A 3-State Analysis of Black-White Disparities in Diabetes Hospitalizations Among Medicaid Beneficiaries.

INTRODUCTION: Although diabetes is one of the leading chronic disease in the country, efforts in primary care and patient self-care management could prevent most of the diabetes-related hospitalizations and produce cost savings and improvements in quality of life. We used information from Medicaid beneficiaries in 3 states to predict racial differences in diabetes hospitalizations and demonstrate how they vary across states. METHODS: We conducted a cross-sectional study to examine differences between black and white patients with diabetes hospitalizations. Information was obtained from the Medicaid Analytic eXtract files. We used multiple logistic regression models to assess the significance of the differences. RESULTS: Analysis included 10 073 adult Medicaid recipients from the states of Mississippi (51%), Georgia (35%), and Michigan (14%). Blacks were more likely to experience longer hospital stays in Georgia (odds ratio [OR] = 1.040; 95% confidence interval [CI]: 1.03-1.06) and Mississippi (OR = 1.048; 95% CI: 1.03-1.07). A majority of patients in both groups were likely to be discharged to their homes for self-care. Black patients had lower odds of repeated stays in Georgia (OR = 0.670; 95% CI: 0.54-0.84), but higher odds in Michigan (OR = 1.580; 95% CI: 1.12-2.24). Similar differences occurred when patients were matched by age and sex. Blacks had lower odds of qualifying for dual Medicare-Medicaid enrollment benefit in Georgia and Mississippi. CONCLUSION: Racial differences in diabetes-related hospitalizations reflect possible inefficiencies in the process of care. Identification of race-specific factors for hospitalizations and implementation of primary care strategies that support effective self-management skills would aid in reducing diabetes hospitalizations and related disparities.

Parenting style and perceptions of children's weight among US Hispanics: a qualitative analysis.

Parental perceptions of their children's weight status may limit their willingness to participate in or acknowledge the importance of early interventions to prevent childhood obesity. This study aimed to examine potential differences in Hispanic mothers' and fathers' perceptions of childhood obesity, lifestyle behaviors and communication preferences to inform the development of culturally appropriate childhood obesity interventions. A qualitative study using focus groups was conducted. Groups (one for mothers and one for fathers) were composed of Hispanic parents (n = 12) with at least one girl and one boy (≤ 10 years old) who were patients at a pediatric clinic in Tennessee, USA. Thirteen major themes clustered into four categories were observed: (i) perceptions of childhood obesity/children's weight; (ii) parenting strategies related to children's dietary behaviors/physical activity; (iii) perceptions of what parents can do to prevent childhood obesity and (iv) parental suggestions for partnering with child care providers to address childhood obesity. Mothers appeared to be more concerned than fathers about their children's weight. Fathers expressed more concern about the girls' weight than boys'. Mothers were more likely than fathers to congratulate their children more often for healthy eating and physical activity. Parents collectively expressed a desire for child care providers (e.g. caregivers, teachers, medical professionals and food assistance programs coordinators) to have a caring attitude about their children, which might in turn serve as a motivating factor in talking about their children's weight. Parental perceptions of their children's weight and healthy lifestyle choices are of potential public health importance since they could affect parental participation in preventive interventions.

Community Stakeholders' Perceptions of the Role of Family in HIV Prevention in Iringa, Tanzania.

Although HIV is identified as a family disease, the overall response to the global HIV epidemic continues to predominantly focus on individuals. The aim of this qualitative study was to explore how the role of the family in HIV prevention is perceived by community-based stakeholders. Understanding the role of the family within the context of the HIV/AIDS is essential for community/public health nurses. In total, 34 stakeholders participated in the study. Three major categories were identified namely: fostering positive intra-familial relations, utilizing external resources, and barriers to family roles. The study findings have implications for community-based HIV family interventions.

Resident Physicians and Cancer Health Disparities: a Survey of Attitudes, Knowledge, and Practice.

