Variation in Quality of Men??s Health Care by Race/Ethnicity and Social Class

Undiagnosed Kidney Injury in Uninsured and Underinsured Diabetic African American Men and Putative Role of Meprin Metalloproteases in Diabetic Nephropathy

Diabetes is the leading cause of chronic kidney disease. African Americans are disproportionately burdened by diabetic kidney disease (DKD) and end stage renal disease (ESRD). Disparities in DKD have genetic and socioeconomic components, yet its prevalence in African Americans is not adequately studied. The current study used multiple biomarkers of DKD to evaluate undiagnosed DKD in uninsured and underinsured African American men in Greensboro, North Carolina. Participants consisted of three groups: nondiabetic controls, diabetic patients without known kidney disease, and diabetic patients with diagnosed DKD. Our data reveal undiagnosed kidney injury in a significant proportion of the diabetic patients, based on levels of both plasma and urinary biomarkers of kidney injury, namely, urinary albumin to creatinine ratio, kidney injury molecule-1, cystatin C, and neutrophil gelatinase-associated lipocalin. We also found that the urinary levels of meprin A, meprin B, and two kidney meprin targets (nidogen-1 and monocytes chemoattractant protein-1) increased with severity of kidney injury, suggesting a potential role for meprin metalloproteases in the pathophysiology of DKD in this subpopulation. The study also demonstrates a need for more aggressive tests to assess kidney injury in uninsured diabetic patients to facilitate early diagnosis and targeted interventions that could slow progression to ESRD.

Quality of Care for Work-Associated Carpal Tunnel Syndrome

OBJECTIVE

To evaluate the quality of care provided to individuals with workers' compensation claims related to Carpal tunnel syndrome (CTS) and identify patient characteristics associated with receiving better care.

METHODS

We recruited subjects with new claims for CTS from 30 occupational clinics affiliated with Kaiser Permanente Northern California. We applied 45 process-oriented quality measures to 477 subjects' medical records, and performed multivariate logistic regression to identify patient characteristics associated with quality.

RESULTS

Overall, 81.6% of care adhered to recommended standards. Certain tasks related to assessing and managing activity were underused. Patients with classic/probable Katz diagrams, positive electrodiagnostic tests, and higher incomes received better care. However, age, sex, and race/ethnicity were not associated with quality.

CONCLUSIONS

Care processes for work-associated CTS frequently adhered to quality measures. Clinical factors were more strongly associated with quality than demographic and socioeconomic ones.

Understanding cancer screening service utilization by Somali men in Minnesota

This study examined factors that influence use of cancer screening by Somali men residing in Minnesota, USA. To better understand why recent immigrants are disproportionately less likely to use screening services, we used the health belief model to explore knowledge, beliefs, and attitudes surrounding cancer screening. We conducted a qualitative study comprised of 20 key informant interviews with Somali community leaders and 8 focus groups with Somali men (n = 44). Somali men commonly believe they are protected from cancer by religious beliefs. This belief, along with a lack of knowledge about screening, increased the likelihood to refrain from screening. Identifying the association between religion and health behaviors may lead to more targeted interventions to address existing disparities in cancer screening in the growing US immigrant population.

Race, insurance type, and stage of presentation among lung cancer patients

The purpose of this study was to determine whether African-American lung cancer patients are diagnosed at a later stage than white patients, regardless of insurance type. The relationship between race and stage at diagnosis by insurance type was assessed using a Poisson regression model, with relative risk as the measure of association. The setting of the study was a large tertiary care cancer center located in the southeastern United States. Patients who were diagnosed with lung cancer between 2001 and 2010 were included in the study. A total of 717 (31%) African-American and 1,634 (69%) white lung cancer patients were treated at our facility during the study period. Adjusting for age, sex, and smoking-related histology, African-American patients were diagnosed at a statistically significant later stage (III/IV versus I/II) than whites for all insurance types, with the exception of Medicaid. Our results suggest that equivalent insurance coverage may not ensure equal presentation of stage between African-American and white lung cancer patients. Future research is needed to determine whether other factors such as treatment delays, suboptimal preventive care, inappropriate specialist referral, community segregation, and a lack of patient trust in health care providers may explain the continuing racial disparities observed in the current study.

