Gender & Health
Call for Papers
Advances in Gender-Based Health Services Research
Chair: Rosaly Correa-de-Araujo, Agency for Healthcare
Research and Quality
Sunday, June 25 • 10:30 am – 12:00 pm
●Gender Differences in the Relationship between
Neighborhood Socioeconomic Characteristics and
Allostatic Load
Chloe Bird, Ph.D., Brian Finch, Ph.D., D. Phuong Do, MPhil,
Jose Escarce, MD, Ph.D., Nicole Lurie, MSPH, Teresa Seeman,
Ph.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: Few studies examine whether potential
biological pathways through which neighborhoods affect
health differ by gender. We examined the extent to which
neighborhood characteristics are related to men’s and
women’s biological markers of stress, based on a summary
index of allostatic load (AL), 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, merged with data
on sociodemographic characteristics of their residential
census tract. AL was measured as a summary score (range 09) 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 14,320 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) were independently
associated with higher AL. Adjusting for individual level
characteristics, living in a census tract with a higher
percentage of households in poverty was associated with a
higher AL for women but not men (coeff. for women = .351, p
= .01 versus -.007 for men, p = .965). In separate analyses,
higher median income (in 10k units) was associated with
lower AL for women but not men (coeff. for women = -.042, p
.001 vs. -.015 for men, p = .302), and percentage of adults in
the tract with less than high school education was associated
with higher AL for women but not men (coeff. for women =
.389, p < .001, vs. .221 for men, p = .056). In contrast, for men
but not women living in a census tract with a higher
percentage of blacks was associated with higher AL (coeff. for
men = .185, p = .027, vs. .075 for women, p = .296).
Conclusions: Gender differences in neighborhood income,
education, and racial composition effects on allostatic load
suggest that neighborhoods themselves may influence both
individual and population health differently for men and
women.
Implications for Policy, Delivery, or Practice: By assessing
potential pathways through which health—and gender
differences in health may be generated, this study contributes
to 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
●Gender Differences in the Intergenerational Connections
Between Child Maltreatment and Intimate Partner
Violence
Xiangming Fang, Ph.D., Phaedra S. Corso, Ph.D.
Presented By: Xiangming Fang, Ph.D., Health Economist,
National Center for Injury Prevention and Control, Centers for
Disease Control and Prevention, 4770 Buford Highway, MS K60, Atlanta, GA 30341; Tel: (770)488-1572; Fax: (770)488-1011;
Email: xfang@cdc.gov
Research Objective: Intimate partner violence (IPV) is a
national problem affecting millions of adults each year in the
United States. Previous research on how child maltreatment
victimization affects future IPV perpetration or victimization
has had some limitations, including inadequate controlling for
confounding factors, unrepresentative samplings, and lack of
adequate investigation of gender differences in the
connections between child maltreatment and adult IPV.
Furthermore, little is known about whether youth violence
(YV) perpetration mediates the effect of child maltreatment on
IPV perpetration, or whether youth violence victimization
mediates the effect of child maltreatment on IPV victimization.
In this study, we use a longitudinal and nationally
representative sample to examine the effects of three forms of
child maltreatment (neglect, physical abuse, and sexual
abuse) and YV perpetration/victimization on IPV
perpetration/victimization, and the role that gender plays in
the developmental relationships.
Study Design: Data describing self-reported YV behaviors
from Wave I of the National Longitudinal Study of Adolescent
Health (Add Health) study (1994 – 1995) were matched with
self-reported IPV perpetration and victimization within young
adult sexual relationships and retrospective reports of child
maltreatment during Wave III (2001 – 2002) of the Add
Health study. Hierarchical Logistic Regression models were
used to analyze the developmental relationship between child
maltreatment and adult IPV perpetration/victimization.
Population Studied: This study included 10,320 participants
(5,724 women and 4,596 men) aged 18 to 26 who reported
being involved in at least one sexual relationship in the two
years preceding Wave III of the Add Health survey.
Principal Findings: Controlling for demographic and socioeconomic variables, childhood physical abuse is a significant
predictor of future IPV perpetration for females, but not for
males. Childhood neglect is significantly predictive of IPV
perpetration for both females and males. Childhood sexual
abuse is not significantly associated with IPV perpetration for
females; however, for males, it is the most significant
predictor of IPV perpetration. YV perpetration is a significant
predictor of IPV perpetration for both males and females. For
females, YV perpetration partly mediates the effect of both
childhood physical abuse and neglect on IPV perpetration. For
males, YV perpetration only mediates the effect of childhood
neglect on IPV perpetration. Findings on the effects of child
maltreatment and YV victimization on IPV victimization will
also be discussed.
Conclusions: In general, victims of child maltreatment are
more likely to be the perpetrators or victims of IPV. However,
gender differences exist for the developmental relationship
between child maltreatment and IPV
perpetration/victimization. YV victimization does not mediate
the effect of any form of child maltreatment on IPV
victimization for either males or females. YV perpetration
partly mediates the effect of both childhood physical abuse
and neglect on IPV perpetration for females, but only
mediates the effect of childhood neglect on IPV perpetration
for males.
Implications for Policy, Delivery, or Practice: IPV prevention
should begin as early as childhood. When designing the
optimal time and settings of IPV prevention programs, it is
important to take into account the gender differences in the
developmental relationship between child maltreatment and
adult IPV perpetration/victimization.
Primary Funding Source: CDC
●Barriers to Colorectal Cancer Screening and to Screening
Decision-Making by Gender
Greta Friedemann-Sanchez, Ph.D., MA, Joan M. Griffin, Ph.D.,
Melissa R. Partin, Ph.D.
Presented By: Greta Friedemann-Sanchez, Ph.D.. MA, Core
Investigator, Center for Chronic Disease Outcomes
Research,CCDOR, VA Medical Center, One Veterans Drive,
Minneapolis, MN 55417; Tel: 612-467-4376; Fax: 612-727-5699;
Email: Greta.Friedemann-Sanchez@med.va.gov
Research Objective: Four screening modalities have been
found to be efficacious at reducing colorectal (CRC) mortality:
Fecal Occult Blood Test, sigmoidoscopy, Double Contrast
Barium Enema, and colonoscopy. National data suggest that
women are less likely to be screened for CRC than men.
Predictors of this gendered difference have not been studied.
The objective of this qualitative research study was to examine
mode-specific gender differences in colorectal cancer
screening barriers and preferences.
Study Design: Six focus groups were conducted with male
and four with female veterans to elicit information about
barriers and facilitators to four screening modes. The groups
were stratified by screening status (screened/unscreened). Six
to eight individuals participated per group. A semi-structured
interview guide was developed to assess perceptions,
attitudes, beliefs and preferences about of CRC screening
options. Discussions were recorded, transcribed, coded and
analyzed according to the conceptual domains present in the
interview guide. In addition, analysis incorporated domains
that arose during the discussions.
Population Studied: Female and male veterans between the
ages of 50 and 75, who received care at the Minneapolis VA
Medical Center’s primary care clinic in the past two years.
Principal Findings: Previous studies on CRC screening
preferences have found that patient’s prefer colonoscopy and
FOBT at nearly equal rates. Our findings indicate similar
screening mode preferences (both females and males
preferred colonoscopy) and attitudes about the relative
importance of colorectal versus reproductive cancer screening
(both perceived screening for reproductive cancers as higher
priority), but notable differences in barriers to screening
completion and information preferences regarding endoscopic
procedures. For instance, women who had a prior endoscopic
procedure viewed the required preparation as a major barrier
to screening, but men did not. Women and men also
expressed significantly different fears (affective versus physical
fears about the procedure, respectively) and information
preferences regarding endoscopic procedures. Finally, women
perceived CRC as a male disease thus feeling less vulnerable
to CRC.
Conclusions: Men and women have similar preferences for
screening mode options but express different barriers to
screening completion. Content of mode-specific information
needs varies by gender. Tailoring by gender the type of
knowledge may facilitate mode choice in a shared decision
context, and it may be warranted given the gendered barriers
by mode and reasoning behind the preferred mode. Providing
specific information addressing type of discomfort (physical
and affective) may also affect individual’s mode preference.
Subtle differences in languages may make significant
differences in the decision-making process and ultimately in
patient’s preferences.
Implications for Policy, Delivery, or Practice: Tailoring
educational materials to gender specific barriers and
information needs may be warranted and may improve
screening among female veterans.
Primary Funding Source: VA
●Hysterectomy and Risk of Cardiovascular Disease: The
Atherosclerosis Risk in Communities (ARIC) Study
Wanda Nicholson, M.D., M.P.H., Keiko Asao, M.P.H., Josef
Coresh, M.D., Ph.D., Frederick Brancati, M.D., M.H.S., Neil R.
Powe, M.D., M.P.H., M.B.A.
Presented By: Wanda Nicholson, M.D., M.P.H., Gynecology
and Obstetrics and Population and Family Health Sciences,
Johns Hopkins Schools of Medicine and Public Health, 600
North Wolfe Street, Phipps 247, Baltimore, MD 21287;
Email: wnichol@jhmi.edu
Research Objective: Cardiovascular disease (CVD), including
coronary heart disease and stroke, are leading causes of death
among U.S. women. Hysterectomy is one of the most
common surgical procedures performed in women with
approximately 600,000 procedures per year in the U.S. Prior
studies have suggested that hysterectomy may be associated
with CVD through a decrease in prostaglandin levels and
vascular contractility. Because of the extensive use of
hysterectomy in the management of gynecological conditions,
our objectives were to estimate the magnitude of association
between hysterectomy status and CVD and to determine
whether hysterectomy is predictive of future CVD.
Study Design: Population-based, prospective cohort analysis
from the Atherosclerosis Risk in Communities (ARIC) Study.
The ARIC Study, designed as a longitudinal study of
atherosclerosis, is a community-based, bi-racial cohort of men
and women recruited between 1987 and 1989 with 9 years of
follow-up. The predictor variable, hysterectomy status, was
categorized as follows: no hysterectomy /no oophorectomy;
hysterectomy alone or with unilateral oophorectomy(USO);
and hysterectomy with bilateral oophorectomy (BSO)]. The
outcomes were incident coronary heart disease (CHD) and
incident stroke defined using standard methods. Incident
rates for CHD and stroke were estimated across hysterectomy
categories. CVD risk factors were compared across
hysterectomy categories. Hysterectomy and risk of CVD was
estimated for 512 incident CHD cases and 259 incident stroke
cases with Cox proportional hazard regression models,
adjusting for socio-demographics, known CVD risk factors and
menopausal status at baseline.
Population Studied: 7,399 White and African-American
women, aged 45-64 years at baseline.
Principal Findings: Women with any type of hysterectomy
were of lower socioeconomic status and were more likely to
have hypertension or diabetes, higher triglyceride levels, and
lower physical activity compared to women with no
hysterectomy/no oophorectomy (all P < 0.05). Incidence rates
(IR) per 1,000 person-years for CHD were highest among
women with hysterectomy/BSO (IR 5.8; 95% Confidence
Interval (CI) 4.8, 7.1) and hysterectomy alone/USO (IR 5.3;
95% CI 4.4, 6.4) and lowest among women with no
hysterectomy/no oophorectomy (IR 5.0; 95% CI 4.5, 5.6).
