Revisiting the behavioral model and access to medical care: does it matter?

The Behavioral Model of Health Services Use was initially developed over 25 years ago. In the interim it has been subject to considerable application, reprobation, and alteration. I review its development and assess its continued relevance.

Competing priorities as a barrier to medical care among homeless adults in Los Angeles

OBJECTIVES

The role of competing priorities as a barrier to the utilization of physical health services was assessed in a subset (n = 363) of a probability sample of homeless adults in Los Angeles.

METHODS

Unadjusted odds of four measures of health services utilization were calculated for those with frequent difficulty in meeting their subsistence needs. These odds were then adjusted for a range of characteristics assumed to affect the utilization of health services among the homeless.

RESULTS

Before and after adjustment, those with frequent subsistence difficulty were less likely to have a regular source of care (odds ratio [OR] = 0.30, 95% confidence interval [CI] = 0.16, 0.53) and more likely to have gone without needed medical care (OR = 1.77, 95% CI = 1.04, 3.00). Subsistence difficulty had no impact on the likelihood of having an outpatient visit or having been hospitalized. Conclusions remained the same after adjustment.

CONCLUSIONS

Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults.

Access to medical care in the U.S.: realized and potential

This paper seeks to provide a framework for understanding differential access to medical care in the U.S. population and to suggest ways to achieve equity of access. The framework is provided by a behavioral model of health services utilization which suggests a sequence of predisposing, enabling and illness variables that determine the number of times people will visit a physician. The model is operationalized using a path analytic technique. The data come from a national survey of the noninstitutionalized U.S. population conducted in late 1975 and early 1976. The results suggest services are generally equitably distributed since age and level of illness are the main determinants of the number of services people receive. However, remaining inequities might be reduced by providing people who report no regular source of medical care with a familiar entry into the health service system.

The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States

OBJECTIVES

To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data.

DESIGN

Survey of a nationally representative sample of 2,864 adults receiving HIV care.

MAIN INDEPENDENT VARIABLES

Going without care because of needing the money for food, clothing, or housing; postponing care because of not having transportation; not being able to get out of work; and being too sick.

MAIN OUTCOME MEASURES

Having fewer than three physician visits in the previous 6 months, visiting an emergency room without being hospitalized; never receiving antiretroviral agents, no prophylaxis for Pneumocystis carinii pneumonia in the previous 6 months for persons at risk, and low overall reported access on a six-item scale.

RESULTS

More than one third of persons (representing >83,000 persons nationally) went without or postponed care for one of the four reasons we studied. In multiple logistic regression analysis, having any one or more of the four competing needs independent variables was associated with significantly greater odds of visiting an emergency room without hospitalization, never receiving antiretroviral agents, and having low overall reported access.

CONCLUSIONS

Competing subsistence needs and other barriers are prevalent among persons receiving care for HIV in the United States, and they act as potent constraints to the receipt of needed medical care. For persons infected with HIV to benefit more fully from recent advances in medical therapy, policy makers may need to address nonmedical needs such as food, clothing, and housing as well as transportation, home care, and employment support.

Intrauterine herpes simplex virus infections

Neonatal herpes simplex virus (HSV) infection is usually acquired at birth, although a few infants have had findings suggestive of intrauterine infection. We describe 13 babies who had clinical manifestations of intrauterine HSV infection, including skin lesions and scars at birth (12), chorioretinitis (eight), microcephaly (seven), hydranencephaly (five), and microphthalmia (two). All infants had combinations of these defects. Infection was proved by viral isolation in each case; all isolates were HSV-2. Two infants died during the first week of life; 10 of the surviving infants had severe neurologic sequelae, and one infant was blind. Four mothers experienced an apparent primary genital HSV infection, and one had recurrent infection, at varying times during gestation. The remaining women denied a history of symptoms of genital HSV infection. These findings indicate that intrauterine HSV infection can occur as a consequence of either primary or recurrent maternal infection and has severe consequences for the fetus.

Balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension

OBJECTIVE

To examine the effect of balloon pulmonary angioplasty (BPA) on chronic thromboembolic pulmonary hypertension (CTEPH) in patients with inoperable disease or persistent pulmonary hypertension after pulmonary endarterectomy.

