Search

Objective: The purpose of this study was to examine the association between intimate partner violence (IPV), abortion, parity, and contraception use., Study Design: We recruited 1463 women for this written questionnaire study of IPV. Patient demographics, contraceptive history, and reproductive history were obtained in the waiting room from patients presenting for gynecologic care., Results: Seventy percent of those eligible participated. Twenty-one percent reported a history of IPV. Partner unwillingness to use birth control, partner desirous of conception, partner creating difficulty for subject's use of birth control, and subjects expressing inability to afford contraception were all positively associated with report of IPV. Each additional pregnancy was associated with 10% greater odds of IPV (95% confidence interval, 1.03-1.17)., Conclusion: Contraception is more difficult to navigate for women experiencing IPV. Providers should consider prescribing contraceptive methods for IPV victims that are not partner dependent.

Neighborhood characteristics such as racial composition and social capital have been widely linked to health outcomes, but the direction of the relationship between these characteristics and health of minority populations is controversial. Given this uncertainty, we examined the relationship between neighborhood racial composition, social capital, and black all-cause mortality between 1997 and 2000 in 68 Philadelphia neighborhoods. Data from the U.S. Census, the Philadelphia Health Management Corporation's 2004 Southeast Pennsylvania Community Health Survey, and city vital statistics were linked by census tract and then aggregated into neighborhoods, which served as the unit of analysis. Neighborhood social capital was measured by a summative score of respondent assessments of: the livability of their community, the likelihood of neighbors helping one another, their sense of belonging, and the trustworthiness of their neighbors. After adjustment for the sociodemographic characteristics of neighborhood residents, black age-adjusted all-cause mortality was significantly higher in neighborhoods that had lower proportion of black residents. Neighborhood social capital was also associated with lower black mortality, with the strongest relationship seen for neighborhoods in the top half of social capital scores. There was a significant interaction between racial composition and social capital, so that the effect of social capital on mortality was greatest in neighborhoods with a higher proportion of black residents and the effect of racial composition was greatest in neighborhoods with high social capital. These results demonstrate that age-adjusted all-cause black mortality is lowest in mostly black neighborhoods with high levels of social capital in Philadelphia.

Objective: Type 2 diabetes is more prevalent and severe among African Americans than among Whites. To elucidate barriers to glucose control that are unique to African Americans with poor glucose control we conducted a qualitative study among veterans with diabetes in an academic Veterans Affairs medical center., Methods: We enrolled African American and White veterans with diabetes; participants' glucose control was described as well controlled or poorly controlled, and groups were organized on the basis of ethnicity and glucose control. Discussions were conducted by using modified nominal group technique to define factors that aided or hindered glucose control., Results: Well-controlled groups similarly reported that self-care, health care, and psychosocial factors were important in controlling glucose. Although poorly controlled African Americans cited self-care as important, they also noted difficulty following self-care practices and the interference of psychosocial factors with glucose control. Poorly controlled Whites were similar. Uniquely, poorly controlled African Americans were less likely to report positive healthcare experiences; their barriers were related to poor access and poor relationships with providers., Conclusions: Poorly controlled African Americans endorsed healthy self-care behaviors but found it difficult to follow through. Interventions targeting the management of stress, depression, mood, and temptation, as well as improved access to and communication with providers may help these patients better manage their glucose and minimize disparities in diabetes outcomes. (Ethn Dis. 2009; 19:121-127)

Background: The US FDA and lay media are important sources of information for the public about the risks of adverse events associated with drugs, yet the quality of FDA and US lay media reports about medication 'black-box' warnings, which highlight potentially severe adverse events from medications, is unknown., Objective: To determine and compare the content of FDA and US lay media reports about medication black-box warnings., Methods: We assessed FDA and US lay media reports about medication black-box warnings published or aired between 1 January 2003 and 31 December 2007 for the presence of six core message components, including (i) the affected drug's brand name; (ii) generic name; (iii) treatment indication; (iv) reason for the black-box warning; (v) clinical recommendations for patients, such as warning signs and symptoms of the adverse effect addressed by the black-box warning; and (vi) encouragement to discuss the issue with a healthcare provider, and additional characteristics., Results: FDA reports presented more core information than lay media reports (median 5 vs 3 message components; p < 0.001). FDA reports were more likely to mention generic names (84.6% vs 18.1%; p < 0.001) of affected drugs, while lay media reports less frequently detailed clinical recommendations for patients (43.9% vs 96.2%; p < 0.001). Only 10.6% of lay media reports encouraged patients to seek additional information from their healthcare provider, compared with 48.1% of FDA reports (p < 0.001)., Conclusions: FDA and US lay media reports about medication black-box warnings presented different information. This may reflect a difference in underlying motivation for reporting of news about risks of adverse drug events. It may also indicate a lack of agreement and understanding about the best methods to communicate risk information to the public, thus indicating areas for future research.

