A. Eugene Washington

Objective and Subjective Assessments of SocioEconomic Status and their Relationship to Self-Rated Health in an Ethnically Diverse Sample of Pregnant Women

A new measure of subjective socioeconomic status (SES) was examined in relation to self-rated physical health in pregnant women. Except among African Americans, subjective SES was significantly related to education, household income, and occupation. Subjective SES was significantly related to self-rated health among all groups. In multiple regression analyses, subjective SES was a significant predictor of self-rated health after the effects of objective indicators were accounted for among White and Chinese American women; among African American women and Latinas, household income was the only significant predictor of self-rated health. After accounting for the effects of subjective SES on health, objective indicators made no additional contribution to explaining health among White and Chinese American women; household income continued to predict health after accounting for subjective SES among Latinas and African American women.

Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants

Wide disparities in obstetric outcomes exist between women of different race/ethnicities. The prevalence of preterm birth, fetal growth restriction, fetal demise, maternal mortality, and inadequate receipt of prenatal care all vary by maternal race/ethnicity. These disparities have their roots in maternal health behaviors, genetics, the physical and social environments, and access to and quality of health care. Elimination of the health inequities because of sociocultural differences or access to or quality of health care will require a multidisciplinary approach. We aim to describe these obstetric disparities, with an eye toward potential etiologies, thereby improving our ability to target appropriate solutions.

A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes

Abstract Objective To compare surgical complications and clinical outcomes after total versus supracervical abdominal hysterectomy for control of abnormal uterine bleeding, symptomatic uterine leiomyomata, or both. Methods We conducted a randomized intervention trial in four US clinical centers among 135 patients who had abdominal hysterectomy for symptomatic uterine leiomyomata, abnormal uterine bleeding refractory to hormonal treatment, or both. Patients were randomly assigned to receive a total or supracervical hysterectomy performed using the surgeons customary technique. Using an intention-to-treat approach, we compared surgical complications and clinical outcomes for 2 years after randomization. Results Sixty-eight participants were assigned to supracervical hysterectomy (SCH) and 67 to total abdominal hysterectomy (TAH). Hysterectomy by either technique led to statistically significant reductions in most symptoms, including pelvic pain or pressure, back pain, urinary incontinence, and voiding dysfunction. Patients randomly assigned to (SCH) tended to have more hospital readmissions than those randomized to TAH, but this difference was not statistically significant. There were no statistically significant differences in the rate of complications, degree of symptom improvement, or activity limitation. Participants weighing more than 100 kg at study entry were twice as likely to be readmitted to the hospital during the 2-year follow-up period (relative risk [RR] 2.18, 95% confidence interval [CI] 1.06, 4.48, P = .034). Conclusion We found no statistically significant differences between (SCH) and TAH in surgical complications and clinical outcomes during 2 years of follow-up.

Procedure-related miscarriages and Down syndrome-affected births: implications for prenatal testing based on women's preferences.

Objective To determine how pregnant women of varying ages, races, ethnicities, and socioeconomic backgrounds value procedure-related miscarriage and Down–syndrome-affected birth. Methods We studied cross-sectionally 534 sociodemographically diverse pregnant women who sought care at obstetric clinics and practices throughout the San Francisco Bay area. Preferences for procedure-related miscarriage and the birth of an infant affected by Down syndrome were assessed using the time trade-off and standard gamble metrics. Because current guidelines assume that procedure-related miscarriage and Down syndrome–affected birth are valued equally, we calculated the difference in preference scores for those two outcomes. We also collected detailed information on demographics, attitudes, and beliefs. Results On average, procedure-related miscarriage was preferable to Down syndrome–affected birth, as evidenced by positive differences in preference scores for them (time trade-off difference: mean = 0.09, median = 0.06; standard gamble difference: mean = 0.11, median = 0.02; P < .001 for both, one-sample sign test). There was substantial subject-to-subject variation in preferences that correlated strongly with attitudes about miscarriage, Down syndrome, and diagnostic testing. Conclusion Pregnant women tend to find the prospect of a Down syndrome–affected birth more burdensome than a procedure-related miscarriage, calling into question the equal risk threshold for prenatal diagnosis. Individual preferences for those outcomes varied profoundly. Current guidelines do not appropriately consider individual preferences in lower-risk women, and the process for developing prenatal testing guidelines should be reconsidered to better reflect individual values.

