County characteristics associated with refusing breast cancer surgery: Evidence from the Surveillance, Epidemiology, and End Results program

BACKGROUND

Individuals' communities impact cancer disparities and are intimately related to social determinants of health. Studies show that personal factors affect treatment refusals for a potentially curable cancer, but few studies have investigated whether community-based characteristics affect the receipt of surgery.

METHODS

We used Surveillance Epidemiology and End Results Program registries from 2010 to 2015 to examine differences in rates of surgery refusal among non-Hispanic White, non-Hispanic Black, and Hispanic women diagnosed with nonmetastatic breast cancer. The community factor measures were based on county-level factors. Sociodemographic and community differences were analyzed using Pearson's χ2 tests and analysis of variance. Multivariate logistic regression of predictors of surgery refusal and the Cox proportional hazard model of disease-specific mortality were performed.

RESULTS

Surgery refusers among non-Hispanic Black and Hispanic all races lived in counties with lower rates of educational attainment, median family and household income, and higher rates of poverty, unemployment, foreign-born, language isolation, urban population, and women more than 40 years old having mammography in last 2 years. Multivariate analysis shows surgery refusal rates increased in counties having a high percentage of urban population and declined in counties with an increased percentage of less than high school level education, unemployment, and median household income. Breast cancer-specific mortality increased significantly with surgery refusal.

CONCLUSION

Residence in counties with the lowest socioeconomic status and disproportionately populated by racial and ethnic minorities is associated with surgery refusal. Given the high mortality associated with refusing surgery, culturally sensitive education on the benefits of care may be appropriate.

Evaluating Decision-Making Capacity: When a False Belief about Ventilators Is the Reason for Refusal of Life-Sustaining Treatment

In this article, we discuss the case of Michael Johnson, an African-American man who sought treatment for respiratory distress due to COVID-19, but who was adamant that he did not want to be intubated due to his belief that ventilators directly cause death. This case prompted reflection about the ways in which a false belief can create uncertainty and complexity for clinicians who are responsible for evaluating decision-making capacity (DMC). In our analysis, we consider the extent to which Mr. Johnson demonstrated capacity according to each of Appelbaum's criteria.1 Although it was fairly clear that Mr. Johnson lacked DMC on the basis of both understanding and appreciation, we found ourselves reflecting upon the false belief that seemed to motivate his refusal. This led us to further consider the ways in which our current social and political environment can complicate evaluations of patients' preferences and reasons for declining life-sustaining interventions. In particular, we consider the impact of the role of misinformation and systemic racism in preparing the grounds for false beliefs. In this article, we discuss the case of Michael Johnson, an African-American man who sought treatment for respiratory distress due to COVID-19, but who was adamant that he did not want to be intubated due to his belief that ventilators directly cause death. This case prompted reflection about the ways in which a false belief can create uncertainty and complexity for clinicians who are responsible for evaluating decision-making capacity (DMC). In our analysis, we consider the extent to which Mr. Johnson demonstrated capacity according to each of Appelbaum’s criteria.1 Although it was fairly clear that Mr. Johnson lacked DMC on the basis of both understanding and appreciation, we found ourselves reflecting upon the false belief that seemed to motivate his refusal. This led us to further consider the ways in which our current social and political environment can complicate evaluations of patients’ preferences and reasons for declining life-sustaining interventions. In particular, we consider the impact of the role of misinformation and systemic racism in preparing the grounds for false beliefs.

A Retrospective Investigation of Neuraxial Anesthesia Rates for Elective Cesarean Delivery Before and During the SARS-CoV-2 Pandemic

BACKGROUND

Our hospital used to perform cesarean delivery under general anesthesia rather than neuraxial anesthesia, mostly because of patient refusal of members of the conservative Bedouin society. According to recommendations implemented by the Israeli Obstetric Anesthesia Society, which were implemented due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, we increased the rate of neuraxial anesthesia among deliveries.

OBJECTIVES

To compare the rates of neuraxial anesthesia in our cesarean population before and during SARS-CoV-2 pandemic.

METHODS

We included consecutive women undergoing an elective cesarean delivery from two time periods: pre-SARS-CoV-2 pandemic (15 February 2019 to 14 April 2019) and during the SARS-CoV-2 pandemic (15 February 2020 to 15 April 2020). We collected demographic data, details about cesarean delivery, and anesthesia complications.

RESULTS

We included 413 parturients undergoing consecutive elective cesarean delivery identified during the study periods: 205 before the SARS-CoV-2 pandemic and 208 during SARS-CoV-2 pandemic. We found a statistically significant difference in neuraxial anesthesia rates between the groups: before the pandemic (92/205, 44.8%) and during (165/208, 79.3%; P < 0.0001).

CONCLUSIONS

We demonstrated that patient and provider education about neuraxial anesthesia can increase its utilization. The addition of a trained obstetric anesthesiologist to the team may have facilitated this transition.

A review of the use of biological mesh products in modern UK surgical practice: a religious and cultural perspective

INTRODUCTION

The UK is an increasingly multicultural society. This change coincides with an increasing use of animal products in medicine and surgery and a change in the UK law of consent. The refusal of Jehovah's Witnesses to accept blood products is well known, but the use of animal products in surgery is a neglected topic. As society becomes more diverse and medicine becomes ever more advanced, there is increasing potential for a mismatch between what is medically possible and what is acceptable from a religious perspective.

METHODS

Surgical products were identified by searching the literature and contacting manufacturing companies. Literature was identified by using PubMed and OVID (MEDLINE). Religious views were established by contacting national bodies for each group.

FINDINGS

The views of common UK religious groups and the constituent parts of biological meshes are summarised in tables intended to be used as a reference during clinical practice. On an elective basis, the Islamic, Hindu. Sikh and Jain leaders contacted had strong views on avoiding animal derived products. The Christian and Jewish leaders contacted did not. All religious leaders contacted accepted the use of mesh derived from human tissue. All products, including those of porcine and bovine origin, were acceptable to all leaders contacted if the procedure was performed to save life. The highlighting of this issue should prompt earlier consideration and discussion in the surgical planning and the consenting process with all final decisions taken by both the surgeon and the individual patient.

Videos to reduce racial disparities in ICD therapy Via Innovative Designs (VIVID) trial: Rational, design and methodology

BACKGROUND

Despite a higher prevalence of sudden cardiac death (SCD), black individuals are less likely than whites to have an implantable cardioverter defibrillator (ICD) implanted. Racial differences in ICD utilization is in part explained by higher refusal rates in black individuals. Decision support can assist with treatment-related uncertainty and prepare patients to make well-informed decisions.

