different dimensions of patient SES may have arisen because of very different mechanisms. More specifically, patient education plays an important role in determining what happens in a clinical encounter. Physicians are distributed unevenly across communities of different socioeconomic profiles.
Implications for Policy, Delivery, or Practice: Physicians need to be informed of the persistent disparities by patient education in clinical communication regarding cancer screening and tailor their efforts to the needs of low-education patients. Quality-improvement efforts targeted at physicians practicing in low-income communities may also be effective in addressing disparities in cancer screening communication by patient income.
Primary Funding Source: NCI, AHRQ
● Racial Disparities and Socioeconomic Status in
Association with Survival in Older Men with
Local/Regional Stage Prostate Cancer
Xianglin L. Du, M.D., Ph.D., Shenying Fang, MS, Ann Coker,
Ph.D., Maureen Sanderson, Ph.D., C Aragaki, J Cormier, M.D.,
Y Xing, B Gor and W Chan, Ph.D.
Presented By: Xianglin L. Du, M.D., Ph.D., Associate
Professor, Division of Epidemiology, University of Texas
School of Public Health, 1200 Herman Pressler Dr, Houston,
TX 77030;
Tel: (713) 500-9956; Fax: (713) 500-9264;
Email: Xianglin.L.Du@uth.tmc.edu
Research Objective: Whether racial differences in cancer survival were due to race/ethnicity, or other factors such as socioeconomic status and treatment, remained poorly explored. This study was to determine the role of socioeconomic factors in racial/ethnic disparities in survival among a large community-based cohort of older men diagnosed with prostate cancer.
Study Design: This was a large retrospective cohort study with up to 11 years of follow-up in older men diagnosed with incident prostate cancer between 1992 and 1999 in the 11
SEER (Surveillance, Epidemiology and End Results) areas in the United States, identified from the SEER-Medicare linked data. These linked data not only provided reliable information on tumor stage and grade (Gleason score) at diagnosis and long-term follow-up of the vital status, but also allowed the examination of various socioeconomic factors at the level of census tract and zip codes. In addition, comorbid conditions and the type of treatment (chemotherapy and hormonal therapy) can be uniquely identified from Medicare claims data.
Population Studied: We studied a cohort of 61,228 men diagnosed with local or regional stage prostate cancer at age
65 years or older in 1992-99 in the 11 SEER areas (the metropolitan areas of San Francisco/Oakland, Detroit, Atlanta, and Seattle; Los Angeles county; the San Jose-Monterey area; and the states of Connecticut, Iowa, New Mexico, Utah and
Hawaii). Of the 61,228 men, 53,764 were Caucasians (non-
Hispanic whites), 6,321 African Americans (non-Hispanic blacks), and 1143 Hispanics.
Principal Findings: Low socioeconomic status was significantly associated with decreasing survival in all men with prostate cancer. Those living in the community with the lowest quartile of socioeconomic status were 31% more likely

to die than those living in the highest quartile (hazard ratio of all-cause mortality: 1.31, 95% confidence interval: 1.25-1.36) after adjustment for patient age, comorbidity, Gleason score, and the type of treatment. Hazard ratio remained almost unchanged after controlling for race/ethnicity (1.32, 1.26-1.38).
Compared to Caucasian men, African Americans were 14% more likely to die and Hispanic men were 15% less likely to die, after controlling for age, tumor grade, Comorbidity, and type of treatment. When additionally controlling for the level of poverty in the community or income, there was no significant difference in all-cause mortality between Caucasian and
African American men. For example, after controlling for income, the hazard ratio in African Americans was no longer significantly higher (1.02, 0.98-1.08) compared to Caucasians, whereas Hispanics still had a significantly lower risk (0.79,
0.71-0.88).
Conclusions: Racial disparities in survival among men with local or regional prostate cancer were largely explained by socioeconomic status and other factors. Lower socioeconomic status appeared to be one of the major barriers to achieving comparable outcomes for men with prostate cancer.
Implications for Policy, Delivery, or Practice: These findings have important public health implications if we are to achieve the goal of the Healthy People 2010, which is to eliminate health disparities among different segments of the population.
Further studies may be needed to address whether this association is true in younger men with prostate cancer.
Primary Funding Source: No Funding
● Socio-Economic Position, Race, or SEP and Race:
Understanding Disparities in Children’s Health,
Psychosocial Well-Being and Cognitive Functioning
Lisa Dubay, Sc.M.
Presented By: Lisa Dubay, Sc.M., Principal Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street, NW, Washington, DC 20037; Tel: (202) 261-5667; Fax:
(202) 223-1149; Email: ldubay@ui.urban.org
Research Objective: Objectives of the study are to adapt and validate Britain’s new National Statistics--Socio-economic
Classification measure for use in the US; to use the measure to document SEP gradients and racial and ethnic disparities in child health, emotional well-being, and cognitive functioning; and to assess the contribution of SEP and race/ethnicity to disparities.
Study Design: The study uses cross-sectional data from the second round of the Child Development Supplement of the
Panel Survey of Income Dynamics. A measure of family based
SEP is developed using parents’ employment status and occupation that categorizes children in to five groups. The validity of the measure is assessed using parent’s education, income, employment benefits, home ownership, and health status. Descriptive and multivariate methods are used to assess the relationship between SEP, race/ethnicity, and child health outcomes. Outcomes considered include general health status, self-esteem and well-being, the presence of behavioral problems, and Woodcock-Johnson tests of achievement. Simulations of the effect on population health of closing the SEP gradients and racial and ethnic disparities are estimated separately and together.
Population Studied: The population studied includes 2907 children who were ages 0 to 12 at the time of the 1997 PSID and whose parents continued to participate in the PSID in
2001. Data analyzed are from round 2 of the CDS and were collected in 2002 and 2003.
Principal Findings: Construct validity of the SEP measure is strong. Large SEP and race/ethnicity gradients were found descriptively, but were reduced in the multivariate models.
Compared to children in the highest SEP group, children in the two lowest classes were 10 and 20 percentage points less likely to be in excellent health, exhibited 2 and 3 more behavior problems, and scored up to 9 and 15 points lower on standardized achievement tests, respectively after adjustment for race/ethnicity and other factors. Few racial/ethnic differences remained in multivariate models but Hispanic children were in worse health and black, Hispanic, and other race children had achievement scores that were 10 points lower than white/non-Hispanic children. Simulations of the contribution of reducing SEP disparities and race/ethnicity disparities to population health indicated that addressing SEP disparities would result in greater improvements in population health than would racial disparities, but that addressing both would generate the greatest improvement.
Conclusions: This analysis reports SEP gradients and race/ethnicity disparities for children across a wide range of child health and functioning outcomes. The gradients and disparities apparent in both psychosocial and cognitive functioning in children may be the origin of adult disparities in health if they place children, as they transition into adulthood, in social and work environments that are more likely to threaten health.
Implications for Policy, Delivery, or Practice: The exclusive policy focus on reducing racial and ethnic disparities is unlikely to be successful. Unless the SEP gradient in health is reduced, racial gaps will persist and SEP gradients cannot be eliminated without closing the race gap. Eliminating SEP gradients would have a larger impact on population health than reducing race disparities, but ameliorating both would produce the greatest improvement.
Primary Funding Source: No Funding
● Exploring the Determinants of Racial and Ethnic
Disparities in Total Knee Arthroplasty: Health Insurance,
Income and Assets
Amresh Hanchate, Ph.D., Yuqing Zhang, Dsc, M.P.H., MB,
David T. Felson, M.D., M.P.H., Arlene S. Ash, Ph.D.
Presented By: Amresh Hanchate, Ph.D., Research Associate,
General Internal Medicine, Boston University School of
Medicine, 720, Harrison Ave, DOB, Suite 1108, Boston, MA
02118; Tel: (617) 638 8889; Fax: (617) 638 8026;
Email: hanchate@bu.edu
Research Objective: To determine the extent to which financial constraints – type of health insurance, income and assets, are associated with the large racial/ethnic disparities in total knee arthroplasty.
Study Design: The outcome measure is the dichotomous response to whether respondent has Total Knee Arthroplasty
(TKA) in the previous two years. Responses from 1998, 2000 and 2002 survey rounds are pooled. Longitudinal logistic regression models estimated to assess association with lagged financial indicators, controlling for lagged demographic and illness burden indicators.

Population Studied: The data source is the longitudinal
Health & Retirement Study (HRS) survey rounds (1994 to
2002) from the Institute of Social Research, University of
Michigan. Analytic sample has a nationally representative sample of 42,336 observations from 18,376 persons (ages 47 to 109) belonging to three racial/ethnic groups – Hispanic, non-Hispanic black and non-Hispanic white. 8,979 (49 percent) persons are under 65 years of age. Excluding persons with a history of joint arthroplasty, 494 first TKAs were observed.
Principal Findings: Compared to white men, TKA rate is only
39% among black men and 44% among Hispanic men. The
TKA rates per 1,000 persons/year are: white=5.4 (CI=[4.5, 6.3]), black=2.1 (CI=[0.7,3.5]) and Hispanic=2.4 (CI=[0.5,4.3]).
Among women the differences are smaller: white=6.5, black=6.9 and Hispanic=4.5. Differences in insurance coverage, household income and assets have sizable and statistically significant association with first TKA. Among those aged 65+, those having secondary insurance have at least 30% higher odds of TKA compared to those with only Medicare Fee for Service – in particular those also with Medicaid have Odds
Ratio (OR)=1.73 (CI= [1.00-2.73] and those with Medicare
HMO have OR=1.49 (CI=[1.05-2.10]). Those with household annual income less than $20,000 or assets less than $20,000 are at least 20% less likely to have TKA. After adjusting for the financial indicators, a significant reduction in residual disparities among Hispanics (OR increases from 0.69 to 0.88 for women, and from 0.49 to 0.61 for men). Among blacks,
OR increases from 0.80 to 0.97 among women, and from 0.32 to 0.37 among men.
Conclusions: While alternative explanations for racial and ethnic disparities have been proposed in medical literature
(including patient aversion to surgery, physician behavior, patient religiosity), this study indicates that much can be learned from focusing simply on financial constraints. For those with limited income and assets, out-of-pocket expenses from TKA may simply be too high given insurance coverage gaps. Further investigation is needed to determine the cause of such gaps, especially among the poor. How many with such gaps are eligible for Medicaid, and how many are eligible but do not enroll?
Implications for Policy, Delivery, or Practice: This study indicates that health insurance gaps, especially among those with low incomes and assets, are key mediators in the low usage of TKA among blacks and Hispanics.
Primary Funding Source: No Funding
● Disparities in Cardiac Care: Are We Developing a Two-
Tiered System
Marsha Regenstein, Ph.D., MCP, Holly Mead, Ph.D., Anthony
Lara, M.H.S.A., Soeurette Cyrprien, Jennifer Trott, Bruce
Siegel, M.D., M.P.H.
Presented By: Marsha Regenstein, Ph.D., MCP, Associate
Research Professor, Health Policy, George Washington
University Medical Center, 2021 K Street, NW, Suite 800,
Washington, DC 20006; Tel: (202) 530-2310; Fax: (202) 296-
0025; Email: marshar@gwu.edu
Research Objective: Despite a vast literature establishing the existence of racial and ethnic disparities in access to health care, delivery of services, and health outcomes, the reasons for disparities are not well understood. Analysis of the availability availability of services, patients’ access to specialty physicians and delivery sites, provider practice styles, and referral patterns within health care markets may provide insights into factors that contribute to health disparities. This project examines how the structure and financing of cardiovascular care in 10 communities with large African American and
Hispanic residents contribute to a two-tiered system with disparities divided along racial and ethnic lines.
Study Design: Ten communities with high numbers of
African American and/or Hispanic residents were selected as the focus of the study. Researchers visited delivery sites and conducted structured interviews with 250+ informants to identify characteristics that could mitigate or exacerbate disparities in cardiac care delivery and outcomes.
Population Studied: Providers who serve large numbers of
African American and Hispanic patients with cardiac conditions in ten U.S. communities.
Principal Findings: Access to hospital-based cardiac care differs within and across communities depending upon coverage and availability of safety net providers (SNPs). We identified three models of hospital-based cardiovascular services to help explain variation in disparities: 1) Funded
SNPs received state/local funding to provide free or discounted care for low-income residents, many of whom are
African American or Hispanic. Funded SNPs offered access to cardiac care that was fairly comparable across coverage categories (and consequently race and ethnicity) but were least likely to offer invasive and interventional cardiac care and more likely to have low cardiac market share relative to other providers. 2) Unfunded SNPs did not receive funding for indigent care and actively competed with other local hospitals for Medicare and privately insured patients. At unfunded
SNPs, minority and non-minority patients often accessed the health system through different entry points with different access to specialty cardiac services, largely because of differences in insurance coverage. Of the three models, unfunded SNPs were most likely to develop a two-tiered system of care based on coverage but resulting in different experiences by race and ethnicity. 3) Non-SNPs were key providers of cardiac services in their community, attracting a strong payer mix within cardiac service lines. Access to a full array of heart services was generally available for minority patients with Medicare and commercial coverage but much less available for minority patients without these resources.
Conclusions: The timely delivery of hospital-based cardiovascular services is largely determined by organizational decisions that favor commercially insured or Medicare patients. To the extent that African American and Hispanic patients are overrepresented in their communities in uninsured and Medicaid populations, access to care is segmented along racial and ethnic lines.
Implications for Policy, Delivery, or Practice: Disparities in cardiovascular care should be discussed within the context of health insurance coverage and access to health services.
Business decisions designed to enhance market share and attract a strong payer mix can have unintended consequences on quality of care and can result in furthering racial and ethnic disparities.
Primary Funding Source: RWJF

Call for Papers
System & Policy Approaches to
Eliminating Healthcare Disparities
Chair: Helen Bursin, Agency for Healthcare
Research and Quality
Sunday, June 25 • 3:45 pm – 5:15 pm
● Evaluation of a State Hospital Regulatory Reform
Addressing Racial Disparities in Use of Cardiac
Angiography
Joel Cantor, Sc.D., Amy Tiedemann, Ph.D., Karl Kronebusch,
Ph.D., Derek DeLia, Ph.D., Ava Stanley, M.D., M.P.H.
Presented By: Joel Cantor, Sc.D., Professor and Director,
Center for State Health Policy, Rutgers University, 55
Commercial Ave, 3rd Floor, New Brunwsick, NJ 08901; Tel:
(732) 932-4653; Fax: (732) 932-0069;
Email: jcantor@ifh.rutgers.edu
Research Objective: Through the mid-1990s NJ used
Certificate of Need (CoN) to limit diagnostic cardiac angiography (CA) capacity. Regulatory reforms beginning in
1997 greatly increased CA capacity, imposed strict minimum volume requirements, required outreach to underserved groups, and created incentives for hospitals seeking cardiac surgery licensure to address CA disparities. The objective of this study is to evaluate the effect of these reforms on the black-white CA use disparity.
Study Design: Reform is evaluated with document review, key informant interviews, and analysis of utilization trends. Trend data are from hospital billing records (NJ) and the National
Hospital Discharge Survey (US). Quantitative analysis focuses on relative use of CA, defined as use by blacks per 10,000 divided by the corresponding number for whites. Ongoing work will contrast NJ trends with neighboring states, expand the time series, and adjust for demographic changes.
Population Studied: NJ and US patients receiving CA in hospitals per population by race.
Principal Findings: According to NJ informants, the main drivers of CA regulatory reform were growing demand from hospitals seeking licensure for lucrative cardiac procedures and an ideological shift in favor of competition over regulation. NJ policymakers forged a compromise between pro-regulatory and pro-competitive forces by linking CA CoN approvals to new access and quality requirements.
Stakeholders reported little faith in the new access regulations but most believed that increasing capacity and linking disparity-reduction to licensure for cardiac surgery would improve CA access. The number of NJ hospitals providing CA roughly doubled after reform (from 26 in 1991-1996 to 52 in
1998 and 49 in 1999-2002). Statewide CA volume grew both before and after reform, but volume in "incumbent" (licensed before reform) facilities declined following reform (1997-98) and grew only slowly after 1998. Hospitals with new CoNs to provide CA were not located in markets with as many minority patients as incumbent hospitals. Still, preliminary evidence suggests that the black-white disparity may have declined following reform. In the years spanning reform, relative use of
CA by blacks compared to whites in NJ grew from 52% (1996) to 67% (1998) and 65% (1999) while changing little nationally
(55% in 1996 versus 60% in 1998 and 57% in 1999).
Conclusions: Faced with a shift away from tight regulation and growing demand from hospitals to provide cardiac services, NJ took a novel approach that blended market competition with rules and incentives to improve quality and increase access to CA among underserved populations. This strategy appears to have significantly increased competition among hospitals for CA patients, including blacks. While the new facilities were not located in areas with large minority populations, the black-white disparity in CA use appears to have declined following reform.
Implications for Policy, Delivery, or Practice: Few studies have documented effective strategies for addressing longstanding racial disparities in cardiac service utilization. In NJ, a strategy promoting market competition and regulatory incentives may have contributed to reduced disparity in use of
CA. Additional analysis underway of use trends in incumbent facilities and contrasts to trends in states without reform may shed light on the mechanisms by which disparities declined in
NJ.
Primary Funding Source: AHRQ
● Improving Chronic Disease Management for
Underserved Populations: A National Evaluation of The
HRSA Health Disparities
Bruce Landon, M.D., M.B.A., Leroi Hicks, M.D., M.P.H., A.
James O'Malley, Ph.D., Tracy Lieu, M.D., M.P.H., Barbara J.
McNeil, M.D., Ph.D., Edward Guadagnoli, Ph.D.
Presented By: Bruce Landon, M.D., M.B.A., Associate
Professor of Health Care Policy, Department of Health Care
Policy, Harvard Medical School, 180 Longwood Avenue,
Boston, MA 02115; Tel: 617-432-3456;
Email: landon@hcp.med.harvard.edu
Research Objective: Significant differences in quality according to race and socioeconomic status are problematic in the US health care system today. While many studies have documented these problems, few have evaluated interventions designed to improve upon current performance. In 1998, the
Bureau of Primary Health Care of the Health Services and
Rescources Administration (HRSA) initiated the Health
Disparities Collaboratives to reduce health disparities and improve the quality of care in Community Health Centers
(CHCs) that collectively serve 15 Million poor and underserved patients. Over 700 CHCs have participated in at least one
Health Disparities Collaborative to date. The objective of this study is to evaluate the effectiveness of the Health Disparities
Collaboratives in improving quality of care for chronic medical conditions.
Study Design: We performed a controlled pre/post intervention study of CHCs participating in a quality improvement collaborative for Diabetes, Asthma, or
Cardiovascular disease (with our assessment focused on hypertension) that were conducted during 2000-2002 by
HRSA and the Institute for Health Care Improvement. The collaboratives use rapid cycle improvement techniques based on "plan, do, study, act" cycles and the Chronic Care Model.
Quality of care measures involving processes and intermediate outcomes of care (e.g., control of hypertension) were abstracted from medical records, and an overall composite measure was created for each condition by taking

the mean of all measures (including both process and outcomes measures) after normalization of each of the individauls scores. Changes in quality were evaluated using hierarchical logistic regression models that controlled for patient characteristics.
Population Studied: We enrolled 44 CHCs participating in a collaborative (13 for asthma, 17 for diabetes, and 14 for hypertension) and 20 non-participating centers (“external” controls) that had not participated in a collaborative after matching on region, size, and location. Each participating clinic also served as a control (“internal” control) for one of the other targeted conditions. From each center, random samples of eligible patients from the one year periods before and after the intervention were selected for chart review.
Principal Findings: We studied 11,153 patients with one of the three target conditions in the experimental and control groups
(3,887 with asthma, 2,904 with diabetes, and 3,362 with hypertension). Intervention clinics showed significant improvement in the overall composite measure of quality when compared to both external controls and internal controls for asthma and diabetes but not for hypertension. For instance, participating asthma centers improved the overall percentage met for the composite quality measure by 15% as compared to 5% for internal controls and 1% for external controls (p<.001 for both comparisons). Individual measures in the areas of screening, treatment, and self-management such as asthma severity assessment, hemoglobin A1C assessment, and diabetic foot exams showed significant improvement. There was no improvement, however, in intermediate outcomes such as control of diabetes (as measured by hemoglobin A1C), hypertension, or cholesterol, or the number of urgent care, emergency room, or hospital visits for asthma patients.
Conclusions: We found that the Heatlh Disparities
Collaboratives significantly improved the extent to which several processes of care were followed for two of the three conditions studied, without any improvement in intermediate outcomes.
Implications for Policy, Delivery, or Practice: Collaborative improvement programs continue to be a cornerstone of quality improvement efforts for CHCs and other health care organizations. Our findings suggest that while the collaboratives have successfully improved the processes of care, improved methods are required to achieve more significant improvements in intermediate outcomes that are the most important determinants of long term chronic disease outcomes.
Primary Funding Source: AHRQ, the Commonwealth Fund
● Improving Institutional Readiness to Change:
Addressing Disparities and Quality Improvement in U.S.
Health Care Organizations
Ann Scheck McAlearney, Sc.D., M.S., Bruce Siegel, M.D.
Presented By: Ann Scheck McAlearney, Sc.D., M.S., Assistant
Professor, Health Services Management and Policy, The Ohio
State University, 1841 Millikin Road, Cunz Hall, 4th Floor,
Columbus, OH 43210-1229; Tel: 614-292-0662; Fax: 614-438-
6859; Email: mcalearney.1@osu.edu
Research Objective: To explore institutional readiness to change around the issues of reducing disparities and improving the quality of cardiovascular care in U.S. hospitals.
Study Design: An extensive qualitative study consisting of 10 case studies of U.S. hospitals conducted between September
2005 and January 2006. Case studies included key informant interviews, surveys, and the collection of organizational documents to investigate readiness to change in hospitals committed to address the issues of reducing disparities and improving cardiovascular care for minority Americans. First, hour- and half-hour-long in-person and telephone interviews were taped, transcribed, and analyzed used deductive and inductive methods, including a grounded theory approach to explore emergent themes. Second, a 130-item mailed and electronic survey asked about organizational change, racial and ethnic disparities, cultural competency, and related topics.
Survey data analyses included descriptive statistics, chisquared analyses, linear regression, and logistic regression.
Organizational change theory provided a conceptual framework for the study.
Population Studied: Case study organizations included academic medical centers, community hospital systems, and free-standing hospitals. Key informant interviews were held with over 200 organizational representatives and physicians.
Survey respondents included physicians and hospital employees from all areas of the organizations.
Principal Findings: Across hospitals, an overwhelming majority of respondents reported that while they believed that disparities are a nationwide problem, they were skeptical that the care provided by their own hospital was an issue. Further, despite the fact that all hospitals had applied to participate in this improvement initiative, there was considerable variation among the hospitals with respect to institutional readiness to change. Smaller, less complex organizations tended to be categorized at a higher stage of change readiness than larger academic centers. Across institutions, factors such as executive leadership support, availability of clinical information systems, experience with quality improvement initiatives, and transparency of data reporting appeared related to organizations’ abilities to both innovate and implement needed changes associated with addressing the issues of disparities and quality improvement in cardiovascular care.
Conclusions: Efforts to change institutional patterns of care to reduce disparities and improve quality can be guided by organizational change and change management models that focus program development and implementation. Health care organizations attempting to address the issue of disparities in care can build support for their initiatives by promoting transparency in data collection and dissemination, and then work to support institutional change by facilitating rapid cycle improvements that can be spread throughout the hospital.
Implications for Policy, Delivery, or Practice: Engaging a hospital’s multiple internal and external stakeholders hospitals in efforts to reduce disparities and improve quality of care will raise awareness about these issues and can help increase the likelihood of program success. Moreover, our work suggests that wider adoption of health information technologies may help address the issue of disparities in care by providing treatment guidance that is both informed and relatively neutral with respect to patient race/ethnicity. Finally, this research has produced several assessment tools (both qualitative and quantitative) that can be used in future evaluations of institutional readiness to change around the issues of disparities reduction and quality improvement.

Primary Funding Source: RWJF
● When Racial Disparities Disappear: Is it a Good News
Story?
Dana B. Mukamel, Ph.D., David L. Weimer, Ph.D., Tom
Buchmueller, Ph.D., Heather Ladd, MS, Alvin I. Mushlin,
M.D., M.S.C.
Presented By: Dana B. Mukamel, Ph.D., Professor and Senior
Fellow, Center for Health Policy Research, University of
California, Irvine, 111 Academy, Suite 220, Irvine, CA 92697-
5800; Tel: (949)824-8873; Fax: (949)824-3388;
Email: dmukamel@uci.edu
Research Objective: Racial disparities in access to high quality cardiac surgeons persisted throughout the 1990s.
Recent data suggest that these disparities no longer exist. The objective of this study is to examine reasons for this change and the resulting equalization in access to high quality care.
Study Design: A retrospective analysis of Medicare fee-forservice claims data augmented with quality measures for cardiac surgeons obtained from the New York State Cardiac
Surgery report and socioeconomic data from the census. The analyses compared referral patterns in the late 1990s to the early 2000s. Hierarchical multivariate regression models were estimated to examine the relationship between race and CABG surgery performed by a high quality surgeon, while controlling for patient risk factors, physician and hospital fixed effects, and heteroscedasticity. The change in the average quality of surgeons in the two periods for Whites and Blacks was decomposed into two components: 1. change due to shifts in patients’ referrals to surgeons of better quality, holding surgeon quality constant; and 2. change due to improvement in surgeons’ quality, holding patients’ referrals constant.
Multivariate regression models were then estimated to identify factors associated with the two types of change minority patient referrals and surgeon quality. Finally, multinomial models were estimated to examine the use of CABG versus angioplasty by race in order to investigate the change in capacity of CABG surgeons and its impact on access.
Population Studied: All of the 227,405 New York State
Medicare fee-for-service patients with cardiac procedures: angiography, angioplasty or CABG during 1997-1999 and
2001-2003.
Principal Findings: In contrast to findings from the 1990s, in the early 2000s Blacks no longer experience disparities in access to high quality surgeons. The elimination of this disparity is traced to both a shift in referrals of Blacks to better surgeons and an improvement in the quality of the surgeons that they accessed historically,p<0.001. About two-thirds of the overall change is due to shift in referrals and one-third is due to improvement in surgeons’ quality. Multivariate analyses suggest that this is explained by the shift from CABG to angioplasty, which opens capacity of the higher quality
CABG surgeons, p=0.019 and allows them to accept minority patients who may not have had access to them in the past.
Other surgeon and patient characteristics are not associated with this phenomenon. The number of CABG surgeries performed on Whites has declined between the two periods while the number for Blacks has increased. The number of angioplasty procedures increased for both races.
Conclusions: Blacks seem to have gained increased access to high quality cardiac surgeons in recent years because fewer white patients are being referred to CABG, thus freeing capacity among high quality providers.
Implications for Policy, Delivery, or Practice: Minority patients are competing with Whites for access to services and for access to the best providers. Efforts to equalize access may, therefore, require increasing capacity, as well as improvement in the quality of low performing providers and decreasing the variations in quality across providers.
Primary Funding Source: NIA, Commonwealth Fund and the
Natioanl Center for Minority Health and health Dispairties
● National Respite Pilot Initiative: Evaluation Results
Suzanne Zerger, MA, Adi Gundlapalli, M.D., Ph.D.
Presented By: Suzanne Zerger, MA, Research Specialist,
National Health Care for the Homeless Council, P.O. Box
60427, Nashville, TN 37206; Tel: 615-226-2292; Fax: 615-226-
1656; Email: szerger@nhchc.org
Research Objective: 1) To identify and document the differing models of care for the delivery of respite services; and,
2) To assess the effect of respite services on the health of homeless people during their stay in respite.
Study Design: This prospective evaluation of a National
Respite Pilot Initiative used a community-based, participatory design. Respite Coordinators from each of the 10 respite pilot programs worked collaboratively with a research team to design all aspects of this study, including specific variables and methodologies. Program-level data (pre-post surveys and interviews with Respite Coordinators) describe the service models in detail and the pros and cons associated with each, lessons learned about implementing respite programs, and anecdotal data on success stories and ethical dilemmas confronted in implementing these programs. Client-level data were obtained on all consenting clients (n=1349; 97% response rate) and the respite services they received during their stay (n=1507 encounters) from each of the 10 respite programs. These data, collected between July 2003-March
2005, include: referral sources; demographic characteristics; hospitalization and treatment histories; diagnoses (and severity of each) made upon admission, during the respite stay and upon discharge; all encounters and treatments during the respite stay (type and number); pre-post outcome measures such as housing, income, and family status; and reasons for exiting the respite program. In addition, data were collected on all individuals who were referred to the respite programs but were not admitted – including their diagnoses and the reasons they could not be admitted.
Population Studied: 1349 adult homeless persons accessing respite services from 10 programs across the U.S.
Principal Findings: Most of the individuals these respite programs serve have multiple, severe, and complex needs, including long histories with homelessness, multiple diagnoses of high severity, and psycho-social needs.
Respite care improves quality of life. This evaluation shows clients’ improved not only in health status, but also in other areas critical to their overall health such as access to health care, health insurance, income, and housing. The need for respite care is vast, and remains largely unmet. All of these programs are struggling to manage rapidly growing need with already limited resources. Several of these programs routinely are unable to admit half to two-thirds of the individuals referred to them for care.

Conclusions: These respite programs are filling a gap in services between those hospitals and clinics unable to serve these clients’ needs and the harsh realities of the street.
These programs have a unique opportunity to assist individuals not only in addressing their acute health needs, but in helping them improve their overall health and the quality of their lives. To be effective in the long-term, however, the necessary housing, treatment programs, and services need to be available for clients when they are discharged from respite.
Implications for Policy, Delivery, or Practice: An increasing managed care environment in hospitals is resulting in shorter hospital stays and more procedures provided on an outpatient basis. The impact on homeless individuals is especially harsh, because they are frequently discharged from the hospital with prescriptions for mediation they cannot afford to have filled, and/or with instructions for follow-up care they are unable to heed, such as bed rest and nutritious food. One response to this gap in health care between hospitals and the streets has been the development of medical respite services for homeless persons. Though respite programs for homeless persons in the U.S. were first developed in 1985, the increasing pressure on clinics and hospitals to discharge people quickly has resulted in a sharp increase in the number of respite programs in just the past few years, and even the creation of a
National Respite Providers Network last year. This National
Respite Pilot Initiative evaluation provides timely data that are greatly needed, including detailed descriptions of models of respite care that work, insights into program development and design, and an understanding of the needs of individuals most likely to require, access, and benefit from these unique services.
Primary Funding Source: HRSA
Call for Papers
The Effect of Patient & Community on
Healthcare Diparities
Chair: Lisa Cooper, Johns Hopkins University
Sunday, June 25 • 5:45 pm – 7:15 pm
● Disparities Start at the Door: Racial Differences in
Consumer Expectations of Physicians and Health Plans
Lisa C. Gary, Ph.D., M.P.H., Mark J. Schlesinger, Ph.D.
Presented By: Lisa C. Gary, Ph.D., M.P.H., Assistant
Professor, Health Care Organization and Policy, UAB School of Public Health, 1530 3rd Ave. South (RPHB 330),
Birmingham, AL 35294-0022; Tel: 205-975-0506;
Email: Lgary@uab.edu
Research Objective: Background: Barriers to healthcare access and evidence of lower quality of healthcare have been documented for Blacks and other minorities across a range of areas including cardiac care, pain management and preventive care. Despite these findings, research has shown that Blacks often have high levels of patient satisfaction. The basis for this conundrum may in part be explained by racial variations in consumer expectations about the health system. Exploring the nature of racial differences in expectations is especially salient as these differences may affect future clinical decision making of patients and patient perceptions of negative health care encounters. For example, consumers with very low expectations of the health system could interpret inadequate care or unfair treatment as good care. If expectations for care are set too low, then low quality care may become acceptable or worse un-noticeable to vulnerable consumers. Objective: In this study, expectations represent normative predictions about what the consumer anticipates will happen in their encounters with physicians and health plans. This “normative” dimension is a function of the social expectations for physician behavior and the health care industry in general. Thus, the purpose of this study was to determine whether minority consumers had different evaluations of how well physicians and health plans meet the social norms/ role expectations for medical professionalism and patient trust.
Study Design: Methods: Data from the Yale/ NYAM
Consumer Trust in Health Care Survey, a nationally representative telephone survey (n=5000), were analyzed using logistic regression. The role expectations included patient advocacy, caring, racial fairness, honesty and technical competence of physicians and health plans.
Principal Findings: Compared to whites, Blacks were more likely to expect limited patient advocacy by physicians even after adjustment for age, health status and other variables
(OR=1.69). Blacks were more likely than whites to endorse the belief that physicians do not provide fair treatment to all of their patients regardless of race (OR=3.04). Latinos also anticipated limited racial fairness in the medical care provided by physicians (OR=1.54). Contrary to the racial fairness findings, Latino and black respondents were less likely to expect uncaring and impersonal treatment among physicians than whites. Interestingly, no race effects for blacks or Latinos were observed for the expectations about the technical competence of physicians despite strong race effects on other physician expectations. Blacks and Latinos shared the same belief that health plans were not likely to treat all consumers fairly regardless of race (OR=2.68, 1.58). Asian/other consumers were more likely to expect dishonesty in health plan practices (OR=1.79) compared to whites.
Conclusions: There are significant racial differences in consumer expectations of physicians and health plans. The lowered expectations of minority consumers may be indicative of the responsiveness of the health system to their current and past health needs. Results are also discussed in terms of how concurrent health care experiences may influence the updating of consumer expectations.
Implications for Policy, Delivery, or Practice: This study shows that measuring and controlling for expectations is methodologically important especially when using patientreported outcomes. The integration of expectations questions into patient satisfaction questionnaires is the focus of future research.
Primary Funding Source: No Funding

● Effects of Medical Mistrust and Perceived Discrimination in the Medical Community on Self-management Practices for African American and Hispanic Patients with
Uncontrolled Hypertension
Paul Hebert, Ph.D., Jodi Casabianca, MS, Leah Tuzzio,
M.P.H., Mary Ann McLaughlin, M.D., M.P.H., Christine
Brown, M.P.H., Jane E. Sisk, Ph.D.
Presented By: Paul Hebert, Ph.D., Assistant Professor, Health
Policy, Mt. Sinai School of Medicine, One Gustave L. Levy
Place, Box 1077, New York, NY 10029; Tel: (212) 659-9191; Fax:
(212) 423-2998; Email: paul.hebert@mssm.edu
Research Objective: Previous studies have shown that patients' perceived discrimination in medicine and medical mistrust are correlated with race and contributes to lower satisfaction with care among African Americans. The purpose of this study is to explore whether these perceptions interfere with the provider-patient relationship in a group of African
American and Hispanic patients with uncontrolled hypertension, leading to lower patient knowledge of hypertension and worse self-reported self-care.
Study Design: The data come from the baseline survey of a randomized controlled trial of disease management for uncontrolled hypertension. The survey administered at enrollment included validated 5-item trust and 4-item discrimination scales. Subjects were also asked questions regarding their knowledge of and behaviors toward important self-managment issues for hypertention. Specifically, patients were asked if they knew that exercising, weight control, and reducing sodium and alcohol, respectively, were critical to controlling HTN. Patients were also asked whether they were engaged in these preventive behaviors, or if they intended to do so. We correlated responses regarding perceived discrimination and mistrust with knowledge and behavior toward preventive self-care.
Population Studied: In 2004/5, we enrolled 416 African
American and Hispanic patients with blood pressure >140/90 from the four hospital clinics and one community health clinic in Harlem, New York City. Patients were 59% Non-Hispanic
Black, 41% Hispanic, 71% female, with mean age 60.7 (range
33 to 94). The mean blood pressure at baseline was 153/86, and 58% of the enrollees were obese.
Principal Findings: Perceptions of racism and mistrust were varied: 53% (95% c.i.: 0.47, 0.58) agreed that racial discrimination in the doctor’s office is common while 26%
(95% c.i.: 0.21, 0.31) agreed that doctors treat minority and white people differently. When asked if they believed patients are misled at hospitals, 67% (95% c.i.: 0.61, 0.72) agreed.
Only 8% (95% c.i.: 0.05, 0.11) responded that they personally had been treated unfairly because of race and 95% (95% c.i.:
0.93, 0.97) said they trusted their own physician. We found no significant correlations between mistrust/discrimination and knowledge of or adherence to diet, exercise, sodium, and alcohol recommendations.
Conclusions: Perceived racism and mistrust though present is not correlated with patient knowledge of or adherence to important preventive behaviors. A possible reason for this may be the trust that patients feel for their own doctor, and their belief that they are treated fairly. Patients in this study followed the advice of their trusted providers, even if they perceived discrimination and mistrust in the larger medical community.
Implications for Policy, Delivery, or Practice: By treating patient's fairly and earning the personal trust of their patients, health care providers may overcome the potentially deleterious effects of mistrust/perceived racism that some minorities report in regards to the medical establishment in general.
Primary Funding Source: NIH's National Center on Minority
Health and Health Disparities
● Chronic Disease as Contagion: The Effect of Social
Influence and Grocery Store Locations on Body Mass
Index
Sanae Inagami, M.D., MPH, Deborah A. Cohen, M.D., MPH,
Henry D. Anaya, Ph.D., Brian K. Finch, Ph.D., Steven M. Asch,
M.D., MPH
Presented By: Sanae Inagami, M.D., MPH, Fellow/Research
Associate, GIM/HSR, UCLA/VA Greater Los Angeles Health
Care System, 11301 Wilshire Blvd (111G), Los Angeles, CA
90025; Tel: 310-478-3711x40385; Fax: 310-268-4933;
Email: sinagami@ucla.edu
Research Objective: Residential neighborhood disadvantage has been associated with increased body mass index (BMI) in individuals, with a disproportionate number of Latinos and
African-Americans affected. Individuals have higher BMI when living in areas where residents frequent grocery stores located in lower socioeconomic areas. (Manuscript in review.) We hypothesized that residents in these areas with greater interactions with their neighbors may have even higher BMI as they may be more greatly influenced by their neighbors compared to those who interact less with their neighbors. We examined whether greater interactions and familiarity with neighbors influence BMI of the individual and whether these may contribute to race/ethnic differences; we also explored other neighborhood factors that may be associated with greater increased interactions.
Study Design: We linked the 2000 US Census data with the
Los Angeles Family and Neighborhood Study (L.A.FANS) database, which consists of 2620 adults sampled from 65 neighborhoods in Los Angeles County. “Neighbor familiarity and interactions” was assessed using a five-item scale related to the respondent's personal association with his/her neighbors. Multilevel linear regressions were used to estimate associations between BMI and “neighbor familiarity” and quality of grocery stores after adjustment for individual level factors (gender, education, age, income, car ownership, race/ethnicity, immigrant status, marital status, employment) and socioeconomic characteristics of residential neighborhoods.
Principal Findings: Individual perception of neighborhood safety and sense of neighborhood social cohesion are inversely related to whether individuals interact with their neighbors. Greater interaction with neighbors is associated with increased BMI (p=0.012). Native Latinos and African-
Americans who interact less with neighbors, who frequent grocery stores located in lower SES neighborhoods, have lower
BMI than would be expected (p=0.042,p=0.002) from the combined independent effects of each. Immigrant Latinos and
African-Americans who travel farther for their groceries have lower BMI (-1.33 BMI units, p=0.01; -1.80 BMI units, p=0.04).
Native Latinos and African-Americans who are more familiar with their neighbors, who frequent grocery stores in lower SES

areas, had higher BMI than would be expected from the combined independent effects of each.
Conclusions: We found complex associations between social processes and BMI that may serve to explain why Latinos and
African-Americans are disproportionately affected by obesity in
Los Angeles. Energy balance behaviors, such as where people shop, what people cook, and what people eat may be the result of neighborhood social influence. The roots of obesity and chronic disease may lie in social patterning of health behavior, and identifying how health is influenced by the individual's perception of and reaction to their neighborhood
(interacting or not interacting with neighbors) may be important in stemming the obesity epidemic.
Implications for Policy, Delivery, or Practice: Health care professionals may need to view obesity within the contagion paradigm and redirect their energies to the level of the neighborhood in order to effect change at the level of the individual.
Primary Funding Source: HRSA, VAHSR&D
● Self-Reported Health Disparities: Discrimination or
Dissatisfaction?
Ninez Ponce, MPP, Ph.D., Gilbert Gee, Ph.D.
Presented By: Ninez Ponce, MPP, Ph.D., Assistant Professor,
Health Services, UCLA School of Public Health, 31-254B Center for the Health Sciences, Los Angeles, CA 90095-1772; Tel: 310-
206-4021; Email: nponce@ucla.edu
Research Objective: Racial discrimination in medical care has been identified as a source of disparities in health status. But patient dissatisfaction with care may also influence the perception of discrimination. We explore the extent of racial differences in reporting discrimination, and examine the independent effects of discrimination and dissatisfaction on measures of self-reported health status and health-related quality of life measures.
Study Design: Perceived discrimination was specified as a dichotomous outcome (1= reporting that one would get better medical care if they belonged to a different racial or ethnic group). Patient dissatisfaction of medical care was a continuous variable from 0=least dissatisfied and 10=most dissatisfied. Covariates included race/ethnicity, age, income as a percent of poverty level, education, gender, rural/urban residence, family composition and health insurance. We tested the effects of perceived discrimination and dissatisfaction on several health outcomes: general health status, count of chronic conditions, physically unhealthy days, mentally unhealthy days, and activity limitation days. We fit logit models on dichotomous outcomes, ordered logit on general health. Chronic conditions were estimated as OLS and physically and mentally unhealthy days and activity limitation days were estimated as negative binomial models.
We used survey weights and jackknifed standard errors to account for the 2003 CHIS multi-stage survey design.
Population Studied: Approximately 39,000 adults who reported a medical encounter in the past two years from the population-based 2003 California Health Interview Survey.
Principal Findings: Racial and ethnic minority groups significantly reported higher odds of perceived discrimination than non-Latino whites (p<0.001 for each group): Latinos
(OR 2.23), Asians (OR 1.82), African Americans (OR 4.03),
American Indians/Alaska Natives (OR 2.87), Pacific Islanders and other single/multiple races (OR 2.25). A one unit increase in the dissatisfaction scale at the mean (1.98) was associated with nearly a 30% increased odds of reporting perceived discrimination. Including the dissatisfaction measure as a covariate increased the odds of reporting discrimination for each of the groups. In the health outcome models, discrimination was consistently and robustly (p<0.001) associated with poorer health. Dissatisfaction was significant at p<0.001 for each outcome except chronic conditions. For each outcome, inclusion of dissatisfaction attenuated the effect of discrimination: poorer general health status (from
OR 1.56 to 1.32), number of chronic conditions (beta 0.059 to
0.057), physically unhealthy days (beta 0.36 to 0.24), mentally unhealthy days (beta 0.54 to 0.41), and activity limitation days
(beta 0.44 to 0.32). The perceived discrimination estimate remained significant across all health status measures, and was 62% to 96% larger than the dissatisfaction estimate.
Conclusions: Racial and ethnic minorities report more discrimination in medical care and this perceived discrimination is strongly associated with poorer health status and worse health-related quality of life. Although patient dissatisfaction of health care in part explains variations in health, discrimination still explains a larger part of health disparities.
Implications for Policy, Delivery, or Practice: Standards set for providers to treat patients equally and fairly are deserving of the same credence given to patient satisfaction ratings as benchmarks for improving the quality of care.
Primary Funding Source: NCI, National Institute of Aging
● Do Ethnic Enclaves Contribute to the Disparities in
Cancer Screening?
Ninez Ponce, MPP, Ph.D.
Presented By: Ninez Ponce, MPP, Ph.D., Assistant Professor,
Health Services, UCLA School of Public Health, 31-254 B
Center for the Health Sciences, Los Angeles, CA 90095-1772;
Tel: 310-206-4021; Email: nponce@ucla.edu
Research Objective: The study focuses on the effects of ethnic enclaves in California and tests whether ethnic concentration in neighborhoods mitigates or promotes receipt of cancer screening tests at the recommended intervals.
Study Design: Two-level hierarchical logit models, stratified by race/ethnicity, on 1) Pap tests, 2) mammograms, and 3) colorectal cancer tests. At the census tract level (Level-2) we measured racial/ethnic concentration, social capital, neighborhood tenure, %population living below poverty,
%non-citizen, and %limited English proficient; at the metropolitan-statistical area (MSA) level, we included HMO penetration, HMO competition, and %staff/group model
HMO. We adjusted for individual characteristics: age, gender, household income, education, family composition, years lived in the US, citizenship, English proficiency, neighborhood tenure, individual social capital index, discrimination in medical care, usual source of care, and health insurance coverage.
Population Studied: Appropriately aged adults, depending on type of cancer screening outcome, residing in metropolitan areas from the population-based 2003 California Health
Interview Survey (n=42,044). Level-2 data obtained from the
2003 CHIS, 2000 US Census, and Interstudy 1999-2000.

