Substitution of formal health care services by Latinos/Hispanics in the US-Mexico border region of South Texas.

BACKGROUND: Pervasive poverty and high uninsurance rates in the US-Mexico border region coupled with rising US health care costs and the availability of alternatives to formal US health services-both in the United States and Mexico-have resulted in widespread use of alternatives to formal US health care. OBJECTIVES: We investigate variation in the purchase of substitutes for formal US health services among border residents reporting health-related cost constraints. Preferences for various means of substitution (informal US services, formal Mexican services, and informal Mexican services) are identified. RESEARCH DESIGN: Cross-sectional study of purposive interview data from the Texas Borderlife Project regarding the purchase of a continuum of informal services/goods, including health care services and prescription medications. SUBJECTS: Study respondents included 320 Latino/Hispanic residents of the Texas border region. MEASURES: Eight health substitutes (medical care, prescription medication, and dental care) were ordered from formal services/goods in Mexico to informal services/goods in Mexico and the US. The independent variable was reporting having gone without seeing a physician in the past 12 months because of cost. RESULTS: Border residents reporting cost constraints were significantly more likely to purchase substitutes for formal US health services. Further, our findings suggest that when substitutes to formal US health care are used, Texas border residents prefer to access formal Mexican health care first, followed by informal US health services. CONCLUSIONS: Increasing access to US health services may require greater effort and resources in border communities given the availability of substitutes for formal health care services in this region.

Attempts by one local health department to provide only essential public health services: a 10-year retrospective case study.

BACKGROUND: Because of local political circumstances, in 1996, the local public health department in Amarillo, Texas, divested itself of almost all personal health services and chose to retain only essential population-based public health services. METHODS: We analyzed function, funding, and staffing for various health department activities in FY 1997 and again in FY 2007. The figures were adjusted for inflation and population growth. We interviewed key personnel about the motivation and effects of the changes that occurred with this 10-year period. RESULTS: The local health department both transferred and reassumed some personal health services during this period. This was primarily in the area of immunization services and care for special population such as refugees. Public health preparedness also became a significant new area of activity. Most personal health services provided by the health department before 1996 remained the function of other health care entities in the community. When adjusted for inflation and population growth, most of the growth in the health department's personnel and budget was the result of state and federally mandated program changes. CONCLUSIONS: Growth in this local health department, which was committed to provide only essential health services, was driven primarily by state and federally mandated programs. Real growth for essential public health services did not occur over a 10-year period.

What is patient safety culture? A review of the literature.

PURPOSE: To organize the properties of safety culture addressed by many studies and to develop a conceptual culture of safety model. DESIGN AND METHODS: A comprehensive review of the culture of safety literature within the U.S. hospital setting. The review was a qualitative meta-analysis from which we generated a conceptual culture of safety framework and developed a typology of the safety culture literature. FINDINGS: Seven subcultures of patient safety culture were identified: (a) leadership, (b) teamwork, (c) evidence-based, (d) communication, (e) learning, (f) just, and (g) patient-centered. CONCLUSIONS: Safety culture is a complex phenomenon that is not clearly understood by hospital leaders, thus making it difficult to operationalize. We found senior leadership accountability key to an organization-wide culture of safety. CLINICAL RELEVANCE: Hospital leaders are increasingly pressured by federal, state, regulatory, and consumer groups to demonstrate an organizational safety culture that assures patients are safe from medical error. This article defines a safety culture framework that may support hospital leadership answer the question "what is a patient safety culture?"

Ethnic differences in in-hospital place of death among older adults in California: effects of individual and contextual characteristics and medical resource supply.

BACKGROUND: : Substantial ethnic differences have been reported in the probability that death will occur in a hospital setting rather than at home, in a hospice, or in a nursing home. To date, no study has investigated the role of both individual characteristics and contextual characteristics, including local health care environments, to explain ethnic differentials in end-of-life care. OBJECTIVES: : The study purpose is to examine ethnic differences in the association between death as a hospital in-patient and individual and contextual characteristics, as well as medical resource supply. RESEARCH DESIGN: : This study employed a secondary data analysis. SUBJECTS: : We used data from the California Death Statistical Master file for the years 1999-2001, which included 472,382 complete cases. These data were geocoded and linked to data from the US Census Bureau and the American Hospital Association. RESULTS: : Death as an in-patient was most common for Asian (54%) and Hispanic immigrants (49%) and least common for non-Hispanic whites (36%) and US-born Asians (41%). Medical resource supply variables are of considerable importance in accounting for ethnic differentials in the probability of dying in a hospital. Residual differences in in-hospital site of death were largest for immigrant populations. CONCLUSIONS: : There are sizeable ethnic differentials in the probability that a death will occur in a hospital in California. These differences are substantially mediated by sociodemographic characteristics of the decedent and local medical care supply. One implication of these findings is that variation exists in the efficiency and quality of end of life care delivered to ethnic minorities.