METHODS

The Videos to reduce racial disparities in ICD therapy Via Innovative Designs (VIVID) study will randomize 350 black individuals with a primary prevention indication for an ICD to a racially concordant/discordant video-based decision support tool or usual care. The composite primary outcome is (1) the decision for ICD placement in the combined video groups compared with usual care and (2) the decision for ICD placement in the racially concordant relative to discordant video group. Additional outcomes include knowledge of ICD therapy and SCD risk; decisional conflict; ICD receipt at 90 days; and a qualitative assessment of ICD decision making in acceptors, decliners, and those undecided.

CONCLUSIONS

In addition to assessing the efficacy of decision support on ICD acceptance among black individuals, VIVID will provide insight into the role of racial concordance in medical decision making. Given the similarities in the root causes of racial/ethnic disparities in care across health disciplines, our approach and findings may be generalizable to decision making in other health care settings.

The perceived barriers to insulin therapy among type 2 diabetic patients

BACKGROUND

Problems may arise with insulin treatment, due to patients' perspective towards it leading to refusal.

OBJECTIVES

To evaluate diabetic patients' refusal towards insulin therapy, and to assess patients' perception and perceived barriers towards insulin.

METHODS

A cross-sectionalstudy, where type 2 diabetics participated in the study during a period, February through March 2017. They were interviewed in person by a questionnaire including three sections; socio-demography, medical history and a health belief model, comprising barriers to use insulin. Five points Likert scale was used to measure patients' perception and barriers towards insulin therapy.

RESULTS

One fourth (24.4%) of the diabetic patients refused insulin. Among the controlled group, 34.4% refused insulin, while 21% refused insulin among the uncontrolled group. The study showed different barriers towards insulin therapy, including fear of injection, pain, insulin injection needs help from others, fear of hypoglycaemia and embarrassment.

CONCLUSION

Diabetics showed a negative attitude towards insulin therapy due to social and psychological factors. The results necessitate the development of a strategy to address problems related with a reluctance to initiate insulin and put a strategy to implement education and better interaction with diabetic team to the stigma from phobia from insulin use.

Race-based experiences of ethnic minority health professionals: Arab physicians and nurses in Israeli public healthcare organizations

Increasing workforce diversity was found to contribute to the narrowing of disparities in health. However, racism toward ethnic minority health professionals has not been adequately researched. In Israel, public healthcare organizations that serve a mixed Jewish-Arab population employ Arab minority healthcare professionals. Instances of prejudice and manifestations of racism toward them, which frequently surface in public discussion and the media, have unfortunately gained little scholarly attention. We used the intergroup contact approach and the theory of the social process of everyday racism as a theoretical framework. The objective of the research was to study race-based experiences of Israeli Arab healthcare professionals.

METHODOLOGY

We used a qualitative research method that allows respondents to describe their views, experiences, beliefs and behavior in the way they think about them. During 2013 and 2014 we conducted in-depth interviews with a snowball sample of 10 Arab physicians and 13 Arab nurses who work in Israeli public hospitals. The study protocol was ethically approved.

FINDINGS

Interviewees noted institutional efforts to maintain egalitarianism and equality. However, at the micro-level, interviewees, mostly nurses, reported instances that ranged from refusal to accept treatment from an Arab nurse, through verbal abuse, to the use of physical violence against them. At the meso-level, interviewees, mostly physicians, reported experiences of institutional discrimination. At the macro-level, one physician reported policy-related discrimination in the context of the immigration of Russian Jewish physicians to Israel.

CONCLUSIONS

We recommend combining the intergroup contact approach with the social process theory of racism to examine minorities' subjective perceptions, especially in conflictual and violent contexts; conducting broad-based quantitative research in Israeli healthcare organizations, which may have important implications for the specific strategies to be used; and emphasizing the importance of institutional support. By reconstructing race-based experiences of ethnic minority health professionals, health organizations can better manage racial situations and reduce their frequency.

The Secret Drama at the Patient's Bedside-Refusal of Treatment Because of the Practitioner's Ethnic Identity: The Medical Staff 's Point of View

Patients' refusal of treatment based on the practitioner's ethnic identity reveals a clash of values: neutrality in medicine versus patient-centered care. Taking the Israeli-Palestinian conflict into account, this article aims at examining Israeli health care professionals' points of view concerning patients' refusal of treatment because of a practitioner's ethnic identity. Fifty in-depth interviews were conducted with 10 managers and 40 health care professionals, Jewish and Arab, employed at 11 public hospitals. Most refusal incidents recorded are unidirectional: Jewish patients refusing to be treated by Arab practitioners. Refusals are usually directed toward nurses and junior medical staff members, especially if recognizable as religious Muslims. Refusals are often initiated by the patients' relatives and occur more frequently during periods of escalation in the conflict. The structural competency approach can be applied to increase awareness of the role of social determinants in shaping patients' ethnic-based treatment refusals and to improve the handling of such incidents.

Addressing patient biases toward physicians

[Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].

Does Doctor Know Best? Cultural competence is patient-centered care

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

Cultural considerations in forensic psychiatry: The issue of forced medication

There has been an ongoing debate regarding the forced use of antipsychotic medications and both the psychiatric and legal professions have reacted strongly to the growing debate. Within the penological context, cases such as Washington v. Harper, Riggins v. Nevada, and Sell v. United States established the framework for determining when antipsychotic medication may be forcibly administered. Medication decisions under the Sell and Riggins cases are to be approved at judicial hearings; whereas, administrative hearings are sufficient for Harper cases. Forensic psychiatrists are also given responsibility in making the legal decision of whether or not to forcibly treat a patient with psychotropic medication against his will. In making this critical decision, a significant factor that is often minimized is the cultural background of the patient. The purpose of this paper is to present cultural factors to be considered in forced medication. Focusing on the culture defense argument, a review of how the legal system has dealt with cultural implications of a case will be presented. This paper will then discuss cultural issues embedded in the assessment, diagnosis, and treatment of psychiatric patients by forensic psychiatrists who are called upon to make the decision of whether or not to force medicate a patient against his will. Lastly, recommendations and a framework for providing a culturally sensitive assessment during the decision to forcibly medicate a patient with psychotropic medication will be offered.

