Are physicians less likely to recommend preventive services to low-SES patients?

Determinants of Hormone Replacement Therapy Knowledge and Current Hormone Replacement Therapy Use

Background: The use of hormone replacement therapy (HRT) to treat menopausal symptoms has declined since the early 2000s, and little is known about the contemporary determinants of use in the United States. We aim to understand women's knowledge of HRT as a treatment of menopausal symptoms and to assess the factors associated with HRT use. Materials and Methods: Weighted multivariate logistic regression models evaluated the correlates of high HRT knowledge and current HRT use among a sample of 2,548 women aged ≥45 years who participated in an online survey between August 2019 and May 2020. Results: In total, 82% of the women surveyed reported experiencing one or more menopausal symptoms, yet only 10.5% reported using HRT. Only 33% reported high HRT knowledge. The odds of reporting high HRT knowledge increased with increasing age. Racial, ethnic minority women were less likely to report high HRT knowledge (adjusted odds ratio [AOR] = 0.69; 95% confidence interval [CI] = 0.5-0.9). Hispanic and non-Hispanic women of other racial and ethnic groups were less likely to use HRT compared with non-Hispanic White women (AOR = 0.3; 95% CI = 0.1-0.6) (AOR = 0.4; CI = 0.2-0.9), respectively. Women experiencing irregular periods were less likely to report current HRT use (AOR = 0.1, 95% CI = 0.4-0.7). Compared with past users, never users appeared to be more risk averse, and reported concern over HRT risks and side effects as reasons for nonuse. Conclusions: Many factors impact women's perceived HRT knowledge level and to a lesser extent HRT use. Future research should better define the most important factors influencing decisions to use HRT for symptom relief.

Multidisciplinary Teams are Essential for Developing Clinical Decision Support to Improve Pediatric Health Outcomes: An Exemplar

Clinical decision support with individualized patient education information can facilitate the translation of evidence-based guidelines into practice to improve pediatric patient outcomes. Interdisciplinary teams are required to develop and implement this technology support into practice. Engineering expertise with attention to three components is required: backend (e.g., data science, predictions), front end (e.g., user interface), and integration (e.g., workflow) must be addressed to achieve useful technology that will be adopted. An engineering framework, Technology Acceptance Model, can be used to guide the development of clinical decision support with patient education materials and includes a partnership with end users, both clinicians and patients.

Impact of Point-of-Care Decision Support Tool on Laboratory Screening for Comorbidities in Children with Obesity

Background: Childhood obesity is associated with dyslipidemia, fatty liver disease, and type 2 diabetes. Expert guidelines recommend screening for these conditions in children with obesity. Aims and objectives: The objective of the study was to compare rates of laboratory screening for dyslipidemia, fatty liver disease, and type 2 diabetes in children with obesity prior to and following implementation of a point-of-care decision support tool. Methods: We performed a retrospective record review of children with body mass index (BMI) ≥95th percentile for age and gender (age 7–18 years) undergoing well-child/sports examination visits. Multivariable logistic regression models were used to adjust for patient and provider confounders. Results: There was no increase in the rates of screening following implementation of the point-of-care decision support tool. Tests were more likely to be recommended in children with severe obesity and in females. Conclusions: The implementation of a point-of-care decision support tool was not associated with improvement in screening rates for dyslipidemia, fatty liver disease, and type 2 diabetes for children with obesity. Further strategies are needed to improve rates of screening for obesity-related comorbid conditions in children with obesity.

Eliciting vulnerable patients' preferences regarding colorectal cancer screening: a systematic review

BACKGROUND

Patient preferences are important to consider in the decision-making process for colorectal cancer (CRC) screening. Vulnerable populations, such as racial/ethnic minorities and low-income, veteran, and rural populations, exhibit lower screening uptake. This systematic review summarizes the existing literature on vulnerable patient populations' preferences regarding CRC screening.

METHODS

We searched the CINAHL, PsycINFO, PubMed, Scopus, and Web of Science databases for articles published between January 1, 1996 and December 31, 2017. We screened studies for eligibility and systematically abstracted and compared study designs and outcomes.

RESULTS

A total of 43 articles met the inclusion criteria, out of 2,106 articles found in our search. These 43 articles were organized by the primary sub-population(s) whose preferences were reported: 27 report on preferences among racial/ethnic minorities, eight among low-income groups, six among veterans, and two among rural populations. The majority of studies (n=34) focused on preferences related to test modality. No single test modality was overwhelmingly supported by all sub-populations, although veterans seemed to prefer colonoscopy. Test attributes such as accuracy, sensitivity, cost, and convenience were also noted as important features. Furthermore, a preference for shared decision-making between vulnerable patients and providers was found.