Family medicine residency educational characteristics and career satisfaction in recent graduates.

BACKGROUND AND OBJECTIVES: Career satisfaction among family physicians has declined over the last 15 years. The purpose of this study was to determine what aspects of residency training are associated with family medicine career satisfaction in recent graduates. METHODS: This was a cross-sectional national survey of 1000 family physicians who graduated within the last 10 years. Questions were primarily Likert type. Exploratory factor analysis was used to identify retained factors. Bivariate and multivariate linear regression analyses were performed to identify residency characteristics, demographics, and current work characteristics that were associated with career satisfaction. RESULTS: The response rate was 55.8% (558/1000). Exploratory factor analysis found three factors that explained the majority of the variance in career satisfaction: overall work life, rigorous residency training, and demographic factors. Many features of residency training were associated with career satisfaction on bivariate analysis. Multivariate analysis found that training that was exceptionally broad and in-depth was independently associated with career satisfaction. The factors with the largest association with career satisfaction were medical career satisfaction and current work satisfaction. DISCUSSION: Our findings suggest that residency education that was broad and in-depth was associated with early family medicine career satisfaction. This construct reflected rigorous training that included hands-on procedural experience, breadth of experiences with patients and illness, and care for complex hospitalized patients.

Ethnic disparities in access to care in post-apartheid South Africa.

OBJECTIVES: We investigated ethnic disparities in obtaining medical care among the 4 major ethnic groups (Blacks, Whites, Coloreds [i.e., those of mixed race], and Asians) in post-apartheid South Africa. METHODS: Data for the study came from the 2002 Afrobarometer: Round II Survey of South Africa. Bivariate and multivariate analyses were used to examine differences across racial and ethnic groups in how often respondents went without medical care. RESULTS: A total of 40.8% of Blacks and 22.9% of Coloreds reported going without medical care at some point in the past year, compared with 10.9% of Whites and 6.9% of Asians. Disparities were found not only in health but in education, income, and basic public health infrastructures. Sociodemographic characteristics and perceptions regarding democracy, markets, and civil society were similar for Blacks and Coloreds and for Whites and Asians. CONCLUSIONS: Fourteen years after the end of apartheid, Blacks and Coloreds in South Africa are still underserved and disadvantaged compared with their White and Asian counterparts, especially regarding health care.

Serum carotenoid levels vary by marital status.

This study examined differences in serum carotenoid levels by marital status. The design was a cross-sectional, nationally representative survey of 16,597 participants ages 18 years and older from the Third National Health and Nutrition Examination Survey. The main outcome measures were serum levels of alpha-carotene, beta-carotene, beta-cryptoxanthin, lutein/zeaxanthin, lycopene, and total carotenoids. Multivariate linear regression was used to model the association of serum carotenoids and marital status by sex and age with adjustments made for age, race/ethnicity, years of education, household income, body mass index, alcohol use, physical activity, serum cotinine, serum cholesterol, and vitamin/mineral supplement use. Among men, never married marital status was associated with lower total carotenoid levels (mean 66.16 microg/dL, P=0.05), lutein/zeaxanthin (mean 15.57 microg/dL [0.27 micromol/L], P=0.01), and lycopene (mean 24.28 microg/dL [0.45 micromol/L], P=0.00) compared to married marital status among men. Divorced marital status was associated with lower lycopene levels (mean 24.23 microg/dL [0.45 micromol/L], P=0.00) compared to married men. Compared to married men, widowed marital status was associated with lower alpha-carotene (mean 2.47 microg/dL [0.05 micromol/L], P=0.02), beta-carotene (mean 11.52 microg/dL [0.21 micromol/L], P=0.04), and lycopene levels (mean 25.15 microg/dL [0.47 micromol/L], P=0.04). Among women, widowed marital status was associated with lower levels of total carotenoids (mean 62.72 microg/dL, P=0.01), alpha-carotene (mean 1.85 microg/dL [0.03 micromol/L], P=0.01), beta-carotene (mean 11.57 microg/dL [0.22 micromol/L], P=0.03), and lutein/zeaxanthin (mean 17.50 microg/dL [0.31 micromol/L], P=0.05) compared to married women. Our conclusion is that serum carotenoid levels varied by marital status, and widowed men and women were at the greatest risk of low carotenoid levels.

