Deborah N. Pearlman

Screening mammography and constructs from the transtheoretical model: Associations using two definitions of the stages-of-adoption

The two purposes of this investigation were: (a) to examine whether an association existed between stages of adopting regular mammography and decision-making constructs from the Transtheoretical Model (TTM) of behavior change, and (b) to determine whether any such associations would be found for each of the two ways of defining the stages-of-adoption. One method integrated past screening history with a report of future intention for screening; the other method used a single item with predetermined response categories. Data were from the baseline survey of 1,323 women aged 50–74 who were recruited as part of an intervention study through a local Health Maintenance Organization. Results showed that both ways of defining stages of adopting regular mammography were associated with decisional balance and processes-of-change. The method that integrated past history plus intention provided somewhat better discrimination among stages. Women who were labeled as being at “Risk of Relapse,” and those who said they waited for a “Provider’s Recommendation,” may be useful groups to add to the set of stages that have been employed so far by the TTM. In addition, a tendency to avoid the health care system in general was used as a process-of-change to complement the mammography-specific processes.

Neighborhood Environment, Racial Position, and Risk of Police-Reported Domestic Violence: A Contextual Analysis

Objectives. The purpose of this study was to examine the contribution of neighborhood socioeconomic conditions to risk of police-reported domestic violence in relation to victims race. Data on race came from police forms legally mandated for the reporting of domestic violence and sexual assault. Methods. Using 1990 U.S. census block group data and data for the years 1996–1998 from Rhode Islands domestic violence surveillance system, the authors generated annual and relative risk of police-reported domestic violence and estimates of trends stratified by age, race (black, Hispanic, or white), and neighborhood measures of socioeconomic conditions. Race-specific linear regression models were constructed with average annual risk of police-reported domestic violence as the dependent variable. Results. Across all levels of neighborhood poverty (<5% to 100% of residents living below the federal poverty level), the risk of police-reported domestic violence was higher for Hispanic and black women than for white women. Results from the linear regression models varied by race. For black women, living in a census block group in which fewer than 10% of adults ages ≥25 years were college-educated contributed independently to risk of police-reported domestic violence. Block group measures of relative poverty (≥20% of residents living below 200% of the poverty line) and unemployment (≥10% of adults ages ≥16 years in the labor force but unemployed) did not add to this excess. For Hispanic women, three neighborhood-level measures were significant: percentage of residents living in relative poverty, percentage of residents without college degrees, and percentage of households monolingual in Spanish. A higher degree of linguistic isolation, as defined by the percentage of monolingual Spanish households, decreased risk among the most isolated block groups for Hispanic women. For white women, neighborhood-level measures of poverty, unemployment, and education were significant determinants of police-reported domestic violence. Conclusion. When data on neighborhood conditions at the block group level and their interaction with individual racial position are linked to population-based surveillance systems, domestic violence intervention and prevention efforts can be improved.

Treatment Variation by Insurance Status for Breast Cancer Patients

Abstract:  Few studies have examined the relationship of insurance status with the presentation and treatment of breast cancer. Using a state cancer registry, we compared tumor presentation and surgical treatments at presentation by insurance status (private insurance, Medicare, Medicaid, or uninsured). Student’s t‐test, Chi‐square test, and ANOVA were used for comparison. P‐values reflect a comparison to insured patients. From 1996 to 2005, there were 6876 cases of invasive breast cancer with either private (n = 3975), Medicare (n = 2592), Medicaid (n = 193), or no insurance (n = 116). The median age (years) at presentation was 55 for private, 76 for Medicare, 54 for Medicaid and 54 for uninsured. The mean and median tumor size (mm) were 18.5 and 15 for private; 20.9 and 15 for Medicare; 24.2 and 18 for Medicaid; and 29.5 and 17 for uninsured, respectively; (p < 0.001 for all). Fewer women with Medicare and Medicaid presented with node negative breast cancers: private, 73.4% node negative; Medicare, 79.5% (p < 0.001); Medicaid, 60.9% (p < 0.001); and uninsured, 58% (p = 0.005). Significantly more uninsured women had no surgical treatment of their breast cancer: 15.5% versus 4.3% for private (p < 0.001). Among women with non‐metastatic T1/T2 tumors, 71.5% with private insurance underwent breast‐conserving surgery (BCS), compared with 64.2% of Medicare (p < 0.001), 65% of Medicaid (p = 0.097), and 65.4% of uninsured (p = 0.234). The rate of reconstruction following mastectomy was higher for private insurance (36.6%), compared with Medicare (3.8%, p < 0.0001), Medicaid (26.1%, p = 0.31), and uninsured (5.0%, p = 0.0038). The presentation of breast cancer in women with no insurance and Medicaid is significantly worse than those with private insurance. Of concern are the lower proportions of BCS and reconstruction among patients who are uninsured or have Medicaid. Reduction of disparities in breast cancer presentation and treatment may be possible by increasing enrollment of uninsured, program‐eligible women in a state‐supported screening and treatment program.