Principal Findings: Asian concentration decreased Pap test screening (estimate: -1.040, p-value: <0.001) and breast cancer screening among Asians (estimate: -0.577, p-value:
0.022). Latino concentration decreased likelihood of any CRC screening among Latinos (estimate: -0.007, p-value: <0.001) and endoscopy in the past 5 years (estimate: -0.008; p-value:
<0.001). However, white concentration improved the likelihood of all types of cancer screenings for whites examined (p-value <0.01 for all outcomes). After adjusting for concentrated disadvantage, collective efficacy, and health care market structure, Latino concentration still decreased the likelihood of CRC screening (estimate: -0.008, p-value: 0.012) and endoscopy (estimate: -0.008, p-value: 0.014). White concentration significantly improved the likelihood of screening for mammography (estimate: 0.325; p-value: 0.016), any CRC test (estimate: 0.414; p-value: 0.001) and endoscopy
(estimate: 0.419; p-value: 0.001). For Asians, high Asian concentration still significantly predicted lower cervical cancer screening, but not lower breast cancer screening, after controlling for socio-ecological and individual level characteristics. Latino concentration was no longer significant after controlling for socio-ecological and individual level characteristics, but linguistic concentration (% Limited
English Proficient in a neighborhood) had a significant negative effect. Black concentration was not significant in any of the models. Among the cancer screening tests, CRC tests were the most sensitive to health care market structure: HMO penetration conferred protective effects for CRC screening among Latinos and whites.
Conclusions: The socio-ecological context of where people live have differential effects by race/ethnicity and by type of cancer screening. A high Asian and Latino concentration reflects a concentrated disadvantage in terms of cancer screening tests. In contrast, we found a protective effect for whites living in mostly white neighborhoods. Health care market variables became prominent with individual interactions suggesting further study to test whether health care market structure might reduce enclave risk.
Implications for Policy, Delivery, or Practice: Large gains can be made in reducing cancer screening disparities if cancer control programs focus on high-density Asian and LEP Latino neighborhoods.
Primary Funding Source: NCI, National Institute of Aging
Call for Papers
Next Generation Measures & Outcomes of Disparities
Chair: Ernest Moy, Agency for Healthcare
Research and Quality
Tuesday, June 27 • 8:45 am – 10:15 am
● The Impact of Racial and Ethnic Disparities in Influenza
Vaccination on Elderly Minority Deaths
Kevin Fiscella, M.D., M.P.H., Richard Dressler, M.D., M.P.H.,
Sean Meldrum, MS, Kathleen Holt, Ph.D.
Presented By: Kevin Fiscella, M.D., MPH, Associate
Professor, Department of Family Medicine and Community &
Preventive Medicine, University of Rochester, 1381 South Ave,
Rochester, NY 14620; Tel: (585) 506-9484 ex 106; Fax: (585)
473-2245; Email: kevin_fiscella@urmc.rochester.edu
Research Objective: To estimate the annual number of minority deaths that would be avoided if influenza vaccination rates among elderly African Americans and Hispanics were equal to elderly white rates or if the Healthy People 2010 influenza vaccination objective were achieved.
Study Design: We used age-, sex-, race-, and ethnicity-specific influenza 2002 data from the Medicare Current Beneficiary
Survey, national vital data, and conservative estimates of the deaths attributed to influenza among vaccinated and unvaccinated elderly in our models. We calculated the difference in current African American and Hispanic influenzarelated deaths and those modeled based on white vaccination rates. We compared these numbers to major causes of death among elderly minorities.
Population Studied: All African American and Hispanic
Medicare Beneficiaries aged 65 and older.
Principal Findings: During 2002, there were 162,490 and
64,580 African American and Hispanic all-cause deaths among elderly Medicare beneficiaries. Of these, 5,890 African
American and 2,220 Hispanic deaths were attributable to influenza. If the minority influenza vaccination rates equaled the white, non-Hispanic rate, there would be 2,110 fewer minority deaths. Achievement of the Healthy People 2010 influenza vaccination objective for the elderly would prevent
4,450 minority deaths annually. The former estimate substantially exceeds the nearly 1,500 combined deaths among elderly African American and Hispanics from homicide, suicide, and motor vehicle accidents. The latter estimate exceeds 3,900 deaths from 10th leading cause of deaths for elderly African Americans and Hispanics.
Conclusions: Based on conservative estimates, elimination of racial and ethnic disparities in influenza vaccination would significantly reduce mortality among elderly African Americans and Hispanics.
Implications for Policy, Delivery, or Practice: Given the substantial impact of these disparities on minority deaths, elimination of racial and ethnic disparities in influenza vaccination and achievement of the Healthy People 2010 objective should become a national priority.
Primary Funding Source: RWJF

● Influenza Vaccination Trends Since 1997: Are We Making
Progress Toward 2010 Goals?
Sharon K. Long, Ph.D., Genevieve Kenney, Ph.D.
Presented By: Sharon K. Long, Ph.D., Principal Research
Associate, , Urban Institute, 2100 M Street NW, Washington,
DC 20037; Tel: 202.261.5656; Fax: 202.223.1149;
Email: slong@ui.urban.org
Research Objective: This study monitors progress toward the
Healthy People 2010 objectives of raising influenza vaccination rates among adults in high priority groups and eliminating racial/ethnic disparities. We also examine the extent to which differences in the characteristics of racial and ethnic minorities explain the racial and ethnic differences in vaccination rates.
Study Design: We rely on data from in-person surveys collected from 1997 to 2004 as part of the National Health
Interview Survey, a nationally representative survey of the civilian non-institutionalized population. Three key subgroups are examined: black non-Hispanic, white non-Hispanic and
Hispanic adults. We examine two important high priority groups: adults aged 65 and older and adults under age 65 with a chronic health condition. We compare targeting effectiveness across the different race and ethnic groups in
2004 relative to that achieved in the seven previous years to assess how well the vaccine is being targeted to the high priority groups and whether that has changed over this time period. To better understand the factors that affect receipt of an influenza vaccination, we estimate multivariate regression models. The multivariate analyses control for individual characteristics such as age, education, health insurance status, and income. Finally, we use decomposition methods to separate the observed racial/ethnic gaps in influenza vaccination rates into two parts: the part that is due to differences in the observed characteristics of the white and black (or white and Hispanic) adults and the part that is due to other factors.
Population Studied: The total sample size for the study consisted of 74,926 adults.
Principal Findings: There has been no meaningful improvement in influenza vaccination rates since 1997 within these high priority groups. In addition, there has been little progress toward narrowing racial and ethnic gaps in vaccination rates, and if anything, the gaps have been growing larger for some groups. Achieving the Healthy 2010 objectives would require a 22 percentage point increase in influenza vaccination rates for the elderly and a 24 percentage point increase for adults under age 65 with a chronic condition.
Even larger increases would be required to bring vaccination rates for racial and ethnic minorities in line with the objectives, since vaccination rates for whites within each high priority group are about 30 percent higher than for blacks and about
22 percent higher than for Hispanics. Very little of the whiteblack gaps in influenza vaccination rates can be explained by differences in underlying observed characteristics. By contrast, much of the white-Hispanic gap is explained by underlying observed characteristics.
Conclusions: Achieving the Healthy People 2010 objectives will require large increases in vaccination rates, particularly among racial and ethnic minorities. The sources of the persistent white-black differences in influenza vaccination rates are not well understood. Additional research is needed to identify the factors that are driving the white-black differences rates, which may include differences in careseeking behavior, in access to providers, or in provider behavior and treatment patterns.
Implications for Policy, Delivery, or Practice: The persistence of low vaccination levels among racial and ethnic minorities suggests that these populations would be disproportionately affected by an influenza pandemic. Greater investments in outreach and education and more effective targeting is important because of the complications and costs associated with influenza, particularly in light of a possible influenza pandemic.
Primary Funding Source: The Urban Institute
● Race, Income, and Operative Time
Jeffrey H. Silber, M.D., Ph.D., Paul R. Rosenbaum, Ph.D.,
Xuemei Zhang, MS, Orit Even-Shoshan, MS
Presented By: Jeffrey H. Silber, M.D., Ph.D., Professor of
Pediatrics and Director, Center for Outcomes Research, The
University of Pennsylvania/The Children's Hospital of
Philadelphia, 3535 Market Street, Suite 1029, Philadelphia, PA
19104; Tel: 215-590-5635; Fax: 215-590-2378; Email:
Silberj@Wharton.UPENN.edu
Research Objective: Operative time is often included in studies of quality and efficiency, and is well known to influence the rate of infection. However, operative time is rarely studied across institutions because of the need for costly chart review.
This paper describes how well the anesthesia claim from
Medicare can estimate chart times, and, using this model, describes how patient race and income are associated with operative time, after adjusting for other patient characteristics, procedure and hospital.
Study Design: To estimate anesthesia minutes in a patient’s chart, we utilized Medicare claims. For 1931 patients we abstracted charts with information that included the time of anesthesia induction and the time of entrance to the recovery room, and fit a model using Theil’s estimate. Using this model, we analyzed claims data to study the relationship between operative time and race and income. Median household income was defined by Zip code, grouping sample size into thirds: higher = above $41,858; lower = below $31,388.
Population Studied: We obtained Medicare claims on all patients who underwent general surgical and orthopedic surgical procedures in Pennsylvania between the ages of 65 and 85 over a two year period (N=77,638). Anesthesia time was estimated from Medicare Part B bills. Specifically, the dataset included claims with minutes of time provided by the anesthesia provider.
Principal Findings: Claim time from Medicare was highly predictive of chart time (Kendall’s tau = 0.93, p < 0.0001, median absolute error = 5.4 minutes). Using Huber’s robust m-estimation, we then studied the influence of race and income on 77,638 claims involving general surgery and orthopedics procedures, adjusting for 25 patient comorbidities, transfer status, MedisGroups Severity Score, procedure, and the individual hospital. The shortest anesthesia time was found in the higher income-white group.
Compared to this group, lower income-black patients had, on average, 8.01 minutes longer anesthesia time (p < 0.0001).
Placing this in context, history of paraplegia (an extremely difficult comorbidity to care for in the operative suite) typically

contributed 5 additional minutes to anesthesia time. Middle income-black patients displayed a 5.20 minute longer anesthesia time (P = 0.0017) than higher income-whites, while higher income-blacks showed no difference in anesthesia time compared to the higher income-white group (0.27 minutes, P
= 0.881). Anesthesia time for the lower income-white group was 1.03 minutes longer than for the higher income-white group (P<0.040) but middle income-whites showed no significant difference from higher income-whites, (0.68 minutes, P = 0.121).
Conclusions: After adjusting for procedure, cormorbidity, severity and hospital, the race and income of a patient appears to be associated with operative time.
Implications for Policy, Delivery, or Practice: It is of obvious concern that a most fundamental aspect of surgery--operative time-- is associated with race and income. Understanding why this occurs will require further study of patients, providers, and provider style of practice. Finally, using Medicare claims from the anesthesia provider enables the study of operative time with potentially vast populations of patients, and consequently provides a view on the practice of surgery that has never before been seen.
Primary Funding Source: AHRQ, The Leonard Davis Institute of Health Economics
● Anxiety/Depression Diagnoses and Antidepressant
Prescribing Patterns by Primary Care and Psychiatric
Specialties, NAMCS 1995-2003
Susan Stockdale, Ph.D., Isabel Lagomasino, M.D., Jeanne
Miranda, Ph.D.
Presented By: Susan Stockdale, Ph.D., Associate Research
Sociologist, Health Services Research Center, UCLA, 10920
Wilshire Blvd., Ste 300, Los Angeles, CA 90024; Tel: 310-794-
3732; Fax: 310-794-3724; Email: sstockdale@mednet.ucla.edu
Research Objective: Ethnic minority patients with depressive disorders are frequently underdiagnosed and undertreated.
National efforts to improve care for depressive and anxiety disorders have targeted primary care settings, the setting where minorities are most likely to seek mental health care, and thus have the potential to reduce disparities in care. This study examined national trends in depressive and anxiety diagnoses and antidepressant prescriptions by psychiatrists and primary care physicians for white, Latino, and black patients.
Study Design: We used data from the US National
Ambulatory Medical Care Survey for 1995 to 2003. Differences by race/ethnicity in diagnoses and prescription patterns over time were examined using standardized predictions based on parameters of multivariate logistic regression models
(controlling for age, gender, and insurance). All analyses were conducted separately for primary care and psychiatric specialties using weights provided by the National Center for
Health Statistics to obtain nationally representative estimates.
Population Studied: Physician office visits to primary care and psychiatric specialties by patients age 18 and over from
1995-2003 (N=52,504).
Principal Findings: Visits to primary care occurring in 2001-
2003 were more likely to result in a depression or anxiety diagnosis as compared with visits in 1995-1997 (OR=1.43,
CI=1.15, 1.79); time trends for the psychiatric specialties were not statistically significant. With diagnoses and prescriptions increasing over time overall, 64%-67% of visits to psychiatrists involving white or Latino patients resulted in a diagnosis of anxiety or depression, compared with about 55% of visits with black patients. In primary care, 4.3%-6% of visits involving white patients resulted in an anxiety/depression diagnosis, compared with about 2.5%-3.5% of visits with black or Latino patients. Prescriptions for antidepressants were more likely for psychiatric visits during the period 1998-2000 (OR=1.47,
CI=1.07, 2.00) (compared with 1995-1997), while for primary care the likelihood was greater during 2001-2003 (OR=1.38,
CI=1.12, 1.70). About 54%-62% of psychiatric visits with
Latinos and whites resulted in a prescription for antidepressants, compared to 50%-59% of visits with black patients. About 6.5%-8% of visits with white patients resulted in prescriptions for antidepressants, compared with 4%-5% of primary care visits with black or Latino patients.
Conclusions: Primary care visits involving black and Latino patients, and psychiatric visits involving black patients, are significantly less likely to result in a diagnosis of depression or anxiety. Psychiatric specialists are equally likely to prescribe anti-depressants to black or Latino patients (as compared with whites), but primary care office visits involving black or Latino patients are less likely to result in a prescription for antidepressants. These differences remain remarkably consistent over time.
Implications for Policy, Delivery, or Practice: While primary care and psychiatric specialists diagnose depression/anxiety less frequently in visits with blacks, and primary care physicians were less likely to diagnose depression/anxiety in visits with Latinos, differences in prescribing practices by race/ethnicity are apparent only for primary care physicians.
This may be a consequence of physician knowledge and ability to identify the disorder, differences in the pathways to care for psychiatric specialties versus primary care, and/or differences in patient preferences.
Primary Funding Source: MacArthur Foundation
● Quality and Inequality in Medicare Managed Care
Amal N. Trivedi, M.D., M.P.H., Alan M. Zaslavsky, Ph.D., Eric
C. Schneider, M.D., MSc, John Z. Ayanian, M.D., M.P.P.
Presented By: Amal N. Trivedi, M.D., MPH, Research Fellow,
Department of Health Care Policy, Harvard Medical School,
180 Longwood Avenue, Boston, MA 02115; Tel: (617)432-3138;
Email: trivedi@hcp.med.harvard.edu
Research Objective: Public reports about the quality of health-care organizations rarely assess whether care is provided equitably to racial subgroups. Our objectives were to assess variations in quality and racial disparity within
Medicare health plans, determine whether high-quality plans have smaller racial disparities in quality, and develop a model for publicly reporting racial disparities in the quality of care of health plans.
Study Design: To determine the correlation between quality and disparity, we fitted multilevel linear models predicting receipt of each HEDIS indicator, adjusted for demographic and health-plan characteristics. For each measure, we classified each health plan with twenty or more eligible black enrollees as having above average, average, or below average quality and disparity by testing whether the plan´s performance rate was both statistically different (p<0.05) from the average rate (using the t-test) and also in the top or

bottom quartile for performance among all plans. Similarly, for each measure, we classified plans as having above average, average or below-average white-black disparity.
Population Studied: We analyzed 448,790 observations for black and white Medicare enrollees in 164 managed care plans from 2001 to 2003 who were eligible for 4 HEDIS outcome measures assessing control of blood pressure for hypertension, glucose for diabetes, and cholesterol for diabetes or coronary disease.
Principal Findings: The mean performance on each HEDIS measure was significantly lower for black enrollees than white enrollees (all P<0.001), with absolute differences ranging from
5% for blood pressure control to 15% for LDL control after a coronary event. For each measure, over three quarters of the total disparity was attributable to differences within plans.
Among all plans, the standard deviation of mean clinical performance rates, derived from multilevel models, ranged from 7.3% for the blood pressure measure to 14.2% for cholesterol control after a coronary event. No significant relation between quality and racial disparity was evident on any of the four outcome measures after controlling for age, gender, and year of measurement. After also controlling for other individual and health-plan characteristics, a larger racial disparity in hemoglobin A1c control was noted in higher quality plans (r=0.4, p<0.001) but no significant association was found for any of the other three HEDIS measures. In adjusted analyses, three health plan characteristics predicted performance for at least 3 of the 4 HEDIS outcome measures we studied. Plans in operation >25 years, plans with >100,000
Medicare enrollees, and staff- or group-model plans had higher performance than younger, smaller and nonstaff/group model plans. No plan-level characteristics were consistently associated with racial disparity. Based on our statistical criteria, only one plan achieved both high quality and low disparity for more than one performance measure.
Conclusions: The results of HEDIS outcome measures vary widely across Medicare health plans and often reveal disparities within health plans. The magnitude of racial disparity in outcomes is not associated with the HEDIS outcomes achieved by a plan.
Implications for Policy, Delivery, or Practice: Plan-specific performance reports stratified by race can provide additional information about equity, a dimension of quality not assessed by most current public reporting systems.
Primary Funding Source: AHRQ
Call for Papers
The Role of Language & Literacy in Healthcare Disparities
Chair: Ninez Ponce, University of California, Los Angeles
Sunday, June 25 • 5:45 pm – 7:14 pm
● Literacy and Mortality among the Elderly
David Baker, M.D., M.P.H., Michael S. Wolf, Ph.D., M.P.H.,
Joseph M. Feinglass, Ph.D., Violeta Carrion, M.S., Julie
Gazmararian, Ph.D., M.P.H.
Presented By: David Baker, M.D., M.P.H., Chief, Division of
General Internal Medicine; Associate Director, Institute for
Healthcare Studies, Medicine, Northwestern University, 676
N. Saint Clair St., Suite 200, Chicago, IL 60611; Tel: (312) 695-
0917; Fax: (312) 695-0951; Email: dwbaker@northwestern.edu
Research Objective: Low literacy has been linked to less knowledge of medical conditions, lower use of preventive services, higher hospitalization rates, and poorer physical and mental health. We conducted this study to determine whether literacy independently predicts mortality.
Study Design: We conducted a prospective cohort study using data from the Literacy and Health of Medicare Managed
Care Enrollees (LHMMCE) study and the National Death
Index (NDI). The LHMMCE conducted in-home interviews in
1997 and measured demographics, health status, and health behaviors. Literacy was measured using the shortened version of the Test of Functional Health Literacy in Adults
(TOFHLA) and patients categorized as having adequate, marginal, or inadequate literacy. The LHMMCE database was merged with all-cause mortality data from the NDI through
2003. To determine whether inadequate or marginal literacy were independent predictors of mortality, we used multivariate
Cox proportional hazards models and sequentially controlled for demographics (age, gender, race/ethnicity, language spoken, site), socioeconomic status (annual income, years of school completed, former occupation), and baseline health, including physical and mental health (SF-36 summary scales), limitations in activities of daily living, and chronic conditions
(hypertension, heart failure, diabetes, coronary artery disease, arthritis, chronic lung disease, and cancer). In addition, we compared the bivariate and multivariate relationship between years of school completed and mortality. Finally, we added health risk behaviors (smoking status, alcohol use, physical activity, body mass index, seatbelt use) to the model to determine whether these mediated the relationship between literacy and mortality.
Population Studied: 3,260 new Medicare managed care enrollees in four U.S. metropolitan areas (Cleveland, OH;
Houston, TX; Tampa, FL; Fort Lauderdale-Miami, FL).
Principal Findings: The crude mortality rates for participants with adequate (N=2,094), marginal (N=366), and inadequate
(N=880) literacy were 18.9%, 28.7%, and 39.4%, respectively; p<0.001. After adjusting for demographics, the hazard ratios
(HR) for inadequate and marginal literacy were 1.88 (95% CI
1.60-2.22) and 1.33 (95% CI 1.07-1.66), respectively. After adding socioeconomic variables, the HRs decreased to 1.74
(95% CI 1.44-2.09) and 1.27 (95% CI 1.02-1.60) respectively. In

the final model that included baseline health variables, the
HRs were 1.61 (95% CI 1.32-1.95) and 1.20 (95% CI 0.95-1.51), respectively. The addition of health risk behaviors to the model did not substantially change these results. In contrast to literacy, years of school completed was not significantly associated with mortality in bivariate analyses and in multivariate models that included literacy; the HRs for 0-8, 9-
11, some college, and college graduate (12 years of education as reference group) were 0.83 (95% CI 0.66-1.06), 0.95 (95%
CI 0.77-1.17), 0.94 (95% CI 0.74-1.17), and 1.23 (95% CI 0.93-
1.60) respectively.
Conclusions: Among community-dwelling elderly, inadequate health literacy is a strong, independent predictor of mortality.
In contrast, education alone was not predictive. Differences in health behaviors do not explain the higher mortality for individuals with inadequate literacy.
Implications for Policy, Delivery, or Practice: Health care providers and payors should consider inadequate literacy as a marker of high risk for adverse outcomes and examine ways to identify patients and try to reduce their risk through intensive patient education or case-management.
Primary Funding Source: NIA, National Institute on Aging
● A Bitter Pill? Language Barriers to Prescriptions for
Patients with Limited English Proficiency (LEP): A Survey of Pharmacies
Michael Bradshaw, BS, Richard Hayney, RPh, Emmanuel
Ngui, DrPH, Glenn Flores, M.D.
Presented By: Michael Bradshaw, BS, 11010 W. Meinecke Ave,
#1, Milwaukee, WI 53226; Tel: (414) 258-7901;
Email: mbradsha@mcw.edu
Research Objective: To contact all Milwaukee County pharmacies to evaluate the ability to provide prescription labels, information packets, and oral communication in non-
English language (NEL)s, assess satisfaction with LEP patient communication, determine pharmacies’ suggestions for improving communication with LEP patients, and identify features of model pharmacies.
Study Design: In this cross-sectional survey of Milwaukee
County pharmacies, a pharmacist or technician at each pharmacy was asked questions by phone, fax or mail. The survey consisted of 45 Likert scale, yes/no, and open-ended questions that addressed selected socio-demographic and language service characteristics of pharmacies.
Population Studied: Pharmacists or technicians of 175
Milwaukee County pharmacies, focusing on interaction with their LEP patients.
Principal Findings: 73% of 175 pharmacies responded. 47% of pharmacies never/only sometimes can print NEL prescription labels, 54% never/only sometimes can prepare
NEL information packets, and 64% never/only sometimes can orally communicate in NELs. For pharmacies that orally communicate in NELs, 11% used patient family members/friends to interpret. Only 55% of pharmacies were satisfied with their LEP patient communication. In multivariate analyses, ability to orally communicate in NELs was significantly associated with chain pharmacies (OR=3.2 [1.1-
9.0]), phone interpreter use (OR=2.9 [1.1-7.3]), and community pharmacies (OR=0.2 [0.1-0.5]). Pharmacies suggestions for improving LEP patient communication included continuing education; chain-wide lists of resources to call; hiring bilingual staff; using phone interpreters; analyzing translation quality/accuracy of labels and information packets; and adding more languages to pharmacy software. Model pharmacies shared a combination of validated NEL computer programs, bilingual staff, and phone interpreters.
Conclusions: About half of the pharmacies surveyed never/only sometimes can print NEL prescription labels, prepare NEL information packets, or orally communicate in
NELs. Almost half are unsatisfied with their LEP patient communication, and 1 in 9 pharmacies that orally communicate in NELs use patient family members/friends to interpret. Chains and those using phone interpreters are more likely and community pharmacies are less likely to be able to orally communicate in NELs. Improvements in pharmacies'
LEP patient communication may result by increasing bilingual staff, the quality and number of NELs in existing computer programs, phone interpreter use, and continuing education.
Implications for Policy, Delivery, or Practice: The study findings suggest that many urban pharmacies may not be providing adequate services to LEP patients, thereby increasing the risk of compromised patient safety. Excellent communication with LEP patients can be achieved by using validated computer programs to prepare NEL prescription labels and information packets, hiring bilingual staff, and using phone interpreters when in-person interpreters are unavailable, as already occurs in certain model pharmacies.
Primary Funding Source: NHLBI
● Pediatricians' Use of Language Services for Limited
English Proficient (LEP) Families: A National Survey
Dennis Kuo, M.D., Karen G. O'Connor, Glenn Flores, M.D.,
Cynthia S. Minkovitz, M.D., M.P.P.
Presented By: Dennis Kuo, M.D., Fellow, General Pediatrics &
Adolescent Medicine, Johns Hopkins University School of
Medicine, 600 North Wolfe Street, Park 364, Baltimore, MD
21287; Tel: (410) 614-0910; Fax: (410) 502-5440;
Email: dkuo5@jhmi.edu
Research Objective: LEP patients confront multiple barriers to health care access in the United States. Adequate language services are essential to providing high quality health care for children. Trained professional interpreters and bilingual providers are associated with improved quality of care for LEP patients, but little is known about pediatricians' use of language services. The research objectives were to examine pediatricians' provision of language services to LEP patients and the physician, practice, and state characteristics associated with use of these services.
Study Design: Data were obtained from the Periodic Survey of
Fellows #60, a nationally representative survey of American
Academy of Pediatrics (AAP) members. 1,829 surveys were mailed and responses obtained from 58%. Use of six language services (bilingual physicians, bilingual staff, bilingual family members, professional interpreters, telephone interpreters, and translated written materials) was assessed.
Multivariate analysis examined factors associated with each language service after adjusting for physician (age, gender, ethnicity), practice (setting, location) and state (LEP prevalence, Medicaid/SCHIP reimbursement) characteristics.
Population Studied: 698 non-trainee US members of the AAP with LEP patients.

Principal Findings: Respondents report a mean of 13.4%
(median=5.0%) of patients with LEP. Female, younger, and
Latino physicians care for higher percentages of LEP patients
(p<.01). Bilingual family members (70%) and bilingual staff
(58%) are the most frequently reported language services.
40% of respondents use professional interpreters and 28% use telephone interpreters. Only 35% of practices provide translated written materials. In bivariate analysis, pediatricians in rural and solo/2-physician practices report higher use of family members and lower use of professional interpreters (p<.01). Family members are among the most frequently used method of interpretation regardless of LEP prevalence in states. In multivariate analysis, pediatricians in states with higher proportions of LEP persons are more likely to use bilingual staff (OR 4.63; 95% CI 3.22, 6.67) but less likely to use professional interpreters (OR .46; 95% CI .31,
.69). Pediatricians in states with Medicaid/SCHIP reimbursement for language services are more likely to use professional interpreters (OR 2.05; 95% CI 1.10, 3.83).
Conclusions: Almost three-quarters of US pediatricians use untrained family member interpreters to communicate with
LEP patients and their families. Smaller and rural practices are at greater risk of using family member interpreters. Most pediatricians do not provide translated written materials.
Pediatricians in regions with the highest proportions of LEP persons are least likely to provide appropriate language services. Medicaid/SCHIP reimbursement for professional language services may increase use of trained interpreters and quality of care for LEP children and their families.
Implications for Policy, Delivery, or Practice: Appropriate language services for LEP patients should be improved as part of ongoing efforts to improve quality of care; in particular, special attention is needed to providing more translated written materials to patients and reducing the use of family members as interpreters. Interventions should be targeted in practices and states with high proportions of LEP patients.
Current efforts to expand third-party reimbursement for language services may help reduce existing health care disparities.
Primary Funding Source: HRSA
● The Digital Divide in Public E-Health: Accessibility and
Privacy in State Health Department Websites
Edward Miller, Ph.D., M.P.A., Darrell West, Ph.D., Edward
Alan Miller, Ph.D., M.P,A.
Presented By: Edward Miller, Ph.D., M.P.A., Assistant
Professor, Taubman Center for Public Policy, Brown
University, 67 George Street, Box 1977, Providence, RI 02912-
1977; Tel: 401-863-9311; Email: edward_a_miller@brown.edu
Research Objective: With the significant increase in online resources at official government health sites have come questions concerning equity of access and the confidentiality of electronic medical materials. The purpose of this paper is to examine accessibility and privacy in the context of state public health department websites.
Study Design: Using a content analysis of health department sites undertaken each year from 2000 to 2005, several different dimensions of accessibility and privacy were investigated: readability levels, disability access, non-English accessibility, and confidentiality. The Flesch-Kincaid method was used to judge the grade-level readability of the front page of each health site. Watchfire’s automated “Bobby” software on usability was used to assess how accessible state health websites were to individuals with various types of impairments. Language access was evaluated by determining whether state health websites provided information in languages other than English or had links to common translation software. Confidentiality was evaluated by examining privacy and security statements.
Population Studied: This studied analyzed public health department websites maintained by the 50 state governments.
Principal Findings: The average grade readability level of state health websites was at 10.9th grade in 2005, with 62 percent reading at the 12th grade level, well above the comprehension level of the typical American. Only 42 percent of public heath sites were accessible to the disabled; only 34 percent provided for non-English translations. Eighty-six percent had privacy policies and 62 percent security policies.
Though there was progress on privacy and security over time, there was little to no progress on the dimensions of accessiblity examined. There was considerable variation across regions, however, though no single region was strong on all aspects of accessibility, privacy, and security.
Conclusions: Ideally, all citizens should share equally in the benefits of digital technology. Based on that standard, however, public e-health clearly has a long way to go. The level at which state public health sites are written represents a major accessibility barrier as do the failure of many government sites to be usable by the disabled or those who do not speak English. This makes it difficult for many people to acquire timely health information, compare health care providers, or access online medical services.
Implications for Policy, Delivery, or Practice: The gap between information haves and have-nots should be a major concern to health care policymakers. Inaccessible websites hurt the underprivileged and make it difficult to justify the technology investment that has taken place in state governments around the country. Unless these concerns are addressed, public e-health will remain the domain of highlyeducated and affluent individuals who speak English and do not suffer from physical impairments.
Primary Funding Source: No Funding
● To Err is Human: Literacy and Misunderstanding of
Prescription Drug Labels
Michael Wolf, MA, M.P.H., Ph.D., Terry Davis, Ph.D., Pat F.
Bass, M.D., M.P.H., Hugh Tilson, M.D., Dr.P.H., Ruth M.
Parker, M.D.
Presented By: Michael Wolf, MA, MPH, Ph.D., Assistant
Professor, Institute for Healthcare Studies, Northwestern
University, 676 N. St. Clair Street Suite200, Chicago, IL 60611;
Tel: 312-695-0459; Email: mswolf@northwestern.edu
Research Objective: Patients’ literacy and their ability to understand medication information have increasingly been viewed as a safety issue. We examined whether adult primary care patients were able to understand instructions found on the primary container label of five common prescription medications. We hypothesized that low literacy would be associated with higher rates of misunderstanding and incorrect demonstration of instructions.
Study Design: In-depth cognitive interviews including a literacy assessment were conducted. The main outcome

measure was understanding of medication label instructions, which was determined by a blinded physician panel review of patients’ verbatim responses for each of the five prescription labels. For one of the medication labels, patients were also asked to calculate how many pills were to be taken daily to test whether understanding translated to an ability to practically demonstrate how to take the medication.
Population Studied: 395 adults who were receiving outpatient primary care services at two community health centers
(Jackson, Michigan; Chicago, Illinois) and at one public hospital clinic (Shreveport, Louisiana) were recruited for the study.
Principal Findings: Rates of understanding ranged from
67.1% to 91.1% for the five medication labels. Forty-six percent of patients misunderstood one or more of the label instructions, and the prevalence rates of misunderstanding one or more labels for adequate, marginal, and low literate patients were 37.7%, 51.5%, and 62.1% respectively. Patients reading at the 6th grade level or below (low literacy) were less able to correctly interpret the meaning of four of the five labels compared to patients with adequate literacy (9th grade and above), with the exception of the instructions associated with the drug Furosemide (p=0.09). After controlling for relevant potential confounding variables and risk factors, both low
(AOR 2.81, 95% CI 1.38-5.71) and marginal (7th-8th grade; AOR
2.13, 95% CI 1.15-3.93) literacy levels were significantly associated with misunderstanding of label instructions.
Among patients with low literacy who properly understood the label instructions (70.7%), less than half were able to demonstrate comprehension (34.7%) of the instructions. In multivariate logistic regression analysis, low literacy was a significant independent predictor of correct demonstration of the label instruction (AOR 4.32, 95% CI 2.10 – 6.92).
Conclusions: Patients with limited literacy are at greater risk for misunderstanding instructions on prescription medication labels, and this may be a common source of medication errors. In addition, correct interpretation of instructions was not an assurance of practical comprehension of the daily administration of a prescribed drug.
Implications for Policy, Delivery, or Practice: New standards should be considered to ensure medication labels are useful to patients. Provider-patient communication on medication administration should also be emphasized.
However,recommended low literacy communication strategies for physicians, such as the ‘teach back’ technique may be inadequate, and actual demonstration of desired patient behaviors should be targeted.
Primary Funding Source: No Funding
Disparities
Poster Session B
Monday, June 26 • 5:30 pm – 7:00 pm
● A Predictive Model of Attrition In a Randomized
Intervention Among African American Women
Mary K Anthony, Ph.D., Lisann Gittner, M.Sc., Salwa
Hassanein, Ph.D. candidate, Jacqueline Martin, RN, PA,
Pamala Murphy, M.D.
Presented By: Mary K Anthony, Ph.D., Associate Professor,
College of Nursing, Kent State University, BO Box 5190, Kent,
OH 44242; Tel: (330) 672-8824; Fax: (330) 672-1564; Email: manthony@kent.edu
Research Objective: African –American women are more obese, have greater difficulty in losing weight and maintaining weight loss. Successful weight loss occurs when interventions are culturally adapted and of sufficient length to change lifestyle behaviors. Unfortunately, extended intervention protocols designed for lifestyle modifications are also the most challenging in maintaining subject retention. The purpose of this study was to identify what personal demographic and social characteristics, health and illness characteristics and self efficacy were predictive of African-
American women’s ongoing participation in a culturally adapted weight loss intervention.
Study Design: One hundred African American middle aged obese women were recruited from a Midwestern HMO. Five cohorts of women were recruited over a 5 month time period and randomized into a 6-month Take HEED: Health Eating and Exercise Decisions intervention. Each 6-month intervention protocol consisted of 15 sessions that included health behavior changes related to diet, nutrition- NCEP Step 1 diet-, motivation and exercise- CHANGE. The initial six sessions were held weekly and the subsequent nine sessions were held every other week. Sessions were facilitated by either a dietitian or African-American Registered Nurse. To date, three cohorts have completed the HEED intervention n = 53.
Preliminary findings are reported, and final model building will be conducted when all five cohorts have completed the HEED intervention March, 2006.
Population Studied: The average age of women was 53.4 years SD = 6.4 with 14.4 years of education. Almost 57% were married, 83% were employed and 50% had an annual income of greater than $50,000. Average body mass index was 37.8
SD = 6.1. Women attended on average 55.7% SD= 26.7% of
HEED sessions.
Principal Findings: Variables from baseline data were assessed for their relationship with the percent of sessions attended. Variables or proxies were chosen based on previously identified barriers to retention. Statistically significant personal and social characteristics included age r =
.39, marital status r = -.31, number of people living in the household r = 29. Likewise health and illness characteristics that were significantly associated with attendance at HEED sessions were the number of comorbid conditions r = .38 and

the degree of pain while exercising r = .41. Nonsignificant factors were income, employment status, previous weight loss attempts, BMI and self efficacy. Anecdotal reasons for not attending HEED sessions included change of jobs, caregiving for family members, illness or change from HMO insurance.
Conclusions: Without an adequate dose of an intervention, success of weight loss programs are jeopardized. These preliminary findings suggest that older women who have social support, and have more health and illness problems are more likely to maintain participation in an extended intervention protocol. These factors have demonstrated an initial relationship to retention of participants that affects the dose of the intervention, its probable success and effectiveness.
Implications for Policy, Delivery, or Practice: Clinical investigations that encourage lifestyle changes are expensive in cost and time and thus identifying culturally relevant factors that affect retention can do much to improve both the participation of minorities in studies to improve health, address health disparities, and decrease the burden on the health care system.
Primary Funding Source: Garfield Memorial Foundation
● Health Status and Complimentary and Alternative
Medicine (CAM): Assessing the Effects of Perceived
Health Status and Satisfaction with Conventional Care on the use of CAM
Winfred Avogo, MA, Jemima Frimpong, M.P.H., Sam Kim,
MA, Patrick Rivers, Ph.D., M.B.A.
Presented By: Winfred Avogo, MA, Graduate Research
Associate, Department of Sociology/Centre for Population
Dynamics, Arizona State University, Arizona State
University/Department of Sociology, Mesa, AZ 85287-4802;
Tel: 480 965 3546; Fax: 480 965 0065; Email: winfred.avogo@asu.edu
Research Objective: Research has shown increasing popularity of various forms of complimentary and alternative care in the US; however, the influence of these therapies have been largely exploratory without a systematic understanding of the individual and institutional factors driving utilization. In this paper, we address the need to develop and test explicit explanatory hypotheses by examining perceived health status and patient satisfaction with conventional care. We hypothesize that CAM utilization varies inversely with perceived health status and the level of satisfaction with conventional care. This relationship is explained by reasons for use of CAM for both patients in good health and the chronically ill.
Study Design: The study uses data from the 2001 Survey on
Disparities in Quality of Health Care conducted by the
Commonwealth Fund. A stratified sample design was used to conduct random-digit dial telephone surveys of a nationally representative sample of adults age 18 and older living in continental United States. The sample was designed to target
African-American, Hispanic and Asian Households. Sample weights are used to correct for the disproportionate sample design and standard errors are adjusted for the complex survey design. The main outcome measure is use of four main
CAM therapies in the last two years. Primary independent variables reflecting the hypothesis of the study are perceived health status and satisfaction with conventional care.
Standard measures of demographic and socio-economic status are included in our analysis as covariates. The chisquare is used to test bivariate relationships between CAM and the main explanatory variables. Multivariate logistic regression methods are used to analyze the effects of health status and other predictors on use of CAM.
Population Studied: An effective sample size of 4684 weighted cases was used.
Principal Findings: Overall, 32 percent of the sample used
CAM therapies. Utilization of CAM therapies varied inversely with health status. Those who were in poor health were 15 % more likely as those in good health to report use of CAM.
Those who were dissatisfied with the overall quality of care they received in the last two years were more likely to use alternative medicine. Those who were in poor health or chronically ill and satisfied with conventional care used CAM more than those who were chronically ill and dissatisfied with conventional care. The chronically ill who were dissatisfied with conventional care used CAM as an alternative rather than complimentary to conventional care.
Conclusions: CAM use among Americans is high. This study shows that the chronically ill, those dissatisfied with conventional care and have difficulties accessing care due to cost, are likely to use CAM. Use among these groups is primarily seen as an alternative rather than complementary to conventional care. Perceived health status is related to enhanced access to conventional care.
Implications for Policy, Delivery, or Practice:
Considerations should be given to the development of a delivery system that effectively incorporates conventional care and CAM into patient care. The impact of this approach could be instrumental in addressing health care cost, satisfaction and quality of care.
Primary Funding Source: No Funding
● Obesity, Ethnicity and Cardiovascular Diseases
Jolene Ayres-Oddiah, John Kwagyan, PH.D
Presented By: Jolene Ayres-Oddiah, M.P.H. Program, Howard
University College of Medicine, 2041 Georgia Ave NW,
Washington, DC 20060; Tel: 202- 865-7213; Email: jkwagyan@howard.edu
Research Objective: Cardiovascular disease is the leading cause of death in the United States and it disproportionately affects African Americans. Obesity is known to be associated with cardiovascular disease risk factors including diabetes mellitus, high cholesterol, and hypertension. African
Americans are more likely to be overweight and suffer greater risk of these cardiovascular diseases than other ethnic groups.
Genetic factors, improper nutrition and physical inactivity have been noted to be the leading cause of these increases in risk among African Americans. However, little or no data examines the prevalence of these cardiovascular disease risk factors in obese individuals in different ethnic groups. The objective of this study is to examine and compare African Americans and
Caucasians, the prevalence of common cardiovascular disease risk factors in the context of obesity.
Study Design: A cross-sectional sample of 3324 individuals, of which 904 were obese, obtained from the National Health and
Nutrition Examinations Survey, NHANES III database were studied. The NHANES III is a survey of a representative sample of the civilian, non-institutionalized population of the

