Inequality in America: the contribution of health centers in reducing and eliminating disparities in access to care.

Reducing and eliminating health status disparities by providing access to appropriate health care is a goal of the nation's health care delivery system. This article reviews the literature that demonstrates a relationship between access to appropriate health care and reductions in health status disparities. Using comprehensive site-level data, patient surveys, and medical record reviews, the authors present an evaluation of the ability of health centers to provide such access. Access to a regular and usual source of care alone can mitigate health status disparities. The safety net health center network has reduced racial/ethnic, income, and insurance status disparities in access to primary care and important preventive screening procedures. In addition, the network has reduced low birth weight disparities for African American infants. Evidence suggests that health centers are successful in reducing and eliminating health access disparities by establishing themselves as their patients' usual and regular source of care. This relationship portends well for reducing and eliminating health status disparities.

HRSA's Models That Work Program: implications for improving access to primary health care.

The main objective of the Models That Work Campaign (MTW) is improving access to health care for vulnerable and underserved populations. A collaboration between the Bureau of Primary Health Care (BPHC) at the Health Resources and Services Administration (HRSA) and 39 cosponsors--among them national associations, state and federal agencies, community-based organizations, foundations, and businesses--this initiative gives recognition and visibility to innovative and effective service delivery models. Models are selected based on a set of criteria that includes delivery of high quality primary care services, community participation, integration of health and social services, quantifiable outcomes, and replicability. Winners of the competition are showcased nationally and hired to provide training to other communities, to document and publish their strategies, and to provide onsite technical assistance on request.

Cancer screening among community health center women: eliminating the gaps.

OBJECTIVE: The elimination of health status gaps among minority and low income populations is part of the mission of community health centers (CHCs). Cervical and breast cancer incidence and mortality are related to both minority and socioeconomic status, and CHCs are in a unique position, by virtue of their target population, to effect positive outcomes through screening and early detection. METHODS: Completed in 1995, the survey described in this article included questions from the 1992 NHIS Cancer Supplement, which collected information on the utilization of cancer-screening services, including Pap smear testing, mammography, and clinical breast examination. RESULTS: CHCs are providing access to Pap smear testing, mammography, and clinical breast examination for women who are at an increased risk for morbidity and mortality associated with cancers of the cervix and breast. A higher proportion of CHC women of most racial and ethnic groups and women below poverty level are up to date on cancer screening than comparison groups. In most cases, CHC women meet or exceed the Healthy People 2000 objectives for the nation.

Health care needs of medically underserved women of color: The role of the Bureau of Primary Health Care.

The Bureau of Primary Health Care (BPHC) was developed to increase access to comprehensive primary and preventive health care and to improve the health status of medically underserved populations. Approximately 43 million Americans fall into this category, and the majority are poor, female, young, and uninsured. Under the Public Health Services Act, BPHC does not provide direct services, but rather assist local communities in identifying populations at risk of poor health outcomes and helps these communities through various programs. One of the newest initiatives of BPHC is the Office of Minority and Women's Health, developed with a mission to help reduce the disparities in the health status of women of racial and ethnic minority populations. This article outlines these disparities and discusses proposals for reducing them.

Improving utilization of breast and cervical cancer screening in your office practice.

It has been well documented that early detection and early intervention for breast and cervical cancer saves lives. However, the challenge is to ensure that physicians' practices are effective in implementing the standard guidelines for screening and that all women are screened and undergo appropriate follow-up. Early detection and intervention are imperative since African-American women are twice as likely as European-American women to die from breast cancer even though the incidence of breast cancer is lower. African-American women have fewer mammograms and are being diagnosed later after metastases have occurred. Studies also show that women are more likely to have mammograms if their physicians so advise. However, the most common reason women give for not obtaining mammograms is, "My doctor never recommended it." By using a simple critical path analysis tool to systematically evaluate an office practice and by implementing practical, simple principles, a physician can increase utilization of breast and cervical cancer screening.

Primary health care and the Midwest flood disaster.

