Case-mix adjustment and the comparison of community health center performance on patient experience measures.

OBJECTIVE: To assess the effect of case-mix adjustment on community health center (CHC) performance on patient experience measures. DATA SOURCES: A Medicaid-managed care plan in Washington State collected patient survey data from 33 CHCs over three fiscal quarters during 2007-2008. The survey included three composite patient experience measures (6-month reports) and two overall ratings of care. The analytic sample includes 2,247 adult patients and 2,859 adults reporting for child patients. STUDY DESIGN: We compared the relative importance of patient case-mix adjusters by calculating each adjuster's predictive power and variability across CHCs. We then evaluated the impact of case-mix adjustment on the relative ranking of CHCs. PRINCIPAL FINDINGS: Important case-mix adjusters included adult self-reported health status or parent-reported child health status, adult age, and educational attainment. The effects of case-mix adjustment on patient reports and ratings were different in the adult and child samples. Adjusting for race/ethnicity and language had a greater impact on parent reports than adult reports, but it impacted ratings similarly across the samples. The impact of adjustment on composites and ratings was modest, but it affected the relative ranking of CHCs. CONCLUSIONS: To ensure equitable comparison of CHC performance on patient experience measures, reports and ratings should be adjusted for adult self-reported health status or parent-reported child health status, adult age, education, race/ethnicity, and survey language. Because of the differential impact of case-mix adjusters for child and adult surveys, initiatives should consider measuring and reporting adult and child scores separately.

Predictors of sexual risk behaviors among newly homeless youth: a longitudinal study.

PURPOSE: To longitudinally examine the association between newly homeless youth individual factors (sociodemographic characteristics, depression, substance use), and structural factors, such as living situation (family, institution, nonfamily), with sexual risk behaviors. METHODS: A cohort of newly homeless youth from Los Angeles County (N = 261; aged 12-20 years) was interviewed at baseline, 3, 6, 12, 18, and 24 months. At each assessment youth were asked about symptoms of depression (using the Brief Symptom Inventory), substance use, living situation, and sexual risk behaviors (number of sexual partners and condom use). Random effects models were used to determine the effects of predictors on the number of sexual partners and on condom use over time, by gender. RESULTS: At baseline, 77% of youth had been sexually active, increasing to 85% of youth at 24 months of follow-up. For predictors of multiple sexual partners, among male youth, these included living in nonfamily settings and using drugs; among females, living situation was not predictive of having multiple sexual partners but drug use was. For condom use, among females, living in a nonfamily setting and drug use decreased the odds of always using condoms; for males, no factors were found to be predictive of condom use. CONCLUSIONS: Living with nonfamily members and drug use appear to be the most salient in explaining sexual risk among newly homeless youth. Our findings indicate that interventions aimed at reducing sexual risk behaviors, and thereby reducing sexually transmitted diseases and HIV among newly homeless youth, need to help youth in finding housing associated with supervision and social support (family and institutional settings) as well as aim to reduce drug use.

The STI and HIV testing practices of primary care providers.

OBJECTIVES: To examine the sexually transmitted infection (STI) and HIV testing practices of primary care providers (PCPs) practicing in predominantly Hispanic communities. METHODS: This is a cross-sectional study. PCPs were identified by matching ZIP codes of physician directories with ZIP codes of Los Angeles County areas that have a population that is > 50% Hispanic (N = 191). PCPs were mailed a survey that assessed their frequencies for asking patients about sexual history, offering STI and safe sex advice, total number of HIV tests ordered in the past six months and their perceived barriers to STI counseling. The survey response rate was 45% (N = 85). RESULTS: Although 73% of PCPs took sexual histories from patients regularly (daily-to-weekly), only 41% offered STI or safe sex advice regularly. PCPs who were white were less likely than those who were Hispanic/Asian/African American/other to take sexual histories from their patients regularly (OR 0.3, 95% CI 0.1-0.9). The total number of HIV tests ordered for patients by PCPs at their practice locations in the past six months were: none (6%), 1-10 tests (27%), 11-20 tests (24%) and > 20 tests (36%). Thirty-six percent of PCPs reported > or = 1 positive HIV test in the past six months. PCPs' perceived barriers to STI counseling included patient's young age (< 16 years), language and presence of patient's relative/partner in consultation room at time of visit. CONCLUSION: Our findings suggest a need for interventions with PCPs practicing in predominantly Hispanic communities to improve their STI and HIV practice patterns.