United States that was conducted periodically from 1988 to
1994 by the National Center for Health Statistics. The survey was designed to estimate the prevalence of common chronic conditions and associated risk factors for disease control and prevention. Chi-Square tests were used to compare the prevalence of hypertension, diabetes and high cholesterol, separately, among non-obese and obese individuals. To reduce the potential influence due to age, data was restricted to an age range from 30 to 55 years.
Population Studied: African Americans and Caucasians aged,
30 to 55 years.
Principal Findings: The data consist of 2291 African
Americans, 36% obese and 957 Caucasians, 39% obese. In general, obese individuals had higher prevalence of hypertension, diabetes and high cholesterol than non-obese individuals. Among the non-obese individuals, the results shows that African Americans has a higher prevalence of hypertension than Caucasians [odds ratio =1.5, CI=(1.2-1.9),p
<0.001], diabetes [odds ratio=1.5, CI=(1.01-2.3), p<0.5] and high cholesterol [odds ratio =1.3, CI=(1.1-1.5), p <0.001].
However, among obese individuals, there were no significant difference in hypertension and diabetes between African
Americans and Caucasians. Obese African Americans had a higher cholesterol levels than Caucasians [odds ratio=1.2,
CI=(1.1-1.9), p<0.01].
Conclusions: The study was undertaken to examine and compare cardiovascular disease risk factors between African
Americans and Caucasians. Consistent with other studies, the prevalence of diabetes, hypertension, and high cholesterol were higher among the obese population than non-obese irrespective of ethnicity. Among non-obese individuals, the prevalence were higher in African Americans than Caucasians.
However, among the obese individuals, the prevalence of these risk factors appears to be the same in both populations.
Implications for Policy, Delivery, or Practice: Promoting healthy lifestyle is essential in reducing the associated cardiovascular disease risk factors in obese population.
Endeavoring in proper cardiovascular exercises and nutritional intakes will promote healthy body weight and reduce the morbidity and mortality associated with obesity.
Primary Funding Source: Nof Funding
● Prevalence of Pain and Associations with Socioeconomic and Health Factors: Results from Two National Surveys.
Amy Bernstein, Sc.D., Alan J. Cohen, M.A.
Presented By: Amy Bernstein, Sc.D., Chief, Analytic Studies
Branch/OAE, , CDC/National Center for Health Statistics, 3311
Toledo Road, Hyattsville, MD 20782; Tel: (301) 458-4700; Fax:
(301) 458-4036; Email: abernstein@cdc.gov
Research Objective: Both perceptions and reporting of pain are subjective. Although prevalence of many different types of reported pain differ markedly by gender, age, race/ethnicity, and poverty, the reasons underlying these differences are not well understood. This analysis documents differences in the prevalence of selected pain measures by racial and ethnic group, and examines correlations between pain and gender, age, health status, poverty, and obesity.
Study Design: Data examined include prevalence of multiple measures of pain, including pain lasting more than 24 hours at some time in the past month; severe headache or migraine; low back pain; and joint pain, by sex, age, race/ethnicity, and poverty. The study also explores the correlations of pain measures with other health status measures, including perceived health status, limitation in usual activity, serious psychological distress, and obesity, among these socioeconomic population subgroups.
Population Studied: Data come from National Health and
Nutrition Examination Survey and the National Health
Interview Survey. Both of these surveys are nationally representative probability samples of the civilian, noninstitutionalized population of the United States.
Principal Findings: Women and white adults report more of almost all types of pain than do men and other racial/ethnic groups. Preliminary results indicate that people of Mexican origin report considerably less pain lasting 24 hours or more over the past month (15%) than do Black-only (22%) or whiteonly Americans (28%). Asians report less pain on all measures examined than do people of other races and ethnicities. Among those reporting pain lasting more than 24 hours, few differences exist in the percentage reporting that the pain had lasted for more than one year by race, ethnicity, or gender. Asian and non-Hispanic black women reported low back pain about 30% more often, and Hispanic women reported it 40% more often than their male counterparts.
Blacks are somewhat less likely to report any joint pain than whites, but they are more likely to identify the joint pain they have as being severe (7 or more on a scale of 1-10). Persons living in poverty reported more back pain, headache, neck pain than nonpoor or near poor adults, and this relationship holds when analyzed by race and ethnicity.
Conclusions: Patterns of pain self-reporting vary considerably by race, ethnicity and poverty, controlling for age and sex, and pain is strongly associated with other health status measures.
Women, white adults, and people living in poverty were more likely to report most types of pain than were men and other racial and ethnic groups.
Implications for Policy, Delivery, or Practice: Results of this analysis may encourage practitioners to query for pain symptoms in particular populations that tend to report less pain, or to learn more about the association of pain reporting with other health status, cultural, and demographic and socioeconomic factors. The relationships between reported pain and race/ethnicity, gender, age and health status are complex and raise important issues for public health initiatives to reduce disparities in health care policy and practice.
Primary Funding Source: No Funding
● Effect of Neighborhood Racial and Ethnic Composition on Disparities in Imaging Utilization
Mythreyi Bhargavan, Ph.D., Cristian Meghea, Ph.D., Jonathan
H. Sunshine, Ph.D.
Presented By: Mythreyi Bhargavan, Ph.D., Director of
Research, Research, American College of Radiology, 1891
Preston White Dr, Reston, VA 20191; Tel: 703-715-4394; Fax:
703-264-2443; Email: mbhargavan@acr.org
Research Objective: Racial and ethnic disparities in health care in the United States have been well-documented in over
600 studies. The small-area variation perspective on these disparities suggests that the long-observed geographic variations in practice patterns may explain some of these disparities, because minorities are geographically

concentrated in certain areas. For identical medical conditions, persons living in high-minority areas may receive a very different set of medical services than those in mostly white neighborhoods. In this study, we examine the role of neighborhood racial/ethnic composition on the utilization of medical imaging, one of the fastest-growing components of healthcare costs in the United States.
Study Design: We examine the extent to which differences in characteristics of the zip-code of a patient’s residence, such as racial and ethnic composition, population density, percentage poor, and other demographic and socio-economic factors, explain differences in imaging utilization, while controlling for individual, provider, and neighborhood characteristics.
Using claims data from a large national employer plan for five years (1999-2003), we identify patients with certain conditions, such as acute upper respiratory tract symptoms, headache, and knee pain, and analyze each condition independently. For each patient who presents with a condition, we analyze the following outcomes: (a) whether an image was ordered, and
(b) the total number of images, (c) the type(s) of image(s)
(CT, MRI, etc.), and (d) total imaging utilization measured in global relative value units (RVUs). We use logistic regression for outcome (a), count-data regression models for (b), multinomial logistic for (c), and log-linear regression for (d).
Explanatory factors include characteristics of the zip-code
(such as percent of population in each minority group, income), physician specialty, practice setting (office, hospital, etc.), type of insurance plan, and available patient characteristics (age, gender, actuarial risk score).
Population Studied: Persons enrolled in the health insurance plan of a large national employer during the years 1999-2003
Principal Findings: Preliminary results on patients with knee pain indicate that controlling for racial/ethnic and socioeconomic characteristics of the zip code and for patient age, gender and risk score, high percent of poor or minority in the zip code have no significant effect on probability of the patient receiving a knee MRI, but personal characteristics (age, gender, risk score) and population density (additional 1% population density results in 7% higher odds of an MRI, p<0.01) do. In contrast, analysis of cardiac imaging indicated that patients who lived in high-Hispanic zip-codes had a lower probability of being imaged than high-white zip-codes.
Among those who were imaged, patients in high-black zipcodes had fewer images than those in high-white zip-codes.
Conclusions: The extent of variation in the utilization of imaging across minority and white zip-codes is different for different conditions. Further analysis of a wider range of criteria will allow us to identify the kinds of symptoms for which neighborhood-based characteristics most affect volume of imaging.
Implications for Policy, Delivery, or Practice: Our results will assist policy makers and payers in designing effective incentive structures and practice guidelines to ensure equitable utilization across demographic categories and geographic areas.
Primary Funding Source: No Funding
● Neighborhood Socio-Economic Status and Allostatic
Load
Chloe Bird, Ph.D., Brian Finch, Ph.D., D. Phuong Do, M.Phil.,
Teresa Seeman, Ph.D., Jose Escarce, M.D., Ph.D., Nicole
Lurie, M.D.
Presented By: Chloe Bird, Ph.D., Sociologist, Health, RAND,
1776 Main Street, Santa Monica, CA 90407-2138; Tel: (310)
393-0411 x6260; Fax: (310) 260-8159; Email: chloe@rand.org
Research Objective: A growing body of research demonstrates relationships between residential neighborhood context and health. However, few studies examine potential biological pathways through which neighborhoods affect health. We examined the extent to which neighborhood characteristics are related to biological markers of stress, based on a summary index of allostatic load, adjusting for individual characteristics.
Study Design: Using 3-level hierarchical linear regression, we analyzed National Health and Nutritional Examination Survey
III (NHANES) interview and laboratory data for 14,413 adults
(ages 19.5 to 90, mean = 48) from 83 counties and 1805 census tracts, merged with data on sociodemographic characteristics of their residential census tract. The sample was 47% male; 43% white 27% black, 26% Hispanic, 4% other; mean income (or mean income/poverty ratio =2.41),
53% employed, and 58% with at least a high school education.
Allostatic load was measured as a summary score (range 0-9) based on clinical cut points for 9 indicators from 3 systems: metabolic (total cholesterol, HDL cholesterol, glycosylated hemoglobin, waist/hip ratio), cardiac (systolic and diastolic blood pressure, radial heart rate) and inflammatory (c-reactive protein, serum albumin).
Population Studied: Our analyses included 14,413 adults from 83 counties and 1805 census tracts, who completed surveys and medical exams, were not missing on key components of the outcome measures, and for whom residential census tract could be geocoded. The sample was
47% male; 43% white 27% black, 26% Hispanic, 4% other.
Subjects ranged in age from 19.5 to 90 (mean = 48); 53% were employed and 58% had at least a high school education. The mean family income/poverty ratio was 2.41.
Principal Findings: Across all models, individual level socioeconomic controls including Hispanic ethnicity (p < .001), lower family income (p < .03), lower education (p < .05), lack of employment (p < .005), age (p < .001) and being male (p <
.001) were independently associated with higher allostatic load. Even after adjusting for these individual characteristics, a higher proportion of adults in the census tract with less than high school education was associated with a higher allostatic load (coefficient = 0.46, p < .0001). In a separate analysis, higher median household income (in 10k units) was associated with lower allostatic load independent of individual characteristics (coefficient = -0.03, p = .01).
Conclusions: Allostatic load is a biomarker of early health decline. The association of lower socioeconomic status with higher allostatic load, controlling for individual characteristics, suggests a potentially crucial pathway through which low-SES neighborhoods may affect both individual and population health.
Implications for Policy, Delivery, or Practice: By assessing potential pathways through which health—and health disparities may be generated, this study is part of a larger

effort aimed at developing an understanding of whether changing neighborhood features, such as neighborhood quality could improve health and reduce health disparities.
The mechanisms through which these effects are produced need to be explored.
Primary Funding Source: NIEHS
● Cancer Incidence in Medicare and Dually Eligible
Beneficiaries: The Intersection of Age, Race, and Poverty
Cathy Bradley, Ph.D., M.P.A., Zhehui Luo, Ph.D., Charles
Given, Ph.D., Caralee Roberts, Ph.D.
Presented By: Cathy Bradley, Ph.D., MPA, Professor, Health
Administration, Virginia Commonwealth University, 1008 E
Clay Street, Richmond, VA 23298-0203; Tel: 804-828-5217; Fax:
804-828-1894; Email: cjbradley@vcu.edu
Research Objective: To examine how socioeconomic status, age, and race influence cancer incidence rates within a publicly insured elderly population.
Study Design: Population-based cohort study individuals diagnosed with a first primary cancer.
Population Studied: All Medicare and Medicaid beneficiaries age 65 years and older identified from the Michigan Tumor
Registry as having a first primary diagnosis of female breast, prostate, colorectal, or lung cancer. A total of 125,900 subjects who were age 65 years and older were identified.
Principal Findings: Lung cancer was the only cancer that definitively occurred at a much higher rate in the dually eligible sample relative to the Medicare sample. Relative to white elderly Medicare patients, elderly white dually eligible patients have lower rates of breast and prostate cancer and slightly elevated rates of colorectal cancer. Dually eligible Blacks, on the other hand, had higher prostate, colorectal, and lung cancer (men only) incidence rates relative to all white patients, regardless of eligibility status. Dually eligible Black men had a
2.5 higher incidence rate of prostate cancer relative to white dually eligible men.
Conclusions: Our findings show that national estimates of disease incidence may underestimate how disparate racial health inequalities truly are among the lowest income groups.
Poor Blacks have much higher rates of cancer relative to poor whites—so much so that the national trend of white women having a higher incidence of breast cancer is not present in the dually eligible sample. There is considerable room for improvement in cancer detection among the low-income.
Implications for Policy, Delivery, or Practice: Our findings have three important policy implications. First, policy makers who are concerned with reducing health care disparities need appropriate data. Further research using population-based datasets such as the linked Tumor Registry, Medicare, and
Medicaid files is needed and should be supplemented, where possible, with individual data regarding education and income. Our findings show that national estimates of disease incidence may underestimate how disparate racial health inequalities truly are among the lowest income groups.
Second, interventions focused on African Americans and lowincome populations are needed to reduce disparities in cancer incidence. These interventions are needed prior to when patients become eligible for Medicare and Medicaid and should encompass environmental and social risk factors in addition to health care factors. Such interventions may reduce mortality, the severity of Medicare’s and Medicaid’s case mix, and health care expenditures. Finally, cancer control efforts are potentially important for reducing the number of dually eligible individuals.
Primary Funding Source: NCI
● Leave No Asthmatic Child Behind: The Cultural
Competency of Asthma Educational Materials
Jane M. Brotanek, M.D., M.P.H., Kristen Grimes, Glenn
Flores, M.D.
Presented By: Jane M. Brotanek, M.D., M.P.H., Assistant
Professor, Pediatrics, Medical College of Wisconsin, 8701
Watertown Plank Road, MS 756, Milwaukee, WI 53226; Tel:
(414) 456-5778; Fax: (414) 456-6385; Email: jbrotane@mcw.edu
Research Objective: Minority children are at high risk for asthma and its associated morbidity and hospitalizations.
Cultural competence leads to higher quality care for asthmatic children, yet it is not known whether asthma educational materials targeting minority children are culturally competent.
The objective of this study was to develop and use a tool to evaluate the cultural competency of asthma educational materials.
Study Design: The Wisconsin Asthma Coalition Disparities
Workgroup, a diverse group of representatives from non-profit organizations, hospitals/clinics, and local/state government, held a series of meetings to develop, test, and apply a tool for evaluating the cultural competency of all asthma educational materials in the state of Wisconsin targeting minorities. The tool, based on the Flores model of cultural competency, consists of 7 domains: language, normative cultural values, folk illnesses, parent/patient beliefs, provider practices, illustrations, and an overall assessment. Asthma educational materials were obtained via multiple letters, emails, and phone calls to healthcare organizations, agencies, and clinics.
Three reviewers from the appropriate cultural group independently evaluated each material using the tool created by the workgroup. All 7 domains were scored using a 5-point
Likert scale (1=poor, 2=fair, 3=good, 4=very good, 5=excellent), and consensus was reached for each score.
Population Studied: Review of asthma educational materials
Principal Findings: Only 17 asthma educational materials targeting minorities exist in the state: 16 for Latinos, 1 for
Native Americans, 0 for African Americans, and 0 for
Asians/Pacific Islanders. Total scores for each material ranged from 1-3, with a mean +/- SD = 2.3 +/- 0.5. The highest mean domain scores were for language (3.5 +/- 1.1) and illustrations
(3.5 +/- 1.2); the lowest score was for folk illnesses (1.1 +/- 0.2), with significant weaknesses identified for normative cultural values (2.6 +/- 0.7); parent/patient beliefs (1.8 +/- 0.7); and provider practices (1.9 +/- 0.6).
Conclusions: Few asthma educational materials targeting minorities exist in the state, and those available are not culturally competent. Most materials targeted Latinos; only 1 targeted Native Americans, and none targeted African-
Americans or Asians/Pacific Islanders. More culturally competent asthma educational materials for minorities are needed.
Primary Funding Source: The Center for the Advancement of
Underserved Children and the Department of Pediatrics,
Medical College of Wisconsin

● Ethinic Disparties and Health Service Usage Post Stroke
Paul Brown, Dr, Lorna Dyall, Dr, Ngaire Kerse, Assoc Prof,
Linda Cameron, Assoc Prof, Kristie Carter, Ms, Valery Feigin,
Assoc Prof
Presented By: Dr. Paul Brown, Senior Health Economist and
Director, Centre for Health Servcies Research and Policy,
School of Population Health, University of Auckland, Private
Bag 92019, Auckland, 0005; Tel: 64-9-373-7599; Fax: 64-9-373-
7503; Email: pm.brown@auckland.ac.nz
Research Objective: Given the increasing incidence of stroke in developed countries, health care systems must ensure their services are providing quality and appropriate services to all.
In a previous study, we demonstrated that there were significant differences in functional status 6 months post stroke between Maori (the indigenous people of New
Zealand), Pacific Islanders, Asians and New Zealand
Europeans. The purpose of this study is to examine whether these differences arise from differences in health service usage and pathway of care post stroke and the extent to which these differences are associated with individual and community level measures of socioeconomic status
Study Design: A population-based stroke incidence study.
Cases were obtained from hospitals, general practitioners, and community workers. All first-ever-in-a-lifetime cases of stroke
(n=1423) were collected in a population-based register in
940,000 residents (aged 15 years) over 12 months in 2002-
2003 in Auckland, New Zealand. Ethnicity was self-identified and grouped in this analysis as New Zealand European,
Maori, Pacific Peoples, Asian and other ethnic groups.
Population Studied: All residents of Auckland, New Zealand who suffered a stroke during the 12 month calendar period in
2002-2003.
Principal Findings: There were significant differences in functional status at 6 months between Maori, Pacific
Islanders, Asians and New Zealand Europeans. The results show the extent that these differences between ethnicities are explained by the following: likelihood of being admitted to residential care post-stroke, use of health services and family support. The results also provide evidence on barriers that exist to accessing services, including information provided at the time of stroke, financial concerns and family support.
Conclusions: Identifying the pathway of care and use of health services can help explain differences in health services usage between people of different ethnic backgrounds.
Implications for Policy, Delivery, or Practice: The results add to our understanding of the reason for differences between ethnic groups in quality of life and functional status post stroke. The implications for the design and delivery of health services is discussed.
Primary Funding Source: NZ Health Research Council
● Contextual and Health Systems Factors on Health
Related Quality of Life of HIV-infected Urban African
American Men
Aaron Buseh, Ph.D, M.P.H., MSN, Kelber, Sheryl, T., MSc.,
Park, Chang. Gi., Ph.D., Stevens, Patricia, E., Ph.D., FAAN
Presented By: Aaron Buseh, Ph.D, M.P.H., MSN, Assistant
Professor, College of Nursing, University of Wisconsin-
Milwaukee, 1921 East Hartford Avenue, Room 569, Milwaukee,
WI 53211; Tel: (414) 229-5462; Fax: (414) 229-5504; Email: aaronbg@uwm.edu
Research Objective: The Centers for Disease Control and
Prevention (CDC) HIV/AIDS surveillance data have identified that HIV/AIDS as a health crisis for African American men. In order to develop effective culturally appropriate intervention programs for black males living with HIV/AIDS, it is essential to identify the factors associated with quality of life in this population. The objectives of this study were to: (a) identify the interpersonal and structural barriers to health care and social services, (b) examine the relationship between the contextual variables, the health system factors, and HRQOL variables, and, (c) suggest culturally appropriate strategies for improvement of quality of life among African American men living with HIV/AIDS.
Study Design: Cross-sectional descriptive survey design was used to examine selected socio-demographic variables, their association and influence on the quality of life among a sample of urban African American males. Data were analyzed using descriptive statistics, followed by correlations and hierarchical multiple regressions statistics.
Population Studied: Participants were recruited through an
African American community-based organization in an urban setting of a large Midwestern state. A snowball sampling technique was used to obtain a sample of (n=55) African
American men (18 years or older) who self-reported as being
HIV-infected. The sample represented a homogenous group of HIV-infected men in regards to sexual orientation, stage of the HIV disease, and years since diagnosis. The men completed self-reported instruments to assess sociodemographic and contextual factors; self-rated health status, health systems barriers, social stigma, and health related quality of life which comprised nine domains.
Principal Findings: Participants ranged in age from 18-66 years, (M = 48.84, SD= 7.67) and the average length of time since diagnosis with HIV infection was (M = 10.79 years SD=
6.4). Most men (72.1%) had a high school diploma and about half (50.5%) had some college or were college graduates.
Majority of the participants (88.9%) were unemployed and single (83.6%). The majority of the men (85%) were enrolled either in a federal or state health insurance program.
Contextual variables of income, education, age, and residential situation were significantly correlated with the HRQOL subscale of provider trust. The better the participants rated their own health status the better they rated their general satisfaction with life, overall life functioning, and were less worried about their health. Clinical stage of their disease was also negatively associated with life satisfaction and with health worries. As barriers to healthcare and social stigma increased,
HRQOL decreased. In hierarchical multiple regression analysis, contextual factors, health systems, and interpersonal factors accounted for between 19 and 63% of the variance in health related quality of life (HRQOL) measures.

Conclusions: Critical to improving the nation’s health, is the understanding of disparities in HIV/AIDS in minority populations. Furthermore, the high rates of new HIV infections among African American men and differences in survival rates for HIV infected African American men require focused research to understand factors leading to disparities and to develop interventions to maximize health consequences associated with HIV infection and co-morbid conditions.
Implications for Policy, Delivery, or Practice: As AIDS becomes a manageable chronic condition it has become necessary to develop culturally appropriate, empirically validated models that will assist health practitioners in working to improve HRQOL among HIV infected African
American men. Therefore, it is imperative for health care researchers and practitioners to increase their understanding of their contribution to improving the HRQOL in this population. The findings from this study indicated broad and far reaching effect of the health systems and interpersonal factors. The measures of structural barriers and social stigma describe what patients have experienced as the result of their interaction with the medical and social services systems. The
HRQOL framework presented in this study serves as one paradigm, explaining almost two-thirds of the variance in some of the HRQOL measures in a community sample of
HIV-infected African American men. Future research with
African American men should also explore whether the
HRQOL model explains QOL in men living with other nonstigmatizing diseases other than HIV/AIDS.
Primary Funding Source: Sigma Theta Tau International
Honor Society of Nursing "Eta Nu Chapter"
● Health Inequities among Vulnerable Groups in India
Chandrima Chatterjee, Ph.D.
Presented By: Chandrima Chatterjee, Ph.D, Research Officer,
Research, Centre for Enquiry into Health and Allied Themes
(CEHAT), Survey No 2804 & 2805, Aram Society Road, Vakola,
Santacruz (E), Mumbai, 400055; Tel: (+91) (0)9821736315;
Fax: (+91) (022) 26673156; Email: chandrima_bchatterjee@yahoo.com
Research Objective: The main objective of the research on vulnerable groups in India was to generate disaggregated information on health disparities among various groups from the human rights perspective. This was to create equity indicators, to integrate equity strata and health indicators into a number of existing data sources, including censuses, vital registries, household surveys, small areas data, and administrative data sources. The information is meant to assist the preparation of a framework for a draft bill, inform public policy, impact the budget process, strengthen appropriate budget allocations and formulate an operational strategy to move towards the goal of Right to Health Care in
India. It would facilitate advocacy campaign and public understanding on issues involving health and human rights violations in India.
Study Design: The information have been collected through the various available sources of macro data ; the National
Family Health Services, Reproductive and Child Health (A household survey), the Census India, apart from micro studies on health of the vulnerable groups namely women, elderly, migrants, disabled or differently abled and indigenous population.
Population Studied: Women,Elderly, Migrants, Disabled,
Indigenous population namely the scheduled castes and scheduled tribes in India
Principal Findings: There are health disparities between the identified groups and the other population in the Indian society. The dimensions and determinants of health disparities are varied ranging from structural, socio-cultural to political resulting in their exclusion from the mainstream society. High rates of morbidity and mortality are found among the vulnerable groups; they face restricted and denial of their access and utilization of health care services as compared to others. The health policies have also excluded them. The trends and patterns of health care financing clearly shows a link between low expenditure and poor health outcomes among the vulnerable groups. The health inequities among the various groups is further worsened in the context of the global changes and challenges, the growth of the private sector and the creation of health markets, rising drug prices,the socio-political structures and the relationships that differentially affects people’s chances of being healthy within a given society, the interrelationships between factors at the individual level and within the social context that increase or decrease the likelihood of achieving and maintaining good health, characteristics of the healthcare system that influence health equity and ineffective policy creating health disparities in terms of health outcomes, access and utilization among various groups.The research in addition also highlights gaps in the National Health Policy that have restricted access and inverted the health outcomes negatively.
Conclusions: There are persistent inequities in health outcomes and health services in terms of its availability in sufficient quantity, and accessibility i.e., nondiscrimination, physical accessibility, economic accessibility /affordability, information accessibility among various groups in India. There is differential distributions of health among different groups and that speaks of the low level of realization of rights.
Identifying barriers to health and providing insights on multisectoral approaches in planning and interventions to support the most vulnerable populations can act as a good strategy in the movement towards the constitutionalization of the right to health as a human right.
Implications for Policy, Delivery, or Practice: The research makes some specific recommendations towards provisions of care and utilization of health services. It suggests a strategy to operationalize right to healthcare in India.
Primary Funding Source: Co-funded by Ford, NOVIB and
Rangoonwala Trust
● Linguistic Concordance in Mental Health Services to
Chinese Immigrants: Does It Reduce Disparity?
Alice Chen, Ph.D.(C), Arminee Kazanjian, DrSoc
Presented By: Alice Chen, Ph.D.(C), , Health Care and
Epidemiology, University of British Columbia, 5804 Fairview
Avenue, Vancouver, B.C., V6T 1Z3; Tel: 604-822-2729; Fax:
604-822-4994; Email: achen@chspr.ubc.ca
Research Objective: Recruiting bilingual and bicultural professionals is often suggested as a strategy to address the disparity in mental health service utilization reported among
Asians or immigrants in North America. The objective of this

study is to examine the relationship between the Chinese language skill of physicians and the rate of mental health consultations and likelihood of mental health diagnoses among recent Chinese immigrants to the Canadian province of British Columbia (BC).
Study Design: This study is a secondary analysis of three linked administrative databases: (1) immigration database – all immigrants who landed in BC in 1985-2000(2) provincial physician payment database – most physician services to BC residents under Canada’s publicly-funded health care system
(3) College of Physicians and Surgeons register – information to identify the Chinese language skill of the physicians. All services provided to the study population by general practitioners (GPs) and psychiatrists in 1992-2001 were included in the analyses.
Population Studied: The study population consists of
Chinese immigrants who landed in BC in 1985-2000 and a sex and age matched control group randomly selected from the enrollees of the provincial health insurance plan. Over
150,000 Chinese immigrants and the same number of controls were included in the study.
Principal Findings: Chinese-speaking GPs and psychiatrists provided 87% and 67%, respectively, of all the consultations to Chinese immigrants, and 23% and 8% of all consultations to controls. Relative to consultation with a non-Chinesespeaking GP, consultation with a Chinese-speaking GP was less likely to be identified as being for mental health reasons, for both immigrants and controls alike (OR=0.78 and 0.43).
Compared to non-Chinese-speaking psychiatrists, Chinesespeaking psychiatrists were less likely to make the diagnosis of depression in their consultations to both immigrants and controls (OR=0.35 and 0.40). Higher proportion of overall care received from Chinese-speaking GPs was associated with lower rates of mental health consultation among immigrants and controls (RR =0.65 and 0.32) and lower odds of ever being diagnosed with depressive disorder (OR =0.52 and
0.35).
Conclusions: Chinese-speaking GPs and psychiatrists provide the majority of general and mental health care to recent
Chinese immigrants in BC. However, Chinese-speaking physicians are less likely to make a mental health diagnosis or treat mental health problems, especially depressive disorder.
Subjects who more often visit Chinese-speaking GPs receive fewer mental health services; the impact is stronger among
Chinese immigrants who rely on Chinese-speaking GPs for most of their care.
Implications for Policy, Delivery, or Practice: While linguistic concordance may enhance the quality of health care in many aspects, bilingual practitioners do not necessarily reduce the disparities in mental health care experienced by linguistic minorities. The practice patterns of these bilingual professionals must be considered when evaluating cultural and linguistic access to care. Cultural values and place of training of the service providers, which are closely related to language skills, may be crucial influences on practice behaviors. These factors need to be addressed in cultural competence education and recruitment programs of foreigntrained professionals if linguistic concordance is to become an effective strategy in reducing disparities.
Primary Funding Source: Canadian Institutes of Health
Research
● Mental Illnesses and Perforating Appendicitis
Yiing-Jenq Chou, M.D., Ph.D., Cheng-Hua Lee, M.D., DrPH,
Nicole Huang, Ph.D., Yea-Jen Hsu, MS, Pen-Jen Wang, Ph.D.
Presented By: Yiing-Jenq Chou, M.D., Ph.D., Associate
Professor, Department of Social Medicine, National Yang
Ming University, 155, Li-Nong Street, Section 2, Taipei, 112;
Tel: 886-2-28201458; Fax: 886-2-28261002; Email: yjchou@ym.edu.tw
Research Objective: Mentally ill patients are postulated to be at a higher risk of hindered access to care for their physical diseases as the psychosis of their mental illness may impair the patient’s capacity to recognize or articulate emerging medical illness. More importantly, not all mentally ill patients are equally vulnerable. In addition to other cognitive impairment and social manifestations, pain insensitivity in schizophrenic patients may make them particularly vulnerable to adverse consequences of physical diseases that are typically pain-causing. As the National Health Insurance program in
Taiwan has successfully reduced financial barriers of access to care for all including mentally ill patients, the purpose of this study was to investigate whether non-financial disparities still exist between patients with and without mental illness, and more specifically, between patients with schizophrenia and other major mental illness.
Study Design: This was a population-based case-control study.
Population Studied: Using the National Health Insurance hospital-discharge data, we compared the likelihood of perforated appendix among 100,578 adults aged 15 and above who were hospitalized for acute appendicitis in Taiwan during the years from 1997 to 2001. The outcome measurement was appendiceal rupture (ICD-9-CM codes 540.0 and 540.1) in all patients hospitalized for acute appendicitis. Appendicitis, not resulting in ruptured appendix, was defined as ICD-9-CM code
540.9. Independent variables included mental disorder status, personal characteristics (age, sex, ethnicity and socioeconomic status (SES)) and hospital characteristics
(ownership, accreditation level, patient volume and geographic location).
Principal Findings: After adjusting for age, gender, ethnicity, socioeconomic status (SES) and hospital characteristics, the presence of schizophrenia was associated with a 2.80 times higher risk of ruptured appendix (odds ratio [OR], 2.80; 95% confidence interval [CI], 2.18-3.61). However, the presence of affective psychoses (OR, 1.15; 95% CI: 0.77-1.73) or other mental disorders (OR, 1.64; 95% CI: 0.93-2.91) was not significant predictor of ruptured appendix.
Conclusions: These findings suggest that given mentally-ill patients having no financial access barriers, they are still in disadvantage to obtain timely treatments for their physical diseases. Of major mental illnesses, schizophrenia, due to its insensitivity to physical pain associated with illness or injury, is most vulnerable to the diseases whose main presenting signs typically include pain.
Implications for Policy, Delivery, or Practice: Taiwan’s experience suggests that improving access to care of mentallyill patients is more than a financial matter. Health care personnel in either psychiatric hospitals and general hospitals who treat patients with severe mental disorders should be able to recognize unique consequences of major mental illnesses which may confound a diagnosis of a serious,

potentially life-threatening physical disease, and pay more attention to these patients with minimal pain and objective signs, in order to minimize possible misdiagnosis or delays in treatment. Case management programs or a better integrated care delivery system for severe psychiatric patients may also serve as powerful aids. For mentally-ill patients, not only their access to mental health services is important, but also their access to non-mental care is equally critical for their health.
Primary Funding Source: No Funding
● Low-Income Parent’s Reports of Communication
Problems with Health Care Providers: Effects of Language and Insurance
Lisa Clemans-Cope, Ph.D., Genevieve Kenney, M.A., Ph.D.
Presented By: Lisa Clemans-Cope, Ph.D., Research Associate,
Health Policy Center, The Urban Institute, 2100 M Street NW,
Washington, DC 20037; Tel: (202) 261-5580; Fax: (202) 223-
1149; Email: lclemans@ui.urban.org
Research Objective: This study examines how parental reports of communication problems with health providers vary among subgroups of low-income children.
Study Design: The data were drawn from the 1999 and 2002
National Survey of America’s Families (NSAF). Bivariate and multivariate analyses, including linear probability models, were used to estimate the relationships between parental report of communication problems with health providers and insurance type, socio-economic, demographic, health factors, and provider type.
Population Studied: We concentrate our analyses on lowincome families in 1999 and 2002. In addition, we study publicly insured Latino children with a Spanish-speaking parent, a sub-group of low-income children that has not been isolated in prior research, despite being a focus of public policy.
Principal Findings: Almost one-quarter of low-income children had parents who reported poor communication with health care providers, and for children whose parents were interviewed in Spanish, the figure was 40 percent. Parents who were foreign-born or who had poor mental health scores were significantly more likely to report communication problems. Almost two-thirds (63 percent) of the sample of low-income publicly covered Latino children whose parents were interviewed in Spanish (n=1,632) report clinics or hospital outpatient departments as their usual source of care.
For this population, these provider types were associated with increased communication problems compared to other provider types.
Conclusions: These findings indicate that communication problems are more prevalent for children whose parents are foreign-born and for those whose parents chose to be interviewed in Spanish relative to other low-income children.
The growing share of the population that is foreign-born or that has limited English proficiency suggests that communication problems between parents and health care providers are likely to increase over time.
Implications for Policy, Delivery, or Practice: In the short term, improving access to translation services, particularly at clinics and hospital outpatient departments could reduce communication problems and improve access for low-income families with limited English proficiency. In the long run, increasing the number of providers who are Spanish speakers or providing bilingual staff with training as professional interpreters may be necessary to improve the quality of communication with providers.
Primary Funding Source: RWJF
● Health Characteristics and Health Care Access Among
Major Racial/Ethnic-Nativity Groups in the United States:
Results from the 1998-2003 National Health Interview
Survey
Achintya Dey, M.A., Jacqueline W. Lucas, M.P.H., Jeannine S.
Schiller, M.P.H.
Presented By: Achintya Dey, M.A., Statistician (Demography),
Center for Disease Control and Prevention, National Center for Health Statistics, 3311 Toledo Road, Room 2330,
Hyattsville, MD 20782; Tel: (301)458-4251; Fax: (301)458-4961;
Email: aad2@cdc.gov
Research Objective: The prevalences of selected physical and mental health characteristics, as well access to care are compared among the U.S.-born and foreign-born adults by four major racial/ethnic subgroups. The association between immigrant health status and length of stay in the U.S. for these subgroups is also examined.
Study Design: Data from the 1998-2003 Sample Adult component of the National Health Interview Survey (NHIS) conducted by the Center for Disease Control and Prevention's
(CDC) National Center for Health Statistics (NCHS) were used to assess demographic and health characteristics of four major racial/ethnic subgroups of U.S.-born and foreign-born adults. Data were analyzed using bivariate and multivariate techniques with the SUDAAN software package.
Population Studied: Four major racial/ethnic subgroups of
U.S.-born and foreign-born adults: Hispanic, non-Hispanic white, non-Hispanic black and non-Hispanic Asian adults
Principal Findings: Preliminary age-adjusted results show that access to care differs for U.S.-born and immigrant adults.
However, despite having limited access to health care and being uninsured, immigrant adults had significantly better health than their U.S.-born counterparts. The results also indicate that health status, chronic health conditions, and health behaviors varied across the immigrant racial/ethnic subgroups by length of stay in the United States.
Conclusions: This analysis describes differences in various sociodemographic, physical, and mental health characteristics among four racial/ethnic subgroups of U.S.-born versus foreign-born adults. The results highlight important differences between immigrant and native-born populations, and underscore the importance of nativity as a factor in health differences among various racial and ethnic populations
Implications for Policy, Delivery, or Practice:
Understanding these differences will assist policy makers in developing culturally diverse community intervention programs and allocating resources to fulfill health care needs.
Primary Funding Source: CDC

● Differential Reporting of Similar Levels of Health among
Sub-groups of the U.S. Population.
Martey Dodoo, Ph.D.
Presented By: Martey Dodoo, Ph.D., Senior Economist, The
Robert Graham Center, 1350 Connecticut Ave, N.W. Ste 201,
Washington, DC 20036; Tel: 202-331-3360; Fax: 202-331-3374;
Email: mdodoo@aafp.org
Research Objective: To answer the following questions: Is there differential health status reporting within US population groups? If yes, how can we assess it, and how is reporting different - e.g.: cut-point shift or index function shift or both?
What are the solutions for problems imposed by such differential reporting in health surveys?
Study Design: To assess individual health status, a popular survey question is: “In general, is your health excellent, very good, good, fair, or poor?” However, researchers have found mainly in studies outside the US that sub-populations with same health levels use different thresholds based on culture, age, gender, education, language, and illness experience, to choose their health status category. Such reporting heterogeneity if found to exist in this country, may invalidate some group comparisons and measures of health inequality.
We assessed differential reporting of self assessed health status (SAH) in the Medical Expenditure Panel Survey (MEPS) using two methods based on mean comparison hypothesis testing, and ordered response logit model estimation. Mean comparison hypothesis testing was used to ascertain if there is differential reporting. To determine how reporting is different, we stratified the sample into sub groups and estimated ordered response models for each sub group. For each sub group we obtained estimates of the index function and the cut points based on the model by Lindeboom and
Doorslaer (2004). We compared between sub-groups using
MEPS data by conditioning on the more objective indicators of health including SF-12 scores.
Lindeboom, Maarten & van Doorslaer, Eddy, 2004. "Cut-point shift and index shift in self-reported health," Journal of Health
Economics, Elsevier, vol. 23(6), pages 1083-1099.
Population Studied: A national probability sample of 19,896 persons 18-64 years old from the 2002 MEPS.
Principal Findings: We found that among US population group pairs at the same level of health (as measured by SF-12 scores), persons in the group with low education or low income tend to under-estimate their health relative to persons with high education or high income respectively. On the other hand, younger persons in the 18-40 year age group tend to over-estimate their health relative to persons 41-65 years old.
We also found that (1) the odds of 18-40 year olds being in a higher health category is about twice the odds of 41-65 year olds, (2) the odds of persons with low education being in a higher health category is only about 65% of those with higher education, and (3) the odds of persons with low income being in higher health category is only about 45% of those with higher income
Conclusions: There is certainly differential health status reporting within US population groups. The differences are mainly with respect to education, income and age. We could not ascertain if the differences are due to cut-point shift or index function shift. Further work within the next month, may shed more light on that (to be reported at the Annual
Meeting).
Implications for Policy, Delivery, or Practice: Differential health status reporting by subgroups of the US population presents a potential problem for the validity of health equality measurements and health level comparisons. Health survey designers would have to supplement national health survey questions on self assessed health status with questions other than those that elicit self-reports of health. Suggestions of supplementary questions will be provided in the presentation.
Primary Funding Source: No Funding
● Access and American Indians: Is Rural Better?
Mark Doescher, M.D., M.S.P.H., J. Elizabeth Jackson, MA,
Dorothy A. Rhoades, M.D., M.P.H.
Presented By: Mark Doescher, M.D., MSPH, Associate
Professor, Family Medicine, University of Washington, 4225
Roosevelt Way NE, Suite 308, Seattle, WA 98105; Tel: (206)
616-9207; Fax: (206) 685-0610;
Email: mdoesche@u.washington.edu
Research Objective: The health status of American Indians
(AI) is among the worst in the nation. Although the majority of
AI live in urban areas, access to care for urban AI has never been reported for a nationally representative sample. Most health services research among AI has been conducted among rural or reservation-based populations. Unlike rural AI, most urban AI do not receive health care services from facilities operated or fully funded by the Indian Health Service.
The objective is to test the hypothesis that urban AI face more barriers to care than rural AI or other racial/ethnic groups by estimating the prevalence of and trends in: (1) having a regular physician; and (2) reporting unmet medical need.
Study Design: National data from the Behavioral Risk Factor
Surveillance System (BRFSS) were used to examine reports of having a regular physician and unmet need for care in the preceding 12 months among adults aged 18 and older
(n=234,315). Race/ethnicity was categorized as American
Indian, African American, Hispanic, Asian/Pacific Islander, and white. The urban-rural continuum was grouped as metropolitan, nonmetropolitan adjacent to a metropolitan area, rural “micropolitan”, and rural “non-core” by 2003
Urban Influence Code categories. Analyses were adjusted for sociodemographic characteristics.
Population Studied: A national sample of noninstitutionalized US adultsm from 50 states and the District of
Columbia.
Principal Findings: In 2002 for all races combined, 20.8% of metropolitan, 18.2% of nonadjacent, nonmetropolitan, 20.1% of micropolitan, and 19.3% of non-core respondents lacked a regular physician. Among AI, 21.6% of metropolitan, 22.6% of nonmetropolitan adjacent, 15.7% of micropolitan, and 17.5% of non-core respondents lacked a regular physician. For all races combined, 6.7% of metropolitan, 6.8% or nonadjacent, nonmetropolitan, 5.8% of micropolitan, and 6.1% of non-core respondents did not receive needed care. Among AI, 8.0% of metropolitan, 8.1% of nonmetropolitan, 4.1% of micropolitan and 6.1% of non-core respondents reported unmet care. Also, trend analyses and analyses categorizing county of residence by IHS catchment area will be presented.
Conclusions: AI residing in the most isolated rural locations had better access to care than other racial/ethnic groups.
However, AI residing in metropolitan counties and rural

counties adjacent to metropolitan ones reported more difficulty accessing care than their more rural counterparts.
Implications for Policy, Delivery, or Practice: While the
Indian Health Service does provide some support for urban
Indian health programs, it is already chronically under funded and allocates less than 2% of its budget to urban programs.
Strategies for improving access to care for urban AI without compromising existing rural programs are needed.
Primary Funding Source: Federal Office of Rural Health
Policy
● Racial Differences in Distrust in Clinical Research Among
Elderly Whites and African Americans
Raegan Durant, M.D., M.P.H., Anna T. R. Legedza, ScD,
Giselle Corbie-Smith, M.D., MSc, Marcie B. Freeman, MEd,
Bruce E. Landon, M.D., M.B.A.
Presented By: Raegan Durant, M.D., M.P.H., Clinical
Research Fellow, Division of General Medicine and Primary
Care, Beth Israel Deaconess Medical Center, 330 Brookline
Avenue, Rose 111, Boston, MA 02215; Tel: 617-667-0487; Fax:
617-667-2751; Email: rdurant@bidmc.harvard.edu
Research Objective: Some previous studies have suggested that African Americans are more distrustful of clinical research than whites. We sought to determine if African Americans’ distrust in clinical research arises from their general perceptions of physicians and the health care system or from their relationships with individual physicians.
Study Design: We assessed responses to 7 previously validated items from a distrust index examining attitudes about clinical research in terms of societal distrust (e.g. general perceptions of physicians and research) and interpersonal distrust (e.g. perceptions of research relating to one's relationship with an individual physician). Trust in one’s primary care provider (PCP) was assessed as an independent variable using the 8-item trust subscale from the
Primary Care Assessment Survey (PCAS). Respondents were grouped into quartiles of trust in a PCP. We also examined other independent variables including knowledge of the
Tuskegee Syphilis Experiment and personal experiences with discrimination in health care. We performed bivariable and multivariable analyses to examine the associations between these factors and responses to the items in the distrust index.
Population Studied: We conducted a mail survey of community-dwelling elderly (age >50) whites and African
Americans in the Boston area.
Principal Findings: We received responses from 829 eligible persons (58% response rate). The study population was 60% white and 40% African American. For two of the items assessing societal distrust, African Americans were more likely than whites to think that they could potentially be “used as guinea pigs” without giving their permission (54% vs. 28%, p<0.0001) or to think that health care providers, in general, prescribe medications as a way of “experimenting on people without your permission” (58% vs. 41%, p<0.0001). However, in the 3rd item assessing societal distrust, African Americans were less likely than whites to believe that they had actually ever received treatment from any health care provider as part of an experiment without giving permission (1.6% vs. 2.9%, p=0.23). There were no racial differences in responses to the index items focused on interpersonal distrust. In a multivariable model, African Americans (OR 2.6, 95% CI
1.9,3.7) and respondents with the least trust in their PCPs (OR
2.8, 95% CI 1.8,4.4) thought it was likely that they might be used a “guinea pig” without permission. African American race (OR 1.9, 95% CI 1.3,2.6) and the lowest level of trust in one’s PCP (OR 1.7, 95% CI 1.1,2.7) were also associated with concerns of unknowingly being involved in an experiment through the receipt of prescription medications. When trust in one’s PCP was removed from these models, however, there was no significant change in the coefficient for African
American race. Neither a history of discrimination in health care or knowledge of the Tuskegee Syphilis Experiment was related to concerns about unwanted experimentation in the three societal distrust items in multivariable models.
Conclusions: Older African Americans have higher levels of societal distrust in clinical research compared to older whites.
Race and trust in PCPs are independently related to societal distrust in clinical research.
Implications for Policy, Delivery, or Practice: Improving
African Americans’ trust in their PCPs alone may not eliminate racial differences in societal distrust.
Primary Funding Source: HRSA
● Health Literacy Measurement Issues for Homeless
Young People
Josephine Ensign, M.P.H., Dr.P.H.
Presented By: Josephine Ensign, M.P.H., DrP.H., Associate
Professor, Psychosocial and Community Health, University of
Washington, UW Box 357263, Seattle, WA 98195; Tel: 206-685-
0816; Fax: 206-685-9551; Email: bjensign@u.washington.edu
Research Objective: In order to design appropriate clinicbased measures of and interventions to improve health literacy for homeless young people, the perspectives of youth affected is important. The objective of this study was to document the views of homeless youth on their health information needs and preferred methods for having health literacy assessed in a primary care setting.
Study Design: The research was a pen and paper anonymous self-administered clinic-based survey. The survey included forced-choice and open-ended questions, and was readability tested at the 5th grade level using the Flesch-Kincaid formula.
Youth were provided with assistance reading the questions by a youth outreach worker familiar to them but not associated with the research team.
Population Studied: The research was conducted over a one month time period (September 2005) with homeless youth ages 13-24 years in a large West-coast city. The homeless young people who participated were recruited from a homeless youth primary care clinic waiting room (either as patients or as friends accompanying patients). The total sample was 35 homeless youth (20 female and 15 male youth), age range 14-24 years, with an average age of 20 years.
Principal Findings: In response to the question “Sometimes people need extra help in reading or understanding how to take medicines or other health information, but are too shy to ask. What do you think is the best way for us to find out if someone needs help?”, all but two of the respondents circled
“ask people in person in a private room”. Of the two who circled “have everyone fill out a short form before they are seen in clinic”, one young person wrote in “But I know a lot of people have a hard time reading, so this wouldn’t work so well”. None circled “don’t ask because it’s too embarrassing”.

