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This paper examines the effects of conversions between For-Profit and Not-For-Profit forms on quality of medical care in California hospitals. The sample includes elderly patients treated in California's private hospitals from 1990 to 1998 for Acute Myocardial Infarction and Congestive Heart Failure. The results suggest that converted hospitals have experienced quality changes before conversion and that ignoring these changes may bias the estimates of conversion effects. Both conversions are found to have some adverse consequences: Hospitals that converted to FP form show an increase in AMI mortality rates, while those converted to NFP status indicate an increase in CHF mortality outcomes. [ABSTRACT FROM AUTHOR]

This paper develops flexibility measures in the context of a multi-firm output based on a generalized average cost function. We then apply this methodology to assess and compare the relative flexibility of hospital services in Québec and California based on two very complete data sets. Results indicate that there is no clear distinction between private and public institutions and that there is no clear distinction between Québec and California hospitals. However, there are clear differences in flexibility among different outputs. This last result suggests that there are bottlenecks in the health care system and calls for a targeted approach on the part of hospital administrators, whether public or private, in Québec or California. [ABSTRACT FROM AUTHOR]

Objective: We recently described the development of a comprehensive database for assessing phytoestrogen exposure in epidemiologic studies. This paper describes the first application of this database and the primary sources of phytoestrogen consumption in non-Asian women.Methods: Four hundred and forty-seven randomly selected African-American, Latina, and white women, ages 50-79 years, residing in California's San Francisco Bay Area and participating as controls in an ongoing population-based case-control study of breast cancer, were included in the present analysis. Average daily consumption of each of seven phytoestrogenic compounds was determined for each woman by combining the values from the new database with food consumption reported on a food-frequency questionnaire.Results: Phytoestrogens in the non-Asian Bay Area diet appear to come primarily from: (1) traditional soy-based foods (e.g. tofu and soy milk); (2) "hidden" sources of soy (e.g. foods containing added soy protein isolate, soy concentrate, or soy flour, e.g. many brands of doughnuts and white bread); and (3) a variety of foods which contain only low to moderate amounts of phytoestrogens per 100 grams but which are frequently consumed (e.g. coffee and orange juice).Conclusions: In the absence of a comprehensive assessment of various phytoestrogens in a wide variety of foods, epidemiologic studies could suffer from the effects of uncontrolled confounding by unmeasured sources of phytoestrogen exposure potentially leading to biased estimates of effect and misinterpretation of findings. [ABSTRACT FROM AUTHOR]

This paper examines relationships among six social factors and infant mortality in California in 1978 and seeks to explain social differentials in terms of two intervening variables. Linked birth and infant death records are analyzed to test for interactions among the social factors and mortality and for causal linkages involving the intervening variables. Social factors are related to the risk of infant mortality in a conditional manner; significant interactions involve maternal age and both birth order and marital status, and race/ethnicity and both education and marital status. Birth weight and prenatal care are important intervening variables but do not fully explain the social differentials. [ABSTRACT FROM AUTHOR]

In this paper, we model unmarried teenagers' decisions about their pregnancy outcome by considering that the teenager contrasts her expected utility (1) as a married mother, (2) as an unmarried mother, or (3) after abortion. We use cross-sectional data on 297 California teenagers aged 13-19 who were pregnant for the first time between 1972 and 1974. Both Anglo and Mexican-American girls are included. We find that pregnant girls who are eligible for or are receiving public assistance are more likely to give birth and remain unmarried. Teenagers with greater time values are more likely to choose abortion, and Mexican-American girls are more likely to carry their pregnancies to term. [ABSTRACT FROM AUTHOR]

Background: Electronic referrals can improve access to subspecialty care in safety net settings. In January 2007, San Francisco General Hospital (SFGH) launched an electronic referral portal that incorporated subspecialist triage, iterative communication with referring providers, and existing electronic health record data to improve access to subspecialty care.Objective: We surveyed primary care providers (PCPs) to assess the impact of electronic referrals on workflow and clinical care.Design: We administered an 18-item, web-based questionnaire to all 368 PCPs who had the option of referring to SFGH.Measurements: We asked participants to rate time spent submitting a referral, guidance of workup, wait times, and change in overall clinical care compared to prior referral methods using 5-point Likert scales. We used multivariate logistic regression to identify variables associated with perceived improvement in overall clinical care.Results: Two hundred ninety-eight PCPs (81.0%) from 24 clinics participated. Over half (55.4%) worked at hospital-based clinics, 27.9% at county-funded community clinics, and 17.1% at non-county-funded community clinics. Most (71.9%) reported that electronic referrals had improved overall clinical care. Providers from non-county-funded clinics (AOR 0.40, 95% CI 0.14-0.79) and those who spent > or =6 min submitting an electronic referral (AOR 0.33, 95%CI 0.18-0.61) were significantly less likely than other participants to report that electronic referrals had improved clinical care.Conclusions: PCPs felt electronic referrals improved health-care access and quality; those who reported a negative impact on workflow were less likely to agree. While electronic referrals hold promise as a tool to improve clinical care, their impact on workflow should be considered. [ABSTRACT FROM AUTHOR]

This paper describes a short-term longitudinal study of the relation between violent victimization in the community and peer rejection among 199 children (mean age = 9.02 years) attending two urban Los Angeles area elementary schools. We used a multi-informant approach to assess victimization by community violence, peer group victimization, peer rejection, and impairments in emotion regulation. These data were collected annually for two consecutive school years. Violent victimization in the community predicted later peer rejection after accounting for the effects of initial levels of peer rejection. Analyses indicated that this relation was mediated by deficient emotion regulation skills. In addition, we found evidence that victimization by community violence and peer rejection are reciprocally related over time. The developmental implications of these findings are discussed. [ABSTRACT FROM AUTHOR]

The development of new pharmaceutical interventions for persons with human immunodeficiency virus (HIV) infection has resulted in extended survival and a need for valid, reliable and responsive instruments to assess health-related QoL (HRQoL). This paper reviews the reliability and validity of an HRQoL instrument, the AIDS Health Assessment Questionnaire (AIDS-HAQ), among persons participating in an observational database of HIV infection. The AIDS-HAQ includes nine subscales: disability, energy, general health, pain, cognitive functioning, mental health, social functioning, health distress and symptoms. Individuals complete the AIDS-HAQ quarterly. Data are reported for 440 individuals entering the study with early HIV infection. Fifty-nine progressed to symptomatic disease and 109 to AIDS after 1 year. The subscales of the instrument resulted in high internal consistency reliability (range = 0.79-0.88). Concurrent validity data reflected the ability to distinguish between patients with increasing disease severity. In all domains, except cognitive functioning, individuals who progressed to AIDS had significant decrements (p < 0.01) in HRQoL compared with symptomatic and asymptomatic patients. Significant decrements (p < 0.01) were observed for disability, general health, energy and symptoms for patients who progressed to symptomatic disease from an asymptomatic status. Individuals who had decreasing CD4+ counts also had significant declines (p < 0.001) in disability, general health, social functioning, pain and symptoms. The AIDS-HAQ is an instrument that can be used when comparing group differences and within group changes in observational databases, naturalistic studies and clinical trials. [ABSTRACT FROM AUTHOR]