Hystererectomy alone/USO (Hazard ratio (HR) 1.02; 95% CI
0.81, 1.31) and hysterectomy/BSO (HR 1.16; 95% CI 0.93, 1.46)
were not statistically significantly associated with the risk of
CHD. Incidence rates for stroke were highest among women
with hysterectomy/BSO (IR 3.4; 95% CI 2.6, 4.4) and
hysterectomy alone/USO (IR 2.7; 95% CI 2.1, 3.6) and lowest
among women with no hysterectomy (IR 2.3; 95% CI 1.9, 2.7).
In adjusted analysis, hysterectomy/BSO was associated with a
48% increased risk of stroke. After adjustment for covariates,
the association was markedly attenuated and no longer
significant (HR 1.25; 95% CI 0.86, 1.80).
Conclusions: While women with hysterectomy alone/USO or
hysterectomy/BSO have a worse CVD risk profile compared to
women without hysterectomy, hysterectomy status is not
predictive of CHD or stroke.
Implications for Policy, Delivery, or Practice: The extent of
CVD risk factors among women undergoing hysterectomy
suggests that clinicians providing gynecological care might
incorporate interventions to reduce CVD risk factors into their
clinical practice. Further research might focus on clinical
pathways common to both hysterectomy and CVD.
Primary Funding Source: National Institute of Diabetes and
Digestive and Kidney Diseases
●Effect of Depression and Comorbid Pain on Retirement:
Gender Differences
Haijun Tian, Ph.D Candidate
Presented By: Haijun Tian, Ph.D Candidate, Doctoral Fellow,
Pardee RAND Graduate School, RAND Corporation, 1776
Main Street, Santa Monica, CA 90407; Tel: 310-699-7988; Fax:
310-260-8151; Email: tian@rand.org
Research Objective: To analyze the effect of depression and
comorbid pain on the transition from employment to full
retirement among older adult workers, and compare
differential effects between male and female workers.
Study Design: Using The Health and Retirement Survey
(HRS), a longitudinal national representative survey of
individuals born between 1931-1941—observations from 19942002, the study conducted multivariate ulogistic regression
analysis with random effects, controlling for sociodemographics, chronic health conditions, insurance status,
and job characteristics. The outcome is full retirement and
primary explanatory variables are: depression only (based on
short-form CESD), pain only (self-report of pain), and
depression with comorbid pain.
Population Studied: Longitudinal data were used from Wave
2 to wave 6 of the Health and Retirement Survey, a nationally
representative sample of older workers with average age of 60.
Principal Findings: Depression and pain status has
differential impacts on retirement for women workers and
men workers. Depression with pain predicts the early
retirement for women, but not for men. Older women workers
with depression and pain are more likely to be fully retired in
two years (OR =1.42, p=0.03) compared to neither condition.
Although the estimated odds ratio (OR) of retirement for older
adult workers with depression and pain is higher than those
with either condition alone, they are not statistically different.
The effect of pain dominates the effect of depression for men
workers. Men with pain only are more likely to be fully retired
compared those with neither condition (OR = 1.25, p=0.03).
Though men with depression and pain also reported higher
odds ratio of retirement, they are not statistically significant.
Conclusions: (1)Depression and pain status has differential
impacts on retirement for women workers and men workers.
(2)Depression and comorbid pain predict retirement, but
depression alone may not.The social consequences of
depression might be overestimated due to the compounding
effect of comorbid pain.
Implications for Policy, Delivery, or Practice: (1) Retirement
costs of depression and pain are probably high for older
women since early retirement usually implies a decrease in an
individual’s earnings and possible loss of insurance (if
individuals are still not qualified for Medicare or do not have
retiree insurance). Therefore older American women with
depression and pain deserve special policy considerations.
(2) The depressed older women with comorbid pain may
benefit from treatment practices and guidelines that address
the duality of these conditions throughout the process of care.
Primary Funding Source: No Funding
Call for Papers
Towards Improved Maternal Health: Policies,
Practices & Programs
Chair: Kristen Kjerulff, Penn State College of Medicine
Sunday, June 25 • 3:45 pm – 5:15 pm
●Variation in the Accucacy of Recorded Maternal Events in
Birth Certificates and Hospital Discharge Data between
Physicians and Certified Nurse-Midwives
Heather Bradford, CNM, ARNP, MSN, Mona Lydon-Rochelle,
Ph.D., CNM
Presented By: Heather Bradford, CNM, ARNP, MSN,
Certified Nurse-Midwive, , Center for Women's Health at
Evergreen, 930 1st Street South, Kirkland, WA 98033; Tel: 425785-2637; Fax: 425-952-0191; Email: hbradford@comcast.net
Research Objective: Certified nurse-midwives (CNMs)
attended nearly 10 percent of U.S. in-hospital vaginal births in
2004, representing a dramatic rise over a two decade period.
CNM professional groups espouse the view that women
delivered by CNMs are more likely than those delivered by
physicians to be socioeconomically disadvantaged and from
racial groups at high risk of adverse perinatal outcomes, are
less likely to receive medical interventions and procedures,
and yet have lower rates of preterm delivery and low birth
weight infants. Data from live-birth certificates and hospital
discharge summaries are relied upon heavily for national
surveillance and research on childbirth. Despite the great
importance of these data sources, the variation in accuracy by
birth attendant in reporting this information has not been
evaluated. The study objective was to compare the accuracy of
recorded maternal medical conditions, pregnancy
complications, intrapartum and postpartum events in birth
certificate and hospital discharge data between physicians and
certified nurse-midwives.
Study Design: We conducted a population-based validation
study of 19 nonfederal short-stay hospitals in Washington
State. Using the medical record as our gold standard, we
estimated the true-positive rates (TPRs) for maternal events
between CNMs and physicians based on the birth certificate
factors, hospital discharge data, and birth certificate and
hospital discharge data combined.
Population Studied: The study sampling frame consisted of
the 26,363 women who had live births at these 19 hospitals
during 2000. We restricted the analyses to the 10 hospitals
that had CNM-attended births, and to women with vaginal
births. For this analysis, 220 women had a CNM-attended
birth, and 2479 women had a physician-attended birth.
Principal Findings: The accuracy of reporting of maternal
medical conditions and pregnancy complications was
consistent between birth attendants except for pregnancyinduced hypertension, where CNM accuracy was greater in the
birth certificate record, with a TPR of 73.3% versus 37.2%.
CNMs had substantially higher TPRs than did physicians for
several intrapartum and postpartum recorded birth certificate
data, including premature rupture of membranes (56.0% vs.
26.1%), augmentation of labor (50.7% vs. 30.5%), and
induction of labor (67.7% vs. 44.7%). CNM reporting was
more accurate when examining birth certificate or hospital
discharge data combined for augmentation of labor (TPR of
50.7% vs. 30.5%). No significant variation in reporting
accuracy was found for hospital discharge data.
Conclusions: We found that birth certificate and hospital
discharge data combined had substantially higher TPRs than
did birth certificate data alone for labor induction,
cephalopelvic disproportion, prolonged rupture of
membranes, gestational diabetes, and pregnancy-induced
hypertension; however, CNMs had consistently higher TPRs
relative to physicians. Our findings highlight discrepancies
between type of birth attendant, which suggests that
researchers conducting perinatal epidemiological studies
should not rely only on birth certificate data when assessing
maternal events. More studies need to be conducted which
evaluate reporting accuracy among birth attendants. Future
research should compare the accuracy of MD and CNM birth
certificate and hospital discharge recorded data in a largepopulation based study.
Implications for Policy, Delivery, or Practice: Given that
CNMS deliver 10% (n=327,000) of all U.S. vaginal births each
year, our findings have important implications for public
health policy, clinical practice, and individual decision-making
among women. If national priorities are to be established and
effective interventions that improve maternal and infant health
are to be practiced, the assessment of factors related to CNM
and MD care using administrative data sources must be
based on both accurate and comparable data.
Primary Funding Source: No Funding
●Preconceptional Health and Health Care Use in the
Central Pennsylvania Women’s Health Study (CePAWHS):
Implications for Preconceptional Health Care
Marianne Hillemeier, Ph.D., MPH, Carol S. Weisman, Ph.D.,
Gary A. Chase, Ph.D., Cynthia H. Chuang, MD, Sara A. Baker,
MSW
Presented By: Marianne Hillemeier, Ph.D., MPH, Assistant
Professor, Health Policy and Administration, The Pennsylvania
State University, 116 Henderson, University Park, PA 16802;
Tel: 814-863-0873; Fax: 814-863-2905; Email: mmh18@psu.edu
Research Objective: To analyze how the health status of
preconceptional women (including women who have never
been pregnant and those who have had a pregnancy) is
associated with health care use, including services related to
pregnancy.
Study Design: Population-based random digit dial telephone
survey. The thirty-minute survey included questions on health
status, health risks, pregnancy history, health care access and
use, and sociodemographics. Health-related variables were
selected based on an integrated perinatal health framework
identifying indicators of women’s health at multiple life stages.
Health measures included chronic conditions, infections,
mental health, health behaviors, and psychosocial stress.
Health care use measures included having a regular physical
examination in the past year, seeing an obstetriciangynecologist in the past two years, and talking to a health care
professional in the past year about planning for pregnancy.
Population Studied: 2,002 women ages 18-45 residing in a
28-county region in predominantly rural Central Pennsylvania.
A subset of 1,335 women with reproductive capacity (excluding
women with hysterectomies, tubal ligations, or other cause of
infertility) is analyzed.
Principal Findings: In factor analyses, health status and
health risk variables clustered in five factors (accounting for
44% of total variance): cardiovascular risks (hypertension,
high cholesterol, diabetes, obesity); biopsychosocial
components of stress; substance use (tobacco, drugs,
alcohol); safety and hygiene (intimate partner violence and
douching); and healthy behaviors (regular physical activity,
fruit and vegetable consumption). Scale scores created from
these factors varied significantly by sociodemographics,
reproductive life stage (preconceptional versus
interconceptional), and health insurance status. Multiple
logistic regression analyses for the three health care use
outcomes show that cardiovascular risks and healthy
behaviors increase the likelihood of receiving a regular exam,
and cardiovascular risks decrease the likelihood of seeing an
obstetrician-gynecologist. Age, reproductive stage, and health
insurance (currently having insurance and continuity of
insurance in the past year) also predicted utilization.
Conclusions: The health care needs of preconceptional
women are diverse and vary by sociodemographic variables.
Among health status indicators, only cardiovascular risks and
healthy behaviors are associated with health care use,
controlling for sociodemographics and health insurance. No
health variables predicted receiving counseling on pregnancy
planning.
Implications for Policy, Delivery, or Practice: Recent
attention to reducing adverse pregnancy outcomes by
improving women’s preconceptional health care (e.g., CDC
Select Panel on Preconception Care) requires information on
the health care needs of women who may become pregnant
and on their health care use patterns. Preconceptional
women with specific health care needs may not be receiving
appropriate health care.
Primary Funding Source: Pennsylvania Department of
Health
●Major Depression Among Mothers: Diagnosis,
Treatment and Disparities
Sandraluz Lara-Cinisomo, Ph.D., Narayan Sastry, Ph.D.