In addition, the majority (n=30) stated that they used public libraries, mainly to look up health and job information on the internet as well as to check e-mail. Most of the young people reported that their main sources of health information were the clinic, friends, and the internet. There were no differences in responses to the survey by gender.
Conclusions: The homeless youth included in this study identified internet access through public libraries as a major source of health information. In addition, all indicated that clinicians should attempt to asses a young person’s health literacy. Most young people thought that health literacy assessment should occur via a one-on-one assessment by a clinician in a private room.
Implications for Policy, Delivery, or Practice: The results of this research indicate a need for the development of brief health literacy assessments appropriate for use in primary care situations with homeless young people. In addition, the results indicate that internet access through public libraries is an important source of health information for homeless young people. Health and media literacy programs targeting homeless youth could benefit from a partnership between public librarians and clinicians specializing in primary care for homeless adolescents and young adults.
Primary Funding Source: AHRQ
● Neighborhood Socioeconomic Characteristics and
Individual Health Behaviors
Jose Escarce, M.D., Chloe E. Bird, Ph.D., Brian Finch, Ph.D., D.
Phuong Do, M.Phil, Teresa Seeman, Ph.D., Nicole Lurie, M.D.,
M.S.P.H.
Presented By: Jose Escarce, M.D., Professor of Medicine,
Medicine, UCLA, 911 Broxton Ave, Los Angeles, CA 90024;
Tel: 310 794 3842; Fax: 310 794 0726; Email: jescarce@mednet.ucla.edu
Research Objective: A growing body of research demonstrates relationships between residential neighborhood context and health. However, few studies have examined the effect of neighborhoods on health behaviors. We examined the extent to which neighborhood poverty is related to binge drinking and sedentary lifestyle, independent of individual characteristics.
Study Design: Using 3-level hierarchical logistic and linear regression, we analyzed National Health and Nutritional
Examination Survey III (NHANES) interview and laboratory data, merged with data on sociodemographic characteristics of their residential census tract. Binge drinking was measured as the number of days in the past year that one consumed 5 or more drinks (mean = 14.1, with 25% reporting having done so once or more). Sedentary lifestyle was measured as whether or not the subject participated in any moderate or vigorous physical activity in the past month (75% report having engaged in moderate or vigorous activity at least once in the past month).
Population Studied: Our analyses included 14,626 adults from 83 counties and 1805 census tracts, who completed surveys and medical exams, were not missing on key components of the outcome measures, and for whom residential census tract could be geocoded. The sample was
47% male; 43% white, 27% black, 26% Hispanic, 4% other.
Subjects ranged in age from 19.5 to 90 (mean = 48); 53% were employed, and 58% had at least a high school education. The mean family income/poverty ratio was 2.41.
Principal Findings: Individual characteristics including income (p < .001), age (p < .001), education (p < .001), being male (p < .001) and being Hispanic (p < .001) were negatively associated with sedentary life style. Even after adjusting for these individual characteristics, residing in a census tract with a higher percentage of households with incomes below the federal poverty line was associated with higher likelihood of sedentary lifestyle (OR= 5.41, p < .0001). Age (p <.001), employment (p < .001), education (p < .05) and being
Hispanic (p < .03) were negatively associated with binge drinking, whereas being male (p<.001) was positively associated. Residing in a census tract with a higher percentage of households in poverty was associated with more frequent binge drinking adjusting for individual characteristics (1.5 more days of binge drinking for every 10% increase in the poverty rate; p < .0001). Results from additional analyses examining smoking will be presented along with analyses of two additional tract-level characteristics
(the percentage of census tract with less than a high school education and median household income).
Conclusions: The association of neighborhood poverty with a lack of physical activity and more binge drinking, controlling for individual characteristics, suggests pathways through which neighborhoods may affect health. Potential mechanisms for these findings include increased fear of crime, fewer parks, more crowding, and more alcohol outlets and advertising in poor neighborhoods.
Implications for Policy, Delivery, or Practice: Neighborhood effects represent one pathway through which neighborhoods ultimately affect health and thus a potential avenue for effective intervention. The mechanisms through which these effects are produced need to be explored.
Primary Funding Source: NIEHS
● Poor Health in the South: An Examination of
Socioeconomic Factors in Eight Southern States.
Rachel Ferencik, MPA, Karen Minyard, Ph.D., Kate Stewart,
M.D, M.P.H., Mei Zhou, M.A, M.S.
Presented By: Rachel Ferencik, MPA, Research Associate, ,
Georgia Health Policy Center, 14 Marietta St., Suite 221,
Atlanta, GA 30303; Tel: (404)651-1294; Fax: (404)651-3147;
Email: rachel@gsu.edu
Research Objective: The Southern Regional Health
Consortium is interested in understanding how socioeconomic factors impact health and whether the south carries a disproportionate burden than the rest of the country in lower socioeconomic attainment. Eight of the most rural and medically underserved states in the country, primarily located in the south, were funded under Robert Wood
Johnson’s Southern Rural Access Program to improve access to health care. (These states -- Alabama, Arkansas, Georgia,
Louisiana, Mississippi, South Carolina, Texas and West
Virginia -- now organize themselves as the Southern Regional
Health Consortium, also known as “SRHC”).
Study Design: A comprehensive literature review was conducted to understand the relationship of socioeconomic factors on health. Using BRFSS, CPS and ARF data, researchers collected and analyzed data on sociodemographic factors, health access and coverage, and health status of these

eight states to determine differences between the SRHC states and the national average.
Population Studied: Data were analyzed from the eight states that comprise the Southern Regional Health Consortium, which include Alabama, Arkansas, Georgia, Louisiana,
Mississippi, South Carolina, Texas and West Virginia in comparison to the rest of the nation.
Principal Findings: We used a causal framework developed by Williams and House (2000) to test our hypothesis that socioeconomic factors play an important role in health disparities and that the south, compared to the nation, carries a disproportionate burden of lower socioeconomic attainment. SRHC states had larger minority populations than the national average (21% v. 29% respectively). Residents in
SRHC states were less educated than the national average.
Almost 10% of the population 25 years and older did not complete high school, compared to 8% of the national average. In SRHC states, 21% of the population 25 years of age and older had completed a college education, compared to 24% of the nation. SRHC states had a smaller white collar labor force than the national average. (58% v. 60% respectively). More residents in SRHC states live below the poverty level compared to the national average (15% v. 11% respectively)
Conclusions: Differences in the socioeconomic factors of race, education, occupation and income between SRHC states and the national average are statistically significant.
Implications for Policy, Delivery, or Practice: Numerous foundations have invested large amounts of money to improve health status by improving access to health coverage and care. The academic literature confirms that strategies to reduce health disparities are largely outside the control of the health sector. The best way to reduce health disparities may be to reduce socioeconomic disparities. Access to health care will not alone close the gap in health disparities if policies do not also address discrimination and disparities in income, education and occupation. Policies and programs should identify the ways in which broader social, economic and political forces constrain or empower people in their health behaviors. Further research is needed to understand the relative effects on health of race, education, occupation and income in the south.
Primary Funding Source: The Robert Wood Johnson
Foundation through the Southern Regional Health
Consortium
● Estimating Disparities in Receipt of Preventives:
Comparison of Self-Report and Medicare Claims data.
Kevin Fiscella, M.D., M.P.H., Kathleen Holt, Ph.D., Peter
Franks, M.D.
Presented By: Kevin Fiscella, M.D., M.P.H., Associate
Professor, Family Medicine; Community & Preventive
Medicine, University of Rochester, 1381 South Ave, Rochester,
NY 14620; Tel: (585) 506-9484 ext 106; Fax: (585) 473-2245;
Email: kevin_fiscella@urmc.rochester.edu
Research Objective: 1) To compare estimates of racial/ethnic disparities in receipt of preventive services based on selfreport with estimates of these disparities based on Medicare claims data. 2) To assess whether differences in insurance or socioeconomic factors explain observed discrepancies in these estimates.
Study Design: We used matching self-report and claims data from the Medicare Current Beneficiary Survey, 1999-2002, for
6 preventive services: cholesterol testing, colorectal cancer screening (fecal occult blood testing or sigmoidoscopy/colonoscopy), influenza vaccination, mammography, Pap smear screening, and prostate specific antigen screening. In multivariate analyses, we examined predictors of “over-reporting” (self-report in the absence of a claim) and “under-reporting” (claim in the absence of selfreport).
Population Studied: Medicare Beneficiaries 65 and older.
Principal Findings: With the exception of PSA screening, racial and ethnic disparities are larger based on Medicare claims than self-report. Absolute differences in age-adjusted receipt of preventive services between whites and minorities for self-report ranged from -3% for cholesterol screening to
18% influenza vaccination. In contrast, differences based on claims ranged from 6% for cholesterol screening to 20% for influenza screening. Multivariate analyses controlling for age, gender, income, educational level, health status, proxy respondents or supplemental insurance showed that minorities are significantly more likely to report receipt of a preventive service in the absence of a supporting claim. Effect sizes ranged from 1.07 (95% CI 0.89- 1.28) for PSA to 1.83
(95% CI 1.49 – 2.25) for Pap smear screening. Rates of underreporting were low and didn’t differ by minority status.
Conclusions: These findings are consistent with either racial/ethnic reporting biases in receipt of preventive care (i.e., that self-report rates are inflated more in minorities than whites) or differences in billing practices among providers serving majority versus minority patients (i.e., claims are inaccurate to a greater degree in providers with large minority practices).
Implications for Policy, Delivery, or Practice: Assessment of national progress towards the elimination of racial/ethnic disparities in preventive care that rely on self-report to monitor success may produce overly optimistic findings. Alternatively, suboptimal billing practices by providers serving minority patients may yield lower reimbursements and provoke spurious assumptions regarding the health care quality they provide. Distinguishing these two alternatives will be critical to improving the care of minority patients
Primary Funding Source: AHRQ
● Disparities in Insurance Coverage, Health Status, and
Access Barriers to Care for Children of Immigrant Parents
Jared Fixmer, BA, Emmanuel Ngui, DrPH, Sandy Tomany-
Korman, MS, Glenn Flores, M.D.
Presented By: Jared Fixmer, BA, Medical Student, Center for the Advancement of Underserved Children, Medical College of
Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226;
Tel: (414)456-8273; Fax: (414)456-6385; Email: jfixmer@mcw.edu
Research Objective: The number of immigrant children in the
US is increasing rapidly, but not enough is known about these children’s health and access to care. The study objectives were to 1) identify disparities in insurance coverage, health status, and barriers to care (BCs) in children of citizen parents (CPs) and non-citizen parents (NCPs); and 2) determine whether a gradient exists in these outcomes across different NCP children subgroups (legal permanent resident parents

[LPRPs], temporary resident parents [TRPs], and undocumented immigrant parents [UIPs]).
Study Design: Cross-sectional survey of parents at inner-city, predominantly Latino community sites in Boston, including supermarkets, hair salons, and laundromats. Participants were asked 74 questions on insurance coverage, BC, and use of health services.
Population Studied: CPs and NCPs of children at urban community sites.
Principal Findings: Of the 1100 parents interviewed, 40% were CPs and 60%, NCPs (29% were LPRPs; 24%, UIPs; and
7%, TRPs). Compared to CP children, NCP children were significantly (P<.05) more likely to be in poor/fair/good health
(40 vs. 47%), lack regular doctors (3 vs. 5%), and to be uninsured (7 vs. 23%), with children of LPRPs (12%), TRPs
(27%), and UIPs (37%) significantly more likely to be uninsured. NCP children were more likely than CP children to not be brought in for needed care due to uninsurance (17 vs.
9%), inability to afford care (14 vs. 7%), language barriers (9 vs. 4%), and immigration issues (8 vs. 1%).
In multivariate analyses, NCP children had significantly higher odds of uninsurance than CP children (OR=2.7 [95% CI, 1.5-
4.6]); among NCP children there was a gradient, with LPRP children at lowest risk (OR=1.6 [0.86, 2.98]), followed by TRP
(OR=3.9 [1.8-8.7]), and UIP children (OR=6.4 [3.3-12.3]). When asked to identify the three most important BCs for their children, LPRPs had twice the odds of CPs of citing insurance difficulties (OR=2.1 [1.2-3.6]). NCPs were more likely than CPs to cite language barriers (OR=3.8 [2.3-6.3]), with LPRPs
(OR=4.4 [2.6-7.5]) and UIPs (OR=2.9 [1.6-5.4]) at highest risk.
TRPs were more likely to not bring children in for needed care due to language barriers (OR=4.1 [1.3-13.1]), while LPRPs were more likely to not bring children for needed care due to long waits in physicians’ offices (OR=1.5 [1.02-2.2]). LPRP children were less likely to be in poor/fair/good health (OR=0.6 [0.4-
0.9]). A gradient was observed for certain outcomes, with
LPRP children experiencing the least severity of these problems and UIP children the greatest severity.
Conclusions: Uninsurance is a major problem and frequent
BC for NCP children, with the highest risk among UIP and
TRP children. Uninsurance, language barriers, and long provider waits frequently cause immigrant children to not be seen for needed care, and a gradient exists for some outcomes, with LPRP children experiencing the least severe problems and UIP children the most severe.
Implications for Policy, Delivery, or Practice: Our findings suggest the need to enhance insurance coverage, reduce BCs, and provide more efficient pediatric services for NCP children, particularly UIP children, who are most at risk for uninsurance and BCs.
Primary Funding Source: No Funding
● Racial and Ethnic Disparities in Prenatal Syphilis
Screening among Florida’s Medicaid Pregnant Women
Norma Gavin, Ph.D., Christina Fowler, Ph.D., E. Kathleen
Adams, Ph.D., Monique Chireau, M.D., M.P.H.
Presented By: Norma Gavin, Ph.D., Senior Research
Economist, , RTI International, 3040 Cornwallis Road,
Research Triangle Park, NC 27709-2194; Tel: (919) 541-6432;
Fax: (919) 990-8454; Email: gavin@rti.org
Research Objective: Syphilis is one of the nation’s most glaring racial disparities in health. Transmission of the disease to the fetus in utero can be prevented through routine prenatal screening and treatment of infected women. Professional medical organizations and the CDC recommend prenatal syphilis screening in the first trimester for all pregnant women and again in the third trimester for women of high risk. This study investigated whether the incidence and timing of prenatal syphilis screening differed among Medicaid-covered pregnant women of different races and ethnicity and the impact that safety net providers and participation in a primary care case management (PCCM) program had on screening rates among the different racial and ethnic groups.
Study Design: We identified syphilis screening tests from outpatient Medicaid claims data during the 9 months prior to delivery. We then computed rates of (1) any syphilis screening during pregnancy; (2) early syphilis screening, defined as a test 5 or more months prior to delivery; and (3) repeat syphilis screening, defined as both a test early in pregnancy and a test within 3 months of delivery. For each screening measure, we ran a logistic regression including race/ethnicity as an explanatory variable along with usual source of prenatal care, an indicator for PCCM, and a set of variables to control for health status and provider availability. We then ran separate regressions for non-Hispanic white, non-Hispanic black and
Hispanic women and compared the magnitude and significance of the coefficients for the usual source of prenatal care and PCCM across the equations.
Population Studied: We included all women with a Medicaidcovered delivery in Florida from October 1, 1999 through
September 30, 2000. We excluded women with incomplete claims or enrollment data, including undocumented aliens, and women with any capitated managed care enrollment or concurrent private insurance or Medicare coverage during pregnancy or delivery. The final sample included 29,542 non-
Hispanic white, 16,275 non-Hispanic black, and 27,726
Hispanic women.
Principal Findings: Only 57% of women had any prenatal syphilis test, 43% of those enrolled in Medicaid 5 or more months had an early test, and 29% of those with an early test had a repeat test. Non-Hispanic black women were significantly less likely than non-Hispanic white women to have any (odds ratio [OR] = 0.95) or early (OR = 0.85) prenatal syphilis screening; Hispanic women were significantly more likely to have a repeat screen (OR = 1.15). Having a safety net provider as a usual source of prenatal care improved the probability of all three race/ethnicity groups receiving any, early or repeat syphilis screening tests, with the largest impact on non-Hispanic whites. Participation in Florida’s PCCM program improved access to care for only non-Hispanic black and Hispanic women.
Conclusions: Among Medicaid pregnant women in Florida, rates of prenatal syphilis screening are generally low and

unexplained racial disparities in screening exist. Despite a higher rate of syphilis among non-Hispanic blacks, these women have significantly lower screening rates.
Implications for Policy, Delivery, or Practice: Clinic-based safety net providers can play an important role in improving screening rates generally whereas PCCM may also reduce disparities. Effective means of reaching and screening non-
Hispanic black women early in their pregnancies are needed.
Primary Funding Source: CDC
● Estimating Medical Expenditure Differences Attributable to Breast Cancer Disparities in the U.S. and Minnesota
Greg Gifford, Ph.D., Scott Leitz, MA
Presented By: Greg Gifford, Ph.D., Research Scientist 3,
Department of Health, State of Minnesota, 85 East Seventh
Place, Suite 300, St. Paul, MN 55101; Tel: (651) 282-5643; Fax:
(651) 282-5628; Email: greg.gifford@health.state.mn.us
Research Objective: Estimate calendar year (CY) 2002 health care expenditure differences associated with racial/ethnic breast cancer disparities in the U.S. and Minnesota.
Study Design: We developed these estimates in two major steps. First, we developed estimates of annual aggregate and per capita expenditures attributable to breast cancer by racial/ethnic populations in the U.S. in CY 2002. Second, we then used the U.S. per capita estimates, adjusted for regional differences to produce Minnesota per capita estimates, and estimates of breast cancer prevalence in Minnesota to calculate annual aggregate and per capita expenditure effects attributable to racial/ethnic differences in breast cancer prevalence in MN in CY 2002.
Population Studied: Adult U.S. and Minnesota women in
2002 differentiated by race/ethncity categories - Hispanic (and any race), Black-not Hispanic, Asian-not Hispanic, and Othernot Hispanic.
Principal Findings: Estimated per capita medical spending attributable to breast cancer in the U.S. in CY 2002 was significantly higher for the Hispanic and Black populations compared to the Asian and Other Race/Not Hispanic
(includes white) populations. It is noteworthy that medical spending attributable to breast cancer for the Asian population was found to be much lower than for the other three racial/ethnic populations. After substituting estimates of adult female breast cancer prevalence and comparable population sizes as of CY 2002 in Minnesota into these methods, we find a pattern of breast cancer attributable medical spending in Minnesota similar to the U.S. pattern.
Conclusions: These and other findings from this study: (1) quantify the greater medical spending burden attributable to the treatment of breast cancer for Hispanic and Black women than for the Asian or Other/White populations in the U.S. as well as Minnesota; (2) suggest the possible roles of differences in breast cancer stage, patient complexity, and rates of relevant preventive services utilization in understanding those differences; and (3) illustrate the potential generalizability of these methods for (a) application to developing estimates of racial/ethnic disparities in medical care expenditures attributable to other diseases, and (b) other states and regions.
Implications for Policy, Delivery, or Practice: The results of this study should be directly applicable to evaluating the cost effectiveness of specific interventions targeting racial/ethnic disparities in breast cancer in both the U.S. as well as the individual states. In fact, this study was undertaken to develop estimates of the “cost” of particular health disparities for use in evaluating the cost-effectiveness of interventions targeting specific breast cancer disparities – one of the priorities of Minnesota’s recently launched cancer control plan
- Cancer Plan Minnesota 2005-2010.
Primary Funding Source: Minnesota Department of Health
● Self Efficacy in Obese African American Women
Beginning a Weight Loss Program
Lisaann Gittner, MSc, Mary Kay Anthony, RN, Ph.D., Pamala
Murphy, M.D., Shirley Moore, RN, Ph.D., Salwa Hassanein,
MSN
Presented By: Lisaann Gittner, MSc, Director of Research,
Division of Research, Kaiser Permanente, 19999 Rockside Rd,
Cleveland, OH 44146; Tel: (440) 735-6431; Fax: (440) 735-
6429; Email: lisaann.gittner@kp.org
Research Objective: Psychometrics of four Self Efficacy
Instruments are compared as predictors of weight loss in
African American (AA) women in a weight loss intervention.
Predictive ability and scale stability of the instruments was determined at baseline and one-month post intervention.
Study Design: This randomized intervention examined the effect of a culturally adapted weight loss program in AA women. The 21-month program (6-months active intervention and 15-months maintenance) used behavior change strategies modified to include spirituality, AA cultural materials, interactive teaching, and sustained peer support. The NCEP
Step 1 diet was modified to include calorie reductions, increased fruit, vegetable, calcium intake, and incorporation of ethnic recipes. Exercise was culturally adapted to include linedancing, brisk walking, and included time for socialization.
The control group received usual care which includes personal dietician visits, nutrition classes, and web based modules.
Descriptive characteristics, self efficacy for exercise adherence, exercise barriers, and eating control were measured at baseline and 1 month after the active intervention.
Psychometric instruments used were: McAuley Self Efficacy:
Exercise Adherence (EA) (Scale 0–100), modified McAuley
Self Efficacy: Exercise Barriers (EB) (Scale 0–100), Weight
Efficacy Lifestyle (WEL) (Scale 0–9), Self Efficacy and
Consumption of Fruit and Vegetable (F/V) (Scale 1–5).
Population Studied: Subjects were 190 AA women between the ages of 40-65 with BMI >30, and members of a
Midwestern HMO.
Principal Findings: Four self efficacy instruments will have construct validity, reliability, and scale stability assessed to determine the best scale to predict weight loss. At baseline there was no correlation of self efficacy with depression, BMI, age, weight, prior weight loss efforts; and all demonstrated good internal consistency (Cronbach’s alpha from 0.943-
0.991). Baseline analysis shows high initial self efficacy for 3 of the 4 instruments [EA x = 76.9+/-25.5SD; Range=0-100; Skew=
-1.297; n=189; EB x = 62.8+/- 23.9SD; Range=3.85-100; Skew= -
.412; n=186; WEL x = 6.12+/-1.65SD; Range = 1.2-8.8; Skew= -
.697; n=16]. For the F/V, self efficacy was x=1.9+/- 0.9SD;
Range= 4.8-1.0 Skew= 1.3; n=178. Once Time 1 data collection is complete (Feb06) the sensitivity of the instruments will be examined.

Conclusions: Interestingly, at baseline there was high beginning self efficacy for exercise and eating control exhibited by most subjects. The self efficacy instruments’ answer distribution patterns were compressed towards one end of the scale, high end compression observed for EA, EB, WEL and low end for F/V. This may limit scale usefulness as a predictor of successful weight loss. There was no indication that initial
BMI, age, depression, and prior weight loss efforts related to exercise and/or food control self efficacy.
Implications for Policy, Delivery, or Practice: These preliminary results do not indicate that a pattern of high self efficacy for healthy eating and exercise behaviors translate into healthy lifestyles. In fact, high self efficacy may interfere with dieter’s efforts by giving them a false sense that weight loss is easier than it actually is leading to a pattern of unsuccessful weight loss attempts. Setting realistic expectations about the difficulty of weight loss and weight maintenance in those subjects with high initial self efficacy may lead to better weight loss.
Primary Funding Source: Garfield Memorial Foundation
● Predictors of Antidepressant Use in Nationally
Representative Sample of U.S. Community-Dwelling
Blacks (African Americans and Caribbean Blacks): Results from the National Survey of American Life
Hector Gonzalez, Ph.D., Thomas W. Croghan, M.D., David R.
Williams, Ph.D., Brady T. West, MA, Willie Underwood III,
M.D., James S. Jackson, Ph.D.
Presented By: Hector Gonzalez, Ph.D., Assistant Professor,
Gerontology and Family Medicine, Wayne State University, 87
East Ferry Street, Knapp Bldg, Detroit, MI 48202; Tel: (313)
577-2297; Fax: (313) 875-0127; Email: hmgonzalez@med.wayne.edu
Research Objective: To determine the prevalence of and predictors of twelve-month antidepressant use among Black
Americans in a nationally representative sample of Blacks
(African Americans and Caribbean Blacks).
Study Design: In-person household survey from 2002 to
2003. The National Survey of American Life (NSAL), along with the National Comorbidity Study-Replication and National
Latino Asian American Study, is part of the Collaborative
Psychiatric Epidemiologic Surveys. Setting: The 48 contiguous
United States.
Population Studied: African American and Caribbean Black household residents ages 18 years and older (n = 5,004) who responded to the NSAL survey.
Principal Findings: African Americans and Caribbean Blacks did not differ significantly in past twelve month antidepressant use. In a combined sample, 4.5% of Blacks had used antidepressants. Few Blacks with lifetime and twelve-month
MDD (10.8%, 13.4%, respectively), dysthymia (11.1%, 11.9%, respectively) and anxiety (10.3%, 14.1%, respectively), any of the aforementioned psychiatric disorders (9.7%, 13.5%, respectively) had used an antidepressant in the past twelve months. Although a small proportion (1.4%) of those with none of the above psychiatric disorders used an antidepressant in the past twelve months, about half of all antidepressant use in the entire sample occurred in those who did not meet criteria for any twelve-month or lifetime psychiatric disorders. A large proportion of Blacks with general medical disorders such as diabetes and hypertension (7.1%) had used an antidepressant. In the multivariate logistic regression models, Blacks with any lifetime and twelve-month
DSM disorders had significantly increased odds of antidepressant use as did those with general medical disorders, but not their interaction terms.
Conclusions: African Americans and Caribbean Blacks had similar estimates of past twelve-month antidepressant use, and when combined into one group, few Blacks in this nationally representative sample had used an antidepressant.
Small proportions of Blacks with MDD, dysthymia and anxiety disorders had used antidepressants in the past twelve months. Although the proportion of Blacks using antidepressants that had no psychiatric disorders were smaller than those with psychiatric disorders; the absolute number of
Blacks with no psychiatric disorders who had used an antidepressant in the past year was much larger than those with psychiatric disorders. Further, Blacks with general medical disorders were likely to receive antidepressant pharmacotherapy independent of the presence of psychiatric disorders.
Implications for Policy, Delivery, or Practice: These findings suggest widespread misuse of antidepressants among Black
Americans, with significant unmet need coexisting with considerable unnecessary treatment.
Primary Funding Source: NIMH
● Admission Diagnosis and Sociodemographic Factors
Influence Patient Outcomes Following Surgical Resection of Colorectal Cancer at Low Volume Hospitals in New
York City 2000
Dennis Graham, MS, RN, NP
Presented By: Dennis Graham, MS, RN, NP, Nurse
Practitioner Clinical Program Director, Nursing, Memorial
Sloan-Kettering Cancer Center, 1275 York Avenue, New York,
NY 10021; Email: grahamd@mskcc.org
Research Objective: This study characterized the differences in admission diagnosis and sociodemographic characteristics of patients undergoing colorectal cancer surgery on at New
York City Hospitals in 2000 performed in low versus high volume hospitals.
Study Design: The New York Statewide Planning and
Research Cooperative System database was queried for patient admission diagnosis; demographic factors; an economic profile, determined by the average adjusted gross income by zip code; and the surgical volume of treating hospital. The 60 hospitals included in the study were grouped by colorectal cancer surgical volume into 4 groups: low, medium, high and highest. Distribution of factors within hospital groups was analyzed by an unadjusted Chi-square.
Population Studied: All patients in New York City hospitals in
2000 with the principle diagnosis by ICD-9 code for colorectal cancer and who had an ICD-9 code for surgical resection of the colorectal cancer during this admission were queried.
Principal Findings: Lower-volume hospitals had the highest number of non-colorectal admissions, Medicaid, Medicare and minority patients as well as the highest inpatient mortality rate and older and poorer patient population. To the contrary, the higher-volume hospitals had lower inpatient mortality, treated patients of younger age and higher AGI and had fewer minority and Medicaid patients than the lower-volume hospitals.

Conclusions: Higher inpatient mortality rate in lower-volume hospitals may, in part, be related to differences in the sociodemographics and admission diagnosis from those patient treated at the at the high-volume centers. These differences should be considered when comparing outcomes across institutions.
Implications for Policy, Delivery, or Practice: This study revealed that 26 percent of patients who had a surgical resection for colorectal cancer in 2000 in New York City were admitted with a non-colorectal diagnosis. Public policy needs to better methods to support early detection of colorectal cancer for the elderly, poor and under-insured.
Primary Funding Source: No Funding
● Obesity Among Inner City Children, Homeless and
Housed
Roy Grant, MA, Sandra Goldsmith, MS, RD, Alan Shapiro,
M.D., Marian Larkin, M.D., Irwin Redlener, M.D.
Presented By: Roy Grant, MA, Director of Research, Policy,
The Children's Health Fund, 215 West 125th Street, New York,
NY 10027; Tel: 212-535-9400; Fax: 212-535-7699; Email: rgrant@chfund.org
Research Objective: Data from the Centers for Disease
Control and Prevention (2000) show that obesity (BMI =>95th percentile) in the U.S. doubled from 1980-2000 among children 6-11 years old (to 16%) and tripled for youth 12-19
(also to 16%). Obese adolescents have an approximately 80% chance of becoming obese adults, with increased risk of type 2 diabetes, hypertension, dyslipidemia, nonalcoholic fatty liver disease, orthopedic disorders, low self-esteem and other potentially preventable conditions. Racial-ethnic disparities are marked. National data show that for children 6-11, 12% of white children are obese compared to 17.6% African-American and 19.6% Hispanic (Mexican). For youth 12-19, these data are
12.8% for white youth compared to 20.5% for African-
American and 19.4% for Hispanic (Mexican). This study compares the prevalence of obesity among inner city minority children and youth age 6-19 years who were housed to those who were homeless.
Study Design: The method was retrospective chart review of patients of the New York Program of The Children’s Health
Fund, a service of Community Pediatrics, Children’s Hospital at Montefiore. Clinical data were coded and analyzed for potential differences based on homeless/housed status, age, gender and race-ethnicity. Data analysis was done in SPSS using chi square, two-tailed Pearson correlation, and ANOVA calculations as appropriate.
Population Studied: The sample was comprised of housed pediatric patients of a federally qualified health center in a medically underserved New York City community, Hunts
Point-Mott Haven in the South Bronx (N=195), and homeless patients domiciled in the city’s family shelter system (N=200).
The patients were 45% African-American, 53% Hispanic
(predominantly Puerto Rican or Mexican); 49% male; mean age for 6-11 year olds was 8.5 years, mean age for 12-19 year olds was 15.5 years.
Principal Findings: Obesity prevalence for homeless children and youth compared to housed was higher but not to a statistically significant degree. Overall obesity prevalence was
30% for homeless patients vs. 25% for housed patients. For ages 6-11, obesity prevalence was 32% homeless vs. 27% housed. For ages 12-19, obesity prevalence was 28% homeless vs. 22% housed. The mean BMI for obese patients was similar for homeless and housed patients (27.7 vs. 27.5; not significant). There were no statistically significant differences in obesity prevalence based on age, gender or race-ethnicity.
These data are consistent data for adult obesity in Hunts
Point-Mott Haven (27%, NYC Department of Health). Overall,
12% of the homeless patients were overweight (BMI 85th-94th percentile) and 3% underweight (BMI=<5th percentile). For the housed patients, 19% were overweight and 3% underweight. Only 55% of homeless and 54% of housed patients had a BMI within normal range.
Conclusions: The health burden of obesity and associated risk appears to be evenly distributed in inner city minority populations of New York City. Prevalence in these high-risk, medically underserved populations exceeds national data for minority children and youth.
Implications for Policy, Delivery, or Practice: These results emphasize the importance of integrating BMI calculation in pediatric primary care for high-risk populations. Weight management interventions, including nutrition counseling, should be available as clinically indicated.
Primary Funding Source: HRSA, The Picower Foundation;
Bristol-Myers Squibb
● Prevalence and Variation of Literacy Skills Among
Veterans
Joan Griffin, Ph.D., Annamay Snyder, M.P.H., Melissa Partin,
Ph.D., Sean Nugent, BA, Siamak Noorbaloochi, Michelle vanRyn, Ph.D., Joseph Grill, MS
Presented By: Joan Griffin, Ph.D., Research Investigator,
Center for Chronic Disease Outcomes Research, Minneapolis
VA Medical Center, One Veterans Drive, Minneapolis, MN
55417; Tel: 612-467-4232; Fax: 612 725 2118; Email: joan.griffin2@med.va.gov
Research Objective: Studies show that people with poor literacy skills have significantly worse health, are less likely to engage in preventative health measures, and have less knowledge about their health. Studies also report that those with the poorest skills do not speak English as a first language or are elderly, poor, African American or Hispanic, and have completed fewer years of schooling. Although poor literacy skills have been suggested as being one reason for disparities in health outcomes, little is known about the prevalence and distribution of poor literacy skills among health care users.
This study’s objective was to determine the prevalence of literacy skills in a large patient population receiving care from the Veterans Health Administration and to assess variation in skills by age, education, income, race, urban/rural and marital status.
Study Design: The study design was observational, based on cross-sectional interviews with patients. The sample was randomly drawn from a list of all patients with upcoming appointments in primary care clinics at one of the four participating medical centers (Minneapolis, MN; Portland,
OR; Durham, NC; and, West Los Angeles, CA).
Population Studied: Randomized patients were sent introductory letters and then recruited by phone. Patients willing to participate in the study completed a face-to-face survey with a trained interviewer. Interviewers collected demographic information and conducted an assessment of

literacy (Short-Test of Functional Health Literacy in Adults, S-
TOFHLA). The S-TOFHLA tests reading comprehension and numeracy skills and classifies literacy by inadequate, marginal and adequate levels of skill.
Principal Findings: Of the 1632 veterans assessed with the S-
TOFHLA, the majority (83%) had adequate literacy skills.
Slightly more than 16% had either inadequate (8%) or marginal skills (8%). In bivariate analyses, those with either inadequate and marginal skills were significantly more likely to be over 75, have less than a high school education, an annual household income less than $20,000, and be widowed. In bivariate analyses the S-TOFHLA did not vary significantly by race. In multivariate analyses, age, education, income, and
African American race were significantly associated with inadequate or marginal skills after adjusting for study site.
Conclusions: A potentially clinically significant proportion of veterans assessed--1 in 6--had inadequate or marginal literacy skills. Consistent with other studies, veterans with poor literacy were more likely to be poor, elderly, African American and have fewer years of formal education.
Implications for Policy, Delivery, or Practice: Vulnerable populations within the VA are more likely to have poor literacy skills than others. Developing effective strategies to improve outcomes for people with poor literacy may help reduce disparities among veterans using VA services.
Primary Funding Source: VA
● Racial Differences in Expectations of Joint Replacement
Surgery Outcomes among Veterans with Osteoarthritis
Peter Groeneveld, M.D., MS, C. Kent Kwoh, M.D., Cathleen J.
Appelt, Ph.D., Jennifer Gutierrez, BA, Abigail L. Resnick, MS,
Said A. Ibrahim, M.D., M.P.H.
Presented By: Peter Groeneveld, M.D., MS, Assistant
Professor of Medicine, Ctr for Health Equity Research and
Promotion, Philadelphia VA Medical Center, 3900 Woodland
Ave - 9East, Philadelphia, PA 19104-4155; Tel: (215) 898-2569;
Fax: (215) 573-8778; Email: peter.groeneveld@va.gov
Research Objective: There are substantial differences in the rates that black and white veterans with osteoarthritis undergo joint replacement surgery. Expectations of the outcomes of surgery such as functional status, pain, and quality of life are likely to influence the willingness of patients to undergo surgery, yet it is unknown if blacks and white differ in their beliefs about the likely benefits of elective joint replacement.
Study Design: We surveyed 365 (179 black, 186 white) veterans with knee osteoarthritis and to 156 (72 black, 84 white) veterans with hip osteoarthritis to assess their expectations for the outcomes of joint replacement surgery.
Patients were eligible to enroll in the study if they indicated moderate or severe joint pain and disability, as indicated by their Western Ontario and McMaster Universities
Osteoarthritis Index. We used Mancuso's previously-validated
Hospital for Special Surgery Joint Replacement Expectations
Survey (HSS-JRES) to assess patients’ expectations for pain relief, functional improvement, and psychological well-being after joint replacement surgery.
Population Studied: The study population comprised veterans ages 50-79 receiving primary care in the Pittsburgh
VA Health Care System or the Philadelphia VA Medical Center.
Principal Findings: Possible scores on the HSS-JRES range from zero to 68 for knee replacement and zero to 72 for hip replacement, with higher scores indicating more optimistic expectations of surgical outcomes. In ordinary least squares regression controlling for survey site, whites scored 5.8 points higher than blacks for knee replacement expectations (95% confidence interval[CI] 2.3–9.4, p=0.001) and 8.1 points higher for hip replacement expectations (95% CI 3.3-13.0, p=0.001).
Twenty-two percent of black patients, but only 13% of white patients, scored below 30 on the knee expectations survey
(p=0.02), and 25% of blacks, but only 10% of whites, scored below 30 on the hip expectations survey (p=0.01).
Conclusions: Among veterans with moderate-to-severe osteoarthritis, whites have substantially higher expectations for the physical, functional, and psychological benefits of joint replacement surgery.
Implications for Policy, Delivery, or Practice: It is possible that this difference in therapeutic expectations is an important cause of the racial disparity in joint replacement procedure rates.
Primary Funding Source: VA
● Smoke-Free Workplace Policies and Health Care
Coverage from 1998-2004: Evidence of Racial Disparities
Jonathon Halbesleben, Ph.D.
Presented By: Jonathon Halbesleben, Ph.D., Research
Assistant Professor, Department of Health Management &
Informatics, University of Missouri, Columbia, 324 Clark Hall,
Columbia, MO 65211; Tel: (573) 884-1723; Fax: (573) 882-6158;
Email: halbeslebenj@health.missouri.edu
Research Objective: Tobacco use, including exposure to environmental tobacco smoke (second-hand smoke) in the workplace, remains a critical public health concern. Previous research has found early evidence that there are racial disparities in smoke-free workplace policies. Similarly, health services researchers and policymakers have consistently drawn attention to concerns with disparities in health care access and insurance. The objective of this research is to understand how disparities in smoke-free work policies intersect with racial disparities in health care coverage.
Study Design: Data from the 1998-2004 Behavioral Risk
Factor Surveillance System (BRFSS) optional Tobacco Use
Module were used to assess the extent to which individuals in different racial groups were covered by a smoke-free workplace policy and health insurance. The data were analyzed across the seven year period in order to discern trends in racial disparities in smoke-free workplace policies.
Population Studied: Civilian adults living in 34 of the United
States and the District of Columbia from 1998-2004.
Principal Findings: This research supports previous findings regarding smoke-free workplace policies, finding that minority workers are less likely to work in a workplace that has a smoke-free workplace policy. Specifically, white, non-Hispanic individuals were most likely to be covered by a smoke-free workplace policy, followed by black, non-Hispanics, followed by workers of Hispanic descent. Additionally, this research found that while workers in all racial groups were more likely to be covered by a smoke-free policy over time, however, the gap between racial groups remained fairly consistent over the seven year period under study. Finally, Hispanics, who were least likely to be working in an environment with a smoke-free workplace policy, were also the least likely to be covered by health care insurance.

