Kevin C. Heslin

The role of medical education in reducing health care disparities : The first ten years of the UCLA/drew medical education program

BACKGROUNDThe University of California, Los Angeles (UCLA)/Charles R. Drew University Medical Education Program was developed to train physicians for practice in underserved areas. The UCLA/Drew Medical Education Program students receive basic science instruction at UCLA and complete their required clinical rotations in South Los Angeles, an impoverished urban community. We have previously shown that, in comparison to their UCLA counterparts, students in the Drew program had greater odds of maintaining their commitment to medically disadvantaged populations over the course of medical education.OBJECTIVETo examine the independent association of graduation from the UCLA/Drew program with subsequent choice of physician practice location. We hypothesized that participation in the UCLA/Drew program predicts future practice in medically disadvantaged areas, controlling for student demographics such as race/ethnicity and gender, indicators of socioeconomic status, and specialty choice.DESIGNRetrospective cohort study.PARTICIPANTSGraduates (1,071) of the UCLA School of Medicine and the UCLA/Drew Medical Education Program from 1985–1995, practicing in California in 2003 based on the address listed in the American Medical Association (AMA) Physician Masterfile.MEASUREMENTSPhysician address was geocoded to a California Medical Service Study Area (MSSA). A medically disadvantaged community was defined as meeting any one of the following criteria: (a) federally designated HPSA or MUA; (b) rural area; (c) high minority area; or (d) high poverty area.RESULTSFifty-three percent of UCLA/Drew graduates are located in medically disadvantaged areas, in contrast to 26.1% of UCLA graduates. In multivariate analyses, underrepresented minority race/ethnicity (OR: 1.57; 95% CI: 1.10–2.25) and participation in the Drew program (OR: 2.47; 95% CI: 1.59–3.83) were independent predictors of future practice in disadvantaged areas.CONCLUSIONSPhysicians who graduated from the UCLA/Drew Medical Education Program have higher odds of practicing in underserved areas than those who completed the traditional UCLA curriculum, even after controlling for other factors such as race/ethnicity. The association between participation in the UCLA/Drew Medical Education Program and physician practice location suggests that medical education programs may reinforce student goals to practice in disadvantaged communities.

Impact of the University of California, Los Angeles/Charles R. Drew University Medical Education Program on medical students' intentions to practice in underserved areas.

Purpose To estimate the impact of a U.S. inner-city medical education program on medical school graduates’ intentions to practice in underserved communities. Method The authors conducted an analysis of secondary data on 1,088 medical students who graduated from either the joint University of California, Los Angeles/Charles R. Drew University Medical Education Program (UCLA/Drew) or the UCLA School of Medicine between 1996 and 2002. Intention to practice in underserved communities was measured using students’ responses to questionnaires administered at matriculation and graduation for program improvement by the Association of American Medical Colleges. Multivariate logistic regression analysis was used to compare the odds of intending to practice in underserved communities among UCLA/Drew students with those of their counterparts in the UCLA School of Medicine. Results Compared with students in the UCLA School of Medicine, UCLA/Drew students had greater adjusted odds of reporting intention to work in underserved communities at graduation, greater odds of maintaining or increasing such intentions between matriculation and graduation, and lower odds of decreased intention to work in underserved communities between matriculation and graduation. Conclusions Training in the UCLA/Drew program was independently associated with intention to practice medicine in underserved communities, suggesting that a medical education program can have a positive effect on students’ goals to practice in underserved areas.

Associations of self-reported oral health with physical and mental health in a nationally representative sample of HIV persons receiving medical care

Background: The impact of oral health on HIV patients has not been sufficiently documented. Objective: To estimate the associations between measures of oral and generic health-related quality of life in persons receiving medical care for HIV. Design: This is a longitudinal study of interview data collected in a probability sample of adults with HIV receiving health care in the US. The data were collected at three points in time. Patients: Two thousand eight hundred and sixty-four HIV-infected adults using medical care. Measurements: Physical and mental health were assessed using 28 items and oral health was assessed using seven items on oral-related pain and discomfort, worry, appearance, and function. Clinical measures included CD4 count, oral symptoms, physical symptoms, and stage of HIV. Physical functioning and emotional well-being were measured on a 0–100 scale with higher scores indicating better health. Oral health was measured using seven items with a five point scale. Results: In multivariate analyses, oral symptoms had the strongest association with oral health-related quality of life. Each additional oral symptom was associated with an average decrease in oral health (0–100 possible range) of 3.97 points (p = 0.000). In addition, oral health was significantly associated with both physical and mental health. A one-point increase in oral health was associated with a 0.05 (p = 0.000) increase in mental health and 0.02 increase in physical health (p = 0.031). Conclusions: Oral health is strongly associated with physical and mental health but provides noteworthy unique information in persons with HIV infection. Thus, physical and mental health measures of HIV patients should incorporate indicators of oral functioning and well-being.