A Multiethnic Study of the Relationship between Fears and Concerns and Refusal Rates

This study builds on previous research that identified fears and concerns heard by procurement coordinators during the donation discussion and that classified those concerns according to the ease with which they can be addressed. In this study, 53 coordinators working for 4 procurement agencies provided data on 323 donation discussions, including fears and concerns expressed by families. The fears and concerns were analyzed by outcome (consent or refusal), race and ethnicity of the family, frequency of reports, and difficulty in addressing. This research confirms many of the findings of the earlier study. The results also indicate that the types of concerns expressed by donor and non–donor families vary somewhat by the family's race and ethnicity. The results can be used to provide training targeted at raising consent rates and to train minority requestors.

Nonadherence with Immunosuppressive Drugs: Us Compared with European Kidney Transplant Recipients

Background

System factors increasingly are suggested as important yet understudied correlates of nonadherence.

Objective

To explore the relationship between healthcare system and prevalence of nonadherence with immunosuppressive regimen by studying variation in nonadherence between European and US kidney transplant recipients and as well as nonadherence in European countries.

Methods

We performed a secondary data analysis on data collected in 3 independent cross-sectional studies using comparable methodology including patients from the United States, the Netherlands, Belgium, and Switzerland. Nonadherence was measured using 1 item of the Siegal questionnaire. Patients were categorized as nonadherent if they reported missing a dose of immunosuppression in the last 4 weeks. Analyses were performed by multiple mixed logistic regression, with center as a random effect and clinical and demographical differences between groups as fixed effects.

Results

1563 US and 614 European patients from 3 different countries (Belgium [n=187], the Netherlands [n=85], and Switzerland [n=342]) were included. Prevalence of nonadherence in the United States and Europe was 19.3% and 13.2.%, respectively. This higher nonadherence in US patients was confirmed in a multiple logistic regression analysis (OR=1.78; 95% CI, 1.10–2.89). Nonadherence differed between Belgium (16%) and the Netherlands (14.1%) (OR=0.27; 95% CI, 0.09–0.80) and between Belgium and Switzerland (11.4%; OR=0.17; 95% CI, 0.0–0.42).

Conclusion

This is the first study showing differences in prevalence of nonadherence between European and US patients and among European patients. Further research should aim at unraveling the dynamics explaining these differences.

Racial Differences in Length of Stay for Patients Who Leave Against Medical Advice from U.S. General Hospitals

There is a paucity of published literature on the length of hospital stays (LOS) for patients who leave against medical advice (AMA) and on the factors that predict their LOS. The purpose of the study is to examine the relationship between race and the LOS for AMA patients after adjusting for patient and hospital characteristics. National Hospital Discharge Survey (NHDS) data were used to describe LOS for AMA patients aged 18 years or older. Patient characteristics included age, sex, race, marital status, insurance, and diagnosis (ICD-9-CM). Hospital characteristics consisted of ownership, region and bed size. LOS was the major outcome measure. Using data from all years 1988–2006, the expected time to AMA discharge was first examined as a function of race, then adjusting for year terms, patient and hospital characteristics, and major medical diagnoses and mental illness. The unadjusted effect of race on the expected time of leaving AMA was about twice the adjusted effect. After controlling for the other covariates, the expected time to AMA discharge is 20% shorter for Blacks than Whites. The most significant predictors included age, insurance coverage, mental illness, gender, and region. Factors identified in this study offer insights into directions for evidence based- health policy to reduce AMA discharges.

Addressing MMR Vaccine Resistance in Minnesota's Somali Community

Over the past 10 years, Minnesota clinicians have noticed increased resistance to MMR vaccination among Somali Minnesotans. Misinformation about a discredited study asserting a link between the MMR vaccine and autism has permeated this community as parents have increasingly become concerned about the prevalence of autism spectrum disorder among their children. As a result, MMR vaccination rates among U.S.-born children of Somali descent are declining. This article reports findings from an investigation by the Minnesota Department of Health, which was undertaken to better understand vaccine hesitancy among Somali Minnesotans. Based on these and other findings, we propose a multi-pronged approach for increasing vaccination rates in this population.

"All my tears were gone": suffering and cancer pain in Southwest American Indians

CONTEXT

Although minority patients with cancer are more likely to be undermedicated for cancer pain than non-Hispanic whites, little is known about the experience of cancer pain in American Indians (AIs).

OBJECTIVES

To describe the experience of cancer and cancer pain in a sample of southwestern AIs.

METHODS

Ethnographic interviews were conducted with 13 patients and 11 health care providers, caregivers, and community members; two questionnaires were used to collect demographic and pain data.

RESULTS

Barriers to pain control among AIs included difficulties describing pain, a belief that cancer pain is inevitable and untreatable, and an aversion to taking opioid pain medication. Prescriber inexperience also was cited as a barrier to pain management. AIs described a strong desire to protect their privacy regarding their illness, and many felt that expressing pain was a sign of weakness. The inability to participate in spiritual and cultural activities caused AIs distress, and some discontinued treatment or missed chemotherapy appointments to engage in these activities.

CONCLUSION

Results revealed new knowledge about the cancer pain experience in AIs. The observation of the close relationship between treatment compliance and the patient's ability to participate in ceremonial and spiritual activities provides new insight into the problem of incomplete cancer treatment in this population. The finding that AI patients have a multidimensional conceptualization of pain will assist clinicians with obtaining more detailed and informative pain assessments.

Why don't out-of-treatment individuals enter methadone treatment programmes?

BACKGROUND

Despite the proven effectiveness of methadone treatment, the majority of heroin-dependent individuals are out-of-treatment.

METHODS

Twenty-six opioid-dependent adults who met the criteria for methadone maintenance who were neither seeking methadone treatment at the time of study enrollment, nor had participated in such treatment during the past 12 months, were recruited from the streets of Baltimore, Maryland through targeted sampling. Ethnographic interviews were conducted to ascertain participants' attitudes toward methadone treatment and their reasons for not seeking treatment.

RESULTS

Barriers to treatment entry included: waiting lists, lack of money or health insurance, and requirements to possess a photo identification card. For some participants, beliefs about methadone such as real or rumored side effects, fear of withdrawal from methadone during an incarceration, or disinterest in adhering to the structure of treatment programmes kept them from applying. In addition, other participants were not willing to commit to indefinite "maintenance" but would have accepted shorter time-limited methadone treatment.

CONCLUSION

Barriers to treatment entry could be overcome by an infusion of public financial support to expand treatment access, which would reduce or eliminate waiting lists, waive treatment-related fees, and/or provide health insurance coverage for treatment. Treatment programmes could overcome some of the barriers by waiving their photo I.D. requirements, permitting time-limited treatment with the option to extend such treatment upon request, and working with corrections agencies to ensure continued methadone treatment upon incarceration.