Presented By: Sandraluz Lara-Cinisomo, Ph.D., Associate
Behavioral Scientist, RAND Corp., 201 N. Craig Street, Suite
202, Pittsburgh, PA 15213; Tel: 412-683-2300 x4459;
Email: slara@rand.org
Research Objective: In this paper, we use data from the Los
Angeles Family and Neighborhood Survey (L.A.FANS) to
examine disparities in diagnosis and treatment in major
depression among mothers by race/ethnicity and immigration
status as well as other key covariates. In addition to providing
large samples of groups of interest, L.A.FANS uses an
instrument that screens for a major depressive episode during
the 12-month period preceding the interview.
Study Design: L.A.FANS collected extensive information on
the household socioeconomic status, health status including
mental health, health insurance, health care utilization, and
many other topics. The response rate among mothers
selected for the survey was 89 percent from the 2,306, which
yielded a sample of 2,052 respondents. Of the mothers who
completed the survey, just over 91 percent had all of the
necessary data for the analysis conducted in this study (N =
1873). L.A.FANS assessed depressive symptoms and major
depression using the Comprehensive International Diagnostic
Interview short form (CIDI-SF) (Kessler, Andrews, Mroczek,
Ustun, & Wittchen, 1998).
Population Studied: Five racial and ethnic groups are
represented in the data. The largest group was Hispanic
mothers (62 percent) followed by non-Hispanic whites (21
percent); there were equal proportions of non-Hispanic black
and Asian and Pacific Islanders (8 percent each). Native
Americans were the smallest group, making up 1 percent of
the total sample. All mothers resided in Los Angeles County,
CA.
Principal Findings: The results indicate that 15 percent of all
mothers in our sample met the classification for major
depression. Racial and ethnic disparities were statistically
significant, as determined by a chi-square test. White and
Hispanic mothers had very similar levels of depression, while
black mothers had substantially higher levels (24 percent) and
Asian and Pacific Islander mothers had substantially lower
levels (7 percent). Of the 285 mothers who met the criteria for
depression, close to 70% had not been diagnosed with
depression by a medical professional or treated for depression
using psychotherapy. Among the remaining 85 mothers, 44%
were diagnosed and treated, 56% were diagnosed and
untreated, and 11% were undiagnosed and taking antidepressants for some other medical concern. Results show
that after controlling to family characteristics (e.g., marital
status), unmarried mothers were significantly (ß= .095; p <
.05) more likely to be depressed compared to married
mothers. Unmarried mothers were also significantly less likely
to be diagnosed or treated for depression. Undocumented
mothers were significantly less likely to be classified as having
major depression compared to documented immigrant
mothers.
Conclusions: Results from this study highlight the prevalence
in depression that exists among mothers. In addition, this
study shows that the majority of mothers with major
depression are not being diagnosed or treatment.
Implications for Policy, Delivery, or Practice: Given the
potentially debilitating effects of depression on an individual
and the effects it can have on her children, efforts must be
made toward increasing diagnosis and treatment of
depression among mothers primarily among unmarried
mothers who tend to have fewer support systems to buffer the
potentially deleterious effects of depression. Further
investigation is necessary to identify factors that protect
undocumented immigrant women from major depression.
Primary Funding Source: National Institute of Child Health
and Human Development
●The Effect of Medicaid Family Planning Expansions on
Unplanned Births
Richard Lindrooth, Ph.D., Jeffrey S. McCullough, Ph.D.
Presented By: Richard Lindrooth, Ph.D., Associate Professor,
Center for Health Economic and Policy Studies, Medical
University of South Carolina, 151B Rutledge Ave P.O. Box
250961, Charleston, SC 29425; Tel: 8437922192; Fax:
8437921358; Email: lindrorc@musc.edu
Research Objective: To measure the effect of Medicaid family
planning expansions on unplanned births and assess the
medical cost offsets of the expansions in selected states.
Study Design: We conduct a retrospective pre-post differencein-difference analysis using data from all 50 states plus the
District of Columbia in 1990-2001. States that did not expand
coverage are used as a control for states that did expand
coverage. The model allows for the policy effect to vary with
both eligibility criteria and duration since program
implementation. Sub-analyses of three states (California, New
Mexico, and South Carolina) that expanded coverage are
conducted to assess the net economic impact of these
programs. This impact is measured as the difference between
Medicaid-expansion programmatic costs and the reduction in
maternity and child health expenditures associated with the
expansion. Multivariate regression is used to control for
socio-economic characteristics.
Population Studied: All births in all 50 states plus the District
of Columbia in 1990-2001 from the 2003 National Vital
Statistics Reports. We control for changes in demographics
used data from the Department of Census. State-level
changes in eligibility criteria for Medicaid coverage of family
planning services is the intervention.
Principal Findings: Medicaid family planning expansions
significantly reduce unplanned births, particularly for women
aged 25 through 39. Postpartum expansions reduce births
primarily for women aged 25-34 whereas income expansions
primarily affect women aged 30-39. The cost of both
postpartum and income-based eligibility expansions are offset
by lower delivery related costs.
Conclusions: Both postpartum and income-based expansions
lead to significantly lower unplanned pregnancies. Incomebased expansions may be more efficacious than postpartum
expansions. The cost of the expansions is offset by reduced
Medicaid expenditures on births.
Implications for Policy, Delivery, or Practice: The cost of
Medicaid family planning expansions is offset by health care
cost savings due to fewer unplanned births. Thus a policy of
increased access to family planning services will be beneficial
from an economic perspective.
Primary Funding Source: Berlex, Inc
●Twelve Weeks After Birth: Women, Work and Health
Patricia McGovern, Ph.D., M.P.H., Dwenda Gjerdingen, M.D.,
MS, Bryan Dowd, Ph.D., Rada Dagher, M.P.H., Laurie
Ukestad, MS, David McCaffrey, BA
Presented By: Patricia McGovern, Ph.D., MPH, Associate
Professor, Division of Environmental Health Sciences,
University of MN, School of Public Health, Mayo BLDG.,
MMC 807,420 Delaware St. SE, Mpls, MN 55455; Tel: 612-6257429; Fax: 612626-4837; Email: pmcg@umn.edu
Research Objective: Mothers of infants are one of the fastest
growing segments of the American labor force, yet relatively
little is known about the association of work characteristics on
women’s recovery from childbirth. This study will identify the
psychosocial work factors associated with women’s
postpartum health 12 weeks after delivery.
Study Design: We employ a model of health and workforce
participation and a prospective cohort design to estimate a
production function for maternal health. Women were
recruited while hospitalized for childbirth and interviewed at
enrollment, 6 and 12 weeks postpartum. Two-Stage Least
Squares was used to estimate the effects of personal and
employment characteristics on maternal health at twelve
weeks after childbirth. Health outcomes were measured with
the SF-12 for general mental and physical health and a list of
28 symptoms commonly experienced during the postpartum
period.
Population Studied: The population included women ages 18
and older residing in the Twin Cities, Minnesota and admitted
to the hospital for childbirth in 2001. Sample selection criteria
included: having had a live, singleton birth at a study hospital,
speaking English, and being employed.
Principal Findings: At twelve weeks postpartum, 661 women
(81% of enrollees) were employed and interviewed. On
average women were 30 years old; 86% were Caucasian, 88%
were married, 47% were primipara, 48% had professional (vs.
14% service and 38% clerical) jobs and 50% had returned to
work. On average, women slept 6.8 (SD: 1.2) hours per night,
being awakened twice. Women reported an average of four
postpartum symptoms (SD: 3.1), most frequently fatigue
(43%), headaches (42%), back or neck pain (38%) and sexual
symptoms (37%). On the SF-12, postpartum women scored
slightly, but significantly higher than national norms with
mean PCS scores of 55.7 (SD: 5.2) vs. 52.7 (SD: 9.1) for
physical health and mean MCS scores of 50.4 (SD: 7.3) vs.
47.2 (SD: 12.1) for mental health Multivariate analyses
revealed that fewer postpartum symptoms were associated
with better preconception health, no prenatal mood problems,
not breastfeeding, more perceived control, more social
support and fewer job-related psychological demands. Better
mental health was associated with no prenatal mood
problems, more perceived control, more social support and
less job stress. Better physical health was associated with
better preconception health for all women and higher levels of
coworker support for working women.
Conclusions: These mothers continue to experience several
childbirth-related symptoms at twelve weeks after delivery
indicating a need for rest and recovery beyond the traditional
postpartum period of four to six weeks. Health care providers
should consider evaluating women on expected symptoms,
functional limitations, fatigue and appropriate length of family
and medical leave in association with return to work. Women
may need assistance to identify modifiable factors that could
decrease job stress and increase control over work and home
including social support from family and coworkers.
Implications for Policy, Delivery, or Practice: Women
experiencing poorer postpartum health may need medical
certification for intermittent leave (which provides for a parttime gradual return to work) rather than straight-time leave
from work under the federal Family and Medical Leave Act.
Primary Funding Source: National Institute for Occupational
Safety & Health
Related Posters
Gender & Health
Poster Session A
Sunday, June 25 • 2:00 pm – 3:30 pm
●Direct Costs of Medical Care for Treating Hepatitis C
Patients in a Veterans Affairs Medical Center.
Titilope Adeniyi, BA, Yvonne Jonk, Ph.D., Eric Dieperink, M.D.,
Astrid Knott Johnson, Ph.D., Samuel Ho, M.D.
Presented By: Titilope Adeniyi, BA, Health Science Specialist,
Hepatitis C Resource Center, Minneapolis VA Medical Center,
One Veterans Drive #111D2, Minneapolis, MN 55417; Tel:
(612) 467-4733; Email: Titilope.Adeniyi@med.va.gov
Research Objective: Of the four strains of Hepatitis C,
genotype 1 is the most prevalent and difficult to treat.
Genotype 1 requires 48 weeks of therapy while genotypes 2-4
(non-genotype 1) require 24 weeks of therapy. Irrespective of
genotype, prior to 2001, combination therapies consisted of
interferon alfa 2B and ribavirin (IR). During 2001 interferon
alfa 2B was replaced with peginterferon creating a new
combination-therapy (PR). Thus, patients were transitioning
from interferon alfa 2B to peginterferon and received all three
antiviral medications during the course of their treatment
(IPR). The purpose of this study is to identify the utilization
and total direct cost of medical care, including outpatient and
pharmaceutical care services associated with treatment and
follow-up of Hepatitis C (HCV) patients. Our secondary
objective is to determine the cost per patient with a sustained
viralogic response (SVR).
Study Design: This study takes the intent-to-treat perspective.
Outpatient utilization and pharmacy data were extracted from
VA administrative databases. Cost data for outpatient care
were extracted from the Health Economics Resource Center’s
outpatient average cost database. Cost data for the
prescriptions medication were derived from the Veterans
Health Information Systems and Technology Architecture
database. All costs are reported in 2003 dollars.
Population Studied: 99 patients with a positive HCV enzymelinked immunoassay (EIA) test conducted at the Minneapolis
VA Medical Center in calendar years 2000 – 2001 and
subsequently treated with pharmacotherapy were included in
the study.