Economic Evaluation of Four Treatments for Low-back Pain: Results From a Randomized Controlled Trial

Objective:We sought to compare total outpatient costs of 4 common treatments for low-back pain (LBP) at 18-months follow-up. Methods:Our work reports on findings from a randomized controlled trial within a large medical group practice treating HMO patients. Patients (n = 681) were assigned to 1 of 4 treatment groups, ie, medical care only (MD), medical care with physical therapy (MDPt), chiropractic care only (DC), or chiropractic care with physical modalities (DCPm). Total outpatient costs, excluding pharmaceuticals, were measured at 18 months. We did not perform a cost-effectiveness analysis because previously published findings showed no clinically meaningful difference in outcomes among the 4 treatment groups. Thirty-seven participants were lost to follow-up at 18 months, leaving a final sample size of n = 654. Results:Adjusting for covariates, DC was 51.9% more expensive than MD (P < 0.001), DCPm 3.2% more expensive than DC (P = 0.76), and MDPt 105.8% more expensive than MD (P < 0.001). The adjusted mean outpatient costs per treatment group were

Racial and ethnic disparities in access to physicians with HIV-related expertise

369 for MD,

Sexual orientation and testing for prostate and colorectal cancers among men in California.

560 for DC,

Community Characteristics and Violence Against Homeless Women in Los Angeles County

579 for DCPm, and

The Effect of Urban Street Gang Densities on Small Area Homicide Incidence in a Large Metropolitan County, 1994–2002

760 for MDPt. Conclusions:This study is the first randomized trial to show higher costs for chiropractic care without producing better clinical outcomes, but our findings are likely to understate the costs of medical care with or without physical therapy because of the absence of pharmaceutical data. Physical therapy provided in combination with medical care and physical modalities provided in combination with chiropractic care do not appear to be cost-effective strategies for treatment of LBP; they produce higher costs without clinically significant improvements in outcome.

Case Management and Access to Services for Homeless Women

AbstractOBJECTIVE: Professional medical associations recommend that physicians who treat patients with human immunodeficiency virus (HIV) have a measurable form of disease-specific expertise, such as high HIV patient volume or infectious diseases certification. Although it is known that racial/ethnic minorities generally have worse access to care than do whites, previous work has not examined disparities in the use of physicians with HIV-related expertise. DESIGN, SETTING, AND PARTICIPANTS: We linked data from a prospective cohort study of 2,207 persons with HIV receiving care in the United States with a cross-sectional survey of 404 physicians caring for them. Using multivariate analysis, we estimated the association of patient race/ethnicity with the experience and training of their physicians, controlling for health status, socioeconomic status, demographic characteristics, and geographic variation in provider supply. RESULTS: Compared with white patients, African Americans were less likely to have an infectious diseases specialist as a regular source of care (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.37 to 0.95). Persons of Alaskan Native, American Indian, Asian, Pacific Islander, or mixed racial background were also less likely than whites to have an infectious diseases specialist (OR, 0.44; 95% CI, 0.23 to 0.83). Conversely, Latino patients had physicians whose HIV patient volume was, on average, 24% higher than the physicians of white patients (incident rate ratio, 1.24; 95% CI, 1.03 to 1.50). CONCLUSIONS: Some groups of racial/ethnic minorities are less likely than are whites to have infectious diseases specialists as a regular source of care. The finding that the physicians of Latino patients had relatively higher HIV caseloads suggests that this particular patient subpopulation has access to HIV expertise. Further work to explain racial/ethnic differences in access to physicians will help in the design of programs and policies to eliminate them.

Use of faith-based social service providers in a representative sample of urban homeless women.

Background:Previous quantitative studies have not compared the use of prostate and colorectal cancer (CRC) testing between gay/bisexual and heterosexual men. Methods:We analyzed cross-sectional data on 19,410 men in the California Health Interview Survey. The percentage of respondents age 50 and over who received prostate and CRC tests was calculated across subgroups defined by self-reported sexual orientation, race/ethnicity, and a combined variable on sexual orientation and race/ethnicity. Multivariate regression analysis was used to identify variables on respondent characteristics that were independently associated with testing. Results:In bivariate analyses, the percentage of gay/bisexual men receiving CRC tests was 6–10% greater than that of heterosexuals. There were no overall differences in prostate-specific antigen (PSA) test use between gay/bisexual and heterosexual men; however, use of these tests by gay/bisexual African Americans was 12–14% lower than that of heterosexual African Americans and 15–28% lower than that of gay/bisexual whites. In multivariate analyses, gay/bisexual men had greater odds of ever receiving CRC tests [odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.06–2.65], and lower odds of having an up-to-date PSA test than did heterosexuals (OR = 0.61; 95% CI = 0.42–0.89). However, interactions between sexual orientation and living situation showed that gay/bisexual men who lived alone had greater odds of receiving PSA tests than did other men (OR = 1.93; 95% CI = 1.23–3.03). Conclusions:Sexual orientation is independently associated with cancer testing among men. Future work should investigate the differences in this association by race/ethnicity and living situation.