Objective: The objective of the study was to determine whether the 2006 Food and Drug Administration approval of Plan B for behind-the-counter status increased availability., Study Design: We conducted a survey in 2005 and 2007 of pharmacies listed in Atlanta, GA, Boston, MA, and Philadelphia, PA. We measured ability to dispense Plan B within 24 hours. Also measured were reasons for lack of availability and cost of Plan B., Results: Pharmacists were interviewed at 1087 pharmacies (75% response rate) in 2005 and 795 pharmacies (82% response rate) in 2007. In 2007, 8% of pharmacies were unable to provide Plan B within 24 hours, compared with 23% of pharmacies in 2005 (P < .001). The total refusal rate in 2007 was half the rate of 2005 (2% vs 4%, P = .004). The average cost of Plan B was $43., Conclusion: Availability of Plan B in Atlanta and Philadelphia increased after it was awarded behind-the-counter status.

Background: Pay for performance (P4P) programs have shown only modest improvements in outcomes and do not target patient behaviors. Many large employers and payers are turning to pay for performance for patients (P4P4P) to reduce health costs and improve the health of their covered populations. How these programs may be perceived by patients is unknown., Objective: To assess patients' opinion of the acceptability of P4P4P., Design: Cross-sectional self-administered survey., Participants: Patients in waiting rooms in two university-based primary care clinics., Measurements: Participants were asked their opinions about paying people to quit smoking, lose weight, control their blood pressure, or control their diabetes., Results: Respondents were split on whether P4P4P is desirable. Thirty-six to 42% thought it was a good/excellent idea to pay smokers to quit smoking, obese people to lose weight, people with hypertension to control their blood pressure, or people with diabetes to control their blood sugar, while 41-44% of the sample thought it was a bad/very bad idea. Smokers and patients who were obese endorsed P4P4P more favorably as a means to achieving tobacco cessation and weight loss than their non-smoking and non-obese counterparts., Conclusions: Acceptance of paying patients for performance by the general population is equivocal. Establishing the efficacy of paying patients for performance may help it gain wider acceptance.

Research to eliminate health disparities in the United States is best approached from the perspective of population health. The objectives of this paper are to: (a) describe how ongoing research at the eight national Centers for Population Health and Health Disparities (CPHHD) is using a population health perspective and a community-based approach to advance the field of health disparities research; and (b) to discuss potential implications of such research for health policies that target some of the determinants of population health.

Objective: Limited data exist on the quality of care for patients with venous thromboembolism (VTE), and it is unknown whether the processes and outcomes of care for this illness differ between African Americans and whites., Study Design and Setting: We retrospectively studied 168 patients hospitalized for VTE in two Veterans Affairs hospitals during fiscal years 2000-2002. Patient characteristics, information about processes of care, and medical outcomes at 90 days after the index VTE event were abstracted from medical records. We used logistic regression to explore associations between race, processes of care, and the overall 90-day complication rate (i.e., death, bleeding, or recurrent VTE), adjusting for patient baseline characteristics., Results: Multivariable analysis demonstrated that administration of warfarin within 1 day of starting heparin (odds ratio [OR] 0.20, 95% confidence interval [CI]: 0.05-0.42) and overlap of heparin and warfarin treatment >or=4 days (OR 0.09, 95% CI: 0.02-0.50) were associated with a lower complication rate, and African American race was associated with a higher complication rate (OR 5.2, 95% CI: 1.3-21.6). Race was not significantly associated with the performance of processes of care in multivariable analysis., Conclusion: Although African Americans had an increased risk of complications following VTE, race was not independently associated with the use of processes of care for VTE.

