Nancy Sohler

The complexities of measuring access to parks and physical activity sites in New York City: a quantitative and qualitative approach

BackgroundProximity to parks and physical activity sites has been linked to an increase in active behaviors, and positive impacts on health outcomes such as lower rates of cardiovascular disease, diabetes, and obesity. Since populations with a low socio-economic status as well as racial and ethnic minorities tend to experience worse health outcomes in the USA, access to parks and physical activity sites may be an environmental justice issue. Geographic Information systems were used to conduct quantitative and qualitative analyses of park accessibility in New York City, which included kernel density estimation, ordinary least squares (global) regression, geographically weighted (local) regression, and longitudinal case studies, consisting of field work and archival research. Accessibility was measured by both density of park acreage and density of physical activity sites. Independent variables included percent non-Hispanic black, percent Hispanic, percent below poverty, percent of adults without high school diploma, percent with limited English-speaking ability, and population density.ResultsThe ordinary least squares linear regression found weak relationships in both the park acreage density and the physical activity site density models (Ra2 = .11 and .23, respectively; AIC = 7162 and 3529, respectively). Geographically weighted regression, however, suggested spatial non-stationarity in both models, indicating disparities in accessibility that vary over space with respect to magnitude and directionality of the relationships (AIC = 2014 and -1241, respectively). The qualitative analysis supported the findings of the local regression, confirming that although there is a geographically inequitable distribution of park space and physical activity sites, it is not globally predicted by race, ethnicity, or socio-economic status.ConclusionThe combination of quantitative and qualitative analyses demonstrated the complexity of the issues around racial and ethnic disparities in park access. They revealed trends that may not have been otherwise detectable, such as the spatially inconsistent relationship between physical activity site density and socio-demographics. In order to establish a more stable global model, a number of additional factors, variables, and methods might be used to quantify park accessibility, such as network analysis of proximity, perception of accessibility and usability, and additional park quality characteristics. Accurate measurement of park accessibility can therefore be important in showing the links between opportunities for active behavior and beneficial health outcomes.

Health services utilization for people with HIV infection : Comparison of a population targeted for outreach with the U.S. population in care

Background:Many persons with HIV infection do not receive consistent ambulatory medical care and are excluded from studies of patients in medical care. However, these hard-to-reach groups are important to study because they may be in greatest need of services. Objective:This study compared the sociodemographic, clinical, and health care utilization characteristics of a multisite sample of HIV-positive persons who were hard to reach with a nationally representative cohort of persons with HIV infection who were receiving care from known HIV providers in the United States and examined whether the independent correlates of low ambulatory utilization differed between the 2 samples. Methods:We compared sociodemographic, clinical, and health care utilization characteristics in 2 samples of adults with HIV infection: 1286 persons from 16 sites across the United States interviewed in 2001–2002 for the Targeted HIV Outreach and Intervention Initiative (Outreach), a study of underserved persons targeted for supportive outreach services; and 2267 persons from the HIV Costs and Services Utilization Study (HCSUS), a probability sample of persons receiving care who were interviewed in 1998. We conducted logistic regression analyses to identify differences between the 2 samples in sociodemographic and clinical associations with ambulatory medical visits. Results:Compared with the HCSUS sample, the Outreach sample had notably greater proportions of black respondents (59% vs. 32%, P = 0.0001), Hispanics (20% vs. 16%), Spanish-speakers (9% vs. 2%, P = 0.02), those with low socioeconomic status (annual income <

Factors affecting willingness to provide buprenorphine treatment

10,000 75% vs. 45%, P = 0.0001), the unemployed, and persons with homelessness, no insurance, and heroin or cocaine use (58% vs. 47%, P = 0.05). They also were more likely to have fewer than 2 ambulatory visits (26% vs. 16%, P = 0.0001), more likely to have emergency room visits or hospitalizations in the prior 6 months, and less likely to be on antiretroviral treatment (82% vs. 58%, P = 0.0001). Nearly all these differences persisted after stratifying for level of ambulatory utilization (fewer than 2 vs. 2 or more in the last 6 months). In multivariate analysis, several variables showed significantly different associations in the 2 samples (interacted) with low ambulatory care utilization. The variables with significant interactions (P values for interaction shown below) had very different adjusted odds ratios (and 95% confidence intervals) for low ambulatory care utilization: age greater than 50 (Outreach 0.55 [0.35–0.88], HCSUS 1.17 [0.65–2.11)], P = 0.05), Hispanic ethnicity (Outreach 0.81 [0.39–1.69], HCSUS 2.34 [1.56–3.52], P = 0.02), low income (Outreach 0.73 [0.56–0.96], HCSUS 1.35 [1.04–1.75], P = 0.002), and heavy alcohol use (Outreach 1.74 [1.23–2.45], HCSUS 1.00 [0.73–1.37], P = 0.02). Having CD4 count less than 50 was associated with elevated odds of low ambulatory medical visits in the Outreach sample (1.53 [1.00–2.36], P = 0.05). Conclusions:Compared with HCSUS, the Outreach sample had far greater proportions of traditionally vulnerable groups, and were less likely to be in care if they had low CD4 counts. Furthermore, heavy alcohol use was only associated with low ambulatory utilization in Outreach. Generalizing from in care populations may not be warranted, while addressing heavy alcohol use may be effective at improving utilization of care for hard-to-reach HIV-positive populations.

