Racial differences in health-related beliefs, attitudes, and experiences of VA cardiac patients: scale development and application

The Association Between Racialized Discrimination in Health Care and Pain Among Black Patients With Mental Health Diagnoses

Chronic pain is a costly and debilitating problem in the United States, and its burdens are exacerbated among socially disadvantaged and stigmatized groups. In a cross-sectional study of Black Veterans with chronic pain at the Atlanta VA Health Care System (N = 380), we used path analysis to explore the roles of racialized discrimination in health care settings, pain self-efficacy, and pain-related fear avoidance beliefs as potential mediators of pain outcomes among Black Veterans with and without an electronic health record-documented mental health diagnosis. In unadjusted bivariate analyses, Black Veterans with a mental health diagnosis (n = 175) reported marginally higher levels of pain-related disability and significantly higher levels of pain interference compared to those without a mental health diagnosis (n = 205). Path analyses revealed that pain-related disability, pain intensity, and pain interference were mediated by higher levels of racialized discrimination in health care and lower pain self-efficacy among Black Veterans with a mental health diagnosis. Pain-related fear avoidance beliefs did not mediate pain outcomes. These findings highlight the need to improve the quality and effectiveness of health care for Black patients with chronic pain through the implementation of antiracism interventions within health care systems. Results further suggest that Black patients with chronic pain who have a mental health diagnosis may benefit from targeted pain management strategies that focus on building self-efficacy for managing pain. PERSPECTIVE: Racialized health care discrimination and pain self-efficacy mediated differences in pain-related disability, pain intensity, and pain interference among Black Veterans with and without a mental health diagnosis. Findings highlight the need for antiracism interventions within health care systems in order to improve the quality of care for Black patients with chronic pain. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01983228.

Racial and Ethnic Differences in Satisfaction with Care Coordination Among VA and non-VA Medicare Beneficiaries

Purpose: Patients who have multiple sources of care are at risk for fragmented and uncoordinated care, which can lead to poorer outcomes. Veteran Medicare beneficiaries who use the Veterans Health Administration (VHA) system (VA users), particularly racial/ethnic minorities, often have complex medical conditions that may require care from multiple sources, leaving them especially vulnerable to the effects of fragmented care. We examined racial/ethnic differences in the level of satisfaction with care coordination among Medicare beneficiaries, comparing those who do and do not use the VHA healthcare system. Methods: We conducted a retrospective, pooled, cross-sectional study of Medicare beneficiaries using the 2009-2011 Medicare Current Beneficiary Survey. The outcomes are self-reported satisfaction with care items related to three dimensions of care coordination: (1) integrated care, (2) care continuity, and (3) follow-up care. We present descriptive statistics and use generalized linear models to examine racial/ethnic differences across VA and non-VA users, after accounting for other demographic characteristics, health status, functional limitations, insurance coverage, and geographic variation. Results: VA users are more likely to be very satisfied with receiving both integrated and follow-up care compared with non-VA users. Despite the existence of significant racial/ethnic disparities in the likelihood of being very satisfied with receiving well-coordinated care in the larger Medicare population, racial/ethnic minority VA users are just as likely as White non-Hispanics to be very satisfied with receiving well-coordinated care. Conclusions: Future research should continue to study care coordination among VA users and reasons for preferring the VA over other healthcare systems, especially among racial/ethnic minority groups.

Taking ACTION to reduce pain: ACTION study rationale, design and protocol of a randomized trial of a proactive telephone-based coaching intervention for chronic musculoskeletal pain among African Americans

Background

Rates of chronic pain are rising sharply in the United States and worldwide. Presently, there is evidence of racial disparities in pain treatment and treatment outcomes in the United States but few interventions designed to address these disparities. There is growing consensus that chronic musculoskeletal pain is best addressed by a biopsychosocial approach that acknowledges the role of psychological and environmental factors, some of which differ by race.

Methods/Design

The primary aim of this randomized controlled trial is to test the effectiveness of a non-pharmacological, self-regulatory intervention, administered proactively by telephone, at improving pain outcomes and increasing walking among African American patients with hip, back and knee pain. Participants assigned to the intervention will receive a telephone counselor delivered pedometer-mediated walking intervention that incorporates action planning and motivational interviewing. The intervention will consist of 6 telephone counseling sessions over an 8–10 week period. Participants randomly assigned to Usual Care will receive an informational brochure and a pedometer. The primary outcome is chronic pain-related physical functioning, assessed at 6 months, by the revised Roland and Morris Disability Questionnaire, a measure recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT). We will also examine whether the intervention improves other IMMPACT-recommended domains (pain intensity, emotional functioning, and ratings of overall improvement). Secondary objectives include examining whether the intervention reduces health care service utilization and use of opioid analgesics and whether key contributors to racial/ethnic disparities targeted by the intervention mediate improvement in chronic pain outcomes Measures will be assessed by mail and phone surveys at baseline, three months, and six months. Data analysis of primary aims will follow intent-to-treat methodology.

Discussion

We will tailor our intervention to address key contributors to racial pain disparities and examine the effects of the intervention on important pain treatment outcomes for African Americans with chronic musculoskeletal pain.

Trial registration

ClinicalTrials.gov: NCT01983228. Registered 6 November 2013.

