Are there race/ethnicity differences in outpatient congestive heart failure management, hospital use, and mortality among an insured population?

OBJECTIVE: The objective of this study was to assess the quality of outpatient care received by patients with congestive heart failure (CHF) and whether differences in care and outcomes exist by race/ethnicity. BACKGROUND: Appropriate outpatient CHF management can improve patient well-being and reduce the need for costly inpatient care. Yet, little is known regarding outpatient CHF management or whether differences in this care exist by race/ethnicity. METHODS: Using automated data sources, we identified a cohort of insured patients seen in an outpatient setting for CHF between September 1992 and August 1993. Medical record abstraction was used to confirm diagnosis of CHF. Patients (N = 566) were followed until September 1998. Race/ethnicity differences in outpatient management and medical care utilization were assessed using generalized estimating equations. Differences in mortality and hospitalization for CHF, controlling for patient characteristics and outpatient management, were assessed using Cox and Andersen-Gill models, respectively. RESULTS: With the exception of beta blocker use and primary care visit frequency, few differences by race/ethnicity in patient characteristics and CHF management were found. However, older black patients had more hospital use both at baseline and during follow up. These differences persisted after adjusting for patient characteristics and clinical management. No race/ethnicity differences were found in mortality. CONCLUSIONS: In an insured population, older black patients with CHF have substantially more hospital use than older white patients. This increased use was not explained by differences in CHF outpatient management. Further research is needed to understand why race/ethnicity differences in hospital use are observed among older patients with CHF.

Prevalence and correlates of HIV serostatus disclosure.

BACKGROUND AND OBJECTIVE: A study of HIV-positive individuals in New Orleans, Louisiana, found that the majority of patients disclosed to their main partners and family members, but less than one fourth disclosed to any casual sex partner. Older age and lower CD4 cell counts were associated with disclosure. GOAL: The goal was to describe patterns of HIV serostatus disclosure among a diverse sample of patients at an HIV outpatient clinic in New Orleans, Louisiana. STUDY DESIGN: A convenience sample of HIV-seropositive patients provided information about disclosure of seropositivity, demographics, date of HIV diagnosis, CD4 cell count, mode of HIV acquisition, and sexual activity since HIV diagnosis. RESULTS: The 269 persons disclosed their HIV status to people in the following categories: main sex partner (74.2%), casual sex partner (24.8%), immediate family member (69.8%), other relative (27.0%), or friend (26.4%). Adolescents were less likely than adults to disclose to a main partner, immediate family member, or a friend. Immunosuppressed persons were more likely than nonimmunosuppressed persons to disclose to a main partner, immediate family member, or another relative. CONCLUSION: Many HIV-infected individuals delay disclosure until their disease has progressed. Interventions such as partner notification and skill-building to facilitate appropriate HIV disclosure are needed.

Demographic factors for utilization of invasive genetic testing after multifetal pregnancy reduction.

OBJECTIVE: Pregnant infertility patients are commonly old enough to be offered prenatal diagnosis. However, they may be reluctant to undergo an additional invasive procedure. We, therefore, sought to determine what demographic factors, including race and ethnic group, influenced patients' decisions to undergo genetic testing in addition to multifetal pregnancy reduction (MFPR). METHODS: We retrospectively reviewed MFPR patients from July 1997 to June 1999 at our institution. Invasive genetic testing was routinely discussed. Maternal age, race, ethnicity, religion, egg source for in vitro fertilization (IVF) patients, and the remaining fetuses following MFPR were analyzed for invasive genetic testing determinants and were compared to our experiences with genetic referents to us for singleton pregnancies. 132 consecutive patients, of whom 49 were >/=35 years, including 15 having IVF with donor eggs, were included. RESULTS: Maternal age was the single most significant determinant of testing. In donor egg cases, donor age was significant. Ethnic background, previous children, and the remaining number of fetuses after MFPR were also significant determinants. CONCLUSION: MFPR patients share similar demographics to the advanced maternal age population. Despite the very stressful situations, our data suggest that maternal age, and therefore genetic risk, is the most important determinant of choosing whether or not to have testing. However, patients' decisions are, to varying degrees, modified by religious and ethnic considerations.

Spontaneous abortions in couples declining multifetal pregnancy reduction.

Multifetal pregnancy reduction (MFPR) has clearly improved the outcomes of multifetal gestations. Several recent reports have also suggested improved outcomes in nonreduced cases, but there have been methodologic concerns about the denominators, i.e. have all cases been included and is there a 'hidden mortality' of unknown lost cases. Here we assessed the outcome of patients telephoning to discuss MFPR, but who chose not to have the procedure. Over a 3-year period, 446 patients had MFPR by one operator. Nineteen patients chose not to have the procedure. There were 11 preterm births, 1 term delivery, and 5 spontaneous losses (7 of 17) prior to 24 weeks, a loss rate of 35%. Two patients delivering triplets had a loss of 1 fetus/neonate. These data suggest that the loss rates of nonreduced pregnancies may be higher than generally thought, making the improvements with MFPR even bigger than generally realized.

HIV-infected persons' knowledge of their sexual partners' HIV status.

The purpose of this study was to measure the accuracy of HIV-infected persons' knowledge of their sexual partners' HIV infection status. HIV-infected persons at two public health clinics reported their knowledge of the HIV infection status of their sexual partners. Actual HIV test results for sexual partners were then linked to survey responses. The association between reported knowledge and actual infection status of partners was estimated by kappa scores and percent agreement. Sixty-four percent (14/22) of partners thought to be infected were actually uninfected, and 42% (8/19) of partners thought to be uninfected were actually infected. The overall percent agreement was 46% (kappa = -0.06), less than that expected by random chance alone. Individuals in committed partnerships were less likely to have accurate knowledge than those in casual partnerships. In conclusion, HIV-infected individuals have poor knowledge regarding their partners' infection status. This may influence sexual behaviors that result in increased transmission.