CONCLUSION

The heterogeneity in study design, populations, and outcomes of the selected studies revealed a wide spectrum of CRC screening preferences within vulnerable populations. More decision aids and discrete choice experiments that focus on vulnerable populations are needed to gain a more nuanced understanding of how vulnerable populations weigh particular features of screening methods. Improved CRC screening rates may be achieved through the alignment of vulnerable populations' preferences with screening program design and provider practices. Collaborative decision-making between providers and vulnerable patients in preventive care decisions may also be important.

Educated but anxious: How emotional states and education levels combine to influence online health information seeking

This study combined conceptual frameworks from health information seeking, appraisal theory of emotions, and social determinants of health literatures to examine how emotional states and education predict online health information seeking. Nationally representative data from the Health Information National Trends Survey (HINTS 4, Cycle 3) were used to test the roles of education, anxiety, anger, sadness, hope, happiness, and an education by anxiety interaction in predicting online health information seeking. Results suggest that women, tablet owners, smartphone owners, the college educated, those who are sad some or all of the time, and those who are anxious most of the time were significantly more likely to seek online health information. Conversely, being angry all of the time decreased the likelihood of seeking. Furthermore, two significant interactions emerged between anxiety and education levels. Discrete psychological states and demographic factors (gender and education) individually and jointly impact information seeking tendencies.

The association of income with health behavior change and disease monitoring among patients with chronic disease

BACKGROUND

Management of chronic diseases requires patients to adhere to recommended health behavior change and complete tests for monitoring. While studies have shown an association between low income and lack of adherence, the reasons why people with low income may be less likely to adhere are unclear. We sought to determine the association between household income and receipt of health behavior change advice, adherence to advice, receipt of recommended monitoring tests, and self-reported reasons for non-adherence/non-receipt.

METHODS

We conducted a population-weighted survey, with 1849 respondents with cardiovascular-related chronic diseases (heart disease, hypertension, diabetes, stroke) from Western Canada (n = 1849). We used log-binomial regression to examine the association between household income and the outcome variables of interest: receipt of advice for and adherence to health behavior change (sodium reduction, dietary improvement, increased physical activity, smoking cessation, weight loss), reasons for non-adherence, receipt of recommended monitoring tests (cholesterol, blood glucose, blood pressure), and reasons for non-receipt of tests.

RESULTS

Behavior change advice was received equally by both low and high income respondents. Low income respondents were more likely than those with high income to not adhere to recommendations regarding smoking cessation (adjusted prevalence rate ratio (PRR): 1.55, 95%CI: 1.09-2.20), and more likely to not receive measurements of blood cholesterol (PRR: 1.72, 95%CI 1.24-2.40) or glucose (PRR: 1.80, 95%CI: 1.26-2.58). Those with low income were less likely to state that non-adherence/non-receipt was due to personal choice, and more likely to state that it was due to an extrinsic factor, such as cost or lack of accessibility.

CONCLUSIONS

There are important income-related differences in the patterns of health behavior change and disease monitoring, as well as reasons for non-adherence or non-receipt. Among those with low income, adherence to health behavior change and monitoring may be improved by addressing modifiable barriers such as cost and access.

Utilizing spatiotemporal analysis of influenza-like illness and rapid tests to focus swine-origin influenza virus intervention

In the spring of 2009, a novel strain of H1N1 swine-origin influenza A virus (S-OIV) emerged in Mexico and the United States, and soon after was declared a pandemic by the World Health Organization. This work examined the ability of real-time reports of influenza-like illness (ILI) symptoms and rapid influenza diagnostic tests (RIDTs) to approximate the spatiotemporal distribution of PCR-confirmed S-OIV cases for the purposes of focusing local intervention efforts. Cluster and age adjusted relative risk patterns of ILI, RIDT, and S-OIV were assessed at a fine spatial scale at different time and space extents within Cameron County, Texas on the US-Mexico border. Space-time patterns of ILI and RIDT were found to effectively characterize the areas with highest geographical risk of S-OIV within the first two weeks of the outbreak. Based on these results, ILI and/or RIDT may prove to be acceptable indicators of the location of S-OIV hotspots. Given that S-OIV data is often difficult to obtain real-time during an outbreak; these findings may be of use to public health officials targeting prevention and response efforts during future flu outbreaks.