Expanding research on the racial disparity in medical treatment with ideas from sociology

While hundreds of studies document racial differences in the use of medical procedures in the United States, by comparison little is known about the causes of these differences. This gap in knowledge should serve as a call to sociologists who, drawing on their disciplinary tradition of studying inequality, could improve understanding of the disparity. This article offers suggestions about how medical sociologists in the USA might bring sociology to the study of racial disparities in medical treatment. The article begins by reviewing the existing approaches to understanding the racial disparity in medical treatment. After considering the extant research and its limits, the article goes on to describe how a few specific concepts from sociology - cultural capital, social networks, self-presentation and social distance, all framed in a race critical framework - and more diverse methodological approaches can advance studies of the racial disparity in medical treatment

Racial disparities in outcomes after cardiac surgery: the role of hospital quality

Patients from racial and ethnic minorities experience higher mortality after cardiac surgery compared to white patients, both during the early postoperative phase as well as long term. A number of factors likely explain poor outcomes in black and minority patients, which include differences in biology, comorbid health conditions, socioeconomic background, and quality of hospital care. Recent evidence suggests that a major factor underlying excess mortality in these groups is due to their over-representation in low-quality hospitals, where all patients regardless of race have worse outcomes. In this review, we examine the factors underlying racial disparities in outcomes after cardiac surgery, with a primary focus on the role of hospital quality.

Patient Decision Control and the Use of Cardiac Catheterization

Background:

Shared decision-making is a key determinant of patient-centered care. A lack of patient involvement in treatment decisions may explain persistent racial disparities in rates of cardiac catheterization (CCATH). To date, limited evidence exists to demonstrate whether patients who engage in shared decision-makingare more or less likely to undergo non-emergency CCATH.

Objective:

To assess the relationship between participation in the decision to undergo a CCATH and the use of CCATH. We also examined whether preference for or actual engagement in decision-making varied by patient race.

Methods:

We analyzed data from 826 male Veterans Administration patients for whom CCATH was indicated and who participated in the Cardiac Decision Making Study.

Results:

After controlling for confounders, patients reporting any degree of decision control were more likely to receive CCATH compared with those reporting no control (doctor made decision without patient input) (54% vs 39%, P<.0001). Across racial groups, patients were equally likely to report a preference for control over decision-making (P=.53) as well as to experience discordance between their preference for control and their perception of the actual decision-making process (P=.59). Therefore, these factors did not mediate racial disparities in rates of CCATH use.

Conclusion:

Shared decision-making is an essential feature of whole-person care. While participation in decision-making may not explain disparities in CCATH rates, further work is required to identify strategies to improve congruence between patients' desire for and actual control over decision-making to actualize patient-centered care.

Racial Differences in Satisfaction with VA Health Care: A Mixed Methods Pilot Study

INTRODUCTION

As satisfied patients are more adherent and play a more active role in their own care, a better understanding of factors associated with patient satisfaction is important.

PURPOSE

In response to a United States Veterans Administration (VA) Hospital Report Card that revealed lower levels of satisfaction with health care for African Americans compared to Whites, we conducted a mixed methods pilot study to obtain preliminary qualitative and quantitative information about possible underlying reasons for these racial differences.

METHODS

We conducted telephone interviews with 30 African American and 31 White veterans with recent inpatient and/or outpatient health care visits at three urban VA Medical Centers. We coded the qualitative interviews in terms of identified themes within defined domains. We summarized racial differences using ordinal logistic regression for Likert scale outcomes and used random effects logistic regression to assess racial differences at the domain level.

RESULTS

Compared to Whites, African Americans were younger (p < 0.001) and better educated (p = 0.04). Qualitatively, African Americans reported less satisfaction with trust/confidence in their VA providers and healthcare system and less satisfaction with patient-provider communication. Quantitatively, African Americans reported less satisfaction with outpatient care (odds ratio = 0.28; 95 % confidence interval (CI) 0.10-0.82), but not inpatient care. At the domain level, African Americans were significantly less likely than Whites to express satisfaction themes in the domain of trust/confidence (odds ratio = 0.36; 95 % CI 0.18-0.73).

CONCLUSION

The current pilot study demonstrates racial differences in satisfaction with outpatient care and identifies some specific sources of dissatisfaction. Future research will include a large national cohort, including Hispanic veterans, in order to gain further insight into the sources of racial and ethnic differences in satisfaction with VA care and inform future interventions.

A qualitative study of barriers to enrollment into free HIV care: perspectives of never-in-care HIV-positive patients and providers in Rakai, Uganda

Background. Early entry into HIV care is low in Sub-Saharan Africa. In Rakai, about a third (31.5%) of HIV-positive clients who knew their serostatus did not enroll into free care services. This qualitative study explored barriers to entry into care from HIV-positive clients who had never enrolled in care and HIV care providers. Methods. We conducted 48 in-depth interviews among HIV-infected individuals aged 15–49 years, who had not entered care within six months of result receipt and referral for free care. Key-informant interviews were conducted with 12 providers. Interviews were audio-recorded and transcripts subjected to thematic content analysis based on the health belief model. Results. Barriers to using HIV care included fear of stigma and HIV disclosure, women's lack of support from male partners, demanding work schedules, and high transport costs. Programmatic barriers included fear of antiretroviral drug side effects, long waiting and travel times, and inadequate staff respect for patients. Denial of HIV status, belief in spiritual healing, and absence of AIDS symptoms were also barriers. Conclusion. Targeted interventions to combat stigma, strengthen couple counseling and health education programs, address gender inequalities, and implement patient-friendly and flexible clinic service hours are needed to address barriers to HIV care.