Conclusions: This research suggests that workers in minority groups may be doubly at risk, as they are more likely to work in a workplace without a smoke-free work policy and are less likely to have health insurance coverage that might help to address the subsequent health problems as a result of their own or others' smoking behavior at work. The correlation between a lack of smoke-free workplace policies and health care insurance coverage may represent a more broad disregard for employee health in some companies; more research is needed to explore why members of certain racial groups are more likely to work at such companies.
Implications for Policy, Delivery, or Practice: This research gives further credence to concerns about the health care of members of racial minority groups in the United States. While this research suggests that there has been improvement over the past seven years with regard to voluntary smoke-free workplace policies, there remain gaps between racial groups in coverage by such policies. Moreover, the incremental growth in smoke-free workplace policies suggests that we are unlikely to meet the target of 100% smoke-free workplace policy coverage detailed in Healthy People 2010. Findings with regard to smoke-free workplace policies and health care coverage suggest a need to explore mandated smoke-free workplace policies and health insurance reform that may address racial disparities.
Primary Funding Source: Centers for Disease Control and
Prevention (CDC) and the Missouri Department of Health and
Senior Services
● Avoidable Hospitalizations: Disparities between Rural and Urban Patients
Margaret Hall, Ph.D., Maria F. Owings, Ph.D., Lola Jean
Kozak, Ph.D.
Presented By: Margaret Hall, Ph.D., Health Statistician,
Hospital Care Statistics Branch, National Center for Health
Statistics, 3311 Toledo Road, Room 3331, Hyattsville, MD
20782; Tel: (301) 458-4252; Fax: (301) 458-4032; Email: mhall@cdc.gov
Research Objective: Avoidable hospitalizations have been considered an indicator of access to timely and appropriate primary health care. Rural residents face a unique combination of socioeconomic and geographic factors that may create barriers to access. Rural/urban disparities in avoidable hospitalization rates may be a reflection of these barriers. Most research literature that reports rural/urban disparities in rates of avoidable hospitalization is based on small-scale or regional studies. The proposed research uses recent, nationally representative data to explore this issue. It will describe rural and urban patients hospitalized for avoidable conditions, and examine factors which might explain rate disparities.
Study Design: Data are from the 2003 National Hospital
Discharge Survey (NHDS), a nationally representative survey of short-stay, nonfederal hospitals in the US. County FIPS codes for patients are used to obtain information from the
Area Resource File on the socioeconomic characteristics and the health care capacity within the patient's county of residence. The OMB definition of metropolitan status based on the 2000 Census is used to define rural and urban.
Metropolitan counties are classified as urban and all others
(micropolitan and noncore counties) are rural. Multivariate logistic regression will identify the independent effects of individual and county-level factors which predict rural compared to urban avoidable hospitalizations.
Population Studied: Rural and urban patients hospitalized for avoidable conditions (including pneumonia, congestive heart failure, asthma, cellulitis, perforated or bleeding ulcer, pyelonephritis, diabetes with ketoacidosis or coma, ruptured appendix, malignant hypertension, hypokalemia, immunizable conditions, and gangrene) in short-term nonfederal hospitals in the United States.
Principal Findings: In 2003, the rate of avoidable hospitalizations per 10,000 population was 198 in rural areas and 123 in urban areas. Patients with avoidable hospitalizations who lived in rural areas were older but had similar numbers of diagnoses as their urban counterparts.
They were likely to live in counties with less education, lower income, and less HMO penetration. The rate of hospital beds was similar for rural and urban residents with avoidable hospitalizations, but rural residents lived in counties with a lower rate of active MD's. Multivariate analyses will be conducted to determine the independent contribution of each individual and county-level variable in predicting patients' rural or urban status.
Conclusions: Higher rural rates of avoidable hospitalizations and lower rates of active physicians may signify problems with access to appropriate primary care.
Implications for Policy, Delivery, or Practice: This project uses nationally representative data on rural and urban residents who had avoidable hospitalizations in order to determine factors which may contribute to disparities between these two groups. This information is crucial for informing national health policymakers as they consider the need for further legislative changes designed to improve access to care in rural areas. Also, it is critical to have data on avoidable hospitalizations for both rural and urban areas for the period prior to the implementation of the Medicare Drug Benefit, since inability to pay for outpatient drugs may contribute to avoidable hospitalizations.
Primary Funding Source: CDC
● Characteristics of Early Inter-Hospital Transfers after ED
Admission
Daniel Handel, M.D., M.P.H., K. John McConnell, Ph.D.,
Christopher J. Lindsell, Ph.D.
Presented By: Daniel Handel, M.D., M.P.H., resident,
Emergency Medicine, University of Cincinnati Medical Center,
7790 Fancycab Ct., Cincinnati, OH 45231; Tel: 513-226-5035;
Fax: 513-558-6434; Email: d.handel@fuse.net
Research Objective: To determine characteristics predictive of early inter-hospital transfer for identifying disparities in access to care after ED admission.
Study Design: This retrospective study used data from the
2002 Healthcare Cost and Utilization Project Nationwide
Inpatient Sample, a nationally representative sample of 7.8 million admissions and 1,000 hospitals. Admitted ED patients who had not died or been transferred to a non-acute care facility within the first day were included. Age, race, sex, socioeconomic status and diagnoses requiring specialist services (e.g. cardiac) were used as patient level predictors of early transfer, while hospital ownership, size, geographic location, and teaching status were explored at the hospital

level. Multivariable logistic regression was used to model predictors of transfer to an acute care facility within one day of admission, with weighted data to provide national estimates.
Population Studied: A nationally representative sample of 7.8 million admissions and 1,000 hospitals.
Principal Findings: 36% of all hospitalizations met inclusion criteria; 45% were female, 17% were black, and mean age was
59.7 years. 1.4% (95% CI 1.3-1.5%) of included hospitalizations resulted in early transfer. Compared to 18-34 year olds, pediatric patients (OR 2.15, 1.87-2.46) and patients between 35 and 84 years-old were more likely transferred while patients over 85 (OR 0.64, 0.57-0.71) were less likely transferred.
Compared to whites, blacks (OR 0.73, 0.66-0.80) and
Hispanics (OR 0.80, 0.71-0.89) were less likely transferred.
Compared to privately insured patients, Medicare (OR 0.64,
0.60-0.69), Medicaid (OR 0.63, 0.57-0.70), and self-pay patients (OR 0.72, 0.65-0.80) were less likely transferred.
Increasing median household income increased the likelihood of transfer. Transfer was more likely from small compared to large hospitals (OR 3.26, 2.82-3.76), and rural compared to urban teaching hospitals (OR 9.95, 7.93-12.49).
Conclusions: Affluence increases the odds of early transfer, suggesting possible disparities in access to care that could be mitigated by direct transfer from the ED.
Implications for Policy, Delivery, or Practice: Assuming that early inter-hospital transfers are medically indicated and in the patients' best interests, results from this study are suggestive that patients who have traditionally not had adequate access to care may be further disadvantaged due to a decrease probability of early and appropriate transfers. EMTALA and other federal regulations must be reviewed to see what health policy implications can be modified to rectify this discrepancy.
Primary Funding Source: No Funding
● Trends of Inter-Hospital Transfer within One Day of ED
Admission: 2001-2003
Daniel Handel, M.D., M.P.H., K. John McConnell, Ph.D.,
Christopher J. Lindsell, Ph.D.
Presented By: Daniel Handel, M.D., M.P.H., Resident
Physician, Emergency Medicine, University of Cincinnati
Medical Center, 7790 Fancycab Ct., Cincinnati, OH 45231; Tel:
513-226-5035; Email: d.handel@fuse.net
Research Objective: There is concern of an increasing rate of inter-hospital patient transfers. The purpose of this study was to determine regional, demographic, insurance, and hospital factors in trends of early inter-hospital transfers over three years.
Study Design: This retrospective study used data from the
2001-2003 Healthcare Cost and Utilization Project Nationwide
Inpatient Sample, a nationally representative sample of 7.8 million admissions and approximately 1,000 hospitals.
Transfer rates were compared between years overall and within the following categories: age, gender, race, type of insurance, income, hospital size, type, and location, region, and diagnoses requiring specialist services (i.e. neurosurgery, cardiac catheterization). Proportions of patients transferred within one day of admission were estimated, with 95% confidence intervals (CI) adjusted for the complex sampling scheme and subgroup analysis.
Population Studied: Admitted ED patients who had not died or been transferred to a non-acute care facility within the first day were included.
Principal Findings: The number of inter-hospital transfers within 24 hours of ED admission declined from 2001 to 2003, from 1.55% (CI, 1.47-1.63) of patients in 2001 to 1.38% (CI 1.30-
1.46) in 2003. The probability of transfer for Medicaid patients decreased significantly, from 1.9% (CI 1.8-2.1) in 2001, to 1.3%
(CI 1.2-1.4) in 2003. Declining trends in transfer were seen in patients 45-64 years old and from larger hospitals. Patients with diagnoses that required specialty services also showed significant decreases in the probability of transfer, from 2.4%
(CI 2.5-2.2) in 2001, to 2.1% (CI 2.0-2.2) in 2003.
Conclusions: Early inter-hospital transfers declined from 2001 to 2003, with the largest decrease in transfers occurring among Medicaid patients. Furthermore, patients in need of specialty services were less likely to be transferred once admitted.
Implications for Policy, Delivery, or Practice: This may be supportive of observed trends towards increasing transfer of patients direct from the ED and more appropriate early disposition by emergency physicians.
Primary Funding Source: No Funding
● Beyond Formal Plans: Using Complex Adaptive Planning and Evaluation (CAPE) Methods to Address Minnesota's
Health Care Disparities
Margaret Hargreaves, M.P.P.
Presented By: Margaret Hargreaves, M.P.P, Senior Associate,
Abt Associates Inc., Email: meg_hargreaves@abtassoc.com
Research Objective: In December 2003, The Minnesota
Department of Health (MDH) and the Minnesota Department of Human Services (DHS) hosted the Governor's Health Care
Disparities Summit, at which the governor charged the leaders of the state's health care industry to take action to deliver culturally and linguistically appropriate health care (CLAS) services to all Minnesotans. The summit's participants formed the Minnesota Health Care Disparities Task Force in
March 2004, to address the issue.With staff support from
MDH and DHS, by early 2005 the task force had developed and started implementing statewide work plans in three areas: provider collection and use of racial and ethnic health care data for quality improvement purposes; the improvement of interpreter services and other patient access issues, and provider cultural competence. At the same time, the task force became involved politically in the state's legislative budget debate over whether to cut state public health insurance programs. This research study examined the strategic use of a government task force to address statewide health care disparities, and specifically the task force's use of new Complex Adaptive Planning and Evaluation (CAPE) methods to facilitate system change, at both organizational and political levels. The findings from this task force case study contribute to the health care disparities system change and the health planning and evaluation literature.
Study Design: This task force was selected for a comprehensive case study because of its use of CAPE methods, based on complex adaptive systems (CAS), agentbased modeling (ABM), conditions of self-organization, and emergent co-evolution theory. This study describes the task force's use of CAPE methods and subsequent actions to

intervene politically in the state's budget process and organizationally, in the state's health care delivery system.
Research methods used included in-depth interviews with task force members and stakeholders, a review of relevant documentation, and participant observation of task force methods, decisions, and processes.
Population Studied: The Minnesota Health Care Disparities
Task Force, a statewide coalition of about 40 health care leaders from all health sectors.
Principal Findings: Unlike traditional health task forces that publish reports, this task force took unprecedented action in both political and organizational arenas, impacting the state's health care system. The task force's efforts helped prevent budget cuts in state public health insurance programs and supported rapid diffusion of innovative CLAS practices throughout the state's health care industry.
Conclusions: CAPE was shown to be an effective tool for helping government-based health task forces move beyond the publication of formal strategic plans to begin taking action, both collectively and as individual task force members, with system-wide results.
Implications for Policy, Delivery, or Practice: The CAPE model complements traditional planning efforts by pairing formal planning elements with opportunities for less scripted, more adaptive action across multiple sectors and levels. The
CAPE model provides a viable alterative to tightly controlled government planning ? a middle ground of complex, adaptive negotiation, collaboration, and co-evolution.
Primary Funding Source: The Minnesota Health Care
Disparities Task Force
● Disparities in Diabetes Prevalence, Risk Factors and Risk of Comorbidities in California Adults
Theresa Hastert, M.P.P, Allison Diamant, M.D., MSHS, Susan
Babey, Ph.D., E. Richard Brown, Ph.D.
Presented By: Theresa Hastert, M.P.P, Research Associate,
UCLA Center for Health Policy Research, 10911 Weyburn Ave.,
Suite 300, Los Angeles, CA 90024; Tel: (310) 794-2827; Email: thastert@ucla.edu
Research Objective: To estimate disparities in diabetes prevalence, comorbidities and risk factors among California adults. To estimate disparities in diabetes prevalence, diabetes risk, and comorbidity risk factors such as tobacco use and hypertension among those diagnosed with diabetes.
Study Design: We used data from the 2003 California Health
Interview Survey (CHIS). CHIS, a random-digit dial (RDD) telephone survey of households drawn from every county in
California, completed interviews with over 42,000 households in 2003. Bivariate analyses were used to examine diabetes prevalence, comorbidities and risk factors among California adults.
Population Studied: We analyzed responses from over
42,000 adults interviewed for CHIS 2003.
Principal Findings: In 2003 6.6% of California adults had been diagnosed with diabetes, up from 6.2% in 2001
(p<0.10). American Indians/Alaska Natives (9.9%) and
African Americans (9.3%) had the highest prevalence.
Prevalence among African Americans was significantly higher than among Latinos (7.5%), Asians (6.4%) or Whites (5.6%).
Although Asians have a comparatively low rate of diabetes, they were the only racial/ethnic group to show a significant increase in diabetes prevalence from 5.0% in 2001 to 6.4% in
2003. In addition, Latinos have the highest prevalence in each of the following age groups: 18-49, 50-64 and 65 and over.
Diabetes prevalence decreases with additional education from
12.0% for those who did not complete eighth grade to 4.5% among college graduates. Prevalence also decreases with increasing income from 8.8% for those with household incomes below 200% of the federal poverty level (FPL) to 5.1% for those with household incomes of at least 300% FPL. High blood pressure and smoking have been linked to increased risk of serious complications such as cardiovascular disease, kidney disease, stroke, and amputation, and among those diagnosed with diabetes, these risk factors vary by race/ethnicity. Overall, 60.9% of those with diabetes have high blood pressure. More African Americans with diabetes have high blood pressure (74.0%) than any other group, followed by Asians (67.2%). Overall, 15.0% of those with diabetes are current smokers, but 39.8% of AI/ANs with diabetes are current smokers, followed by African Americans
(20.7%). Disparities also exist in risk factors for developing diabetes. Overweight and obesity are major diabetes risk factors. Among all adults not diagnosed with diabetes, 54.0% are either overweight or obese; however, significantly more
Latinos (64.8%), African Americans (63.7%) and AI/ANs
(62.7%) are overweight or obese compared to whites (52.5%) or Asians (31.4%), placing these groups at increased risk for developing diabetes.
Conclusions: African Americans, American Indian/Alaska
Natives and Latinos have the highest diabetes prevalence, and are at greatest risk for developing diabetes and complications from diabetes. African Americans with diabetes have the greatest prevalence of hypertension putting them at increased risk for end-stage-renal-disease, hemodialysis and kidney transplantation, as well as high rates of smoking putting them at increased risk for amputation.
Implications for Policy, Delivery, or Practice: African
Americans, American Indian/Alaska Natives and Latinos stand to benefit the most from interventions targeted at diabetes prevention and management.
Primary Funding Source: The California Endowment
● Are There Age Differences in Lipid and Glycemic Care
Among Elderly Veterans with Diabetes?
Drew Helmer, M.D., MS, Mangala Rajan, M.B.A., Usha
Sambamoorthi, Ph.D., Leonard Pogach, M.D., M.B.A.
Presented By: Drew Helmer, M.D., MS, Physician,
Researcher, VA-NJHCS, 385 Tremont Ave (129), East Orange,
NJ 07018; Email: helmer@njneuromed.org
Research Objective: There is little research supporting agespecific diabetes care standards for the elderly and guidelines recommend making diabetes care decisions on an individual basis. The primary objective of the study is to compare patterns of diabetes care between the “young-old” (65-74 years) and “old-old” (>or= 75 years) using a nation-wide database of veterans.
Study Design: We tested for association between age and diabetes care among the elderly in 2000 in this retrospective analysis of merged Veterans Health Administration (VHA) and
Medicare administrative data. Diabetes care measures consisted of hemoglobin A1c (HA1c) and low-density lipoprotein (LDL) testing in VHA or Medicare data, and HA1c

greater than 9% (HA1c>9) and LDL greater than 130mg/dL
(LDL>130) in VHA data. We tested the null hypothesis of no differences in care between the “young-old” (65-74 years) and
“old-old” (>= 75 years) using logistic regression adjusting for socioeconomic status (gender, race/ethnicity, marital status), comorbid conditions (mental health disorder, comorbidity score (DxCG)), access (priority group status, Medicare Part B enrollment, Medicaid enrolled, distance to nearest VHA facility), and dual-system use (VHA vs. non-VHA). We included cardiology care for LDL outcomes and cardiology and endocrinology care for HA1c outcomes. We also examined interaction terms for age and specialty care variables.
Population Studied: Veterans with diabetes enrolled in the
VHA and Medicare fee-for-service in 1999 and 2000 who had one or more face-to-face visit in the VHA in 2000 and were alive at year’s end (n=194,772).
Principal Findings: Overall, 71% of young-old (n=120,000) and 70% of old-old (n=74,772) had HA1c measured and 66% of young-old and 62% of old-old had LDL measured. Among those who had LDL tested (90,592) 18.6% of the young-old and 18.3% of old-old had LDL>130. Among those who had
HA1c tested (112,168) 12.8% of young-old and 9.4% of old-old had HA1c>9. The age differences in care were statistically significant for HA1c control and LDL testing. Cardiology care was associated with increased likelihood of LDL testing. The age-cardiologist interaction term was significant and positive for LDL testing. The age-endocrinology interaction term was significant and positive for HA1c>9.
Conclusions: Compared to the young-old, the old-old are significantly less likely to have LDL testing and poor glycemic control. However, the magnitude of the differences may not be considered clinically significant. The association between older age and better glycemic control is likely due to survival bias or unadjusted socioeconomic or disease factors.
Cardiologist care is associated with better lipid management and attenuates the age discrepancy in LDL testing.
Implications for Policy, Delivery, or Practice: It appears that clinicians are treating elderly patients with diabetes to similar standards.
Primary Funding Source: VA
● Race Disparities in Delivery of Invasive Cardiology
Procedures at Academic Health Centers
Samuel Hohmann, Ph.D., MSHSM, Sandra Magnetti, Dr.P.H.
Presented By: Samuel Hohmann, Ph.D., MSHSM, Senior
Research Analyst, Information Architecture, University
HealthSystem Consortium, 2001 Spring Road, Suite 700, Oak
Brook, IL 60523; Tel: (630) 942-1740; Email: hohmann@uhc.edu
Research Objective: The evidence is clear that minority patients are less likely to receive invasive cardiac procedures.
These disparitites remain after adjustments for demographics.
Providing drug eluting stent (DES) implants, a rapidly adopted practice since 2003, has varied by race. The objective of this research project was to determine if there are race disparities in providing new invasive cardiology technologies to patients at academic medical centers (AMCs).
Study Design: Retrospective cohort study. An index was developed to represent the proportion of patients receiving coronary DES implants versus the number of patients receiving any type of coronary stent implant. Overall DES indexes as well as AMC-specific DES indexes were derived.
Persistence of race disparity based on DES index was examined by age, gender, payer, comorbidities, severity of illness (SOI), admission status, LOS, and individual AMC stent volume.
Population Studied: 63,933 patients discharged from AMCs who had coronary stent implants between April 2002 and June
2005. The data was from the University HealthSystem
Consortium Clinical Data Base which contains UB-92 billing abstract information.
Principal Findings: There are statistically significant differences proportions of patients having bare metal stent
(BMS) vs. DES implants by race. The DES index for white patients increased from 32.6% to 91.2% between April 2002 and June 2005 while it increased from 20.8% to 88.7% among
African Americans in the same period. While the gap narrowed, a statistically significant difference remained. The disparity between white and African American DES indexes persisted by age, gender, payer, comorbidities, severity of illness (SOI), and admission status, the difference being about
10% (and statistically signficant) across all comparisons. The smallest difference was between white and African American patients with the highest severity of illness score, 52.0% among African American patients versus 55.0% among white patients. Institutional DES indexes for white and African
American patients were highly correlated, i.e., higher AMC
DES indexes for white patients were associated with higher
AMC DES indexes for African American patients. There was more variation in this relationship among AMCs with lower overall DES indexes. When AMCs were sorted by their African
American DES indexes in decreasing order, the percent of white patients receiving DES iimplants varied extensively, even though proportionally, white patients received more DES implants. There were differences in rate of adoption of DES technology across AMCs. Within three months, a third of the
AMCs already had DES indexes greater than the overall average for the year. Another third did not cross that threshold until 11 or 12 months after introduction, and about
20 percent did not reach that threshold in the first year after availability of the new technology. Some of the disparity may be a consequence of availability of DES at AMCs with high proportions of African Americans and low percentages of DES implants.
Conclusions: This bivariate analysis suggests a large, significant race disparity in providing DES implants. The proportions are affected by proportions of African Americans receiving care at an AMC as well as the number of patients receiving staents at the AMC. While disparities exist, the issue may be explained by access/availability, and access barriers were not considered in this study. Differential adoption of the use of DES implants may result in unequal access to DES.
Implications for Policy, Delivery, or Practice: Race disparities can be identified and better understood through access to hospital discharge data. Results like these can be used to examine outcomes of care and provide insights to improve quality of care. The results can drive policy development to address disparities and support the need for resources to eliminate or reduce disparities. To do this we must determine what incentives/disincentives there are for use of new technologies, create awareness of unequal access to new technology, and develop strategies to ensure equal access.

Primary Funding Source: No Funding
● Racial Differences in Hospital Very Low Birthweight
Neonatal Mortality
Elizabeth Howell, M.D., M.P.P., Paul Hebert, Ph.D., Samprit
Chatterjee, Ph.D., Mark R. Chassin, M.D., M.P.H,. M.P.P.
Presented By: Elizabeth Howell, M.D., M.P.P., Assistant
Professor, Health Policy, Mount Sinai Medical Center, One
Gustave L. Levy Place, New York, NY ; Tel: (212) 659 9567; Fax:
(212) 423 2998; Email: elizabeth.howell@msnyuhealth.org
Research Objective: To rank New York City hospitals delivering very low birthweight infants by risk-adjusted neonatal mortality. To assess differences in the racial distribution of very low birthweight births among New York
City hospitals. To estimate the extent to which any such differences are associated with the disparity in neonatal mortality between Blacks and Whites in New York City.
Study Design: This was a population-based cohort study of
New York City very low birthweight infants. The primary outcome was risk-adjusted neonatal mortality. We ranked
New York City hospitals by risk-adjusted neonatal mortality and then assessed differences in the distribution of Black and
White births among these hospitals. We estimated the effect of racial differences in distribution of hospital births on Black very low birthweight neonatal mortality.
Population Studied: We used New York City Vital Statistics records on all live births and deaths of infants weighing 500 to
1499 grams born in 45 hospitals from January 1, 1996 through
December 31, 2001 (N=11,828). We excluded infants who were delivered outside of a hospital setting or had missing birthweights.
Principal Findings: Risk-adjusted neonatal mortality for very low birth weight infants in New York City hospitals ranged from 9.6 to 27.2 per 1000 births. Distribution of births among hospitals ranked from lowest to highest risk-adjusted mortality differed for Black and White mothers (p=0.006). White infants were more likely to be delivered in low mortality hospitals: 49% of White versus 29% of Black very low birthweight infants delivered in the lowest mortality tertile of hospitals. If there were no racial difference in hospital choice of birth we estimate that Black VLBW mortality would be reduced by 6.6 deaths per 1000 VLBW births per year. This number represents 34.2% of the racial disparity in VLBW neonatal mortality in New York City.
Conclusions: New York City hospitals vary widely in VLBW risk-adjusted neonatal mortality. Differences in distribution of very low birthweight Black and White births in New York City hospitals partially explain the racial disparity in neonatal very low birthweight mortality.
Implications for Policy, Delivery, or Practice: Our data suggests that some of the racial disparities in neonatal mortality rates may be related to where Black and White VLBW infants are born. Variations among hospitals in the use of effective treatments for VLBW babies may be responsible for some of the racial disparity in neonatal mortality. Detailed research examining practice patterns for the management of prematurity is needed.
Primary Funding Source: AHRQ, Commonwealth Fund;
National Center for Minority Health and Health Disparities
● A National Sutdy of Asthma Prevalence and Trends in
Urban and Rural Counties, 2000-20003
J. Elizabeth Jackson, MA, Mark Doescher, M.D., MSPH, Gary
Hart, Ph.D.
Presented By: J. Elizabeth Jackson, MA, Research Assistant,
Family Medicine, University of Washington, 4225 Roosevelt
Way NE, Suite 308, Seattle, WA 98105; Tel: (206) 685-1990;
Fax: (206) 685-0610; Email: bjackson@u.washington.edu
Research Objective: Asthma has long been considered a problem of urban populations, but it is not an insignificant problem in rural areas. Unfortunately, detailed information on asthma prevalence and recent trends in rural locations is limited. The objective of this study is to estimate the prevalence of and recent trends in asthma among US adults residing in metropolitan and non-metropolitan counties, as well as to identify specific rural groups at particular risk.
Study Design: Analysis of data from the Behavioral Risk
Factor Surveillance System (BRFSS) national sample for the years 2000 (n=184,450), 2001 (n=212,510), 2002 (n=247,964), and 2003 (n=264,684). The outcomes measured were asthma diagnosis and current asthma symptoms, from self-report.
Population Studied: Non-institutionalized US adults, using repeated samples drawn from all states and the District of
Columbia.
Principal Findings: In 2003, adjusted prevalence of asthma diagnosis ever was 12.0% for metropolitan counties and
11.0% for non-metropolitan counties (p<.001). The adjusted prevalence of asthma symptoms given a prior diagnosis was
65.8% in metropolitan counties vs. 66.5% in non-metropolitan counties (p=.554). Symptoms were most prevalent among non-metropolitan African Americans, Native Americans, those over 65, and those with less than a high school diploma.
Prevalence of asthma diagnosis has trended upwards for both metropolitan and non-metropolitan counties between 2000 and 2003; prevalence of current symptoms has declined over the same period.
Conclusions: The prevalence of asthma is increasing at a similar rate among residents of both metropolitan and nonmetropolitan counties. However, until 2003 the prevalence of current asthma symptoms was higher for residents of nonmetropolitan counties and remains especially problematic for rural African Americans, Native Americans, seniors and those with low educational attainment.
Implications for Policy, Delivery, or Practice: Asthma is a national problem requiring increased attention in both rural and urban areas. However, particular efforts are needed to improve the use of asthma controller medications in several high-risk, rural groups.
Primary Funding Source: Federal Office Of Rural Health
Policy

● Does Having More Information Explain Observed Racial
Disparities in Kidney Transplant Preferences?
Cara James
Presented By: Cara James, Health Care Policy, Harvard
Unversity, 180 Longwood Ave., Boston, MA 02115; Tel: 617-
493-1701; Email: cjames@fas.harvard.edu
Research Objective: Research suggests that African-
Americans with end-stage renal disease (ESRD) are less likely to want a kidney transplant and are less certain about their decision. The primary objective of this study is to determine whether differences in sources of information explain observed racial disparities in kidney transplant decision certainty. This study also examines whether increasing the number of sources from which a patient receives information increases decision certainty, and whether it raises expectations for transplant outcomes.
Study Design: This was a cross-sectional study of hemodialysis patients in four geographic areas of the United
States (Alabama, southern California, Michigan, and the mid-
Atlantic region of Maryland, Virginia, and the District of
Columbia). Telephone interviews were conducted on a stratified random sample of black and white men and women in these regions to obtain information about transplant preferences and information sources used in the decision process. Patients who began dialysis between May 1996 and
June 1997 were interviewed at home close to 10 months after initiation of dialysis. Medical records were reviewed by renalnetwork staff to collect information on comorbidities and referrals for transplant evaluations. Logistic regressions were run to examine the relationship between information and decision certainty, as well as racial differences in the number of information sources used in the transplantation process.
All analyses were adjusted for demographic characteristics including gender, age, education and income.
Population Studied: The population studied consisted of hemodialysis patients between the ages of 18 and 54.
Pediatric patients were not sampled. The initial sampling process yielded 1933 patients. After excluding 254 patients for reasons including death, relocation, and cognitive impairments, 1679 patients were eligible for the study.
Principal Findings: After controlling for demographic characteristics, patients with more sources of information were more likely to want a transplant (OR=1.16, p=.01), be certain about their decision (OR=1.15, p<.01), and have better expectations regarding quality and length of life following transplant (OR=1.07, p=.03 and OR=1.11, p<.01 respectively) than patients with fewer sources. Black patients had fewer sources than white patients (6.34 vs. 6.58, p=.02), and were less likely to say they received enough information (73% vs.
82%, p<.01). They also had lower expectations than whites for a much better quality of life following transplant (OR=.74, p=.01), but were as likely as whites to believe they would live much longer. Blacks are less certain in their transplant decision than whites (OR=0.67, p=.01). However, this difference decreases after adjusting for sources of information
(OR=0.73, p=.04). The interaction term for race and sources was also significant (p=.02).
Conclusions: Observed racial disparities in transplant decision certainty decreased after adjustment for the amount of information patients had. However, disparities persist.
Findings also suggest that disparities exist not just in the amount of information black and white patients receive, but in how that information is processed.
Implications for Policy, Delivery, or Practice: Increasing the amount of information all patients receive can improve treatment decisions and reduce disparities. However, more research is needed to understand how the information is processed, and which sources are most influential.
Primary Funding Source: WKK
● The Future of Health Care for People with Disabilities
Who Do Not Receive Social Insurance Benefits
Tricia Johnson, Ph.D., William G. Johnson, Ph.D.
Presented By: Tricia Johnson, Ph.D., Assistant Professor,
Health Systems Management, Rush University, 1700 West
Van Buren Street, TOB Suite 126B, Chicago, IL 60612; Tel:
(312) 942-7107; Fax: (312) 942-4957; Email: tricia_j_johnson@rush.edu
Research Objective: The increasing number of people with disabilities under age 65 will profoundly affect public policy towards disability by increasing the administrative burden on programs such as Social Security Disability Insurance (SSDI) and Medicare. The aging of the baby boom population will substantially increase the number of people with disabilities who do not qualify for disability benefits. Failure to address the health care needs for persons with disabilities prior to retirement is likely to increase long terms costs to Medicare by increasing the severity of illness once these persons reach retirement age. This paper estimates the number of people with disabilities under age 65 who do not receive disability benefits and projects the number without benefits through
2025 to quantify the uncompensated health care burden of disability. Simulations are conducted to understand how changes in the underlying characteristics of the population will affect these projections.
Study Design: This study estimates health care expenditures for people with disabilities who do not receive benefits using a two-part generalized linear model. A simulation model is developed to explore the effects of different assumptions about the demographic characteristics and health conditions of the population on the prevalence of disability and health care expenditures. The 1996 panel of the Survey of Income and Program Participation is used to estimate the number of people with disabilities who do not receive benefits. The 1997 to 2000 Cost and Use Files of the Medicare Current
Beneficiary Survey are used to estimate health care expenditures for people with disabilities who do not receive benefits, simulating costs as if they received benefits.
Population Studied: Persons with disabilities under the normal retirement age who do not receive Social Security
Disability Insurance or Medicare.
Principal Findings: Nearly 23% (2.8 million [M]) of people with disabilities did not receive SSDI benefits and had no recent work experience in 2000, and 67% (8.9M) of those with disabilities did not receive SSDI benefits overall. These estimates will increase to 3.7M and 11.4M respectively by 2025.
Health care expenditures for people with disabilities without recent work experience and no SSDI benefits were estimated at $20.7 billion (B) in 2000 and will increase to $29.3B in
2025.
Conclusions: People with disabilities who do not receive SSDI benefits represent the hidden population of Americans with

disabilities. The reported prevalence of disability is sharply reduced if only Social Security statistics are used. Results emphasize that the problem of uninsured losses among
Americans with disabilities who do not qualify for social insurance benefits will be one of the most important, unsolved dilemmas for society created by the baby boom generation.
Implications for Policy, Delivery, or Practice: These results provide a unique insight into the impact of the baby boom generation on the health care industry and the problems to be faced by aging baby boomers who will not have access to
SSDI and Medicare. Estimates suggest that the burden of dealing with both the health care and income needs of this very large population will be borne by the families of persons with disabilities or by the Medicaid system.
Primary Funding Source: Disability Research Institute at the
University of Illinois at Urbana-Champaign
● 10 Years of Research on Access to and Predictors of End of Life Cancer Care for more than 20,000 Adults in Nova
Scotia, Canada
Grace Johnston, Ph.D., Meaghan O'Brien, MHSA, Jun Gao,
MSc, Ron Dewar, MSc, Beverley Lawson, MSc, Frederick
Burge, M.D., MSc
Presented By: Grace Johnston, Ph.D., Associate Professor,
School of Health Services Administration, Dalhousie
University, 5599 Fenwick Street, Halifax, Nova Scotia, B3H
1R2; Tel: (902)494-1309; Fax: (902)494-6849; Email:
Grace.Johnston@Dal.Ca
Research Objective: To determine the percentage of adult cancer patients dying at home and receiving various forms of end of life care in Nova Scotia (NS) Canada, and to identify predictors of their health services provision.
Study Design: Administrative data for 24,000 NS adults who died of cancer between 1994 and 2003 were obtained by linking NS Cancer Centre, Halifax and Cape Breton Palliative
Care Program (PCP), and 1996 and 2001 census information.
For deaths from 1992 to 1998, hospital and physician billing data have also been linked, and these data are now being updated. Multivariate logistic regression analysis was used to identify the odds and predictors of dying out-of-hospital.
Population Studied: 24,000 NS adults who died of cancer between 1994 and 2003
Principal Findings: Only 26.9% died at home. Those significantly more likely to die at home were female (Odds ratio [OR]=1.3), over 85 years (2.4), residing in a nursing home
(12.3), registered in a PCP: Cape Breton (1.5), Halifax (1.1), living in an upper income community (1.2), dying from breast
(1.2), colorectal (1.2) or prostate (1.1) cancer, and living >120 days after their cancer diagnosis (2.6). Those less likely to die at home were living outside the largest metropolitan area in
Cape Breton (0.7) or other non-Halifax county (0.7), received palliative radiation (0.9), a medical oncology consultation in their last year (0.9) or lived in a non-official language community (0.8). Time in hospital prior to death varies but is generally decreasing. From 1992-8 in Nova Scotia, the percentage of persons dying in hospital decreased from 80.2% to 69.8%. In 1992, adults diagnosed with cancer spent an average of 30 days in hospital in the last six months of life. By
1996, this dropped to 22 days. Longer stays were associated with medical specialist visits (Rate Ratio [RR] for 3-6 visits=1.26, 7-13=1.45, >13=2.17), dying in hospital (RR=2.09), dying outside the major urban centre, long term care facility
Family Physician (FP) visit (RR=1.28), PCP admission
(RR=1.16), palliative radiation (RR=1.13), and older age. Shorter stays were associated with more recent year of death, regular office hour FP visit(s) (RR for 1-4 visits=0.75, >4=0.58), FP home visit(s) (RR=0.87) and after hours FP office visit(s)
(RR=0.81). Length of stay varied by cancer type. Income was not a significant predictor.
Conclusions: End of life care may be improved by focusing on
PCP, nursing home and oncology services as well as community and clinical factors.
Implications for Policy, Delivery, or Practice: Most cancer patients die in hospital, yet up to 90% prefer to die at home.
Historic decisions in Canada contributed to this situation.
With no national comprehensive palliative care plan, end-oflife care evolved in response to local leadership. Determining the factors associated with spending less time in hospital is important in developing policies and programs that optimize the use of health care resources and help people spend their last days at home. The methods and data we are developing will help evaluate and develop models of care for the expected increase in need as the baby boomer cohort ages.
Primary Funding Source: Canadian Institutes for Health
Research
● Public Hospitals, Quality and Disparities: Are We There
Yet?
Karen Jones, MS, Bruce Siegel, M.D., M.P.H., Marsha
Regenstein, Ph.D., MCP, Anne Beal, M.D., M.P.H.
Presented By: Karen Jones, MS, Senior Research Scientist,
Health Policy, George Washington University School of Public
Health and Health Services, 2021 K St, NW, Ste 800,
Washington, DC 20006; Tel: 202-530-2349; Fax: 202-296-
0025; Email: kcjones@gwu.edu
Research Objective: The Institute of Medicine report Unequal
Treatment recommended the use of evidence-based guidelines to reduce health care disparities and promote quality. With the Hospital Quality Alliance (HQA) there is now regular public reporting of quality data. We sought to understand 1) whether hospitals treating many minority patients are measuring quality by race and ethnicity; 2) the challenges they face in such analysis; 3) whether they are finding disparities in care; and 4) their views on the public reporting of quality by race and ethnicity.
Study Design: We selected public hospitals around the nation that serve many minority cardiac patients. The hospitals were asked to provide HQA measures by race and ethnicity from the first and second quarters of 2004. This was followed by structured interviews with 32 clinical and administrative staff at these hospitals, examining their process of obtaining and reporting quality, race and ethnicity data, their use of such data to improve quality, and their views on public reporting.
Population Studied: Our sample consisted of six geographically dispersed large public hospitals. Three of these hospitals had a majority of Hispanic patients, two had a majority of black patients and the sixth had approximately equal percentages of Hispanic and black patients. Five hospitals completed all phases of the study.
Principal Findings: Performance on quality measures did not vary substantially by race or ethnicity within these hospitals.

