Daniel L. Howard

Racial differences in PSA screening interval and stage at diagnosis.

ObjectivesThis study examined PSA screening interval of black and white men aged 65 or older and its association with prostate cancer stage at diagnosis.MethodsSEER-Medicare data were examined for 18,067 black and white men diagnosed with prostate cancer between 1994 and 2002. Logistic regression was used to assess the association between race, PSA screening interval, and stage at diagnosis. Analysis also controlled for age, marital status, comorbidity, diagnosis year, geographic region, income, and receipt of surgery.ResultsCompared to whites, blacks diagnosed with prostate cancer were more likely to have had a longer PSA screening interval prior to diagnosis, including a greater likelihood of no pre-diagnosis use of PSA screening. Controlling for PSA screening interval was associated with a reduction in blacks’ relative odds of being diagnosed with advanced (stage III or IV) prostate cancer, to a point that the stage at diagnosis was not statistically different from that of whites (OR=1.12, 95% CI=0.98–1.29). Longer intra-PSA intervals were systematically associated with greater odds of diagnosis with advanced disease.ConclusionsMore frequent or systematic PSA screening may be a pathway to reducing racial differences in prostate cancer stage at diagnosis, and, by extension, mortality.

Distribution of African Americans in residential care/assisted living and nursing homes: More evidence of racial disparity?

OBJECTIVES In this study, we examined racial separation in long-term care. METHODS We used a survey of a stratified sample of 181 residential care/assisted living (RC/AL) facilities and 39 nursing homes in 4 states. RESULTS Most African Americans resided in nursing homes and smaller RC/AL facilities and tended to be concentrated in a few predominantly African American facilities, whereas the vast majority of Whites resided in predominantly White facilities. Facilities housing African Americans tended to be located in rural, nonpoor, African American communities, to admit individuals with mental retardation and difficulty in ambulating, and to have lower ratings of cleanliness/maintenance and lighting. CONCLUSIONS These racial disparities may result from economic factors, exclusionary practices, or resident choice. Whether separation relates to inequities in care is undetermined.

Developing effective interuniversity partnerships and community-based research to address health disparities.

Health disparities are an enormous challenge to American society. Addressing these disparities is a priority for U.S. society and especially for institutions of higher learning, with their threefold mission of education, service, and research. Collaboration across multiple intellectual disciplines will be critical as universities address health disparities. In addition, universities must collaborate with communities, with state partners, and with each other. Development of these collaborations must be sensitive to the history and unique characteristics of each academic institution and population. The authors describe the challenges of all three types of collaboration, but primarily focus on collaboration between research-intensive universities and historically black colleges and universities. The authors describe a four-year collaboration between Shaw University and the University of North Carolina at Chapel Hill (UNC-CH). These universities strategically developed multiple research initiatives to address health disparities, building on modest early success and personal relationships. These activities included participation by Shaw faculty in faculty development activities, multiple collaborative pilot studies, and joint participation in securing grants from the Agency for Health care Research and Quality of the federal Department of Health and Human Services and the National Institutes of Health, including a P-60 Project EXPORT center grant. These multiple activities were sometimes led by UNC-CH, sometimes by Shaw University. Open discussion of problems as they arose, realistic expectations, and mutual recognition of the strengths of each institution and its faculty have been critical in achieving successful collaboration to date.

Patterns in Prostate-Specific Antigen Test Use and Digital Rectal Examinations in the Behavioral Risk Factor Surveillance System, 2002-2006