Effect of Race and Ethnicity on Outcomes With Drug-Eluting and Bare Metal Stents

Background—

Black, Hispanic, and Asian patients have been underrepresented in percutaneous coronary intervention clinical trials; therefore, there are limited data available on outcomes for these race/ethnicity groups.

Methods and Results—

We examined outcomes in 423 965 patients in the National Cardiovascular Data Registry CathPCI Registry database linked to Medicare claims for follow-up. Within each race/ethnicity group, we examined trends in drug-eluting stent (DES) use, 30-month outcomes, and relative outcomes of DES versus bare metal stents. Overall, 390 351 white, 20 191 black, 9342 Hispanic, and 4171 Asian patients > 65 years of age underwent stent implantation from 2004 through 2008 at 940 National Cardiovascular Data Registry participating sites. Trends in adoption of DES were similar across all groups. Relative to whites, black and Hispanic patients undergoing percutaneous coronary intervention had higher long-term risks of death and myocardial infarction (blacks: hazard ratio, 1.28; 95% confidence interval, 1.24–1.32; Hispanics: hazard ratio, 1.15; 95% confidence interval, 1.10–1.21). Long-term outcomes were similar in Asians and whites (hazard ratio, 0.99; 95% confidence interval, 0.92–1.08). Use of DES was associated with better 30-month survival and lower myocardial infarction rates compared with the use of bare metal stents among all race/ethnicity groups except Hispanics, who had similar outcomes with DES or bare metal stents.

Conclusions—

Black and Hispanic patients undergoing percutaneous coronary intervention had worse long-term outcomes relative to white and Asian patients. Compared with bare metal stent use, DES use was generally associated with superior long-term outcomes in all racial and ethnic groups, although these differences were not statistically significant in Hispanic patients.

Association between health beliefs and health behavior in early pregnancy

Folate-supplementation significantly reduces the risk of neural tube defects. The aim of this research was to reveal associations between health beliefs and folate -supplementation as well as other elements of health behavior among Hungarian women early in their pregnancy. Three-hundred and seven women in early pregnancy completed the second part of Health and Illness Scale. Factor structure of health beliefs was established and associations of factors with pregnancy planning, folate-intake, vitamin-intake, smoking-habits and alcohol-consumption were tested. A six factor health model was formulated; the factor named 'mental capacities and abilities' was associated with greater chance on folate-intake, vitamin-intake and prepared pregnancy, as well as a reduced chance of smoking. The factors 'destiny', 'measures aiming at prevention', and 'relatives and acquaintances' related to lower chance on folate-intake. The health belief factor representing Internal Health Locus of Control was associated with more than one component of healthy behavior, while factors of external dimensions (Powerful Others Health Locus of Control and Chance Health Locus of Control) were predictive on unhealthy behavioral tendencies. New approaches aiming to shift one's health beliefs and health locus of control from external causes to internal dimensions are needed in order to reach greater openness towards health-improving interventions.

Care and outcomes of Asian-American acute myocardial infarction patients: findings from the American Heart Association Get With The Guidelines-Coronary Artery Disease program

BACKGROUND

Asian-Americans represent an important United States minority population, yet there are limited data regarding the clinical care and outcomes of Asian-Americans following acute myocardial infarction (AMI). Using data from the American Heart Association Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program, we compared use of and trends in evidence-based care AMI processes and outcome in Asian-American versus white patients.

METHODS AND RESULTS

We analyzed 107,403 AMI patients (4412 Asian-Americans, 4.1%) from 382 United States centers participating in the Get With The Guidelines-Coronary Artery Disease program between 2003 and 2008. Use of 6 AMI performance measures, composite "defect-free" care (proportion receiving all eligible performance measures), door-to-balloon time, and in-hospital mortality were examined. Trends in care over this time period were explored. Compared with whites, Asian-American AMI patients were significantly older, more likely to be covered by Medicaid and recruited in the west region, and had a higher prevalence of diabetes, hypertension, heart failure, and smoking. In-hospital unadjusted mortality was higher among Asian-American patients. Overall, Asian-Americans were comparable with whites regarding the baseline quality of care, except that Asian-Americans were less likely to get smoking cessation counseling (65.6% versus 81.5%). Asian-American AMI patients experienced improvement in the 6 individual measures (P≤0.048), defect-free care (P<0.001), and door-to-balloon time (P<0.001). The improvement rates were similar for both Asian-Americans and whites. Compared with whites, the adjusted in-hospital mortality rate was higher for Asian-Americans (adjusted relative risk: 1.16; 95% confidence interval: 1.00-1.35; P=0.04).

CONCLUSIONS

Evidence-based care for AMI processes improved significantly over the period of 2003 to 2008 for Asian-American and white patients in the Get With The Guidelines-Coronary Artery Disease program. Differences in care between Asian-Americans and whites, when present, were reduced over time.

