Barbara Leake

The UCLA Prostate Cancer Index: development, reliability, and validity of a health-related quality of life measure.

OBJECTIVES The need for accurate measures of health-related quality of life (HRQOL) in men treated for prostate cancer is of paramount importance because patients may survive for many years after their diagnosis. Hence, interest has increased in choosing treatments that optimize both the quality and quantity of life in patients with this disease. This study sought to develop and evaluate a self-administered, multiitem, disease-specific instrument to capture the health concerns central to the quality of life of men treated for early stage prostate cancer. METHODS After focus group analysis and pilot testing, the instrument was tested with a large retrospective, cross-sectional survey. Exploratory factor analysis and multitrait scaling analysis were used to facilitate the formation of six scales containing 20 disease-targeted items that address impairment in the urinary, bowel, and sexual domains. The psychometric properties of the new scales were assessed by measuring test-retest reliability, internal consistency reliability, and construct validity. Performance on the new scales was compared with scores on other established cancer-related health-related quality of life instruments. Two hundred fifty-five long-term survivors of prostate cancer treatment and 273 age-matched and ZIP code-matched comparison subjects without prostate cancer from a large managed care population in California were studied. Mean age was 72.7 years. In addition to the new scales, the RAND 36-Item Health Survey (SF-36) was used as a generic core measure, and a cancer-related health-related quality of life instrument (the Cancer Rehabilitation System-Short Form) was used to provide construct validity. RESULTS For the new scales, test-retest reliability ranged from 0.66 to 0.93, and internal consistency ranged from 0.65 to 0.93. Disease-targeted measures of function and bother in the three domains correlated substantially with one another. Scale scores correlated well with related, established scales. Men undergoing prostatectomy or pelvic irradiation demonstrated the expected differences in performance on the disease-specific health-related quality of life scales when compared with each other or with comparison subjects. Age was inversely related to sexual and bowel function. CONCLUSIONS The UCLA Prostate Cancer Index performed well in this population of older men with and without prostate cancer. It demonstrated good psychometric properties and appeared to be well understood and easily completed. The high response among patients suggests that these men especially are interested in addressing both the general and disease-specific concerns that impact their daily quality of life.

Agreement between face-to-face and telephone-administered versions of the depression section of the NIMH diagnostic interview schedule

To increase the feasibility of identifying persons with depressive disorders in a large-scale health policy study, we tested the concordance between face-to-face and telephone-administered versions of the depression section of the NIMH Diagnostic Interview Schedule (DIS). This section was administered over the telephone to 230 English-speaking participants of the Los Angeles site of the NIMH Epidemiologic Catchment Area Program (ECA) after their completion of a face-to-face interview (Wave II) with the full DIS. Time lag between interviews was 3 months, on the average. Persons with depressive symptoms were oversampled. Using the face-to-face version as the criterion measure, the sensitivity, specificity, and positive predictive value of the telephone version for identifying the presence or absence of any lifetime unipolar depressive disorder were 71, 89, and 63 percent, respectively; the kappa statistic was 0.57, and agreement was unbiased. The comparable figures for concordance between two face-to-face interviews administered one year apart to the same subjects were 54, 89, and 60 percent and 0.45 (kappa), respectively. Thus, disagreement was due primarily to test-retest unreliability of the DIS rather than the method of administration.