BACKGROUND Studies have examined prostate-specific antigen (PSA) test and digital rectal examination (DRE) use among men; however, few have examined use of these procedures together over time. This study examined use of the PSA test and DRE among men over time and identified correlates associated with test use for the PSA test only, the DRE only, and both procedures combined. METHODS The Behavioral Risk Factor Surveillance System (BRFSS) collected information on prostate cancer test use among 229,574 men aged 40 or older over 3 years (2002, 2004, and 2006). Patterns of PSA test and DRE use were examined overall and by selected demographic and health-related characteristics. Correlates of recent PSA test and DRE use were determined using logistic regression. RESULTS Overall trends for years 2002-2006 were a significant increase for PSA use only and a significant decrease of PSA and DRE use combined. Having had a recent PSA test (within 2 years) only; a recent DRE only; or both tests varied by sociodemographic and health-related variables, including age, race/ethnicity, marital status, levels of education and income, body mass index, health insurance status, and having a personal doctor or health care provider. CONCLUSION Although major organizations are not in agreement about the efficacy of prostate cancer screening, the PSA test and DRE continue to be utilized regularly by a majority of American men over age 40. PSA test and DRE use in this population provide a basis for addressing issues related to screening.

Physician-Patient Racial Concordance, Continuity of Care, and Patterns of Care for Hypertension

To assess the effects of physician-patient racial concordance and continuity of care on hypertension outcomes, we described patterns of care for hypertension; we used cross-tabulations and repeated measures (generalized estimating equations) analyses with panel survey data from elderly persons interviewed and examined in 1987 and 1990. Continuity of care was associated with recognition of hypertension, receipt of medication, and lower incidence of undetected hypertension. Physician race had little effect, but continuity is important for successful management of hypertension in older persons.

Culturally competent treatment of African American clients among a national sample of outpatient substance abuse treatment units

This study measures the level of cultural competency with respect to African American clients that exists among a national sample of outpatient substance abuse treatment (OSAT) units and determines the relationship of cultural competency to various characteristics of these units and their clients. The study utilizes cross-sectional data from the 1995 National Drug Abuse Treatment System Survey (NDATSS). The sample for NDATSS was randomly selected from a comprehensive list of OSAT programs compiled by the Institute for Social Research at the University of Michigan in 1994. Of the nationally representative, stratified sample of 699 units, 618 (88%) participated. Spearman correlation, analysis of variance, Behrens-Fisher t-tests, and chi-square were used for bivariate comparisons. Culturally competent units are typically public, federal-funded organizations. Staffs of culturally competent units are typically college-educated with specialized treatment certification. High severity of illness as well as increased social distresses is pervasive among the clients of culturally competent units. Consideration of this client profile may be a key determinant in evaluating the effectiveness of cultural competency for African American substance abusers.

The effect of hospital and surgeon volume on racial differences in recurrence-free survival after radical prostatectomy.

Objective:This study investigates associations between hospital and surgeon volume, and racial differences in recurrence after surgery for prostate cancer. Methods:Data from the 1991 to 2002 Surveillance, Epidemiology, and End-Results-Medicare database were examined for 962 black and 7387 white men who received surgery for prostate cancer within 6 months of diagnosis during 1993–1999. Cox regression models were used to estimate the relationships between volume (grouped in tertiles), recurrence or death, and race, controlling for age, Gleason grade, and comorbidity score. Results:Prostate cancer recurrence-free survival rates improved with hospital and surgical volume. Black men were more likely to experience recurrence than white men [hazard ratio (HR) = 1.34; 95% confidence interval (CI): 1.20–1.50]. Stratification by hospital volume revealed that racial differences persisted for medium and high volume hospitals, even after covariate adjustments (medium HR = 1.30, 95% CI: 1.04–1.61; high HR = 1.36, 95% CI: 1.07–1.73). Racial differences persisted within medium and high levels of surgeon volume as well (medium HR = 1.43, 95% CI: 1.10–1.85; high HR = 1.57, 95% CI: 1.14–2.16). Conclusions:High hospital and physician volumes were not associated with reduced racial differences in recurrence-free survival after prostate cancer surgery, contrary to expectation. This study suggests that social and behavioral characteristics, and some aspects of access, may play a larger role than organizational or systemic characteristics with regard to recurrence-free survival for this population.

