Racial disparities in pediatric access to kidney transplantation: does socioeconomic status play a role?

Racial disparities persist in access to renal transplantation in the United States, but the degree to which patient and neighborhood socioeconomic status (SES) impacts racial disparities in deceased donor renal transplantation access has not been examined in the pediatric and adolescent end-stage renal disease (ESRD) population. We examined the interplay of race and SES in a population-based cohort of all incident pediatric ESRD patients <21 years from the United States Renal Data System from 2000 to 2008, followed through September 2009. Of 8452 patients included, 30.8% were black, 27.6% white-Hispanic, 44.3% female and 28.0% lived in poor neighborhoods. A total of 63.4% of the study population was placed on the waiting list and 32.5% received a deceased donor transplant. Racial disparities persisted in transplant even after adjustment for SES, where minorities were less likely to receive a transplant compared to whites, and this disparity was more pronounced among patients 18-20 years. Disparities in access to the waiting list were mitigated in Hispanic patients with private health insurance. Our study suggests that racial disparities in transplant access worsen as pediatric patients transition into young adulthood, and that SES does not explain all of the racial differences in access to kidney transplantation.

The role of race and poverty on steps to kidney transplantation in the Southeastern United States.

Racial disparities in access to renal transplantation exist, but the effects of race and socioeconomic status (SES) on early steps of renal transplantation have not been well explored. Adult patients referred for renal transplant evaluation at a single transplant center in the Southeastern United States from 2005 to 2007, followed through May 2010, were examined. Demographic and clinical data were obtained from patient's medical records and then linked with United States Renal Data System and American Community Survey Census data. Cox models examined the effect of race on referral, evaluation, waitlisting and organ receipt. Of 2291 patients, 64.9% were black, the mean age was 49.4 years and 33.6% lived in poor neighborhoods. Racial disparities were observed in access to referral, transplant evaluation, waitlisting and organ receipt. SES explained almost one-third of the lower rate of transplant among black versus white patients, but even after adjustment for demographic, clinical and SES factors, blacks had a 59% lower rate of transplant than whites (hazard ratio = 0.41; 95% confidence interval: 0.28-0.58). Results suggest that improving access to healthcare may reduce some, but not all, of the racial disparities in access to kidney transplantation.

Health literacy and performance on the Mini-Mental State Examination.

The objectives of the study were to determine the relationship between functional health literacy and performance on the Mini-Mental State Examination (MMSE). New Medicare managed-care enrollees aged 65 years and older, living independently in the community in four US cities (Cleveland, Houston, Tampa, and Fort Lauderdale/Miami), were eligible to participate. In-home interviews were conducted to determine demographics and health status, and interviewers then administered the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the MMSE. We then determined the relationship between functional health literacy and the MMSE, including total scores, subscale scores (orientation to time, orientation to place, registration, attention and calculation, recall, language, and visual construction), and individual items. Functional health literacy was linearly related to the total MMSE score across the entire range of S-TOFHLA scores (R(2) = 0.39, p < 0.001). This relationship between health literacy and MMSE was consistent across all MMSE subscales and individual items. Adjustment for chronic conditions and self-reported overall health did not change the relationship between health literacy and MMSE score. Health literacy was related to MMSE performance even for subscales of the MMSE that were not postulated to be directly dependent on reading ability or education (e.g. delayed recall). These results suggest that the lower MMSE scores for patients with low health literacy are only partly due to 'test bias' and also result from true differences in cognitive functioning. 'Adjusting' MMSE scores for an individual's functional health literacy may be inappropriate because it may mask true differences in cognitive functioning.

Why do women douche? Results from a qualitative study.

