Nancy R. Kressin

Agreement Between Administrative Data and Patients’ Self-Reports of Race/Ethnicity

OBJECTIVES We examined agreement of administrative data with self-reported race/ethnicity and identified correlates of agreement. METHODS We used Veterans Affairs administrative data and VA 1999 Large Health survey race/ethnicity data. RESULTS Relatively low rates of agreement (approximately 60%) between data sources were largely the result of administrative data from patients whose race/ethnicity was unknown, with least agreement for Native American, Asian, and Pacific Islander patients. After exclusion of patients with missing race/ethnicity, agreement improved except for Native Americans. Agreement did not increase substantially after inclusion of data from individuals indicating multiple race/ethnicities. Patients for whom there was better agreement between data sources tended to be less educated, non-solitary living, younger, and White; to have sufficient food; and to use more inpatient Department of Veterans Affairs (VA) care. CONCLUSIONS Better reporting of race/ethnicity data will improve agreement between data sources. Previous studies using VA administrative data may have underestimated racial disparities.

Self-Reported vs Administrative Race/Ethnicity Data and Study Results

Concerns about administrative data on race/ethnicity have led some researchers to consider self-reported race/ethnicity as superior.1–5 However, few studies have examined the differential impact of the source of race/ethnicity data, that is, observed or selfreported, on study outcomes. We investigated whether differences in reporting of race/ethnicity led to different results with regard to the use of one therapeutic dental procedure, root canal therapy.

Racial differences in how patients perceive physician communication regarding cardiac testing.

Objectives. Recent studies documenting racial variation in the use of cardiac procedures highlight the need to understand if there are racial differences in processes of communication and decision making. Investigations of patients’ perceptions of their interaction with providers regarding cardiac testing were conducted. Methods. Four focus groups were convened with 13 patients who had undergone cardiac stress testing with positive results, stratified by race (white vs. black). Verbatim transcripts of discussions of their interactions with providers relating to their cardiac problems were analyzed qualitatively by a team of behavioral scientists and general internists to identify significant dimensions of communication and patient-provider relationships. Results. Four domains of communication were identified that appeared to bear on patients’ comfort and preferences regarding cardiac procedures. First, the substance of the information that was provided by physicians and other providers was described as incomplete, vague, ambiguous, and unclear. Second, some recommendations either were inconsistent with expectations or awakened fears based on distressing previous experiences. Third, patients said they needed to be convinced of the need for additional, invasive tests and therapeutic procedures, and in some cases providers’ arguments failed in this regard. Fourth, the patients highlighted the importance of trusting their provider. Although there were no apparent differences by race in patients’ perception of the information they received, black patients consistently expressed a preference for building a relationship with physicians (trust) before agreeing to an invasive cardiac procedure, and just as consistently complained that trust was lacking. Conversely, white patients tended to emphasize that they were inadequately convinced of the need for recommended procedures. Conclusions. This study provided qualitative information regarding patients’ perceptions of physician-patient communication and racial differences in such perceptions. For both black and white patients, we found problematic aspects of the patients’ experiences regarding communication about cardiac testing. Our findings suggest that although patients desire clarity from physicians, they are often confused regarding the information received. Both a lack of substance and vagueness of the information received may be linked to feelings of mistrust toward physicians when considering further diagnostic testing. Mistrust may be a source of some of the documented racial variation in health care utilization.

Perceptions of Race/Ethnicity-Based Discrimination: A Review of Measures and Evaluation of Their Usefulness for the Health Care Setting

Background. To assess discrimination in health care, reliable, valid, and comprehensive measures of racism/discrimination are needed. Objective. To review literature on measures of perceived race/ethnicity-based discrimination and evaluate their characteristics and usefulness in assessing discrimination from health care providers. Methods. Literature review of measures of perceived race/ethnicity-based discrimination (1966–2007), using MEDLINE, PsycINFO, and Social Science Citation Index. Results. We identified 34 measures of racism/discrimination; 16 specifically assessed dynamics in the health care setting. Few measures were theoretically based; most assessed only general dimensions of racism and focused specifically on the experiences of African American patients. Acceptable psychometric properties were documented for about half of the instruments. Conclusions. Additional measures are needed for detailed assessments of perceived discrimination in the health care setting; they should be relevant for a wide variety of racial/ethnic groups, and they must assess how racism/discrimination affects health care decision making and treatments offered.

ASSESSING ORAL HEALTH-RELATED QUALITY OF LIFE : FINDINGS FROM THE NORMATIVE AGING STUDY

The contribution of oral health to health-related quality of life (HQOL) has seldom been examined. This study was designed to develop and validate a measure of oral health-related quality of life (OHQOL), examine relations between OHQOL and HQOL, and explore OHQOLs relation to problem-based dental care utilization in a sample of 1,242 older men, using data gathered by a mail survey. Factor analysis of eight oral health items revealed that three items related to the impact of oral conditions on daily functioning defined a factor labeled OHQOL. Factor analysis of the HQOL items and these three OHQOL items showed that OHQOL represents a separate and independent factor. Correlational analyses supported the construct validity of the OHQOL measure: Men with better OHQOL scores reported less dental pain or discomfort, fewer eating problems, and less problem-based dental care utilization. Logistic regression analysis showed that the measures of dental pain and oral discomfort were related positively to utilization, whereas OHQOL was related negatively. These results suggest that OHQOL represents a separate and distinct facet of HQOL that is associated with dental care utilization. Thus they support the validity of the OHQOL construct and suggest its use in future studies of HQOL.

