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Background: Three-quarters of patients who undergo total hip replacement (THR) receive postsurgical rehabilitation care in an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF), or through a home health agency. The objectives of this study are to examine racial differences where THR recipients receive postsurgical rehabilitation care and determine whether discharge destination is associated with hospital readmission. Methods: Using the Pennsylvania Health Care Cost Containment Council database, we selected African American (AA) or white adults who underwent THR surgery (n = 68,016). We used multinomial logistic regression models to assess the relationship between race and postsurgical discharge destination. We calculated 90-day hospital readmission as function of discharge destination. Results: Among patients Conclusions: Compared to whites, AAs who underwent THR were more likely to be discharged to an IRF or SNF. Discharge to either facility was associated with a higher risk of hospital readmission.

Background There are marked racial/ethnic disparities in the utilization of hip joint replacement in the US. Differences in post-surgical rehabilitation care may influence this disparity. There is relatively little research on racial variations in post-hip joint replacement surgery care processes. Objectives The main objective of this analysis was to examine racial differences in where patients go for post-acute care rehabilitation after elective hip replacement surgery. We also assessed whether or not where patients go for post-surgery rehabilitation care impacts quality of care markers such as 90-day hospital readmission. Methods A retrospective, large regional dataset analysis using the Pennsylvania Health Care Cost Containment Council database was performed. Patients who underwent elective hip replacement surgery and discharged from Pennsylvania hospitals between fiscal years 2008–2012 were selected. Post-surgery rehabilitation destinations options included: home with self-care, home with home health (HH) care; skilled nursing facility (SNF) and in-patient rehab facility (IRF). We used multinomial logistic regression models to estimate unadjusted and adjusted relative risk ratios (aRRRs) of being discharged home with HH care, to a SNF or to an IRF (vs. home with self-care) after surgery, comparing African-American (AA) to white patients. Multivariable models adjusted for patient-level and facility-level variables associated (p Results Among all patients analyzed, 4,391 self-identified as AA and 63,625 self-identified as white. Among those The Figure summarizes the unadjusted (UN) and adjusted (ADJ) RRRs of referral to an IRF, SNF and HH care (vs. home self-care) in AAs (vs. whites) by age group. Among patients Conclusions Compared to whites, AA patients who underwent hip replacement were more likely to be discharged to an IRF or SNF. Furthermore, discharge to either IRF or SNF was associated with higher risk of hospital readmission. Disclosure of Interest None declared

A TKA is the most effective and cost-effective surgical option for moderate to severe osteoarthritis (OA) of the knee. Yet, black patients are less willing to undergo knee replacement surgery than white patients. Decision aids help people understand treatment options and consider the personal importance of possible benefits and harms of treatments, including TKA.We asked: (1) Does a patient-centered intervention consisting of a decision aid for knee OA and motivational interviewing improve the proportion of referrals of blacks with knee OA to orthopaedic surgery? (2) Does the intervention increase patients' willingness to undergo TKA?Adults who self-identified as black who were at least 50 years old with moderate to severe knee OA were enrolled from urban primary care clinics in a two-group randomized, controlled trial. A total of 1253 patients were screened for eligibility, and 760 were excluded for not meeting inclusion criteria, declining to participate, or other reasons. Four hundred ninety-three patients were randomized and completed the intervention; three had missing referral data at followup. The mean age of the patients was 61 years, and 51% were women. The majority had an annual household income less than USD 15,000. Participants in the treatment group were shown a decision-aid video and had a brief session with a trained counselor in motivational interviewing. Participants in the control group received an educational booklet about OA that did not mention joint replacement. The two groups had comparable demographic and socioeconomic characteristics. The primary outcome was referral to orthopaedic surgery 12 months after treatment exposure. Receipt of referral was defined as the receipt of a recommendation or prescription from a primary care provider for orthopaedic evaluation. The secondary outcome was change in patient willingness to undergo TKA based on patient self-report.The odds of receiving a referral to orthopaedic surgery did not differ between the two study groups (36%, 90 of 253 of the control group; 32%, 76 of 240 of the treatment group; odds ratio [OR], 0.81; 95% CI, 0.56-1.18; p = 0.277). At 2 weeks followup, there was no difference between the treatment and the control groups in terms of increased willingness to consider TKA relative to baseline (34%, 67 of 200 patients in the treatment group; 33%, 68 of 208 patients in the control group; OR, 1.06; p = 0.779). At 12 months followup, the percent increase in willingness to undergo TKA still did not differ between patients in the treatment and control groups (29%, 49 of 174 in the treatment group; 27%, 51 of 191 in the control group; OR, 1.10; p = 0.679).A combination decision aid and motivational interviewing strategy was no better than an educational pamphlet in improving patients' preferences toward joint replacement surgery for knee OA. The type of intervention treatment also did not affect access to surgical evaluation. Other tools that target patient knowledge, beliefs, and attitudes regarding surgical treatments for OA may be further developed and tested in the future.Level I, therapeutic study.

