摘要:

Background.Research on racial and ethnic health disparities in the United States requires that self-report measures, developed primarily in mainstream samples, are appropriate when applied in diverse groups. To compare groups, mean scores must reflect true scores and have minimal bias, assumptions that have not been tested for many self-report measures used in this research.Objective.To identify conceptual and psychometric issues that need to be addressed to assure the quality of self-report measures being used in health disparities research.Methods.We present 2 broad conceptual frameworks for health disparities research and describe the main research questions and measurement issues for 4 key concepts hypothesized as potential mechanisms of health disparities: socioeconomic status, discrimination, acculturation, and quality of care. This article is based on a small conference convened by 6 Resource Centers for Minority Aging Research (RCMAR) measurement cores. We integrate written materials prepared for the conference by quantitative and qualitative measurement specialists and cross-cultural researchers, conference discussions, and current literature.Results.Problems in the quality of the conceptualizations and measures were found for all 4 concepts, and little is known about the extent to which measures of these concepts can be interpreted similarly across diverse groups. Many problems also apply to other concepts relevant to health disparities. We propose an agenda for accomplishing this challenging measurement research.Conclusions.The current national commitment to reduce health disparities may be compromised without more research on measurement quality. Integrated, systematic efforts are needed to move this work forward, including collaborative efforts and special initiatives.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Black Americans with diabetes have a higher burden of illness and mortality than do white Americans. However, the extent to which differences in medical care processes and treatment intensity contribute to poorer diabetes outcomes is unknown.Objective.To assess racial disparities in the quality of diabetes care processes, intermediate outcomes, and treatment intensity.Methods.We conducted an observational study of 801 white and 115 black patients who completed the Diabetes Quality Improvement Project survey (response rate = 72%) in 21 Veterans Affairs (VA) facilities using survey data; medical record information on receipt of diabetes services (A1c, low-density lipoprotein [LDL], nephropathy screen, and foot and dilated eye examinations), and intermediate outcomes (glucose control measured by A1c; cholesterol control measured by LDL; and achieved level of blood pressure); and pharmacy data on filled prescriptions.Results.There were no racial differences in receipt of an A1c test or foot examination. Blacks were less likely than whites to have LDL checked in the past 2 years (72% vs. 80%,P<0.05) and to have a dilated eye examination (50% vs. 63%,P<0.01). Even after adjusting for patients’ age, education, income, insulin use, diabetes self-management, duration, severity, comorbidities, and health services utilization, racial disparities in receipt of an LDL test and eye examination persisted. After taking into account the nested structure of the data using a random intercepts model, blacks remained significantly less likely to have LDL testing than whites who received care within the same facility (68% vs. 83%,P<0.01). In contrast, there were no longer differences in receipt of eye examinations, suggesting that black patients were more likely to be receiving care at facilities with overall lower rates of eye examinations. After adjusting for patient characteristics and facility effects, black patients were substantially more likely than whites to have poor cholesterol control (LDL ⩾130) and blood pressure control (BP ⩾140/90 mm Hg) (P<0.01). Among those with poor blood pressure and lipid control, blacks received as intensive treatment as whites for these conditions.Conclusions.We found racial disparities in some diabetes care process and intermediate outcome quality measures, but not in intensity of treatment for those patients with poor control. Disparities in receipt of eye examinations were the result of black patients being more likely to receive care at lower-performing facilities, whereas for other quality measures, racial disparities within facilities were substantial.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.The role of race/ethnicity in the receipt of arthritis-specific health care has not been well defined.Objective.To examine the association of race/ethnicity with the utilization of arthritis health care among community-dwelling older adults.Research Design.We used a computer-assisted telephone interview.Subjects.A population-based random sample was drawn from 6 preselected Alabama counties. Eligible respondents had self-reported arthritis and were over 50 years of age; 1424 people responded to the survey.Measures.Logistic regression was used to examine the association of race/ethnicity with the use of conventional (including use of a rheumatologist, primary care physician, and prescription arthritis medicines) and complementary and alternative medicines (CAM), including the use of chiropractic care, glucosamine and/or chondroitin, and herbals.Results.Reflecting stratified sampling, respondents were white (n = 852, 60%) or black (n = 528, 37%), female (72%), and had a mean age of 65 years. After multivariable adjustment, race/ethnicity was not a significant determinant of receiving rheumatology care or prescription arthritis medicines. However, whites were more likely than blacks to have seen a primary care physician for arthritis care (adjusted odds ratio [OR], 1.49; 95% confidence interval [CI], 1.12–1.98) or to have used CAM (OR, 1.47; 95% CI, 1.13–1.91) and twice as likely to have used glucosamine and/or chondroitin (OR, 1.99; 95% CI, 1.30–3.05).Conclusion.In this population of community-dwelling older adults, white race was significantly associated with CAM use and visits to primary care physicians for arthritis care. In contrast, the use of specialists and prescription arthritis medications was better explained by factors other than race/ethnicity, which included female gender, urban residence, higher educational level, and other arthritis-specific variables.