Objective: The availability of emergency contraception (EC) depends on pharmacy stocking practices and pharmacist willingness to dispense the medication. We aimed to describe the availability of EC in areas governed by different state policies regarding pharmacist behavior., Study Design: A telephone survey was conducted between October 1 and December 31, 2005, of every pharmacy listed in the metropolitan areas of Atlanta, Philadelphia and Boston. We asked whether pharmacies could fill a prescription for EC within 24 h and, if not, why not., Results: We interviewed pharmacists at 1085 pharmacies (response rate of 75%). Overall, 23% were unable to fill a prescription for EC within 24 h. The rate of being unable to fill was 35% in Atlanta, 23% in Philadelphia and 4% in Boston (p<.001). Refusal rates were low: 4% overall; 8% in Atlanta; 3% in Philadelphia and 0% in Boston., Conclusions: Variation in state policy predicted the availability of EC. The most common reason for not being able to fill a prescription within 24 h was not having the medication in stock.

Background: Despite the popularity of medical student-run health clinics among U.S. medical schools, there is no information about how many clinics exist, how many students volunteer there, or how many patients they see and what services they offer., Objective: We describe, for the first time, the prevalence and operation of medical student-run health clinics nationwide., Design and Participants: A web-based survey was sent to all 124 Association of American Medical Colleges allopathic schools in the 50 states., Results: Ninety-four schools responded (76%); 49 schools had at least 1 student-run clinic (52%). Fifty-nine student-run clinics provided detailed data on their operation. The average clinic had 16 student volunteers a week, and most incorporated preclinical students (56/59, 93%). Nationally, clinics reported more than 36,000 annual patient-physician visits, in addition to more non-visit encounters. Patients were predominantly minority: 31% Hispanic; 31% Black/African American; 25% White; 11% Asian; and 3% Native American or other. Most student-run health clinics had resources both to treat acute illness and also to manage chronic conditions. Clinics were most often funded by private grants (42/59, 71%); among 27 clinics disclosing finances, a median annual operating budget of $12,000 was reported., Conclusions: Medical student-run health clinics offer myriad services to disadvantaged patients and are also a notable phenomenon in medical education. Wider considerations of community health and medical education should not neglect the local role of a student-run health clinic.

Background: Poor adherence to antihypertensives has been shown to be a significant factor in poor blood pressure (BP) control. Providers' communication with patients about their medication-taking behavior may be central to improving adherence., Objective: The goal of this study was to characterize the ways in which providers ask patients about medication taking., Design: Clinical encounters between primary care providers and hypertensive patients were audiotaped at 3 Department of Veterans' Affairs medical centers., Participants: Primary care providers (n=9) and African-American and Caucasian patients (n=38) who were diagnosed with hypertension (HTN)., Approach: Transcribed audiotapes of clinical encounters were coded by 2 investigators using qualitative analysis based on sociolinguistic techniques to identify ways of asking about medication taking. Electronic medical records were reviewed after the visit to determine the BP measurement for the day of the taped encounter., Results: Four different aspects of asking about medication were identified: structure, temporality, style and content. Open-ended questions generated the most discussion, while closed-ended declarative statements led to the least discussion. Collaborative style and use of lay language were also seen to facilitate discussions. In 39% of encounters, providers did not ask about medication taking. Among patients with uncontrolled HTN, providers did not ask about medications 33% of the time., Conclusion: Providers often do not ask about medication-taking behavior, and may not use the most effective communication strategies when they do. Focusing on the ways in which providers ask about patients' adherence to medications may improve BP control.

Context: Despite theoretical concerns that health care related distrust may lead to poor health outcomes by interfering with effective health care, little is currently known about the prevalence or outcomes of distrust of the health care system in the United States., Objective: To investigate the association between distrust of the health care system and self-reported health status among the general population in the United States., Design: Random-digit-dialing telephone survey., Participants: Nine hundred and sixty-one adult residents of the continental U.S., Primary Measures: Distrust of the health care system and self-reported health status., Results: Distrust of the health care system is relatively high in the United States, with between 20% and 80% of respondents reporting distrust for each item on the Health Care System Distrust scale and a median scale score of 31 (potential range from 10 to 50). Distrust of the health care system is strongly associated with self-reported fair/poor health (odds ratio [OR] 1.40%, 95% confidence interval [CI] 1.12 to 1.75 for each standard deviation increase in distrust), even after adjusting for sociodemographic characteristics, access to health care and trust in primary physicians. In contrast, low trust in one's primary physician is much lower (only 10% to 20% of respondents reported distrust for each item) and is not associated with health status., Conclusions: Distrust of the health care system is relatively high in the general population in the United States and is strongly associated with worse self-reported health. Further studies are needed to assess the direction of this association and the mechanisms involved.

