Nicole Lurie

Contribution of Public Parks to Physical Activity

OBJECTIVES Parks provide places for people to experience nature, engage in physical activity, and relax. We studied how residents in low-income, minority communities use public, urban neighborhood parks and how parks contribute to physical activity. METHODS In 8 public parks, we used direct observation to document the number, gender, race/ethnicity, age group, and activity level of park users 4 times per day, 7 days per week. We also interviewed 713 park users and 605 area residents living within 2 miles of each park. RESULTS On average, over 2000 individuals were counted in each park, and about two thirds were sedentary when observed. More males than females used the parks, and males were twice as likely to be vigorously active. Interviewees identified the park as the most common place they exercised. Both park use and exercise levels of individuals were predicted by proximity of their residence to the park. CONCLUSIONS Public parks are critical resources for physical activity in minority communities. Because residential proximity is strongly associated with physical activity and park use, the number and location of parks are currently insufficient to serve local populations well.

Preventive Care for Women -- Does the Sex of the Physician Matter?

BACKGROUND Emphasis on ensuring womens access to preventive health services has increased over the past decade. Relatively little attention has been paid to whether the sex of the physician affects the rates of cancer screening among women. We examined differences between male and female physicians in the frequency of screening mammograms and Pap smears among women patients enrolled in a large Midwestern health plan. METHODS We identified claims for mammography and Pap tests submitted by primary care physicians for 97,962 women, 18 to 75 years of age, who were enrolled in the health plan in 1990. The sex of the physician was manually coded, and the physicians age was obtained from the state licensing board. After identifying a principal physician for each woman, we calculated the frequency of mammography and Pap smears for each physician, using the number of women in his or her practice during 1990 as the denominator. Using unconditional logistic regression, we also calculated the odds ratio of having a Pap smear or mammogram for women patients with female physicians as compared with those with male physicians, controlling for the physicians and the patients age. RESULTS Crude rates for Pap smears and mammography were higher for the patients of female than male physicians in most age groups of physicians. The largest differences between female and male physicians were in the rates of Pap smears among the youngest physicians. For the subgroup of women enrolled in the health plan for a year who saw only one physician, after adjustment for the patients age and the physicians age and specialty, the odds ratio for having a Pap smear was 1.99 (95 percent confidence interval, 1.72 to 2.30) for the patients of female physicians as compared with those of male physicians. For women 40 years old and older, the odds ratio for having a mammogram was 1.41 (95 percent confidence interval, 1.22 to 1.63). For both Pap smears and mammography, the differences between female and male physicians in screening rates were much more pronounced in internal medicine and family practice than in obstetrics and gynecology. CONCLUSIONS Women are more likely to undergo screening with Pap smears and mammograms if they see female rather than male physicians, particularly if the physician is an internist or family practitioner.

Does Utilization of Screening Mammography Explain Racial and Ethnic Differences in Breast Cancer