Financial hardship, unmet medical need, and health self-efficacy among African American men

BACKGROUND

Health self-efficacy (the confidence to take care of one's health) is a key component in ensuring that individuals are active partners in their health and health care. The purpose of this study was to determine the association between financial hardship and health self-efficacy among African American men and to determine if unmet medical need due to cost potentially mediates this association.

METHOD

Cross-sectional analysis was conducted using data from a convenience sample of African American men who attended a 1-day annual community health fair in Northeast Ohio (N = 279). Modified Poisson regression models were estimated to obtain the relative risk of reporting low health self-efficacy. After adjusting for sociodemographic characteristics, those reporting financial hardship were 2.91 times, RR = 2.91 (confidence interval [1.24, 6.83]; p < .05), more likely to report low health self-efficacy. When unmet medical need due to cost was added to the model, the association between financial hardship and low health self-efficacy was no longer statistically significant.

CONCLUSION

Our results suggest that the association between financial hardship and health self-efficacy can be explained by unmet medical need due to cost. Possible intervention efforts among African American men with low financial resources should consider expanding clinical and community-based health assessments to capture financial hardship and unmet medical need due to cost as potential contributors to low health self-efficacy.

How Do African American Men Rate Their Health Care? An Analysis of the Consumer Assessment of Health Plans 2003-2006

African American (AA) men remain one of the most disconnected groups from health care. This study examines the association between AA men’s rating of health care and rating of their personal physician. The sample included 12,074 AA men aged 18 years or older from the 2003 to 2006 waves of the Consumer Assessment of Healthcare Providers and Systems Adult Commercial Health Plan Survey. Multilevel models were used to obtain adjusted means rating of health care systems and personal physician, and the relationship of ratings with the rating of personal physician. The adjusted means were 80 (on a 100-point scale) for most health ratings and composite health care scores: personal physician (83.9), specialist (83.66), health care (82.34), getting needed care (89.57), physician communication (83.17), medical staff courtesy (86.58), and customer service helpfulness (88.37). Physician communication was the strongest predictor for physician rating. AA men’s health is understudied, and additional research is warranted to improve how they interface with the health care system.

Disparities in survival improvement for metastatic colorectal cancer by race/ethnicity and age in the United States

PURPOSE

Previous studies documented significant increase in overall survival for metastatic colorectal cancer (CRC) since the late 1990s coinciding with the introduction and dissemination of new treatments. We examined whether this survival increase differed across major racial/ethnic populations and age groups.

METHODS

We identified patients diagnosed with primary metastatic colorectal cancer during 1992-2009 from 13 population-based cancer registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results Program, which cover about 14 % of the US population. The 5-year cause-specific survival rates were calculated using SEER*Stat software.

RESULTS

From 1992-1997 to 2004-2009, 5-year cause-specific survival rates increased significantly from 9.8 % (95 % CI 9.2-10.4) to 15.7 % (95 % CI 14.7-16.6) in non-Hispanic whites and from 11.4 % (95 % CI 9.4-13.6) to 17.7 % (95 % CI 15.1-20.5) in non-Hispanic Asians, but not in non-Hispanic blacks [from 8.6 % (95 % CI 7.2-10.1) to 9.8 % (95 % CI 8.1-11.8)] or Hispanics [from 14.0 % (95 % CI 11.8-16.3) to 16.4 % (95 % CI 14.0-19.0)]. By age group, survival rates increased significantly for the 20-64-year age group and 65 years or older age group in non-Hispanic whites, although the improvement in the older non-Hispanic whites was substantially smaller. Rates also increased in non-Hispanic Asians for the 20-64-year age group although marginally nonsignificant. In contrast, survival rates did not show significant increases in both younger and older age groups in non-Hispanic blacks and Hispanics.

CONCLUSION

Non-Hispanic blacks, Hispanics, and older patients diagnosed with metastatic CRC have not equally benefitted from the introduction and dissemination of new treatments.

