Sarita A. Mohanty

Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis

OBJECTIVES We compared the health care expenditures of immigrants residing in the United States with health care expenditures of US-born persons. METHODS We used the 1998 Medical Expenditure Panel Survey linked to the 1996-1997 National Health Interview Survey to analyze data on 18398 US-born persons and 2843 immigrants. Using a 2-part regression model, we estimated total health care expenditures, as well as expenditures for emergency department (ED) visits, office-based visits, hospital-based outpatient visits, inpatient visits, and prescription drugs. RESULTS Immigrants accounted for

Diabetes and cardiovascular disease among asian indians in the united states

39.5 billion (SE=

I want to be taking my own last breath: patients' reflections on illness when presenting to the emergency department at the end of life.

4 billion) in health care expenditures. After multivariate adjustment, per capita total health care expenditures of immigrants were 55% lower than those of US-born persons (

Emergency department research in palliative care: challenges in recruitment.

1139 vs

Chronic Kidney Disease and US Healthcare Resource Utilization in a Nationally Representative Sample

2546). Similarly, expenditures for uninsured and publicly insured immigrants were approximately half those of their US-born counterparts. Immigrant children had 74% lower per capita health care expenditures than US-born children. However, ED expenditures were more than 3 times higher for immigrant children than for US-born children. CONCLUSIONS Health care expenditures are substantially lower for immigrants than for US-born persons. Our study refutes the assumption that immigrants represent a disproportionate financial burden on the US health care system.

Treatment Preferences: Impact of Risk and Benefit in Decision Making

AbstractCONTEXT: Studies, mostly from outside the United States, have found high prevalence of diabetes, coronary heart disease (CHD), and hypertension among Asian Indians, despite low rates of associated risk factors. OBJECTIVE: To analyze the prevalence of obesity, diabetes, CHD, hypertension, and other associated risk factors among Asian Indians in the United States compared to non-Hispanic whites. DESIGN, SETTING, AND SUBJECTS: Cross-sectional study using data from the National Health Interview Survey (NHIS) for 1997, 1998, 1999, and 2000. We analyzed 87,846 non-Hispanic whites and 555 Asian Indians. MAIN OUTCOME MEASURES: Whether a subject reported having diabetes, CHD, or hypertension. RESULTS: Asian Indians had lower average body mass indices (BMIs) than non-Hispanic whites and lower rates of tobacco use, but were less physically active. In multivariate analysis controlling for age and BMI, Asian Indians had significantly higher odds of borderline or overt diabetes (adjusted OR [AOR], 2.70; 95% confidence interval [CI], 1.72 to 4.23). Multivariate analysis also showed that Asian Indians had nonsignificantly lower odds ratios for CHD (AOR, 0.58; 95% CI, 0.25 to 1.35) and significantly lower odds of reporting hypertension (AOR, 0.58; 95% CI, 0.42 to 0.82) compared to non-Hispanic whites. CONCLUSION: Asian Indians in the United States have higher odds of being diabetic despite lower rates of obesity. Unlike studies on Asian Indians in India and the United Kingdom, we found no evidence of an elevated risk of CHD or hypertension. We need more reliable national data on Asian Indians to understand their particular health behaviors and cardiovascular risks. Research and preventive efforts should focus on reducing diabetes among Asian Indians.

Effects of hospital closures and hospital characteristics on emergency department ambulance diversion, Los Angeles County, 1998 to 2004.

OBJECTIVE To understand perceptions regarding their illness of patients who present to the Emergency Department at the end of life. METHODS Semistructured one-on-one interviews were performed with a convenience sample of seriously ill, Emergency Department (ED) patients with advanced illness presenting to an urban, public hospital. A bilingual Latina health promoter used a predetermined discussion guide to conduct all interviews. Non-English- or Non-Spanish-speaking patients and those with uncontrolled symptoms or cognitive deficits were excluded. All interviews were recorded and transcribed, and grounded theory methodology was used to analyze the results. RESULTS Thirteen patients with advanced illness participated, 8 of whom were Spanish-speaking only. Because of difficulty accessing care and financial concerns, patients with advanced illness present to EDs when their pain or other symptoms are out of control. The majority derive great comfort and strength from their faith in God, who they believe determines their fate. Most listed spending time with family, and not being a burden, as most important at the end of life, and many expressed a preference to die at home surrounded by loved ones. Almost none had spoken to physicians about their care preferences. CONCLUSIONS Patients with advanced illness present to the ED of a safety net hospital when symptoms are out of control. They have many financial concerns, want to spend their remaining days with family, and do not want to be a burden. Most derive immense comfort from faith in God, but do not feel they have control over their own fate.