Emotional distress and mental health service use among urban homeless adolescents.

The Expanded Behavioral Model for Vulnerable Populations was used to examine the predisposing, enabling, and need factors associated with mental health service use in a homeless adolescent sample (N = 688). Among all youth, 32% perceived a need for help with mental health problems and 15% met Brief-Symptom Inventory (BSI) criteria for emotional distress. The rate of mental health service use in our sample was 32%. One enabling factor, having a case manager/discussed mental health concerns, and one need factor, which met criteria for BSI, were found to be associated with mental health service use in the past 3 months. The majority of youth who used mental health services had obtained services from crisis centers. Among those who perceived a need for help with mental health problems but who did not use services, the most common barrier was not knowing where to go or what service to use (57%). These findings suggest that due to the high prevalence of mental health problems among homeless youth, it would be helpful for service providers coming into contact with youth to make them aware of existing community resources for mental health services; making youth aware of these resources may in turn decrease the rate of crisis center use and instead allow youth to receive mental health services in outpatient settings that provide continuity of care.

Newly homeless youth STD testing patterns over time.

PURPOSE: To use the Behavioral Model for Vulnerable Populations to examine the predisposing and need characteristics of newly homeless youth that are associated with sexually transmitted disease (STD) testing over time. METHODS: A longitudinal cohort of newly homeless youth from Los Angeles County (n = 261; ages 12-20 years) were followed for 24 months. Youth were interviewed at baseline, 3, 6, 12, 18, and 24 months, and asked about their background, housing situation, emotional distress (using the Brief-Symptom Inventory), substance use, sexual risk behaviors, and their STD testing rates. We modeled our longitudinal data using logistic random effects models. RESULTS: Characteristics of homeless youth that were associated with STD testing in our multivariate model included time in study (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1-1.6), age at baseline (OR 1.2, 95% CI 1.1-1.4), being African-American (OR 2.7, 95% CI 1.4-5.3), being from a mixed race/ethnic group (OR 2.8, 95% CI 1.3-5.8), self-identifying as a gay/bisexual male (OR 2.9, 95% CI 1.2-6.9), self-identifying as a heterosexual female (OR 2.2, 95% CI 1.3-3.7), using amphetamines (OR 1.7, 95% CI 1.1-2.6), and history of having gotten someone/becoming pregnant (OR 2.3, 95% CI 1.4-3.9). Youth who lived in an apartment were less likely to have received an STD test than youth who lived in other types of housing (OR .4, 95% CI .2-.9). Sexual risk behaviors such as inconsistent condom use (OR 1.0, 95% CI .6-1.4) and number of sexual partners over past 3 months (OR 1.1, 95% CI 1.0-1.1) were not predictive of STD testing over time. CONCLUSIONS: A need exists for interventions to target young newly homeless youth who engage in high-risk sexual behaviors to increase their STD testing rates and thereby decrease their risk for HIV infection.

Predictors of sexually transmitted infection testing among sexually active homeless youth.

We examined the association between sexual risk behaviors and sexually transmitted infection (STI) testing in a sample of homeless youth. Of 261 youth interviewed, 50% had been sexually active in the past 3 months. Gender variation in sexual behaviors and risk were found. Boys were more likely than girls to engage in anal sex (46% vs. 15%), to have 3 or more sexual partners (46% vs. 17%) and to engage in anonymous sex (38% vs. 21%). Girls were less likely to use condoms consistently and more likely to engage in sex with a partner suspected of having an STI (20% vs. 4%). In the past 3 months, the STI testing rates were similar for boys and girls (46%). However, girls were more likely to have positive STI results (46% vs. 9%). In a multivariate logistic regression analysis, the only variable that was an independent predictor of STI testing was having either gotten someone or having become pregnant in the past 3 months. High-risk sexual behaviors did not predict STI testing in our sample. Outreach programs are needed that target sexually active homeless youth for early STI testing and treatment.