DESIGN

Observational cohort study.

SETTING

Referred patients with inoperable or persistent CTEPH.

PATIENTS

Twenty consecutive CTEPH patients (10 females), aged 60±10 years.

INTERVENTIONS BPA MAIN OUTCOME MEASURES

Right heart catheterisation, functional capacity (cardiopulmonary exercise testing (CPET) and NYHA class) and blood sampled biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin T examined at the time of diagnosis and repeated in all patients 3 months after the last BPA.

RESULTS

Seventy-three catheterisations were performed with 18.6±6.1 BPAs per patient on segmental and subsegmental arteries. Two deaths occurred following the first BPA, with an overall 10% periprocedural death rate. Reperfusion oedema complicated seven procedures. Comparisons before and after BPA showed significant haemodynamic improvements, including decreased mean pulmonary artery pressure (mPAP) (45±11 mm Hg vs 33±10 mm Hg; p<0.001) and increased cardiac output (4.9±1.6 L/min vs 5.4±1.9 L/min; p=0.011). Reduced right ventricular strain was indicated by significantly lower plasma levels of NT-proBNP and troponin T. Significant improvement in functional capacity was evident as assessed by NYHA class (3.0±0.5 vs 2.0±0.5; p<0.001) and CPET (13.6±5.6 mL/kg/min vs 17.0±6.5 mL/kg/min; p<0.001). Seventeen patients (85%) were alive after 51±30 months of follow-up.

CONCLUSIONS

BPA may offer an alternative form of treatment in selected CTEPH patients. While prognostic markers such as haemodynamics, functional capacity and biomarkers improve, significant periprocedural complications must be recognised. Randomised trials are warranted.

Teenage girls and elderly women living in northern Europe have low winter vitamin D status

OBJECTIVE

To determine the vitamin D status (serum 25-hydroxyvitamin D; S-25OHD) in adolescent girls and elderly community-dwelling women living in four countries of northern Europe and to explain differences in S-25OHD concentrations between and within the countries.

DESIGN

A cross-sectional observational study conducted in a standardised way during February-March. S-25OHD was analysed by high-performance liquid chromatography. Vitamin D and calcium intake was calculated using a standardised food composition database.

SETTING

Denmark, Finland, Ireland, and Poland.

SUBJECTS

A total of 199 girls (mean (s.d.) age 12.6 (0.5) y) and 221 women (mean (s.d.) age 71.8 (1.4) y).

RESULTS

The median (inter quartiles) concentration of S-25OHD was 29.4 (20.3, 38.3) nmol/l for the girls and 40.7 (28.0, 54.2) nmol/l for the women. S-25OHD below 25 nmol/l was found in 37% of the girls and 17% of the women, and S-25OHD below 50 nmol/l was found in 92% of the girls and 37% of the women. Positive significant determinants for S-25OHD in girls were use of vitamin D supplements, and in women sun habits, dietary vitamin D intake, use of vitamin D and calcium supplements. Body mass index and smoking were negative determinants in women. For women predictors could explain the differences between countries (P(country) = 0.09, R(2) = 0.39), but for girls the difference remained significant even after including predictors (P(country) = 0.03, R(2) = 0.15).

CONCLUSION

Vitamin D status is low in northern Europe during winter. More than one-third of the adolescent girls have vitamin D status below 25 nmol/l and almost all are below 50 nmol/l. Two-thirds of the elderly community-dwelling women have vitamin D status below 50 nmol/l. Use of vitamin D supplements is a significant positive determinant for S-25OHD for both girls and women (P = 0.001).

SPONSORSHIP

The European Fifth Framework Programme (Contract No. QLK1-CT-2000-00623).

Acculturation and leisure-time physical inactivity in Mexican American adults: results from NHANES III, 1988-1994

OBJECTIVES

This study examined the relationship between acculturation and leisure-time physical inactivity among Mexican American adults.

METHODS

Using data from the Third National Health and Nutrition Examination Survey, we estimated the prevalence of physical inactivity according to place of birth and language used at home.

