Mark P. Doescher

Disparities in Health Care by Race, Ethnicity, and Language Among the Insured:Findings From a National Sample

Background: Racial and ethnic disparities in health care have been well documented, but poorly explained. Objective: To examine the effect of access barriers, including English fluency, on racial and ethnic disparities in health care. Research Design: Cross-sectional analysis of the Community Tracking Survey (1996–1997). Subjects: Adults 18 to 64 years with private or Medicaid health insurance. Measures: Independent variables included race, ethnicity, and English fluency. Dependent variables included having had a physician or mental health visit, influenza vaccination, or mammogram during the past year. Results: The health care use pattern for English-speaking Hispanic patients was not significantly different than for non-Hispanic white patients in the crude or multivariate models. In contrast, Spanish-speaking Hispanic patients were significantly less likely than non-Hispanic white patients to have had a physician visit (RR, 0.77; 95% CI, 0.72–0.83), mental health visit (RR, 0.50; 95% CI, 0.32–0.76), or influenza vaccination (RR, 0.30; 95% CI, 0.15–0.52). After adjustment for predisposing, need, and enabling factors, Spanish-speaking Hispanic patients showed significantly lower use than non-Hispanic white patients across all four measures. Black patients had a significantly lower crude relative risk of having received an influenza vaccination (RR, 0.73; 95% CI, 0.58–0.87). Adjustment for additional factors had little impact on this effect, but resulted in black patients being significantly less likely than non-Hispanic white patients to have had a visit with a mental health professional (RR, 0.46; 95% CI, 0.37–0.55). Conclusions: Among insured nonelderly adults, there are appreciable disparities in health-care use by race and Hispanic ethnicity. Ethnic disparities in care are largely explained by differences in English fluency, but racial disparities in care are not explained by commonly used access factors.

Trends in Professional Advice to Lose Weight Among Obese Adults, 1994 to 2000

AbstractCONTEXT: Obesity is a fast-growing threat to public health in the U.S., but information on trends in professional advice to lose weight is limited. OBJECTIVE: We studied whether rising obesity prevalence in the U.S. was accompanied by an increasing trend in professional advice to lose weight among obese adults. DESIGN AND PARTICIPANTS: We used the Behavioral Risk Factor Surveillance System, a cross-sectional prevalence study, from 1994 (n= 10,705), 1996 (n=13,800), 1998 (n=18,816), and 2000 (n=26,454) to examine changes in advice reported by obese adults seen for primary care. MEASUREMENTS: Self-reported advice from a health care professional to lose weight. RESULTS: From 1994 to 2000, the proportion of obese persons receiving advice to lose weight fell from 44.0% to 40.0%. Among obese persons not graduating from high school, advice declined from 41.4% to 31.8%; and for those with annual household incomes below

Trends in cervical and breast cancer screening practices among women in rural and urban areas of the United States.

25,000, advice dropped from 44.3% to 38.1%. In contrast, the prevalence of advice among obese persons with a college degree or in the highest income group remained relatively stable and high (>45%) over the study period. CONCLUSIONS: Disparities in professional advice to lose weight associated with income and educational attainment increased from 1994 to 2000. There is a need for mechanisms that allow health care professionals to devote sufficient attention to weight control and to link with evidence-based weight loss interventions, especially those that target groups most at risk for obesity.

Age-Related Disparities in Cancer Screening: Analysis of 2001 Behavioral Risk Factor Surveillance System Data

OBJECTIVE The objective of this study was to assess rural-urban differences in mammography and Papanicolaou (Pap) smear screening. METHODS Data from the Behavioral Risk Factor Surveillance System (1994-2000, 2002, 2004) were used to examine trends in these two tests by rural-urban residence location. RESULTS In 2004, 70.8 percent of rural and 75.7 percent of urban respondents had received timely mammography; this difference remained significant in adjusted analyses and was greatest for women in remote rural locations. Although overall participation in mammography increased over time, a persistent rural-urban gap was identified. In contrast, in 2004, while 83.1 percent of rural and 86.1 percent of urban respondents had received a timely Pap test, the adjusted difference was not significant and Pap testing did not improve over time. Advanced age and low socioeconomic status were associated with a lack of screening. CONCLUSIONS Over an 11-year interval, mammography screening improved nationally, but women living in rural locations remained less likely than their urban counterparts to receive this test. However, no secular improvement in Pap testing was found, and no significant rural-urban differences were observed. POLICY IMPLICATIONS Interventions to improve breast cancer screening are needed for rural women. Such efforts should target older women and those with low socioeconomic status.