Background/objectives: This study examined the long-term relation of lipid-soluble micronutrients with diet quality as assessed by four a priori-defined dietary patterns.Subjects/methods: In a prospective design, nutritional biomarkers (carotenoids, tocopherols, retinol, and coenzyme Q10) were measured using a validated HPLC-based assay. General linear models were applied to obtain covariate-adjusted means of biomarkers for tertiles of four a priori diet quality indices: Healthy Eating Index (HEI) 2010, Alternative HEI (AHEI) 2010, Alternate Mediterranean Diet Score (aMED), and Dietary Approaches to Stop Hypertension (DASH). For a subcohort of 8367 participants within the Multiethnic Cohort (MEC), diet was assessed by a validated quantitative food frequency questionnaire in 1993-96 and serum was collected in 2001-06.Results: Participants with the highest diet-quality scores had significantly higher serum concentrations of all carotenoids, total tocopherols, and α-tocopherol, whereas γ-tocopherol was inversely associated with diet quality. Adjusted means for the lowest vs. highest tertile of HEI 2010 were 1.2 vs. 1.5 mg/L for total carotenoids, 11.4 vs. 12.3 mg/L for total tocopherols, and 1.9 vs. 1.6 mg/L for γ-tocopherol (ptrend < 0.0001). The associations for the other dietary indices were similar; no indication for sex and ethnic differences was detected. Vegetable and fruit components were major predictors of most circulating micronutrients, but most other components were also associated.Conclusions: Higher diet-quality scores measured by four a priori diet quality indices were significantly associated higher serum concentrations of carotenoids and α-tocopherol, whereas γ-tocopherol was inversely associated with diet quality. [ABSTRACT FROM AUTHOR]

Background: Patients with cirrhosis are at high readmission risk. Using a large statewide database, we evaluated the effect of hospital cirrhosis-related patient volume on 30-day readmissions in patients with cirrhosis.Methods: We conducted a retrospective study of the Healthcare Cost and Utilization Project State Inpatient Database for adult patients with cirrhosis, as defined by International Classification of Diseases, Ninth Revision (ICD-9) codes, hospitalized in California between 2009 and 2011. Multivariable logistic regression analysis was performed to evaluate the effect of hospital volume on 30-day readmissions.Results: A total of 69,612 patients with cirrhosis were identified in 405 hospitals; 24,062 patients were discharged from the top 10% of hospitals (N = 41) by cirrhosis volume, and 45,550 patients in the bottom 90% (N = 364). Compared with higher-volume centers, lower-volume hospitals cared for patients with similar average Quan-Charlson-Deyo (QCD) comorbidity scores (6.54 vs. 6.68), similar proportion of hepatitis B and fatty liver disease, lower proportion of hepatitis C (34.8 vs. 41.5%) but greater proportion of alcoholic liver disease (53.1 vs. 47.4%). Multivariable logistic regression analysis demonstrated admission to a lower-volume hospital did not predict 30-day readmission (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.92-1.01) after adjusting for sociodemographics, QCD score, cirrhosis severity, and hospital characteristics. Instead, liver transplant center status significantly decreased the risk of readmission (OR 0.87, 95% CI 0.80-0.94). Ascites, hepatic encephalopathy, hepatocellular carcinoma, higher QCD, and presence of alcoholic liver disease and hepatitis C were also independent predictors.Conclusions: Readmissions within 30 days were common among patients with cirrhosis hospitalized in California. While hospital cirrhosis volume did not predict 30-day readmissions, liver transplant center status was protective of readmissions. Medically complicated patients with cirrhosis at hospitals without liver transplant centers may benefit from additional support to prevent readmission. [ABSTRACT FROM AUTHOR]

In order to reduce gender dysphoria and combat stigma, transgender women often affirm their gender through social and medical transition, which may include cross-sex hormone therapy. This study examined associations between medically monitored hormone use and hormone misuse (non-prescribed hormone use including "fillers"), structural inequities (access to housing, health insurance, and income), and social network dynamics among 271 transgender women in Los Angeles. Hormone use status was coded trichotomously (hormone use, hormone misuse, no hormone use), and robust multinomial logistic regression as well as novel social network analysis was conducted to examine associations. Results demonstrated that younger, African-American/Black transgender women were most likely to engage in hormone misuse compared to transgender women who were older or non-African-American/Black. One-third of the sample reported sex work as a main source of income, and this group was more likely to misuse hormones than those with another primary source of income. Transgender women with access to stable housing and health insurance were most likely to engage in medically monitored hormone use. Social network analysis revealed that transgender women with a greater number of hormone-using network alters were most likely to misuse hormones, but that using the Internet to find transgender friends mitigated this association. Results demonstrate the multifaceted risk profile of transgender women who use and misuse hormones, including that social networks play an important role in hormone usage among transgender women. [ABSTRACT FROM AUTHOR]

Health volunteerism has been associated with positive health outcomes for volunteers and the communities they serve. This work suggests that there may be an added value to providing underserved populations with information and skills to be agents of change. The current study is a first step toward testing this hypothesis. The purpose is to identify how volunteerism may result in improved cancer health among Latina and African American women volunteers. A purposive sample of 40 Latina and African American female adults who had participated in cancer volunteerism in the past 5 years was recruited by community advocates and flyers distributed throughout community venues in San Diego, CA. This qualitative study included semi-structured focus groups. Participants indicated that volunteerism not only improved their health but also the health of their family and friends. Such perceptions aligned with the high rates of self-report lifetime cancer screening rates among age-eligible patients (e.g., 83-93 % breast; 90-93 % cervical; 79-92 % colorectal). Identified mechanisms included exposure to evidence-based information, health-protective social norms and support, and pressure to be a healthy role model. Our findings suggest that train-the-trainer and volunteer-driven interventions may have unintended health-protective effects for participating staff, especially Latina and African American women. [ABSTRACT FROM AUTHOR]

Purpose: To describe the utilization of gene expression profiling (GEP) among California breast cancer patients, identify predictors of use of GEP, and evaluate how utilization of GEP influenced treatment of early-stage breast cancer.Methods: All women diagnosed with hormone-receptor-positive, node-negative breast cancer reported to the California Cancer Registry between January 2008 and December 2010 were linked to Oncotype DX (ODX) assay results.Results: Overall, 26.7 % of 23,789 eligible patients underwent the assay during the study period. Women age 65 or older were much less likely than women under age 50 to be tested (15.1 vs. 41.4 %, p < 0.001). Black women were slightly less likely and Asian women were slightly more likely than non-Hispanic white women to undergo GEP with the ODX assay (22.2 and 28.9 vs. 26.9 %, respectively, p < 0.001). Patients residing in low SES census tracts had the lowest use of the test (8.9 %), with the proportion increasing with higher SES category. Women with Medicaid health insurance were less likely than other women to be tested (17.7 vs. 27.5 %, p < 0.001). Receipt of adjuvant chemotherapy (ACT) was associated with the ODX recurrence score, although only 63 % of patients whose recurrence scores indicated a high benefit received ACT. Of patients not tested, 15 % received ACT.Conclusions: Nearly three-fourths of eligible breast cancer patients in California during the 3-year period 2008 through 2010 did not undergo GEP. As a result, it is likely that many women unnecessarily received ACT and suffered associated morbidity. In addition, some high-risk women who would have benefited most from ACT were not identified. [ABSTRACT FROM AUTHOR]

Although vaccination against the Human Papilloma Virus (HPV) reduces the risk of related morbidities, the vaccine uptake remains low in adolescents. This has been attributed to limited parental knowledge and misconceptions. In this cross sectional study, we assessed the (1) clarity of educational material informing Hispanic mothers about HPV, cervical cancer and the HPV vaccine, (2) determined vaccination acceptability and (3) identified predictors of vaccine acceptance in an underserved health setting. 418 Hispanic mothers received the educational material and completed an anonymous survey. 91 % of participants understood most or all of the information provided. 77 % of participants reported vaccine acceptance for their children; this increased to 84 % when only those with children eligible to receive vaccination were included. Significant positive predictors of maternal acceptance of the HPV vaccine for their children were understanding most or all of the provided information, older age and acceptance of the HPV vaccine for themselves. Concerns about safety and general dislike of vaccines were negatively associated with HPV vaccine acceptance. Prior knowledge, level of education, previous relevant gynecologic history, general willingness to vaccinate and other general beliefs about vaccines were not significantly associated with HPV vaccine acceptance. The majority of participants reported understanding of the provided educational material. Vaccine acceptability was fairly high, but was even higher among those who understood the information. This study documents a cost-effective way to provide Hispanic mothers with easy-to-understand HPV-related information that could increase parental vaccine acceptability and future vaccine uptake among their children. [ABSTRACT FROM AUTHOR]