Purpose Short-term reactions to BRCA1 and BRCA2 (BRCA1/2) genetic test results have been described in several reports, but the long-terms effects of testing have not been examined extensively. Methods We conducted an observational study to characterize the long-term impact of genetic testing for BRCA1/2 mutations in 167 women who had received genetic test results at least 4 years ago. We also evaluated the relationship between genetic testing–specific reactions and breast and ovarian cancer screening to determine the behavioral significance of adverse reactions. Results Seventy-four percent of women were not experiencing any distress regarding their test result, 41% were not experiencing any uncertainty, and 51% had a score for positive experiences that was suggestive of low levels of adverse reactions in terms of family support and communication. Mutation carriers (odds ratio, 3.96; 95% CI, 1.44 to 10.89; P = .01) were most likely to experience distress. Only less time since disclosure was related significantly to experiencing uncertainty (odds ratio, 0.62; 95% CI, 0.44 to 0.88; P = .008). In terms of cancer screening, 81% of women had a mammogram during the year before study enrollment, 25% had magnetic resonance imaging (MRI), 20% had a transvaginal ultrasound, and 20% had a CA-125. Experiencing distress was associated significantly with having a CA-125 (χ2 = 3.89, P = .05), and uncertainty was associated with having an MRI (χ2 = 8.90, P = .003). Conclusion Our findings show that women are not likely to experience genetic testing concerns several years after receiving BRCA1/2 test results; distress and uncertainty are not likely to have adverse effects on screening among women at risk for hereditary disease.

This observational study evaluated utilization of religious coping strategies among 95 African American women who were at increased risk for having a BRCA1/BRCA2 (BRCA1/2) mutation. Overall, women reported high levels of collaborative coping; however, women with fewer than 2 affected relatives (beta = -1.97, P = 0.04) and those who had a lower perceived risk of having a BRCA1/2 mutation (beta = -2.72, P = 0.01) reported significantly greater collaborative coping. These results suggest that African American women may be likely to use collaborative strategies to cope with cancer-related stressors. It may be important to discuss utilization of religious coping efforts during genetic counseling with African American women.

Although knowledge about genetic concepts is important for individuals to be active participants in medical technologies that use genetic science, limited information is available on knowledge about basic genetic concepts and terminology in African Americans. The purpose of this study was to evaluate knowledge about general genetic concepts and medical genetics terminology among African Americans and to identify factors having independent associations with knowledge. Participants were 109 adult African Americans enrolled in a study on attitudes about race, genetics, and smoking. The majority of respondents were knowledgeable about general genetic concepts, but were less knowledgeable about medical genetics terminology. Education was the only factor independently associated with knowledge about sporadic disorders in multivariate logistic regression analysis. Respondents with at least some college education were most likely to be knowledgeable about sporadic disorders (OR=2.70, 95% CI=1.10, 6.67, p=.03). The results of this study suggest that genetics education targeted to African Americans may need to focus on increasing understanding about technical concepts related to genetics.