Racially Disproportionate Admission Rates for Ambulatory Care Sensitive Conditions in North Carolina

Objective. This study examines race variations in quality of care through the proxy of ambulatory care sensitive (ACS) conditions. Hospital admission rates for eight ACS conditions were examined for African American and white Medicare beneficiaries in North Carolina. Temporal variations for ACS were also examined. Method. Enrollment and inpatient claims files from the Centers for Medicare and Medicaid Services (CMS) for a 1999–2002 cohort who were aged 65 years or older in 1999 were examined. Descriptive statistics were computed for each year. Cochran-Mantel Haenszel tests were performed to assess differences in the admission rates for both individual and aggregate ACS conditions controlling for time. The Cochran-Armitage test for trend was used to evaluate changes in admission rates over time. Results. African Americans had higher admission rates for five of the eight ACS conditions. The highest rates were for diabetes among African Americans (odds ratio [OR]=2.86; 95% confidence interval [CI] [2.73, 2.99]) and adult asthma (OR=1.51; 95% CI [1.43, 1.61]). African Americans tended to have lower ACS admission rates than white patients for chronic obstructive pulmonary disease (OR=0.67; 95% CI [0.65, 0.69]); bacterial pneumonia (OR=0.86; 95% CI [0.84, 0.89]), and angina (OR=0.90; 95% CI [0.84, 0.97]). Conclusions. Using the ACS proxy for quality of health care as applied to examining race and ethnicity is a promising approach, though challenges remain. Admissions for ACS conditions between African American and white patients differ, but it is unclear why. This exploratory study must lead to an examination of social, economic, historical, and cultural factors for preventive, remedial, and beneficial policy initiatives.

Physician-Patient Racial Matching, Effectiveness of Care, Use of Services, and Patient Satisfaction:

The authors examined how racial matching between older patients and physicians relates to effectiveness of care, use of services, and satisfaction with care. In this cross-sectional, community-based cohort study, 2,867 elderly African American and White North Carolina residents with regular physicians were interviewed and screened for hypertension (HBP). African Americans were more likely than Whites to be told they had HBP, to receive HBP medication, and to take it regardless of their physician’s race. White elders with African American physicians were more likely to report that they delayed care quite often. African American elders were less likely to delay care quite often, regardless of their physicians’ race. These results did not support the position that African Americans require treatment by African American physicians to achieve better care. Although elders of both races who had African American physicians were less satisfied with care received, interpretation of this finding is difficult without better measurement of patient satisfaction.

Gunshot victims at a major level i trauma center: a study of 343,866 emergency department visits

BACKGROUND Disturbing trends regarding the sex, age, and race of gunshot victims have been reported in previous national studies; however, gunshot trends have not been well documented in individual cities in the southeastern United States. OBJECTIVES 1) Analyze trends in gunshot wounds, particularly the association between gunshot wounds and race, among victims presenting to a Level I Trauma Center in Middle Tennessee; 2) Compare specific characteristics of gunshot victims to the general Emergency Department (ED) population. METHODS This is a retrospective cohort study of 343,866 ED visits from 2004 to 2009. RESULTS Compared to the general ED population, gunshot victims were more predominantly male (87.5% vs. 43.4%), black (57.6% vs. 29.5%), younger (47.8% under age 25 years vs. 31.6%), and demonstrated higher Medicaid enrollment (78.6% vs. 44.7%). The majority of black gunshot victims were aged 18-25 years (47.1%) and victims of assault (65.9%). Non-black gunshot victims suffered more unintentional (40.2% vs. 28.2%) and self-inflicted (9.1% vs. 0.4%) injuries and were more evenly distributed among ages 18-55 years. Black patients were 3.03 (95% confidence interval 2.93-3.14) times more likely to present to this ED for gunshot wounds than non-black patients, after controlling for age, sex, and insurance status (p < 0.001). CONCLUSIONS Our study demonstrates that black patients between 18 and 25 years of age presenting to this trauma center are more likely to be victims of gun violence than their non-black counterparts. Our study evaluates trends in gun violence in the Southeast, particularly in relation to race, age, and insurance status.