RESULTS

Spanish-speaking Mexican Americans had a higher prevalence of physical inactivity during leisure time than those who spoke mostly English, independent of place of birth.

CONCLUSIONS

Acculturation seems to be positively associated with participation in leisure-time physical activity.

Pain as a major cause of postoperative nausea

The incidence of nausea in relation to pain was recorded in 104 patients after abdominal operations. Ten per cent of the patients had episodes of nausea not related to pain. One hundred and fourteen episodes of concomitant pain and nausea were recorded in 61 patients (58.6 per cent). The intravenous injection of morphine or ketobemidone relieved nausea as well as pain in 80 per cent of the episodes. Relief of pain with persistence of nausea was uncommon and if pain relief was inadequate nausea was unabated. Nausea was provoked by 3.4 per cent of the morphine injections, but all patients tolerated similar doses of morphine on other occasions without nausea. Nausea often accompanies pain in the early postoperative period and can be relieved concomitant with the pain by the intravenous use of opiates in adequate doses in a high proportion of cases.

Violence victimization after HIV infection in a US probability sample of adult patients in primary care

OBJECTIVES

This study estimated the proportion of HIV-infected adults who have been assaulted by a partner or someone important to them since their HIV diagnosis and the extent to which they reported HIV-seropositive status as a cause of the violence.

METHODS

Study participants were from a nationally representative probability sample of 2864 HIV-infected adults who were receiving medical care and were enrolled in the HIV Costs and Service Utilization Study. All interviews (91% in person, 9% by telephone) were conducted with computer-assisted personal interviewing instruments. Interviews began in January 1996 and ended 15 months later.

RESULTS

Overall, 20.5% of the women, 11.5% of the men who reported having sex with men, and 7.5% of the heterosexual men reported physical harm since diagnosis, of whom nearly half reported HIV-seropositive status as a cause of violent episodes.

CONCLUSIONS

HIV-related care is an appropriate setting for routine assessment of violence. Programs to cross-train staff in antiviolence agencies and HIV care facilities need to be developed for men and women with HIV infection.

A new injectable bulking agent for treatment of stress urinary incontinence: results of a multicenter, randomized, controlled, double-blind study of Durasphere

OBJECTIVES

To assess the safety and effectiveness of Durasphere compared with bovine collagen in the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD).

METHODS

This multicenter, randomized, controlled, double-blind trial was composed of 355 women diagnosed with SUI due to ISD and used a standardized pad test and the Stamey continence grade as the primary endpoints. The participants' ages ranged from 26 to 84 years. All patients had an abdominal leak point pressure of less than 90 cm H(2)O (average 51).

RESULTS

At 12 months after the first injection, the two materials were equivalent with respect to the improvement in continence grade and pad weight testing. Less Durasphere was injected to obtain comparable clinical results (Durasphere 4.83 mL versus bovine collagen 6.23 mL, P <0.001). When examined 1 year after the date of the last treatment, 49 (80.3%) of the 61 women treated with Durasphere showed improvement of 1 continence grade or more compared with 47 (69.1%) of 68 women treated with bovine collagen (P value for difference = 0.162). Although the adverse events reported for both groups were similar, the Durasphere group had an increased short-term risk of urgency and urinary retention.

CONCLUSIONS

The use of Durasphere for the treatment of SUI due to ISD was equally effective as bovine collagen and used less material. The U.S. Food and Drug Administration granted market approval for Durasphere on September 13, 1999. The product design and initial clinical data suggest the potential for greater durability of the clinical benefit, with the possibility of a permanent solution for SUI due to ISD in some patients.

Short sleep duration and large variability in sleep duration are independently associated with dietary risk factors for obesity in Danish school children

BACKGROUND

Lack of sleep and increased consumption of energy-dense foods and sugar-sweetened beverages (SSBs) have all been suggested as factors contributing to the increased prevalence of overweight and obesity.

OBJECTIVE

To evaluate whether objectively measured sleep duration (average and day-to-day variability) as well as parent-reported sleep problems are independently associated with proposed dietary risk factors for overweight and obesity in 8-11-year-old children.