Context Breast cancer mortality rates have fallen but still differ by race and ethnicity. One explanation might be differences in mammography use. Content These investigators linked data from mammography registries to tumor registries and showed that African-American and Hispanic women have longer intervals between mammography and are more likely to have advanced-stage tumors at diagnosis and to die of breast cancer than white women. However, in women with similar screening histories, these rates were similar regardless of race or ethnicity. Implications Differences in mammography use may explain ethnic disparities in the incidence of advanced-stage breast cancer and in mortality rates. The Editors Breast cancer mortality rates in the United States began to decrease in the 1990s (1) because of increased use of screening mammography and improved breast cancer treatment (2, 3). However, these decreases have primarily benefited non-Hispanic white women, whereas the mortality rate for breast cancer in African-American women changed little (1). Although racial and ethnic differences in breast cancer mortality rates have been consistently documented (1, 4-9), reasons for the persistence of these differences have been difficult to ascertain (10). Possible explanations include differences in biological characteristics of tumors (11-13); patient characteristics, such as obesity, that may affect prognosis; mammography use (14, 15); timeliness and completeness of breast cancer diagnosis and treatment (16, 17); social factors, such as education, literacy, and cultural beliefs; and economic factors, such as income level and health insurance coverage, that might affect a patients access to and choices for breast cancer screening and treatment (18-22). Stage at diagnosis, the strongest predictor of breast cancer survival (23), is proportionally higher in all non-Asian minority groups than in white women (8). Although minority women have historically undergone less mammography than white women (14), several recent surveys have found only small differences in mammography use between white and nonwhite women (24, 25). These observations raised doubt that tumors go undiagnosed until later stages in minority women because of infrequent breast cancer screening (26). However, the 2 most widely cited surveys of mammography use are based on self-report and only inquire about recent use, not adherence over time (24, 25). We explored stage of disease at diagnosis, tumor characteristics (including size and grade), and lymph node involvement among women of different races and ethnicities whose patterns of mammography use were similar. We hypothesized that differences in tumor characteristics may result primarily from differences in mammography use and that women with similar patterns of mammography use may have similar tumor characteristics. We had sufficient sample sizes within each racial and ethnic group and obtained sufficiently detailed data regarding mammography use to permit stratification of the cohort by pattern of mammography use; this technique enabled us to compare tumor characteristics among women with similar screening histories. Methods Data Source We pooled data from facilities that participate in 7 mammography registries that form the National Cancer Institutefunded Breast Cancer Surveillance Consortium: San Francisco Mammography Registry, San Francisco, California; Group Health Cooperative, Seattle, Washington; Colorado Mammography Project, Denver, Colorado; Vermont Breast Cancer Surveillance System, Burlington, Vermont; New Hampshire Mammography Network, Lebanon, New Hampshire; Carolina Mammography Registry, Chapel Hill, North Carolina; and New Mexico Mammography Project, Albuquerque, New Mexico. The data consisted of information sent to the registries regarding all mammographic evaluations performed at these facilities, including radiology reports and breast health surveys. The surveys, which were completed by patients at each mammography examination, included questions regarding race, ethnicity, presence of breast symptoms, and previous mammography use. Breast cancer diagnoses and tumor characteristics were obtained through linkage with state tumor registries; regional Surveillance, Epidemiology, and End Results programs; and hospital-based pathology services. Previous research has shown that at least 94% of cancer cases are identified through these linkages (27). Each surveillance registry captures most mammography case reports within its respective geographic area, and mammograms in these registries include approximately 2% of mammographic examinations performed in the United States. Each registry obtains annual approval from its institutional review board to collect mammography-related information and to link with tumor registries. Participants This study included women without a history of breast cancer who were 40 years of age and older who had undergone mammography at least once for screening or diagnostic purposes between 1996 and 2002 (n= 1010515). We categorized the race and ethnicity of the participating women (the mammography registry cohort) as non-Hispanic white (n= 789997), non-Hispanic African American/black (n= 62408), Hispanic (n= 90642), Asian/Pacific Islander (n= 49867), or Native American/Native Alaskan (n= 17601). We excluded women who did not report their race or ethnicity (n= 133235 [12%]) or reported mixed or other race (n= 6003 [<1%]). Breast cancer was diagnosed in a subset of the women in the mammography registry cohort (Table 1). Table 1. General Categorization of Study Participants Characterization of Mammography Use We included all mammographic evaluations in eligible women that were performed during the study period. We characterized each mammogram that was included in the study by the time interval between that mammogram and the one most recently preceding it. We determined these intervals by using examination dates that were recorded in the database (data were available for 85% of patients) and self-reported dates that the remaining women provided at the time of their examination. The mammography screening intervals were categorized into the following groups: within 1 year (4 to 17 months); 2 years (18 to 29 months); 3 years (30 to 41 months); and 4 years or longer (>41 months). At the time of each mammogram, women completed a breast health survey and provided the date of their last mammogram. We created 2 classifications for first mammograms. Mammography was classified as a first screening if the radiologist coded the examination as screening and the woman reported no breast symptoms. The mammogram was classified as diagnostic if the radiologist coded the examination as diagnostic or if the woman reported a breast mass or nipple discharge. Women whose first mammogram was diagnostic were assigned to the never screened group. Of note, a woman could have had mammography more than once during the study period and therefore could contribute more than 1 observation to the analyses. A woman could have observations that were categorized into different mammography screening intervals. For example, a woman could have had her first mammographic evaluation in 1998 and had subsequent mammography in 1999 and 2001. Her first mammogram would have been categorized as a first screening or as diagnostic, depending on the radiologists indication for that examination and whether the patient reported symptoms. Her second mammogram would have been categorized in the 1 year group, and her third mammography would have been categorized in the 2 year group. Breast Cancer To determine breast cancer status, we tracked each participants mammogram for 365 days following the date it had been obtained or until the patient underwent her next mammographic examination (whichever came first). Consequently, each tumor was associated with a single mammogramthat obtained closest to the date of diagnosis. We characterized breast cancer as either invasive or ductal carcinoma in situ. Large tumors were defined as invasive tumors that were 15 mm or larger in diameter. We used the TNM (tumor, node, metastasis) system (which is based on the criteria of the American Joint Committee on Cancer) to classify stage at diagnosis as 0 (ductal carcinoma in situ), 1, 2, 3, or 4 (28); advanced-stage tumors were defined as invasive lesions of stage 2 or higher. High-grade tumors were defined as invasive lesions of grades 3 and 4. Lymph node status was defined as positive, negative, or unknown. Advanced disease was defined as the presence of a large, advanced-stage, high-grade tumor or lymph nodepositive tumor at the time of diagnosis. Statistical Analysis We calculated the frequency distributions of various risk factors for all women in the mammography registry cohort. Among the subset of women with breast cancer (n= 17558), we calculated the proportion of tumors that were invasive and, among invasive tumors, the proportion that were advanced-stage or high-grade tumors; we then calculated the distribution by race and ethnicity. For all women in the cohort, we evaluated whether overall and advanced cancer rates per 1000 mammograms were similar across racial and ethnic groups after we adjusted for age and registry by using Poisson regression. We then calculated whether adjusted overall and advanced cancer rates per 1000 mammograms were similar across mammography screening interval groups. Because overall and advanced cancer rates varied across racial and ethnic groups (P< 0.001) and by previous mammography use (P< 0.001), and because mammography use potentially varied by race and ethnicity, we modeled cancer rates among similarly screened women in each ethnic group. We used Poisson regression to adjust for age and registry; an interaction term between race and ethnicity and previous mammography use was included in the Poisson model to allow for possible differences in the association between ethnicity and cancer rates by mammography group