Differentials by socioeconomic status and institutional characteristics in preventive service utilization by older persons in Costa Rica

Objective.The goals of this article are to assess the level of preventive service utilization by older persons in Costa Rica and to determine whether there are differentials in utilization across socioeconomic status (SES) and institutional characteristics. Method. Using data from the Costa Rican Study on Longevity and Healthy Aging (CRELES) project, a study of healthy aging in Costa Rica, the authors use self-reported information on preventive service utilization. The SES differentials are studied using logistic regressions. Results. Preventive services linked to cardiovascular disease prevention are frequently utilized; preventive services linked to cancer screening, vaccination, and sense impairments are not so widely used. Higher SES people are more likely to utilize most preventive services. Utilization rates among uninsured seniors are lower than among their insured peers. Home visits by community health workers are positively associated with higher utilization rates. Discussion. The SES disparities in preventive service utilization exist in Costa Rica, and institutional characteristics are positively associated with increasing utilization.

Use of an electronic medical record system to support primary care recommendations to prevent, identify, and manage childhood obesity

Many primary care physicians are not providing care that is consistent with recommendations to prevent, to identify, and to manage childhood obesity. This report presents modifications made to the electronic medical record system of a large pediatric health care system, using a quality improvement approach, to support these recommendations and office system changes. Although it is possible to make practice changes secondary to electronic medical record system enhancements, challenges to development and implementation exist.

Evaluating quality of primary care using the electronic medical record

Healthcare organizations are under increasing pressure to evaluate and report the level of quality in their health services. The electronic medical record (EMR) has been used in acute care settings to provide clinical data for quality evaluations. The implementation of the EMR in primary care settings is a more recent development, and as a result, the EMR has not been widely used to evaluate quality in primary care. Little research exists that uses the primary care medical record as a source of data. What remains to be seen is the extent to which EMRs contain the variables needed to address quality of primary care. This article describes a study that investigated the viability of the EMR as a database for evaluating quality in a women's primary health clinic.

Thiazide diuretics for hypertension: prescribing practices and predictors of use in 194,761 elderly patients with hypertension

BACKGROUND

Although several small studies have reported underuse of thiazide diuretics for elderly hypertensive patients, those factors which influence initial choice of first-line antihypertensive treatment are unknown.

OBJECTIVES

: The objective of this study was to explore prescribing practices for antihypertensives in the elderly and determine which factors are associated with thiazide diuretic use as first-line treatment

METHODS

This population-based cohort study used linked administrative databases for all elderly patients (> or =66 years of age) first treated for hypertension between July 1, 1994, and March 31, 2002, in Ontario, Canada.

RESULTS

Of the 194,761 patients in our cohort, 68,858 (35%) were prescribed a thiazide diuretic as their first anti-hypertensive agent. On multivariate analysis, factors associated with being prescribed a thiazide as first-line treatment included age (adjusted odds ratio [AOR], 1.72 [95% CI, 1.67-1.78] for octogenarians compared with patients aged 66-69 years) and having multiple comorbidities (AOR, 1.24 [95% CI, 1.16-1.29] for Charlson scores of 2 and AOR, 1.52 [95% CI, 1.37-1.61] for Charlson scores of > or =3). On the other hand, men (AOR, 0.64 [95% CI 0.63-0.65]) and hypertensives with diabetes (AOR, 0.22 [95% CI, 0.21-0.23]) were substantially less likely to be prescribed thiazide diuretics as first-line treatment. Socioeconomic status was not associated with use of thiazide diuretics.

CONCLUSIONS

One third of initial antihypertensive prescriptions for elderly patients were for thiazides in our publicly funded health care system with universal drug coverage. Socioeconomic status did not influence use of thiazides, but age, sex, and comorbidities did.

Effects of sex, age, and visits on receipt of preventive healthcare services: a secondary analysis of national data

BACKGROUND

Sex and age may exert a combined influence on receipt of preventive services with differences due to number of ambulatory care visits.

METHODS

We used nationally representative data to determine weighted percentages and adjusted odds ratios of men and women stratified by age group who received selected preventive services. The presence of interaction between sex and age group was tested using adjusted models and retested after adding number of visits.

RESULTS

Men were less likely than women to have received blood pressure screening (aOR 0.44;0.40-0.50), cholesterol screening (aOR 0.72;0.65-0.79), tobacco cessation counseling (aOR 0.66;0.55-0.78), and checkups (aOR 0.53;0.49-0.57). In younger age groups, men were particularly less likely than women to have received these services. In adjusted models, this observed interaction between sex and age group persisted only for blood pressure measurement (p = .016) and routine checkups (p < .001). When adjusting for number of visits, the interaction of age on receipt of blood pressure checks was mitigated but men were still overall less likely to receive the service.