Prevalence and reasons for insulin refusal in Bangladeshi patients with poorly controlled Type 2 diabetes in East London

AIMS

To determine the prevalence and reasons for refusal to commence insulin in Bangladeshi patients with Type 2 diabetes.

METHODS

A survey of 212 Bangladeshi patients seen in a hospital diabetes unit, with poor glycaemic control (HbA(1c)>or= 8.0%) on maximum oral glucose-lowering therapy, in whom insulin was deemed necessary. Patients who refused insulin were invited to attend focus groups. Data were analysed by thematic content analysis using the constant comparative method.

RESULTS

Of 212 patients offered insulin, 122 (57.5%) commenced insulin immediately, 47 (22.1%) started insulin within 6 months and 43 (20.3%) refused to commence insulin despite repeated counselling. Thirty-six (83.7%) of those who refused insulin agreed to participate in focus groups. Reasons for insulin refusal included: disease severity--perceptions that requirement for insulin was an indicator of a more serious stage of their condition; insulin leading to premature death--common suggestion that commencing insulin led to early death; loss of control--including fear of hypoglycaemia, weight gain, loss of independence and reliance on others to give insulin or look for signs of hypoglycaemia; lack of perception of benefits--poor perception of the benefits of improved glycaemic control on quality of life and cardiovascular risk; needle anxiety--a significant proportion of subjects conveyed concern over frequent injections.

CONCLUSIONS

Insulin refusal is common in Bangladeshi subjects with Type 2 diabetes and poor glycaemic control. A number of factors contribute to this, and methods to overcome the barriers to insulin therapy need to be sought.

Medication use among inner-city patients after hospital discharge: patient-reported barriers and solutions

OBJECTIVES

To better characterize medication-related problems among inner-city patients after hospital discharge and to suggest potential interventions.

PATIENTS AND METHODS

Between August 9, 2005, and April 3, 2006, we interviewed 84 patients hospitalized with acute coronary syndromes at Grady Memorial Hospital in downtown Atlanta, GA, and contacted them by telephone about 2 weeks later. English-speaking patients who managed their own medications were studied. Patients reported their adherence with filling prescriptions and taking medications after discharge, as well as barriers to and potential enablers of proper medication use.

RESULTS

Most of the 84 respondents were African American (74 [88%]), male (49 [58%]), and middle-aged (mean age, 54.5 years). Only 40% of patients filled their prescriptions on the day of discharge, 20% filled them 1 or 2 days later, and 18% waited 3 to 9 days; 22% had not filled their prescriptions by the time of the follow-up telephone call (median, 12 days; interquartile range, 8-18 days). Transportation, cost, and wait times at the pharmacy were cited as the main barriers. Many patients reported it was somewhat or very difficult to understand why they were prescribed medications (21%), how to take them (11%), or how to reconcile them with the medications they had been taking before hospitalization (16%). About half the patients (40 [48%]) reported some degree of nonadherence after discharge. Patients noted that several forms of assistance could improve medication use after discharge, including lower medication costs (75%), a follow-up telephone call (68%), transportation to the pharmacy (65%), pharmacist counseling before discharge (64%), and a pillbox (56%).

CONCLUSION

Patients often delay filling prescriptions and have difficulty understanding medication regimens after hospital discharge. Interventions that reduce medication costs, facilitate transportation, improve medication counseling, and supply such organizing aids as pillboxes might be beneficial.

Client retention in residential drug treatment for Latinos

Client drop out from treatment is of great concern to the substance abuse field. Completion rates across modalities vary from low to moderate, not ideal since length of stay has been positively and consistently associated with better client outcomes. The study explored whether client characteristics shown to be related to retention were associated with treatment completion and treatment duration for a sample of 164 Latino substance users who entered a culturally focused residential program. In-person client interviews were conducted within a week of program admission. Logistic regression analysis was used to examine research questions. Clients most likely to drop out had self-reported co-occurring psychiatric diagnoses; they were 81% less likely to complete the program, suggesting that clients with mental health problems have a more difficult time remaining in residential treatment. Clients using drugs in the three months prior to entry were three and a half times more likely to be in the shorter stay group, and clients who lived in institutions prior to program entry were three times more likely to be in the longer-stay group. Factors contributing to drop out for this Latino sample were similar to those identified in the literature for non-Latino samples. Methods for addressing the needs of clients with co-occurring disorders are discussed.

Does knowledge matter?: intentional medication nonadherence among middle-aged Korean Americans with high blood pressure

AIM

To examine predictors of intentional and unintentional nonadherence to antihypertensive medication regimens and their relationships to blood pressure outcomes.

BACKGROUND

Although poor adherence to medical regimens is a major concern in the care of patients with high blood pressure (HBP), our understanding of the complex behavior related to adherence is limited. Moreover, few studies have been devoted to understanding adherence issues in ethnic minority groups, such as the interplay between cultural beliefs and HBP medication-taking behaviors.

DESIGN

A cross-sectional analysis was performed to assess the factors affecting nonadherence to antihypertensive medication regimens.

METHODS

The data used in this analysis came from an ongoing HBP intervention trial involving middle-aged (40-64 years) Korean Americans with HBP. A total of 445 Korean Americans with HBP was enrolled in the trial at baseline. Of these, 208 participants who were on antihypertensive medication were included in the analysis. Using multivariate logistic regression, we examined theoretically selected variables to assess their relationships to intentional and unintentional nonadherence in this sample.

RESULTS

Approximately 53.8% of the subjects endorsed 1 or more types of nonadherent behaviors. After controlling for demographic variables, multivariate analysis revealed that a greater number of side effects from the medication (adjusted odds ratio [OR], 1.19; 95% confidence interval [CI], 1.07 to 1.33) and a lower level of HBP knowledge (adjusted OR, 0.89; 95% CI, 0.79 to 0.99) were significantly associated with intentional nonadherence. Unintentional nonadherence was less strongly associated with the study variables examined in the analysis.

CONCLUSION

Our findings indicate that intentional nonadherence to antihypertensive medication that stems from incomplete knowledge of HBP treatment is prevalent among middle-aged Korean Americans with HBP. The results highlight the strong need for an intervention that focuses on increasing patient knowledge about HBP, including the benefits and side effects of antihypertensive medication. This type of focused intervention may help reduce intentional nonadherence to antihypertensive medications and ultimately result in achieving adequate BP control in this high-risk group.

