R. Paul Duncan

Risk indicators of edentulism, partial tooth loss and prosthetic status among black and white middle-aged and older adults

OBJECTIVES To describe the prevalence and risk indicators of edentulism; to describe the frequencies of wearing removable dentures; to describe the prevalence and risk indicators of fixed prosthetic restorations; to test the hypothesis that fixed prosthetic restorations are most likely to have been placed in persons at lower risk for dental and periodontal diseases, and to test the hypothesis that, with dental disease, dental behaviors, dental attitudes and ability to afford crowns taken into account, blacks are less likely than whites to have received crowns. METHODS The Florida Dental Care Study is a cohort study of subjects 45 years old or older. A telephone screening interview was done as a first stage to identify 5254 subjects who met eligibility requirements and who self-reported whether they were edentulous. In a second stage, a subsample of dentate subjects was contacted after they completed their telephone screening interview. Of these, 873 subjects completed a baseline in-person interview and dental examination. RESULTS A total of 19% of first-stage subjects were edentulous. In a single multiple logistic regression, having a poorer self-rated level of general health was significantly associated with edentulism, as were being poor, older and white. Among the second-stage participants (all of whom were dentate), several prosthetic patterns were observed. For example, a total of 64% of maxillary full denture wearers reported wearing their denture all the time. Participants had also received numerous fixed prosthodontic services. The proportion of subjects with at least one crown varied widely by subject characteristics. CONCLUSIONS A substantial percentage of non-ideal frequencies of wearing removable prostheses was reported, as were prosthesis-related soreness and broken prostheses. Although we expected and observed an association between having a fixed prosthetic crown and periodontal status, dental fillings, dental attitudes and financial resources, a residual association with race suggests that blacks are much less likely to receive prosthetic crowns. The several possible reasons for this circumstance warrant further investigation.

Pain and the use of outpatient Services among persons with HIV: Results from a nationally representative survey

BackgroundThe negative impact of pain on health-related quality of life has been documented for persons with human immunodeficiency virus (HIV). Furthermore, pain could be an important factor in seeking medical care. However, the relationship between pain and health service utilization is poorly understood. ObjectivesThe objective of this study was to investigate the effect of pain on use of outpatient services among a nationally representative sample of adults receiving medical care for HIV using Andersen’s Behavioral Model of Health Services Use. MethodsWe used Poisson regression to assess outpatient use over 6 months among 2267 respondents in the HIV Cost and Services Utilization Study. Key predisposing variables include gender and race/ethnicity. Enabling factors include income and insurance. Need factors include pain, CD4 count, and diagnosis of acquired immunodeficiency syndrome (AIDS). ResultsSixty-seven percent of respondents reported experiencing pain during the previous 4 weeks. Self-reported pain was higher among those with AIDS, intravenous drug-using females, the unemployed, and those without a baccalaureate degree, but lower among blacks. Patients reporting more pain and those developing more pain used more outpatient services. Poorer health (CD4 count <50 cells/mm3, less energy) was also associated with higher use. Persons with Medicare, Medicaid, or private insurance were more likely to have used outpatient services than the uninsured. Persons with a private HMO were no more likely to use services than those without insurance. ConclusionsImproved pain management could reduce outpatient use for persons experiencing pain and lead to substantial cost savings. Inequalities in outpatient use related to insurance are evident.

National Institutes of Health State-of-the-Science Conference Statement: Enhancing Use and Quality of Colorectal Cancer Screening

Each year, nearly 150 000 persons receive a diagnosis of colorectal cancer (CRC) and 50 000 die of the disease. Screening reduces CRC mortality, but many eligible patients do not receive screening....

The pivotal impact of center characteristics on survival of candidates listed for deceased donor kidney transplantation.