Challenges of health measurement in studies of health disparities

Health disparities are increasingly studied in and across a growing array of societies. While novel contexts and comparisons are a promising development, this commentary highlights four challenges to finding appropriate and adequate health measures when making comparisons across groups within a society or across distinctive societies. These challenges affect the accuracy with which we characterize the degree of inequality, limiting possibilities for effectively targeting resources to improve health and reduce disparities. First, comparisons may be challenged by different distributions of disease and second, by variation in the availability and quality of vital events and census data often used to measure health. Third, the comparability of self-reported information about specific health conditions may vary across social groups or societies because of diagnosis bias or diagnosis avoidance. Fourth, self-reported overall health measures or measures of specific symptoms may not be comparable across groups if they use different reference groups or interpret questions or concepts differently. We explain specific issues that make up each type of challenge and show how they may lead to underestimates or inflation of estimated health disparities. We also discuss approaches that have been used to address them in prior research, note where further innovation is needed to solve lingering problems, and make recommendations for improving future research. Many of our examples are drawn from South Africa or the United States, societies characterized by substantial socioeconomic inequality across ethnic groups and wide disparities in many health outcomes, but the issues explored throughout apply to a wide variety of contexts and inquiries.

Disparities in preventive health services among Somali immigrants and refugees

African immigrants and refugees-almost half of them from Somalia-account for one of the fastest-growing groups in the United States. There is reason to suspect that Somali-Americans may be at risk for low completion of recommended preventive health services. This study's aim was to quantify disparities in preventive health services among Somali patients compared with non-Somali patients in an academic primary care practice in Rochester, Minn. It also examined the effect of medical interpreters, emergency department visits, and primary care visits on the completion of preventive services. Rates of pap smears, vaccinations (influenza, pneumococcus, and tetanus), lipid screening, colorectal cancer screening, and mammography were assessed in Somali and non-Somali patients during the second quarter of 2008. Data were collected regarding the utilization of medical interpreters, emergency services, and primary care services among Somali patients. Results were reported using standard descriptive statistics. Of the 91,557 patients identified in the database, 810 were Somali. Somali patients had significantly lower completion rates of colorectal cancer screening, mammography, pap smears, and influenza vaccination than non-Somali patients. Use of medical interpreters and primary care services were generally associated with higher completion rates of preventive services. There are significant discrepancies in the provision of preventive health services to Somali patients compared with that of non-Somali patients. These findings suggest the need to identify the root causes of these discrepancies so that interventions may be crafted to close the gap.

Factors that mediate racial/ethnic disparities in US fetal death rates

OBJECTIVES

We sought to determine the importance of socioeconomic factors, maternal comorbid conditions, antepartum and intrapartum complications of pregnancy, and fetal factors in mediating racial disparities in fetal deaths. METHODS. We undertook a mediation analysis on a retrospective cohort study of hospital-based deliveries with a gestational age between 23 and 44 weeks in California, Missouri, and Pennsylvania from 1993 to 2005 (n = 7,104,674).

RESULTS

Among non-Hispanic Black women and Hispanic women, the fetal death rate was higher than among non-Hispanic White women (5.9 and 3.6 per 1000 deliveries, respectively, vs 2.6 per 1000 deliveries; P < .01). For Black women, fetal factors mediated the largest percentage (49.6%; 95% confidence interval [CI] = 42.7, 54.7) of the disparity in fetal deaths, whereas antepartum and intrapartum factors mediated some of the difference in fetal deaths for both Black and Asian women. Among Hispanic women, socioeconomic factors mediated 35.8% of the disparity in fetal deaths (95% CI = 25.8%, 46.2%).

CONCLUSIONS

The factors that mediate racial/ethnic disparities in fetal death differ depending on the racial/ethnic group. Interventions targeting mediating factors specific to racial/ethnic groups, such as improved access to care, may help reduce US fetal death disparities.

Increased mortality risk among the visually impaired: the roles of mental well-being and preventive care practices

PURPOSE

Mechanisms by which visual impairment (VI) increases mortality risk are poorly understood. We estimated the direct and indirect effects of self-rated VI on risk of mortality through mental well-being and preventive care practice mechanisms.