Performance was high on select measures across hospitals, but at some institutions as few as five percent of all patients received recommended care such as heart failure discharge instructions. No hospital had examined its HQA measures by race or ethnicity prior to participation in this study. Obtaining these data by race and ethnicity was difficult for some sites and variation in race and ethnicity classification and collection precluded inter-hospital comparisons. Hospital interviewees were divided over whether HQA data should be publicly reported by race and ethnicity.
Conclusions: There was no evidence of disparate care using the HQA measures, and hospitals are not routinely using quality data to detect any such patterns. This analysis is difficult for them given their frequent reliance on contracted data vendors. The use of quality improvement techniques to improve care is essentially universal, but is not viewed as a strategy to address disparities. Both technical and perceptual challenges will need to be overcome if quality data by race and ethnicity is to be publicly reported.
Implications for Policy, Delivery, or Practice: While the
HQA measures may not be the most sensitive tools for detecting disparities within institutions, reducing disparities may entail improving overall quality at providers with large minority populations. From this limited sample it seems that hospital leaders and clinicians are not viewing disparities as a quality of care issue. Given increasing competing demands for quality reporting coupled with technical obstacles, hospitals are not likely to begin routine analysis of quality data by race and ethnicity in the absence of some external mandate.
Primary Funding Source: CWF
● Patterns and Predictors of Home Health and Hospice
Utilization Among Older Adults with Cancer
Meredith Kilgore, Ph.D., Locher Julie, Ph.D., Micheal Morrisey,
Ph.D., Christine Ritchie, M.D.
Presented By: Meredith Kilgore, Ph.D., Assistant Professor,
Health Care Organization and Policy, UAB School of Public
Health, 1665 University Blvd. RPHB 330, Birmingham, AL
35294-0022; Tel: (205) 975-8840; Fax: (205) 934-3347; Email: mkilgore@uab.edu
Research Objective: The primary aim of this paper is to describe patterns of home health and hospice use among older cancer patients. A secondary aim is to identify predictors of home care and hospice utilization. Finally, this study examines the extent to which home health and hospice are substitutes or complementary services.
Study Design: Retrospective analysis using the SEER-
Medicare Database, a linkage of the Surveillance,
Epidemiology and End Results Program of the National
Cancer Institute and Medicare Claims.
Population Studied: Three analytic samples were. The first consisted of all cases who had ever had a diagnosis of cancer and were eligible for services in calendar year 1999
(n=120,072). The second and third were sub-samples of these and consisted of cases with a new cancer diagnosis in 1999
(n=46,373) and cases who died in 1999 (n=41,483).
Principal Findings: For all persons with a diagnosis of cancer,
29.0% accessed home health services and 10.7% used hospice services. Home health utilization is higher among non-whites, and hospice utilization is higher among whites.
Women used home health and hospice more often than men; and married men had the lowest rates of utilization for both services. Less than half of patients used any services prior to death. However, patients who used home health services were twice as likely to use hospice services.
Conclusions: There is a relative underutilization of community-based services among older cancer patients, especially prior to death, particularly among married men and non-whites.
Implications for Policy, Delivery, or Practice: Future studies should address optimal use of home health and hospice in this population, and how the patterns observed in our study would be influenced by how a dual-provider divides services among two separate billing opportunities, either home health or hospice.
Primary Funding Source: NCI, UAB Center for Aging
● Effect of State Medicaid and Medigap Eligibility Policies on the Enrollment and Health Outcomes of Disabled
Beneficiaries
Jill Klingner, MS, RN, Ira Moscovice, Ph.D., Robert Town,
Ph.D., Kathleen Call, Ph.D.
Presented By: Jill Klingner, MS RN, Research Assistant,
Health Services Research Policy and Administration,
University of Minnesota, 2221 University Ave SE Suite 112,
Minneapolis, MN 55414; Tel: 612-626-6251; Fax: 612-626-6270;
Email: klin0089@umn.edu
Research Objective: To determine the effect of state
Medicaid eligibility and Medigap guarantee offer policies on the enrollment in Medicaid or Medigap supplemental policies for the disabled under-65 Medicare beneficiaries and the effect of supplemental insurance on their self-reported health and functional status.
Study Design: This study is a natural experiment using changes in state Medicaid and Medigap offering and eligibility policies over the 5-year period of 1997-2001, to estimate the effect of these policies on Medicaid and Medigap enrollment and subsequent health outcomes in the disabled under-65
Medicare beneficiaries. Multinomial logit with fixed state and year effects and robust standard errors clustered by state was used to estimate the effect of the state policies on enrollment in Medigap and Medicaid. Linear regression with instrumental variables and state and year fixed effects was used to estimate the supplemental insurance policy effect on health and functional status.
Population Studied: The study subjects are disabled, under-
65 Medicare beneficiaries in the Medicare Current Beneficiary
Survey (MCBS) sample from 1997-2001.
Principal Findings: Medicaid eligibility and Medigap guarantee-offer policies have significant effects on enrollment in Medicaid and Medigap, though not entirely as expected.
Medicaid enrollment is decreased by the income limit or percent of Federal Poverty Level required for Medicaid eligibility. The number of prescription Medigap plans required to be offered has a negative affect on Medicaid enrollment, suggesting that the Medigap prescription plans compete with
Medicaid for enrollment. State prescription drug programs also decrease Medicaid enrollment. Medigap enrollment is affected by one of the Medicaid related state policies, the
Medicaid buy-in policy, suggesting that not all disabled with
Medicaid eligibility select Medicaid. An increase of number of

Medigap prescription plans required to be offered increases
Medigap enrollment, suggesting that the availability of prescription drug plans increases the selection of Medigap supplemental coverage. The effect of supplemental insurances on disabled health outcomes is mixed. Subsets of disabled Medicare beneficiaries appear to have improved or declined health outcomes related to different types of supplemental health insurance coverage. This is not surprising given the diversity of the disabled population.
Medicare HMOs appear to have a positive effect on functional status change. Medigap coverage neared significance for improving health status change. Prescription drug coverage improved heath status for those with only one condition.
Conclusions: Beneficiaries’ enrollment in supplemental health insurance policies appears to be strongly influenced by the availability of prescription drug coverage. Future estimations of the health effect of supplemental insurance coverage for this diverse sample will require a more complete understanding of their healthcare utilization needs.
Implications for Policy, Delivery, or Practice: States may be able to decrease their Medicaid enrollment by supporting prescription drug plans for the disabled or Medigap prescription drug guarantee-offer plan requirements for the disabled. Examination of the effect of the guarantee-offer of prescription plans (H, I, J) on Medicaid enrollment of elderly beneficiaries is indicated. More studies of the health outcome effect of supplemental coverage for subsets of disabled
Medicare beneficiaries are indicated.
Primary Funding Source: No Funding
● Impacts of State Policy on Racial/Ethnic Disparities in
Use of High-Volume Hospitals
Karl Kronebusch, Ph.D., Bradford Gray, Ph.D., Mark
Schlesinger, Ph.D., Tracey Thomas, M.P.H., Edward Miller,
Ph.D.
Presented By: Karl Kronebusch, Ph.D., Associate Professor,
School of Public Affairs, Baruch College / CUNY, 1 Bernard
Baruch Way / D-901, New York, NY 10010; Tel: 646-660-6809;
Email: karl_kronebusch@baruch.cuny.edu
Research Objective: Most studies of the impact of policy on disparities focus on policies that are deliberately designed to alter disparities. Disparities, however, may be equally affected by policies designed for other ends, but which nonetheless have important and often unintended consequences on the magnitude of racial/ethnic disparities concerning medical care. The objective of this study is to determine whether and how these policies affect racial/ethnic disparities in use of high quality medical providers, defined as use of high-volume hospitals for those medical services for which there is evidence of a positive relationship between volume and outcomes.
Study Design: The study analyzes hospital discharge data for
20 services for which there is a demonstrated volumeoutcome relationship compared to 6 services with no such demonstrated relationship. Multivariate models control for patient characteristics that affect utilization, including demographic characteristics, distance to hospitals, and insurance status. The analysis utilizes difference-in-difference contrasts between these services over time and the policy variation between and within these states.
Population Studied: Hospital discharge records obtained from the State Inpatient Data of the Health Care Utilization
Project (HCUP) for 1995-96 and 2001-02 from four states
(Arizona, Florida, New Jersey, Wisconsin) chosen to reflect a mix of racial and ethnic population groups in the U.S. and the range of urban and rural settings.
Principal Findings: We examine two main policy approaches:
First, state policies that concentrate services, including certificate-of-need programs that limit the number of hospitals providing particular services, and efforts to promote centers of excellence. In general, concentration of services should tend to increase the likelihood that patients use high-volume providers, and to reduce the extent of racial/ethnic disparities.
Second, information strategies designed to facilitate consumer choice of high-quality hospitals. We theorize that quality-informed decisionmaking will arise as information about the relationship between volume and quality has become more widely known. Due to their comparatively lower levels of income and education, racial/ethnic minorities are less likely to be able to engage in quality-informed decisions, and so we hypothesize that this information by itself may actually lead to increases in the extent of disparities in the use of high-volume hospitals. We also examine state policies concerning payments for charity care and Medicaid managed care contracting, which will affect hospital use for those racial/ethnic minorities who are uninsured or insured through Medicaid.
Conclusions: We discuss how state policies might affect highvolume hospital use, and how our empirical results contribute to understanding the interactions between consumer decisionmaking and public policy as they relate to disparities in hospital use.
Implications for Policy, Delivery, or Practice: The results will aid policymakers in the design of policies to address racial/ethnic disparities in utilization of high quality providers.
Primary Funding Source: RWJF
● Access to Medical and Dental Care: Does Travel Burden
Differ by Race and Ethnicity?
Sarah Laditka, Ph.D., M.B.A., Janice C. Probst, Ph.D., Jong-Yi
Wang, Ph.D., MS, Andy O. Johnson, M.P.H.
Presented By: Sarah Laditka, Ph.D., M.B.A., Associate
Professor, Health Services Policy and Management, University of South Carolina, 800 Sumter Street, Columbia, SC 29208;
Tel: (803) 777-1496; Fax: (803) 777-1836; Email: sladitka@gwm.sc.edu
Research Objective: Greater travel time is often associated with reduced access to care. A better understanding of distances and mode of travel for individuals seeking health care is particularly useful for vulnerable populations, such racial and ethnic minorities, who experience transportation barriers. We examined travel to care patterns by race and ethnicity. We used a broad category of “medical/dental” as a measure of health related travel. This measure provides actual travel distance, in both miles and minutes, from the persons actually making the trip.
Study Design: A cross-sectional analysis of the National
Household Travel Survey (NHTS). The NHTS is a nationally representative sample of households, recruited by telephone, who kept travel logs for one week between March 2001 and
May 2002. We subset the analysis to individuals making at

least one trip for medical/dental care. The outcome variables were distance to care (miles) and travel time (minutes). The independent variables were residence (rural/urban) and race
(white, Black, Hispanic, American Indian/Alaska Natives,
AI/AN, Asian/Pacific Islanders, A/PI). Covariates included sociodemographics (sex, age, education, occupation, income), medical conditions limiting driving (yes/no), travel characteristics (perceived road conditions, day of week, personal vehicle/other), and ecological factors (population density, job density). Descriptive and multivariate analyses were conducted in SAS-callable SUDAAN to account for the
NHTS sampling design. Logistic regression also examined the odds of spending more than 30 minutes traveling for care, holding other factors constant.
Population Studied: Respondents to the 2001 NHTS: 3,926 trips, made by 2,433 households.
Principal Findings: A routine medical/dental care trip averaged 11.0 miles (median, 5.4 miles) and took 22.3 minutes
(median, 14.9 minutes). Mean travel to care distances were nearly identical for whites and blacks, at 9.82 and 10.1 miles.
AI/AN traveled furthest for care (18.1 miles), followed by
Hispanics (12.0 miles). A/PI reported the shortest travel distances, 6.7 miles. Whites (20.4 minutes) and A/PI (17.0) reported the shortest travel times, with Hispanics (23.0),
Blacks (29.4), and AI/AN (38.3) spending more time in travel.
Rural residence was associated with increased travel distance and time. In the analyses of odds spending more than 30 minutes traveling for care, Black and Hispanics were more likely to have extended travel time than were whites. Rural residence, perceived poor driving conditions, being a passenger rather than driver, and night travel were associated with longer travel times.
Conclusions: Based on an analysis of completed trips, minorities invest more time to travel for medical/dental care than whites, especially those spending more than 30 minutes traveling for care. AI/AN populations, in particular, are disadvantaged. Anticipated travel burden, not captured in this study, may serve as another barrier to accessing medical/dental care among minorities.
Implications for Policy, Delivery, or Practice: Providers should be aware of transportation patterns when locating safety net sites. Reliance on public transportation can result in greater travel burdens for minorities, even when distances are similar. Policies should explore additional transportation strategies in rural areas. Further research is needed to determine effects of distance on compliance with specific therapeutic regimens including provider visits and prescription filling.
Primary Funding Source: HRSA
● The Interactive Effect of Health Literacy and Social
Support on Health Status among Medicare Enrollees
Shoou-Yih Daniel Lee, Ph.D., Ahsan M. Arozullah, M.D.,
M.P.H., Young I. Cho, Ph.D., Kathleen S. Crittenden, Ph.D.
Presented By: Shoou-Yih Daniel 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; Email: sylee@email.unc.edu
Research Objective: Low health literacy--i.e., lack of ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions--has been identified as a major health care problem. Based on one estimate, the cost of low health literacy ranged from $30 billion to $73 billion in 1998 US dollars. The adverse consequences of low health literacy are particularly pronounced in the elderly population because of the prevalence of chronic illnesses that require the elderly to follow an intensive and complex medical regime (medications, daily monitoring, routine physician visits, tests, etc.).
However, decisions of health care arrangements for the elderly are often made jointly with family members or loved ones.
Social support also has a positive impact on the health of the elderly. In this study, we examine whether social support interacts with health literacy in affecting the health status of older adults. We expect that high social support may alleviate the adverse effect of low health literacy in the elderly population.
Study Design: A cross-sectional survey of Medicare enrollees aged 65 and over in 2003-04. Health literacy was assessed using the Test of Functional Health Literacy in Adults. Social support was measured by a composite score constructed using the MOS scale. Health literacy was indicated by selfreported general health, SF-12 physical health, and SF-12 mental health. The interactive effect was tested using three dummy variables in OLS regression: (1) high health literacy and high social support (HHL-HSS), (2) high health literacy and low social support (HHL-LSS), and (3) low health literacy and high social support (LHL-HSS), with the low health literacy and low social support (LHL-LSS) group as the reference. Control variables included gender, ethnicity, age, education, and marital status.
Population Studied: 489 elderly Medicare enrollees.
Principal Findings: The average level of health status was highest in the HHL-HSS group and lowest in the LHL-LSS group. Results of the multivariate analysis showed: (1) HHL-
HSS (p<.001) and HHL-LSS (p<.01) were positively associated with general health status, (2) HHL-HSS (p<.01) was positively associated with physical health status, and (3) HHL-
HSS (p<.001), HHL-LSS (p<.05), and LHL-HSS (p<.001) were positively related to mental health status.
Conclusions: In general, there was an interaction between health literacy and social support in influencing the health status of Medicare enrollees. High social support appeared to alleviate the adverse effect of low health literacy on mental health. High social support appeared to enhance the positive effect of high health literacy on general and physical health.
Implications for Policy, Delivery, or Practice: Both social support and health literacy are important determinants for health status in Medicare enrollees. It is necessary to consider the individual’s social conditions while assessing the impact of health literacy on health status. Furthermore, it may be useful to design intervention programs on individual differences in health literacy as well as differences in social support.
Primary Funding Source: AHRQ

● Evaluation of the Tailored Patient Navigator Programs for the Underserved Populations with Cancer
Chyongchiou J. Lin, Ph.D., Karen Schwaderer, RN, BSN, Keith
Morgenlander, M.P.H., Edmund Ricci, Ph.D., Dwight E.
Heron, M.D.
Presented By: Chyongchiou J. Lin, Ph.D., Visiting Associate
Professor, Radiation Oncology, University of Pittsburgh,
Shadyside Place 110, 580 South Aiken Ave, Pittsburgh, PA
15232; Tel: 412-235-1060; Fax: 412-235-1313; Email: cjlin@pitt.edu
Research Objective: Cancer is the second leading cause of death in the United States and in Pennsylvania. Cancer mortality rates for African American men and women in
Pennsylvania are higher than their white counterparts and racial disparities are increasing. The Patient Navigator
Program (PNP) was designed to overcome barriers to cancer treatment in minorities and underserved populations. The purpose of this study is to describe and evaluate the PNP for the Radiation Oncology Cooperative Outreach Group
(ROCOG), a 5-hospital Cancer Disparities Research
Partnership (CDRP) in Pennsylvania.
Study Design: The PNP is an innovative case management and outreach program in which “navigators” help patients overcome barriers to cancer treatment. The PNP is designed to enhance timely entrance into the healthcare system for patients with positive pathology for cancer, through coordination of support services, transportation and assistance with insurance and other financial issues. The
PNP, working with two community hospitals in Pennsylvania, as well as community and faith-based organizations, is targeting two populations, inner-city African Americans and residents of non-urban and socio-economically deprived areas.
The types of barriers for participants, types of assistance provided, and the amount of time the patient navigators spend on each issue raised or needed by patients are recorded. Patient and physician satisfaction surveys regarding the PNP were conducted.
Population Studied: To date, the study has enrolled 23
African Americans and 77 non-African Americans from the target areas who have a confirmed diagnosis of cancer.
Principal Findings: Among the 100 participants enrolled from
January through November, 2005, 30.5% of enrollees within the urban facility were African Americans versus 12.2% at the non-urban facility. Among those who requested services, the navigator spent an average of 64.7 minutes per patient in the urban facility and 76 minutes per patient in the non-urban facility. The majority of requests for services were related to finance (54.2%), transportation (42.4%) or referral to the
American Cancer Society (ACS) Patient Services (35.6%) in the urban facility. In the non-urban facility, the distribution of service requests was 41.5% for referrals to the ACS Patient
Services, 24.4% transportation issues, and 22% financial issues. Health insurance approval, out-of-pocket payment, and transportation were listed as the primary barriers to treatment in both facilities. All patients participating in the
PNP reported that they would use the service again and would recommend the program to others.
Conclusions: While the PNP is a new initiative, there has been a steady patient demand for PNP services in both hospitals. All patients participating in the Program were satisfied with the services. Our findings may further improve our understanding of the barriers to cancer care for minorities and underserved populations and how to reduce disparities in cancer care. Finances and transportation issues appear to be the cornerstone of our patient’s non-medical barriers and future research should address these specific needs in this population.
Implications for Policy, Delivery, or Practice: Our evaluation of the PNP assessed what services are most needed by cancer patients and how much time is required for each service. This provides a model for future replication and comparison.
Primary Funding Source: NCI
● Reducing Global Health Disparities: Emerging Initiatives for Developing Drugs for Diseases of Poverty
Helene Levens Lipton, Ph.D., Jacob Doll, Corey Langenbach,
M.P.H., Janet M. Berreman, M.D., M.P.H.
Presented By: Helene Levens Lipton, Ph.D., Professor Health
Policy and Pharmacy, Schools of Pharmacy and Medicine,
University of California, San Francisco, 3333 California Street,
Suite 420, Box 0613, San Francisco, CA 94118; Tel: (415)476-
2964; Fax: (415)502-0792; Email: liptonh@pharmacy.ucsf.edu
Research Objective: Few disparities illustrate more starkly the health challenges faced by developing countries than the socalled 90/10 gap: only 10 percent of the annual worldwide health R&D expenditure of US105 billion dollars is allocated for diseases that cause 90 percent of the global disease burden. Between 1975 and 1999, only 1 percent of nearly 1400 newly marketed chemical entities were for such diseases.
Because few data are available in the literature to evaluate innovation in drug development for diseases of poverty, we systematically review and evaluate emerging initiatives and suggest future policy directions.
Study Design: We selected four case-studies after: 1, performing a literature review on global health and development; 2, reviewing initiatives cataloged in an online database of public-private global health partnerships; and 3, conducting a series of key-informant interviews. Selected case studies evaluated were advance purchase commitments; novel regulatory approval of a rotavirus vaccine; a pharmaceutical peace corps; and a nonprofit drug company. For each initiative we identify potential strengths, discuss challenges faced, and examine policy implications.
Population Studied: Not applicable.
Principal Findings: Successful initiatives foster collaboration among key stakeholders and have the potential to further drug development for neglected diseases. Advance Purchase
Agreements, APCs,--arrangements in which a sponsor, e.g. global health organization, developed country government, and/or philanthropic organization, guarantees a price for a new product needed in the developing world, e.g. a malaria vaccine,--potentially benefit all involved parties; challenges, however, include determining affordable pricing, setting the purchase commitment size, enforcing the agreement, and anticipating global health priorities. The novel regulatory approval of Rotarix vaccine in Mexico without prior FDA approval brought a needed vaccine rapidly to market in a developing country, but raises ethical concerns and may be an inefficient path to international regulatory approval. Pfizer’s
Global Health Fellows program enables volunteer pharmaceutical professionals to provide expertise to developing countries and strengthens drug industry ties with

nonprofit groups and governmental organizations. Crosscultural differences in expectations and abilities, however, have posed challenges and long-term effects are unclear. A nonprofit drug company, OneWorld Health, identifies previously developed promising drug candidates for neglected diseases. Paromomycin is being developed as a new treatment for visceral leishmaniasis, and will be submitted for regulatory approval in India. Despite early success in forming collaborations with biotechnology, academe and philanthropic organizations, engaging the for-profit pharmaceutical industry remains a challenge.
Conclusions: These innovations show promising early achievements in drug development for diseases of poverty.
However, serious challenges confront each model.
Additionally, they do not address other important barriers to redressing global health disparities.
Implications for Policy, Delivery, or Practice:
Considerations of drug distribution systems, health care infrastructure, ease of drug delivery and administration, and affordable pricing need to be addressed. Evaluations of these emerging programs’ impact, e.g. cost-effectiveness analyses and outcomes assessment, are needed to facilitate evidencebased policy decisions designed to reduce global disparities in access to essential drugs.
Primary Funding Source: University of California at San
Francisco
● Tuberculosis: The Shameful Truth About Health
Disparities
Ana Lopez - De fede, Ph.D., Karen Kirtland, Ph.D., Muriel
Harris, Phs
Presented By: Ana Lopez - De fede, Ph.D., Research Associate
Professor, Institute for Families in Society, Universty of South
Carolina, 1600 Hampton Street - 5th Floor, Columbia, SC
20208; Tel: 803-777-5294; Fax: 803-777-1120; Email: adefede@sc.edu
Research Objective: Tuberculosis continues to be a major health threat in the United States with minimal efforts placed on public education to increase knowledge about the disease among native-born US residents. The objective of this study is to examine the role of race and place of residence residency on knowledge and perceived risk of tuberculosis
Study Design: The study uses data from the 1994, 2002, and
2004 National Health Interview Survey, the only nationwide survey documenting knowledge about TB and its risk factors.
Socio-demographic and geographic variables (age, sex, education, annual household income, employment status, and census region) were taken from the sample adult questionnaire. A measure of perceived risk and knowledge of tuberculosis was obtained from NHIS. All analysis were stratified by race (African American ,White and Hispanic)and census regions (South, Northeast, West and Midwest). For each census region, multiple logistic regression analysis was used to calculate the adjusted odds ratio (AOR, with 95% confidence intervals) of the association between perceived risk of tuberculosis and knowledge of TB after adjusting for sociodemographic characteristics to include race and variables that differed by race. For all models, perceived risk of tuberculosis was treated as a dichotomized variable (high to medium risk versus low to no risk), and the independent variable that measures how much knowledge the respondent had of tuberculosis was also dichotomized (a lot to some knowledge versus a little to no knowledge).
Population Studied: A nationally representative sample of adults who participated in the National Health Interview
Survey. The number observed varied by survey year and region from a high of 33, 000 to a low of 20,000.
Principal Findings: Knowledge about tuberculosis and race of the respondent were strongly associated with perceived risk of tuberculosis in every region. Respondents with a lot or some knowledge of the disease were 1.6 to 2.8 times more likely to perceive a high to medium risk as compared to respondents with a little or no knowledge. Black respondents were at least twice as likely to perceive a high to moderate risk compared to other races in all regions except the South (AOR=1.56). In addition, knowing someone with tuberculosis was strongly associated with perceived risk in all regions except the South.
However, knowing there is a cure for tuberculosis was related to perceived risk in the South but not anywhere else in the nation. Nationally, a respondents knowledge about tuberculosis, knowing someone with tuberculosis, and being
Black were most strongly associated with perceived high to medium risk of getting the disease.
Conclusions: Racial and socioeconomic disparities in knowledge and perceive risk of tuberculosis remain higher for
African Americans than any other racial group. Knowledge of tuberculosis is closely associated with perceived risk of the disease providing information form which to guide prevention and treatment initiatives.
Implications for Policy, Delivery, or Practice: This study has clinical and public health related implications. Although tuberculosis has been declining in the United States, it is increasing among certain high risk groups with regional variations reflecting demographic trends. Tuberculosis is treatable and curable. Knowledge of tuberculosis is a key factor in the fight to eliminate health disparities among
African Americans.
Primary Funding Source: CDC
● Health Insurance Coverage Along the US-Mexico Border
Jill A. Marsteller, Ph.D. M.P.P, Juan Albertorio, M.D.
Presented By: Jill A. Marsteller, Ph.D. M.P.P, Contractor,
DHCS/HCSB, National Center for Health Statistics, 3311
Toledo Rd. Suite 3312, Hyattsville, MD 20782; Tel:
301.458.4098; Fax: 301.458.4032; Email: JMarsteller@cdc.gov
Research Objective: To address health disparities issues along the US-Mexico Border, in 2000 the US-Mexico Border
Health Commission (USMBHC) established a 10-year disease prevention and health promotion program called Healthy
Border 2010. This program, like the Healthy People 2010 US program, sets goals for improvement and monitors progress.
One selected health indicator is health insurance coverage among Border populations. Estimates of health insurance coverage for regions smaller than state level are quite limited, and estimates based on ethnicity for Border region residents have been previously unavailable. This presentation will describe the USMBHC and the National Center for Health
Statistics‘ Healthy Border 2010 Program, estimate the current lack of health insurance coverage along the Border, compare coverage rates among Hispanics and Non-Hispanics and identify covariates of health insurance coverage on the Border.

Study Design: The authors merged four years of the National
Health Interview Survey (NHIS), 2000-2003, and calculated lack of health insurance coverage for the population in US counties along the US-Mexico Border. Estimates were stratified by ethnicity and geographic area (the US, the four states on the US-Mexico Border (AZ, TX, NM, CA), and the
Border counties within these states). A logistic regression will test the influence of demographic and health related variables on insurance status among residents of the Border region, with particular attention to differences between Hispanics and
Non-Hispanics.
Population Studied: The civilian noninstitutionalized population residing in sampled primary statistical units along the US-Mexico Border.
Principal Findings: Within counties on the US-Mexico
Border, 22.9% were uninsured and 44.1% of these had lacked coverage for a year or more. In the Border counties, 38.2% of
Hispanics were uninsured compared to 12% of Non-
Hispanics. At all geographic levels examined, uninsurance was considerably higher for Hispanics. The difference between
Hispanics and Non-Hispanics was larger in the Border states than nationally and larger still in the Border counties than in the Border states.
Conclusions: In comparison with US estimates, disparity in insurance coverage along the Border is strongly evidenced.
Specifically, the Hispanic population at the Border are substantially more likely than Hispanics and Non-Hispanics in any other US region examined to lack health insurance coverage at the time of the interview.
Implications for Policy, Delivery, or Practice: Addressing access to health insurance for the population residing along the US-Mexico Border may be particularly difficult because, as we know from the literature, the Border populations is mobile, multicultural and faces a challenging socio-economic reality.
Coverage goals may best be addressed through international cooperative activities such as the USMBHC.
Primary Funding Source: No Funding
● Racial and Ethnic Disparities in Mammography
Screening Over the Period 1996 - 2003
Cristian Meghea, Ph.D., Mythreyi Bhargavan, Ph.D., Jonathan
H. Sunshine, Ph.D., Cristian Meghea, Ph.D.
Presented By: Cristian Meghea, Ph.D., Senior Researcher,
Research, American College of Radiology, 1891 Preston White
Drive, Reston, VA 20191; Tel: 703-648-8983; Email: cmeghea@acr.org
Research Objective: Breast cancer mortality decreased by
24% between 1990 and 2000, but there are persistent variations in mortality rates by race and ethnicity. Early detection by mammography screening had a sizeable contribution to the reduction in breast cancer mortality.
The objective of this paper is to measure racial and ethnic disparities in mammography screening in 2003 and trends over time since 1996. The paper will measure disparities between white and black women and expand the analysis to
Hispanic and Asian women as well.
Study Design: We use claims data for five years, 1999-2003, on all medical services provided under a large national employer plan (LNEP); and the Medical Expenditure Panel
Surveys (MEPS) for 1996-2003. LNEP covers millions of individuals but has no information on an individual’s race/ethnicity or socio-economic status. We instead measure disparities between high minority neighborhoods and white neighborhoods. Advantages of the MEPS surveys are that they are nationally representative and they have detailed information on individual and family race/ethnicity and socioeconomic characteristics. Two measures are used: percent of women age 40 and older who had a mammogram in 2003, from MEPS’s medical records; and percent of MEPS respondents who said they had a mammogram in the past two years. We also use multivariate regression analysis to isolate the individual effects of race and other characteristics on variations in mammography screening.
Population Studied: Women age 40 or older.
Principal Findings: Overall, 38% of women age 40 or older living in predominantly white neighborhoods had a mammogram in 2003; only 33% of enrollees living in black neighborhoods had screening mammograms in 2003, while the statistic for Hispanics and Asians were 29% and 31%.
Using LNEP, we will also examine trends since 1999. MEPS medical records show that 28% of all white women age 40 or older in US had a screening mammogram in 1998, while only
18% of black women had one. The percentages for Hispanic women and Asian women were 15% and 21%. The disparities persisted in 2003: 30% of white women age 40 or older had a mammogram, while only 19% of black women, 17% of
Hispanic women, and 16% of Asian women had one. When asked if they had a mammogram in the past two years, 70% of white women answered “yes” in 1998, and 69% of black women answered the same. The percentages for Hispanic women and Asian women were 61% and 48%. The numbers in 2003 were 72% for white women, 72% for black women,
62% for Hispanic women, and 56% for Asian women.
Regression results show that racial and ethnic disparities remain even after controlling for other factors.
Conclusions: Estimates of disparities in mammography screening between white and black women depend on how the question is asked. Our finding persists over time, and is present in two different datasets. However, there are clear disparities in mammography screening between white and
Hispanic and Asian women.
Implications for Policy, Delivery, or Practice: The results of this paper will help policy makers understand the extent of disparities in mammography screening between various demographic groups, and design the appropriate policies to ensure equitable utilization.
Primary Funding Source: No Funding
● The Association of Depression with Missed Days of
Employment Among persons with Chronic Conditions. Is there a Race/Ethnicity Effect?
David Mosen, Ph.D., M.P.H., Rachel Gold, Ph.D., M.P.H.,
Renee N Saris-Baglama, Ph.D., Chris Jentz, MHSA, Winston
Wong, M.D., MS
Presented By: David Mosen, Ph.D., M.P.H., Senior Program
Evaluation Consultant, , KP Center for Health Research, 3800
N. Interstate Avenue, Portland, OR 97227-1110; Tel: 503-335-
6637; Fax: 503-335-2424; Email: david.m.mosen@kpchr.org
Research Objective: Previous research has found that depression may be associated with a greater likelihood of missed employment among persons with chronic conditions.
However, less is known about whether the association

between depression status and missed days of employment varies by race/ethnicity. The objective of this study is to twofold: 1) To determine the impact of depression status on missed days of employment among a population with chronic conditions and 2) To determine whether this relationship varies between racial/ethnic groups.
Study Design: We examined survey data for 1,202 employed adults with chronic conditions enrolled in a large staff model
HMO. Members with on or more of five chronic conditions
(asthma, diabetes, chronic pain, heart failure, coronary artery disease) were identified from 2003 patient data, using HEDIS and registry inclusion criteria. In Fall 2004, the same patients were surveyed regarding health status using the SF-8 Health
Survey, which yields physical (PCS) and mental (MCS) component scores. Based on previously published research, patients with an MCS < 42 are likely to have depression.
Additionally, respondents reported any missed days of employment in the past 28 days due to their health conditions. Logistic Regression was used to examine the independent association of depression status on missed days of employment, adjusting for age, gender, educational attainment, and geographic location. Three logistic models were constructed: 1) overall and 2) stratified by white and nonwhite ethnicities.
Population Studied: Employed adults with 1 or more chronic conditions (mean age = 50.4). About 30% of the population was non-white.
Principal Findings: Depression status was independently associated (OR=2.12, 95% CI = 1.43-4.89) with an increased likelihood of missed days of employment. This association was strongest in the non-white population (OR=2.64, 95% CI
= 1.49-3.00). There was no significant association between depression status and missed days of employment in the white population (OR=1.25, 95% CI = 0.72-2.15).
Conclusions: We found that likely depression status was independently associated with increased likelihood of missed days of employment. Our research suggests that depression may impact employment-based outcomes more acutely in minority populations than white populations.
Implications for Policy, Delivery, or Practice: Because depression is associated with an increased likelihood of missed days of employment in minority populations in particular, further efforts are needed to better recognize and treat depression in this population. Future research should evaluate the impact of such interventions on employmentbased outcomes in minority populations.
Primary Funding Source: KPCMI
● Trends in Racial and Ethnic Disparities in Health Care
Quality
Ernest Moy, M.D., M.P.H., Elizabeth Dayton, MA, Karen Ho,
M.H.S.
Presented By: Ernest Moy, M.D., M.P.H., Senior Service
Fellow, Center for Quality Improvement and Patient Safety,
Agency for Healthcare Research and Quality, 540 Gaither
Road, Rockville, MD 20850; Tel: 301-427-1329; Fax: 301-427-
1341; Email: emoy@ahrq.gov
Research Objective: To examine changes over time in racial and ethnic disparities across a broad range of health care quality measures.
Study Design: Data come from the 2005 National Healthcare
Disparities Report, which compiled national estimates on 200 measures of health care quality from 3 dozen data sources.
Measures cover the quality dimensions of effectiveness, safety, timeliness, and patient centeredness. Analyses focus on 46 core measures selected by consensus from the full measure set and comparisons of whites, blacks, and
Hispanics. For each core measure, disparities are measured in both absolute and relative terms. Disparities for a baseline year and for the most current year of data are compared to assess trends in disparities.
Population Studied: Most measures cover the civilian, noninstitutionalized U.S. population. Some measures are appropriate for specific groups defined by age and gender.
Nursing home measures are specific to residents of these facilities.
Principal Findings: Disparities are pervasive: Blacks receive poorer quality of care than whites for over 40% of core measures; Hispanics receive poorer care for over half of core measures.
Some disparities are diminishing: Over time, more black-white differences in care are getting smaller than are getting larger.
However, for Hispanics, the reverse is true; more Hispanicwhite differences are getting larger than are getting smaller.
Conclusions: Tracking disparities over time is important to gauge our progress towards the goal of eliminating health care disparities and to identify groups and areas in greatest need of intervention.
Implications for Policy, Delivery, or Practice: Communities should measure their disparities in health care, track changes in disparities over time, and compare their local experience with national benchmarks presented in the annual National
Healthcare Disparities Reports.
Primary Funding Source: No Funding
● Obesity in Native American Elders
Kyle Muus, Ph.D., Leander McDonald, Ph.D., Richard Ludtke,
Ph.D., Alan Allery, Ph.D.
Presented By: Kyle Muus, Ph.D., Research Associate, Center for Rural Health, University of North Dakota, PO Box 9037,
Grand Forks, ND 58202; Tel: (701) 777-3848; Fax: (701) 777-
6779; Email: klmuus@medicine.nodak.edu
Research Objective: Research questions include:
What is the prevalence of obesity in Native American elders?
By gender and age cohorts? How do Native obesity rates compare to all U.S. elders? What’s that relationship between rurality and prevalence of obesity among Native American elders? Does the presence of obesity increase the likelihood of having co-morbid health conditions among Native American elders?
Study Design: Descriptive, cross-sectional survey
Population Studied: 8,119 Native Americans aged 55 years and older.
Principal Findings: Of the respondents, 43.2% were classified as obese, about one-third (33.0%) were overweight, and approximately one-quarter (23.7%) were classified as having normal or low weight. By age, the youngest elders (ages 55-64) were most likely to be obese. By gender, females were more likely to be obese. By geography, urban-based Native elders were more likely to be obese, compared to rural elders.
Obesity prevalence rates among Native elders were

substantially higher than for U.S. all races, particularly for younger cohorts. Obese Native American elders were more likely to have certain chronic health conditions, compared to their non-obese counterparts. Obesity significantly increased the likelihood of having hypertension, arthritis, diabetes, asthma, and congestive heart failure, after controlling for age, gender, education, and income.
Conclusions: Native Americans elders, especially females, were substantially more likely to be obese than their U.S. elder counterparts. Younger Natives were much more apt to be obese than Natives in the older cohorts. Finally, obese Native elders were significantly more likely to have one or more chronic diseases than non-obese Native elders.
Implications for Policy, Delivery, or Practice: Based on these findings, specific recommendations relate to increases in: prevention efforts including health promotion, screening and wellness programs; disease management programs including access to services and a focus on preventing comorbidity; and Native elders’ access to insurance programs such as Medicare. Native American elders can prevent obesity through concerted efforts to improve and maintain good nutritional and exercise regimens. Elders who are obese should work with their health care provider to lose weight and increase physical activity, which has the following associated health benefits: decreased likelihood of having a stroke or developing diabetes; reduced blood pressure; improved cholesterol; reduced blood sugar; and slowed progression of arthritis and reduction of joint damage/pain.
Primary Funding Source: Administration on Aging
● Effects of Antidiscrimination Legislation on Minority
Access to Quality Care
Ari Mwachofi, Ph.D., Geraldine Ross, Ph.D.
Presented By: Ari Mwachofi, Ph.D., Assistant Professor,
Health Administration and Policy, OUHSC, 801 NE 13th St,
Oklahoma City, OK 73104; Tel: (405) 271-2114; Fax: (405) 271-
1868; Email: amwachof@ouhsc.edu
Research Objective: The purpose of the study is to determine the extent to which legislation and judicial edicts can improve minority access to quality care.
Study Design: Using Rehabilitation Services Administration data on closed cases, the study compares African American access to rehabilitation services in 2004 to their access in 1937 before anti-discrimination legislation. It analyzes: total participation in rehabilitation programs relative to needs; types of services rendered; relative expenditures; and outcomes for Whites and for African Americans.
Population Studied: The study uses 291,135 cases from the sixteen southern states and 150,018 cases from seven northern states for a total of 441,153 cases that were closed by rehabilitation services in 2004. This sample includes white and African American clients.
Principal Findings: The study finds a significant improvement in the numbers of minority clients accessing services. There is also an improvement in spending on minority clients. However the study finds that the antidiscrimination legislation has not improved the quality of care received by minority clients to the same extent as the improvement in terms of numbers accessing services. There is still a lack of equity in the quality of services rendered and in the outcomes.
Conclusions: Antidiscrimination policies will improve access to care defined in terms of numbers of clients receiving services. Improving the quality of services received by minorities will take more than antidiscrimination legislation and judicial decisions.
Implications for Policy, Delivery, or Practice:
Antidiscrimination legislation would be more effective if it included ways of monitoring and ensuring improvements/equity in quality of serviced rendered minority populations.
Primary Funding Source: No Funding
● Gender, Race, and Socioeconomic Disparities in
Inpatient Quality of Care Measures
Helen Neikirk, M.A., Raj Behal, M.D., M.P.H.
Presented By: Helen Neikirk, M.A., Program Director, Analytic
Services, Clinical Informatics, University HealthSystem
Consortium, 2001 Spring Rd, Ste 700, Oak Brook, IL 60523;
Tel: (630) 954-2462; Fax: (630) 954-5879; Email: neikirk@uhc.edu
Research Objective: To identify gender, race, and socioeconomic disparities in performance on inpatient quality of care measures in National Association of Public Hospitals
(NAPH) members and non-NAPH members.
Study Design: Performance of NAPH and non-NAPH hospitals on the JCAHO/CMS quality measures for AMI, heart failure and pneumonia was compared for three types of disparity: males vs. females, Whites vs. non-Whites, and low income vs. higher income patients. Low income was based on primary payer being Medicaid, self pay/uninsured, charity, or medically indigent services. In addition to performance on individual quality measures, a composite measure was created for each measure set (i.e., AMI, heart failure, pneumonia) to indicate the percentage of patients who were eligible for at least one measure in a measure set that received all of the recommended elements of care for which they qualified. Only patients who received all of the elements of care for which they were eligible were counted in the numerator for the composite rates.
Population Studied: Data for all JCAHO/CMS core quality measures for discharges from University HealthSystem
Consortium member hospitals during the time period January
2004 - June 2005 (N = 144,708). Hospitals were grouped into
NAPH members (37,255 discharges) and non-NAPH members
(107,453 discharges).
Principal Findings: Statistically significant differences were found for many individual quality measures in both NAPH and non-NAPH hospitals across all disparity types. Non-White patients with LVSD were significantly more likely to have ACE inhibitors prescribed for both AMI and heart failure in NAPH hospitals. In non-NAPH hospitals this was true only for heart failure. For AMI and heart failure a significantly higher percentage of White patients received all of the care elements for which they were eligible in both NAPH and non-NAPH hospitals. For pneumonia a significantly higher percentage of non-White patients received all of the care elements in non-
NAPH hospitals. Significantly higher proportions of males received all of the elements of care for AMI and pneumonia and a significantly higher percentage of females received all of the care elements for heart failure in non-NAPH hospitals.
Low income AMI and heart failure patients were significantly

less likely to receive all of the elements of care for which they were eligible in both NAPH and non-NAPH hospitals. For pneumonia, this pattern was reversed with a significantly higher percentage of low income patients receiving all care elements in both NAPH and non-NAPH hospitals.
Conclusions: Disparities in care exist in both NAPH and non-
NAPH hospitals with regard to race, gender and income/payer status. Compared to heart failure and pneumonia, a higher percentage of AMI patients received all of the elements of care for which they were eligible in both NAPH and non-NAPH hospitals regardless of their race, gender or income/payer status. Heart failure patients are least likely to receive all of the elements of care for which they are eligible in both NAPH and non-NAPH hospitals regardless of race, gender or income.
Implications for Policy, Delivery, or Practice: Hospitals that are members of NAPH are sometimes referred to as "safety net" hospitals whose mission is to care for the disadvantaged in society. This study provides evidence that quality of care disparities with regard to race, gender and income exist in these "safety net" hospitals as well as in other hospitals.
Primary Funding Source: No Funding
● Is Perceived Racial Discrimination Associated with
Quality of Life and Self-Reported Chronic Conditions?
Results from the 2002 North Carolina BRFSS Survey.
Emmanuel M. Ngui, DrPH, Ziya Gizlice, Ph.D.
Presented By: Emmanuel M. Ngui, DrPH, Assistant Professor of Pediatrics, Epidemiology and Health Policy, Department of
Pediatrics, Medical College of Wisconsin, 8701 Watertown
Plank Rd, Milwaukee, WI 53226; Tel: 414 456-4302; Fax: 414
456-6385; Email: engui@mcw.edu
Research Objective: The study objectives were to examine the association of 1) self-reported emotional symptoms (ES) and physical symptoms (PS) due to perceived racial discrimination
(PRD); and 2) PRD experiences when seeking healthcare with quality of life (QOL) and self-reported physician-diagnosed chronic conditions.
Study Design: Cross-sectional data from the 2002 North
Carolina Behavioral Risk Factor Surveillance System (BRFSS).
PRD was assessed using self-reported 1) ES(i.e., angry, sad, or frustrated) and PS (i.e., headache, upset stomach, or pounding heart) due to racial treatment within the past 30 days; and 2) perceived differential racial treatment when seeking healthcare within the past 30 days. Dependent variables included: 1) five QOL measures (perceived disability, self-rated fair or poor health status(HS), seven or more days of poor physical health (PH), seven or more days of poor mental health (MH), and activity limitation (AL) in the past month chronic), and 2) self-reported physician-diagnosed chronic conditions (arthritis, diabetes, and current asthma).
Multivariate analyses adjusted for race, gender, age, education level, and household income.
Population Studied: Random sample of North Carolina adults.
Principal Findings: Seven percent of North Carolina adults reported ES and PS associated with PRD in the past 30 days, with African-Americans disproportionately more likely than whites to report ES (17% vs. 3%), PS (8% vs. 1%), and experiences that were worse than other races when seeking health care (7% vs. 1%). Adjusting for other relevant covariates, the odds of having a disability (OR=2.1; 95% CI
[1.16-3.95], fair/poor HS (OR=2.1; [1.12-3.82], poor PH (OR=2.0
[1.09-3.61], poor MH (OR=2.2; 1.24-3.87], more ALs (OR=3.1;
[1.64-5.85], and arthritis (OR=2.6; [1.41-4.97]) were two to three times higher among respondents who reported ES/PS due to
PRD. Adjusting for other covariates (including health insurance coverage), the odds of having a disability (OR=2.9;
[1.46-5.62], fair/poor HS (OR=2.6; [1.22-5.41], poor PH (OR=3.6
[2.06-6.28], MH (OR=3.5;1.94-6.29], AL (OR=3.6; [1.81-7.26]), and arthritis (OR=3.0; [1.51-6.14]) in the past month were three to four times greater among those who reported experiences that were worse than other races when seeking health care, compared to those who reported experiences that were the same as other races.
Conclusions: ES and PS due to PRD and perceived worse treatment when seeking care are strongly associated with adverse health outcomes including poor QOL and chronic conditions such as arthritis among adults. African-Americans are at a greater risk of experiencing ES/PS due to PRD and are more likely to encounter PRD when seeking care than whites.
These associations persist even after adjustment for relevant covariates.
Implications for Policy, Delivery, or Practice: Our findings suggest the need for increased awareness of the potential role of PRD on health and health disparities, and more research to examine the mechanism through which PRD influences health and QOL. The study findings also underscore the need for policies and strategies that reduce and eliminate racial discrimination or unequal racial treatment our society and in the healthcare system.
Primary Funding Source: No Funding
● Are Pediatric Asthmatics Receiving the Necessary
Medications?
Jeannette Oshitoye, Ph.D.
Presented By: Jeannette Oshitoye, Ph.D., Adjunct Professor,
Social Sciences, University of Texas at Dallas, 2915 Antares
Circle, Garland, TX 75044; Tel: 972-925-6428;
Email: Joshitoye@dallasisd.org
Research Objective: To determine whether asthmatic patients are receiving required medications outlined by the
National Asthma Guidelines.
Study Design: This study analyzes data from the Medical
Expenditure Panel Survey (MEPS). It uses a multinomial logit regression to predict the probability of a pediatric asthma patient receiving appropriate medications as outlined in the national guidelines.
Population Studied: U.S. asthmatics between the ages of 5-17 years old
Principal Findings: African Americans and Latinos are least likely to receive the required medications as outlined by the
National Asthma Guidelines. African Americans and Latinos are least likely to receive the required medications as outlined by the National Asthma Guidelines. Having insurance had no effect on the results.
Conclusions: African Americans and Latinos are least likely to receive the required medications as outlined by the National
Asthma Guidelines. Having insurance had no effect on the results. It is proposed that this is due to a lack of cultural competency or the part of physicians.