Hospital readmissions for childhood asthma: the role of individual and neighborhood factors.

Objectives. This study used a Cox proportional hazards model to determine whether neighborhood characteristics are associated with risk of readmission for childhood asthma independently of individual characteristics. Methods. Rhode Island Hospital Discharge Data from 2001 to 2005 were used to identify children younger than 19 years of age at the time of the index (i.e., first) asthma admission, defined as a primary diagnosis of asthma or a primary diagnosis of respiratory illness with a secondary or tertiary diagnosis of asthma (n=2,919). Hazard ratios of repeat hospitalizations for childhood asthma from 2001 to 2005 were estimated, controlling for individual- and neighborhood-level variables. Results. During the study period, 15% of the sample was readmitted for asthma (n=451). In the unadjusted cumulative hazard curves, children residing in the census tracts with the highest proportion of crowded housing conditions, racial minority residents, or neighborhood-level poverty had higher cumulative hospital readmission rates as compared with children who resided in less disadvantaged neighborhoods. In the fully adjusted models, children insured by Medicaid at the time of their index admission had readmission rates that were 33% higher than children who were privately insured. Conclusion. Our findings suggest that differences in health-care coverage are associated with higher readmission rates for pediatric asthma, but the relationship between neighborhood inequality and repeat hospitalizations for pediatric asthma requires further exploration. Social indicators such as minority race, Medicaid health insurance, and neighborhood markers of economic disadvantage are tightly interwoven in the U.S. and teasing these relationships apart is important in asthma disparities research.

Improving surveillance of intimate partner violence by use of multiple data sources

BACKGROUND Intimate partner violence (IPV) is a significant public health problem in the United States. Estimates of incidence and prevalence vary widely, depending on the data source used. Combining information from different sources can enhance our understanding of IPV. METHODS In this paper, we used 1998 data from the Rhode Island (RI) Department of Health Violence Against Women Public Health Surveillance System to describe the prevalence of IPV reported to police, the demographic characteristics and help-seeking efforts of women reporting IPV, and characteristics of IPV incidents. We used data from the 1998 RI Department of Health Behavioral Risk Factor Surveillance System survey to examine associations between health care use and health outcomes of victims and nonvictims of IPV, and to explore the correlates of IPV. We also discuss the use of both narrow and broad definitions of IPV. RESULTS Our findings show that the definition of IPV and the source used to identify IPV victims can produce a markedly different picture of IPV victims, and that combining information from different data sources can enhance our understanding of IPV. An important finding for health care providers is that IPV victims do not appear to be significantly different from nonvictims in their access to and utilization of routine health care, and that more than 60% of victims at highest risk for injury reported seeing a health care provider because of IPV. CONCLUSIONS Our findings underscore the importance of health care providers addressing IPV and its consequences among their patients.