Cancer perceptions of South African mothers and daughters: implications for health promotion programs

Cancer is one of the leading causes of death worldwide. A major reason why women do not obtain cancer screening procedures relates to the high levels of fear associated with cancer. In this study, we explored South African mothers' and daughters' reaction to the word "cancer" specifically. The study sample included 157 randomly selected mother and adolescent daughter pairs from an urban community in Cape Town, South Africa. Mothers and their adolescent daughters had very similar responses to the term "cancer." We found that most South African mothers and daughters had a fear-based attitude toward the illness. When we asked mothers what they immediately thought of upon hearing "cancer," a majority of women (69%) thought of death, and another 43% thought of suffering and the detrimental consequences of the illness. Similarly, 50% of the daughters also thought of death, and 42% thought of the detrimental aspects of cancer. Fatalistic attitudes and negative emotional reactions have important implications in cancer prevention and need to be addressed within a public health context.

Race differences in cardiac catheterization: the role of social contextual variables

BACKGROUND

Race differences in the receipt of invasive cardiac procedures are well-documented but the etiology remains poorly understood.

OBJECTIVE

We examined how social contextual variables were related to race differences in the likelihood of receiving cardiac catheterization in a sample of veterans who were recommended to undergo the procedure by a physician.

DESIGN

Prospective observational cohort study.

PARTICIPANTS

A subsample from a study examining race disparities in cardiac catheterization of 48 Black/African American and 189 White veterans who were recommended by a physician to undergo cardiac catheterization.

MEASURES

We assessed social contextual variables (e.g., knowing somebody who had the procedure, being encouraged by family or friends), clinical variables (e.g., hypertension, maximal medical therapy), and if participants received cardiac catheterization at any point during the study.

KEY RESULTS

Blacks/African Americans were less likely to undergo cardiac catheterization compared to Whites even after controlling for age, education, and clinical variables (OR = 0.31; 95% CI, 0.13, 0.75). After controlling for demographic and clinical variables, three social contextual variables were significantly related to increased likelihood of receiving catheterization: knowing someone who had undergone the procedure (OR = 3.14; 95% CI, 1.70, 8.74), social support (OR = 2.05; 95% CI, 1.17, 2.78), and being encouraged by family to have procedure (OR = 1.45; 95% CI, 1.08, 1.90). After adding the social contextual variables, race was no longer significantly related to the likelihood of receiving catheterization, thus suggesting that social context plays an important role in the relationship between race and cardiac catheterization.

CONCLUSIONS

Our results suggest that social contextual factors are related to the likelihood of receiving recommended care. In addition, accounting for these relationships attenuated the observed race disparities between Whites and Blacks/African Americans who were recommended to undergo cardiac catheterization by their physicians.

An overview about hepatitis C: a devastating virus

Hepatitis C (HCV) is the disease that has affected around 200 million people globally. HCV is a life threatening human pathogen, not only because of its high prevalence and worldwide burden but also because of the potentially serious complications of persistent HCV infection. Chronicity of the disease leads to cirrhosis, hepatocellular carcinoma and end-stage liver disease. HCV positive hepatocytes vary between less than 5% and up to 100%, indicating the high rate of replication of viral RNA. HCV has a very high mutational rate that enables it to escape the immune system. Viral diversity has two levels; the genotypes and Quasiaspecies. Major HCV genotypes constitute genotype 1, 2, 3, 4, 5 and 6 while more than 50 subtypes are known. All HCV genotypes have their particular patterns of geographical distribution and a slight drift in viral population has been observed in some parts of the globe.

Diabetes-related support, regimen adherence, and health decline among older adults

OBJECTIVES. Social support is generally conceptualized as health promoting; however, there is little consensus regarding the mechanisms through which support is protective. Illness support has been proposed to promote regimen adherence and subsequent prevention of health decline. We hypothesize that (a) support for regimen adherence is negatively associated with self-reported health decline among older diabetic adults and that (b) regimen adherence is negatively associated with health decline among older diabetic adults.

METHODS

We used the Health and Retirement Study data on individuals over the age of 60 years with type 2 diabetes mellitus (n = 1,788), examining change in self-reported health status over a 2-year period using binomial and cumulative ordinal logistic regression models.

RESULTS

Diabetic support is not significantly associated with health decline, but it is strongly associated with adherence to health-promoting activities consisting of a diabetic regimen. Therefore, the extent to which one receives illness support for a given regimen component is highly positively associated with adhering to that component, although this adherence does not necessarily translate into protection against perceived decline in health.

CONCLUSIONS

Illness-related support appears to be a mechanism through which social support matters in the diabetic population. Although this relationship did not extend to prevention of health status decline among diabetics, the relationship between support and illness management is promising.

Racial differences in the evaluation and treatment of hepatitis C among veterans: a retrospective cohort study

OBJECTIVES

We examined the association between race and hepatitis C virus (HCV) evaluation and treatment of veterans in the Northwest Network of the Department of Veterans Affairs (VA).

METHODS

In our retrospective cohort study, we used medical records to determine antiviral treatment of 4263 HCV-infected patients from 8 VA medical centers. Secondary outcomes included specialty referrals, laboratory evaluation, viral genotype testing, and liver biopsy. Multiple logistic regression was used to adjust for clinical (measured through laboratory results and International Classification of Diseases, Ninth Revision, codes) and sociodemographic factors.

RESULTS

Blacks were less than half as likely as Whites to receive antiviral treatment (odds ratio [OR]=0.38; 95% confidence interval [CI]=0.23, 0.63). Both had similar odds of referral and liver biopsy. However, Blacks were significantly less likely to have complete laboratory evaluation (OR=0.67; 95% CI=0.52, 0.88) and viral genotype testing (OR=0.68; 95% CI=0.51, 0.90).