Factors Associated with Obesity and Coronary Heart Disease in People with Intellectual Disabilities

Buprenorphine is an effective long-term opioid agonist treatment. As the only pharmacological treatment for opioid dependence readily available in office-based settings, buprenorphine may facilitate a historic shift in addiction treatment from treatment facilities to general medical practices. Although many patients have benefited from the availability of buprenorphine in the United States, almost half of current prescribers are addiction specialists suggesting that buprenorphine treatment has not yet fully penetrated general practice settings. We examined factors affecting willingness to offer buprenorphine treatment among physicians with different levels of prescribing experience. Based on their prescribing practices, physicians were classified as experienced, novice, or as a nonprescriber and asked to assess the extent to which a list of factors impacted their prescription of buprenorphine. Several factors affected willingness to prescribe buprenorphine for all physicians: staff training; access to counseling and alternate treatment; visit time; buprenorphine availability; and pain medications concerns. Compared with other physicians, experienced prescribers were less concerned about induction logistics and access to expert consultation, clinical guidelines, and mental health services. They were more concerned with reimbursement. These data provide important insight into physician concerns about buprenorphine and have implications for practice, education, and policy change that may effectively support widespread adoption of buprenorphine.

Barriers to Obtaining Waivers to Prescribe Buprenorphine for Opioid Addiction Treatment Among HIV Physicians

Advances in health care for people with intellectual disabilities (ID) that have resulted in increased longevity also force health care providers, researchers, and policymakers to question the adequacy of chronic disease management for the growing number of middle aged and elderly persons in this population. We report on sociodemographic and clinical factors associated with obesity, hypertension, hypercholesterolemia, and diabetes mellitus in an ethnically/racially diverse sample of people with ID in New York City. Administrative and chart review data were collected from a community-based specialty medical practice for people with intellectual disabilities. Adult subjects were included if they had an intellectual disability, lived in the community either independently or with relatives, received all of their planned, outpatient health care services though this practice, and had a primary care visit within the study period. One hundred twenty-six (43.0%) persons were obese, 58 (19.9%) had hypertension, 77 (26.5%) had hypercholesterolemia, and 13 (4.5%) had diabetes mellitus. Age, gender, and BMI (for the latter three conditions) were the most consistent risk factors. Intellectual functioning and behavioral problems were not associated with greater odds of these conditions. This study provides crucial information for improving community-based primary care for people with intellectual disabilities. Specifically, these findings highlight the importance of constructing innovative strategies to mitigate chronic disease risk factors in this population that involve community-based case management service providers who can help adults with ID and their families adopt needed lifestyle and behavior changes.

Home- versus office-based buprenorphine inductions for opioid-dependent patients

BackgroundIllicit drug use is common among HIV-infected individuals. Buprenorphine enables physicians to simultaneously treat HIV and opioid dependence, offering opportunities to improve health outcomes. Despite this, few physicians prescribe buprenorphine.ObjectiveTo examine barriers to obtaining waivers to prescribe buprenorphine.DesignCross-sectional survey study.Participants375 physicians attending HIV educational conferences in six cities in 2006.ApproachAnonymous questionnaires were distributed and analyzed to test whether confidence addressing drug problems and perceived barriers to prescribing buprenorphine were associated with having a buprenorphine waiver, using chi-square, t tests, and logistic regression.Results25.1% of HIV physicians had waivers to prescribe buprenorphine. In bivariate analyses, physicians with waivers versus those without waivers were less likely to be male (51.1 vs 63.7%, p < .05), more likely to be in New York (51.1 vs 29.5%, p < .01), less likely to be infectious disease specialists (25.5 vs 41.6%, p < .05), and more likely to be general internists (43.6 vs 33.5%, p < .05). Adjusting for physician characteristics, confidence addressing drug problems (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [95% CI] = 1.08–3.88) and concern about lack of access to addiction experts (AOR = 0.56, 95% CI = 0.32–0.97) were significantly associated with having a buprenorphine waiver.ConclusionsAmong HIV physicians attending educational conferences, confidence addressing drug problems was positively associated with having a buprenorphine waiver, and concern about lack of access to addiction experts was negatively associated with it. HIV physicians are uniquely positioned to provide opioid addiction treatment in the HIV primary care setting. Understanding and remediating barriers HIV physicians face may lead to new opportunities to improve outcomes for opioid-dependent HIV-infected patients.