METHODS

Using complete data from 12,987 adult participants of the 2000 Medical Expenditure Panel Survey with mortality linkage through 2006, we undertook structural equation modeling using two latent variables representing mental well-being and poor preventive care to examine multiple effect pathways of self-rated VI on all-cause mortality. Generalized linear structural equation modeling was used to simultaneously estimate pathways including the latent variables and Cox regression model, with adjustment for controls and the complex sample survey design.

RESULTS

VI increased the risk of mortality directly after adjusting for mental well-being and other covariates (hazard ratio [HR] = 1.25 [95% confidence interval: 1.01, 1.55]). Poor preventive care practices were unrelated to VI and to mortality. Mental well-being decreased mortality risk (HR = 0.68 [0.64, 0.74], P < 0.001). VI adversely affected mental well-being (β = -0.54 [-0.65, -0.43]; P < 0.001). VI also increased mortality risk indirectly through mental well-being (HR = 1.23 [1.16, 1.30]). The total effect of VI on mortality including its influence through mental well-being was HR 1.53 [1.24, 1.90]. Similar but slightly stronger patterns of association were found when examining cardiovascular disease-related mortality, but not cancer-related mortality.

CONCLUSIONS

VI increases the risk of mortality directly and indirectly through its adverse impact on mental well-being. Prevention of disabling ocular conditions remains a public health priority along with more aggressive diagnosis and treatment of depression and other mental health conditions in those living with VI.

Patterns of social support among lymphoma patients considering stem cell transplantation

There is lack of literature addressing factors that influence the process of care for patients with hematological malignancies. We evaluated the forms of social support available for patients with relapsed lymphoma considering stem cell transplantation and examined the influence of support on treatment delay. Data were collected from 119 patients with relapsed lymphoma using a questionnaire to capture sociodemographic information and emotional, informational, and instrumental forms of social support. Sixty-four percent of the patients were married, 56% had children over 18 years of age, 43% were employed, and 72% had private health insurance. Family members formed a major source of emotional support (83%), while 47% of patients considered personal prayers to be important. While 79% of patients received clinical support from nurses, few received formal group support or formal peer support (6.7% and 1.7% respectively). Support from extended family and peer groups reduced the likelihood of treatment delays. The potential benefits of peer group support should be reinforced for patients considering transplantation given how infrequent this form of social support is utilized and its positive impact on the process of care. Future studies should test the impact of social support on health outcomes especially among the underserved population.

A black-white comparison of the quality of stage-specific colon cancer treatment

BACKGROUND

Several studies have attributed racial disparities in cancer incidence and mortality to variances in socioeconomic status and health insurance coverage. However, an Institute of Medicine report found that blacks received lower quality care than whites after controlling for health insurance, income, and disease severity.

METHODS

To examine the effects of race on colorectal cancer outcomes within a single setting, the authors performed a retrospective cohort study that analyzed the cancer registry, billing, and medical records of 365 university hospital patients (175 blacks and 190 whites) diagnosed with stage II-IV colon cancer between 2000 and 2005. Racial differences in the quality (effectiveness and timeliness) of stage-specific colon cancer treatment (colectomy and chemotherapy) were examined after adjusting for socioeconomic status, health insurance coverage, sex, age, and marital status.

RESULTS

Blacks and whites had similar sociodemographic characteristics, tumor stage and site, quality of care, and health outcomes. Age and diagnostic stage were predictors of quality of care and mortality. Although few patients (5.8%) were uninsured, they were more likely to present at advanced stages (61.9% at stage IV) and die (76.2%) than privately insured and publicly insured patients (p = .002).

CONCLUSIONS

In a population without racial differences in socioeconomic status or insurance coverage, patients receive the same quality of care, regardless of racial distinction, and have similar health outcomes. Age, diagnostic stage, and health insurance coverage remained independently associated with mortality. Future studies of disparities in colon cancer treatment should examine sociocultural barriers to accessing appropriate care in various healthcare settings.

Racial, socioeconomic, and rural-urban disparities in obesity-related bariatric surgery

BACKGROUND

Morbid obesity is associated with serious health and social consequences, high medical costs and is increasing in the USA, particularly among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long-term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, insurance categories, socioeconomic, and comorbidity levels.