Principal Findings: Genotype 1 patients treated with IR
(n=28), IPR (n=19), and PR (n=24) therapy, received 438.4,
796.5, and 223.5 days of antiviral medication treatment at a
cost of $9,322 and $17,987 and $11,256 respectively. Nongenotype 1 patients treated with IR (n=20), IPR (n=5), and PR
(n=3) therapy received an average of 226.8, 690.4 and 141.7
days of antiviral medication treatment at a cost of $7,621,
$13,665 and $9,568 respectively. Genotype 1 patients treated
with IR, IPR, and PR therapy and followed for a year and a half
to determine cure rates averaged 16.3, 19.2, and 6.4 Hepatitis
C related clinic visits at a cost of $1,787, $1,998 and $669
respectively. Non-genotype 1 patients treated with IR, IPR, and
PR averaged 12.3, 9.0 and 5.3 Hepatitis C related clinic visits at
a cost of $1,309, $941 and $534 respectively. The overall cost
per SVR rate for the entire cohort is $33,128 (n=38). Genotype
1 patients had an overall cost per SVR rate of $44,407 (n=22).
Genotype 1 IR, IPR, and PR patients had a cost per cure rate of
$38,882 (n=8), $47,463 (n=8), and $47,700 (n=6) respectively.
Non-genotype 1 patients had an overall cost per SVR rate of
$17,620 (n=16). Non-genotype 1 IR, IPR, and PR patients had
a cost per SVR rate of $13,737 (n=13), $24,343 (n=3), and ‘NA’
(n=0) respectively.
Conclusions: Largely due to treatment patterns, the cost of
treating genotype 1 patients is more substantial than the cost
of treating non-genotype 1 patients. As treatment efficacy
(%SVR) improves, the Cost per SVR decreases.
Implications for Policy, Delivery, or Practice: These data
represent real-world costs for hepatitis-C related care that
would provide more accurate cost-benefit or cost-effectiveness
analyses.
Primary Funding Source: Hepatitis C Resource Center
●Increasing Chlamydia trachomatis (Ct) Screening of
Young, Sexually Active Women Enrolled in Commercial
Health Plans
Adam Atherly, Ph.D., Sarah Blake, MA
Presented By: Adam Atherly, Ph.D., Associate Professor,
Health Policy and Management, Emory University, 1518 Clifton
Rd NE, Atlanta, GA 30322; Tel: 404-727-1175; Fax: 404-7279198; Email: adam.atherly@emory.edu
Research Objective: To identify best practices among
commercial health plans to increase low Chlamydia
trachomatis (Ct) screening rates among young, sexually active
women. The Ct bacterium is the most frequently reported
infectious disease in the United States, with total annual
spending estimated to be over 2 billion dollars and an
estimated 4 million new cases diagnosed each year. However,
approximately 75% of women infected with Ct are
asymptomatic and do not realize they are infected. Left
untreated, Ct may lead to ectopic pregnancy, infertility, pelvic
inflammatory disease and an increased susceptibility to
human immunodeficiency virus. Routine testing is the most
effective method available to identify women infected with Ct,
however many women at risk for Ct are not routinely screened
with only 16% of females aged 12-19 enrolled in a managed
care organization had been tested for Ct during a 2 year
period. NCQA reports that although the Ct screening
increased by 2 percentage points in 2002, the top-performing
plans still only screened 38.5 percent of sexually active women
ages 16 to 26.
Study Design: We used plan level NCQA quality data to
identify commercial health plans. The health plans were then
contacted, and qualitative interviews were conducted to
identify health plan activities that lead to high Ct screening
rates by providers.
Population Studied: Plans were selected which were either
high performing (in the top quarter of all plans) or had
demonstrated an increase in Ct screening rates of at least 3
percentage points over the last 2-3 years. Interviews were
restricted to plans reporting Ct screening rates to NCQA for at
least 3 years, plans with enrollment of at least 1,000
commercially insured women age 15-26 years, and plans that
were not staff model managed care plans.
Principal Findings: Health plans demonstrated two unique
sets of issues in improving the Ct screening rates. First,
providers within the health plans are often unaware of the
extent of Ct in commercial health plans and they often view Ct
as a problem restricted to lower income, Medicaid
populations. Second, health plans have problems in receiving
accurate data on Ct screening rates. Most health plans
indicated that if Ct screening became a HEDIS accreditation
criteria, it would become more important to achieve high
screening rates.
Conclusions: There are several potential avenues that have
been used by successful health plans to improve provider
screening rates. Provider education, including “Chlamydia
tool kits,” newsletters, continuing education programs, and
feedback have proven successful in modifying provider
behavior. Also, improved data and data collection capabilities
can provider a more accurate picture of the true Ct screening
rates.
Implications for Policy, Delivery, or Practice: Although Ct
screening rates are currently low, there are a number of
possible approaches available to commercial health plans to
increase Ct rates. Policy implications point to important
needed improvements in women’s health and communicable
disease control in privately insured populations.
Primary Funding Source: AHRQ
●Social and Demographic Factors Associated with
Antenatal Care Use in East Timor
Domin Chan, M.H.S., Ph.C., Marcia Weaver, Ph.D., Susan
Thompson, M.P.H., MaryAnne Mercer, Dr.P.H.
Presented By: Domin Chan, M.H.S., Ph.C., Doctoral
Candidate, Health Services, University of Washington, 6728
11th Ave NW, Seattle, WA 98117; Tel: 206-277-4159; Fax: 206764-2935; Email: dominc@u.washington.edu
Research Objective: This study examines the relationship
between individual factors, social factors, and antenatal care
use in Timor Leste. Infant mortality in East Timor (Timor
Leste) is high (70-95 per 1000 live births). Most women live in
rural areas where access to health facilities is poor. Antenatal
care is important to improving infant health outcomes and
reducing infant mortality.
Study Design: Data was taken from the first Timor Leste
Demographic and General Health Survey 2003. Multivariate
logistic regression was used to assess factors associated with
antenatal care use and adequacy. Adequate antenatal care use,
defined by the Timor Leste Ministry of Health, is at least one
visit in the first and second trimesters, and at least two visits
in the third trimester.
Population Studied: A sample of women who had a live birth
in the five years preceding the survey (N=3391) were asked
about antenatal care use, frequency, and timing for the most
recent birth.
Principal Findings: In Timor Leste, 36.3% women had an
antenatal care visit for their most recent birth and about 19.5
% had the recommended adequate use of four or more
antenatal care visits. Higher education of women was
significantly associated with antenatal care use and adequacy.
Higher self-estimated socioeconomic status (SES) was related
to antenatal care use (OR=2.4 for top 10% SES, p<0.001) but
not antenatal care adequacy. Longer time to the closest health
provider (10 minutes) was related to lower likelihood of
antenatal care use. Electricity, which is present mainly in
urban areas, was also associated with antenatal care use
(OR=2.5, p<0.001) and adequacy (OR=1.7, p=0.001). Women
whose most recent birth was her sixth or more were less likely
to have adequate antenatal care (OR=0.65, p=0.44).
The role of women in household decision-making and its
relationship with antenatal care use and adequacy was more
complex. Women having joint control with their husbands
over social visits and medical care services were associated
with adequate antenatal care use (OR= 1.7, p=0.037 and
OR=1.5, p=0.038 respectively). Women who had joint control
of their health care decision-making with their husbands were
more likely to have adequate antenatal care use (OR=1.53,
p=0.037). However, women having joint decision-making on
large household purchases was associated with 32% lower
odds of any antenatal care use (OR=0.67, p=0.016) and 54%
lower odds of adequate antenatal care use (OR=0.46,
p<0.001) than women whose husbands controlled large
purchase decisions.
Conclusions: Women’s education and higher socioeconomic
status were positively associated with antenatal care use.
Longer time or distance to the closest health provider was
associated with less antenatal care use. Women who had joint
control with their husbands of their social visits, health care
services and health care decision-making were more likely to
have adequate antenatal care use.
Implications for Policy, Delivery, or Practice: Efforts to
improve antenatal care use in Timor Leste might focus on
enhancing women’s education and on improving access
through such means as, transportation and basic
infrastructure or outreach services such as mobile clinics.
Poor women and those of very high parity need to be targeted
for services.
Primary Funding Source: No Funding
●An Exploration of the Relationship Among Gender,
Comorbidities, and Pain
Sheila Franco
Presented By: Sheila Franco, CDC/NCHS, 3311 Toledo Road
Room 6221, Hyattsville, MD 20782; Tel: 301-458-4331; Fax: 301458-4038; Email: boe5@cdc.gov
Research Objective: Pain costs the nation directly in the costs
to treat it, and indirectly in lower work productivity, lost work
days, and job-related disability. For individuals with pain, it
affects their quality of life and physical and mental functioning.
In recent decades, the medical community has increasingly
recognized the importance of treating and controlling pain. In
general, women report more pain than men. This analysis
examines differences in selected measures of reported pain by
gender. In addition, it investigates whether women and men
with similar comorbid conditions are as likely to report pain.
Study Design: Two nationally representative surveys from the
National Center for Health Statistics are used to examine
pain—The National Health and Nutrition Examination Survey
(NHANES) and the National Health Interview Survey (NHIS).
NHANES collects data from physical exams and information
on family characteristics during interviews. NHIS obtains data
on illnesses, injuries, chronic conditions, and other health
topics through household interviews. Different durations and
types of pain are examined. Bivariate and multivariate
analyses using SAS and SUDAAN are conducted.
Population Studied: The analysis is limited to adults age 20
and older.
Principal Findings: Results from the NHANES reveal that
one-quarter of adults report experiencing pain in the past
month that lasted more than 24 hours. Those reporting pain
are more likely to report comorbid conditions including heart
disease, thyroid conditions, stroke, and arthritis than those
not reporting pain. Women report more pain—migraines, low
back pain, neck pain, pain lasting more than 24 hours, and
joint pain within the past year—than men, even after
controlling for age and race/ethnicity. Women with heart
disease are more likely to report pain than men with heart
disease. Almost one-third of NHIS adult respondents report
that they experienced joint pain in the past month. Women
are twice as likely as men to report they had a severe headache
or migraine in the past three months. Both women and men
with pain are more likely to report comorbid conditions,
including heart disease and arthritis. However, women with
heart disease, diabetes, and obesity are more likely than men
with these conditions to report pain. In contrast, women and
men with arthritis and depression symptoms are equally likely
to report most measures of pain.
Conclusions: Experiencing pain is associated with increased
reporting of comorbid conditions including heart disease and
arthritis. Examining men and women with several common
conditions reveals that women with heart disease, diabetes,
and obesity are more likely to report pain than men with these
conditions.
Implications for Policy, Delivery, or Practice: Both men and
women with pain report more comorbid conditions than
those without pain. This may reflect poorer general health,
different perceptions of pain or reporting of pain, or
differential treatment of those with pain and comorbid
conditions. Practitioners should be aware of differences in
pain prevalence, as well as the complex relationships among
pain, comorbid conditions, and gender, when evaluating
patients with pain.