Background:There are currently over half a million end-stage renal disease patients and >70,000 patients listed to receive a deceased donor kidney transplant in the United States. To receive a deceased donor transplant, patients are placed on a waiting list at one of approximately 240 centers. Although candidate decisions to list at a particular center may often be made passively (based on proximity or physician referral), the important question remains as to whether the center of listing has a significant impact on patient outcomes. Methods:The study evaluated adult kidney transplant candidates in the United States listed from 1995 to 2000 (n = 108,928) with follow-up through 2006. The primary outcome of patient survival was investigated with survival models evaluated with respect to 4 center characteristics (volume, donor quality, waiting time, past performance). Center characteristics derived from years preceding listing, simulating information that could be attainable for prospective candidates. Results:Center waiting time had a marked association with survival (Adjusted hazard ratio = 1.32, 95% confidence interval: 1.27–1.38 for the longest waiting times). Past performance and donor quality also had significant association with survival; center volume was not a significant factor. The cumulative impact of center factors resulted in an average 4-year difference in life expectancy. Center characteristics at listing were strongly correlated with levels at the time of transplantation and centers with the “best” characteristics were located in every region of the country. Conclusions:Center characteristics have significant impact on kidney transplant candidate survival. Information regarding the variability and importance of center factors should be clearly disseminated to transplant candidates.

Race Differences in the Health of Elders who Live Alone

This investigation was initiated to determine whether older African Americans who live alone are in poorer health than their White counterparts who live under the same circumstances. Data on 5 measures of health were collected in telephone interviews with a stratified random sample of community-dwelling elders (n = 1,189). Analysis of weighted data indicate that there were fewer differences in health by race among older persons who lived alone compared to elders who lived with others. Where racial differences in health did exist among older adults who lived alone, the differences could only sometimes be accounted for by population composition factors that are known to influence health.

Older Floridians' attitudes toward and use of dental care.

Older Floridians (mean age 78 years) were interviewed regarding their use of dental care, attitudes toward dental care, and other characteristics hypothesized as being explanatory of dental care use. Fifty-two percent of respondents reported having been to a dentist within the past year, and 31% had not been within the previous 5 years. Five constructs measured attitudes toward dental care and dental health: (a) the importance placed on regular dental care and oral hygiene, (b) the importance of avoiding tobacco to prevent oral cancer, (c) the value of dental care, (d) negative aspects of dental care, and (e) satisfaction with the last dental visit. In a multivariate model, the value of dental care and importance of regular care and oral hygiene were significantly correlated with dental care use. These findings are consistent with the conclusion that attitudes contribute to understanding dental care use in later life, a contribution that is independent of the direct effects of socioeconomic status and dentate status.

Community-based nursing: Continence care for older rural women☆

Abstract The current emphasis on community-based health care makes necessary the implementation and evaluation of nursing practice models that address specific health problems, such as urinary incontinence, of older women living at home in rural communities.

Race and Residence Differences in the Use of Formal Services by Older Adults

Using a longitudinal panel that oversampled older (65+) African Americans and rural residents of north Florida, this study examines race and residence differences in the use of four services: two community-based services (senior centers and special transportation) and two home-based services (homemaker and nursing care). Significant differences across race and residence groups in the use of these services were identified. Black elders, especially rural Blacks, had higher odds of using community-based services, net of other sociodemographic, social support, and health characteristics. In contrast, rural elders were most likely to use homemaker services, controlling for other factors including race. Neither race nor residence was a significant predictor of the use of in-home nursing services in this sample. The findings are discussed within the context of the importance of examining both the individual and combined influences of race and residence on formal service use.

Implementing a Continuous Quality Improvement Program in a Community Hospital

Hospitals and other health care institutions have been slow to adopt some of the quality innovations developed in manufacturing. The growing literature on these methods includes few specifics on how to implement the process in health care institutions. This article describes a single community hospitals implementation of the Hospital Corporation of Americas Hospitalwide Quality Improvement Process, a model developed from the Deming method of statistics-based continuous quality improvement. The article addresses common questions about implementation, citing both examples of success and areas of difficulty.

Coverage of the Uninsured and Underinsured

Traditionally, Americans have obtained individual and family health insurance coverage in one of three ways. Some have been covered by public programs (Medicaid for the very poor, Medicare for the ...