DESIGN

In this cross-sectional study, data on sleep duration and day-to-day variability in sleep duration were measured in 676 Danish, apparently healthy children by an objective measure (actigraphy) for 8 nights, and the Children's Sleep Habits Questionnaire (CSHQ) was filled out by the parents. Diet was recorded using a web-based food record for 7 consecutive days. Fasting blood samples were obtained for measurements of plasma leptin and ghrelin levels.

RESULTS

Sleep duration (h per night) was negatively associated with energy density (ED) of the diet (β = -0.32 kJ g(-1)), added sugar (β = -1.50 E%) and SSBs (β = -1.07 E%) (all P ≤ 0.003). Furthermore, variability in sleep duration (10-min per night) was positively associated with SSBs (β = 0.20 E%, P = 0.03), independent of sleep duration, and CSHQ score was positively associated with ED (β = 0.16 kJ g(-1), P = 0.04). All of these associations were independent of potential confounders (age, sex, pubertal status, height, weight, screen time, moderate-to-vigorous physical activity and parental education and ethnicity).

CONCLUSION

Our study suggests that short sleep duration, high sleep duration variability and experiencing sleep problems are all associated with a poor, obesity-promoting diet in children.

Delayed medical care after diagnosis in a US national probability sample of persons infected with human immunodeficiency virus

OBJECTIVE

To identify health care and patient factors associated with delayed initial medical care for human immunodeficiency virus (HIV) infection.

DESIGN

Survey of a national probability sample of persons with HIV in care.

SETTING

Medical practices in the contiguous United States.

PATIENTS

Cohort A (N = 1540) was diagnosed by February 1993 and was in care within 3 years; cohort B (N = 1960) was diagnosed by February 1995 and was in care within 1 year of diagnosis.

MAIN OUTCOME MEASURE

More than 3- or 6-month delay.

RESULTS

Delay of more than 3 months occurred for 29% of cohort A (median, 1 year) and 17% of cohort B. Having a usual source of care at diagnosis reduced delay, with adjusted odds ratios (ORs) of 0.61 (95% confidence interval [CI], 0.48-0.77) in cohort A and 0. 70 (95% CI, 0.50-0.99) in cohort B. Medicaid coverage at diagnosis showed lower adjusted ORs of delay compared with private insurance (cohort A: adjusted OR, 0.52; 95% CI, 0.30-0.92; cohort B: adjusted OR, 0.48; 95% CI, 0.27-0.85). Compared with whites, Latinos had 53% and 95% higher adjusted ORs of delay (P<.05) in cohorts A and B, respectively, and African Americans had a higher adjusted OR in cohort A (1.56; 95% CI, 1.19-2.04). The health care factors showed similar effects on delay of greater than 6 months.

CONCLUSIONS

Medicaid insurance and a usual source of care were protective against delay after HIV diagnosis. After full adjustment, delay was still greater for Latinos and, to a lesser extent, African Americans compared with whites.

The persistence of race and ethnicity in the use of long-term care

We examine the use of nursing homes, formal personal care, informal Activities of Daily Living (ADL) assistance, and no care to identify racial differences in their use. Using the 1987 National Medical Expenditure Survey of both nursing homes and the community, multinominal logistic regressions controlled for predisposing, enabling, and need variables as well as other types of service use. Additional state-level variables make few changes in race/ethnicity parameters, indicating that race/ethnicity are not simply proxies for state-level variables. Older African Americans are less likely to use nursing homes than similar whites, with the lower institutionalization replaced by a higher use of paid home care, informal-only care, and no care. This suggests that formal in-home community care is not fully compensating for the racial differences in nursing home use. Persistent effects of race/ethnicity could be the result of culture, class, and/or discrimination that may impair equitable access to services.