How Does Managed Care Manage the Frail Elderly? The Case of Hospital Readmissions in Fee-For-Service Versus HMO Systems

OBJECTIVES This study examined whether hospital readmissions varied among the frail elderly in managed care versus fee-for-service (FFS) systems. SETTING AND PARTICIPANTS Random sample of 450 patients, aged 65 and over, from a large vertically integrated health care system in San Diego, California. Participants were receiving physician-authorized home health and survived and 18-month follow-up period. MAIN OUTCOME MEASURES Multiple logistic regression analyses were used to conduct comparisons of readmissions and preventable readmissions by plan type. Two methods to identify preventable readmissions were developed, one based on a computerized algorithm of service use patterns, and another based on blind clinical review. RESULTS The odds of having a preventable hospital readmission within 90 days of an index admission were 3.51 (P = 0.06) to 5.82 (P = 0.02) times as high for Medicare HMO enrollees compared to Medicare FFS participants, depending on the method used to assess preventability. Readmission patterns were similar for Medicare HMO enrollees and FFS study participants dually enrolled in Medicare and Medicaid. CONCLUSION In this group of frail elderly Medicare beneficiaries, those enrolled in an HMO were more likely to have a preventable hospital readmission than those receiving care under FFS. These results suggest that policies promoting stringent approaches to utilization control (e.g., early hospital discharge, reduced levels of post-acute care, and restricted use of home health services) may be problematic for the frail elderly.

Domestic violence incidents with children witnesses: findings from Rhode Island surveillance data.

In this study we analyze factors associated with children witnessing police-reported domestic violence (DV) and determine the age distribution of children witnessing. Rhode Island Department of Health surveillance data (1996-1998) from police forms were used to assess demographic characteristics of victims, characteristics of incidents, whether children were present, and childrens ages. Victim gender, age, race/ethnicity, relationship to suspect, and whether the victim was assaulted were all strong predictors of children witnessing a DV incident. Almost half (48%) of the children who witnessed DV incidents were less than 6 years old. To reach these young children, prevention and intervention programs will need to target parents and caretakers of young children and/or pediatricians.

TRANSITIONS IN HEALTH CARE USE AND EXPENDITURES AMONG FRAIL OLDER ADULTS BY PAYOR/PROVIDER TYPE

OBJECTIVES: To assess whether transitions in health care expenditures differed over time by payor/provider type: Medicare fee‐for‐service (FFS), Medicaid‐Medicare, and Medicare HMO.

Stages of Adopting Regular Screening Mammography Do Women Differ in Decisional Balance Within Stages

This study examined whether distinct subgroups of women could be identified within stages of adoption for screening mammography. These subgroups may represent differential readiness to move to the next stage of the adoption continuum. Data were from a baseline survey of 1323 women between the ages of 50 and 74 years who were recruited through a staff- model HMO for an intervention study to increase rates of mammography. Multiple regression models were used to identify correlates of positive decisional balance within each of four stages of adoption, and an index of positive indicators was developed from the significant correlates for each stage. Analysis of variance showed that the number of positive indicators discriminated women within each stage. This information can be used to develop more effective tailored interventions to increase the percentage of women receiving mammograms on a regular schedule.

Association between sexual behaviors, bullying victimization and suicidal ideation in a national sample of high school students: implications of a sexual double standard.

PURPOSE The sexual double standard is the notion that women are more harshly judged for their sexual behaviors than men. The purpose of this study was to investigate if the sexual double standard could explain gender differences in bullying victimization among adolescents and the extent to which that relationship correlated with depression and suicidal ideation. METHODS Analyses were conducted using a sample of high school students (n = 13,065) from the 2011 Youth Risk Behavior Survey, a cross-sectional and national school-based survey conducted by the Centers for Disease Control and Prevention. Data were assessed using multiple logistic regression, gender-stratified analyses, and interaction terms. FINDINGS Students who engaged in sexual intercourse (sexually active) had higher odds of being bullied. When this association was stratified by gender, odds of being bullying increased for girls (odds ratio [OR], 1.83; 95% CI, 1.58-2.13) and decreased for boys (OR, 0.94; 95% CI, 0.77-1.16). Sexually active students who were bullied also displayed more than five times (OR, 5.65; 95% CI, 4.71-6.78) the adjusted odds of depression and three times (adjusted OR, 3.38; 95% CI, 2.65-4.32) the adjusted odds of suicidal ideation compared with students who reported neither of those behavioral characteristics. When stratified by gender, girls had slightly higher odds of depression and suicidal ideation but overall, the odds remained strong for both genders. CONCLUSIONS Results provide some evidence that a sexual double standard exists and may play a prominent role in bullying victimization among girls. Therefore, addressing the sexual double may be important to consider when tailoring school bullying intervention programs.