Racial and Ethnic Disparities in Care The Perspectives of Cardiologists

Background—Despite extensive documentation of racial and ethnic disparities in care, provider awareness of disparities has been thought to be low. To be effective, educational efforts for physicians must consider providers’ knowledge and beliefs about what causes disparities and what can be done about them. Methods and Results—We conducted a Web-based survey of 344 cardiologists to determine their level of awareness of disparities and views of underlying causes. Responses were assessed by means of 5-point Likert scales. Thirty-four percent of cardiologists agreed that disparities existed in care overall in the US healthcare system, and 33% agreed that disparities existed in cardiovascular care. Only 12% felt disparities existed in their own hospital setting, and even fewer, 5%, thought disparities existed in the care of their own patients. Despite this, most respondents rated the strength of the evidence about disparities as “very strong” or “strong.” Respondents identified many potential causes for disparities in care but were more likely to endorse patient and system level factors (eg, insurance status or adherence) rather than provider level factors. Conclusions—Cardiologists’ awareness of disparities in care remains low, and awareness is inversely proportional to proximity to their own practice setting.

Integrating social media into emergency-preparedness efforts.

Social media are changing the way people communicate both in their day-to-day lives and during disasters that threaten public health. Engaging with and using such media may help the emergency-management community to respond to disasters.

Conceptualizing and defining public health emergency preparedness

Since September 11, 2001, and the anthrax attacks that followed, a substantial federal investment—totaling well in excess of

Neighborhoods and cumulative biological risk profiles by race/ethnicity in a national sample of U.S. Adults: NHANES III.

5 billion—has been made to increase our nation’s ability to prepare for, and respond to, public health emergencies. Yet despite anecdotal reports suggesting that progress has been made, it is unclear whether these investments have left the nation better prepared to respond to a bioterrorist attack, pandemic influenza, or any other large-scale public health emergency. This situation is not because of a shortage of measures of preparedness. Over the past 5 years, federal agencies, state health departments, and various nongovernmental organizations have proposed and implemented myriad measures of public health emergency preparedness. But these efforts have not resulted in a clear picture of the nation’s preparedness owing to ambiguous and uncertain preparedness goals, a lack of agreement about what the measures should aim at and how they should be interpreted, and a weak system of accountability for producing results.1 Measures often vary considerably across agencies and shift dramatically from year to year, leaving state and local health officials, businesses, nonprofits, and citizens confused and perplexed by a maze of overlapping and sometimes contradictory requirements, checklists, and ideas about what constitutes preparedness.2–4 What our nation needs in order to bring coherence to the debate is a clear definition of public health emergency preparedness and an articulation of the key elements that characterize a well-prepared community. In this editorial, we propose a candidate definition of public health emergency preparedness and describe its key elements. Both the definition and the elements were developed by a diverse panel of experts convened by RAND in February 2007. We propose the following definition: public health emergency preparedness (PHEP) is the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities. Preparedness involves a coordinated and continuous process of planning and implementation that relies on measuring performance and taking corrective action. In developing the definition, we considered what constitutes a public health emergency, what public health emergency preparedness requires, and who is involved in it.