METHODS

We examined 159,116 records representing 774,000 patients with morbid obesity from the 2006 Nationwide Inpatient Sample. We determined the likelihood, expressed in odds ratios, of bariatric surgery associated with each patient characteristic using survey-weighted univariate logistic regression. We also performed multivariate logistic regression, assuming all patient factors were independent.

RESULTS

After adjusting for patient-level characteristics, the most rural residents were 23% less likely to receive bariatric surgery than urban residents. Other demographic features associated with significantly lower odds ratios for bariatric surgery included minority status, male gender, lower income, older age, non-private insurance status, and higher comorbidity. Rural-dwelling patients who are non-white, male, poorer, older, sicker, and non-privately insured almost never received bariatric surgery (OR = 0.0089).

CONCLUSIONS

Though obesity is more prevalent among middle-aged, rural, economically disadvantaged, and racial/ethnic minority populations, these patients are unlikely to access bariatric surgery. Because obesity is a leading cause of preventable morbidity and mortality in the USA, effective treatments should be made available to all patients who might benefit. Current Medicare/Medicaid policies that reimburse only high volume centers may effectively deny rural residents who rely on these insurance programs for bariatric surgery.

Cancer prevention behaviors in low-income urban whites: an understudied problem

Low-income urban whites in the United States have largely gone unexamined in health disparities research. In this study, we explored cancer prevention behaviors in this population. We compared data on whites with low socioeconomic status (SES) from the 2003 Exploring Health Disparities in Integrated Communities Study in Southwest Baltimore, Maryland (EHDIC-SWB) with nationally representative data for low SES white respondents from the 2003 National Health Interview Survey (NHIS). Rates for health behaviors and health indicators for whites from the EHDIC-SWB study as compared to NHIS prevalence estimates were as follows: current cigarette smoking, 59% (31% nationally); current regular drinking, 5% (5% nationally); overweight, 26% (32% nationally); obesity, 30% (22% nationally); mammography in the past 2 years, 50% (57% nationally); Pap smear in the past 2 years, 64% (68% nationally); screening for colon cancer in the past 2 years, 41% (30% nationally); and fair or poor self-reported health, 37% (22% nationally). Several cancer prevention behaviors and health indicators for white EHDIC-SWB respondents were far from the Healthy People 2010 objectives. This study provides rare estimates of cancer-related health and health care measures in an understudied population in the United States. Findings illustrate the need for further examination of health behaviors in low SES white urban populations who may share health risks with their poor minority urban counterparts.

Candidate quality of care indicators for localized bladder cancer

The surgical management of clinically localized bladder cancer is challenging, and the quality of care delivered to patients with bladder cancer is a subject of increasing interest. Multiple large studies have examined the association between surgical volume and outcomes after radical cystectomy. These studies generally find lower mortality and complication rates at high-volume centers, though interpretation of the data must be tempered by limitations of the datasets driving the studies. Benefits of regionalization of care also must be weighed against other measures proven to predict outcomes; a delay in time to cystectomy beyond 3 months, for example, is strongly associated with increased mortality. Other candidate process measures supported by existing literature include adequacy of lymphadenectomy as measured by nodal yield and availability or offering of orthotopic diversion when appropriate. Assessment and reporting of bladder cancer outcomes should be risk adjusted based on oncologic risk factors and patient comorbid illness. Perioperative morbidity and mortality, cause-specific survival, and overall survival are all key measures. Assessment of health-related quality of life after bladder cancer treatment should also be standardized for reporting. Multiple survey instruments have been developed in recent years, but none has yet been well validated or widely adopted. In particular, capturing variation in quality of life outcomes between patients undergoing bladder-sparing protocols vs. continent diversion vs. incontinent diversion is an important but difficult goal that has not yet been met. The urologic oncology community should take a strong lead in achieving consensus regarding the definition, assessment, and reporting of quality of care data for bladder cancer.