Although African American breast cancer survivors are at increased risk for developing breast cancer again, empirical data are not available on breast cancer risk perceptions in these women. This study characterized perceived risk of developing breast cancer in African American breast cancer survivors at risk for having a BRCA1 or BRCA1 (BRCA1/2) mutation and identified factors having significant independent associations with risk perceptions. Participants were 95 African American breast cancer survivors at an increased risk for having a BRCA1/2 mutation. Risk perceptions and sociodemographic, clinical, treatment, and sociocultural factors were collected during a structured telephone interview. Most women reported that they had the same or lower risk of developing breast cancer again compared with other women (53%); however, a substantial minority of women (47%) reported that they had a higher or much higher risk. Factors having significant independent associations with heightened risk perceptions included having a ≥10% prior probability of having a BRCA1/2 mutation [odds ratio (OR), 2.91; 95% confidence interval (95% CI), 1.09-7.72; P = 0.03] and more years of formal education (OR, 2.74; 95% CI, 1.02-7.36; P = 0.05). In addition, women who thought about the past a lot were three times more likely to report heightened risk perceptions compared with those who did not think about the past a lot (OR, 3.72; 95% CI, 1.45-9.57; P = 0.01). These results suggest that it may be important to ensure adequate risk comprehension among African American women as part of genetic counseling for inherited breast-ovarian cancer risk. Discussion of risk perceptions within the context of existing beliefs and values may facilitate this process. (Cancer Epidemiol Biomarkers Prev 2007;16(2):244–8)

Despite the importance of breast cancer screening to reduce morbidity and mortality, limited information is available on screening practices among African American women with a family history that is suggestive of hereditary breast cancer.To describe adherence to breast cancer screening recommendations among African American women with a family history that is suggestive of hereditary disease.Participants were unaffected African American women (n=65) who had a family history of cancer that was suggestive of hereditary breast cancer. Breast cancer screening practices were evaluated by self-report. The study was conducted at the University of Pennsylvania in Philadelphia, PA. Women were recruited to participate in the study from February 2003-December 2005.Most women were adherent to recommendations for mammography (75%) and CBE (93%). A sizeable minority of women (41%) also performed excessive BSE. Being older than age 50 was associated significantly with mammography adherence (FET0.05). Employment had a significant independent association with BSE; unemployed women were most likely to perform excessive BSE (OR=3.28, 95% CI: 1.05, 10.21, p0.05).The results of this study suggest a complex pattern of breast cancer screening practices among African American women at increased risk for hereditary breast cancer.

PurposeThis study evaluated the process of recruiting African American women to participate in genetic counseling research for BRCA1 and BRCA2 (BRCA1/2) mutations with respect to referral, study enrollment, and participation in genetic counseling.Patients and MethodsAfrican American women (n = 783) were referred for study enrollment.ResultsOf 783 referrals, 164 (21%) women were eligible for enrollment. Eligible women were most likely to be referred from oncology clinics (44%) and were least likely to be referred from general medical practices (11%; χ2= 96.80; P = .0001). Overall, 62% of eligible women enrolled onto the study and 50% of enrollees completed genetic counseling. Women with a stronger family history of cancer (odds ratio [OR] = 3.18; 95% CI, 1.36 to 7.44; P = .01) and those referred from oncology clinics and community oncology resources (OR = 2.97; 95% CI, 1.34 to 6.58; P = .01) were most likely to enroll onto the study. Referral from oncology clinics was associated significantly with participation in genetic counseling (OR = 5.46; 95% CI, 1.44 to 20.60; P = .01).ConclusionDespite receiving a large number of referrals, only a small subset of women were eligible for enrollment. Oncology settings were the most effective at identifying eligible African American women and general medical practices were the least effective. Factors associated with enrollment included having a stronger family history of cancer and being referred from oncology clinics and community oncology resources. Referral from oncology clinics was the only factor associated significantly with participation in genetic counseling. Education about hereditary breast cancer may be needed among primary care providers to enhance appropriate referral of African American women to genetic counseling for BRCA1/2 mutations.