Background: For more than a decade, the presence of diabetes has been considered a coronary heart disease (CHD) "risk equivalent". Objective: The objective of this study was to revisit the concept of risk equivalence by comparing the risk of subsequent CHD events among individuals with or without history of diabetes or CHD in a large contemporary real-world cohort over a period of 10 years (2002 to 2011). Design: Population-based prospective cohort analysis. Participants: We studied a cohort of 1,586,061 adult members (ages 30-90 years) of Kaiser Permanente Northern California, an integrated health care delivery system. Main Measurements: We calculated hazard ratios (HRs) from Cox proportional hazard models for CHD among four fixed cohorts, defined by prevalent (baseline) risk group: no history of diabetes or CHD (None), prior CHD alone (CHD), diabetes alone (DM), and diabetes and prior CHD (DM + CHD). Key Results: We observed 80,012 new CHD events over the follow-up period (~10,980,800 person-years). After multivariable adjustment, the HRs (reference: None) for new CHD events were as follows: CHD alone, 2.8 (95% CI, 2.7-2.85); DM alone 1.7 (95% CI, 1.66-1.74); DM + CHD, 3.9 (95% CI, 3.8-4.0). Individuals with diabetes alone had significantly lower risk of CHD across all age and sex strata compared to those with CHD alone (12.2 versus 22.5 per 1000 person-years). The risk of future CHD for patients with a history of either DM or CHD was similar only among those with diabetes of long duration (≥10 years). Conclusions: Not all individuals with diabetes should be unconditionally assumed to be a risk equivalent of those with prior CHD. [ABSTRACT FROM AUTHOR]

Purpose: To compare information from self-report and electronic medical records for four common comorbidities (diabetes, hypertension, myocardial infarction, and other heart diseases).Methods: We pooled data from two multiethnic studies (one case-control and one survivor cohort) enrolling 1,936 women diagnosed with breast cancer, who were members of Kaiser Permanente Northern California.Results: Concordance varied by comorbidity; kappa values ranged from 0.50 for other heart diseases to 0.87 for diabetes. Sensitivities for comorbidities from self-report versus medical record were similar for racial/ethnic minorities and non-Hispanic Whites, and did not vary by age, neighborhood socioeconomic status, or education. Women with a longer history of comorbidity or who took medications for the comorbidity were more likely to report the condition. Hazard ratios for all-cause mortality were not consistently affected by source of comorbidity information; the hazard ratio was lower for diabetes, but higher for the other comorbidities when medical record versus self-report was used. Model fit was better when the medical record versus self-reported data were used.Conclusions: Comorbidities are increasingly recognized to influence the survival of patients with breast or other cancers. Potential effects of misclassification of comorbidity status should be considered in the interpretation of research results. [ABSTRACT FROM AUTHOR]

Background: The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with dual-energy x-ray absorptiometry (DXA) for women aged ≥ 65 years and younger women with increased risk. "Choosing Wisely" initiatives advise avoiding DXA screening in women younger than 65 years without osteoporosis risk factors.Objective: We aimed to determine the extent to which DXA screening is used in accordance with USPSTF recommendations within a regional health system.Design: This was a retrospective longitudinal cohort study within 13 primary care clinics in the Sacramento, CA region.Patients: The study included 50,995 women aged 40-85 years without prior osteoporosis screening, diagnosis, or treatment attending primary care visits from 2006 to 2012, observed for a mean of 4.4 years.Main Measures: We examined incidence of DXA screening. Covariates included age, race/ethnicity, and osteoporosis risk factors (body mass index < 20, glucocorticoid use, secondary osteoporosis, prior high-risk facture, rheumatoid arthritis, alcohol abuse, and current smoking).Key Results: Among previously unscreened women for whom the USPSTF recommends screening, 7-year cumulative incidence of DXA screening was 58.8 % among women aged 60-64 years with ≥ 1 risk factor (95 % CI: 51.9-65.8 %), 57.8 % for women aged 65-74 years (95 % CI: 55.6-60.0 %), and 42.7 % for women aged ≥ 75 years (95 % CI: 38.7-46.7 %). Among women for whom the USPSTF does not recommend screening, 7-year cumulative incidence was 45.5 % among women aged 50-59 years (95 % CI 44.1-46.9 %) and 58.6 % among women aged 60-64 years without risk factors (95 % CI 55.9-61.4 %).Conclusions: DXA screening was underused in women at increased fracture risk, including women aged ≥ 65 years. Meanwhile, DXA screening was common among women at low fracture risk, such as younger women without osteoporosis risk factors. Interventions may be needed to augment the value of population screening for osteoporosis. [ABSTRACT FROM AUTHOR]

African-American men who have sex with men (AA MSM) have been disproportionately infected with and affected by HIV and other STIs in San Francisco and the USA. The true scope and scale of the HIV epidemic in this population has not been quantified, in part because the size of this population remains unknown. We used the successive sampling population size estimation (SS-PSE) method, a new Bayesian approach to population size estimation that incorporates network size data routinely collected in respondent-driven sampling (RDS) studies, to estimate the number of AA MSM in San Francisco. This method was applied to data from a 2009 RDS study of AA MSM. An estimate from a separate study of local AA MSM was used to model the prior distribution of the population size. Two-hundred and fifty-six AA MSM were included in the RDS survey. The estimated population size was 4917 (95% CI 1267-28,771), using a flat prior estimated 1882 (95% CI 919-2463) as a lower acceptable bound, and a large prior estimated 6762 (95% CI 1994-13,863) as an acceptable upper bound. Point estimates from the SS-PSE were consistent with estimates from multiplier methods using external data. The SS-PSE method is easily integrated into RDS studies and therefore provides a simple and appealing tool to rapidly produce estimates of the size of key populations otherwise difficult to reach and enumerate. [ABSTRACT FROM AUTHOR]

Research on neighborhoods and health has been growing. However, studies have not investigated the association of specific neighborhood measures, including socioeconomic and built environments, with cancer incidence or outcomes. We developed the California Neighborhoods Data System (CNDS), an integrated system of small area-level measures of socioeconomic and built environments for California, which can be readily linked to individual-level geocoded records. The CNDS includes measures such as socioeconomic status, population density, racial residential segregation, ethnic enclaves, distance to hospitals, walkable destinations, and street connectivity. Linking the CNDS to geocoded cancer patient information from the California Cancer Registry, we demonstrate the variability of CNDS measures by neighborhood socioeconomic status and predominant race/ethnicity for the 7,049 California census tracts, as well as by patient race/ethnicity. The CNDS represents an efficient and cost-effective resource for cancer epidemiology and control. It expands our ability to understand the role of neighborhoods with regard to cancer incidence and outcomes. Used in conjunction with cancer registry data, these additional contextual measures enable the type of transdisciplinary, "cells-to-society" research that is now being recognized as necessary for addressing population disparities in cancer incidence and outcomes. [ABSTRACT FROM AUTHOR]

Objective: To investigate how birthplace influences the incidence of papillary thyroid cancer among Asian American women.Methods: Birthplace- and ethnic-specific age-adjusted and age-specific incidence rates were calculated using data from the California Cancer Registry for the period 1988-2004. Birthplace was statistically imputed for 30% of cases using a validated imputation method based on age at Social Security number issuance. Population estimates were obtained from the US Census. Incidence rate ratios (IRR) and 95% confidence intervals (CI) were estimated for foreign-born vs. US-born women.Results: Age-adjusted incidence rates of papillary thyroid cancer among Filipina (13.7 per 100,000) and Vietnamese (12.7) women were more than double those of Japanese women (6.2). US-born Chinese (IRR = 0.48, 95% CI: 0.40-0.59) and Filipina women (IRR = 0.74, 95% CI: 0.58-0.96) had significantly higher rates than those who were foreign-born; the opposite was observed for Japanese women (IRR = 1.55, 95% CI: 1.17-2.08). The age-specific patterns among all foreign-born Asian women and US-born Japanese women showed a slow steady increase in incidence until age 70. However, among US-born Asian women (except Japanese), substantially elevated incidence rates during the reproductive and menopausal years were evident.Conclusions: Ethnic- and birthplace-variation in papillary thyroid cancer incidence can provide insight into the etiology of this increasingly common and understudied cancer. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether obesity and hormone therapy (HT) are associated with ovarian cancer risk among women in the California Teachers Study cohort.Methods: Of 56,091 women age ≥ 45 years, 277 developed epithelial ovarian cancer between 1995 and 2007. Multivariate Cox regression was performed.Results: Among women who never used HT, greater adult weight gain, waist circumference and waist-to-height ratio, but not adult BMI, increased risk of ovarian cancer. Compared to women who never used HT and had a stable adult weight, risk of ovarian cancer was increased in women who gained ≥ 40 lb (relative risk (RR) 1.8, 95% confidence interval (CI): 1.0-3.0) or used HT for >5 years (RR 2.3 95% CI: 1.3-4.1). Having both exposures (RR 1.9, 95% CI: 0.99-3.5), however, did not increase risk more than having either alone. Results were similar for waist circumference and weight-to-height ratio; however, differences across HT groups were not statistically significant.Conclusions: This study suggests that abdominal adiposity and weight gain, but not overall obesity, increase ovarian cancer risk and that there may be a threshold level beyond which additional hormones, whether exogenous or endogenous, do not result in additional elevation in risk. However, large pooled analyses are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

This cross-sectional study assessed vitamin D status of healthy infants and young children undergoing routine care in a medical center pediatric clinic in Sacramento, CA, and evaluated associations of status with markers of vitamin D function. Such data have not recently been reported from similar locations with sunny climates that should minimize risk of deficiency. Exposures included diet, supplement use, and sun exposure, and outcomes included plasma 25-hydroxy vitamin D (25[OH]D), parathyroid hormone (PTH), bone-specific alkaline phosphatase, and eight markers of immune activation. The median age of the 173 subjects was 12 months (range, 6-19); 49% were female. The median 25(OH)D was 85 nmol/l (range, 9-198); five subjects (2.9%) had <27.5 nmol/l, indicative of deficiency; 14 (8.1%) had <50 nmol/l, and 49 (28.3%) had <75 nmol/l. Most subjects (154; 89%) received some vitamin-D-fortified cow's milk or formula while 19 (11%) received breast milk as the only milk source. Breastfeeding was associated with risk of vitamin D deficiency (p < 0.001). Subjects with 25(OH)D <27.5 nmol/l had elevated PTH (p = 0.007). Only four of 35 breastfed infants (11%) consuming <500 ml/day vitamin-D-fortified formula or milk received vitamin D supplements. Plasma interleukin (IL)-1β was significantly higher (p = 0.036) in infants in the highest vs. lowest 25(OH)D decile. In conclusion, this study demonstrates that vitamin D deficiency with elevated PTH remains a risk for breastfed subjects not receiving supplemental vitamin D even in a region with a sunny, temperate climate. Strategies to improve supplementation should be sought. [ABSTRACT FROM AUTHOR]

Background: We investigated the association between hypertension, antihypertensive (AH) medication use, and breast cancer in a large prospective study, the California Teachers Study (CTS).Methods: Information on history of hypertension and lifetime regular use of AH medications was collected from 114,549 women in 1995-1996. Among them, 4,151 invasive breast cancers were diagnosed between 1995 and 2006. Additional information on AH use was collected from 73,742 women in 2000-2001, and 1,714 of these women were subsequently diagnosed with breast cancer. Cox proportional hazards regression was used to estimate relative risks (RR) and 95% confidence intervals (CI) for breast cancer.Results: Use of AH medication for ≥5 years, when compared with no use, was associated with a modest increased risk of invasive breast cancer (RR = 1.18, 95%CI 1.02-1.36). This increased risk appeared to be confined to estrogen receptor (ER)-positive tumors (RR = 1.21, 95%CI 1.03-1.43) and pre-/peri-menopausal women (RR = 1.58, 95%CI 1.11-2.25).Conclusions: Increased risk of invasive breast cancer was observed for long-term (≥5 years) AH use, and this appeared to be confined to ER + breast cancer and younger women. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether hormone therapy (HT) and obesity are associated with endometrial cancer risk among postmenopausal women in the California Teachers Study cohort.Methods: Of 28,418 postmenopausal women, 395 developed type 1 endometrial cancer between 1995 and 2006. Multivariate Cox regression was performed to estimate relative risks (RR), stratified by HT use (never used, ever estrogen alone (ET) or exclusively estrogen-plus-progestin (EPT)).Results: Among women who never used HT, overall and abdominal adiposity were associated with increased risk; when evaluated simultaneously, abdominal adiposity was more strongly associated (RR 2.2, 95% confidence interval (CI): 1.1-4.5 for waist >or=35 vs. <35 inches). Among women who ever used ET, risk was increased in women with BMI >or= 25 kg/m(2) (RR 1.6, 95% CI: 1.1-2.3 vs. <25 kg/m(2)). Neither overall nor abdominal obesity was associated with risk in women who exclusively used EPT (p-interaction <0.001 for BMI by HT use).Conclusions: Among women who never used HT, risk was strongly positively related to obesity and may have been influenced more by abdominal than by overall adiposity; however, due to small numbers, this latter finding requires replication. Among women who ever used ET, being overweight at baseline predicted higher risk, whereas use of EPT mitigated any effects of obesity. [ABSTRACT FROM AUTHOR]

Background and Aim: Intestinal and extra-intestinal complications are associated with inflammatory bowel disease (IBD) but their exact incidence is not well known. In order to improve our understanding of their incidence and impact, we assessed the complications associated with ulcerative colitis (UC) and Crohn's disease (CD) in a population-based study in Medicaid patients.Methods: We utilized a retrospective cohort design and identified cases of UC and CD using Medi-Cal, the Medicaid program for the State of California. The disease cohort was age- and gender-matched to four controls each and the intestinal and extra-intestinal complications of CD and UC (analyzed separately) were studied over a period of 5 years following the initial diagnosis.Results: For UC, the total number of intestinal complications, per 100 cases, was 92 observed compared to 21 expected; the total number of extra-intestinal complications was 42 observed compared to 30 expected. For CD, the number of intestinal complications was 81 observed compared to 20 expected and for extra-intestinal complications, 37 observed compared to 26 expected (all p < 0.001). For both UC and CD, bleeding was the most frequently seen intestinal complication, while the most common extra-intestinal complication was osteoporosis.Conclusions: IBD is associated with several intestinal and extra-intestinal complications of variable incidence and risk. Success of therapeutic regimens should be measured by decreases in incidence, risks, and costs of these complications, in addition to the usual impact on disease activity. [ABSTRACT FROM AUTHOR]

Background: The majority of states have enacted price transparency laws to allow patients to shop for care and to prevent price discrimination of the uninsured. In California, hospitals must provide a price estimate to a requesting uninsured patient and cannot bill for an amount greater than the reimbursement the hospital would receive from a government payer.Objective: To assess the response rate of California hospitals to a patient price request and to compare the price estimates received to Medicare reimbursement.Design: We sent letters to California acute-care hospitals from a fictional uninsured patient requesting an estimate for one of three common elective procedures: a laparoscopic cholecystectomy, a hysterectomy, or routine screening colonoscopy.Participants: Three hundred and fifty-three hospitals in California.Measurements: Hospital response rates, difference between price estimates received, and Medicare reimbursement for equivalent procedures.Results: Only 28% (98/353) of hospitals responded and their response varied in content. Of the 98 responses, 15 (15%) did not provide a quote and instead asked for more information such as the billing code, 55 (56%) provided a price estimate for hospital services only, 10 (10%) included both physician and hospital services, and 18 (18%) did not specify what was covered. The median discounted price estimate was higher than Medicare reimbursement rates for all procedures: hysterectomy ($17,403 vs. $5,569; p<0.001), cholecystectomy ($14,014 vs. $7,196; p<0.001) and colonoscopy ($2,017 vs. $216; p<0.001).Conclusions: Current California legislation fails to meet its objective of enabling uninsured patients to compare prices for hospital-based health care services. [ABSTRACT FROM AUTHOR]

Background: Patient experience measures are central to many pay-for-performance (P4P) programs nationally, but the effect of performance-based financial incentives on improving patient care experiences has not been assessed.Methods: The study uses Clinician & Group CAHPS data from commercially insured adult patients (n = 124,021) who had visits with 1,444 primary care physicians from 25 California medical groups between 2003 and 2006. Medical directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the patient experience improvement activities adopted by groups. Multilevel regression models were used to assess the relationship between performance change on patient care experience measures and medical group characteristics, financial incentives, and performance improvement activities.Results: Over the course of the study period, physicians improved performance on the physician-patient communication (0.62 point annual increase, p < 0.001), care coordination (0.48 point annual increase, p < 0.001), and office staff interaction (0.22 point annual increase, p = 0.02) measures. Physicians with lower baseline performance on patient experience measures experienced larger improvements (p < 0.001). Greater emphasis on clinical quality and patient experience criteria in individual physician incentive formulas was associated with larger improvements on the care coordination (p < 0.01) and office staff interaction (p < 0.01) measures. By contrast, greater emphasis on productivity and efficiency criteria was associated with declines in performance on the physician communication (p < 0.01) and office staff interaction (p < 0.001) composites.Conclusions: In the context of statewide measurement, reporting, and performance-based financial incentives, patient care experiences significantly improved. In order to promote patient-centered care in pay for performance and public reporting programs, the mechanisms by which program features influence performance improvement should be clarified. [ABSTRACT FROM AUTHOR]

Background and Objectives: There is growing international concern that food insecurity may negatively impact antiretroviral (ARV) treatment outcomes, but no studies have directly evaluated the effect of food insecurity on viral load suppression and antiretroviral adherence. We hypothesized that food insecurity would be associated with poor virologic response among homeless and marginally housed HIV-positive ARV-treated patients.Design: This is a cross-sectional study.Participants and Setting: Participants were ARV-treated homeless and marginally housed persons receiving adherence monitoring with unannounced pill counts in the Research on Access to Care in the Homeless (REACH) Cohort.Measurements: Food insecurity was measured by the Household Food Insecurity Access Scale (HFIAS). The primary outcome was suppression of HIV viral RNA to <50 copies/ml. We used multivariate logistic regression to assess whether food insecurity was associated with viral suppression.Results: Among 104 participants, 51% were food secure, 24% were mildly or moderately food insecure and 25% were severely food insecure. Severely food insecure participants were less likely to have adherence > or =80%. In adjusted analyses, severe food insecurity was associated with a 77% lower odds of viral suppression (95% CI = 0.06-0.82) when controlling for all covariates. In analyses stratified by adherence level, severe food insecurity was associated with an 85% lower odds of viral suppression (95% CI = 0.02-0.99) among those with < or =80% adherence and a 66% lower odds among those with >80% adherence (95% CI = 0.06-1.81).Conclusions: Food insecurity is present in half of the HIV-positive urban poor in San Francisco, one of the best resourced settings for HIV-positive individuals in the United States, and is associated with incomplete viral suppression. These findings suggest that ensuring access to food should be an integral component of public health HIV programs serving impoverished populations. [ABSTRACT FROM AUTHOR]

Objective: With 2.3 million breast cancer survivors in the US today, identification of modifiable factors associated with breast cancer recurrence and survival is increasingly important. Only recently new studies have been designed to examine the impact of lifestyle factors on prognosis, including Pathways, a prospective study of women with breast cancer in Kaiser Permanente Northern California (KPNC).Methods: Pathways aims to examine the effect on recurrence and survival of (1) lifestyle factors such as diet, physical activity, quality of life, and use of alternative therapies and (2) molecular factors such as genetic polymorphisms involved in metabolism of chemotherapeutic agents. Eligibility includes any woman diagnosed with invasive breast cancer within KPNC, no previous diagnosis of other invasive cancer, age 21 years or older, and ability to speak English, Spanish, Cantonese, or Mandarin. Newly diagnosed patients are identified daily from electronic pathology records and are enrolled within two months of diagnosis. An extensive baseline interview is conducted, blood and saliva samples are collected, and body measurements are taken. Women are followed for lifestyle updates, treatment, and outcomes by self-report and query of KPNC databases.Results: Recruitment began in 9 January, 2006, and as of 16 January, 2008, 1,539 women have been enrolled along with collection of 1,323 blood samples (86%) and 1,398 saliva samples (91%).Conclusions: The Pathways Study will become a rich resource to examine behavioral and molecular factors and breast cancer prognosis. [ABSTRACT FROM AUTHOR]

Background: Human papillomavirus (HPV) testing is increasingly being used to determine the optimal cervical cancer screening interval in older women. Little is known about women's attitudes toward HPV testing or how these attitudes may influence medical discussions about cervical cancer screening.Methods: Preferences for HPV and concomitant Papanicolaou (Pap) testing were assessed through in-person interviews with diverse women aged 50 to 80 years recruited from community and university-based practices.Results: Eight hundred and sixty-five women (257 White, 87 African American, 149 Latina, and 372 Asian) were interviewed. Approximately 60% of participants wanted to be tested for HPV and another 15% would undergo testing if recommended by their physician. Among those wanting HPV testing, 94% would want more frequent than annual Pap tests if they had a positive HPV test and a normal Pap test. Two thirds of those under age 65 would be willing to switch to triennial Pap testing, and half of those aged 65 and older would be willing to discontinue Pap testing, if they had a negative HPV test and normal Pap test. Preferences for testing varied by ethnicity, age, place of birth, and cancer history.Conclusions: The majority of older women were willing to use HPV testing to make decisions about frequency and duration of cervical cancer screening, but up to one third would want at least annual, ongoing screening regardless of HPV test results. Efforts should be made to ensure that HPV testing is used to reinforce appropriate utilization of screening tests. [ABSTRACT FROM AUTHOR]

Much recent research on sexual minorities has used couples-based samples, which--by construction--provide no information on nonpartnered individuals. We present the first systematic empirical analysis of partnership and cohabitation among self-identified gay men and lesbians using two independent, large, population-wwbased data sources from California. These data indicate that 37%-46% of gay men and 51%-62% of lesbians aged 18-59 are in cohabiting partnerships (compared with 62% of heterosexual individuals in coresidential unions at comparable ages). Unlike previous research, we find that white and highly educated gay men and lesbians are more likely to be partnered, and we confirm that same-sex cohabiting partners in our data have demographic characteristics that are similar to California same-sex couples from Census 2000. We also present the first detailed analysis of officially registered domestic partnerships in California. We find that almost half of partnered lesbians are officially registered with the local or state government, while less than a quarter of partnered gay men are officially registered. We conclude with implications of our findings for couples-based research on gay men and lesbians, as well as recommendations for survey data collection. [ABSTRACT FROM AUTHOR]

Background: Residence in disadvantaged neighborhoods is associated with poorer access to healthy foods.Objective: To understand associations between the neighborhood food resource environment and residents' health status and body mass index (BMI) for adults with and without chronic conditions.Design: Cross-sectional multilevel analysis.Participants: 2,536 adults from the 2000-2001 Los Angeles Family and Neighborhood Survey.Measurements: The food resource environment was defined as the number of chain supermarkets, independent supermarkets, small markets, or convenience stores per roadway miles in the census tract. The main dependent variables were self-rated health, dichotomized as excellent or fair/poor, and body mass index (BMI). Multilevel regression models examined the association between the food resource environment and both BMI and the odds of reporting excellent health after adjustment for neighborhood SES and individual characteristics.Results: More chain supermarkets per roadway mile in a census tract was associated with higher adjusted rates of reporting excellent health (33%, 38%, and 43% for those in the lowest, middle, and highest tertiles of chain supermarkets) and lower adjusted mean BMI (27, 26, and 25 kg/m(2)) for residents without a chronic condition, but not those with a chronic condition. In contrast, having more convenience stores per roadway mile was associated with lower health ratings only among adults with a chronic condition (39%, 32%, and 27% for the lowest to highest tertile of convenience stores).Conclusion: Health status and BMI are associated with the local food environment, but the associations differ by type of market and presence of a chronic condition. [ABSTRACT FROM AUTHOR]

Background: Despite the availability of effective hypertension, hyperlipidemia, and hyperglycemia therapies, target levels of systolic blood pressure (SBP), LDL-cholesterol (LDL-c), and hemoglobin A1c control are often not achieved.Objective: To examine the relative importance of patient medication nonadherence versus clinician lack of therapy intensification in explaining above target cardiovascular disease (CVD) risk factor levels.Design: Cross-sectional assessment.Participants: In 2005, 161,697 Kaiser Permanente Northern California adult diabetes patients were included in the study.Measurement: "Above target" was defined as most recent A1c >/=7.0% for hyperglycemia, LDL-c >/=100 mg/dL for hyperlipidemia, and SBP >/=130 mmHg for hypertension. Poor adherence was defined as medication gaps for >/=20% of days covered for all medications for each condition separately. Treatment intensification was defined as an increase in the number of drug classes, increased dosage of a class, or a switch to a different class within the 3 months before or after notation of above target levels.Results: Poor adherence was found in 20-23% of patients across the 3 conditions. No evidence of poor adherence with no treatment intensification was found in 30% of hyperglycemia patients, 47% of hyperlipidemia patients, and 36% of hypertension patients. Poor adherence or lack of therapy intensification was evident in 53-68% of patients above target levels across conditions.Conclusions: Both nonadherence and lack of treatment intensification occur frequently in patients above target for CVD risk factor levels; however, lack of therapy intensification was somewhat more common. Quality improvement efforts should focus on these modifiable barriers to CVD risk factor control. [ABSTRACT FROM AUTHOR]

Background: Informed consent is legally and ethically required before invasive non-emergent procedures. Language barriers make obtaining informed consent more complex.Objective: Determine the impact of language barriers on documentation of informed consent among patients in a teaching hospital with on-site interpreter services.Design: Matched retrospective chart review study.Subjects: Eligible Chinese- and Spanish-speaking patients with limited English proficiency (LEP) who received a thoracentesis, paracentesis, or lumbar puncture were matched with eligible English-speaking patients by procedure, hospital service, and date of procedure.Measurements: Charts were reviewed for documentation of informed consent (IC), including a procedure note documenting an IC discussion and a signed consent form. For LEP patients, full documentation of informed consent also included evidence of interpretation, or a consent form in the patient's primary language.Results: Seventy-four procedures in LEP patients were matched with 74 procedures in English speakers. Charts of English-speaking patients were more likely than those of LEP patients to contain full documentation of informed consent (53% vs 28%; odds ratio (OR): 2.81; 95% CI, 1.42-5.56; p = 0.003). Upon multivariate analysis adjusting for patient and service factors, English speakers remained more likely than LEP patients to have full documentation of informed consent (Adj OR: 3.10; 95% CI, 1.49-6.47; p = 0.003). When examining the components of informed consent, charts of English-speaking and LEP patients were similar in the proportion documenting a consent discussion; however, charts of English speakers were more likely to contain a signed consent form in any language (85% vs 70%, p = 0.03).Conclusions: Despite the availability of on-site professional interpreter services, hospitalized patients who do not speak English are less likely to have documentation of informed consent for common invasive procedures. Hospital quality initiatives should consider monitoring informed consent for LEP patients. [ABSTRACT FROM AUTHOR]

Background: Language and culture relate in complex ways. Addressing this complexity in the context of language translation is a challenge when caring for patients with limited English proficiency (LEP).Objective: To examine processes of care related to language, culture and translation in an LEP population is the objective of this study.Design: We used community based participatory research to examine the experiences of Russian-speaking cancer patients in San Francisco, California. A Russian Cancer Information Taskforce (RCIT), including community-based organizations, local government, and clinics, participated in all phases of the study.Participants: A purposeful sample of 74 individuals were the participants of the study.Approach: The RCIT shaped research themes and facilitated access to participants. Methods were focus groups, individual interviews, and participant observation. RCIT reviewed data and provided guidance in interpreting results.Results: Four themes emerged. (1) Local Russian-language resources were seen as inadequate and relatively unavailable compared to other non-English languages; (2) a taboo about the word "cancer" led to language "games" surrounding disclosure; (3) this taboo, and other dynamics of care, reflected expectations that Russian speakers derived from experiences in their countries of origin; (4) using interpreters as cultural brokers or establishing support groups for Russian speakers could help address barriers.Conclusions: The language barriers experienced by this LEP population reflect cultural and linguistic issues. Providers should consider partnering with trained interpreters to address the intertwining of language and culture. [ABSTRACT FROM AUTHOR]

Background: Atypical antipsychotics have been associated with metabolic abnormalities including impaired glucose metabolism, exacerbation of existing diabetes mellitus and new-onset type 2 diabetes. Not all atypical antipsychotic agents appear to have the same propensity to cause these complications.Objective: To assess diabetic ketoacidosis risk in patients receiving risperidone or olanzapine.Methods: California Medicaid data were evaluated for the presence of a diabetic ketoacidosis hospital claim (9th Edition of the International Classification of Diseases code 2501x) for patients receiving an atypical antipsychotic agent between July 1997 and September 2000. Initial prescription claims were identified for risperidone, olanzapine, clozapine, quetiapine and multiple atypical medications; however, the final analysis was restricted to risperidone and olanzapine owing to sample size challenges in the clozapine and quetiapine groups. Cases were specified if a claim occurred within 45 days after antipsychotic dispensation. Potential confounding variables and duration of antipsychotic exposure were included.Results: Initial users of risperidone (n = 51,330; 31 diabetic ketoacidosis) and olanzapine (n = 51,302; 55 diabetic ketoacidosis) were identified between July 1997 and September 2000. The adjusted risk of diabetic ketoacidosis for olanzapine versus risperidone was 1.62 (p = 0.033). The risk of diabetic ketoacidosis was associated with a longer duration of drug exposure. A progressive and statistically significant divergence in risk was observed between the two treatment groups after the first 30 days of therapy. For risperidone patients, diabetic ketoacidosis risk stabilised after the first 90 days; for olanzapine patients, diabetic ketoacidosis risk continued to increase until 360 days (study duration). For exposures of >30 days, >90 days and >180 days, diabetic ketoacidosis risk was 1.7 (p = 0.026), 2.4 (p = 0.004) and 3.5 (p = 0.001) times greater for olanzapine than risperidone. Treatment group, age, African American race and the presence of schizophrenia or diabetes were significant predictors of diabetic ketoacidosis.Conclusion: The risk of diabetic ketoacidosis appears to be greater for patients exposed to olanzapine compared with risperidone after adjusting for confounding factors. This risk appears to increase with longer duration of exposure to olanzapine. [ABSTRACT FROM AUTHOR]

We analyze Program Realignment, California's 1991 policy of decentralizing control of health, mental health, and social services, from the state to the counties. Drawing from the economics literature on intergovernmental transfers and using data constructed for this study, we analyze the impact of Realignment on uninsured health spending. We find a change in the pattern of spending on indigent health services by counties following decentralization. Our results suggest, however, that county-level governments maintain a level of commitment to social-service spending that recent studies indicate may be lacking at the state level. [ABSTRACT FROM AUTHOR]

Background: Federal law obligates health care providers receiving federal funding to ensure language access to limited English-proficient (LEP) individuals who cannot communicate with their provider.Objective: To determine whether LEP individual awareness of this law improved language access through interpreter utilization.Design, Setting, and Participants: In June 2003, a telephone survey of 1,200 Californians was conducted in 11 non-English languages.Measurements: The survey included items on English proficiency, awareness of language law, health care utilization, and communication methods. Language access was defined as having a provider who speaks the individual's language (language-concordant) or utilizing an interpreter.Results: There were 1,000 LEP participants, of whom 371 (37%) were aware of the language law. Four hundred and ninety-one (49%) of LEP participants had a language-concordant provider. Of the remaining 509 LEP participants without a language-concordant provider, 111 (22%) reported interpreter utilization in the health care setting. After controlling for age, gender, education, income, insurance status, years in the United States, health care utilization, and level of English proficiency, awareness of law was not associated with interpreter utilization (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.38, 1.17; P=.16), but was associated with having a language-concordant provider (OR 1.64; 95% CI 1.19, 2.26; P=.003).Conclusion: Awareness of language law is not sufficient to resolve language barriers for LEP individuals. Provider and organization level barriers to language access must be addressed. [ABSTRACT FROM AUTHOR]

Background: Little is known about the relation between perceptions of health care discrimination and use of health services.Objectives: To determine the prevalence of perceived discrimination in health care, its association with use of preventive services, and the contribution of perceived discrimination to disparities in these services by race/ethnicity, gender, and insurance status.Design, Setting, and Participants: Cross-sectional study of 54,968 respondents to the 2001 California Health Interview Survey.Measurements: Subjects were asked about experience with discrimination in receiving health care and use of 6 preventive health services, all within the previous 12 months.Methods: We used multivariate logistic regression with propensity-score methods to examine the adjusted relationship between perceived discrimination and receipt of preventive care.Results: Discrimination was reported by 4.7% of respondents, and among these respondents the most commonly reported reasons were related to type of insurance (27.6%), race or ethnicity (13.7%), and income (6.7%). In adjusted analyses, persons who reported discrimination were less likely to receive 4 preventive services (cholesterol testing for cardiovascular disease, hemoglobin A1c testing and eye exams for diabetes, and flu shots), but not 2 other services (aspirin for cardiovascular disease, prostate specific antigen testing). Adjusting for perceived discrimination did not significantly change the relative likelihood of receipt of preventive care by race/ethnicity, gender, and insurance status.Conclusions: Persons who report discrimination may be less likely to receive some preventive health services. However, perceived discrimination is unlikely to account for a large portion of observed disparities in receipt of preventive care. [ABSTRACT FROM AUTHOR]

Introduction: Though ruptured appendicitis is not a contraindication to laparoscopic appendectomy (LA), most surgeons have not embraced LA as the first-line approach to ruptured appendicitis. In fact, in 2002, the Cochrane Database Review concluded: 1) the clinical effects of LA are "small and of limited clinical relevance," and 2) the effects of LA in perforated appendicitis require further study.Objective: To study the effects of LA vs open appendectomy (OA) among adults with appendicitis.Methods: In 2003, 272 adults underwent appendectomy at a large County hospital, and were enrolled in a prospective clinical pathway that detailed their hospital course from time of diagnosis to discharge. Data included patient demographics, time elapse from diagnosis to surgery, surgical technique (LA vs. OA), operative diagnosis (acute vs perforated appendicitis) and post-operative length of stay (LOS).Results: Complete data was obtained for 264 (97%) patients. Patient demographics were similar in the LA and OA groups (p > 0.05). Patients with LA had a significantly shorter LOS than OA by 1.6 days (p < 0.05). This LOS was significantly shorter among those with ruptured appendicitis vs. non-ruptured appendicitis (2.0 days vs. 0.3 day reduction, p = 0.0357). Rank-order multiple regression analysis, controlling for all other factors, showed laparoscopy to have a significant effect on postoperative LOS in all appendicitis cases, especially ruptured appendicitis.Conclusions: The two-day reduction in LOS among those with ruptured appendicitis who underwent LA was significant enough to overcome the smaller benefit of LA in acute appendicitis. From a hospital utilization point of view, LA should be considered as the first-line approach for all patients with appendicitis. [ABSTRACT FROM AUTHOR]

A cohort of 197 Medicaid-insured patients presenting for treatment in Kaiser Permanente's outpatient chemical dependency treatment program were observed the year prior to their program intake visit and followed for 3 years afterwards, to compare their medical costs and utilization to demographically matched commercially insured patients entering the same programs. The Medicaid-insured patients on average incurred medical costs 60% higher than non-Medicaid patients during the 12-month preintake period ($5402 vs $3377). [corrected] During the 3 years subsequently, however, both groups of chemical dependency patients displayed significant declines in medical costs, averaging 30% from the baseline period to the third year of follow-up. Cost trends reflected declines in use of hospital days, emergency department visits, and nonemergent outpatient visits. These results may help address concerns among Medicaid managed care providers and payers by giving a more realistic account of the long-term costs of this group of high-utilizing enrollees. [ABSTRACT FROM AUTHOR]

Objective: The phenomenon of somatization was explored in relation to the experiences of acculturation, stress, support, and distress.Methods: A representative community sample of 1,747 Chinese Americans (aged 18-65 years), selected by a multi-stage household sampling design, in the Los Angeles County was interviewed to tap their psychiatric diagnoses, symptomatology, level of acculturation, stress, and support.Results: Across all indices, Chinese Americans' level of somatic symptoms, impairment related to somatization, and percentage of meeting the Somatic Symptom Index 5/5 (SSI 5/5) criterion were comparable to those found in other populations. Length of residence in the U. S. and acculturation were not related to somatization. Regression analyses showed that anxiety, depression, gender, age, education, stressors, and support were significantly related to somatization, ps < 0.05. Somatizers tended to perceive themselves with poor health and utilized both Western and indigenous Chinese medicine.Conclusion: The importance of demographics, psychological distress, and stress was emphasized in the explanation of somatization tendencies among immigrant Chinese Americans. Somatization might be a stress response with regard to increased distress severity and psychosocial stressors rather than a cultural response to express psychological problems in somatic terms. [ABSTRACT FROM AUTHOR]

In this article I propose that gender inequality promotes--directly or indirectly--vulnerability to HIV as a consequence of a multidimensional violence (structural, symbolic and physical) experienced by injection drug using (IDU) women in The Mission District (San Francisco). Given the female subordinated position stipulated by the street ideology, I analyze how drug dependence afforded by precarious strategies of subsistence places IDU women under multiple dangers and threats. In this setting, unequal gender relations are part of a complex system of transactions in the street economy and a way to reduce or increase the everyday violence. Facing multiple dangers and risks, some women adopt a subordinated position, some try to negotiate the conditions of the exchanges and the others resist the exploitation. Finally, everyday violence under conditions of gender inequality and scarcity of resources imposes a logic defined by the challenge of survival under the threat of immediate dangers, which transform HIV into a secondary risk. [ABSTRACT FROM AUTHOR]

Changing patterns of maternal employment, coupled with stronger work requirements for welfare recipients, are increasing the demand for child care. For many families, the cost of child care creates a financial burden; for mothers with low incomes and those who are former welfare recipients, these costs may be an insurmountable barrier to employment or economic self-sufficiency. Despite increased public spending in this area, the receipt of any child care subsidy appears to be a relatively rare and uncertain event. In this study, we use data from a sample of low-income single mothers (current and recent welfare recipients in California) to estimate the probability of their receiving child care subsidies and the effect of this probability on labor market activity. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the role of parental occupations in the etiology of childhood brain tumors (CBT).Methods: Population-based case-control studies were conducted concurrently in seven countries under the coordination of the International Agency for Research on Cancer, gathering 1,218 cases and 2,223 controls. We report here the findings related to parental occupations during the 5-year period before the child's birth. Risk estimates related to a number of paternal and maternal occupations were obtained by unconditional logistic regression adjusted for age, sex, year of birth, and center, for all types of CBT combined and for the subgroups of astroglial, primitive neuroectodermal tumors (PNET), and other glial tumors.Results: An increased risk in relation with agricultural work was seen for all CBT combined and for other glial tumors. Increased risks for all tumors and PNET were seen for paternal occupation as an electrician; the same pattern held for maternal occupation when children under 5 were selected. Paternal occupation as a driver or mechanic, and maternal work in an environment related to motor-vehicles were associated with an increased risk for all CBT and astroglial tumors. More case mothers compared to control mothers were employed in the textile industry.Conclusion: Our study reinforces previous findings relative to the role of parental work in agriculture, electricity, or motor-vehicle related occupations and maternal work in the textile industry. It does not confirm previous associations with work environments including aerospace, the chemical industry, or the food industry, or with maternal occupation as a hairdresser, a nurse, or a sewing machinist, and paternal occupation as a welder. [ABSTRACT FROM AUTHOR]

Objective: Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated.Design: Cross-sectional survey.Setting/participants: A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group.Measurements and Main Results: We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction.Conclusions: Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves. [ABSTRACT FROM AUTHOR]

Objectives: Sigmoidoscopy screening and fecal occult blood (FOB) tests have been demonstrated as effective ways to reduce mortality from colorectal cancer. However, most studies of colorectal cancer screening and cancer mortality have not taken into consideration lifestyle factors that could account for the observed associations. The purpose of this study was to determine the association between screening and incidence of colon cancer, taking into consideration important lifestyle factors.Methods: We estimated the association between screening and colon cancer after taking into consideration health and lifestyle factors using data obtained as part of population-based case-control study of incident colon cancers.Results: Sigmoidoscopy screening, especially as part of a checkup, was protective against incident colon cancer in both men (OR 0.56, 95% CI 0.44-0.77) and women (OR 0.53, 95% CI 0.33-0.77) after adjusting for other risk factors for colon cancer. For men, associations were stronger for distal tumors (OR 0.48, 95% CI 0.31-0.71) than for proximal tumors (OR 0.67, 95% CI 0.45-1.11). We did not observe significant associations between FOB test and colon cancer. Differences in characteristics between those who were screened and not screened were also observed. Men were more likely to report having a sigmoidoscopy as part of a checkup than were women, as were people with higher levels of education. People who reported having a sigmoidoscopy as part of a checkup also reported eating diets lower in fat and higher in fiber, folate, and vegetables. Men were more likely to report higher levels of physical activity, and women were more likely to report taking hormone replacement therapy (HRT) if they also reported a sigmoidoscopy. Both men and women who reported a sigmoidoscopy for screening purposes were more likely to have a family history of colorectal cancer.Conclusions: These data provide additional support for the benefits of having a screening sigmoidoscopy. The associations between screening sigmoidoscopy and colon cancer do not appear to be the result of lifestyle factors. [ABSTRACT FROM AUTHOR]

We use recently released, nationally representative data from the National Health Interview Survey-Multiple Cause of Death linked file to model the association of religious attendance and sociodemographic, health, and behavioral correlates with overall and cause-specific mortality. Religious attendance is associated with U.S. adult mortality in a graded fashion: People who never attend exhibit 1.87 times the risk of death in the follow-up period compared with people who attend more than once a week. This translates into a seven-year difference in life expectancy at age 20 between those who never attend and those who attend more than once a week. Health selectivity is responsible for a portion of the religious attendance effect: People who do not attend church or religious services are also more likely to be unhealthy and, consequently, to die. However, religious attendance also works through increased social ties and behavioral factors to decrease the risks of death. And although the magnitude of the association between religious attendance and mortality varies by cause of death, the direction of the association is consistent across causes. [ABSTRACT FROM AUTHOR]

Purpose: To examine whether ethnic differences in low birth weight babies of low-income women may be explained in part by group differences in prenatal health behaviors and psychosocial factors.Methods: A prospective, survey of 1,071 low-income, primiparous African-American and Mexican-origin women was conducted in Los Angeles County, California. In face-to-face interviews, data were obtained on substance use, prenatal stress, social support, attitudes toward pregnancy, initiation of prenatal care, and medical risk. Medical chart data were abstracted regarding medical risk factors and labor, delivery, and neonatal data. Interview data were linked with birth outcome data retrieved from maternal medical records. Structural equation modeling was used to test a hypothesized model in which differences in birth weight were expected to be mediated by ethnic differences in substance use, psychosocial factors, and medical risk.Results: As expected, African-American women delivered babies of earlier gestational age and lower birth weight than did women of Mexican origin. Direct predictors of low birth weight were use of drugs and cigarettes, prenatal stress, and positive attitudes toward pregnancy; together, these factors accounted for the observed ethnic differences in birth weight.Conclusion: These data contribute to our understanding of the factors that may account for ethnic-associated differences in low birth weight. [ABSTRACT FROM AUTHOR]

Demographers are often interested in the environmental impacts of population growth. I examine the impact of growth specifically on air quality in California. In recent decades, California has suffered from notoriously polluted air and has experienced rapid population growth. Despite the population growth, air quality actually has improved since the early 1980s due to aggressive regulatory efforts. Using data for 56 counties, I analyze the contribution of population growth to trends in atmospheric emissions of five regulated pollutants from 1980 to 1990, controlling for trends in per capita income and regulatory efforts. The analysis is disaggregated by source of emissions and demonstrates that population growth is strongly associated with some sources of emissions but not with others. Thus, the overall impact of population growth depends upon the composition of production and consumption activities in each county. I also explore whether the trend in number of households predicts better than the trend in number of persons, and whether the impact of population growth depends upon the age structure or source of growth (immigration or domestic increase). Generally, these alternative specifications of population do not improve the models of atmospheric emissions. [ABSTRACT FROM AUTHOR]