Primary Funding Source: No Funding
●Differential Diffusion of new HIV Technologies in the
U.S.: HAART as an Examplar
Allen Fremont, M.D., Ph.D., David Eisenman, M.D., MSHS,
Laura Bogart, Ph.D., Chloe Bird, Ph.D., Rebecca Collins, Ph.D.,
Daniela Golinelli, Ph.D., William Cunningham, M.D., M.P.H.
Presented By: Allen Fremont, M.D., Ph.D., Natural Scientist,
Health, RAND, 1776 Main Street, PO Box 2138, Santa Monica,
CA 90407-2139; Tel: 310 393 0411 x7569; Email:
fremont@rand.org
Research Objective: We sought to examine whether diffusion
of new HIV technologies is slower for women in the U.S., the
source of any such disparities, and whether disparities narrow
over time as technologies become more established. In
investigating these issues, we considered diffusion of highly
active antiretroviral therapy (HAART)in the late 1990s as a key
example of an emerging technology for treating patients with
HIV.
Study Design: Prospective cohort study comparing rates of
HAART use at 3 points in time among HIV infected
individuals receiving medical care, stratified by gender/risk
group (i.e., women, heterosexual men, and gay/bisexual men)
and race (i.e., white, black, Latino, other).
Population Studied: We examined data from 3 waves of a
national probability sample of 1,421 HIV-infected adults in HIV
care who were enrolled in the HIV Cost and Services
Utilization Study (HCSUS) from January 1996 to December
1998.
Principal Findings: There were significant differences among
the three groups at every time-point. At the first two study
waves, women and heterosexual men had lower use of
HAART compared to gay/bisexual men. By late 1998, women
were still the least likely of the three groups to receive HAART,
although the gap had narrowed, and all groups had increased
rates of utilization. At the final observation, 48.9% of women
were receiving HAART compared to 58.1% of gay/bisexual
men and 57.3% of heterosexual men (p < 0.01). Thus, the
disparity decreased from approximately 100% greater HAART
utilization by gay/bisexual men compared with women, to only
17%. Gender disparities in 1998 were only partially explained
by women’s lower income and educational levels.
Conclusions: Our findings suggest that differential diffusion
can lead to gender disparities in HIV care. The diffusion of
HAART between 1996 and late 1998 decreased, but did not
eliminate, gender disparities favoring gay/bisexual men. Our
results are consistent with diffusion theory, which posits that
the diffusion of innovations happens slowest for vulnerable
populations compared to more privileged groups, as newer
technologies are most rapidly adopted by or provided to
individuals with greater advantage.
Implications for Policy, Delivery, or Practice: Policies that
reduce the impact of income and education inequalities on
health care may help to narrow gender disparities for new HIV
technologies, but other factors may also disadvantage women.
Primary Funding Source: NICHD
●Teenage Pregnancy and School Dropouts in Texas: Effect
on Earnings
Percy Galimbertti, M.D., M.S., Ph.D.
Presented By: Percy Galimbertti, M.D., M.S., Ph.D., Research
Scientist, Health Science Center, Rural and Community Health
Institute, Texas A&M University, 301 Tarrow, 7th Floor, College
Station, TX 77840; Tel: (979) 458-7249; Fax: (979) 458-7213;
Email: galimbertti@tamhsc.edu
Research Objective: Prior studies have identified negative
social, psychological, and economic consequences of teenage
pregnancy and school dropout event. Most of the studies on
income have compared the performance of high school
graduates to school dropouts. Our study investigates the
effects of the dropout event because of teenage pregnancy on
yearly earnings, as compared to other female dropouts who
left school because of other reasons. The study also performs
a descriptive analysis of the characteristics of the sample,
grouped by the reasons for leaving school.
Study Design: The study analyzes data from the Texas
Education Agency that was incorporated into the Texas
Schools Microdata Panel of the Green Center for the Study of
Science and Society of the University of Texas at Dallas. The
sample is composed by five cohorts of female dropouts from
Texas public schools (1994 to 1998). Their yearly earnings
have been constructed using data from the Texas Workforce
Commission reports from 2000 to 2002. The evaluation of
the impact of the dropout event due to teenage pregnancy on
income uses statistical regression analyses (Ordinary Least
Squares and the Heckman Selection model). Among the
control variables, we included demographics, economic
indicator, immigrant status, individual ability measured by the
Texas Assessment of Academic Skills, and a set of different
“types” of dropouts according to their reason for leaving
school.
Population Studied: We studied a cohort comprised of all
female students who dropped out from Texas public schools
between 1994 and 1998. The total number of female dropouts
during that period was 62,791. However, we selected only the
individuals with a recorded reason for leaving school, and
those who were at most 19 years old when they left school.
The final sample was comprised of 38,550 female students.
Principal Findings: The regression statistical analyses show a
consistent and significant negative effect (at alpha level =
0.01) of dropping out of school because of teenage pregnancy
on yearly earnings, when compared to female dropouts who
left school because of other reasons. Other things being equal,
female students who left school because of teenage pregnancy
had lower income that students who dropped out of school
because of other reasons (2,800 dollars or 20% lower in a
two-year period).
Conclusions: In addition to the health risks associated with
early motherhood and the social and psychological
consequences of teenage pregnancy, female students who
leave school due to teenage pregnancy have lower income
levels, compared to other female school dropouts. The
income disparity found in our study must be added to the
already large negative effect of dropping out of school (for any
reason) on earnings, when compared to other women who
did not drop out of school.
Implications for Policy, Delivery, or Practice:
Interdisciplinary efforts are required in order to decrease the
incidence of teenage pregnancy, a topic that has important
social, economic, and health implications (physical and
psychological). Preventive programs should include efforts to
increase health literacy and awareness on this topic. Social
programs should include support for young mothers in the
labor market.
Primary Funding Source: No Funding
●Perinatal Depression: A Systematic Review of Prevalence
and Incidence
Norma Gavin, Ph.D., Bradley N. Gaynes, M.D., M.P.H.,
Kathleen N. Lohr, Ph.D., Samantha Meltzer-Brody, M.D.,
M.P.H., Gerald Gartlehner, M.D., M.P.H., Tammeka Swinson,
BA
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: Estimates of the prevalence of perinatal
depression vary widely—from 5% to more than 25% of
pregnant women and new mothers. To estimate disease
burden more accurately and thereby better target and
prioritize health care expenditures, we need more precise
estimates of the condition’s prevalence and incidence. We
systematically reviewed evidence on the prevalence and
incidence of perinatal depression to determine whether
adequate evidence currently exists to define a more precise
estimate.
Study Design: We searched MEDLINE, CINAHL, PsycINFO,
and Sociofile, conducted hand searches, and consulted
experts to identify English-language articles published from
1980 through March 2004 on the prevalence or incidence of
perinatal depression. We included prospective cross-sectional,
cohort, and case-control studies that used a structured clinical
interview to assess women for major depression or minor
depression during pregnancy or the first year postpartum. We
excluded studies that relied solely on self-report screens and
studies that did not distinguish women with major or minor
depression from those with bipolar disorder, primary
psychotic disorders, or maternity blues. We combined all
estimates with the same diagnosis, estimate type, and time
period using meta-analytic techniques and analyzed
associations between the prevalence of depression and study
characteristics in a series of meta-regressions.
Population Studied: Pregnant women and new mothers up
to 12 months after delivery and nonchildbearing women of
similar age in developed countries.
Principal Findings: Of the 109 articles reviewed, the 28
meeting our inclusion criteria provided 88 estimates of the
point prevalence, 29 estimates of the period prevalence, 33
estimates of the incidence of perinatal depression. Only 3
studies included a comparison group. The studies were
generally too small for reliable subgroup analyses. For major
and minor depression together, the combined point
prevalence estimates from meta-analyses ranged from 6.5% to
12.9% at different trimesters of pregnancy and months in the
first postpartum year, and the combined period prevalence
shows that as many as 19.2% of women have a depressive
episode during the first 3 months postpartum. For major
depression alone, the combined point prevalence estimates
ranged from 1.0% to 5.6%, and the combined period
prevalence was 7.1% during the first 3 months postpartum.
Most episodes have onset following delivery. We found no
significant differences between the combined estimates and
the prevalence of depression among nonchildbearing women
of similar age. However, all estimates have wide 95%
confidence intervals, showing significant uncertainty in their
true levels. The following study characteristics significantly
influenced the prevalence of perinatal depression: the risk
status of women at study entry, their socioeconomic status,
the interview methods, and the diagnostic criteria used to
identify cases.
Conclusions: To better delineate periods of peak prevalence
and incidence for perinatal depression and identify high risk
subpopulations, we need studies with larger and more
representative samples.
Implications for Policy, Delivery, or Practice: Many women
experience depression during the perinatal period, with
potentially devastating consequences for them, their infants,
and other family members. It behooves us to take
opportunities provided through regular prenatal and
postpartum physician contacts to screen for depression.
Primary Funding Source: AHRQ
●How Accurate are Perinatal Depression Screens? A
Systematic Review of the Evidence
Bradley N. Gaynes, M.D., M.P.H., Norma Gavin, Ph.D.,
Samantha Meltzer-Brody, M.D., M.P.H., Gerald Gartlehner,
M.D., M.P.H., William C. Miller, M.D., Ph.D., Kathleen Lohr,
Ph.D.
Presented By: Bradley N. Gaynes, M.D., M.P.H., Associate
Professor of Psychiatry, Psychiatry, University of North
Carolina School of Medicine, CB # 7160, Chapel Hill, NC
27599-7160; Tel: 919-966-8028; Fax: 919-843-4370; Email:
bgaynes@med.unc.edu
Research Objective: Pre-natal and postpartum visits provide
opportunities for depression screening. Although many
screening instruments have been developed or modified to
detect major and minor depression in pregnant and newly
delivered women, the evidence on their screening accuracy
relative to a reference standard has yet to be systematically
reviewed and assessed. Accordingly, we reviewed the
evidence on perinatal depression screening accuracy.
Study Design: We searched MEDLINE, CINAHL, PsycINFO,
Sociofile, and the Cochrane Library (1980 through March
2004); performed bibliographic hand searches; and consulted
experts. We selected studies that were published in English,
provided original data allowing calculation of sensitivity and
specificity, and confirmed depression using a reference
standard. For each instrument and associated cutoff, we
calculated sensitivity and specificity. When three or more
studies used a specific cutoff, we estimated a pooled
sensitivity and specificity using meta-analytic methods.
Population Studied: Pregnant women and mothers up to one
year after delivery. Studies could be conducted in any clinical
setting but had to be from a developed country to increase the
likelihood of being generalizable to the US population. We
excluded studies that exclusively addressed bipolar disorder, a
primary psychotic disorder, or maternity blues and those that
included women with known depressive disorders at the
outset (for whom a screen would not provide new
information). We focus here on English-language instruments,
given their greater relevance to our population of interest.
Principal Findings: Of ninety-six articles reviewed, ten studies
met inclusion criteria. In general, studies were of fair to good
quality, although external validity was only poor to fair.