Despite attention to psychological issues during genetic counselling and testing for hereditary breast and ovarian cancer risk, limited information is available on cancer-specific distress among African American women being targeted for participation in counselling and testing. Therefore, the purpose of this study is to examine cancer-specific distress in African American women at an increased risk of hereditary breast and ovarian cancer and to identify factors having significant associations with distress in this population. Respondents were 141 African American women identified for participation in genetic counselling and testing for BRCA1/2 mutations. Overall, respondents reported moderate levels of cancer-specific distress. Younger age (coefficient=6.0, p=0.001), being unemployed (coefficient=-5.0, p=0.01), and having a personal history of cancer (coefficient=5.0, p=0.02) had significant associations with intrusion. Younger age was also associated significantly with greater avoidance (r=6.0, p=0.02). These results suggest that African American women aged 50 and younger, those who are unemployed and women with a personal history of breast or ovarian cancer may be the most vulnerable to experiencing elevated levels of distress during genetic counselling and testing. Greater attention to psychological issues, including concerns about cancer and cancer risks, may be needed during genetic counselling and testing for BRCA1/2 mutations with these women.

Importance Black patients with advanced osteoarthritis (OA) of the knee are significantly less likely than white patients to undergo surgery. No strategies have been proved to improve access to surgery for black patients with end-stage OA of the knee. Objective To assess whether a decision aid improves access to total knee replacement (TKR) surgery for black patients with OA of the knee. Design, Setting, and Participants In a randomized clinical trial, 336 eligible participants who self-identified as black and 50 years or older with chronic and frequent knee pain, a Western Ontario McMaster Universities Osteoarthritis Index score of at least 39, and radiographic evidence of OA of the knee were recruited from December 1, 2010, to May 31, 2014, at 3 medical centers. Exclusion criteria were history of major joint replacement, terminal illness, inflammatory arthritis, prosthetic leg, cognitive impairment, lack of a telephone, or contraindications to elective replacement surgery. Data were analyzed on a per-protocol and intention-to-treat (ITT) basis. Exposure Access to a decision aid for OA of the knee, a 40-minute video that describes the risks and benefits of TKR surgery. Main Outcomes and Measures Receipt of TKR surgery within 12 months and/or a recommendation for TKR surgery from an orthopedic surgeon within 6 months after the intervention. Results Among 336 patients (101 men [30.1%]; 235 women [69.9%]; mean [SD] age, 59.1 [7.2] years) randomized to the intervention or control group, 13 of 168 controls (7.7%) and 25 of 168 intervention patients (14.9%) underwent TKR within 12 months ( P = .04). These changes represent a 70% increase in the TKR rate, which increased by 86% (11 of 154 [7.1%] vs 23 of 150 [15.3%]; P = .02) in the per-protocol sample. Twenty-six controls (15.5%) and 34 intervention patients (20.2%) in the ITT analysis received a recommendation for surgery within 6 months ( P = .25). The difference in the surgery recommendation rate between the controls (24 of 154 [15.6%]) and the intervention group (31 of 150 [20.7%]) in the per-protocol analysis also was not statistically significant ( P = .25). Adjustment for study site yielded similar results: for receipt of TKR at 12 months, adjusted ORs were 2.10 (95% CI, 1.04-4.27) for the ITT analysis and 2.39 (95% CI, 1.12-5.10) for the per-protocol analysis; for recommendation of TKR at 6 months, 1.39 (95% CI, 0.79-2.44) and 1.41 (95% CI, 0.78-2.55). Conclusions and Relevance A decision aid increased rates of TKR among black patients. However, rates of recommendation for surgery did not differ significantly. A patient-centered counseling and educational intervention may help to address racial variations in the use of TKR for the management of end-stage OA of the knee. Trial Registration clinicaltrials.gov Identifer:NCT01851785

Low rates of genetic counseling among African American women have generated concerns about disparities; however, to the extent that women's decisions to accept or decline counseling are consistent with their values, then lower participation may reflect preferences and not disparities. We evaluated the extent to which women were satisfied with their decision about participating in genetic counseling for BRCA1/2 mutations and identified variables that were associated significantly with satisfaction. Prospective study of decision satisfaction with 135 African American women who had a minimum 5% prior probability of having a BRCA1/2 mutation. Decision satisfaction was evaluated one month after women were offered participation in genetic counseling using a structured questionnaire. Women were satisfied with their participation decision; more than 80% reported that their decision was consistent with their family values. However, women who declined pre-test counseling had significantly lower satisfaction scores. Our findings highlight the importance ensuring that racial differences that are due to preferences and values are not misclassified as disparities in order to identify and address the root causes of disparate treatment.