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Numerous studies have documented substantial differences by race and gender in the use of coronary artery bypass graft surgery and percutaneous coronary angioplasty. However, few studies have examined whether these differences reflect problems in quality of care.Method.We selected a random sample stratified by gender, race, and income of 5026 Medicare beneficiaries aged 65 to 75 who underwent inpatient coronary angiography during 1991 to 1992 in 1 of 5 states. We compared the frequency of 2 problems in quality by race and gender: underuse or the failure to receive a clinically indicated revascularization procedure and receipt of revascularization when it was not clinically indicated. We used 2 independent sets of criteria developed by the RAND Corporation and the American College of Cardiology/American Hospital Association (ACC/AHA). We also examined survival of the cohort through March 31, 1994.Results.Revascularization procedures were clinically indicated more frequently among whites than blacks and among men than women. Failure to receive revascularization when it was indicated was more common among blacks than among whites (40% vs. 23–24%, depending on the criteria, bothP<0.001) but similar among men and women (25% vs. 22–24%,P>0.05). Racial disparities remained similar after adjusting for patient and hospital characteristics. Among patients rated inappropriate, use of procedures was greater for whites than blacks using RAND criteria (10.5% vs. 5.8%,P<0.01) and greater for men than for women (14.2% vs. 5.3% by RAND criteria,P= 0.001; 8.2% vs. 4.0%% by ACC/AHA criteria,P= 0.04). After multivariate adjustment, the disparities for race and gender remained similar and were statistically significant using RAND criteria. Mortality rates tended to validate our appropriateness criteria for underuse.Conclusions.Racial differences in procedure use reflect higher rates of clinical appropriateness among whites, greater underuse among blacks, and more frequent revascularization when it was not clinically indicated among whites. Underuse is associated with higher mortality. In contrast, men had higher rates of clinical appropriateness and were more likely to receive revascularization when it was not clinically indicated. There was no evidence of greater underuse among women.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Racial disparities have been widely documented in medical care, but variations in dental care have not been well examined.Objectives.To determine if there is racial variation in use of root canal therapy versus tooth extraction across different levels of dental insurance coverage and adjusting for other factors known to influence treatment decisions.Methods.Within 3 different categories of insurance coverage, we examined whether there were racial differences in the provision of the tooth-sparing treatment of root canal therapy (vs. tooth extraction) among 54,423 users of outpatient Veterans Affairs dental care in 1998. Regression analyses adjusted for the severity of tooth- and gum-related disease, age, sex, medical and psychiatric comorbidities, prior use of preventive dental services, tooth extraction and root canal therapy, and clustering by geographic region.Results.In the adjusted regression models, black patients and those with unknown race were less likely overall to receive root canal therapy than whites, whereas Asians were more likely. Among patients with eligibility for continuing and comprehensive dental care, blacks were less likely and Asians more likely to receive root canals than whites. For patients covered only for emergency dental care, Hispanics had a higher likelihood of receiving root canal therapy. Among all other types of coverage, there were no significant racial differences in the care received.Conclusion.We observed substantial racial variations in the provision of root canal therapy among patients treated in Department of Veterans Affairs dental clinics. Future research should identify the causes of such variations.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Relatively little is known about the association between menopause and health-related quality of life (HRQL) across ethnic groups.Objectives.To examine the association between HRQL and early perimenopause and ethnicity, adjusting for health, lifestyle, psychosocial, and sociodemographic factors.Research Design.Questionnaires were administered to pre- and early perimenopausal women.Subjects.We studied a cohort of 3302 black, Chinese, Hispanic, Japanese, and white women aged 42 to 52 years from the multisite Study of Women’s Health Across the Nation (SWAN).Measures.We measured HRQL, menstrual regularity, and a variety of covariates. HRQL was assessed with 5 subscales from the Short Form-36; impaired functioning was defined as being in the 25% most impaired on a subscale.Results.In unadjusted, but not adjusted, analyses, significantly more early perimenopausal women, as compared with premenopausal women, were classified as having impaired functioning on each of the 5 subscales. For 4 of the subscales, the effect of menopausal status was explained by menopause-related symptoms. There were significant ethnic group differences across all 5 subscales in unadjusted analyses. Ethnicity was no longer significant for the Vitality or Role–Emotional subscales when adjusted for health variables or for the Role–Physical subscale when analyses were adjusted for socioeconomic status, health, lifestyle, or social circumstances. Ethnicity remained significant for the Bodily Pain and Social Functioning subscales, even in adjusted analyses.Conclusions.Early perimenopause is not associated with impaired functioning when adjusted for symptoms. Significant ethnic differences in HRQL exist. Some, but not all, differences can be explained by differences in health, lifestyle, and social circumstances.