Specifically, the study populations were nearly entirely white,
so the accuracy of these screeners in other populations is
unclear. A major limitation in the available evidence is the very
small number of depressed patients involved, a fact that
results in substantial imprecision in the point estimate of
sensitivity and prevented us from determining an ideal cutoff
point. For pregnant women, one study involving few
depressed patients provided limited information. For
postpartum women with major depression, specificity for all
screeners was relatively high, but sensitivities varied
considerably. The Edinburgh Postnatal Depression Scale and
the Postpartum Depression Screening Scale appeared more
sensitive (estimates from 0.75 to 1.0) than the Beck
Depression Inventory (estimates from 0.32 to 0.68), but wide
confidence intervals overlapped substantially. For postpartum
women with major or minor depression, tools performed less
accurately.
Conclusions: Available evidence, although limited, indicates
that perinatal depression screens are feasible and perform
similarly to those used in primary care. Further research
requires larger numbers of depressed patients and the use of
more representative populations.
Implications for Policy, Delivery, or Practice: Screening
instruments with reasonable test characteristics appear
feasible to use in a perinatal population with a depression
prevalence between 5% and 10%. Since using these tools likely
carries low risk and each has reasonable specificity (and, thus,
a reasonable positive predictive value), maximizing sensitivity
can guide tool selection. The standard cutoffs of 13 for the
EPDS and 81 for the PDSS appear to be acceptable thresholds.
Primary Funding Source: AHRQ, National Institute of Mental
Health
●Predictors of Breast Cancer Fatalism Among Women in
Mississippi
Allyson Hall, Ph.D., Amal Khoury, Ph.D., Ellen Lopez, Ph.D.
Presented By: Allyson Hall, Ph.D., Research Assoc Prof,
Health Services Research, Management, and Policy, University
of Florida, PO Box 100195, Gainesville, FL 32608; Tel: 352 273
5129; Fax: 352 273 5061; Email: ahall@phhp.ufl.edu
Research Objective: Cancer fatalism, ‘the belief that cancer is
death sentence’, has been shown to be a deterrent to cancer
screening participation. The aim of this study was to examine
predictors of breast cancer fatalism including:
sociodemographic characteristics, personal and vicarious
experiences with cancer, perceptions of the health care
system, and knowledge about breast cancer.
Study Design: This cross-sectional study examined data from
a 2003 statewide survey of women (40+ years) residing in
Mississippi. Survey questions were developed from an
extensive literature review, and from information gathered
during six focus groups conducted with women in the state.
The outcome variable, ‘breast cancer fatalism’ was based on
survey respondents’ level of agreement with the statement
‘breast cancer is a death sentence’. Women were classified
as either having a fatalistic attitude (i.e. agreed or strongly
agreed with the statement) or as not having a fatalistic
attitude (i.e. disagreed or strongly disagreed with the
statement). Bivariate analyses compared the characteristics
of women who reported a fatalistic attitude to those who did
not report a fatalistic attitude. Logistic regression examined
the association between fatalism and the explanatory
variables.
Population Studied: The survey sample included 1,050
women. Women with a previous breast cancer diagnosis, and
those who responded ‘don’t know’ to the fatalism statement
were excluded from the analysis, resulting in a sample size of
958. The mean age was 59 years. Half of the women had a
high-school diploma or less, about 1/3 reported a family
history of breast cancer, and almost 1/3 were classified as
holding fatalistic attitudes towards breast cancer.
Principal Findings: Analyses revealed that women who were
older, less educated, African American, and had a family
history of breast cancer were more likely to hold a fatalistic
attitude towards the disease. However, other characteristics
such as household income, marital status, and perceived
health status were not significantly associated with a fatalistic
belief. Women who rated their overall quality of care
negatively, and indicated that they believed that ‘doctors hide
information from people of their race’ were also likely to report
a fatalistic attitude, as were women who thought that ‘breast
cancer cannot be cured if found early’ and that ‘treatment can
be worse than the disease’.
Conclusions: Although several socioeconomic characteristics
were found to be related to a fatalistic attitude, a woman’s
perception of their health care experiences and their attitudes
about breast cancer were also important. In sum, women
who had mistrust of the health care system and held negative
attitudes about breast cancer treatment were more likely to be
fatalistic.
Implications for Policy, Delivery, or Practice: Findings from
this study support the development of targeted communitybased educational programs tailored predominately toward
African American women. The purpose of such educational
programs would be to enhance knowledge and positive
attitudes about breast cancer prevention and treatment. In
addition, hospitals and other health care providers are
encouraged to work towards improving overall perceptions of
the delivery system.
Primary Funding Source: Susan G. Koman Breast Cancer
Foundation
●Demographic, Health Status, Health Insurance and
Health Care Utilization Trends for Medicare Beneficiaries
by Veteran Status: 1992-2002
Yvonne Jonk, Ph.D., Andrea Cutting, MA, Heidi O'Connor,
MS, Tamara Schult, MS, Dowd, Bryan, Ph.D., Feldman, Roger,
Ph.D.
Presented By: Yvonne Jonk, Ph.D., Health Economist, Center
for Chronic Disease Outcomes Research, Minneapolis VA
Medical Center, One Veterans Drive 1110, Minneapolis, MN
55417; Tel: (612) 467-3882; Fax: (612) 725-2118; Email:
yvonne.jonk@med.va.gov
Research Objective: Analyze trends in the demographic
characteristics, health status, health insurance, and health
care utilization of veteran and non-veteran Medicare
beneficiaries over the past decade. Given the Veterans Health
Administration (VHA’s) administrative changes and
expansions in eligibility guidelines in the mid-90’s, trends in
veterans’ use of VHA health care services are also analyzed.
Study Design: An observational study utilizing longitudinal
cohort survey data. The Medicare Current Beneficiary Survey
identifies veterans and serves as the primary data source in
analyzing health care utilization. The data set provides
comprehensive information on health and socioeconomic
status, health insurance, and utilization of health care
services.
Population Studied: A nationally representative sample of
11,471 veteran and 38,732 non-veteran Medicare beneficiaries
in 1992-2002.
Principal Findings: Over the past decade, veterans
consistently comprised over a quarter of Medicare
beneficiaries. While the vast majority of veterans were white
males over the age of 65, approximately three-quarters of nonveteran Medicare beneficiaries were female. In the early 90’s
a higher percentage of veterans were in the 65-74 year age
range than non-veterans with these age differences
diminishing over time. While veterans were less likely to be
black and less likely to be of Hispanic ethnicity, the percent
Hispanic has been steadily increasing over time for both
veteran and non-veteran groups. Although both groups have
become better educated over time, a higher percentage of
veterans have attended college, were more likely to be
working, more likely to be married, and earned higher incomes
than non-veterans. Although health status measures
remained fairly consistent over time for both groups, a higher
percentage of veterans reported no problems with Activities of
Daily Living (ADLs) and Independent ADLs than non-veterans.
Veterans were more likely to live in the community versus an
institutional facility than non-veterans. Interestingly, the
percent of veterans reporting a service connected disability
declined from 14.6% in 1992 to a low of 10.4% in 2001. While
the majority of veterans and non-veterans were enrolled in
both Medicare A and B, the percent enrolled in Medicare
HMOs has been steadily increasing from 6-7% in 1992 to
almost 20% in 2000. Veterans were 6-7 times less likely to be
enrolled in Medicaid than non-veterans. An increasing
reliance on Medicaid was realized for both groups. Veterans’
use of VHA services increased from 10% in 1992 to 24% in
2002. While use of VHA inpatient services has held steady, all
veteran Medicare beneficiaries increased their use of VHA
outpatient and prescription drug services in the late 90’s.
Conclusions: The veteran Medicare population appears to be
less racially and ethnically diverse than non-veterans, in better
health, and less reliant on Medicaid. This trend was
accompanied by veterans’ increasing reliance on the VHA as
an important source of coverage for outpatient and
prescription drug services.
Implications for Policy, Delivery, or Practice: The additional
impact of an aging veteran population, the growth of the
Medicare eligible veteran population, and their reliance on
VHA coverage for outpatient and prescription drugs will
continue to challenge VHA’s budget in the coming years.
Primary Funding Source: VA
●Qualitative Research to Identify Women’s Preferences
and Inform Design: Creating a New Model Smoking
Cessation Program for Women Veterans
Judith Katzburg, Ph.D., M.P.H., RN, Melissa Farmer, Ph.D.,
Ines Poza, Ph.D., Scott E. Sherman, M.D., M.P.H.
Presented By: Judith Katzburg, Ph.D., M.P.H., RN, Health
Services Researcher, Center for the Study of Healthcare
Provider Behavior, VA Greater Los Angeles Healthcare System,
16111 Plummer St., Sepulveda, CA 91343; Tel: 818-891-7711
x5443; Fax: 818-895-5838; Email: jkatzbur@ucla.edu
Research Objective: There is a high prevalence of smoking
(30%) for both men and women using Veterans Health
Administration services (VA); current VA tobacco control
efforts appear to be less effective for women than for men.
There is little available literature regarding tailoring a smoking
cessation program to better meet women’s needs. Our
intermediate goal was to develop a consumer-driven approach
in the design of a new program. The long term goal was to
develop and implement a new model smoking cessation
program for women, taking into consideration women’s needs
and preferences.
Study Design: We conducted a series of concept
development focus groups with female smokers to identify
potential new smoking cessation interventions. A
professional moderator led the sessions, which were audiotaped. Transcripts were reviewed by two researchers. They
independently classified themes within the Ideal Program
domain, based on an initial line-by-line reading using
standardized techniques to examine for repetitions,
similarities and differences, within and across groups, as
described by Ryan & Bernard, 2003.
Population Studied: Women who attended the Women’s
Health Program at one of two VA sites were recruited by
phone. A total of 310 women were contacted, and 45 reported
being current smokers; 23 women smokers participated in one
of four focus groups (group size – 5-7).
Principal Findings: Within the domain Ideal Program, two
key themes were generated from the focus group discussions:
Support and Choice/Control. First, the women wanted
support. Types of support included emotional support and
education or information. Emotional support, both to quit
and to prevent relapse, was discussed across all groups. Peer
(other smokers) and professional support were important
sources of support. Formats for providing support included
individual and group models. In addition to support, the
women also wanted choices and control in a smoking
cessation program suggesting the need for an individualized
program. The heterogeneity of women’s preferences further
supported the need for an individualized program.
Conclusions: The focus groups generated important
hypotheses regarding the necessary components of a
smoking-cessation program for women veterans. The results
of these focus groups were presented to an expert panel which
then designed a new smoking cessation program for women,
predicated on the expressed desires of women in conjunction
with current evidence-based research. It is hoped that this
new menu-driven program (which offers numerous choices as
to type, source, and format of the intervention as well as for
sources for support) will better meet women veteran’s needs.
The implementation and evaluation of a successful program
will, in part, substantiate the hypotheses generated by the
focus groups.
Implications for Policy, Delivery, or Practice: The use of
qualitative methods, to inform development of a new smoking
cessation intervention designed to best meet women veteran’s
needs, proved informative. Variations in preferences
regarding support as well as an expressed desire for
choice/control were suggestive of the need to create an
individualized program. The use of focus groups to inform
program design may serve as a model for creating new
smoking cessation interventions for other minority or
vulnerable populations.