Urban–rural disparities in colorectal cancer screening: cross-sectional analysis of 1998–2005 data from the Centers for Disease Control's Behavioral Risk Factor Surveillance Study

PURPOSE Although few studies have explored age-related health care disparities, some researchers have asserted such disparities uniformly disfavor the elderly and are largely attributable to ageism in the health care system. We compared age-related patterns of screening for colorectal cancer with those for breast and prostate cancer in persons aged 50 years and older. METHODS We analyzed data for all adults aged 50 years and older (N = 88,213) in the 2001 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative, telephone-administered survey of personal health behaviors. Main outcome measures were adjusted prevalence by 5-year age-groups of colorectal cancer screening using fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy for men and women; rates of mammography screening for women; and rates of prostate-specific antigen (PSA) screening for men. RESULTS After adjustment for race/ethnicity, education level, income, health insurance, and self-rated health, predicted reported colorectal cancer screening (all modalities) increased significantly from when patients reached age 50 years until 70 to 74 years (66.0%, standard error [SE] 0.8%), remained constant until age 80 years, and then declined. The age-related gain in colorectal cancer screening was confined to whites among patients older than 60 years. Reported PSA screening increased until age 75 to 79 years (79.3%, SE 1.1%) and then declined, whereas reported mammography screening peaked at age 55 to 59 years (83.3%, SE 1.2%) and then declined. CONCLUSIONS Significant age-related disparities appear to exist for both evidence-based and non–evidence-based cancer-screening interventions. The issue of age-related disparities in cancer screening is complex, with the direction of disparity favoring the elderly for some services yet disfavoring them for others.

Preventive care: Does continuity count?

Despite the existence of effective screening, colorectal cancer remains the second leading cause of cancer death in the United States. Identification of disparities in colorectal cancer screening will allow for targeted interventions to achieve national goals for screening. The objective of this study was to contrast colorectal cancer screening rates in urban and rural populations in the United States. The study design comprised a cross‐sectional study in the United States 1998–2005. Behavioral Risk Factor Surveillance System data from 1998 to 2005 were the method and data source. The primary outcome was self‐report up‐to‐date colorectal cancer screening (fecal occult blood test in last 12 months, flexible sigmoidoscopy in last 5 years, or colonoscopy in last 10 years). Geographic location (urban vs. rural) was used as independent variable. Multivariate analysis controlled for demographic and health characteristics of respondents. After adjustment for demographic and health characteristics, rural residents had lower colorectal cancer screening rates (48%; 95% CI 48, 49%) as compared with urban residents (54%, 95% CI 53, 55%). Remote rural residents had the lowest screening rates overall (45%, 95% CI 43, 46%). From 1998 to 2005, rates of screening by colonoscopy or flexible sigmoidoscopy increased in both urban and rural populations. During the same time, rates of screening by fecal occult blood test decreased in urban populations and increased in rural populations. Persistent disparities in colorectal cancer screening affect rural populations. The types of screening tests used for colorectal cancer screening are different in rural and urban areas. Future research to reduce this disparity should focus on screening methods that are acceptable and feasible in rural areas.

A Qualitative Study of Depression in Primary Care: Missed Opportunities for Diagnosis and Education

OBJECTIVE: To examine the impact of provider continuity on preventive care among adults who have a regular site of care.DESIGN: Logistic regression analyses were conducted to explore whether continuity, categorized as having no regular care, site continuity, or provider continuity, was associated with receipt of 3 preventive care services (influenza vaccination, receipt of a mammogram, and smoking cessation advice), independent of predisposing, need, and enabling factors.PARTICIPANTS: This study examined 42,664 persons with private, Medicaid, Medicare, or no health insurance coverage who reported either having no site of care or being seen in a physician’s office, HMO, hospital outpatient department, or other health center.SETTING: The 1996/1997 Community Tracking Study (CTS) household survey, a telephone-based survey providing a crosssectional sample of 60,446 U.S. adults aged 18 and older representing the U.S. housed, noninstitutionalized population.MEASUREMENTS AND MAIN RESULTS: After adjustment for differences in predisposing, enabling, and need factors, site continuity was associated with significant increases of 10.4% in influenza vaccinations (P=.006) and 12.6% in mammography (P=.001), and a nonsignificant increase of 5.6% in smoking cessation advice (P=.13) compared to having no regular site of care. After adjustment for these factors, provider continuity was associated with an additional improvement of 6.0% in influenza vaccinations (P=.01) and 6.2% in mammography (P=.04), and a nonsignificant increase of 2.5% in smoking cessation advice (P=.30) compared to site continuity.CONCLUSIONS: Provider continuity and site continuity are independently associated with receipt of preventive services. Compared to having no regular site of care, having site continuity was associated with increased receipt of influenza vaccination and mammography and, compared to having site continuity, having provider continuity was associated with further increases in the receipt of these two preventive services.

Prescription drug coverage, health, and medication acquisition among seniors with one or more chronic conditions

Purpose: Depression is one of the most commonly encountered chronic conditions in primary care, yet it remains substantially underdiagnosed and undertreated. We sought to gain a better understanding of barriers to diagnosis of and entering treatment for depression in primary care. Methods: We conducted and analyzed interviews with 15 subjects currently being treated for depression recruited from primary care clinics in an academic medical center and an academic public hospital. We asked about experiences with being diagnosed with depression and starting treatment, focusing on barriers to diagnosis, subject understanding of depression, and information issues related to treatment decisions. Results: Subjects reported many visits to primary care practitioners without the question of depression being raised. The majority had recurrent depression. Many reported that they did not receive enough information about depression and its treatment options. In the majority of cases, practitioners decided the course of treatment with little input from the patients. Conclusions: In this sample of depressed patients, we found evidence of frequent missed diagnoses, substantial information gaps, and limited patient understanding and choice of treatment options. Quality improvement efforts should address not only screening and follow-up but patient education about depression and treatment options along with elicitation of treatment preferences.

Examination of Trends and Evidence‐Based Elements in State Physical Education Legislation: A Content Analysis

Background:The unabated rise in medication costs particularly affects older persons with chronic conditions that require long-term medication use, but how prescription benefits affect medication adherence for such persons has received limited study. Objective:We sought to study the relationship among prescription benefit status, health, and medication acquisition in a sample of elderly HMO enrollees with 1 or more common, chronic conditions. Research Design:We implemented a cross-sectional cohort study using primary survey data collected in 2000 and administrative data from the previous 2 years. Subjects:Subjects were aged 67 years of age and older, continuously enrolled in a Medicare + Choice program for at least 2 years, and diagnosed with 1 or more of hypertension, diabetes, congestive heart failure, and coronary artery disease (n = 3073). Measures:Outcomes were the mean daily number of essential therapeutic drug classes and refill adherence. Results:In multivariate models, persons without a prescription benefit acquired medications in 0.15 fewer therapeutic classes daily and experienced lower refill adherence (approximately 7 fewer days of necessary medications during the course of 2 years) than those with a prescription benefit. A significant interaction revealed that, among those without a benefit, persons in poor health acquired medications in 0.73 more therapeutic classes daily than persons in excellent health; health status did not significantly influence medication acquisition for those with a benefit. Conclusions:Coverage of prescription drugs is important for improving access to essential medications for persons with the studied chronic conditions. A Medicare drug benefit that provides unimpeded access to medications needed to treat such conditions may improve medication acquisition and, ultimately, health.

Impact of Healthcare Delivery System on Where HMO-Enrolled Seniors Purchase Medications:

OBJECTIVES To develop a comprehensive inventory of state physical education (PE) legislation, examine trends in bill introduction, and compare bill factors. METHODS State PE legislation from January 2001 to July 2007 was identified using a legislative database. Analysis included components of evidence-based school PE from the Community Guide and other authoritative sources: minutes in PE, PE activity, teacher certification, and an environmental element, including facilities and equipment. Researchers abstracted information from each bill and a composite list was developed. RESULTS In total, 781 bills were analyzed with 162 enacted. Of the 272 bills that contained at least 1 evidence-based element, 43 were enacted. Only 4 bills included all 4 evidence-based elements. Of these 4, 1 was enacted. Funding was mentioned in 175 of the bills introduced (37 enacted) and an evaluation component was present in 172 of the bills (49 enacted). CONCLUSIONS Based on this analysis, we showed that PE is frequently introduced, yet the proportion of bills with evidence-based elements is low. Future research is needed to provide the types of evidence required for development of quality PE legislation.