Many studies evaluating racial disparities in health come from the Veterans Health Administration (VHA) and are based on secondary and administrative data. Often race/ethnicity data are missing in these sources. Knowing how investigators treat missing data is critical in evaluating potential biases. The objectives of this systematic review were to quantify: (1) the data sources for VHA racial/ethnic disparity studies; (2) how missing race/ethnicity data were handled; and (3) the extent of missing race/ethnicity data. Two trained reviewers independently abstracted 114 articles. The Patient Treatment File was the most common source of race/ethnicity data (n=49). For just over half of the articles we were unable to determine if there were missing race/ethnicity data (n=58). When missing race/ethnicity data were quantified, the proportion of instances for which the data were missing ranged from 0% to 48%. Missing race/ethnicity data are frequently present in VHA secondary and administrative data sources, but, the proportion of instances for which such data are missing is explicitly discussed or quantified in only about 50% of all articles using these sources.

Objectives: During the mid-1990s, the Veterans Health Administration (VHA) reorganized and placed greater emphasis on high-quality primary care. To determine whether the reorganization was associated with changes in patterns of out-patient VHA use, we sought to evaluate changes in characteristics of veterans who use VHA outpatient services between 1992 and 2000., Methods: We merged 2 waves of the National Survey of Veterans to determine changes in patterns of outpatient care use. We evaluated the extent to which veterans who received outpatient care received that care from the VHA., Results: The odds ratio for VHA-only outpatient care relative to non-VHA-only care in 2000 relative to 1992 was 1.75 (95% confidence interval [CI]=1.51, 2.04), and the odds ratio for dual relative to non-VHA-only care was 1.22 (95% CI=1.08, 1.37). Veterans who were older, had low incomes, and had no additional health insurance coverage were most likely to increase their use of VHA outpatient care., Conclusions: Our results suggest that the VHA is increasingly serving veterans who have trouble accessing the private health care system.

Background: Study of the racial-ethnic biases of medical students is necessary to further understand health disparities. The objectives of this study were to (a) determine if medical students exhibit racial biases, (b) assess whether there are differences in racial biases among medical students who have and have not received a curriculum in cultural sensitivity, and (c) determine if these findings vary by student race-ethnicity., Description: We evaluated medical students' preferences in hiring hypothetical candidates for a research scholarship and a research assistant position. Each student received a packet containing four curricula vitae (CVs) with attached photographs. Three CVs and photographs were identical. The fourth CV was identical, but in half the packets the photograph was of an African American man and in the other half of a White man. Students were asked to provide ratings of suitability., Evaluation: The African American candidate received better ratings than the White candidate. There were no differences in the ratings by student curriculum receipt or race-ethnicity., Conclusion: We found no evidence that an African American candidate was discriminated against by medical students.

Objective: This study investigates how physician gender affects reactions to six model patients., Methods: Telephone interviews with 3205 internists and family or general physicians were completed between 1996 and 1997 for the Community Tracking Study. Physicians responded to six vignettes describing model patients with presentations designed to have multiple appropriate treatment plans: a 50-year-old man with a 1-month history of exertional chest pain who may need a referral to a cardiologist, a 60-year-old man with a normal digital rectal examination (DRE) who may benefit from a prostate-specific antigen (PSA) test, a 40-year-old married woman with vaginal itching and discharge who may benefit from an office visit, a 60-year-old man with symptoms of benign prostatic hypertrophy (BPH) who may benefit from a urological consultation, a 35-year-old man with back pain and a new left footdrop who may benefit from an MRI, and a 50-year-old man with elevated cholesterol and no other cardiac risk factors who may benefit from cholesterol-lowering agents., Results: Female physicians are significantly more likely than males to refer a patient with BPH to a urologist (37.5% vs. 24.9%, p < 0.001). Male physicians are significantly more likely to recommend that a woman with vaginal itching and discharge have an office visit (52.7% vs. 40.6%, p < 0.001). Male physicians recommend cholesterol-lowering agents slightly more often than women physicians (39.4% vs. 36.4%, p < 0.03) and recommend a PSA test more often than female physicians (73.1% vs. 64.4%, p < 0.001). Neither physician attributes, practice characteristics, referral patterns, nor geographical traits account for the disparity between male and female physicians in the treatment of BPH. Approximately 40% of the gender gap in treatment of vaginal itching and discharge can be attributed to physician attributes. The association between provider gender and the decision to prescribe cholesterol-lowering agents and the association between provider gender and recommending a PSA test are explained by physician attributes., Conclusions: Gender differences in treatment seem to appear most strongly for genital-specific conditions. The results may suggest that physicians use fewer resources to treat the genital-specific conditions of patients who share their sex.