OBJECTIVES: To explore women's attitudes and practices related to douching. METHODS: We conducted focus groups between July and December 1999 with 34 black and 27 white women enrolled in a managed care plan in Memphis, Tennessee. Participants were at least 18 years of age and had douched at some time in their lives. Five groups were held with black women and five with white women. RESULTS: The focus groups identified 13 themes that fell in four broad categories: general perceptions about feminine hygiene, douching behavior, factors perpetuating douching, and health information. Each of these categories is briefly discussed with supporting evidence. CONCLUSIONS: First, women have deeply-rooted beliefs about the critical role of douching in making them feel clean. Second, douching generally starts at a young age and is reinforced by family, friends, and the media. Third, douching is a very difficult behavior to change; any efforts to influence this behavior must consider women's beliefs and the media marketing efforts that promote douching. Finally, simplistic interventions that only provide risk information about douching are not likely to result in behavior change.

How contraceptive use patterns differ by pregnancy intention: implications for counseling.

To increase awareness of issues to include in contraceptive counseling-the objectives of this study were to evaluate: 1) how contraceptive use patterns (eg, non-use), level of effectiveness of contraceptive method, and sociodemographic characteristics may be associated with the occurrence of unintended pregnancy; 2) patterns of health care use for women with intended and unintended pregnancy; and 3) the association between contraceptive use patterns and sociodemographic characteristics. In-person interviews were conducted with 279 women enrolled in a Medicaid managed care health plan who had been pregnant in the last 5 years. Self-reported measures of pregnancy intention, contraceptive use, and health care use were collected. The relationships of pregnancy intention with contraceptive use patterns, level of effectiveness of contraceptive method used, and patterns of recent health care use were assessed. Differences in contraceptive use patterns by sociodemographic groups were assessed. Seventy-eight percent of women reported an unintended pregnancy. Non-use of birth control the month before conception was reported by 57% of women with unintended pregnancies and 84% of women with intended pregnancies. Use of birth control of low effectiveness was reported by 20% of women with unintended pregnancies and 8% of women with intended pregnancies. Non-use or use of contraceptive methods of low effectiveness did not differ for women in different sociodemographic groups regardless of pregnancy intention status. A majority of women reported recent health care use. Health care providers should be aware that women who have no intention for pregnancy may not be using an effective contraceptive method NOR have an effective pattern of contraceptive use.

Physician characteristics and the initiation of beta-adrenergic blocking agent therapy after acute myocardial infarction in a managed care population.

OBJECTIVE: To determine the association between physician characteristics and the use of beta-adrenergic blocking agents after acute myocardial infarction in a national managed care organization. STUDY DESIGN: Retrospective administrative data analysis. PARTICIPANTS AND METHODS: The study cohort consisted of 473 physicians who prescribed the medications and 578 patients who (1) experienced an acute myocardial infarction between January 1, 1995, and December 31, 1996, with at least 1 cardiac medication claim within 7 days of hospital discharge; (2) were not previously taking beta-adrenergic blocking agents; and (3) had none of several defined contraindications to the medication. Using multivariate models, we assessed the relation between physician characteristics and initiation of beta-adrenergic blocking agent therapy, controlling for patient characteristics and cardiac treatments. RESULTS: Sixty-two percent of patients filled a prescription for beta-adrenergic blocking agents within 7 days of hospital discharge. Physician characteristics, including specialty and region of hospitalization, were independently associated with the use beta-adrenergic blocking agents. Family practice physicians and other noninternists were much less likely than cardiologists to prescribe beta-adrenergic blocking agents. The other most important predictors of the use of beta-adrenergic blocking agents were region of hospitalization and patient age. CONCLUSIONS: Physician characteristics are associated with the use of beta-adrenergic blocking agents. Although there are opportunities to improve practice for all physicians, family practice physicians and noninternists have the most opportunity to improve.

The association between age and health literacy among elderly persons.

