Improved hospital-level risk adjustment for surveillance of healthcare-associated bloodstream infections: a retrospective cohort study.

BACKGROUND: To allow direct comparison of bloodstream infection (BSI) rates between hospitals for performance measurement, observed rates need to be risk adjusted according to the types of patients cared for by the hospital. However, attribute data on all individual patients are often unavailable and hospital-level risk adjustment needs to be done using indirect indicator variables of patient case mix, such as hospital level. We aimed to identify medical services associated with high or low BSI rates, and to evaluate the services provided by the hospital as indicators that can be used for more objective hospital-level risk adjustment. METHODS: From February 2001-December 2007, 1719 monthly BSI counts were available from 18 hospitals in Queensland, Australia. BSI outcomes were stratified into four groups: overall BSI (OBSI), Staphylococcus aureus BSI (STAPH), intravascular device-related S. aureus BSI (IVD-STAPH) and methicillin-resistant S. aureus BSI (MRSA). Twelve services were considered as candidate risk-adjustment variables. For OBSI, STAPH and IVD-STAPH, we developed generalized estimating equation Poisson regression models that accounted for autocorrelation in longitudinal counts. Due to a lack of autocorrelation, a standard logistic regression model was specified for MRSA. RESULTS: Four risk services were identified for OBSI: AIDS (IRR 2.14, 95% CI 1.20 to 3.82), infectious diseases (IRR 2.72, 95% CI 1.97 to 3.76), oncology (IRR 1.60, 95% CI 1.29 to 1.98) and bone marrow transplants (IRR 1.52, 95% CI 1.14 to 2.03). Four protective services were also found. A similar but smaller group of risk and protective services were found for the other outcomes. Acceptable agreement between observed and fitted values was found for the OBSI and STAPH models but not for the IVD-STAPH and MRSA models. However, the IVD-STAPH and MRSA models successfully discriminated between hospitals with higher and lower BSI rates. CONCLUSION: The high model goodness-of-fit and the higher frequency of OBSI and STAPH outcomes indicated that hospital-specific risk adjustment based on medical services provided would be useful for these outcomes in Queensland. The low frequency of IVD-STAPH and MRSA outcomes indicated that development of a hospital-level risk score was a more valid method of risk adjustment for these outcomes.

Bladder cancer: race differences in extent of disease at diagnosis.

BACKGROUND: Blacks are less likely than whites to develop bladder cancer; although once diagnosed, blacks experience poorer survival. This study sought to examine multiple biological and behavioral factors and their influence on extent of disease. METHODS: A population-based cohort of black bladder cancer patients and a random sample of frequency-matched white bladder cancer patients, stratified by age, gender, and race were identified through cancer registry systems in metropolitan Atlanta, New Orleans, and the San Francisco/Oakland area. Patients were ages 20-79 years at bladder cancer diagnosis from 1985-1987, and had no previous cancer history. Medical records were reviewed at initial diagnosis. Of the patients selected for study, a total of 77% of patients was interviewed. Grade, stage, and other variables (including age, socioeconomic status, symptom duration, and smoking history) were recorded. Extent of disease was modeled in 497 patients with urothelial carcinoma using logistic regression. RESULTS: Extent of disease at diagnosis was significantly greater in Blacks than in Whites. Older age group, higher tumor grade, larger tumors, and presence of carcinoma in situ were related to greater extent of disease in blacks and in whites. Large disparities between blacks and whites were found for socioeconomic status and source of care. Blacks had greater symptom duration and higher grade. Black women were more likely to have invasive disease than white women; this difference was not seen among men. Blacks in unskilled occupational categories, perhaps reflecting socioeconomic factors, were at much higher risk for muscle invasion than whites. CONCLUSIONS: While specific relationships between variables were noted, an overall pattern defining black and white differences in stage did not emerge. Future studies should examine the basis upon which occupation and life style factors operate by using biochemical and molecular methods to study the genetic factors involved.

National Action Plan on Breast Cancer workshop on multicultural aspects of cancer etiology. A conceptual framework for the planning of ethno-oncology.