Hypertensive patients' race, health beliefs, process of care, and medication adherence.

BACKGROUNDAfrican Americans have higher rates of hypertension and worse blood pressure (BP) control than Whites, and poorer medication adherence may contribute to this phenomenon. We explored associations among patients’ race, self-reported experiences with clinicians, attitudes and beliefs about hypertension, and ultimately, medication adherence, among a sample with no racial disparities in BP control, to determine what lessons we could learn from patients and providers in this setting.METHODSWe recruited 793 White and African-American (58%) patients previously diagnosed with hypertension from 3 VA medical centers to participate in survey assessments of each of the above dimensions, subsequent to a primary care clinic visit.RESULTSAfrican-American patients’ providers were significantly more active in advising and counseling about hypertension care and medication adherence. African-American patients indicated greater knowledge or heightened awareness of the importance of controlling their BP, but there were no race differences on a summary adherence measure. In multivariate models modeling medication adherence, race was not significant, but having been told to split one’s pills, believing one’s BP continues to be high, and having one’s provider discuss things to do to make it easier to take BP medications were each significantly associated with worse adherence, whereas having more confidence in one’s ability to take BP medications as prescribed was associated with better adherence (all p’s  ≤ .02).CONCLUSIONWhen both physicians and patients take BP management seriously, disparities in BP adherence and control may be reduced.

Increased Preventive Practices Lead to Greater Tooth Retention

Prior research has rarely examined the impact of ADA-recommended preventive practices on tooth retention. We hypothesized that better oral hygiene leads to increased tooth retention. We examined the association of cross-sectional and long-term assessments of preventive practices, as well as various combinations of hygiene practices, with tooth retention. Among 736 male participants in the VA Dental Longitudinal Study, we utilized cross-sectional and longitudinal self-reports of toothbrushing, dental floss use, annual prophylaxis, and combinations of such behaviors, and examined their association with clinically assessed numbers of teeth. Baseline and long-term hygiene behaviors (except brushing) were associated with an increased baseline number of teeth and decreased subsequent tooth loss. Use of multiple hygiene behaviors was associated with greater tooth retention, cross-sectionally and longitudinally. Adherence to ADA recommendations for preventive care leads to better oral health, and consistently practicing preventive behaviors over the long term confers greater benefits than doing so over the short term.

Chronic Kidney Disease Is Associated with Angiographic Coronary Artery Disease

Background/Aims: Patients with chronic kidney disease (CKD) have a dramatically increased risk for cardiovascular mortality. Few prior studies have examined the independent association of CKD with coronary anatomy. Methods: We evaluated the relationship between CKD and severe coronary artery disease (CAD) in 261 male veterans with nuclear perfusion imaging tests suggesting coronary ischemia. We used chart review and patient and provider interviews to collect demographics, clinical characteristics, and coronary anatomy results. We defined CKD as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2, based on the creatinine obtained prior to angiography. We defined significant coronary obstruction as at least one 70% or greater stenosis. We used logistic regression to determine whether CKD was independently associated with significant coronary obstruction. Results: The likelihood of CAD increased monotonically with decreasing eGFR, from 51% among patients with eGFR ≧90 ml/min/1.73 m2 to 84% in those with eGFR <30 ml/min/1.73 m2 (p = 0.0046). Patients with CKD were more likely than those without CKD to have at least one significant coronary obstruction (75.9 vs. 60.7%, p = 0.016). Patients with CKD also had more significant CAD, that is, were more likely to have three-vessel and/or left main disease than those without CKD (34.9 vs. 16.9%, p = 0.0035). In logistic regression analysis, controlling for demographics and comorbidity, CKD continued to be independently associated with the presence of significant CAD (p = 0.0071). Conclusion: CKD patients have a high prevalence of obstructive coronary disease, which may contribute to their high cardiovascular mortality.

Snacking Habits and Caries in Young Children

Dental caries is caused by a combination of infection and diet. This disease, if left untreated, may lead to pain, and impair the quality of life, nutritional status and development of young children. The objective was to investigate the association between snacking and caries in a population at high risk of dental caries. American preschool children (n = 1,206) were recruited in the offices of paediatricians. Data on sociodemographic characteristics, oral hygiene, breast-feeding, use of bottle and snacking were collected by questionnaire. Plaque presence, the number of teeth and their caries status (deft) were scored. The children sampled were 61% Black, 27% White and 10% Asian. Of the 1- to 2-, 2- to 3- and 3- to 4-year-old children, 93.8, 82.4 and 77.3% were caries free, and their mean caries scores were 0.16, 0.58 and 0.93, respectively. Multivariate partial least squares (PLS) modelling revealed plaque presence, lowest income, descriptors for tooth exposure time (number of teeth and age) and cariogenic challenge (total intake of sugar-containing snacks and chips/crisps, and chips intake with a sugar-containing drink) to be associated with more caries. These differences were also found in univariate analyses; in addition, children who continued breast-feeding after falling asleep had significantly higher deft values than those who did not. PLS modelling revealed that eating chips clustered with eating many sweet snacks, candies, popcorn and ice cream. We conclude that, in addition to the traditional risk indicators for caries – presence of plaque, sugar intake and socioeconomic status –, consumption of chips was associated with caries in young children.

Setting a research agenda for medical overuse

Although overuse in medicine is gaining increased attention, many questions remain unanswered. Dan Morgan and colleagues propose an agenda for coordinated research to improve our understanding of the problem