OBJECTIVE: To examine why older age groups have worse functional health literacy. METHODS: Home interviews were conducted with community-dwelling elderly persons (n = 2,774) to determine demographics, years of school completed, newspaper reading frequency, chronic diseases, and health status. Participants completed the Short Test of Functional Health Literacy in Adults (S-TOFHLA, range 0-100) and the Mini Mental State Examination (MMSE). RESULTS: Mean S-TOFHLA scores declined 1.4 points (95% CI 1.3-1.5) for every year increase in age (p < .001). After adjusting for sex, race, ethnicity, and education, the S-TOFHLA score declined 1.3 points (95% CI 1.2-1.4) for every year increase in age. Even after adjustment for performance on the MMSE, the S-TOFHLA score declined 0.9 points (95% CI 0.8-1.0) for every year increase in age (p < .001). Differences in newspaper reading frequency, visual acuity, chronic medical conditions, and health status, did not explain the lower literacy of older participants. DISCUSSION: Functional health literacy was markedly lower among older age groups even after adjusting for differences in MMSE performance, newspaper reading frequency, health status, and visual acuity. Future studies should prospectively examine whether functional literacy declines with age and whether this is explained by declines in cognitive function.

Violence and reproductive health: current knowledge and future research directions.

OBJECTIVES: Despite the scope of violence against women and its importance for reproductive health, very few scientific data about the relationship between violence and reproductive health issues are available. METHODS: The current knowledge base for several issues specific to violence and reproductive health, including association of violence with pregnancy, pregnancy intention, contraception use, pregnancy terminations, and pregnancy outcomes, are reviewed and suggestions are provided for future research. RESULTS: Despite the limitations of current research and some inconclusive results, the existing research base clearly documents several important points: (1) violence occurs commonly during pregnancy (an estimated 4%-8% of pregnancies): (2) violence is associated with unintended pregnancies and may be related to inconsistent contraceptive use; and (3) the research is inconclusive about the relationship between violence and pregnancy outcomes. CONCLUSIONS: Improved knowledge of the risk factors for violence is critical for effective intervention design and implementation. Four areas that need improvement for development of new research studies examining violence and reproductive-related issues include (1) broadening of study populations, (2) refining data collection methodologies, (3) obtaining additional information about violence and other factors, and (4) developing and evaluating screening and intervention programs. The research and health care communities should act collaboratively to improve our understanding of why violence against women occurs, how it specifically affects reproductive health status, and what prevention strategies may be effective.

Pregnancy intendedness and physical abuse around the time of pregnancy: findings from the pregnancy risk assessment monitoring system, 1996-1997. PRAMS Working Group. Pregnancy Risk Assessment Monitoring System.

OBJECTIVE: This study examines whether unintended pregnancy is associated with physical abuse of women occurring around the time of pregnancy, independent of other factors. METHODS: In 1996-1997, state-specific population-based data were obtained from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 39,348 women in 14 states who had delivered a live-born infant within the previous 2-6 months. The study questionnaire asked about maternal behaviors and characteristics around the time of pregnancy. RESULTS: Women who had mistimed or unwanted pregnancies reported significantly higher levels of abuse at any time during the 12 months before conception or during pregnancy (12.6% and 15.3%, respectively) compared with those with intended pregnancies (5.3%). Higher rates of abuse were reported by women who were younger, Black, unmarried, less educated, on Medicaid, living in crowded conditions, entering prenatal care late, or smoking during the third trimester. Overall, women with unintended pregnancies had 2.5 times the risk of experiencing physical abuse compared with those whose pregnancies were intended. This association was modified by maternal characteristics, the association was strongest among women who were older, more educated, White, married, not on Medicaid, not living in crowded conditions, receiving first trimester prenatal care, or nonsmoking during the third trimester. CONCLUSIONS: Women with unintended pregnancies are at increased risk of physical abuse around the time of pregnancy compared with women whose pregnancies are intended. Prenatal care can provide an important point of contact where women can be screened for violence and referred to services that can assist them.

Breast-feeding education and support: association with the decision to breast-feed.