Primary Funding Source: No Funding
●Developing a Survey Item for a Health Plan Performance
Measure for Osteoporosis Testing in Older Women
Heather LaBelle, MA, Min Gayles, M.P.H., Lok Wong, MHS,
Alix Love, M.P.H., Claudia Squire, M.P.H.
Presented By: Heather LaBelle, MA, Health Care Analyst,
Quality Measurement, NCQA, 2000 L Street NW,
Washington, DC 20036; Tel: 202-955-3563; Fax: 202-955-3599;
Email: labelle@ncqa.org
Research Objective: To develop a quality of care measure for
health plans to improve prevention of osteoporosis and
increase appropriate treatment of osteoporosis in older
women based on USPSTF guideline recommendations that
women over 65 should receive routine screening for
osteoporosis.
Study Design: A clinical expert panel was convened to
develop measurement specifications and survey questions
based on existing guidelines. Cognitive testing was conducted
to develop and test the survey question. Two rounds of
concept testing were conducted to identify appropriate terms
for the survey question. An additional two rounds of cognitive
interviews were conducted to test the respondents’ question
comprehension, recall, and decision processes to identify
whether they had a bone density test to check for
osteoporosis.
Population Studied: In 2005, a total of 20 female Medicare
beneficiaries 65 years and older who had not participated in a
health study in the last 6 months were recruited into the study
from North Carolina, representing a diverse selection of
education, race, age, and osteoporosis screening and testing
status. The study sample also included respondents who had
a visit to a doctor and a fall or problem with balance or
walking during the past year.
Principal Findings: Two rounds of concept testing identified
terms for osteoporosis that resonated with respondents
including osteoporosis and brittle bones. The interviews also
elicited that bone density test was the best term to describe
osteoporosis testing. The terms selected by respondents were
used to develop the survey question assessed in the two
rounds of cognitive interviews. Based on the interviews,
examples of where the test may be administered to
differentiate this test from an x-ray were added to further
clarify the question. The final question developed was: “Have
you ever had a bone density test to check for osteoporosis,
sometimes thought of as “brittle bones”? This test may have
been done to your back, hip, wrist, heel or finger.”
Conclusions: The question was well understood by older
women and resonated in the population. The study validated
the new survey question for a HEDIS performance measure
that will assess if women at risk for osteoporosis have
received a bone density test for routine screening and
appropriate management. The HEDIS measure Osteoporosis
Testing in Older Women will be implemented in 2006 and the
survey question will be included in the Medicare Health
Outcomes Survey.
Implications for Policy, Delivery, or Practice: This measure
will improve osteoporosis prevention and management in
older women. The prevalence of osteoporosis is high among
older women, placing them at higher risk for falls and
osteoporotic-fractures, including debilitating hip fractures.
Health plans can develop quality improvement interventions
to educate patients and providers on osteoporosis.
Appropriate and timely identification and management of
osteoporosis will improve the quality of life of seniors.
Primary Funding Source: CMS
●Talk to her: Health Care Counseling for Women in the
Clinical Setting
Alina Salganicoff, Ph.D., Usha Ranji, MS
Presented By: Alina Salganicoff, Ph.D., Vice President,
Women's Health Policy, Kaiser Family Foundation, 2400 Sand
Hill Road, Menlo Park, CA 94025; Tel: 650-854-9400; Fax: 650854-4800; Email: alinas@kff.org
Research Objective: To assess the extent to which women
and their physicians discuss issues of primary prevention in
the clinical setting.
Study Design: A nationally representative telephone survey of
2,766 women ages 18 and older, in English/Spanish, was
conducted on a range of health care issues such as health
status, insurance, health utilization, and provider
relationships. African American, Latina, and low-income
women were over sampled.
Population Studied: Women ages 18 and older, residing in
the continental U.S.
Principal Findings: While over half of adult women cite
health care providers as their primary source of health
information (53%), a sizable share of women report that they
have not discussed several important prevention topics with a
provider in the prior three years. While counseling rates were
highest for diet, exercise, and nutrition (55%) and calcium and
bone loss (43%), just one-third (33%) of women report
discussing smoking, 29% mental health issues, and 20%
alcohol or drug use with their health care provider in the past
3 years. Having a usual source of care was associated with
significantly higher counseling rates. With regard to sexual
health, less than one-third of reproductive age (18 to 44)
women report having discussed sexual history with a provider
(31%), and rates were lower for discussions about sexually
transmitted diseases (28%), emergency contraception (14%),
and domestic or dating violence (12%). Lower-income
women and women of color were found to have higher
screening rates on sexual health issues than white women.
There were few differences between women who had
identified that they also had an OB/GYN provider.
Conclusions: Despite growing attention to the important role
of early intervention and healthy behaviors in health
promotion and disease prevention, a sizable share of women
do not get needed counseling when they see the doctor.
Provider information and counseling on health risks remains
an important tool for health promotion, but needs to be
improved to reach more women.
Implications for Policy, Delivery, or Practice: It is
increasingly becoming accepted that health care screening
and counseling is part of a high quality health care experience.
Despite the growing acceptance of the importance of
counseling, many women are not given the information and
screening that is recommended during a health care visit.
With growing attention to the health care consumer’s role in
maintaining their health and well-being, there is still much
that needs to be done to assure that the educational
opportunity in the health visit is not lost. Despite the fact that
women still rely heavily on health care providers as their
primary source of health care information, physicians often do
not have time to offer counseling and education and are not
reimbursed for the time it takes to provide these high-touch
services. Furthermore, many providers may not have received
the necessary training to provide counseling in these areas,
particularly in the area of mental illness, sexual health, and
physical abuse. Given the potential payoff in terms of healthy
behaviors and prevention, this is an area that needs further
attention in the clinical setting.
Primary Funding Source: Foundation
●Mammography
Jeremiah Schuur, M.D., Akash Shah, BS, Howard Forman,
M.D., M.B.A., Cary Gross, M.D.
Presented By: Jeremiah Schuur, M.D., Robert Wood Johnson
Clinical Scholar, Internal Medicine, VA Medical Center, West
Haven, CT & Yale University, School of Medicine, IE-61 SHM,
PO Box 208088, New Haven, CT 06520-8088; Tel: 203-7375357; Fax: 203-785-3461; Email: jeremiah.schuur@yale.edu
Research Objective: Women insured by Medicaid utilize
mammography less frequently than women with Medicare. It
is unknown if practice-level variables are a root-cause of this
finding. We examined the impact of insurance type and
reimbursement rates on successful scheduling of a prompt
appointment for a diagnostic mammogram.
Study Design: Randomized crossover experiment of
mammography facilities in 11 states. To assess variation in
Medicaid reimbursement we calculated a state-level Medicaid
to Medicare Reimbursement Ratio (MMRR) for unilateral
diagnostic mammography (CPT code 76090). We chose five
states with high MMRR (mean=1.03 of Medicare; NY, NE, OK,
AR and VA); five states with low MMRR (mean=0.31; MO, NJ,
NH, UT and CO); and Connecticut (mid-MMRR=0.51). We
chose one or two Hospital Referral Regions (HRR) per state,
as defined in the Dartmouth Atlas of Healthcare, and called
each facility within selected HRRs and all facilities in
Connecticut. Four trained research assistants called
mammography facilities as standardized patients (SPs). The
SP was a 50 year old woman who recently moved to the area
and needed a diagnostic mammogram to assess a recent
“abnormal mammogram.” The SP stated her insurance prior
to scheduling an appointment and negotiated the third next
available appointment. Each facility was called twice,
separated by at least one week. Insurance (Medicaid vs.
Medicare) was randomized between calls. Our primary
outcomes were (1) acceptance of Medicaid and/or Medicare
(defined as scheduling an appointment with the SP) and (2)
the wait time from call to appointment. We defined “timely”
appointments as those scheduled within 20 business days.
Our analysis included all facilities that performed diagnostic
mammograms and where both calls were completed. We
used McNemar’s test to compare the proportion of scheduled
appointments by insurance type and paired T-tests to
compare wait times by insurance type and MMRR.
Population Studied: We called 520 mammography facilities
in 11 states.
Principal Findings: There was no association between
Medicaid reimbursement and access to diagnostic
mammography. 90% of facilities performed diagnostic
mammography. We completed calls to 97.7% of eligible
facilities. Overall, 381 of 432 (88.2%) facilities accepted
Medicaid while 417 of 432 (96.5%) facilities accepted Medicare
(p<.0001). There was no significant difference in the
proportion of “timely” appointments between Medicaid and
Medicare (93.6% vs. 92.8%; p=0.51). There was no significant
difference between mean wait times comparing Medicaid (9.8,
median=7.5) with Medicare (9.9, median=8.0; p=0.82).
Insurance acceptance, timeliness and difference in wait times
did not differ when stratified by MMRR (high vs. low).
Conclusions: Women with Medicaid insurance do not
experience significant delays in scheduling diagnostic
mammograms compared to similar women with Medicare.
Fewer facilities accept Medicaid than Medicare, but this is of
questionable clinical significance as more than 85% accept
Medicaid and timeliness didn’t differ between insurance types.
Medicaid reimbursement level does not significantly impact
any of our three measures of access to diagnostic
mammography.
Implications for Policy, Delivery, or Practice: Action to
improve mammography access should focus on outreach,
awareness and case management with at-risk patients and
communities rather than on increasing Medicaid
reimbursement for mammography providers.
Primary Funding Source: Internal Funds
●Trends in Breast and Cervical Cancer Screening Rates,
1999 – 2003
Sarah Shih, M.P.H., Russell Mardon, Ph.D., Richard Dixon,
M.D., FACP, Steve Coughlin, Ph.D., Mona Saraiya, M.D.,
M.P.H., Florence Tangka, Ph.D.
Presented By: Sarah Shih, M.P.H., Senior Healthcare Analyst,
Research and Analysis, National Committee for Quality
Assurance, 401 Hunter Ave., City Island, NY 10464; Tel: 718885-2544; Fax: 202-955-3599; Email: shih@ncqa.org
Research Objective: To evaluate the trends and regional
performance of cervical and breast cancer screening as
reported by the Health Plan Employer Data and Information
Set (HEDIS®).
Study Design: Few national data sources exist to track the
quality of health care. Data collected using HEDIS
specifications were used to follow the national and regional
trends of cervical and breast cancer screening. Rates were
calculated for commercial and Medicaid managed care
organizations (MCOs) and stratified by census regions as well
as for selected health plan and member characteristics.
Population Studied: Commercial and Medicaid MCOs
reporting HEDIS to the National Committee for Quality
Assurance (NCQA) from 2000 to 2004 (services provided in
calendar years 1999 to 2003). Approximately 87.5% of the
commercially insured and 38.7% of the Medicaid insured are
represented in the data reported in this study.
Principal Findings: Overall rates of screening have increased
slightly for breast and cervical cancer. The national average
for cervical cancer screening rates in commercial MCOs,
increased by 7.8 percentage points from 74.7%. The increase
in the breast cancer screening rate was only about half a
percentage point (75.4% to 75.9%). Improvement in
screening rates for Medicaid MCOs was greater, with 5.7 point
increase from 49.6% for breast cancer and 10 point increase
from 51.5% for cervical cancer. Regional trends exhibit
continued increases in each region for both screening rates.