Internal medicine patients’ expectations for care during office visits

AbstractObjective: To describe internal medicine patients’ expectations for care during office visits and to examine the relationship between fulfillment of expectations for care and visit satisfaction. Design: Survey of patients and their physicians. Setting: The internal medicine practice of faculty and housestaff at a large academic center in Southern California. Patients: 396 patients aged 18 to 65 years were approached in the clinic waiting room prior to their scheduled visits; 337 (85% ) agreed to participate and 304 (77%) turned in completed questionnaires. Postvisit physician surveys were received in 88% of the cases. Main measurements: The patients’ previsit reports of the elements of care they thought necessary for their physicians to provide; the patients’ and physicians’ postvisit reports of the elements of care actually provided; and the patients’ satisfaction with care. Results: Among 28 specific elements of care, seven were considered necessary by a majority of the patients (examination of the eyes/ears/nose/throat, lungs, heart, and abdomen; blood testing; prognostic counseling; and discussion of patients’ own ideas about management). A higher number of elements of care were thought necessary by patients who were nonwhite and had not completed college. Up to 38% of the patients reported not receiving elements of care they had considered necessary; specific agreement between physicians and patients about care not received ranged from 63% to 100%. Not receiving certain “necessary” elements of care was associated with lower visit satisfaction. Conclusion: Internal medicine patients at the center studied had specific expectations for the content of their physician visits. However, they routinely failed to receive some of the items they thought necessary. Unless patients’ expectations are carefully elicited and dealt with, the physician-patient relationship may be adversely affected.

AIDS-related knowledge, perceptions, and behaviors among impoverished minority women.

OBJECTIVES The aims of this study were to (1) describe AIDS-related knowledge, perceptions, and risky behaviors of impoverished African-American and high- and low-acculturated Latina women; (2) delineate relationships involving high-risk behaviors; and (3) determine whether risky behaviors differ by race and levels of acculturation. METHODS Survey instruments were administered to 1173 impoverished women of color residing in homeless shelters and drug recovery programs. RESULTS Differences based on ethnicity and level of acculturation were found in AIDS-related knowledge, perceived risk of acquiring AIDS, and risky behaviors. Low-acculturated Latinas reported low perceived risk and were least likely to engage in illegal drug use and sexual activity with multiple partners. Intravenous drug use was most prevalent among high-acculturated Latinas, whereas nonintravenous drug use and high-risk sexual activity was most prevalent among African-American women. CONCLUSIONS The data indicate the need for culturally sensitive AIDS prevention programs for women that deal with general issues of drug use and unprotected sex, and that include separate sessions for women of different ethnic backgrounds and acculturation levels to address specialized areas of concern.

Racial and ethnic disparities in the use of cardiovascular procedures: associations with type of health insurance.

OBJECTIVES This study examined whether disparities in the use of cardiovascular procedures exist among African Americans, Latinos, and Asians relative to White patients, within health insurance categories. METHODS Hospital discharge records (n = 104,952) of Los Angeles Country, California, residents with possible coronary artery disease were analyzed. RESULTS After adjustment for confounders, lower odds of procedure use were found for African American and Latino patients for most types of insurance. Asians and Pacific Islanders had odds of procedure use similar to those of White patients. Disparities were absent among the privately insured. CONCLUSIONS Racial and ethnic disparities in procedure rates were evident in all types of insurance except private insurance.

Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988.

OBJECTIVES The purpose of the study was to compare use of invasive cardiovascular procedures among Latino, Asian, African-American, and White patients. METHODS In a cross-sectional study of hospital discharge data, multiple logistic regression was used to model use of coronary artery angiography, bypass graft surgery, and angioplasty among adult Los Angeles County residents discharged from California hospitals between 1986 and 1988 with primary diagnoses consistent with possible ischemic heart disease. RESULTS After potential demographic, socioeconomic, and clinical confounders, including hospital procedure volume, were controlled, Latinos were less likely than Whites to undergo angiography (odds ratio [OR] = 0.90) and bypass graft surgery (OR = 0.87). African Americans were less likely to receive bypass graft surgery (OR = 0.62) and angioplasty (OR = 0.80). Asians were as likely as Whites to receive each procedure. The impact of adjustment for hospital procedure volume was greater for Latinos and Asians than for African Americans. CONCLUSIONS Administrative data suggest that disparities in use of invasive cardiovascular procedures are not limited to African Americans. Hospital procedure volume appears to be an important factor related to such disparities. The causes of racial/ethnic differences in reported procedure rates remain unclear.