CONTEXT: Rates of breast-feeding in the United States are well below the Healthy People 2000 objective of 75% and do not meet recent American Academy of Pediatrics guidelines. OBJECTIVE: To identify factors associated with the initiation and duration of breast-feeding in managed care enrollees who had had a normal vaginal delivery. DESIGN: Telephone survey of 5213 new mothers (4 to 6 months postpartum) enrolled in commercial managed care plans (response rate 72%). MAIN OUTCOME MEASURES: Starting breast-feeding (ever vs never) and duration of breast-feeding (< or = 6 weeks vs > 6 weeks). ANALYSIS: Logistic regression models controlling for sociodemographic variables. Given the prevalence of the outcome, odds ratios were converted to relative risks (RRs). RESULTS: Seventy-five percent of respondents reported ever breast-feeding, and of those women, 75% reported breast-feeding for more than 6 weeks. In adjusted multivariate analyses, breast-feeding was affected by education, employment, and marital status. Women who were more likely to breast-feed were those who attended childbirth classes (RR, 1.16; 95% CI, 1.11 to 1.20), those who received prenatal breast-feeding advice (RR, 1.24; CI, 1.19 to 1.27), and those who received postpartum breast-feeding assistance (RR, 1.31; CI, 1.15 to 1.34). Breast-feeding for more than 6 weeks postpartum was associated with education, employment status, and the adequacy of postpartum information. CONCLUSIONS: These findings suggest that health plans and employees may promote breast-feeding by providing breast-feeding education and support.

Prenatal care for low-income women enrolled in a managed-care organization.

OBJECTIVE: To determine barriers to prenatal care among managed-care enrollees who receive Medicaid. METHODS: In-person interviews were conducted with women 13-45 years old who were members of the Prudential HealthCare Community Plan in Memphis, Tennessee. Interview data were linked to medical chart reviews for 200 women who were currently pregnant or had delivered a baby since enrollment in Prudential. Factors related to untimely entry to prenatal care and inadequate prenatal visits were examined. RESULTS: More than half of the respondents had either untimely entry to or inadequate prenatal care. Overall, 89% of respondents had favorable attitudes about prenatal care. Several system and personal factors were associated with receipt of early or adequate prenatal care. Multivariate analysis showed that one system and two personal factors remained significantly related to entry to prenatal care. Women who entered Prudential during pregnancy were 2.4 times more likely (95% CI 1.1, 5.0) to receive late care than women who enrolled before pregnancy. Women who felt too tired to go for care were 2.2 times more likely (95% CI 1.0, 4.9) to receive late care. Women who experienced physical violence during pregnancy were 3.5 times more likely (95% CI 1.0, 12.0) to receive late care. Multivariate analysis with adequacy of prenatal care as the outcome showed several personal factors that increased odds of receiving inadequate prenatal care; however, only help from the infant's father was significantly related to adequacy of prenatal care. Women who did not have much help from the infant's father were 1.9 times more likely not to have adequate care (95% CI 1.0, 3.6). CONCLUSION: Even when affordable care was available, many low-income women did not avail themselves of it. Although women knew the importance of prenatal care, there was a gap between attitudes and actually seeking appropriate care. System and personal factors need to be addressed to overcome barriers to prenatal care.

Health literacy among Medicare enrollees in a managed care organization.

CONTEXT: Elderly patients may have limited ability to read and comprehend medical information pertinent to their health. OBJECTIVE: To determine the prevalence of low functional health literacy among community-dwelling Medicare enrollees in a national managed care organization. DESIGN: Cross-sectional survey. SETTING: Four Prudential HealthCare plans (Cleveland, Ohio; Houston, Tex; south Florida; Tampa, Fla). PARTICIPANTS: A total of 3260 new Medicare enrollees aged 65 years or older were interviewed in person between June and December 1997 (853 in Cleveland, 498 in Houston, 975 in south Florida, 934 in Tampa); 2956 spoke English and 304 spoke Spanish as their native language. MAIN OUTCOME MEASURE; Functional health literacy as measured by the Short Test of Functional Health Literacy in Adults. RESULTS: Overall, 33.9% of English-speaking and 53.9% of Spanish-speaking respondents had inadequate or marginal health literacy. The prevalence of inadequate or marginal functional health literacy among English speakers ranged from 26.8% to 44.0%. In multivariate analysis, study location, race/language, age, years of school completed, occupation, and cognitive impairment were significantly associated with inadequate or marginal literacy. Reading ability declined dramatically with age, even after adjusting for years of school completed and cognitive impairment. The adjusted odds ratio for having inadequate or marginal health literacy was 8.62 (95% confidence interval, 5.55-13.38) for enrollees aged 85 years or older compared with individuals aged 65 to 69 years. CONCLUSIONS: Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. Low health literacy may impair elderly patients' understanding of health messages and limit their ability to care for their medical problems.