CONCLUSIONS

Race is associated with receipt of medical care for various medical conditions. Further investigation is warranted to help understand whether patient preference or provider bias may explain why HCV-infected Blacks were less likely to receive medical care than Whites.

Racial and ethnic disparities in the VA health care system: a systematic review

OBJECTIVES

To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the "equal access" Veterans Affairs (VA) health care system.

METHODS

We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA.

RESULTS

Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient-provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients' medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups.

CONCLUSIONS

Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.

Chronic kidney disease is associated with angiographic coronary artery disease

BACKGROUND/AIMS

Patients with chronic kidney disease (CKD) have a dramatically increased risk for cardiovascular mortality. Few prior studies have examined the independent association of CKD with coronary anatomy.

METHODS

We evaluated the relationship between CKD and severe coronary artery disease (CAD) in 261 male veterans with nuclear perfusion imaging tests suggesting coronary ischemia. We used chart review and patient and provider interviews to collect demographics, clinical characteristics, and coronary anatomy results. We defined CKD as an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2, based on the creatinine obtained prior to angiography. We defined significant coronary obstruction as at least one 70% or greater stenosis. We used logistic regression to determine whether CKD was independently associated with significant coronary obstruction.

RESULTS

The likelihood of CAD increased monotonically with decreasing eGFR, from 51% among patients with eGFR or = 90 ml/min/1.73 m2 to 84% in those with eGFR < 30 ml/min/1.73 m2 (p = 0.0046). Patients with CKD were more likely than those without CKD to have at least one significant coronary obstruction (75.9 vs. 60.7%, p = 0.016). Patients with CKD also had more significant CAD, that is, were more likely to have three-vessel and/or left main disease than those without CKD (34.9 vs. 16.9%, p = 0.0035). In logistic regression analysis, controlling for demographics and comorbidity, CKD continued to be independently associated with the presence of significant CAD (p = 0.0071).

CONCLUSION

CKD patients have a high prevalence of obstructive coronary disease, which may contribute to their high cardiovascular mortality.

Program design and evaluation strategies for the Special Projects of National Significance Outreach Initiative

Through its Targeted HIV Outreach and Intervention Model Development (Outreach Initiative), the Health Resources and Services Administration's Special Projects of National Significance (SPNS) program funded ten demonstration sites to implement and evaluate strategies to engage and retain underserved populations living with HIV/AIDS (PLWHA) in HIV primary medical care. The 10 sites were located in urban areas across the United States. Target populations were women, youth, people of color, and people with histories of incarceration, substance use, homelessness, or mental illness. Program interventions included outreach, motivational interventions, case management, and other ancillary services to connect and sustain people in HIV medical care. To evaluate outcomes from this initiative, a multisite study consisting of client interviews administered at 6-month intervals, documentation of program contacts, and medical chart abstractions of CD4 and viral load values and HIV primary care visits was conducted. This paper describes the study design and methods used to implement and evaluate this large multisite initiative. Strengths and limitations of the study design are discussed.

Living with HIV but without medical care: barriers to engagement

This cross-sectional study examined factors associated with the receipt of HIV medical care among people who know their HIV status and are not newly diagnosed with HIV. Interviews were conducted with 1133 HIV-positive individuals between October 2003 and July 2005 who enrolled in 1 of 10 outreach programs across the country. The sample was predominantly non-white (86%), male (59%), and unstably housed (61%), with a past history of cocaine use (68%). Twelve percent had received no HIV medical care in the 6 months prior to the interview. Those with no care were similar to those who received some HIV care in sociodemographic characteristics, but in multivariate analysis were less likely to have a case manager (p < 0.001) or use mental health services (p < .001), had lower mental health status scores (p < 0.05), were more likely to be active drug users (p < 0.01), had greater unmet support service needs (p < 0.05) and reported that health beliefs were a barrier to care (p < 0.001). Interventions to engage people in HIV medical care need to address barriers to care through linkages with mental health, substance abuse treatment and support services, and address the health beliefs that deter people from seeking care.

Apparent racial disparity in the utilization of invasive testing for risk assessment of cardiac patients undergoing noncardiac surgery

BACKGROUND

Studies on racial disparity in the use of cardiac diagnostic procedures are limited because they were conducted in the acute clinical setting without control for patient knowledge and emotional state or used models not controlling for racism. Using the setting (model) of elective evaluation of known, stable, cardiac patients undergoing noncardiac surgery, where the surgeon/anesthesiologist's personal interest precludes expression of potential racial bias, we assessed for racial differences in the utilization of diverse cardiac diagnostic procedures for risk assessment and optimization.

METHODS

This is a secondary analysis of data from 314 consecutive patients [92 (29%) African-American, 222 (71%) Caucasian] with coronary artery disease (CAD), cardiomyopathy (ejection fraction <45%), or treatment-requiring arrhythmias, who underwent noncardiac surgery.

RESULTS

The incidence of angina, prior myocardial infarction, and ischemic cardiomyopathy was higher in Caucasians (75%, 68%, and 164%, P<.0001, respectively), while nonischemic cardiomyopathy was more prevalent among African-Americans (84%, P<.0001). While, multivariately, African race predicted underuse of coronary angiography (odds ratio: 0.10, 95% confidence interval: 0.04-0.26, P<.0001), this predictor was eliminated when presence of CAD plus cardiomyopathy was factored in as a surrogate of severity. The use of noninvasive cardiac procedures and the 30-day mortality and morbidity did not differ by race.