The association of marital status and hospice use in the USA.

BACKGROUND: Married individuals are more likely to use hospice than unmarried individuals. We examine this association and how it is influenced by gender. METHODS: Medicare beneficiaries dying of cancer were studied. RESULTS: Currently married (OR 1.36 95% C.I. 1.28-1.45) or ever married (OR 1.23 95% C.I. 1.16-1.31) subjects were more likely to use hospice than never married subjects. A significant interaction between marital status and gender (P < .001) was observed. CONCLUSIONS: Subjects likely to enroll in hospice are subjects likely to have greater supportive relationships.

Hospice use by Hispanic and non-Hispanic white cancer decedents.

OBJECTIVE: To investigate rates of hospice use between Hispanic and non-Hispanic white Medicare beneficiaries diagnosed with cancer using data from a large, population-based study. DATA SOURCES: Secondary data from the linked SEER-Medicare database including the SEER areas of Los Angeles, San Francisco, and San Jose-Monterey, California, and the state of New Mexico. All subjects were Hispanic or non-Hispanic whites, aged 67 and older, had a cancer diagnosis of breast, colorectal, lung, or prostate cancer from 1991-1996, and died of cancer from 1991-1998. STUDY DESIGN: This study employed a retrospective cohort design to compare rates of hospice use between Hispanics and non-Hispanic whites across patient characteristics and over time. PRINCIPAL FINDINGS: Rates of hospice use were similar for Hispanics (39.2 percent) and non-Hispanic whites (41.5 percent). In a bivariate logistic regression model, Hispanics were significantly less likely to use hospice than non-Hispanic whites (OR 0.91; 95 percent CI 0.85-0.97). However, after adjusting for age, marital status, sex, educational attainment, income, urban versus rural residence, and type of insurance using multivariate logistic regression analysis, the estimated odds for being a hospice user among Hispanics is similar to the odds of being a hospice user among non-Hispanic whites (OR 1.05; 95 percent CI 0.98-1.13). Stratified analyses revealed significant differences between ethnic groups in the use of hospice by type of insurance and SEER area, indicating interactions between ethnicity and these variables. CONCLUSIONS: Our findings indicate similar rates of hospice use for Hispanics and non-Hispanic whites diagnosed with one of the four leading cancers. Additional studies from other national registries may be necessary to confirm these findings.

Decreasing variation in the use of hospice among older adults with breast, colorectal, lung, and prostate cancer.

BACKGROUND: Utilization of hospice services has been shown to vary by place of residence and patient characteristics. OBJECTIVES: The purpose of this study was to examine whether such variation has changed over time. Hospice utilization is examined as a function of sociodemographic characteristics, geographic location, type of insurance, and year of death. RESEARCH DESIGN: This study used a retrospective cohort design. SUBJECTS: We used data from the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database to study hospice utilization in subjects aged 67 and older diagnosed with breast, colorectal, lung, or prostate cancer from 1991 to 1996 and who died between 1991 and 1999. RESULTS: Of the 170,136 subjects aged 67 and older who died from 1991 through 1999, 51,345 (30.2%) were enrolled in hospice before they died. Hospice utilization varied significantly by patient characteristics, including type of insurance, age, marital status, race and ethnicity, gender, urban versus rural residence, type of cancer, income level, and education level. This variation, however, decreased over time for subgroups defined by type of insurance, marital status, urban residence, and income. Variation in hospice use increased over time as a function of age and type of cancer. There was no change in variation in use in blacks compared with non-Hispanic whites over time. CONCLUSIONS: The variation in hospice use by several patient characteristics is decreasing over time, a finding consistent with the manner in which new medical technologies diffuse.

Hospice use by older women dying with breast cancer between 1991 and 1996.

The purpose of this study was to assess the use of hospice by women dying with breast cancer as a function of time period, geographic area, and patient characteristics. We used data from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database to study hospice care use in the United States in women aged 65 and older, diagnosed with breast cancer from 1986 to 1996, who died from 1991 to 1996. Of the 25,161 women who met those criteria, 5,198 (20.7%) were enrolled in hospice before they died. The rate of hospice use in this population increased from 11.5% in 1991 to 27.1% in 1996. Use of hospice care was inversely related to age and was higher among those who were married. There were no differences in use by ethnicity. Rates of use varied significantly by geographic area. Future research should further examine why rates of hospice use differ by geographic area and certain patient characteristics.