This presentation addresses the significance and implications of cancer research planning as it relates to the diversity of ethnic groups in the U.S. and indicates the limitations and potential benefits to be derived from such research. It stresses the importance of an adequate statistical data base and the relative importance of genetic and lifestyle factors in cancer etiology.

Cancer rate differentials between blacks and whites in three metropolitan areas: a 10-year comparison.

This article compares cancer rate differentials for 1989-1993 and 1979-1981 between black and whites in Los Angeles, Nashville, and Atlanta, In Los Angeles and Atlanta, the black/white relative risk of lung cancer incidence has increased. While the relative risk for prostate cancer has decreased, blacks still show an excess incidence. White women still show a higher incidence of breast cancer, but the risk is closer to one. In all three cities, the excesses of black male lung cancer and female breast cancer mortalities have increased. The excess of black prostate cancer mortality increased in Atlanta and Nashville but decreased in Los Angeles. The excess of black cervical cancer mortality fell in Los Angeles and Atlanta but rose in Nashville. These results indicate a continuing need to develop and implement culturally sensitive interventions targeted at the black population.

Attitudes of African Americans regarding screening for prostate cancer.

The purpose of this study was to identify attitudes associated with the willingness of African Americans to participate in prostate cancer screening. Subjects > or = 40 years were recruited from South Central Los Angeles. Fifty-six respondents were divided into low or middle socioeconomic groups based on education and occupation. Focus group discussions were conducted to assess knowledge, attitudes, and beliefs about prostate cancer screening and treatment, willingness to participate in screening, incentives and barriers toward participating in screening, and source of medical care. The middle socioeconomic respondents expressed a greater willingness to participate in prostate screening. This difference was attributed to their greater knowledge about the disease and screening procedures, enhanced access to health promotion activities, being less fearful of discovering abnormal results, exposure to more aggressive behavior on the part of the provider with respect to screening, and receiving medical care in an environment that is more respectful toward the consumer. Efforts to increase minority participation in prostate cancer screening or prevention studies must take these findings into consideration.

Attitude of African-Americans regarding prostate cancer clinical trials.

The purpose of this study was to qualitatively assess attitudes associated with the willingness of African-Americans to participate in prostate cancer clinical trials. Fifty-six African-American males, 40 years of age and older, were recruited from South Central Los Angeles. Respondents were divided into lower or middle socio-economic groups based on education and occupation. Focus group discussions were conducted to assess their knowledge about prostate cancer and willingness to participate in prostate cancer clinical trials. In addition, information was obtained to identify their incentives and barriers towards participating in prostate cancer research. Middle socio-economic respondents expressed a greater willingness to participate in prostate cancer clinical trials than did men of lower socio-economic status. Many indicated that they would be more likely to participate if they were encouraged to do so by a physician or researcher who was viewed as being competent and compassionate. Barriers to participation in prostate cancer clinical trials included concerns about drug toxicity, medical experimentation and distrust of the medical establishment. Endeavors aimed at increasing minority representation in prostate cancer clinical studies should address these issues.

Determinants of black/white differences in colon cancer survival.