CONCLUSION

In a racism-proof model of preoperative evaluation of stable cardiac veterans, the racial disparity in the use of invasive procedures was related to epidemiologic differences. In addition, the parity in mortality and morbidity corroborates no underuse of diagnostic procedures among African-Americans.

Racial differences in attitudes toward innovative medical technology

BACKGROUND

New medical technologies are used at different rates among whites and blacks. This variation may be partially explained by racial differences in patient innovativeness-the propensity of patients to adopt unfamiliar therapies.

OBJECTIVE

To measure how innovativeness varies among patients and how it may influence patients' attitudes toward new medical technologies.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Primary care patients (n=171-108 blacks, 63 whites) at an urban Veterans Affairs medical center.

MEASUREMENTS

Respondents answered questions about their general innovativeness and innovativeness regarding medical technology, and they responded to a vignette describing either a hypothetical new prescription drug or implantable device.

RESULTS

There were no significant racial differences in general innovativeness, but whites had higher medical technology innovativeness (P=.001). Whites were also more likely to accept the new prescription drug (P=.003), but did not differ from blacks in acceptance of the new implantable device. In multivariate analyses, lower medical technology innovativeness scores among blacks were significantly associated with less favorable reactions to both the prescription drug (P<.001) and the medical device (P<.001). In contrast, although whites with lower medical technology innovativeness were similarly less inclined to accept the new implantable device (P=.02), there was no significant association between medical technology innovativeness and positive attitudes to the new prescription drug among whites.

CONCLUSIONS

Blacks and whites have differing attitudes toward medical innovation. These differences are associated with significant racial differences in response to particular health care technologies. These findings suggest potentially remediable causes for racial differences in the utilization of innovative medical technologies.

Racial Differences in Prevalence of Coronary Obstructions Among Men With Positive Nuclear Imaging Studies

OBJECTIVES

The purpose of this research was to compare coronary obstruction between clinically similar African Americans (AA) and white persons undergoing coronary angiography.

BACKGROUND

African Americans have higher rates of coronary death than whites, but are less likely to undergo coronary revascularization. Although differences in coronary anatomy do not explain racial difference in revascularization rates, several studies of clinically diverse persons undergoing coronary angiography have found less obstructive coronary disease in AA than clinically similar whites.

METHODS

We studied 52 AA and 259 white male veterans who had both a positive nuclear perfusion imaging study and coronary angiography within 90 days of that study in five Department of Veterans Affairs hospitals. We used chart review and patient interview to collect demographics, clinical characteristics, and coronary anatomy results. Before angiography, we asked physicians to estimate the likelihood of coronary obstruction.

RESULTS

The treating physicians' estimates of coronary disease likelihood were similar for AA (79.5%) and whites (83.0%); AA were less likely to have any coronary obstruction (63.5% vs. 76.5%, p = 0.05) and had significantly less severe coronary disease (p = 0.01) than whites. African Americans continued to be less likely to have coronary obstruction in analyses controlling for clinical features, including the physician's estimate of the likelihood of coronary obstruction.

CONCLUSIONS

These results suggest that AA have less coronary obstruction than apparently clinically similar whites. Further studies are required to confirm our findings and better understand the paradox that AA are less likely to have obstructive coronary disease and more likely to suffer mortality from coronary disease.

Physicians' perceptions of patients' social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease

OBJECTIVES

A growing body of evidence suggests that provider decisionmaking contributes to racial/ethnic disparities in care. We examined the factors mediating the relationship between patient race/ethnicity and provider recommendations for coronary artery bypass graft surgery.

METHODS

Analyses were conducted with a data set that included medical record, angiogram, and provider survey data on postangiogram encounters with patients who were categorized as appropriate candidates for coronary artery bypass graft surgery.

RESULTS

Race significantly influenced physician recommendations among male, but not female, patients. Physicians' perceptions of patients' education and physical activity preferences were significant predictors of their recommendations, independent of clinical factors, appropriateness, payer, and physician characteristics. Furthermore, these variables mediated the effects of patient race on provider recommendations.

CONCLUSIONS

Our findings point to the importance of research and intervention strategies addressing the ways in which providers' beliefs about patients mediate disparities in treatment. In addition, they highlight the need for discourse and consensus development on the role of social factors in clinical decisionmaking.

Perceived barriers to health care access in a treated population

OBJECTIVE

Health care access may be a significant contributor to health outcome. However, few data exist on perception of barriers by patients in treatment, and attending a clinic visit does not mean that no barriers exist. Understanding barriers for treated populations is particularly important in optimizing care for high vulnerability populations, such as those with mental illness and the elderly.

METHOD

A structured interview, demographic questionnaire, and SF-12 were administered to 324 veterans presenting for primary care or mental health appointments at a Veterans Affairs medical center. Principle components analysis was performed and relationships to vulnerability characteristics were identified.

RESULTS

Most interview items showed modest mean levels but high variance. Responses were stable over three to six weeks. As hypothesized, perceived total barriers were greater in participants from several vulnerable populations: those receiving treatment for mental health problems, those with disabilities, and those with worse physical and mental function. Minority participants did not perceive greater barriers. An "inverted-U" relationship with age was found. Principal components analysis assigned 18 items across six clinically meaningful subscales. Participants with mental health treatment perceived greater barriers in three subscales including provider communication. Curvilinear relationships were again seen between subscales and age.