Ethnicity, aging, and oral health outcomes: a conceptual framework

An expanded version of Andersen's Behavioral Model of Health Services Utilization is used as the theoretical and analytical framework for the International Collaborative Study of Oral Health Outcomes (ICS-II). The conceptual framework for understanding determinants of oral health is based on a "systems" perspective. The framework posits that characteristics of the external environment, the dental care delivery system, and the personal characteristics of the population influence oral health behaviors. The expanded behavioral model conceptualizes health behaviors (oral hygiene practices and dental services utilization) as intermediate dependent variables, which in turn influence oral health outcomes (evaluated, perceived, patient satisfaction). The framework is presented with an increased focus on the effects of race-ethnicity and age cohort, the major exogenous variables used in this study for systematic assessment of the differences in the multitude of factors influencing oral health. The framework can be applied by policy analysis and health services managers to help describe, predict, and explain population-based health behaviors and health outcomes.

Changes in plasma hormones across the menstrual cycle in patients with menstrually related mood disorder and in control subjects

A variety of hypotheses have been proposed to explain the premenstrual syndromes. These hypotheses serve as rationales for an equally diverse range of proposed treatments. To investigate these hypotheses, we obtained multiple blood samples across the menstrual cycle in women with well-characterized menstrually related mood disorder and in control subjects. No diagnosis-related differences were observed in the levels or patterns of secretion of progesterone, estradiol, follicle-stimulating hormone, luteinizing hormone, testosterone-estradiol-binding globulin, dehydroepiandrosterone sulfate, dihydrotestosterone, prolactin, or cortisol. Our data suggest that premenstrual syndrome does not represent a simple hormonal deficiency and that the cited rationales for several of the proposed treatments are of questionable merit.

Effect of case management on unmet needs and utilization of medical care and medications among HIV-infected persons

BACKGROUND

Although case management has been advocated as a method for improving the care of chronically ill persons, its effectiveness is poorly understood.

OBJECTIVE

To assess the effect of case managers on unmet need for supportive services and utilization of medical care and medications among HIV-infected persons.

DESIGN

Baseline and follow-up interview of a national probability sample.

SETTING

Inpatient and outpatient medical facilities in the United States.

PARTICIPANTS

2437 HIV-infected adults representing 217 081 patients receiving medical care.

MEASUREMENTS

Outcomes measured at follow-up were unmet need for supportive services, medical care utilization (ambulatory visits, emergency department visits, and hospitalizations), and use of HIV medication (receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis).

RESULTS

At baseline, 56.5% of the sample had contact with a case manager in the previous 6 months. In multiple logistic regression analyses that adjusted for potential confounders, contact with a case manager at baseline was associated with decreased unmet need for income assistance (odds ratio [OR], 0.57 [95% CI, 0.36 to 0.91]), health insurance (OR, 0.54 [CI, 0.33 to 0.89]), home health care (OR, 0.29 [CI, 0.15 to 0.56]), and emotional counseling (OR, 0.62 [CI, 0.41 to 0.94]) at follow-up. Contact with case managers was not significantly associated with utilization of ambulatory care (OR, 0.77 [CI, 0.57 to 1.04]), hospitalization (OR, 1.13 [CI, 0.84 to 1.54]), or emergency department visits (OR, 1.30 [CI, 0.97 to 1.73]) but was associated with higher utilization of two-drug (OR, 1.58 [CI, 1.23 to 2.03]) and three-drug (OR, 1.34 [CI, 1.00 to 1.80]) antiretroviral regimens and of treatment with protease inhibitors or non-nucleoside reverse transcriptase inhibitors (OR, 1.29 [CI, 1.02 to 1.64]) at follow-up.

CONCLUSIONS

Case management appears to be associated with fewer unmet needs and higher use of HIV medications in patients receiving HIV treatment.

Methodological issues in health care surveys of the Spanish heritage population

This paper examines national survey data on access to medical care to explore methodological issues associated with conducting health care surveys of Spanish-heritage persons. These include problems of identifying and sampling such groups, achieving respondent cooperation, designing valid interview protocols, and controlling biases that may result from the cultural specificity of the concepts being studied. The findings suggest that more attention should be given to the following in designing health care surveys of Spanish-heritage individuals: cultural and economic heterogeneity of "Spanish-heritage" grouping, validity studies of health care utilization, and yea-saying tendencies related to health care attitude items. Given that there is a paucity of information available on methodological problems associated with health care surveys of Spanish-heritage persons, these analyses should serve to inform researchers of issues to be taken into account in designing such studies and to suggest useful hypotheses to explore in evaluating the validity of social survey data on minority (especially non-English speaking) populations' health care practices.