Reading skills and family planning knowledge and practices in a low-income managed-care population.

OBJECTIVE: To examine the relationship between reading ability and family planning knowledge and practices among Medicaid managed care enrollees. METHODS: A total of 406 women age 19-45 years enrolled in TennCare and members of Prudential HealthCare Community Plan in Memphis, Tennessee were interviewed to determine their methods of contraception, desire for additional information about contraceptives, and knowledge about the time in menstrual cycle they are at highest risk for pregnancy. Patient reading ability was assessed by an abbreviated version of the Test of Functional Health Literacy of Adults. The independent associations between reading ability, desire for additional contraceptive information, and knowledge about the highest risk time for pregnancy were assessed with logistic regression. RESULTS: Almost 10% of the respondents had low reading skills. Women who had used an intrauterine device, douching, rhythm, or levonorgestrel implants as methods of birth control had higher rates of low reading skills than women who used other methods of birth control. Compared with women with good reading skills, women with low reading skills were 2.2 times (95% confidence interval [CI] 1.1, 4.4) more likely to want to know more about birth control methods and 4.4 times (95% CI 2.2, 9.0) more likely to have incorrect knowledge about when they were most likely to get pregnant. These relationships were significant even after controlling for age, race, and marital status. CONCLUSION: Health providers and organizations that serve historically underserved populations must understand that some individuals have a low level of reading ability that limits family planning education.

Development of a brief test to measure functional health literacy.

We describe the development of an abbreviated version of the Test of Functional Health Literacy in Adults (TOFHLA) to measure patients' ability to read and understand health-related materials. The TOFHLA was reduced from 17 Numeracy items and 3 prose passages to 4 Numeracy items and 2 prose passages (S-TOFHLA). The maximum time for administration was reduced from 22 minutes to 12. In a group of 211 patients given the S-TOFHLA, Cronbach's alpha was 0.68 for the 4 Numeracy items and 0.97 for the 36 items in the 2 prose passages. The correlation (Spearman) between the S-TOFHLA and the Rapid Estimate of Adult Literacy in Medicine (REALM) was 0.80, although there were important disagreements between the two tests. The S-TOFHLA is a practical measure of functional health literacy with good reliability and validity that can be used by health educators to identify individuals who require special assistance to achieve learning goals.

Economic aspects of the perinatal hospital stay.

This article concentrates on the economics of the perinatal hospital stay for normal vaginal and cesarean section deliveries. Published studies in the United States are reviewed under three headings: inpatient costs for traditional stays, outpatient costs for postpartum services, and costs for short stays with follow-up services. Despite the increasing attention on length of stay after delivery, there has been minimal research examining the true costs of an early discharge program and services compared with longer hospital stays. Formal analysis of alternative strategies and well-designed clinical studies are needed before an optimal policy for caring for mothers and infants can be identified.

Violence during pregnancy: measurement issues.

OBJECTIVES: Standardized quantitative methods are needed to study occurrence and timing of violence in relation to pregnancy and to study the context in which pregnancy-related violence occurs. METHODS: Data from three published studies of prevalence of violence during pregnancy are used to illustrate ways to measure the association of violence in relation to pregnancy. RESULTS: Four patterns of violence in relation to pregnancy are identified, and related research issues are discussed. Also, 2 population-based surveys that address the suggestions presented here are discussed. CONCLUSIONS: Better measurement of the association between violence and pregnancy will facilitate development of data-based prevention and intervention programs.

Violence and adverse pregnancy outcomes: a review of the literature and directions for future research.