Beyond race or ethnicity and socioeconomic status : Predictors of prenatal testing for down syndrome

OBJECTIVE: To identify predictors of prenatal genetic testing decisions and explore whether racial or ethnic and socioeconomic differences are explained by knowledge, attitudes, and preferences. METHODS: This was a prospective cohort study of 827 English-, Spanish-, or Chinese-speaking pregnant women presenting for care by 20 weeks of gestation at 1 of 23 San Francisco Bay–area obstetrics clinics and practices. Our primary outcome measure for women aged less than 35 years was any prenatal genetic testing use compared with none, and for women aged 35 years or older, prenatal testing strategy (no testing, screening test first, straight to invasive diagnostic testing). Baseline questionnaires were completed before any prenatal test use; test use was assessed after 30 gestational weeks. RESULTS: Among women aged less than 35 years, no racial or ethnic differences in test use emerged. Multivariable analyses yielded three testing predictors: prenatal care site (P = .024), inclination to terminate pregnancy of a Down-syndrome–affected fetus (odds ratio 2.94, P = .002) and belief that modern medicine interferes too much in pregnancy (odds ratio .85, P = .036). Among women aged 35 years or older, observed racial or ethnic and socioeconomic differences in testing strategy were mediated by faith and fatalism, value of testing information, and perceived miscarriage risk. Multivariable predictors of testing strategy included these 3 mediators (P = .035, P < .001, P = .037, respectively) and health care system distrust (P = .045). A total of 29.5% of screen-positive women declined amniocentesis; 6.6% of women screening negative underwent amniocentesis. CONCLUSION: Racial or ethnic and socioeconomic differences in prenatal testing strategy are mediated by risk perception and attitudes. Screening is not the best choice for many women. Optimal prenatal testing counseling requires clarification of risks and consideration of key attitudes and preferences regarding the possible sequence of events after testing decisions. LEVEL OF EVIDENCE: II-2

Sexual functioning after total compared with supracervical hysterectomy: a randomized trial.

OBJECTIVE: To compare sexual functioning and health-related quality-of-life outcomes of total abdominal hysterectomy (TAH) and supracervical hysterectomy (SCH) among women with symptomatic uterine leiomyomata or abnormal uterine bleeding refractory to hormonal management. METHODS: We randomly assigned 135 women scheduled to undergo abdominal hysterectomy in 4 U.S. clinical centers to either a total or supracervical procedure. The primary outcome was sexual functioning at 2 years, as assessed by the Medical Outcomes Study Sexual Problems Scale. Secondary outcomes included specific aspects of sexual functioning and health-related quality-of-life at 6 months and 2 years. RESULTS: Sexual problems improved dramatically in both randomized groups during the first 6 months and plateaued by 1 year. Health-related quality-of-life scores also improved in both groups. At 2 years, both groups reported few problems with sexual functioning (mean score on the Sexual Problems Scale for SCH group 82, TAH group 80, on a 0-to-100 scale with 100 indicating an absence of problems; difference = +2, 95% confidence interval –8 to + 11), and there were no significant differences between groups. CONCLUSION: Supracervical and total abdominal hysterectomy result in similar sexual functioning and health-related quality of life during 2 years of follow-up. This information can help guide physicians as they discuss surgical options with their patients. LEVEL OF EVIDENCE: I

Racial and ethnic disparities in benign gynecologic conditions and associated surgeries.

Common gynecologic conditions and surgeries may vary significantly by race or ethnicity. Uterine fibroid tumors are more prevalent in black women, and black women may have larger, more numerous fibroid tumors that cause worse symptoms and greater myomectomy complications. Some, but not all, studies have found a higher prevalence of endometriosis among Asian women. Race and ethnicity are also associated with hysterectomy rate, route, and complications. Overall, the current literature has significant deficits in the identification of racial and ethnic disparities in the incidence of fibroid tumors, endometriosis, and hysterectomy. Further research is needed to better define racial and ethnic differences in these conditions and to examine the complex mechanisms that may result in associated health disparities.

Frequency of cervical smear abnormalities within 3 years of normal cytology.

Abstract Objective: To compare cervical screening outcomes associated with age and three screening intervals, 1, 2, and 3 years. Methods: We did a prospective cohort study comprising 128,805 women at community-based clinics throughout the United States who were screened for cervical cancer within 3 years of normal smears through the National Breast and Cervical Cancer Early Detection Program. We determined the incidence of cytologic abnormalities defined as atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (SIL), high-grade SIL, and suggestive of squamous cell cancer. Results: Over the 3 years after normal smear results, the incidence of new smears interpreted as high-grade SIL or suggestive of squamous cell cancer (high-grade SIL or worse) was 66 of 10,000 for women under 30 years old, 22 of 10,000 for those 30–49 years, 15 of 10,000 for those 50–64 years, and 10 of 10,000 for those over 65 years. Age-adjusted incidence rates of high-grade SIL or worse were similar for women screened at 9–12 months (25 of 10,000), 13–24 months (29 of 10,000), and 25–36 months (33 of 10,000) after normal smears ( P = .46). Age-adjusted incidence rates of ASCUS, the most common cytologic abnormality, did not change ( P = .36). Incidence of smears interpreted as low-grade SIL increased as time from the normal smear increased ( P = .01). Conclusions: Within 3 years after normal cytology results, cervical smears interpreted as high-grade SIL or worse are uncommon, and the incidence rate is unrelated to the time since last normal smear. Optimal screening strategies for women with recent normal cytology results should be based on comprehensive modeling studies that incorporate the true risks and benefits of repetitive screening.

Pelvic inflammatory disease and its sequelae in adolescents

Pelvic Inflammatory Disease (PID) is the most common serious complication of sexually transmitted diseases (STDs). Each year over one million women in the United States experience an episode of PID, with approximately 16-20% of cases occurring in teenagers. Acute PID increases a womans risk for recurrent PID, chronic pelvic pain, infertility, and ectopic pregnancy. Recent reports indicating that PID rates are rising and are highest among adolescent females aged 15-19 underscore the need to remain current on the clinical as well as the epidemiologic aspects of PID. We present such an update in this article. Trends in incidence and key risk factors are discussed; besides adolescence itself and STD, other important categories of risk factors include sexual activity, contraceptive method, and previous episode(s) of PID. The polymicrobial nature of PID is discussed along with an analysis of the role of specific organisms, such as Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobic and aerobic bacteria, and mycoplasmas in PID. Early diagnosis and the institution of appropriate treatment regimens are essential to the prevention of PIDs devastating sequelae. Clinicians must maintain a high index of suspicion for the wide range of clinical presentations associated with PID and be prepared to provide effective management, including proper evaluation and prompt treatment of sexual partners.

Can Preference Scores for Discrete States Be Used to Derive. Preference Scores for an Entire Path of Events? An Application to Prenatal Diagnosis

The authors conducted a study exploring whether preferences for sequences of events can be approximated by preferences for component discrete states. Visual-analog- scale (VAS) and standard-gamble (SG) scores for a subset of the possible sequences of events (path states) and component temporary and chronic outcomes (discrete states) that can follow prenatal diagnostic decisions were elicited from 121 pregnant women facing a choice between chorionic villus sampling and amniocentesis. For in dividuals, preference scores for path states could not be predicted easily from discrete- state scores. Mean path-state VAS scores, however, were predicted reasonably ac curately by multiple regression models (R2 = 0.85 and 0.82 for two different anchoring schemes), with most measured scores lying within the 95% confidence intervals of the derived scores. It is concluded that, for individual patient decision making, preferences for path states should be elicited. When mean preference values for a population are sought, however, it may be reasonable to derive regression weights from a subset of respondents and then to apply those weights to preferences for discrete states elicited from a larger group. Key words: utility measurement; patient preferences; multiple re gression ; standard gamble; visual analog scaling; prenatal diagnosis. (Med Decis Mak ing 1997;17:42-55))