Mechanisms for racial and ethnic disparities in glycemic control in middle-aged and older Americans in the health and retirement study

BACKGROUND

Mechanisms for racial/ethnic disparities in glycemic control are poorly understood.

METHODS

A nationally representative sample of 1901 respondents 55 years or older with diabetes mellitus completed a mailed survey in 2003; 1233 respondents completed valid at-home hemoglobin A(1c) (HbA(1c)) kits. We constructed multivariate regression models with survey weights to examine racial/ethnic differences in HbA(1c) control and to explore the association of HbA(1c) level with sociodemographic and clinical factors, access to and quality of diabetes health care, and self-management behaviors and attitudes.

RESULTS

There were no significant racial/ethnic differences in HbA(1c) levels in respondents not taking antihyperglycemic medications. In 1034 respondents taking medications, the mean HbA(1c) value (expressed as percentage of total hemoglobin) was 8.07% in black respondents and 8.14% in Latino respondents compared with 7.22% in white respondents (P < .001). Black respondents had worse medication adherence than white respondents, and Latino respondents had more diabetes-specific emotional distress (P < .001). Adjusting for hypothesized mechanisms accounted for 14.0% of the higher HbA(1c) levels in black respondents and 19.0% in Latinos, with the full model explaining 22.0% of the variance. Besides black and Latino ethnicity, only insulin use (P < .001), age younger than 65 years (P = .007), longer diabetes duration (P = .004), and lower self-reported medication adherence (P = .04) were independently associated with higher HbA(1c) levels.

CONCLUSIONS

Latino and African American respondents had worse glycemic control than white respondents. Socioeconomic, clinical, health care, and self-management measures explained approximately a fifth of the HbA(1c) differences. One potentially modifiable factor for which there were racial disparities--medication adherence--was among the most significant independent predictors of glycemic control.

[Informed consent of minors--emphasizing the terminally ill]

The article deals with the capacity of a minor about to undergo medical treatment to give informed consent, or the right to refuse and withhold such treatment. The paper discusses the applicability of the principles of The Patient's Rights Law to minors, in view of the provisions of the Legal Capacity and Guardianship Law, which categorically denies all minors the option to be involved in or participate in legal decisions, including those concerning their medical treatment. In view of the mental capacity of present day minors, and the principle on which informed consent is based, it seems that the "modern" minor's developing skills surpass those that were attributed to the minor in the 1960s, at the time when the Legal Capacity Law was enacted. It is suggested that it is our legal and moral obligation to modify the current legal state, as minors do not possess the right to participate in decisions concerning their own medical procedures, but for rare specific exceptions. This article was written in line with the practice adopted worldwide concerning the rights available to minors within the medical system, the United Nations Convention on the Rights of the Child, the Report of Judge Rotlevy's Commission and the Terminally Ill Patient Law. The paper attempts to generate a conceptual and cultural change in the attitude of the medical system towards the care of minors and their families.

Cognitive impairment, psychiatric disorders, and problematic behaviors in a tribal nursing home

OBJECTIVE

Residents' cognitive, psychiatric, and behavioral statuses were examined as part of a larger study of care in a nursing home (NH) owned and operated by a Northern Plains American Indian tribe.

METHOD

Reviews of 45 medical records and semistructured interviews with 36 staff were completed.

RESULTS

Creekside residents had considerable psychiatric and behavioral morbidity. High prevalences of non-Alzheimer's disease dementia, cognitive impairment, anxious symptomatology, and resistance to care were met with psychopharmacotherapy, reorientation, and informal techniques for behavior management. Significant depressive, anxious, psychotic, and behavioral symptoms remained. Staff interpretations of resident problems consisted of an ethnopsychological schema emphasizing resident loneliness, grumpiness, and propensity to "fight" rather than formal psychiatric nosology.

DISCUSSION

Tribal NH residents were likely underdiagnosed for dementia and anxiety. Residual behavioral and psychiatric symptomatology suggest room for improvement in the NH's behavioral management regimen. Need for greater attention to conceptual, diagnostic, clinical, and documentation processes in the NH setting is noted.

The perinatal autopsy: Pertinent issues in multicultural Western Europe

Western Europe is in a demographic transition with increasing multicultural societies. Health professionals have to understand the background, religious and cultural aspects of parents to counsel them regarding an autopsy in the event of a perinatal loss. Autopsy rates have declined over the past decades, the major limiting factor being the granting of permission for an autopsy, possibly because of adverse publicity or reluctance of doctors to obtain consent. Autopsy has proved its value in revealing unsuspected findings. The public can be convinced of this utility by means of good information notwithstanding their religious or cultural background.

Surgical treatment preferences in Chinese-American women with early-stage breast cancer

Breast-conserving treatment (BCT) is considered preferable to radical or modified radical mastectomy (MRM) for most women diagnosed with early-stage breast cancer. Studies have found that Chinese-American women are more likely to be treated with MRM, regardless of age or stage of disease. The central question posed in this study is: what are the cultural factors that influence the selection of treatments by Chinese-American patients and the presentation of treatment options by providers? Focused group discussions, semi-structured interviews, and ethnographic observations were conducted with 69 Chinese-American women and 14 health professionals. Results indicated that (1) many Chinese-American women, regardless of age, migration status, education, and income level, expressed a preference for MRM because it was seen as safer; (2) this was primarily a communal belief that even women who had BCT felt pressure to conform to; (3) some women felt pressured into the BCT decision by their physician and/or were unhappy with their choice; (4) patient and physician bias and difficulties with translation issues and supplemental materials all led to cross-cultural miscommunication; and (5) this miscommunication was cited as a reason for (a) not completing treatment regimes or (b) drastic changes in the treatment selected.

Tailored interventions for screening mammography among a sample of initially non-adherent women: when is a booster dose important?

OBJECTIVE

To assess added value of a booster dose of a tailored mammography intervention.

METHODS

Participants, non-adherent at baseline, were randomly assigned to usual care or one of three tailored interventions. Intervention group members (n=657) were further randomly assigned to receive/not receive a booster intervention dose. Electronic record mammography data were collected following initial intervention and at 6 and 15 months post-booster.

RESULTS

Booster had no effect among women not screened after first intervention dose (n=337). Among women screened after initial dose (n=320), booster predicted re-screening at 6 but not 15 months. A boosterxrace interaction showed a booster effect at 6 months for African Americans (OR=4.66, p=.0005) but not Caucasians (OR=0.74, p=.44).

CONCLUSIONS

Findings suggest if a first-dose intervention does not facilitate screening, neither will a booster dose. However, among women for whom a first dose is effective, boosters can facilitate timely repeat adherence, especially among African Americans. At 6 months booster recipients were less likely to be off-schedule but, by 15 months, the groups were similar.