CONCLUSIONS

Even individuals "in care" perceive barriers. Members of vulnerable populations, particularly those receiving mental health treatment, perceive greater barriers. Data support a multi-dimensional conceptualization of perceived barriers, and different subgroups experience different patterns of barriers.

The influence of ethnicity on patient satisfaction

OBJECTIVE

To investigate the influence of ethnicity on patient satisfaction with hospitalization care.

METHODS

We conducted a random selection, cross-sectional study. Data were collected by telephone interviews over a three-year period utilizing a 16-question survey. Patients were excluded from the study if they were admitted for an obstetric visit, physical rehabilitation, or psychiatric illness or if we were unable to reach them by telephone. We used logistic regression to compare ethnicity with the responses for each of the 16 questions while controlling for three confounders (age, gender, and insurance status). For each question, patient responses of excellent and very good were considered satisfied. Patient responses of good, fair, and poor were considered not satisfied.

RESULTS

We surveyed 7,795 patients. Compared to African-Americans, non-Hispanic white Americans were significantly older, included more males, and were insured by Medicaid less often (p < 0.05). Using multivariate analysis, we found that seven of the 16 questions exhibited significant satisfaction differences. African-Americans expressed significantly less satisfaction for two of six questions related to nursing care, two of three questions related to entire staff care, one of two question related to physician care, and one of three questions related to overall satisfaction (p < 0.05). However, African-Americans expressed significantly more satisfaction for one question related to nursing care. There was no difference between the two groups for nine of the 16 questions, including both questions regarding communication and coordination.

CONCLUSION

African-Americans reported significantly lower rates of satisfaction compared to non-Hispanic white Americans for six of 16 questions regarding satisfaction during hospitalization care.

Racial differences in attitudes regarding cardiovascular disease prevention and treatment: a qualitative study

The objective of this study was to explore coronary heart disease (CHD) health care experiences and beliefs of African-American and white patients to elicit potential causes of racial disparities in CHD outcomes. Twenty-four patients (14 white, 10 African-American) with established CHD participated in one of four focus groups. Using qualitative methods, verbatim transcripts of the groups were analyzed by independent investigators to identify key themes. We identified four themes: risk factor knowledge, physician--patient relationship, medical system access, and treatment beliefs. Racial differences were apparent in the experience of racism as a stress, knowledge of specifics of CHD risk factors, and assertiveness in the physician--patient relationship. These findings suggest that strategies to improve risk factor knowledge and to enable African-American patients to become active partners in their medical care may lead to improved CHD morbidity and mortality in this population. The efficacy of such interventions would need to be tested in further work.

Patients' beliefs about racism, preferences for physician race, and satisfaction with care

PURPOSE

Few studies have attempted to link patients' beliefs about racism in the health care system with how they use and experience health care.

METHODS

Using telephone survey data from a national sample of 1,479 whites, 1,189 African Americans, and 983 Latinos, we explored patients' beliefs about racism, their preferences for the race and ethnicity of their physician, and their satisfaction with that physician. A scale was developed to reflect patients' beliefs about racism. Race-stratified analyses assessed associations between patients' beliefs, racial preferences for physicians, choice of physician, and satisfaction with care.

RESULTS

Among African Americans, stronger beliefs about racial discrimination in health care were associated with preferring an African American physician (P <.001). Whereas only 22% of African Americans preferred an African American physician, those who preferred a African American physician and had an African American physician were more likely to rate their physician as excellent than did African Americans who preferred a African American physician but had a non-African American physician (57% vs 20%, P <.001). Latinos with stronger beliefs about discrimination in health care were more likely to prefer a Latino physician (P <.001). One third of Latinos preferred a Latino physician. Though not statistically significant, those who preferred and had a Latino physician rated their physician higher than Latinos who preferred a Latino physician but had a non-Latino physician (40% vs 29%).

CONCLUSIONS

Many African Americans and Latinos perceive racism in the health care system, and those who do are more likely to prefer a physician of their own race or ethnicity. African Americans who have preferences are more often satisfied with their care when their own physicians match their preferences.

Racial differences in cardiac catheterization as a function of patients' beliefs

OBJECTIVES

We examined racial differences in cardiac catheterization rates and reviewed whether patients' beliefs or other variables were associated with observed disparities.

METHODS

We did a prospective observational cohort study of 1045 White and African American patients at 5 Veterans Affairs (VA) medical centers whose nuclear imaging studies indicated reversible cardiac ischemia.

RESULTS

There were few demographic differences between White and African American patients in our sample. African Americans were less likely than Whites to undergo cardiac catheterization. African Americans were more likely than Whites to indicate a strong reliance on religion and to report racial and social class discrimination and were less likely to indicate a generalized trust in people but did not differ from White patients on numerous other attitudes about health and health care. Neither sociodemographic or clinical characteristics nor patients' beliefs explained the observed disparities, but physicians' assessments of the procedure's importance and patients' likelihood of coronary disease seemed to account for differences not otherwise explained.

CONCLUSIONS

Patients' preferences are not the likely source of racial disparities in the use of cardiac catheterization among veterans using VA care, but physicians' assessments warrant further attention.