Implications for Policy, Delivery, or Practice: These findings could have significant policy implications especially in regards to medical school training and continuing education credits for new and practicing physicians.
Primary Funding Source: No Funding
● Self-Order Purchasing of Antibacterial in a Developing
Country – India
Bhagirathkumar Patel, M.Pharm., Ph.D., Mr Nikhl Patel,
B.Pharm., Ramesh K. Goyal, Ph.D., Jigneshkumar Patel, M.Sc.
Presented By: Bhagirathkumar Patel, M.Pharm., Ph.D.,
Pharmacologist, Pharmacology, Shri B M SHah College Of
Pharmacy, College Campus, MODASA, 383315; Tel: +91
9426391015; Email: bhagirath70@yahoo.com
Research Objective: With ever widening medical research and an increasing supply of miracle drugs being discovered and made available, antibacterial resistance is global public health service problem. In the present study, a profile of 1178 self orders were monitored at retail pharmacy outlets of North
Gujarat, India with the aim of investigating status of self purchase of antibiotics amongst the non medical population.
Study Design: Data regarding self-order purchase profiles were collected by qualified pharmacist, using specially prepared and pre-tested questionnaires. The collected data were tabulated and analyzed by using normal proportion test.
Population Studied: Total population is around 2 millions in the area of North Gujarat, India.
Principal Findings: It was observed that 45% of patients purchasing over the counter (OTC) antibiotics did not purchase a sufficient quantity of antibiotics to cover the minimum duration of therapy. The most often respondents indicated following antibiotics for self-medication: Penicillins-
42% (Amoxycillin/Ampicillin), Quinolones-20%, Cotrimoxozole-16%, Cephalosporines-14%, Erythromycin-13%, and Tetracyclines-6%. However, since patient in irregular dosage schedule purchased them, resistant strains of highly pathogenic organism may develop.
Conclusions: Rationalization of self-medication and introduction of extended professional services should be directed towards achieving better patient heath care.
Implications for Policy, Delivery, or Practice: Health care professional (pharmacist) can play a greater role in health education by providing information to the public about the detrimental effects on health of the irregular an unnecessary use of the broad-spectrum antibacterials.
Primary Funding Source: No Funding
● Is Lower Hospital Mortality Among Blacks Unique to the
Veterans Administration?
Daniel Polsky, Ph.D., Judith Lave, Ph.D., Ashish Jha, M.D.,
M.P.H., Mark Pauly, Ph.D., Zhen Chen, Ph.D., Kevin Volpp,
M.D., Ph.D.
Presented By: Daniel Polsky, Ph.D., Affiliate Investigator/
Assistant Professor, Center for Health Equity Research and
Promotion, Philadelphia VA Medical Center, Blockley Hall,
Rm. 1212, Philadelphia, PA 19104-6021; Tel: (215) 573-5752; Fax:
(215) 898-0611; Email: polsky@mail.med.upenn.edu
Research Objective: 30-day mortality following hospital admission within VA is lower for black patients relative to white patients; a finding that contrasts sharply with the lower treatment levels and life expectancy for U.S. blacks. This differential finding may be a result of VA’s integrated health care system which reduces barriers to care through subsidized comprehensive health care services. Our objective was to examine the role of systems of care in racial health disparities by comparing 30-day mortality for whites and blacks following hospital admission to VA and non-VA hospitals.
Study Design: Retrospective observational study. We examined 30-day mortality rates for blacks and whites following hospital admission for six medical conditions between 1996 and 2001 in all acute care VA hospitals, and in acute care non-VA hospitals in Pennsylvania and California.
Discharge data were linked to death certificate data and data from the Beneficiary Identification Record Locator System within the VA for information on out of hospital deaths.
Logistic regression was used to adjust for differences in demographic factors, comorbidities, and race within VA and non-VA hospitals. Interactions between race, hospital system, and age were tested.
Population Studied: The dataset consisted of 346,301 VA patients and 2,935,543 non VA patients, admitted to VA hospitals nationwide or non-VA hospitals in Pennsylvania or
California with a principal diagnosis of one of 6 AHRQ
Inpatient Quality Indicators: acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, hip fracture, pneumonia, or stroke.
Principal Findings: Among subjects under 65, blacks and whites had similar 30-day mortality for 5 of 6 conditions in both VA and non-VA hospitals. For example, odds ratios for
AMI: VA:1.13, 95%CI: 0.94-1.37; and non-VA:0.95, 95%CI:0.86-
1.04. Among those over age 65, blacks were less likely to die than whites in both VA and non-VA hospitals. Odds ratio AMI:
VA:0.81 95%CI:0.72-0.91; non-VA:0.84 95%CI:0.79-0.88. The gap in mortality between blacks and whites was comparable between VA and non-VA hospitals in 4 of the 6 conditions. In the other two conditions, CHF and pneumonia, this gap in mortality favored blacks more in non-VA hospitals compared to VA hospitals.
Conclusions: These findings suggest that factors associated with better 30-day mortality for blacks are not unique to VA.
Implications for Policy, Delivery, or Practice: These results suggest that interventions aimed at reducing health disparities and improving health outcomes and life expectancy of blacks may need to focus on settings besides hospital care.
Primary Funding Source: VA, VA Health Services Research &
Development
● A New Approach to Facilitating Substance Use Disorder
Treatment Effectiveness, Efficiency and Accountability
Janice Pringle, Ph.D., Michael T. Flaherty, Ph.D., Amy
Shanahan, Stephanie Murtaugh
Presented By: Janice Pringle, Ph.D., Scientific Director, ,
Institute for Research, Education, and Training in Addictions
(IRETA), 425 Sixth Ave, Pittsburgh, PA 15219; Tel: 412-258-8556;
Fax: 412-258-8554; Email: pringlej@ireta.org
Research Objective: Examine the impact of applying a complex approach addressing organizational/system leadership, real time performance measurement and feedback, an internal learning strategy using an industry-based process improvement strategy, training on an appropriate evidencebased practice, and an application of a continuum of care

approach to substance use disorder treatment (SUD) upon performance indicators such as treatment process (access and retention) and patient recovery progress (housing status, employment status, alcohol and drug use profile, and criminal justice involvement).
Study Design: A multi-disciplinary team applied ongoing training, mentoring, and implemented a real time performance measurement and reporting system within a system of SUD treatment in Western Pennsylvania using protocols embedded within complex adaptive systems theory.
The team gathered data describing how the project was implemented, and collected three waves of performance measurement data along various indicators of treatment process and recovery progress for patients receiving outpatient and residential SUD treatment. Focus groups, key informant interviews and surveys were used to describe/improve the implementation process.
Population Studied: Over 400 adult (18 and older) persons with SUDs who sought various levels of inpatient or outpatient treatment within one system of care.
Principal Findings: Process data collected indicated that all four elements of the system were key to the success of the project (leadership, internal/external learning, performance measurement, and a clinical model). Sustaining and expanding the effort was supported best by changes in leadership style that articulated a clear vision for the work being conducted, and a process for achieving that vision.
Staff buy in was accelerated when the effort launched a successful, concurrent paperwork reduction effort. Results of this pilot have been promising. Some of the findings include:
Reduced amount of time between first contact and first treatment session from an average of 14 days to 48 hours.
Increased program census over one year period by at least
50%. Increased program revenues over one year period by over 25% (in a fee for service environment). Reduced provider-developed redundant and unnecessary paperwork burden by approximately 40%. Statistically significantly increased client retention (p< 0.008) over ten month period.
Clients who completed treatment and who were referred from the County jail - 84% had ceased drug and alcohol use, 60% were employed, 92% had no probation/parole violation and
100% were stably housed six months after discharge.
Conclusions: The use of complex adaptive systems theory, as it is applied in other healthcare , which underscores the use of simultaneous strategies along clearly identified system
“levers” holds much promise in establishing, sustaining and expanding efforts to facilitate SUD treatment effectiveness, efficiency and accountability.
Implications for Policy, Delivery, or Practice: This approach holds promise for use by federal, state and private payers to address quality issues in SUD treatment. The authors strongly suggest payers consider this approach when applying training, performance measurement and process improvement approaches currently being supported at the federal level (i.e.,
NOMs, NIATx), each of which have had limited impact upon treatment quality. This approach could also have profound implications for how NIH funds and translates scientific findings into practice, which is often based upon simple assumptions about organizational/system behavior.
Primary Funding Source: No Funding
● Complementary and Alternative Medicine Use in Chinese and White
Hude Quan, M.D. Ph.D., Daniel Lai, Ph.D., Delaine Johnson,
MA, Marja Verhoef, Ph.D., Richard Musto, M.D.
Presented By: Hude Quan, M.D. Ph.D., Assistant Professor,
Community Health Sciences, University of Calgary, 3330
Hospital Dr. NW, Calgary, T2N 4N1; Tel: (403) 944 8912; Fax:
(403) 210 3818; Email: hquan@ucalgary.ca
Research Objective: Complementary and alternative medicine (CAM) is commonly utilized. Health care professionals and health policy makers need to know what
CAM therapies are being used by their patients. CAM is closely related to cultural background. Acupuncture and herbal therapies originated in China. Therefore, there may be significant differences in characteristics of Chinese and White
CAM users. Hence, this study aimed to describe the differences and similarities in CAM use between the Chinese and the White Canadian populations. Currently, few data are available on this topic.
Study Design: A cross-sectional telephone survey was conducted in English and two Chinese dialects (Cantonese and Mandarin) in a large Canadian city (Calgary). Information on utilization of 12 CAM modalities in the past 12 months was collected.
Population Studied: The target population of this study consisted of Chinese and White aged 18 or over in Calgary. We randomly selected telephone numbers listed with a Chinese surname from the 2004 Calgary telephone directory to obtain
Chinese Canadians. We then randomly selected telephone numbers from remaining names. Those selected were asked to identify their ethnicity. Only White were included.
Principal Findings: Of 1727 Chinese and 1948 White surveyed, 850 (49.2%) Chinese and 805 (41.3%)White responded to the survey. Of the Chinese respondents, 80.5% used CAM, mainly vitamins and/or mineral supplements
(58.4%), herbal remedies (48.7%), massage therapy (17.1%), and chiropractic (8.4%). Of the white respondents, 86.3% used CAM, mainly vitamins and/or mineral supplements
(79.1%), herbal remedies (33.7%), massage therapy (30.4%) and chiropractic (21.2%). Acupuncture use was similar in both groups: 8.2% in Chinese and 7.9% in White participants. The remaining 8 CAM modalities surveyed (including naturopath, homeopathy, amino acids or enzyme supplements, Ayurvedic medicine, biofeedback training, hypnosis and Reiki) were less frequently used by both Chinese and White participants. White participants were more likely to use multiple-CAM modalities than Chinese. For example, 14.0% White used 4 or more CAM modalities versus 5.0% Chinese in the last 12 months.
Conclusions: Chinese and White Calgarians were similar with respect to overall CAM use. However, the level of CAM utilization varied by type of CAM therapy between Chinese and
White. Chinese utilized herbal therapies far more than acupuncture although both are traditional Chinese therapies.
The variation may be related to patient’s knowledge and beliefs about effectiveness of individual CAM modularity.
Primary Funding Source: Alberta Heritage Foundation for
Medical Research

● Cancer Patients' Attitudes toward Cancer Trials
Peggy Schuber, DSN, RN
Presented By: Peggy Schuber, DSN, RN, Assistant Professor of Community Health Nursing, School of Nursing, University of Nevada, Las Vegas, 4505 maryland pkwy, Las Vegas, NV
89154; Tel: 702-895-5440; Fax: 702-895-4807; Email: peggy.schuber@unlv.edu
Research Objective: Accurate measurement of attitudes toward participation in cancer treatment trials (CTs) and cancer prevention trials (CPTs) across varied groups could assist health researchers and educators when addressing attitudinal barriers to participation in these trials.
Study Design: Two newly developed scales to measure attitudes toward CTs and CPTs comprise the Attitudes toward
Cancer Trials Scales (ACTS). These scales were used to evaluate the prevalence of positive and negative attitudes toward cancer treatment and prevention trials in a random stratified population of cancer patients.
Population Studied: The CT and CPT scales with sociodemographic and cancer trial history variables were distributed in a mail survey of former patients (N = 1,703) of a comprehensive cancer center that yielded 925 usable responses (54% response rate).
Principal Findings: Prevalence of favorable attitudes toward
CTs and CPTs was 66% and 69%, respectively. There were no significant differences in mean scores by cancer site or gender, but African Americans had more positive attitudes toward cancer trials than European Americans. Multiple regression analysis indicated that older age, lower education level, and prior CT participation, but not ethnicity, were associated with more favorable attitudes toward CTs. Prior CT participation and prior CPT participation were associated with more favorable attitudes toward CPTs. Ethnicity was significantly associated with response rate. Evidence of reliability and construct validity of both scales is presented.
Conclusions: Use of a psychometrically sound instrument to measure attitudes may lead to a better understanding of the reasons for decisions regarding participation in CTs and CPTs.
Implications for Policy, Delivery, or Practice: Access to cancer trials and cancer prevention trials should be ensured across demographic groups.
Primary Funding Source: AHRQ
● Non-Utilization of Outpatient Care in Iran:Differntials and Determinants
Saeid Shahraz, M.D., Emmanuela Gakidou, Ph.D., Mohsen
Naghavi, M.D. Ph.D., Hamid Reza Jamshidi, Ph.D., Diania
Lee, Bs, Goran Tomson, M.D. Ph.D.
Presented By: Saeid Shahraz, M.D., Post Doc Fellow, Harvard
Initiative for Global Health, 104 Mount Auburn street ,3rd
Floor, Cambridge, MA 02138; Tel: (617) 495-8236; Fax: (617)
495-8231; Email: saeid_shahraz@harvard.edu
Research Objective: To measure the distribution of refraining behavior across income groups in Iran and illustrate reasons for non-utilization.
Study Design: Perceived need for care was measured for a two week recall period, with an additional 14-item questionnaire detailing reasons for refraining from care
(defined as allopathic or traditional medicine). Income groups were assigned using a dichotomous hierarchical ordered probit (DIHOPIT) model based on asset ownership, and the concentration index was calculated to quantify utilization inequality across income groups. Additionally, a Chi-squared statistic was used to compare the proportions, and the association between independent covariates and the binary dependent variable of refraining were obtained from a logistic regression analysis.
Population Studied: We used the data from the 2002 Iranian
National Healthcare Cost and Utilization Survey implemented by the Ministry of Health and Medical Education. A nationally representative sample was obtained by using probabilities proportional to size, resulting in a total of 3479 households comprising 16860 individuals (50.3% male).
Principal Findings: With a response rate of 95%,
3624(21.6%) out of 16807 respondents expressed a need to outpatient care over the last 2 weeks. From those with a perceived need, 1079 (29.8%) refrained from seeking a care; from those who sought a care 97.8% received it. The concentration index was calculated as -0.172 (SE: 0.003), indicating that the poor refrain from visiting healthcare more often than the better-off. Economic barriers and selfmedication were the two most common explanations for refraining behavior expressed by the population. 18.9% and
65% of the wealthiest and poorest quintiles mentioned economic barriers as the reason for refraining, respectively
(p<0.0000). The corresponding figures for self-medication were 38.7% and 23.8 %.( p<0.0000). Increased odds of refraining were found for rural populations, males, the lowest two income quintiles, the uninsured, and those with household heads with low education levels.
Conclusions: The proportion of the population who sought no care was comparable with that of some other nations, and results show that the poor are less likely to seek care than the better-off. This implies the need for further research to assess the possible impact of any targeted intervention in order to reduce the inequality gap in refraining behavior. Furthermore, the problems behind self-medication and drug use remain unanswered and need to be investigated thoroughly.
Implications for Policy, Delivery, or Practice: As the poor are more likely to refuse seeking healthcare than the well-off, policies aiming to increase access of poor households to healthcare may positively affect the absolute level of the population health and help reduce the health inequalities in the population.
Primary Funding Source: No Funding
● The Role of Perceived Racism and Race-Based
Residential Segregation on Cancer Behavioral Risk Profiles
Salma Shariff-Marco, M.P.H.
Presented By: Salma Shariff-Marco, M.P.H., Ph.D. Candidate,
Health, Behavior and Society, Johns Hopkins Bloomberg
School of Public Health, 6101 43rd Street, Riverdale, MD
20737; Tel: (301) 277-4536; Email: sshariff@jhsph.edu
Research Objective: The objectives of this research are to: 1) describe the range of racism experienced by racial/ethnic groups in California; 2) describe the relationship between racism (perceived racism at the individual level and segregation at the county level) and cancer prevention behaviors; and 3) identify potential mediators and moderators of the relationship including socioeconomic position, immigration status, acculturation (e.g., language, length of US

residence), and neighborhood characteristics between racism and cancer prevention.
Study Design: Using cross-sectional data from the 2003
California Health Interview Survey, the study draws from over
42,000 adult respondents representing the five major aggregate racial/ethnic groups in the US. Perceived racism is measured with questions about general exposure to racism as well as exposure within the health care context. Segregation is measured on two dimensions, unevenness and exposure via
Index of Dissimilarity and Isolation Index. Cancer prevention will be measured with a set of primary (e.g., avoiding tobacco use, regular exercise) and secondary (e.g., early detection) prevention behaviors. Exploratory analysis is conducted primarily using univariate and bivariate analyses. For RQ2 &
RQ3, ordinal logistic regression and multilevel modeling are utilized for the individual level and multilevel analyses, respectively.
Population Studied: The study population includes all adult respondents from 2003 CHIS who have never been diagnosed with cancer, are not pregnant and did not have a proxy interview. In addition, all respondents have provided responses to cancer prevention and perceived racism and have been successfully geo-coded to a census tract. The 6 major racial/ethnic groups considered in the study include
Latinos, Non-Hispanic African Americans, Non-Hispanic
Asians/Pacific Islanders, Non-Hispanic American
Indians/Alaskan Natives, and Non-Hispanic Whites.
Principal Findings: Approximately 20% of the respondents reported experiencing overall discrimination sometimes, often or frequently, while 6% of the respondents reported experiencing discrimination within the health care context.
These responses varied by race/ethnicity, ranging from 12% to
60% for overall discrimination and 3%-14% within the health care context. Overall, secondary cancer prevention is more strongly associated with both measures of racism compared to primary cancer prevention in unadjusted analyses. These associations vary by race/ethnicity.
Conclusions: Preliminary findings of unadjusted analyses suggest that the relationship between racism and the two types of cancer prevention (primary and secondary) differ.
Increased exposure to racism is associated with decreased participation in primary prevention and increased participation in secondary prevention. A major limitation of this study is that the data are cross-sectional and thus, causal inferences are not possible.
Implications for Policy, Delivery, or Practice: The research provides information on the prevalence of perceived racism across all major racial/ethnic groups and the effect that it has on preventive behaviors. The research findings may support and inform health care setting interventions addressing discrimination and promoting cultural competency.
Primary Funding Source: No Funding
● Variance in Outcomes and Care Patterns for Diabetes by
Insurance Status: What Are the Underlying Causes?
Jay Shen, Ph.D., Elmer Washington, M.D., M.P.H.
Presented By: Jay Shen, Ph.D., Associate Professor, Health
Administration, Governors State University, One University
Parkway, University Park, IL 60466; Tel: (708) 235-2131; Fax:
(708) 534-8041; Email: j-shen@govst.edu
Research Objective: To evaluate patterns of hospital based care for patients with Type-2 diabetes of varying insurance statuses since increase in uninsured population has become a serious policy issue in recent years.
Study Design: Data were classified and evaluated according to insurance status. Accompanying information on sociodemographic variables were included for comparison as well. All admissions where Type-2 diabetes was entered as any diagnostic code (primary, secondary, tertiary, etc. were classified in one of three tiers based upon the primary diagnosis. Tier 1 included those diagnoses that were likely to unrelated to the diagnosis of diabetes (e.g. cerebral hemorrhage, salmonella, etc.). For certain infectious primary diagnoses (e.g. salmonella), the presence of diabetes may have been more likely to cause the infection to be more severe, however, the primary determinant of infection was more likely to be exposure as opposed to host characteristics.
Tier 2 included those diagnoses for which diabetes was a noted risk factor (e.g. myocardial infarction, cellulitis, etc.).
Tier 3 included those diagnoses that virtually never occur in the absence of diabetes (e.g. Kimmelstein Wilson nephrosclerosis, hyperosmolar coma, etc.). In addition, we evaluated patterns of admission for principal diagnoses of acute hypoglycemia and acute hyperglycemia across insurance groups.
Population Studied: 642,610 patients included in the 2001
National Inpatient Sample. Among them, 141,406 were privately insured, 56,461 were covered by Medicaid, and
20,046 were uninsured. The remaining were Medicare patients.
Principal Findings: Medicaid (6.1%) and uninsured patients
(6.8%) were more likely to be admitted with a tier 3 diagnosis than the private insurance counterparts (4.4%) (odds ratios
(OR) [95% confidence interval (CI)], 1.25 [1.19, 1.31] for
Medicaid patients and 1.36 [1.27, 1.45] for uninsured). Further, compared to patients covered by privated insurance, uninsured patients were more likely to be admitted with an acute, severe hyperglycemic episode (OR [CI], 1.91 [1.57, 2.31]) while both Medicaid and uninsured patients were more likely to be admitted with an acute hypoglycemic episode (OR [CI],
1.20 [1.13, 1.28] for Medicaid patients and 1.43 [1.30, 1.57] for uninsured patients). Finally, uninsured patients had the youngest average age of admission (52.9 years) followed by
Medicaid (54.7 years). The average age for the privately insured patients was 57.4 years.
Conclusions: This study suggests that uninsured populations are more likely to be admitted to the hospital at a relatively young age as a result of a diabetic complication that could be prevented or delayed. Uninsured patients were also more likely to be admitted from an episode related to acute, uncontrolled hyperglycemia generally suggesting that this group had the most difficulty with access to care. While Medicaid patients were also more likely to be admitted from a diabetic complication that might have been delayed by timely access to

appropriate outpatient care, they had comparable risk of being admitted for acute, severe hyperglycemia when compared to the privately insured group. Although Medicaid patients had a lower risk of being admitted with an acute hypoglycemic episode when compared to the uninsured, the risk was higher than for patients with private insurance.
Implications for Policy, Delivery, or Practice: Policies focused on provider reimbursement directly tied to care for the uninsured are critical to reducing disparities in this population. With respect to Medicaid populations, funding for appropriate levels of case management to improve care coordination and follow up are likely to improve outcomes.
Primary Funding Source: AHRQ
● Findings from the Planning and Launch of a National
Disparities Collaborative
Bruce Siegel, M.D.,M.P.H., Marcia J. Wilson, M.B.A., Lea
Nolan, MS, Lissette Vaquerano, Khoa Nguyen, M.P.H.,
Deborah Bear
Presented By: Bruce Siegel, M.D.,M.P.H., Research Professor,
Health Policy, George Washington University School of Public
Health and Health Services, 2021 K St, NW, Ste 800,
Washington, DC 20006; Tel: 2025302399; Fax: 202-296-0025;
Email: siegelmd@gwu.edu
Research Objective: Expecting Success is a national initiative that seeks to use quality improvement techniques to reduce disparities in heart failure and acute myocardial infarction care for African-Americans and Latinos. We sought to understand the visibility of disparities in health care for health system leaders as part of the planning and design process for this collaborative. We also attempted to characterize the extent to which hospitals applying to the program collected race and ethnicity data and engaged in initiatives to reduce disparities.
Study Design: Key informants were identified through discussions with health care philanthropies, professional associations and researchers. These informants were then interviewed for one hour using a semi-structured instrument.
Information from these interviews was used to construct a 22 item web-based letter of intent (LOI) used by hospitals to indicate interest in applying to the collaborative. The LOI included questions on hospital characteristics as well as past quality improvement and disparities initiatives.
Population Studied: Forty-two individuals were interviewed, including healthcare system, association and philanthropy leaders, and researchers and clinicians. Subsequently 122 hospitals completed the LOI. Of these, 29 were community hospitals, 59 were teaching institutions, and 34 identified as academic medical centers. The largest group (82) was private not-for-profit institutions, with 68 serving a mainly urban market.
Principal Findings: In the initial planning phase all of the interviewees reported that disparities in health care are not viewed as an important quality of care issue by American hospitals. Data from the subsequent LOI revealed that 118 of the 122 applicant hospitals reported they collect data on patients’ race and ethnicity, and 84 stated they could analyze quality data by race and ethnicity. However only six hospitals indicated that they had planned or implemented formal quality improvement initiatives specifically designed to reduce ethnic or racial disparities in hospital care.
Conclusions: Disparities in health care are not yet an area of operational or quality improvement focus for hospitals, despite the fact that “equity” is one of the six domains of quality identified by the Institute of Medicine. The lack of specific disparity reduction projects among the applicant hospitals is especially surprising given 1) that the applicant hospitals may be a sample expected to be biased towards institutions with an interest in disparities; and 2) almost all collect race and ethnicity data on patients.
Implications for Policy, Delivery, or Practice: Disparities are not “top-of-mind" for health systems leadership, and are not a major focus of hospital quality activities. Changing this may require concerted campaigns to link disparities to the movement to improve quality, and to demonstrate that quality improvement initiatives can indeed reduce disparities in clinical settings. Current policies around hospital accreditation, data reporting and regulation may also need to be reformed to create incentives for hospitals to view health care disparities as priorities.
Primary Funding Source: RWJF
● A Comparison of Demographics, Social History, Clinical
Outcomes, and Resource Utilization by Insurance Payer
Group in Patients Undergoing Total Hip Replacement
Surgery
Amanda Smith, M.P.H., Adrian Hinman, M.D.
Presented By: Amanda Smith, M.P.H., Research Director,
Orthopaedic Surgery, UCSF, 3333 California St., #265, San
Francisco, CA 94116; Tel: 415-439-9472; Email: smitha@ucsf.edu
Research Objective: Numerous studies have shown that
Medicaid patients have less access to medical care, but few studies have focused on the consequences of reduced access by the poor to needed specialty care. The purpose of this study was to determine if Medicaid patients receiving a primary total hip replacement differed from other patients with respect to baseline demographic characteristics, social history, clinical outcomes, and resource utilization.
Study Design: A retrospective chart review of subjects who received a primary total hip replacement (THR) was conducted and stratified by insurance payer groups (subjects reporting more than one source of insurance were excluded).
Baseline demographic information, social history, operative data, resource utilization and clinical outcomes (using the
Harris Hip Score, a measure of functional outcomes in total hip replacement surgery) were compared between Medicaid,
Medicare and managed care participants. Additionally, we measured how far patients lived from the clinic where they were having surgery to measure discrepancies in access.
Population Studied: Consecutive patients at an academic medical clinic who received a primary total hip replacement who had at least 16 months of post-operative follow-up.
Patients were excluded from analysis if they had a total hip replacement (THR) contra-laterally, any revision surgery, or a total knee replacement within this 16 month post-operative period. Records for 78 Medicaid, 54 Medicare and 54 managed care participants were analyzed.
Principal Findings: In terms of demographics there were statistically significantly more African-American (p<.05) and
Hispanic (p<.05) patients in the Medicaid group and they were significantly more likely to be single that their Medicare

or managed-care counterparts (p<.05). Additionally, though
Medicaid patients were more likely to smoke tobacco than
Medicare and managed-care patients (p<.05) there was no statistically significant difference in history of psychiatric illness, abuse of non-prescription drugs, use of heavy narcotics, or abuse of alcohol. After adjusting for age, we found a significant difference in clinical outcomes between insurance groups in the pre- (p<.0001) and post-operative (at
6 months p<.0001 and at 1 year p< .0001) using the Harris
Hip Scores, although the rate of improvement in hip function and pain after primary total hip replacement was similar between all three groups (p = .41). Compared to other payer groups, Medicaid patients had to travel twice as far to receive treatment (median of 66.0 miles vs. 38.3 miles). However, the resource utilization, defined by the amount of appointments listed as cancellations or no-shows, and the total number of appointments needed both pre-operatively and postoperatively, was not different among the two groups.
Conclusions: Medicaid patients start out at baseline with similar co-morbidities and demographics as other payer groups, but present with significantly lower Harris Hip Scores.
Decreased access to health care and increased time to presentation may account for the decreased functional scores seen at the time of presentation. Additionally, although the number of appointments, cancellations and no-shows was not significantly different between payer groups, there was a trend for the Medicaid patients to have fewer pre-operative visits, which also would also indicate their hip function was more impaired than patients with other insurance payers.
Implications for Policy, Delivery, or Practice: As a greater number of hospitals and clinics are turning away Medi-Cal patients, they have to travel further for their care, present at later stages of disease and are in greater need of treatment and therefore undergo treatment sooner after initial presentation than patients in other insurance groups who have more ready access. While decreased reimbursement is implicated as the main cause of the dwindling acceptance of
Medi-Cal insurance, the complex social situations of Medi-Cal patients, who are frequently unemployed and marginally housed, may cause some providers to be reluctant to see and treat Medi-Cal patients. While our results indicate that Medi-
Cal patients are more likely to be single therefore perhaps lacking a support structure, they were not significantly more likely to engage in recreational drug use, alcohol abuse or heavy narcotic use than other patients, nor were they more likely than other patients to miss or cancel their appointments.
Primary Funding Source: No Funding
● Do Racial Disparities in Access to Care and Physician
Trust Influence Prostate Cancer Screening?
Pamela Spain, Ph.D., Paul Godley, M.D.
Presented By: Pamela Spain, Ph.D., Postdoctoral Research
Fellow, Cecil G. Sheps Center for Health Services Research,
The University of North Carolina at Chapel Hill, 725 Martin
Luther King Jr. Blvd., Chapel Hill, NC 27599; Tel: (919) 966-
7123; Email: pspain@schsr.unc.edu
Research Objective: Screening rates for prostate cancer are lower in black men than in white men. Studies suggest that physician trust and access to care, two factors for which there are also documented racial disparities, may drive cancer screening rates. This study investigated how race, physician trust, and access to care influence screening with prostate specific antigen (PSA) in North Carolina men.
Study Design: Incident prostate cancer cases were identified from the North Carolina Central Cancer Registry, and standardized telephone questionnaires were conducted between November 2001 and July 2004. Physician trust was measured as agreement with the statement “Overall, I trust my physician.” Access variables included income, health insurance status, access to a physician for prostate problems, and having had regular checkups in the 12 months prior to diagnosis. The outcome variable was self-reported use of PSA examinations in the 12 months prior to diagnosis. The bivariate relationship between race and PSA usage was examined using chi-square analyses. For descriptive purposes, the bivariate relationship between race and both trust and access was also examined. Subsequently, multivariate logistic regression examined whether the relationship between race and PSA usage remained when simultaneously considering access and trust.
Population Studied: White (n=347) and black (n=207) men between 40 and 75 years diagnosed with prostate cancer within three months prior to the survey (total n = 554).
Principal Findings: Bivariate analyses revealed that compared with whites, blacks were less likely to have had regular PSAs
(p<.01). Ninety-two percent of whites and 69% of blacks reported having regular PSAs in the last 12 months.
Compared with whites, blacks also had less access to care, as they were more likely to be uninsured (8% vs. 2%), more to make less than $20,000 annually (11% vs. 5%), less likely to have seen a doctor’s office for their prostate problem (71% vs.
85%), and less likely to have had regular checkups in the 12 months prior to diagnosis (89% vs. 96%) (all p<.05). Blacks were also less trusting of their physician (87% vs. 97%, p<.05).
Logistic regression revealed that whites were over four times as likely as blacks to have had regular PSAs (OR: 4.4, 2.7-7.0).
Moreover, race retained predictive power when simultaneously considering trust and access, although trust was not a significant predictor. The multivariate model revealed that men who were most likely to have had regular
PSAs had regular checkups prior to diagnosis (OR: 7.8, 3.4-
17.7), were white (OR:3.0,1.7-5.1), and saw a doctor’s office for their prostate problems (OR: 2.0,1.1-3.5) (all p<.05).
Conclusions: Race, access to a doctor’s office, and access to regular checkups significantly predict who is likely to undergo
PSA screenings in North Carolina men with prostate cancer.
When considered with these other variables, physician trust does not significantly impact PSA usage.
Implications for Policy, Delivery, or Practice: This work indicates the need to examine disparities in PSA screening rates from many perspectives. Interventions to improve access to care as well as education about recommended screening services may reduce health disparities in prostate cancer outcomes.
Primary Funding Source: AHRQ

● Geographic Access to Primary Care Physicians Accepting
Medicaid: Evidence of a Racial Disparity in Rural South
Carolina
John Stewart, MS, M.P.H., Ana Lopez De Fede, Ph.D.
Presented By: John Stewart, MS, M.P.H., GIS Manager,
Institute for Families in Society, University of South Carolina,
1600 Hampton St, Columbia, SC 29208; Tel: (803) 777-5516;
Fax: (803) 777-1120; Email: jstewart@gwm.sc.edu
Research Objective: Serious health disparities exist between
African Americans and whites in South Carolina. Travel distance to affordable primary care may be one barrier to good health, especially for low income, rural residents of the state.
This study evaluates travel distance to primary care physicians accepting Medicaid for residents of African American rural communities versus all other rural communities in South
Carolina.
Study Design: Address records for physicians providing primary care to South Carolina Medicaid recipients in 2003 (n
= 3,372) were geocoded (geographically located) using
MapMarkerPlus, an automated geocoding software package.
Rural communities were defined as county subdivisions
(census civil divisions) in South Carolina with 100% rural populations (n = 155; Census 2000, SF3). Rural subdivisions were grouped into two classes, African American (with a population composition > 75% African American; n = 11) and all others (n = 144). Using a geographic information system
(GIS), actual travel distance (not straight-line distance) was measured from the population center of each rural subdivision to the office of the nearest primary care physician accepting Medicaid. Differences in travel distance for residents of African American rural communities versus all other rural communities were evaluated by comparing the mean distance traveled by both groups.
Population Studied: Residents of all rural county subdivisions in South Carolina (2000).
Principal Findings: For rural South Carolina residents, travel distance to the nearest Medicaid primary care provider ranges from less than one mile to 28 miles. On average, residents of
African American rural communities must travel farther for
Medicaid primary care than residents of all other rural communities (11.1 miles versus 7.2 miles; p < .01).
Conclusions: Particularly in the absence of local pubic transportation, travel distance to affordable primary care may be a barrier for residents of predominantly African American rural communities.
Implications for Policy, Delivery, or Practice: Initiatives to reduce health disparities in the rural South must evaluate geographic access to affordable care. Health care policy makers must consider supporting the survival of health care facilities intrinsic rural areas to increase access to primary care services. An initiative that sustains and expands the number of physicians serving rural African American communities continues to be priority.
Primary Funding Source: Other Government Agency
● Location Decisions of Mammography Facilities:
Racial/Ethnic Disparities Across Zip-Codes
Jonathan Sunshine, Ph.D., Mythreyi Bhargavan, Ph.D.
Presented By: Jonathan Sunshine, Ph.D., Senior Director of
Research, Research, American College of Radiology, 1891
Preston White Dr, Reston, VA 20191; Tel: 703-648-8924; Fax:
703-264-2443; Email: mbhargavan@acr.org
Research Objective: Among women age 40 and older, minority women have been found to have mammograms at a lower rate than white women. One potential cause may be that minority women live in neighborhoods with no mammography facilities in proximity to them, or because facilities in their neighborhoods are inadequately committed to patient service. The objective of this study is to measure if high percentage of minority population influences facility location decisions, above and beyond socio-economic factors, in terms of two sets of outcomes: (a) whether mammography facilities locate in or near the zip-code, and (b) commitment to patient service of mammography facilities in it.
Study Design: The unit of analysis is the zip-code, referred to here as the target zip-code. Target zip-codes are categorized as high-white, high-black, high-Hispanic, and high-Asian based on the race and ethnicity of the largest sub-population in the zip-code. Quantitative outcomes of interest for the target zipcode are (i) presence of a mammography facility, (ii) the number of facilities per 100,000 women age 40 and older, and (iii) distance to nearest facility if the target zip-code has none. The explanatory variables are socio-economic characteristics of the target and surrounding zip-codes.
Outcome (i) will be estimated using simple logistic regression and (ii) and (iii) with linear and log-linear regression. In addition, logistic regression is used to compare mammography facilities in high-minority and high-white zipcodes in terms qualitative factors, such as whether the facility accepts Medicaid and charity patients, language skills and minority composition of front office and technologist staff, types of outreach activities, etc. Data on demographic and socio-economic characteristics of zip-codes are obtained from the US Census. The list of mammography facilities and their zip-codes is obtained from the American College of Radiology
(ACR) and Food and Drug Administration (FDA) databases of accredited mammography facilities. Patient-service commitment was measured using a pilot phone survey of 105 mammography facilities.
Population Studied: Women age 40 and older in each zipcode
Principal Findings: We find no large differences in the minority composition of the population (31% vs. 30% minority respectively) between zip codes with and without mammography facilities. However, controlling for zip-code socio-economics and population density, high black and
Hispanic zip-codes are much less likely to have a mammography facility in them than predominantly white zipcodes (for example, 10% increase in the black percentage of the population decreases the odds of a facility in the zip-code by 14%). Facilities in high minority zip-codes seem to be more committed to patient service than those in high-white areas, for example, one-half of the facilities surveyed in high-
Hispanic and three-fifths of those in high-black zip-codes use posters and flyers for outreach into the community to educate

women about mammograms, whereas less than one-third of the facilities in the high-white zip-codes do.
Conclusions: High-minority zip-codes are less likely to have mammography facilities, but facilities in high-minority zipcodes may be more committed to patient care than those in high-white zip-codes.
Implications for Policy, Delivery, or Practice: Financial incentives to mammography facilities to locate in highminority neighborhoods are likely to be an effective tool in reducing racial/ethnic disparities in access to mammography.
Primary Funding Source: No Funding
● Prevalence & Factors Related To Utilization of Mental
Health/Substance Use Services among Asian Pacific
Islander Women in the Hawaii Healthy Start Program
Van Ta, M.P.H., BS, BA, Hee-soon Juon, Ph.D., Andrea C.
Gielen, ScD, ScM, CHES, Anne Duggan, ScD, Donald
Steinwachs, Ph.D., MS
Presented By: Van Ta, M.P.H., BS, BA, Doctoral Candidate,
Health Policy and Management, Johns Hopkins University,
5424 W. 2nd St., Santa Ana, CA 92703; Tel: (714) 623-6308;
Email: vta@jhsph.edu
Research Objective: The study goal is to elucidate our understanding of the prevalence of and factors for utilization of Mental Health/Substance Use (MH/SU) services among
Asian Pacific Islanders (API) women, particularly those with specific risk factors: depressive symptoms, substance use, and/or experience with intimate partner violence (IPV).
Specific aims for the paper are to: 1) Determine the prevalence of MH/SU service utilization by race, other socio-demographic factors, and risk factors; 2) Compare the odds of MH/SU service utilization by race; 3) Assess the impact of sociodemographic and risk factors on MH/SU service utilization.
Study Design: Data were derived from a randomized trial of
Hawaii’s “Healthy Start Program” (“HSP”), a home visiting program targeted to families at risk for maltreatment of their newborns. “At-risk” (AR) families were enrolled in 1994-1995, randomized to experimental and control groups, and followed until the children were in Grade 3. When the children were in
Grade 1, an additional comparison group of “not at risk”
(NAR) families was recruited. The analyses reported here relate to those who participated in Grade 1 follow-up.
Descriptive statistics were calculated to estimate population parameters. Bivariate analysis, exploratory analysis of potential effect modification and multiple logistic regression were performed. The binary outcome is “Ever utilized MH/SU services” (Yes/No).
Population Studied: At Grade 1, 709 mothers participated in the study (491 AR and 218 NAR). It consisted of 97 White, 218
Asian, 191 Native Hawaiian and Other Pacific Islander
(NHOPI) and 203 No Primary Affiliation/Other (NPA).
Principal Findings: Overall, 151 (21.3%) of the mothers reported ever using MH/SU services. MH/SU service use differed among racial/ethnic groups: White (19.2%), Asian
(22.5%), NHOPI (23.2%) and NPA (35.1%). Bivariate logistic regression revealed that compared with White, the odds ratio
(OR) of MH/SU service utilization for Asian was 0.43
(p<0.01), NHOPI was 0.53 (p<0.05) and NPA was 0.83
(p=0.49). MH/SU service utilization was significantly increased by depressive symptoms (OR=2.56, p<0.01), substance use [illicit drug use (OR=3.25, p<0.01) and problem alcohol use (OR=2.44, p<0.01)], and/or lifetime experience with IPV (psychological aggression, physical assault, sexual coercion) (OR: 3.16, p<0.01). Prevalence and odds of MH/SU service use was also greater for mothers who were not married, had been unemployed in the past 12 months, lived below the federal poverty level, had public vs. private insurance, and had low levels of social support. There was no significant difference between AR and NAR groups (p=0.10).
Racial/ethnic group differences in MH/SU utilization remain after controlling for these variables.
Conclusions: To our knowledge, little MH/SU utilization research has focused on API (especially NHOPI) populations in the U.S. The study results strongly indicate that API women, compared with Whites, are less likely to have ever received needed MH/SU services.
Implications for Policy, Delivery, or Practice: Future research should examine the barriers and facilitators to accessing needed treatments for these disorders. The role of culture should be investigated in influencing an API’s woman decision to seek treatment. These results highlight the urgent need to address a priority area – mental health disparities in racial/ethnic minority populations.
Primary Funding Source: No Funding
● Diabetic Screening Rates Among Native Hawaiians,
Filipinos, and Whites in Hawaii
Deborah Taira, ScD, Komal Warty, BS, Deborah A. Taira, ScD
Presented By: Deborah Taira, ScD, Research Manager, Care
Management, HMSA (BCBS of Hawaii), 818 Keeaumoku
Street, Honolulu, HI 96808-0860; Tel: 8089485337; Fax: 808-
948-6043; Email: deb_taira@hmsa.com
Research Objective: To examine rates of screenings (retinal eye exam, lipid levels, HA1C) for Native Hawaiians, Filipinos, and whites with diabetes. To determine the extent to which any existing disparities are reduced when we control for income level and other patient characteristics.
Study Design: Retrospective observational study. Selfreported ethnicity information from member surveys was merged with administrative (claims) data using unique identifiers. Multivariable logistic regression analyses were used to determine whether there were differences in each of the three screenings related to race or ethnicity. These models adjusted for age, gender, ACG morbidity level, region, household income and type of coverage (HMO, PPO,
Medicare cost contract).
Population Studied: All diabetic patients enrolled in a large health plan in Hawaii who had diabetes in 2004 and were
Native Hawaiian (n=2866), Filipino (n=2017), or white
(n=1759).
Principal Findings: Native Hawaiians were younger on average [62 years, SD(13)] than Filipinos [65 years, SD(13)] or whites [66 years, SD(13)]. Filipino and Native Hawaiian patients were more likely than whites to be female (56% for
Filipinos and Native Hawaiians vs 45% for whites). Morbidity levels were highest for whites, with 37% have a morbidity level of 5 compared to 27% of Native Hawaiians and 25% of
Filipinos. Census tract income level was approximately $3000 higher for whites than for Filipinos and Native Hawaiians.
Native Hawaiians were more likely to be enrolled in the PPO
(70%) than whites (62%) and Filipinos (61%). After adjustment, Native Hawaiians were less likely to receive A1C