PRACTICE IMPLICATIONS

Boosters may effect when, but not whether, women continue screening.

Discharges against medical advice: are race/ethnicity predictors?

BACKGROUND

Prior literature suggests that blacks are more likely to be discharged against medical advice (DAMA).

OBJECTIVE

We examined whether DAMA from general hospitals varies by race/ethnicity and whether this variation is explained by individual and hospital factors. DESIGN, SUBJECTS, AND MEASUREMENTS: We conducted cross-sectional analyses of 1998 to 2000 hospital discharge data, linked to the American Hospital Association data, on adults admitted for acute general hospital care in California, Florida, and New York. A series of hierarchical logistic regression analyses explored factors associated with DAMA, initially adjusting for age and gender, then sequentially adding adjustment for comorbidities, individual socio-economic factors, and finally hospital characteristics.

RESULTS

Compared with whites, blacks had a 2-fold higher age-gender adjusted odds of DAMA, a risk that progressively diminished with increasing adjustment (final adjusted odds ratio [OR] = 0.95, 95% confidence interval [CI] = 0.91, 1.00). While Hispanics had an increased risk of DAMA in age-gender-adjusted analyses, the final model revealed a protective effect (adjusted OR = 0.66, 95% CI = 0.62, 0.70), similar to that observed for Asians.

CONCLUSIONS

Disparities in DAMA affecting minority patients in general hospitals are largely accounted for by individual and hospital socio-economic factors. The absence of any adjusted disparity affecting blacks, and the protective effect observed for Hispanics and other minorities suggest that individual discrimination and poor communication are not primary determinants of DAMA, but where patients are admitted does contribute to disparities in DAMA.

Challenging perceptions of non-compliance with rheumatic fever prophylaxis in a remote Aboriginal community

AIM

To identify factors that affect rheumatic fever prophylaxis for remote-living Aboriginal patients, and to determine the proportion who received adequate prophylaxis.

DESIGN AND SETTING

Interview (with analysis based on principles of grounded theory) of patients with a history of rheumatic fever or rheumatic heart disease and their relatives, and health service providers in a remote Aboriginal community; audit of benzathine penicillin coverage of patients with rheumatic heart disease.

PARTICIPANTS

15 patients with rheumatic heart disease or a history of rheumatic fever, 18 relatives and 18 health care workers.

RESULTS

Patients felt that the role of the clinic was not only to care for them physically, but that staff should also show nurturing holistic care to generate trust and treatment compliance. Differing expectations between patients and health care providers relating to the responsibility for care of patients absent from the community was a significant factor in patients missing injections. Neither a biomedical understanding of the disease nor a sense of taking responsibility for one's own health were clearly related to treatment uptake. Patients did not generally refuse injections, and 59% received adequate prophylaxis (> 75% of prescribed injections).

CONCLUSION

In this Aboriginal community, concepts of being cared for and nurtured, and belonging to a health service were important determinants of compliance.

Healthcare workers who elected not to receive smallpox vaccination

BACKGROUND

The goal of the National Smallpox Vaccination Program was to vaccinate a cadre of healthcare workers and first responders who could care for smallpox patients in the event of an attack.

METHODS

Using a convenience sample of health departments (n=49) and hospitals (n=60) in five states, we conducted a telephone interview between July 2003 and April 2004 of healthcare workers and first responders who chose not to receive smallpox vaccination. (Data were analyzed in 2004 and 2005.)

RESULTS

The response rate was 63%. Of 1895 respondents, 723 (38.2%) reported having a contraindication, 280 (14.8%) reported being contraindicated because of a household member's condition, and 892 (47.0%) reported having no contraindication to smallpox vaccination. Among respondents with no contraindication, the leading reasons for nonvaccination were concerns about side effects (20.6%) and not feeling that the risk of outbreak was high enough (19.5%). More than half (54.8%) were somewhat or very concerned about having an adverse reaction to the vaccine; Hispanics, blacks, and Asians were significantly more likely than whites to be somewhat or very concerned about side effects. Less than one fifth (17.9%) reported that there was a policy to financially compensate employees who developed side effects from vaccination, and 40.7% reported that there was a policy to provide liability coverage to employees who transmitted vaccinia to a patient.

CONCLUSIONS

Many people who chose not to receive smallpox vaccine perceived their personal risk-benefit balance as not favoring vaccination. The success of future smallpox vaccination efforts or vaccination against other bioterrorist health threats depends on addressing potential barriers to participation including compensation and liability issues, in addition to clearly communicating risks and benefits.

[Social and healthy circumstances of women's decision about applying hormonal replacement therapy]

The aim of the study was to evaluate the frequency of hormonal replacement therapy (HRT) application among Polish women aged 40-65, patients of five selected health care institutions located in south-eastern Poland and to determine the most significant factors that influence women's decision to initiate HRT. The next purpose was to establish how the women learned about the possibility of receiving HRT. Women, who never decided to take sex hormones, were asked about the reasons of such decision.

MATERIAL AND METHODS

The study comprised a group of 1033 women aged 40-65 years living in south-eastern Poland, the patients of various hospital wards and outpatient clinics. The study was conducted from January 2003 to December 2004 using categorized interview technique. The interview questionnaire was constructed by the authors. The statistical analysis was performed on the basis of the chi2 test of independence; log-linear analysis and Pareto's analysis were also used.

RESULTS

Research result analysis proves that 30.5% of the examined women have used HRT currently or in the past. The sociodemographic and healthy variables that showed positive correlation with receiving hormonal treatment by midlife women were: age 51-65 years, the presence of climacteric ailments, the absence of monthly bleedings, possessing of permanent life partner and good self-estimation of one's financial status. It was not revealed that better educated women more frequently decide to take HRT. The main sources of women's knowledge about HRT were the mass media and health service employees. Among the reasons for not taking up hormonal treatment the most significant were: lack or small intensification of menopausal ailments as well as the fear of side effects of hormonal replacement therapy.

Barriers to uptake and adherence with malaria prophylaxis by the African community in London, England: focus group study

BACKGROUND

Rates of imported malaria in the UK and other European countries are increasing, and particularly the more serious Plasmodium falciparum malaria. This study investigated beliefs about malaria and barriers to the uptake and adherence to malaria prophylaxis experienced by African descent individuals in inner London who have low rates of use of malaria prophylaxis and high risks of P. falciparum malaria.