Examining racial disparities in colorectal cancer care

African Americans are disproportionately burdened with colorectal cancer. Although incidence and mortality rates have declined in the past two decades, the disparity in health outcomes has progressively increased. This comprehensive review examines the existing literature regarding racial disparities in colorectal cancer screening, stage at diagnosis, and treatment to determine if differences exist in the quality of care delivered to African Americans. A comprehensive review of relevant literature was performed. Two databases (EBSCOHOST Academic Search Premier and Scopus) were searched from 2000 to 2007. Articles that assessed racial disparities in colorectal cancer screening, stage of disease at diagnosis, and treatment were selected. The majority of studies identified examined colorectal cancer screening outcomes. Although racial disparities in screening have diminished in recent years, African American men and women continue to have higher colorectal cancer incidence and mortality rates and are diagnosed at more advanced stages. Several studies regarding stage of disease at diagnosis identified socioeconomic status (SES) and health insurance status as major determinants of disparity. However, some studies found significant racial disparities even after controlling for these factors. Racial disparities in treatment were also found at various diagnostic stages. Many factors affecting disparities between African Americans and Whites in colorectal cancer incidence and mortality remain unexplained. Although the importance of tumor biology, genetics, and lifestyle risk factors have been established, prime sociodemographic factors need further examination to understand variances in the care of African Americans diagnosed with colorectal cancer.

Promoting culturally appropriate colorectal cancer screening through a health educator: a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer mortality in the US. Surveys reveal low CRC screening levels among Asians in the US, including Chinese Americans.

METHODS

A randomized controlled trial was conducted with Chinese patients to evaluate a clinic-based, culturally and linguistically appropriate intervention promoting fecal occult blood test (FOBT) screening. The multifaceted intervention included a trilingual and bicultural health educator, bilingual materials (a video, a motivational pamphlet, an informational pamphlet, and FOBT instructions), and three FOBT cards. Patients in the control arm received usual care. Our primary outcome measure was FOBT screening within 6 months after randomization. The proportion of FOBT completion in the intervention and control arms was compared by using a chi-square test, and logistic regression analysis was performed to adjust for the effects of sociodemographic variables and prior screening history. Potential effect modifications were also tested by using logistic regression models.

RESULTS

Our intervention had a strong effect on FOBT completion (intervention group, 69.5%; control group, 27.6%), and the adjusted odds of FOBT slightly increased to over 6-fold greater in the intervention arm compared with the control arm. No effect modification by age, gender, language, insurance, or prior FOBT was found.

CONCLUSIONS

The authors' multifaceted, culturally appropriate intervention significantly increased FOBT screening in a group of low-income and less-acculturated minority patients. Given the large effect size, future research should determine the effective core component(s) that can increase CRC screening in both the general and minority populations.

Disparities in preventive procedures: comparisons of self-report and Medicare claims data

Background

Racial/ethnic disparities are assessed using either self-report or claims data. We compared these two data sources and examined contributors to discrepancies in estimates of disparities.

Methods

We analyzed self-report and matching claims data from Medicare Beneficiaries 65 and older who participated in the Medicare Current Beneficiary Survey, 1999–2002. Six preventive procedures were included: PSA testing, influenza vaccination, Pap smear testing, cholesterol testing, mammography, and colorectal cancer testing. We examined predictors of self-reports in the absence of claims and claims in the absence of self-reports.

Results

With the exception of PSA testing, racial/ethnic disparities in preventive procedures are generally larger when using Medicare claims than when using patients' self-report. Analyses adjusting for age, gender, income, educational level, health status, proxy response and supplemental insurance showed that minorities were more likely to self-report preventive procedures in the absence of claims. Adjusted odds ratios ranged from 1.07 (95% CI: 0.88 – 1.30) for PSA testing to 1.83 (95% CI: 1.46 – 2.30) for Pap smear testing. Rates of claims in the absence of self-report were low. Minorities were more likely to have PSA test claims in the absence of self-reports (1.55 95% CI: 1.17 – 2.06), but were less likely to have influenza vaccination claims in the absence of self-reports (0.69 95% CI: 0.51 – 0.93).