Workforce development initiatives designed to mitigate cancer health disparities focus primarily on oncologists rather than on primary care providers (PCPs) who could be better positioned to address the issue at the preventive and community levels. The purpose of this project was to assess primary care resident physicians' self-perceived attitudes and comfort level in addressing cancer health disparities. Resident physicians in their first- through third-year of training in family, internal, preventive/occupational medicine, and obstetrics and gynecology (OB/GYN) at three academic centers responded to a 13-question survey in the spring of 2013. Descriptive and chi-square statistics were performed to analyze responses to (1) attitudes about cross-cultural communication and understanding, (2) knowledge about sources of cancer health disparities, (3) self-reported preparedness to provide cross-cultural cancer care and skills to manage specific situations, and (4) relevance of cancer-disparity education to clinical practice. A total of 78 (70.9 %) residents responded to the survey. Twenty three (29.5 %) of the respondents felt they did not understand the socio-demographic characteristics of their patients' communities, and 20 (25.6 %) did not feel capable of discussing current cancer-related care guidelines when the patients' personal beliefs conflict with their own. Few of the relationships between residency program and location with outcome measures met the criteria for statistical significance. Family medicine residents were the most likely to report in that it was hard to interact with persons from other cultures. As PCPs will play a key role in addressing cancer health disparities, effective educational opportunities in cancer care by primary care residents are warranted.

Cost and Predictors of Hospitalizations for Ambulatory Care - Sensitive Conditions Among Medicaid Enrollees in Comprehensive Managed Care Plans.

INTRODUCTION: Preventable hospitalizations are responsible for increasing the cost of health care and reflect ineffectiveness of the health services in the primary care setting. The objective of this study was to assess expenditure for hospitalizations and utilize expenditure differentials to determine factors associated with ambulatory care - sensitive conditions (ACSCs) hospitalizations. METHODS: A cross-sectional study of hospitalizations among Medicaid enrollees in comprehensive managed care plans in 2009 was conducted. A total of 25 581 patients were included in the analysis. Expenditures on hospitalizations were examined at the 50th, 75th, 90th, and 95th expenditure percentiles both at the bivariate level and in the logistic regression model to determine the impact of differing expenditure on ACSC hospitalizations. RESULTS: Compared with patients without ACSC admissions, a larger proportion of patients with ACSC hospitalizations required advanced treatment or died on admission. Overall mean expenditures were higher for the ACSC group than for non-ACSC group (US$18 070 vs US$14 452). Whites and blacks had higher expenditures for ACSC hospitalization than Hispanics at all expenditure percentiles. Patient's age remained a consistent predictor of ACSC hospitalization across all expenditure percentiles. Patients with ACSC were less likely to have a procedure on admission; however, the likelihood decreased as expenditure percentiles increased. At the median expenditure, blacks and Hispanics were more likely than other race/ethnic groups to have ACSC hospitalizations (odds ratio [OR]: 1.307, 95% confidence interval [CI]: 1.013-1.686 and OR 1.252, 95% CI: 1.060-1.479, respectively). CONCLUSION: Future review of delivery and monitoring of services at the primary care setting should include managed care plans in order to enhance access and overall quality of care for optimal utilization of the resources.

Prostate Cancer Screening and Mortality in Blacks and Whites: A Hospital-based Case-Control Study.

BACKGROUND: Prostate cancer incidence and mortality are substantially higher in Black than in white men. Prostate cancer screening remains controversial. This study was conducted to assess the impact of, and racial differences in, prostate cancer screening on prostate cancer mortality. METHODS: This was a case-control study of Black and White men in eight hospitals. Cases were deaths related to prostate cancer; controls were hospital-based subjects that were frequency-matched to cases based on age and race. Multivariable logistic regression was used to test the association between screening and prostate cancer mortality. RESULTS: Cases had fewer PSA (prostate-specific antigen) tests than controls (1.73 vs. 3.98, p<0.001). White controls had higher rates of PSA tests than other sub-groups. There was no difference in PSA testing between Black cases and controls. Mean co-morbidity was 10.3 in cases and 2.63 in controls. Prostate cancer mortality was 55 to 57% lower among the screened persons. Individuals who died of prostate cancer related causes were less likely to have received PSA testing (OR=0.65; 95% Cl 0.56-0.75). CONCLUSIONS: The odds of dying from prostate cancer were lower among white men receiving screening tests. Having less co-morbidity was associated with lower odds of mortality in both races. This study raises the possibility that screening for prostate cancer with the PSA test may be more effective in white than in Black men.