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.The profile-based SF-12 has a low respondent burden and is used widely in clinical settings to monitor health and evaluate programs. Deriving preference scores for the SF-12 health profile would permit its use in cost-effectiveness analyses. Previous mapping studies of SF family instruments to preference-based instruments have not examined convergent validity or performance in low-income, minority populations.Objectives.To map the SF-12 to the EuroQol (EQ-5D Index) and the Health Utilities Index Mark 3 (HUI3) in a low-income, predominantly minority sample.Research Design.We used a cross-sectional survey data.Subjects.We studied a convenience sample of 240 low-income, predominantly Latino and black patients attending a community health center in New York.Measures.We used separate regressions of the EQ-5D Index and HUI3 onto the physical (PCS-12) and mental (MCS-12) components of the SF-12 scores as measures.Results.For the EQ-5D Index regression, the adjusted variance explained was 58% (bootstrap validation 95% confidence interval [CI], 46–66). For the HUI3 regression, the adjusted variance explained was 51% (bootstrap 95% CI, 39–59). The correlation coefficient between the 2 predicted measures was 0.96. The correlation of the predicted HUI3 with the EQ-5D Index (0.73) and the predicted EQ-5D Index with the HUI3 (0.70) exceeded that between the 2 original preference-based measures themselves (0.69).Conclusions.These pilot results suggest that the SF-12 could be successfully mapped to both the EQ-5D Index and HUI3, yielding preference-based scores that demonstrate convergent validity in a low-income, minority sample.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.A number of self-administered questionnaires are available for assessing depression severity, including the 9-item Patient Health Questionnaire depression module (PHQ-9). Because even briefer measures might be desirable for use in busy clinical settings or as part of comprehensive health questionnaires, we evaluated a 2-item version of the PHQ depression module, the PHQ-2.Methods.The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past 2 weeks, scoring each as 0 (“not at all”) to 3 (“nearly every day”). The PHQ-2 was completed by 6000 patients in 8 primary care clinics and 7 obstetrics–gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.Results.As PHQ-2 depression severity increased from 0 to 6, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and healthcare utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-2 score ≥3 had a sensitivity of 83% and a specificity of 92% for major depression. Likelihood ratio and receiver operator characteristic analysis identified a PHQ-2 score of 3 as the optimal cutpoint for screening purposes. Results were similar in the primary care and obstetrics–gynecology samples.Conclusion.The construct and criterion validity of the PHQ-2 make it an attractive measure for depression screening.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective.Nonattendance is a major health services research and management issue that has received little attention or systematic study in Asia. We examined the independent associations between waiting time, doctor shopping, and nonattendance in specialist outpatient clinics of 4 large public hospitals in Hong Kong.Research Design.Case-control study.Setting and Participants.A total of 6495 attenders and nonattenders enrolled from July 2000 through October 2001.Pain Outcome Measures.Odds ratios (ORs) and associated 95% confidence intervals (CI) for nonattendance.Results.Longer waiting times (adjusted OR2nd quartile, 1.67; 95% CI, 1.38–2.03; adjusted OR3rd quartile, 1.90; 95% CI, 1.56–2.30; adjusted OR4th quartile, 2.30; 95% CI, 1.91-2.78) and doctor-shopping behavior (adjusted OR, 2.91; 95% CI, 2.51–3.38) were independent risk factors for nonattendance. These effects were robust after multivariate adjustment and testing for effect modification. They also appeared to persist uniformly across hospitals and specialties. There was no demonstrable relationship between waiting time and doctor shopping.Conclusions.This is the largest study of nonattendance at outpatient clinics and the first such study carried out in Asia. Targeted strategies should be implemented and evaluated using these results to reduce waiting time, doctor shopping, and ultimately nonattendance.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.We examine the ability of various publicly available risk models to identify high-cost individuals and enrollee groups using multi-HMO administrative data.Methods.Five risk-adjustment models (the Global Risk-Adjustment Model [GRAM], Diagnostic Cost Groups [DCGs], Adjusted Clinical Groups [ACGs], RxRisk, and Prior-expense) were estimated on a multi-HMO administrative data set of 1.5 million individual-level observations for 1995–1996. Models produced distributions of individual-level annual expense forecasts for comparison to actual values. Prespecified “high-cost” thresholds were set within each distribution. The area under the receiver operating characteristic curve (AUC) for “high-cost” prevalences of 1% and 0.5% was calculated, as was the proportion of “high-cost” dollars correctly identified. Results are based on a separate 106,000-observation validation dataset.Main Results.For “high-cost” prevalence targets of 1% and 0.5%, ACGs, DCGs, GRAM, and Prior-expense are very comparable in overall discrimination (AUCs, 0.83–0.86). Given a 0.5% prevalence target and a 0.5% prediction threshold, DCGs, GRAM, and Prior-expense captured $963,000 (approximately 3%) more “high-cost” sample dollars than other models. DCGs captured the most “high-cost” dollars among enrollees with asthma, diabetes, and depression; predictive performance among demographic groups (Medicaid members, members over 64, and children under 13) varied across models.Conclusions.Risk models can efficiently identify enrollees who are likely to generate future high costs and who could benefit from case management. The dollar value of improved prediction performance of the most accurate risk models should be meaningful to decision-makers and encourage their broader use for identifying high costs.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID