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Context: Although health care-related distrust may contribute to racial disparities in health and health care in the US, current evidence about racial differences in distrust is often conflicting, largely limited to measures of physician trust, and rarely linked to multidimensional trust or distrust., Objective: To test the hypothesis that racial differences in health care system distrust are more closely linked to values distrust than to competence distrust., Design: Cross-sectional telephone survey., Participants: Two hundred fifty-five individuals (144 black, 92 white) who had been treated in primary care practices or the emergency department of a large, urban Mid-Atlantic health system., Primary Measures: Race, scores on the overall health care system distrust scale and on the 2 distrust subscales, values distrust and competence distrust., Results: In univariate analysis, overall health care system distrust scores were slightly higher among blacks than whites (25.8 vs 24.1, p = .05); however, this difference was driven by racial differences in values distrust scores (15.4 vs 13.8, p = .003) rather than in competence distrust scores (10.4 vs 10.3, p = .85). After adjustment for socioeconomic status, health/psychological status, and health care access, individuals in the top quartile of values distrust were significantly more likely to be black (odds ratio = 2.60, 95% confidence interval = 1.03-6.58), but there was no significant association between race and competence distrust., Conclusions: Racial differences in health care system distrust are complex with far greater differences seen in the domain of values distrust than in competence distrust. This framework may be useful for explaining the mixed results of studies of race and health care-related distrust to date, for the design of future studies exploring the causes of racial disparities in health and health care, and for the development and testing of novel strategies for reducing these disparities.

Context: Growing evidence suggests that most forms of distrust are multidimensional, including domains of technical competence and value congruence. Prior measures of health care system distrust have not reflected this multidimensional structure and may be limiting research into the role of health care system distrust in health and health care in the US., Objective: To develop a revised a scale of health care system distrust., Design: Three phase study, including focus groups, pilot testing and a cross-sectional telephone survey., Participants: A total of 404 individuals recruited directly from the Greater Philadelphia area or through the University of Pennsylvania Health System., Results: Multilevel consensus coding of focus group transcripts identified 2 primary domains of competence and values with the values domain having subthemes of honesty, motives, and equity. Iterative testing of the initial 76 items led to a final scale of 9 items with a Cronbach's alpha of 0.83. Factor analysis demonstrated a 2-factor structure, corresponding to the domains of values and competence. The values subscale (5 items) had a Cronbach's alpha of 0.73 and the competence subscale (4 items) had a Cronbach's alpha of 0.77. These psychometric properties were similar among African Americans and Whites., Conclusions: A novel 9-item scale of Health Care System Distrust with high reliability allows the assessment of the 2 primary domains of distrust (values and competence) and may facilitate research in this area.

When BRCA1/2 testing became commercially available in 1996, many U.S. experts voiced concern about the potential for indiscriminate use of testing among low-risk women. Supporting this concern, several early surveys of interest in genetic testing suggested that genetic testing for cancer susceptibility might appeal most to individuals at low risk of carrying a mutation. To identify factors associated with early use of clinical BRCA1/2 testing, a case-control study was conducted at a large academic health system in the metropolitan Philadelphia region. A total of 167 women underwent genetic counseling for clinical BRCA1/2 testing between 1996 and 1997 (cases) compared with 138 women who were seen in faculty general internal medicine practices over the same period (controls). In this study we measured the risk factors for breast cancer, the risk factors for carrying a BRCA1/2 mutation, and sociodemographic characteristics. Use of BRCA1/2 counseling between 1996 and 1997 was positively associated with family but no personal history of breast cancer (odds ratio (OR), 22.4; 95% confidence interval (CI), 9.3-54.3); family and personal history of breast cancer (OR, 150.3; 95% CI, 24.1-939.6); being Caucasian and non-Jewish (OR, 4.1; 95% CI, 1.3-13.5); being Caucasian and Jewish (OR, 8.8; 95% CI, 2.2-35.5); and being married (OR, 3.2; 95% CI, 1.6-6.3). Use of BRCA1/2 counseling was inversely associated with increasing age (OR, 0.07; 95% CI, 0.02-0.28 for >60 compared to <50). As suggested by the association with family history, use of counseling was associated with having a higher predicted risk of breast cancer and a higher predicted risk of carrying a BRCA1 mutation (P < 0.0001). Women who sought clinical BRCA1/2 testing in the year after it became commercially available were not the "worried well," but women at significantly increased risk of carrying a mutation. However, even after adjusting for breast cancer risk, there was a substantial racial disparity in use of BRCA1/2 testing. These findings suggest that ensuring equal access to testing for high-risk individuals irrespective of race may be as important for the future of predictive genetic testing as restricting the use of testing among low-risk individuals., (Copyright 2002 Wiley-Liss, Inc.)

Background: Presentation of information using survival or mortality (i.e., incidence) curves offers a potentially powerful method of communication because such curves provide information about risk over time in a relatively simple graphic format. However, the effect of framing as survival versus mortality on understanding and treatment choice is not known., Methods: In this study, 451 individuals awaiting jury duty at the Philadelphia City Courthouse were randomized to receive 1 of 3 questionnaires: (1) survival curves, (2) mortality curves, or (3) both survival and mortality curves. Each questionnaire included a brief description of a hypothetical treatment decision, survival curve graphs and/or mortality curve graphs presenting the outcome of the treatment, and questions measuring understanding of the information contained in the graphs and preference for undergoing treatment. After completing a brief practice exercise, participants were asked to answer questions assessing their ability to interpret single points on a curve and the difference between curves, and then to decide whether they would choose to undergo preventive surgery for 3 different scenarios in which the benefit of surgery varied., Results: Participants who received only survival curves or who received both survival and mortality curves were significantly more accurate in answering questions about the information than participants who received only mortality curves (P < 0.05). For 2 of the 3 treatment presentations, participants who received only mortality curves were significantly less likely to prefer preventive surgery than participants who received survival curves only or both survival and mortality curves (P < 0.05). The effect of framing on understanding was greatest among participants with less than a college education and among non-Caucasian participants., Conclusion: Framing graphic risk information as chance of death over time results in lower levels of understanding and less interest in preventive surgery than framing as chance of survival over time.