Conclusion

These findings are consistent with either racial/ethnic reporting biases in receipt of preventive procedures or less efficient Medicare billing among providers with large minority practices.

Addressing racial and ethnic disparities in health care: using federal data to support local programs to eliminate disparities

To reduce racial and ethnic disparities in health care, managers, policy makers, and researchers need valid and reliable data on the race and ethnicity of individuals and populations. The federal government is one of the most important sources of such data. In this paper we review the strengths and weaknesses of federal data that pertain to racial and ethnic disparities in health care. We describe recent developments that are likely to influence how these data can be used in the future and discuss how local programs could make use of these data.

Hospital admission rates for a racially diverse low-income cohort of patients with diabetes: the Urban Diabetes Study

OBJECTIVE

We sought to determine the frequency and costs of hospitalization and to assess possible racial/ethnic disparities in a large cohort of low-income patients with diabetes who had received primary care at municipal health clinics.

METHODS

Administrative data from Philadelphia Health Care Centers were linked with discharge data from Pennsylvania hospitals for March 1993 through December 2001. We tested differences in hospitalization rates and mean hospital charges by age, gender, and race/ethnicity.

RESULTS

A total of 18,800 patients with diabetes experienced 30,528 hospital admissions, for a hospitalization rate of 0.35 per person-year. Rates rose with age and with the interaction of male gender and age. Rates for non-Hispanic Whites were higher than those for African Americans, whereas those for Hispanics, Asian Americans, and "others" were lower. Patients who were hospitalized at least 5 times made up 10.5% of the study population and accounted for 64% of hospital admissions and hospital charges in this cohort.

CONCLUSIONS

Hospitalization rates for this low-income cohort with access to primary care and pharmacy services were comparable to those of other diabetic patient populations, suggesting that reducing financial barriers to care may have benefited these patients. A subgroup of patients with multiple hospitalizations accounted for the majority of hospital admissions.

Colorectal Cancer in Hispanics

BACKGROUND

While colorectal cancer (CRC) incidence and mortality rates have declined slightly over the past decade, there remain marked differences by ethnicity. Our aim was to investigate ethnic differences in occurrence, clinical presentation and outcome of CRC at a tertiary university center that serves a predominantly Hispanic population.

METHODS

Prospectively collected data from the tumor registry on patients diagnosed with colorectal cancer from 1985 through 2001 was examined. Age at diagnosis, mode of presentation, sex, tumor location, ethnicity, TNM stage, and survivals were assessed and ethnic differences were sought.

RESULTS

Records from 453 patients with CRC were reviewed. There were 296 (65%) patients that were Hispanics, 112 (25%) non-Hispanic Whites, 37 (8%) African Americans, and 8 (2%) of other or unknown ethnicity. Compared with non-Hispanic Whites, Hispanics presented at a younger age (58.5 +/- 14 versus 53.6 +/- 12.73, respectively; P < 0.01), with a significantly greater incidence of stage IV disease (19% versus 32%, respectively; P = 0.02). They had significantly poorer age-adjusted survival (median survival of 92 months for <55 years and 77 months for >55 years versus 48 months for <55 years and 48 months for >55 years, respectively; adjusted log rank P = 0.045). There were no differences in tumor location, mode of presentation or adjuvant treatment received.

CONCLUSIONS

Hispanic patients with CRC in our catchment area present at a younger age with more metastatic disease and have a poorer survival than non-Hispanic Whites. Modification of screening criteria and treatment paradigms may be required for Hispanics.

Latino populations: a unique opportunity for the study of race, genetics, and social environment in epidemiological research

Latinos are the largest minority population in the United States. Although usually classified as a single ethnic group by researchers, Latinos are heterogeneous from cultural, socioeconomic, and genetic perspectives. From a cultural and social perspective, Latinos represent a wide variety of national origins and ethnic and cultural groups, with a full spectrum of social class. From a genetic perspective, Latinos are descended from indigenous American, European, and African populations. We review the historical events that led to the formation of contemporary Latino populations and use results from recent genetic and clinical studies to illustrate the unique opportunity Latino groups offer for studying the interaction between racial, genetic, and environmental contributions to disease occurrence and drug response.