However, the gap between the highest and lowest performing
regions still remains. For example, the difference in regional
averages for cervical cancer screening rates in Medicaid
MCOs between New England and South Central is over 20
percentage points, despite a 13 point improvement in the
South Central region from 43.7% in 1999. A similar
performance pattern is observed in commercial MCOs though
the gap (8.8 pts) is smaller between the same regions. We
further explored other explanations for the differences in
performance rates, including MCO characteristics. Few
characteristics were associated with plan performance,
although plans that have consistently reported HEDIS data for
more than one year have higher rates for all the preventive
service indicators.
Conclusions: Although rates have increased for breast and
cervical cancer screening between 1999 and 2003, there is
room for improvement, especially for cervical cancer screening
and for regions that still lag behind the national average for
both cancer screenings. HEDIS provides an additional data
source to track trends in preventive services as similar
observations regarding national trends in screening rates have
been observed with data sources compiled by the National
Centers for Health Statistics. However, more detailed
information is needed by race/ethnicity and age groups in
order to better target improvement activities.
Implications for Policy, Delivery, or Practice: Health People
2010 targets for breast and cervical cancer screening rates are
achievable as 75% of the commercial MCOs have met the
70% screening rate goal and about 10% of the Medicaid
MCOs have done so also. However, for cervical cancer
screening, only a handful of MCOs have met the 90%
screening rate goal. As early detection and treatment is the
most effective method for reducing deaths from breast and
cervical cancer, additional information is needed to better
understand what contributes to the variation in screening
rates.
Primary Funding Source: CDC, Through a grant from Office
of Women's Health
●Gender and Safety – Diagnosis-specific Analyses of
Claims
Vibeke Sparring, MSc, Pia Maria Jonsson, M.D., Ph.D.
Presented By: Vibeke Sparring, MSc, Ph.D. student, Medical
Management Centre, Karolinska Institutet, Berzelius vag 3,
Stockholm, 17177; Tel: +46852486324; Fax: +46852483600;
Email: vibeke.sparring@ki.se
Research Objective: The aim of the study is to identify and
analyse general trends and specific problems in the
management of men and women with coronary heart disease,
diabetes mellitus, primary hip arthrosis and cataract based on
information from the database of the Patient Insurance Fund.
Specific aims of the study is: - to describe gender-specific
trends in the occurrence of reported adverse events and the
severity of consequent injury, - to analyse the distribution of
these events on different healthcare regions, levels of care,
types of healthcare organisations, personnel categories and
medical specialties, - to compare the occurrence of different
types of adverse events and the severity of consequent injury
between men and women with the four diagnoses, - to identify
specific risk situations and safety problems related to the
management of men and women with the four diagnoses.
Study Design: The cases registered with one of the four
diagnoses were selected. All the registered cases during the
corresponding periods constituted comparison groups. As a
first step, the data has been analysed by looking for gender
disparities in general. The second step is to analyse the
material on the basis of the specific aims mentioned above.
Population Studied: The Swedish Patient Insurance operates
on a “no fault” principle and gives economic compensation to
patients who have got physical or mental injury as a
consequence of medical treatment. Compensation is granted
regardless of medical responsibility or malpractice. Excluded
from compensation are complications that are regarded as a
part of “normal” risk-taking in medical care. Since the start in
the 1970’s, more than 100,000 claims have been filed and
more than 40 percent of the claims have given rise to
compensation. Data about these cases are available in a
numerical database, including both information about the
involved healthcare provider and the patient. Since the mid
1990’s, also the cases not compensated by the insurance have
been included in the database.
Principal Findings: Preliminary results show that out of the
20,299 claims registered 1997-2003 (10,072,471 discharges),
women accounted for 60.8% of the claims and men for
39.2%. For patients with the primary diagnosis ischemic heart
disease the total number of claims where 610 (535,887
discharges), 32.8% were women and 67.2% men. Claims from
patients with diabetes mellitus totalled a number of 61
(118,190 discharges), 36.1% women and 63.9% men. Hip
arthrosis had 753 claims (136,561 discharges) whereof women
accounted for 66.3% and men for 33.7%. Cataract surgery
(19,136 discharges) led to 99 complaints. Women accounted
for 60.6% of these claims and men for 39.4%. In general,
women have a 3% higher payrate than men.
Conclusions: The study shows that diagnosis-specific
analyses could be a way of approaching this database.
Disparities are generally found when combining gender and
age. Having looked at IF gender disparities exists, the second
phase will focuse on WHY?
Implications for Policy, Delivery, or Practice: The results of
the study can serve as a starting point for future genderspecific analyses of the social and economic consequences of
safety problems.
Primary Funding Source: No Funding
●Sustained Reduction in Neonatal Intensive Care Unit
Admission Rates in a Medicaid Managed Care Program
Using a Prenatal Care Program with a Strong Social
Outreach Emphasis
Joseph Stankaitis, M.D., M.P.H., Howard R. Brill, Ph.D.,
Darlene M. Walker, RN, MS, FNP, Deborah Peartree, BSN,
MS, Mardy Sandler, MSW
Presented By: Joseph Stankaitis, M.D., M.P.H., Chief Medical
Officer, , Monroe Plan for Medical Care, 2700 Elmwood
Avenue, Rochester, NY 14618; Tel: (585) 256-8425; Fax: (585)
697-1734; Email: jstankaitis@monroeplan.com
Research Objective: Neonatal Intensive Care Unit (NICU)
Admission Rates are an important birth outcome indicator for
Medicaid managed care organizations and a major cost driver
for medical expenses. The objective for this quality
improvement project was to reduce NICU admission rates by
at least 15% and maintain that reduction. This was to be
accomplished through the development and implementation
of an aggressive prenatal care program that through the use of
the Center for Health Care Strategies’ Best Clinical and
Administrative Practices (BCAP) Program’s principles would
enhance approaches to identification, stratification, outreach,
and intervention for high-risk pregnant women.
Study Design: The organization performed a longitudinal,
population-based review of its birth outcomes from 1997
through and including 2004 focusing on Neonatal Intensive
Care Unit (NICU) Admission Rates. Return on Investment
evaluation reflected attributable incremental program costs
and resultant savings. Interventions initially included:
enhanced identification and stratification of high-risk women
with the use of a health risk assessment form; outreach
through nursing care coordination offering home visits,
transportation, support services, social work services, and
connection to other community-based organizations; and the
implementation of a strong informatics structure. Beginning
in 2002, the organization contracted with a community-based
organization to provide “high touch” social outreach for
women with significant psychosocial problems.
Population Studied: The population of concern was that of
pregnant women enrolled in a Medicaid managed care
program who delivered an infant. The number of live births
attributed to this population started at 604 in 1998 and
progressively grew to 1,778 in 2004.
Principal Findings: NICU admission rates decreased from
108/1,000 births in 1998 to 57/1,000 births in 2003 and
continued its sustained results in 2004 with a NICU
admission rate of 35/1,000 births. There were no secular
trends to impact these observations. The Return on
Investment from the incremental program enhancements
approaches three dollars for every dollar expended.
Conclusions: A program that identifies its high-risk pregnant
enrollees in a timely fashion provides outreach using a strong
nursing care coordination and social work emphasis, and has
a strong informatics structure should form the basis for an
effective Medicaid managed care prenatal care program. It
appears that the addition of “high touch” social outreach will
significantly enhance improved birth outcomes for this highrisk population. The Return on Investment supports the
business case for this approach.
Implications for Policy, Delivery, or Practice:
Implementation of aggressive, high-touch, prenatal care
programs can significantly improve birth outcomes and
decrease costs for low-income and working poor women
enrolled in governmental programs.
Primary Funding Source: The Medicaid managed care
organization directly funded the project. The Robert Wood
Johnson Foundation through the Center for Health Care
Strategies provided the support to allow the reporting
organization to participate in the BCAP Program.
●Diffusion of Innovation: The VA’s Experiment in
Delivering Comprehensive Women’s Health Care
Elizabeth Yano, Ph.D., MSPH, Caroline Goldzweig, M.D.,
M.P.H., Ismelda Canelo, BA, Donna L. Washington, M.D.,
M.P.H.
Presented By: Elizabeth Yano, Ph.D., MSPH, Deputy Director,
Research Service, VA Greater Los Angeles HSR&D Center of
Excellence, 16111 Plummer Street (Mailcode 152), Sepulveda,
CA 91343; Tel: (818) 895-9449; Fax: (818) 895-5838; Email:
elizabeth.yano@va.gov
Research Objective: Most of the 1.7 million U.S. women
veterans obtain all or most of their medical care outside the
Veterans Affairs (VA) health care system. However, the
changing demographics of today’s military have made women
veterans the fastest growing segment of new VA users.
Historically, concerns about the availability and quality of
women’s health services in VA medical centers led Congress
to approve landmark legislation earmarking funds to enhance
access to high-quality women’s health care. The VA used a
portion of the appropriation to launch eight Comprehensive
Women’s Health Centers (comprehensive WHCs), designed
to serve as exemplars for the development of VA women’s
health care throughout the system. We evaluated the
evolution of VA women’s health care over the 10 years since
the inception of those first programs to determine the VA’s
organizational readiness for taking on women veterans’ health
care needs.
Study Design: In the first national assessment of how VA
women’s health care is organized, we surveyed the network
directors, medical center directors and senior women’s health
clinicians regarding the organizational structure, service
availability, and practice arrangements for delivering primary
care and gender-specific services at each geographically
distinct health care facility (100%, 91%, and 83% response
rates, respectively). Using expert panel methods, we created
an organizational taxonomy of women’s health care delivery
models, applied it to these results, and compared structural
and service quality differences among the original VA
Comprehensive WHCs, sites that had subsequently adopted
WHCs, and sites with more traditional primary care clinics
(PCCs).
Population Studied: All VA health care facilities serving 400
or more women veterans in the U.S. (n=166 medical centers
and community-based outpatient clinics).
Principal Findings: Gender-specific service availability in
WHCs is roughly comparable to that of the original centers
with important exceptions in mental health care,
mammography services and osteoporosis management.
Comprehensive WHCs were more likely to offer same-gender
providers (p<.05), women’s health training programs (p<.01),
separate women’s mental health clinics (p<.001) and separate
space and greater privacy (p<.05); they were also open more
half-days per week (7.9 vs. 5.4), had on average an additional
MD (2.9 vs. 1.8) and were more likely to integrate OB-GYN
MDs (2.4 vs. 0.8, p<.0001), as well as other specialty MDs
and trainees compared to WHCs. These larger programs were
also more likely to have undergone program closures in
education (p<.001) and staffing losses (p<.05) over the
previous two years compared to WHCs or PCCs.
Conclusions: The VA’s investment in establishing
comprehensive women’s health care in VA settings has led to
a substantial expansion of access to women’s clinics over the
past decade, though not of comparable size or scope of
practice.
Implications for Policy, Delivery, or Practice: While
substantial progress has been made, diffusion of
comprehensive women’s health care is as yet incomplete.
More research is needed to examine the incremental
differences in quality and patient satisfaction associated with
these different care models and features, while the business
case for managers faced with relatively small female patient
caseloads should also be examined.
Primary Funding Source: VA