CONCLUSION

Men are significantly less likely than women to receive certain preventive services, and younger men even more so. Some of this discrepancy is secondary to a difference in number of ambulatory care visits.

Vulnerability and the receipt of recommended preventive services: the influence of multiple risk factors

CONTEXT

Previous studies have confirmed the independent associations of race/ethnicity, socioeconomic status, and potential access with the receipt of preventive care. More pragmatic models of vulnerability are needed to examine the concomitant influence of multiple risk factors.

OBJECTIVE

To operationalize vulnerability as risk profiles of predisposing (race/ethnicity and education) and enabling (eg, income, health insurance, and having a regular source of care) factors, and their association with the receipt of preventive care.

STUDY DESIGN

Cross-sectional data on 14,983 adults from the Household Component of the 1996 Medical Expenditure Panel Survey.

MAIN OUTCOME MEASURES

Receipt of recommended preventive care: blood pressure and cholesterol screening, flu shot, Papanicolaou test, mammogram, and dental visit.

RESULTS

Controlling for other factors, analyses of risk profiles revealed a clear dose-response relationship with the receipt of preventive care regardless of race/ethnicity. In the total sample, having more risk factors was associated with a lower prevalence of, for example, receiving a cholesterol screening: 1 risk (PR=0.77; CI, 0.71-0.84), 2 risks (PR=0.56; CI, 0.49-0.64), and 3+ risks (PR=0.34; CI, 0.25-0.43).

CONCLUSION

Sizeable disparities in the receipt of recommended preventive services were found in relation to increasing vulnerability risk profiles. Without attention to such co-occurring risks, it is unlikely that substantial gains will be made in reducing disparities in the incidence of and mortality from the most common preventable diseases in the United States.

Who are the elderly who never receive influenza immunization?

OBJECTIVE

This paper estimates the rates of lifetime nonreceipt of influenza immunization among elderly and examines variations in the lifetime nonreceipt of immunization by gender, race and ethnic group, socioeconomic status, access to health care, and health status.

METHODS

Cross-sectional, nationally representative data on 5557 adults older than 50 years of age and living in the community from the 2000 Medical Expenditure Panel Survey are used. Lifetime nonreceipt of influenza immunization was analyzed with bivariate and multivariate statistical techniques.

FINDINGS

Thirty-one percent of the elderly reported never receiving influenza immunization and 20% reported irregular immunization. Higher odds of lifetime nonreceipt of vaccination and irregular vaccination were seen among African-Americans, young-old, current smokers, and those with no usual source of care.

CONCLUSIONS

Future campaigns to increase immunization rates should be tailored to target this hard-to-reach group of individuals.

Vulnerability and unmet health care needs. The influence of multiple risk factors

CONTEXT

Previous studies have demonstrated a strong association between minority race, low socioeconomic status (SES), and lack of potential access to care (e.g., no insurance coverage and no regular source of care) and poor receipt of health care services. Most studies have examined the independent effects of these risk factors for poor access, but more practical models are needed to account for the clustering of multiple risks.

OBJECTIVE

To present a profile of risk factors for poor access based on income, insurance coverage, and having a regular source of care, and examine the association of the profiles with unmet health care needs due to cost. Relationships are examined by race/ethnicity.

DESIGN

Analysis of 32,374 adults from the 2000 National Health Interview Survey.

MAIN OUTCOME MEASURES

Reported unmet needs due to cost: missing/delaying needed medical care, and delaying obtaining prescriptions, mental health care, or dental care.

RESULTS

Controlling for personal demographic and community factors, individuals who were low income, uninsured, and had no regular source of care were more likely to miss or delay needed health care services due to cost. After controlling for these risk factors, whites were more likely than other racial/ethnic groups to report unmet needs. When presented as a risk profile, a clear gradient existed in the likelihood of having an unmet need according to the number of risk factors, regardless of racial/ethnic group.

CONCLUSION

Unmet health care needs due to cost increased with higher risk profiles for each racial and ethnic group. Without attention to these co-occurring risk factors for poor access, it is unlikely that substantial reductions in disparities will be made in assuring access to needed health care services among vulnerable populations.

Prospective evaluation of screening colonoscopy: who is being screened?

BACKGROUND

Universal access to medical procedures is deemed an advantage of the Canadian health care system. The purposes of this prospective study were to determine the degree to which the practice of colon cancer screening by colonoscopy differed among socioeconomic classes and to assess adherence to screening guidelines.