Substantial racial disparities exist in heart disease. African Americans have the highest rates of cardiovascular disease (CVD). The prevalence of cardiovascular risk factors is greatest among racial minorities. African Americans are more likely to be diabetic, physically inactive, and overweight compared to whites. Additionally, African Americans participate in cardiovascular risk reduction behaviors such as diet control, exercise, and weight management at lower rates compared to individuals from other racial groups. Primary prevention of CVD through the adoption of healthy diet and physical activity behaviors is recommended to reduce the risk of developing CVD. According to health behavior theories, people must perceive themselves as susceptible to disease to adopt a preventive behavior. Few studies have examined psychological and sociocultural factors that influence cardiovascular risk perception in African Americans. As part of a randomized trial comparing the effects of integrated versus disease specific risk education in a community-based sample of African Americans, we (1) evaluated perceived risk of developing CVD and (2) identified factors having significant independent association with risk perception. The sample consisted of 199 African American adults who were on average 45.0 years (± 9.9) old. The participants were 53% male and 47% female. Approximately 23% of the participants were at intermediate or high risk for CVD. Most (83%) participants received medical care in a doctor’s office, clinic, or community health center and had a recent visit (≤ 1 year) to a doctor (84%). More than half (62%) of participants did not perceive themselves to be at increased CVD risk. In the multivariate model that controlled for age, objective risk (β=1.85, p=0.03), a family history of CVD (β=0.47, p=0.006), a recent doctor visit (β=1.90, p=0.03), and usual source of health care (β=-2.24, p=0.008) had a significant association with risk perception. Our results suggest that usual source of health care is important to perceived risk of developing CVD. This could be because provider interaction is important in appropriate CVD risk perception. Future research is needed to evaluate the content of patient-provider discussions about CVD in different settings.

Although retention is a critical component of longitudinal cancer genetics research, limited empirical data are available on predictors of study retention among populations that are difficult to enroll. We evaluated predictors of retention in cancer genetics research among African American women at increased risk for having a BRCA1 and BRCA2 (BRCA1/2) mutation. Participants were African American women (n = 192) at increased risk for hereditary breast-ovarian cancer who were enrolled in a longitudinal genetic counseling research study. Retention was evaluated separately for the 1- and 6-month follow-ups and in terms of overall retention (e.g., completion of both telephone interviews). Seventy-three percent of women and 65% of women were retained at the 1- and 6-month follow-ups respectively; in terms of overall retention, 60% of women were retained in both follow-up telephone interviews. Predictors of retention at 1-month included being employed (OR = 2.47, 95% CI = 1.24, 4.93, P = 0.01) whereas predictors of overall retention included having a personal history of breast and/or ovarian cancer (OR = 2.06, 95% CI = 1.07, 3.95, P = 0.03) and having completed genetic counseling (OR = 2.63, 95% CI = 1.39, 4.98, P = 0.003). These data suggest that once enrolled in genetic counseling research, the majority of African American women will continue to participate, especially if concrete clinical services are provided. © 2007 Wiley-Liss, Inc.

The purpose of this study was to describe beliefs about the influence of genetic and environmental factors on tobacco use among African Americans and to identify factors that are independently associated with these beliefs.Participants were 94 adult African American men and women who were enrolled in a study on race, genetics, and smoking.Beliefs about factors involved in smoking initiation and cessation were evaluated by self-report during a structured telephone survey.Smoking status was not associated significantly with beliefs about the influence of genetic or environmental factors; however, gender and education level were associated significantly with beliefs about the influence of environmental factors. Men (beta = -1.71, P = .01) reported significantly greater beliefs about the influence of environmental factors on tobacco use compared to women. Higher education was also associated with greater beliefs about the influence of environmental factors (beta = 1.81, P = .01). Only income level was associated significantly with beliefs about the influence of genetic factors. Respondents with incomesor = dollar 20,000 reported significantly greater beliefs about the influence of genetic factors compared to those with higher incomes (beta = -.92, P = .02).These results suggest that African Americans believe that biological factors such as genes play a limited role in tobacco use behaviors. Sociodemographic factors, rather than tobacco use, are important to beliefs about tobacco use among African Americans.