A comparison of Hispanic and white adolescent females' use of family planning services in California.

CONTEXT: In California, the adolescent birthrate among Hispanics is three times that among whites. Because Hispanics are projected to make up one-half of the state's adolescents by 2020, it is important to determine how cultural and health policy-relevant factors are linked to this group's use of family planning services. METHODS: Data from the 2001 California Health Interview Survey were used to examine characteristics of Hispanic and white females aged 14-17, including patterns of use of family planning services in the past year. Multivariate logistic regression analyses were conducted to assess the association between selected characteristics and use of family planning services. RESULTS: Compared with white adolescents, Hispanic adolescents came from poorer families, had a poorer health status, less commonly had a regular source of primary health care and had lower rates of alcohol and drug use, and of sexual experience. Although the proportion of sexually experienced Hispanics who had used family planning services was similar to that of whites (34% and 27%, respectively), the proportion who had ever been pregnant and used such services was significantly larger (42% vs. 9%). In the multivariate analysis, Hispanic adolescents who had ever been pregnant were significantly more likely than whites who had not to have used family planning services in the past year (odds ratio, 11.6). CONCLUSIONS: A need exists for family planning programs to target Hispanic adolescents before they become pregnant, and to send a clear message that contraceptive services are available and should be used before a woman ever has a pregnancy.

HIV health care services for Mexican migrants.

This article reviews the literature on HIV/AIDS health care services for Mexican migrants in the United States. Because so little research has been conducted on Mexican migrants per se, we include literature on Latinos/Hispanics in the United States, because some characteristics may be shared. Furthermore, we focus special attention on data from California because it is on the front line of issues regarding health care for Mexican migrants. The types of health care services needed to improve on the quality of care provided to Mexican migrants living with HIV are highlighted, and recommendations are made for future interventions, research, and binational collaborations.

The association of access to medical care with regular source of care and sociodemographic characteristics in patients with HIV and tuberculosis.

PURPOSE: To examine satisfaction with access to health care in two populations, one with HIV and one with TB, and examine the effect of having a regular doctor and sociodemographic characteristics. DESIGN: Cross-Sectional survey. PATIENTS: A sample of HIV inpatients hospitalized at seven Los Angeles sites (N = 217) and TB outpatients chosen randomly from the Los Angeles County TB Registry Census (N = 313). ANALYSIS: We performed bivariate and multivariate regression analyses of satisfaction with access to care on gender, race/ethnicity, age, education, income, insurance, and having a regular doctor. MAIN OUTCOME MEASURES: A six-item scale of satisfaction with access to care (range 0-100; Cronbach's alpha 0.87). RESULTS: The mean satisfaction with access score for the HIV sample was significantly lower than the TB sample (53.5 vs. 61.2, p<0.001). The HIV sample multivariate analysis (including all the variables) showed that increasing age (p<0.021 and having a regular doctor (p<0.002) were associated with better access, and that low income (p<0.005) was associated with poor access. In the TB sample analysis, only increasing age was associated with better satisfaction with access to care (p< 0.01). CONCLUSION: HIV patients receiving care in the private sector reported less satisfaction with access to care compared to TB patients receiving care in the public health sector. The traditional factors of socio-economic status and having a regular doctor were associated with satisfaction with access-to-care in the HIV sample but not the TB sample. Our findings suggest that certain characteristics of the TB public health programs may explain these differences and suggests that, perhaps, the existence of a similar public health program for vulnerable low-income populations with HIV would improve their satisfaction with access, as well.