Risk factors for hepatitis C virus infection among homeless adults

OBJECTIVE: To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use.DESIGN: Assays were conducted on stored sera. Socio-demographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay.SETTINGS: Shelters (N=36) and outdoor locations in Los Angeles.PARTICIPANTS: Eight hundred eighty-four homeless women and/or partners or friends.RESULTS: Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for socio-demographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one’s own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users.CONCLUSIONS: Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.

The practices of general and subspecialty internists in counseling about smoking and exercise

We compared the practices of subspecialists and general internists in counseling about smoking and exercise, using data from a study of recent graduates of United States training programs in internal medicine. Information on the characteristics of physicians and their clinical practices was obtained from self-report questionnaires. The internists most likely to counsel smokers regardless of the presence or absence of diseases associated with smoking are cardiologists, pulmonary specialists, nephrologists, and generalists trained in a primary care residency funded by the Robert Wood Johnson Foundation or Health Resources Administration. Most internists practice tertiary prevention by counseling a high percentage of smokers with heart or lung disease. Rheumatologists counsel a higher percentage of all patients with poor exercise habits but a lower percentage of such patients with heart disease than do other internists. The differences in counseling related to training are not explained by different levels of involvement as a primary care physician. Rather, these differences appear to reflect training and subspecialty-specific priorities for counseling.

Predictors of mortality in older patients following medical intensive care: the importance of functional status.

Objective: We examined predictors of hospital and 6‐month mortality in older Medical Intensive Care Unit (MICU) patients with particular attention to age and functional status. Age is generally thought to be strongly associated with intensive care outcomes, but this relationship may be confounded by age‐related changes. These age‐related changes may be approximated by changes in functional status (FS).

Impoverished diabetic patients whose doctors facilitate their participation in medical decision making are more satisfied with their care.

OBJECTIVE: Greater participation in medical decision making is generally advocated for patients, and often advocated for those with diabetes. Although some studies suggest that diabetic patients prefer to participate less in decision making than do healthy patients, the empirical relationship between such participation and diabetic patients’ satisfaction with their care is currently unknown. We sought to characterize the relationship between aspects of diabetic patients’ participation in medical decision making and their satisfaction with care.DESIGN: Cross-sectional observational study.SETTING: A general medical county hospital-affiliated clinic.PARTICIPANTS: One hundred ninety-eight patients with type 2 diabetes.MAIN MEASURES: Interviews conducted prior to the doctor visit assessed patients’ desire to participate in medical decision making, baseline satisfaction (using a standardized measure), and sociodemographic and clinical characteristics. Postvisit interviews of those patients assessed their visit satisfaction and perception of their doctor’s facilitation of patient involvement in care. A discrepancy score was computed for each subject to reflect the difference between the previsit stated desire regarding participation and the postvisit report of their experience of participation.RESULTS: Overall, patients reported low postvisit satisfaction relative to national standards (mean of 70 on a 98-point scale). Patients perceived a high level of facilitation of participation (mean 88 on a 100-point scale). Facilitation of participation and the discrepancy score both independently predicted greater visit satisfaction. In particular, a 13-point (1 SD) increase in the perceived facilitation score resulted in a 12-point (0.87 SD) increase in patient satisfaction, and a 1.22 point increase (1 SD) in the discrepancy score (the extent to which the patient was allowed more participation than, at previsit, he or she desired) resulted in a 6-point (0.5 SD) increase in the satisfaction score, even after controlling for initial desire to participate. For women, but not for men, physician facilitation of participation was a positive predictor of satisfaction; for men, but not women, desire to participate was a significant positive predictor of visit satisfaction.CONCLUSION: Clinicians may feel reassured that encouraging even initially reluctant patients with diabetes to participate in medical decision making may be associated with increased patient satisfaction. Greater patient participation has the potential to improve diabetic self-care because of the likely positive effect of patient satisfaction on adherence to treatment. Further research to assess the prospective effects of enhancing physician facilitation of patient participation is likely to yield important information for the effective treatment of chronically ill patients.