DESIGN

Five focus groups conducted with 44 volunteers of African origin living in south London. Transcripts were analysed qualitatively.

RESULTS

Failure to access the drugs prior to travel was influenced by perceptions of malaria as a low threat, non-serious and easily treatable, and a belief that they were vaccinated or somehow not at personal risk, together with concerns about side effects of the drugs, dislike of the taste and disbelief by some participants of the drugs effectiveness. Health service barriers included the cost of drugs, waiting times for appointments and uncertainty regarding appropriate medication. Adherence to the prophylaxis was hindered by difficulties in remembering complex regimes, a lack of understanding of the rationale for continuing the drugs after return to the UK and the practice of leaving drugs for relatives in Africa. However, there was some variability in beliefs and practices that appeared to be associated with socio-economic status, prior experience of malaria and the local organisation and delivery of primary care travel services.

CONCLUSIONS

Much non-adherence is 'intentional' and reflects both beliefs common to all travellers and the particular circumstances and experiences of migrants of African descent. However, there was considerable variability in beliefs and practices among participants that reflects the heterogeneity within the West African community in their socio-economic position and circumstances. Changing behaviours requires a multi-dimensional approach involving community-based health promotion that targets the beliefs of this ethnic group and health service measures.

Barriers to Following the Back-to-Sleep Recommendations: Insights From Focus Groups With Inner-City Caregivers

BACKGROUND

African American infants have a higher incidence of SIDS and increased risk of being placed in the prone position for sleep.

OBJECTIVE

To determine new barriers and more information about previously identified barriers that interfere with adherence to the Back-to-Sleep recommendations among inner-city, primarily African Americans.

DESIGN/METHODS

We conducted 9 focus groups with caregivers of infants and young children from women, infants, and children centers and clinics in New Haven and Boston. Themes were identified using standard qualitative techniques.

RESULTS

Forty-nine caregivers participated, of whom 86% were African American, 6% were Hispanic, 4% were white, and 4% were other. Four themes were identified: 1) SAFETY: Participants chose the position for their infants based on which position they believed to be the safest. Some participants did not choose to put their infants in the supine position for sleep because they feared their infants would choke; 2) Advice: Participants relied on the advice of more experienced female family members. Health care providers were not uniformly a trusted source of advice; 3) Comfort: Participants made choices about their infants sleeping positions based on their perceptions of whether the infants appeared comfortable. Participants thought that their infants appeared more comfortable in the prone position; 4) Knowledge: Some participants had either limited or erroneous knowledge about the Back-to-Sleep recommendations.

CONCLUSIONS

We identified multiple barriers to adherence to recommendations regarding infant sleep position. Data obtained from these focus groups could be used to design educational interventions aimed at improving communication about and adherence to the Back-to-Sleep recommendations.

Predictors of failed attendances in a multi-specialty outpatient centre using electronic databases

Background

Failure to keep outpatient medical appointments results in inefficiencies and costs. The objective of this study is to show the factors in an existing electronic database that affect failed appointments and to develop a predictive probability model to increase the effectiveness of interventions.

Methods

A retrospective study was conducted on outpatient clinic attendances at Tan Tock Seng Hospital, Singapore from 2000 to 2004. 22864 patients were randomly sampled for analysis. The outcome measure was failed outpatient appointments according to each patient's latest appointment.

Results

Failures comprised of 21% of all appointments and 39% when using the patients' latest appointment. Using odds ratios from the mutliple logistic regression analysis, age group (0.75 to 0.84 for groups above 40 years compared to below 20 years), race (1.48 for Malays, 1.61 for Indians compared to Chinese), days from scheduling to appointment (2.38 for more than 21 days compared to less than 7 days), previous failed appointments (1.79 for more than 60% failures and 4.38 for no previous appointments, compared with less than 20% failures), provision of cell phone number (0.10 for providing numbers compared to otherwise) and distance from hospital (1.14 for more than 14 km compared to less than 6 km) were significantly associated with failed appointments. The predicted probability model's diagnostic accuracy to predict failures is more than 80%.

Conclusion

A few key variables have shown to adequately account for and predict failed appointments using existing electronic databases. These can be used to develop integrative technological solutions in the outpatient clinic.

Factors associated with medication adherence in African American and white patients with bipolar disorder

BACKGROUND

African American patients may be less likely than white patients to adhere to maintenance pharmacotherapy for bipolar disorder. The purpose of this study was to examine rates of medication nonadherence, self-perceived reasons for nonadherence, and attitudes associated with non-adherence in these ethnic groups.

METHOD

20 African American and 30 white subjects with DSM-IV bipolar I disorder participated in this study. At a single follow-up visit with patients at least 4 months after their first hospitalization for acute mania, we assessed demographics, symptom severity, degrees of adherence, reasons for non-adherence, and self-perceptions regarding factors previously associated with nonadherence using a visual analog scale (VAS). The cross-sectional data that are the subject of this report were obtained from July 1, 2002, through June 30, 2004.

RESULTS

Over 50% of participants in each group were currently either fully or partially nonadherent with medications. Greater than 20% of participants in each group denied having bipolar disorder and described physical side effects from medications as contributing to nonadherence. In principal components analysis of the VAS, 2 components were identified. The first component contained patient-related factors associated with nonadherence, while the second contained a combination of illness- and medication-related factors. African American participants were more likely to endorse patient-related factors associated with nonadherence relative to white participants. Specifically, African Americans self-endorsed a fear of becoming addicted to medications and feeling that medications were symbols of mental illness.

CONCLUSION

Findings suggest that both African American and white patients with bipolar disorder demonstrate poor medication adherence that they attribute to illness/medication-related factors (denial of illness, physical side effects). However, patient-related factors (fear of addiction, medication as a symbol of illness) accounted for ethnic differences on self-perceived ratings of nonadherence factors. Differences in the reasons for nonadherence relative to culturally biased self-perceptions may help explain nonadherence behaviors in the African American community.

Adherence to oral hypoglycemic agents in Hawaii

INTRODUCTION

Adherence to oral hypoglycemic agents is essential to reducing the poor health outcomes of populations at high risk for developing diabetes and its chronic complications. The goal of this study was to identify characteristics of patients in Hawaii least likely to adhere to oral hypoglycemic agents.

METHODS

This retrospective administrative data analysis included prescription refill claims for oral hypoglycemic agents from January 1, 1999, through June 30, 2003 (n = 20,685). Multivariate logistic regression analysis was used to examine the relationship between adherence and patient characteristics.