Is lipid-lowering therapy underused by African Americans at high risk of coronary heart disease within the VA health care system?

OBJECTIVES

We examined whether racial differences exist in cholesterol monitoring, use of lipid-lowering agents, and achievement of guideline-recommended low-density lipoprotein (LDL) levels for secondary prevention of coronary heart disease.

METHODS

We reviewed charts for 1045 African American and White patients with coronary heart disease at 5 Veterans Affairs (VA) hospitals.

RESULTS

Lipid levels were obtained in 67.0% of patients. Whites and African Americans had similar screening rates and mean lipid levels. Among the 544 ideal candidates for therapy, rates of treatment and achievement of target LDL levels were similar.

CONCLUSIONS

We found no disparities in cholesterol management. This absence of disparities may be the result of VA quality improvement initiatives or prescription coverage through the VA health care system.

Race and Gender Disparities in Rates of Cardiac Revascularization

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, both P<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.

Racial Disparities in Diabetes Care Processes, Outcomes, and Treatment Intensity

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 > or =130) and blood pressure control (BP > or =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.

Coronary Heart Disease Prevention and Lifestyle Interventions

Unless action is directed to address the multiple influences on coronary heart disease (CHD) risk reduction behaviors, across all population groups, the aims of Healthy People 2010 with regard to CHD will not be realized. Health-promotion and disease-prevention models, including a framework for primordial, primary, and secondary prevention provided by an American Heart Association task force, and a model for interventions to eliminate health disparities are reviewed. The role of culture, ethnicity, race, and socioeconomic status and how these concepts have been studied in recent lifestyle interventions aimed at CHD risk reduction is explored. Finally, these findings are synthesized to provide suggestions for nursing care delivery in primary and tertiary care settings.

Racial and sex differences in refusal of coronary angiography

PURPOSE

To determine the effect of patient refusal on racial and sex differences in the use of coronary angiography and in outcomes among elderly patients with acute myocardial infarction.

SUBJECTS AND METHODS

We included Medicare beneficiary patients admitted to hospitals performing coronary angiography from February 1994 through July 1995. In-hospital use and refusal of coronary angiography were determined, and adjusted for patient, hospital, and physician characteristics.

RESULTS

Of 124,691 patients, 53,671 (43%) underwent angiography during hospitalization and 2881 (2.3%) refused. Patients refusing angiography were more likely to be female (odds ratio [OR] = 1.37; 95% confidence interval [CI]: 1.23 to 1.53), black (OR = 1.26 vs. whites; 95% CI: 1.02 to 1.56), and older (OR = 2.25 per 10-year increase; 95% CI: 2.05 to 2.43) than patients who underwent angiography. Angiography use was lower in blacks (OR = 0.78; 95% CI: 0.72 to 0.83) than in whites, and lower in women (OR = 0.83; 95% CI: 0.80 to 0.86) than in men. Increased refusal explained 6% (95% CI: -3% to 15%) of the difference in angiography use between whites and blacks, and 16% (95% CI: 10% to 22%) of the difference between men and women. After adjustment for patient characteristics, refusal of angiography was not associated with worse survival at 1 year (OR = 0.99; 95% CI: 0.82 to 1.20).

CONCLUSION

Among Medicare beneficiaries, elderly female and black patients are more likely to refuse angiography than are male and white patients. However, patient refusal is uncommon and accounts for only a small fraction of the racial and sex differences in use of angiography after myocardial infarction.

Racial differences in how patients perceive physician communication regarding cardiac testing

OBJECTIVES

Recent studies documenting racial variation in the use of cardiac procedures highlight the need to understand if there are racial differences in processes of communication and decision making. Investigations of patients' perceptions of their interaction with providers regarding cardiac testing were conducted.

METHODS

Four focus groups were convened with 13 patients who had undergone cardiac stress testing with positive results, stratified by race (white vs. black). Verbatim transcripts of discussions of their interactions with providers relating to their cardiac problems were analyzed qualitatively by a team of behavioral scientists and general internists to identify significant dimensions of communication and patient-provider relationships.

RESULTS

Four domains of communication were identified that appeared to bear on patients' comfort and preferences regarding cardiac procedures. First, the substance of the information that was provided by physicians and other providers was described as incomplete, vague, ambiguous, and unclear. Second, some recommendations either were inconsistent with expectations or awakened fears based on distressing previous experiences. Third, patients said they needed to be convinced of the need for additional, invasive tests and therapeutic procedures, and in some cases providers' arguments failed in this regard. Fourth, the patients highlighted the importance of trusting their provider. Although there were no apparent differences by race in patients' perception of the information they received, black patients consistently expressed a preference for building a relationship with physicians (trust) before agreeing to an invasive cardiac procedure, and just as consistently complained that trust was lacking. Conversely, white patients tended to emphasize that they were inadequately convinced of the need for recommended procedures.

CONCLUSIONS

This study provided qualitative information regarding patients' perceptions of physician-patient communication and racial differences in such perceptions. For both black and white patients, we found problematic aspects of the patients' experiences regarding communication about cardiac testing. Our findings suggest that although patients desire clarity from physicians, they are often confused regarding the information received. Both a lack of substance and vagueness of the information received may be linked to feelings of mistrust toward physicians when considering further diagnostic testing. Mistrust may be a source of some of the documented racial variation in health care utilization.