The national profile of access to medical care: where do we stand?

This paper presents analyses of recent national survey data on access to medical care. In particular, information on major access indicators and special problems associated with the economic and political climate of the 1980s collected in a 1982 national telephone survey of 6,610 United States adults and children, representing some 4,802 families, is compared with previous national surveys for key population subgroups--by age, place of residence, income, race, insurance coverage, and type of regular source of care. In general, the findings show that favorable progress has been made, but some inequities continue to persist. Some traditionally disadvantaged groups are more likely to have a regular family doctor, private insurance coverage, have been to a doctor, or had certain preventive tests and procedures than was true for them in the past. On the other hand, compared to the more economically and/or socially advantaged groups in 1982, they have still not "caught up" entirely. There also is evidence that they may be hardest hit by the exacerbation of the financial barriers to care that result from unemployment, inflation, and cutbacks in health program eligibility and benefits that have characterized the decade of the 1980s.

Cerebral emboli during left heart catheterization may cause acute brain injury

AIMS

Left heart catheterization carries a risk for cerebral complications. The aims of this prospective study were to determine the frequency and composition of catheterization-related cerebral microemboli and to detect cerebral morphological changes and acute cognitive impairment due to catheterization.

METHODS AND RESULTS

Forty-seven unselected patients undergoing elective left heart catheterization, either by transradial or by transfemoral access, were monitored for cerebral microemboli using multifrequency transcranial Doppler. Cerebral magnetic resonance imaging (MRI) with diffusion-weighted imaging sequences and neuropsychological assessments were carried out on the day before and the day after catheterization. A median number of 754 cerebral microemboli were detected: 92.1% were gaseous and 7.9% were solid. New cerebral lesions were observed in 15.2% of the transradial, but none of the transfemoral, catheterization patients (P=0.567). These lesions were significantly associated with a higher number of solid microemboli (P=0.016) and a longer fluoroscopy time (P=0.039). There was also a significantly higher number of solid microemboli during transradial than during transfemoral catheterization (P=0.012). Cognitive impairment following the investigations was associated with the degree of pre-catheterization cerebral MRI injury (P=0.03).

CONCLUSION

During left heart catheterization, cerebral microemboli, especially those which are solid, may damage the brain. Cardiac catheterization may therefore pose a greater risk for the brain than previously acknowledged.

Determinants of regular source of care among homeless adults in Los Angeles

OBJECTIVES

The authors explore the determinants of having a regular source of care in a community-based probability sample of homeless adults in Los Angeles. Results from this study should be more representative than those from previous studies of the homeless that are clinic- or shelter-based. In addition to those factors found to be barriers to regular sources of care in the general population, we hypothesized that psychosocial characteristics of the homeless and the homeless lifestyle would negatively impact their likelihood of having a regular source of care.

METHODS

The authors conducted a multiple logistic regression to predict regular source of care among the homeless, using an adaptation of the Behavioral Model of health services utilization as an analytic framework.

RESULTS

Fifty-seven percent of the sample reported that they had a regular source of care. Of those with a source of care, 30% reported a hospital outpatient department; 25% reported a community or homeless clinic; 23% reported a hospital emergency room; 14% reported a government clinic; and 9% reported a private physician's office as their source of care. Some factors found to be barriers to having a regular source of care in the general population (male, Hispanic, young age) also were barriers among homeless adults. Additional barriers in this sample included homelessness-related characteristics such as competing needs, long-term homelessness, and social isolation. Chronic mental illness and chronic substance dependence were not related to having a source of care among the homeless. Characteristics that increased the likelihood of having a regular source of care in the general population (poor health status, Medicaid) were not related to having a regular source of care among the homeless.

CONCLUSIONS

In a context of limited resources, the distribution of regular source of care among the homeless appears to be highly inequitable. Although some of the characteristics identifying those with a regular source of care suggest differential patterns of behavior across subgroups, others suggest differential advantage in access to care and a lack of fit between the needs of the homeless and the organization of health services.