BACKGROUND: Blacks have lower survival rates for colon cancer than whites, possibly related to more advanced stages of disease at diagnosis and to socioeconomic differences between blacks and whites. While the black/white difference in colon cancer survival is well documented, the few studies that have investigated this difference have been limited by the modest number and type of explanatory factors that were considered. PURPOSE: We analyzed data from the National Cancer Institute Black/White Cancer Survival Study to determine 1) what characteristics might contribute to the racial difference in colon cancer survival and 2) if a survival disparity remained between black and white patients after adjustment was made for these characteristics. METHODS: This prospective study included 454 blacks and a stratified random sample of 521 whites, aged 20-79 years, with cancer of the colon diagnosed from January 1, 1985, through December 31, 1986, and who were residents of the metropolitan areas of Atlanta, New Orleans, and San Francisco/Oakland. Follow-up was truncated on December 31, 1990. Cox proportional hazards regression was used to estimate the death rate among blacks relative to that among whites after adjustment for potential explanatory factors, including sociodemographic factors, concurrent (comorbid) medical conditions, stage at diagnosis, tumor characteristics, and treatment. All P values were calculated from two-tailed tests of statistical significance. RESULTS: After adjustment for age, sex, and geographic area, the black-to-white mortality hazard ratio (HR) was 1.5 (95% confidence interval [CI] = 1.2-1.9), indicating that the risk of death among black patients was 50% higher than that among white patients. Further adjustment for stage reduced the excess cancer mortality to 20% (HR = 1.2; 95% CI = 1.0-1.5), decreasing the overall racial difference in excess mortality from 50% to 20% or to a 60% reduction in excess mortality. Although adjustment for poverty reduced the excess mortality by 20%, adjusting for both stage and poverty did not further reduce the racial difference. Among patients with stages II and III disease, blacks had lower survival rates than whites (HR = 1.8; 95% CI = 1.0-3.1 and HR - 1.5; 95% CI = 1.0-2.3, respectively). Among those patients with metastatic disease (stage IV), survival was similar for whites and blacks. CONCLUSIONS: Stage at diagnosis accounted for more than half of the excess colon cancer mortality observed among blacks. Poverty and other socioeconomic conditions, general health status, tumor characteristics, and general patterns of treatment did not further explain the remaining survival disadvantage among blacks. IMPLICATIONS: Because the racial disparity was confined to earlier stages, future studies should investigate whether blacks have more advanced disease at diagnosis and whether less aggressive treatment is provided because of understanding.

Medunsa and the training of black doctors for South Africa.

Medunsa, the Medical University of Southern Africa, was founded in 1976 to address both the under-representation of blacks in the health professions and the lack of good health care in the homelands. The university trains most of the black physicians, dentists, veterinarians, and allied health professionals in South Africa, and it places a great emphasis on community service and preventive medicine. Medunsa also has programs to help socially and academically disadvantaged applicants. In some respects, the ongoing development of Medunsa mirrors that of historically black health professions schools in the United States, and Medunsa struggles with some of the same problems. Medunsa can learn from the histories of these American schools as it faces the challenges of the post-apartheid era; in turn, all U.S. schools can learn from Medunsa's history as they struggle with physician supply questions and health care reform issues.

Anatomic site distribution of colon cancer by race and other colon cancer risk factors.

PURPOSE: Black patients with colon cancer are more likely to have poorer survival from colon cancer than are white patients. To determine whether anatomic site differences might contribute to survival differences, we compared anatomic site distributions of black and white patients. METHODS: As part of the Black/White Cancer Survival Study, we collected medical record data for 1,045 patients from Atlanta, New Orleans, and San Francisco/Oakland, newly diagnosed in 1985 or 1986 and interviewed 745 of them. RESULTS: In polychotomous logistic regression analysis, site was related to stage, grade, and histologic type and among women with age, parity, and possibly smoking. However, it was not related to race, except perhaps among men age 65 and older, among whom blacks were somewhat likely to have more transverse and distal, not proximal, cancer. These relations were consistent across subgroups and were independent of other factors examined. CONCLUSION: Results suggest that site differences are unlikely to contribute to poorer survival commonly observed among black colon cancer patients in the United States.

Drew/Meharry/Morehouse Consortium Cancer Center: an approach to targeted research in minority institutions.

This article describes the process by which three private minority medical schools planned and developed a consortium cancer research center focusing on the prevention of cancer in the African-American population. Several lessons were learned that may have relevance as minority schools search for ways to improve the health status of blacks.

Making cancer prevention effective for African-Americans.

In order to reduce the racial disparities in cancer death rates, prevention programs designed for minorities must concentrate on the cancer sites and intervention methods which offer the greatest promise for closing the mortality gap. Generally accepted methods to achieve these results were recently published by the U.S. Preventive Services Task Force. Effective intervention recommendations will be increased when researchers understand the cultural differences of minorities, communicate clearly, collaborate with other programs, and treat the program participants with respect.

Cancer rate differentials between blacks and whites of three metropolitan areas.

This article presents a comparison of the cancer incidence and mortality rates for the populations of the metropolitan areas of Los Angeles, Atlanta, and Nashville. The results reveal that cancer of the lung, prostate, breast, and cervix should be of major concern to all, but especially to blacks and residents of Nashville. The findings have specific implications for the prevention of cancer in the black population of the United States.