Race, outpatient mental health service use, and survival after an AIDS diagnosis in the highly active antiretroviral therapy era.

We examined the relationships between survival after AIDS diagnosis and outpatient mental health service use among men with history of highly active antiretroviral therapy (HAART). Analysis involved 1913 black and 1684 white men with AIDS who received HIV care in 2003 in the Veterans Affairs health care system. Negative binomial regression was used to assess the association between service use and length of AIDS diagnosis. Patients with longer survival after AIDS had higher rates of outpatient visits for stress and adjustment disorders as well as for mood, anxiety, and sexual disorders. Blacks had more visits for stress and adjustment disorders (7.4 versus 5.1; p < 0.05). Multiple regression analysis showed that prolonged survival after AIDS (incident rate ratios [IRR] = 1.87; 95% confidence interval [CI] = 1.25-2.77), having CD4 cell count less than 200 cells/mm(3) (IRR = 1.91; 95% CI = 1.19-3.04), and mortality (IRR = 3.84; 95% CI = 1.29-11.43) were associated with greater number of visits for mood, anxiety, and sexual disorders. Injection drug users (IRR = 3.52; 95% CI = 1.94-6.38), men who have sex with men (IRR = 2.87; 95% CI = 1.62-5.06), and patients with AIDS-defining illness (IRR = 2.48; 95% CI = 1.47-4.17) had greater rates of visits for stress and adjustment disorders. Survival after AIDS is associated with mental health service use. As more HIV-infected persons survive longer, adequate risk assessment of mental health concerns that considers race and HIV risk factors should be undertaken to effectively address the impact of mental health on treatment outcomes and mortality.

Operating environment and USA nursing homes' participation in the subacute care market: a longitudinal analysis.

We examined the impact of environmental factors on USA nursing homes' participation in the subacute care market. Findings suggest that the Balanced Budget Act of 1997 did not have a significant impact in the participation of nursing homes in the subacute care market from 1998 to 2000. However, there was a declining trend in the participation of nursing homes in the subacute care market after the implementation of Medicare prospective payment system (PPS). Furthermore, nursing homes with a higher proportion of Medicare residents were more likely to exit the subacute care market after PPS. Results also suggest that nursing homes have responded strategically to the environmental demand for subacute care services. Nursing homes located in markets with higher Medicare managed care penetration were more likely to offer subacute care services. Environmental munificence was also an important predictor of nursing home innovation into subacute care. Nursing homes in states with higher Medicaid reimbursement and those in less competitive markets were more likely to participate in the subacute care market.

Person-vehicle-environment interactions predicting crash-related injury among older drivers.

OBJECTIVE: The object of this research was to identify interactions among person, vehicle, and environment factors associated with crashes and injuries among older drivers. METHOD: We quantified risk factors and interactions for 5,744 drivers. RESULTS: Women had a high crash risk during mornings (8:00 a.m.-1:00 p.m.; odds ratio [OR] = 1.73, confidence interval [CI] = 1.40-2.14) or afternoons (2:00 p.m.-8:00 p.m.; OR = 1.74, CI = 1.41-2.15); alcohol-related crashes were the least likely to occur during mornings (OR = 0.19, CI = 0.12-0.31). The greatest crash risk with another vehicle occurred during afternoons (OR = 3.89, CI = 2.41-5.05). Injury had interactions with fixed-object crashes (OR = 427, CI = 182.9-998.24), no seatbelt (OR = 5.69, CI = 3.90-8.29), female gender (OR = 1.54, CI = 1.67-1.92), and mornings (OR = 1.40, CI = 1.01-1.94). CONCLUSION: An opportunity for crash and injury prevention research and shaping longer-range evaluation policies emerged.