Does Patient–Provider Racial/Ethnic Concordance Influence Ratings of Trust in People with HIV Infection?

Recent legislation permits the treatment of opioid-dependent patients with buprenorphine in the primary care setting, opening doors for the development of new treatment models for opioid dependence. We modified national buprenorphine treatment guidelines to emphasize patient self-management by giving patients the opportunity to choose to have buprenorphine inductions at home or the physicians office. We examined whether patients who had home-based inductions achieved greater 30-day retention than patients who had traditional office-based inductions in a study of 115 opioid-dependent patients treated in an inner-city health center. Retention was similar in both groups: 50 (78.1%) in office-based group versus 40 (78.4%) in home-based group, p = .97. Several patient characteristics were associated with choosing office- versus home-based inductions, which likely influenced these results. We conclude that opioid dependence can be successfully managed in the primary care setting. Approaches that encourage patient involvement in treatment for opioid dependence can be beneficial.

Improving Adherence to HIV Quality of Care Indicators in Persons With Opioid Dependence: The Role of Buprenorphine

Despite widely available and effective treatments, there are racial/ethnic disparities in HIV-related mortality rates. The reason for inadequate HIV/AIDS management among minority populations is not fully understood, however recent research indicates that patients rate the quality of their health care higher if they are racially/ethnically concordant with their providers. As trust plays prominently on health care ratings, we examined whether racial/ethnicity concordance was associated with two dimensions of trust, trust in the provider and mistrust in the health care system, in 380 HIV infected people New York City. In this sample, concordance was associated with lower mistrust in the health care system, but not with trust in provider. We conclude that in this patient population and within the health care system available to them, racial/ethnic concordance might be more important for helping patients to understand and navigate the health care system rather than in interpersonal relationships with a single provider.

Perceived Discrimination Among Severely Disadvantaged People with HIV Infection

Background:Opioid-dependent HIV-infected patients are less likely to receive HIV quality of care indicators (QIs) compared with nondependent patients. Buprenorphine/naloxone maintenance therapy (bup/nx) could affect the quality of HIV care for opioid-dependent patients. Methods:We abstracted 16 QIs from medical records at nine HIV clinics 12 months before and after initiation of bup/nx versus other treatment for opioid dependence. Summary quality scores (number of QIs received/number eligible × 100) were calculated. We compared change in QIs and summary quality scores in patients receiving bup/nx versus other participants. Results:One hundred ninety-four of 268 participants (72%) received bup/nx and 74 (28%) received other treatment. Mean summary quality scores increased over 12 months for participants receiving bup/nx (45.6% to 51.6%, P < 0.001) but not other treatment (48.6% to 47.8%, P = 0.788). Bup/nx participants experienced improvements in six of 16 HIV QIs versus three of 16 QIs in other participants. Improvements were mostly in preventive and monitoring care domains. In multivariable analysis, bup/nx was associated with improved summary quality score (β 8.55; 95% confidence interval, 2.06-15.0). Conclusions:In this observational cohort study, HIV-infected patients with opioid dependence received approximately half of HIV QIs at baseline. Buprenorphine treatment was associated with improvement in HIV QIs at 12 months. Integration of bup/nx into HIV clinics may increase receipt of high-quality HIV care. Further research is required to assess the effect of improved quality of HIV care on clinical outcomes.

Factors associated with complicated buprenorphine inductions

Objectives. Studies continue to document that people with human immunodeficiency virus (HIV) experience discrimination in their interactions with the health-care system, which can have negative implications for maintaining continuity in care and outcomes. We explored the patient characteristics associated with perceived discrimination and whether these experiences are associated with health-care system quality ratings in a survey of severely disadvantaged people with HIV who are at great risk of inconsistent access to appropriate health care. Methods. Five hundred and twenty-three participants were recruited from temporary housing facilities for people with HIV in the New York City area and administered a survey using audio computer-assisted self-interviewing technology. Results. Of the 207 participants (39.6%) who reported experiencing discrimination in the health-care system, the most common attributions were HIV infection (n=122, 59.8%), drug use (n=100, 49.8%), homelessness (n=71, 34.6%), and race/ethnicity (n=69, 35.2%). Length of time HIV infected, use of non-prescription opioids, white race, higher education, female gender, younger age, and poorer self-reported health status were all significantly associated with greater odds of perceived discrimination. After adjusting for participant characteristics, perceived discrimination was significantly associated with poorer participant ratings of quality of health care. Conclusions. Members of this vulnerable population commonly report experiences of discrimination from within the health-care system and these experiences are associated with poor health-care ratings. These findings support the need for closer examination of the adequacy of cultural competency training within the HIV health-care delivery system to improve access to appropriate care for disadvantaged people.