RESULTS

Adherence was found to be strongly associated with age and ethnicity. Relative to the age subset 55 to 64 years, adherence increased as age increased, reaching a peak at age 74 (odds ratio [OR] 1.1; 95% confidence interval [CI], 1.0-1.20). Past the age of 85, adherence declined (OR 0.90; 95% CI, 0.82-0.98). Relative to white patients, the odds ratio of adherence was highest for Japanese patients (OR 1.20; 95% CI, 1.0-1.30) and lowest for Filipino patients (OR 0.78; 95% CI, 0.68-0.90). Gender was not associated with adherence.

CONCLUSION

Differences in adherence to oral hypoglycemic agents were found to be related to ethnicity and age. Adherence was found to be lowest in younger patients and Filipino patients. This is a significant finding considering that younger diabetic patients have been shown to have the poorest glycemic control and worst health outcomes. Although the literature on adherence to oral hypoglycemic agents and health outcomes in Filipino patients is limited, studies support an increased risk for developing diabetes in this group. This information can be used to target younger patients and Filipino patients to improve their adherence to oral hypoglycemic agents.

Parents' refusal of medical treatment for cultural or religious beliefs: an ethnographic study of health care professionals' experiences

Pediatric nurses working in acute care settings serving religious and culturally diverse families may encounter parents whose beliefs influence treatment decisions. Previous literature describes how these complex situations lead to emotional distress and strained relationships between health care provider and family members. An ethnographic study was conducted to investigate the impact of parental treatment refusal on the bedside interactions between pediatric nurses and parents. Twenty in-depth interviews with nurses were conducted, and extensive field notes were taken during data collection. Emotional feelings associated with possible loss of guardianship and subsequent mandated treatment, the impact of the situation on the nurses' health and stress levels, and functional status were all explored. Three themes were identified following interpretive narrative analysis of transcriptions and field notes: weathering the storm of moral conflict, closeness and involvement versus distance and retreat, and battles between the supportive and oppositional groups. The findings of the study lead to a deeper understanding of the complexities of the ethical dilemma surrounding treatment refusal in pediatrics.

Parents' health and demographic characteristics predict noncompliance with well-child visits

BACKGROUND

The purpose of this study was to investigate factors related to well-child visit noncompliance in an ethnically diverse family practice clinic population.

METHODS

Participants included 146 parents (131 mothers and 15 fathers) of children aged 0 to 24 months who received care at a St. Paul residency clinic. Participants completed telephone surveys that asked about their demographic characteristics, attitudes toward well-child visits, whether the most recent planned well-child visit had been kept, and their own and their child's health characteristics.

RESULTS

All participants thought that well-child visits were important, with immunizations being the highest rated reason for importance. Fourteen percent of parents said they had missed a recent well-child visit, mostly because they forgot. More than three fourths of parents believed visit reminders were helpful, and the preferred type of reminder was a telephone call. Noncompliance with well-child visits was associated with the parent's depressive symptoms, transportation difficulties, working at a job, having private (vs public) health insurance, and being older (vs younger).

CONCLUSIONS

These results suggest that well-child visit compliance might be enhanced by visit reminders and improved access to transportation. The relationship of well-child visit noncompliance to parental depressive symptoms, if verified in other populations, points to a need for greater surveillance of children/families who do not schedule or keep well-child visits.

Parents' refusal of medical treatment based on religious and/or cultural beliefs: the law, ethical principles, and clinical implications

When parents apply religious or cultural beliefs concerning spiritual healing, faith healing, or preference for prayer over traditional health care for children, concerns develop. Medical care is considered one of the most basic of all human needs, and yet parents may elect to apply religious or cultural beliefs in place of traditional Western medical care for their children. Because memberships in religious groups that have beliefs concerning prayer and health care for children are increasing, the topic is of great importance for pediatric health professionals. This article describes parental refusal of medical care, and it discusses the legal, ethical, and clinical implications.

An ethnography of nonadherence: culture, poverty, and tuberculosis in urban Bolivia

The author conducted a focused descriptive ethnographic study of nonadherence with tuberculosis (TB) therapy among Aymara-speaking residents of the city of La Paz, Bolivia. A cohort of patient-informants was identified from the District III TB Control Registry of La Paz as having been nonadherent with their TB medication protocol. From June to August 1998, ethnographic material was collected through participant-observation and repeated interviews and visits in homes, workplaces, clinics, and the community. Ethnographic analysis revealed structural barriers to be more important than cultural differences in the production of nonadherence. Though informants maintained a variety of beliefs and practices related to Aymara medicine, the majority of patients were comfortable with a biomedical model of tuberculosis and maintained belief in the efficacy of antituberculosis chemotherapy and desire to finish treatment. Patients overwhelmingly cited hidden costs of treatments, poor access to care, ethnic discrimination, and prior maltreatment by the health system as reasons for abandoning treatment. These data suggest that overemphasis of cultural difference without exploration of other social dimensions of health care delivery can obscure a more practical understanding of nonadherence in marginalized populations.

Race and patient refusal of invasive cardiac procedures

OBJECTIVE

To determine whether patients' decisions are an important determinant of nonuse of invasive cardiac procedures and whether decisions vary by race.

DESIGN

Observational prospective cohort.

PARTICIPANTS

Patients (N= 681) enrolled at the exercise treadmill or the cardiac catheterization laboratories at a large Veterans Affairs hospital.

MEASURES

Doctors' recommendations and patients' decisions were determined by both direct observation of doctor and patient verbal behavior and by review of medical charts. Performance of coronary angiography, angioplasty, and bypass surgery were determined by chart review for a minimum of 3 months follow-up.

RESULTS

Coronary angiography was recommended after treadmill testing for 83 of 375 patients and 72 patients underwent angiography. Among 306 patients undergoing angiography, recommendations for coronary angioplasty or bypass surgery were given to 113 and 45 patients and were completed for 98 and 33 patients, respectively. Recommendations were not significantly different by race. However, 4 of 83 (4.8%) patients declined or did not return for recommended angiograms and this was somewhat more likely among black and Hispanic patients, compared with white patients (13% and 33% vs 2%; P =.05). No patients declined angioplasty and 2 of 45 (4.4%) patients declined or did not return for recommended bypass surgery. Other recommended procedures were not completed after further medical evaluation (n = 32). There was no difference (P >.05) by race/ethnicity in doctor-level reasons for nonreceipt of recommended invasive cardiac procedures.

CONCLUSIONS

Patient decisions to decline recommended invasive cardiac procedures were infrequent and may explain only a small fraction of racial disparities in the use of invasive cardiac procedures.