Background: Although influenza immunization significantly reduces mortality from influenza, over one third of elderly Americans are not immunized each year. Low rates of immunization are particularly concerning among African-American low-income populations. Preliminary interviews suggested that fear of undisclosed ingredients in the influenza vaccine may impede vaccine acceptance in this vulnerable population., Objectives: To assess the role of concern about vaccine contents and other factors in the use of influenza immunization among a predominantly African-American low-income urban population., Methods: Cross-sectional, health-system-population-based, telephone survey of a random sample of West Philadelphia residents aged > or =65 years., Results: Of 659 eligible individuals, 486 (73.8%) were successfully interviewed. Concern about undisclosed shot contents was reported by 132 (20%) respondents and was inversely associated with vaccine receipt (OR 0. 49, 95% CI 0.26-0.91). This association was similar among African Americans and Caucasians. In addition, receipt of influenza vaccine was inversely associated with belief that immunization is inconvenient (OR 0.14, 95% CI 0.05-0.36), belief that immunization is painful (OR 0.21, 95% CI 0.08-0.54), and history of previous side effects (OR 0.33, 95% CI 0.18-0.60), and positively associated with physician recommendation (OR 3.22, 95% CI 1.76-5.93)., Conclusions: In a low-income urban population, concern about undisclosed vaccine contents appears to impede acceptance of influenza immunization among both African Americans and Caucasians. Directly addressing this concern offers a new approach to increasing immunization in this vulnerable population.

Objective: Establish prevalence rates of urinary tract infection (UTI) in febrile infants and young girls in an emergency department (ED) by demographics and clinical parameters., Methods: Cross-sectional prevalence survey of 2411 (83%) of all infants younger than 12 months and girls younger than 2 years of age presenting to the ED with a fever (>/=38.5 degrees C) who did not have a definite source for their fever and who were not on antibiotics or immunosuppressed. Otitis media, gastroenteritis, and upper respiratory infection were considered potential but not definite sources of fever., Results: Overall prevalence of UTI (growth of >/=10(4) CFU/mL of a urinary tract pathogen) was 3.3% (95% confidence interval [CI]: 2.6,4.0). Higher prevalences occurred in whites (10.7%; 95% CI: 7.1,14.3), girls (4.3%; 95% CI: 3.3,5.3), uncircumcised boys (8.0%; 95% CI: 1.9,14.1), and those who did not have another potential source for their fever (5.9%; 95% CI: 3.8,8. 0), had a history of UTI (9.3%; 95% CI: 3.0,20.3), malodorous urine or hematuria (8.6%; 95% CI: 2.8,19.0), appeared "ill" (5.7%; 95% CI: 4.0,7.4), had abdominal or suprapubic tenderness on examination (13. 2%; 95% CI: 3.7,30.7), or had fever >/=39 degrees C (3.9%; 95% CI: 3. 0,4.8). White girls had a 16.1% (95% CI: 10.6,21.6) prevalence of UTI., Conclusions: UTI is prevalent in young children, particularly white girls, without a definite source of fever. Specific clinical signs and symptoms of UTI are uncommon, and the presence of another potential source of fever such as upper respiratory infection or otitis media is not reliable in excluding UTI.

Background: Controversy exists as to whether low-osmolality radiographic contrast agents, which have less detrimental pharmacological effects but are considerably more expensive than high-osmolality agents, should be used universally or only for selected high-risk patients., Methods and Results: A randomized, double-blind study was used to compare the frequency and severity of adverse events in 2245 consecutive patients undergoing diagnostic cardiac angiography. Two thousand one hundred sixty-six patients were successfully randomized to either iohexol, a low-osmolality contrast agent, or diatrizoate (as Hypaque 76), a high-osmolality agent. The end point event included clinically important adverse events (which jeopardized the patient or required aggressive treatment), contrast agent-related procedure abbreviations, and conversion to open-label contrast agent. Clinically important end point events were associated with increased age, New York Heart Association functional class, left ventricular end-diastolic pressure, arteriovenous oxygen difference, severity of coronary artery disease, and history of a previous reaction to contrast agent. End point events were less frequent in patients receiving iohexol (2.6% versus 4.6%; adjusted odds ratio, 1.59; 95% confidence interval, 0.97-2.60; P = .07). The difference in event frequency between iohexol and diatrizoate was confined to the highest-risk quartile of the patient population. An algorithm was developed to classify patients as being at high or low risk for an event based on patient age, New York Heart Association class, history of a prior contrast reaction, and left ventricular end-diastolic pressure. Application of this algorithm for selective use of low-osmolality agents only for high-risk patients to a theoretical population of 1000 patients reduced contrast agent costs 66% without increasing the frequency of contrast agent-related adverse events., Conclusions: The advantages of low-osmolality contrast agents are clinically important in patients with severe heart disease but are not in less ill patients. Universal use of low-osmolality agents for cardiac angiography in an unselected population is not necessary. Appropriately guided selective use of low-osmolality contrast agents is feasible and has the potential to reduce cost substantially without compromising safety or effectiveness.