Is food insufficiency associated with health status and health care utilization among adults with diabetes?

OBJECTIVES

Preliminary studies have shown that among adults with diabetes, food insufficiency has adverse health consequences, including hypoglycemic episodes and increased need for health care services. The purpose of this study was to determine the prevalence of food insufficiency and to describe the association of food insufficiency with health status and health care utilization in a national sample of adults with diabetes.

METHODS

We analyzed data from adults with diabetes ( n =1,503) interviewed in the Third National Health and Nutrition Examination Survey. Bivariate and multivariate analyses were used to examine the relationship of food insufficiency to self-reported health status and health care utilization.

RESULTS

Six percent of adults with diabetes reported food insufficiency, representing more than 568,600 persons nationally (95% confidence interval, 368,400 to 768,800). Food insufficiency was more common among those with incomes below the federal poverty level (17% vs 4%, P < or = .001). Adults with diabetes who were food insufficient were more likely to report fair or poor health status than those who were not (63% vs 43%; odds ratio, 2.2; P=.05). In a multivariate analysis, fair or poor health status was independently associated with poverty, nonwhite race, low educational achievement, and number of chronic diseases, but not with food insufficiency. Diabetic adults who were food insufficient reported more physician encounters, either in clinic or by phone, than those who were food secure (12 vs 7, P<.05). In a multivariate linear regression, food insufficiency remained independently associated with increased physician utilization among adults with diabetes. There was no association between food insufficiency and hospitalization in bivariate analysis.

CONCLUSIONS

Food insufficiency is relatively common among low-income adults with diabetes and was associated with higher physician utilization.

Prevalence and predictors of highly active antiretroviral therapy use in patients with HIV infection in the united states. HCSUS Consortium. HIV Cost and Services Utilization

BACKGROUND

Highly active antiretroviral therapy (HAART) became standard for HIV in 1996. Studies at that time showed that most people infected with HIV had initiated HAART, but that members of minority groups and poor people had lower HAART use. It is not known whether high levels of HAART use have been sustained or whether socioeconomic and racial disparities have diminished over time.

OBJECTIVES

To determine the proportion of patients who had received and were receiving HAART by January 1998, and to evaluate predictors of HAART receipt.

DESIGN AND PARTICIPANTS

Prospective cohort study of a national probability sample of 2267 adults receiving HIV care who completed baseline, first follow-up, and second follow-up interviews from January 1996 to January 1998.

MAIN OUTCOME VARIABLES

Proportion currently using HAART at second follow-up (August 1997 to January 1998), contrasted with the cumulative proportions using HAART at any time before January 1998 and before December 1996.

ANALYSES

Bivariate and multiple logistic regression analysis of population characteristics predicting current use of HAART at the time of the second follow-up interview.

RESULTS

The proportion of patients ever having received HAART increased from 37% in December 1996 to 71% by January 1998, but only 53% of people were receiving HAART at the time of the second follow-up interview. Differences between sociodemographic groups in ever using HAART narrowed after 1996. In bivariate analysis, several groups remained significantly less likely to be using HAART at the time of the second follow-up interview: blacks, male and female drug users, female heterosexuals, people with less education, those uninsured and insured by Medicaid, those in the Northeast, and those with CD4 counts of >/=500 cells/microl (all p <.05). Using multiple logistic regression analysis, low CD4 count (for CD4 <50 cells/microl: odds ratio [OR], 3.20; p <.001) remained a significant predictor of current HAART use at the time of the second follow-up interview, but lack of insurance (OR, 0.71; p <.05) predicted not receiving HAART.

CONCLUSIONS

The proportion of persons under HIV care in the United States who had ever received HAART increased to over 70% of the affected population by January 1998 and the disparities in use between groups narrowed but did not disappear. However, nearly half of those eligible for HAART according to the U.S. Department of Health and Human Services guidelines were not actually receiving it nearly 2 years after these medications were first introduced. Strategies to promote the initiation and continuation of HAART are needed for those without contraindications and those who can tolerate it.