Objectives: (1) To describe the accuracy of self-report and administrative claims for measuring mammography adherence among low-income women; (2) to determine whether the accuracy of self-report differed between telephone interview and mailed questionnaire; and (3) to explore whether the method of measuring adherence affected associations between mammography adherence and participant sociodemographic characteristics., Design: Retrospective cohort study of women receiving care from a Philadelphia Medicaid Managed Care Organization (MCO)., Participants: Three hundred and ninety-nine low-income women eligible for screening mammography of whom 64% were African American, 14% Caucasian, 13% Hispanic, and 8% Asian American., Measures: Self-reported use of mammography screening, administrative mammography claims data, and dates of mammograms from radiology facility records. The "gold standard" categorized women as having undergone screening if they had either a billing claim or facility record for a mammogram in the past 12 months., Main Results: Two hundred and eighty-three of the 399 women reported having had a mammogram in the past 12 months. The sensitivity of self-report was 0.93, specificity was 0.54, positive predictive value was 0.70, and negative predictive value was 0.86. One hundred and seventy-nine of the 399 women had a claim for a mammogram in the past 12 months. The sensitivity of claims data was 0.83 with a negative predictive value of 0.84. The sensitivity of self-report was higher with telephone data collection (0.98) than with mailed data collection (0.82), while the specificity was higher with mail (0.64) than telephone (0.50). African American race was associated with adherence to screening recommendations when mammography use was measured by self-report (RR 1.31, P = 0.002) but not when it was measured by claims or facility validation (RR 1.03, P = 0.56, and RR 1.12, P = 0.15, respectively)., Conclusions: Accurate measurement of adherence to mammography screening among low-income women is difficult. Self-report substantially overestimates adherence (particularly when collected through telephone interviews), while also misclassifying some women who underwent screening as not having been screened (particularly when collected through mailed questionnaires). In contrast, administrative claims data substantially underestimates adherence. Inaccurate measurement of mammography adherence can lead to a biased understanding of the factors associated with adherence.

In middle-aged people, social class is one of the strongest predictors of mortality. However, to date, research prospectively evaluating the relationship between social class and mortality in the older persons has produced conflicting results. This may be due to the lack of clinical covariates in many analyses. The objective of this study was to determine the relationship between social class markers-education, income, husband's work history, and personal work history-and mortality in a cohort of older women, after adjusting for clinical and behavioral factors. The participants were 737 ambulatory, community-living women, age 72 and older, followed from 1989 to 1993. In addition to education attained, present income, husband's work history, and personal work history, proportional hazard models adjusted for age, race, marital status, number of chronic conditions, number of medications used, Activities of Daily Living status, Mini-Mental State Exam score, physical activity, and alcohol use. In multivariable models personal work history was the only social class marker that remained significantly associated with mortality. Compared with managers and professionals, women who never worked outside the home had a 3.5 greater risk of death (95% CI, 1.6-7.5), while women who had worked in partly/unskilled or skilled professions were over two and a half times more likely to die; the adjusted hazard ratios were 2.7 (95% CI, 1.2-6.4) and 2.7 (95% CI, 1.3-5.7), respectively. In this population of older women, personal work history was the only social class marker predictive of mortality.

Previous research of addictive substances suggests that use of alcohol, illicit drugs, and tobacco is overrepresented on prime-time television (TV). These studies, however, have relied on frequency counts of the substance, rather than the prevalence of use among characters. Therefore, the objectives of this study were to compare the prevalence of alcohol, illicit drug, and tobacco users among characters on prime-time TV during 1995 and 1996 with rates of use in the United States. In addition, we determined if the ratio of male to female, young to old, and white to minority addictive substance users on prime-time TV were similar to the equivalent U.S. ratios. Comparing results for prime-time TV characters versus the U.S. population (respectively), 11.0% (99% CI, 9.8-12.1) drank alcohol versus 51.0%; 0.8% (99% CI, 0.5-1.1) used illicit drugs versus 6.1%; and 2.5% (99% CI, 2.0-3.1) smoked tobacco versus 28.9%. In addition, no consistent pattern was evident in our analyses that assessed whether addictive substance users on prime-time TV were more frequently represented as men, young, or minority compared to the similar U.S. ratio. These results indicate that contrary to prevailing beliefs, alcohol, illicit drug, and tobacco users are uncommon on prime-time TV and are less prevalent than in the U.S. population.