screening than whites [OR 0.76, 95%CI (0.7,0.9)], while
Filipino screening rates were similar to those of whites. Both
Filipinos [OR 1.3, 95%CI (1.1,1.5)]and Native Hawaiians [OR
1.2, 95%CI (1.0,1.3)] were more likely than whites to receive retinal eye exams and lipid level screening [Native Hawaiian
OR 1.2, 9%%CI (1.0,1.3) and Filipino OR 1.5 95%CI (1.3,1.8)].
Unadjusted results were similar except that differences between whites and Hawaiians for retinal eye exams and lipid level testing did not reach statistical significance.
Conclusions: After adjustmet, while Native Hawaiians have significantly lower rates of A1C screening than whites, they have higher rates of screenings for lipid levels and retinal eye exams. Filipinos screenings rates are similar to whites for
A1C, and higher for lipid levels and retinal eye exams.
Implications for Policy, Delivery, or Practice: Native
Hawaiians are known to have a high prevalence of diabetes. It may be that outreach efforts to Native Hawaiians and Filipinos are improving their quality of care; however, additional targeting interventions may be needed to improve A1C screening among Native Hawaiians.
Primary Funding Source: Grant number P20MD00173 from the National Institutes of Health, National Center on Minority
Health and Health Disparities
● Neighborhood-Level Correlates of Racial/Ethnic
Disparities in Physical Activity
Stephanie Taylor, Ph.D., Elizabeth Malcolm, M.D., John
Romley, Ph.D.
Presented By: Stephanie Taylor, Ph.D., Assoc. Social Scientist,
RAND, PO Box 2138, M5S, Santa Monica, CA 90407; Tel: 310-
393-0411 x7965; Fax: ; Email: staylor@rand.org
Research Objective: Racial/ethnic disparities exist for physical activity (PA), an important disease-preventive behavior. Opportunities for PA vary across geographic regions such as neighborhoods. However, only one study has examined a few neighborhood characteristics as correlates of racial/ethnic disparities in PA. Furthermore, when examining
PA, most examine only exercise-related PA, not PA that includes all bodily movement. This paper addresses two questions: 1) do racial/ethnic disparities vary geographically and, if so, 2) which of twelve neighborhood characteristics correlate with that geographic variation, controlling for individuals’ characteristics? That is, are racial/ethnic disparities in PA stronger in some neighborhoods and weaker in others, and what might explain that?
Study Design: PA is defined two ways: 1) meeting Health
People 2010 guidelines versus not and 2) being at least moderately active versus not. Respondents reported the number of minutes and days in a typical week that they vigorously or moderately exercise or performed vigorous activities for at least ten minutes without stopping. We used individual-level data from the most recent (2001 and 2003)
Los Angeles (L.A.) County Health Surveys. Neighborhoods were operationalized as census tracts (n=1,630). Eleven neighborhood variables were examined: two measures of land use, two measures of street connectivity, residential density, perceived safety, number of arrests, percentage of land space that is park space, racial/ethnic composition, racial/ethnic diversity, mean household income. Cross-sectional, random effects (multi-level) analyses were conducted of individuals nested within neighborhoods. Individuals’ gender, education, age, hours worked, income, marital status, physical disability, smoking status, self-reported general health status, and having a chronic health condition all were controlled for.
Population Studied: A population-based, random, telephonesurvey sample of adults in L.A. County who provided accurate cross street data so they could be assigned census tracts
(n=12,901).
Principal Findings: Racial/ethnic disparities in both types of
PA existed. Asian Pacific Islanders (APIs) were half as likely as
Whites to meet the PA guidelines and almost half as likely
(OR=0.6) to be at least moderately PA. There also was a trend for Latinos (p=0.06) to be more likely than Whites to be at least moderately PA(OR=1.2). The disparities for both PA measures were stronger in some neighborhoods than others.
When residential density and individuals’ perceptions of neighborhood safety were simultaneiously included in the model predicting guideline-meeting PA, the disparities disappeared. Similarly, when percentage of park space was in the model predicting moderate or better PA, the disparities disappeared. Residents of neighborhoods with higher residential densities were more likely to meet the PA guidelines and those perceiving their neighborhoods to be unsafe were less likely. Residents of neighborhoods with more park space were more likely to be least moderately PA.
Conclusions: Neighborhood characteristics may partially explain racial/ethnic disparities in PA.
Implications for Policy, Delivery, or Practice: Improving neighborhood safety through increased police, street lighting or community walking groups may increase the likelihood of pleasure walking or exercising. Also, further research should be conducted to understand what it is about living in densely packed housing areas that is linked to increased likelihoods of being PA. It could be that these urban areas offer more opportunities for utilitarian or social walking.
Primary Funding Source: National Inst Environmental
Health Sciences
● Neighborhood and Patient Level Effects on Response to a Cancer Care Survey
Diana Tisnado, Ph.D., Jennifer Malin, M.D., Ph.D., May Tao,
M.D., Patti Ganz, M.D., Katherine Kahn, M.D.
Presented By: Diana Tisnado, Ph.D., Adjunct Assistant
Professor, Division of General Internal Medicine and Health
Services Research, UCLA, 911 Broxton Plaza, Box 951736, Los
Angeles, CA 90095; Tel: (310)794-0711; Fax: (310)794-0732;
Email: dtisnado@mednet.ucla.edu
Research Objective: It is understood that patient demographic characteristics influence survey response, and characteristics associated with non-response are often also correlated with important health outcomes, raising concerns about non-response bias. There is also increasing interest in the effects of neighborhood characteristics on health. We evaluate the marginal impact of neighborhood characteristics on the likelihood of survey response among breast cancer patients in Los Angeles County.
Study Design: We enriched existing Los Angeles County
Cancer Surveillance Program (CSP) data for women diagnosed with breast cancer in 2000 with 2000 Census data, and data from the California Office of Statewide Health
Planning and Development (OSHPD) on hospital characteristics thought to influence quality of care. Patient

demographics (age, race/ethnicity), census tract and primary hospital were derived from CSP data, and cancer stage from registry. Using census data, we identified Poverty Areas
(>=20% of population below the federal poverty level);
Undereducated Areas (>25% of the adult population lacks high school degree); obtained percentages of nonwhites, unemployed, foreign-born, and limited English proficiency, and linked these to individuals by census tract. Percentages were categorized into quartiles. Using OSHPD data, we identified hospital characteristics: size, ownership (Public,
Non-profit, For-profit), teaching (High, Low, or None), and hospital breast cancer volume, using a count of study patients seen at each hospital. We defined High Volume as >= 75th percentile. We also identified American College of Surgeons
(ACOS)-approved cancer programs. In all, 2005 women had both complete census tract and hospital information. We tested the impact on likelihood of CATI response of patient, neighborhood and hospital characteristics using unadjusted and adjusted logistic regression, testing for interactions between race/ethnicity and neighborhood characteristics.
Analyses were adjusted for patient clustering within hospital.
Population Studied: A population-based sample of women diagnosed with incident breast cancer in Los Angeles County in 2000.
Principal Findings: Unadjusted analyses show older age, black, Hispanic, and Other race/ethnicity (versus white), more advanced stage (versus ductal carcinoma in situ), low volume primary hospital, and all neighborhood characteristics were significantly, negatively associated with CATI response.
Logistic regression results controlling for patient demographic characteristics and cancer stage indicate response was significantly, negatively associated with increasing age
(O.R.=0.96, p<0.001), black, Hispanic, and Other race/ethnicity (p<0.001 for all), and stage III cancer (O.R.
0.49, p< 0.001). Controlling for hospital characteristics did not change these effects. Low hospital volume was negatively associated with response (O.R.=0.77, p<0.01). The addition of neighborhood-level characteristics to the model yielded a significant likelihood ratio test (p<0.05). Poverty area was significantly, negatively associated with response (O.R.=0.79, p<0.001). The p-value of Hispanic ethnicity increased (0.04 to
0.06), but effects and significance levels of other individual and hospital-level characteristics persisted. No interactions were significant.
Conclusions: The potential effects on response rates of patient and neighborhood characteristics should be considered in survey design and implementation.
Implications for Policy, Delivery, or Practice: Individuals of lower socioeconomic status who may be less likely to participate in survey research are the very individuals at risk for experiencing health disparities. Understanding the determinants of participation is important to understanding the limitations of existing data and to guide improvements in future data collection efforts.
Primary Funding Source: NCI, Department of Defense
Breast Cancer Research Program
● The Language Spoken at Home and Disparities in
Medical and Oral Health, Access to Care, and Use of
Services in US Children
Sandra Tomany-Korman, MS, Glenn Flores, M.D.
Presented By: Sandra Tomany-Korman, MS, Statistician,
Pediatrics, Medical College of Wisconsin, 8701 Watertown
Plank Rd, Milwaukee, WI 53074; Tel: 414-456-4193; Fax: 414-
456-6385; Email: stomany@mcw.edu
Research Objective: 47 million Americans speak a non-
English primary language at home (NEPL), but little is known about health disparities for NEPL children. Our objective was to identify disparities for NEPL children in medical and oral health, access to care, and use of services.
Study Design: The National Survey of Childhood Health was a phone survey in 2003-2004 of a national random sample of parents of 102,353 children 0-17 years old. Disparities in medical and oral health and healthcare were examined for
NEPL children compared to children with English as the primary language at home (EPL). Multivariate analyses were performed to adjust for race/ethnicity, age, insurance coverage, income, parental education and employment, and number of children and adults in the household.
Population Studied: A national random sample of parents of
102,353 children 0-17 years old interviewed in the National
Survey of Childhood Health, a phone survey in conducted in
2003-2004.
Principal Findings: Thirteen percent of US children
(equivalent to 9.2 million) live in NEPL households; NEPL children are significantly (P<.05) more likely than EPL children to be Latino (87%) or Asian/Pacific Islander (7%), poor (42 vs.
13%), and to have unemployed and non-high-school graduate parents. Significantly higher proportions of NEPL children are uninsured (27 vs. 6%), sporadically insured (20 vs. 10%), not in excellent/very good health (43 vs. 12%), overweight/at risk for overweight (48 vs. 39%), and have teeth in fair/poor condition (27 vs. 7%). NEPL children more often have no usual source of care (USC; 38 vs. 13%), made no medical (27 vs. 12%) or dental (14 vs. 6%) visits in the past year, and had problems getting specialty care (40 vs. 23%), but less often receive mental healthcare (4 vs. 7%) and are able to get help from USCs via phone (68 vs. 81%). NEPL children more often did not receive needed medical care due to cost (43 vs. 26%) or no insurance (59 vs. 39%) and did not receive needed dental care due to health plan problems (20 vs. 8%). Latino and Asian NEPL children had several unique disparities compared to white NEPL children. Almost all disparities persisted in multivariate analyses; for example, NEPL children were significantly more likely than EPL children to not be in excellent/very good health (OR=2.7 [95% CI, 2.3-3.1]), to have teeth in suboptimal condition (OR=1.9 [1.6, 2.1]), to have no
USC (OR=1.7 [1.4-1.9]), and to have problems getting specialty care (OR=1.7 [1.2-2.3]).
Conclusions: Compared to EPL children, NEPL children experience multiple disparities in medical and oral health, access to care, and use of services.
Implications for Policy, Delivery, or Practice: The study findings suggest that disparities for NEPL children in medical and oral health, access to care, and use of services could be reduced or eliminated by decreasing language barriers in the healthcare of NEPL children. One effective policy measure for addressing these disparities and language barriers would be

nationwide third-party reimbursement for medical interpreter services.
Primary Funding Source: No Funding
● Parents Helping Parents Fight Asthma: A Successful
Intervention for Educating Urban Minority Parents of
Asthmatic Children on How to Help Other Urban Minority
Parents with Asthmatic Children
Sandra Tomany-Korman, MS, Glenn Flores, M.D., Christina
Snowden-Bridon, Laurie Smrz, Rhonda Duerst
Presented By: Sandra Tomany-Korman, MS, Statistician,
Pediatrics, Medical College of Wisconsin, 8701 Watertown
Plank Rd, Milwaukee, WI 53226; Tel: 414-456-4193; Fax: 414-
456-6385; Email: stomany@mcw.edu
Research Objective: Urban minority children have the highest rates of ED visits, hospitalizations, and mortality due to asthma. Inadequate parental education is associated with preventable pediatric asthma hospitalizations. Effective asthma education programs are needed targeting urban minority parents. Our objective was to evaluate whether a comprehensive, hands-on curriculum is effective in educating urban minority parents about childhood asthma.
Study Design: As part of a larger study on parent mentors
(PMs) and managing childhood asthma, we recruited urban
African-American (AA) and Latino (L) mothers of asthmatic children from a pediatric asthma clinic to serve as PMs for other urban minority parents with asthmatic children. Using a structured curriculum, PMs participated in two-day training sessions led by an asthma nurse specialist and program coordinator. Each participant received a training manual; curriculum topics included triggers, medications, asthma pathophysiology, peak-flow meters, written care plans, and preventing hospitalizations. An emphasis was placed on hands-on learning; sessions included identifying triggers in a mock apartment. A 34-item test was administered pre- and post-training to assess PM knowledge.
Population Studied: Nine parent mentors that completed two days of asthma education training sessions.
Principal Findings: The mean age of the 9 PMs completing training was 36 years; all were female and high school graduates, 33% were married, 44% were poor, 33% were unemployed, 67% were AA and 33% were L. The mean (SD) pre-test score was 77.7% (5.3%), and mean post test score was 89.9% (5.0%), representing a statistically significant score increase (P<.0001). PMs had the greatest score improvements on questions on controller medications, whether asthma is curable, and preventing hospitalizations, and the least improvement on a question on how albuterol works. PMs were very satisfied with the sessions, commenting, "I learned more in these couple days of training than I have their whole lives with asthma," and "I learned quite a bit: how to breathe in so that all the medicine is taken in, why roaches are a trigger for asthma, etc."
Conclusions: A comprehensive, hands-on curriculum is effective in educating urban minority parents about childhood asthma, and results in high levels of parental satisfaction.
Implications for Policy, Delivery, or Practice: Lack of adequate parental education about childhood asthma is known to be associated with preventable pediatric asthma hospitalizations. This curriculum may prove useful in educating urban minority parents about childhood asthma.
Primary Funding Source: CWF, Robert Wood Johnson
Foundation
● Racial/Ethnic (R/E) Disparities in Medical and Oral
Health, Access to Care, and Use of Services in US Children
Sandra Tomany-Korman, MS, Glenn Flores, M.D.
Presented By: Sandra Tomany-Korman, MS, Statistician,
Pediatrics, Medical College of Wisconsin, 8701 Watertown
Plank Rd, Milwaukee, WI 53226; Tel: 414-456-4193; Fax: 414-
456-6385; Email: stomany@mcw.edu
Research Objective: Not enough is known about the national prevalence of racial and ethnic (R/E) disparities in children's medical and dental care. The study objective was to examine
R/E disparities in medical and oral health and healthcare in a national sample.
Study Design: The National Survey of Childhood Health was a phone survey in 2003-2004 of a national random sample of parents of 102,353 children 0-17 years old. Disparities in medical and oral health and healthcare were examined for non-Latino white (W), non-Latino African-American (AA),
Latino (L), Asian/Pacific-Islander (API), Native American
(NA), and multiracial (MR) children. Multivariate analyses were performed to adjust for primary language at home, age, insurance coverage, income, parental education and employment, and number of children and adults in the household.
Population Studied: A national random sample of parents of
102,353 children 0-17 years old interviewed in the National
Survey of Childhood Health, a phone survey conducted in
2003-2004.
Principal Findings: Many significant (P<.05) R/E disparities were noted; for example, uninsurance rates were 6% for Ws,
21% for Ls, 15% for NAs, 7% for AAs, and 4% for APIs, and the proportions with a usual source of care (USC) were: Ws,
90%; NAs, 61%; Ls, 68%, AAs, 77%; and APIs, 87%. The following disparities persisted for 1 or more minority groups in multivariate analyses: increased odds of suboptimal health status, overweight, asthma, activity limitations, behavioral/speech problems, emotional difficulties, suboptimal dental health, uninsurance, no medical or dental visit in the past year, ED visits, unmet medical and dental needs, transportation barriers to care, not receiving prescription medications, not receiving mental healthcare, no
USC, USC communication problems, and problems getting specialty care. For example, compared with Ws, the ORs (95%
CI) of having teeth in less than excellent condition were: APIs,
1.8 (1.3-1.6); AAs, 1.6 (1.4-1.7); Ls, 1.5 (1.4-1.7); and NAs, 1.4
(1.1-1.8). Certain disparities were particularly marked for specific R/E groups: for AAs, asthma, behavior problems, skin disorders, speech problems, and unmet prescription needs; for NAs, hearing/vision problems, ED visits, no USC, and unmet medical and dental needs; and for APIs, inferior oral health, not seeing a doctor in the past year, and problems getting specialty care. MR children also experienced many disparities.
Conclusions: Minority children experience multiple disparities in medical and oral health, access to care, and use of services.
Certain disparities are particularly marked for specific R/E groups, and MR children experience many disparities.
Implications for Policy, Delivery, or Practice: The study findings suggest that greater attention needs to be paid to R/E

disparities in US children's medical and dental care.
Healthcare providers and policymakers particularly should be aware of the unique but often overlooked disparities for Native
American, Asian/Pacific Islander, and multiracial children.
Primary Funding Source: No Funding
● Relationships Between Rurality, Home Healthcare
Service use and Patient Outcomes
Catherine Vanderboom, Ph.D., RN, Elizabeth Madigan, Ph.D.,
RN
Presented By: Catherine Vanderboom, Ph.D., RN, Tel: 216-
445-5690; Email: cev@cwru.edu
Research Objective: Determine if degree of rurality and home healthcare service use influence patient outcomes, specifically for hospitalization, use of emergent care, and ability to ambulate. The direct effects of rurality and indirect effects through home healthcare service use (visits per patient) on patient outcomes were examined in the context of agency and community characteristics. Methods: Patient outcomes
(hospitalization, emergent care, and functional status for ambulation) were obtained the Home Health Compare website, a CMS database of risk-adjusted publicly reported patient outcomes from all Medicare certified home healthcare agencies. Home healthcare service use data (annual number of home visits and number of patients) were obtained from
Medicare cost reports. Degree of rurality was determined using the Rural-Urban Continuum Codes (RUCC) aggregated into four categories -- urban, suburban, town, and rural.
Community income data (mean household income and poverty level) were obtained from the U.S. Census.
Population Studied: A stratified random sample of 241 home healthcare agencies was selected from the Home Health
Compare website. Agency data were linked with RUCC, cost report, and census data. Principal Findings: Path analysis was used to examine the relationships in the model. Initial regression analysis indicated that hospitalization was the only outcome associated with rurality, agency characteristics or home healthcare service use. For hospitalization, the overall equation was significant with 15% explained variance. There was no difference in hospitalization based on degree of rurality. Approximately 26-29% of patients were hospitalized within all degrees of rurality. Increased visits per patient and low-income community status were associated with increased hospitalization across all geographic groups. Rural home agencies were smaller, nonprofit, hospital-operated, and provided fewer visits per patient than more urban agencies.
Four variables (rurality, ownership type, agency size, and hospital operated) influenced visits per patient and, indirectly, hospitalization. Conclusions: Increased home visits and lowincome status were associated with increased hospitalization across all degrees of rurality. Prior differences in outcomes based on rurality are no longer apparent. Although rurality did not have a direct effect on hospitalization, increased rurality was associated with decreased home healthcare service use.
Implications for Research, Policy or Practice: Increased numbers of home visits associated with hospitalization suggests that higher levels of care may be needed to identify, stabilize, and triage patients to the appropriate care setting.
Rural agencies continue to be challenged to maintain patient outcomes while providing fewer services. Fewer home visits in rural areas constitutes a long term concern associated with increasing numbers of elders and fewer formal and informal providers. Increased hospitalization among low-income individuals may be indicative of gaps in health insurance and lifelong health disparities. Older women are especially vulnerable due to their tendency to live longer, alone and in poverty. Primary Funding Source: T32 predoctoral fellowship and a grant from the Center for Community Based Care
Research Objective: Determine if degree of rurality and home healthcare service use influence patient outcomes, specifically for hospitalization, use of emergent care, and ability to ambulate. The direct effects of rurality and indirect effects through home healthcare service use (visits per patient) on patient outcomes were examined in the context of agency and community characteristics. Methods: Patient outcomes
(hospitalization, emergent care, and functional status for ambulation) were obtained the Home Health Compare website, a CMS database of risk-adjusted publicly reported patient outcomes from all Medicare certified home healthcare agencies. Home healthcare service use data (annual number of home visits and number of patients) were obtained from
Medicare cost reports. Degree of rurality was determined using the Rural-Urban Continuum Codes (RUCC) aggregated into four categories -- urban, suburban, town, and rural.
Community income data (mean household income and poverty level) were obtained from the U.S. Census.
Population Studied: A stratified random sample of 241 home healthcare agencies was selected from the Home Health
Compare website. Agency data were linked with RUCC, cost report, and census data. Principal Findings: Path analysis was used to examine the relationships in the model. Initial regression analysis indicated that hospitalization was the only outcome associated with rurality, agency characteristics or home healthcare service use. For hospitalization, the overall equation was significant with 15% explained variance. There was no difference in hospitalization based on degree of rurality. Approximately 26-29% of patients were hospitalized within all degrees of rurality. Increased visits per patient and low-income community status were associated with increased hospitalization across all geographic groups. Rural home agencies were smaller, nonprofit, hospital-operated, and provided fewer visits per patient than more urban agencies.
Four variables (rurality, ownership type, agency size, and hospital operated) influenced visits per patient and, indirectly, hospitalization. Conclusions: Increased home visits and lowincome status were associated with increased hospitalization across all degrees of rurality. Prior differences in outcomes based on rurality are no longer apparent. Although rurality did not have a direct effect on hospitalization, increased rurality was associated with decreased home healthcare service use.
Implications for Research, Policy or Practice: Increased numbers of home visits associated with hospitalization suggests that higher levels of care may be needed to identify, stabilize, and triage patients to the appropriate care setting.
Rural agencies continue to be challenged to maintain patient outcomes while providing fewer services. Fewer home visits in rural areas constitutes a long term concern associated with increasing numbers of elders and fewer formal and informal providers. Increased hospitalization among low-income individuals may be indicative of gaps in health insurance and lifelong health disparities. Older women are especially vulnerable due to their tendency to live longer, alone and in

poverty. Primary Funding Source: T32 predoctoral fellowship and a grant from the Center for Community Based Care
Research Objective: Determine if degree of rurality and home healthcare service use influence patient outcomes, specifically for hospitalization, use of emergent care, and ability to ambulate. The direct effects of rurality and indirect effects through home healthcare service use (visits per patient) on patient outcomes were examined in the context of agency and community characteristics.
Study Design: Patient outcomes (hospitalization, emergent care, and functional status for ambulation) were obtained the
Home Health Compare website, a CMS database of riskadjusted publicly reported patient outcomes from all Medicare certified home healthcare agencies. Home healthcare service use data (annual number of home visits and number of patients) were obtained from Medicare cost reports. Degree of rurality was determined using the Rural-Urban Continuum
Codes (RUCC) aggregated into four categories -- urban, suburban, town, and rural. Community income data (mean household income and poverty level) were obtained from the
U.S. Census.
Population Studied: A stratified random sample of 241 home healthcare agencies was selected from the Home Health
Compare website. Agency data were linked with RUCC, cost report, and census data.
Principal Findings: Path analysis was used to examine the relationships in the model. Initial regression analysis indicated that hospitalization was the only outcome associated with rurality, agency characteristics or home healthcare service use.
For hospitalization, the overall equation was significant with
15% explained variance. There was no difference in hospitalization based on degree of rurality. Approximately 26-
29% of patients were hospitalized within all degrees of rurality.
Increased visits per patient and low-income community status were associated with increased hospitalization across all geographic groups. Rural home agencies were smaller, nonprofit, hospital-operated, and provided fewer visits per patient than more urban agencies. Four variables (rurality, ownership type, agency size, and hospital operated) influenced visits per patient and, indirectly, hospitalization.
Conclusions: Increased home visits and low-income status were associated with increased hospitalization across all degrees of rurality. Prior differences in outcomes based on rurality are no longer apparent. Although rurality did not have a direct effect on hospitalization, increased rurality was associated with decreased home healthcare service use.
Implications for Policy, Delivery, or Practice: Increased numbers of home visits associated with hospitalization suggests that higher levels of care may be needed to identify, stabilize, and triage patients to the appropriate care setting.
Rural agencies continue to be challenged to maintain patient outcomes while providing fewer services. Fewer home visits in rural areas constitutes a long term concern associated with increasing numbers of elders and fewer formal and informal providers. Increased hospitalization among low-income individuals may be indicative of gaps in health insurance and lifelong health disparities. Older women are especially vulnerable due to their tendency to live longer, alone and in poverty.
Primary Funding Source: T32 predoctoral fellowship and a grant from the Center for Community Based Care
● Racial Disparities in Quality of Preventive Care at
VAMCs, Contract CBOC, and VA-staffed CBOC
Song Wang, M.S., Chuan-Fen Liu, Ph.D., M.P.H., Michael K.
Chapko, Ph.D., Mark W. Perkins, PharmD, Matthew L.
Maciejewski, Ph.D.
Presented By: Song Wang, M.S., Research Assistant, Health
Services Research & Development Center of Excellence,
Northwest Center for Outcomes Research in Older Adults, VA
Puget Sound Health Care System HSR&D, 1100 Olive Way,
Suite 1400, Seattle, WA 98101; Tel: (206) 277-4161; Fax: (206)
764-2935; Email: Song.Wang@va.gov
Research Objective: Racial disparities in the quality of care for patients with chronic conditions have been found in health care systems. This study examines whether there exist racial differences in the quality of preventive care for VA primary care patients with diabetes or chronic obstructive pulmonary disease (COPD).
Study Design: Veterans’ race (e.g., African American,
Hispanic, or Caucasian), ICD-9-identified chronic condition
(e.g., diabetes or COPD), and CPT-4-identified preventive care
(e.g., dilated eye exam or influenza vaccination) were obtained from VA administrative data. We stratified the analysis by patients receiving primary care in different delivery systems, including VA medical centers (VAMCs) and community-based outpatient clinics (CBOCs) whose mission is primary care provision. For CBOC patients, we further stratified the analysis by Contract and VA-staffed CBOCs. Racial disparities were measured by the relative risk of receiving influenza vaccinations and dilated eye exams in a year, based on generalized linear models with a Huber-White adjustment for heteroskedasticity.
Population Studied: Our sample included 11,181 veterans with diabetes and 6,074 veterans with COPD that were seen in
72 parent VAMCs, 32 Contract CBOCs, and 76 VA-staffed
CBOCs from 10/1/99 to 10/1/01.
Principal Findings: Overall, 26% of COPD population received at least one influenza vaccination in fiscal year (FY)
2000, and the proportion increased to 32% in FY 2001. 19% of diabetes population received at least one dilated eye exam in
FY 2000, and the proportion increased to 21% in FY 2001.
Among diabetic VAMC patients, African-Americans were less likely to receive dilated eye exam than Caucasians (p<0.0001).
In VA-staffed CBOCs, African-American veterans with diabetes were more likely to receive dilated eye exam than Caucasians
(p<0.01). Hispanic veterans with diabetes had comparable probabilities of receiving dilated eye exam comparing to
Caucasians in either VAMCs or VA-Staffed CBOCs. Racial differences were not significant among veterans with COPD in receiving influenza vaccination in VAMCs or CBOCs.
Conclusions: Racial disparities in the provision of diabetesrelated preventive care exist in VAMCs, but VA-staffed CBOCs provide dilated eye exam to a higher proportion of African-
American veterans with diabetes. However, preventive care for veterans with diabetes or COPD is still provided at lower levels than is recommended in VA and ADA guidelines.
Implications for Policy, Delivery, or Practice: Given the inadequate level of preventive care to veterans with diabetes provided in VA’s delivery systems (e.g., dilated eye exam), VA must examine the reasons for the quality deficit and develop intervention strategies to improve diabetic preventive care. It may be useful to understand whether clinical practice style,

staffing, information technology or organizational culture in
VA-staffed CBOCs are responsible for their equitable quality of care standards, which will provide pointers for improvement for VAMCs.
Primary Funding Source: VA
● Comparison of Changes in Health Care Expenditure and
Self-Perceived Health Status from 1996 to 2001 across
Racial and Ethnic Groups in the United States
Junling Wang, Ph.D., C. Daniel Mullins, Ph.D., Ilene H.
Zuckerman, Pharm.D., Ph.D., Shelley I. White-Means, Ph.D.,
Meghan A. Hufstader, B.A., Genene A. Walker, M.S.
Presented By: Junling Wang, Ph.D., Assistant Professor,
Pharmaceutical Sciences, University of Tennessee, 847
Monroe Ave., Room 205R, Memphis, TN 38163; Tel: (901)
448-3601; Fax: (901) 448-4731; Email: jwang26@utmem.edu
Research Objective: Previous literature reported that (1) minority populations have lower health status than non-
Hispanic whites, and (2) minority populations also have spent fewer health care dollars. The objective of this study is to explore whether the returns on health care dollars are different across racial and ethnic groups in the period between 1996 and 2001. If the returns on health care dollars are higher in producing health among minority populations, it would suggest possibly narrowing disparities in health status.
Study Design: This is a non-experimental study using secondary database.
Population Studied: The study population was a nationally representative sample of non-institutionalized U.S. civilians in the Medical Expenditure Panel Survey (1996 and 2001). The racial and ethnic disparities were examined separately by comparing non-Hispanic whites to non-Hispanic blacks and
Hispanic whites, respectively (Hispanic blacks were excluded from the analysis because of small sample size). The changes in self-perceived health status from 1996 to 2001 were compared across racial and ethnic groups using an ordered logistic regression. The changes in health expenditure were compared using classical linear regression (a two-part model was also employed to confirm the results of classical linear model). In the regression models, we controlled for age, gender, census regions, metropolitan statistical area, poverty categories, educational levels, and health insurance status.
Principal Findings: The study sample included 31,258 non-
Hispanic whites, 7,349 non-Hispanic blacks, 11,248 Hispanic whites. From the descriptive analysis, we found that compared with non-Hispanic whites, non-Hispanic blacks were 22.98% more likely to report an increase in self-perceived health status category (p=0.016) from 1996 to 2001; Hispanic whites are 2.81% more likely to report an increase in selfperceived health status (P=0.732); non-Hispanic blacks had
$132 lower increase in health expenditure (P=0.608) and
Hispanic whites had $556 lower increase in health expenditure from 1996 to 2001 (P=0.002). However, the rates of changes in health expenditures across racial and ethnic groups from
1996 to 2001 were not significant after controlling for confounders. Neither were rates of changes in health status across racial and ethnic groups.
Conclusions: Rates of changes from 1996 to 2001 in health expenditures and self-perceived health status did not differ across racial and ethnic groups.
Implications for Policy, Delivery, or Practice: When the rates of changes in health expenditures and self-perceived health status do not differ across racial and ethnic groups, it seems that rates of return on health care dollars do not differ across racial and ethnic groups in the way that health care dollars are spent in the years between 1996 and 2001
(inclusive). However, the health status is lower among minority populations. This research suggests that the only way that the health status of the minority populations will be compatible with that of the majority population is if there is a change in the way that health care dollars are spent. We need to either increase the efficiency of way the health care dollars are spent among minority populations or increase the total amount of health care dollars spent on these populations.
Primary Funding Source: No Funding
● Why do we need to be Concerned about the Quality of
Rade Code in VA and Medicare Data?
Iris Wei, Dr.P.H., Beth A. Virnig, Ph.D., M.P.H., Robert O.
Morgan, Ph.D.
Presented By: Iris Wei, Dr.P.H., Michael E. DeBakey VA
Medical Center, 2002 Holcombe Blvd. (152), Houston, TX
77030; Tel: (713) 794-8648; Email: wei.iris@med.va.gov
Research Objective: Medicare administrative and claims data maintained by the Centers for Medicare and Medicaid Services
(CMS) provide a rich source of information for examining racial and ethnic disparities in health care use. Similarly, the
National Patient Care Database (NPCD) maintained by the
Veterans’ Health Administration (VA) Office of Information also have been used extensively by researchers and policymakers for assessing equity among VA-users. However, there have been concerns that the race code in the Medicare data drastically under-estimate Hispanics (less then 40% could be identified) and that the race code in the VA NPCD are in poor quality (approximately 40% are missing). Here, we demonstrate a method of using a Spanish surname match to augment the race codes and evaluate its effectiveness in improving the accuracy of race/ethnicity identification and reducing bias in interpreting the Medicare and VA data.
Study Design: Data was obtained by a mail survey from
Medicare-enrolled male veterans residing in six large U.S. metropolitan areas in 2002. We conducted a Spanish surname match to the Medicare data before drawing our race- and ethnicity-specific survey sample (black, Hispanic, and white). Using three types of race code (self-report, Medicare, and surname-match), we compared the racial/ethnic representation in terms of socio-demographic characteristics, health status, health conditions, and health care utilizations among 2,086 Medicare-enrolled male veterans.
Population Studied: Medicare-enrolled male veterans aged
>=65 who resided in six large U.S. metropolitan areas in six states (CA, CO, FL, IL, NY, and TX) in 2002.
Principal Findings: The Spanish surname matching substantially improved the identification of Hispanics and whites compared to the Medicare race code alone--using selfreported race/ethnicity identification as the gold standard.
The surname matching did not show as much effect for blacks because the Medicare race code is more accurate for blacks.
In general, the surname-matched race code depicted close representation of veterans similar to the self-reported race

codes. By using the race code in Medicare data, we found over- or under-estimations of several individual characteristics
(e.g., geographic distribution, health conditions)--particularly among Hispanics. These discrepancies were largely corrected by using the surname-matched race code.
Conclusions: Our findings demonstrate that by using the race code in Medicare data, studies could produce biased estimates. This is likely to be true for studies using VA race codes considering the substantial amount of missing race codes in the VA data. Using a Spanish surname match to augment the Medicare or VA race codes, one can generate more unbiased study results and interpretations.
Implications for Policy, Delivery, or Practice: The use of a surname match to supplement the Medicare or VA race codes can greatly enhance researchers’ and policymakers’ ability to examine health care equity.
Primary Funding Source: VA
● Health Care Disparity Measurement in a Medicaid
Managed Care Workgroup
Karl Weimer, M.P.H., Constance Martin, MHA, David Nerenz,
Ph.D., Jane Deane Clark, Ph.D.
Presented By: Karl Weimer, M.P.H., Senior Research Officer,
Measurement & Evaluation, Center for Health Care Strategies,
PO Box 3469, Princeton, NJ 08543; Tel: 609-895-8610; Fax:
609-895-9648; Email: kweimer@chcs.org
Research Objective: While numerous health plans survey members to assess disparities in care to guide quality improvement activities, plan efforts are rarely focused on reducing disparities across the entire health plan.
Standardizing disparity and related quality of care measures will ensure that managed care providers, plans, and states have a clear picture of how an organization is reducing disparities and improving quality. It will also pinpoint where initiatives are positively impacting ethnic groups as well as improving the quality of care within specific clinical areas.
Study Design: Health plans participating in initiatives led by the Center for Health Care Strategies (CHCS) to reduce ethnic and racial health disparities are testing a novel approach to measure and quantify disparities in care and quality across several clinical areas and ethnic groups. To date, 12 organizations have submitted baseline data on nine HEDIS measures across the following clinical areas: adolescent immunization, asthma, diabetes, and prenatal care. The
Disparities Index measures each health plan’s progress toward eliminating disparities by the percent difference between each racial and ethnic subgroup rate and the most favorable or “best” subgroup rate for each measure. A reduction in the percent difference from the “best” racial/ethnic group rate is interpreted as a reduction in disparity. The Quality component of the Index provides similar, plan level information in comparison to the 75th percentile HEDIS Quality of Care rates for Medicaid health plans. The overall Disparity Index should not be calculated or reported without the quality component.
Population Studied: The measures will be produced for the total population of one target racial/ethnic subgroup and at least two additional population subgroups. Plans will have a minimum sample size for each measure within each racial/ethnic subgroup:• American Indian or Alaska Native
• Asian or Pacific Islander • Black or African American (non-
Hispanic) • Black or African American (Hispanic) • Hispanic or Latino • White
Principal Findings: This initiative is still in progress. Baseline and follow-up data have been collected from one participant in the CHCS disparities initiative to test the Disparity Index. The results from the test data show that a reduction in disparities does not necessarily correspond to an improvement in quality.
Health Plan A has shown a reduction in disparities from baseline as well as a decrease in the overall quality component. It is important to note that these results do not cover the entire project period. Health Plan A: Disparity
Index, Baseline=13.7% average difference (across 5 HEDIS measures) Disparity Index, Follow-up=4.9% Quality
Component, Baseline=43.1% average difference (across 5
HEDIS measures) Quality Component, Follow-up=37.3%
Conclusions: Collection of baseline Disparity Index data from the CHCS disparity initiative is proceeding and expected to provide comparable baseline and follow-up measurements over several clinical areas.
Implications for Policy, Delivery, or Practice: Health plans will be able to use the Disparity Index to target future disparity reduction efforts. A Disparity Index will inform participants about an overall pattern of disparities at the plan level, and, if used in multiple time periods, whether the disparities experienced by racial/ethnic groups are increasing or decreasing.
Primary Funding Source: RWJF
● The Cultural Universal of Concern over Status:
Applications to Disparities and other Health Services
Issues
W Pete Welch, Ph.D., Michael Finch, Ph.D.
Presented By: W Pete Welch, Ph.D., 5642 N 20th St.,
Arlington, VA 22205; Tel: 703-909-3087; Email: w.pete.welch@gmail.com
Research Objective: The presumption of social science in the second half of the twentieth century has been that culture can almost completely modify the behavior of humans. However, there are important behavioral patterns that are found in all cultures, such as the concern over status (e.g., disliking humiliation). This paper attempts to ground a number of health services phenomena in this cultural universal. In doing so, it helps to provide a theoretical foundation to our field.
Study Design: Status-seeking behavior appears to be universal across human cultures. In support of this anthropological evidence, dominant individuals in most mammalian species have priority for mates and food.
Presumably, dominant individuals are more likely to pass on their genes to future generations than nondominant individuals. Although the concern over status is universal over cultures, the source of status is not necessarily the same across cultures.
Principal Findings: This concern over status plays a key role in apparently unrelated health services issues. Prominent among these are the (perceived) shame associated with seeking treatment for certain conditions (e.g., mental health and AIDS), the stigma associated with enrollment in Medicaid and other social welfare programs, physician anger over the shame of malpractice suits, and the need for providers to be respectful toward patients. The prevalence of these issues

across national cultures will be discussed, as will their relevance in understanding disparities in health and health services across cultural groups within national systems.
Conclusions: Shame, stigma, and related issues fit into a theoretical framework as defensible as the economic model of the desire for material goods. By understanding the ubiquitousness of status-related issues, health services researchers would more quickly recognize the role of status in novel contexts, both in novel categories of issues and when working internationally.
Primary Funding Source: No Funding
● Racial and Ethnic Disparities in the Financial Burden of
Prescription Drugs among older Americans
Tom Xu, Ph.D., Tyrone Borders, Ph.D.,
Presented By: Tom Xu, Ph.D., Assistant Professor, Family &
Community Medicine, Texas Tech University Health Sciences
Center, 3601 4th St. MS 8161, Lubbock, TX 79430; Tel:
(806)743-6983; Fax: (806)743-1292; Email: Ke.Xu@ttuhsc.edu
Research Objective: To examine racial and ethnic disparities in the financial burden of prescription drugs among older
Americans using a market and an egalitarian models.
Study Design: A nationally representative data set, the
Medical Expenditure Panel Survey 2002, was used. The financial burden of prescription drugs was measured by the out-of-pocket expenditure and proportion. The market orientation defines disparities as different financial burdens borne by subpopulations with the same utilization level.
Disparities in financial burden are said to be eliminated when for the same amount of medical services/products received, all members of the society pay the same amount. The egalitarian orientation defines disparities as different financial burdens borne by subpopulations with the same health level.
That is, patients with the same health level should pay the same, regardless of the variations of the utilization levels that may be caused by the health care system. It is clear that the policy implications of the two orientations are different.
To demonstrate whether racial and ethnic disparities in financial burden among Rx users would persist after controlling for other characteristics of the respondents, multivariate analyses were conducted. In the market model, in which disparities were evaluated against the utilization level, the total number of Rx, the average refills per Rx, and the average quantity per Rx were controlled for in addition to the other independent variables such as demographics. In the egalitarian model, where disparities were evaluated against patients’ health needs, disease dummy variables and the two
SF-12 variables were included. To provide nationally representative estimates for the elderly subpopulation in the
US in 2002, person weights, primary sampling units and strata were controlled for in all analyses.
Population Studied: 65 years of age or older
Principal Findings: Raw racial and ethnic disparities were observed in the bivariate analyses between non-Hispanic whites and Hispanics in the out-of-pocket (OOP) expenditure and proportion, and between non-Hispanic whites and non-
Hispanic blacks in the out-of-pocket proportion. After controlling for either utilization or health and the other independent variables, significant racial and ethnic disparities in the financial burden of prescription drugs, either measured by OOP expenditure or proportion, were not found. The only exception was that using the need adjustment, NH other races had a lower OOP expenditure than NH whites. The adjusted difference was approximately $331.
Insurance status contributed the most to the disparities in the financial burden of prescription drugs. Having insurance in addition to Medicare lowered the OOP expenditure and proportion in both the market and the egalitarian models. In particular, having Medicaid had the greatest impact.
Controlling for other variables, have Medicaid lowered the
OOP expenditure by $1,054 (utilization adjustment) or $917
(need adjustment). It also lowered the OOP proportion by
38.3% (utilization adjustment) or 38.7% (need adjustment).
Conclusions: The disparities in the financial burden of prescription drugs between non-Hispanic elderly whites and
Hispanics may be attributable to differences in utilization patterns. However, whether health disparities contribute to disparities in the financial burden of prescription drugs requires studies of specific diseases.
Primary Funding Source: No Funding