METHODS

Consecutive patients scheduled to undergo colonoscopy at a single center between August 2000 and August 2002 completed a questionnaire that determined patient characteristics and indications for the procedure. The patients were divided into two groups: screening patients, defined as individuals who indicated they were undergoing colonoscopy for screening purposes and were asymptomatic, and a control group, which comprised patients undergoing colonoscopy because of symptoms. Statistical analysis was performed to determine if patients in the screening group had different characteristics with respect to socioeconomic class, compared with the control group.

RESULTS

A total of 1088 patients completed the questionnaire: 707 (65%) had colonoscopy because of symptoms, compared with 381 (35%) who underwent a screening examination. Mean age and marital status were similar in both groups. Of all colonoscopy procedures, there was a significantly greater proportion of men undergoing colonoscopy for screening purposes: 199 (52.2%) vs. 294 (41.6%) in the symptomatic group ( p = 0.001). Based on the Cochran-Armitage test, patients in the screening group had significantly higher education levels ( p = 0.004) and household incomes ( p = 0.001).

CONCLUSIONS

Income and education level, two indices of socioeconomic status, are statistically significantly higher in patients undergoing screening colonoscopy compared with those having colonoscopy for any other reason.

Physician screening for multiple behavioral health risk factors

BACKGROUND

Screening rates in primary care for single behavioral health risk factors are widely documented. However, such risk factors cluster in individuals and populations. This article examines the number and types of behavioral risk factors that U.S. adults reported, and reported having been screened for in their last routine medical checkup.

METHODS

The sample consisted of 16,818 adults from the 1998 National Health Interview Survey who reported having a routine checkup in the past year. Respondents completed questions regarding four behavioral risk factors (physical inactivity, overweight, cigarette smoking, risky drinking), and provider screening for behaviors related to these risk factors.

RESULTS

Half of the sample (52.0%) reported having two or more of the four risk factors, and more than half (59.4%) were screened for two or more risk behaviors during their last routine checkup, although 28.6% reported being screened for none of them. Respondents reporting at least one risk factor were screened for an average of 57.7% of their own risk factors. Women, adults with lower levels of income and education, and those aged 65 and older, reported being screened for fewer of their risk factors.

CONCLUSIONS

While guidelines for risk factor screening and intervention typically focus on single behavioral risk factors, most primary care patients present with, and are screened for, more than one. Behavioral risk factor screening tools and interventions must be expanded to cover multiple risks. Additionally, efforts are needed to reduce the substantial missed opportunities for screening, and to eliminate demographic disparities in screening practices and accuracy.

Implementation of a cancer prevention program for working class, multiethnic populations

BACKGROUND

This paper describes the implementation of the Healthy Directions-Health Centers intervention and examines the characteristics of participants associated with completion of intervention activities. Healthy Directions-Health Centers was designed to address social contextual factors relevant to cancer prevention interventions for working class, multi-ethnic populations.

METHODS

Ten community health centers were paired and randomly assigned to intervention or control. Patients who resided in low income, multi-ethnic neighborhoods were approached for participation. This study targeted fruit and vegetable consumption, red meat consumption, multi-vitamin intake, and physical activity. The intervention components consisted of: (1) a brief study endorsement from a clinician; (2) an in-person counseling session with a health advisor; (3) four follow-up telephone counseling sessions; and (4) multiple distributions of tailored materials.

RESULTS

Among the 1,088 intervention group participants, 978 participants (90%) completed at least five out of six intervention activities. Participants who missed clinical appointments were less likely to complete all components of the intervention. Participant characteristics that predicted receipt of clinician endorsement differed from characteristics that predicted completion of health advisor activities. Low acculturation did not present a barrier to delivery of the intervention once the participant was enrolled.

CONCLUSIONS

Collection and reporting on process evaluation results can help explain variations in program implementation.

Controlling Blood Pressure in 50% of All Hypertensive Patients: An Achievable Goal in the Healthy People 2010 Report?

Background

One important objective defined in the Healthy People 2010 report was to improve blood pressure (BP) control to < 140/90 mm Hg in 50% of all hypertensive patients. Because the US population is becoming older, more obese, and ethnically diverse, the health and economic benefits of reaching this goal become more valuable each year. Hypertension control rates are currently at ∼ 31% of all hypertensives and have risen slowly and erratically since 1988. In the absence of a coordinated strategic plan, achieving this critically important goal for BP control is highly unlikely.

Methods

A selected literature review was undertaken to briefly assess the cardiovascular benefits of controlling hypertension. Greater focus was placed on variables that impact hypertension awareness, treatment, and control. The impact on hypertension control rates of theoretic changes in awareness, treatment, and control individually and collectively was examined. Four categories of potential barriers to optimizing BP control are discussed: systems, provider, patient, and treatment factors.

Results

Raising awareness to 80% of all hypertensives, ensuring treatment of 90% of aware hypertensives, and controlling BP to < 140/90 mm Hg in 70% of treated patients would achieve control rates of 50%.

Conclusions

The barriers to achieving the Healthy People 2010 goal of controlling hypertension in 50% of all patients are formidable but appear to be resolvable with a coordinated strategic plan. Given projected demographic changes in the United States, the health and economic benefits of attaining the national goal for hypertension control would seem to merit a serious integrated effort.

Effectiveness and equity of serum cholesterol and blood pressure testing: a population-based study in Spain

BACKGROUND

This study examined the effectiveness and equity of serum cholesterol and blood pressure testing in Spain.

METHODS

Data were taken from a household survey of 3680 persons of the Basque Country, a region in northern Spain. Analyses were performed using logistic regression, controlling for need, equity, and predisposing factors for serum cholesterol and blood pressure testing. Proxies for need were age, subjective health and cardiovascular risk factors, such as tobacco and alcohol consumption, physical activity at work and at leisure time, and body mass index. Proxies for equity were sex, educational level, and province of residence, and predisposing factors for testing were the marital status and the number of medical visits in the preceding year.

RESULTS

The percentage of subjects that had their cholesterol measured rose with age and worse subjective health, but showed no association with any cardiovascular risk factor except body mass index, for which a positive association was observed (P for linear trend, 0.0351). The percentage of subjects with serum cholesterol checked also rose with educational level (P for linear trend, 0.0024). Moreover, women were less likely to have their cholesterolemia tested than men (OR, 0.79; 95% CI, 0.67-0.94). Educational and sex differences in cholesterol testing increased after adjustment for the number of medical visits. Similar results were obtained for blood pressure testing.

CONCLUSIONS

Serum cholesterol and blood pressure testing are not performed according to cardiovascular risk, which compromise its effectiveness. Moreover, there are social inequalities in testing, to which healthcare professionals could be contributing.

Participation in recreational physical activity: why do socioeconomic groups differ?

This qualitative study explored how influences on recreational physical activity (RPA) were patterned by socioeconomic position. Face-to-face interviews were conducted with 10 males and 10 females in three socioeconomic groups (N = 60). Influences salient across all groups included previous opportunities, physical health. social assistance. safety. environmental aesthetics and urban design, physical and health benefits, and barriers of self-consciousness, low skill, and weather/time of year. Influences more salient to the high socioeconomic group included social benefits, achieving a balanced lifestyle, and the barrier of an unpredictable lifestyle. Influences more salient to the high and mid socioeconomic groups included efficacy, perceived need, activity demands, affiliation, emotional benefits, and the barrier of competing demands. Influences more salient to the low socioeconomic group included poor health and barriers of inconvenient access and low personal functioning. Data suggest that efforts to increase RPA in the population should include both general and socioeconomically targeted strategies.

Reform and remembrance: the place of the private sector in the future of health care policy

Although the nation failed during the past decade to enact large-scale, structural change in government health policy, it has seen health care in the private sector remodeled dramatically during the same period. In this article I argue that a new round of equally significant changes is quite possible, this time at the hands of the national government. More specifically, I argue that for a variety of reasons, both enduring and more recently born, support for the private sector and the market in health care is relatively weak: that given likely trends in costs, demographics, and inequalities, it is likely to get even weaker; and that in the potential coming crisis of the health care system. there will be a real opportunity for seizing the agenda and winning policy battles on the part of would-be reformers pushing large-scale, public sector-oriented changes that go well beyond the recent reform efforts directed at managed care and HMOs.

Community-acquired pneumonia in older people: the need for a broader perspective

Community-acquired pneumonia (CAP) poses a substantial threat to the health of older adults. The incidence of this infection and mortality associated with it increase with age. Despite the considerable effect of CAP on older adults, little is known about the effect of socioeconomic and environmental factors on CAP in older people. This paper argues that broader determinants, including socioeconomic status (SES), nutrition, and factors in the physical environment such as exposure to tobacco smoke and air pollution need to be evaluated as potential risk factors for CAP in older adults. Data suggesting a relationship between low SES and risk of acquiring CAP exist; possible causal pathways include increased exposure through crowding or increased susceptibility to infection. Inadequate nutrition, exposure to tobacco smoke, air pollution, and not receiving immunization may predispose older people to lower respiratory tract infection. This study reviews current evidence for these potential risk factors and suggests priorities for research. A thorough understanding of these factors and their underlying biological mechanisms is needed to develop successful health-promotion strategies such as better immunization strategies and educational programs about nutrition. Determining the effect of air pollution on CAP in older adults is important in terms of reducing personal risk to older individuals and for healthcare agencies charged with formulating policy to protect the health of older adults.

Healthcare system factors and colorectal cancer screening

BACKGROUND

Developing effective programs to promote colorectal cancer (CRC) screening requires understanding of the effect of healthcare system factors on access to screening and adherence to guidelines.

METHODS

This study assessed the role of insurance status, type of plan, the frequency of preventive health visits, and provider recommendation on utilization of CRC screening tests using a cross-sectional, random-digit-dial survey of 1002 Massachusetts residents aged > or =50.

RESULTS

A broad definition of CRC screening status included colonoscopy or barium enema (screening or diagnostic) within 10 years, flexible sigmoidoscopy (FSIG) within 5 years, and fecal occult blood testing (FOBT) in the past year as options; 51.7% of subjects aged 50 to 64 and 61.5% of older subjects were current. The uninsured had the lowest current testing rate. Among insured participants, type of insurance had little impact on CRC testing; older subjects enrolled in HMOs had marginally higher rates, although not statistically significant. Increased frequency of preventive health visits and ever receiving a physician's recommendation for FSIG or ever receiving FOBT cards were associated with higher rates of CRC screening among both age groups.

CONCLUSIONS

Even when broad criteria are used to define current CRC screening status, a substantial proportion of the age-eligible population remains underscreened. Obtaining regular preventive care and receiving a physician's recommendation for screening appear to be potent facilitators of screening that should be considered in designing promotional efforts.

Sociodemographic diversity and behavioral medicine

The broad array of economic and cultural diversity in the U.S. population correlates with and impacts on the study of behavioral aspects of health. The purpose of this article was to provide a selective overview of behavioral medicine research on sociodemographically diverse populations, with a focus on ethnicity, gender, and socioeconomic status. Suggestions are provided with regard to methodological refinement of research and insights into possible future directions in behavioral medicine research on ethnically and economically diverse populations.

Nonresponse bias: does it affect measurement of clinician behavior?

BACKGROUND

Previous studies of nonresponders have not assessed the effects of nonresponse on the accuracy of clinician behavior measurements. Knowledge of these effects is critical to both research and quality improvement.

OBJECTIVE

To evaluate the hypothesis that nonresponders to a survey would not adversely affect the ability to measure rates of preventive services.

RESEARCH DESIGN

Four primary-care medical practices participating in a randomized clinical trial provided an unusual opportunity to compare the medical record-documented care of both responders and nonresponders to a survey of their patients.

SUBJECTS

Three hundred forty-five nonresponders and 321 responders to a questionnaire requesting participation in the study.

MEASURES

Differences in patient characteristics and diseases and documentation of screening and management of tobacco use, hypertension, and hypercholesterolemia.

RESULTS

Although the survey process resulted in a response rate of only 52.5% and some statistically significant differences in responder and nonresponder characteristics, there were no differences in management behavior regarding cardiovascular risk factors. Responders were more likely to have adjusted documentation of tobacco use (OR = 1.4), blood pressure measurement (OR = 9.8), and cholesterol testing (OR = 2.0), but not family history of cardiovascular disease. The most striking difference in subject characteristics was that 22.0% of nonresponders and only 12.1% of responders were tobacco users (P = 0.002).

CONCLUSIONS

This study confirms that survey nonresponders may have some different characteristics and risk factor screening rates than responders. However, if confirmed by others, nonresponders who have risk factors identified may not be managed differently than responders.

Disparities in hormone replacement therapy use by socioeconomic status in a primary care population

The use of hormone replacement therapy (HRT) is a controversial decision for many women, yet few studies have evaluated the socio-demographic, psychological, and behavioral correlates of HRT use. This cross-sectional, mailed survey evaluated the associations of socioeconomic status, preventive health behaviors, knowledge and perceptions about HRT-related risks and benefits with HRT use among 428 women 50-70 years old in Vermont. The overall prevalence of HRT use was 40%. Women of moderate to high income were three times more likely than those of low income to use HRT. HRT use was significantly higher among women whose physician had encouraged use (58%) than among those who received ambivalent recommendations from their physicians (20%). Hysterectomy, higher income, younger age, regular adherence to cervical cancer screening, and recommendation by a provider were significantly associated with HRT use in multivariate analyses. There were no differences in HRT use according to level of concern about heart disease, osteoporosis, or breast cancer. A recommendation by a health care provider is a powerful predictor of HRT use, but disparities in use exist by socioeconomic status. Future research should examine why lower income women are less likely to use HRT and whether the discrepancy is due to inconsistent recommendations by health care providers.

The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

OBJECTIVES

This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population.

METHODS

In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties.

RESULTS

Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income).

CONCLUSIONS

Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.

Medical schools, affirmative action, and the neglected role of social class

Medical schools' affirmative action policies traditionally focus on race and give relatively little consideration to applicants' socioeconomic status or "social class." However, recent challenges to affirmative action have raised the prospect of using social class, instead of race, as the basis for preferential admissions decisions in an effort to maintain or increase student diversity. This article reviews the evidence for class-based affirmative action in medicine and concludes that it might be an effective supplement to, rather than a replacement for, race-based affirmative action. The authors consider the research literature on (1) medical students' socioeconomic background, (2) the impact of social class on medical treatment and physician-patient communication, and (3) correlations between physicians' socioeconomic origins and their service patterns to the disadvantaged. They also reference sociological literature on distinctions between race and class and Americans' discomfort with "social class."

Influence of patient education on profiles of physician practices

BACKGROUND

Few data are available about the effect of patient socioeconomic status on profiles of physician practices.

OBJECTIVE

To determine the ways in which adjustment for patients' level of education (as a measure of socioeconomic status) changes profiles of physician practices.

DESIGN

Cross-sectional survey of patients in physician practices.

SETTING

Managed care organization in western New York State.

PARTICIPANTS

A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician.

MEASUREMENTS

Ranks of physicians for patient physical and mental health (Short Form 12-Item Health Survey) and satisfaction (Patient Satisfaction Questionnaire), adjusted for patient age, sex, morbidity, and education.

RESULTS

Physicians whose patients had a lower mean level of education had significantly better ranks for patient physical and mental health status after adjustment for patients' level of education level than they did before adjustment (P < 0.001); this result was not seen for patient satisfaction. After adjustment for patients' level of education, each 1-year decrease in mean educational level was associated with a rank that improved by 8.1 (95% CI, 6.6 to 9.6) for patient physical health status and by 4.9 (CI, 3.9 to 5.9) for patient mental health status. Adjustment for education had similar effects for practices with more educated patients and those with less educated patients.

CONCLUSIONS

Profiles of physician practices that base ratings of physician performance on patients' physical and mental health status are substantially affected by patients' level of education. However, these results do not suggest that physicians who care for less educated patients provide worse care. Physician profiling should account for differences in patients' level of education.

The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review

OBJECTIVE

To critically review the literature concerning the accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease among the general population.

METHOD

A literature search was conducted on three major health research databases: MEDLINE, HealthPLAN, and PsychLit. The bibliographies of located articles were also checked for additional relevant references. Studies meeting the following five inclusion criteria were included in the review: They were investigating the accuracy of self-report among the general population, as opposed to among clinical populations. They employed an adequate and appropriate gold standard. At least 70% of respondents consented to validation, where validation imposed minimal demands on the respondent; and 60% consent to validation was considered acceptable where validation imposed a greater burden. They had a sample size capable of estimating sensitivity and specificity rates with 95% confidence intervals of width +/-10%. The time lag between collection of the self-report and validation data for physical measures did not exceed one month.

RESULTS

Twenty-four of 66 identified studies met all the inclusion criteria described above. In the vast majority, self-report data consistently underestimated the proportion of individuals considered "at-risk." Similarly, community prevalences of risk factors were considerably higher according to gold standard data sources than they were according to self-report data.

CONCLUSIONS

This review casts serious doubts on the wisdom of relying exclusively on self-reported health information. It suggests that caution should be exercised both when trying to identify at-risk individuals and when estimating the prevalence of risk factors among the general population. The review also suggests a number of ways in which the accuracy of individuals' self-reported health information can be maximized.

Conceptualizing vulnerable populations health-related research

BACKGROUND

A conceptual model for vulnerable populations research relates resource availability and relative risk to health status. The model has a population-based focus that places responsibility for the collective health status of its citizens with the community. Vulnerable populations are social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality. There is considerable research evidence to support the major relationships in the model. Conceptual links that need additional research are identified.

CONCLUSIONS

The implications for research include a variety of methodological problems related to recruiting and retaining participants, instrumentation, and data collection. Research designs are needed that move beyond descriptive and epidemiological approaches to interventional and outcome studies. Ethical considerations take on special significance with vulnerable populations.