Emergency Medicine Physicians' Perspectives of Providing Palliative Care in an Emergency Department

Dear Editor: Measuring the health outcomes of studies involving seriously ill patients in acute care settings can be challenging. Recruiting patients who are severely ill and under physical and emotional distress is often complicated by rapid changes in clinical status and high acuity. The difficulty encountered by palliative care researchers due to issues of nonenrollment is real and leads to biased studies that exclude the exact group of patients we wish to evaluate. Emergency departments (EDs) can provide an ideal opportunity to study patients with significant palliative care needs. Early intervention in the ED can lead to more timely provision of care, including direct referral to hospice, and can be cost effective due to reduced hospital length of stay. While this group of patients is important to study, there are as yet no published randomized controlled trials in the ED that measure outcomes of palliative care interventions. We recently completed enrollment for a prospective, randomized trial of an ED-based palliative care intervention (EDHELP), which compared an early palliative care consult (within 4 hours of consult initiation) to standard care (patients typically seen by the palliative care team at the discretion of the inpatient team or after 8 hours). Outcome data will be presented in a future article. This letter discusses the enrollment issues of this study. The study was conducted in the ED of a large public hospital serving a largely Latino population. Bilingual and bicultural staff recruited patients in the ED. We block-randomized by week as to whether a patient received an early palliative care consult versus standard care. The consent could only be completed by the patient, not by surrogates. Palliative care services were explained to the patient during the consent process. The study design and procedures were approved by the study site’s Institutional Review Board. Approximately 390 patients were offered participation in the study. The majority of patients had cancer (64%, n1⁄4 251) followed by organ failure (23%, n1⁄4 88). Only approximately half (49%, n1⁄4 193) passed a cognitive screen, spoke Spanish or English, and agreed to participate. The most common reason for not enrolling was the inability to complete the interview due to acuity (38%, n1⁄4 74). One quarter of the patients who did not enroll stated concerns about signing a consent form. We also lost 16 patients because of transfer to home or the inpatient bed prior to the study completion. Cultural and socioeconomic factors may have influenced recruitment. A study among a predominantly African American population found a ‘‘recruitment triangle’’ that influences whether patients will enroll in a study. The triangle arms include the patient, family members and friends, and treatment team (typically the primary physician). The triangle was pivotal in gaining patient trust. Among Latinos, family is also highly valued, and family member inclusion in the consent process would have likely increased recruitment. Ling et al. recommend that during enrollment in palliative care trials, investigators should not use the same methods as a trial for a new cancer therapeutic agent—they should reduce the requirements for enrollment and create realistic entry criteria. Similar to our study, Ling et al. found the following common reasons given for unwillingness to participate: (1) deterioration in condition; (2) transfer to another unit; (3) inability to give consent; or (4) family objection. Many of our study patients preferred to have family present, could not make the decision alone, or had family object to consent. Our nonenrolled study patients may have had an unclear understanding of what palliative care services can offer. While we tailored the consent to provide information about the service, there may have been patient concerns that were not addressed. In prospective trials, it is not always clear that a fully informed evaluation of the pros and cons of participation and nonparticipation has taken place. Research trials to study the impact of palliative care into the ED are important. When conducting such trials, investigators must consider barriers to recruitment and be creative and attuned to the specific needs of the targeted population. Enrollment of patients in future studies may require Institutional Review Boards to accept presumed or emergency consents that is often are being used in resuscitation research. In order to answer key palliative care questions and in the end improve care for patients at the end of life, such approaches to enrollment should be advocated. Ultimately, this group of patients with high acuity in need of palliative care deserve patients in need of palliative care deserve further investigation; however, investigators must be aware of the challenges in recruitment.

Predictors of on-call specialist response times in California emergency departments.

Background: Chronic kidney disease (CKD) is a prevalent condition; however, little is known about healthcare resource utilization (HRU) by CKD patients. Methods: This analysis included NHANES participants aged ≥18 years, with serum creatinine, urine protein, and hemoglobin measurements. We assessed the association between CKD (stratified by stage) and HRU based on self-reported physician visits and hospitalizations in the year preceding the survey. Results: Of the 15,258 included in this analysis, 2,110 had early CKD (stage 1 and 2 CKD) and 1,121 had late CKD (stage 3 and 4 CKD). Mean (SE) number of annual physician visits were 3.51 (0.08), 4.43 (0.18), and 6.53 (0.38) for participants with no CKD, early CKD, and late CKD, respectively. Mean (SE) number of annual hospitalizations were 0.15 (0.01), 0.19 (0.01), and 0.42 (0.03) for participants with no CKD, early CKD, and late CKD, respectively. Participants with late CKD were more likely to have more physician visits (OR 1.81, 95% CI 1.46, 2.23) and have more hospital admissions (OR 2.12, 95% CI 1.66, 2.71) compared with participants with early CKD or no CKD. Conclusions: In this analysis, late stage CKD was associated with increased HRU, suggesting the need for early identification and treatment of CKD and its associated conditions.

Are medical records a more reliable and valid source of CD4 count, viral load, and outpatient visit data than self-reports? A comparison with electronic medical records as the gold standard

Understanding treatment preferences of seriously ill patients is complex. Previous studies have shown a correlation between the burden and outcome of a treatment and the likelihood a patient will accept a given intervention. In this study the Willingness to Accept Life Sustaining Treatment (WALT) survey was used in a predominantly Latino population receiving care at a large urban safety net hospital. Eligible patients were cared for by one of four clinics: (1) human immunodeficiency virus (HIV); (2) geriatrics; (3) oncology; or (4) cardiology. Hypothetical scenarios reflecting outcomes of resuscitation were presented and patients were given information on the burden and outcome of treatment. They were then given the option of accepting or declining treatment; 237 completed the survey. Patients in our study were willing to accept a high level of cognitive (vegetative state) and functional (bed-bound) impairment even when the chance of recovery was exceedingly low.