Age-related differences in quality of life in cancer patients: a pilot study of a cancer care coordination/home-telehealth program.

The cancer care dialogues model emphasizes daily telehealth interactions between patients and a care coordinator (a registered nurse serving as a liaison to the oncologist) to assist patients in the management of common chemotherapy-related symptoms at home. We examined the impact of the dialogues on age-related differences in health-related quality of life (HRQOL) among newly diagnosed cancer patients receiving chemotherapy. We assessed HRQOL among 34 patients, including 15 older adults (65 years or older) and 19 younger adults who were followed for 6 months. Older patients consistently reported better HRQOL scores over the treatment period. In multivariate analysis, older patients reported 10.35 points higher in HRQOL (P = .007). In addition, patients who reported no nervousness while undergoing chemotherapy had an 8.60-point increase in HRQOL scores (P = .012). The dialogues model can make important improvement in symptom management and HRQOL, especially in older adults receiving chemotherapy. Older and younger adults with cancer may benefit equally in cancer treatment in a setting with appropriately managed symptoms. The dialogues model offers promising potential for promoting nurses' better understanding of both the patient needs as the patient receives treatment and innovative technologies in patient management.

Remote patient-provider communication and quality of life: empirical test of a dialogic model of cancer care.

We examined the feasibility of a Cancer Care Dialogues Model, with daily telehealth interactions between patients at home and their care coordinator, who acted as an adjunct to the oncologist. The patient and the care coordinator used a home messaging device, connected via the ordinary telephone network. Thirty-four patients with a new diagnosis of cancer and whose treatment plan included chemotherapy taken at a single clinic were enrolled and followed for six months. The home messaging device collected information daily on common symptoms associated with chemotherapy. On average, the patients had the home messaging device for 120 days (range 30-180). The mean cooperation rate was 84% (range 4-100). No variables were significantly associated with patient cooperation in the dialogues over time. The health-related quality of life (HRQL) mean score at baseline was 73.9 (SD 15.4), and the mean score at six months was 78.4 (SD 14.5). After adjusting for demographic and clinical factors, there was a 6.5-point increase in HRQL score between the baseline and end of treatment, which represented an important clinical difference. Management of nervousness/worry over time through cancer care dialogues is important in maintaining HRQL and can be assisted by remote home messaging.

The Balanced Budget Act (1997) and the supplyof nursing home subacute care.

This article examines the impact of the Medicare prospective payment system (PPS) on the supply of subacute care services by nursing homes. A quasi-experimental interrupted time-series design using Heckman's two-stage regression model is employed to test for changes before and after the implementation of Medicare PPS. Our findings suggest that the change in Medicare reimbursement from cost-based to PPS under the Balanced Budget Act of 1997 resulted in a decrease of 1.7 percent in the supply of subacute care beds by nursing homes. However, this was a one-time, short-term negative effect. The supply of nursing home subacute care remained stable in the long-term. Other environmental factors, such as Medicare hospital discharges, hospital-based subacute care, Medicare managed care penetration, availability of home health, and per capita income were associated with nursing home subacute care supply. Organizational-level factors, such as occupancy rate, RN staff mix, and Medicare payer mix were also predictors of nursing home subacute care supply.

Theoretical and methodological issues in conducting research related to health care utilization among individuals with HIV infection.

Although empirical information on resource use during HIV infection is vital to improving quality of care, the issues involved in conducting research on resource use have received little attention in the medical literature. The purpose of this paper is to review the theoretical and methodological issues of conducting research on health care utilization patterns among persons with HIV/AIDS. Conceptual definitions of utilization are compared and contrasted. Three theoretical frameworks, the Andersen Behavioral Model, the Health Belief Model, and the Biopsychosocial Model are described to illustrate their applicability in future research studies. Research designs, measurement considerations, sampling approaches, and existing data sources on utilization are reviewed. Recommendations for health care utilization research are summarized and highlight the importance of designing studies and generating data for investigation of the factors facilitating patients' use of an optimal array of services including prevention, long-term, and rehabilitation care.

Review: use of health care services among persons living with HIV infection: state of the science and future directions.

Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.