How do house officers spend their nights? A time study of internal medicine house staff on call.

PURPOSE To examine race/ethnic-specific patterns of association between neighborhood socioeconomic status (NSES) and a cumulative biological risk index in a nationally representative population. METHODS The study sample included 13,199 white, black, and Mexican-American men and women, ages 20 and older, who attended the National Health and Examination Survey examination (1988-1994). Neighborhoods were defined as census tracts and linked to U.S. Census measures from 1990 and 2000, interpolated to the survey year; the NSES score included measures of income, education, poverty, and unemployment and was categorized into quintiles, with the highest indicating greater NSES. A summary biological risk score, allostatic load (AL; range 0-9), was created from 9 biological indicators of elevated risk: serum levels of C-reactive protein, albumin, glycated hemoglobin, total and high-density lipoprotein cholesterol, waist-to-hip ratio, systolic and diastolic blood pressure, and resting heart rate. Regression models stratified by race/ethnicity examined AL as a continuous and dichotomous (>or=3 vs. <3) outcome. RESULTS We found strong inverse associations between NSES and AL for black subjects, after adjusting for age, sex, U.S. birth, urban location, and individual SES. These associations were weaker and less consistent for Mexican Americans and whites. CONCLUSIONS Our results indicate that living in low NSES neighborhoods is most strongly associated with greater cumulative biological risk profiles in the black U.S. population.

Does receipt of seasonal influenza vaccine predict intention to receive novel H1N1 vaccine: evidence from a nationally representative survey of U.S. adults.

Recommendations to limit the working hours of house staff are forcing directors of training programs to reevaluate how house officers spend their time. We studied how 35 house officers in internal medicine spent their on-call time in three teaching hospitals: an urban county hospital, a university hospital, and a regional Veterans Administration medical center. Trained observers accompanied each member of different on-call teams for five nights and quantified how their time was spent. Teams consisting of residents and interns admitted three new patients per night at the Veterans Administration hospital, six at the university hospital, and eight at the county hospital. Each house officer received 16 to 25 calls per night. Up to 12 percent of their time was spent doing procedures (such as inserting intravenous catheters or drawing blood specimens) most of which could have been done by nonphysicians. From 87 to 175 minutes of on-call time was spent in direct patient evaluation, and the mean time spent on each new-patient evaluation ranged from 17 to 31 minutes. The mean time before the evaluation was interrupted ranged from 7 to 11 minutes. In contrast, 66 to 197 minutes per night was spent documenting new-patient evaluations in the hospital record. The average sleep time ranged from 122 to 273 minutes; however, the mean time before sleep was interrupted ranged from 40 to 86 minutes. We conclude that while on call, house officers spend relatively little time in direct patient contact, but they spend considerable time charting. They are frequently interrupted while working and trying to sleep. These data may be useful in finding administrative ways to improve patient care and the experience of the house staff while on call and in evaluating the effect of reforms.

Does place explain racial health disparities? Quantifying the contribution of residential context to the Black/white health gap in the United States

We analyze data on the intention of U.S. adults to receive novel H1N1 vaccine if available this fall, and studies the relationship between the intention to be vaccinated against novel H1N1 and the uptake of seasonal influenza vaccine last year. We surveyed a nationally representative sample of U.S. adults (n=2067) via the Internet between May 26th and June 8th, 2009. Our results imply a vaccination rate for novel H1N1 of 49.6%, which corresponds to roughly 115 million adult vaccinations. Moreover, novel H1N1 vaccination intentions are strongly associated with seasonal influenza vaccinations, suggesting common attitudinal barriers to both vaccines.