Client factors associated with length of stay in methadone treatment among heroin users who inject drugs: quantitative analysis of state-level substance abuse treatment utilization data.

The objective of this study was to examine, for a population of 8,258 adult injection drug users (IDUs) who all had entered a Massachusetts licensed methadone maintenance treatment program (MMT) between 1996 and 2002, client factors associated with remaining in MMT for a minimum of 1 year after program entry. Two binomial logistic regression models were developed. The first model examined the association between age, sex, race/ethnicity, parental status, employment status, educational status, health insurance status, homelessness status, having injected drugs in the past month, residential treatment use, number of overall treatment admissions, and whether a client's longest consecutive stay in MMT had lasted for 1 year or more. Second, to examine the stability of the statistical relationships identified in the first logistic regression model, a second logistic regression model examined whether there were significant differences in client level characteristics between those who used MMT for 6 months or less compared with their counterparts. Those who were older, women, those who were not homeless, those who resided with their children, those who had public health insurance, and those who had not used residential treatment were significantly more likely to have stayed in MMT for at least 1 year or more. In contrast, those who were younger, males, homeless, did not live with children, had no insurance, and had used residential treatment were significantly more likely to have stayed in MMT for 6 months or less compared with their counterparts. Those who stayed in MMT for 1 year or more were more likely to have stable lives compared with those who dropped out of MMT before a year. Providing services to improve MMT clients' employment, housing, and family stability may help improve MMT retention rates. Second, clients with a history of having used residential substance abuse treatment were more likely to stay in MMT for a shorter time period compared with their counterparts. The extent to which treatment bifurcation is a matter of choice or related to other factors needs to be further explored.

Resident physicians' preparedness to provide cross-cultural care.

CONTEXT: Two recent reports from the Institute of Medicine cited cross-cultural training as a mechanism to address racial and ethnic disparities in health care, but little is known about residents' educational experience in this area. OBJECTIVE: To assess residents' attitudes about cross-cultural care, perceptions of their preparedness to deliver quality care to diverse patient populations, and educational experiences and educational climate regarding cross-cultural training. DESIGN, SETTING, AND PARTICIPANTS: A survey was mailed in the winter of 2003 to a stratified random sample of 3435 resident physicians in their final year of training in emergency medicine, family practice, internal medicine, obstetrics/gynecology, pediatrics, psychiatry, or general surgery at US academic health centers. RESULTS: Responses were obtained from 2047 (60%) of the sample. Virtually all (96%) of the residents indicated that it was moderately or very important to address cultural issues when providing care. The number of respondents who indicated that they believed they were not prepared to care for diverse cultures in a general sense was only 8%. However, a larger percentage of respondents believed they were not prepared to provide specific components of cross-cultural care, including caring for patients with health beliefs at odds with Western medicine (25%), new immigrants (25%), and patients whose religious beliefs affect treatment (20%). In addition, 24% indicated that they lacked the skills to identify relevant cultural customs that impact medical care. In contrast, only a small percentage of respondents (1%-2%) indicated that they were not prepared to treat clinical conditions or perform procedures common in their specialty. Approximately one third to half of the respondents reported receiving little or no instruction in specific areas of cross-cultural care beyond what was learned in medical school. Forty-one percent (family medicine) to 83% (surgery and obstetrics/gynecology) of respondents reported receiving little or no evaluation in cross-cultural care during their residencies. Barriers to delivering cross-cultural care included lack of time (58%) and lack of role models (31%). CONCLUSIONS: Resident physicians' self-reported preparedness to deliver cross-cultural care lags well behind preparedness in other clinical and technical areas. Although cross-cultural care was perceived to be important, there was little clinical time allotted during residency to address cultural issues, and there was little training, formal evaluation, or role modeling. These mixed educational messages indicate the need for significant improvement in cross-cultural education to help eliminate racial and ethnic disparities in health care.

Mixed messages: residents' experiences learning cross-cultural care.

PURPOSE: An Institute of Medicine report issued in 2002 cited cross-cultural training as a mechanism to address racial and ethnic disparities in health care, but little is known about residents' training and capabilities to provide quality care to diverse populations. This article explores a select group of residents' perceptions of their preparedness to deliver quality care to diverse populations. METHOD: Seven focus groups and ten individual interviews were conducted with 68 residents in locations nationwide. Qualitative analysis of focus-group and individual interview transcripts was performed to assess residents' perceptions of (1) preparedness to deliver care to diverse patients; (2) educational climate; and (3) training experiences. RESULTS: Most residents in this study noted the importance of cross-cultural care yet reported little formal training in this area. Residents wanted more formal training yet expressed concern that culture-specific training could lead to stereotyping. Most residents had developed ad hoc, informal skills to care for diverse patients. Although residents perceived institutional endorsement, they sensed it was a low priority due to lack of time and resources. CONCLUSIONS: Residents in this study reported receiving mixed messages about cross-cultural care. They were told it is important, yet they received little formal training and did not have time to treat diverse patients in a culturally sensitive manner. As a result, many developed coping behaviors rather than skills based on formally taught best practices. Training environments need to increase training to enhance residents' preparedness to deliver high-quality cross-cultural care if the medical profession is to achieve the goals set by the Institute of Medicine.

The Institute of Medicine report "Unequal Treatment": implications for academic health centers.

BACKGROUND: The United States has achieved dramatic improvements in overall health and life expectancy, largely due to initiatives in public health, health promotion and disease prevention. Academic health centers have played a major role in this effort, given their mission of engaging in research, educating health professionals, providing primary and specialty medical services, and caring for the poor and uninsured. However, national data indicate that minority Americans have poorer health outcomes (compared to whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer and HIV/AIDS. Two factors contribute heavily to these racial and ethnic disparities in health: minorities are subjected to adverse social determinants, and they are disproportionately represented among the uninsured. In the last twenty years, however, the literature has highlighted the fact that racial and ethnic disparities occur not only in health, but also in health care. The Institute of Medicine Report, "Unequal Treatment." The Institute of Medicine (IOM) was asked to determine the extent of racial and ethnic disparities in health care. Their report, entitled "Unequal Treatment," found that racial and ethnic disparities in health care do exist, and that many sources, including health care systems, health care providers, patients and utilization managers, are contributors. Recommendations from "Unequal Treatment": Implications for Academic Health Centers. The IOM Report, "Unequal Treatment," provides a series of recommendations to address racial and ethnic disparities in health care, targeted to a broad audience (the executive summary and full IOM Report can be found at www.nap.edu under the search heading "Unequal Treatment"). Several of the recommendations speak directly to the mission and roles of academic health centers, and have clear and direct implications for patient care, education, and research. These recommendations include collecting and reporting health care access and utilization data by patient=s race/ethnicity, encouraging the use of evidence-based guidelines and quality improvement, supporting the use of language interpretation services in the clinical setting, increasing awareness of racial/ethnic disparities in health care, increasing the proportion of underrepresented minorities in the health care workforce, integrating cross-cultural education into the training of all health care professionals, and conducting further research to identify sources of disparities and promising interventions. CONCLUSION: "Unequal Treatment" provides the first detailed, systematic examination of racial/ethnic disparities in health care, and provides a blueprint for how to address them. The report=s recommendations are broad in scope, yet have direct implications for academic health centers.