Although prior studies have shown that African American smokers are likely to carry some of the genetic variants associated with smoking risk, additional research with African American smokers is needed to replicate these findings. Limited information is available on interest in participating in research to identify genetic risk factors for smoking among African American smokers; therefore, the goals of the present study were to describe intentions to participate in smoking and genetics research, and to determine factors that are associated with participation intentions. Subjects were 128 African American male and female adult smokers. Sociodemographic characteristics, clinical factors, attitudes about genetic testing, and intentions to participate in genetics research were evaluated during a structured telephone interview. Overall, 58% of respondents reported that they would be very likely to participate in research to identify genetic risk factors for smoking. Greater beliefs about the benefits of participating in medical research (odds ratio, 3.17; 95% confidence interval, 1.45-6.94; P = 0.004) and fewer perceptions of the limitations and risks of genetic testing (odds ratio, 0.90; 95% confidence interval, 0.82-0.98; P = 0.01) had significant independent associations with reporting a high likelihood of participating in this type of research. Recruitment messages and protocols that address the benefits of research participation, as well as concerns about the limitations and risks of genetic testing, may enhance African American participation in research on genetics and smoking. (Cancer Epidemiol Biomarkers Prev 2006;(15)1:150–3)

Back ground: Although African American breast cancer survivors are most likely to gain weight following diagnosis and treatment compared to women from other ethnic groups, limited information is available on psychological and behavioral reactions to weight change in this population. Objectives: To explore perceptions and reactions to weight change in African American breast cancer survivors. Methodology: A parallel mixed methods approach was used to explore experiences with and reactions to weight change following breast cancer diagnosis and treatment. Participants were 16 short- and long-term African American breast cancer survivors. Results: Nine out of 16 participants gained weight following diagnosis and treatment and most participants were concerned about these changes. Most participants were also interested in diet and exercise programs; however, a holistic and common sense approach to diet and physical activity emerged as key themes. Conclusions: Although prior reports have found that African American women in the general population report a greater tolerance for larger body sizes, most participants in this study were concerned about changes in their weight and were actively trying to minimize weight gain. Several themes emerged regarding physical activity and dietary behaviors; overall, participants described a holistic and practical approach to these behaviors. Copyright © 2005 John Wiley & Sons, Ltd.

Purpose: To evaluate attitudes about the benefits, limitations, and risks of genetic testing for BRCA1 and BRCA2 (BRCA1/2) mutations and explore testing intentions in African American women at increased risk for hereditary breast cancer. Methods: Attitudes and intentions were evaluated by telephone in African American women (n = 74) at moderate and high risk for having a BRCA1/2 mutation. Results: Attitudes about the benefits of genetic testing were endorsed at a higher rate relative to limitations and risks; however, only 30% of respondents indicated that they would definitely have testing. In regression analysis, women most likely to be considering testing were those with fatalistic beliefs about cancer and those who believed they had a BRCA1/2 mutation. Women who had two or more affected relatives were also most likely to be considering testing. Women who had a personal history of cancer and those who believed they were at high risk for developing breast cancer were most likely to report greater limitations and risks. Pros scores were higher among women older than age 50 and those who were unemployed. Conclusion: Although African American women at moderate and high risk for BRCA1/2 mutations report favorable attitudes about genetic testing, interest in testing may be limited. Women affected with cancer and those who believe they are at a higher risk for developing breast cancer may be most concerned about the negative consequences of testing. Increased attention may need to be given to beliefs about genetic testing and testing motivations during genetic counseling with African American women.