The Midwest flood disaster of 1993 ravaged communities across a 9-State area. Homes were destroyed, roads closed, and services disrupted. Economic costs, including loss of revenue from farming and loss of jobs, are estimated at more than $1 billion. Even as people continue to rebuild their lives 1 year later, renewed flooding has occurred in some areas. A community-based primary health care system can be described as a system of services that (a) offers all members of a family continuous, comprehensive, quality health services throughout their lives; (b) includes case management and coordinated referrals to other related services when necessary; (c) is usually provided by family practitioners, general internists, general pediatricians, obstetricians-gynecologists, nurse practitioners, certified nurse midwives, and physician assistants; and (d) has community involvement in the development and management of the system to assure that it meets the changing needs and the diversity of the people it is designed to serve. This paper uses the floods to describe the impact of a disaster on primary health care services and primary health care systems. This includes changes in the demand for services (as evidenced by the frequency and type of patient visits) and the ability of the system to respond to these changes. The effect of a disaster on access to primary health care is discussed.

Sickle cell anaemia trial.

The major cause of death in sickle cell anaemia is from infection, especially infection caused by Streptococcus pneumoniae. Meningitis, pneumonia and septicaemia caused by this organism are the primary types of infection leading to death. Children under three years of age are at highest risk. We have known for over twenty years that approximately 30 per cent of the infants born with sickle cell anaemia will become infected in the first three years of life and one-third can be expected to die from the infection. These data were the reason that we conducted the Prophylactic Penicillin Study (PROPS), a trial to investigate the effectiveness of oral prophylactic penicillin in preventing severe infection due to S. pneumoniae. This investigation was a very efficient, cost effective study because of its timeliness and its conduct within the framework of an ongoing study. Moreover, the question being answered was simple and focused with up-to-date data that permitted accurate estimates of sample size and incidence.

Prophylaxis with oral penicillin in children with sickle cell anemia. A randomized trial.

Children with sickle cell anemia have an increased susceptibility to bacterial infections, especially to those caused by Streptococcus pneumoniae. We therefore conducted a multicenter, randomized, double-blind, placebo-controlled clinical trial to test whether the regular, daily administration of oral penicillin would reduce the incidence of documented septicemia due to S.pneumoniae in children with sickle cell anemia who were under the age of three years at the time of entry. The children were randomly assigned to receive either 125 mg of penicillin V potassium (105 children) or placebo (110 children) twice daily. The trial was terminated 8 months early, after an average of 15 months of follow-up, when an 84 percent reduction in the incidence of infection was observed in the group treated with penicillin, as compared with the group given placebo (13 of 110 patients vs. 2 of 105; P = 0.0025), with no deaths from pneumococcal septicemia occurring in the penicillin group but three deaths from the infection occurring in the placebo group. On the basis of these results, we conclude that children should be screened in the neonatal period for sickle cell hemoglobinopathy and that those with sickle cell anemia should receive prophylactic therapy with oral penicillin by four months of age to decrease the morbidity and mortality associated with pneumococcal septicemia.

Evaluation of clinical severity in sickle cell disease.

For a severity classification of sickle cell disease to be accepted, it is necessary that clinicians agree upon relative disease severity between patients. This condition was shown to be satisfied for a randomly selected group of patients evaluated by four persons. All rank correlation coefficients between observer pairs were highly significant. Representative severity indices based on history and recent hospital events also correlated significantly with evaluator ranking. The results show that, in principle, a classification of sickle cell disease patients by severity is possible. Such a classification would be most useful to evaluate the prognostic significance of particular signs or symptoms, or the success of various treatments in affecting severity of disease.

Decreased opsonization for Streptococcus pneumoniae in sickle cell disease: studies on selected complement components and immunoglobulins.

Opsonic activity for Streptococcus pneumoniae in the sera of patients with sickle cell disease was reduced in comparison to the opsonic activity of sera from age-matched normal children. No difference in opsonic activity for Escherichi coli was observed in the sera from patients or normals. Total hemolytic complement, conversion of C3 by inulin and cobra venom factor, and levels of C3, factor B, properdin, C3b inactivator, and immunoglobulins G, A, and M were normal in patients' sera. The opsonic abnormality for S. pneumoniae was attributed to a deficiency of serum proteins rather than to an inhibitor of opsonic function. The data suggest that decreased opsonization was not associated with a deficiency of those complement components or immunoglobulins measured in this study.