INTRODUCTION: Violence during pregnancy has been estimated to affect between 0.9% and 20.1% of pregnant women in the United States. This article presents a review of the research on the potential association between violence during pregnancy and adverse outcomes, explores mechanisms by which violence might influence pregnancy outcomes, and suggests directions for future research aimed at the development of successful interventions. METHODS: A review of the literature pertaining to violence during pregnancy and adverse pregnancy outcomes, trauma, and stress during pregnancy was completed. RESULTS: Overall, no pregnancy outcome was consistently found to be associated with violence during pregnancy. The trauma literature offers insight about the effects that injuries caused by physical violence might have on pregnancy outcomes. Information from the stress literature investigates potential mechanisms through which physical violence could indirectly affect pregnancy outcomes. The trauma and stress literature offers methodologic approaches that could be employed in future research on violence during pregnancy and pregnancy outcomes. CONCLUSIONS: This review lays the groundwork for the development of a future research agenda to investigate the association between violence during pregnancy and adverse outcomes. Future research should include quantitative and qualitative approaches, and investigation into the mechanisms and antecedents of how violence during pregnancy may lead to adverse outcomes. Only with such information can successful interventions to limit violence and its potential effects during pregnancy be implemented.

Delayed entry into prenatal care: effect of physical violence.

OBJECTIVE: To assess whether women who experienced physical violence by their partner during the 12 months before delivery were more likely to delay entry into prenatal care than were women who had not experienced physical violence. METHODS: We analyzed data from the Pregnancy Risk Assessment Monitoring System. The sample included 27,836 women who delivered live infants during 1993-1994 in nine states and were surveyed 2-6 months after delivery. We calculated risk ratios and 95% confidence intervals (CIs) to measure the association between physical violence within the 12 months before delivery and entry into prenatal care. RESULTS: The prevalence of delayed entry into prenatal care (entering after the first trimester) was 18.1% and that of reported physical violence was 4.7%. Overall, women who experienced physical violence were 1.8 times more likely (95% CI 1.5, 2.1) to have delayed entry into prenatal care than women who had not experienced such violence. When stratifying by selected maternal characteristics, this association was found only for groups of women who were 25 years of age or older or were of higher socioeconomic status. CONCLUSION: Older women and women of higher socioeconomic status who reported physical violence were more likely to delay entry into prenatal care than younger or less affluent women.

Maternity experiences in a managed care organization.

We conducted a telephone survey of female managed care enrollees who recently had a normal vaginal delivery to examine the relationship between hospital length-of-stay and maternal characteristics, pregnancy factors, length-of-stay preferences, and postdischarge experiences. Results indicated that length-of-stay varied by maternal characteristics and pregnancy factors. Length-of-stay and maternal or newborn readmissions were not statistically associated. Most respondents reported that they would be willing to go home within twenty-four hours after future deliveries if additional services were provided. Emphasis should be placed on which services can be provided to prepare and assist mothers through the perinatal period.

Barriers to prenatal care among Medicaid managed care enrollees: patient and provider perceptions.

To identify what patients and providers perceive as barriers to prenatal care among women enrolled in a Medicaid managed care plan, focus group discussions of: 1) women, 13 to 45 years of age, enrolled in a Medicaid managed care plan and 2) providers (physicians, nurse practitioners, nurses, and medical assistants) that serve this population were conducted at a location in the community by professional facilitators. Forty-two enrolled women and 22 providers participated. Based on an interpretive analysis of comments regarding perceived barriers towards receiving prenatal care by patients and providers, we found some perceived barriers that were similar for both groups. Both groups of respondents thought that problems with transportation, knowledge of TennCare, and substance abuse were barriers to receiving prenatal care. Providers mentioned lack of enrollee's education, need for child care, and limited hours of operation; and patients mentioned treatment by office personnel, lack of rapport with health providers and lack of recognition of pregnancy as additional barriers. Understanding both patient and provider perspectives of the barriers to receiving care is the first step towards meeting the needs of the target population. Health plans that serve the historically underserved population must take a specialized approach that adapts to the population's distinct needs.